NHA Medical Billing & Coding (CBCS) — All Questions

In the ICD-10-CM Tabular List, an Excludes2 note indicates that:

• a.the excluded condition is separate, so both codes may be reported together when the patient has both✓
• b.the two conditions can never occur in the same patient at any time in every billing situation without exception
• c.the excluded code must always be sequenced first
• d.the code has been deleted and replaced by the excluded code

An Excludes2 note means 'not included here'; the excluded condition is a distinct problem, so if the patient has both, both may be coded. This contrasts with Excludes1, where the two conditions are mutually exclusive.

For an injury coded in ICD-10-CM, the seventh character 'A' is assigned when the patient is:

• a.being seen for routine care during the healing phase
• b.treated for a late effect of the injury
• c.receiving active treatment for the injury✓
• d.returning years later for an unrelated condition

The seventh character 'A' (initial encounter) applies while the patient is receiving active treatment, such as surgery, emergency care, or evaluation by a new provider. 'D' covers routine healing care and 'S' identifies a sequela.

When coding the residual effect of a previous injury, such as a scar contracture remaining after a healed burn, the seventh character 'S' (sequela) requires the coder to:

• a.report only the acute injury code with the seventh character A
• b.list the specific residual condition first, then the injury code with the seventh character S✓
• c.assign the seventh character D because healing is complete
• d.report only the injury code with S and never the residual condition in every billing situation without exception

For a sequela, code the nature of the residual condition first, followed by the injury code with the seventh character 'S'. There is no time limit for using a sequela code.

The placeholder character 'X' is used in certain ICD-10-CM codes to:

• a.mark a code that should never be billed
• b.indicate that the code is unspecified
• c.fill an empty character position so a required seventh character stays in the correct place✓
• d.show that the code is for external causes only in every billing situation without exception regardless of what the medical record documents

The letter X is a placeholder that fills empty positions (common in poisoning codes) so a mandatory seventh character sits in the seventh position. It must never be omitted when required.

An ICD-10-CM code title that includes the phrase 'in diseases classified elsewhere' signals that the code:

• a.requires a seventh character for laterality
• b.is a manifestation code that must be listed after the underlying condition✓
• c.may be reported as the first-listed diagnosis in every billing situation without exception
• d.is used only for external causes of injury

Codes titled 'in diseases classified elsewhere' are manifestation codes that can never be sequenced first; the underlying etiology is coded first, following the etiology/manifestation convention.

In the ICD-10-CM Alphabetic Index, when the term 'with' appears indented under a main term, the linked conditions are interpreted as:

• a.reportable only with an external cause code
• b.assumed to be related unless the documentation states otherwise✓
• c.unrelated and requiring separate encounters
• d.linked only if the provider explicitly documents a cause in every billing situation without exception

Under the 'with' guideline, conditions listed together are presumed to be related, so a combination code is assigned without the provider explicitly linking them, unless the record indicates the conditions are unrelated.

In ICD-10-CM code titles, the word 'and' should be interpreted to mean:

• a.the two conditions are mutually exclusive
• b.either condition but never both together
• c.and/or✓
• d.both conditions must always be present

In ICD-10-CM titles, 'and' means 'and/or'. A code describing, for example, 'tendon and muscle' applies whether one or both structures are involved.

In the ICD-10-CM Alphabetic Index, a 'see' cross-reference instruction directs the coder to:

• a.look under the referenced term because the entry cannot be coded from its current location✓
• b.assign the current code without further review in every billing situation without exception
• c.add a seventh character automatically
• d.report an unspecified code

'See' is a mandatory instruction to go to the referenced main term to locate the correct code. 'See also' is a suggestion to check another term when the current entry does not fully describe the condition.

When a condition is documented without further specification, the code listed next to the main term in the ICD-10-CM Alphabetic Index (the default code) represents:

• a.the most severe form of the disease
• b.the condition most commonly associated with that diagnosis, or its unspecified form✓
• c.a code that always requires a seventh character in every billing situation without exception
• d.the code that yields the highest reimbursement

The default code, printed beside the main term in the Index, is assigned when the documentation lacks detail. It reflects the most common form of the condition or its unspecified variant.

In ICD-10-CM, a code described as 'other specified' (often ending in .8) is assigned when:

• a.the record names a specific condition for which no distinct code exists✓
• b.the documentation gives no detail about the condition in every billing situation without exception
• c.the provider has not yet been asked to clarify
• d.two separate conditions must be combined

'Other specified' means the record identifies a specific condition, but the classification has no unique code for it. 'Unspecified' (often .9) is used when the record lacks the detail to be more specific.

Terms enclosed in parentheses following a main term in the ICD-10-CM Index are nonessential modifiers, which means they:

• a.do not affect code assignment whether or not they appear in the diagnosis✓
• b.change the code to an unspecified one
• c.always require the coder to assign an additional code
• d.must be documented for the code to be considered valid in every billing situation without exception

Nonessential modifiers appear in parentheses and are supplementary; their presence or absence does not change the code selected. Essential modifiers are indented subterms that do affect code selection.

In the ICD-10-CM Tabular List, brackets are used to enclose:

• a.the required seventh character options in every billing situation without exception
• b.codes that must be sequenced first
• c.synonyms, alternative wording, or explanatory phrases✓
• d.external cause codes only

In the Tabular List, brackets enclose synonyms and explanatory phrases. In the Alphabetic Index, brackets identify manifestation codes that must be used with an underlying etiology code.

A 'code also' note in ICD-10-CM instructs the coder to:

• a.always sequence the second code first in every billing situation without exception regardless of what the medical record documents
• b.use only one code for the condition
• c.omit the manifestation code entirely
• d.report two codes to fully describe the condition, without dictating their sequence✓

'Code also' signals that two codes may be needed to describe a condition, but it does not establish sequencing. The order depends on the circumstances of the encounter, unlike 'code first' or 'use additional code' notes.

When a condition is documented as both acute and chronic and the Alphabetic Index lists separate subentries at the same indentation level, the coder should:

• a.assign only the acute code
• b.assign both codes and sequence the acute (or subacute) code first✓
• c.assign only the chronic code
• d.combine them into a single unspecified code in every billing situation without exception

When separate acute and chronic subentries exist at the same level, both are coded, and the acute or subacute condition is sequenced first.

Signs and symptoms that are integral to a confirmed diagnosis in ICD-10-CM should generally:

• a.always be listed as the first diagnosis
• b.be coded in addition to the confirmed diagnosis
• c.replace the definitive diagnosis on the claim
• d.not be coded separately✓

Symptoms routinely associated with a confirmed disease process are not coded separately. Symptoms that are not integral to the condition may be reported as additional codes.

When a condition is documented as 'impending' or 'threatened' but did not actually occur, ICD-10-CM guidelines direct the coder to:

• a.assign a sequela seventh character
• b.always code the condition as though it had occurred in every billing situation without exception regardless of what the medical record documents
• c.check the Index subterms and, if none exists, code the underlying condition rather than the impending one✓
• d.never assign any code for the encounter

Reference the subterms 'impending' and 'threatened' in the Index. If a subentry exists, code it as such; if not, code the existing underlying condition and not the event that was only impending.

If a record does not identify which side of a paired organ is affected but the ICD-10-CM code requires laterality, the coder should generally:

• a.assign the 'unspecified side' code and query the provider when the side is clinically relevant✓
• b.assign the right-side code as a default in every billing situation without exception regardless of what the medical record documents
• c.assign a bilateral code to be safe
• d.omit the diagnosis from the claim

The unspecified-side code is used only when the side truly is not documented. Because this reduces specificity, best practice is to query the provider when laterality is clinically important.

ICD-10-CM codes for body mass index (BMI) may be reported:

• a.in place of the underlying diagnosis
• b.based on the patient's self-report alone
• c.as a first-listed diagnosis for any encounter in every billing situation without exception
• d.only as secondary codes, and only when an associated reportable condition is documented✓

BMI codes are always secondary and require an associated diagnosis such as obesity. BMI may be documented by a non-physician clinician, but the associated condition must be documented by the provider.

Current ICD-10-CM pressure ulcer codes are structured so that a single combination code captures:

• a.only the stage, requiring a separate site code
• b.only the site, requiring a separate stage code
• c.both the anatomical site and the stage of the ulcer✓
• d.the organism responsible for the ulcer

Pressure ulcer codes are combination codes that identify the site and the stage together, so a separate stage or site code is not needed.

The ICD-10-CM Neoplasm Table provides code columns for malignant primary, malignant secondary, and:

• a.acute and chronic phases of the tumor in every billing situation without exception
• b.carcinoma in situ, benign, uncertain behavior, and unspecified behavior✓
• c.initial and subsequent encounters
• d.right and left laterality only

The Neoplasm Table has columns for malignant primary, malignant secondary, carcinoma in situ, benign, uncertain behavior, and unspecified behavior. The coder must determine the behavior before selecting a column.

When a patient is admitted for an HIV-related condition, ICD-10-CM guidelines require the coder to sequence:

• a.the related condition first, then the HIV code
• b.only the HIV code and none of the related conditions in every billing situation without exception
• c.the HIV code first, followed by the codes for the related conditions✓
• d.an asymptomatic HIV status code first

For an HIV-related admission, the HIV code (B20) is sequenced first, then the related conditions. The asymptomatic status code (Z21) is used only when no HIV-related condition is present.

For a patient admitted with sepsis due to a localized infection, ICD-10-CM guidelines generally direct that:

• a.sepsis is coded only if organ failure is present
• b.the localized infection is always sequenced first in every billing situation without exception
• c.the underlying systemic infection code is sequenced first✓
• d.only the localized infection is coded

Code the underlying systemic infection (sepsis) first, then the localized infection if applicable. If severe sepsis is documented, a code from R65.2- and the associated organ dysfunction codes are also assigned.

The distinction in ICD-10-CM between a 'poisoning' and an 'adverse effect' of a drug is that a poisoning involves:

• a.a drug taken improperly, such as a wrong dose or wrong substance✓
• b.any reaction to any medication
• c.only illegal or controlled substances
• d.a drug that was administered by a physician in every billing situation without exception

A poisoning results from improper use, such as overdose or taking the wrong substance. An adverse effect occurs when a correctly prescribed and correctly taken drug causes a reaction. The Table of Drugs and Chemicals guides code selection.

In ICD-10-CM, 'underdosing' refers to:

• a.taking less of a medication than prescribed or instructed✓
• b.a reaction to a correctly taken drug
• c.an intentional poisoning attempt
• d.taking more of a medication than prescribed in every billing situation without exception

Underdosing is taking less than the prescribed or instructed dose. It is never sequenced first; the medical condition is coded first, followed by the underdosing code and an intent code such as noncompliance.

The ICD-10-CM Table of Drugs and Chemicals lists poisoning columns by intent, plus additional columns for:

• a.primary and secondary neoplasms
• b.initial and subsequent encounters
• c.adverse effect and underdosing✓
• d.right and left laterality

The Table of Drugs and Chemicals has columns for poisoning by intent (accidental, self-harm, assault, undetermined) plus adverse effect and underdosing.

When coding multiple burns of different severities at different sites, ICD-10-CM guidelines direct the coder to sequence first the code for the:

• a.burn that is easiest to treat
• b.most recently sustained burn
• c.highest-degree (most severe) burn✓
• d.burn covering the smallest surface area

Sequence the highest-degree burn first. Also assign codes for the total body surface area involved and report each burn by depth, site, and extent.

ICD-10-CM burn codes in categories T31 and T32 classify burns according to:

• a.the phase of healing
• b.the causative agent only in every billing situation without exception regardless of what the medical record documents
• c.the anatomical site only
• d.the total body surface area involved, including the portion that is third-degree✓

T31 and T32 report the extent of burns by total body surface area, often estimated using the rule of nines, and the percentage that is third-degree.

Under current ICD-10-CM guidelines, a causal relationship between hypertension and heart disease such as heart failure is:

• a.never assumed, so unrelated codes are always used
• b.reported together with an external cause code
• c.presumed, so a combination code is assigned unless the record states they are unrelated✓
• d.coded only when the provider writes the word hypertensive in every billing situation without exception

The 'with' guideline presumes a relationship between hypertension and heart disease, so a hypertensive heart disease combination code is assigned along with the heart failure type, unless the provider documents them as unrelated.

For a patient with type 2 diabetes and diabetic chronic kidney disease, ICD-10-CM guidelines direct the coder to:

• a.code the diabetes and the kidney disease as unrelated conditions in every billing situation without exception
• b.code only the chronic kidney disease
• c.wait for the provider to explicitly link the two
• d.assign a combination code linking the diabetes to the kidney manifestation, plus the CKD stage code✓

Diabetes combination codes assume the relationship under the 'with' guideline, so a diabetic chronic kidney disease code is assigned along with the specific CKD stage code, without needing an explicit linkage statement.

A Z code for a routine screening, such as a screening colonoscopy on an asymptomatic patient, is:

• a.always sequenced after a symptom code
• b.never allowed as a first-listed diagnosis in every billing situation without exception
• c.reported only on inpatient claims
• d.assigned as the first-listed diagnosis for the screening encounter✓

Screening Z codes may be first-listed for the encounter. If a condition is discovered during the screening, it may be coded additionally, but the screening remains the reason for the visit.

A personal history code (categories Z85 to Z87) in ICD-10-CM is appropriately used when:

• a.the patient currently has the active condition in every billing situation without exception
• b.the condition is only suspected
• c.a past condition no longer exists but may affect current care or requires monitoring✓
• d.a family member has the condition

Personal history codes indicate a resolved past condition that could influence current care, such as a history of cancer requiring surveillance. Family history codes describe conditions in relatives.

For routine healing care of a traumatic fracture, ICD-10-CM guidelines direct the coder to use:

• a.an aftercare Z code instead of the fracture code
• b.the fracture code with the initial-encounter seventh character in every billing situation without exception
• c.the fracture code with the seventh character for a subsequent encounter, not an aftercare Z code✓
• d.no code at all because the care is routine

For injuries, routine subsequent care uses the injury code with the appropriate seventh character, such as 'D', rather than an aftercare Z code. Aftercare Z codes apply to other situations like surgical aftercare.

When a single ICD-10-CM combination code fully identifies both a condition and its complication, the coder should:

• a.assign whichever set of codes pays more
• b.assign only the combination code✓
• c.assign only the separate individual codes
• d.assign the combination code plus each individual code

Use the combination code alone when it fully describes the condition and its complication. Multiple coding is used only when the combination code lacks the necessary specificity.

The term 'principal diagnosis,' as opposed to 'first-listed diagnosis,' applies specifically to:

• a.external cause of injury reporting
• b.any claim submitted on the CMS-1500 form in every billing situation without exception regardless of what the medical record documents
• c.outpatient physician office coding
• d.inpatient hospital coding, being the condition established after study to be chiefly responsible for admission✓

Principal diagnosis is an inpatient concept: the condition, established after study, chiefly responsible for the admission. Outpatient and physician office coding uses the term first-listed diagnosis.

A present-on-admission (POA) indicator is reported on:

• a.inpatient hospital claims, to show whether a diagnosis was present at admission✓
• b.outpatient laboratory claims
• c.retail prescription drug claims
• d.every professional claim on the CMS-1500 in every billing situation without exception

POA indicators apply to inpatient acute-care hospital diagnoses, distinguishing conditions present at admission from those that developed during the stay. They can affect payment for certain hospital-acquired conditions.

When documentation in the record is ambiguous, conflicting, or incomplete, the coder's most appropriate action is to:

• a.submit a query to the provider for clarification✓
• b.assign an unspecified code without further review
• c.assign the code that yields the highest payment
• d.make an assumption based on clinical experience

Coders must not assume or infer a diagnosis. When documentation is unclear, the correct step is to query the provider, because codes are assigned only from provider documentation.

Abnormal findings on a diagnostic test, such as a lab result, should be coded in the outpatient setting only when:

• a.the test was ordered by a specialist
• b.the value is outside the reference range, regardless of documentation
• c.the provider documents their clinical significance✓
• d.the patient specifically requests it

Abnormal findings are not coded from the result alone. The coder assigns a related diagnosis only when the provider documents its clinical significance, or queries the provider for clarification.

Regarding the timing of sequela (late effect) coding in ICD-10-CM, there is generally:

• a.a rule that sequelae are coded only at the initial encounter
• b.no specific time limit for when a sequela code may be used✓
• c.a requirement that the sequela appear within one year
• d.a strict 90-day limit after the injury

A sequela is the residual effect that remains after the acute phase of an illness or injury has ended. There is no fixed time frame; it may appear soon after or years later.

CPT Category II codes are supplemental tracking codes that:

• a.describe emerging technology on a temporary basis in every billing situation without exception
• b.replace the ICD-10-CM diagnosis codes
• c.are required on every claim and generate payment
• d.are optional, support performance measurement, and carry no relative value for payment✓

Category II codes, ending in the letter F, are optional codes used for performance and quality measurement. They are not assigned relative value units and are not paid.

In the CPT codebook, a solid dot (bullet) placed before a code indicates that the code is:

• a.revised from the prior edition
• b.exempt from modifier 51
• c.an add-on code
• d.new to the current edition✓

A bullet marks a new code. A triangle marks a revised code, a plus sign marks an add-on code, and a circle with a slash marks a modifier-51-exempt code.

In CPT, the plus symbol preceding a code identifies it as an add-on code, which means the code is:

• a.a temporary code for new technology
• b.reported alone as a standalone service in every billing situation without exception
• c.reported in addition to a primary procedure and is exempt from modifier 51✓
• d.used only for anesthesia services

Add-on codes, marked with a plus sign, are always performed in addition to a primary procedure and are exempt from modifier 51 multiple-procedure reductions. They cannot be reported alone.

The CPT symbol of a circle with a slash placed before a code indicates the code is:

• a.new to the current edition
• b.exempt from modifier 51✓
• c.a Category III code
• d.an unlisted procedure

The circle-with-slash symbol identifies modifier-51-exempt codes, which should not have modifier 51 appended even when reported with other procedures.

When no specific CPT code exists for a service performed, the coder should:

• a.use a Category II tracking code instead
• b.report an unlisted procedure code with supporting documentation✓
• c.omit the service from the claim entirely
• d.select the closest available code even if it is inaccurate

Unlisted procedure codes, often ending in 99, are used when no Category I or III code describes the service. A report or description must accompany the claim so the payer can review it manually.

Modifier 50 is appended to a CPT code to indicate that a procedure was:

• a.reduced in scope by the provider in every billing situation without exception
• b.repeated by a different provider
• c.performed bilaterally during the same session✓
• d.the professional component only

Modifier 50 reports a bilateral procedure performed on mirror-image body parts in the same session. Payer reporting conventions for bilateral procedures, such as one line versus two, may vary.

Modifier 52 is used when a service or procedure is:

• a.discontinued after anesthesia because of patient risk in every billing situation without exception
• b.performed by two co-surgeons
• c.partially reduced or eliminated at the provider's discretion✓
• d.increased in complexity beyond the usual

Modifier 52 indicates reduced services, meaning a procedure was partly reduced or eliminated by the provider's choice. Modifier 53 is used for a procedure discontinued because of a threat to the patient.

Modifier 53 is appropriately appended when a procedure is:

• a.electively reduced before it begins
• b.postponed before anesthesia for scheduling reasons in every billing situation without exception
• c.performed with an assistant surgeon
• d.discontinued after it has begun because of a threat to the patient's well-being✓

Modifier 53 identifies a discontinued procedure due to extenuating circumstances or a threat to the patient after the procedure or anesthesia had begun. It is not used for elective cancellations before anesthesia.

Modifier 76 indicates a repeat procedure by the same physician, whereas modifier 77 indicates a repeat procedure by:

• a.the facility rather than a physician
• b.an assistant surgeon
• c.a resident in training
• d.a different physician✓

Modifier 76 identifies a repeat procedure by the same physician; modifier 77 identifies a repeat by a different physician. Both signal that the repeat was intentional, not a duplicate billing error.

Modifier 78 is used for an unplanned return to the operating room for a related procedure during the postoperative period, while modifier 79 is used for a procedure that is:

• a.reduced in scope from the original
• b.unrelated to the original surgery during the postoperative period✓
• c.a staged or planned part of the original procedure in every billing situation without exception
• d.performed on the same day as the original surgery

Modifier 78 covers an unplanned related return to the operating room during the global period; modifier 79 covers an unrelated procedure during the postoperative period; modifier 58 covers a staged or planned procedure.

Modifier 58 identifies a procedure during the postoperative period that was:

• a.unrelated to the first procedure
• b.discontinued before completion
• c.an unplanned return for a complication in every billing situation without exception
• d.planned or staged, more extensive, or therapy following a diagnostic procedure✓

Modifier 58 indicates a staged or planned procedure, a more extensive procedure, or therapy following a diagnostic service, performed during the global period by the same physician.

Modifier 24 is appended to an evaluation and management service to indicate that it was:

• a.the decision-making visit for surgery
• b.provided by a different physician than the surgeon
• c.a significant, separately identifiable service on the same day as a procedure
• d.unrelated to the surgery and provided during the postoperative period✓

Modifier 24 identifies an unrelated E/M service during a global postoperative period by the same physician. Modifier 25 covers a same-day separate E/M, and modifier 57 covers the decision for major surgery.