CSLB General Building (B) — All Questions

In ICD-10-CM, what does the abbreviation NOS in the Alphabetic Index or Tabular List indicate?

• a.The code requires an additional character to be complete
• b.The documentation is unspecified, so an 'unspecified' code is assigned✓
• c.The condition should never be coded as a primary diagnosis
• d.Two separate codes must be combined into one

NOS stands for 'not otherwise specified' and is equivalent to 'unspecified.' It is used when the medical record lacks the detail needed to assign a more specific code. Coders should query the provider when greater specificity is clinically documented but not captured.

An ICD-10-CM code shown with a dash (for example, S52.5-) in a coding reference most directly signals that:

• a.The code has been deleted from the current code set
• b.The code may only be used for external causes
• c.Additional characters are required to reach a valid, complete code✓
• d.The code is exempt from the diagnosis present-on-admission indicator

A trailing dash is a placeholder convention indicating that the code is incomplete and needs one or more additional characters. Submitting a truncated code that lacks required characters will cause the claim to be rejected. The coder must consult the Tabular List to assign all required characters, including any seventh character.

The ICD-10-CM convention 'code first' instructs the coder to:

• a.Sequence the underlying etiology or cause before the manifestation code✓
• b.Always list the code with the highest numeric value first
• c.Report only the manifestation and omit the underlying condition
• d.Assign the code that generates the highest reimbursement first

'Code first' is a sequencing instruction telling the coder to list the underlying condition or etiology ahead of the associated manifestation. Manifestation codes cannot stand alone as a first-listed or principal diagnosis. This mirrors the etiology/manifestation convention found throughout the code set.

In the ICD-10-CM Tabular List, the note 'Excludes1' means:

• a.The two conditions may be coded together when both are documented
• b.An additional code should be assigned to fully describe the condition
• c.The excluded code is an acceptable synonym for the listed code
• d.The two conditions are mutually exclusive and should not be coded together✓

An Excludes1 note is a 'not coded here' instruction indicating the two conditions cannot occur together and should never be reported on the same encounter for the same condition. In contrast, an Excludes2 note means the excluded condition is separate and may be coded additionally if the patient has both. Confusing the two notes is a common source of coding errors.

Which seventh character in an ICD-10-CM injury code identifies a subsequent (follow-up) encounter during the healing phase?

• a.A, for initial encounter
• b.D, for subsequent encounter✓
• c.S, for sequela
• d.X, for a placeholder

For most injury and external-cause codes, the seventh character 'D' denotes a subsequent encounter, when the patient is receiving routine care during the healing or recovery phase. 'A' is the initial encounter for active treatment, and 'S' identifies a sequela, or late effect. The letter X can serve as a placeholder to fill empty character positions so the seventh character stays in the correct slot.

The main term used to locate a diagnosis in the ICD-10-CM Alphabetic Index is generally:

• a.The anatomical site of the condition
• b.The name of the treating provider's specialty
• c.The condition, disease, or reason for the encounter✓
• d.The type of insurance the patient carries

Diagnoses are indexed by the condition, disease, injury, or symptom (the main term), not by the body site. Anatomical site and other details usually appear as subterms indented beneath the main term. Coders locate the term in the Index, then verify the code in the Tabular List before final assignment.

The Current Procedural Terminology (CPT) code set is divided into three categories. Category I codes primarily describe:

• a.Widely performed procedures and services with FDA-approved technology✓
• b.Performance-measurement and quality tracking data
• c.Emerging or experimental technologies and services
• d.Durable medical equipment and supplies

Category I CPT codes are five-digit numeric codes representing established procedures and services that are consistent with contemporary medical practice. Category II codes are supplemental tracking codes for performance measurement, and Category III codes are temporary codes for emerging technology. Only Category I codes have relative value units assigned for standard payment.

CPT Category III codes are best described as:

• a.Permanent codes for well-established surgical procedures
• b.Codes used exclusively for anesthesia services
• c.Quality-measurement codes that carry no procedure meaning
• d.Temporary codes for emerging technologies, services, and procedures✓

Category III codes are temporary alphanumeric codes (four digits followed by the letter T) used to track new and emerging technologies. Using them allows data collection on utilization and outcomes before a service may be considered for Category I status. They are archived or converted after a set period if not adopted.

HCPCS Level II codes are chiefly used to report:

• a.Physician evaluation and management visits
• b.Products, supplies, and services not covered by CPT, such as durable medical equipment and certain drugs✓
• c.Inpatient hospital room-and-board charges
• d.International diagnosis classifications

HCPCS Level II is a national code set (alphanumeric, one letter followed by four digits) maintained by CMS to report items such as durable medical equipment, prosthetics, orthotics, supplies, ambulance services, and drugs administered other than by mouth. These are items generally not found in CPT (HCPCS Level I). Payers rely on Level II codes to adjudicate supply and drug claims.

A modifier appended to a CPT code is used to:

• a.Change the fundamental definition of the procedure code
• b.Replace the diagnosis code on the claim
• c.Indicate that a service was altered by a specific circumstance without changing the code's core meaning✓
• d.Signal that the claim is being submitted late

Modifiers are two-character codes that provide additional information about a service, such as that a procedure was bilateral, was reduced, or was performed by more than one provider, without redefining the procedure itself. Correct modifier use supports clean claims and appropriate reimbursement. Omitting a needed modifier is a frequent cause of denials.

Modifier 26 is appended to a diagnostic service to indicate that only the:

• a.Professional component (the physician's interpretation) is being billed✓
• b.Technical component (equipment and supplies) is being billed
• c.Global service including both components is being billed
• d.Service was performed by a resident under supervision

Many diagnostic tests, such as radiology, have a professional component (the provider's interpretation and report) and a technical component (the equipment, supplies, and technician). Modifier 26 reports the professional component alone. Modifier TC reports the technical component, and a code billed without either modifier represents the global (combined) service.

Modifier 25 is most appropriately used to report:

• a.A staged or planned return to the operating room
• b.A bilateral procedure performed on paired organs
• c.A repeat laboratory test on the same day
• d.A significant, separately identifiable E/M service by the same provider on the same day as another procedure✓

Modifier 25 tells the payer that on the day a minor procedure was performed, the provider also delivered a distinct, medically necessary evaluation and management service beyond the usual pre- and post-procedure work. Documentation must clearly support the separate E/M service. Misuse of modifier 25 is a common audit target.

Three key components historically used to determine the level of an evaluation and management (E/M) service are:

• a.Diagnosis, procedure, and place of service
• b.History, examination, and medical decision making✓
• c.Modifier, units, and charge amount
• d.Payer, plan type, and deductible status

Traditional E/M level selection was based on the extent of the history, the examination, and the complexity of medical decision making. Contemporary office-visit guidelines allow the level to be chosen by medical decision making or by total time on the date of service. Accurate documentation of these elements supports the code selected.

When selecting an office E/M visit level by time under current guidelines, the coder should count:

• a.Only the minutes spent face-to-face performing the exam
• b.Only the time the patient spent in the waiting room
• c.The total qualifying provider time spent on the date of the encounter, including certain non-face-to-face work✓
• d.The average time all patients spend in the practice that day

Current office and outpatient E/M guidelines permit level selection based on the provider's total time on the date of the encounter, which can include reviewing records, ordering tests, documenting, and coordinating care, not just face-to-face minutes. The provider must document the total time. Alternatively, the level may be chosen by medical decision making.

In coding, 'medical necessity' generally means that a service is:

• a.Reasonable and necessary for the diagnosis or treatment of the patient's condition✓
• b.The most expensive option available to the provider
• c.Requested by the patient regardless of clinical indication
• d.Always covered by every insurance plan

Medical necessity is the standard that a service must be appropriate and needed to evaluate or treat the patient's documented condition to qualify for payment. The diagnosis code must support the procedure code billed. Services deemed not medically necessary are commonly denied even when correctly coded.

The primary or first-listed diagnosis on an outpatient claim should represent:

• a.The condition that is easiest to code
• b.Any chronic condition the patient has ever had
• c.The diagnosis with the highest reimbursement
• d.The main condition, chiefly responsible for the services provided during the encounter✓

For outpatient encounters, the first-listed diagnosis is the reason chiefly responsible for the services rendered that day. Coexisting conditions that affect treatment may be reported as additional diagnoses. Correct sequencing supports both medical necessity and accurate reimbursement.

When a definitive diagnosis has not been established at the end of an outpatient encounter, ICD-10-CM guidelines direct the coder to report:

• a.A probable or 'rule-out' diagnosis as if confirmed
• b.The documented signs, symptoms, or reason for the encounter✓
• c.No diagnosis code at all
• d.The most serious disease that could explain the symptoms

For outpatient and physician office coding, conditions described as 'probable,' 'suspected,' or 'rule out' are not coded as confirmed. Instead, the coder reports the signs, symptoms, or the reason for the visit to the highest known level of certainty. This differs from inpatient rules, where uncertain diagnoses may sometimes be coded.

The instructional note 'use additional code' in ICD-10-CM tells the coder to:

• a.Delete the primary code and use only the additional one
• b.Never assign more than one code for the encounter
• c.Report a secondary code to fully describe the condition when documentation supports it✓
• d.Assign a modifier instead of a second code

'Use additional code' is a convention prompting the coder to add a secondary code that gives a more complete picture, such as an infectious organism or an associated manifestation, when the record supports it. It works together with 'code first' notes to enforce proper sequencing. Ignoring these notes can lead to incomplete claims.

In CPT, an add-on code is one that:

• a.Describes an additional service performed with a primary procedure and cannot be reported alone✓
• b.Replaces the primary procedure code entirely
• c.Can only be used for laboratory panels
• d.Is always reported without any other code

Add-on codes represent services that are always performed in addition to a primary procedure and are typically identified with a plus symbol in CPT. They are exempt from certain multiple-procedure payment reductions and must be reported alongside their primary code. Reporting an add-on code alone will cause a denial.

The 'global surgical package' concept in CPT means that the payment for a surgery generally includes:

• a.Only the incision itself
• b.The surgeon's fee plus all unrelated future care for a year
• c.Nothing beyond the operating room time
• d.The operation plus related preoperative and normal postoperative care for a defined period✓

A surgical package bundles the procedure with typical preoperative evaluation and routine postoperative follow-up during a defined global period. Services within that period that are routine follow-up are not billed separately. Care unrelated to the surgery, or a return to the operating room, may be reported with appropriate modifiers.

Which statement about the ICD-10-CM external cause codes (the V, W, X, and Y codes) is correct?

• a.They may be used as a first-listed or principal diagnosis
• b.They provide supplemental detail about how an injury occurred and are never sequenced first✓
• c.They replace the injury code entirely
• d.They are only used for laboratory results

External cause codes describe the mechanism, intent, place, and activity related to an injury or condition, adding useful public-health detail. They are always secondary and cannot serve as the principal or first-listed diagnosis. Their use is generally voluntary unless mandated by a state or payer.

A 'combination code' in ICD-10-CM is a single code that:

• a.Combines a CPT and an ICD-10-CM code
• b.Merges two unrelated encounters
• c.Classifies two diagnoses, or a diagnosis with an associated manifestation or complication, in one code✓
• d.Represents a bundled surgical package

A combination code captures either two diagnoses, or a diagnosis together with an associated secondary process or complication, in a single code. When a combination code fully describes the condition, only that code is assigned. Assigning separate codes instead would result in unnecessary and potentially incorrect reporting.

In CPT surgical coding, modifier 59 is used to identify a:

• a.Distinct procedural service that is separate from other services performed the same day✓
• b.Bilateral procedure
• c.Professional component only
• d.Reduced service

Modifier 59 indicates that a procedure was distinct or independent from other non-E/M services performed on the same day, such as a different session, site, or organ system. It is used to bypass certain edits when services are truly separate. Because it is frequently misused, more specific X-modifiers were introduced and documentation must support the distinct service.

Which of the following best describes the correct order of coding steps?

• a.Assign the code from the Tabular List, then skip the Index
• b.Locate the main term in the Alphabetic Index, then verify the code in the Tabular List✓
• c.Choose the code with the highest payment, then confirm with the payer
• d.Read only the Index and never consult the Tabular List

Proper coding always begins in the Alphabetic Index to locate the main term and any subterms, followed by verification in the Tabular List where all conventions, notes, and character requirements are checked. Coding directly from the Index alone risks missing required characters or instructional notes. This two-step process helps ensure accurate, complete code assignment.

The 'Z codes' in ICD-10-CM are primarily used to report:

• a.Only fatal conditions
• b.External causes of morbidity
• c.Poisonings and toxic effects
• d.Factors influencing health status and contact with health services, such as screenings or aftercare✓

Z codes describe reasons for encounters other than a current illness or injury, such as routine examinations, immunizations, screenings, aftercare, and personal or family history. Some Z codes may be first-listed while others are only secondary. They help explain the medical necessity of preventive and follow-up visits.

When laterality applies to an ICD-10-CM code, the coder must specify:

• a.The severity of the pain only
• b.The provider's specialty
• c.Whether the condition affects the right, left, or is bilateral✓
• d.The date of the injury

Many ICD-10-CM codes require documentation of laterality, identifying the right side, left side, or bilateral involvement of a paired body part. When the record does not state the side, an 'unspecified' code may be the only option, but this reduces specificity. Coders should query the provider when laterality is clinically relevant but missing.

In CPT, the '-51' modifier is generally appended to indicate:

• a.Multiple procedures performed at the same session by the same provider✓
• b.A telehealth service
• c.A repeat clinical laboratory test
• d.That the patient is deceased

Modifier 51 signals that more than one procedure was performed during the same encounter, which may trigger multiple-procedure payment reductions on the lesser services. It is not appended to add-on codes or to codes designated as modifier-51 exempt. Some payers apply the reduction automatically rather than requiring the modifier.

Upcoding, which is prohibited, refers to:

• a.Reporting a lower-level service than was documented
• b.Reporting a higher-level or more complex service than was actually documented or performed✓
• c.Bundling two codes into one appropriately
• d.Using the correct modifier on a claim

Upcoding is the improper practice of assigning a code that reflects a more severe diagnosis or more expensive service than the documentation supports, in order to obtain higher payment. It is considered fraudulent and can trigger penalties. Coders must assign codes strictly according to the medical record.

Unbundling in coding refers to:

• a.Combining several services into one comprehensive code correctly
• b.Reporting only the primary code of a package
• c.Assigning the least specific diagnosis available
• d.Billing separately for services that should be reported together under a single comprehensive code✓

Unbundling occurs when component parts of a single comprehensive procedure are reported as separate codes to increase reimbursement. National Correct Coding Initiative edits are designed to detect and prevent this. When done to gain higher payment, unbundling is considered abusive or fraudulent billing.

The National Correct Coding Initiative (NCCI) edits are used primarily to:

• a.Set the fee schedule amounts for each code
• b.Determine patient deductibles
• c.Prevent improper payment when incorrect code combinations are reported✓
• d.Assign diagnosis codes automatically

NCCI edits, maintained by CMS, identify pairs of codes that generally should not be billed together for the same patient on the same day, as well as units-of-service limits. They help promote correct coding and prevent improper payments. A modifier may sometimes override an edit when documentation supports a distinct service.

Which resource lists CPT modifiers and their definitions and is essential for accurate procedural coding?

• a.The CPT codebook, including its appendices✓
• b.The CMS-1500 claim form instructions only
• c.The patient's insurance card
• d.The remittance advice

The CPT codebook contains the modifiers along with guidelines and appendices that define their proper use. Coders rely on these official descriptions to append modifiers accurately. Using an outdated or incomplete reference can lead to incorrect modifier application and denials.

The ICD-10-CM Official Guidelines for Coding and Reporting are best described as:

• a.Optional suggestions that payers may ignore
• b.Authoritative rules that accompany the code set and must be followed for accurate code assignment✓
• c.A list of covered services by insurance plan
• d.The fee schedule for each diagnosis

The Official Guidelines are a set of rules developed to accompany and complement the ICD-10-CM conventions and instructions, and adherence to them is required under HIPAA. They govern selection and sequencing of codes in various settings. Coders must apply both the conventions in the code set and these guidelines together.