RHIA Clinical Classification Systems and Coding 1 — Questions and Answers
Question 1: In ICD-10-CM, what is the maximum number of characters a code can have?
- 5
- 6
- 7 (Correct answer)
- 8
Correct answer: 7
ICD-10-CM codes can have up to 7 characters, with the first three characters identifying the category and additional characters providing specificity.
Question 2: Which coding guideline requires that the condition established after study to be chiefly responsible for occasioning the admission is sequenced first?
- Uniform Hospital Discharge Data Set rule
- Principal diagnosis definition (Correct answer)
- Present on Admission rule
- Complication sequencing rule
Correct answer: Principal diagnosis definition
The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission to the hospital, per the UHDDS definition.
Question 3: CPT codes are organized into how many main sections (categories)?
- 4
- 5
- 6 (Correct answer)
- 7
Correct answer: 6
CPT is organized into 6 main sections: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine.
Question 4: HCPCS Level II codes are used primarily to report what type of services?
- Physician procedures covered by CPT
- Supplies, equipment, and non-physician services not in CPT (Correct answer)
- Inpatient hospital diagnoses
- Pharmacy dispensing fees only
Correct answer: Supplies, equipment, and non-physician services not in CPT
HCPCS Level II codes supplement CPT to cover supplies, durable medical equipment, ambulance services, and other services not represented in CPT.
Question 5: The MS-DRG system is used to classify inpatient cases primarily for which payer?
- Medicaid
- Commercial insurance
- Medicare (Correct answer)
- TRICARE
Correct answer: Medicare
Medicare Severity-Diagnosis Related Groups (MS-DRGs) are used by Medicare under the Inpatient Prospective Payment System (IPPS) to determine hospital reimbursement.
Question 6: In ICD-10-CM, the instruction 'Code first' is used to indicate what type of coding sequence?
- The condition should always be sequenced as principal diagnosis
- An underlying condition must be coded before the manifestation (Correct answer)
- The code requires an additional external cause code
- The code is used only for outpatient reporting
Correct answer: An underlying condition must be coded before the manifestation
'Code first' instructs the coder to sequence the underlying etiology before the manifestation when both are present, following the etiology/manifestation convention.
Question 7: Which ICD-10-CM convention indicates that two codes may be required to fully describe a condition?
- Excludes1
- Code also
- Use additional code (Correct answer)
- Includes note
Correct answer: Use additional code
'Use additional code' instructs the coder to assign a secondary code to provide more complete information about the condition or its manifestation.
RHIA Clinical Classification Systems and Coding 1
In ICD-10-CM, what is the maximum number of characters a code can have?