RHIT Medical Coding Principles 5 — Questions and Answers
Question 1: Which coding system is used primarily for outpatient and physician office procedure coding in the United States?
- ICD-10-PCS
- CPT (Current Procedural Terminology) (Correct answer)
- SNOMED CT
- ICD-10-CM
Correct answer: CPT (Current Procedural Terminology)
CPT, maintained by the AMA, is the standard system for coding outpatient procedures and physician services.
Question 2: In ICD-10-PCS, which root operation would be assigned for the surgical removal of a kidney?
- Excision
- Resection (Correct answer)
- Extraction
- Destruction
Correct answer: Resection
Resection means cutting out or off all of a body part without replacement, which applies to complete organ removal.
Question 3: What is a 'CC' (complication or comorbidity) in the context of MS-DRG assignment?
- A secondary diagnosis that substantially increases hospital resource use (Correct answer)
- Any documented chronic disease
- A principal diagnosis that requires surgical intervention
- A laboratory finding noted in the record
Correct answer: A secondary diagnosis that substantially increases hospital resource use
CCs are secondary diagnoses that increase resource consumption and affect MS-DRG grouping and hospital reimbursement.
Question 4: Under outpatient coding guidelines, which diagnosis should be reported first for a patient presenting with chest pain who is ruled out for MI?
- Acute MI (since it was ruled out)
- Chest pain — the sign/symptom that led to the encounter (Correct answer)
- Atherosclerosis as the likely etiology
- A Z code for observation
Correct answer: Chest pain — the sign/symptom that led to the encounter
For outpatients, signs and symptoms are coded when a definitive diagnosis has not been confirmed.
Question 5: A modifier -25 is appended to an E/M code on the same day as a minor procedure. What does this indicate?
- The E/M was a pre-operative evaluation only
- A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure (Correct answer)
- The procedure was bilateral
- The E/M service was provided by a different physician
Correct answer: A significant, separately identifiable E/M service was performed by the same physician on the same day as the procedure
Modifier -25 signals that the E/M service was distinct from the procedure and warrants separate reimbursement.
Question 6: Which Z code category is used to capture screening examinations for conditions in patients with no signs or symptoms?
- Z00–Z13 (Encounters for examinations) (Correct answer)
- Z23 (Immunizations)
- Z77–Z99 (Health hazard status)
- Z55–Z65 (Social determinants)
Correct answer: Z00–Z13 (Encounters for examinations)
ICD-10-CM Z00–Z13 includes codes for routine and screening examinations in asymptomatic patients.
Question 7: When a patient is admitted for chemotherapy and also has the malignancy being treated, what is the correct principal diagnosis?
- The malignancy
- The encounter for antineoplastic chemotherapy (Z51.11) (Correct answer)
- A chemotherapy complication code
- The secondary site if metastasis is present
Correct answer: The encounter for antineoplastic chemotherapy (Z51.11)
Per ICD-10-CM guidelines, when the purpose of the encounter is chemotherapy, Z51.11 is sequenced as principal diagnosis.
RHIT Medical Coding Principles 5
Which coding system is used primarily for outpatient and physician office procedure coding in the United States?