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CAMC Part 1 Exam study materials
CAMC Part 1 Exam study resources

CAMC Part 1 Exam practice questions

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Question 1Medical Terminology and Anatomy/Pathophysiology Foundations

Which term describes a decrease in the number of circulating red blood cells relative to plasma volume?

  1. Anemia Correct answer.
  2. Polycythemia
  3. Thrombocytopenia
  4. Leukocytosis

Explanation

Anemia denotes a reduction in red cell mass or hemoglobin concentration, which reduces oxygen-carrying capacity. The other terms describe increased white cells, decreased platelets, or increased red cell mass respectively.

Question 2Medical Terminology and Anatomy/Pathophysiology Foundations

The suffix '-itis' as used in 'pericarditis' indicates which of the following?

  1. Excision
  2. Inflammation Correct answer.
  3. Softening
  4. Enlargement

Explanation

The suffix -itis consistently signals inflammation of the structure named by the root, so pericarditis is inflammation of the pericardium. Recognizing this suffix helps decode a large family of clinical terms.

Question 3Medical Terminology and Anatomy/Pathophysiology Foundations

Which directional term correctly describes the position of the stomach relative to the spinal column?

  1. Superior
  2. Lateral
  3. Anterior Correct answer.
  4. Posterior

Explanation

In standard anatomic position the stomach lies ventral to the vertebral column, so it is anterior to it. Posterior would place it behind the spine, which is anatomically incorrect.

Question 4Medical Terminology and Anatomy/Pathophysiology Foundations

Which blood vessel type is characterized by thin walls, low pressure, and valves that prevent backflow?

  1. Artery
  2. Vein Correct answer.
  3. Capillary
  4. Arteriole

Explanation

Veins carry blood at low pressure and rely on valves and surrounding muscle contraction to return blood to the heart. Arteries and arterioles have thicker muscular walls and operate at higher pressure.

Question 5Medical Terminology and Anatomy/Pathophysiology Foundations

A patient record notes 'dyspnea on exertion.' Which interpretation is most accurate?

  1. Shortness of breath triggered by physical activity Correct answer.
  2. Cough productive of blood
  3. Absence of breathing during sleep
  4. Chest pain radiating to the arm

Explanation

Dyspnea means difficult or labored breathing, and 'on exertion' specifies that it is provoked by activity. The prefix dys- denotes difficulty or abnormality rather than absence.

Question 6Medical Terminology and Anatomy/Pathophysiology Foundations

Which combining form refers to the kidney?

  1. Cyst/o
  2. Nephr/o Correct answer.
  3. Hepat/o
  4. Ren/o

Explanation

Nephr/o is the combining form for kidney, seen in terms such as nephritis and nephrology. Ren/o also refers to kidney, so the question distinguishes the Greek-derived form from the Latin-derived one.

Question 7Medical Terminology and Anatomy/Pathophysiology Foundations

Which plane divides the body into equal right and left halves?

  1. Transverse
  2. Oblique
  3. Frontal
  4. Midsagittal Correct answer.

Explanation

The midsagittal plane passes through the midline and produces equal right and left halves. Other sagittal planes produce unequal halves, while frontal and transverse planes divide the body differently.

Question 8Medical Terminology and Anatomy/Pathophysiology Foundations

Which term describes the normal narrowing of a blood vessel lumen?

  1. Atherosclerosis
  2. Vasoconstriction Correct answer.
  3. Aneurysm
  4. Vasodilation

Explanation

Vasoconstriction is the physiologic contraction of vascular smooth muscle that narrows the lumen. It is a normal regulatory mechanism, unlike pathologic narrowing from plaque.

Question 9Medical Terminology and Anatomy/Pathophysiology Foundations

A patient has a blood pressure of 88/54 mmHg with cool extremities. Which term best characterizes this finding?

  1. Hypotension Correct answer.
  2. Hypertension
  3. Bradycardia
  4. Tachycardia

Explanation

A systolic pressure below roughly 90 mmHg defines hypotension, and the cool extremities suggest poor perfusion. Hypertension is elevated pressure, while tachycardia and bradycardia describe heart rate rather than pressure.

Question 10Medical Terminology and Anatomy/Pathophysiology Foundations

Which term means surgical creation of an opening into the colon?

  1. Colostomy Correct answer.
  2. Colotomy
  3. Colitis
  4. Colectomy

Explanation

The suffix -ostomy denotes creating a stoma or surgical opening, so colostomy is an opening into the colon. The other suffixes describe removal, incision, or inflammation.

Question 11Medical Terminology and Anatomy/Pathophysiology Foundations

Which structure separates the thoracic cavity from the abdominal cavity?

  1. Pleura
  2. Diaphragm Correct answer.
  3. Mediastinum
  4. Peritoneum

Explanation

The diaphragm is the dome-shaped muscle that forms the floor of the thoracic cavity and the roof of the abdominal cavity. It also serves as the principal muscle of inspiration.

Question 12Medical Terminology and Anatomy/Pathophysiology Foundations

Which electrolyte disturbance is most directly associated with cardiac dysrhythmias and peaked T waves?

  1. Hyperkalemia Correct answer.
  2. Hypochloremia
  3. Hypocalcemia
  4. Hypernatremia

Explanation

Elevated serum potassium depolarizes cardiac membranes and produces peaked T waves, widened QRS complexes, and risk of lethal dysrhythmia. This makes potassium the electrolyte most closely tied to rhythm disturbance.

Question 13Medical Terminology and Anatomy/Pathophysiology Foundations

The term 'cyanosis' most specifically refers to which clinical finding?

  1. Yellowing of the skin and sclera
  2. Bluish discoloration of skin and mucous membranes Correct answer.
  3. Pale, blanched skin
  4. Redness and warmth of the skin

Explanation

Cyanosis derives from the root cyan-, meaning blue, and describes bluish discoloration from deoxygenated hemoglobin. It is a sign of impaired oxygenation rather than of bile or inflammation.

Question 14Medical Terminology and Anatomy/Pathophysiology Foundations

A term ending in '-penia' most likely describes which type of condition?

  1. A rupture
  2. An excess
  3. A deficiency Correct answer.
  4. A fixation

Explanation

The suffix -penia denotes deficiency or abnormal reduction, as in leukopenia and thrombocytopenia. Confusing it with -osis, which often denotes an abnormal increase, is a common source of error.

Question 15Medical Terminology and Anatomy/Pathophysiology Foundations

Which statement best describes the role of the sinoatrial node?

  1. It regulates systemic vascular resistance
  2. It delays the impulse before ventricular contraction
  3. It generates the electrical impulse that initiates each heartbeat Correct answer.
  4. It conducts impulses directly to the ventricular myocardium

Explanation

The sinoatrial node is the heart's primary pacemaker, spontaneously depolarizing to initiate each cardiac cycle. The atrioventricular node provides the delay that lets the atria empty before ventricular contraction.

Question 16Medical Terminology and Anatomy/Pathophysiology Foundations

Which term correctly describes a fracture in which the bone breaks through the skin?

  1. Greenstick fracture
  2. Closed fracture
  3. Open fracture Correct answer.
  4. Comminuted fracture

Explanation

An open (compound) fracture involves a wound through which the bone communicates with the external environment, raising infection risk. Closed fractures do not breach the skin.

Question 17Medical Terminology and Anatomy/Pathophysiology Foundations

A patient is described as having 'orthopnea.' Which finding would support this term?

  1. Dyspnea that occurs when lying flat and improves when sitting upright Correct answer.
  2. Dyspnea that occurs only during exercise
  3. Coughing after swallowing
  4. Pain on deep inspiration

Explanation

Orthopnea combines ortho- (upright) with -pnea (breathing) and describes breathlessness relieved by assuming an upright position. It commonly reflects pulmonary congestion or heart failure.

Question 18Medical Terminology and Anatomy/Pathophysiology Foundations

Which statement about the autonomic nervous system is accurate?

  1. The sympathetic division generally increases heart rate and blood pressure Correct answer.
  2. The parasympathetic division generally increases heart rate
  3. The parasympathetic division controls skeletal muscle contraction
  4. The sympathetic division is solely responsible for digestion

Explanation

Sympathetic activation produces the fight-or-flight response, raising heart rate, contractility, and vascular tone. Parasympathetic activity promotes rest and digestion, slowing the heart.

Question 19Medical Terminology and Anatomy/Pathophysiology Foundations

Which term best describes the process by which a cell engulfs solid particles such as bacteria?

  1. Phagocytosis Correct answer.
  2. Osmosis
  3. Diffusion
  4. Pinocytosis

Explanation

Phagocytosis is the engulfment of solid material by a cell membrane, central to neutrophil and macrophage function. Pinocytosis takes in fluid, while osmosis and diffusion are passive transport processes.

Question 20Medical Terminology and Anatomy/Pathophysiology Foundations

A patient's lab report shows 'hyperglycemia.' Which interpretation is correct?

  1. Elevated blood glucose Correct answer.
  2. Low blood potassium
  3. Low blood glucose
  4. Elevated blood calcium

Explanation

The prefix hyper- means above normal and glyc/o refers to glucose, so hyperglycemia is elevated blood glucose. The suffix -emia denotes a blood condition.

Question 21Medical Terminology and Anatomy/Pathophysiology Foundations

Which mechanism most directly explains how the kidneys regulate acid-base balance?

  1. Filtration of plasma proteins into the urine
  2. Excretion of bicarbonate and retention of hydrogen ions
  3. Reabsorption of bicarbonate and excretion of hydrogen ions Correct answer.
  4. Production of carbonic anhydrase inhibitors

Explanation

Renal tubules reclaim filtered bicarbonate and secrete hydrogen ions, restoring plasma pH over hours to days. The lungs handle rapid pH changes via carbon dioxide elimination.

Question 22Medical Terminology and Anatomy/Pathophysiology Foundations

Which finding is most consistent with left-sided heart failure rather than right-sided failure?

  1. Jugular venous distention
  2. Ascites
  3. Peripheral edema with hepatomegaly
  4. Pulmonary edema with dyspnea Correct answer.

Explanation

Left ventricular failure backs blood up into the pulmonary circulation, causing pulmonary congestion and edema. Right-sided failure backs blood into the systemic venous circulation, producing peripheral edema, JVD, and hepatomegaly.

Question 23Medical Terminology and Anatomy/Pathophysiology Foundations

A patient with chronic obstructive pulmonary disease retains carbon dioxide. Which acid-base disturbance is expected?

  1. Respiratory alkalosis
  2. Metabolic alkalosis
  3. Respiratory acidosis Correct answer.
  4. Metabolic acidosis

Explanation

Alveolar hypoventilation raises arterial carbon dioxide, which forms carbonic acid and lowers pH, producing respiratory acidosis. Renal bicarbonate retention partially compensates over time.

Question 24Medical Terminology and Anatomy/Pathophysiology Foundations

Which statement correctly distinguishes an artery from a vein in terms of blood oxygen content in the systemic circulation?

  1. Systemic veins carry blood at higher pressure than arteries
  2. Systemic arteries carry deoxygenated blood toward the heart
  3. Systemic veins carry oxygenated blood away from the heart
  4. Systemic arteries carry oxygenated blood away from the heart Correct answer.

Explanation

In the systemic circuit, arteries carry oxygenated blood from the left ventricle to tissues, and veins return deoxygenated blood to the right atrium. The pulmonary circuit is the exception, where the pattern reverses.

Question 25Medical Terminology and Anatomy/Pathophysiology Foundations

Which pathophysiologic sequence best explains edema formation in hypoalbuminemia?

  1. Increased capillary hydrostatic pressure forces fluid into the interstitium
  2. Lymphatic obstruction prevents reabsorption of interstitial fluid
  3. Reduced plasma oncotic pressure lowers the capillary-to-interstitial osmotic gradient, favoring fluid movement into tissues Correct answer.
  4. Increased capillary permeability allows protein-rich fluid into tissues

Explanation

Albumin is the main contributor to plasma oncotic pressure, which pulls fluid back into capillaries. When albumin falls, that inward pull weakens and fluid shifts into the interstitium, producing edema.

Question 26Medical Terminology and Anatomy/Pathophysiology Foundations

A medical record documents a patient's blood pressure as 148/94 mmHg. Which term correctly classifies the 94 mmHg component of this reading?

  1. Pulse pressure
  2. Systolic pressure
  3. Mean arterial pressure
  4. Diastolic pressure Correct answer.

Explanation

Blood pressure is recorded as systolic pressure over diastolic pressure, so the second (lower) number represents the diastolic pressure, the arterial pressure remaining during ventricular relaxation. Systolic pressure is the higher first number generated during ventricular contraction, while pulse pressure is the difference between the two values.

Question 27Medical Terminology and Anatomy/Pathophysiology Foundations

A pathology report describes tissue that has changed from one mature cell type into another mature cell type, as seen in the bronchial lining of a long-term smoker. Which term describes this adaptation?

  1. Metaplasia Correct answer.
  2. Anaplasia
  3. Hyperplasia
  4. Dysplasia

Explanation

Metaplasia is the reversible replacement of one differentiated cell type with another mature cell type, commonly squamous change in airway epithelium exposed to chronic irritation such as tobacco smoke. It differs from dysplasia, which involves disordered growth and atypia rather than a simple switch of mature cell type.

Question 28Medical Terminology and Anatomy/Pathophysiology Foundations

A patient's arterial blood gas shows a pH of 7.28, a PaCO2 of 55 mmHg, and a bicarbonate of 26 mEq/L. Which acid-base disturbance do these values most directly indicate?

  1. Uncompensated metabolic alkalosis
  2. Uncompensated respiratory acidosis Correct answer.
  3. Uncompensated metabolic acidosis
  4. Compensated respiratory alkalosis

Explanation

A low pH with an elevated PaCO2 and a bicarbonate within the normal reference range indicates respiratory acidosis without metabolic compensation, since carbon dioxide retention lowers pH. Compensation would be suggested by a raised bicarbonate, which is absent here.

Question 29Medical Terminology and Anatomy/Pathophysiology Foundations

A patient with a history of recurrent peptic ulcer disease is found to have a lesion eroding the posterior wall of the stomach. Which vessel lies most directly posterior to the stomach and is at risk in this situation?

  1. Splenic artery Correct answer.
  2. Left gastric artery
  3. Gastroduodenal artery
  4. Superior mesenteric artery

Explanation

The splenic artery runs along the superior border of the pancreas directly posterior to the stomach, so a posterior gastric ulcer can erode into it and cause severe hemorrhage. The gastroduodenal artery lies posterior to the first part of the duodenum, not the stomach body.

Question 30Medical Terminology and Anatomy/Pathophysiology Foundations

A patient develops weakness and cardiac conduction delay, and laboratory testing shows a serum potassium of 6.9 mEq/L. Which pathophysiologic mechanism best explains how hyperkalemia alters cardiac and skeletal muscle excitability?

  1. Elevated extracellular potassium depletes intracellular potassium, causing cells to become unresponsive to stimuli
  2. Elevated extracellular potassium selectively blocks sodium channels, preventing depolarization of excitable tissue
  3. Elevated extracellular potassium raises the resting membrane potential toward threshold, initially increasing then depressing excitability Correct answer.
  4. Elevated extracellular potassium hyperpolarizes the resting membrane potential, reducing excitability throughout

Explanation

The resting membrane potential depends largely on the ratio of intracellular to extracellular potassium; a rise in extracellular potassium reduces this gradient and shifts the resting potential closer to threshold. This initially makes cells more excitable, but sustained elevation inactivates sodium channels and ultimately depresses conduction, producing weakness and dysrhythmias.

Question 31ICD-10-CM Diagnosis Coding Conventions and Guidelines

In ICD-10-CM, what does the instruction "Excludes1" indicate beneath a code?

  1. The excluded condition is reported only when the provider documents a cause-and-effect link
  2. The excluded condition may be coded with the code above it if both conditions are documented
  3. The excluded condition must be sequenced first whenever it appears on the record
  4. The excluded condition is never coded with the code above it because the two cannot occur together Correct answer.

Explanation

An Excludes1 note means the two codes are mutually exclusive: the excluded condition is not coded here because it represents a completely different condition that cannot logically coexist with the code above it. Coders should look for the correct code elsewhere in the classification rather than reporting both.

Question 32ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient with acute bronchitis who also has documented chronic obstructive bronchitis is coded. Which guideline governs the combined reporting of these two conditions?

  1. Code only the acute bronchitis because acute conditions always take precedence
  2. Code only the chronic obstructive bronchitis because chronic conditions are sequenced first
  3. Code both conditions, sequencing the acute bronchitis first Correct answer.
  4. Code both conditions, sequencing the chronic obstructive bronchitis first

Explanation

When a patient has both an acute and a chronic respiratory condition and the record does not state which is responsible for the encounter, both are coded and the acute condition is sequenced first, per the acute/chronic combination guideline. The chronic condition follows as an additional diagnosis.

Question 33ICD-10-CM Diagnosis Coding Conventions and Guidelines

Which statement best describes how the ICD-10-CM alphabetic index should be used when assigning diagnosis codes?

  1. The tabular list is used first and the index is consulted only to confirm the code's title
  2. The index and tabular list are interchangeable and either may be used alone
  3. The index is used to locate candidate codes, which are then verified in the tabular list for full description and instructions Correct answer.
  4. The index alone establishes the final code and the tabular list is consulted only for unusual cases

Explanation

The alphabetic index is an entry point for locating candidate codes, but every code must be verified in the tabular list, where the complete code description, seventh characters, and instructional notes appear. Relying on the index alone risks selecting an incomplete or invalid code.

Question 34ICD-10-CM Diagnosis Coding Conventions and Guidelines

A record documents "pneumonia due to Staphylococcus aureus." How should the causal relationship be coded?

  1. Code the staphylococcal infection only, because the organism is the underlying cause
  2. Code both the pneumonia and the staphylococcal infection, linking them with an additional code
  3. Code pneumonia only, because the organism is identified in the record
  4. Code pneumonia with an additional code for the staphylococcal infection, following the combination-code instruction Correct answer.

Explanation

When the index entry under the condition directs the coder to an additional code for the causative organism, the condition is coded first with the organism code added. The combination-code entry for pneumonia due to Staphylococcus aureus provides exactly this instruction.

Question 35ICD-10-CM Diagnosis Coding Conventions and Guidelines

Under ICD-10-CM guidelines, when is a sign or symptom code reported in place of a definitive diagnosis code?

  1. When a definitive diagnosis has not been established by the provider at the time of the encounter Correct answer.
  2. When the provider has documented a definitive diagnosis but the coder cannot locate its code
  3. When the sign or symptom is more specific than any available diagnosis code
  4. When the patient requests that the symptom be reported instead of the diagnosis

Explanation

Signs and symptoms are coded when no definitive diagnosis has been established; the guideline directs coders not to code symptoms that are integral to a confirmed diagnosis. Once the provider documents a definitive diagnosis, that diagnosis is reported rather than the presenting symptom.

Question 36ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient is seen for a pressure ulcer of the right heel. The record documents the site and stage. Which coding approach reflects the ICD-10-CM pressure ulcer guidelines?

  1. Code the pressure ulcer with a code that identifies both site and stage, plus a code for the associated gangrene if present Correct answer.
  2. Code the pressure ulcer site and stage with separate codes for each element
  3. Code only the stage of the pressure ulcer, because stage drives reimbursement
  4. Code only the site of the pressure ulcer, because the stage is a nursing assessment

Explanation

ICD-10-CM provides combination codes that capture both the site and the stage of a pressure ulcer in a single code. When gangrene is documented as associated with the ulcer, an additional code for gangrene is reported.

Question 37ICD-10-CM Diagnosis Coding Conventions and Guidelines

What is the purpose of the ICD-10-CM Official Guidelines for Coding and Reporting?

  1. To replace the tabular list when the two conflict
  2. To provide rules that accompany the classification and must be followed when assigning codes Correct answer.
  3. To establish physician reimbursement rates for each diagnosis code
  4. To list every acceptable abbreviation for provider documentation

Explanation

The official guidelines are published with the classification and set out the conventions coders must follow when selecting and sequencing codes. They supplement the tabular list and index rather than replacing them.

Question 38ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient is admitted with sepsis and the provider documents severe sepsis with acute respiratory failure. How is sequencing determined?

  1. The sepsis code is sequenced first, with the acute respiratory failure reported as an additional diagnosis Correct answer.
  2. The respiratory failure is sequenced first only if the sepsis is hospital-acquired
  3. Only the sepsis code is reported because organ dysfunction is included in the sepsis code
  4. The respiratory failure is sequenced first because it is the most life-threatening condition

Explanation

When severe sepsis is present, the systemic infection code is sequenced first and the code for the acute organ dysfunction, here acute respiratory failure, follows. The organ dysfunction is not included in the sepsis code and must be reported separately.

Question 39ICD-10-CM Diagnosis Coding Conventions and Guidelines

How should a coder interpret the word "with" in the ICD-10-CM alphabetic index?

  1. It means the conditions are mutually exclusive and cannot be coded together
  2. It means the two conditions must be linked by the provider as cause and effect
  3. It means the two conditions are presumed related when both are documented, unless the index instructs otherwise Correct answer.
  4. It means the second condition must be confirmed by a laboratory test

Explanation

The word "with" in the index establishes a presumed causal or associative relationship between two conditions documented in the same record. The coder does not need the provider to state the link explicitly unless the guidelines direct otherwise.

Question 40ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient with diabetes is documented as having diabetic nephropathy. Under ICD-10-CM, how is this reported?

  1. A combination code for diabetes with kidney complication, with the diabetes sequenced first Correct answer.
  2. Two codes for diabetes and nephropathy, sequenced in the order the provider listed them
  3. The diabetes code alone, because nephropathy is a routine complication of diabetes
  4. The nephropathy code alone, because the kidney disease is the condition being managed

Explanation

Diabetes with a documented complication is captured with a combination code that identifies the type of diabetes and the specific complication. The diabetes code is sequenced first, and the complication is included in the combination code rather than reported separately.

Question 41ICD-10-CM Diagnosis Coding Conventions and Guidelines

What does the ICD-10-CM convention of a "code also" note require the coder to do?

  1. Report an additional code that is required to fully describe the condition Correct answer.
  2. Ignore the note unless the additional condition is the reason for admission
  3. Report the additional code only when the physician requests it
  4. Choose between the two codes based on the principal diagnosis

Explanation

A "code also" note directs the coder to report an additional code along with the code above it, because the additional code is needed for a complete description. The additional code does not replace the code above it.

Question 42ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient is seen with hematuria and the provider has not yet established a diagnosis. Which coding action is appropriate?

  1. Code the hematuria and a suspected urinary tract infection together
  2. Code a probable urinary tract infection because hematuria most often indicates infection
  3. Code nothing and return the record to the provider for a diagnosis
  4. Code the hematuria as a symptom because no definitive diagnosis is documented Correct answer.

Explanation

When no definitive diagnosis is established at the time of the encounter, the presenting sign or symptom is coded. Coding a suspected condition would be improper because the provider has not confirmed it.

Question 43ICD-10-CM Diagnosis Coding Conventions and Guidelines

How does an Excludes2 note differ from an Excludes1 note in ICD-10-CM?

  1. Excludes2 means the excluded condition is a complication of the code above it
  2. Excludes2 means the excluded condition is not part of the condition represented by the code, but it may still be reported if documented Correct answer.
  3. Excludes2 means the excluded condition is always sequenced first
  4. Excludes2 means the excluded condition must never be coded with the code above it

Explanation

An Excludes2 note indicates that the excluded condition is not part of the condition represented by the code, yet the patient may have both conditions at the same time, in which case both codes may be reported. This contrasts with Excludes1, which prohibits reporting the two codes together.

Question 44ICD-10-CM Diagnosis Coding Conventions and Guidelines

When a patient is admitted for a complication of a chronic condition, which sequencing rule generally applies?

  1. Only the complication is reported because the chronic condition is already known
  2. The chronic condition and complication are sequenced alphabetically
  3. The complication is sequenced first, with the chronic condition reported as an additional diagnosis Correct answer.
  4. The chronic condition is sequenced first because it is the underlying cause

Explanation

When the encounter is for a complication of a chronic condition, the complication is the reason for the encounter and is sequenced first, with the chronic condition reported as an additional diagnosis. This reflects the condition chiefly responsible for the services provided.

Question 45ICD-10-CM Diagnosis Coding Conventions and Guidelines

A record documents a fracture of the right femur that is still under active treatment. A subsequent encounter code should be assigned only when which condition is met?

  1. The fracture is no longer receiving active treatment and is in the healing phase Correct answer.
  2. The patient has returned for any follow-up visit regardless of treatment status
  3. The patient has been seen for the fracture more than once
  4. The fracture was surgically repaired during the initial encounter

Explanation

Subsequent encounter codes for fractures apply when the patient is receiving routine care during the healing or recovery phase, after active treatment has concluded. Active treatment of the fracture is coded with the initial encounter code regardless of how many times the patient is seen.

Question 46ICD-10-CM Diagnosis Coding Conventions and Guidelines

In ICD-10-CM, what does the seventh character "A" represent in an injury code?

  1. A subsequent encounter for routine healing
  2. The initial encounter for active treatment of the injury Correct answer.
  3. A sequela of the injury
  4. An unspecified encounter type

Explanation

The seventh character A designates the initial encounter, meaning active treatment of the injury is being provided. The seventh character is required for injury codes and communicates the phase of care.

Question 47ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient with known hypertension is admitted with acute systolic heart failure. The record documents both conditions, and the index entry for heart failure includes hypertension. How should the coder proceed?

  1. Code only the hypertension because it is the underlying cause
  2. Code the combination code for hypertensive heart failure with heart failure, sequencing the hypertension code first Correct answer.
  3. Code heart failure and hypertension as separate codes, sequencing heart failure first
  4. Code only the heart failure because hypertension is a chronic condition

Explanation

The classification provides combination codes for hypertensive heart disease, so a single code captures both hypertension and heart failure. The hypertension code is sequenced first, with the heart failure code following, reflecting the causal relationship.

Question 48ICD-10-CM Diagnosis Coding Conventions and Guidelines

Which of the following best describes a "principal diagnosis" in the inpatient setting?

  1. The condition listed first on the discharge summary by the physician
  2. The condition that, after study, is chiefly responsible for the admission Correct answer.
  3. The most severe condition the patient has during the stay
  4. The condition that requires the most expensive treatment

Explanation

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission. It is determined by the coder from the record, not simply by the order in which conditions are listed.

Question 49ICD-10-CM Diagnosis Coding Conventions and Guidelines

A patient is seen for a routine annual gynecologic examination with no complaints or abnormalities documented. Which code is most appropriate?

  1. A code for the encounter for a general gynecologic examination without complaint Correct answer.
  2. A code for the patient's age group with no additional detail
  3. A code for a symptom the patient might develop
  4. A code for a well-woman encounter with a screening for cervical cancer

Explanation

When a routine examination is performed and no complaints or abnormalities are documented, the encounter is coded with the code for a general examination of the relevant body system without complaint. Screening codes are used only when a specific screening is the purpose of the visit.

Question 50ICD-10-CM Diagnosis Coding Conventions and Guidelines

What does the ICD-10-CM convention of a placeholder character "X" signify in a code?

  1. The character indicates an unspecified diagnosis
  2. The character is optional and may be omitted
  3. The character means the code is invalid and should not be reported
  4. The character is required so the code reaches the proper length and the seventh character is in the correct position Correct answer.

Explanation

A placeholder X is used when a code requires a seventh character but the code itself is shorter than six characters, so the X fills the empty position. The character ensures the seventh character occupies its correct position and the code is valid.