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CCS (Customs & Trade Compliance Certifications) practice questions

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Question 1Coding Knowledge and Skills

In ICD-10-CM, what does the seventh character typically convey when it is required in a code?

  1. The anatomical laterality of the condition
  2. The patient's age at the time of the encounter
  3. The severity grade assigned by the provider
  4. The episode of care or encounter type Correct answer.

Explanation

ICD-10-CM reserves the seventh character position for encounter or episode-of-care information, such as initial encounter, subsequent encounter, or sequela. Laterality is usually captured in a separate character earlier in the code, not the seventh position. Coders must supply the seventh character whenever the code requires it or the code is invalid.

Question 2Coding Knowledge and Skills

A coder reads the ICD-10-CM tabular list entry: "K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding." What does the word "without" in the title indicate about code assignment?

  1. It is a nonessential modifier that may be disregarded
  2. It is an instructional note requiring a query to the provider
  3. It is part of the code's defining description and must be supported by documentation Correct answer.
  4. It is a placeholder awaiting a future code expansion

Explanation

Words such as "with" and "without" in a code title are part of the code's clinical definition, not optional descriptors. The documentation must support the specific condition described, so "without bleeding" must be documented to assign that code. If bleeding is present, a different code from the same family applies.

Question 3Coding Knowledge and Skills

In the ICD-10-CM Alphabetic Index, what is the significance of a term printed in bold type?

  1. It marks a code that requires a seventh character
  2. It signals that the term is a subterm only
  3. It identifies a nonessential modifier
  4. It indicates the term is a main term to be referenced Correct answer.

Explanation

Boldface type in the Alphabetic Index identifies main terms, which are the conditions or nouns the coder should look up first. Subterms appear indented beneath the main term in regular type. Recognizing boldface helps coders navigate the index efficiently and avoid searching under the wrong term.

Question 4Coding Knowledge and Skills

A patient is seen for a follow-up visit after a healed ankle fracture. The provider documents only the fracture history with no current symptoms. Under ICD-10-CM, which code family applies?

  1. Sequela code for the ankle fracture
  2. Acute fracture code for the ankle
  3. Personal history code for the fracture Correct answer.
  4. Encounter for orthopedic aftercare

Explanation

When a condition no longer exists and no residual symptoms are being treated, a personal history code (Z code) is appropriate. Sequela codes require an active late effect of the original condition, and acute fracture codes require current injury. Aftercare codes apply only when ongoing treatment of the injury is being provided.

Question 5Coding Knowledge and Skills

In CPT, what distinguishes an add-on code from a stand-alone procedure code?

  1. It is exempt from National Correct Coding Initiative edits
  2. It may only be reported in addition to a primary procedure and is never reported alone Correct answer.
  3. It is always reported with modifier 51 to indicate multiple procedures
  4. It may be reported alone when the primary procedure is not performed

Explanation

Add-on codes describe services that are always performed in conjunction with a primary procedure and must never be reported alone. In CPT they are identified by the add-on symbol and have a specific list of primary codes they may accompany. They are also generally exempt from multiple procedure reduction rather than from NCCI edits.

Question 6Coding Knowledge and Skills

A physician performs a procedure on the right hand and a separate, unrelated procedure on the left hand during the same operative session. Which modifier pairing best reflects this scenario?

  1. Modifier 51 on the first procedure only
  2. Modifier RT on one procedure and LT on the other Correct answer.
  3. Modifier 50 on both procedures
  4. Modifier 59 on the first procedure only

Explanation

When distinct procedures are performed on opposite sides of the body, the anatomical modifiers RT and LT identify the laterality of each service. Modifier 50 is used for a bilateral procedure performed on paired organs, not for two separate unilateral procedures. Using RT and LT supports medical necessity and reduces duplicate-claim denials.

Question 7Coding Knowledge and Skills

Under the CPT Evaluation and Management guidelines, what does the term "established patient" mean for an office visit?

  1. A patient who has been enrolled in the practice's patient portal
  2. A patient who has received professional services from the physician or same specialty group within the past three years Correct answer.
  3. A patient whose insurance has previously paid a claim for the practice
  4. A patient who has been seen by any provider in the practice within the past three years

Explanation

An established patient is one who has received professional services from the exact physician or another physician of the same specialty in the same group practice within the past three years. Merely being registered with the practice or having prior claims paid does not establish the relationship. The definition is based on the professional service relationship, not administrative factors.

Question 8Coding Knowledge and Skills

In the 2021 and later office/outpatient E/M guidelines, which three elements are used to select the level of service for a new patient visit?

  1. Time alone, with no other option
  2. Counseling, coordination of care, and nature of the presenting problem
  3. History, examination, and medical decision making
  4. Medical decision making or total time on the date of the encounter Correct answer.

Explanation

The revised office/outpatient E/M guidelines allow the level of service to be selected based either on medical decision making or on total time spent on the date of the encounter. The older history and examination elements no longer determine the level for these codes. Time is defined as total time, including both face-to-face and non-face-to-face activities on that date.

Question 9Coding Knowledge and Skills

Under the revised E/M guidelines, a problem that is undiagnosed and presents a high risk of morbidity is classified as which level of medical decision making?

  1. Straightforward
  2. Low
  3. High Correct answer.
  4. Moderate

Explanation

The number and complexity of problems addressed is one of the three MDM elements, and an undiagnosed problem with a high risk of morbidity meets the high level. Problems with uncertain prognosis or that threaten bodily function also support high complexity. Coders must match the documented problem to the correct risk category.

Question 10Coding Knowledge and Skills

A provider documents an E/M service and a minor surgical procedure with a 0-day global period on the same day. What does the global surgery rule generally require?

  1. The E/M service is separately reportable with modifier 25 if it is significant and separately identifiable Correct answer.
  2. The E/M service is reported with modifier 57
  3. The E/M service is always bundled without exception
  4. The E/M service must be reported with modifier 24

Explanation

For minor procedures with a 0-day or 10-day global period, the E/M service is bundled unless it is significant and separately identifiable, in which case modifier 25 is appended. Modifier 57 applies to the decision for major surgery, not minor procedures. Modifier 24 applies to unrelated E/M services during a postoperative period.

Question 11Coding Knowledge and Skills

What is the primary purpose of the National Correct Coding Initiative (NCCI) edits?

  1. To assign relative value units to CPT codes
  2. To establish the fee schedule for Medicare services
  3. To prevent improper payment for code pairs that should not be billed together Correct answer.
  4. To determine the global period for surgical procedures

Explanation

NCCI edits promote correct coding by identifying code pairs that are not appropriately reported together on the same claim. The edits include procedure-to-procedure and medically unlikely edits. They do not set fees, global periods, or RVUs, which are handled by other payment systems.

Question 12Coding Knowledge and Skills

A claim is submitted with a procedure code that is not covered by the patient's diagnosis according to the payer's LCD. Which coding action is most appropriate?

  1. Submit the claim without a diagnosis code
  2. Change the diagnosis to one that supports the procedure
  3. Review the documentation and submit an ABN or query the provider as needed Correct answer.
  4. Append modifier 59 to force payment

Explanation

When a service appears noncovered based on an LCD, the coder should review the documentation and, if appropriate, obtain an Advance Beneficiary Notice or query the provider for clarification. Altering the diagnosis to obtain payment is fraudulent. Modifiers cannot be used to override medical necessity, and a diagnosis is required on the claim.

Question 13Coding Knowledge and Skills

What does an Advance Beneficiary Notice of Noncoverage (ABN) accomplish in Medicare billing?

  1. It informs the patient that a service may not be covered and shifts financial responsibility if Medicare denies it Correct answer.
  2. It authorizes the provider to bill the patient without a diagnosis code
  3. It replaces the need for medical necessity documentation
  4. It guarantees payment for the service by Medicare

Explanation

An ABN informs a Medicare beneficiary in advance that a service may be denied as not medically necessary or noncovered. If the patient signs and Medicare denies the claim, the provider may bill the patient. The ABN does not guarantee payment, replace documentation, or waive diagnosis requirements.

Question 14Coding Knowledge and Skills

In the CPT surgical section, what does the term "global period" refer to?

  1. The waiting period before a patient may be seen for follow-up
  2. The time frame during which the surgical package includes related postoperative services Correct answer.
  3. The period during which the surgeon must obtain a second opinion
  4. The number of days before a claim must be filed

Explanation

The global period defines the days surrounding a surgical procedure during which routine preoperative and postoperative services are included in the procedure payment. Global periods are typically 0, 10, or 90 days. Services unrelated to the surgery may be reported separately with appropriate modifiers.

Question 15Coding Knowledge and Skills

A patient presents for a scheduled screening colonoscopy. During the procedure, a polyp is found and removed. How should the coder select the primary diagnosis code?

  1. Report only the polyp code with no screening code
  2. Report the screening code first, followed by the polyp code Correct answer.
  3. Report the polyp code as the primary diagnosis
  4. Report only the screening code

Explanation

When a screening colonoscopy becomes diagnostic because a polyp is found and removed, the screening code is reported first as the reason for the encounter, followed by the polyp diagnosis. This sequencing reflects that the encounter began as a screening. Reporting only the polyp code omits the screening intent of the visit.

Question 16Coding Knowledge and Skills

In ICD-10-CM, what does the term "excludes1" indicate in the tabular list?

  1. The excluded condition requires a query to the provider
  2. The excluded condition is always reported as a secondary diagnosis
  3. The excluded condition cannot be reported with the code because the two conditions cannot occur together Correct answer.
  4. The excluded condition may be reported with the code if documented

Explanation

An Excludes1 note indicates that the excluded condition is not coded with the code in question because the conditions are mutually exclusive. An Excludes2 note, by contrast, indicates that the excluded condition may be reported separately when present. Confusing the two notes leads to incorrect code assignment.

Question 17Coding Knowledge and Skills

Which of the following best describes the purpose of the CPT code set?

  1. To determine the eligibility of patients for Medicaid
  2. To list the relative value units used in the Medicare fee schedule
  3. To classify inpatient diagnoses for hospital reimbursement
  4. To describe medical services and procedures performed by physicians and other qualified health care professionals Correct answer.

Explanation

CPT is a system of descriptive terms and codes for reporting medical services and procedures performed by physicians and other qualified health care professionals. Diagnosis classification is handled by ICD-10-CM, and eligibility is determined by payer rules. RVUs are published separately in the Medicare fee schedule.

Question 18Coding Knowledge and Skills

A surgeon performs a procedure and documents that a second, distinct procedure was performed through a separate incision. Which modifier most appropriately identifies the distinct procedural service?

  1. Modifier 22
  2. Modifier 62
  3. Modifier 25
  4. Modifier 59 Correct answer.

Explanation

Modifier 59 identifies procedures or services that are distinct and independent from other services performed on the same day. It is used when a separate incision, site, or session justifies separate reporting. Modifier 22 describes increased procedural services, and modifier 62 describes co-surgery.

Question 19Coding Knowledge and Skills

What is the correct use of modifier 26 in radiology coding?

  1. It indicates a repeat imaging study
  2. It indicates a bilateral imaging study
  3. It identifies the professional component when the physician interprets the image Correct answer.
  4. It identifies the technical component of the imaging service

Explanation

Modifier 26 identifies the professional component of a diagnostic service, such as a radiologist's interpretation, when the global service is split. The technical component is identified with modifier TC. Modifier 26 does not describe laterality or repeat studies.

Question 20Coding Knowledge and Skills

A patient is seen in the emergency department for chest pain, and the ED physician orders an EKG. The hospital's EKG equipment and technician perform the test. Which modifier identifies the facility's technical component?

  1. Modifier 26
  2. Modifier 51
  3. Modifier 57
  4. Modifier TC Correct answer.

Explanation

Modifier TC identifies the technical component of a diagnostic service, which includes equipment, supplies, and technician time. Modifier 26 identifies only the professional interpretation. Using TC appropriately allows the facility to bill for its portion of the service.

Question 21Coding Knowledge and Skills

In ICD-10-PCS, what is the purpose of the seventh character in a code structure?

  1. It identifies the approach
  2. It identifies the root operation
  3. It identifies the body system
  4. It identifies the qualifier that provides additional specificity Correct answer.

Explanation

ICD-10-PCS codes have seven characters, each with a defined meaning; the seventh character is the qualifier, which adds specificity to the procedure. The body system, root operation, and approach occupy earlier character positions. Selecting the correct qualifier is essential for accurate inpatient procedure coding.

Question 22Coding Knowledge and Skills

Which root operation in ICD-10-PCS describes taking out or off all of a body part without replacement?

  1. Resection Correct answer.
  2. Removal
  3. Excision
  4. Extraction

Explanation

Resection means cutting out or off all of a body part without replacement. Excision refers to partial removal, while extraction describes pulling or stripping out a body part. Removal refers to taking out or off a device from a body part.

Question 23Coding Knowledge and Skills

In ICD-10-PCS, which character position identifies the root operation?

  1. Second
  2. First
  3. Third Correct answer.
  4. Fourth

Explanation

The third character of an ICD-10-PCS code specifies the root operation, which defines the objective of the procedure. The first character identifies the section, the second the body system, and the fourth the body part. Correctly identifying the root operation is central to choosing the right code.

Question 24Coding Knowledge and Skills

A coder is reviewing a claim and notices that a procedure code was reported with modifier 51 when the procedure is exempt from multiple procedure reduction. What is the most likely outcome?

  1. The procedure will be automatically upgraded to a higher-paying code
  2. The procedure will be paid at 100 percent of the fee schedule
  3. The modifier is accepted and has no effect on payment Correct answer.
  4. The claim will be denied for using an inappropriate modifier

Explanation

Modifier 51 on a procedure that is exempt from multiple procedure reduction is generally accepted but has no payment effect because the procedure is already exempt. It does not cause denial in most systems, nor does it increase payment. Coders should still avoid appending it unnecessarily to maintain clean claims.

Question 25Coding Knowledge and Skills

What does the term "upcoding" refer to in medical coding?

  1. Submitting a claim after the filing deadline
  2. Using an outdated code set
  3. Reporting a service that was not performed
  4. Assigning a code for a higher level of service than was documented Correct answer.

Explanation

Upcoding is the practice of assigning a code that represents a higher level or more complex service than the documentation supports, which is a form of fraud. It differs from unbundling, which involves reporting components of a bundled service separately. Both practices can result in audits and penalties.

Question 26Coding Knowledge and Skills

When a coder assigns a CPT code, which component of the code set is being applied when the physician's documentation is compared against the code's required elements before selecting the code?

  1. The payer's fee schedule
  2. The hospital's charge master
  3. The code's descriptor and guidelines Correct answer.
  4. The patient's insurance eligibility

Explanation

CPT codes must be assigned based on the code descriptor and its accompanying guidelines, which define the procedure's intent and required documentation. Fee schedules and charge masters affect payment, not code selection, and eligibility has no bearing on which code describes the service.

Question 27Coding Knowledge and Skills

A coder is reviewing a medical record and needs to locate the official rules that govern how a subsection of CPT codes should be reported. Where should the coder look first?

  1. The payer's provider manual
  2. The guidelines placed at the beginning of the relevant CPT section Correct answer.
  3. The CPT code descriptors themselves
  4. The ICD-10-CM tabular list

Explanation

CPT section guidelines appear before the codes in each section and establish reporting rules that apply to those codes. Descriptors alone are brief and do not carry all reporting instructions, while the tabular list and payer manuals address different code sets or contractual policies.

Question 28Coding Knowledge and Skills

In ICD-10-CM, what does a code that is listed as a secondary code with an instructional note reading "code first" indicate about sequencing?

  1. The manifestation code should be sequenced first
  2. The secondary code should be omitted from the claim
  3. Either code may be sequenced first at the coder's discretion
  4. The underlying condition should be sequenced before the manifestation code Correct answer.

Explanation

A "code first" note identifies an underlying etiology that must be reported before the manifestation code. The manifestation code follows because it describes the condition caused by the underlying disease. Sequencing is not discretionary, and neither code is omitted.

Question 29Coding Knowledge and Skills

A coder is selecting an ICD-10-PCS code for a procedure and must determine which character position identifies the body system involved. Which character position is the body system?

  1. The fourth character
  2. The first character
  3. The third character
  4. The second character Correct answer.

Explanation

The seven characters of an ICD-10-PCS code are section, body system, root operation, body part, approach, device, and qualifier. The body system is therefore the second character, while the first identifies the section and the third identifies the root operation.

Question 30Coding Knowledge and Skills

What is the purpose of a coding compliance audit in a physician practice?

  1. To verify that documented services are supported and coded according to official guidelines Correct answer.
  2. To determine the practice's malpractice premium
  3. To replace the need for physician documentation
  4. To increase the number of claims submitted each month

Explanation

A compliance audit compares submitted codes against the supporting documentation to confirm accuracy and adherence to coding rules. It is a quality-control process, not a volume driver, and it does not substitute for documentation or set insurance premiums.

Question 31Coding Knowledge and Skills

A coder sees the abbreviation "HCPCS" in a payer policy. Which statement correctly describes the HCPCS Level II code set?

  1. It consists of five-character alphanumeric codes for supplies, drugs, and services not described by CPT Correct answer.
  2. It is used exclusively by the Veterans Health Administration
  3. It is maintained by the CDC for reporting diagnoses
  4. It consists of five-digit numeric codes used only for inpatient procedures

Explanation

HCPCS Level II codes begin with a letter followed by four digits and describe items such as supplies, durable medical equipment, and drugs. CPT is the numeric Level I system, and diagnosis coding is handled by ICD-10-CM, not HCPCS.

Question 32Coding Knowledge and Skills

A coder is choosing between two codes that both appear to describe a procedure. Which principle best guides the selection?

  1. Select the code that most specifically and completely describes the documented procedure Correct answer.
  2. Select the code with the highest relative value unit
  3. Select the code with the shortest descriptor
  4. Select the code the patient requested

Explanation

Coding requires the most specific code that fully captures the documented service, consistent with the coding principle of specificity. Reimbursement value and patient preference are not valid coding criteria, and descriptor length is irrelevant.

Question 33Coding Knowledge and Skills

A coder is told that a diagnosis code is "unspecified." What does this generally mean in ICD-10-CM?

  1. The condition has been ruled out and should not be coded
  2. The code requires an additional procedure code to be valid
  3. The documentation does not provide enough detail to assign a more specific code Correct answer.
  4. The code may only be used on inpatient claims

Explanation

Unspecified codes exist for situations where the record lacks the detail needed for a more specific code, and coders should query the provider when possible. They are not limited to inpatient settings, and they do not signify a ruled-out condition.

Question 34Coding Knowledge and Skills

A physician documents an office visit and a separate, medically necessary procedure on the same day. The procedure carries a 10-day global period. Which modifier should the coder consider appending to the E/M code to show the service was significant and separately identifiable?

  1. Modifier 26
  2. Modifier 59
  3. Modifier 25 Correct answer.
  4. Modifier 51

Explanation

Modifier 25 indicates that an E/M service performed on the same day as a procedure was significant, separately identifiable, and above the usual work of the procedure. Modifier 26 applies to the professional component of diagnostic tests, modifier 51 addresses multiple procedures, and modifier 59 addresses distinct procedural services.

Question 35Coding Knowledge and Skills

A coder is reviewing documentation for a wound repair and needs to select the correct code. Which factor most directly determines the code selection in the integumentary section?

  1. The number of sutures used
  2. The location of the clinic
  3. The length of the wound and the complexity of the repair Correct answer.
  4. The patient's age and weight

Explanation

Repair codes in the integumentary section are selected by the length of the wound and the complexity of the repair, such as simple, intermediate, or complex. Suture count and patient demographics do not drive code selection.

Question 36Coding Knowledge and Skills

A coder must determine whether a lesion excision code applies. Which documentation element is most important to confirm before assigning the code?

  1. Whether the patient had prior imaging
  2. Whether the patient was fasting
  3. Whether the lesion was benign or malignant and its size and location Correct answer.
  4. Whether the physician used a local or general anesthetic

Explanation

Excision codes are selected based on the lesion's nature (benign or malignant), its size, and its anatomic site. Anesthesia type, fasting status, and prior imaging do not determine the excision code.

Question 37Coding Knowledge and Skills

A coder is assigning an anesthesia code for a procedure. Which factor is used to select the anesthesia CPT code?

  1. The length of the operative report
  2. The patient's insurance plan
  3. The surgeon's specialty
  4. The anatomic site and procedure performed Correct answer.

Explanation

Anesthesia codes are organized by the anatomic site and the procedure being performed, with qualifying circumstances and physical status modifiers added as appropriate. Payer, surgeon specialty, and report length do not determine the anesthesia code.

Question 38Coding Knowledge and Skills

A coder is reporting a radiology service that includes both a technical component and a professional component. Which modifier indicates that only the professional component is being billed?

  1. Modifier 50
  2. Modifier 26 Correct answer.
  3. Modifier TC
  4. Modifier 76

Explanation

Modifier 26 identifies the professional component of a diagnostic test, while modifier TC identifies the technical component. Modifier 50 denotes bilateral procedures, and modifier 76 indicates a repeat procedure by the same physician.

Question 39Coding Knowledge and Skills

A coder is reviewing a pathology report and must assign a code for a laboratory test. Which principle applies when the test is performed in a hospital outpatient setting?

  1. The test is not reportable in the outpatient setting
  2. The laboratory reports the professional component
  3. The facility reports the technical component and the physician reports the professional interpretation Correct answer.
  4. The physician reports both the technical and professional components

Explanation

In a hospital outpatient setting, the facility bills the technical component while the interpreting physician bills the professional component. The physician does not report the technical component, and the laboratory does not report the professional interpretation.

Question 40Coding Knowledge and Skills

A coder is selecting an ICD-10-CM code for a diabetic patient with a complication. What does the coding convention for diabetes mellitus with complications require?

  1. Only the diabetes code with no manifestation
  2. A single combination code only, with no additional codes
  3. An underlying diabetes code followed by a code for the specific manifestation Correct answer.
  4. Only the manifestation code

Explanation

ICD-10-CM requires coding the underlying diabetes mellitus along with the specific manifestation, following the "code first" or combination-code instructions in the tabular list. Reporting only one code would omit essential clinical information.

Question 41Coding Knowledge and Skills

A coder is reviewing documentation for an outpatient surgery and sees that the physician performed a procedure that was begun laparoscopically and converted to an open approach. How should this be coded?

  1. Code both the laparoscopic and open procedures
  2. Code the open procedure that was ultimately performed Correct answer.
  3. Code the procedure as unlisted
  4. Code only the laparoscopic procedure

Explanation

When a laparoscopic procedure is converted to an open approach, the coder reports the open procedure that was actually completed. The abandoned laparoscopic attempt is not separately coded, and an unlisted code is not appropriate.

Question 42Coding Knowledge and Skills

A coder must determine whether a procedure is bundled with another service. Which resource is the primary source for national bundling edits?

  1. The National Correct Coding Initiative edits Correct answer.
  2. The ICD-10-CM index
  3. The hospital's bylaws
  4. The physician's fee schedule

Explanation

The National Correct Coding Initiative edits identify code pairs that should not be reported together because one is considered integral to the other. The ICD-10-CM index addresses diagnoses, and fee schedules and bylaws do not define bundling.

Question 43Coding Knowledge and Skills

A coder is reviewing a claim where a service was denied because the diagnosis did not meet the payer's medical necessity policy. Which action is most appropriate?

  1. Write off the balance immediately
  2. Resubmit the same claim without changes
  3. Change the diagnosis code to one the payer covers
  4. Review the payer's coverage policy and the documentation to determine whether an appeal with supporting records is warranted Correct answer.

Explanation

A denial based on medical necessity should prompt a review of the payer's policy and the clinical documentation to determine whether the claim can be supported on appeal. Altering the diagnosis to obtain payment would misrepresent the record, and resubmitting unchanged or writing off the balance may be premature.

Question 44Coding Knowledge and Skills

A coder is reviewing an operative report for a patient who had two distinct procedures performed through separate incisions in different body areas. Which modifier supports separate reporting of the second procedure?

  1. Modifier 59 Correct answer.
  2. Modifier 25
  3. Modifier 26
  4. Modifier 51

Explanation

Modifier 59 is used to indicate that a procedure is distinct and independent from other services performed on the same day, such as through a separate incision or in a different anatomic site. Modifier 25 applies to E/M services, modifier 26 to professional components, and modifier 51 to multiple procedures with payment reduction.

Question 45Coding Knowledge and Skills

A coder is reviewing a record where the physician documented a service as "possible fracture" before imaging results were available. What coding approach applies to this uncertain diagnosis in the outpatient setting?

  1. Code the signs and symptoms that prompted the encounter Correct answer.
  2. Code the fracture as confirmed
  3. Do not code the encounter at all
  4. Code an unspecified fracture code

Explanation

In the outpatient setting, diagnoses documented as possible, probable, or suspected are not coded as confirmed; instead, the signs and symptoms that prompted the visit are reported. Coding the fracture as confirmed would misrepresent the record, and the encounter is still reportable.

Question 46Coding Knowledge and Skills

A coder is assigning a code for a bilateral procedure when the code descriptor does not specify bilateral. Which modifier is used to indicate the procedure was performed on both sides?

  1. Modifier 51
  2. Modifier 62
  3. Modifier 58
  4. Modifier 50 Correct answer.

Explanation

Modifier 50 indicates a bilateral procedure when the code does not already specify bilateral. Modifier 51 indicates multiple procedures, modifier 58 a staged procedure, and modifier 62 two surgeons.

Question 47Coding Knowledge and Skills

A coder is reviewing an inpatient record and needs to determine the principal diagnosis. Which definition applies to the principal diagnosis for an inpatient admission?

  1. The most severe diagnosis listed in the record
  2. The diagnosis with the highest payment weight
  3. The first diagnosis documented by the physician
  4. The condition established after study to be chiefly responsible for the admission Correct answer.

Explanation

The principal diagnosis is defined as the condition established after study to be chiefly responsible for occasioning the admission. It is not simply the first-listed or most severe diagnosis, and payment weight does not determine it.

Question 48Coding Knowledge and Skills

A coder is reviewing a record where the patient was admitted for pneumonia and also has chronic heart failure that required monitoring during the stay. How should the additional diagnosis of heart failure be reported?

  1. As an external cause code
  2. As the principal diagnosis because it is chronic
  3. As a secondary diagnosis because it was clinically evaluated and monitored during the stay Correct answer.
  4. Not reported because it was present on admission

Explanation

A condition that is clinically evaluated, monitored, or treated during the stay should be reported as a secondary diagnosis even if it is chronic and not the reason for admission. Being present on admission does not exclude reporting, and an external cause code describes how an injury occurred.

Question 49Coding Knowledge and Skills

A coder is reviewing documentation that uses the term "history of" for a condition that has resolved. How should this be handled in ICD-10-CM?

  1. Assign the appropriate history code, since the condition no longer exists Correct answer.
  2. Assign a complication code
  3. Assign an unspecified code for the condition
  4. Assign the acute condition code

Explanation

When a condition has resolved and is no longer being treated, a history code (such as a Z code) is assigned rather than the acute condition code. Coding the resolved condition as active would misrepresent the patient's current status.

Question 50Coding Knowledge and Skills

A coder is reviewing a record with two diagnoses that both meet the definition of principal diagnosis. Which principle guides the selection?

  1. Neither diagnosis is coded
  2. The diagnosis listed last in the record is principal
  3. Either may be sequenced first, following the facility's or payer's guidance for such cases Correct answer.
  4. The more severe diagnosis must always be first

Explanation

When two conditions both meet the definition of principal diagnosis, either may be sequenced first, and the coder follows the facility's or payer's guidance for selecting among them. Severity and documentation order do not by themselves resolve the choice, and both conditions are coded.