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The principal diagnosis is defined as the most serious condition during a patient's hospital stay.


The American Hospital Association is responsible for the development of ICD-10-PCS.


A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.

Carries an anesthetic shock.
Is surgical in nature.
Requires specialized training.

A significant procedure is one that:


The removal of a tooth is an example of an extraction.


The root operation that is defined as cutting out or off, without replacement, all of a body part is:


The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.


The ICD-10-PCS has a seven character alphanumeric code structure.


The Official Guidelines for Coding and Reporting are updated every year.


In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary. The aspiration pneumonia is coded as if it exists.

Abdominal pain, peptic ulcer disease, cholecystitis

The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis. Which diagnosis should be reported?


The root operation that is defined as freeing of a body part is:


It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."


In the inpatient setting, a CPT code would be assigned for a procedure code.


The root operation that is defined as taking into or letting out of fluids and/or gases in a part of a body is:


In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.


The tabular list contains grids that represent the last four characters of a procedure code.

Exacerbation of asthma

Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma. What is the principal diagnosis?

Revision of device in

The root operation is defined as correcting a portion of a previously performed procedure is:


In the inpatient setting, a procedure code from ICD-9-CM Volume 3 would be assigned to identify a procedure.

Urinary tract infection

Patient is admitted with dysuria due to a severe urinary tract infection. Which diagnosis should be reported?

Uniform Hospital Discharge Data Set

The acronym UHDDS stands for:


The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.

Both peptic ulcer disease and chronic cholecystitis (either can be principal)

The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis. Which diagnoses should be reported?


When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.


CPT is used to code:


The CPT code book is updated:


Who publishes the CPT code book?

A diagnosis

What must each procedure submitted on a claim be linked to?

Evaluation and Management

What does E/M stand for in CPT?


A CPT code is a ____ digit number with the possiblity of a two digit modifier.


A two digit ___ may be added after the main CPT number when necessary to indicate that additional factors should be considered or to further explain the situation.


A ___ in the CPT code book indicates a new code.


A ___ separates main and subordinate clauses in code description -- used to save space.


An ____ patient has been seen by the doctor or a doctor from that practice within the past three years.

Medical Decision Making

MDM stands for:

Durable Medical Equipment

DME stands for:

Base + Time + Modifying * Conversion Factor

What is the anesthesia formula?


Where is specific coding information about each section located in the CPT code book?

Current Procedural Terminology

CPT stands for:

CMS 1500

The universal health insurance form for submission for outpatient services is the:

Very low birth weight

VLBW stands for:


If the index shows the following suggested numbers 99211-99214, this is called a ____ of numbers.

Physical status modifiers, qualifying circumstances

When coding anesthesia, there are two types of modifiers you add when given the information. List one of these modifiers.


A patient who has not been formally admitted to a health care facility like a hospital is called an:


The highest level of examination is the:


The first visit made by the doctor with the patient is called an ___ visit.


The second visit made by the doctor with the patient is called the ___ visit.


Semicolons and indentations are used in CPT code book to save:

1. Never code directly from the index.
2. Analyze the statement or description provided that designates the item that requires a code.
3. Identify the main term in the index.
4. Check for relevant subterms under the main term.
5. Note the code(s) found after the selected main term or subterm.
6. Verify the code in the tabular.

CPT Coding Process:

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