Title: Module 1: Chapters 1-6
Course: Introduction to Coding and Classification Systems > Section: Module 1: Introduction to Coding and Classification

Q: Name the four elements that make up the ICD-9-CM.
- Diseases, injuries, surgeries, procedures
- Injuries, complications, comorbidities, procedures
- Surgeries, injuries, complications, diseases
- Procedures, diseases, complications, comorbidities
A: Diseases, injuries, surgeries, procedures

Q: Where does the coder verify correct codes for diagnoses?
- Tabular List of Diseases and Injuries (Volume 1)
- Alphabetical Index of Diseases and Injuries (Volume 2)
- Tabular List and Alphabetic Index of Procedures (Volume 3)
A: Tabular List of Diseases and Injuries (Volume 1)

Q: The supplemental classifications are included in which volume of ICD-9-CM?
- Volume 1
- Volume 2
- Volume 3
A: Volume 1

Q: Where are the Hypertension and Neoplasm tables located?
- Volume 1
- Volume 2
- Volume 3
A: Volume 2

Q: Which type of instructional note is used in the Tabular List of Diseases to identify a code for a condition that is a manifestation of an underlying disease?
- Use additional code note.
- Code first underlying condition note.
- Code, if applicable, any causal condition first note.
- Inclusion and exclusion note.
A: Code first underlying condition note.

Q: Terms in parentheses should always be present and will always affect the code to which it is assigned.
- True
- False
A: False

Q: What does the word "and" mean when it appears in a code title, such as "Unspecified anomalies of face and neck"?
- The condition is present in both face and neck.
- The condition may be present in either the face or neck.
- The condition may be present in either both the face and neck, or in the face or neck.
A: The condition may be present in either both the face and neck, or in the face or neck.

Q: Which of the following punctuation marks is not used in ICD-9-CM?
- Parentheses
- Colons
- Semicolons
- Square brackets
A: Semicolons

Q: What is the definition of principal diagnosis?
- The reason the patient was seen in any setting.
- The principal diagnosis is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital.
A: The principal diagnosis is defined as the condition established after study to be chiefly responsible for admission of the patient to the hospital.

Q: Why is the designation of the correct principal diagnosis so important?
Feedback: The designation of the correct principal diagnosis is important because the information is used in cost comparisons, in care analysis, and in utilization review. It is also crucial for reimbursement because many third-party payers (including Medicare) base reimbursement primarily on principal diagnosis.

Q: Name and explain three of the official guidelines for designating the principal diagnosis.
Feedback: Two or more diagnoses that equally meet the definition for principal diagnosis. b. A symptom followed by contrasting/comparative diagnoses. c. Original treatment plan not carried out. d. Two or more comparable or contrasting conditions.

Q: What conditions must be met in order for a diagnosis to be listed as an "other" diagnosis?
Feedback: Conditions that affect the episode of hospital care in terms of any of the following may be listed as "other" diagnoses: Clinical evaluation, Therapeutic treatment, Further evaluation by diagnostic studies, procedures or consultation, Extended length of hospital stay, Increased nursing care and/or monitoring

Q: The admission diagnosis must always be the same as the principal diagnosis for inpatient admissions.
- True
- False
A: False

Q: Why is it important to review the entire medical record before assigning diagnosis codes?
Feedback: It is important to review the entire medical record because some diagnoses, operations and procedures are frequently not listed on the face sheet or are not described in sufficient detail, making a review of operative reports, pathology reports, and other special reports imperative. Reviewing the entire medical record will ensure complete and accurate coding.

Q: Code assignment is based solely on the attending physician documentation.
- T
- F.
A: T

Q: Where does a physician list the final diagnoses?
- Admission record (face sheet)
- Progress notes
- Discharge summary
- Any of the above
A: Any of the above

Q: The coder must be sure that the medical record documentation supports code assignment.
- True
- False
A: True

Q: Where does the coder look up the codes for diagnoses?
- Tabular List of Diseases and Injuries (Volume 1)
- Alphabetical Index of Diseases and Injuries (Volume 2)
- Tabular List and Alphabetic Index of Procedures (Volume 3)
A: Alphabetical Index of Diseases and Injuries (Volume 2)

Q: Once a code number entry has been located in the Alphabetic Index, the code may be assigned without further verification.
- True
- False
A: False

Q: If a main term cannot be located in the Alphabetic Index, what should the coder do?
- Consider a synonym, eponym, or other alternative term.
- Call the doctor.
- Assign an unspecified code.
- All of the above.
A: All of the above.

Q: In the outpatient setting, it is appropriate to assign diagnoses qualified as "possible," "probably," "likely," "questionable," or "rule out" as if they were present.
- True
- False
A: False

Q: What is the meaning of the term "late effect" in ICD-9-CM?
- A late effect is a residual condition that remains after the termination of the acute phase of an illness or injury.
- A late effect is the old condition which is gone and not treated.
A: A late effect is a residual condition that remains after the termination of the acute phase of an illness or injury.

Q: A patient presents to the Emergency Room complaining of chest pain. The physician's final diagnostic statement is "atypical chest pain, myocardial infarction ruled out." What diagnosis code is assigned for this ER visit?
- Assign code 786.59, Chest pain, other, as the first listed diagnosis for this encounter.
- Assign code 401.9 hypertension, unspecified.
- Assign code 410.9, myocardial infarction, unspecified
A: Assign code 786.59, Chest pain, other, as the first listed diagnosis for this encounter.