Clinical Coding Systems
Exam Materials
Course Introduction
Clinical Coding Systems introduces students to the principles, methodologies, and applications of coding systems used in healthcare settings to classify medical diagnoses, procedures, and services. The course covers major coding standards such as ICD (International Classification of Diseases), CPT (Current Procedural Terminology), and HCPCS (Healthcare Common Procedure Coding System), exploring their structure, guidelines, and real-world use in electronic health records, billing, research, and quality measurement. Students will learn how accurate coding supports healthcare delivery, compliance, and reimbursement, while also examining ethical considerations, data quality, and the impact of evolving coding systems on healthcare operations.
Recommended Textbook
The Complete Diagnosis Coding Solution 3rd Edition by Shelley Safian
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23 Chapters
1144 Verified Questions
1144 Flashcards
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Page 2
Chapter 1: Introduction to Diagnostic Coding
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Sample Questions
Q1) What is the most important factor to consider when coding?
A) Accuracy
B) Productivity
C) Timeliness
D) All of these
Answer: A
Q2) The physician documented Jacob's diagnosis as a chest cold. The coder assigned a code for bronchitis. This is an example of:
A) coding for coverage.
B) double billing.
C) following correct coding guidelines.
D) upcoding.
Answer: D
Q3) The seven steps of accurate coding include:
A) coding only documented conditions.
B) coding the problems told to you by the nurse.
C) coding only the chief complaint.
D) coding the patient's history.
Answer: A
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Page 3
Chapter 2: Introduction to ICD-10-CM
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Sample Questions
Q1) How many volumes does the ICD-10-CM coding manual contain?
A) 1
B) 2
C) 3
D) 4
Answer: B
Q2) Logan fractured his ankle when he fell off a ladder this morning at work. Logan works at the local paint factory. The x-ray shows a non-displaced bimalleolar fracture of his right lower leg. What code(s) should you report?
A) S82.844A
B) S82.844A, W11.XXXA
C) S82.844A, W11.XXXA, Y92.63, Y99.0
D) S82.844D, W11, Y92.63, Y99.1
Answer: C
Q3) The Alphabetic Index lists diagnoses by:
A) anatomical site.
B) condition.
C) level of disease.
D) All of these
Answer: B
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Chapter 3: General Guidelines and Notations
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Sample Questions
Q1) Hypopiesis and hypotension will be reported with:
A) one code for hypertension.
B) two codes, one for hypopiesis and one for hypotension.
C) one code because hypopiesis and hypotension use the same code.
D) two codes, one for hypotension and one for cardiovascular collapse.
Answer: C
Q2) Which of the following facilities is permitted to code a diagnosis identified as probable?
A) Physician's office
B) Inpatient hospital facility
C) Outpatient hospital facility
D) Urgent care
Answer: B
Q3) A primary malignant neoplasm of the right femur is coded as:
A) D16.20.
B) C79.51.
C) C40.20.
D) C40.21.
Answer: D
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Page 5
Chapter 4: Coding Infectious Diseases
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Sample Questions
Q1) Lice and mites are examples of:
A) bacteria.
B) fungi.
C) parasites.
D) viruses.
Q2) Rick is diagnosed with a fish tapeworm infection. How is this coded?
A) B68.0
B) B68.1
C) B69.0
D) B70.0
Q3) When a pathogen has infected multiple countries, this is referred to as (a[n]):
A) epidemic.
B) endemic.
C) pandemic.
D) nosocomial.
Q4) When coding for high-risk heterosexual behavior, what code is assigned?
A) Z20.6
B) Z11.4
C) Z72.51
D) Z72.811
Page 6
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Chapter 5: Coding Neoplasms
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Sample Questions
Q1) What term describes cancer that has spread throughout the body?
A) Disseminated cancer
B) Generalized cancer
C) Widely metastatic cancer
D) All of these
Q2) The first column in the neoplasm table is used to list the:
A) anatomical site.
B) malignant primary.
C) malignant secondary.
D) Ca in situ.
Q3) Which is the correct code assigned for a person being seen for a cervical cancer screening?
A) Z12.1
B) Z12.4
C) Z51.1
D) Z86.001
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Chapter 6: Coding Diseases of the Blood and Immune Mechanism
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Sample Questions
Q1) Which of the following tests measures blood sugar levels?
A) Creatinine
B) Glucose
C) Erythrocyte sedimentation rate
D) Hematocrit
Q2) What is the correct code assignment for a 40-year-old patient who is admitted with idiopathic cryoglobulinemia?
A) D89.0
B) D89.1
C) D89.2
D) D89.3
Q3) Rhonda came to the ER with the complaint of chest pain and fever. After an examination and testing, Rhonda is diagnosed with sickle-cell thalassemia with acute chest syndrome. What code would you report for this condition?
A) D57.40
B) D57.411
C) D57.412
D) D57.4811
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Chapter 7: Coding Conditions of the Endocrine and Metabolic Systems
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Sample Questions
Q1) Which of the following glands releases serotonin?
A) Adrenal
B) Pineal
C) Pituitary
D) Thyroid
Q2) What percentage of diabetics develops diabetic foot ulcers?
A) 10 percent
B) 20 percent
C) 30 percent
D) 40 percent
Q3) What is the correct code assigned for a patient with Hunter's syndrome?
A) E76.1
B) E76.21
C) E76.3
D) E77.1
Q4) How many adrenocortical hormones are produced in the adrenal glands?
A) 10
B) 20
C) 25
D) More than 25
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Chapter 8: Coding Mental and Behavioral Disorders
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Sample Questions
Q1) Ongoing, regular consumption of a substance with significant resulting clinical manifestations is known as:
A) abuse.
B) dependence.
C) use.
D) None of these
Q2) What is the correct code for opioid use with withdrawal?
A) F11.90
B) F11.92
C) F11.920
D) F11.93
Q3) What are the ends of neurons called?
A) Dendrites
B) Synapses
C) Transmitters
D) None of these
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Page 10
Chapter 9: Coding Nervous System Conditions
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Sample Questions
Q1) Which nerves stimulate skeletal muscle?
A) Asomatic nerves
B) Somatic nerves
C) Vasopressin nerves
D) Vasomotor nerves
Q2) Which nervous system includes all the neurons, nerves, ganglia, and plexuses?
A) Autonomic nervous system
B) Central nervous system
C) Peripheral nervous system
D) None of these
Q3) Which layer of the meninges is the outermost?
A) Arachnoid mater
B) Basal mater
C) Dura mater
D) Pia mater
Q4) Where in the documentation can a coder read about the patient's mental status?
A) History of present illness
B) Glasgow Coma Scale
C) Physical exam
D) Stroke assessment
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Chapter 10: Coding Diseases of the Eye and Adnexa
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Sample Questions
Q1) Which of the following is also known as pink eye?
A) Blepharitis
B) Dacryocystitis
C) Proptosis
D) Conjunctivitis
Q2) What is the correct code for a patient with a corneal abscess of the left eye?
A) H16.311
B) H16.312
C) H16.313
D) H16.3129
Q3) How many stages of diabetic retinopathy development are there?
A) 1
B) 2
C) 3
D) 4
Q4) Which of the following is an abnormal displacement of the eyeball?
A) Blepharitis
B) Dacryocystitis
C) Proptosis
D) Conjunctivitis
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Chapter 11: Coding Diseases of the Auditory System Ears
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Sample Questions
Q1) Which of the following tests is used to evaluate how well words and other sounds are heard at varying volumes?
A) Basic screening test
B) Tuning fork test
C) Pure tone hearing test
D) Frequency test
Q2) What is the correct code for mixed conductive and sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side?
A) H90.42
B) H90.5
C) H90.72
D) H90.8
Q3) What is the correct code for high-frequency deafness, right ear?
A) H91.90
B) H91.91
C) H91.92
D) H91.93
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13
Chapter 12: Coding Circulatory Conditions
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Sample Questions
Q1) Which of these conditions is an irregular heartbeat?
A) Angina
B) Cardiac arrest
C) Dyspnea
D) Arrhythmia
Q2) Which of these conditions means that the patient is having trouble breathing?
A) Angina
B) Cardiac arrest
C) Dyspnea
D) Arrhythmia
Q3) What is the correct code for a patient diagnosed with renovascular hypertension?
A) I10
B) I11.0
C) I15.0
D) I15.9
Q4) Which of the following is the correct code for ventricular septal defect?
A) I51.0
B) I51.1
C) Q21.0
D) Q21.2
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Chapter 13: Coding Respiratory Conditions
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Sample Questions
Q1) What is the correct code assigned for a patient with pneumonia due to MRSA?
A) J15.20
B) J15.21
C) J15.211
D) J15.212
Q2) How many parts does the breathing process include?
A) 1
B) 2
C) 3
D) 4
Q3) Bringing oxygen into the body and delivering it into the circulatory system is known as:
A) expiration.
B) inspiration.
C) aspiration.
D) respiration.
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Page 15
Chapter 14: Coding Diseases of the Digestive System
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Sample Questions
Q1) What is the correct code for an acute gastric ulcer with perforation?
A) K25.0
B) K25.1
C) K25.2
D) K25.3
Q2) A fasting glucose level lower than ____ mg/dl may indicate liver disease.
A) 40
B) 50
C) 60
D) 70
Q3) What is the correct code for a Barrett's ulcer with bleeding?
A) K22.0
B) K22.11
C) K22.1
D) K22.10
Q4) Another name for the oral cavity is the:
A) cheeks.
B) lips.
C) mouth.
D) tongue.
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Chapter 15: Coding Diseases of the Integumentary System
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Sample Questions
Q1) Which of the following might longitudinal ridges in the nail signify?
A) Kidney failure
B) Iron deficiency
C) Cardiovascular disease
D) All of these
Q2) In which stage of pressure ulcers are there blisters on the skin?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4 I
Q3) In which stage of pressure ulcers is there a crater with visible damage to the tissue below the skin?
A) Stage 1
B) Stage 2
C) Stage 3
D) Stage 4
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Chapter 16: Coding Muscular Conditions
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Sample Questions
Q1) Which of the following is not a shoulder muscle?
A) Deltoid
B) Trochlea
C) Infraspinatus
D) Teres major
Q2) Which of the following muscles straightens an arm or leg?
A) Abductor muscle
B) Adductor muscle
C) Extensor muscle
D) Flexor muscle
Q3) Which of the following is not an upper leg muscle?
A) Gemellus
B) Pectineus
C) Quadriceps
D) Rectus femoris
Q4) Which of the following is a sac filled with fluid located adjacent to a joint?
A) Articulation
B) Bursa
C) Ligament
D) Tendon
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Chapter 17: Coding Skeletal Conditions
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Sample Questions
Q1) Which of the following types of fractures happens when the bone has been placed inward?
A) Avulsion
B) Burst
C) Comminuted
D) Depressed
Q2) What are the correct codes for a patient with a displaced trimalleolar fracture of the right lower leg resulting from a fall into a manhole?
A) S82.841A, W17.1XXA
B) S82.844A, W17.1XXA
C) S82.851A, W17.1XXA
D) S82.854A, W17.1XXA
Q3) What is the correct code for a patient seen for malunion of a displaced fracture of the coronoid process of the right ulna?
A) S52.041A
B) S52.041D
C) S52.041G
D) S52.041P
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Chapter 18: Coding Diseases of the Urinary System
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Sample Questions
Q1) Which of the following is a true statement for a coder?
A) If a patient has both hypertension and CKD, the coder is to assume a cause-and-effect relationship.
B) If a patient has both hypertension and CKD, the coder cannot assume a cause-and-effect relationship.
C) If a patient has both hypertension and CKD, the coder will only code hypertension.
D) If a patient has both hypertension and CKD, the coder will only code CKD.
Q2) What is the correct code for a patient with stage 4 chronic kidney disease?
A) N18.1
B) N18.2
C) N18.3
D) N18.4
Q3) Which of the following glomerular filtration rates indicates stage 4 chronic kidney disease?
A) 15-29 mL/min
B) 30-59 mL/min
C) 60-89 mL/min
D) 90-120 mL/min
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Chapter 19: Coding for Obstetrics and Gynecology
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Sample Questions
Q1) Which of the following is considered a pregnancy complication?
A) If it threatens the pregnant state
B) If it threatens the health of the woman
C) If it influences the manner in which the woman is treated
D) All of these
Q2) What is the average gestation for a baby from conception to birth?
A) 38 weeks
B) 40 weeks
C) 42 weeks
D) 44 weeks
Q3) Uterine fibroids are found to be benign what percentage of the time?
A) 50 percent
B) 75 percent
C) 85 percent
D) 99 percent
Q4) What is the correct code for acute oophoritis with salpingitis?
A) N70.02
B) N70.03
C) N70.12
D) N70.13
Page 21
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Chapter 20: Coding Congenital and Pediatric Conditions
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Sample Questions
Q1) Brady Branson was delivered today via vaginal delivery at 40 weeks. Brady was a large baby at 4,700 grams, and forceps were used to extract him during the delivery. Brady suffered from scalp injury due to the forceps. What are the correct codes to assign?
A) Z38.00, P03.1, P08.0
B) Z38.00, P03.2, P08.0
C) Z38.01, P03.1, P08.0
D) Z38.01, P03.2, P08.0
Q2) Which of the following describes an irregular structural development?
A) Anomaly
B) Congenital
C) Malformation
D) Preexisting
Q3) What is the correct code for a patient with an atrial septal defect?
A) Q21.0
B) Q21.1
C) Q22.0
D) Q22.1
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22
Chapter 21: Coding Injuries, Poisonings, and Certain Other
Consequences of External Causes
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Sample Questions
Q1) Sophia Smith was weeding her garden this morning and got a splinter stuck in her right thumb. What codes are assigned?
A) S61.041A, W45.8XXD, Y92.017XA, Y93.H2
B) S61.041A, W45.8XXA, Y92.017, Y93.H2
C) S61.042A, W45.8XXD, Y92.017, Y93.H2
D) S61.042A, W45.8XXA, Y92.017, Y93.H2
Q2) What is the correct code for an adverse effect of niacin?
A) T46.7X1A
B) T46.7X3A
C) T46.7X4A
D) T46.7X5A
Q3) Carson Canterbury is seen in the office today. Carson is two years old and accidentally drank a bottle of Metamucil. Carson has been vomiting for about two hours. What is/are the correct code(s) assigned?
A) T47.4X1A
B) T47.4X2A, R11.10
C) T47.4X1A, R11.10
D) R11.10
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Chapter 22: Factors Influencing Health Status and Contact
With Health Services
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Sample Questions
Q1) Bobby Billson is seen today for fitting of a complete right artificial arm. What is the correct code assignment?
A) Z44.011
B) Z44.012
C) Z44.021
D) Z44.022
Q2) What is the correct code for an examination following a work accident?
A) Z04.1
B) Z04.2
C) Z04.3
D) Z04.6
Q3) Carina Friday delivered a healthy newborn six weeks ago and is now presenting for a postpartum follow-up visit. What is the correct code assignment?
A) Z39.0
B) Z39.1
C) Z39.2
D) O80
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Page 24
Chapter 23: Hospital Inpatient Diagnosis Coding
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Sample Questions
Q1) Who typically assigns the DRG for the patient's case?
A) The coder
B) The physician
C) The coding supervisor
D) The DRG grouper
Q2) Twenty-three-month-old Jamee Hudson was found by his mother to have an empty bottle of naproxen. The mother is unsure whether Jamee took any of the pills or where the pills are. Jamee is brought in for work-up. All the labs come back normal, and the examination does not find any evidence that Jamee swallowed any of the pills. What is/are the correct code(s) and POA assignment(s)?
A) Z03.6-1
B) Z03.6-Y
C) T39.311A-Y
D) Z03.6-1, T39.311A-Y
Q3) Which of the following is NOT part of the clinical information collected in the UHDDS?
A) Provider information
B) Diagnoses
C) Procedures
D) External causes of injury
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Page 25