HIMT 1400 Coding and Classification ICD
Basic Midterm Review Exam QUESTIONS
AND CORRECT ANSWERS
1. The Alphabetic Index and Tabular List
The ICD-10-CM is divided into the __________ Index, an alphabetical list of terms and their
corresponding code, and the _____________ List, a structured list of codes divided into
chapters based on body system or condition. The Alphabetic Index consists of the following
parts: the Index of _________and _______, the Index of ______ _______of Injury, the Table
of _________ and the Table of ________ and _________. - CORRECT
ANSWER Alphabetic, Tabular, Diseases , Injury,External Causes , Neoplasms, Drugs,
Chemicals
2. Punctuation
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose
supplementary words that may be present or absent in the statement of a disease or procedure
without affecting the code number to which it is assigned. The terms within the parentheses
are referred to as ________ ________. - CORRECT ANSWER nonessential modifiers.
3. Excludes1
A type 1 Excludes note is a pure excludes note. It means _______ ____ _____.
An Excludes1 note indicates that the code excluded should never be used at the same time as
the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur
together, such as a congenital form versus an acquired form of the same condition. -
CORRECT ANSWER "NOT CODED HERE!"
Excludes2
A type 2 Excludes note represents _____ ______ _____________________. An excludes2
note indicates that the condition excluded is not part of the condition represented by the code,
but a patient may have both conditions at the same time. When an Excludes2 note appears
under a code, it is acceptable to use both the code and the excluded code together, when
appropriate. - CORRECT ANSWER "NOT INCLUDED HERE"
4. "And"
, The word "and" should be interpreted to mean_____ _____ or _____ when it appears in a
title. For example, cases of "tuberculosis of bones", "tuberculosis of joints" and "tuberculosis
of bones and joints" are classified to subcategory A18.0, Tuberculosis of bones and joints. -
CORRECT ANSWER either "and" "or"
5. "See" and "See Also"
The "see" instruction following a main term in the Alphabetic Index indicates that another
term should be referenced. It is ___________ to go to the main term referenced with the
"see" note to locate the correct code. - CORRECT ANSWER necessary
A "see also" instruction following a main term in the Alphabetic Index instructs that there is
another main term that may also be referenced that may provide additional Alphabetic Index
entries that may be useful. It is ______ ______ to follow the "see also" note when the original
main term provides the necessary code. - CORRECT ANSWER not necessary
6. Conditions that are an integral part of a disease process
Signs and symptoms that are associated ________ with a disease process should not be
assigned as additional codes, unless otherwise instructed by the classification.
Conditions that are not an integral part of a disease process
Additional signs and symptoms that_____ ______be associated routinely with a disease
process should be coded when present. - CORRECT ANSWER routinely, may not
7. Reporting Same Diagnosis Code More than Once
Each unique ICD-10-CM diagnosis code may be______ ______ ______ for an encounter.
This applies to bilateral conditions when there are no distinct codes identifying laterality or
two different conditions classified to the same ICD-10-CM diagnosis code. - CORRECT
ANSWER reported only once
8. Documentation of Complications of Care
Code assignment is based on the_______ documentation of the ________ between the
condition and the care or procedure. The guideline extends to any complications of care,
regardless of the chapter the code is located in. It is important to note that not all conditions
that occur during or following medical care or surgery are classified as complications. There
must be a ____ -____ -_____ relationship between the care provided and the condition, and
an indication in the documentation that it is a complication. Query the provider for
Basic Midterm Review Exam QUESTIONS
AND CORRECT ANSWERS
1. The Alphabetic Index and Tabular List
The ICD-10-CM is divided into the __________ Index, an alphabetical list of terms and their
corresponding code, and the _____________ List, a structured list of codes divided into
chapters based on body system or condition. The Alphabetic Index consists of the following
parts: the Index of _________and _______, the Index of ______ _______of Injury, the Table
of _________ and the Table of ________ and _________. - CORRECT
ANSWER Alphabetic, Tabular, Diseases , Injury,External Causes , Neoplasms, Drugs,
Chemicals
2. Punctuation
( ) Parentheses are used in both the Alphabetic Index and Tabular List to enclose
supplementary words that may be present or absent in the statement of a disease or procedure
without affecting the code number to which it is assigned. The terms within the parentheses
are referred to as ________ ________. - CORRECT ANSWER nonessential modifiers.
3. Excludes1
A type 1 Excludes note is a pure excludes note. It means _______ ____ _____.
An Excludes1 note indicates that the code excluded should never be used at the same time as
the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur
together, such as a congenital form versus an acquired form of the same condition. -
CORRECT ANSWER "NOT CODED HERE!"
Excludes2
A type 2 Excludes note represents _____ ______ _____________________. An excludes2
note indicates that the condition excluded is not part of the condition represented by the code,
but a patient may have both conditions at the same time. When an Excludes2 note appears
under a code, it is acceptable to use both the code and the excluded code together, when
appropriate. - CORRECT ANSWER "NOT INCLUDED HERE"
4. "And"
, The word "and" should be interpreted to mean_____ _____ or _____ when it appears in a
title. For example, cases of "tuberculosis of bones", "tuberculosis of joints" and "tuberculosis
of bones and joints" are classified to subcategory A18.0, Tuberculosis of bones and joints. -
CORRECT ANSWER either "and" "or"
5. "See" and "See Also"
The "see" instruction following a main term in the Alphabetic Index indicates that another
term should be referenced. It is ___________ to go to the main term referenced with the
"see" note to locate the correct code. - CORRECT ANSWER necessary
A "see also" instruction following a main term in the Alphabetic Index instructs that there is
another main term that may also be referenced that may provide additional Alphabetic Index
entries that may be useful. It is ______ ______ to follow the "see also" note when the original
main term provides the necessary code. - CORRECT ANSWER not necessary
6. Conditions that are an integral part of a disease process
Signs and symptoms that are associated ________ with a disease process should not be
assigned as additional codes, unless otherwise instructed by the classification.
Conditions that are not an integral part of a disease process
Additional signs and symptoms that_____ ______be associated routinely with a disease
process should be coded when present. - CORRECT ANSWER routinely, may not
7. Reporting Same Diagnosis Code More than Once
Each unique ICD-10-CM diagnosis code may be______ ______ ______ for an encounter.
This applies to bilateral conditions when there are no distinct codes identifying laterality or
two different conditions classified to the same ICD-10-CM diagnosis code. - CORRECT
ANSWER reported only once
8. Documentation of Complications of Care
Code assignment is based on the_______ documentation of the ________ between the
condition and the care or procedure. The guideline extends to any complications of care,
regardless of the chapter the code is located in. It is important to note that not all conditions
that occur during or following medical care or surgery are classified as complications. There
must be a ____ -____ -_____ relationship between the care provided and the condition, and
an indication in the documentation that it is a complication. Query the provider for
