5. The reason given by a patient for seeking health care is referred to as the
A. chief complaint. C. brief history.
B. primary diagnosis. D. morbidity factor.
6. Which one of the following items must be included in a general multisystem examination of a constitutional system?
A. Vital signs C. Auscultation of the lungs
B. Inspection of teeth and gums D. Palpation of lymph nodes
7. The abbreviation NOS is used
A. when a separate code for a specific condition isn’t provided in the classification
B. when the medical record doesn’t provide enough information to permit assignment
of a more specific code.
C. to indicate that another code may describe the condition more completely or
D. to provide assurance that the code is correct by listing various terms that are
covered by the code.
8. In the Alphabetic Index to Procedures, locate the correct code for “ligation and stripping
of varicose veins in the lower limb.” Verify the code in the Tabular List. The code is
A. 38.50. C. 38.58.
B. 38.53. D. 38.59.
9. One of the factors used to determine CABG procedure codes is the number
of _______ involved.
A. catheters C. vessels
B. organs D. physicians
10. Which of the following codes is used for the main term in the diagnosis “closed
dislocation of the sternum”?
A. 839.61 C. 839.71
B. 839.8 D. 839.9
11. A 50-year-old new female patient has had a sore throat and head congestion for five
days. The physician performs an expanded problem focused history and examination.
What is the correct code for this service?
A. 99201 C. 99212
B. 99202 D. 99213
12. A discharge summary contains the diagnosis “acute ethmoidal sinusitis.” Which
of the following codes found in the Alphabetic Index represents the correct entry for
A. 461.2 C. 473.2
B. 461.9 D. 473.9
13. Which one of the following subsections of the E/M section has separate codes for new
and established patients?
A. Office or Other Outpatient Services
B. Hospital Observation Services
C. Initial Inpatient Consultation
D. Emergency Department Services
14. Which of the following initial inpatient consultation codes is used in situations involving
an expanded problem focused history and examination and straightforward medical
A. 99251 C. 99253
B. 99252 D. 99254
15. Which of the following E codes take priority over all other E codes?
A. Cataclysmic events C. Suicide and self-inflicted injury
B. Transport accidents D. Child or adult abuse
16. Single braces are used in the Tabular List to
A. indicate fifth digits required with a code.
B. connect terms on both sides of the braces.
C. include nonessential modifiers and alternative codes.
D. connect a series of terms on the left with one term on the right.
17. An operative report shows “open reduction of humerus for separation of epiphysis, with
internal fixation.” Identify the correct code in the Alphabetic Index to Procedures and
verify it in the Tabular List.
A. 79.3 C. 79.5
B. 79.31 D. 79.51
18. The chief complaint, a brief history of present illness, and a problem-specific review of
systems are documented in what type of history level for E/M coding?
A. Detailed C. Expanded problem focused
B. Brief D. Comprehensive
19. An attending physician asks a specialist to see a patient about a specific problem and
to advise him regarding treatment. This situation is called a
A. confirmatory consultation. C. transfer of care.
B. referral. D. consultation.
20. When coding late effects, the code for the _______ is usually sequenced first.
A. original cause C. modifier
B. residual condition D. complication
21. Provide a code for the following situation: initial admission to hospital for observation
care with a detailed history and examination and moderate decision making.
A. 99217 C. 99219
B. 99218 D. 99220
22. What is the main term in the diagnosis “pituitary gland with hypofunction”?
A. Ablation C. Gland
B. Pituitary D. Hypofunction
23. A physician provides an office consultation for a new patient. The history and examination
levels are comprehensive and the medical decision making is of high complexity.
What is the correct code for this situation?
A. 99254 C. 99244
B. 99255 D. 99245
24. Provide the ICD-9-CM and CPT codes for a history and physical examination of a single
liveborn delivered in hospital by caesarian section.
A. V30.00, 99430 C. V30.02, 99432
B. V30.01, 99460 D. V30.03, 99433
25. _______ are used to indicate factors influencing health status and contact with
A. Manifestation codes C. E codes
B. Cross-reference codes D. V codes
26. In the Tabular List, where would you find alternative terms and explanatory phrases?
A. In square brackets C. In double braces
B. After a colon D. In parentheses
27. The examination level for code 99203 is
A. problem focused. C. comprehensive.
B. expanded problem focused. D. detailed.
28. According to the Tabular List for code 463, which one of the following conditions is
excluded from the code?
A. Follicular tonsillitis C. Septic sore throat
B. Acute viral tonsillitis D. Septic tonsillitis
29. Which of the following range of codes is located in the Evaluation and Management
section of the CPT manual?
A. 90001–90699 C. 89000–89999
B. 99201–99450 D. 80600–88999
30. J codes in the HCPCS Level II system are used to indicate
A. bandages. C. durable medical equipment.
B. medications and dosages. D. ambulance services.
31. The _______ medical decision-making category includes minimal diagnoses, minimal
complexity of data, and minimal risk of complications.
A. straightforward C. low complexity
B. simple D. uncomplex
32. When is it correct to assign a four-digit category code?
A. When a manifestation code is given
B. When no fifth-digit subcategory codes are in that category
C. When the cross reference tells you to do so
D. When there are no nonessential modifiers
33. Which of the following ICD-9-CM and CPT codes would you use to describe a
cardiovascular stress test on a patient with an abnormal electrocardiogram?
A. 794.31, 93015 C. 787.1, 93012
B. 793.40, 93000 D. V70.01, 93014
34. Which of the following codes is used for initial neonatal intensive care?
A. 99468 C. 99471
B. 99469 D. 99472
35. When coding, you should always use the Tabular List to
A. verify the codes you’ve located in the Alphabetic Index.
B. locate codes not found in the Alphabetic Index.
C. find the range of codes for a particular disease.
D. determine if there are any cross references for the code.
36. How many bulleted topics must be included in documentation relating to a detailed
A. 1–5 C. 7
B. 6 D. Any 12
37. Which of the following categories is used to code heart conditions caused by hypertension?
A. 429 C. 402
B. 425 D. 405
38. Which of the following codes would be used for a one-hour therapeutic infusion under
the supervision of a physician?
A. 96365 C. 96367
B. 96366 D. 96369
39. In the Alphabetic Index to Procedures, locate the correct code for “open drainage of
the chest by incision.” Verify the code in the Tabular List.
A. 34.09 C. 34.04
B. 34.05 D. 34.01
40. Which of the following range of codes is used to report Emergency Department Services?
A. 99271–99280 C. 99289–99297
B. 99281–99288 D. 99298–99305
41. Which of the following physical status modifiers would be used to code a patient with a
mild systemic disease?
A. P1 C. P3
B. P2 D. P4
42. What is the code for the unlisted surgery procedure for the inner ear?
A. 25999 C. 58999
B. 43499 D. 69949
43. Anesthesia procedure codes are grouped according to
A. patient status. C. anatomic site.
B. time required. D. procedure used.
44. Which of the following code ranges is used to report a coronary bypass graft using
A. 33510–33516 C. 33517–33523
B. 33533–33545 D. 33533–33536
45. Which of the following HCPCS Level II modifiers is used to indicate a procedure performed
on the thumb of the left hand?
A. -FA C. -FT
B. -F1 D. -L1
46. A diagnosis of spinal stenosis of the lumbar spine is coded to
A. 723.00. C. 724.01.
B. 724.00. D. 724.02.
47. Which of the following range of codes is used to describe laparoscopic removal of
A. 47562–47564 C. 56340–56342
B. 47611–47620 D. 56345–56347
48. Which of the following procedures is used to correct sleep apnea?
A. ICCE C. ERCP
B. PEG D. UPPP
49. In addition to the CPT codes, _______ are frequently used when reporting general
surgical procedures to provide better detail.
A. modifiers C. physician signatures
B. ICD-9-CM codes D. anesthesiologist reports
50. Which of the following procedures involves inserting an endoscope past the third part
of the duodenum?
A. ERCP C. EGD
B. Esophagoscopy D. Ileoscopy