The root operation of resection applies to which of the following?
a. Removal of the entire body part and removal of an entire lobe of the liver
b.
... [Show More] Partial incidental appendectomy and the closure portion of a procedure
c. Blunt, digital, manual, or mechanical lysis of adhesions
d. Partial cholecystectomy - ANSWER-A. Removal of the entire body part and removal of an entire lobe of the liver.
When coding benign neoplasm of the skin, the section noted above directs the coder to:
D23- Other benign neoplasms of skinIncludes:
Benign neoplasm of hair follicles
Benign neoplasm of sebaceous glands
Benign neoplasm of sweat glands
Excludes 1: benign lipomatous neoplasms of skin (D17.0-D17.3)
melanocytic nevi (D22.-)
a. Use category D23 for benign neoplasm of sweat glands
b. Use category D23 for melanocytic nevi
c. Use category D23 for benign lipomatous neoplasms of skin
d. Use category D23 for malignant neoplasm of the skin - ANSWER-A. Use category D23 for benign neoplasm of sweat glands
A 64-year-old female was discharged with the final diagnosis of acute renal failure and hypertension. What coding rule applies?
a. Use combination code of hypertension and renal failure.
b. Use separate codes for hypertension and chronic renal failure.
c. Use separate codes for hypertension and acute renal failure.
d. Use separate codes for elevated blood pressure and chronic renal failure. - ANSWER-C Use separate codes for hypertension and acute renal failure
Coding professionals need to have surgical references in order to discriminate between:
a. Correct and incorrect documentation based on Joint Commission requirements
b. Reportable and nonreportable procedures
c. Chemotherapeutic drugs
d. A comorbid condition and a complication that prolongs the length of stay - ANSWER-B. Reportable and non reportable procedures
A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would increase the MS-DRG weight?
a. Respiratory failure
b. Atrial fibrillation
c. Hypertension
d. History of myocardial infarction - ANSWER-A. Respiratory failure
If a patient has undergone an outpatient echocardiogram and the cardiologist concludes in the report that the patient has mitral regurgitation, the coder should:
a. Assign a diagnostic code for mitral regurgitation
b. Query the physician about the diagnosis
c. Code an abnormal finding of the echocardiogram
d. No code can be assigned - ANSWER-A. Assign a diagnostic code for mitral regurgitation
A patient was treated in the emergency department with lacerations of the neck and underwent a repair of two (2) wounds of the neck (2.0 cm and 1.4 cm) with layered closure. What are the diagnosis (excluding external cause codes) and procedure codes assigned?
S11.91XA Laceration without foreign body of unspecified part of neck, initial encounter
S11.92XA Laceration with foreign body of unspecified part of neck, initial encounter
0HQ4XZZ Repair neck skin, external approach
12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less
12042 Repair, intermediate, wounds of neck, hands, feet, and/or external genitalia; 2.6 cm to 7.5 cm
a. S11.91XA, 0HQ4XZZ
b. S11.92XA, 0HQ4XZZ
c. S11.92XA, 12041, 12041
d. S11.91XA, 12042 - ANSWER-D. S11.91XA, 12042
A patient is admitted to an acute care facility for detoxification from alcohol and barbiturate intoxication with chronic alcoholism and barbiturate abuse. The patient also has cirrhosis of the liver due to alcoholism. What codes should be assigned?
a. F10.229, F13.129, K70.30, HZ2ZZZZ
b. F10.129, F13.229, K70.30, HZ2ZZZZ
c. F10.29, F13.129, K70.10, HZ2ZZXZ
d. F10.229, F13.129, K70.9, HZ2ZZZZ - ANSWER-A. F10.229, F13.129, K70.30, HZ2ZZZZ
Patient with renal tumors received percutaneous cryotherapy ablation of three tumors on the right kidney in the same operative episode at Memorial Hospital. Assign a CPT code for this procedure.
50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed
50590 Lithotripsy, extracorporeal shock wave
50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency
50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy
a. 50250
b. 50590
c. 50592
d. 50593 - ANSWER-D. 50593
When coding a documented ventilator-associated pneumonia (VAP), what codes should be assigned first for ICD-10-CM and then supported by CPT?
a. The pneumonia is coded first; the CPT will be from code range 94010 to 94799
b. The complication of surgery diagnosis is coded first, then the VAP, with the CPT will be from code range 99500 to 99602
c. The specific code for ventilator-associated pneumonia is coded first and the organism is coded as a secondary code if known; the CPT will be from code range 94002 to 94005
d. An additional code for the type of pneumonia, that is, lobar or pneumonia NOS, is coded; the CPT will be from code range 33946 to 33989 - ANSWER-c. The specific code for ventilator-associated pneumonia is coded first and the organism is coded as a secondary code if known; the CPT will be from code range 94002 to 94005
A nurse inadvertently recorded an incorrect vital sign in a patient electronic health record. The next day, a correction was made in the electronic health record. This resulted in the corrected vital sign being recorded at the time the correction was made due to the software. What would be the result of this correction?
a. The vital signs would be listed in the correct sequence.
b. When a correction is made in an electronic health record, the incorrect data is deleted.
c. The quality of patient care would not be affected.
d. There was a distorted trend line of vital signs data. - ANSWER-d. There was a distorted trend line of vital signs data.
Poor-quality data collection and reporting can affect:
a. Patient care, documentation, revenue generation, outcomes evaluation, and public health reporting
b. Use of patient record for legal purposes
c. Patient care, communication, research activities, and public health reporting
d. All of the above - ANSWER-d. All of the above
The billing department has requested that copies of the final coding summary with associated code meanings for Medicare be printed remotely in the admission department. Currently they request the summaries only when there is an unspecified procedure. Each time the coding supervisor goes to the admission department, the coding summaries have been left on a table near the patient entrance. Of the actions presented here, what would be the best action for the coding supervisor to take?
a. Comply with the request.
b. Refuse to undertake this without further explanation.
c. Ignore the request.
d. Explain to the billing department supervisor that leaving the coding summary in public view violates the patient's right to privacy. - ANSWER-d. Explain to the billing department supervisor that leaving the coding summary in public view violates the patient's right to privacy.
What percentage will the facility be paid for procedure code 10060?
989323 T 10060 0006 $500
989323 T 64605 0220 $1,000
a. 50%
b. 75%
c. 0%
d. 100% - ANSWER-a. 50%
To correct an entry in the medical record, the provider should:
a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order
b. Draw a double line through the error, initial and date, add the reason for the correction
c. Draw a single line through the error, and add the correct information in chronological order
d. Draw several lines through the error, obliterate the documentation as much as possible, initial and date, add the correct information in chronological order - ANSWER-a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order
Most hospitals require a medical record is completed within:
a. 5 days
b. 10 days
c. 7 days
d. 30 days - ANSWER-d. 30 days
The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate?
a. Unstable angina
b. Myocardial infarction
c. Congestive heart failure
d. Mitral valve stenosis - ANSWER-b. Myocardial infarction
Two areas of documentation in the health record that are significant areas of focus of accrediting agencies are:
a. Incident reports notation in the medical record and attorney's notes
b. Past medical reports and social worker's notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - ANSWER-c. Timeliness and legibility of medical documents
A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded?
a. Acute pulmonary edema
b. Congestive heart failure
c. Acute pulmonary edema and congestive heart failure
d. Unable to determine based on the information provided - ANSWER-b. Congestive heart failure
Using the following evaluation and management map, which answers represent documentation that should be considered when assigning an E/M code for hospital acuity points assignment?
a. The surgical procedure performed
b. The anesthesia provided
c. Number of tests ordered
d. The post visit follow-up date - ANSWER-c. Number of tests ordered
Assign the code(s) for diagnostic left and right cardiac catheterization, left and right coronary arteriogram with low osmolar contrast and fluoroscopic guidance.
4A023N6 Measurement of cardiac sampling and pressure, right heart, percutaneous approach
4A023N7 Measurement of cardiac sampling and pressure, left heart, percutaneous approach
4A023N8 Measurement of cardiac sampling and pressure, bilateral, percutaneous approach
B2141ZZ Fluoroscopy of right heart using low osmolar contrast
B2151ZZ Fluoroscopy of left heart using low osmolar contrast
B2161ZZ Fluoroscopy of right and left heart using low osmolar contrast
B2111ZZ Fluoroscopy of multiple coronary arteries using low osmolar contrast
a. 4A023N6, 4A023N7
b. 4A023N8, B2111ZZ
c. 4A023N6
d. 4A023N7 - ANSWER-b. 4A023N8, B2111ZZ
The patient is admitted for chest pain and is found to have an acute inferior myocardial infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient underwent a CABG ×2 from aorta to the right anterior descending and right obtuse, autologous venous tissue using the left greater saphenous vein which was harvested via an open approach. Cardiopulmonary bypass was utilized. The appropriate sequencing and ICD codes for the hospitalization would be:
a. R07.9, I21.34, I48.91, I22.9, 021109W, 5A1221Z
b. I21.19, I48.91, I22.9, I48.91, 021109W
c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z
d. I22.1, I48.91, I21.19, 021109W - ANSWER-c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z
A 23-year-old female is admitted for shock following treatment of a miscarriage. The pathology report from the previous admission reveals that the patient had no decidua or products of conception in the tissue removed. This encounter would be coded as:
a. O03.81, Spontaneous abortion complicated by shock
b. O08.9, Complication following abortion and ectopic and molar pregnancies
c. R57.9, Shock NOS
d. T81.10XA, Postoperative shock - ANSWER-b. O08.9, Complication following abortion and ectopic and molar pregnancies
The committee responsible for medical record completion reports to which medical staff committee?
a. Compliance Committee
b. Medical Executive Committee
c. Discharge Planning Committee
d. Nursing Executive Committee - ANSWER-b. Medical Executive Committee
A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct?
a. The colposcopy and endometrial biopsy are represented by a combination code.
b. Two codes would be used with modifier -59 appended.
c. Two codes would be used in accordance with CPT code instructions.
d. Only one code is used and it does not state that it includes endometrial biopsy specifically. - ANSWER-c. Two codes would be used in accordance with CPT code instructions.
When a Medicare patient receives an injection of IM penicillin G benzathine, 100,000 units only, what is the appropriate code assignment?
96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
J0558 Injection, penicillin G benzathine, and penicillin G procaine 100,000 unitsJ0561 Injection, penicillin G benzathine, 100,000 units
a. 96372
b. J0558
c. 96374
d. 96372, J0561 - ANSWER-d. 96372, J0561
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and the:
a. Length of the lesion as described in the pathology report
b. Dimension of the specimen submitted as described in the pathology report
c. Width times the length of the lesion as described in the operative report
d. Diameter of the lesion as well as the margins excised as described in the operative report - ANSWER-d. Diameter of the lesion as well as the margins excised as described in the operative report
The use of the outpatient code editor (OCE) is designed to:
a. Correct documentation of home health visits
b. Facilitate reporting of adverse drug events
c. Reduce the use of computer assisted coding
d. Identify incomplete or incorrect claims - ANSWER-d. Identify incomplete or incorrect claims
A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient also has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." What is the next step for the coder?
a. Code sepsis as the principal with a secondary diagnosis of urinary tract infection due to E. coli.
b. Code urinary tract infection with sepsis as a secondary diagnosis.
c. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms.
d. Ask the physician whether the patient had septic shock so that this may be used as the principal diagnosis. - ANSWER-c. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms.
A patient is admitted because of congestive heart failure (CHF). During the treatment of the CHF, the patient was also found to have elevated liver function tests. The physician worked up the elevated liver function tests but was not able to determine a diagnosis. The following diagnoses should be assigned:
a. Congestive heart failure with liver disease
b. Abnormal liver function tests
c. Congestive heart failure and abnormal liver function tests
d. Congestive heart failure - ANSWER-c. Congestive heart failure and abnormal liver function tests
The use of standard protocols to enable different computer systems to communicate is referred to as:
a. Digital assistance
b. A data set
c. Interoperability
d. Pay for communication - ANSWER-c. Interoperability
Data accuracy is also referred to as:
a. Consistency
b. Comprehensiveness
c. Timeliness
d. Validity - ANSWER-d. Validity
A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is:
a. Computer
b. Validity
c. Responsive
d. Preventive - ANSWER-d. Preventive
A bronchoscopy with biopsy of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure codes?
a. −50, Bilateral procedure
b. −51, Multiple procedures
c. −LT, Left side
d. No modifiers should be reported. - ANSWER-d. No modifiers should be reported.
Based on the AHIMA Code of Ethics, which of the following is not considered an ethical activity?
a. Coding audits
b. Using medical records for educational purposes within the department
c. Reviewing the history and physical of a coworker when not part of work assignment
d. Completion of code assignment - ANSWER-c. Reviewing the history and physical of a coworker when not part of work assignment
A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is performed with resection of the joint with implant in the first left toe proximal phalanx. What codes would be assigned?
a. M20.12, 28291-LT
b. M20.22, 28291-TA
c. M20.31, 28291-TA
d. M20.12, 28291-TA - ANSWER-d. M20.12, 28291-TA
According to the UHDDS, the definition of a secondary diagnosis is a condition that:
a. Is recorded in the patient record
b. Receives evaluation and is documented by the physician
c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care
d. Is considered to be essential by the physicians involved and is reflected in the record - ANSWER-c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care
A facility located near a national park has a significant number of snake bites, and patients receive treatment with antivenom in urgent-care settings. Sometimes a patient is admitted to the hospital after several days. Can the urgent-care setting provide the hospital with a list of names of patients treated with snake antivenom?
a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot be provided.
b. A list of names could be provided.
c. No information can be obtained under any circumstances.
d. A list of patients may be available after consultation with the national park ranger. - ANSWER-a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot be provided.
An 84-year-old woman was admitted and discharged with hemiplegia and aphasia. A CT scan of the brain was performed that revealed an acute cerebral infarction and a possible small brain mass. After further testing, the patient was discharged with a final diagnosis of acute cerebral infarction. The condition(s) that should be coded are:
a. Acute cerebral infarction
b. Hemiplegia and aphasia
c. Acute cerebral infarction, hemiplegia, and aphasia
d. Possible brain mass, hemiplegia, and aphasia - ANSWER-c. Acute cerebral infarction, hemiplegia, and aphasia
A quality improvement study showed that maternity cases are not being coded with the correct diagnostic codes reflecting the need for a cesarean section delivery. What index could be used to evaluate this?
a. Birth certificate registry or master patient index
b. Transcription registry or correspondence registry
c. Quality improvement or operative registry
d. Disease index from billing and reimbursement data - ANSWER-d. Disease index from billing and reimbursement data
According to the UHDDS, section III, the definition of other diagnoses is all conditions that:
a. Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay
b. Receive evaluation and are documented by the physician
c. Receive clinical evaluation, therapeutic treatment, further evaluation, extend the length of stay, increase nursing monitoring/care
d. Are considered to be essential by the physicians involved and are reflected in the record - ANSWER-a. Coexist at the time of admission, that develop subsequently, or that affect the treatment [Show Less]