1. 45-year-old patient admitted with Insulin dependent diabetes. The type of diabetes is not specified in the medical record. How should this be
... [Show More] coded?
a. E11.9, Z79.4
b. E11.8
c. E11.8, Z79.4
d. Z79.4, E11.8 - ANSWER-a. E11.9, Z79.4
If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus. Code Z79.4, Long term (current) use of insulin, should also be assigned for patients who take insulin (CMS 2018a, Section I.C.4.a.2, 34).
The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates the cyst using palpation, and an incision is created. The cyst is then excised. What is the correct CPT code assignment for this service?
a. 60200
b. 60210
c. 60280
d. 60281 - ANSWER-d. 60281
CPT code 60281 is accessed using index entry Cyst, thyroglossal duct, excision resulting in code range 60280-60281. Code 60281 is correct for recurrent (AMA CPT Professional Edition 2018, 385).
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 Medicare Conditions of Participation and the Joint Commission require that the medical record is completed no later than 30 days following discharge of the patient (Brickner 2016, 84).
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
MS-DRG 280 (weight = 01.6577) for myocardial infarction with respiratory failure would change the MS-DRG. MS-DRG 282 (weight = 00.75863) would be assigned for myocardial infarction alone, with atrial fibrillation, with hypertension, and with history of myocardial infarction (Medicare Grouper Version 35).
According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a:
a. Proctosigmoidoscopy
b. Sigmoidoscopy
c. Colonoscopy
d. Proctoscopy - ANSWER-c. Colonoscopy
A colonoscopy is an examination of the entire colon, from the rectum to the cecum that may include the terminal ileum. In general, a colonoscopy examines the colon to a level of 60 cm or higher (Smith 2018, 135-136).
According to the UHDDS, in order to assign a code for another diagnosis, documentation must be present that:
a. The condition is recorded in the patient record by a dietary clerk
b. The condition is present in the admission department data
c. The condition was clinically evaluated or therapeutically treated, extended the length of hospital stay, or increased nursing care or monitoring
d. The condition is considered to be essential by the family - ANSWER-c. The condition was clinically evaluated or therapeutically treated, extended the length of hospital stay, or increased nursing care or monitoring
For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care or monitoring (CMS 2018a, Section III, 105-106).
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
If an error is corrected, the healthcare provider who made the error should draw a single line through the error, add a note explaining the error, initial and date it, and add the correct information in chronological order (Sayles 2016, 65). Further, AHIMA principles for health record documentation specify the prior statement as the proper method for correcting an error in the paper-based records in order to maintain a legally sound record. This process is based on the ASTM and HL7 standards for error correction (AHIMA e-HIM Work Group on Maintaining the Legal EHR, 2005).
A patient was admitted to the emergency department with chest pain and was diagnosed with aborted myocardial infarction with acute myocardial ischemia. There was no prior cardiac surgery. The cardiac enzymes were normal. The appropriate coding of the diagnosis for this case is:
a. I21.3, ST elevation (STEMI) myocardial infarction of unspecified site
b. I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris
c. I24.8, Other forms of acute ischemic heart disease
d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction - ANSWER-d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction
Acute ischemic heart disease or acute myocardial ischemia in a patient does not always indicate an infarction. It is often possible to prevent infarction by means of surgery or the use of thrombolytic agents if the patient is treated promptly. Using the main term, ischemia, then the subterms of myocardium and acute, the alphabetic index reflects that I24.0 is the correct code for an acute myocardial ischemia without myocardial infarction (Leon-Chisen 2018, 391).
After a patient is discharged from the hospital, the medical record must be reviewed for:
a. Inclusion of all incident reports
b. Certain basic reports (for example, history and physical, discharge summary, etc.)
c. Voided prescription pads
d. Personal case notes from all mental health providers - ANSWER-b. Certain basic reports (for example, history and physical, discharge summary, etc.)
In order to determine if a medical record is complete, it must be reviewed for certain basic reports including the presence of a history and physical, signed progress notes, and a discharge summary if applicable (Reynolds and Sharp 2016, 123-125). The incident report should never be filed in the medical record (Carter and Palmer 2016, 522); voided prescription pads are not used during a patient hospitalization; personal case notes from mental health providers are kept separate from the official record. While there are a number of documents required for the hospital medical record to be complete, the ones described in option b present the best answer (Rinehart-Thompson 2017c, 189)
A 70-year-old patient was admitted with pneumonia. The history and physical documented that the patient has a history of diabetes, hypertension, and migraine headache about 10 years ago without recurrence. The patient was administered IV antibiotics, metformin, and Altace during the hospitalization. Which conditions would be reported at the time of discharge?
a. Pneumonia, diabetes, hypertension, and migraine headaches
b. Pneumonia, diabetes, hypertension, and history of migraine headaches
c. Pneumonia, diabetes, and hypertension
d. Pneumonia - ANSWER-c. Pneumonia, diabetes, and hypertension
Pneumonia, diabetes, hypertension should be coded. The migraine headaches are a past condition and would not be coded as per the reporting guidelines for the UHDDS for "other conditions" (CMS 2018a, Section III, 105-106).
The outpatient code editor (OCE) has all of the following types of edits except:
a. Claim accuracy
b. Discharge date discrepancy
c. Assigning APCs to the claim
d. Age and sex edits - ANSWER-b. Discharge date discrepancy
The OCE has four basic functions: editing the data on the claims for accuracy, specifying the action the MAC should take when specific edits occur, assigning APCs to the claim (for hospital outpatient services), and determining payment-related conditions that require direct reference to HCPCS codes or modifiers. (Smith 2018, 299).
During an ambulatory surgery visit for excision of a malignant melanoma of the right forearm, the attending surgeon listed history of benign breast cyst, history of hypertension currently on Tenormin, and a current hammer toe. Which conditions are to be coded?
a. Malignant melanoma of forearm, hypertension
b. Malignant melanoma of the right forearm, benign breast cyst, hypertension, and hammer toe
c. Malignant melanoma of the right forearm, benign breast cyst, and hypertension
d. Malignant melanoma of the right forearm, benign breast cyst - ANSWER-a. Malignant melanoma of forearm, hypertension
Assign codes for malignant melanoma of forearm, hypertension. Code chronic conditions if they affect the patient's treatment. The hypertension was being treated with a current medication and for this reason the hypertension is coded (CMS 2018a, Section IV.A.1. and Section IV.J., 108-109).
A patient is readmitted two weeks after a laminectomy for spinal stenosis with a headache and documentation that the headache is due to a tear in the dura accidently that occurred during the prior laminectomy surgery. The patient is taken to the operating room for repair of the dura. The diagnosis code(s) assigned for this admission would be:
a. M48.061, Spinal stenosis, lumbar region, without neurogenic claudication
b. G97.41, Accidental puncture or laceration of dura during a procedure
c. G97.1, Other reaction to spinal and lumbar puncture
d. S34.109A, Unspecified injury to unspecified level of lumbar spinal cord, initial encounter - ANSWER-b. G97.41, Accidental puncture or laceration of dura during a procedure
A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intraoperatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery can result in leakage of cerebrospinal fluid (CSF), leading to CSF headache, caudal displacement of the brain, subdural hematoma, spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula (CMS 2018a, Section I.B.16, 18).
During an admission for congestive heart failure (CHF), a chest x-ray was done to evaluate for the presence of CHF. An asymptomatic hernia was also found for which no treatment or evaluation was done. What is the reason that the hernia should not be coded?
a. The patient's primary condition of interest is the CHF.
b. The hernia is an incidental finding and does not meet the UHDDS requirements.
c. The patient is asymptomatic.
d. The condition does not impact the reimbursement. - ANSWER-b. The hernia is an incidental finding and does not meet the UHDDS requirements.
The hernia is an incidental finding. The condition does not meet the UHDDS criteria of an "other" condition (CMS 2018a, Section III, 105-106).
A patient is admitted to the hospital due to a fracture of the right hip and is scheduled for an open reduction with internal fixation. The patient developed cardiac arrhythmia which results in an inability to do the planned surgery. Assign a code for the principal diagnosis.
a. Status post fracture
b. Cardiac arrhythmia
c. Right hip fracture
d. Admission for possible fracture - ANSWER-c. Right hip fracture
The condition after study that occasioned the admission should be sequenced first even if the plan of treatment was not carried out due to unforeseen circumstances (CMS 2018a, Section II.F., 103).
The Joint Commission considers what kind of management to be important for safe, quality care?
a. Resource management
b. Recycling management
c. Information management
d. Incremental management - ANSWER-c. Information management
The goal of information management is to support decision-making (Sandefer 2016, 344).
During an outpatient visit, the attending physician did not define a problem at the conclusion of an emergency department (ED) visit. The coder should:
a. Assign a code from the list of conditions in the history that occurred in the past
b. Assign a code for the reason for the last visit to the ED
c. Assign codes for abnormal laboratory findings
d. Assign a code for the chief complaint as the reason for the visit - ANSWER-d. Assign a code for the chief complaint as the reason for the visit
In the absence of a diagnosis or defined problem, the chief compliant should be coded as the reason for the visit (CMS 2018a, Section IV.G., 109).
A 75-year-old woman is admitted to the hospital after tripping and falling at home. She underwent an open reduction with internal fixation of the femur. Which of the following would be important to capture in addition to diagnostic codes?
a. External cause codes for Cause of Injury and Place of Occurrence
b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status
c. External cause codes for Cause of Injury, Place of Occurrence, and Activity
d. External cause codes for Cause of Injury only - ANSWER-b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status
External cause of injury codes are used to provide information about how an injury occurred, the intent (intentional or unintentional), where the injury occurred, and the status of the person at the time the injury occurred. In the case of a person who seeks care for an injury or other health condition that resulted from an activity, or when an activity contributed to the injury or health condition, activity codes are used to describe the activity (CMS 2018a, Section I.20., 81).
A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct?
a. The colposcopy and endometrial biopsy are [Show Less]