A 23 year old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She afebrile at this time and is treated
... [Show More] with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principle diagnosis?
a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy
c. R57.9, Shock, unspecified
d. T81.10XA, Postprocedural shock unspecified, initial encounter - ANSWER-a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
A psychiatrist documents that a patient has wide mood swings from excessive happiness to loss of energy and crying. What condition is suspected?
a. Bipolar disorder
b. Major depression
c. Anxiety
d. Psychosis - ANSWER-A. Bipolar disorder
A patient with a cephalic presentation anticipating a vaginal delivery failed to progress. After measurement of the fetal head and a trial of oxytocin, the patient underwent a cesarean section. What condition should the coder suspect and query the physician about?
a. Twin pregnancy
b. Early delivery
c. Eclampsia
d. Cephalopelvic disproportion - ANSWER-d. Cephalopelvic disproportion
A 45 year old woman underwent a carotid bypass and experienced a significant drop in blood pressure during the surgery. The documentation suggested the patient may have had a myocardial infarction. In accordance with coding guidelines, what should the coder do?
a. Code complication of surgery NOS.
b. Query the physician to determine if the patient had hypotension.
c. Query the physician to determine if there was a complication of surgery.
d. Code preoperative shock. - ANSWER-c. Query the physician to determine if there was a complication of surgery.
If a patient's discharge summary does not contain a diagnosis that is documented by the anesthesiologist in a preoperative evaluation and that would impact MS-DRG assignment, the coder should:
a. Code only from the discharge diagnosis
b. Code the diagnosis reflected on the anesthesia preoperative evaluation
c. Code the most severe symptom
d. Query the attending physician regarding the clinical significance of that diagnosis - ANSWER-d. Query the attending physician regarding the clinical significance of that diagnosis
A patient has documentation of esophageal varices. What condition may be related that may affect the coding?
a. Arthritis
b. Liver disease
c. Chronic obstructive pulmonary disease
d. Erythema - ANSWER-b. Liver disease
A patient admitted with acute abdominal pain, is fount to have appendicitis, and has an appendectomy. The patient has a length of stay for 2 days. What type of patient encounter is this?
a. Impatient
b. Outpatient
c. Long term care
d. Rehabilitation - ANSWER-a. Inpatient
A patient was treated in the emergency department for a swollen knee and an aspiration of the joint was performed. The patient was then discharged home. It is important to make sure that which of the following are documented and captured for billing purposes?
a. X-ray and other types of radiology examination
b. Procedures performed including the aspiration of the joint
c. Examination and management in the emergency department
d. All services provided including diagnostic and treatment procedures, as well as physician services - ANSWER-d. All services provided including diagnostic and treatment procedures, as well as physician services.
A patient has documentation on the discharge summary of urosepsis. The coding staff queries the attending physician about the condition and is provided further information that the patient has septicemia. This is in alignment with the laboratory test and medication given but the diagnosis of septicemia was not documented by the physician. How should the physician be requested to document the septicemia?
a. A brand new history and physical should be dictated to replace the one in the record.
b. An addendum to the chart should be written.
c. The new information should be squeezed in between lines within the progress notes of the last day.
d. The query sheet will be sufficient to document this information. - ANSWER-b. An addendum to the chart should be written.
The committee responsible for medical record completion reports to which medical staff committee?
a. Chief executive officer of the facility
b. Medical Executive Committee
c. Discharge Planning Committee
d. Chief nursing officer - ANSWER-b. Medical Executive Committee
Two areas of documentation in the medial record that are significant areas of focus of accrediting agencies are:
a. Incident reports notion in the medical record and attorney's notes
b. Past medical reports and social worker notes
c. Timeliness and legibility of medical documents
d. Patient documentation and pastoral counseling - ANSWER-c. Timeliness and legibility of medical documents
In teaching facilities where electronic signatures are used for residents and attending physicians:
a. Attending signature is all that is needed
b. Resident signature is all that is needed
c. Resident should co-sign after that attending signs the document
d. Attending should co-sign after the resident signs the document - ANSWER-d. Attending should co-sign after the resident signs the document
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 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
An inpatient is discharged with a diagnosis of "either irritable bowel or pancreatitis". Which condition would be the principal diagnosis?
a. Code both and sequence according to the circumstances of the admission
b. Pancreatitis
c. Irritable bowel syndrome
d. Observation fro suspected gastrointestinal condition - ANSWER-a. Code both and sequence according to the circumstances of the admission
A 55 year old male was transferred to a nursing home for continuing care because of ventilator dependence following complications of cardiac bypass surgery. He was readmitted three weeks later due to ventilator associated pneumonia(VAP) due to Pseudomonas aeruginosa. How should this be coded?
a. T88.9XXA, J18.9, B96.5
b. J16.8
c. J95.851, B96.5
d. J15.1, J95.851 - ANSWER-c. J95.851, B96.5
A patient take Coumadin as prescribed, and correctly administered. However, the patient develops hematuria secondary to the Coumadin use. The correct coding assignment for this case would be :
a. Poisoning due to Coumadin
b. Unspecified adverse reaction to Coumadin
c. Hematuria, poisoning due to Coumadin
d. Hematuria, adverse reaction to Coumadin - ANSWER-d. Hematuria, adverse reaction to Coumadin
A patient is admitted with lethargy, congestive heart failure, and pleural effusion. The patient underwent treatment with diuretics for the CHF, which has cleared. The pleural effusion required a thoracentesis to determine the cause. At the time of discharge, the effusion was decreased but not resolved. The correct coding assignment for this case would be:
a. Congestive heart failure
b. Pleural effusion
c. Congestive heart failure and pleural effusion
d. Lethargy, congestive heart failure and pleural effusion - ANSWER-c. Congestive heart failure and pleural effusion
A patient with human immunodeficiency virus (HIV) with methicillin susceptible pneumonia due to Staphylococcus aureus was discharged from the acute-care setting. How should this be coded?
a. B20, J17
b. B20, J15.20
c. B20, J15.211
d. B20, J15.212 - ANSWER-c. B20, J15.211
A patient has a diabetic ulcer of the right foot. How should this patient's record be coded?
a. E11.40, L97.419
b. E11.40, L97.409
c. E11.69, L97.419
d. E11.621, L97.419 - ANSWER-d. E11.621, L97.419
Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension.
a. I10, I50.9
b. I11.0
c. I50.23, I10
d. I11.0, I50.9 - ANSWER-d. I11.0, I50.9
A patient has squamous cell carcinoma of the knee. What code should be assigned for this diagnosis?
a. C49.20
b. C43.70
c. C44.721
d. C76.50 - ANSWER-c. C44.721
A patient is seen for evaluation of a right orbital roof fracture. How should this be coded?
a. S02.19XA
b. S02.31XA
c. S02.92XA
d. S02.91XA - ANSWER-a. S02.19XA
A patient was seen for first- and second-degree burns of the upper thigh. How should this be coded?
a. T29.099A
b. T24.019A
c. T24.119A, T24.219A
d. T24.219A - ANSWER-d. T24.219A
Suicide attempt with overdose of Percocet. How should this be coded?
a. F11.10, T40.2X2A
b. T40.2X2A
c. F11.10, T40.2X5A
d. T40.2X5A - ANSWER-b. T40.2X2A
Itching due to drug reaction to an antihistamine. What code should be assigned?
a. R89.2, T45.0X1A
b. R89.2, T45.0X5A
c. T50.905A, T45.0X1A
d. L29.9, T45.0X5A - ANSWER-d. L29.9, T45.0X5A
Acute peptic ulcer with perforation and hemorrhage and resulting blood loss anemia. What codes should be assigned?
a. K27.1, D62
b. K27.0, D62
c. K27.0, D50.0
d. K27.2, D50.0 - ANSWER-d. K27.2, D50.0
Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures:
a. Use the terminology "manipulation" rather than "reduction" of fracture.
b. Include internal fixation in all codes.
c. Do not include application of cast.
d. Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture. - ANSWER-a. Use the terminology "manipulation" rather than "reduction" of fracture.
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder would assign:
a. Two CPT codes expressing each laceration repair
b. One CPT code for the largest laceration
c. One CPT code, adding the lengths of the lacerations together
d. One CPT code for the most complex closure - ANSWER-c. One CPT code, adding the lengths of the lacerations together
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
a. Simple
b. Intermediate
c. Not specified
d. Complex - ANSWER-d. Complex
The patient was monitored under general anesthesia for keratoplasty including excision of diseased cornea. A controlled depth-setting blade was used to cut partially into the recipient's cornea in a manner to allow the lamellar graft to fit. Which CPT code should be assigned?
a. 67510
b. 65730
c. 65750
d. 65755 - ANSWER-a. 67510
Assign the correct CPT code for a 50 year old female patient admitted to outpatient surgery department for laparoscopic surgical repair of a recurrent, incarcerated incisional hernia with mesh insertion.
a. 49561
b. 49565
c. 49566
d. 49657 - ANSWER-d. 49657
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.
a. 50250
b. 50590
c. 50592
d. 50593 - ANSWER-d. 50593
In outpatient surgery, a PTCA is completed with insertion of a drug eluting stent in the left circumflex artery and a non-drug eluting stent inserted into the left anterior descending artery of this 56 year old female. Assign the correct CPT code(s) for this procedure.
a. 92921, 92920
b. 92920-LC, 92921-LD
c. G0291-LC
d. G0290-LC - ANSWER-d. G0290-LC
Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS procedure code for this surgery.
a. 0BQR4ZZ
b. 0BQR0ZZ
c. 0BQS4ZZ
d. 0BQS0ZZ - ANSWER-a. 0BQR4ZZ
Patient presents in the ER with thrombosis of a loop PTFE hemodialysis fistula without mechanical complications. The physician performed a percutaneous thrombectomy of the left brachial vein. Assign a facility code for this outpatient procedure.
a. 05CA3ZZ
b. 36831
c. 37184
d. 36832 - ANSWER-b. 36831
Physician performed a myringotomy under general anesthesia for insertion of bilateral ventilating tubes on a 4 year old male. This is due to chronic otitis media. What is the correct CPT code assignment and what modifier should be appended to this procedure code?
a. 69421-RT
b. 69421-LT
c. 69436-51
d. 69436-50 - ANSWER-d. 69436-50
Removal of two skin tags on chest (0.3 cm and 0.5cm). What is the correct CPT code(s) assignment?
a. 11200, 11201
b. 11305, 11305
c. 11305
d. 11200 - ANSWER-d. 11200
In outpatient surgery, a patient undergoes a direct laryngoscopy with operating microscope. What code should be assigned?
a. 31515
b. 31520
c. 31525
d. 31526 - ANSWER-d. 31526
If a patient is admitted with a substance-related psychosis, what is coded?
a. The psychosis is coded first and the drug or alcohol dependence is coded second
b. The drug or alcohol dependence is coded first
c. The drug or alcohol dependence is not coded.
d. The psychosis is not coded. - ANSWER-a. The psychosis is coded first and the drug or alcohol dependence is coded second.
When coding a documented ventilator associated pneumonia(VAP), what codes should be assigned?
a. The pneumonia is coded first.
b. The complication of surgery is coded first.
c. The specific code for ventilator associated pneumonia is coded first and the organism is coded as a secondary code if known
d. An additional code for the type of pneumonia, that is, lobar or pneumonia NOS, is coded. - ANSWER-c. The specific code for ventilator associated pneumonia is coded first and the organism is coded as a secondary code if known.
When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrase?
a. Intractable pneumonia
b. Refractory asthma and severe, intractable wheezing
c. Airway obstruction relieved by bronchodilators
d. Limited but pronounced wheezing - ANSWER-b. Refractory asthma and severe, intractable wheezing
Gastrointestinal bleeding manifests as:
a. Hematemesis which indicates acute upper gastrointestinal hemorrhage
b. Petechia
c. Vomiting
d. Constipation which indicates upper or lower gastrointestinal hemorrhage - ANSWER-a. Hematemesis which indicates acute upper gastrointestinal hemorrhage
Mechanical ventilation codes require consideration of which of the following?
a. The time when a tracheal tube is inserted
b. The replacement of an endotracheal tube
c. The start time of endotracheal tube insertion followed by mechanical ventilation
d. Mechanical ventilation during surgery - ANSWER-c. The start time of endotracheal tube insertion followed by mechanical ventilation
An example of beast reconstruction is:
a. Total reconstruction
b. Insertion of drains
c. Removal of lymph nodes
d. Mammography - ANSWER-a. Total reconstruction
Name the types of pacemaker devices that each have a unique ICD-10-PCS code.
a. Dual chamber rate responsive
b. Single chamber rate responsive, and dual chamber
c. Multiple chamber
d. Multiple chamber rate responsive - ANSWER-b. Single chamber rate responsive and dual chamber
If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD-10-PCS code?
a. The approach to the definitive surgery
b. Suture method
c. Exploratory surgery
d. Open biopsy and definitive surgery - ANSWER-d. Open biopsy and definitive surgery
A patient was given heparin during hospitalization for a deep vein thrombophlebitis of the right lower extremity. The patient had back pain and the nurse was not answering the bell, so he decided to take two aspirin. The interaction between the aspirin and heparin caused a subcutaneous hemorrhage of the thigh of the right lower extremity. How should the interaction between the aspirin and heparin be coded?
a. Poisoning codes for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions
b. Poisoning codes for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as principal
c. Adverse effects of drugs for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions
d. Adverse effects of drugs for aspirin and heparin as secondary diagnoses, and subcutaneous hemorrhage of the thigh of the right lower extremity as principal - ANSWER-a. Poisoning codes for aspirin and heparin, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions
A 77 year old patient has hypertensive heart disease with congestive heart failure and stage 5 renal disease. What codes would be assigned?
a. I11.0, Hypertensive heart disease with heart failure
b. I13.2, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease; N18.5 Chronic kidney disease, stage 5; I50.9, heart failure, unspecified
c. I50.9, Heart failure, unspecified
d. N18.6, End stage renal disease - ANSWER-b. I13.2, Hypertensive heart disease and chronic kidney disease with heart failure and stage 5 chronic kidney disease or end stage renal disease; N18.5, Chronic kidney disease, stage 5; I50.9, Heart failure, unspecified
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 female patient is diagnosed with congestive heart failure and also has a stage IV pressure ulcer. Which of the following POA indicators must be present so that the ulcer will be classified as a MCC for this admission?
a. N
b. Y
c. W
d. U - ANSWER-b. Y
A patient is admitted to a healthcare facility with ataxia and syncope. The patient has a history of lung cancer. The patient also has a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. The principal diagnosis should be:
a. Fractured arm
b. Syncope
c. Metastatic carcinoma of the brain
d. Carcinoma of the lung - ANSWER-c. Metastatic carcinoma of the brain
A 78 year old patient is admitted with shortness of breath and a chest x-ray reveals infiltrates in the lung with pleural effusion. The patient also has a history of hypertension with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath is relieved. From the information given, what is the probable principle diagnosis?
a. Pneumonia
b. Congestive heart failure
c. Pleural effusion
d. Chronic obstructive pulmonary disease - ANSWER-b. Congestive heart failure
A patient is admitted with abdominal pain. The discharge documentation states "pancreatitis vs. noncalculus cholecystitis" as the final diagnoses. Both the diagnoses are equally treated. Based on coding guidelines, what is the correct sequencing for these diagnoses?
a. Sequence either the pancreatitis or non calculus cholecystitis first
b. Pancreatitis; non calculus cholecystitis; abdominal pain
c. Non calculus cholecytitis; pancreatitis
d. Sequence the abdominal pain first, followed by pancreatitis and non calculus cholecytitis as secondary diagnosis - ANSWER-a. Sequence either the pancreatitis or non calculus cholecystitis first
An inpatient undergoes a procedure and has a postoperative complication during the hospitalization. The insurance company will not pay for the entire amount requested. Which POA indicator is likely part of the cause?
a. N
b. Y
c. W
d. U - ANSWER-a. N
The best answer to describe how the UHDDS defines a comorbidity as a diagnosis that:
a. Affects the payment rate
b. Occurs after admission
c. Is not documented
d. Pre-exists before admission - ANSWER-d. Pre-exists before admission
A significant procedures is one that requires all of the following except:
a. Is surgical in nature
b. Carries a genetic risk
c. Carries an anesthetic risk
d. Requires specialized training - ANSWER-b. Genetic risk
The Uniform Bill 2004 supports, among other things, the transition to:
a. An integrated health care delivery system
b. A morbidity registry system [Show Less]