AHIMA CCS EXAM | QUESTIONS WITH 100% CORRECT ANSWERS | VERIFIED | UPDATED 2024, Exams of Nursing

Download AHIMA CCS EXAM | QUESTIONS WITH 100% CORRECT ANSWERS | VERIFIED | UPDATED 2024 and more Exams Nursing in PDF only on Docsity! AHIMA CCS EXAM | QUESTIONS WITH 100% CORRECT ANSWERS | VERIFIED | UPDATED 2024 Carcinoma in situ - CORRECT ANSWER - Tumor cells that are undergoing malignant changes but are still confined to the point of origin without invasion of the surrounding normal tissue Examples of carcinoma in situ - CORRECT ANSWER - Intraepithelial infiltrating 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 - CORRECT ANSWER - b The CPK elevation with MB enzymes elevated and the EKG ST changes denote a possible Ml (Leon-Chisen 2013, 386-387). A patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis· is Escherichia coli, urinary tract infection. Which of the following represents the correct diagnoses and appropriate sequence of those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli, urinary tract infection d. Urinary tract infection, Escherichia coli - CORRECT ANSWER - d Symptoms are not coded when a definitive diagnosis is present on discharge. The patient discharge diagnosis of urinary tract infection. The organism (E. coli) is coded with a seco diagnosis code (B96.20) which is to be added as an additional code to identify the bacterial agent (HHS 2014, Section II.A., 98). A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant. What action(s) should the coding staff take? a. Query the physician. b. Assign the codes for the postoperative transplant rejection. c. Assign only the code for the transplant rejection. d. Assign only the code for heart failure. - CORRECT ANSWER - a When the documentation is not clear regarding a potential complication, it is appropriate query the physician (HHS 2014, Section I.B.16, 16; Leon-Chisen 2013, 43-44). A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. What potential diagnosis most closely fits the patient's overall symptoms? a. Insomnia b. Major depression c. Reye's syndrome d. Bipolar disorder - CORRECT ANSWER - b The symptoms provided are indicative of a depressive disorder (Leon-Chisen 2013, 175). Inpatient: Admission for inguinal hernia repair. This 30-year-old patient has acquired immunodeficiency syndrome (AIDS) but is not symptomatic at this time due to medication regimen. The procedure performed was a right indirect inguinal herniorrhaphy via open approach. - CORRECT ANSWER - ICD-10-CM: K40.90, B20, ICD-10-PCS: OYQ50ZZ (Schraffenberger 2013, 82-84,252) Inpatient: A 75-year-old male patient was admitted from a nursing home with dehydration and dysphagia due to a previous stroke. During hospitalization the patient was rehydrated and transferred back to the nursing home. - CORRECT ANSWER - ICD- 10-CM: E86.0, I69.391 (Schraffenberger 2013, 131, 209-210). Stroke= cerebral infarction Inpatient: 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. - CORRECT ANSWER - ICD-10- CM: F10.229, F13.129, K70.30, (Schraffenberger 2013, 140-143.) ICD-10-PCS HZ2ZZZZ (Leon-Chisen 2014, 186). ICD-10-PCS: 4A023N7, B2111ZZ (Schraffenberger 2013, 202-204). Inpatient: This is the first admission for a patient with adenocarcinoma of the right lower lung who was also found with metastasis to the brain. The patient underwent a right lower lung lobectomy via laparotomy. - CORRECT ANSWER - ICD-10-CM: C34.31, C79.31, ICD-10-PCS: OBTFOZZ (Schraffenberger 2013, Chapter 5, 99). Inpatient: A patient has metastatic adenocarcinoma of bone. - CORRECT ANSWER - ICD-10- CM: C80.1, C79.51 (Schraffenberger 2013, 99). Inpatient: A patient is admitted with metastatic carcinoma from breast to liver with previous bilateral mastectomy and no reoccurrence at the primary site. - CORRECT ANSWER - ICD-10-CM: C78.7, Z85.3, Z90.13 (Schraffenberger 2013, 478). Inpatient: A young woman was admitted after a car hit her from behind while she waited for a bus on the sidewalk. She sustained a fractured fibula shaft and patella on the left leg with a break in the skin at the midcalf. The patient required an open reduction of the left fibula fracture. - CORRECT ANSWER - ICD- 10-CM: S82.402A, S82.002A, T14.8, Y92.480, V03.10XA, ICD-10-PCS: OQSKOZZ (Schraffenberger 2013, 380-381, 443, 428). Inpatient: Syncope; bradycardia ruled out; due to taking Valium as prescribed by a physician. Patient also took an antihistamine as directed on the package without consulting a healthcare provider. - CORRECT ANSWER - ICD-10-CM: T42.4X1A, T45.0X1A, R55-The patient took over-the-counter medications with a prescription medication without consulting the prescribing physician. This is a poisoning. Per the Official ICD-10-CM Guidelines for Coding and Reporting, I.C.19.e.5.b.: Nonprescribed drug taken with correctly prescribed and properly administered drug: If a nonprescribed drug or medicinal agent was taken in combination jVith a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from the interaction of the two drugs would be classified as a poisoning (HHS 2014, Section I, 19, e, Sa; Schraffenberger 2013, 406-407). Inpatient: Sepsis due to the presence of an indwelling urinary catheter with a positive blood culture reflected in the progress notes of Staphylococcus aureus sepsis. - CORRECT ANSWER - ICD-10-CM: T83.51XA, A41.01 (Leon-Chisen 2013, 150, 154, 535). Inpatient: Respiratory distress syndrome, 26-day-old baby, temporary tracheostomy completed. - CORRECT ANSWER - ICD-10-CM: P22.0, ICD-10-PCS: OB110F4 (Schraffenberger 2013, 339; Coding Clinic 1986 Nov.-Dec., 6; 1" Quarter 1989, 10) Ambulatory/Outpatient Noncardiac chest pain, esophageal acid reflux test. - CORRECT ANSWER - ICD-10- CM: R07.89; CPT: 91034 (Schraffenberger 2013, 362-363; CPT Assistant May 2005,3) Ambulatory/Outpatient Annual screening mammogram. - CORRECT ANSWER - ICD-10-CM: Z12.31 CPT:77057 (Schraffenberger 2013, 462; CPT Assistant March 2007, 7) Ambulatory/Outpatient Excision of basal cell carcinoma, 1.9-cm lesion left upper eyelid. - CORRECT ANSWER - ICD-10-CM: C44.119; CPT: 11642 (Schraffenberger 2013, 99-100; CPT Assistant Fa11199-. _ May 1996, 11; Feb. 2008, 8; Feb. 2010, 3; CPT Changes: An Insider's View 2003). Ambulatory/Outpatient Hallux valgus repair with resection of the joint with implant in the first left toe proximal phalanx. - CORRECT ANSWER - CD-10-CM: M20.12; CPT: 28293-TA (Schraffenberger 2013, 305; CPT Assistant Dec. 1996. 6; CPT Assistant Jan. 2007, 31). Ambulatory/Outpatient Metastatic ovarian cancer to the pleura. Thoracoscopic pleurodesis. - CORRECT ANSWER - ICD-10-CM: C78.2, C56.9; CPT: 32650 (Schraffenberger 2013, 100-101; CPT Assistant F 1994, 1, 6; CPT Changes: An Insider's View 2002). Ambulatory/Outpatient Symptomatic bradycardia due to sick sinus syndrome with replacement of dual chamber pacemaker generator with removal of old generator. - CORRECT ANSWER - ICD-10-CM: 149.5; CPT: 33228 (Schraffenberger 2013, 206, 362-363; CPT Changes: An In-sider's View 2003; CPT Assistant Summer 1994, 10, 19; CPT Assistant Nov. 1999, 16; CPT CHANGES 200,2013 Ambulatory/Outpatient Esophagogastroduodenoscopy with sclerotherapy of esophageal varices. - CORRECT ANSWER - ICD-10-CM: 185.00; CPT: 43243 Leon-Chisen 2013, 246; Smith 2015, 115; CPT assistant Spring 1994, 4). Ambulatory/Outpatient Transurethral resection of the prostate for benign prostatic hypertrophy with electrocautery. - CORRECT ANSWER - ICD-10-CM: N40.0; CPT: 52601 ( Schraffenberger 2013, 294-295; Smith 2015, 134; CPT Assistant Nov. 1997, 20; CPT Assistant April2001, 4; CPT Assistant June 2003, 6). Ambulatory/Outpatient Cryosurgical destruction of simple papilloma of the penis. - CORRECT ANSWER - ICD-10-CM: D29.0; CPT: 54056 (Schraffenberger 2013, 103; Smith 2015, 134). Ambulatory/Outpatient The care rendered to the patient and the patient's response must be documented in the medical record (LaTour and Eichenwald Maki 2013, 264; Sayles 2013, 70). Authentication of health record entries means to: a. Create facsimiles of documents b. Prove authorship of documents c. Develop documents d. Use a rubber stamp on random sets of documents - CORRECT ANSWER - b Authentication is the act of verifying a claim of identity (Sayles 2013, 381). In order to prove authorship of documents they are required to be authenticated by a signature (LaTour and Eichenwald Maki 2013, 264). The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for non-adherence must be specified in: a. Hospital rules and regulations b. Conditions of nonparticipation c. Medical staff bylaws d. Nursing staff policies - CORRECT ANSWER - c The medical staff bylaws are required by accreditation and regulatory organizations to refer to the timeline required for completion (LaTour and Eichenwald Maki 2013, 240; Sayles 2014, 353). A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded in the order of sequence. a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina c. Gastroenteritis, abdominal pain, angina d. Diarrhea, chronic obstructive pulmonary disease, angina - CORRECT ANSWER - b The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline II.A, 98 for additional information on coding of symptoms, signs, and ill-defined conditions. A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. What diagnostic codes should be used and how should they be sequenced? Z12.11 Encounter for screening for malignant neoplasm of colon D12.6 Benign neoplasm of colon, unspecified a. Z12.11 b. Dl2.6 Encounter for screening for malignant neoplasm of colon Benign neoplasm of colon, unspecified c. Zl2.ll,Dl2.6 d. D12.6, Z12.11 - CORRECT ANSWER - c The circumstances of the encounter are for a screening colonoscopy. Because of this the screening, colonoscopy is listed first, followed by a code for the polyps (HHS 2014, Section I.C.21.c.5, 88). 023-Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (017.0-017.3) melanocytic nevi (022.-) When coding benign neoplasm of the skin, the section noted above directs the coder to: 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 - CORRECT ANSWER - a Excludes note 1 is defined as never code here (HHS 2014, I.A.12.a, 10). 023-Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (017.0-017.3) melanocytic nevi (022.-) When coding benign lipomatous neoplasms of skin, the section noted above directs the coder to: a. Use category D23 b. Use a code from D17.0-D17.3 c. Use code E88.2 d. Use category D22 - CORRECT ANSWER - b Excludes note 1 is defined as never code here (HHS 2014, I.A.12.a, 10). A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct? E11.9 -Type 2 diabetes mellitus without complications E11.29 -Type 2 diabetes mellitus with other diabetic kidney complication H25.9 - Unspecified age-related cataract H25.21 -Age-related cataract, morgagnian type, right eye H25.041 -Posterior subcapsular polar age-related cataract, right eye I10-Essential hypertension 112.9 -Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified chronic kidney disease N17.9 -Acute kidney failure, unspecified a. H25.21, E11.29, 112.9, N17.9 b. H25.041, E11.9, 110, N17.9 c. H25.9, E11.29, 112.9, N17.9 d. H25.041, E11.9, !12.9 - CORRECT ANSWER - b The patient has posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus (with no designated causal relationship to the cataracts), hypertension, acute renal failure. The hypertension is not related to the renal failure as it is acute and not chronic. Because of this, a combination code for hypertension and chronic renal failure is not coded (HHS 2014, Section I.B.9, 14). d Acute exacerbation of COPD is coded as J44.1. The hypertension is present with the chronic renal disease. Because of this, a combination code for hypertension and chronic renal disease is coded. In addition, the stage of the kidney disease is also coded (HHS 2014, Section I.B.9, 14). - CORRECT ANSWER -