CCS Exam 1 With 100% Correct Answers - Medical Coding Practice Questions, Exams of Advanced Education

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CCS Exam 1 With 100% Correct Answers

The patient is seen in the pain clinic for chronic neoplasm-related pain that was known to be caused by the metastatic bone carcinoma of the vertebra that has spread from carcinoma of the left main bronchus of the lung. How should this be coded? a. C34.02, Malignant neoplasm of left main bronchus b. G89.3, Neoplasm related pain (acute) (chronic) c. G89.3, Neoplasm related pain (acute) (chronic); C79.51, Secondary malignant neoplasm of bone; C34.02, Malignant neoplasm of left main bronchus d. C79.51, Secondary malignant neoplasm of bone; G89.3, Neoplasm related pain (acute) (chronic) -Correct Answer: C Code G89.3 is assigned to pain documented as being related, associated, or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic. Code G89.3 may be sequenced as the primary diagnosis when the reason for the encounter is specifically for pain management. An additional code(s) is assigned for the underlying neoplastic disease (CMS 2020a, Section I.C.6.b.5., 44). A patient underwent excision of a malignant lesion of the skin of the chest that measured 1.0 cm, and there was a 0.2-cm margin on both sides. Based on the 2020 CPT codes, which code would be used for the procedure? a. 11401, Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; exciseddiameter 0.6 to 1.0 cm b. 11601, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm c. 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm d. 11402, Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; exciseddiameter 1.1 to 2.0 cm -Correct Answer: C The size of the lesion plus the margins are included in coding the excision. Excised diameter: 1.0 cm + 0.2 cm + 0.2 cm = 1.4 cm (AMA CPT Professional Edition 2020, 86). A laparoscopic tubal ligation with Falope ring is completed. What is the correct CPT code assignment? 49321Laparoscopy, surgical; with biopsy (single or multiple) 58662Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring)

a. 58662 b. 58670 c. 58671 d. 49321 -Correct Answer: C For tubal ligation, which may be performed by ligation, transection, or other occlusion of the fallopian tubes, the coder should refer to codes 58600-58615 for abdominal or vaginal approaches. For laparoscopic tubal ligation with the use of Falope rings, code 58671 is assigned (Kuehn 2020, 176). A patient is admitted to the hospital for pain due to displacement of pacemaker electrode. The patient also has hypothyroidism due to partial thyroidectomy seven years ago and a breast cyst. Using a guide wire, the pacemaker electrode was relocated and Synthroid was given during hospitalization. The codes (excluding External Cause codes) that should be assigned are: T82.110ABreakdown (mechanical) of cardiac electrode, initial encounter T82.110DBreakdown (mechanical) of cardiac electrode, subsequent encounter T82.120ADisplacement of cardiac electrode, initial encounter T82.120SDisplacement of cardiac electrode, sequela N60.09Solitary cyst of unspecified breast E89.0Postsurgical hypothyroidism 02WA3MZRevision of cardiac lead in heart, percutaneous approach 02WA4MZRevision of cardiac lead in heart, percutaneous endoscopic approach 02WA0MZRevision of cardiac lead in heart, open approach a. T82.110A, E89.0, 02WA3MZ b. T82.110D, E89.0, N60.09, 02WA4MZ c. T82.120A, E89.0, 02WA3MZ d. T82.120S, E89.0, N60.09, 02WA0MZ -Correct Answer: C 02WA3MZ, Revision of device in, Heart, percutaneous, cardiac lead, no qualifier. Code T82.110A pertains to mechanical complications and would not be used. In this case, there is pain due to the displacement of the electrode. The breast cyst (N60.09) would not be coded because it does not meet the criteria of the UHDDS as a secondary condition; it is an incidental finding and does not have any bearing on the current hospital stay. Review the Alphabetic Index under Absence, thyroid, with hypothyroidism, which directs the coder to code E89.0 (CMS 2020a, Section III, 110-112). A maternity patient is admitted in labor at 43 weeks. She has a spontaneous delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? O80Encounter for full-term uncomplicated delivery O48.0Post-term pregnancy O48.1Prolonged pregnancy O66.5Attempted application of vacuum extractor and forceps

a. O48. b. O48. c. O d. O66.5 -Correct Answer: B When an admission involves delivery, the principal diagnosis should identify the main circumstance or complication of the delivery. The code for normal delivery cannot be used because there is a complication of pregnancy, that it is prolonged at 43 weeks. Prolonged pregnancy is pregnancy that extends beyond 42 weeks of gestation (CMS 2020a, Section I.C.15.b., 62). 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. What is the principal diagnosis? a. Status post fracture b. Cardiac arrhythmia c. Right hip fracture d. Cancelled procedure -Correct Answer: C 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 2020a, Section II.F., 108). Patient admitted with hemorrhage due to placenta previa with twin pregnancy. This patient had two prior (cesarean section) deliveries. Emergency C-section was performed due to the hemorrhage. The appropriate principal diagnosis would be: a. Prior cesarean sections b. Placenta previa without hemorrhage c. Twin gestation d. Placenta previa with hemorrhage -Correct Answer: D The principal diagnosis should be the condition established after study that was responsible for the patient's admission. If the patient was admitted with a condition that resulted in the performance of a cesarean procedure, that condition should be sequenced as the principal diagnosis. If the reason for the admission or encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission or encounter should be selected as the principal diagnosis, even if a cesarean was performed (CMS 2020a, Section I.C.15.b.4, 62-63). A patient presents to a facility with a history of prostate cancer and mental confusion on admission. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain reveals metastatic carcinoma of the brain. The correct coding and sequencing of this patient's record is: a. Metastatic carcinoma of the brain, carcinoma of the prostate, mental confusion

b. Mental confusion, history of carcinoma of the prostate, metastatic carcinoma of the brain c. Metastatic carcinoma of the brain, history of carcinoma of the prostate d. Carcinoma of the prostate, metastatic carcinoma to the brain -Correct Answer: C Metastatic carcinoma of the brain; history of carcinoma of the prostate. The patient does not have a current cancer of the prostate however is being admitted and treated for metastatic cancer (to the brain, from the prostate). Mental confusion does not meet the UHDDS qualifications for being coded as an additional diagnosis (CMS 2020a, Section I.C.2.b., 30 and I.C.2.m., 35). A patient with GERD presents to a facility for upper endoscopy submucosal injection of material near the lower esophageal sphincter. The correct coding and sequencing of this patient's record is: K20.9Esophagitis, unspecified K21.0Gastro-esophageal disease with esophagitisK21.9Gastro-esophageal disease without esophagitis 43235Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 43236with directed submucosal injection(s), any substance 43257with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease 43270with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post- dilation and guide wire passage, when performed. -58Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period −59Distinct procedural service a. K20.9, 43257 b. K21.0, 43235, 43236 c. K21.9, 43236 d. K21.9, K20.9, 43270-58, 43236-59 -Correct Answer: C The patient has GERD, which is gastroesophageal disease without esophagitis. A variety of substances can be injected into the submucosal space of the digestive tract through a sheathed needle-tipped catheter inserted through an endoscope (CPT Assistant May 2005, 3-6). 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 -Correct Answer: C 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. Since this endoscope advanced beyond the splenic flexure, this

procedure is considered a colonoscopy (according to Colonoscopy Decision Tree in CPT) (Smith 2020, 142-145). If a patient is admitted with pneumococcal pneumonia and severe pneumococcal sepsis, the coder should: a. Assign codes for sepsis and pneumonia b. Assign codes for sepsis, pneumonia, and severe sepsis c. Assign only a code for pneumococcal pneumonia d. Review the chart to determine if septic shock could be coded first -Correct Answer: B Coding of severe sepsis due to a localized infection requires the assignment of three codes. A code for the systemic infection is sequenced first followed by the code for the localized infection and a code from category R65.2 (CMS 2020a, Section I.C.1.d., 24- 27). A patient was admitted to the hospital with unstable angina and congestive heart failure. The unstable angina is treated with nitrates, and intravenous Lasix is given to manage the heart failure. What is the appropriate coding action? a. Assign only the code for the congestive heart failure. b. Assign the codes for the unstable angina and congestive heart failure, sequence either first. c. Query the physician about which diagnoses to code. d. Assign only the code for the unstable angina. -Correct Answer: B Both diagnoses meet the definition of principal diagnosis equally, and either may be sequenced first (CMS 2020a, Section II.C., 107-110; Leon-Chisen 2020, 26-27). A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of the bladder. The patient's presenting symptom is hematuria. What is the correct facility code assignment for this procedure? 52000Cystourethroscopy (separate procedure) 52204Cystourethroscopy with biopsy(s) −22Increased procedural services a. 52000 b. 52000- c. 52204 d. 52204, 52204-22 -Correct Answer: C CPT code 52204 is reported only once, irrespective of how many biopsy specimens are obtained and how the specimens are sent for pathologic examination (CPT Assistant Aug. 2009, 6). Modifier 22 is not appropriate because it is not approved for hospital outpatient use (AMA CPT Professional Edition, 2020, Appendix A). A patient has blepharoplasty of the left upper eyelid. What modifier should be used with the procedure? a. LT b. TA

c. E d. F2 -Correct Answer: C E1 is the modifier which signifies left upper eyelid (AMA 2020, 815) Facilities may use X modifiers in place of which other modifier? a. 25 b. 27 c. 52 d. 59 -Correct Answer: D X modifiers (XU, XE, XP, and XS) may be used instead of modifier 59 (AMA 2020, 812- 815). A sigmoidectomy takes the physician more time than originally planned. The reason was extensive lysis of adhesions which took over two hours. What modifier can the physician use to indicate this procedure required increased time? a. 22 b. 26 c. 52 d. 59 -Correct Answer: A Modifier 22 will convey the increased procedural service associated with the surgery (AMA 2020, 809). A patient is admitted to the hospital with shortness of breath and congestive heart failure and subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. The correct sequencing of the diagnoses in this case would be: a. Congestive heart failure and respiratory failure b. Respiratory failure c. Respiratory failure and congestive heart failure d. Shortness of breath, congestive heart failure, and respiratory failure -Correct Answer: A Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis. Shortness of Breath is a symptom inherent to CHF and therefore is not coded (CMS 2020a, Section I.C.10.b., 53-54). A patient was admitted with end stage renal disease (ESRD) following kidney transplant. The patient undergoes dialysis during admission. The patient's angina and chronic obstructive pulmonary disease are managed with medication while admitted. The diagnoses would be sequenced as: a. Status post kidney transplant; ESRD, chronic obstructive pulmonary disease; angina b. ESRD; status post kidney transplant; chronic obstructive pulmonary disease; angina c. Angina; ESRD, status post kidney transplant; chronic obstructive pulmonary disease

d. Chronic obstructive pulmonary disease; ESRD; status post kidney transplant; angina -Correct Answer: B The reason for the patient's admission was the ESRD, which needed treatment with dialysis. This means the ESRD should be sequenced first. Additional diagnosis can be coded in any order (CMS 2020a, Section I.C.14.a.2, 59-60). A patient comes to the ER with chest pain and shortness of breath. An EKG was performed, and the patient's history of COPD was noted. Unstable angina was diagnosed as the chest pain came on while the patient was at rest and did not resolve with nitroglycerin. The patient was admitted for a left heart catheterization, coronary arteriography using two catheters and left ventricular angiography. The patient was found to have arteriosclerotic heart disease. The patient has no history of cardiac surgery. The appropriate sequencing of ICD-10-CM and CPT codes would be: I20.0Unstable anginaI20.9Angina pectoris, unspecified I25.10Atherosclerotic heart disease of native coronary artery without angina pectoris I25.110Atherosclerotic heart disease of native coronary artery with unstable angina pectoris I25.119Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris J44.9Chronic obstructive pulmonary disease R06.02Shortness of breathR07.9Chest pain, unspecified 93452Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93453Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed 93454Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; 93458with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed a. R07.9, R06.02, I25.119, 93452, 93458 b. J44.9, I20.0, I25.110, 93454, 93453 c. I20.9, J44.9, 93453 d. I25.110, J44.9, 93458 -Correct Answer: D Code I25.110 is assigned to show coronary artery disease in a native coronary artery and is used when a patient has unstable angina with coronary artery disease and no history of coronary bypass graft (CABG) surgery (Schraffenberger and Palkie 2020, 312-314). Code 93458 includes intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation as described for code 93454 as well as left heart catheterization and intraprocedural injection(s) (AMA CPT Professional Edition 2020, 679-683, Cardiac Catheterization Table, 684-685, Injection Procedure Guidelines). Patient was admitted with pneumonia. Sputum cultures on day three of admission indicate a Klebsiella pneumonia. What is the POA status for the Klebsiella pneumonia and why?

a. Y, because the pneumonia was present on admission, even though the organism was not verified until days later b. N, because the type of pneumonia was not verified until after admission c. U, because the coder must query the physician for POA status in this case d. W, because the physician cannot tell if the reason for the pneumonia at the time of admission was the Klebsiella or not -Correct Answer: A When a code has multiple clinical concepts, such as an infection and the causative organism, it is appropriate to code it as POA regardless of the fact that the culture results are not known until days after admission (CMS 2020a, Appendix I, 117). A patient has a hernia repair done as an outpatient. In recovery, the patient develops tachycardia and shortness of breath, is diagnosed with postoperative atrial fibrillation, and is subsequently admitted. What is the POA indicator for the postoperative atrial fibrillation? a. Y b. N c. U d. W -Correct Answer: A The POA indicator for conditions that arise prior to admission including those as an outpatient is Y (CMS 2020a, Appendix I, 117). A patient is admitted with acute gastritis. On the second day of admission, the patient has hematemesis. The patient is also being treated for long-standing hypertension and diabetes, along with recently diagnosed hypothyroidism. Which of the patient's diagnoses will have a POA indicator of N? a. Diabetes b. Hypothyroidism c. Hypertension d. Acute gastritis -Correct Answer: D The acute gastritis will warrant a POA indicator of N since there is a combination code for the gastritis with bleeding and the bleeding did not occur until after admission (CMS 2020a, Appendix I, 117). Which type of conditions are always considered present on admission? a. Obstetrical b. Congenital c. Those with an acute exacerbation d. Those that represent an injury -Correct Answer: B In accordance with the POA guidelines, congenital conditions are always considered POA (CMS 2020a, Appendix I, 117). A patient is admitted for seizures. What is the appropriate POA for the external cause code of W06.XXXA assigned because the patient fell out of bed during a seizure in the emergency department? a. Y b. N

c. U d. W -Correct Answer: A The patient fell out of bed prior to admission, so the POA indicator for the fall is Y for yes (CMS 2020a, Appendix I, 117). The outpatient code editor (OCE) has all of the following types of edits except: a. Sex and procedure edits b. Valid diagnosis code edits c. Invalid revenue code edits d. Diagnosis and age edits -Correct Answer: B The OCE has a large number of edits that a claim must go through in order to identify errors. The OCE looks at invalid diagnosis codes, but not valid ones (Casto 2018, 256- 257). Determining medical necessity for outpatient services includes all the following except: a. Local coverage determinations (LCDs) b. National coverage determinations (NCDs) c. Diagnoses linked to procedures by claims-processing software tests ensuring that the procedure is cross-referenced, or linked, correctly to an acceptable diagnosis code for that service d. Requiring new HCPCS codes be developed to replace codes in the CPT code book - Correct Answer: D Several tools and references are used to support the reimbursement process including the fee schedule and the current National Correct Coding Initiatives edits. Other valuable resources are Medicare's Carrier Manual, Medicare's National Coverage Determinations Manual, and local coverage determinations (LCDs) (Kuehn 2020, 373- 376). The National Correct Coding Initiative (NCCI) Edits apply to services billed by: a. The same provider, for same beneficiary, on same date of service b. All providers, for the same beneficiary, on the same date of service c. The same provider, for the same beneficiary, for all dates of service related to the encounter d. All providers, for the same beneficiary, for all dates of service related to the encounter -Correct Answer: A NCCI edits apply to services billed by the same provider for the same beneficiary on the same date of service (Kuehn 2020, 377). If the principal diagnosis is an initial anterior wall myocardial infarction, which procedure will result in the highest MS-DRG assignment? a. Mechanical ventilator b. Insertion central venous catheter c. Right heart cardiac catheterization

d. Transbronchial lung biopsy -Correct Answer: D MS-DRG 264 (weight = 03.2481) for myocardial infarction with transbronchial lung biopsy would result in the highest reimbursement. MS-DRG 282 (weight = 00.7379) would be assigned for the myocardial infarction with insertion central venous catheter, with mechanical ventilator, or with a right heart catheterization (CMS 2019b). Medicare payment to physicians for services rendered is made under the: a. Outpatient Prospective Payment System b. Resource-based Relative Value Scale c. Ambulatory Payment Classification d. Conditions of Participation -Correct Answer: B Physician payment from Medicare is based on the Resource-based Relative Value Scale (RBRVS) (Kuehn 2020, 365). Inpatient procedures are coded with: a. HCPCS b. CPT c. ICD-10-PCS d. ICD-O -Correct Answer: C The UHDDS specifies ICD-10-PCS as the code system for inpatient procedures (CMS 2020b, 1). Under the Inpatient Prospective Payment System (IPPS), what can be used to measure the cost of care for inpatients? a. MS-DRG assignment b. RBRVS c. Case-mix index d. SOI-ROM -Correct Answer: C Calculation of the case-mix index is a way for a facility to measure resource consumption and cost of care (Casto 2018, 116). The abstracting of this data element has an impact on the DRG reimbursement. a. Date of service b. Discharge disposition c. Admission source d. Medical record number -Correct Answer: B The discharge disposition impacts facility DRG reimbursement (Schraffenberger and Palkie 2020, 408). Which of the following is a data element that coders typically are tasked with abstracting? a. Blood type b. Date of admission

c. Sex d. Date of surgery -Correct Answer: D The date of surgery is typically abstracted by coding professionals. While the other elements are also collected, b and c are usually gathered during the registration process, and the blood type is not normally part of the abstract process (Sayles 2020,

Dr. Jones is the attending physician for a patient admitted with aspiration of a ballpoint pen cap. Dr. Westwood is the provider who performed a direct laryngoscopy with foreign body removal on the patient the afternoon of admission. Monitoring of the patient's respiratory status continued for 36 hours after the procedure as severe swelling of the larynx was noted during the laryngoscopy. On the morning of discharge, the patient was noted to have acute, suppurative otitis media of the right ear and Dr. Phillips performed a myringotomy with tube insertion under general anesthesia with assistance from Dr. Johannsen, the resident.Upon discharge, which physician will be assigned to the principal procedure that was performed? a. Dr. Jones b. Dr. Westwood c. Dr. Johannsen d. Dr. Phillips -Correct Answer: B The principal procedure in this scenario was the laryngoscopy to remove the foreign body performed by Dr. Westwood (Sayles 2020, 70). When a patient goes home with an order for home health to start one week after an inpatient admission, this is categorized as a(n): a. Discharge b. Transfer c. Readmission d. Outlier -Correct Answer: A A written order for home health to begin within three days of inpatient discharge is considered a transfer. Beyond that, it is a discharge (Casto 2018, 125). 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 -Correct Answer: A MS-DRG 280 (weight = 01.6309) for myocardial infarction with respiratory failure would change the MS-DRG. MS-DRG 282 (weight = 00.7379) would be assigned for myocardial infarction alone, with atrial fibrillation, with hypertension, and with history of myocardial infarction (CMS 2019b).

Documentation in the record reveals that a patient is admitted with an acute exacerbation of COPD (MS-DRG 192). A higher-paying MS-DRG may be appropriate if documentation is present in the record at the time the decision was made to admit the patient that confirms a diagnosis associated with which of the following? a. Angina and treated with nitroglycerin prn b. Atrial fibrillation and underwent a cardioversion c. Respiratory failure treated with intubation and mechanical ventilation for 23 hours d. Anemia and was given a blood transfusion -Correct Answer: C MS-DRG 0208 is a correct reflection of the patient's severity illness and appropriate reimbursement based on the documentation when compared to the MS-DRG associated with acute exacerbation of COPD (Leon-Chisen 2020, 225-226). A female patient is diagnosed with congestive heart failure. Which of the following will increase the MS-DRG weight if present on admission? a. Atrial fibrillation b. Stage III pressure ulcer of coccyx c. Blood loss anemia d. Coronary artery disease -Correct Answer: B MS-DRG 291 (weight = 01.3458) for congestive heart failure with stage III pressure ulcer would optimize the MS-DRG. MS-DRG 293 (weight = 00.6553) is assigned for congestive heart failure alone, with atrial fibrillation, with blood loss anemia, and with coronary artery disease all remain the same (CMS 2019b). Major complications and comorbidities (MCCs) are determined to require the greatest degree of resources with a payment group and also reflect the greatest_____. a. ROM b. ROI c. SOI d. SNF -Correct Answer: C MCCs reflect the greatest degree of severity of illness (SOI) (Casto 2018, 118). Which of the following diagnoses qualifies as MCC? a. Coronary artery disease b. Aortic stenosis c. Type 2 myocardial infarction d. Unspecified atrial fibrillation -Correct Answer: C A diagnosis of type 2 MI is considered a major complication/comorbidity (Optum 360 2019, 648). A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus

d. Chronic obstructive asthma -Correct Answer: C "Status asthmaticus is an acute asthmatic attack in which the degree of bronchial obstruction is not relieved by the usual treatment, such as by epinephrine or aminophylline" (Schraffenberger and Palkie 2020, 352-353). A 23-year-old female is admitted for shock following treatment of an ectopic pregnancy. This encounter would be coded as: a. O03.81, Spontaneous abortion complicated by shock b. O08.3, Complication following ectopic and molar pregnancies c. R57.9, Shock NOS d. T81.10XA, Postoperative shock -Correct Answer: B When a patient is readmitted because a complication has developed following discharge for a treated ectopic pregnancy, a code from category O08 is assigned as the principal diagnosis (Leon-Chisen 2020, 357-358). 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 -Correct Answer: B When a patient has pulmonary edema that is due to congestive heart failure, only the congestive heart failure should be coded (Leon-Chisen 2020, 400-401). A 28-year-old male with a history of IV heroin dependence is admitted for pneumonia. A pulmonologist is consulted to assist with the patient's treatment and an antibiotic for Pneumocystis carinii pneumonia is administered. Low potassium is treated as well. The final diagnoses were coded as: B20, B59, E87.6, and F11.21. What is the discrepancy noted between the coding and the documentation? a. The "history of " code reflects abuse rather than dependence b. The correct code for the pneumonia should be J18. c. The assignment of B20 has no supportive documentation d. The hypokalemia should not be coded as that is integral to the pneumonia -Correct Answer: C The diagnosis of HIV (B20) has no supporting diagnosis documented. In this case a query would be appropriate to determine if the patient has HIV since he is a previous IV drug user and the type of pneumonia is often seen in patients with an HIV diagnosis (Schraffenberger and Palkie 2020, 123-127). A patient is admitted post-back surgery with uncontrolled pain and leakage at the surgical site. Vitals show a fever of 101 with some tachycardia noted as well. The attending physician documents inflammation, with an infectious disease consultant documenting Staphylococcus aureus infection based on the lab culture. How should the coder resolve the discrepancy between the diagnoses documented? a. Code the inflammation since that is what the attending physician documented

b. Code the infection since the consultant was specific regarding the type of infection c. Code the infection based on the lab culture results d. Query the attending physician to clarify the conflicting documentation -Correct Answer: D When there is conflicting information in the patient's medical record, a query to the attending physician is warranted to ask for clarification (AHIMA 2019c). A coder has noted that a particular nurse practitioner is sending orders for outpatient testing with the diagnosis listed as "possible" or "rule out" without any accompanying signs or symptoms or abnormal findings suggestive of the possible diagnosis. What action should the coder take? a. Nothing, code the diagnosis as if it exists since this is an outpatient b. Use an observation code for the encounter c. Ask for outpatient CDI specialist to educate the NP on the guidelines for outpatient coding which do not permit the use of "possible" or "rule out" diagnoses d. Report the nurse practitioner to quality management and billing as this practice is causing billing delays and increase in the discharge not final billed metric -Correct Answer: C The NP should be educated on the outpatient coding guidelines in order to recognize the need for reporting signs/symptoms or abnormal findings rather than uncertain diagnoses in the outpatient setting (AHIMA House of Delegates 2016). An operative report indicates the physician performed metatarsal surgery but all other information in the record points to need for metacarpal surgery. What step should the coder take upon this discovery? a. Code the metatarsal surgery as that is what is documented in the operative report b. Code the metacarpal surgery since the op report was clearly an error c. Query the physician to determine which body area the surgery involved d. Suspend the chart and contact the coding supervisor as to which procedure to code - Correct Answer: C When there is conflicting information in the patient record, the coder should query the physician for clarification (AHIMA 2019c). A patient is seen in the ED with leg edema and headache. The patient denies shortness of breath, chest pain, and chills. The patient has a chest x-ray, CT of the head, and lab work. A doppler scan was done to evaluate for a DVT, which was negative. Final diagnoses in the ED was swelling of leg, migraine, and chest pain. What is the discrepancy in this documentation? a. Swelling is not documented outside the final diagnosis b. There was no chest pain by patient report c. Possible DVT should have been listed as final diagnosis d. No testing was provided to assess migraine -Correct Answer: B The patient reports not having chest pain, yet it is identified as a diagnosis by the provider (AHIMA Work Group 2013). The most challenging type of provider query is issued for:

a. Determining cause and effect b. Establishing clinical validation c. Resolving documentation conflict d. Clarifying acuity or specificity -Correct Answer: B The most challenging query type is for clinical validation and may best be addressed by clinical documentation specialists (AHIMA 2019c). When creating a compliant query to clarify conflicting information from the surgeon and the attending physician, to whom should the query be directed? a. Surgeon b. Attending physician c. Medical staff director d. Medical records committee chairperson -Correct Answer: B It is the responsibility of the attending physician to clarify conflicting documentation in the patient's record (AHIMA 2019c). When a compliant query remains unanswered, what is the next step for the coder? a. Ask the HIM director to place the physician on suspension until the query is answered. b. Alert the CEO that the query is outstanding, requesting a fine until the query is answered. c. Refer to the internal escalation policy and follow the process outlined therein. d. Report the physician to the peer review committee for disciplinary measures. -Correct Answer: C Every facility should have an internal escalation policy in place to address the process that should be followed if a query remains unanswered. This may include involving the coding supervisor or manager, the physician advisor, or administration (AHIMA 2019c). When creating compliant queries coders should: a. Query once without further follow up b. Query multiple times until the desired diagnosis is provided c. Query once with additional follow up if necessary d. Query unlimited times until every discrepancy is resolved -Correct Answer: C AHIMA's Guidelines for Achieving a Compliant Query Practice instruct that additional queries may be necessary based on the information provided in the first query response. It is permissible to issue another query in that circumstance (AHIMA 2019c). Verbal queries: a. Are not permissible in any circumstance b. Must have a written response in the record for coding purposes c. Have different rules or criteria than written queries d. Are not required to be documented as long as the physician responds verbally - Correct Answer: B In order for coding to utilize information provided in a physician response, the information must be documented in the legal health record (AHIMA 2019c).

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. -Correct Answer: C The term urosepsis is a nonspecific term. It has no default code in the Alphabetic Index. Should providers use this term, they must be queried for clarification (CMS 2020a, Section I.C.1.d., 24). A patient has findings suggestive of chronic obstructive pulmonary disease (COPD) on chest x-ray. The attending physician mentions the x-ray finding in one progress note but no medication, treatment, or further evaluation is provided. The coder should: a. Query the attending physician regarding the x-ray finding b. Code the condition because the documentation reflects it c. Question the radiologist regarding whether to code this condition d. Use a code from abnormal findings to reflect the condition -Correct Answer: A Query the attending physician regarding the clinical significance of the findings and request that appropriate documentation be provided. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must meet the UHDDS definitions; it is not clear if COPD does (CMS 2020a, Section III, 111-112). If a patient undergoes an inpatient procedure and the final summary diagnosis is different from the diagnosis on the pathology report, the coder should: a. Code only from the discharge diagnoses b. Code the diagnosis reflected on the pathology report c. Code the most severe symptom d. Query the attending physician as to the final diagnosis -Correct Answer: D Coding strictly from the pathology report is not appropriate as the coder is assigning a diagnosis without the attending physician's corroboration. It is therefore appropriate to query the physician (CMS 2020a, Section III, 111-112). A 56-year-old woman is admitted to an acute-care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of hospitalization, a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should: a. Use an excisional debridement code as these charts are rarely reviewed to verify the excisional debridement. b. Code with a nonexcisional debridement procedure code.

c. Query the healthcare provider who performed the procedure to determine if the debridement was excisional. d. Eliminate the procedure code all together. -Correct Answer: C Excisional debridement can be performed in the operating room, the emergency department, or at the bedside. Coders are encouraged to work with the physician and other healthcare providers to ensure that the documentation in the health record is very specific regarding the type of debridement performed. If there is any question as to whether the debridement is excisional or nonexcisional, the provider should be queried for clarification (Schraffenberger and Palkie 2020, 416). Patient presents with lower left quadrant abdominal pain with normal white cell count. X- ray showed sigmoid diverticulitis. Patient underwent a resection of sigmoid colon with anastomosis, developing a postoperative ileus after surgery. Nausea abated after resolution of the ileus. What is the query opportunity for this case? a. Was the diverticulitis perforated? b. Was the nausea postoperative? c. Was there an associated abscess with the diverticulitis? d. Was the postoperative ileus a complication? -Correct Answer: D It is acceptable to query regarding the status of the postoperative ileus being a complication or not based on the documentation. Documentation does not suggest perforation or abscess associated with the diverticulitis, and the nausea is a symptom of the ileus and not separately reportable (AHIMA 2019c). A 64-year-old female is admitted to the hospital with nausea, vomiting, and edema. The patient has a history of diabetes and takes Metformin and Lisinopril as prescribed. Blood sugar and blood pressure are monitored while admitted. On the discharge summary, the final diagnoses of acute renal failure and diabetes are documented. What is the query opportunity for this record? a. Is the acute renal failure linked to the diabetes? b. Does the patient have hypertension? c. Does the patient have chronic renal failure? d. Is the diabetes out of control? -Correct Answer: B Based on the documentation that the patient takes an antihypertensive drug (Lisinopril), and blood pressure was monitored throughout the stay, a diagnosis of hypertension may be suspected (AHIMA 2019c). Most hospitals require a medical record to be completed within: a. 5 days b. 10 days c. 7 days d. 30 days -Correct Answer: D 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 2020, 97).

To correct an entry in a paper-based 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 inchronological 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 -Correct Answer: A 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 2020, 78). 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). 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 -Correct Answer: B 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 Morey 2020, 125-126). The incident report should never be filed in the medical record (Carter and Palmer 2020, 572); 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, 189-190). A completed and signed operative report needs clarification of the size of the skin lesions that were removed. What process is used for that clarification? a. Amendment b. Addendum c. Update d. Revision -Correct Answer: A Once a document has been completed and signed, clarification takes place through an amendment (Sayles 2020, 78). Which of the following would be considered a hospital-acquired condition when the POA indicator is N? a. DVT following a gastric procedure

b. Diabetes with neuropathy c. Catheter-associated urinary tract infection d. Foreign body in the thumb -Correct Answer: C When a catheter-associated urinary tract infection is not present on admission, it is considered a hospital-acquired condition (Casto 2018, 294). When a POA indicator for a HAC that is the only CC/MCC condition on the record is listed as N, what happens to the reimbursement for that account? a. Nothing, the reimbursement is not impacted as this is an internal quality monitoring code b. The reimbursement goes up since the condition was not present on admission and more resources were needed to care for the patient c. The reimbursement goes down since the condition was not present on admission and could/ should have been prevented using best practices d. The reimbursement is placed on hold until the physician clarifies why the patient did not have the condition on admission -Correct Answer: C Hospital-acquired conditions with a POA indicator of N will negatively impact reimbursement if they are the only CC/MCC on the record. If there are other CC/MCC codes reported then the reimbursement is not affected (Casto 2018, 294). Which of the following may be considered a hospital-acquired condition? a. Diabetic foot ulcer b. Stage 2 coccyx pressure ulcer c. Calf ulcer, left leg, with muscle necrosis d. Right elbow pressure ulcer, stage 4 -Correct Answer: D Stage 3 and 4 pressure ulcers are on the HAC list (CMS 2020c). Which of the following statements best describes how the retention of records should be determined? a. Unless state law requires longer periods of time, specific patient health information should be retained for HIPAA established minimum time periods. b. AHIMA has published specific guidelines for retention of health information and these guidelines should be followed for records retention. c. The Joint Commission has developed standards for retention of health information which must be followed to maintain accreditation and these standards should be adhered to with regard to time frames. d. Health records should be retained according to their use in a facility and the state and federal laws do not apply to the retention of this health information. -Correct Answer: A The HIM professional must know the retention statutes and retention periods in his or her state of employment. When state laws are stricter than HIPAA, retention periods should be based on state law, Otherwise, minimum retention periods are based on HIPAA (Reynolds and Morey 2020, 135-137; Rinehart-Thompson 2017c, 193-197). The form that must be completed in order to permit a specific disclosure of protected health information is called a(n): a. Authorization

b. Consent c. Access d. Redisclosure -Correct Answer: A The HIPAA Privacy Rule has outlined specific requirements for an authorization form which is used for disclosures (Rinehart-Thompson 2017a, 222). The minimum necessary requirement would apply in which scenario below? a. When disclosure is to the secretary of HHS for investigation b. When disclosure is required by law c. When disclosure is for payment d. When disclosure is made to the personal representative of the individual -Correct Answer: C Disclosures made for payment fall under the minimum necessary doctrine, while in the other circumstances listed, the minimum necessary standard does not apply (Rinehart- Thompson 2017a, 232-233). What is the term used when protected health information has been disclosed inappropriately? a. Exposure b. Breach c. Violation d. Infraction -Correct Answer: B Under HITECH, when there has been unauthorized access or disclosure of protected health information, a breach is found to have occurred (Rinehart-Thompson 2017b, 250- 251). What is the term used for applying the HIPAA privacy rule over state rule(s) which are less strict? a. Exception b. Preemption c. Exclusion d. Predominance -Correct Answer: B Preemption means to supersede and in circumstances when the federal law of HIPAA is more strict than the state laws related to protected health information, HIPAA should be applied (Rinehart-Thompson 2017b, 254-255). A contract coder works for a hospital and, in the course of daily work, routinely accesses protected patient health information. Under HIPAA, what should be in place to permit access and protect patient privacy? a. AHIMA credential b. Business associate agreement c. Vendor license d. Patient authorization -Correct Answer: B A business associate agreement should be in place with vendors, including contract coders, to protect patient privacy (Brodnik 2017, 346).

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 -Correct Answer: C Reviewing the history and physical of a coworker when not part of assigned work is not ethical because the review is not part of designated work. This violates the ethical principal of acting with integrity and behaving in a trustworthy manner (AHIMA 2019; Rinehart-Thompson 2017c, 210). After consulting with a physician, a coding supervisor has issued an internal policy stating that all bedside debridement be coded as excisional. Is this an ethical practice for a coder to follow? Why or why not? a. Yes, physician guidance provided basis for the policy. b. Yes, coders must follow internal policies of the facilities where they are employed. c. No, coding supervisors cannot make internal policies without approval of administration. d. No, internal policies cannot conflict with requirements provided in coding guidelines, conventions, and so on. -Correct Answer: D Ethical Coding Guideline 1.2 states that internal policies may not conflict with the coding rules, conventions, guidelines, etc. of the coding classifications nor with any official coding advice (AHIMA House of Delegates 2016). It is unethical for a coder to query: a. Retrospectively b. When the response will impact reimbursement c. Based on information in a previous encounter d. Multiple times on the same patient record -Correct Answer: C AHIMA's Standards of Ethical Coding state in guideline 4.5 that information from previous encounters should not be used to generate a query (AHIMA House of Delegates 2016). A patient came in for surgery and developed a post-operative infection. The patient had multiple comorbid conditions, which provided several CC and MCC conditions that were captured in coding. However, the coder left off the post-op infection code knowing it would impact the physician's quality of care score. Is this acceptable, ethical practice? Why or why not? a. Yes; since it will not impact reimbursement, there is no issue. b. Yes; coders have discretion in which codes to assign on every case. c. No; the coding of the post-op infection would have impacted reimbursement. d. No; coders cannot intentionally omit codes in order to affect quality scores. -Correct Answer: D AHIMA's Standards of Ethical Coding state in guideline 5.4 that it is not appropriate to omit codes for diagnoses or procedures that could impact quality of care reporting (AHIMA House of Delegates 2016).

Which of the following is an ethical way to handle an internal coding policy that conflicts with coding guidelines? a. Report the concern through the organization's compliance hotline b. Talk with fellow coders to develop your own plan c. Ignore the internal policy and follow coding guidelines d. Wait six months to see if the policy gets changed and then report your concern - Correct Answer: A AHIMA's Standards of Ethical Coding state in guideline 5.2 that it is appropriate to alert the organization about the issue with one way being use of the organization's hotline (AHIMA House of Delegates 2016). In addition to credentialed coders, AHIMA's Standards of Ethical Coding apply to which groups below? a. Non-credentialed coders and students b. Students, and attorneys c. Attorneys and auditors d. Case managers, and non-credentialed coders -Correct Answer: A Non-credentialed coders and students are considered as under the umbrella of the term "coding professional" and, therefore, subject to AHIMA's Standards of Ethical Coding (AHIMA House of Delegates 2016). A diabetic patient was admitted for a treatment of a pressure ulcer. The patient also has a history of diabetic neuropathy and retinopathy. The patient is blind and additional nursing care and extended time with the patient was required. Which conditions should be coded at discharge? a. Pressure ulcer, history of neurologic condition, history of retinal condition, diabetes b. Pressure ulcer, diabetic neuropathy and diabetic retinopathy, and blindness c. Pressure ulcer, diabetic neuropathy d. Pressure ulcer, diabetic retinopathy, and blindness -Correct Answer: B Pressure ulcer, diabetic neuropathy and diabetic retinopathy, and blindness should be coded. Diabetes and related conditions are chronic conditions that ordinarily should be coded and the patient required nursing care because of her blindness (CMS 2020a, Section I.C.4.a., 36) A patient admitted with shoulder pain has an inpatient discharge with principal diagnosis of either peptic ulcer or cholecystitis documented on the history and physical. Both are equally treated and well documented. A coder should: a. Code based on the circumstances of admission and if both are equally treated, code either as principal b. Use a code from the abnormal findings category c. Code to the most severe symptom only d. Code shoulder pain followed by both peptic ulcer, cholecystitis -Correct Answer: A In those rare instances when two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of

the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first (CMS 2020a, Section II.D, 108). During an admission for congestive heart failure (CHF), a chest x-ray was done to evaluate the severity of the 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. -Correct Answer: B The hernia is an incidental finding. The condition does not meet the UHDDS criteria of an "other" condition (CMS 2020a, Section III, 110-112). 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 -Correct Answer: A The UHDDS item 11-b defines other diagnoses as "all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received or the length of stay" (CMS 2020a, Section III, 110-112) Which patient specific UHDDS items also have the potential to an impact on MS-DRG assignment? a. Race and residence b. Residence and sex c. Sex and discharge disposition d. Discharge disposition and race -Correct Answer: C The UHDDS data elements of sex and discharge disposition are also factors in determining some MS-DRGs (Schraffenberger and Palkie 2020, 92).