CCS-P Exam Questions and Answers: Medical Terminology, Exams of Advanced Education

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Characterisitics of an uncomplicated delivery - Correct Answer-Delivery requiring minimal or no assistance, with or without episiotomy, without fetal manipulation [e.g., rotation version] or instrumentation [forceps] of a spontaneous, cephalic, vaginal, full- term, single, live-born infant. This code is for use as a single diagnosis code and is not to be used with any other code from chapter 15 Creutzfeldt-Jakob disease - Correct Answer-rapidly progressive, invariably fatal neurodegenerative disorder believed to be caused by an abnormal isoform of a cellular glycoprotein known as the prion protein. What is commonly used to treat hypothyroidism - Correct Answer-Levothyroxine (synthroid) Klebsiella - Correct Answer-Non-modal, gram negative, oxidase negative bacteria What is needed to assign a preventative medicine code - Correct Answer-Patient Age What do you code if the type of diabetes is not documented - Correct Answer-Type two type 1 diabetes mellitus - Correct Answer-Insulin dependent, children type 2 diabetes mellitus - Correct Answer-diabetes in which either the body produces insufficient insulin or insulin resistance (a defective use of the insulin that is produced) occurs; the patient usually is not dependent on insulin for survival Can an outcome of delivery code stand alone - Correct Answer-No, it is not a principal diagnosis, only things that can be prinicipal diagnosis can stand alone. What is the order of diagnosis and procedure codes - Correct Answer-Diagnosis codes first, procedure codes second. What is a missed abortion - Correct Answer-Happens Prior to the completion of 20 weeks gestation with retention in the uterus How do you code sequella - Correct Answer-Code the residual condition and then the cause of the sequella (origninal condition) How do you code if dominant is not specified for upper limb for hemiplegia and hemiparesis? - Correct Answer-Left is non dominant right is dominant.

Conchal Bowl - Correct Answer-Part of the auricular cartilage commonly used as an autologous graft Resection - Correct Answer-Process of cutting out tissue or part of an organ Carcinoma - Correct Answer-a cancer arising in the epithelial tissue of the skin or of the lining of the internal organs. Decubitus Ulcer - Correct Answer-Bed Sore MRSA colonization - Correct Answer-The patient currently has MRSA Benign Prostatic Hypertrophy - Correct Answer-A benign (not cancer) condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine. Also called benign prostatic hyperplasia and BPH. Mechanical Complications - Correct Answer-Breakdowns, displacement, leakage Non- Mechanical Complications - Correct Answer-infection or inflammatory reactions How long is the acute care time period following a myocardial Infarction? - Correct Answer-4 weeks following the first episode of care status migrainosus - Correct Answer-migraine attack that persists for > 72 hours and often leads to hospitalization Detoxification - Correct Answer-Active management of withdrawal symptoms for a patient who is dependent on alcohol or drugs. Personal History - Correct Answer-The condition no longer exists and the patient is not receiving treatment When is a Tracheostomy considered planned - Correct Answer-When a patient is on long term ventiliation Morselized Bone - Correct Answer-Bone that has been crushed to confirm to the area receiving the graft Osteomyelitis - Correct Answer-infection of the bone Sequestrectomy - Correct Answer-the removal of dead spicules or portions, especially of bone Excise - Correct Answer-To cut out of; remove Craterization - Correct Answer-Drill holes to remove masses

saucerization - Correct Answer-Surgical excavation of tissue to form a shallow depression to facilitate drainage from infected areas of a wound. Diaphysectomy - Correct Answer-Removal of part of the shaft of a long bone Currette - Correct Answer-surgical instrument designed for scraping or deriding biological tissue or debris Keratotic lesions - Correct Answer-Premalignant Lesions Aortopulmonary Septal Defect (fenestration) (Hole) - Correct Answer-Abnormal connection between ascending aorta and main pulm artery above the semiulnar valves CT colonography (virtual colonoscopy) - Correct Answer-use of CT scanning or MRI to obtain an interior view of the colon, less invasive provision - Correct Answer-the action of providing or supplying something for use New Patient - Correct Answer-A patient who has not seen the physician or a physician of the same specialty or subspecialty within the same practice group for three or more years. Are consultation codes an option for medicare - Correct Answer-No How do you round when coding drug dosage - Correct Answer-Round up Modifier -50 is assigned when - Correct Answer-There is a bilateral procedure Gastroschisis - Correct Answer-birth defect of the abdominal (belly) wall. The baby's intestines are found outside of the baby's body, exiting through a hole beside the belly button. The hole can be small or large and sometimes other organs, such as the stomach and liver, can also be found outside of the baby's body. Ompholocele - Correct Answer-Birth defect where there is a thin layer of skin only outside the babies intestines salpingectomy - Correct Answer-removal of the fallopian tube(s) oophorectomy - Correct Answer-removal of ovaries Fistula - Correct Answer-abnormal passageway between two organs or between an internal organ and the body surface What are the great vessels - Correct Answer-the superior and inferior vena cava, the pulmonary artery, the pulmonary vein, and the aorta.

Ectopic - Correct Answer-Out of place What is the labia majora? - Correct Answer-Large outer folds of the vulva What are womans external genital organs (vulva) - Correct Answer-Mons pubis, labia majora, labia manora, bartholin glands and clitoris Where is the cephalic vein located? - Correct Answer-on the cranial surface of the forearm Brachiocephalic - Correct Answer-relating to both arm and head anastomosis - Correct Answer-surgical joining of two ducts, vessels, or bowel segments to allow flow from one to another Should you report an office visit code if the patient is admitted to the hospital - Correct Answer-No What do the subcategories of preventive medicine distinguish - Correct Answer-New and established patients, age ranges What modifier do you use if the provider decides the patient needs surgery - Correct Answer- What percent of the allowed fee to PAR physicians receive - Correct Answer-80% What percent of the allowed fee do non par not accepting assignment physicians receive from medicare - Correct Answer- When surgery is cancelled what is the principal diagnosis - Correct Answer-It stays as the reason for admission What is Medicare's limiting charge rule - Correct Answer-A non-par physician can only charge 95% of the PAR amount x 115% Diagnosis distribution Report - Correct Answer-All ICD-10 CM codes used during the previous year What are the characteristics of data quality - Correct Answer-Accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, integrity, precision, relevancy and timelines. What is modifier AI - Correct Answer-Means that the physician is the main physician of record

Deficit Reduction Act of 2005 - Correct Answer-Made compliance programs mandatory Coding policies should include the following: - Correct Answer-AHIMA code of Ethics, AHIMA standards of ethical coding, official coding guidelines, federal and state law, internal policy bone marrow aspiration - Correct Answer-needle aspiration of bone marrow tissue for pathologic examination only marrow bone marrow biopsy - Correct Answer-Removes the bone and the marrow For psychotherapy codes, what time should you chose? - Correct Answer-The one closest to the time documented Orchiectomy - Correct Answer-surgical removal of one or both testicles If the pathology report provides a more specific diagnosis what should you do? - Correct Answer-Use that diagnosis What can Protonix treat - Correct Answer-Esophagitis Pappila - Correct Answer-Small rounded protuberance on the body or an organ Adenocarcinoma - Correct Answer-A malignant tumor formed from glandular structures in the epithelial tissue serous papillary adenocarcinoma - Correct Answer-Ovary epithelial tissue - Correct Answer-Tissue that covers outside of the body and lines organs and cavities. Longitudinal Health Record - Correct Answer-A record compiled about a patient for various encounters across various health systems A discharge summary must be completed in how many days unless facility policy says otherwise - Correct Answer- Candidiasis - Correct Answer-Fungal infections caused by yeast Spontaneous abortion - Correct Answer-miscarriage missed abortion - Correct Answer-death of a fetus or embryo within the uterus that is not naturally expelled after death How long after birth is the newborn period - Correct Answer-28 days

Over how many weeks gestation is considered a prolonged pregnancy - Correct Answer- ventricular septal defect - Correct Answer-abnormal communication or opening in the ventricular septum that allows blood to flow from the left to right ventricle abnormally Amniocentesis - Correct Answer-Sample of amniotic fluid using a hollow needle inserted into the uterus to test for development abnormalities in a fetus Is asthma considered a type of COPD? - Correct Answer-No, unless it is said to be obstructed What makes a pressure ulcer stage 3 - Correct Answer-full thickness skin loss involving damage or necrosis into subcutaneous soft tissue Carcinoma in Situ - Correct Answer-cancer in the early stage before invading surrounding tissue Dysplasia - Correct Answer-Abnormal cells, sometimes coming before cancer aplastic anemia - Correct Answer-Failure of bone marrow to produce enough red blood cells sickle cell anemia - Correct Answer-hereditary disorder of abnormal hemoglobin producing sickle-shaped erythrocytes and hemolysis Paroxysmal Supraventricular Tachycardia (PSVT) - Correct Answer-Episode of rapid heart rate that start in the part above the ventricles. associated with congenital accessory atrial conduciton pathway, stress, hypoxia, hypokalemia, caffeine or marijuana use, stimulant use, digitalis toxicity Atrial Flutter - Correct Answer-irregular beating of the atria; often described as "a-flutter with 2 to 1 block or 3 to 1 block" Sick Sinus Sydrome - Correct Answer-Heart rhythm disorder that says the pacemaker is not working properly Wolf-Parkinson-White Syndrome - Correct Answer-Extra electrical conductor in heart, causing rapid heart rate common in infants and children Impacted Fracture - Correct Answer-broken bone ends are forced into each other greenstick fracture - Correct Answer-bending and incomplete break of a bone; most often seen in children Pathologic Fracture - Correct Answer-fracture caused by diseased or weakened bone

transverse fracture - Correct Answer-complete fracture that is straight across the bone at right angles to the long axis of the bone Asthma exacerbation - Correct Answer-Acute or subacute episode of progressive worsening of asthma Non Healing burns are also known as - Correct Answer-Acute Burns Papillary serous carcinoma - Correct Answer-Uncommon form of endometrial cancer often found in post menopausal woman When can you code an evaluation and management based on time - Correct Answer- When counseling and coordination are more than 50% of the visit Dual Chamber Pacemaker - Correct Answer-Pacemaker that stimulates the atrium and ventricle; dual-chamber pacing is also called physiologic pacing Modifier 32 - Correct Answer-Used to indicate that the service provided was required by a third party payer, governmental, legislative, or regulatory body Modifier 54 - Correct Answer-surgical care only, When one physician performs the procedure and one provides preop/post op care only What procedure do you perform for a depressed skull fracture? - Correct Answer- Elevation of depressed skull fracture What is a cranioplasty? - Correct Answer-surgical repair of the skull after surgery or injury to the skull What codes should you use to describe admission and discharge on the same date? - Correct Answer-Observation or Inpatient care trabeculotomy - Correct Answer-incision of the orbital network of the eye to promote intraocular circulation and decrease IOP trabeculoplasty - Correct Answer-Removes eye pressure Sclera - Correct Answer-white of the eye trabeculectomy - Correct Answer-surgical creation of a drain to reduce intraocular pressure Transforaminal approach - Correct Answer-Passing between muscle panes Hallux Rigidus - Correct Answer-arthritis of the metatarsalphalangeal joint

Cheilectomy - Correct Answer-Remove extra bone from joint of big toe resection - Correct Answer-removal of part or all of a structure, organ, or tissue Shunt - Correct Answer-a hole or a small passage which moves, or allows movement of, fluid from one part of the body to another When should you use the surgical preparation codes? - Correct Answer-Skin sub, graft, flap or negative pressure wound therapy bronchus - Correct Answer-major air passages of the lungs that diverge from the windpipe Ligament - Correct Answer-Connects bone to bone Ipsilateral - Correct Answer-same side Neurrorrhaphy - Correct Answer-Surgical suturing of a divided nerve ondandetron - Correct Answer-Can prevent nausea and vomiting status asthmaticus - Correct Answer-Acute asthmatic attack that does not respond to normal medication Asthma with Acute Exacerbation - Correct Answer-Decreases from baseline Linking - Correct Answer-Informs the payor of the diagnosis associated with the procedure on a claim Stark legislation - Correct Answer-Limits referrals to places the provider has a financial interest in What criteria must be met to code 99490 - Correct Answer-1. Patient must have at least 2 chronic conditions that are expected to last for 12 months or until the death of the patient

2. The chronic conditions must put the patient at risk for death or serious decline
3. comprehensive care plan established. implemented, revised, monitored
4. this code is used for 20 minutes Laminectomy - Correct Answer-Remove the lamina or the back part of the vertebra Minimum Necessary Rule - Correct Answer-A rule that covered entities may disclose only the amount of protected health information absolutely necessary to carry out a particular function

Which bodies provide guidlines for ICD-10 CM coding? Who has to approve? - Correct Answer-1. CMS and National Center for Health Statistics

2. AHIMA, American Hospital Association Abuse - Correct Answer-Billing practices that are inconsistent with acceptable fiscal policies. (Inadvertent) intracapsular cataract extraction (ICCE) - Correct Answer-Removal of lens and surrounding lens capsule keratometry - Correct Answer-measurement of the cornea Vitrectomy - Correct Answer-surgical removal of all or part of the vitreous humor Tendon - Correct Answer-Attaches muscle to bone Ligament - Correct Answer-attaches bone to bone