CCS PRACTICE EXAM 1 & 2 LATEST EXAM 2023-2024 ACTUAL EXAM 200+ QUESTIONS AND CORRECT, Exams of Nursing

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1. 45 - year-old patient admitted with Insulin dependent diabetes. The type of diabetes is not specified in the medical record. How should this be coded? a. E11.9, Z79. b. E11. c. E11.8, Z79. d. Z79.4, E11.8 - ANSWERS- a. E11.9, Z79. If the type of diabetes mellitus is not documented in the medical record the default is E11.-, Type 2 diabetes mellitus. Code Z79.4, Long term (current) use of insulin, should also be assigned for patients who take insulin (CMS 2018a, Section I.C.4.a.2, 34). The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates the cyst using palpation, and an incision is created. The cyst is then excised. What is the correct CPT code assignment for this service? a. 60200 b. 60210 c. 60280 d. 60281 - ANSWERS- d. 60281 CPT code 60281 is accessed using index entry Cyst, thyroglossal duct, excision resulting in code range 60280 - 60281. Code 60281 is correct for recurrent (AMA CPT Professional Edition 2018, 385). Most hospitals require a medical record is completed within: a. 5 days b. 10 days c. 7 days d. 30 days - ANSWERS- d. 30 days

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The Medicare Conditions of Participation and the Joint Commission require that the medical record is completed no later than 30 days following discharge of the patient (Brickner 2016, 84). A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would increase the MS-DRG weight? a. Respiratory failure b. Atrial fibrillation c. Hypertension d. History of myocardial infarction - ANSWERS- a. Respiratory failure MS-DRG 280 (weight = 01.6577) for myocardial infarction with respiratory failure would change the MS-DRG. MS-DRG 282 (weight = 00.75863) would be assigned for myocardial infarction alone, with atrial fibrillation, with hypertension, and with history of myocardial infarction (Medicare Grouper Version 35). According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy - ANSWERS- c. Colonoscopy A colonoscopy is an examination of the entire colon, from the rectum to the cecum that may include the terminal ileum. In general, a colonoscopy examines the colon to a level of 60 cm or higher (Smith 2018, 135- 136 ). According to the UHDDS, in order to assign a code for another diagnosis, documentation must be present that: a. The condition is recorded in the patient record by a dietary clerk b. The condition is present in the admission department data c. The condition was clinically evaluated or therapeutically treated, extended the length of hospital stay, or increased nursing care or monitoring

d. The condition is considered to be essential by the family - ANSWERS- c. The condition was clinically evaluated or therapeutically treated, extended the length of hospital stay, or increased nursing care or monitoring For reporting purposes the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care or monitoring (CMS 2018a, Section III, 105-106). To correct an entry in the medical record, the provider should: a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order b. Draw a double line through the error, initial and date, add the reason for the correction c. Draw a single line through the error, and add the correct information in chronological order d. Draw several lines through the error, obliterate the documentation as much as possible, initial and date, add the correct information in chronological order - ANSWERS- a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order If an error is corrected, the healthcare provider who made the error should draw a single line through the error, add a note explaining the error, initial and date it, and add the correct information in chronological order (Sayles 2016, 65). Further, AHIMA principles for health record documentation specify the prior statement as the proper method for correcting an error in the paper-based records in order to maintain a legally sound record. This process is based on the ASTM and HL7 standards for error correction (AHIMA e-HIM Work Group on Maintaining the Legal EHR, 2005). A patient was admitted to the emergency department with chest pain and was diagnosed with aborted myocardial infarction with acute myocardial ischemia. There was no prior cardiac surgery. The cardiac enzymes were normal. The appropriate coding of the diagnosis for this case is: a. I21.3, ST elevation (STEMI) myocardial infarction of unspecified site b. I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris

c. I24.8, Other forms of acute ischemic heart disease d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction - ANSWERS- d. I24.0, Acute coronary thrombosis not resulting in myocardial infarction Acute ischemic heart disease or acute myocardial ischemia in a patient does not always indicate an infarction. It is often possible to prevent infarction by means of surgery or the use of thrombolytic agents if the patient is treated promptly. Using the main term, ischemia, then the subterms of myocardium and acute, the alphabetic index reflects that I24.0 is the correct code for an acute myocardial ischemia without myocardial infarction (Leon-Chisen 2018, 391). After a patient is discharged from the hospital, the medical record must be reviewed for: a. Inclusion of all incident reports b. Certain basic reports (for example, history and physical, discharge summary, etc.) c. Voided prescription pads d. Personal case notes from all mental health providers - ANSWERS- b. Certain basic reports (for example, history and physical, discharge summary, etc.) In order to determine if a medical record is complete, it must be reviewed for certain basic reports including the presence of a history and physical, signed progress notes, and a discharge summary if applicable (Reynolds and Sharp 2016, 123 - 125). The incident report should never be filed in the medical record (Carter and Palmer 2016, 522); voided prescription pads are not used during a patient hospitalization; personal case notes from mental health providers are kept separate from the official record. While there are a number of documents required for the hospital medical record to be complete, the ones described in option b present the best answer (Rinehart-Thompson 2017c, 189) A 70 - year-old patient was admitted with pneumonia. The history and physical documented that the patient has a history of diabetes, hypertension, and migraine headache about 10 years ago without recurrence. The patient was administered IV antibiotics, metformin, and Altace during the hospitalization. Which conditions would be reported at the time of discharge? a. Pneumonia, diabetes, hypertension, and migraine headaches b. Pneumonia, diabetes, hypertension, and history of migraine headaches c. Pneumonia, diabetes, and hypertension

d. Pneumonia - ANSWERS- c. Pneumonia, diabetes, and hypertension Pneumonia, diabetes, hypertension should be coded. The migraine headaches are a past condition and would not be coded as per the reporting guidelines for the UHDDS for "other conditions" (CMS 2018a, Section III, 105-106). The outpatient code editor (OCE) has all of the following types of edits except: a. Claim accuracy b. Discharge date discrepancy c. Assigning APCs to the claim d. Age and sex edits - ANSWERS- b. Discharge date discrepancy The OCE has four basic functions: editing the data on the claims for accuracy, specifying the action the MAC should take when specific edits occur, assigning APCs to the claim (for hospital outpatient services), and determining payment-related conditions that require direct reference to HCPCS codes or modifiers. (Smith 2018, 299). During an ambulatory surgery visit for excision of a malignant melanoma of the right forearm, the attending surgeon listed history of benign breast cyst, history of hypertension currently on Tenormin, and a current hammer toe. Which conditions are to be coded? a. Malignant melanoma of forearm, hypertension b. Malignant melanoma of the right forearm, benign breast cyst, hypertension, and hammer toe c. Malignant melanoma of the right forearm, benign breast cyst, and hypertension d. Malignant melanoma of the right forearm, benign breast cyst - ANSWERS- a. Malignant melanoma of forearm, hypertension Assign codes for malignant melanoma of forearm, hypertension. Code chronic conditions if they affect the patient's treatment. The hypertension was being treated with a current medication and for this reason the hypertension is coded (CMS 2018a, Section IV.A.1. and Section IV.J., 108-109). A patient is readmitted two weeks after a laminectomy for spinal stenosis with a headache and documentation that the headache is due to a tear in the dura accidently that occurred during the

prior laminectomy surgery. The patient is taken to the operating room for repair of the dura. The diagnosis code(s) assigned for this admission would be: a. M48.061, Spinal stenosis, lumbar region, without neurogenic claudication b. G97.41, Accidental puncture or laceration of dura during a procedure c. G97.1, Other reaction to spinal and lumbar puncture d. S34.109A, Unspecified injury to unspecified level of lumbar spinal cord, initial encounter - ANSWERS- b. G97.41, Accidental puncture or laceration of dura during a procedure A tear in the dura that occurs during spinal surgery is not unusual and is typically repaired intraoperatively when identified. Primary closure of the dural tear is usually accomplished. Dural tears that are not discovered during surgery can result in leakage of cerebrospinal fluid (CSF), leading to CSF headache, caudal displacement of the brain, subdural hematoma, spinal meningitis, pseudomeningocele and/or a dural cutaneous fistula (CMS 2018a, Section I.B.16, 18). During an admission for congestive heart failure (CHF), a chest x-ray was done to evaluate for the presence of CHF. An asymptomatic hernia was also found for which no treatment or evaluation was done. What is the reason that the hernia should not be coded? a. The patient's primary condition of interest is the CHF. b. The hernia is an incidental finding and does not meet the UHDDS requirements. c. The patient is asymptomatic. d. The condition does not impact the reimbursement. - ANSWERS- b. The hernia is an incidental finding and does not meet the UHDDS requirements. The hernia is an incidental finding. The condition does not meet the UHDDS criteria of an "other" condition (CMS 2018a, Section III, 105-106). A patient is admitted to the hospital due to a fracture of the right hip and is scheduled for an open reduction with internal fixation. The patient developed cardiac arrhythmia which results in an inability to do the planned surgery. Assign a code for the principal diagnosis. a. Status post fracture b. Cardiac arrhythmia

c. Right hip fracture d. Admission for possible fracture - ANSWERS- c. Right hip fracture The condition after study that occasioned the admission should be sequenced first even if the plan of treatment was not carried out due to unforeseen circumstances (CMS 2018a, Section II.F., 103). The Joint Commission considers what kind of management to be important for safe, quality care? a. Resource management b. Recycling management c. Information management d. Incremental management - ANSWERS- c. Information management The goal of information management is to support decision-making (Sandefer 2016, 344). During an outpatient visit, the attending physician did not define a problem at the conclusion of an emergency department (ED) visit. The coder should: a. Assign a code from the list of conditions in the history that occurred in the past b. Assign a code for the reason for the last visit to the ED c. Assign codes for abnormal laboratory findings d. Assign a code for the chief complaint as the reason for the visit - ANSWERS- d. Assign a code for the chief complaint as the reason for the visit In the absence of a diagnosis or defined problem, the chief compliant should be coded as the reason for the visit (CMS 2018a, Section IV.G., 109). A 75-year-old woman is admitted to the hospital after tripping and falling at home. She underwent an open reduction with internal fixation of the femur. Which of the following would be important to capture in addition to diagnostic codes?

a. External cause codes for Cause of Injury and Place of Occurrence b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status c. External cause codes for Cause of Injury, Place of Occurrence, and Activity d. External cause codes for Cause of Injury only - ANSWERS- b. External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status External cause of injury codes are used to provide information about how an injury occurred, the intent (intentional or unintentional), where the injury occurred, and the status of the person at the time the injury occurred. In the case of a person who seeks care for an injury or other health condition that resulted from an activity, or when an activity contributed to the injury or health condition, activity codes are used to describe the activity (CMS 2018a, Section I.20., 81). A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct? a. The colposcopy and endometrial biopsy are represented by a combination code. b. Two codes would be used with modifier - 59 appended. c. Two codes would be used in accordance with CPT code instructions. d. Only one code is used and it does not state that it includes endometrial biopsy specifically.

• ANSWERS- c. Two codes would be used in accordance with CPT code instructions. The endometrial biopsy (58110) is an add-on code and there are specific directions in the CPT book to use this code in conjunction with the code for the colposcopy (CPT Assistant June 2006, 16-17). A 65-year-old man is admitted due to an acute myocardial infarction. The patient also has coronary artery disease. How should this be coded? a. CAD, AMI b. AMI c. AMI, CAD d. Query the physician for the principal diagnosis - ANSWERS- c. AMI, CAD

If a patient with coronary artery disease is admitted due to an acute myocardial infarction (AMI), the AMI should be sequenced before the coronary artery disease (CMS 2018a, Section I.C.9.b, 44). A virtual screening colonoscopy would be coded as: 45378 Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 45391 Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures 74263 Computed tomographic (CT) colonography, screening including image postprocessing 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; not requiring image postprocessing on an independent workstation - ANSWERS- 74263 Computed tomographic (CT) colonography, screening including image postprocessing CT colonography uses CT scanning to obtain an interior view of the colon (the large intestine) that is otherwise only seen with a more invasive procedure where an endoscope is inserted into the rectum. Computed tomographic (CT) colonography, screening, including image postprocessing (AMA CPT Professional Edition 2018, 458). A patient is prescribed Diazepam and reports taking more than the prescribed amount. The patient is admitted to the hospital for complete work up. The final diagnosis is documented as Diazepam use and abuse. How should this be coded? a. F13. b. F13. c. F13. d. F13.11 - ANSWERS- c. F13.

Diazepam is a sedative. When use and abuse are documented, assign only the code for abuse (CMS 2018a, Section I.C.5.b.2., 37). 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 - ANSWERS- a. Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay The quality of data is most directly tied to the: a. Conditions treated in surrounding healthcare settings b. Surgical case review committee c. Length of hospital stay d. Use or application of the data - ANSWERS- d. Use or application of the data The use or application of the data and the purpose for the collection of the data is key to understanding its quality (Johns 2016, 84-85; Amatayakul 2016a, 416-419). When coding "arthrocentesis," the code assignment is determined by: a. Contrast used b. Size of the joint c. Approach d. Description of the closure - ANSWERS- b. Size of the joint The size of the joint is a key determination because arthrocentesis codes are based on whether the joint is small, intermediate, or major (AMA CPT Professional Edition 2018, 111).

A 65 - year-old male patient is being assessed for possible colon cancer and treated in the special procedure unit of the hospital. He undergoes a colonoscopy into the ascending colon with biopsy of a suspicious area in the transverse colon using the cold biopsy forceps. In addition, a colonic ultrasound of the area is performed, with transmural biopsy of an area of the mesentery adjacent to the transverse colon. Assign the appropriate CPT codes. a. 45384, 45342 b. 45380, 45391 c. 45384, 45392 d. 45380, 45392 - ANSWERS- d. 45380, 45392 Use index entry Colonoscopy, flexible, biopsy to assign CPT 45380 and entry Colonoscopy, flexible, ultrasound for 45392. The CPT coding guidelines and descriptions of colonoscopy codes and the Colonoscopy Decision Tree should be referenced for correct coding of these procedures (AMA CPT Professional Edition 2018, 314-317). A child has second- and third-degree burns of the left lower leg and second- and third-degree burns of the lower back with a total of 16 percent total body surface area (TBSA), 9 percent third-degree. What is the correct code assignment? a. T24.301A, T21.34XA, T31. b. T24.302D, T21.34XD, T31. c. T24.302A, T21.34XA, T31. d. T24.301D, T21.34XD, T31.10 - ANSWERS- c. T24.302A, T21.34XA, T31. T24.302A, T21.34XA, T31.10, Burns classified to the same site but with different degrees are coded to the highest degree of burn (CMS 2018a, Section I.C.19.d.2, 75). An additional code for the extent of the body surface involved may also be assigned (CMS 2018a, Section I.C.19.d.6, 75). In CPT, unlisted codes are reported only if: a. There is not a current CPT category I code available b. There is not a current CPT category III code available c. There is not a current CPT category II code available d. There is not a HCPCS Level II code or a current CPT level III code - ANSWERS- d. There is not a HCPCS Level II code or a current CPT level III code

Before any unlisted code is assigned, the coding professional should review HCPCS Level II (national) codes to confirm that CMS has not developed a specific code for the procedure or service in question. CPT Category III codes, which are developed specifically for reporting new technology, should also be reviewed. CPT guidelines support the use of a Category III code instead of a Category I unlisted code (Smith 2018, 24) With regard to the implementation of ICD- 10 - CM, all of the following are correct except: a. ICD- 10 - CM was developed by NCHS b. ICD- 10 - CM and ICD- 10 - PCS was fully implemented on October 1, 2016 c. ICD- 10 is already being used in the United States for death certificate coding d. The process of adoption of ICD- 10 - CM is specified in HIPAA - ANSWERS- b. ICD- 10 - CM and ICD- 10 - PCS was fully implemented on October 1, 2016 Full compliance is expected for claims received for encounters and discharges occurring on or after 10/1/2015 (Leon-Chisen 2018, 6). A patient is admitted to the hospital during the postpartum period as a result of developing a thromboembolism or pulmonary blood clot leading to respiratory failure. What is the principal diagnosis? a. O88. b. J96.0 0 c. O88. d. O88.22 - ANSWERS- a. O88. The obstetric code is sequenced first because chapter 15 (obstetric) codes have sequencing priority over codes from other ICD- 10 - CM chapters (CMS 2018a, Section I.C.15.a.1, 56). A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? O80 Encounter for full-term uncomplicated delivery

O48.0 Post-term pregnancy O48.1 Prolonged pregnancy O66.5 Attempted application of vacuum extractor and forceps a. O48. b. O48. c. O d. O66.5 - ANSWERS- b. O48. 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 because the pregnancy is prolonged (CMS 2018a, Section I.C.15.b., 59). If a patient has undergone an outpatient echocardiogram and the cardiologist concludes in the report that the patient has mitral regurgitation, the coder should: a. Assign a diagnostic code for mitral regurgitation b. Query the physician about the diagnosis c. Code an abnormal finding of the echocardiogram d. No code can be assigned - ANSWERS- a. Assign a diagnostic code for mitral regurgitation Assign a diagnostic code for mitral regurgitation. If the diagnostic test has been interpreted by a physician the coder can assign a diagnosis (CMS 2018a, Section IV.K., 110). Documentation in the record reveals that a patient is admitted with an acute exacerbation of COPD (MS-DRG 192). A higher-paying 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 was treated with nitroglycerin prn for chest pain b. Atrial fibrillation and underwent a cardioversion while hospitalized c. Blood gases of pO2 of 58, pCO2 of 55, pH of 7.32 upon admission and treated with intubation and mechanical ventilation for 23 hours

d. Anemia and was given a blood transfusion - ANSWERS- c. Blood gases of pO2 of 58, pCO2 of 55, pH of 7.32 upon admission and treated with intubation and mechanical ventilation for 23 hours The acute exacerbation of COPD with blood gas values of pO2 of 58, pCO2 of 55, pH of 7. reflects possible respiratory failure. The patient was treated with intubation and mechanical ventilation for 23 hours. 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 2018, 229-231). Which of the following is not part of a facility coding compliance plan? a. Regular internal audits b. Audits performed by objective external reviewers c. Coding audits performed by payers d. Sharing and discussing results with coding staff - ANSWERS- c. Coding audits performed by payers Reviewing the results of payers' audits is valuable, but payers are an external entity. As far as a facility coding compliance plan, incorporating internal and external auditing into the coding compliance plan has proven to be the best strategy. Internal auditing enables managers to see firsthand where their units' strengths and weaknesses lie. External auditing provides an unbiased view of a department's performance. Together, internal and external audits help coding managers build effective education plans for their units (Casto and Forrestal 2015, 44- 45). A 75 - year-old female was admitted for acute myocardial infarction and underwent a diagnostic cardiac catheterization. Following the catheterization, the patient developed a thrombophlebitis documented as due to the catheter in the common femoral artery. The thrombophlebitis would be coded as: a. T81.718A, Complication of other artery following a procedure, not elsewhere classified, initial encounter b. I97.51, Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure c. I72.4, Aneurysm of artery of lower extremity

d. I97.52, Accidental puncture and laceration of a circulatory system organ or structure during other procedure - ANSWERS- a. T81.718A, Complication of other artery following a procedure, not elsewhere classified, initial encounter Thrombophlebitis occurred in the artery where the catheterization was performed and the cause of the thrombophlebitis is documented as due to the catheterization. Thrombophlebitis resulting from a procedure is listed as T81.72. When the tabular is reviewed, this code relates to a vein. The exercise states that the artery is the location of the thrombophlebitis. Therefore a code from the T81.718 category is used (CMS 2018a, Section I.B.16, 18). If a patient is admitted with pneumococcal pneumonia and severe pneumococcal sepsis, the coder should: a. Assign a code for only the sepsis and pneumonia b. Assign a code for the sepsis, pneumonia, and severe sepsis c. Assign only a code for pneumococcal pneumonia d. Review the chart to determine if septic shock could be used first - ANSWERS- b. Assign a code for the sepsis, pneumonia, and severe sepsis A patient with pneumococcal sepsis and pneumococcal pneumonia also has severe sepsis. Careful review of the ICD- 10 - CM Official Guidelines for Coding and Reporting provides information related to the coding and sequencing of sepsis, severe sepsis, and localized infection, such as pneumonia (CMS 2018a, Section I.C.1.d., 21). 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 - ANSWERS- a. Query the attending physician regarding the x-ray finding 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 2018a, Section III, 105-106). When an inpatient has had multiple tests to evaluate an abnormal finding but no definitive diagnosis has been documented, the coder should: a. Assign a code for the abnormal finding without confirming with the physician b. Assign codes for all of the abnormal results of the tests c. Assign a diagnosis code based on the coder's judgment d. Query the physician regarding whether a diagnosis should be assigned or not - ANSWERS- d. Query the physician regarding whether a diagnosis should be assigned or not Query the physician regarding whether a diagnosis should be assigned or not. It is not within the coder's scope of practice to diagnose a condition (CMS 2018a, Section III, 105-106). 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 - ANSWERS- d. Query the attending physician as to the final diagnosis 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 2018a, Section III, 105-106). A patient is admitted to undergo a laparoscopic cholecystectomy. Following the insertion of the laparoscope into the abdominal cavity, the patient experienced a cardiac arrhythmia and the procedure was terminated. The patient experienced a potentially compensable event resulting in an incident report. Which department may request to see the patient's record? a. Pediatrics b. Risk Management

c. Surgical Supply d. Dietary Services - ANSWERS- b. Risk Management The role of the risk manager is to collect and analyze information on actual losses and potential risks and to design systems that lessen potential losses in the future. An incident report is a structured tool used to collect data and information about any event not consistent with routine operational procedures (Carter and Palmer 2016, 522- 5 26). A nurse inadvertently recorded an incorrect vital sign in a patient electronic health record. The next day, a correction was made in the electronic health record. This resulted in the corrected vital sign being recorded at the time the correction was made due to the software. What would be the result of this correction? a. The vital signs would be listed in the correct sequence. b. When a correction is made in an electronic health record, the incorrect data is deleted. c. The quality of patient care would not be affected. d. There was a distorted trend line of vital signs data. - ANSWERS- d. There was a distorted trend line of vital signs data. In the paper chart, a line can be drawn through an erroneous entry, initialed, and the correction made along the margin. In an electronic record, the correction may be placed in the wrong sequence, which may adversely impact patient care (Sayles 2016, 70). 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 - ANSWERS- d. Placenta previa with hemorrhage 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 2018a, Section I.C.15.b., 58). The "code, if applicable, any causal condition first" note in the ICD- 10 - CM tabular lists indicates that this code may be assigned when the causal condition is unknown or not applicable. When the causal condition is known, the code for that condition may be reported as which type of diagnosis? a. Comorbidity b. Manifestation c. Principal d. Qualified - ANSWERS- c. Principal "Code, if applicable, any causal condition first" notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis (CMS 2018a, Section I.B.7, 15). 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, admission for chemotherapy c. Metastatic carcinoma of the brain, history of carcinoma of the prostate d. Carcinoma of the prostate, metastatic carcinoma to the brain - ANSWERS- c. Metastatic carcinoma of the brain, history of carcinoma of the prostate 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) (CMS 2018a, Section I.C.2.b., 28 and I.C.2.m., 33). Assign the code(s) for mammographic guidance for bilateral breast needle localization for a lesion placement with biopsy.

10022 Fine needle aspiration, with imaging guidance 19081 Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet) when performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion including stereotactic guidance 19082 Biopsy, breast with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure.) a. 19082 b. 10022 c. 19081, 19082 d. 19081 - ANSWERS- c. 19081, 19082 The localization and aspiration require two codes to identify placement of the localization device, 19081 for the first lesion and 19082 for the second lesion in the other breast (Smith 2018, 88-89; AMA CPT Professional Edition 2018, 99). A patient is admitted with spotting and fever. She is found to have been treated for a miscarriage (spontaneous abortion), which was resolved two weeks prior to this admission. She is treated with aspiration dilation and curettage and products of conception are found. She is found to be septic. Which of the following diagnoses should be principal diagnosis? a. Complications following abortion and ectopic or other pregnancy b. Complications of spontaneous abortion with sepsis c. Sepsis d. Sepsis following incomplete spontaneous abortion - ANSWERS- d. Sepsis following incomplete spontaneous abortion This patient was previously treated for the spontaneous abortion but the presence of the products of conception denotes that the abortion was not completed during the prior episode of care. Because of this and the fact that she now has sepsis, this is coded as sepsis following an incomplete spontaneous abortion (CMS 2018a, Section I.C.15.j., 61; CMS 2018a, Section I.C.15.q., 64). During a coronary artery bypass surgery, the patient underwent saphenous bypass grafts; from the aorta to the left anterior descending branch of the left main coronary artery, and the left

posterior descending of the left main coronary artery. The patient also underwent a repositioning of the mammary artery to the right coronary artery. Choose the best description for this procedure. a. Three aortocoronary grafts b. Two aortocoronary grafts and one mammary-coronary graft c. Two aortocoronary grafts and two saphenous bypass grafts d. Three aortocoronary grafts and one mammary-coronary graft - ANSWERS- b. Two aortocoronary grafts and one mammary-coronary graft It is rare for only one coronary artery to be bypassed, and it is also fairly common to perform both an internal mammary-coronary artery bypass and an aortocoronary bypass at the same operative episode (Schraffenberger and Palkie 2018, 324-326). Coding professionals need to have surgical references in order to discriminate between: a. Correct and incorrect documentation based on Joint Commission requirements b. Reportable and nonreportable procedures c. Chemotherapeutic drugs d. A comorbid condition and a complication that prolongs the length of stay - ANSWERS- b. Reportable and nonreportable procedures Surgical procedure names can be similar and it is important to have reference books in which to look up procedures in order to determine reportable and nonreportable procedures (Smith 2018, 37). The most succinct definition of where information comes from is: a. Shredded documents b. Common blips of data c. Processed data d. Measurement of extremities - ANSWERS- c. Processed data Unprocessed data are not useful for decision-making and for this reason processing data creates information that is useful (Johns 2016, 78).

A patient underwent an excision of a malignant lesion of the chest that measured 1.0 cm and there was a 0.2-cm margin on both sides. Based on the 2018 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; excised diameter 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; excised diameter 1.1 to 2.0 cm - ANSWERS- c. 11602, Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm 11602: Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm. 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 (Smith 2018, 69-70). A patient is admitted with hypotension due to dobutamine taken and prescribed correctly. How should this be coded? a. I95.1, Orthostatic hypotension T44.5X5A, Adverse effect of predominantly beta- adrenoreceptor agonists, initial encounter b. I95.2, Hypotension due to drugs T44.5X5A, Adverse effect of predominantly beta- adrenoreceptor agonists, initial encounter c. I95.89, Other hypotension T44.995A, Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter d. I95.81, Postprocedural hypotension T44.995A, Adverse effect of predominantly beta- adrenoreceptor agonists, initial encounter - ANSWERS- b. I95.2, Hypotension due to drugs T44.5X5A, Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter This is an adverse effect of a drug as the dobutamine was prescribed correctly and the patient took it correctly. Hypotension, should be assigned to describe the condition related to the adverse effect. A "T" code should be assigned to indicate that it is an adverse effect of the drug (CMS 2018a, Section I.C.19.e., 76).

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 - ANSWERS- b. Congestive heart failure When a patient has pulmonary edema that is due to congestive heart failure, only the congestive heart failure should be coded (Leon-Chisen 2018, 394-395). 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 - ANSWERS- b. Pressure ulcer, diabetic neuropathy and diabetic retinopathy, and blindness 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 2018a, Section I.C.4.a., 34). A patient 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

d. Code shoulder pain, peptic ulcer, cholecystitis - ANSWERS- a. Code based on the circumstances of admission and if both are equally treated, code either as principal 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 2018a, Section II.D, 103). 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 c. Blood loss anemia d. Coronary artery disease - ANSWERS- b. Stage III pressure ulcer MS-DRG 291 (weight = 01.4759) for congestive heart failure with stage III pressure ulcer would optimize the MS-DRG. MS-DRG 293 (weight = 00.6736) is assigned for congestive heart failure alone, with atrial fibrillation, with blood loss anemia, and with coronary artery disease all remain the same (Medicare Grouper Version 35). 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 - ANSWERS- d. Requiring new HCPCS codes be developed to replace codes in the CPT code book 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 2018, 369- 3 72). CCS PRACTISE EXAM 2 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 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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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. - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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 - ANSWERS-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. - ANSWERS-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 - ANSWERS-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 - ANSWERS-c. Timeliness and legibility of medical documents