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CCS PREP EXAM Section 1
Conventions, General coding guidelines
and chapt spec guidelines Questions &
Answers
How are changes made to ICD-10-PCS? A. Changes are made by 3M. B. Changes are made by the American College of Surgeons. C. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS. D. Changes are made by the World Health Organization. - ANSWERSC. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS. How is a bilateral condition coded if no bilateral code is provided? - ANSWERSIf no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. When a patient has a bilateral condition and each side is treated during separate encounters, how is it coded when one side is treated first and the second side is treated on a separate encounter? - ANSWERSWhen a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters).
The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. Which of the following organizations developed ICD-10-PCS? A. World Health Organization B. AHIMA C. 3M under contract to the Centers for Medicare & Medicaid Services D. National Center for Health Statistics - ANSWERS3M under contract to the Centers for Medicare & Medicaid Services What does the second character represent in the ICD-10-PCS code structure in the Medical and Surgical Section? A. Section B. Body system C. Root operation D. Body part - ANSWERSBody system Which of the following statements is NOT one of the conditions that must be met in order for multiple procedures performed during the same operative episode to be coded separately? A. The same root operation is performed on different body parts as defined by distinct values of the body part character. B. The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value. C. Multiple root operations with the same objectives are performed on the same body part. D. The intended root operation is attempted using one approach but is converted to a different approach. - ANSWERSA. Multiple root operations with the same objectives are performed on the same body part.
- If a procedure is attempted by a surgeon but is not successful, what should the coding professional do? A. Not code the procedure. B. Code to the root operation performed and if no root operation performed code to inspection. C. Query the surgeon for instructions D. Code the procedure attempted with a qualifier for "attempted." - ANSWERSCode to the root operation performed and if no root operation performed code to inspection. Which of the following root operations is an example of a root operation "to take out some or all of a body part"?
External cause codes should never be used as a principal or first listed diagnosis. True or false - ANSWERSTRUE Which of the following types of Z codes are used when the initial treatment of a disease has been completed, but the patient requires continued care during the healing or recovery phase? Admission for follow-up examination Admission or encounter for aftercare management Admission for observation and evaluation Screening examinations - ANSWERSAdmission or encounter for aftercare management The aftercare Z codes should be used to report aftercare for injuries. True or False. - ANSWERSFalse. A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. Colonoscopy was normal. Assign the appropriate code(s) and sequence according to coding guidelines. - ANSWERSZ12.11, Encounter for screening for malignant neoplasm of colon Z80.0, Family history of malignant neoplasm of digestive organs 0DJD8ZZ Inspection of lower intestinal tract, via natural or artificial opening endoscopic A patient had carcinoma of the descending colon, which was resected one year prior to this outpatient encounter. Patient is now seen for colonoscopy to evaluate anastomosis and remaining colon. Colonoscopy showed a normal anastomosis and no evidence of cancer recurrence. Assign the appropriate diagnosis and procedure code(s) and sequence according to coding guidelines. - ANSWERSZ08, Encounter for follow-up examination after completed treatment for malignant neoplasm Z85.038, Personal history of other malignant neoplasm of large intestine Z90.49, Acquired absence of other specified parts of digestive tract Procedure code: 0DJD8ZZ, Inspection of lower intestinal tract, via natural or artificial opening endoscopic Source: Coding Clinic for ICD-9-CM, First Quarter 1995, p. 4. A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter? - ANSWERSZ13.820, Encounter for screening for osteoporosis Z78.0, Asymptomatic menopausal state A woman with no symptoms is referred to the hospital outpatient x-ray department for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. How should this
encounter be coded? - ANSWERSZ12.31, Encounter for screening mammogram for malignant neoplasm of breast Z80.3, Family history of malignant neoplasm of breast Source: Coding Clinic for ICD-9-CM, Second Quarter 2003, p. 4. Which of the following statements refers to "abnormal findings" for codes describing health examinations with abnormal findings? Condition/diagnosis that is newly found Change in severity of a chronic condition, during a routine physical exam None of the above A and B - ANSWERSA and B A patient is being seen for aftercare treatment of fracture of left radius. How should this encounter be coded? Z51. T14.90XD S52.92XD S52.92XA - ANSWERSS52.92XD Codes from chapter 18 are assigned as secondary codes under which of the following circumstances? A.When the symptom or sign is not integral to the underlying condition B.When it affects payment C.When desired D.Never - ANSWERSWhen the symptom or sign is not integral to the underlying condition If the coder notes clinical findings outside the normal range but no related diagnosis is stated, what should the coder do? A. Review the conditions possibly responsible for the abnormal findings and select a code for one of those conditions. B. Code the abnormal finding. C. Review the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned. D. Review the medical record and code the abnormal finding as a "possible, probable" diagnosis. - ANSWERSReview the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned.
I35.0, Aortic stenosis I25.10, CAD I25.2 Old MI Z95.1, Presence of aortocoronary bypass graft Comments: Assign code R10.13 as the first-listed diagnosis, since the physician determined that epigastric pain was the reason for the encounter and the Index leads to this code assignment. Even though the patient has a history of gastroesophageal reflux, the physician would need to document that the pain was due to the gastroesophageal reflux in order to assign it as the first-listed diagnosis. Source: Coding Clinic for ICD-9-CM, First Quarter 2002, p. 5. the patient is an 81-year-old female who presented to the emergency department in a coma after having suffered a large intraventricular hemorrhage due to hypertension. How should this be coded? - ANSWERSI61.5 Nontraumatic intracerebral hemorrhage, intraventricular R40.20, Unspecified coma I10, Essential (primary) hypertension Comments: Assign code I61.5 as the principal diagnosis. Codes R40.20 and I10 should be assigned as additional diagnoses. Coma is not inherent to intracerebral hemorrhage. It is appropriate to assign an additional code for the coma. Assigning codes for both the intraventricular hemorrhage and coma will allow information regarding the severity of the patient's condition to be captured. Source: Coding Clinic for ICD-9-CM, First Quarter 2012, p. 14. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, p.
When the reason for admission is both sepsis (or severe sepsis) and a localized infection (e.g., pneumonia or cellulitis), which condition should be assigned as the principal or first-listed diagnosis? A.Sepsis or severe sepsis B.Localized infection C.Either sepsis or the localized infection; it doesn't matter. D. It depends on the circumstances of admission. - ANSWERSSepsis or severe sepsis What does the term "severe sepsis" usually refer to? A.A bad case of sepsis B.Sepsis with associated acute or multiple organ dysfunction C. Systemic inflammatory response syndrome with infection D. Sepsis with fever - ANSWERSC. Systemic inflammatory response syndrome with infection
A 42-year-old patient with documented history of HIV disease is currently managed on antiretroviral medications. Assign the appropriate codes. - ANSWERSB20, Human immunodeficiency virus (HIV) disease Z79.899, Other long term (current) drug therapy Reference: Chapter 1a2i of the Official Coding Rules & Guidelines and Coding Clinic 1st Quarter, 2022 state diagnosis code B20 is appropriate for patients with documented HIV disease on antivirals. Coding Clinic 4th Quarter, 2020, pages 97-98 clarified HIV disease is specifically classified to code B20. It would not be appropriate to report B without provider documentation of either HIV related illness, HIV disease or AIDS. A nursing home resident who sustained a hypoxic brain injury 8 years ago was hospitalized with increasing respiratory failure and fever due to bilateral pneumonia and severe sepsis. The patient has recurrent seizures due to the old intracranial injury, with loss of consciousness from an accidental fall. Final diagnoses: (1) Severe sepsis, (2) bilateral pneumonia, (3) acute respiratory failure, (4) recurrent seizures due to old intracranial injury Assign the appropriate codes. - ANSWERSA41.9, Sepsis, unspecified organism R65.20, Severe sepsis without septic shock J18.9, Pneumonia, unspecified J96.00, Acute respiratory failure, unspecified whether with hypoxia or hypercapnia G40.909, Epilepsy, unspecified, not intractable, without status epilepticus S06.9.x9S, Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela W19.xxxS, Unspecified fall, sequela Comments: (1) The underlying systemic infection is sequenced as principal diagnosis. Since the causal organism is not documented, code A41.9 is assigned, followed by the code for severe sepsis, which is followed by the code for pneumonia, the localized infection. (2) Assign an additional code for respiratory failure, the associated acute organ dysfunction. (3) The code for recurrent seizures, the residual condition of the brain injury, is also reported. (4) The cause of the residual condition, the brain injury, is sequenced after the code for the late effect (residual condition). (5) The external cause of injury code, with the seventh character for sequela, is also assigned. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2014 Revised Edition, pp. 150-152. A 59-year-old female type I diabetic patient presented with a history of fatigue, loss of appetite, and abdominal pain. Hepatomegaly was present on abdominal ultrasound.
B. It should not be coded as confirmed; this condition is an exception to the general guideline for "possible," "probable" conditions. C. It should always be coded as the principal diagnosis. D. It depends on the circumstances of admission. - ANSWERSB. It should not be coded as confirmed; this condition is an exception to the general guideline for "possible," "probable" conditions. How should an encounter of a patient with fever and cough with a positive COVID- 19 test without provider confirmation of the significance of the test result be coded? A. Assign code U07.1, COVID- B. Assign only codes for the symptoms (fever, cough) since the provider has not linked the test result to the symptoms. C. Assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases since the provider has not linked the symptoms nor the test results to COVID-19. D. None of the above, a physician query is necessary before determining the correct code. - ANSWERSA. Assign code U07.1, COVID-
- How should an encounter of an asymptomatic patient tested to confirm a current COVID-19 infection during a COVID-19 pandemic be coded? The test results were negative. A. Z01.84, Encounter for antibody response examination B. Z20.822, Contact with and (suspected) exposure to COVID-19. C. Z11.59, Encounter for screening for other viral diseases D. Z03.818, Encounter for observation for suspected exposure to other biological agents ruled out. References: ICD-10-CM Guidelines COVID-19, Exposure to COVID-19. - ANSWERSZ20.822, Contact with and (suspected) exposure to COVID-19. The diabetes mellitus codes are combination codes that include: A.The type of diabetes, the body system affected, and whether the patient is on insulin. B.The type of diabetes, the body system affected, and the complication affecting the body system. C.The type of diabetes, the complication affecting the body system, and whether the patient is on insulin. D.The type of diabetes, the complication affecting the body system, and whether the diabetes is controlled or uncontrolled. - ANSWERSThe type of diabetes, the body system affected, and the complication affecting the body system. Secondary diabetes may be due to: A.Drug or chemical B.Infection
C.Removal of pancreas D.All of the above - ANSWERSD.All of the above Which of the following statements is true with regards to coding pregnant diabetic women? A.Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. No code other diabetes code (E08-E13) should be assigned. B. Pregnant women who are diabetic should be assigned the appropriate diabetes code (E08-E13) first, followed by a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium. C. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-E13). D. Pregnant women who are diabetic should be assigned either a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, or the appropriate diabetes mellitus code (E08-E13). The sequencing does not - ANSWERSC. Pregnant women who are diabetic should be assigned a code from category O24, Diabetes mellitus in pregnancy, childbirth and the puerperium, first, followed by the appropriate diabetes mellitus code (E08-E13). A type II diabetic patient on long term insulin and metformin was admitted because of nephrotic syndrome. Renal biopsy of the left kidney found amyloid deposition but was negative for diabetic nephropathy. Rapid deterioration in renal function, sudden increase in proteinuria, and the absence of diabetic retinopathy also ruled out diabetic nephropathy. Final diagnoses: (1) Glomerulonephritis with nephrotic syndrome due to amyloidosis, (2) type II diabetes mellitus, (3) percutaneous biopsy kidney. Assign the appropriate codes. - ANSWERSCodes: E85.4, N08, E11.9, Z79.4, Z79.84, 0TB13ZX Comments: (1) In this example, the nephropathy is related to amyloidosis and is not a complication of the diabetes mellitus. The underlying condition, the amyloidosis, is sequenced as principal diagnosis, and the manifestation, the nephrosis, is coded as an additional diagnosis. (2) Since there is no cause and effect between diabetes and glomerulonephritis, code E11.9 is assigned for diabetes with no associated complication. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 163 A 47-year-old male was seen in the emergency room with complaints of nausea, vomiting, diarrhea, and cramping. The patient is a known diabetic whose diabetes is secondary to history of blunt trauma to the pancreas. Blood sugar levels on admission were greater than 600.
Comments: (1) Codes for gestational diabetes are in subcategory O24.4. Only the code for insulin-controlled diabetes is required when the patient is treated with both diet and insulin. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 165. When the provider documentation refers to use, abuse, and dependence of the same substance, what is the coding hierarchy? A.Assign codes for the use and dependence. B. Assign only the code for dependence. C.Assign codes for the use, abuse, and dependence. D. Assign codes for the abuse and dependence. - ANSWERSB. Assign only the code for dependence An 87-year-old woman was admitted to the hospital due to a fracture of her left femur after a fall. Her son relates his mother has shown increasingly odd behavior. She seemed to think that he was trying to snatch her purse as he helped her into the car for a ride to church. As she became upset, she tried to get away from him and tripped in her confusion. During the physician's examination, she was disoriented and displayed irrational fears. An open reduction is performed with placement of a metal plate and large screw across the fracture into the femoral head to hold the bones in place. Final diagnoses: (1) Intertrochanteric fracture of the left femur, (2) probable late onset Alzheimer's dementia with behavioral disturbance, (3) hypertension, (4) fall, (5) open reduction with internal fixation. Assign the appropriate codes. - ANSWERSCodes: S72.142A, G30.1, F02.81, I10, W19.xxxA, 0QS704Z Comments: (1) Code F02.81 is assigned to identify the presence of concomitant behavioral disturbances—such as aggressive, combative, or violent behavior— disturbances that are due to the effects of the Alzheimer's disease. The underlying condition that is associated with the dementia is coded before the dementia code. (2) The fracture reduction classified to the root operation "reposition." The trochanter is classified to the body part "upper femur." References: ICD-10-CM Coding Handbook, 2014 Revised Edition, pp. 173, 206, and 487; and Coding Clinic, Fourth Quarter 2000, pp. 40- A patient was admitted with methicillin resistant Staphylococcus aureus (MRSA) cellulitis and abscess of the left thigh due to continuous self-prescribed steroid injections. Patient treated with intravenous antibiotics and excisional debridement. Final diagnoses: (1) Cellulitis and abscess of the thigh due to contaminated needle, (2) self-prescribed steroid abuse, (3) MRSA, (4) excisional debridement skin and fascia. Assign the appropriate codes. - ANSWERSCodes: L03.116, L02.416, B95.62, F55.3, W46.1xxA, 0JBM0ZZ
Comments: (1) When a patient is admitted for treatment of a physical complaint that is related to substance use, the physical condition is sequenced first, followed by the code for the abuse or dependence. References: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 182, and Coding Clinic, Second Quarter 2006, p. 7. An elderly female patient was taken to the emergency medicine department by his family when she became unusually agitated and aggressive. MRI of the brain showed no evidence of infarct, hemorrhage, lesion, or significant abnormality. Infectious workup was also negative. Antibiotic therapy was started with slow improvement in mental status. Antithyroid peroxidase antibodies were positive. Final diagnoses: (1) Altered mental status due to Hashimoto's encephalopathy, (2) MRI brain. Assign the appropriate codes - ANSWERSCodes: E06.3, G93.49, B030ZZZ Comments: (1) Code R41.82, Altered mental status, unspecified, is not assigned when the cause of the change in mental status is known. The condition, in this case Hashimoto's encephalopathy, is coded. (2) Since the encephalopathy is documented by the provider to be secondary to Hashimoto's disease, code G93.49. References: ICD-10-CM Coding Handbook, 2021 Revised Edition, The patient was admitted for epistaxis and coagulopathy due to therapeutic anticoagulation medication for atrial fibrillation. There is recent history of resection of a mass of the vestibule of the mouth with graft repair and radiation therapy. When seen in the physician office, the patient's Coumadin was discontinued due to high protime. Although the Coumadin was stopped, the pro-time continued to rise. Protime corrected with frozen plasma during hospitalization. Final diagnoses: (1) Epistaxis secondary to Coumadin, (2) recurrent cancer of vestibule of the mouth, (3) atrial fibrillation, (4) transfusion non-autologous plasma through peripheral vein. Assign the appropriate codes. - ANSWERSCodes: D68.32, R04.0, T45.515A, C06.1, I48.91, Z79.01, 30233K Comments: (1) The principal diagnosis is D68.32 (see Coding Clinic. D68.318 is not appropriate for patients on anticoagulant therapy. The circumstances of the admit will determine principal dx. In this case, the epistaxis is an adverse effect that resulted in "coagulopathy" and listed first. R04.0 will be used as an additional diagnosis per Coding Clinic. (2) Code T45.515A is assigned for the adverse effect of the anticoagulant. References: ICD-10-CM Coding Handbook, 2014 Revised Edition, pp. 197-198, and Coding Clinic, 1st Quarter, 2016 page 14..
procedure as the Baeveldt shunt is an acqueous device specific to drainage procedures using a shunt to drain via catheter. Reference: Coding Clinic, 1st Quarter, 2019 page 27-28. Patient was diagnosed with a left humeral fracture when she fell after tripping over a rug at home. The arm was placed in a sling until reduction with internal fixation could be performed at a later date, and the patient was given medication for control of pain. The patient was seen the next day because the pain was not well controlled. No recent or remote tobacco, alcohol, or illicit drug use was documented. Patient is currently being admitted for acute pain control protocol. Final diagnoses: (1) Admit due to poor pain control, (2) fracture of the humerus, (3) hypertension, (4) NIDDM. Assign the appropriate codes. - ANSWERSCodes: G89.11, S42.302A, I10, E11.9, W18.09xA Comments: (1) Assign code G89.11 as principal diagnosis. When pain control or pain management is the reason for the admission/encounter, the category G89 code is listed as principal diagnosis. The underlying cause of the pain should be reported as an additional diagnosis. (2) The seventh character A is assigned for as long as the patient is receiving active treatment for the fracture. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 210, and pp. 481-
A 67-year-old male was found by his family in an altered state. He has a 50-year history of seizure disorder, so paramedics were called to the home where they witnessed a grand mal seizure. The patient's family tells doctors that he has acute bronchitis and has been poorly compliant with his antiepileptic medications. Patient is admitted in a nonresponsive and lethargic state. CT of head is negative for significant acute pathology. Final diagnoses: (1) Postictal state following grand mal seizure, (2) epilepsy, (3) acute bronchitis, (4) CT of head. Assign the appropriate codes. - ANSWERSCodes: G40.409, J20.9, Z91.14, BW28ZZZ Comments: (1) Category G40 is assigned for seizures that the physician documents are due to epilepsy. Reference: ICD-10-CM Coding Handbook, 2014 Revised Edition, p. 206. If a condition complicating the pregnancy develops prior to the current admission/encounter or represents a pre-existing condition, which trimester character should be assigned? A.The trimester character for the trimester at the time of the admission/encounter. B.The trimester character for the trimester when the condition developed.
C.The trimester character will depend on the circumstances of admission. D.The trimester character at the time of discharge. - ANSWERSA.The trimester character for the trimester at the time of the admission/encounter. When an inpatient hospitalization encompasses more than one trimester and remains in the hospital into a subsequent trimester, which trimester character should be assigned for the antepartum complication code? A.The trimester character for the trimester at the time of the admission/encounter. B.The trimester character for the trimester when the condition developed. C.The trimester character will depend on the circumstances of admission. D.The trimester character at the time of discharge. - ANSWERSB.The trimester character for the trimester when the condition developed. Code O80, Encounter for full-term uncomplicated delivery, is used only when the delivery is entirely normal with a single liveborn outcome. Which of the following situations would not prevent the use of code O80? A.Any postpartum complications. B.An antepartum complication experienced during pregnancy has resolved before the time of admission. C.There is fetal manipulation with forceps. D.There are multiple births. - ANSWERSB.An antepartum complication experienced during pregnancy has resolved before the time of admission. The postpartum period, clinically termed the "puerperium," begins immediately after delivery and includes how many of the subsequent weeks? A.Two B.Four C.Six D.Eight - ANSWERSC.Six What is the correct ICD-10-PCS root operation for Cesarean deliveries? A.Delivery B.Removal C.Extraction D.Reposition - ANSWERSC.Extraction A patient is being treated for congestive heart failure (CHF) and dilated cardiomyopathy related to previous pregnancy following delivery five months ago. The patient complains of swelling of the feet, orthopnea, and palpitations. CT was performed to rule out recurrent pulmonary embolus. Patient was maintained on Coumadin due to previous pulmonary embolism. Patient was admitted to monitor with full-dose heparinization and to treat CHF with intravenous diuretic, ace inhibitors, beta blockers, and Digoxin. A biventricular defibrillator is implanted in the chest (open approach) with insertion of right and left ventricle lead and defibrillator lead into coronary vein (percutaneous approach) vein during the hospitalization.
A patient, who delivered at 39 weeks had a routine vaginal delivery of a normal infant. She has asthma for which she takes an inhaler. However, she suffered an obstetrical periurethral laceration during delivery. Final diagnoses and procedures: (1) Spontaneous vaginal delivery complicated by periurethral obstetric laceration, (2) Asthma, (3) assisted vaginal delivery, (4) suture of periurethral laceration. Assign the appropriate codes. - ANSWERSCodes: O99.52, J45.909, O71.82, Z37.0, Z3A.39, 10E0XZZ, 0UQMXZZ Comments: (1) The ICD-10-PCS guideline pertaining to "peri" (B4.1b) only applies when a more specific body-part value is not available. (2) In this case, although the body part was described as "peri-urethral," it is the vulvar tissue, not the urethral tissue, that is torn; a specific body part exists in ICD-10-PCS for "vulva." (3) The patient has asthma for which she takes an inhaler. There were no complications of pregnancy other than the patient having asthma. Therefore, per O99.52 would be principal. A pregnant patient presents to the hospital at over 40 weeks gestation in active labor. Artificial rupture of the fetal membranes (AROM) is carried out, and Pitocin is given intravenously in the peripheral vein to augment labor. The patient had a spontaneous vaginal delivery of a liveborn infant without complication. Final diagnoses and procedures: (1) Normal spontaneous vaginal delivery, (2) manually assisted delivery, (3) artificial rupture of fetal membranes. Assign the appropriate codes. - ANSWERSCodes: O48.0, Z3A.40, Z37.0, 10E0XZZ, 10907ZC Comments: (1) The administration of Pitocin to augment active labor is not coded separately. (2) In this case, the patient presented in active labor; therefore, do not assign a separate code for the administration of Pitocin. When Pitocin is given to induce labor, it should be coded. Reference: ICD-10-CM and ICD-10-PCSCoding Handbook, 2017 revised Edition, p. 335 If an expelled fetus has a period of gestation of more than 20 weeks but less than 37 weeks, what is it considered? A.Spontaneous abortion B.Abortion C.Preterm labor with preterm delivery D.Molar pregnancy - ANSWERSC.Preterm labor with preterm delivery ER note: pelvic pain, positive Beta HCG, and positive Chandelier's sign with vaginal bleeding. Diagnosis consistent with ectopic pregnancy. Patient was admitted and agreed to proceed with left salpingectomy and removal of tubal pregnancy. Two additional cystic lesions made up a large part of the ovary. When they were excised, the
small segment of the remaining left ovary was judged to be unsuitable due to endometriosis, so a left oophorectomy was performed en toto. Final diagnoses: (1) Ruptured left tubal ectopic pregnancy, (2) left ovarian follicular cysts, (3) Left ovarian endometriosis, (4) laparoscopic removal of left tubal pregnancy and left ovary cystectomy was performed. Assign the appropriate codes. - ANSWERSCodes: O00.102, N83.02, N80.1, 10T24ZZ, 0UT64ZZ, 0UT14ZZ, Comments: (1) The cyst and endometriosis are not reported with Chapter 15 codes since these conditions are not complications of a viable pregnancy. (2) Codes 10T24ZZ and 0UT64ZZ are assigned for the removal of tubal pregnancy with total removal of the tube. (3) Code 0UT14ZZ is assigned for removal of the left ovary due to cysts and endometriosis. Reference: ICD-10-CM and ICD-10-PCS Coding Handbook, 2013 Revised Edition, pp. 349- A pregnant patient at 18 weeks' gestation presents for elective termination of pregnancy due to fetal anomalies. Potassium chloride (KCl) was injected into the fetal heart with cessation of fetal cardiac activity. A laminaria was then placed and followed by Pitocin in the peripheral vein, percutaneous approach. The fetus was expelled spontaneously without complication. Final diagnosis: Elective abortion due to fetal anomalies Assign the codes. - ANSWERSCodes: Z33.2, 035.9XX0, 10A07ZX, 10A07ZW, 3E033VJ Comments: (1) Code Z33.2 is assigned as the principal diagnosis since the patient presented for a legally induced abortion due to known or suspected fetal abnormalities. (2) Since an abortifacient and laminaria were both used, codes 10A03ZZ and 10A07ZW are assigned. Code 3E033VJ describes the Pitocin induction. When the type of congenital anomaly is specified, but no specific code is provided, what should the coder do? A.Assign the code for other specified anomaly of that type and site. B.Assign additional codes for manifestations of the anomaly. C.Query the physician for instructions. D.A and B - ANSWERSD.A and B A three-week-old infant is admitted with projectile vomiting and dehydration. The vomiting is due to the pyloric stenosis. A pyloromyotomy is performed for pyloric stenosis. Final diagnoses: (1) Pyloric stenosis, (2) dehydration, (3) pyloromyotomy.
