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CERTIFIED CODING SPECIALIST (CCS) EXAM PREP
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Carcinoma in situ ANS >>> Tumour cells that are undergoing malignant changes but are still confined to the point of origin without invasion of the surrounding normal tissue Examples of carcinoma in situ ANS >>> Intraepithelial infiltrating The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate? a. Unstable angina b. Myocardial infarction
c. Congestive heart failure d. Mitral valve stenosis ANS >>> b The CPK elevation with MB enzymes elevated and the EKG ST changes denote a possible Me (Leon-Chinen 2013, 386-387). A patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis· is Escherichia coli, urinary tract infection. Which of the following represents the correct diagnoses and appropriate sequence of those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli, urinary tract infection d. Urinary tract infection, Escherichia coli ANS >>> d Symptoms are not coded when a definitive diagnosis is present on discharge. The patient discharge diagnosis of urinary tract infection. The organism (E. coli) is coded with a seco diagnosis code (B96.20) which is to be added as an additional code to identify the bacterial agent (HHS 2014, Section II.A., 98). A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant. What action(s) should the coding staff take?
Inpatient: Admission for inguinal hernia repair. This 30-year-old patient has acquired immunodeficiency syndrome (AIDS) but is not symptomatic at this time due to medication regimen. The procedure performed was a right indirect inguinal herniorrhaphy via open approach. ANS >>> ICD- 10 - CM: K40.90, B20, ICD- 10 - PCS: OYQ50ZZ (Schraffenberger 2013, 82-84,252) Inpatient: A 75-year-old male patient was admitted from a nursing home with dehydration and dysphagia due to a previous stroke. During hospitalization the patient was rehydrated and transferred back to the nursing home. ANS >>> ICD- 10 - CM: E86.0, I69. (Schraffenberger 2013, 131, 209-210). Stroke= cerebral infarction Inpatient: A patient is admitted to an acute care facility for detoxification from alcohol and barbiturate intoxication with chronic alcoholism and
barbiturate abuse. The patient also has cirrhosis of the liver due to alcoholism. ANS >>> ICD- 10 - CM: F10.229, F13.129, K70.30, (Schraffenberger 2013, 140-143.) ICD- 10 - PCS HZ2ZZZZ (Leon-chisel 2014, 186). Inpatient: A 30-year-old patient was seen in the emergency department for recurrent epileptic seizures. The patient also had tic douloureux. ANS >>> ICD- 10 - CM: G40.909, G50. (Schraffenberger 2013,158-159). Inpatient: A patient was admitted to an acute care facility with a temperature of 102 and atrial fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the physician of pneumonia in the progress notes and discharge summary. The patient was treated with
ICD- 10 - PCS: OT788DZ, OTC08ZZ
(Leon-chisel 2013, 269). Inpatient: A 77-year-old nursing home patient was admitted to the acute care setting for excisional debridement of decubitus stage 3 ulcer of the right heel via surgical excision in the OR. The patient also has degenerative joint disease of both knees. ANS >>> ICD- 10 - CM: L89.613, M17.0, ICD- 10 - PCS: OJBQOZZ (Schraffenberger 2013, 265-266, 278, 282-284). Inpatient: 45 - year-old woman was admitted to the inpatient setting for a displacement of a lumbar intervertebral disk. This was treated with a laminectomy and diskectomy. ANS >>> ICD- 10 - CM: M51.26, ICD- 10 - PCS: OSB20ZZ, OQBOOZZ (Schraffenberger 2013,279, 282-284).
Inpatient: A 34-year-old woman delivered a live born, term baby boy (39 weeks) with macrosomia. She had a haemorrhage following an episiotomy with a low forceps delivery but prior to expulsion of the placenta. ANS >>> ICD- 10 - CM: 067.9, 033.7, Z37.0, Z3A.39, ICD- 10 - PCS: 10D07Z3, OW8NXZZ- The patient had a haemorrhage that occurred after delivery but before the expulsion of the placenta. This haemorrhage, by definition, occurred in the third stage of Labor (Schraffenberger 2013, 270, 278- 283, 313). Inpatient: A single, newborn, term live-born baby boy, born in hospital via vaginal delivery. ANS >>> ICD- 10 - CM: Z38. (Schraffenberger 2013, 340). Inpatient: Twin newborns, both born prematurely at 32 weeks via caesarean section, 1,002 g was the birth weight of the first twin, whose mate was stillborn. The baby was admitted to the nursery from the delivery room.
underwent a right lower lung lobectomy via laparotomy. ANS >>> ICD- 10 - CM: C34.31, C79.31, ICD- 10 - PCS: OBTFOZZ (Schraffenberger 2013, Chapter 5, 99). Inpatient: A patient has metastatic adenocarcinoma of bone. ANS >>> ICD- 10 - CM: C80.1, C79. (Schraffenberger 2013, 99). Inpatient: A patient is admitted with metastatic carcinoma from breast to liver with previous bilateral mastectomy and no reoccurrence at the primary site. ANS >>> ICD- 10 - CM: C78.7, Z85.3, Z90. (Schraffenberger 2013, 478). Inpatient:
A young woman was admitted after a car hit her from behind while she waited for a bus on the sidewalk. She sustained a fractured fibula shaft and patella on the left leg with a break in the skin at the midcalf. The patient required an open reduction of the left fibula fracture. ANS >>> ICD- 10 - CM: S82.402A, S82.002A, T14.8, Y92.480, V03.10XA, ICD- 10 - PCS: OQSKOZZ (Schraffenberger 2013, 380-381, 443, 428). Inpatient: Syncope; bradycardia ruled out; due to taking Valium as prescribed by a physician. Patient also took an antihistamine as directed on the package without consulting a healthcare provider. ANS >>> ICD- 10 - CM: T42.4X1A, T45.0X1A, R55-The patient took over-the-counter medications with a prescription medication without consulting the prescribing physician. This is a poisoning. Per the Official ICD- 10 - CM Guidelines for Coding and Reporting, I.C.19.e.5.b.: Nonprescribed drug taken with correctly prescribed and properly administered drug: If a nonprescribed drug or medicinal agent was taken in combination Javits a correctly prescribed and properly administered drug, any drug toxicity or other reaction resulting from
Noncardiac chest pain, oesophageal acid reflux test. ANS >>> ICD- 10 - CM: R07.89; CPT: 91034 (Schraffenberger 2013, 362-363; CPT Assistant May 2005,3) Ambulatory/Outpatient Annual screening mammogram. ANS >>> ICD- 10 - CM: Z12. CPT: (Schraffenberger 2013, 462; CPT Assistant March 2007, 7) Ambulatory/Outpatient Excision of basal cell carcinoma, 1.9-cm lesion left upper eyelid. ANS >>> ICD- 10 - CM: C44.119; CPT: 11642 (Schraffenberger 2013, 99-100; CPT Assistant Fa11199-. _ May 1996, 11; Feb. 2008, 8; Feb. 2010, 3; CPT Changes: An Insider's View 2003). Ambulatory/Outpatient
Hallux valgus repair with resection of the joint with implant in the first left toe proximal phalanx. ANS >>> CD- 10 - CM: M20.12; CPT: 28293-TA (Schraffenberger 2013, 305; CPT Assistant Dec. 1996. 6; CPT Assistant Jan. 2007, 31). Ambulatory/Outpatient Metastatic ovarian cancer to the pleura. Thoracoscopic pleurodesis. ANS
ICD- 10 - CM: C78.2, C56.9; CPT: 32650 (Schraffenberger 2013, 100-101; CPT Assistant F 1994, 1, 6; CPT Changes: An Insider's View 2002). Ambulatory/Outpatient Symptomatic bradycardia due to sick sinus syndrome with replacement of dual chamber pacemaker generator with removal of old generator. ANS >>> ICD- 10 - CM: 149.5; CPT: 33228 (Schraffenberger 2013, 206, 362- 363; CPT Changes: An In-sider's View 2003; CPT Assistant Summer 1994, 10, 19; CPT Assistant Nov. 1999, 16; CPT CHANGES 200,
(Schraffenberger 2013, 103; Smith 2015, 134). Ambulatory/Outpatient Dysfunctional uterine bleeding for which hysteroscopy with endometrial ablation was undertaken. ANS >>> CD- 10 - CM: N93.8; CPT: 58563 (Schraffenberger 2013, 296; CPT Assistant Nov. 1999,2: March 2000, 10; March 2002, 11; CPT Changes: An Insider's View 2000, 2002). Ambulatory/Outpatient Incompetent cervix in second trimester with removal of cervical cerclage under spinal anaesthesia in a pregnant woman. ANS >>> ICD- 10 - CM: 034.32; CPT: 59871 (Leon-Chinen 2013, 343; CPT Assistant Nov. 1997, 2 CPT Assistant Nov. 2006, 21; CPT Assistant Feb. 2007, 10) A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an
intestinal obstruction of the left colon due to adhesions from a prior abdominal surgery. The patient underwent an exploratory laparotomy with lysis of adhesions. What conditions should be coded? a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of adhesions b. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, laparotomy, lysis of adhesions c. Abdominal adhesions with obstruction, lysis of adhesions d. Abdominal adhesions and abdominal obstruction, postoperative complications of the digestive system, lysis of adhesions ANS >>> c The patient has abdominal adhesions with obstruction, and lysis of adhesions was performed. The abdominal pain is not coded as it is a symptom (HHS 2014, Section I.B.4, 13; Leon-chisel 2013,140) A patient has a principal diagnosis of pneumonia (118.9) (MS-DRG 195).
a. Review the operative report to determine what procedure codes to use and also to determine the site or sites of endometriosis so codes with the highest specificity may be assigned, and use infertility as a principal diagnosis. b. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified, and assign a principal diagnosis of infertility. c. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified as principal, and assign a secondary diagnosis of infertility. d. Review the operative report to determine what procedure codes to use and also ANS >>> d There may be endometrial implants throughout the pelvic cavity which may attach to various anatomic structures such as the fallopian tube, ovary, and momentums. These locations should be identified so that the appropriate diagnostic codes can be assigned and the appropriate procedure codes can be assigned based on the destruction of the endometrial implants. Therefore, the correct answer is to review the operative report to determine what procedure codes to use and determine the site or sites of endometriosis so that codes with the highest specificity may be assigned. Also, use the diagnosis of infertility
as a secondary condition (Schraffenberger 2013, 296; Leon-chisel 2013, 33, 271). In order to establish the adequacy of documentation in the medical record the following must be reflected: a. Decisions of patient's caregivers b. Quantitative analysis of the number of pages c. Ancillary forms and consents d. Care rendered to the patient and the patient's response ANS >>> d The care rendered to the patient and the patient's response must be documented in the medical record (LaTour and Eichenwald Maki 2013, 264; Sayles 2013, 70). Authentication of health record entries means to: a. Create facsimiles of documents b. Prove authorship of documents
