Certified Coding Specialist (CCS) Exam Preparation With Complete Solutions Latest Update, Exams of Nursing

Download Certified Coding Specialist (CCS) Exam Preparation With Complete Solutions Latest Update and more Exams Nursing in PDF only on Docsity! Certified Coding Specialist (CCS) Exam Preparation With Complete Solutions Latest Update Diagnostic-related groups (DRGs) and ambulatory patient classifications (APCs) are similar in that they are both: a. Determined by HCPCS codes b. Focused on hospital outpatients c. Focused on hospital inpatients d. Prospective payment systems - correct answers d. Prospective payment systems ** Both are types of prospective payment systems (Casto and Forrestal 2015, 6). A patient is treated for esophageal varices with hemorrhage due to cirrhosis. The diagnostic codes that would be assigned are: I85.01 Esophageal varices with bleeding I85.11 Secondary esophageal varices with bleeding K74.60 Unspecified cirrhosis of liver - correct answers d. K74.60, I85.11 K74.60: Unspecified cirrhosis of liver I85.11:Secondary esophageal varices with bleeding **The patient has cirrhosis of the liver with resulting bleeding esophageal varices. Cirrhosis of liver is sequenced first followed by the code for the bleeding esophageal varices (HHS 2017, Section I.A.13, 11). Assign the code(s) for bronchoscopy with bilateral transbronchial biopsy for each lobe of each lung. 31628 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe 31629 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) 31632 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when perf - correct answers Assign the code(s) for endoscopic sinusotomy with bilateral anterior ethmoidectomy. 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) A 55-year-old patient has hypertensive heart disease with congestive heart failure. What code would be assigned? a. I15.8, Other secondary hypertension b. I11.0, Hypertensive heart disease with heart failure and I50.9, Heart failure, unspecified c. I50.9, Heart failure, unspecified and I15.0, Renovascular hypertension d. N18.6, End stage renal disease - correct answers b. I11.0, Hypertensive heart disease with heart failure and I50.9, Heart failure, unspecified ** There is a cause and effect relationship established between the hypertension and the congestive heart failure. A separate code for the congestive heart failure is assigned based on the "code also" note (HHS 2017, Section I.C.9.a., 40). A surgeon would like to undertake a research study on his patients with stage II malignant melanoma of the back, who have undergone wide excision of the melanoma. What work processes and associated software could be used to provide this information? a. Obtain a summary of the cases from the cancer registry, import them into a spreadsheet, and provide to the surgeon. b. Obtain a summary of the cases from the chart completion software, import them into a spreadsheet, and provide to the surgeon. c - correct answers a. Obtain a summary of the cases from the cancer registry, import them into a spreadsheet, and provide to the surgeon. **The cancer registry can be used to undertake studies in addition to reporting cases to a central registry (Sharp and Madlock-Brown 2016, 173). A facility located near a national park has a significant number of snake bites, and patients receive treatment with antivenom in urgent-care settings. Sometimes a patient is admitted to the hospital after several days. Can the urgent-care setting provide the hospital with a list of names of patients treated with snake antivenom? a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot - correct answers a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot be provided. **Only records that are required for care or authorized by the patient can be released by the urgent-care facility to the acute-care facility (Brodnik 2012, 225; Rinehart- Thompson 2016b, 243-247). What diagnoses and procedures should be reported for recurrent left inguinal hernia with laparoscopic repair? K40.30 Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent K40.31 Unilateral inguinal hernia, with obstruction, without gangrene, recurrent K40.91 Unilateral inguinal hernia, without mention of obstruction or gangrene, recurrent 49520 Repair recurrent inguinal hernia, any age; reducible 49521 Repair recurrent inguinal hernia, any age; incarcerated - correct answers c. K40.91:Unilateral inguinal hernia, without mention of obstruction or gangrene, recurrent 49651:Laparoscopy, surgical; repair recurrent inguinal hernia **The patient has a recurrent hernia without obstruction and this is captured in diagnosis code K40.91 (Leon- Chisen 2017, 253; CPT Assistant Nov. 1999, 24; March 2000, 9). poisonings and adverse effects of drugs (Leon-Chisen 2017, 487-488). Medicare reimbursement depends on all of the following, except: a. The correct designation of the principal diagnosis b. Policies and procedures of the medical staff c. The presence or absence of additional codes that represent complications, comorbidities, or major complications/comorbidities d. Procedures performed - correct answers b. Policies and procedures of the medical staff **Policies and procedures of the medical staff are not relevant. But the presence or absence of additional codes that represent complications, comorbidities, or major complications/ comorbidities are all important to determine the MS-DRG as part of Medicare Acute Inpatient Prospective Payment System (Leon-Chisen 2017, 566; Rinehart-Thompson 2016a, 240-241). A 35-year-old woman has hypertension with acute renal failure and stage 3 chronic kidney disease. What code would be assigned? a. N17.9, Acute kidney failure, unspecified b. I13.2, Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease c. I50.9, Heart failure, unspecified d. N17.9, Acute kidney failure, unspecified and I12.9, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or u - correct answers d. N17.9, Acute kidney failure, unspecified and I12.9, Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease and N18.3, Chronic kidney disease, stage 3 (moderate) **Code the hypertension with stage 3 chronic kidney disease. In this case, both hypertension and chronic kidney disease are documented and a combination code is used. Also the code for the stage 3 chronic kidney disease must be assigned due to the "code also" note. The acute renal failure is identified with a separate code (HHS 2017, Section I.C.9.a., 40; HHS 2017, Section I.C.14.a., 53). A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately, what steps must the coder take? 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 wher - correct answers d. 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 the diagnosis of infertility as a secondary condition. ** There may be endometrial implants throughout the pelvic cavity which may attach to various anatomic structures such as the fallopian tube, ovary, and omentum. 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 2017, 455-457; Leon-Chisen 2017, 272). A patient is admitted to a psychiatric unit of an acute- care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a a. Sputum culture reflects growth of normal flora. b. Patient has a positive gram stain. c. Patient is found to have dysphagia with aspiration. d. Patient has nonproductive sputum. - correct answers c. Patient is found to have dysphagia with aspiration. ** Patient is found to have dysphagia with aspiration is the correct answer because it changes the coding to aspiration pneumonia and would result in MS-DRG 179 RESPIRATORY INFECTIONS & INFLAMMATIONS W/O CC/MCC, which has a weight of 0.9325 (Medicare Grouper Version Used: 2017). This is in comparison to MS-DRG 0195, SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC MDC: 04 which has a DRG weight of 0.7028 (Medicare Grouper Version Used: 2017). A method of checking the accuracy of data is to: a. Validate the purpose for the data collection b. Warehouse data on a regular basis c. Authenticate all end users d. Ensure that each record or entry within the database is correct - correct answers d. Ensure that each record or entry within the database is correct ** A good process to ensure the data is accurate is to make certain each record or entry within the database is correct (Sharp and Madlock-Brown 2016, 195). Assign the code(s) for chest x-ray, complete. 71010 Radiologic examination, chest; single view, frontal 71020 Radiologic examination, chest, 2 views, frontal and lateral 71030 Radiologic examination, chest, complete, minimum 4 views 71035 Radiologic examination, chest, special views (eg, lateral decubitus, Bucky studies) a. 71020 b. 71030 c. 71010, 71035 d. 71035 - correct answers b. 71030 Radiologic examination, chest, complete, minimum 4 views **The code for a complete chest x-ray includes a minimum of four views and does not include computer- aided detection or fluoroscopy (CPT Assistant July 2007, 6; Dec. 2009, 14). A 45-year-old female with chronic ulcerative enterocolitis and steroid induced osteoporosis due to long-term steroid therapy. What codes should be assigned? K50.00 Crohn's disease of small intestine without complications K51.00 Ulcerative pancolitis without complications M81.0 Age-related osteoporosis without current pathological fracture M81.8 Other osteoporosis without current pathological fracture T38.0X5A Adverse effects of glucocorticoids and synthetic analogues, initial encounter Z79.52 L - correct answers a. K51.00: Ulcerative pancolitis without complications. M81.8:Other osteoporosis without current pathological fracture. T38.0X5A: Adverse effects of glucocorticoids and synthetic analogues, initial encounter. Z79.52:Long term (current) use of systemic steroids **The ulcerative colitis and osteoporosis should be coded as well as the adverse effect and long term use of the steroid (HHS 2017, Section I.C.19.e, 74). I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease I12.9 Hypertensive chronic kidney disease, stage 1 through stage 4, or unspecified with chronic kidney disease J44.1 Chronic obstructive pulmonary disease with exacerbation J44.9 Chronic obstructive pulmonary disease, unspecified N18.5 Chronic kidney disease, stage 5 a - correct answers d. J44.1, I12.0, N18.5 J44.1 Chronic obstructive pulmonary disease with exacerbation. I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease. N18.5 Chronic kidney disease, stage 5 **Acute exacerbation of COPD is coded as J44.1. The hypertension is present with the chronic renal disease. Because of this, a combination code for hypertension and chronic renal disease is coded. In addition, the stage of the kidney disease is also coded (HHS 2017, Section I.C.14.a, 53). A data map or crosswalk consists of: a. Terms used to describe paths between classifications and vocabularies b. A map of time frames for multiple project completion c. A descriptive list of data names d. Normalized data attributes - correct answers a. Terms used to describe paths between classifications and vocabularies **There are several definitions of mapping and crosswalks but an important one in healthcare is that they are used to describe paths between classifications and terminologies (Palkie 2016, 164-165). The patient was admitted for breast carcinoma in the right breast at two o'clock. This was removed via lumpectomy. The patient was found to have 1 of 7 lymph nodes positive for carcinoma during axillary lymph node dissection. One of the patient's neighbors who is also a coworker at the hospital called the coding department to get the patient's diagnosis because she is a cancer survivor herself. The coder should: a. Discuss the case with the coworker b. Report the incident to hospital security c - correct answers d. Explain that discussing the case would violate the patient's right to privacy ** Disclosing information without the patient's written consent violates the patient's right to privacy (Brodnik 2012, 231, 414; Gordon and Gordon 2016a, 615-616). The requirements for documentation and record completion (documents such as history and physicals, discharge summaries, and consultations) as well as penalties for non-adherence must be specified in: a. Hospital rules and regulations b. Conditions of nonparticipation c. Medical staff bylaws d. Nursing staff policies - correct answers c. Medical staff bylaws **The medical staff bylaws are required by accreditation and regulatory organizations to refer to the timeline required for completion (Malmgren and Solberg 2016, 240; Brinda 2016, 166). 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug +96415 Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) −51 Multiple procedures a. 96413, 96415, 96415 b. 96413, 96415-51 c. 96413, 96 - correct answers a. 96413: Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug. +96415: Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) +96415: Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure.) **Three codes are needed to capture the initial hour and the two additional hours. Modifier -51 would not be used in this case because modifiers are not used with add-on codes To accurately code wound closures, what questions need to be answered? a. The number of surgical procedures undertaken b. What type of repair was undertaken: simple, intermediate, or complex and the site or body part involved, and the extent of the wound? c. Number of tests ordered and Supplies used d. What is the length of the repair in centimeters? - correct answers b. What type of repair was undertaken: simple, intermediate, or complex and the site or body part involved, and the extent of the wound? **The answers to these two questions in addition to the length must be known in order to code repairs correctly (Smith 2016, 69-70; AMA CPT Professional Edition 2017, 75). 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 - correct answers b. Myocardial infarction **The CPK elevation with MB enzymes elevated and the EKG ST changes denote a possible MI (Leon-Chisen 2017, 386-392). Generally, data quality is defined as: a. Ensuring the greatest amount of data possible is obtained from the medical record b. Ensuring the accuracy and completeness of an organization's data c. Ensuring accuracy of the case-mix index d. Ensuring the optimal reimbursement for each encounter - correct answers b. Ensuring the accuracy and completeness of an organization's data **Data quality may have slightly different meanings because there are several disciplines that work with data in healthcare. Generally, ensuring the accuracy and completeness of an organization's data is a definition that can be agreed upon by the organization detail all data elements and their corresponding attributes. A 12-year-old boy was seen in an ambulatory surgical center for pain in his right arm. The x-ray showed fracture of ulna. Patient underwent closed reduction of fracture right proximal ulna. What diagnostic and procedure codes should be assigned? S52.101A Unspecified fracture of upper end of right radius, initial encounter for closed fracture S52.101B Unspecified fracture of upper end of right radius, initial encounter for open fracture S52.001A Unspecified fracture of upper end of right ulna, i - correct answers d. S52.001A, 24675 S52.001A: Unspecified fracture of upper end of right ulna, initial encounter for closed fracture. 24675: Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process(es) ); with manipulation **The patient has a fracture of the right proximal ulna and closed reduction is necessary. In the ICD-10-CM codebook, under Fracture, ulna, proximal, the coder is referred to Fracture, ulna, upper end. The term "manipulation" is used to indicate reduction in CPT (AMA CPT Professional Edition 2017, 104). [Note: Since this is an ambulatory surgery center case, CPT codes are assigned, rather than ICD-10-PCS codes.] Authentication of health record entries means to: a. Create facsimiles of documents b. Prove authorship of documents c. Develop documents d. Use a rubber stamp on random sets of documents - correct answers b. Prove authorship of documents **Authentication is the act of verifying a claim of identity (Brickner 2016, 89). In order to prove authorship of documents they are required to be authenticated by a signature A patient is admitted with hemoptysis. A bronchoscopy with transbronchial biopsy of the lower lobe was undertaken that revealed squamous cell carcinoma of the right lung. Which conditions should be identified as present on admission? C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31 Malignant neoplasm of lower lobe, right bronchus or lung P26.9 Unspecified pulmonary hemorrhage originating in the perinatal period R04.2 Hemoptysis a. C34.30 b. R04.2 c. C34.31, R04.2 d. - correct answers c. C34.31, R04.2 C34.31: Malignant neoplasm of lower lobe, right bronchus or lung R04.2: Hemoptysis **The diagnosis after study (lung cancer) was present on admission as well as the symptom (hemoptysis). Code P26.9 would not be assigned because it is not diagnosed and only applies to the perinatal period (HHS 2017, Appendix I, 109-114). Current Procedural Terminology (CPT) defines a separate procedure as which of the following? Wide excision of 0.65-cm malignant melanoma (margins included) from right forearm. The diagnosis and procedure codes reported are: C43.61 Malignant melanoma of right upper limb, including shoulder C76.41 Malignant neoplasm of right upper limb 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms, or legs; excised diameter 0.6 to 1.0 cm 11601 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm 25075 - correct answers c. C43.61:Malignant melanoma of right upper limb, including shoulder 11601:Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm **The melanoma is coded to the site of the lesion and the procedure code is determined based on the size of the lesion as well as the margins excised A laparoscopic tubal ligation is completed. What is the correct CPT code assignment? 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 Laparoscopy, surgical; with occlus - correct answers b. 58670: Laparoscopy, surgical; with fulguration of oviducts (with or without transection) **The code that best fits the ligation is the fulguration because there are no clips or excision or lesion completed during the procedure What diagnoses and procedures should be reported for colonoscopy with cauterization of diverticular bleeding? K57.30 Diverticulosis of large intestine without perforation or abscess without bleeding K57.31 Diverticulosis of large intestine without perforation or abscess with bleeding K57.33 Diverticulitis of large intestine without perforation or abscess with bleeding K92.2 Gastrointestinal hemorrhage, unspecified 45330 Sigmoidoscopy, flexible; diagnostic, including collection of specimens(s) b - correct answers b. K57.31:Diverticulosis of large intestine without perforation or abscess with bleeding 45382:Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma, coagulator) **The bleeding is included in the code for diverticulosis and therefore a second code is not warranted (CPT Assistant 4th Quarter 1990, 20-24). Cystourethroscopy with removal of two lesions of separate locations in the bladder, one is 1.5-cm bladder tumor anterior wall and one is 0.75-cm in the lateral wall. What coding rule applies? a. Two CPT codes should be used with a modifier -59. b. Two CPT codes should be used. c. Code only the CPT code for cystourethroscopy. d. Code only the largest tumor. - correct answers d. Code only the largest tumor. 0W8NXZZ: Division of female perineum, external approach **The physician may word the delivery as "normal" but the coder cannot use O80 unless the patient meets the criteria for using it. The patient has a nuchal cord around the baby's neck which precludes the use of O80 (HHS 2017, Section I.C.15.n, 60). If a patient has a principal diagnosis of septicemia, which of the following procedures will increase the MS-DRG assignment the most? a. Bronchoscopy with left bronchus biopsy (0BB74ZX) b. Debridement of toenail (0HBRXZZ) c. Nonexcisional debridement of skin ulcer of perineum with abrasion (0HD9XZZ) d. Respiratory Ventilation, Greater than 96 Consecutive Hours (5A1955Z) - correct answers d. Respiratory Ventilation, Greater than 96 Consecutive Hours (5A1955Z) **The ventilator management is the procedure that will impact the MS-DRG to provide appropriate reimbursement. The MS-DRG with the highest weight is 870 (Medicare Grouper Version 2017). Respiratory Ventilation, Greater than 96 Consecutive Hours (5A1955Z). Medicare DRG assigned: 0870, SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS DRG weight = 05.8960. Incorrect answer option explanations provided for clarity: a. Bronchoscopy with biopsy (0BB74ZX) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0283 (incorrect) b. Debridement of toenail (0HBRXZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0283 (incorrect) c. Nonexcisional debridement of skin ulcer with abrasion (0HD9XZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weig When coding benign lipomatous neoplasms of skin, the section noted above directs the coder to: D23- Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (D17.0-D17.3) melanocytic nevi (D22.-) a. Use category D23 b. Use a code from D17.0-D17.3 c. Use code E88.2 d. Use category D22 - correct answers b. Use a code from D17.0-D17.3 **Excludes note 1 directs the coder to D17.0-D17.3 (HHS 2017, I.A.12a, 11). The patient is admitted for chest pain and is found to have an acute inferior myocardial infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient underwent a CABG X2 from aorta to the right anterior descending and right obtuse, autologous venous tissue using the left greater saphenous vein which was mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct? E11.36 Type 2 diabetes mellitus without complications E11.29 Type 2 diabetes mellitus with other diabetic kidney complication H25.9 Unspecified age-related cataract H25.21 Age-related cataract, morgagnian type, right eye H25.041 Posterior subc - correct answers b. H25.041: E11.36:Type 2 diabetes mellitus without complications I10:Essential hypertension N17.9:Acute kidney failure, unspecified **The patient has posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus, hypertension, acute renal failure. The hypertension is not related to the renal failure as it is acute and not chronic. Because of this, a combination code for hypertension and chronic renal failure is not coded (HHS 2017, Sections A.15. and I.B.9., 15., and AHA Coding Clinic 2016 2nd Quarter, 36- 37). 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? a. Query the physician. b. Assign the codes for the postoperative transplant rejection. c. Assign only the code for the transplant rejection. d. Assign only the code for heart failure. - correct answers a. Query the physician. **When the documentation is not clear regarding a potential complication, it is appropriate to query the physician (HHS 2017, Section II.B., 101; Leon-Chisen 2017, 42-44). The UHDDS definition of principal diagnosis does not apply to the coding of outpatient encounters because: a. There is not enough documentation b. Usually there are multiple reasons for the encounter c. No after study element is involved as continued evaluation cannot occur d. A pre-admission work up is not available - correct answers c. No after study element is involved as continued evaluation cannot occur **The principal diagnosis requires that the condition after study, which occasioned the patient's admission to the hospital, be assigned as the principal diagnosis. In the outpatient setting, no after study element is involved as continued evaluation cannot occur (Leon-Chisen 2017, 30; HHS 2017, Section IV, 104). UHDDS :Uniforn Hospital Discharge Data Set - correct answers Uniform Hospital Discharge Data Set (UHDDS) Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals. Minimum set of items based on standard definitions to provide consistent data for multiple users. Required for reporting Medicare and Medicaid patients. Assign the code(s) for bilateral epidural lumbar injection of steroids: 62282 Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions, with or without other therapeutic substance; epidural, lumbar, sacral [caudal]) 62311 Injection(s), of diagnostic or therapeutic substance(s) (including anesthetic,antispasmodic, opioid, a. -50, Bilateral procedure b. -51, Multiple procedures c. -59, Distinct procedural service d. -99, Multiple modifiers - correct answers c. -59, Distinct procedural service **The surgery is done on two distinct body systems with two distinct approaches. This warrants the use of -59 (CPT Assistant Sept. 2001). Before an organization can measure the quality of information it produces it must: a. Establish a data quality committee b. Investigate if there are fraudulent processes in current use c. Determine all attributes of poor quality d. Establish data standards within the organization - correct answers d. Establish data standards within the organization **Data can only be identified as high-quality when they conform to a recognized standard (Sharp and Madlock- Brown 2016, 193). In 2000, the Centers for Medicare and Medicaid Services (CMS) issued the final rule on the outpatient prospective payment system (OPPS). This program: a. Identified the payment structure for long-term care b. Divided outpatient services into fixed-payment groups c. Created less opportunity for health information management professionals d. Facilitated greater use of ICD-9-CM procedure codes - correct answers b. Divided outpatient services into fixed- payment groups **This final rule established APCs by dividing outpatient services into fixed-payment groups (Smith 2017, 261). (OPPS) outpatient prospective payment system - correct answers outpatient prospective payment system (OPPS). Assign the code for dilation and curettage for retained products of conception abortion at 11 weeks' gestation. 10A07ZW Abortion of products of conception, laminaria, via natural or artificial opening 10A07ZZ Abortion of products of conception, via natural or artificial opening 10D17ZZ Extraction of products of conception, retained, via natural or artificial opening 10D27ZZ Extraction of products of conception, ectopic, via natural or artificial opening a. 10D17ZZ b. 10A07ZZ c. 10A07ZW d. 10D2 - correct answers a. 10D17ZZ: Extraction of products of conception, retained, via natural or artificial opening **The procedure code assigned is associated with the diagnosis of missed abortion. The diagnosis of missed abortion denotes that the patient has retained products of conception that in other circumstances may have resulted in a miscarriage (Leon-Chisen 2017, 355). 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 **Codes must reflect the twin gestation as well as preterm labor and delivery. Additionally a code from O30- must be coded with multiple gestations (Leon-Chisen 2017, 323, 327). A patient is admitted with acute respiratory failure, hypertension, and congestive heart failure. The patient was intubated upon admission to the hospital. What are the correct diagnosis codes and sequencing? I10 Essential hypertension I50.9 Heart failure, unspecified J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia a. J96.00, I10, I50.9 b. I50.9, J96.00, I10 c. J96.20 - correct answers a. J96.00, I10, I50.9 J96.00: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia I10: Essential hypertension I50.9: Heart failure, unspecified **The patient was admitted and treated for the respiratory failure. The other conditions present are also coded (Leon-Chisen 2017, 232-234; HHS 2017, Section I.C.10.b., 48). A quality improvement study showed that newborn codes associated with maternal conditions are not being coded as often as they should. What HIM software could be used to identify the mother's chart so it can be reviewed at the time the newborn record is coded? a. Birth certificate registry or master patient index b. Transcription registry or correspondence registry c. Quality improvement or operative registry d. Pathology or laboratory information - correct answers a. Birth certificate registry or master patient index **Several data sources can assist the process of improving data quality in this scenario (Sharp and Madlock-Brown 2016, 194-199). The case-mix index for the information provided above is: a. 0.679 b. 0.89 c. 1.5 d. 0.75 - correct answers c. 1.5 ***(10 × 2.0) + (10 × 1.5) + (10 × 1.0) / 30 = 1.5 The case mix can be determined by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG. The sum of all the weights is the case mix. Dividing the case mix by the total number of MS-DRGs is the case-mix index (Edgerton 2016, 501; Casto and Forrestal 2015, 115; Horton 2016, 401-402). The patient is discharged with hemiplegia and aphasia associated with a cerebral infarction of the left side of the brain due to cerebral artery stenosis. The patient is right- handed and also has a history of hypertension and compensated congestive heart failure (both conditions currently controlled on medication and treated while in the hospital). What code assignment would be appropriate? G81.90 Hemiplegia, unspecified affecting unspecified side G81.91 Hemiplegia, unspecified affecting right - correct answers a. I63.50, G81.91, R47.01, I50.9, I11.0 the Tabular List. When looking in the index under Hypertension, the coding professional is ultimately referred to cardiorenal with heart failure with stage 5 or end stage renal disease. In the Tabular List, code also notes indicate to code the type of heart failure and the stage of renal A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded in the order of sequence. a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina c. Gastroenteritis, abdominal pain, angina d. Diarrhea, ch - correct answers b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina **The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline II.A for additional information on coding of symptoms, signs, and ill-defined conditions (HHS 2017, Section II.A., 100). Assign the code(s) for extraction of extracapsular cataract with simultaneous intraocular lens insertion in the right eye. 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorhexi - correct answers c. 66984-RT Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification) -RT Right side **Both the extraction of the cataract and the insertion of the lens are included in the single CPT code. The -RT modifier should be used to indicate the right eye was involved (CPT Assistant Nov. 2003, 10; March 2005, 11; Sept. 2009, 5). When coding benign neoplasm of the skin, the section noted above directs the coder to: D23- Other benign neoplasms of skin Includes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (D17.0-D17.3) melanocytic nevi (D22.-) a. Use category D23 for benign neoplasm of sweat glands b. Use category D23 for melanocytic nevi c. Use category D23 for benign lipomatous neoplasms of skin d. Use category D23 - correct answers a. Use category D23 for benign neoplasm of sweat glands **Excludes note 1 is defined as never code here (HHS 2017, I.A.12a, 11). 1. Assign the code(s) for bronchoscopy with bilateral transbronchial biopsy for each lobe of each lung. 31628 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial lung biopsy(s), single lobe