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Certified Coding Specialist Practice
Exam
A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She is afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which one of the following
should be the principal diagnosis? - Correct answer 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 energy and crying. What condition is suspected? - Correct
answer Bipolar disorder
A patient with a cephalic presentation anticipating a vaginal delivery failed to progress. After measurement of the fetal head and a trail of oxycontin, the patient underwent a cesarean section. What condition should the coder suspect and query the physician
about? - Correct answer 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 infraction. In accordance with the coding guidelines, what should the
coding professional do? - Correct answer Query the physician to determine fi there
was a compliance of surgery If a patient's discharge summary does not contain that is documented by the anesthesiologist in a postoperative evaluation and that is diagnosis would impact MS- DRG assignment, the coder should _____________________________________. -
Correct answer Query the attending physician regarding the clinical significance of
that diagnosis A patient record has documentation of esophageal varices. What condition may be
related that may affect coding? - Correct answer Liver disease
A patient admitted with acute abdominal pain is found to have appendicitis and has an appendectomy. The patient has a length of stay of two days. What type of patient
encounter is this? - Correct answer 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? - Correct answer 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 tests and medication given, but the diagnosis of septicemia was not documented by the physician. How should the physician be requested to document the septicemia? -
Correct answer An addendum to the chart should be written
The committee responsible for medical record completion reports to which medical staff
committee? - Correct answer Medical Executive Committee
Two areas of documentation in the health record that are significant areas of focus of
accrediting agencies are _________________. - Correct answer Timeliness and
legibility of medical documents In teaching facilities where electronic signatures are used for residents and attending
physicians ________________________________________. - Correct
answer Attending should cosign after the resident signs the documentation
An 84-year-old woman was admitted and discharged with hemiplegia and aphasia. A CT scan of the brain was performed that revealed an acute cerebral infarction and a possible small brain mass. After further testing, the patient was discharged with a final diagnosis of acute cerebral infarction. The condition(s) that should be coded are
___________________________________. - Correct answer Acute cerebral
infarction, hemiplegia, and aphasia According to the AHIMA Standards of Ethical Coding, "A coder should protect the confidentially of the health record at all times and refuse to access protected health information not required for coding-related activities." Which one of the following is not
considered a coding-related activity? - Correct answer Risk analysis of medical
record documentation An inpatient is discharged with a diagnosis of "either irritable bowel or pancreatitis"
Which condition would be the principal diagnosis? - Correct answer Code both and
sequence according to the circumstances of the admission A 55-year-old male was transferred to a nursing home for continuing care because of ventilator dependence following complications of cardiac bypass surgery. He was readmitted three weeks later due to ventilator associates pneumonia (VAP) due to
Pseudomanas aeruginosa. How should this be coded? - Correct answer J95.
ventilator associated pneumonia, B96.5 pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere A patient takes Coumadin as prescribed and correctly administered. However, the patient develops hematuria secondary to the Coumadin use. The correct coding
unspecified, with both hemorrhage and perforation; D50.0, iron deficiency anemia secondary to blood loss (chronic) According to the UHDDS, the definition of a secondary diagnosis is a condition that __________________________________________________________________. -
Correct answer Receives clinical evaluation, therapeutic treatment, further
evaluation, extends the length of stay, and increases nursing monitoring and care A patient is admitted to a healthcare facility with ataxia and syncope. The patient has a history of lung cancer. The patient also has a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the brain and undergoes radiation therapy to the brain. The principal diagnosis should be ___________________________________________. -
Correct answer Metastatic carcinoma of the brain
A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals infiltrates in the lung with pleural effusion. The patient also had an history of hypertension with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath is relieved. From the information given, what is the probable
principal diagnosis? - Correct answer Congestive heart failure
A patient is admitted with abdominal pain. The discharge documentation states "pancreatitis vs. noncalculus cholecystitis" as the final diagnoses. Both diagnoses are equally treated. Based on coding guidelines, what is the correct sequencing for these
diagnoses? - Correct answer Sequence either the pancreatitis vs. noncalculus
cholecystitis first The best answer to describe how the UHDDS defines a comorbidity is a diagnosis that
________________________________________________. - Correct answer Pre-
exists before admission Form CMS-1450, also known as the UB-04, supported among other things, this
important change for HIM use of ____________________. - Correct answer ICD-10-
CM and ICD-10-PCS A condition that is established after study to be chiefly responsible for the admission is
the ________________________________________. - Correct answer Principal
diagnosis A patient is admitted as an inpatient and discharged with chest pain. After evaluation it is suspected the patient may have gastroesophgeal reflux disease (GERD). The final diagnosis was "Rule out GERD". The correct code assignment would be
________________________. - Correct answer K21.9, gastro-esophageal reflux
disease without esophagitis
Which of the following is not part of a coding compliance plan? - Correct
answer Coding audits performed by payers
A patient was admitted with Type 1 diabetes with proliferative diabetic retinopathy to have surgery for traction retinal detachment for macular edema. What additional
information should be included in a query to correctly code this diagnosis? - Correct
answer All of this information is needed to correctly code
Physician documentation indicates that a patient has duodenitis. What additional
information is needed to correctly code this diagnosis? - Correct answer If there is
active bleeding An encounter was for management of the complication of dehydration associated with a neoplasm, and the treatment was only for the complication. The complication of a neoplasm is always coded first, followed by the appropriate code(s) for the neoplasm.
The exception to this is for ______________________. - Correct answer Anemia
A patient was admitted directly from his primary physician's office due to suspected avian influenza, along with signs and symptoms of avian influenza. The patient left against medical advice (AMA) before confirmatory lab tests could be drawn to identify the virus. The principal diagnosis should be coded from category ____________. -
Correct answer J11, influenza due to unidentified influenza virus
How should an annual screening mammogram with CAD be coded? - Correct
answer Z12.31, encounter for screening mammogram for malignant neoplasm of
breast; 77067, screening mammography, bilateral (2-view study of each breast), including CAD when performed Assign the best answer to complete the following sentence. The CPT codes for
treatment of fractures _______________________________________. - Correct
answer Use the terminology "manipulation" rather than "reduction" of fracture
In CPT, if a patient has two lacerations of the am that are repaired with simple closures,
the coder would assign ___________________________. - Correct answer Two
CPT codes expressing each laceration repair According to CPT, a repair of a laceration that includes retention sutures would be
considered what type of closure? - Correct answer Complex closure
The patient was monitored under general anesthesia for keratoplasty including excision of diseased cornea. A controlled depth-setting blade was used to cut partially into the recipient's cornea in a manner to allow the lamellar graft to fit. Which CPT code should
In outpatient surgery, a patient undergoes a direct laparoscopy with operating
microscope. What code should be assigned? - Correct answer 31526, laryngoscopy
direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope A patient is admitted with a substance-related psychosis. Daily medication management by a pharmacist was provided for 15 minutes each day. What diagnoses and
procedures should be coded? - Correct answer The psychosis first and the drug or
alcohol dependence is coded second; use CPT code 99605 for the initial day, and 99606 each subsequent day When coding a documented ventilator associated pneumonia (VAP), what codes should
be assigned first ICD-10-CM and then supported by CPT? - Correct answer The
specific code for ventilator-associated pneumonia NOS, is coded; the CPT will be from code range 33946 to 33989 A patient received 45 minutes of continuous inhalation treatment with an aerosol medication. What terms and phases should be identified to substantiate that status
asthmaticus is present? What CPT code should be assigned? - Correct
answer Refractory asthma and severe, intractable wheezing, 94640
The patient had an esophagosocy to control a GI bleed. The coder would expect to see the following documentation in the chart for the diagnosis since gastrointestinal bleeding
manifests as ____________________________________. - Correct
answer Hematemesis, which indicates acute upper gastrointestinal hemorrhage, an
indication for procedure code 43227
Mechanical ventilation codes require consideration of which of the following? - Correct
answer The start time of endotracheal tube insertion followed by time on mechanical
ventilation An example of breast reconstruction is ___________________________________. -
Correct answer Latissimus dorsi flap, without prosthetic implant
Name the types of pacemaker devices that each have a unique ICD-10-PCS code. -
Correct answer Single chamber, single chamber rate responsive, and dual chamber
IF a patient undergoes and open biopsy immediately before the definitive surgery for a
frozen section, how should this be coded with ICD-10-PCS codes? - Correct
answer Open biopsy and definitive surgery
A 75-year-old male patient was given heparin during hospitalization for a deep vein thrombophelebitiis of the right lower extremity. He was scheduled to have an insertion of intravascular vena cava filter into the femoral vein by endovascular approach the following day. The patient had back pain and the nurse was not answering the bell, so
he decided to take two aspirin. The interaction between the aspirin and heparin caused a subcutaneous hemorrhage of the thigh of the right lower extremity. How should the interaction between aspirin and heparin be coded? Assuming the interaction was
resolved, what CPT code would be used for the procedure. - Correct
answer Poisoning codes for aspirin and heparin as principal diagnosis, and
subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions; CPT 37191 A 77-year-old patient has hypertensive heart disease with congestive heart failure and with stage 5 renal disease. The patient presented to the ED where she received critical
care services for 110 minutes. What codes would be assigned? - Correct
answer I13.2, hypertensive heart and chronic kidney disease with heart disease with
stage 5 chronic kidney disease, or end stage renal disease; N18.5, chronic kidney disease, stage 5; I50.9, heart failure, unspecified; 99291, 99292 x 2 Medicare severity diagnostic-related groups (MS-DRGs) and ambulatory patient classifications (APCs) are dissimilar in that
_______________________________________________. - Correct answer There
is only one MS-DRG per inpatient discharge but one or more APCs per outpatient visit A patient is admitted with vaginal bleeding. One of the concurrent coding analysis reviewing information in the chart has determined that there may be additional procedure code but there is no typed operative report to provide definitive information. Coding the additional procedure would be considered an ethical practice if
___________________________________________. - Correct answer Under no
circumstances would this be done Which of the following is a key part of an internal coding compliance for facility-based
evaluation and management code asssignment? - Correct answer Regular internal
audits comparing the code assignment the facility guidelines A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is performed with resection of the joint with implant in the first left toe proximal phalanx.
What codes would be assigned? - Correct answer M20.12, hallux valgus (acquired),
left foot; 28291-LT, hallux rigidus correction with cheilectomy, debridement and capsular release of the 1st metatarsophalangeal joint; with implant A patient presents for esophageal varices without bleeding. There is no diagnosed cause of the condition. The procedure performed is esophagogastroduodencopy with
sclerotherapy of esophageal varices. What codes would be assigned? - Correct
answer I85.00, esophageal varices without bleeding; 43243 an EGD with injection
sclerosis of esophageal and/or gastric varices A 70-year-old male patient presents with BPH without LUTS. Transurethral resection of the prostate for benign prostatic hypertrophy with electrocautery is performed. What
transfusions given in the facility during the designated quarter along with the ordering physicians and lab values for RBC. Import the list in a spreadsheet and filter the data by using the RBC predetermined values or lower in the facility criteria for blood transfusions. A quality improvement study showed that maternity cases are not being coded with the correct diagnostic codes reflecting the need for a cesarean section delivery. What index
could be used to evaluate this? - Correct answer Disease index from billing and
reimbursement data The Health Information Technology for Economic and Clinical Health (HITECH) Act is
providing incentives for _______________________. - Correct answer Promoting
Interoperability Program The use of standard protocols to enable different computer systems to communicate is
referred as ___________________________________. - Correct
answer Interoperability
The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were miscoded as malignant during the last six months. To address this situation, what
work processes could be undertaken? - Correct answer Obtain the cases of
malignant colon tumors from both the cancer registry and the billing system; import both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor registry but are coded as malignant in the billing system. These cases should be manually reviewed to ensure they are not carcinoid tumors.
Which of the following is not a function of the outpatient code editor (OCE)? - Correct
answer Determining payment-related conditions that require direct reference to ICD-
10-CM codes
According to CPT guidelines, a colonoscopy includes _______________. - Correct
answer Examination of the entire colon, from the rectum to the cecum, and may
include the examination of the terminal ileum A female patient with hematochezia presents to the hospital outpatient surgery department for a colonoscopy but the procedure was not performed due to elevated
blood pressure. What is the first-listed diagnosis for this encounter? - Correct
answer Hematochezia
From the information provided, what would be the total reimbursement for this patient? -
Correct answer $3,
What percentage will the facility be paid for procedure code 10060? - Correct
answer 100%
If another status S procedure were performed, how much would the facility receive for
the second status S procedure? - Correct answer 100%
A Pap smear cannot be interpreted because the sample was inadequate. What type of
diagnosis code should be assigned? - Correct answer Code for unsatisfactory
cytology smear If a diagnosis of rule-out pneumonia with cough and malaise is specified in an emergency department visit, the coder should assign a code for
______________________________. - Correct answer Cough and malasie
Which of the following services are paid under the outpatient prospective payment
system (OPPS)? - Correct answer Outpatient hernia repair
What is assigned to CPT codes to indicate whether a service or procedure will be
reimbursed under the OPPS? - Correct answer Payment status indictors
The case mix for the information provided above is __________________. - Correct
answer 45
The information provided that
______________________________________________. - Correct answer The
payment is lowest for patients with DRG 193 Data accuracy is also referred to as ________________________________. -
Correct answer Validity
A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is ________________________. -
Correct answer Preventive
The patient was admitted for prostate carcinoma. This was treated with radiation. A member of the medical staff who was not associated with the patient's care requests to
see the patient's record. What should the coder do? - Correct answer Explain that
providing the record would violate the privacy policy In most circumstances, the person who authorizes release of medical information is
________________________. - Correct answer Patient
