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Certified Coding Specialist Practice
Test with Complete Solutions
A 7-year-old patient was admitted in the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? - ANS-Asthma with status asthmaticus A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis". What is the next step for the coder? - ANS-Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms During a coronary artery bypass surgery, the patient underwent saphenous bypass grafts; from the aorta to the left anterior descending branch of the left main coronary artery, and the left posterior descending of the left main coronary artery. The patient also underwent a repositioning of the mammary artery. Choose the best description for this procedure. - ANS-Two aortocoronary grafts and one mammary-coronary graft According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a ________________________. - ANS-Colonoscopy Infusion of Herceptin, a monoclonal antibody used for treatment of breast cancer in patients carrying a certain mutation of the HER2 gene, is classified as ___________________. - ANS-Molecular targets A patient has findings suggestive of chronic obstructive pulmonary disease (COPD) on chest x-ray. The attending physician mentions the x-ray. The attending physician mentions the x-ray finding in one progress note but no medication, treatment, or further evaluation is provided. The coder should __________________________________________. - ANS-Query the attending physician regarding the X-ray findings If a patient undergoes an inpatient procedure and the final summary diagnosis is different from the diagnosis on the pathology report, the coder should _____________________________. - ANS-Query the attending physician as to the final diagnosis A 56-year-old woman is admitted to an acute-care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of
hospitalization, a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should ____________________________________. - ANS-Query the healthcare provider who performed the procedure to determine if the debridement was excisional A 23-year-old female is admitted for shock following treatment of a miscarriage. The pathology report from the previous admission reveals that the patient had no decidua or products of conception in the tissue removed. This encounter would be coded as ___________________________. - ANS-O08.9, Complication following abortion and ectopic and molar pregnancies Most hospitals require a medical record is completed with ____________________. - ANS-30 days To correct an entry in the medical record, the provider should ________________________________________. - ANS-Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order After a patient is discharged from the hospital, the medical record must be reviewed for ___________________________________. - ANS-Certain basic reports (for example, history and physical, discharge summary, etc.) A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded? - ANS-Congestive heart failure A 65-year-old patient is admitted with pain and loosening of a left hip prosthesis. The acetabular component has loosened and become painful. The patient was admitted for open removal and replacement of the acetabular component of the left hip prosthesis. What is the appropriate code(s) for the admission? - ANS-T84.031A- Mechanical loosening of internal left hip prosthetic joint, initial encounter, 0SPB0JZ- removal of synthetic substitute from left hip joint, open approach, and 0SRE0JZ- replacement of left hip joint, acetabular surface with synthetic substitute, open approach A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? - ANS-O48.1- prolonged pregnancy With regard to the implementation of ICD-10-CM, all of the following are correct except ___________________________________________. - ANS-ICD-10-CM was developed by NCHS A 75-year-old female was admitted for acute myocardial infarction and underwent a diagnostic cardiac catherization. Following the cauterization, the patient developed a thrombophlebitis documented as due to the catheter in common femoral artery. The thrombophlebitis would be coded as ________________________________. - ANS-
__________________________________________. - ANS-End-stage renal disease; status post kidney transplant; chronic obstructive pulmonary disease; angina A patient is admitted to the hospital due to a fracture of the right hip and is scheduled for an open reduction with internal fixation. The patient developed cardiac arrhythmia which results in an inability to do the planned surgery. What is the principal diagnosis? - ANS- Right hip fracture Which of the following is not part of a facility coding compliance plan? - ANS-Coding audits performed by payers A 30-year-old woman with a 6-year history of anorexia nervosa was seen in her physician's office because of significant weight loss over the past three months, going from 82 pounds down to 53 pounds. She was admitted to the hospital to increase body weight and to be given nutrition counseling because of her severe malnutrition. How should this be coded? - ANS-F55.00, Anorexia nervosa, unspecified, E43, Unspecified severe protein-calorie malnutrition A 55-year-old patient with AIDS admitted with traumatic comminuted fracture femur shaft, right leg, initial encounter. The coder should _______________________________. - ANS-Assign a code for the fracture and the AIDS The patient is seen in the pain clinic for chronic neoplasm-related pain that was known to be caused by the metastatic bone carcinoma of the vertebra that has spread from carcinoma of the left main bronchus of the lung. How should this be coded? - ANS- G89.3, Neoplasm related pain (acute) (chronic); C79.51, Secondary malignant neoplasm of bone; C34.02, Malignant neoplasm of left main bronchus A 45-year-old man with known AIDS is admitted to the hospital for treatment of Pneumocystis pneumonia. What is the principal diagnosis code? - ANS-B20- AIDS A patient is prescribed diazepam and reports taking more than the prescribed amount. The patient is admitted to the hospital for complete work up. The final diagnosis is documented as diazepam use and abuse. How should this be coded? - ANS-F13.10- Sedative, hypnotic, or anxiolytic abuse, uncomplicated A 65-year-old male patient is being assessed for possible colon cancer and treated in the special procedure unit of the hospital. He undergoes a colonoscopy into the ascending colon with biopsy of a suspicious area in the transverse colon using the cold biopsy forceps. In addition, a colonic ultrasound of the area is performed, with transmural biopsy of an area of the mesentery adjacent to the transverse colon. Assign the appropriate CPT codes __________________________________. - ANS-45380- colonoscopy, flexible; with biopsy, single or multiple; 45392- colonoscopy, flexible, proximal to splenic flexure
The patient is diagnosed with a recurrent thyroglossal duct cyst. The surgeon locates the cyst using palpation, and an incision is created. The cyst is then excised. What is correct CPT code assignment for this service? - ANS-60281- excision of thyroglossal duct cyst or sinus; recurrent A patient is admitted for chest pain. The patient was stabilized and discharged. In a subsequent admission, the patient was admitted as an outpatient for a left heart catherization, coronary arteriography using two catheters and left ventricular angiography, the patient was found to have arteriosclerotic heart disease. The patient has no history of cardiac surgery. The appropriate sequencing of ICD-10-CM and CPT codes for the outpatient catherization would be _________________. - ANS-I25.10- atherosclerotic heart disease of native coronary artery without angina pectoris; 93458- with left heart catherization including intraprocedural injection(s) for left ventriculography, when performed Documentation in the record reveals that a patient is admitted with an acute exacerbation of COPD (MS-DRG 192). A higher pay DRG may be appropriate if documentation is present in the record at the time the decision was made to admit the patient that confirms a diagnosis associated with which of the following _____________________________. - ANS-Blood gases of pO2 of 58, pCO2 of 55, pH of 7.32 open admission and treated with intubations and mechanical ventilation for 23 hours A female patient is discharged with congestive heart failure. Which of the following will increase the MS-DRG weight if present on admission? - ANS-Stage III pressure ulcer If the principal diagnosis is an initial episode of an anterior wall myocardial infarction, which procedure will result in the higher DRG? - ANS-Transbrochial lung biopsy A patient is admitted with spotting and fever. She is found to have been treated for a miscarriage (spontaneous abortion), which was resolved two weeks prior to this admission. She is treated with aspiration dilation and curettage and products of conception are found. She is found to be septic. Which of the following diagnoses should be principal diagnosis? - ANS-Complications following abortion and ectopic or other pregnancy A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would increase the MS-DRG weight? - ANS-Respiratory failure During an admission for congestive heart failure (CHF), a chest x-ray was done to evaluate for the presence of CHF. An asymptomatic hernia was also found for which no treatment or evaluation was done. What is the reason that the hernia should not be coded? - ANS-The hernia is an incidental findings and does not meet the UHDDS requirements
C80.2, malignant neoplasm associated with transplanted organ, C22.0, liver cell carcinoma A child has second- and third-degree burns of the left lower leg and second- and third- degree burns of the lower back with a total of 16 percent total body surface areas (TBSA), 9 percent third-degree. What is the correct code assignment? - ANS-T24.302A- burn of third degree of unspecified site of left lower limb, except ankle and foot, initial encounter, T21.34XA- burn of third degree of lower back, initial encounter, T31.10, diagnosis of burns involving 10-19% of body surface with 0% to 9% third degree burns The "code, if applicable, any causal condition first" note in the ICD-10-CM tabular lists indicates that this code may be assigned when the causal condition is unknown or not applicable. When the causal condition is known, the code for that condition may be reported as which of diagnosis? - ANS-Principal 45-year-old patient admitted with insulin dependent diabetes. The type of diabetes is not specified in the medical record. How should this be coded? - ANS-E11.9- type 2 diabetes mellitus without complications, Z79.4- long term (current) use of insulin A 65-year-old man is admitted due to an acute myocardial infraction. The patient also has coronary artery disease. How should this be coded? - ANS-AMI, CAD A patient is admitted to the hospital during the postpartum period as a result of developing a thromboembolism or pulmonary blood clot leading to respiratory failure. What is the principal diagnosis? - ANS-O22.23- a diagnosis of superficial thrombophlebitis in pregnancy, third trimester Patient admitted with hemorrhage due to placenta previa with twin pregnancy. This patient had two prior (caesarean section) deliveries. Emergency C-section was performed due to the hemorrhage. The appropriate principal diagnosis would be __________________________________. - ANS-Placenta previa with hemorrhage A 70-year-old patient was admitted with pneumonia. The history and physical documented that the patient has a history of diabetes, hypertension, and migraine headache about 10 years ago without recurrence. The patient was administered IV antibiotics, metformin, and Altace during the hospitalization. Which conditions would be reported at the time of discharge? - ANS-Pneumonia, diabetes, and hypertension A diabetic patient was admitted for a treatment of a pressure ulcer. The patient also has a history of diabetic neuropathy and retinopathy. The patient is also blind and additional nursing care and extended time with the patient was required. Which conditions should be coded at discharge? - ANS-Pressure ulcer, diabetic neuropathy and diabetic retinopathy, and blindness A patient has an inpatient discharge with principal diagnosis of either peptic ulcer or cholecystitis documented on the history and physical. Both are equally treated and well
documented. A coder should ______________________________________. - ANS- Code based on the circumstances of admission and if both are equally treated, code either as principal A 75-year-old woman is admitted to the hospital after tripping and falling at home. She underwent an open reduction with internal fixation of the femur. Which of the following would be important to capture in addition to diagnostic codes? - ANS-External cause codes for Cause of Injury, Place of Occurrence, Activity, and Status In CPT, unlisted codes are reported only if _________________________. - ANS- There is not a HCPCS Level II code or a current CPT level III code A virtual screening colonoscopy would be coded as __________. - ANS-74263- computed tomographic CT colonography, screening including image postprocessing A patient underwent an excision of a malignant lesion of the chest that measured 1.0cm and there was a 0.2-cm margin on both sides. Based on the 2019 CPT codes, which code would be used for the procedure? - ANS-11602- Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent a percutaneous intradiscal electrothermal annuloplasty (IDET) in the radiology suite. What ICD-10-PCS code should be used? - ANS-0S523ZZ- Destruction, lumbar vertebral disc, percutaneous approach A laparoscopic tubular ligation with Falope ring is completed. What is the correct CPT code assignment? - ANS-58671, laparoscopy, surgical, with occlusion of oviducts by device (e.g., band, clip, Falope ring) 67-year-old patient presents with carcinoma of multiple overlapping sites of the bladder. Diagnosis cystoscopy and transurethral fulguration of bladder lesions (1.9 cm, 6.0 cm) are undertaken. The appropriate CPT codes would be ______________________________________________. - ANS-52240, cystrourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of large bladder tumor(s) A patient presents to a facility for upper endoscopy implant of material into the muscle of the lower esophageal sphincter. The correct coding and sequencing of this patient's record is ____________________________. - ANS-43236, with directed submucosal injection(s), any substance A patient undergoes colposcopy with endometrial biopsy. Which of the following is correct? - ANS-Two codes would be used in accordance with CPT code instructions
clip, metallic pellet), when performed, and imaging of biopsy specimen, when performed, percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) Patient is recently diagnosed with a renal cyst. Patient presents today for treatment. The renal cyst is aspirated by percutaneous needle. What is the correct code to report? - ANS-50390, aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Which of the following is the correct code for the laser destruction of polyps during proctosigmoidectomy? - ANS-45315, proctosigmoidoscopy, rigid A patient has a retinal detachment and presents today for repair. The procedure note documents repair of a retinal detachment with a retinopathy. What is the correct procedure code? - ANS-67110, repair of retinal detachment by injection by injection of air or other gas (e.g. pneumatic retinoplexy) From the information provided, how many APCs would impact this patient's total reimbursement? - ANS- What percentage will the facility be paid for procedure code 25500? - ANS-100% If another status T procedure were performed, how much would the facility receive for the second status T procedure? - ANS-50% This 18-year-old patient with an abnormal blood test underwent bone marrow aspiration from the sternum. The area was cleaned with antiseptic solution, and a local anesthetic was injected. The needle was inserted beneath the skin and rotated into the cortex and the sample taken. The needle was repositioned slightly, and a new syringe attached, and a second sample was obtained. These were sent to the laboratory for analysis. The results show acute lymphoblastic leukemia. What is the correct CPT code? - ANS- 38220, diagnostic bone marrow aspiration The outpatient code editor (OCE) has all of the following types of edits except _______________________. - ANS-Age and sex edits The case-mix index for the information provided above to ____________. - ANS-2. The information provided shows that _________________________________. - ANS- The payment is higher for patients with pneumonia with CCs than without A nurse inadvertently records an incorrect vital sign in a patient electronic health record. The next day, a correction was made in the electronic health record. This resulted in the corrected vital sign being recorded at the time the correction was made due to the software. What would be the result of this correction? - ANS-There was a distorted trend line of vital signs date
According to the UHDDS, in order to assign a code for another diagnosis, documentation must be present that ______________________________________________. - ANS-The condition was clinically evaluated or therapeutically treated, extended the length of hospital stay, or increased nursing care or monitoring The quality of data is most directly tied to the ______________________. - ANS-Use or application of the data Poor-quality data collection and reporting can affect __________________________________________________. - ANS-Patient care, documentation, revenue generation, outcomes evaluation, and public health reporting, use of record for legal purposes, and patient care, communication, research activities, and public health reporting (all of the above) The most succinct definition of where information comes from is ________________________________. - ANS-Proceeded data The Joint Commission considers what kind of management to be important for safe, quality care? - ANS-Information management Based on the AHIMA Code of Ethics, which of the following is not considered an ethical activity? - ANS-Reviewing the history and physical of a coworker when not part of work assignment Retention policies for the health information department depend on organizational retention policies that must be in accordance with local, state, and federal laws and regulations. These policies vary from institution to institution. In many instances, healthcare institution may retain health records longer than the law requires. Which of the following best describes how the retention of records should be determined? - ANS- Unless state or federal law requires longer periods of time, specific patient health information should be retained for established minimum time periods A patient is admitted to undergo a laparoscopic cholecystectomy. Following the insertion of the laparoscope into the abdominal cavity, the patient experienced a cardiac arrhythmia and the procedure was terminated. The patient experienced a potentially compensable event resulting in an incident report. Which department may request to see the patient's record? - ANS-Risk management
