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Chp 16 Coding Practice Questions &
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Tricia Thornwell, a 68-year-old female, was going walking when she fell down the icy front steps of her house; now she can't bear weight on her right leg. She is brought into the ER by ambulance. After the ER physician completed a thorough exam and reviewed the x-ray, he diagnosed her with a femoral neck base fracture, nondisplaced. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Fracture What type? Traumatic What is the anatomical site? Femur What is the location? Upper end, neck Do any of the following apply to the condition? Nondisplaced What is the laterality? Right Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No
If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S72.044A Second diagnosis Where should you begin to look up the code in the coding manual? External cause of injuries index What is the key term? Fall from What? Stairs Due to? Ice and snow Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes
What is the key term? Sprain What is the anatomical site? Ankle What is the location? Calcaneofibular ligament What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? Yes If so does the Code also note apply to the case study? No Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S93.412A
Second diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Sprain What is the anatomical site? Ankle What is the location? Tibiofibular ligament What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the Billy Ugro, a 7-year-old male, was brought in by his mother. Billy was playing this afternoon in his backyard on the sliding board and fell, scraping his left cheek. Dr. Tucker, his pediatrician, examines the area and cleans and dresses the wound. Billy is diagnosed with a second-degree abrasion. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Abrasion What is the anatomical site? Cheek What degree Second Do any of the following apply to the condition? None of these What is the laterality? Left Do any of the following apply to the condition? Initial encounter
Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No C PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555- PATIENT: KIM, LINDA ACCOUNT/EHR #: KIMLI DATE: 09/16/ Attending Physician: Oscar R. Prader, MD S: This new Pt is a 29-year-old female who presents with splatter burns on the back of her right hand and her right cheek. She stated that she was deep-frying shrimp for a dinner party at her home in the kitchen and the grease splattered unexpectedly. O: Ht. 5′6″, Wt. 152 lb., R 20. Skin is red and blistered on both sites. There is some epidermal loss. Area was cleansed with antiseptic, and ointment was applied before a clean gauze bandage was put on the hand. The facial area was also cleansed and bandaged. A: Second-degree burns to back of hand and face. P: 1. Rx: Aspirin for pain, prn
- Return in 1 week for dressing change. - ANSWERSDiagnosis Code(s) T23.261A T20.26XA T31. X10.2XXA Y92. Y93.G Y99. WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555- PATIENT: O'MALLEY, REGINA ACCOUNT/EHR #: OMALRE DATE: 09/16/ Attending Physician: Renee O. Bracker, MD
S: Pt is a 6-year-old female seen in our emergency facility. She was brought in by ambulance, accompanied by her mother. Mother states that they were baking cookies when the phone rang; she turned to answer it and when she returned, the child was unconscious on the kitchen (apartment) floor, a bottle of wintergreen oil found empty next to the patient. O: Pt is listless and unresponsive. Respiration labored, BP 80/65, P slow and erratic. Skin is pale and moist. Stomach pumped. Pt responding to treatment. A: Poisoning by overdose of wintergreen oil, accidental P: Admit to pediatric unit. - ANSWERSDiagnosis Code(s) T49.3X1A R40. Y92. Y93.G Y99. PRADER, BRACKER, & ASSOCIATESA Complete Health Care Facility159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555- PATIENT: ZIMMER, CYRUSACCOUNT/EHR #: ZIMMCY001DATE: 09/16/ Attending Physician: Oscar R. Prader, MD S: This new Pt is a 56-year-old male who was involved in an accident when the motorcycle he was driving was struck by a car on a street near his house. Cyrus admits to riding motorcycles for recreation. He is complaining about some neck pain. He has tingling into his hand and feet. He states that his left arm hurts when he tries to pull it overhead. PMH is remarkable for kidney trouble. Past bronchoscopy, laparoscopy, and kidney stone surgery, otherwise noncontributory as per the medical history form completed by the patient and reviewed this encounter. O: Ht. 5′9″, Wt. 181 lb., R 18. On exam, the left shoulder demonstrates full passive motion. He has normal strength testing. He has no deformity. He - ANSWERSDiagnosis Code(s) S12.110A S43.015A V23.4XXA Y92. Y93. Y99. Michael George, a 28-year-old male, presents today with a wound to his lower right leg. Michael stated this morning at home he accidentally stepped on his cat's tail and the cat bit him. The cat has been vaccinated for rabies. Dr. Coleman examines, cleans, and dresses the area and prescribes a round of antibiotics as a precaution. - ANSWERSWhat is the principal diagnosis code?
If so does the Use additional code note apply to the case study? Yes Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? T24.211A Second diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Burns What extent? Less than 10% Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is the Carolina Tanner, an 18-year-old female, came into the emergency department with a wrist sprain where a baseball had hit her. She is on her school baseball team and was
at a practice game being played on the school baseball field and got hit by the ball. She was in obvious pain, and the wrist was swollen and too painful upon attempts to flex. After Dr. Rodgers reviewed the x-ray Carolina is diagnosed with a Salter-Harris, type II fracture of the distal radius, left. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Sprain What is the anatomical site? Ankle What is the location? Calcaneofibular ligament What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? Yes If so does the Code also note apply to the case study? No Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No
Do any of the following apply to the condition? None of these What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? Yes If so does the Code also note apply to the case study? No Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S71.112A Second diagnosis Where should you begin to look up the code in the coding manual? External cause of injuries index
What is the key term? Contact With? Knife Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notatio Jamie McIntyre, a 43-year-old female, presents today with a painful blister on her right hand. Jamie is trying to get in shape and has begun to play handball. Dr. Brown completes an examination and diagnoses Jamie with a superficial blister on the palm of her hand between the third and fourth metacarpals. - ANSWERSPrimary diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Blister What is the anatomical site? Hand Do any of the following apply to the condition? None of these What is the laterality? Right Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note
If so does the Code also note apply to the Dean Williams, a 5-year-old male, is brought into the ED by ambulance. Dean's grandmother stated he was playing in the yard where she has ornamental plants. One plant has mezereon berries and the birds were eating them, so Dean ate one too. Dean began to have a choking sensation. Dr. Adams completes a thorough examination and the laboratory results confirmed the diagnosis of accidental poisoning. - ANSWERSWhat is the principal diagnosis code? T62.1X1A What is the second diagnosis code? R09. What is the third diagnosis code? Y92. PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555- PATIENT: JANKOWSKI, HILDA ACCOUNT/EHR #: JANKHI DATE: 07/16/ Attending Physician: Renee O. Bracker, MD S: Patient, a 9-year-old female, was brought in by her mother. She had just returned from a school hiking trip in the mountains when her parents noticed a problem with her right shoulder. The patient states that her shoulder started bothering her early Sunday morning, but by the time she arrived home Sunday evening, it was much worse. Her mother called a nurse hotline and the nurse suggested an anti-inflammatory, so the parents gave her 250 mg of Tylenol. The patient is right-handed and noticed, upon waking this morning, that she could not move her arm without a great deal of pain and that her hand was tingling, particularly her fingers. She denies any fall or accident during the trip. O: Exam r - ANSWERSDiagnosis Code(s) S43.141A Y92. Y93. Y99. Kim Horton, a 4-year-old female, is brought in today by her father. Kim was playing with her father's pocket change and swallowed a nickel. Dr. Grebner, her pediatrician, notes labored breathing and orders an x-ray, which shows the nickel is lodged in the
oropharynx. Dr. Grebner is able to remove the nickel without difficulty. - ANSWERSWhat is the principal diagnosis code? T17.290A Janie Walters, a 27-year-old female, presents today with burns on her left hand. Over the weekend, Janie was at a campout and while toasting marshmallows over a bonfire, got too close to the flame, burning her left fingers. Dr. Platzs thoroughly examines Janie's hand and fingers, noting redness with blisters on the second, third, and fourth phalanges. Janie is diagnosed with second-degree burns of the fingers, multiple sites. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Burns What is the anatomical site? Finger Do any of the following apply to the condition? Multiple site Do any of the following apply to the condition? None of these What is the laterality? Left What degree? Second Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? Yes
Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Fracture What type? Traumatic What is the anatomical site? Tibia What type? Oblique Do any of the following apply to the condition? None of these What is the laterality? Right Do any of the following apply to the condition? Initial encounter Do any of the following apply to the condition? Open fracture type I Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No
Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S82.231B Second diagnosis Where should you begin to look up the code in the coding manual? External cause of injuries index What is the key term? Struck by What? Object Do any of the following apply to the condition? Projected Do any of the following apply to the condition? In sports What type of object? Baseball Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of D
