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CCS Medical Exam 2
This episode of care occurs in the ER which is an outpatient setting, therefore, a CPT code should be used. CPT code 36904 correctly identifies the thrombectomy procedure because it specifies the site of the thrombectomy as "dialysis circuit." 36904 includes imaging guidance, diagnostic angiography, catheter placement, and intraprocedural pharmacological thrombolytic injections" (Kirchoff 2009, 203). Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD- 10 - PCS procedure code for this surgery. 0BQT4ZZRepair diaphragm, percutaneous endoscopic approach 0BQT3ZZRepair diaphragm, percutaneous approach 0WQF4ZZRepair abdominal wall, percutaneous endoscopic approach 0BQT0ZZRepair diaphragm, open approach a. 0BQT4ZZ b. 0BQT3ZZ c. 0WQF4ZZ d. 0BQT0ZZ - ✔✔Correct Answer: A Heart failure is assigned a combination code when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those patients with heart failure (CMS 2020a, Section I.C.9.a.1, 46-47). A patient is seen for evaluation of a right orbital roof fracture. How should this be coded? S02.121AFracture of orbital roof, right side, initial encounter for closed fracture S02.31XAFracture of orbital floor, right side, initial encounter for closed fracture S02.92XAUnspecified fracture of facial bones, initial encounter for closed fracture S02.91XAUnspecified fracture of skull, initial encounter for closed fracture
a. S02.121A b. S02.31XA c. S02.92XA d. S02.91XA - ✔✔Correct Answer: A Alphabetic Index for fracture, traumatic; orbit, orbital; roof guides the coder to S02.12. Evaluation of a fracture is an example of active treatment which is reported with 7th character "A" (Schraffenberger and Palkie 2020, 580-584). Patient presents in the ER with thrombosis of a loop PTFE hemodialysis fistula without mechanical complications. The physician performed a percutaneous thrombectomy of the left brachial vein. Assign a facility code for this outpatient procedure. 05CA3ZZExtirpation of matter from left brachial vein, percutaneous approach 36904Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s) 36832Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) 37184Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intrapro - ✔✔Correct Answer: B Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. I10Essential (primary) hypertension I11.0Hypertensive heart disease with heart failure I50.9Heart failure, unspecified I50.23Acute on chronic systolic (congestive) heart failure a. I10, I50. b. I11. c. I50.23, I
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 firstlisted diagnosis for this encounter? a. Elevated blood pressure b. Hematochezia c. Procedure not performed due to contraindication d. Procedure not performed for other reason - ✔✔Correct Answer: B When a patient presents for outpatient surgery, code the reason for the surgery as the firstlisted diagnosis (reason for the encounter) even if the surgery is not performed due to a contraindication (CMS 2020a, Section IV.A.1., 113). A 55-year-old patient with AIDS admitted after being struck by car while walking in a parking lot. She has a comminuted, right femoral shaft fracture and a contusion of both hands and right elbow abrasion. The principal diagnosis should be the: a. AIDS b. Fractured femur c. Abrasion elbow d. Contusion hand - ✔✔Correct Answer: B If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (for example, the nature of injury code) should be the principal diagnosis. The most severe injury should be sequenced first. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions (CMS 2020a, Section I.C.1.a.2.b., 21). A patient takes Coumadin as prescribed and correctly administered. However, the patient develops hematuria secondary to the Coumadin use. The correct coding assignment for this case would be: a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria, poisoning due to Coumadin d. Hematuria, adverse reaction to Coumadin - ✔✔Correct Answer: D
An adverse reaction can occur when a drug was correctly prescribed and administered. In the case of an adverse reaction, the manifestation is coded first (Hematuria) followed by a T code for the medication (Coumadin) (CMS 2020a, Section I.C.19.e.5(a), 81). A patient with human immunodeficiency virus (HIV) with methicillin susceptible pneumonia due to Staphylococcus aureus was discharged from the acute-care setting. The physician documented that the pneumonia was HIV related. How should this be coded?B20Human immunodeficiency virus [HIV] disease J15.20Pneumonia due to staphylococcus, unspecified J15.211Pneumonia due to methicillin susceptible Staphylococcus aureus J15.212Pneumonia due to methicillin resistant Staphylococcus aureus J17Pneumonia in diseases classified elsewhere a. B20, J b. J15.20, B c. B20, J15. d. J15.212, B20 - ✔✔Correct Answer: C This is a confirmed HIV case; therefore, the HIV is sequenced as principal diagnosis, followed by the additional diagnosis code for the MSSA pneumonia (CMS 2020a, Section I.C.1.a., 21). A patient has a diabetic ulcer of the right foot. How should this patient's record be coded? E11.40Type 2 diabetes mellitus with diabetic neuropathy, unspecified E11.621Type 2 diabetes mellitus with foot ulcer E11.69Type 2 diabetes mellitus with other specified complication L97.409Non-pressure chronic ulcer of unspecified heel and midfoot with unspecified severity L97.419Non-pressure chronic ulcer of right heel and midfoot with unspecified severity a. E11.40, L97.
c. K21.9, Gastroesophageal reflux disease without esophagitis d. R07.9, Chest pain, unspecified - ✔✔Correct Answer: C In the inpatient setting, rule out diagnoses are coded as if they exist. In this case, the patient has chest pain and the reason for the chest pain is rule out gastroesophageal reflux disease (GERD). This requires that the GERD be coded as the first-listed diagnosis (CMS 2020a, Section II, H., 109). If a patient undergoes an open biopsy for a frozen section immediately before the definitive surgery, how should this be coded with ICD- 10 - PCS codes? a. Definitive surgery only b. Open biopsy only c. Exploratory surgery d. Open biopsy and definitive surgery - ✔✔Correct Answer: D The open biopsy is performed prior to the definitive surgery so that the pathologist can perform a frozen section of the tissue to determine malignancy. Approaches, suturing, and closure are not coded separately. Exploratory surgery is not coded when definitive surgery is performed (Schraffenberger and Palkie 2020, 178, 200, 392). The physician performed a bilateral myringotomy under general anesthesia for insertion of ventilating tubes on a 4-year-old male. This is due to chronic otitis media. What is the correct CPT code assignment and what modifier should be appended (if applicable) to this procedure code? 69421Myringotomy including aspiration and/or Eustachian tube inflation requiring general anesthesia 69436Tympanostomy (requiring insertion of ventilating tube), general anesthesia −50Bilateral procedure −51Multiple procedures −RTRight side −LTLeft side a. 69421-RT, LT b. 69421-LT c. 69436- 51
d. 69436- 50 - ✔✔Correct Answer: D A myringotomy for insertion of ventilating tubes is a tympanostomy, which is described by codes 69433-69436. Code 69436, Tympanostomy (requiring insertion of ventilating tube), general anesthesia describes the procedure performed. In addition, this procedure was performed bilaterally, therefore, modifier - 50 is added (Smith 2020, 50, 188 - 189). In outpatient surgery, a PTCA is completed with insertion of a drug-eluting stent in the left circumflex artery and a non-drug-eluting stent inserted into the left anterior descending artery of this 56-year-old female. Assign the correct CPT code(s) and modifier(s) for this procedure. 92920Percutaneous transluminal coronary angioplasty; single major coronary artery or branch +92921each additional branch of a major coronary artery (List separately in additional to code for primary procedure.) 92928Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch +92929each additional branch of a major coronary artery (List separately in addition to code for primary procedure.) −LCLeft circumflex coronary artery −LDLeft anterior descending coronary artery a. 92921, 92920 b. 92928-LC, 92928-LD c. 92920-LC, 92921-LD, 92928-LC, 92929-LD d. 929 - ✔✔Correct Answer: B CPT codes 92928-LC and 92928-LD would be reported for transcatheter stenting (Smith 2020, 278). Itching due to drug reaction to an antihistamine, properly taken. What are the appropriate codes and sequencing for this scenario?L29.9Pruritus, unspecified R89.2Abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissues
d. Qualified - ✔✔Correct Answer: C "Code, if applicable, any causal condition first" notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable. If a causal condition is known, then the code for that condition should be sequenced as the principal or first-listed diagnosis (CMS 2020a, Section I.B.7, 15). 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. What is the appropriate reporting and sequencing of these diagnoses? a. Diabetes, pneumonia, hypertension, and migraine headaches b. Pneumonia, diabetes, hypertension, and history of migraine headaches c. Pneumonia, diabetes, and hypertension d. Hypertension, diabetes, and pneumonia - ✔✔Correct Answer: C Pneumonia, diabetes, hypertension should be coded with the principal diagnosis of pneumonia since that was the reason for the admission. The migraine headaches are a past condition and would not be coded as per the reporting guidelines for the UHDDS for "other conditions" (CMS 2020a, Section III, 110-112). Patient is admitted for removal of the gallbladder due to chronic cholecystitis. While performing a common bile duct exploration, a non-obstructive calculus was found and removed as well. Assign the correct coding sequence for a total laparoscopic cholecystectomy with percutaneous endoscopic removal of common bile duct stones. a. 0FC90ZZ, Extirpation of matter from common bile duct, open approach 0FB40ZZ, Excision of gallbladder, open approach b. 0FB40ZZ, Excision of gallbladder, open approach c. 0FC94ZZ, Extirpation of matter from common bile duct, percutaneous endoscopic approach 0FT40ZZ, Resection of gallbladder, open approach d. 0FT44ZZ, Resection of gallbladder, percutaneous endoscopic approach and 0FC94ZZ, Extirpation of matter from common bile duct, percutaneous endoscopic approach - ✔✔Correct Answer: D Selection of principal procedure guideline 1 indicates that when definitive procedures are performed for treatment of both the principal and secondary diagnoses, the procedure most closely related to the principal diagnosis is sequenced as the principal
procedure. Since the patient was admitted for the cholecystitis, the cholecystectomy is the principal procedure. The common bile duct exploration is not assigned separately since the calculus was removed. The root operations for these two procedures are Resection for the total cholecystectomy and Extirpation for the removal of the common bile duct calculus (Leon-Chisen 2020, 247-248). A patient is admitted with hypotension due to dobutamine taken and prescribed correctly. How should this be coded and sequenced? a. T44.5X5A, Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter I95.1, Orthostatic hypotension b. I95.2, Hypotension due to drugs T44.5X5A, Adverse effect of predominantly beta-adrenoreceptor agonists, initial encounter c. T44.5X1A Poisoning by predominantly beta-adrenoreceptor agonists, initial encounter I95.89, Other hypotension d. T44.5X1A Poisoning by predominantly beta-adrenoreceptor agonists, initial encounter I95.81, Postprocedural hypotension - ✔✔Correct Answer: B This is an adverse effect of a drug as the dobutamine was prescribed correctly and the patient took it correctly. Hypotension, should be assigned to describe the condition related to the adverse effect. A "T" code should be assigned as a secondary diagnosis code to indicate that it is an adverse effect of the drug (CMS 2020a, Section I.C.19.e., 80 - 83). A female patient is diagnosed with congestive heart failure and also has a stage IV pressure ulcer. Which of the following POA indicators must be present so that the ulcer will be classified as an MCC for this admission? a. N b. Y c. W d. U - ✔✔Correct Answer: B CMS designates stage III and IV pressure ulcers as a hospital acquired condition (HAC). If a HAC diagnosis is present at admission (Y), it will be classified as CC or MCC and will impact MS-DRG reimbursement by raising the relative weight of the MS-
d. W - ✔✔Correct Answer: A Chronic conditions should have a POA indicator of Y, even if they are diagnosed after admission (CMS 2020a, 117-121) Which of the following is not a function of the outpatient code editor (OCE)? a. Editing the data on the claim for accuracy b. Specifying the action the FI should take when specific edits occur c. Assigning APCs to the claim (for hospital outpatient services) d. Determining payment-related conditions that require direct reference to ICD- 10 - CM codes - ✔✔Correct Answer: D The outpatient code editor (OCE) performs four basic functions: editing the data on the claim for accuracy, specifying the action the fiscal intermediary should take when specific edits occur, assigning APCs to the claim (for hospital outpatient services), and determining payment-related conditions that require direct reference to HCPCS codes or modifiers (Smith 2020, 314-315). A patient comes into the hospital with chest pain, shortness of breath, and a history of COPD. An MRI, chest x-ray, troponin, and CKMB are ordered. A coder might expect a medical necessity edit to be triggered for which test? a. Troponin b. Chest x-ray c. MRI d. CKMB - ✔✔Correct Answer: C The chest x-ray, CKMB, and troponin are all related to the diagnoses given, but there is no diagnosis that supports medical necessity for the MRI (Casto 2018, 256). A coder assigns both 47562 and 47600 on the same patient's record. What coding edit should be triggered? a. Medical necessity b. Medically unlikely c. Sex/procedure edit
d. Diagnosis/age edit - ✔✔Correct Answer: B These codes are both for cholecystectomy; one performed laparoscopically, one performed via an open approach. This should trigger a medically unlikely edit since the patient only has one gallbladder to remove, which would be done with one method or another, but not both (Casto 2018, 256). A Medicare patient admitted as an inpatient with acute abdominal pain is found to have appendicitis and has an appendectomy. The patient has a length of stay of two days. Reimbursement will be paid under which classification system? a. MS-DRG b. APG c. RBRVS d. APC - ✔✔Correct Answer: A Medicare reimburses inpatient stays based on MS-DRGs (Casto 2018, 116-118). Medicare severity diagnostic-related groups (MS-DRGs) and ambulatory patient classifications (APCs) are dissimilar in that: a. There is only one MS-DRG per inpatient discharge but one or more APCs per outpatient visit b. There are many MS-DRGs per inpatient discharge but only one APC per outpatient visit c. There are more possible MS-DRGs for inpatients than there are APCs for outpatients d. There are up to three MS-DRGs per each inpatient discharge but there are up to seven APCs per outpatient visit - ✔✔Correct Answer: A There is only one MS-DRG per inpatient discharge but there can be one or more APCs per outpatient visit (Casto 2018, 115-128, 156-168). Which of the following services are paid under the outpatient prospective payment system (OPPS)? a. Ambulance services b. Same-day surgeries c. Physician fees
Comorbid conditions are the data elements that a coding professional would abstract from the record (Schraffenberger and Palkie 2020, 93). What factors of the APR-DRG system allow for capturing the extent of the patient's conditions and expected loss of life while an inpatient? a. Severity of illness and risk of mortality b. Severity of diagnosis and risk of morbidity c. Complications and comorbidities d. Hospital acquired conditions and present on admission - ✔✔Correct Answer: A SOI and ROM are the factors that are used in the APR-DRG system to classify how ill a patient is and whether they are expected to die while admitted (Foltz et al. 2016). Which of the following diabetic conditions is considered an MCC? a. Type II diabetes without complication b. Type I diabetes without complication c. Type I diabetes with ketoacidosis d. Type II diabetes with polyneuropathy - ✔✔Correct Answer: C The Type I diabetes with ketoacidosis is considered an MCC (Optum 360, 2019). Which of the following injuries would you expect to see with an MCC designation? a. Dislocation of jaw b. Laceration with foreign body of the neck c. Fout-part humeral fracture of surgical neck d. Blister of the right eyelid and periocular area - ✔✔Correct Answer: C The fracture condition is the one with the MCC designation. None of the other conditions are MCCs or even CCs (Optum 360, 2019). A psychiatrist documents that a patient has wide mood swings ranging from excessive happiness to loss of energy and crying. What condition could be suggested by the psychiatrist's documentation?
a. Bipolar disorder b. Major depression c. Anxiety d. Psychosis - ✔✔Correct Answer: A Recurring mood changes that result in periods of severe depression alternating with extreme elation that are beyond the normal range of mood swings are called bipolar or circular disorders (Schraffenberger and Palkie 2020, 216). A patient record has documentation of esophageal varices. Which condition, if related, would affect coding? a. Arthritis b. Liver disease c. Chronic obstructive pulmonary disease d. Erythema - ✔✔Correct Answer: B Esophageal varices are often associated with cirrhosis of the liver. If documented, dual coding is required with the underlying condition coded first (Schraffenberger and Palkie 2020, 370-372). A patient is admitted with lethargy, congestive heart failure, and pleural effusion. The patient underwent treatment with diuretics for the CHF, which has cleared. The pleural effusion required a thoracentesis to determine the cause. At the time of discharge, the effusion was decreased but not resolved. The correct coding assignment for this case would be: a. Congestive heart failure b. Pleural effusion c. Congestive heart failure and pleural effusion d. Lethargy, congestive heart failure, and pleural effusion - ✔✔Correct Answer: C Pleural effusion can be a symptom of CHF; however, in this case, it can be coded because it meets the definition for coding additional diagnosis (it required a diagnostic procedure and it was still unresolved at discharge) (CMS 2020a, Section III, 110-112). The sequencing of the two codes would depend on the documentation and circumstances of the admission.
a. Specific location on the arm of each laceration b. If tissue adhesive was utilized c. The type of repair that was performed for each laceration d. If anesthesia was necessary for the procedure - ✔✔Correct Answer: C When multiple wounds are repaired with the same closure type (for example, simple), lengths of the wounds in the same classification and from all anatomical sites that are grouped together into the same code descriptor should be added together (Smith 2020, 83 - 84). The patient had an esophagoscopy to control a GI bleed. The coder would expect to see the following documentation in the chart for the diagnosis since upper gastrointestinal bleeding manifests as: a. Hematemesis b. Occult bleeding c. Melena d. Hematochezia - ✔✔Correct Answer: A Upper gastrointestinal bleeding manifests as hematemesis (Schraffenberger and Palkie 2020, 380-381). A patient was admitted with pneumonia. A sputum culture was able to identify Mycoplasma pneumoniae which the consulting pulmonologist documented as the cause of the pneumonia. The patient was also diagnosed with an E. coli UTI. In the final diagnosis statement, the attending physician documents E. coli pneumonia and UTI. How will the coder code the pneumonia? a. Assign the code based on the final diagnostic statement b. Assign the pneumonia code based on the consultant's documentation c. Assign the pneumonia code based on the sputum result d. Query the attending provider to clarify the pneumonia organism - ✔✔Correct Answer: D When there is conflicting documentation in the record, the attending physician should be asked to clarify by the use of a query (AHIMA 2019c).
A short-stay procedure H&P indicates a patient is coming for a left nephroureteral catheter exchange. The interventional radiologist performs the procedure and states that using the existing access, he places a guide wire into the kidney and removed the catheter. With the same access, over the guide wire the new nephroureteral catheter is inserted into the right kidney and ureter. What needs to be clarified in this scenario? a. Was the approach open or closed b. Was it done on the left or right c. Was this done percutaneously d. Was this procedure done under anesthesia - ✔✔Correct Answer: B There is a discrepancy noted between the laterality in the H&P and the procedure report. Clarification is necessary in order to code correctly (AHIMA 2019c). A patient has presented for back surgery with a diagnosis of lumbar stenosis. Documentation notes the patient has leg pain, tingling, and cramping as a result of the stenosis. In the patient's final diagnosis, the surgeon notes only lumbar stenosis. What other diagnosis appears to be missing from this statement based on the information provided? a. Neurogenic claudication b. Neuropathy c. Degenerative disc d. Spondylosis - ✔✔Correct Answer: A The patient is suffering from leg pain, tingling, and cramping which when present with lumbar stenosis are indicative of neurogenic claudication. A query should be initiated to determine if that is part of the patient's condition, as it impacts the code chosen for reporting (AHIMA 2019c). When a patient is admitted and a discrepancy is noted in the documentation while the patient is still on the unit, who is responsible for obtaining clarity on the information? a. The charge nurse b. The clinical documentation specialist c. The coding professional d. The case manager - ✔✔Correct Answer: B
