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CCS Certified Coding Specialist Exam
Current Procedural Terminology (CPT) defines a separate procedure as which of the following? a. When performed in conjunction with another service, is considered an integral part of the major service b. Provision of anesthesia c. Joint aspiration is required d. Pre-operative evaluation is not required - ✔✔a. When performed in conjunction with another service, is considered an integral part of the major service 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 - ✔✔d. K74.60, I85. 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 - ✔✔ Assign the code(s) for endoscopic sinusotomy with bilateral anterior ethmoidectomy. 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) −50 Bilateral procedurea. a. 31254 b. 31254- 50 c. 31254, 31254 d. 31231 - ✔✔b. 31254- 50 31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) −50 Bilateral procedurea. ** A code for the anterior ethmoidectomy is assigned and to denote the bilateral procedure, a modifier of - 50 is added (CPT Assistant Winter 1993, 23; Jan. 1997, 4; Sept. 1997, 10; Oct. 1997, 5; Dec. 2001, 6; May 2003, 5). The sinusotomy is not coded separately, as it is a diagnostic procedure. The most common language used for both data definition language and data manipulation language is: a. Unified modeling language b. JAVA c. Perl d. Structured query language - ✔✔d. Structured query language
** 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 - ✔✔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 - ✔✔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 - ✔✔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). .In order to accurately code a cardiac catheterization, what needs to be determined based on a review of the documentation? a. The approach and the side of the heart (chambers) into which the catheter was inserted b. The approach, the side of the heart (chambers) into which the catheter was inserted, as well as any additional procedures performed c. The duration of the procedure d. If there is documentation of the procedure in the medical record that stents are considered - ✔✔b. The approach, the side of the heart (chambers) into which the catheter was inserted, as well as any additional procedures performed A condition is present on admission when: a. It is the principal diagnosis b. It is accordance with medical staff bylaws
**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 - ✔✔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 - ✔✔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 change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. What potential diagnosis most closely fits the patient's overall symptoms? a. Insomnia b. Major depression c. Reye's synd - ✔✔b. Major depression The CPT definition of a surgical package contains which of the following? a. The surgical procedure(s) b. Follow-up surgery c. Preoperative tests d. Yearly follow-up visits - ✔✔a.The surgical procedure(s) **The surgical package refers to a combination of individual services provided during one surgical operation (Smith 2017, 55).
** 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 - ✔✔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 - ✔✔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 - ✔✔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). ** In order to determine the correct procedure code, the lengths of the wounds repaired with the same type of closure are added together (AMA CPT Professional Edition 2017, 75, Surgery/ Integumentary Section directions). [Note: Since this is an emergency department visit, CPT codes are assigned, rather than ICD- 10 - PCS codes.] A patient was treated in the emergency department with lacerations of the neck and underwent a repair of two (2) wounds of the neck (2.0 cm and 1.4 cm) with layered closure. What are the diagnosis (excluding external cause codes) and procedure codes assigned?
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 - ✔✔d. J44.1, I12.0, N18. 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 - ✔✔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 - ✔✔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 - ✔✔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). A bronchoscopy with biopsy of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure codes?
**When an question is asked about an outpatient acuity map, the coder must review the map and determine the relevant elements that make up the means by which a CPT code and level is assigned. In the case of this map, and in this question, the number of tests ordered is the answer. Assign the code(s) for chemotherapy for 3 hours' infusion. 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 - ✔✔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? - ✔✔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 - ✔✔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 - ✔✔b. Ensuring the accuracy and completeness of an organization's data
a. Data models are entities that store individual data; data dictionaries are an alphabetic index of all data values b. Data models are used for relational databases only; data dictionaries are used for objectoriented databases c. Data models provide the conceptual and graphical framework that helps define the entity and its attributes; data dictionaries provide details on - ✔✔c. Data models provide the conceptual and graphical framework that helps define the entity and its attributes; data dictionaries provide details on each data element **Data models provide a conceptual framework and graphical representation that help in defining data elements. Data dictionaries are documents that explain in 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 - ✔✔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 - ✔✔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. b. R04. c. C34.31, R04. d. - ✔✔c. C34.31, R04. C34.31: Malignant neoplasm of lower lobe, right bronchus or lung
