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Medical Coding and Documentation in Clinical Practice, Exams of Medicine

Texas State University Medicine

Medical Coding and Documentation in Clinical Practice Medical Coding and Documentation in Clinical Practice

Typology: Exams

2024/2025

Available from 11/27/2025

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Medical Coding and Documentation in

Clinical Practice

1. A patient is admitted with spotting. She had been treated two

weeks previously for a miscarriage with sepsis. The sepsis had

resolved, and she is afebrile at this time. She is treated with an

aspiration dilation and curettage and products of conception are

found. Which of the following should be the principal diagnosis?

a. Miscarriage

b. Complications of spontaneous abortion with sepsis

c. Sepsis

d. Spontaneous abortion with sepsis - ANSWERS-a. Miscarriage

2. If a patient has an excision of a malignant lesion of the skin,

the CPT code is determined by the body area from which the

excision occurs and which of the following?

a. Length of the lesion as described in the pathology report

b. Dimension of the specimen submitted as described in the

pathology report

c. Width times the length of the lesion as described in the

operative report

d. Diameter of the lesion as well as the most narrow margins

required to adequately excise the lesion described in the

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Medical Coding and Documentation in

Clinical Practice

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage and products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis - ANSWERS-a. Miscarriage
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the

operative report - ANSWERS-d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management - ANSWERS-a. Congestive heart failure, respiratory failure, ventilator management
Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-10-PCS d. SNOMED CT - ANSWERS-a. CPT

A female patient is admitted for stress incontinence. A urethral suspension to reposition the urethra via open approach is performed. Assign the correct ICD-10-CM diagnosis and/or procedure codes. a. N39.3, 0TJB8ZZ b. N23, 0TSD0ZZ c. N39.3, 0TSD0ZZ d. R32, 0TSD4ZZ - ANSWERS-c. N39.3, 0TSD0ZZ
A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient? a. Abdominal pain b. Cholecystitis c. Hypertension d. Diabetes - ANSWERS-b. Cholecystitis
Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?

a. 49496 b. 49501 c. 49507 d. 49521 - ANSWERS-c. 49507

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina c. Gastroenteritis; abdominal pain; angina d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina - ANSWERS-b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina
A 65-year-old female was admitted to the hospital. She was diagnosed with sepsis secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? a. A41.89, K57.92, R10.

Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. In this context, "confirmation" __________. a. Does not require documentation of the type of test performed; the physician's diagnostic statement that the condition is confirmed is sufficient b. Requires the documentation of the type of test in addition to the physician's diagnostic statement c. Must be provided by the laboratory findings report d. Requires that the Public Health Agency be contacted - ANSWERS-a. Does not require documentation of the type of test performed; the physician's diagnostic statement that the condition is confirmed is sufficient
A 7-year-old patient was admitted to 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? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus d. Chronic obstructive asthma - ANSWERS-c. Asthma with status asthmaticus

A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension. a. J44.1, J44.9, I12.9, N18. b. J44.1, N18.9, I c. J44.9, N18.9, I d. J44.1, I12.9, N18.9 - ANSWERS-d. J44.1, I12.9, N18.
What does the fourth character of an ICD-10-CM diagnosis code capture? a. Anatomic site b. Severity c. Etiology d. Supplemental information - ANSWERS-c. Etiology
Identify the diagnosis code(s) for carcinoma in situ of vocal cord. a. D02. b. C32. c. D49. d. D14.1 - ANSWERS-a. D02.

d. Principal diagnosis - ANSWERS-b. Complication

A patient is admitted to an acute-care hospital for alcohol abuse and uncomplicated alcohol withdrawal syndrome due to chronic alcoholism. His blood alcohol level on admission was 10mg/100mL. a. F10.230, F10.10, Y90. b. F10. c. F10.10, Y90. d. F10.230, Y90.0 - ANSWERS-d. F10.230, Y90.
Assign the correct CPT code for the following procedure: Reposition of the pacemaker electrode. a. 33226 b. 33243 c. 33217 d. 33215 - ANSWERS-d. 33215
A 35-year-old male was admitted with heartburn that has not improved with over-the-counter medications. An esophagoscopy and closed esophageal biopsy at the upper esophagus was performed. The physician documented esophageal reflux with esophagitis as the final diagnosis based on pathological examination. Identify the correct diagnosis and procedure codes.

a. K23, 0DJ07ZZ b. K20.9, 0DB58ZX c. K21.0, 0DB18ZX d. K21.9, 0DB18ZX - ANSWERS-c. K21.0, 0DB18ZX

Which volume of ICD-10-CM contains the Tabular and Alphabetic Index of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. None of the above - ANSWERS-d. None of the above
Patient has been diagnosed with acute depression, sleep- related teeth grinding and psychogenic dysmenorrhea. The appropriate code assignment is: a. F32.8, F45. b. F32.9, F45. c. F32.9, F45.8, G47. d. F32.9, G47.53 - ANSWERS-c. F32.9, F45.8, G47.

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension - ANSWERS-a. Catheter-associated urinary tract infection
A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Before billing, the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist - ANSWERS-c. Code basal cell carcinoma

Identify the correct diagnosis code(s) for adenoma of left adrenal cortex with Conn's syndrome. a. D35.02, E26. b. D35. c. E26. d. E26.01, D35.7 - ANSWERS-a. D35.02, E26.
The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. a. 31622, 31640 b. 31622, 31623 c. 31623 d. 31625 - ANSWERS-c. 31623
A patient is admitted with abdominal pain. The physician documents the discharge diagnosis as pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis b. Pancreatitis; noncalculus cholecystitis; abdominal pain c. Noncalculus cholecystitis; pancreatitis; abdominal pain

b. E11.9, H25. c. E11.9, H25. d. H25.012, E11.9, 08RK3JZ - ANSWERS-d. H25.012, E11.9, 08RK3JZ

The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure? a. 49000, 58940, 58700 b. 58940, 58720- c. 49000, 58720 d. 58720 - ANSWERS-d. 58720
The patient was admitted with major depression current episode severe, recurrent. What is the correct ICD-10-CM diagnosis code assignment for this condition? a. F33. b. F33. c. F32. d. F31.81 - ANSWERS-a. F33.
An exception to the Excludes 1 definition is the circumstance when the two conditions __________.

a. Are unrelated to each other. b. Are related to each other. c. Will not be assigned as the principal diagnosis. d. Are injuries with external cause codes. - ANSWERS-a. Are unrelated to each other.

A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "chest pain versus GERD." The correct ICD-10-CM code is: a. Z03.89 Encounter for observation for other suspected diseases and conditions ruled out b. R10.11 Right upper quadrant abdominal pain c. K21.9 Gastro-esophageal reflux disease d. R07.9 Chest pain, unspecified - ANSWERS-d. R07.9 Chest pain, unspecified
Patient was admitted through the emergency department following a fall from a ladder while painting an interior bathroom in his farmhouse. He had contusions of the scalp and face and a displaced open fracture of the anterior wall of the right acetabulum. The fracture site was excisionally debrided and the fracture was reduced by open procedure with an internal fixation device inserted. Which is the correct code assignment?

c. Only to one specific code d. To all codes within that chapter - ANSWERS-b. To all codes within that category

Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment? a. C67.3, Z85.51, 0T5B8ZZ, 0TJB8ZZ b. C79.11, 0T5B8ZZ c. C67.3, 0T5B8ZZ d. C79.11, C67.3, 0T5B8ZZ - ANSWERS-c. C67.3, 0T5B8ZZ
If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, __________. a. Code E10, Type 1 diabetes mellitus, should be assigned. b. Code E11, Type 2 diabetes mellitus, should be assigned. c. Query the endocrinologist or attending physician. d. Check the physician orders or medical order record for additional information. - ANSWERS-b. Code E11, Type 2 diabetes mellitus, should be assigned.

Which of the following organizations is responsible for updating the procedure classification of ICD-10-PCS? a. Centers for Disease Control (CDC) b. Centers for Medicare and Medicaid Services (CMS) c. National Center for Health Statistics (NCHS) d. World Health Organization (WHO) - ANSWERS-b. Centers for Medicare and Medicaid Services (CMS)
Which of the following is not a way that ICD-10-CM improves coding accuracy? a. Reduces sequencing problems by combining conditions into one code b. Provides laterality options c. Captures more details for injuries, diabetes, and postoperative complications d. Increases cross-referencing - ANSWERS-d. Increases cross- referencing
A 45-year-old female is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. D50.0, N93.

Medical Coding and Documentation in Clinical Practice, Exams of Medicine

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Medical Coding and Documentation in

Clinical Practice