Medical Coding and Documentation Practices, Exams of Nursing

Download Medical Coding and Documentation Practices and more Exams Nursing in PDF only on Docsity! Actual solution. 2024 Wellcare Mastery Exam solut ion manual c. To facilitate optimum patient care The central focus of all clinical documentation should be to demonstrate the quality of care provided to the patient with detail and accuracy to facilitate optimum patient care. - answer ✅✅What is the central focus of clinical documentation? a. Protection against mal-practice claims b. Communication to office staff and other departments about the patient's care c. To facilitate optimum patient care d. Communication to other the providers and ancillary personnel concerning the patient encounter d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies Clinical documentation improvement is a proactive measure. The CDS will develop and monitor policies and procedures that affect the documentation process. CDI should begin at the front end of all services and care. Prevention of documentation issues is the key. See Page 1 - answer ✅✅The CDEO will focus his or her attention on records requested for post payment review. a. Yes, CDEOs only review records that might be an audit concern and require physician education. b. Yes, CDEOs only review records for paid claims by government payers. c. No, CDEOs do not review records unless it is requested by the compliance officier. d. No, CDEOs review records on a proactive basis to prevent documentation deficiencies c. Prevent deficient documentation The CDEO will review the findings of the auditor to determine what should be done to resolve documentation the issues on a proactive basis to prevent documentation and compliance risks. - answer ✅✅The CDEO will review the findings of the auditor in order to: a. Reprocess claims b. Make an addendum to the medical record c. Prevent deficient documentation d. Know what accounts should be adjusted off I, II, III, and IV may arise. - answer ✅✅Quality assurance of patient care is only evident if: a. The patient maintains a state of optimum health b. Visits are only required for well-checks or injury c. The patient survey and ROS does not change d. If it is documented in the patient's medical record b. Documentation reviews can be performed on a prospective basis. CDI programs are intended to be performed on a prospective basis to improve documentation deficiencies prior to claim submission. The intent is to identify deficiencies and make the appropriate corrections and prevent future deficiencies. CDI programs can also include retrospective reviews. - answer ✅✅Which of the following statements is TRUE regarding clinical documentation improvement efforts? a. Documentation reviews should be limited to the costliest chronic conditions to treat. b. Documentation reviews can be performed on a prospective basis. c. Documentation reviews must be completed yearly. d. Documentation reviews require access to the denial data. a. It encourages physician participation. Getting physicians involved in CDI helps to gain physician buy in and encourages other physicians to participate and is a great way to educate physicians. - answer ✅✅Why is it important to involve physicians in Clinical Documentation Improvement (CDI) programs? a. It encourages physician participation. b. It helps justify the need for CDI programs. c. It will eliminate the need to query providers. d. It will help providers time management. b. Failure to include the instructions for post procedure care and potential complications. Although all the choices are deficiencies in capturing patient information, failure to inform a patient of potential post-operative complications could impact the patient's recovery. In this question, you are determining the option that affects clinical care of the patient. - answer ✅✅Which of the following documentation deficiencies has a negative impact on patient outcomes? a. Failure to indicate the date of the patient's last blood test. b. Failure to include the instructions for post procedure care and potential complications. c. Failure to sign the patient's medical records provided by another physician. d. Failure to report the patient's pharmacy preference for insurance participation. d. Provide examples of the provider's documentation deficiencies with suggestions for improvement. Effective provider education regarding documentation deficiencies is to provide examples of the physician's documentation deficiency and feedback and tips on how to correct the deficiency. - answer ✅✅What is an effective method for communicating documentation deficiencies to a provider? a. Provide documentation tips for the most common chronic conditions treated. b. Provide the documentation deficiency report quarterly. c. Provide a report to the medical director that includes the findings for all the providers in the practice. d. Provide examples of the provider's documentation deficiencies with suggestions for improvement. I, II, and IV It is appropriate to work towards proper reimbursement but the goal of CDI should never be increasing or lowering revenue. - answer ✅✅Which of the following is/are considered a purpose of documentation improvement programs? I. Improve patient outcomes. II. Prepare physicians to provide documentation that supports quality measures. III. Promote coding lower level services. IV. Improve the provider query process. c. Provide a detailed record of the care provided to the patient. The main goal for detailed medical records is to promote the continuity of care for the patient. This allows providers to communicate - answer ✅✅How can an effective CDI program improve patient outcomes? a. Maximize the reimbursement received. b. Prohibit claim processing errors. c. Provide a detailed record of the care provided to the patient. d. Allow providers to support higher levels of E/M services. I, II, III, IV, V - answer ✅✅What are some common documentation deficiencies? I. Incorrect dates of service II. Misspelled words III. Inconsistencies within the record IV. Incomplete dictation V. Missing orders for diagnostic tests b. Focus on the highest risk area For a CDI program to be effective, the CDEO should focus on correction of documentation deficiencies for identified risk areas specific to the practice. - answer ✅✅When initiating a CDI program, which of the following statements is TRUE? a. Focus on services with the highest reimbursement b. Focus on the highest risk area c. Focus on chronic illnesses d. Focus on preventive medicine services d. Employer who solely establishes and maintains the plan with fewer than 50 participants. - answer ✅✅What type of health plan is exempt from HIPAA? a. Health maintenance organizations b. Government insurers c. Church-sponsored group health plans d. Employer who solely establishes and maintains the plan with fewer than 50 participants. d. Standards for how protected health information is used. - answer ✅✅What standards are set by the Privacy Rule set? a. Pre-existing standards b. Group health standards c. Transaction and code set standards d. Standards for how protected health information is used a. Psychotherapy notes. Areas excluded from the rights of access are psychotherapy notes, information related to legal proceedings, and certain lab results or information held by research laboratories. - answer ✅✅Which option would be excluded from an individual's right to access their PHI? a. Psychotherapy notes b. Family practice notes c. Emergency department notes d. Operative reports c. Reliable means to clearly identify the original content and the modified content. For electronic health records (EHR), the amendment, correction, or delayed entry must be distinctly identified. There must also be a way to provide a reliable means to clearly identify the original content and the modified content. The person altering the record and the date of the revision, amendment, or addenda must also be documented. - answer ✅✅When a correction is made in an electronic health record, what must exist? a. Identity of a witness to the correction made in the electronic health record. b. The entire medical record duplicated with the corrections only made to the duplication. c. Reliable means to clearly identify the original content and the modified content. d. There are no requirements for corrections to electronic medical records. d. A specific requirement does not exist. There are no specific requirements as to how the medical records must be retained. They may be kept in their original format, or reproduced in a way that is legally acceptable. The most important component of retention is that the record is protected, to ensure the security and integrity of the records. - answer ✅✅How must medical records be retained? a. Electronically b. Paper format c. Microfiche d. A specific requirement does not exist b. The permitted and required uses of PHI by the business associate. - answer ✅✅What must be included in a business associate agreement? a. The name of each person who will see the PHI. b. The permitted and required uses of PHI by the business associate. c. Each record that is shared with the business associate must be identified individually, included names and dates of service. d. There are no requirements for what is included in the business associate agreement. b. When there is retribution for the use and disclosure. c. When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary. d. When the covered entity has policies and procedures in place to identify each person who has incidentally had access to the record. a. Establish their own standards - answer ✅✅What are healthcare institutions to do in the absence of clearly defined laws and regulations relating to the content of a medical record? a. Establish their own standards b. Not put any in place c. Call HHS and ask for clarification d. Continue practicing without guidance until an issue arises a. Indication for surgery - answer ✅✅Which section of an operative report would you expect to find the reason or medical necessity for the procedure? a. Indication for surgery b. Body of the operative report c. Findings d. In the office visit prior to the surgery a. IU; because it can be mistaken for IV or the number 10. - answer ✅✅According to the Joint Commission (JC) Official "Do Not Use" List, what would be considered an abbreviation that should not be used in a medical record and why? a. IU; because it can be mistaken for IV or the number 10. b. HTN; because there should be more specification on the type of hypertension. c. PRN; because it may be misunderstood to be a privacy issue. d. IV; because it can be mistaken for IU. b. From the body of the operative note - answer ✅✅In an operative note, where should information be taken to ensure accurate assignment of a CPT® code? a. From the header, where the title of the planned surgery is listed. b. From the body of the operative note c. From the OR schedule, based on how the procedure was scheduled by the physician. d. From the findings area of the report d. Health Care Fraud and Abuse Control Program - answer ✅✅What program was established by HIPAA to combat fraud and abuse committed against all health plans, both public and private? a. Health and Human Services Fraud Prevention Program b. Compliance Program c. OIG HEAT d. Health Care Fraud and Abuse Control Program b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). - answer ✅✅How long does HIPAA require medical records to be maintained? a. Five years from the date of its creation or the date from which it was last in effect (whichever is later). b. Six years from the date of its creation or the date from which it was last in effect (whichever is later). c. Ten years from the date of its creation or the date from which it was last in effect (whichever is later). d. Five years past the date of death of the patient. d. Assistant surgeon Each provider involved in a surgical case is expected to document the portion of the surgical procedure they performed with the exception of a surgical assistant. When a surgery requires the help of a surgical assistant, the primary surgeon documents the operative report. The primary surgeon should clearly explain in the indications section of the note why an assistant was necessary, and what the assistant surgeon performed that required the assistance. - answer ✅✅Which type of provider is not required to dictate his or her own operative report? a. Primary surgeon b. Co-surgeon c. Surgeons in a surgical team d. Assistant surgeon a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. - answer ✅✅What information does a privacy practice notice contain? a. Elements to notify individuals as to how the covered entity will use and disclose the PHI. b. Notification of each person who has access to their record and what access level they will have. law, though, intent is required for knowing violations. The Anti- Kickback law requires proof of intention. The law state the person must "knowingly and willfully" violate the law. The "willful" verbiage is not founding the Stark law. - answer ✅✅What is on of the differences between the Stark law and the Anti-Kickback law? a. The Start law refers to fraudulent billing; the Anti-Kickback law refers to remuneration for self referrals. b. No intent must be proven for the Anti-Kickback law; the Stark law requires proof of intention. c. The Anti-kickback law refers to fraudulent billing; the Stark law refers to remuneration for self referrals. d. No intent must be proven for the Stark law; the Anti-Kickback law requires proof of intention. a. No, the OIG does not specify the IRO to be used, but does retain the right to notify the provider i they must select a new IRO. - answer ✅✅In a Corporate Integrity Agreement (CIA), does the OID specify the Independent Review Organization to be used? a. No, the OIG does not specify the IRO to be used, but does retain the right to notify the provider i they must select a new IRO. b. No, the OIG does not have nay input on the IRO used under any circumstance. c. Yes, the CIA will identify five IROs that can be used for the CIA Review. d. Yes, the specific IRO will be named in the CIA. c. Identifying employees on the exclusions list. The OIG has identified seven elements that should be present in every compliance plan based on criteria adopted by the federal government in the federal sentencing guidelines. The OIG lists seven fundamental elements for an effective compliance program, which are: 1-Implementing written policies, procedures and standards of conduct; 2-Designating a compliance officer and/or compliance committee; 3-Conducting effective training and education; 4-Developing effective lines of communication; 5- Enforcing standards through well-publicized disciplinary guidelines; 6-Conducting internal monitoring and auditing; and 7-Responding promptly to detected offenses and developing corrective action - answer ✅✅Which option is NOT part of the seven elements that should be included in a compliance plan based on the OIG's recommendations? a. Conducting effective training and education b. Responding promptly to detected offenses and developing corrective action c. Identifying employees on the exclusions list d. Developing effective lines of communication b. The provider must apply for reinstatement. - answer ✅✅When a provider is excluded under the Exclusions Statute, what must he or she do at the end of the exclusionary period? a. The provider is automatically reinstated. b. The provider must apply for reinstatement. c. The provider cannot be reinstated once excluded. d. The provider must apply for a group provider number. b. TriCare payments as a result of military war-related accidents. - answer ✅✅The OIG Work Plan summarizes new and ongoing reviews and activities that the OIG plans to pursue during the next fiscal year and beyond. What factor is NOT considered when evaluating proposals for the Work Plan? a. Mandatory requirements for OIG reviews, as set forth in laws, regulations, or other directive. b. TriCare payments as a result of military war-related accidents. c. Work to be performed in collaboration with partner organizations' management's actions to implement our recommendations from previous reviews. d. Requests made or concerns raised by Congress, HHS management, or the Office of Management and Budget b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. - answer ✅✅When non-compliance is identified, what does the OIG recommended? a. Take disciplinary action and document the date of the incident, name of the person responsible for taking action, the follow-up action taken, and a list of claims that were affected by the action. b. Take disciplinary action and document the date of the incident, name of the reporting party, name of the person responsible for taking action, and the follow-up action taken. c. Immediately terminate employment for the party found in non- compliance, regardless of the severity of the offense, document the date of the termination, file a corrected claim on all claims affected. d. Continue to watch the employee in non-compliance until the incidents meet a federal level before taking action. a. Providing deficiencies in documentation. A CDEO professional to educate providers and facilities of billing practices or services that have been identified by the OIG as high risk for fraud and abuse and which will be the focus of the OIG's audits for the coming year. It may also help in forming the scope of service than is documented to help cover the cost of his declining practice. Would this be fraud or abuse, and why? a. Abuse; charging one level higher on each visit does not show intent. b. Abuse; the provider's practice is common and therefore would not be considered fraudulent. c. Fraud; any over-coding of services would be considered fraudulent. d. Fraud; the provider intentionally over-coded to gain financially. c. Five years - answer ✅✅When a physician is banned from participating in any Federal or State health care program by the OIG under the Exclusion Statute (42 U.S.C. § 1320a-7), what is the minimum term of exclusion that can be applied? a. Sixty days b. One year c. Five years d. Ten years d. The person committing the violation decides to voluntarily opt out of the Medicare program - answer ✅✅Which one of the following options is a NOT a requirement for financial penalties to be mitigated in a federal False Claims Act case? a. The person committing the violation self discloses within 30 days of knowing about the violation. b. The person in violation fully cooperates with the investigation. c. No criminal prosecution, civil action, or administrative action has commenced with respect to the violation. d. The person committing the violation decides to voluntarily opt out of the Medicare program b. A person who brings a civil action for a violation for him-/herself and for the U.S. Government. - answer ✅✅What is a Qui Tam Relator? a. A person assigned to investigate accusations of fraudulent billing. b. A person who brings a civil action for a violation for him-/herself and for the U.S. Government. c. The defendant in a Qui Tam case. d. The employer of the defendant in a Qui Tam case. b. 15-25 percent of the money recovered - answer ✅✅A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes? a. 10-15 percent of the money recovered b. 15-25 percent of the money recovered c. 10-15 percent of the total claim amount d. 25-40 percent of the total claim amount b. an action that results in unnecessary costs to a Federal health care program, either directly or indirectly - answer ✅✅What is the definition of abuse? a. making false statements or misrepresenting facts to obtain an undeserved benefit or payment from a federal health care program b. an action that results in unnecessary costs to a Federal health care program, either directly or indirectly c. reporting the submission of false claims d. practicing medicine while on the exclusions list of the OIG a. date of incident, name of the reporting party, name of the person responsible for taking action, follow-up action taken. - answer ✅✅Based on the compliance program guidance documents by the OIG, what should be documented when non-compliant conduct is found? a. date of incident, name of the reporting party, name of the person responsible for taking action, follow-up action taken. b. date of the incident, date of termination of the employee in non- compliance. c. action found to be non-compliant, date the employee's name was reported to the OIG. d. date of the incident, date the OIG received the report on the investigation c. A provider requiring the coding staff to intentionally code E/M services one level higher than documented. - answer ✅✅What action would be considered fraud rather than abuse? a. Increased level of E/M visits based on electronic health record documentation. b. A provider utilizing modifier 25 on all E/M visits reported with a minor procedure. c. A provider requiring the coding staff to intentionally code E/M services one level higher than documented. d. A keying error. III. To allow the coder to clarify the correct ICD-10-CM code to be reported IV. To clarify if a patient has a manifestation of a chronic illness V. To keep compliant documentation a priority for the provider VI. To resolve obscure documentation b. Please review the patient's chart and document the indications for Tamoxifen therapy. Tamoxifen is used to treat some types of breast cancer in men and women. It is also used to lower a woman's chance of developing breast cancer if she has a high risk (such as a family history of breast cancer). - answer ✅✅In the past medical history, the patient is documented as having had breast cancer treated with a unilateral mastectomy four years ago. In the assessment, it is noted that the patient is currently on Tamoxifen. For this encounter, which query is most appropriate? a. Please review this patient's chart and clarify whether the patient has a resolved or active breast cancer. b. Please review the patient's chart and document the indications for Tamoxifen therapy. c. Was a reconstruction performed at the time of the mastectomy? d. Please review the documentation and indicate the dosage of the medication. a. Review the documentation for services identified on the OIG Work Plan that are performed in your practice and provide feedback regarding documentation deficiencies identified. Review of the OIG Workplan provides information on services that will be audited by the OIG. It is a best practice to review the services that appear on the OIG workplan that you are performing in your office. - answer ✅✅As a CDI professional, how can you utilize information provided in the OIG Work Plan to improve documentation? a. Review the documentation for services identified on the OIG Work Plan that are performed in your practice and provide feedback regarding documentation deficiencies identified. b. Review the findings from the OIG Work Plan audit to determine potential revenue opportunities for your practice. c. When presented with a refund request from a private payer, do not allow the refund unless the service is included on the OIG Work Plan. d. Review the quarterly release of the OIG Work Plan. c. Home visits are covered if medical necessity is supported by the documentation. - answer ✅✅According to the OIG Work Plan, the reasonableness of physician home visits is being reviewed. Which of the following statements is TRUE? a. Improper payments were made for office visits. b. Home visits are never reimbursed by Medicare. c. Home visits are covered if medical necessity is supported by the documentation. d. Improper payments were made for beneficiaries requiring skilled services. d. all of the above - answer ✅✅What is an acceptable format for a provider query? Select all that apply. a. Multiple Choice b. Yes/No with option for other c. Open-Ended d. all of the above b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. - answer ✅✅Which statement is TRUE regarding the CMS Stars quality rating system? a. Quality bonus payments are made to physician who score at least four stars. b. Quality bonus payments are made to Medicare Advantage plans who score at least four stars. c. Quality bonus payments are made to physician who score at least five stars. d. Quality bonus payments are made to Medicare Advantage plans who score at least five stars. c. I, II, III, and V - answer ✅✅MIPS includes which performance categories? I. Promoting Interoperability II. Cost III. Improvement Activities IV. Quantity V. Quality a. I and II b. I, III, and V c. I, II, III, and V d. I, II, III, IV, and V b. Identify plans with the lowest risk scores. c. Identify top performing doctors. d. Identify top performing health plans. c. Avoiding errors caused by illegible handwriting. Benefits of e-prescribing include: - Avoiding errors caused by illegible handwriting - Avoided telephone miscommunication between the pharmacy and the office - Immediate access to a patient's medication history and, in some instances, information related to their general medical condition - Immediate warning and alert systems about potential patient drug-drug, drug-disease, drug-allergy interactions, and dosing errors - Point of care provider access to the patient's payer formulary benefits Improved monitoring of the use of controlled substances - answer ✅✅Which of the following is a benefit of e-Prescribing? a. Reduction of prescription cost. b. Eliminating ALL errors in documentation. c. Avoiding errors caused by illegible handwriting. d. Availability of access for prescription drugs b. Avoid fraud and abuse - answer ✅✅Which of the following is NOT a benefit for providers to utilize electronic health records? a. Improve quality, safety, and efficiency b. Avoid fraud and abuse c. Improve care efficiencies d. Continuity of care a. Point of care provider access to the patient's payer formulary benefits. The provider can determine if a medication they want to prescribe is covered under the patient's insurance prior to sending an e- prescription. - answer ✅✅E-prescribing electronically transmits new and refill prescriptions to a community or mail order pharmacy. What is an advantage to E-Prescribing (eRx)? a. Point of care provider access to the patient's payer formulary benefits. b. Increase security to patient's medical history and current conditions. c. Decrease in patient illegal drug use. d. Increased awareness of physician's who over-prescribe medications. d. Attention to renal insufficiency - answer ✅✅Based on the HEDIS measure Diabetes Comprehenisve Care, which of the following would qualify for medical attention to nephropathy? a. Attention to neuropathy b. Attention to epilepsy c. Attention to retinopathy d. Attention to renal insufficiency d. I, II, III, IV, and V Many measures include: ICD-10-CM, ICD-10-PCS, CPT®/HCPCS, MS-DRGs, UB-04 revenue or type of bill codes, and CMS-1500 place of service codes. - answer ✅✅HEDIS includes codes from which of the following code sets? I. CPT® II. HCPCS Level II III. ICD-10-PCS IV. CMS-1500 place of service V. MS-DRG a. III and V b. I, III, and V c. I, II, and III d. I, II, III, IV, and V a. Chiropractors - answer ✅✅Which of the following are eligible providers (EPs) for Medicare under the MIPS Quality Payment Program? a. Chiropractors b. Diabetic educators c. Pharmacists d. Registered Nurses b. An eligible provider can receive partial credit towards the total composite score for promoting interoperability. The quality category offers the highest weight for reporting measures. Promoting interoperability reporting allows an eligible provider to receive partial credit toward the total composit score, a. A patient diagnosed with MDD who has a poor medication interaction with his medication for HTN and antidepressants. 1P is appended when the performance measure is not met due to medical reasons. Code 4064F is a Category II CPT® code that identifies a patient with MMD, MDD, ADOL who is prescribed an anti-depressant. - answer ✅✅Which of the following scenarios supports reporting 4064F-1P? a. A patient diagnosed with MDD who has a poor medication interaction with his medication for HTN and antidepressants. b. A patient diagnosed with MDD who is already taking antidepressants. c. A patient diagnosed with ADOL taking Cymbalta 20 mg twice daily. d. A patient diagnosed with MMD who has not taken Cymbalta for a week because her prescription ran out and she is waiting for the refill to become available. d. I, II, and IV Rationale: Individual EPs may choose to report quality information through one of the following methods: 1. Medicare Part B claims 2. Qualified PQRS registry 3. Direct Electronic Health Record (EHR) using Certified EHR Technology (CEHRT) 4. CEHRT via Data Submission Vendor 5. Qualified clinical data registry (QCDR) - answer ✅✅How can an independent provider report quality measures? I. Claims II. Registry III. CMS web interface IV. Electronic health record a. I b. I and II c. I, II, III and IV d. I, II, and IV b. A provider attempts to perform foreign body removal via bronchoscopy. The provider is not successful and decides to perform a thoracotomy to remove the intrapulmonary foreign body, which increased the time to perform the procedure. Modifier 22 is never reported with E/M codes. Modifier 22 can be reported with an endoscopic procedure is converted to an open procedure if it increases the difficulty or time required to perform the service. - answer ✅✅Which scenario qualifies for modifier 22? Modifier 22-Increased procedural services a. A patient returns three days post gastric bypass with an infection at one of the incision sites. The provider debrides the infected tissue to promote healing. b. A provider attempts to perform foreign body removal via bronchoscopy. The provider is not successful and decides to perform a thoracotomy to remove the intrapulmonary foreign body, which increased the time to perform the procedure. c. A patient presents five days after having a lumpectomy of her right breast. The pathology shows the margins were not clear. The provider must perform a mastectomy of the right breast. d. A patient presents for a follow up to discuss the test results from a liver biopsy. The visit takes an additional twenty minutes due to the extensive amount of questions. c. The provider should make a good faith effort to estimate the cost within $100 or 25% of the actual cost, whichever is greater, on the ABN before requesting the beneficiary's signature. - answer ✅✅Which statement is TRUE regarding an Advance Beneficiary Notice (ABN)? a. One ABN will cover all procedures performed on a Medicare beneficiary by that provider. b. An ABN should be given to the patient to sign after a service has been denied as not medically necessary. c. The provider should make a good faith effort to estimate the cost within $100 or 25% of the actual cost, whichever is greater, on the ABN before requesting the beneficiary's signature. d. The ABN is optional. The provider may bill a Medicare beneficiary for services denied not medically necessary with or without a signed ABN. a. Delayed surgical wound closure to promote healing When the provider plans the procedure in stages, modifier 58 is appended to the staged procedure. - answer ✅✅Which of the following scenarios qualifies for modifier 58? Modifier 58-Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period. b. CDPS - answer ✅✅Which risk adjustment model is most commonly used by Medicaid? a. HCC b. CDPS c. Blended d. Fee for service d. All options are correct - answer ✅✅The HCC risk adjustment model: a. Helps forecast anticipated health costs b. Adjusts payments based on diagnoses c. Helps identify patients with higher medical needs d. All options are correct c. Chronic Disability Payment System - answer ✅✅What does the abbreviation CDPS indicate? a. Chronic Disability Provider Services b. Chronic Diagnosis Processing System c. Chronic Disability Payment System d. Chronic Diagnosis Payment System c. Yearly - answer ✅✅How often does CMS normalize risk scores and update the list of diagnosis codes for HCC coding? a. Monthly b. Quarterly c. Yearly d. Every two years b. A patient with a RAF score of 2.65 will likely consume more health care in the coming year than a patient with a RAF score of 1.06. The higher the RAF score, the more health care services a patient will more likely consume. - answer ✅✅Which of the following statements is true regarding RAFs? a. A patient with a RAF score of 2.65 receives a payment bonus if their healthcare improves. b. A patient with a RAF score of 2.65 will likely consume more health care in the coming year than a patient with a RAF score of 1.06. c. A patient with a RAF score of 2.65 will likely consume less health care in the coming year than a patient with a RAF score of 1.06. d. A patient's RAF score is determined based on the cost of patient's medical care for the previous year. I, II, and V The provider did not document a causal link for the diabetes and cataract. Although not needed for code selection, it is best practice for the provider to document all causal links for quality care. CHF is not cured and likely overlooked when documenting the diagnoses in 2016. Emphysema and below the knee amputation (BKA) do not improve and it is likely the provider did not document the conditions or forgot to code them in 2016. Because the chronic atrial fibrillation was not documented in 2015, it is likely a new diagnosis in 2016. - answer ✅✅In October, a Medicare Advantage Organization (MAO) audit of a provider's submitted diagnoses determines conflicting diagnoses submitted from two consecutive years. The following diagnoses were reported for the patient. FY 20X1 Diagnoses: Emphysema Type 2 Diabetes Stage 3 CKD CHF, left sided Diabetic cataract BKA Diagnoses through October, 20X2: Chronic atrial fibrillation Diabetes Cataract Which of the following statements is TRUE? I. The provider likely overlooked linking diabetes to cataract in 20X2. II. The provider likely overlooked documenting left-sided CHF in 20X2. III. The patient's emphysema was cured in 20X2. IV. The patient's BKA improved in 20X2. V. The patient likely development a new diagnosis of chronic atrial fibrillation in 20X2. I, II, III, IV, and V I, II, and V c. ICD-10-CM codes d. Patient co-payment amount a. CMS creates NCDs to inform providers when a service is considered medically necessary. CMS has the power under the Social Security Act to determine on a case-by-case basis if the method of treating a patient is reasonable and necessary. For all payers, even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a NCD, LCD, or a clinically accepted standard of practice. In addition, the NCD and LCDs list ICD-10- CM codes for diagnoses that are considered medically necessary. In some cases, the NCDs and LCDS also list diagnosis codes that are NOT considered medically necessary. - answer ✅✅Which of the following statements is TRUE regarding medical necessity? a. CMS creates NCDs to inform providers when a service is considered medically necessary. b. If the provider performs the service it will be considered medically necessary. c. If the patient does not respond to the treatment provided, the service is not considered medically necessary. d. CMS releases edits to CPT® codes to indicate which procedures are considered medically necessary. c. I, IV and V RVUs are configured using three components: 1. Physician work—time, skill, training, and intensity of service provided 2. Practice expense—reflects the cost of ancillary personnel, supplies, and office overhead 3. Professional liability/malpractice insurance - answer ✅✅Which components are used to determine RVUs? I. Physician work II. Physician admitting privileges III. Location of the practice IV. Practice expense V. Malpractice insurance a. I and II b. I, II, IV and V c. I, IV and V d. I, III, and IV c. Evaluation of the patient in the recovery room The CPT® codebook describes the surgery package as including: • Subsequent to the decision for surgery, E/M services on the date immediately prior to or on the date of the procedure (including history and physical) • Local anesthesia: defined as local infiltration, metacarpal/metatarsal/digital block, or topical anesthesia• Operation itself • Immediate post-operative care, including dictation of operative notes, talking with family and other physicians • Writing orders • Evaluation of patient in post-anesthesia recovery• Normal, uncomplicated follow-up care - answer ✅✅Which of the following services are included in the global surgical package? a. General anesthesia b. Physical therapy services following hip replacement c. Evaluation of the patient in the recovery room d. Transportation of the patient to a rehab facility if needed b. XXX Status indicator XXX: The global concept does not apply to this code. (e.g., Evaluation and Management services, Anesthesia, Laboratory and Radiology procedures) CPT® 10021, 36593, 38220, 44720. 000: Endoscopies or minor procedures with preoperative and postoperative relative values on the day of the procedure only are reimbursable. Evaluation and management services on the same day of the procedure are generally not payable. (eg, CPT®, 43255, 53020, 67346). YYY: These are unlisted codes, and subject to individual pricing. (eg, CPT® 19499, 20999, 44979). ZZZ: Represents add-on codes. They are related to another service and are always included in the global period of the primary service. (eg, CPT® 27358, 44955, 67335). - answer ✅✅Which status indicator identifies procedures where the global concept does not apply? a. 000 b. XXX c. YYY organ is coded. Look in the Alphabetic Index for Complication/transplant/malignant neoplasm which directs you to C80.2. In the Tabular List C80.2 has a note to code first the complication code (T86.-) and to use an additional code for the specific malignancy. C - answer ✅✅Four years post hepatic transplant, the patient is recently diagnosed with combined hepatocellular carcinoma and cholangiocarcinoma of the liver. What ICD-10-CM codes are reported? a. C80.2, C22.0 b. T86.49, C80.2, C22.0, C22.1, Z94.4 c. T86.49, C80.2, C22.0 d. C80.2, C22.0, C22.1, Z94.4 C80.2-Malignant neoplasm assoc with transplanted organ C22.0-Liver Cell Carcinoma C22.1-Intrahepatic bile duct carcinoma T86.49-Other complications of liver transplant Z94.4-Liver Transplant Status c. J96.00, J90 According to ICD-10-CM guideline I.C.10.b.1, acute respiratory failure can be a primary diagnosis with another acute diagnosis if it is clear the respiratory failure was responsible for the patient being admitted. Look in the ICD-10-CM Alphabetic Index for Failure/respiration, respiratory/acute J96.0-. We do not have documentation supporting hypercapnia or hypoxia, so the respiratory failure is unspecified which is code J96.00. Then, in the Alphabetic Index, look for Effusion/chest which directs you to see Effusion, pleura. Effusion/pleura, pleurisy, pleuritic, pleuropericardial directs you to J90. Confirm code selection in the Tabular List. - answer ✅✅A 63 year-old came in to the ED with severe shortness of breath and goes into respiratory failure. He was intubated and admitted for acute respiratory failure. Chest X-ray shows he has pleural effusion. What ICD-10-CM code(s) is/are reported? a. J96.00 b. J94.0, J96.01 c. J96.00, J90 d. J94.0, J96.00, R09.1 J90-Pleural Effusion, NEC J96.00-ARF, unspecified whether with hypoxia or hypercapnia J96.01-ARF with hypoxia J94.0-Chylous Effusion R09.1-Pleurisy b. E10.11 In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/type 1/with/ketoacidosis/with coma guiding you to code E10.11. Code Z79.4 Long term use of insulin is not required for a type 1 diabetic because these patients are insulin dependent. Verify code selection in the Tabular List. - answer ✅✅Friends brought a young male with type 1 diabetes to the emergency department, in a comatose state. He was admitted with ketoacidosis and was resuscitated with saline hydration via insulin drip. After regaining consciousness, the patient reported that the morning of admission he was experiencing nausea and vomiting and decided not to take his insulin because he had not eaten. He was treated with intravenous hydration and insulin drip. By the following morning, his laboratory work was within normal range and he was experiencing no symptoms. What ICD-10-CM codes are reported? a. E10.10, R06.4, Z79.4 b. E10.11 c. E11.01, Z79.4 d. E11.01, R06.4 E10.10-DM 1 with Ketoacidosis w/o coma E10.11-DM 1 with ketoacidosis w/coma E11.01-DM 2 with hyperosmolarity w/coma R06.4-Hyperventilition Z79.4-Long term use of insulin b. G30.0, F02.80 In the ICD-10-CM Alphabetic Index, look for Alzheimer's diseases or sclerosis and you are directed to see Disease, Alzheimer's. Look for Disease, diseased/Alzheimer's/early onset which directs you to G30.0 [F02.80]. The code in brackets indicates a manifestation code. When we verify the G30.0 code in the Tabular List there is an instructional note under code section G30 that confirms that we should code also the dementia. F02.80 is the correct code because the provider does not mention any behavioral disturbances. Sequencing rules tell us that the manifestation code always follows the etiology code. Codes F29 Psychosis and R41.3 Memory loss are not reported because these are signs and symptoms of Alzheimer's. See ICD-10-CM guideline I.B.4. - answer ✅✅A 58 year-old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD-10-CM codes are reported? c. I12.0, I51.5 d. I10, N18.5, 151.5 I12.0-Hypertensive CKD with stage 5 CKD or ESRD N18.5-CKD, stage 5 I51.5-Myocardial degeneration I13.11-Hypertensive heart & CKD W/O HF, stage 5 CKD, or ESRD I10-HTN a. N39.0, B96.5, I10 Per ICD-10-CM guideline IV.H Uncertain Diagnosis, we would not code diagnoses documented as probable, suspected, questionable, rule out or working diagnosis, or other similar terms indicating uncertainty. During the course of the patient's stay septicemia was ruled out and would not be coded. The reason for the visit was to treat the urinary tract infection, making that code primary. Look in the ICD-10-CM Alphabetic Index for Infection/urinary (tract) NEC directing you to code N39.0. Look in the Tabular List for code N39.0. There is an instructional note stating, "Use additional code to identify infectious agent." This note must always be followed when the organism is known. The note states "Pseudomonas showed in the urine culture." Look in the Alphabetic Index for Infection/Pseudomonas NEC/as cause of disease classified elsewhere which directs you to B96.5. Hematuria (R31.9) is integral to a uri - answer ✅✅An elderly male patient presents to the ED complaining of a high fever the day prior to the encounter and of extreme lethargy. He has a history of benign hypertension which has been elevated. On arrival he was examined by his primary care physician and admitted, with possible septic urinary tract infection and concern for his elevated blood pressure. He was noted to have hematuria and a urine culture is performed. Positive UTI and pseudomonas showed in the urine culture and IV antibiotics were administered. During the course of the day, his fever decreased and his lethargy improved. As the IV fluids were decreased, he resumed a benign hypertensive state. On the next hospital day, his primary care physician noted the urine was clear and he was discharged on oral antibiotics, with septicemia ruled out. What ICD-10-CM codes should be reported? a. N39.0, B96.5, I10 b. A41.9, I10, R31.9, N39.0 c. A41.52, N39.0, I10 d. B96.5, N39.0, I10, R31.9 N39.0-UTI, site not specified B96.5 -Pseudomonas as the cause of diseases classified elsewhere I10-HTN A41.9-Sepsis, unspecified organism R31.9-Hematuria A41.52-Sepsis d/t pseudomonas c. J44.0, J20.9, F17.210 In the ICD-10-CM Alphabetic Index look for Disease, diseased/pulmonary/chronic obstructive/with/acute bronchitis J44.0. In the Tabular List, there is an instructional note to code also to identify the infection. For this example, the infection is reported with a code from category code J20 Acute Bronchitis. Because there is no indication of the infectious agent for the acute bronchitis, an unspecified code is used. Look for Bronchitis/acute or subacute (with bronchospasm or obstruction) J20.9. In the Tabular List category J44 has a note to code also the type of asthma which is not applicable to this case so it is not coded. J44 also has a note to report an additional code for use of or exposure to smoke. The patient is currently still smoking and is dependent on cigarettes. Look for Dependence (on)/nicotine/cigarettes F17.210. Verify code selection in the Tabular List. - answer ✅✅A 65 year-old female patient returns to her primary care provider for follow up of an upper respiratory infection diagnosed the previous week. Her condition has not improved and her cough has increased. She has a long history of smoking. She currently smokes one pack a day and is dependent on the cigarettes. She uses a bronchodilator for her COPD. The provider changes her antibiotics to treat her acute bronchitis with COPD. What ICD-10-CM codes are reported for this visit? a. J44.9, J20.9, Z72.0 b. J44.0, Z72.0 c. J44.0, J20.9, F17.210 d. J44.0, J21.9, F17.210 J44.9- COPD, unspecified J20.9- Acute Bronchitis, unspecified Z72.0- Tobbaco use J44.0-COPD with acute Lower respiratory infection F17.210-Nicotine dependence, cigarettes, uncomplicated J21.9-Acute Bronchiolitis, unspecified c. C78.2, C34.91, J91.0 The patient has malignant pleural effusion. Look in the ICD-10-CM Alphabetic Index for Effusion/pleura, pleurisy, pleuritic, pleuropericardial/malignant directing you to code J91.0. In the G40.909 - Migraine, unspecified, not intractable without migrainous G43.919 - Epilepsy, unspecified, intractable without status epilepticus a. F31.12, E03.9, G43.909 In the ICD-10-CM Alphabetic Index look for Disorder/bipolar/current (or most recent) episode/manic/without psychotic features/moderate guiding you to code F31.12. No code assignment is necessary for depression because depression is a component of bipolar disorder. Although not psychiatric conditions, both hypothyroidism and migraine headaches are coexisting conditions under treatment and are coded. In the Alphabetic Index, look for Hypothyroidism which directs you to E03.9 and look for Migraine directing you to code G43.90-. Verify the codes in the Tabular List. When reviewing code G43.90 in the Tabular List, a 6 th character of 9 is selected because there is no mention of an intractable migraine or status migrainosus. - answer ✅✅A young female, was brought to the clinic by her sister. She has had periods of severe depression for many years and is on Lithium. Her provider also manages her manic-depressive psychosis, hypothyroidism, and migraine headaches. Additional medications are Synthroid and Midrin. During the past week, she became manic, running all her credit cards to the limit, getting inappropriately involved in a friend's suicide attempt, quitting her job, and trying to take over the pulpit at church. On the day of the clinic visit, she threatened to strike the telephone repairman with a lead pipe. She was admitted for Lithium adjustment. Diagnoses are: moderate manic-depressive bipolar with circular current manic state, hypothyroidism, and migraine. What ICD-10-CM codes are reported? a. F31.12, E03.9, G43.909 b. F31.62, E03.9, G43.911 c. F31.32, E03.9, G43.909 d. F31.89, G43.911, E03.8 F31.12 - Bipolar disorder, current episode manic without psychotic features, moderate E03.9 - Hypothyroidism, unspecified G43.909 - Migraine, unspecified, not intractable, without status migrainous F31.62 - Bipolar disorder, current episode mixed, moderate G43.911 - Migraine, unspecified, intractable, with status migrainous F31.32 - Bipolar disorder, current episode depressed, moderate F31.89 - Other bipolar disorder E03.8 - other specified hypothyroidism a. I21.09 According to ICD-10-CM guideline I.C.9.e.1, the ICD-10-CM codes for acute myocardial infarction (AMI) identify the site, such as anterolateral wall or true posterior wall. The same section goes on to state that if STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI. Look in the ICD-10-CM Alphabetic Index for Infarct, infarction/myocardium, myocardial (acute) (with stated duration of 4 weeks or less)/ST elevation (STEMI)/anterior (anteroapical) (anterolateral) (anteroseptal) (Q wave) (wall) which directs you to I21.09. Verify code selection in the Tabular List. - answer ✅✅The patient was given thrombolytic therapy for an acute myocardial infarction (STEMI) of the anterolateral wall which converted to a NSTEMI. What ICD-10-CM code is reported? a. I21.09 - ST elevation (STEMI) MI involving other coronary after of anterior wall b. I22.8 - Subsequent ST elevation (STEMI) MI of other sites c. I21.29 - ST elevation (STEMI) MI involving other coronary after of anterior wall d. I22.0 - Subsequent ST elevation (STEMI) MI of anterior wall d.C25.1, E08.11, Z79.4 The patient's diabetes is due to the pancreatic cancer as an underlying condition. In the ICD-10-CM Alphabetic Index look for Diabetes, diabetic (mellitus) (sugar)/due to underlying condition/with/ketoacidosis/with coma E08.11. In the Tabular List under category code E08 an instructional note indicates to code the underlying condition first. In the Table of Neoplasms look for Neoplasm, neoplastic/pancreas/body and select the code from the Malignant Primary column which directs the coder to C25.1. There is also coding guidance under category code E08 to use additional code for patients who routinely use insulin. Report code Z79.4 which is found in the Alphabetic Index under Long-term (current) (prophylactic) drug therapy (use of)/insulin directing you to code Z79.4. Verify code selection in the Tabular List. - answer ✅✅A patient is being treated for ketoacidosis and diabetic coma due to malignant neoplasm of the pancreatic body. The patient uses insulin routinely. What ICD-10-CM codes are reported? a.E13.11, C25.1 b.E10.11, C25.2, Z79.4 c.C25.9, E08.11 d.C25.1, E08.11, Z79.4 E13.11 - Other specified DM with ketoacidosis with coma ICD-10-CM guideline I.C.9.a.1 indicates when the documentation specifically states the two conditions are unrelated between hypertension and heart disease, they are coded separately. In this case, there is no causal relationship coded. Look in the ICD-10-CM Alphabetic Index for Failure/heart/systolic (congestive)/chronic (congestive) directing you to I50.22. Then, look for Hypertension which directs you to I10. Verify code selection in the Tabular List. - answer ✅✅The patient has a history of unstable angina, hypertension, and chronic systolic heart failure. He is seen in the ED after prolonged chest pain that was not relieved by medication. Cardiac enzymes are elevated, and EKG shows anterior infarct. A decision was made to perform a cardiac catheterization and coronary angiography. Left heart catheterization was performed in order to perform a left ventriculogram. He tolerated the procedure well and will be discharged. His final diagnosis is chronic systolic heart failure and hypertension. The two conditions are unrelated. What ICD-10-CM code(s) is/are reported? a. I50.22, I10 b. I11.0 c. I11.0, I10 d. I11.0, I50.22 I50.22 - Chronic system CHF I10 - Essential (primary) HTN I11.0 - Hypertensive heart with HF c. N18.3, D63.1 In the ICD-10-CM Alphabetic Index look for Anemia/in (due to) (with)/chronic kidney disease or Anemia/erythropoietin resistant anemia (EPO resistant anemia) guiding you to code D63.1. In the Tabular List at D63.1 there is an instructional note stating to code first underlying chronic kidney disease. Look in the Alphabetic Index for Disease, diseased/kidney/chronic/stage 3 (moderate) guiding you to code N18.3. Verify code selection in the Tabular List. - answer ✅✅A patient sees the nephrologist for a B-12 injection to treat erythropoietin resistant anemia due to stage 3 chronic kidney disease. What ICD-10-CM codes are reported? a. N18.9, D63.8 b. D63.1, N18.3 c. N18.3, D63.1 d. D63.8, N18.9 N18.9 - CKD, unspecified D63.8 - Anemia in other chronic disease classified elsewhere (manifestation) D63.1 - Anemia in CKD (manifestation) N18.3 - CKD, stage 3 (moderate) c. F03.91 In ICD-10-CM Alphabetic Index look for Dementia/with/aggressive behavior directing you to F03.91. Next, look for Dementia/with/combative behavior directing you to F03.91. Verify the codes in the Tabular List. Both manifestations are reported with the same code, so it is only reported once according to ICD-10-CM guideline I.B.12. - answer ✅✅The provider sees a 70 year-old patient with a documented history in the past few months of being combative and aggressive in the nursing home. The provider diagnoses the patient with dementia and refers the patient to a neurologist for further evaluation on her combative and aggressive behavior that she has been displaying. What ICD-10-CM code(s) is/are reported? a. F03.90, F03.91 b. F03.91, F03.91 c. F03.91 d. F03.90 F03.90 - Unspecified dementia without behavioral disturbance F03.91 - Unspecified dementia with behavioral disturbance a. R56.9, F10.129 There is no indication that the convulsions were an epileptic seizure , a code from subcategory G40.50- is not reported. The convulsions were brought on by the intake of alcohol. Look in the ICD-10-CM Alphabetic Index for Convulsions directing you to code R56.9. Documentation states alcohol abuse not alcoholism with intoxication. Look in the Alphabetic Index for Abuse/alcohol/with/intoxication directing you to F10.129. Verify code selection in the Tabular List. - answer ✅✅A patient is brought in by the ambulance having convulsions. After examination and workup is complete, it is determined the convulsions were due to alcohol abuse with intoxication. What ICD-10-CM code(s) is/are reported? a. R56.9, F10.129 b. F10.129 c. G40.509, F10.120 d. G40.501, R56.9, F10.129 R56.9 - unspecified convulsions F10.129 - ETOH abuse with intoxication, unspecified d. E85.4, N08 In the ICD-10-CM Alphabetic Index look for Glomerulonephritis/in (due to)/amyloidosis guiding you to codes E85.4 [N08]. In the Alphabetic Index the brackets identify manifestation codes. In the Tabular List code N08 has an instructional note to code first underlying disease, such as amyloidosis (E85.-). Your primary code is E85.4 for Amyloidosis followed by N08 for the manifested Glomerulonephritis. Verify code selection in the Tabular List. - answer ✅✅A patient with amyloidosis being treated for glomerulonephritis. What ICD-10-CM codes are reported? a. E85.3, N08 b. N08, E85.4 c. N08, E85.3 d. E85.4, N08 E85.3 - Secondary Systemic amyloidosis N08 - Glomerular disorders in diseases classified elsewhere (manifestation) E85.4 - Organ-limited amyloidosis a. H44.641, Z18.11 In the ICD-10-CM Alphabetic Index look for Foreign body/intraocular/old, retained/magnetic/posterior wall guiding you to code H44.64-. In the Tabular List, 6 th character 1 is assigned for the right eye. Subcategory code H44.6 has instructions to use an additional code to identify the foreign body (Z18.11). Z18.11 identifies a retained magnetic fragment. Verify code selection in the Tabular List. - answer ✅✅After referral from the ED, patient is seeing the ophthalmologist to examine an old injury with retained magnetic iron metal foreign body in his posterior wall within the right eye with the possibility of infection. What ICD-10- CM codes are reported? a. H44.641, Z18.11 b. H44.741, Z18.11 c. S05.51XD, Z18.11 d. S05.51XA, Z18.11 H44.641 - Retained (old) magnetic FB in posterior wall of globe, right eye H44.741 - Retained (nonmagnetic) (old) FB in posterior wall of globe, right eye Z18.11 - Retained magnetic metal fragments S05.51XD - Penetrating wound with FB of right eyeball, subsequent encounter S05.51XA - Penetrating wound with FB of right eyeball, initial encounter c. B20, C46.0, K13.21, R16.1 According to ICD-10-CM guideline I.C.1.a.2.a, if a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, followed by additional diagnosis codes for all reported HIV-related conditions. In the ICD-10-CM Alphabetic Index look for Human/immunodeficiency virus (HIV) disease (infection) B20. Because Kaposi's sarcoma is neoplastic lesions caused by an opportunistic infection common in HIV, it is coded as AIDS instead of asymptomatic HIV (Z21). In the Alphabetic Index look for Kaposi's/sarcoma/skin (multiple sites) directing you to C46.0. For leukoplakia look for Leukoplakia/lip directing you to K13.21. Look for Splenomegaly directing you to R16.1. Verify code selection in the Tabular List. - answer ✅✅An HIV positive patient was admitted with skin lesions on the chest and back. Biopsies were taken, and the pathologic diagnosis was Kaposi's sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical examination. Discharge diagnoses: (1) HIV infection, (2) Kaposi's sarcoma, back and chest, (3) leukoplakia (4) splenomegaly. What ICD-10-CM codes should be reported? a. B20, C46.0, K13.21, R16.1, Z21 b. R16.1, C46.0, R16.1, Z21 c. B20, C46.0, K13.21, R16.1 d. Z21, C46.0, K13.21, R16.1 B20 - HIV disease C46.0 - Kaposi's sarcoma of skin K13.21 - Leukoplakia of real mucosa, including tongue R16.1 - Splenomegaly, NEC Z21 - Asymptomatic HIV infection status b. E66.01, Z68.42 In the ICD-10-CM Alphabetic Index look for Obesity/morbid guiding you to code E66.01. In the Tabular List there is note under subcategory code E66 to use an additional code to identify the BMI (Z68.1-Z68.45). Look at this range in the Tabular List. The second code is Z68.42 indicating a BMI of 45.0 - 49.9 adult. This can be found in the Alphabetic Index by looking for Body, bodies/mass index (BMI)/adult/45.0-49.9 referring you to Z68.42. Verify code selection in the Tabular List. - answer ✅✅A 33 year-old patient visits his primary care provider to discuss lap band procedure for his morbid obesity. His caloric intake is in excess of 4,000 calories per day and his BMI is currently 45. What ICD-10-CM code(s) is/are reported? C22.9 - Malignant neoplasm of liver, not specified as primary or secondary C50.019 - Malignant neoplasm of nippy and areola, unspecified female breast d. S01.412A, S51.812A, Y04.0XXA, Y92.29 Look in the ICD-10-CM Alphabetic Index for Laceration/cheek (external) directing you to S01.41-. In the Tabular List a 6 th character 2 is selected for the left cheek and 7 th character A is selected for the initial encounter. Next, look in the Alphabetic Index for Laceration/forearm/left S51.812-. In the Tabular List a 7 th character A is selected for the initial encounter. The abrasion on the face is not reported because ICD-10-CM guideline I.C.19.b.1 indicates superficial injures such as abrasions or contusions are not coded when associated with more severe injures of the same site. To report the circumstances surrounding the injury, look in the ICD-10-CM External Cause of Injuries Index for Brawl (hand) (fist) (foot) directing you to Y04.0-. In the Tabular List, placeholder X are used for the 5 th and 6 th characters and 7 th character A is selected for initial encounter. T - answer ✅✅A 47 year-old male was treated in the ED after being involved in a fight at a local pub. The patient sustained two lacerations, one to the left cheek and one to the left forearm. Abrasions were also on the left cheek. What ICD- 10-CM codes are reported? a. S01.412A, S51.812A, S00.81XA, Y04.0XXA, Y92.29 b. S01.412D, S51.812D, S00.81XD, Y04.0XXD, Y92.29 c. S01.412D, S51.812D, Y04.0XXD, Y92.29 d. S01.412A, S51.812A, Y04.0XXA, Y92.29 S01.412A - Laceration without FB of Left cheek and temporomadibular area, initial encounter S01.412D - Laceration without FB of Left cheek and temporomadibular area, subsequent encounter S51.812A - Laceration without FB of left forearm, initial encounter S51.812D - Laceration without FB of left forearm, subsequent encounter S00.81XA - Abrasion of other part of head, initial encounter S00.81XD - Abrasion of other part of head, subsequent encounter Y04.0XXA - Assault by unarmed brawl or fight, initial encounter Y04.0XXD - Assault by unarmed brawl or fight, subsequent encounter Y92.29 - Other specified public building as the place of occurrent of the external cause a.S82.899P The malunion fracture is a complication of the initial fracture. Per ICD-10-CM guideline I.C.19.c.1 "Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7 th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R)." In the ICD-10- CM Alphabetic Index, look for Fracture, traumatic/ankle which guides you toS82.899. In the Tabular List the 7 thcharacter P is chosen for subsequent encounter for fracture with malunion. According to ICD-10-CM guideline 1.B.10, the code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect. - answer ✅✅After suffering a fracture of the ankle three months ago, a 69 year-old patient presented with what was found to be a malunion fracture. She was treated with additional surgery and discharged. Which injury diagnosis code(s) is/are assigned? a.S82.899P b.S82.899A c.S82.899A, S82.899P d.S82.899A, S82.899S S82.899P - Other fracture of unspecified lower leg, subsequent encounter for closed fracture with malunion S82.899A - Other fracture of unspecified lower leg, initial encounter for closed fracture S82.899S - Other fracture of unspecified lower leg, sequela c.S62.001K A nonunion fracture is when the broken bone has failed to heal or is not healing. According to ICD-10-CM guideline I.C.19.c.1 Care of complications of fractures, such as malunion and nonunion, is reported with the appropriate 7 th character for subsequent care. The fracture was due to an accident and there is no mention of osteoporosis so this is a traumatic fracture. In the ICD-10-CM Alphabetic Index, look for Fracture, traumatic/scaphoid (hand) and you are directed to see also Fracture, carpal, navicular. In the Alphabetic Index, look for Fracture, traumatic/carpal bone(s)/navicular guides you to S62.00-. In the Tabular List a 6 th character 1 is selected for the right wrist and 7 th character K is selected for a subsequent encounter for fracture with nonunion. Verify code selection in the Tabular List. - answer ✅✅A 63 year-old fractured her scaphoid bone in her right wrist three months ago in an accident. She now presents with a nonunion of the scaphoid bone. What ICD-10-CM code is reported? a.S62.001A b.M84.433A c.S62.001K H93.13 - Tinnitus, bilateral R11.2 - Nausea with vomiting, unspecified R40.0 - somnolence (drowsiness) T39.011A - Poisoning by asa, accidental (unintentional), initial encounter a. S81.852A, Z20.3, Z23, W54.0XXA The child had open bite wounds to her left leg from a dog bite. Look in the ICD-10-CM Alphabetic Index for Bite(s) (animal) (human)/leg (lower) S81.85-. In the Tabular List, 6 th character 2 is reported for the left leg and 7 th character A is applied for the initial encounter. She did not have rabies but was exposed to it because the dog was known to have rabies. This exposure to rabies is reported. Look in the Alphabetic Index for Exposure (to)/rabies directing you to Z20.3. She received a rabies vaccination. Look in the Alphabetic Index for Immunization/encounter for directing you to Z23. Next, the circumstances for the injury are reported. The only thing we know is that it is a dog bite. Look in the ICD-10-CM External Cause of Injuries Index for Bite, bitten by/dog directing you to W54.0-. In the Tabular List the 7 th character A is applied for the initial encounter. Two placehol - answer ✅✅A 7 year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the open bite wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What ICD-10-CM codes are reported? a. S81.852A, Z20.3, Z23, W54.0XXA b. S81.812A, Z20.3, Z23, W54.0XXA c. S81.852A, Z23, W54.0XXA d. S81.812A, A82.9, Z23, W54.0XXA A82.9 - Rabies, unspecified S81.812A - Laceration without FB, LLE, initial S81.852A - Open bite, LLE, initial encounter Z20.3 - Contact with and (suspected) exposure to rabies Z23 - encounter for immunization W54.0XXA - bitten by dog, initial encounter a.T23.301A, T24.232A Burns are classified as burns or corrosions in ICD-10-CM. In this scenario, there is no specification as to what caused the burns, but they are stated as burns. ICD-10-CM guideline I.C.19.d.1 indicates to sequence first the code that reflects the highest degree of burn when more than one is present. In this case, the third degree burn on the right hand is listed first. In the ICD-10-CM Alphabetic Index, look for Burn/hand(s)/right/third degree directing you to T23.301-. In the Tabular List, a 7 th character A is reported for the initial encounter (active treatment). ICD-10-CM guideline I.C.19.d.2 indicates to code burns of the same site, but of different degrees to the subcategory identifying the highest degree recorded. Therefore, report second degree burns to the left calf. Look in the Alphabetic Index for Burn/calf/left/second degree T24.232. In the Tabular List a 7 th character A is reported - answer ✅✅A child is seen in a hospital based pediatric clinic for active treatment of 10% first and second degree burns to the left calf area and 5% third degree burns on her right hand. What ICD-10-CM codes are reported? a.T23.301A, T24.232A b.T23.291A, T24.202A c.T23.301A, T24.232A, T24.132A d.T24.202A, T23.301A, T24.132A d.Z23 In the ICD-10-CM Alphabetic Index look for Vaccination (prophylactic)/encounter for which guides you to code Z23. Verify the code selection and refer to the notes in the Tabular List. The patient does not have these diseases so you cannot code for them, only for the vaccine encounter. - answer ✅✅A 12 month-old receives the following vaccinations: Hepatitis B, Hib, Varicella, and Mumps- measles-rubella. What ICD-10-CM code(s) is/are reported for the vaccinations? a.B19.10, B01.9, B26.9, B05.9, B06.9 b.B19.10, B01.9, B26.9, B05.9, B06.9, Z23 c.Z23, B19.10, B01.9, B26.9, B05.9, B06.9 d.Z23 a.T22.212D In the ICD-10-CM Alphabetic Index look for Burn/forearm/left/second degree, guiding you to subcategory T22.212. Per ICD-10-CM guideline I.C.19.a indicates that the 7 th character D subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an X-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition." Verify code selection in the Tabular List. - answer ✅✅A patient is coming in for follow up of a second-degree burn on the left forearm. The provider notes the burn is healing well. He is to come back in two weeks for continued care to checkup on the healing of the burn. What ICD-10-CM code is reported? subsequent encounter for fracture with routine healing. Cast change and removal are listed as examples of fracture aftercare in the ICD-10-CM guideline I.C.19.c.1. ICD-10-CM guideline I.C.20.a.2 instructs you to use the external cause code for the length of the treatment. In the ICD-10-CM External Cause of Injuries Index look for Fall, falling/from, off, out of/ladder directi - answer ✅✅A 60 year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. The fracture is healing normally. What ICD-10-CM code(s) is/are reported? a.S92.002A b.S92.002A, W11.XXXA c.S92.002D d.S92.002D, W11.XXXD b.O03.1 ICD-10-CM guideline I.C.15.q.2 indicates when a patient has retained products of conception following a spontaneous abortion, report a code from category O03 Spontaneous abortion even when the patient has been discharged with a diagnosis of complete abortion previously. This is an incomplete abortion because there are retained products of conception. Look in the ICD-10-CM Alphabetic Index for Abortion/incomplete (spontaneous)/complicated by/hemorrhage (delayed) (excessive) directing you to O03.1. Verify code selection in the Tabular List. - answer ✅✅A patient had a spontaneous complete abortion three days ago. She returns to the ED and is bleeding. After the ED provider examines her, she still has retained products of conception (POC). What ICD-10-CM code is reported for this encounter? a.O02.1 b.O03.1 c.O04.6 d.O03.6 a.O86.13 The postpartum period is also known as the puerperal period. In the ICD-10-CM Alphabetic Index look for Puerperal, puerperium (complicated by, complications)/vaginitis or Vaginitis/puerperal (postpartum) which directs you to code O86.13. Verify code selection in the Tabular List. - answer ✅✅The patient has vaginitis three days after she was discharged from the hospital where she had a vaginal delivery of a healthy baby girl. What ICD-10-CM code is reported? a.O86.13 b.O23.599 c.N76.1 d.N76.0 b.T87.40 In the ICD-10-CM Alphabetic Index look for Complication (s) (from) (of)/amputation stump (surgical) (late) NEC/infection or inflammation/lower limb guiding you to subcategory T87.4-. The Tabular List shows that a 5 th character is needed to complete the code. The documentation does not state which side has the amputation which makes 0 the correct 5 th character. Code S88.119D is not reported because the encounter is not for a patient with a traumatic amputation. Verify code selection in the Tabular List. - answer ✅✅Ten days following a surgical below the knee amputation, the patient sees her provider. The provider notes that the amputation stump is not healing and is infected. What ICD-10- CM code(s) is/are reported? a.S88.119D b.T87.40 c.T87.89 d.T87.43, T87.44 a. T21.31XA, T22.391A, T22.392A, T24.291A, T24.292A, T31.32 ICD-10-CM guideline I.C.19.d.1 states to sequence first the code that reflects the highest degree of burn when more than one burn is present. In this case, the burns on her chest and arms are third degree and are reported first. In the ICD-10-CM Alphabetic Index look for Burn/chest wall/third degree, referring you to subcategory T21.31. Because the question indicates arms and legs (plural) we will code multiple sites of the right and left upper and lower limbs. In the Alphabetic Index look for Burn/upper limb/multiple sites/left/third degree directing you to subcategory T22.392-, and Burn/upper limb/multiple sites/right/third degree directing you to T22.391-. Next look for Burn/lower/limb/multiple sites/left/second degree directing you to subcategory T24.292-. Look for Burn/lower/limb/multiple sites/right/second degree directing you to subcategory T24.291-. - answer ✅✅A 3 year-old is brought to the burn unit after pulling a pot of hot soup off the stove and spilling it on herself. She sustained 18% second degree burns on her legs and 20% third degree burns on her chest and arms. Total body surface area burned is 38%. What ICD-10-CM codes are reported for the burns (do not include external cause codes for the accident)? a. T21.31XA, T22.391A, T22.392A, T24.291A, T24.292A, T31.32 b. T24.299A, T21.31XA, T22.399A, T31.32 c. T21.21XA, T22.20XA, T24.209A, T31.23 d. T21.31, T22.20, T24.209, T31.32 c. Persuasive d. The writing style is irrelevant d. All of the above - answer ✅✅What should an audit report identify? a. Key findings identified b. An analysis of the findings c. Rationale and recommendations d. All of the above d. Context - answer ✅✅The statement "he slipped and fell while walking up the stairs" would be considered which element of HPI? a. Modifying factors b. Associated signs and symptoms c. Location d. Context b. Date of when the initial problem occured - answer ✅✅Which one of the following is not a documentation requirement for a radiology report to assign a CPT ® code? a. Referring physician b. Date of when the initial problem occured c. Number of radiology views taken d. Patient history c. Retain the actual images - answer ✅✅When referring to radiological services, what is the requirement for the images obtained? a. As long as there is a written report, the images are not important. b. They only need to be retained if abnormalities are identified. c. Retain the actual images d. There are no specific guidelines for images. D. I and II - answer ✅✅Clinical Documentation Improvement (CDI) programs can help: I. Build effective documentation compliance policies II. Capture clinical data required for continuity of care III. Promote failures identified in documentation review A. I and III B. I, II and III C. II and III D. I and II B. Failure to include the complications of drug for prescriptions taken by a patient. - answer ✅✅Which of the following documentation deficiencies have a negative impact on patient outcomes? A. Failure to indicate the patient's insurance information. B. Failure to include the complications of drug for prescriptions taken by a patient. C. Failure to sign the patient's documented review of systems when obtaining a history. D. Failure to report the patient's employment in the social history. B. Display in your query the Index entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to report. - answer ✅✅A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with the diagnosis of marasmus. Your correct response: A. Congratulate the physician for correctly capturing an often- overlooked malnutrition diagnosis. B. Display in your query the Index entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to report. C. Report code E41 D. Report code R54 B. I, II, III, IV, and V Depending on the documentation issue, any of these responses might be appropriate. Failing to address flaws in documentation can result in medical errors, financial losses and diminished patient care - answer ✅✅The best approach when querying a physician regarding documentation is to approach the problem as one of: I. Evidence based medicine II. Financial motive III. Malpractice liability IV. Documentation impact on reimbursement V. Documentation impact on compliance A. ll, IV, and V