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Certified Coding Specialist ICD10 Practice
Exam #2 Came from Certified Coding
Specialist Exam Prep 9th Edition
Textbook
Domain 1 Clinical Documentation
Domain 2 Diagnosis Coding
Domain 3 Procedure Coding
Domain 4 Reporting Requirements for Inpatient
Services
Domain 5 Reporting Requirements for Outpatient
Services
Domain 6 Data Quality Management
Domain 7 Privacy, Confidentiality, Legal, and Ethical
Issues
A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She is afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which one of the following should be the principal diagnosis? - Answer O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion
A psychiatrist documents that a patient has wide mood swings from excessive happiness to loss energy and crying. What condition is suspected? - Answer Bipolar disorder A patient with a cephalic presentation anticipating a vaginal delivery failed to progress. After measurement of the fetal head and a trail of oxycontin, the patient underwent a cesarean section. What condition should the coder suspect and query the physician about? - Answer Cephalopelvic disproportion A 45-year-old woman underwent a carotid bypass and experienced a significant drop in blood pressure during the surgery. The documentation suggested the patient may have had a myocardial infraction. In accordance with the coding guidelines, what should the coding professional do? - Answer Query the physician to determine fi there was a compliance of surgery If a patient's discharge summary does not contain that is documented by the anesthesiologist in a postoperative evaluation and that is diagnosis would impact MS-DRG assignment, the coder should _____________________________________. - Answer Query the attending physician regarding the clinical significance of that diagnosis A patient record has documentation of esophageal varices. What condition may be related that may affect coding? - Answer Liver disease A patient admitted with acute abdominal pain is found to have appendicitis and has an appendectomy. The patient has a length of stay of two days. What type of patient encounter is this? - Answer Inpatient A patient was treated in the emergency department for a swollen knee and an aspiration of the joint was performed. The patient was then discharged home. It is important to make sure that which of the following are documented and captured for billing purposes? - Answer All services provided including diagnostic and treatment procedures, as well as physician services A patient has documentation on the discharge summary of urosepsis. The coding staff queries the attending physician about the condition and is provided further information that the patient has septicemia. This is in alignment with the laboratory tests and medication given, but the diagnosis of septicemia was not documented by the physician. How should the physician
A patient takes Coumadin as prescribed and correctly administered. However, the patient develops hematuria secondary to the Coumadin use. The correct coding assignment for this case would be _______________________________. - Answer Hematuria, adverse reaction to Coumadin A patient is admitted with lethargy, congestive heart failure, and pleural effusion. The patient underwent treatment with diuretics for the CHF, which has cleared. The pleural effusion required a thoraccentesis to determine the cause. At the time of discharge, the effusion was decreased but not resolved. The correct coding assignment for this case would be ___________________________________________. - Answer Congestive heart failure and pleural effusion A patient with human immunodeficiency virus (HIV) with methicillin susceptible due to Staphylococcus aureus was discharged from the acute-care setting. How should this be coded? - Answer B20 human immunodeficiency virus [HIV] disease; J15.211 pneumonia due to methicillin susceptible Staphylococcus aureus A patient has a diabetic ulcer of the right foot. How should this patient's record be coded? - Answer E11.621 type 2 diabetes mellitus with right foot; L97.419 non-pressure chronic ulcer of right heel and midfoot with specified severity Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. - Answer I11.0, hypertensive heart disease with heart failure; I50.9, heart failure, unspecified A patient has squamous cell carcinoma of the knee. What code should be assigned for this diagnosis? - Answer C44.721, squamous cell carcinoma of the skin of unspecified lower limb, including hip A patient is seen for evaluation of a right orbital roof fracture. How should this be coded? - Answer S02.19XA, other fracture of base of skull, initial encounter for closed fracture A patient was seen for first- and second-degree burns of the upper thigh. How should this be coded? - Answer T24.219A, burn of second degree of unspecified thigh, initial encounter
Suicide attempt with overdose of Percocet. How should this be coded? - Answer T40.2X2A, poisoning by other opioids, intentional self-harm, initial encounter Itching due to drug reaction to an antihistamine. What codes should be assigned? - Answer L29.9, Pruitius, unspecified; T45.0X5A, adverse effect of antiallergic and antimetric drugs, initial encounter Acute peptic ulcer with perforation and hemorrhage and resulting blood loss anemia. What codes should be assigned? - Answer K27.2, acute peptic ulcer, site unspecified, with both hemorrhage and perforation; D50.0, iron deficiency anemia secondary to blood loss (chronic) According to the UHDDS, the definition of a secondary diagnosis is a condition that __________________________________________________________________. - Answer Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, and increases nursing monitoring and care A patient is admitted to a healthcare facility with ataxia and syncope. The patient has a history of lung cancer. The patient also has a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the brain and undergoes radiation therapy to the brain. The principal diagnosis should be ___________________________________________. - Answer Metastatic carcinoma of the brain A 78-year-old patient is admitted with shortness of breath and a chest x-ray reveals infiltrates in the lung with pleural effusion. The patient also had an history of hypertension with left ventricular hypertrophy. The patient is given Lasix and the shortness of breath is relieved. From the information given, what is the probable principal diagnosis? - Answer Congestive heart failure A patient is admitted with abdominal pain. The discharge documentation states "pancreatitis vs. noncalculus cholecystitis" as the final diagnoses. Both diagnoses are equally treated. Based on coding guidelines, what is the correct sequencing for these diagnoses? - Answer Sequence either the pancreatitis vs. noncalculus cholecystitis first
A patient was admitted directly from his primary physician's office due to suspected avian influenza, along with signs and symptoms of avian influenza. The patient left against medical advice (AMA) before confirmatory lab tests could be drawn to identify the virus. The principal diagnosis should be coded from category ____________. - Answer J11, influenza due to unidentified influenza virus How should an annual screening mammogram with CAD be coded? - Answer Z12.31, encounter for screening mammogram for malignant neoplasm of breast; 77067, screening mammography, bilateral (2-view study of each breast), including CAD when performed Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures _______________________________________. - Answer Use the terminology "manipulation" rather than "reduction" of fracture In CPT, if a patient has two lacerations of the am that are repaired with simple closures, the coder would assign ___________________________. - Answer Two CPT codes expressing each laceration repair According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? - Answer Complex closure The patient was monitored under general anesthesia for keratoplasty including excision of diseased cornea. A controlled depth-setting blade was used to cut partially into the recipient's cornea in a manner to allow the lamellar graft to fit. Which CPT code should be assigned? - Answer 65710, keratoplasty (corneal transplant); anterior lamellar Assign the correct CPT code for a 50-year-old female patient admitted to outpatient surgery department for a laparoscopic surgical repair of a recurrent, incarcerated incisional hernia with mesh insertion. - Answer 49657, laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated Patient with renal tumors received with percutaneous cryotherapy ablation of three tumors on the right kidney in the same operative episode at Memorial Hospital. Assign a CPT code for this procedure. - Answer 50593, ablation, renal tumor(s), unilateral, percutaneous, cryotherapy
In outpatient surgery, a PTCA is completed with insertion of a drug-eluting stent in the left circumflex artery and a non-drug eluting stent inserted into the left anterior descending artery of this 56-year-old female. Assign the correct CPT code(s) for this proceudure. - Answer 92928-LC, percutaneous transcathter placement of intracornary stent(s), with coronary angioplasty when performed; single major coronary artery or branch left circumflex coronary artery; 92929-LD each additional branch of a major coronary (list separately in addition to code for primary purpose) left anterior descending coronary artery Patient admitted o laparoscopic repair of right diaphragmatic hernia. Assign the ICD- 10 - PCS procedure code for this surgery. - Answer 0BQT4ZZ, repair diaphragm, open approach Patient presents in the ER with thrombosis of a loop PTFE hemodialysis fistula without mechanical complications. The physician performed a percutaneous thrombectomy of the left branchial vein. Assign a facility code fo this outpatient procedure. - Answer 36904, percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolyisis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thromblytic injection(s) The physician performed a myringotomy under general anesthesia for insertion of bilateral ventilating tubes on a 4-year-old male. This is due to chronic otitis media. What is the correct CPT code assignment and what modifier should be appended (if applicable) to this procedure code? - Answer 69436 - 50, tympanostomy (requiring insertion of ventilating tube), general anesthesia bilateral procedure Removal of two (2) skin tags on chest (0.3cm and 0.5cm). What is the correct CPT code assignment? - Answer 11200, removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions In outpatient surgery, a patient undergoes a direct laparoscopy with operating microscope. What code should be assigned? - Answer 31526, laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope
A 75-year-old male patient was given heparin during hospitalization for a deep vein thrombophelebitiis of the right lower extremity. He was scheduled to have an insertion of intravascular vena cava filter into the femoral vein by endovascular approach the following day. The patient had back pain and the nurse was not answering the bell, so he decided to take two aspirin. The interaction between the aspirin and heparin caused a subcutaneous hemorrhage of the thigh of the right lower extremity. How should the interaction between aspirin and heparin be coded? Assuming the interaction was resolved, what CPT code would be used for the procedure. - Answer Poisoning codes for aspirin and heparin as principal diagnosis, and subcutaneous hemorrhage of the thigh of the right lower extremity as secondary conditions; CPT 37191 A 77-year-old patient has hypertensive heart disease with congestive heart failure and with stage 5 renal disease. The patient presented to the ED where she received critical care services for 110 minutes. What codes would be assigned? - Answer I13.2, hypertensive heart and chronic kidney disease with heart disease with stage 5 chronic kidney disease, or end stage renal disease; N18.5, chronic kidney disease, stage 5; I50.9, heart failure, unspecified; 99291, 99292 x 2 Medicare severity diagnostic-related groups (MS-DRGs) and ambulatory patient classifications (APCs) are dissimilar in that _______________________________________________. - Answer There is only one MS-DRG per inpatient discharge but one or more APCs per outpatient visit A patient is admitted with vaginal bleeding. One of the concurrent coding analysis reviewing information in the chart has determined that there may be additional procedure code but there is no typed operative report to provide definitive information. Coding the additional procedure would be considered an ethical practice if ___________________________________________. - Answer Under no circumstances would this be done Which of the following is a key part of an internal coding compliance for facility-based evaluation and management code asssignment? - Answer Regular internal audits comparing the code assignment the facility guidelines A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is performed with resection of the joint with implant in the first
left toe proximal phalanx. What codes would be assigned? - Answer M20.12, hallux valgus (acquired), left foot; 28291-LT, hallux rigidus correction with cheilectomy, debridement and capsular release of the 1st metatarsophalangeal joint; with implant A patient presents for esophageal varices without bleeding. There is no diagnosed cause of the condition. The procedure performed is esophagogastroduodencopy with sclerotherapy of esophageal varices. What codes would be assigned? - Answer I85.00, esophageal varices without bleeding; 43243 an EGD with injection sclerosis of esophageal and/or gastric varices A 7 0 - year-old male patient presents with BPH without LUTS. Transurethral resection of the prostate for benign prostatic hypertrophy with electrocautery is performed. What codes would be assigned? - Answer N40.0, benign prostatic hyperplasia without lower urinary tract symptoms; 52601, transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete A male patient presents for cryosurgical destruction of simple papiloma of the penis. The postoperative documentation confirms a benign neoplasm of the skin of the penis. What codes would be assigned? - Answer D29.0, benign neoplasm of penis; 54056 destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple A female patient presents for DUB, for which hysteroscopy with endometrial ablation was undertaken. What codes would be assigned? - Answer N93.8, other specified abnormal uterine and vaginal bleeding; 58563 laparoscopic/hysteroscopic procedures on the corpus uteri A female patient in her second trimester underwent removal of cervical cerclage under spinal anesthesia. The cerclage had been placed for an insufficient cervix. What codes would be assigned for the removal? - Answer O34.32, maternal care for cervical incompetence, second trimester; 59871, other procedures for maternity care and delivery A female patient is diagnosed with congestive heart failure and also has a stage IV pressure ulcer. Which of the following POA indicators must be
The use of standard protocols to enable different computer systems to communicate is referred as ___________________________________. - Answer Interoperability The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were miscoded as malignant during the last six months. To address this situation, what work processes could be undertaken? - Answer Obtain the cases of malignant colon tumors from both the cancer registry and the billing system; import both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor registry but are coded as malignant in the billing system. These cases should be manually reviewed to ensure they are not carcinoid tumors. Which of the following is not a function of the outpatient code editor (OCE)? - Answer Determining payment-related conditions that require direct reference to ICD- 10 - CM codes According to CPT guidelines, a colonoscopy includes _______________. - Answer Examination of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum A female patient with hematochezia presents to the hospital outpatient surgery department for a colonoscopy but the procedure was not performed due to elevated blood pressure. What is the first-listed diagnosis for this encounter? - Answer Hematochezia From the information provided, what would be the total reimbursement for this patient? - Answer $3, What percentage will the facility be paid for procedure code 10060? - Answer 100% If another status S procedure were performed, how much would the facility receive for the second status S procedure? - Answer 100% A Pap smear cannot be interpreted because the sample was inadequate. What type of diagnosis code should be assigned? - Answer Code for unsatisfactory cytology smear
If a diagnosis of rule-out pneumonia with cough and malaise is specified in an emergency department visit, the coder should assign a code for ______________________________. - Answer Cough and malasie Which of the following services are paid under the outpatient prospective payment system (OPPS)? - Answer Outpatient hernia repair What is assigned to CPT codes to indicate whether a service or procedure will be reimbursed under the OPPS? - Answer Payment status indictors The case mix for the information provided above is __________________. - Answer 45 The information provided that ______________________________________________. - Answer The payment is lowest for patients with DRG 193 Data accuracy is also referred to as ________________________________. - Answer Validity A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is ________________________. - Answer Preventive The patient was admitted for prostate carcinoma. This was treated with radiation. A member of the medical staff who was not associated with the patient's care requests to see the patient's record. What should the coder do? - Answer Explain that providing the record would violate the privacy policy In most circumstances, the person who authorizes release of medical information is ________________________. - Answer Patient
