RA Exam Review

What information is required when submitting documentation to support a diagnosis for a RADV/IVA?

A single DOS for outpatient records and the full inpatient set for hospital records

Which of the following physician assessments support the correct coding of CKD stage 2, code N18.2? A. A/P: Mild CKD B. Assessment and Plan: Moderate CKD C. Assessment: Severe Chronic Kidney Disease D. A/P: ESRD

A. A/P: Mild CKD ICD-10-CM guideline I.C.14.a.1 states the stages of chronic kidney disease. Mild CKD is reported with N18.2.

What is predictive modeling? A. Analysis of data to determine a hypothesis related to the future health care needs of patients B. Cost comparison of health care costs generated locally versus nationally C. Comparison of money saved with risk adjustment models compared to fee-for-service models D. Chronic disease management education to prevent high health care costs

A. Analysis of data to determine a hypothesis related to the future health care needs of patients Predictive modeling is an analytical review of known data elements to establish a hypothesis—or educated guess—related to the future health of patients or suspected current diagnoses felt to be present with varying certainty. Predictive modeling is often used by health plans and other health specialists as a way to anticipate potential future diagnoses for an individual patient, as well as groups of individuals to prepare for those medical needs.

Which statement is TRUE regarding the HCC blended model? A. Eases the transition from one year's model to the next because of potential lost values B. Requires additional resources to code records working under two different models C. Allows for fee-for-service model incorporation into the risk adjustment factor score D. Results in loss of revenue in the first year which can be recouped the following year

A. Eases the transition from one year's model to the next because of potential lost values The blended methodology was chosen to ensure ease of transition from one model to the next because of their vast differences and potential lost values.

Retrospective audits provide insurance companies with ability to scrub/correct their data which accomplishes which of the following? I.Provides opportunities to increase revenue by submitting additional codes II.Provides opportunities to compare claims data to the documentation and submit deletions if the documentation does not support what was on the claim III.Provides opportunities to correct coding errors prior to data being submitted A. I and II B. I C. II D. II and III

A. I and II Retrospective chart audits have been commonly used to increase revenue, but for companies that want to do the "right" thing and to decrease the financial risk during RADV audits, comparing the claims to the documentation and where there are discrepancies submit deletes (remove ICD-10-CM code from CMS data base) and to submit additional codes is the best use of the retrospective chart audits

Which medical record(s) can be submitted for HCC validation? I. Physician office progress note II. Outpatient Hospital III. Critical Access Hospital IV. Laboratory test results V. Diagnostic X-rays A. I, II, and III B. IV C. I, II, III, and IV D. I, II, III, IV, and V

A. I, II, and III Laboratory reports and radiology reports cannot be submitted for HCC validation.

Patient is seen in his physician's office and diagnosed with benign hypertension and Stage 3 chronic kidney disease. Select the diagnosis codes. A. I12.9, N18.3 B. I10, N18.3 C. I12.9, N18.6 D. I10, N18.9

A. I12.9, N18.3 According to ICD-10-CM guideline I.C.9.a.2, a causal relationship is always assumed with hypertension and chronic kidney disease. Look in the ICD-10-CM Alphabetic Index for Hypertension/kidney/stage 1 through stage 4 chronic kidney disease. The instructional note under code I12.9 indicates to report an additional code for the stage of chronic kidney disease. This is stage 3; therefore, N18.3 is also reported.

This 75-year-old male with no prior cardiac history has had exertional dyspnea. A stress test was markedly positive. He underwent cardiac catheterization today, he was found to have normal left ventricular function. There was severe disease affecting the left anterior descending and circumflex coronary arteries. There was no significant disease affecting the right coronary artery. Dr. Internal Medicine has asked me to see the patient for consideration of further intervention. The patient is known to have hypertension. There is no history of diabetes or hyperlipidemia. He is status post hemorrhoidectomy. Status post inguinal hernia repair. Status post Esophagogastroduodenoscopy for an esophageal ulcer due to gastroesophageal reflux. He is allergic to PENICILLIN (the patient believes he had a rash to penicillin, although it was so many years ago that he cannot accurately recall). Current Medications are: Aspirin 325 mg p.o. qd., Atacand 16 mg p.o. qd., Aciphex 20mg p.o. bid. The patient is married and was accompanied with his wife. He is a farmer and works as a repairman for farm equipment. He does not smoke. A review of systems was reviewed and are all-negative except for above. These records are located in his inpatient record dated 03/05/2015. The patient is a healthy-appearing man who appeared younger than 75. He was afebrile. P 70 and electrocardiogram monitor showed that he was in normal sinus rhythm. B/P is 160/70, Ht 171cm, Wt 75 kg. Lungs were clear to auscultation. Heart tones normal. Examination of his abdomen was negative. His extremities were normal with normal dorsalis pedis pulses bilaterally. There was no cervical bruit audible. There was no gross neurologic deficit. Impression: Severe multivessel coronary artery disease with exertional dyspnea. The patient and his wife were fully informed regarding his problem and the recommended management of further intervention. We discussed risks and benefit of further cardiovascular intervention. The risks attendant with the operation were understood. I have discussed the plan with Dr. Cardio surgeon and he has agreed to perform the procedure on his patient. Based on the documentation provided, which diagnosis are reported for risk adjustment purposes? A. I25.10, I10 B. I25.10, R06.00 C. I25.10 D. I25.110

A. I25.10, I10 The patient is diagnosed with CAD. In the ICD-10-CM Alphabetic Index, look for Arteriosclerosis/coronary. There is no indication the patient has angina. Code also for the patient's chronic condition of hypertension.

Patient is admitted to the hospital for treatment of a Subarachnoid Hemorrhage. The patient has hypertension and is being evaluated by Neurosurgery for possible surgical intervention. Assign the correct ICD-10-CM code(s) for the admission. A. I60.9, I10 B. I10, I60.9 C. I60.9 D. I61.9, I10

A. I60.9, I10 There is an instructional note under category I60-I69 in the Tabular List that indicates to use additional code to identify presence of hypertension.

Data mining is performed to: A. Idenity data that might be related to patient risk scores B. Look for opportunities for clinical staff incentives C. Make sure that low performing providers are penalized for poor outcomes D. To evaluate the effectiveness of compliance plans

A. Idenity data that might be related to patient risk scores Data mining is performed to evaluate all aspects known on each member/patient to be sure that all potential risk is identified so that all necessary health care may be potentially planned.

What is the function of the thyroid gland? A. It secretes hormones regulating body metabolism and blood calcium B. It secretes hormones regulating the secretion of insulin and hemoglobin C. It secretes hormones regulating mood and growth hormones D. It secretes hormones regulating the immune system and blood calcium

A. It secretes hormones regulating body metabolism and blood calcium It secretes hormones regulating body metabolism and blood calcium.

In order for a coder to properly code for a vascular ulcer, which of the following must be included by the treating provider in the documentation? A. Location and type of ulcer must be described for vascular ulcers B. Size and location of ulcer must be described for vascular ulcers C. Size and type of ulcer must be described for vascular ulcers D. Only the location of the ulcer must be described for vascular ulcers

A. Location and type of ulcer must be described for vascular ulcers The treating provider must call it an ulcer and must include a description of the location and type of ulcer in order to code a vascular ulcer.

The provider sees a patient in the Emergency room for acute flank pain. The patient has high blood pressure after serial BPs taken. The ultrasound shows acute pyelonephritis. The provider documents acute pyelonephritis and secondary hypertension. Assign the correct ICD-10-CM codes. A. N10, I15.8 B. N11.0, I15.8 C. N11.0, I10 D. N10, I10

A. N10, I15.8

The star ratings program monitors: A. Performance of Medicare Advantage plans B. Fraud and abuse C. Adherence to state scope of practice D. Performance of Medicare providers

A. Performance of Medicare Advantage plans Medicare uses a Star Rating System to measure how well Medicare Advantage and prescription drug (Part D) plans perform. Medicare scores how well plans did in several categories, including quality of care and customer service.

Risk Adjustment is a: A. Prospective payment system B. Retrospective payment system C. Fee-for-service payment system D. Case rate payment system

A. Prospective payment system Risk adjustment is a prospective payment model. It uses diagnostic information from a base year to predict Medicare benefit costs for the following year.

Which of the following is an example of fraud? A. Reporting a diabetic manifestation to increase the risk score. B. Submitting a record for a RADV audit which includes diagnoses that were not previously reported. C. Training physicians to document causal relationships for manifestations for chronic illnesses when present. D. Setting a policy to report all patient's with DM and CKD as a diabetic manifestation.

A. Reporting a diabetic manifestation to increase the risk score. Intentionally reporting a diagnosis that is not supported by the documentation in order to raise a risk score is fraud.

An AV fistula connects: A. The aorta to a vein B. An artery to a varicose vein C. An artery to a vein D. An artery to a ventricle

A. The aorta to a vein An AV (Arteriovenous) fistula is a connection between an artery and a vein.

In order for a code to be counted as part of the current CMS HCC model, what is the criteria a diagnosis code must meet? A. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC) B. The diagnosis is a history code C. The diagnosis has never been reported D. The diagnosis is an acute condition

A. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC) A current model diagnosis code must meet the following criteria: 1. The diagnosis is included in the CMS-Hierarchical Condition Category (CMS-HCC), Prescription Drug (CMS-RxHCC) or End Stage Renal Disease (CMS-HCC ESRD) risk adjustment models. 2. The diagnosis must be received from one of the three provider types (hospital inpatient, hospital outpatient, and physician) covered by the risk adjustment requirements. 3. The diagnosis must be collected according to the risk adjustment data collection instructions.

Patient presents to her physician 10 weeks following a true posterior wall myocardial infarction. The patient is still symptomatic and is receiving care related to the myocardial infarction. What is the correct first-listed ICD-10-CM code for this condition? A. Z51.89 B. I21.29 C. I22.8 D. I25.2

A. Z51.89 Because it is past four weeks and the patient is still symptomatic, according to ICD-10-CM guidelines, Section 1.C.9.e.1 For encounters after the 4 week time frame and the patient is still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, rather than a code from category I21.

Which of the following is NOT TRUE regarding Atherosclerosis?

Affects the veins Atherosclerosis, or hardening of the arteries, is a condition in which plaque builds up inside the arteries. Plaque is made of cholesterol, fatty substances, cellular waste products, calcium and fibrin (a clotting material in the blood). Veins are not affected by atherosclerosis.

Breast Cancer Treatement

Anastrozole is used to treat breast cancer in women who have gone through menopause. It works by lowering estrogen hormone levels to help shrink tumors and slow their growth. Tamoxifen is prescribed for women who have breast cancer with tumors fueled by estrogen. The medication blocks the action of estrogen.

A 32 year-old patient suffered a crush and avulsion type injury which has now resulted in loss of the fourth and fifth digits at the metacarpophalangeal joint levels, loss of the index and long fingers through the proximal phalanx proximal aspect and soft tissue loss dorsally over the left hand. What is (are) the appropriate diagnosis code(s)? A. S63.261A, S63.263A, S67.191A, S67.193A B. M20.092 C. Z89.022, S63.261A, S63.263A D. M20.092, S67.191A, S67.193A

Assign code M20.092 Other deformity of left finger(s), as the principal diagnosis. Code Z89.022, Acquired absence of left finger(s), is not an acceptable principal diagnosis. Code Z89.022 should not be reported as an additional diagnosis with code M20.092 because it is listed under the Excludes1 note.

Patient is admitted to the hospital with streptococcal sepsis which has caused pneumonia. What codes are assigned? A. A49.1, T91.4XXA B. A40.9, J16.8 C. A40.9 D. A49.1, J18.9

B. A40.9, J16.8 Per ICD-10-CM guideline I.C.1.b.4: A localized infection, such as pneumonia or cellulitis, a code for the systemic infection (A40.-) should be assigned first and the code for the localized infection should be assigned as a secondary code. To find the codes look in the ICD-10-CM Alphabetic Index for Sepsis/Streptococcus, streptococcal. Then code the pneumonia found in the ICD-10-CM Alphabetic Index under Pneumonia/specified/organism J16.8. Verify all codes in the Tabular List.

Which risk adjustment model is used by Medicaid programs? A. HCC B. CDPS C. ZIPC D. PQRS

B. CDPS Medicaid uses the Chronic Illness and Disability Payment System (CDPS)

Which risk adjustment model incorporates high, medium, and low risk in the numeric value? A. HCC B. CDPS C. ACA-HHS D. Medicare Advantage

B. CDPS CDPS diagnoses also carry a numeric value for risk, they are also rated as "high," "medium," and "low" risk overall. This rating is used in hierarchal value setting.

Choose the best medical record for a RADV audit to include all the diagnoses in this scenario: • CMS is requesting diabetes mellitus with neuropathy to be validated • Assume all the notes are signed by the provider and the diagnoses are supported by the documentation A. Chart #1: DOS 1/1/20XX—Diagnoses: DM, PVD B. Chart #2: DOS 4/2/20XX—Diagnoses: DM with neurologic manifestations, polyneuropathy, CKD C. Chart # 3: DOS 7/7/20XX—Diagnoses: DM with neurologic manifestations D. Chart # 4: DOS 9/9/20XX—Diagnosis: DM, HTN

B. Chart #2: DOS 4/2/20XX—Diagnoses: DM with neurologic manifestations, polyneuropathy, CKD When a diabetic manifestation is reported a combination code is used to include the type of diabetes and the manifestation. The record that supports the condition in question is chart #2.

In order for a MA Plan to improve their revenue, which of the following statements describes the correct approach a plan should take to accomplish this? A. Code all diagnoses listed in the patient's problem list B. Develop a prospective and retrospective review to capture all accurate diagnoses C. Target diagnosis code selection for the most high risk diagnoses which yield more reimbursement D. Transfer healthy patients out of the network and focus on treating patients with chronic conditions

B. Develop a prospective and retrospective review to capture all accurate diagnoses For a plan to increase revenue, it should develop an HCC capture strategy from a prospective approach versus a retrospective approach. When an MA plan focuses HCC capture solely from a retrospective approach, the plan risks being exhausted by the tedious nature and high cost of using an outside vendor for large numbers of medical charts. When the provider sees the member one to two times a year, the provider can review the problem list and accurately report all existing chronic disease processes to the MA plan. This prospective approach improves the MA plan's ability to capture more HCC codes for better reimbursement and eliminates the need for expensive retrospective chart reviews in the future.

73 year-old visits his primary care physician to discuss lap band procedure for his morbid obesity. His BMI is currently 45. What ICD-10-CM code(s) should be reported? A. E66.9 B. E66.01, Z68.42 C. E66.1, Z68.42 D. Z68.42, E66.01

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 you will see the code for morbid obesity E66.01 states "due to excess calories." Even though the documentation does not indicate due to excess calories the Alphabetic Index directs you to report code E66.01 for morbid obesity. In the Tabular List, there is a note under subcategory code E66.- to Use an additional code to identify the BMI (Z68.-). Look at the code range for Z68 in the Tabular List. The second code is Z68.42 indicating a BMI of 45.0 - 49.9 adult.

If you were using a predictive model and the results were: • The member had a DME claim for oxygen. • The member had an Rx Claim for a bronchodilator. • The member had a medical claim which included a PFT. Which diagnosis would you predict this member has? A. Hypertension B. Emphysema C. CHF D. Diabetes

B. Emphysema Patient's with emphysema are treated with medications such as bronchodilators and inhaled steroids. Treatments also include pulmonary rehab, nutrition therapy and supplemental oxygen. Typical tests run for emphysema include chest X-rays, lab tests and lung function tests.

Excessive potassium in the blood is referred to as: A. Hematuria B. Hyperkalemia C. Hypoproteinemia D. Hypernatremia

B. Hyperkalemia

A 72 year-old female returns today to the family practice clinic at the university hospital for a scheduled appointment. She is returning after previous visit of 2 years ago, with history of HTN, diabetes, CHF presents. She has shortness of breath and chest pain radiating to her right arm. She was in her normal state of health until 2 hours prior to arrival. She also admits nausea, diaphoresis, she denies any palpitations she admits shortness of breath and difficulty getting a deep breath. She denies any abdominal pain. Denies any pain in the extremities, weakness, numbness, tingling. She had no loss of consciousness or altered mental status. She has no other complaints. Allergies: Codeine Medications: Potassium, Lasix, Correg, Gliburide, Aspirin, and Nitroglycerin, sublingual prn She did not take any of her sublingual nitro with the onset of this chest pain. Patient is a non-smoker, married for forty years Family history significant for Diabetes type II, also Coronary disease/MI in mother and father before the age of 50. Review of systems: Otherwise negative. Temp: 98.2 P: 112 R: 18 somewhat labored BP: 184/98 Pulse ox is 92% on room air Elderly female appears her stated age. She is a/o x3, Mild/moderate respiratory distress. She is pale and diaphoretic, resting on the gurney. PERRL, EOMI, conjunctivae clear TM's clear, nasopharynx and oropharynx pink and moist. Neck: soft supple JVD is present. Heart: regular rhythm, no click, rub, murmur, gallop. Tachycardic at 120 bpm. Lungs show fine crackles and wet rhawls throughout. Lung sounds present in all fields. Abdomen: obese, soft, NDNT, no mass or hepatosplenomegaly, bowel sounds present time 4 with no bruits. Musculoskeletal: ROM, Strength in upper and lower extremities are normal. Neurologic: Cranial nerves III-XII grossly intact, no evidence of focal deficits. Sensation normal and equal in upper and lower extremities, DTR's 2+ at patella, Achilles, biceps, triceps brachioradialis. Pulses 2+ dorsalis pedis, radials, carotids. There are faint carotid bruits right sided. Lab data obtained shows chemistry was normal except for potassium, which was high at 5.2. CBC shows normal white count. H/H is normal as well as platelet count. EKG shows sinus tachycardia at a rate of 122 bpm. LVH is noted no evidence of ischemia or infarct. Chest x-ray shows pulmonary edema with widened cardiac silhouette. PT, PTT, CK, Troponin I, are all normal. Patient was given an aspirin upon arrival to the clinic. She was given lasix 60 mg IV. She was also placed on nitroglycerin and accupril was given. Patient had diuresis of about 1400cc of urine over the next 45 minutes Impression: Acute exacerbation of congestive heart failure Hypertension Coronary artery disease DM Type II Plan: Patient will be admitted to the floor under her cardiologist and followed by her primary care physician as well. Based on the documentation provided, which diagnosis codes are reported for risk adjustment purposes? A. I50.9, I11.0, I25.10, E11.65 B. I50.9, I11.0, I25.10, E11.9 C. I50.21, I11.0, I25.110, E11.65 D. I50.31, I11.0, I25.110, E11.9

B. I50.9, I11.0, I25.10, E11.9 The patient is diagnosed with an exacerbation of CHF, HTN, CAD and diabetes. All the conditions documented are chronic conditions which are assigned an HCC risk score.

Which of the following signatures is acceptable? I. Signed but not read II. Electronically produced: John Smith III. Dictated but not read IV. Electronically signed and authenticated by John Smith, MD V. Signature stamp: John Smith, MD A. II, III, and V B. IV C. II and IV D. I, II, III, IV, and V

B. IV

Which cells produce hormones to regulate blood sugar? A. Eosinophils B. Pancreatic islets C. Hemoglobin D. Target cells

B. Pancreatic islets

What does the abbreviation RAPS indicate? A. Risk Adjustment Provider Service B. Risk Adjustment Processing System C. Risk Auditing Process System D. Risk Auditing Provider System

B. Risk Adjustment Processing System

Which statement is TRUE regarding risk adjustment models? A. Additional reimbursement is alloted for acute care B. Risk scores are used to adjust payments for each beneficiary's expected expenditures C. Risk scores are used to monitor health care outcomes and response to treatment for each patient D. Determination of payment is made based on the first assessment of the patient during a calendar year

B. Risk scores are used to adjust payments for each beneficiary's expected expenditures Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Risk adjustment is used to adjust bidding and payment based on the health status and demographic characteristics of an enrollee. Risk scores measure individual beneficiaries' relative risk and risk scores are used to adjust payments for each beneficiary's expected expenditures.

A 65 year-old male patient was admitted with ascending cellulitis and infection of a 2nd, 3rd, and 4th toes amputation site. What are the appropriate diagnosis codes for this? A. E11.9, T87.40 B. T87.40, L03.039 C. L03.039, E11.9 D. Z89.429, T87.40

B. T87.40, L03.039 Assign code T87.40, Infection of amputation stump, unspecified extremity as the principal diagnosis with an additional code of L03.039, Cellulitis of unspecified toe. close

Which statement is TRUE regarding RADV audits? A. A cover page is not necessary B. The purpose is to validate submitted HCC data C. Conducted randomly throughout the year D. CMS creates a special cover page for each patient being audited

B. The purpose is to validate submitted HCC data The purpose is to ensure risk adjusted payment integrity and accuracy by verifying the HCC submitted is supported in the medical record. CMS requires that their cover letter be used, and stress that organizations may not create their own cover page.

A 66 year-old male patient with AIDS presents with new onset of shortness of breath. Tests confirm the patient has pneumocystis carinii pneumonia. Select the appropriate diagnosis code(s).

B20, B59 The Official ICD-10-CM guideline I.C.1.a.2., indicates if a patient is admitted with an HIV-related condition you first sequence B20 followed the code for the HIV-related condition. Shortness of breath is a symptom of the pneumonia and not reported (ICD-10-CM guideline I.B.5).

During a retrospective chart audit for a XYZ Medicare Advantage Company, it is determined a diagnosis submitted is not supported by medical record. There is no additional information to validate the diagnosis. The member is part of a health plan that has 1,500 members and the insurance company received $350 for this diagnosis. This HCC is chosen for a RADV audit. Using the CMS extrapolation methodology, how much could the company have saved if it deleted this code during the retrospective chart audit process? A. $1,500 B. $350 C. $525,000 D. There is not a financial penalty

C. $525,000 The value of invalidated HCCs is extrapolated across the entire plan population ($350 x 1,500)

In order to avoid risk adjustment coding errors, a coder must be aware of Disease Hierarchies within the HCC categories. Which of the following sentences best describes what a Disease Hierarchy is? A. Core information submitted by MA organizations for each diagnoses submitted B. CMS risk adjusts payments for a beneficiary using the CMS-HCC dialysis model C. A disease hierarchy is combined of multiple ICD-9-CM/ICD-10-CM diagnosis codes that address multiple levels of severity for a disease with varying levels of associated medical costs D. Three to five digit codes used to describe the clinical reason for a patient's treatment

C. A disease hierarchy is combined of multiple ICD-9-CM/ICD-10-CM diagnosis codes that address multiple levels of severity for a disease with varying levels of associated medical costs A Disease Hierarchy is combined of multiple ICD-9-CM/ICD-10-CM diagnosis codes that address multiple levels of severity for a disease with varying levels of associated medical costs, which allow an MA Plan to factor a members costs accurately with proper diagnosis code selection that equates to a corresponding HCC code.

Which of the following codes should be coded as a history code once the patient has been discharged from the hospital? A. Diabetes type 2 controlled B. Breast cancer C. Acute Respiratory Failure D. CKD Stage 4

C. Acute Respiratory Failure Once the patient has been discharged from the hospital, these conditions should no longer be coded. In some cases, it's appropriate to code the "history of" code, or the underlying condition. But coding these conditions in the office setting is only appropriate if the patient presents in the office and is (generally) transported by ambulance to the hospital. •CVA •Sepsis •Acute MI (except in 1st 8 weeks) •Acute Coronary Syndrome •Non-ST Elevation MI (NSTEMI) •Unstable Angina •Acute Respiratory Failure

A patient is being treated for diabetes with hypoglycemia and coma due to malignant neoplasm of pancreas. The patient uses insulin routinely but is not dependent. What ICD-10-CM codes should be reported? A. E11.641, C25.9 B. C25.9, E10.641, Z79.4 C. C25.9, E08.641, Z79.4 D. E08.641, C25.9

C. C25.9, E08.641, Z79.4 The patient's diabetes is due to the pancreatic cancer and is reported as secondary diabetes. When diabetes is caused by another disease or illness, it is considered secondary diabetes. In the ICD-10-CM Alphabetic Index, look for Diabetes/due to underlying condition/with/hypoglycemia/with coma E08.641. Next go to the Table of Neoplasms look for Neoplasm, neoplastic/pancreas/Malignant Primary column C25.9. In the Tabular List there is an instructional note under category code E08 that indicates to Code first the underlying condition. The neoplasm code is reported first. For patients who routinely use insulin, use code Z79.4 (ICD-10-CM guideline I.C.4.a.6.a.) which is found in the Alphabetic Index under Long-term (current) (prophylactic) drug therapy (use of)/insulin Z79.4. Verify code selection in the Tabular List.

A 65 year-old male presents to the office with history of ongoing diabetes which has been controlled with insulin for follow-up exam with his family practice physician, during this encounter the physician notes a chronic diabetic wound of his right greater toe and determines gangrene has set in. After examination and testing the family practice physician recommends the gentleman to be seen by a general surgeon for treatment of his gangrene of his right great toe. What are the correct diagnoses to report for this encounter? A. I96, E11.51, Z79.4 B. Z79.4, E10.52 C. E11.52, Z79.4 D. E11.51, I70.269, Z79.4

C. E11.52, Z79.4 When coding for a diabetic with gangrene, first select a code for the diabetes with gangrene combination code. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic (mellitus) (sugar)/type 2/with/gangrene which directs you to E11.52. Next, the patient is treated with insulin which is reported with Z79.4

Which of the following is NOT considered part of the HCC coding process? A. Assessments, plans, all active chronic conditions, and diagnosis codes documented in charts annually. B. Coding precision and specificity: Coders have the ability to conduct prospective chart reviews to capture missed chronic conditions that have been documented, but not submitted, by the provider or group. C. HCC codes should be submitted without validation from the medical record in order to meet the CMS calendar deadline D. The plan sends to risk adjustment processing system (RAPS) diagnosis codes that are converted to HCC codes.

C. HCC codes should be submitted without validation from the medical record in order to meet the CMS calendar deadline

Chronic and acute conditions/diagnoses from the previous year that Risk Adjust are used to establish reimbursement for patient care provided by the MA plan. Which of the following statements is TRUE? A. HCCs must be captured every 12 months for CMS to reimburse/ DM with a manifestation (complication) requires that you document and code the manifestation as well B. Health Risk is re-determined every year/ Document all clinical findings in the medical record C. Health Risk is re-determined every year/ Document all clinical findings in the medical record/HCCs must be captured every 12 months for CMS to reimburse D. Document all clinical findings in the medical record (chart)/ the medical record is used to support ICD-10-CM and HCC coding

C. Health Risk is re-determined every year/ Document all clinical findings in the medical record/HCCs must be captured every 12 months for CMS to reimburse Chronic and acute Conditions/Diagnoses from the previous year that Risk Adjust are used to establish reimbursement for patient care provided by the MA plan. HCCs must be captured every 12 months for CMS to reimburse. Health Risk is re-determined every year.

Predictive Modeling can use many data elements. Which are beneficial for identifying a person with COPD? I. DME claims II. Rx claims III. Therapy claims A. I B. II and III C. I, II , and III D. None of the above

C. I, II , and III Patients with COPD can require oxygen provided by DME providers, medications, and pulmonary rehab which is considered a therapy service.

Which of the following can effect RAF score? I.Reporting the manifestation of a chronic illness II. Disease interactions III. Patient age IV. Reporting acute illnesses (eg, URI and UTI) A. I and II B. I and IV C. I, II, and III D. I, II, III, and IV

C. I, II, and III RAF scores are determined based on patient demographics and condition categories. Certain combinations of coexisting diagnoses for an individual can increase medical costs more than the additive nature of the CMS-HCC model reflects. The CMS-HCC model recognizes these higher costs by incorporating disease interactions in the model. Acute illnesses such as URI and UTI are not assigned a risk value.

A patient is coming in for follow up of his essential hypertension and cardiomegaly. Both conditions are stable and he is told to continue with his medications. What ICD-10-CM code(s) should be reported? A. I11.0, I51.7 B. I10, I51.7 C. I11.9 D. I10, I51.9

C. I11.9 Per ICD-10-CM guideline I.C.9.a. indicates: The classification presumes a causal relationship between hypertension and heart involvement, as two conditions are linked by the the term "with" in the Alphabetic Index. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. Look in the Alphabetic Index for Hypertension/heart (disease) (conditions in I51.4-I51.9 due to hypertension referring you to I11.9 Cardiomegaly code, I51.7, is not reported. There is an Excludes1 note under category code I51 that indicates not to report any condition in I51.4-I51.9 due to hypertension (I11.-).

A patient is admitted after being found unresponsive at home. The patient had right-sided hemiplegia and aphasia from a previous CVA. The physician documents a current CVA as the final diagnosis and the patient is transferred for rehabilitation. What ICD-10-CM code(s) should be reported? A. I63.50 B. I67.89, I62.9, R47.01 C. I63.9, I69.951, I69.920 D. I67.89, I69.851, I69.920

C. I63.9, I69.951, I69.920 Per ICD-10-CM guideline I.C.7.d.2, tells us codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current CVA and deficits from an old CVA. Look in the ICD-10-CM Alphabetic Index for Accident/cerebrovascular (current) I63.9. Also look for Sequela (of)/ disease/cerebrovascular/hemiplegia I69.95-. ICD-10-CM guideline I.C.6.a indicates: Should the affected side be documented, but not specified as dominant or non-dominant, and the classification system does not indicate a default, code selection is as follows: For ambidextrous patients, the default should be dominant; If the left side is affected, the default is non-dominant; if the right side is affected, the default is dominant. Then, look for Sequela (of)/disease/cerebrovascular/aphasia I69.920. Verify code selection in the Tabular List.

CC: Patient is here to discuss catapress Rx and also patient has a nonproductive cough, nasal drainage and sinus congestion/pressure. Symptoms for a few days. Subjective HPI: She is back on her Catapress patch and doing well Earwax, used Debrox Cough, wheezing and nasal congestion for a few days ROS: Constitutional: Denies symptoms other than stated above. ENMT: Denies ENMT symptoms other than stated above. Cardiovascular: Denies chest pain, edema and palpitations. Respiratory: Denies symptoms other than stated above. Gastrointestinal: Denies gastrointestinal symptoms. Genitourinary: Denies urinary symptoms. Psych: Stable w/o acute changes. Current Meds: Lancets, Onetouch Test Strips, Citalopram Hydrobromide 40 mg, Simvastatin 40 mg, Glipizide 10 mg, Metformin HCL 1000 mg, Benztropine Mesylate 1 mg, One Touch Glucose Monitor, Catapres-TTS- 1 0.1 mg/24hr Allergies: NKDA Social History: Marital status: Single. Lives in an assisted living facility. Personal Habits: Cigarette Use: None. Alcohol: Denies alcohol use. Drug Use: Denies Drug Use. Daily Caffeine: Consumes on average 4 sodas per day. Reviewed, no changes. Objective BP: 124/72. Pulse: 88. T: 97.7. RR: 20. HT: 63" 5'3", WT: 2091b Constitutional: No signs of apparent distress present. ENMT: Tympanic membranes: not visible due to impacted cerumen. Congestion of the nasal mucosae. Posterior pharynx is normal. Neck: Palpation reveals no lymphadenopathy. Thyroid exhibits no thyromegaly. No JVD. Respiratory: Respiration rate is normal. Auscultate good airflow. Mild expiratory wheezes appreciated over the lungs bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. Extremities: No clubbing, cyanosis or edema. Abdomen: Abdomen Is Benign. Musculoskeletal: Walks with a normal gait. Skin: Skin is warm and dry. Psych: Patient's attitude is cooperative. No apparent anxiety, depression, or agitation. Patient shows good eye contact. Patient had increased cough response with attempted irrigation which subsided immediately. Assessment #1: J06.9 URI Upper Respiratory Infections Acute Unspecified Sites Plan for #1: Med Current: Zithromax Z-Pak 250 mg as directed Proventil HFA108 mcg/act 2 puff q 4h pm Assessment #2: E11.9 Diabetes Mellitus W/O Complication Type II or Unspecified Controlled Plan for #2: Med Current: Glipizide 10 mg 1 po bid Metformin HCL 1000 mg 1 po bid Lab: Diabetic Panel Follow-up: after lab work Assessment #3: H61.23 Impacted Cerumen Plan for #3: Referral: ENT referral After the coder reviews the documentation, which codes are recommended to be reported that will affect the HCC risk adjustment value? I. J06.9 II. E11.9 III. H61.23 A. I, II and III B. I, III C. II D. II and III

C. II The only diagnosis the patient has that affects the HCC risk adjustment value is E11.9. Typically, acute illnesses are not relevant for HCC risk adjustment coding. Examples of these conditions include, URI, UTI, otitis media, impacted cerumen, cold, viral syndrome, and sinusitis.

When is it appropriate to use history of malignancy, from category Z85? A. Once the malignancy is removed from that site B. When the patient cancels treatment for that site C. It has been excised and no further treatment directed to the site D. When the patient has a lapse in treatment

C. It has been excised and no further treatment directed to the site Per ICD-10-CM guideline I.C.2.d, when a primary malignancy has been excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.

Subjective: 1 Patient presents to clinic today for multiple complaints. First, he is here for follow-up of his hypertension. He has been doing well on his labetalol, is not having any difficulties. However, over the last week he has had an upper respirator infection and has been taking Sudafed-based cold products without noting what is on these. He has not taken his blood pressure at home since he has been sick. Next issue is that he is having some trouble with his knees. Anytime he gets up to move, his knees are stiff in particular when he starts walking or going down stairs his knees ache. The more steps he does, the better this becomes. It is more of an ache and stiffness than actual pain. A while ago, his right knee was bothering him quite significantly in regards to pain. This was injected with 80 mg of Depo-Medrol here in the office and this has helped with the pain but still has stiffness and achy. This is particular in morning -when he gets up. He was requesting a referral for a possible surgical intervention at this time. Other complaints today include a rash or possible fungus of the feet. He has been having troubles with this for a while, just thickening and callusing of his feet and some discoloration and would like this looked at. Next issue is since he had been taking blood pressure medicines he has been having some problem with erectile dysfunction mainly with getting and maintaining an erection. He was wondering if he has the option of trying a Viagra or other similar medication. 2. He was given a letter stating that his blood sugar was elevated. He should come in to discuss diabetes. 3. Next issue is he has a rash on his scalp that he has been doing shampoo in the past for. This has helped somewhat but has never resolved completely. He would like this looked at also today. Objective: Today, respirations 18. Pulse is 92. Blood pressure is 150/88. This is on Sudafed. Temp is 99. Weight is 164. Height 568-1/2 inches. In general, this is a 60-year-old obese male, very pleasant here with his wife who has slight nasal congestion in the office today. Skin is warm and moist. General: Sclerae are white. Examination of the feet noted to have some thickening and scaling with some calluses noted. Sensation is intact with good vascular supply. There is no discoloration noted. This is mainly between the toes and the dorsum of the foot distally. Heart was regular rate and rhythm. Lungs are clear to auscultation. No wheezes, rhonchi or rales. Knees noted to have x-rays that were done in the beginning of the year that shows possible arthritis in both knees. Examination of the scalp revealed multiple patches, scaliness and flaky skin that are in circular areas more prominent on the edge of the circle with some central clearing. A Wood's lamp was used and noted that these areas fluoresced. Assessment/Plan: 1. Hypertension slightly elevated today but patient has been taking Sudafed. Patient was instructed to avoid all pseudoephedrine and we will recheck this in a month. 2. Diabetes mellitus. This is a new diagnosis for him. We will send him to diabetic management and we will start him on Glucophage 500 mg twice a day. We will also get a hemoglobin A1c and microalbumin to creatinine ratio, basic metabolic and CBC today. 3. Eczema of the feet. Were given some Lac-Hydrin to be used. He is instructed on good diabetic foot care. 4. Bilateral knee pain consistent with osteoarthritis of his knees. 5. Tinea capitis. We will give him some Diflucan for 4 weeks to see if this clears it up. If this continues to be a problem, may need to do scraping or a biopsy. 6. Erectile dysfunction. Patient will be given some samples of Viagra to see if this helps. Patient is to return to the clinic in a month for continued care. The diagnoses reported include: I10, E11.9, L25.9, M17.9, B35.0, N52.9 What diagnosis code would NOT be reported? A. I10 B. E11.9 C. M17.9 D. B35.0

C. M17.9 Diagnoses documented as consistent with are considered uncertain. A code for knee pain is appropriate for this documentation, not OA.

Which of the following elements would NOT be taken into consideration for risk adjustment? A. The number of years a patient has been covered under Medicare Advantage B. Gender C. Procedure codes D. Place of service

C. Procedure codes all risk adjustment programs utilize diagnosis codes to "adjust" potential risks for patients, there are additional elements taken into consideration, including: Age Gender Race Socioeconomic status Insurance status (Medicare, Medicaid, dual-eligible, etc.) Procedure codes Place of service codes Special patient-specific conditions (i.e. such as being enrolled in hospice or being an ESRD (end stage renal disease) patient), etc.

Which of the following records would be a good source for a retrospective chart audit?

Cardiologist records

Patient presents to OB for routine obstetric care. The nurse takes the patient's blood pressure and it reads 140/80. The physician sees the patient and documents the following in the assessment and plan: "A/P: Hypertension, Transient, Check BP at home daily and return to clinic in two days for nurse BP check ". Assign the correct ICD-10-CM code(s).

Conditions listed on the problem list for a diabetic patient are coded as complications of the diabetes ICD-10-CM guideline I.C.9.a.7, indicates to assign a code from category O13 for transient hypertension in pregnancy. The trimester and the weeks of gestation are not documented resulting in use of unspecified codes.

Which statement is TRUE regarding hierarchies? A. Used exclusively by CMS for Medicare Advantage plans B. Mandated to be used for all Medicaid payment models C. Utlized by some private payers D. All of the above

D. All of the above Hierarchies are used in Medicare, some Medicaid models and commercial models for payments

Which of the following is appropriate to assign ICD-10-CM code N18.9? I. Chronic Renal Disease II. Chronic Renal Failure III. Chronic Kidney Disease Unspecified IV. Chronic Renal Insufficiency A. I B. I, II, and IV C. III D. I, II, III, and IV

D. I, II, III, and IV Answer III is correct because it is included in the description of ICD-10-CM code N18.9. Answers I, II, and IV are the listed under the Inclusion Terms under code N18.9 and therefore also correct.

Patient with coronary arteriosclerosis disease (CAD) sees his cardiologist to discuss a coronary artery bypass graft (CABG). This would be the patient's first CABG. What ICD-10-CM code should be reported? A. I25.110 B. I25.810 C. I25.790 D. I25.10

D. I25.10 A patient with CAD and no history of a previous CABG indicates it would be the patient's native coronary artery (it has not been replaced or bypassed). In the ICD-10-CM Alphabetic Index look for Arteriosclerosis/coronary/artery guiding you to code I25.10. Verify code selection in the Tabular List.

What is the correct code assignment for a residual deficit of muscle weakness secondary to late effect of cerebrovascular accident? A. I69.959, M62.81 B. M62.81, I69.998 C. I69.959, I69.998 D. I69.998, M62.81

D. I69.998, M62.81 Report I69.998 Other sequelae following unspecified cerebrovascular disease and code M62.81 Muscle weakness, for residual muscle weakness secondary to late effect (sequelae) of cerebrovascular accident. Therefore, when the physician documents weakness secondary to an old CVA, you cannot code I69.959. Physicians must be educated regarding this rule, so that they can adjust their documentation going forward.

Do the HCC category hierarchies play a role in which medical record to submit for a RADV? I. No, there are no benefits in taking hierarchies into consideration II. No, CMS will treat all diagnosis with the same financial weight III. Yes, CMS will accept a lower or higher HCC to validate an HCC within the same category IV. Yes, there can be a financial gain by submitting a higher hierarchy HCC A. I B. II C. III D. III and IV

D. III and IV CMS states for HCCs in a Hierarchy category can be submitted; either of lower risk score or higher risk score.

Which of the following regarding HEDIS is NOT true? A. It is the acronym for Healthcare Effectiveness Data and Information Set B. It's developer and sponsor is the National Committee for Quality Assurance (NCQA), a not-for-profit, non-government organization C. It is a set of standardized performance measures designed to assess the quality of health care and services provided by managed care plans D. It is a division of the Centers for Medicare and Medicaid Services

D. It is a division of the Centers for Medicare and Medicaid Services

70 year-old with COPD is admitted to the hospital for acute exacerbation of chronic bronchial asthma. What diagnosis code(s) should be reported? A. J44.1 B. J45.901, J44.9 C. J45.901 D. J44.1, J45.901

D. J44.1, J45.901 In the ICD-10-CM Alphabetic Index look for Asthma/with chronic obstructive pulmonary disease (COPD)/with/exacerbation (acute) leads you to code J44.1. In the Tabular List category code J44 has an includes note that indicates asthma with COPD; however, there is also an instructional note that indicates to code also type of asthma, if applicable. Code J45.901 is also reported.

Which statement is coded as a history of condition? A. Patient presents with a history of colon cancer. He is currently getting chemotherapy administered by his oncologist. B. Patient has a history of osteoarthritis currently taking celebrex. C. Patient presents with CHF complaining of shortness of breath. D. Patient presents for a follow up of hypertension. She has a history of breast cancer.

D. Patient presents for a follow up of hypertension. She has a history of breast cancer. A notation indicating "history of cancer," without an indication of current cancer treatment is codes as a history of cancer.

Which of the following general statements is NOT TRUE regarding Risk Adjustment practices and Quality? A. Health Care Plans with Four Star Quality Ratings can still improve their score because the highest rating is a Five B. From a data discovery perspective, they are essentially inseparable C. Data Collection for HEDIS and Star Ratings Programs can be achieved during their prospective member evaluations D. Quality Measures like Star Ratings and HEDIS have no correlation with the medical record information that is collected in support of risk adjustment

D. Quality Measures like Star Ratings and HEDIS have no correlation with the medical record information that is collected in support of risk adjustment Medicare recently began a Stars Ratings program, which will monitor quality of care endeavors by carriers. While plans not obtaining four stars or better may be penalized, plans that achieve higher quality ratings can achieve higher payments. CMS is also highlighting plans that have achieved an overall quality rating of five star with a High Performer or gold star icon so that patients with Medicare can easily find high quality plans.

Which provider is NOT an approved provider for diagnosis code capture under the HCC model? A. LCSW B. CRNA C. Podiatrist D. Registered nurse

D. Registered nurse Nurses are not approved providers unless they are a clinical nurse specialist, CRNA or NP.

What is the code assignment requirement for chronic kidney disease requiring dialysis?

Diagnosed with CKD and is on chronic dialysis/receiving kidney transplants

The definition of a best medical record for a RADV audit is:

Documentation that validates the requested HCC plus validates an additional HCC, contains all the necessary documentation elements, but is missing the provider signature, for which a signed CMS attestation was provided but not signed by the provider

Sex: Female. Age: 69 years-old. Nurse Note: Patient presents today with wanting to get back on track. Also wants to go back on synthroid, also wants to lose weight, otherwise no other complaints. Subjective CC: Stopped meds, feels tired, gained 20 pounds in a year. HPI: above ROS: Constitution: Reports weight change, but denies chills, fatigue and fever, tired. Eyes: Denies visual disturbance. Cardiovascular: Denies chest pain and palpitations. Respiratory: Denies cough, dyspnea and wheezing. Gastrointestinal: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena, nausea and vomiting. Genitourinary: Denies dysuria, frequency, hematuria, incontinence, nocturia and urgency. Musculoskeletal: Denies arthralgia and myalgia. Skin: Denies rashes, no pain or bleed. Neuro: Denies neurologic symptoms. Psych: Denies symptoms other than stated above. Stress caring for others. Current Meds: None. Allergies: NKDA PMH: Mammogram: (5/2008). Pelvic/Pap Exam: (5/2008). Blood Test: (5/2007). Bone Density Test: never within 10 years. Dental: (4/2008). Eye Exam: (2/2007) Reviewed and updated. Family History: Father: Hypertension; MI. Mother: Hypertension. Reviewed and updated. Social History: Highest level of education completed is 12th grade. Marital status: Married. Lives with spouse and grandson. Household pets include fish. Personal Habits: Cigarette Use: None. Alcohol: Rare. Daily Caffeine: Consumes on average three cups of coffee per day. Reviewed and updated. Objective BP: 142/84 P: 68 T: 98.5 RR: 16 HT: 65" 5'5" WT: 2241b BMI: 37.3 LMP: HYSTERECTOMY Exam: Constitution: Appears overweight. No signs of apparent distress present. Neck: Palpation reveals no lymphadenopathy. No masses appreciated. Thyroid exhibits no thyromegaly. No JVD. Respiratory: Respiration rate is normal. No wheezing. Auscultate good airflow. Lungs are clear bilaterally. Cardiovascular: Rate is regular. Rhythm is regular. No heart murmur appreciated. Extremities: No clubbing, cyanosis or edema. Abdomen: Bowel sounds are normoactive. Palpation of the abdomen reveals no CVA tenderness. Muscle guarding, rebound tenderness or tenderness. No abdominal masses. No palpable hepatosplenomegaly. Skin: Skin is warm and dry. Assessment #1: Hypothyroidism Plan for #1: Lab: Comp Metabolic Panel I/P TSH (Ultra-Sensitive) Urinalysis Routine T4 Assessment #2: Obesity Plan for #2: Follow-up: Fasting labs then return one month to review and do annual GYN then. At that visit, will arrange biopsy face/temple lesion, order mammogram and she's considering screen c scope.

E03.9, E66.9, Z68.37 The patient is diagnosed with hypothyroidism and obesity. As documented the obesity is unspecified. A code is reported for the BMI that was documented in the exam. The patient has a family history of hypertension and MI. It is not the patient's conditions.

What is/are the correct code(s) for a nursing home patient with severe dementia often caught wandering off from the floor?

F03.90, Z91.83 In the ICD-10-CM Alphabetic Index look for Dementia/with behavioral disturbance. The behavioral disturbance is the wandering. There is an instructional note under code Z91.83 indicates to code first underlying disorder.

Which of the following medications are prescribed to cancer patients to eradicate the cancer or for prophylaxis? I. Tamoxifen II. Anastrozole III. Januvia IV. Crestor

I and II

Predictive models are used to identify people who are at high risk of chronic illnesses having higher medical claims; what can a provider do with this information to decrease the medical costs? I. Develop disease management education programs II. Involve clinical staff to help with coordination of care III. Refer the patients with chronic illnesses to be treated by another provider IV. Determine the return on investment when referring to a specialist for chronic illnesses

I and II Predictive modeling can help providers identify patients with chronic illnesses who would benefit from disease management education and coordination of care.

Which of the following statements are TRUE regarding the prostate? I. It is part of the male reproductive system II. It helps make and store seminal fluid III. It makes testosterone IV. It is part of the female urinary system

I and II The prostate gland makes fluid that forms part of semen. The prostate lies just below the bladder in front of the rectum in male patients. It surrounds the urethra (the tube that carries urine and semen through the penis and out of the body).

Which organ(s) is/are contained in the thoracic cavity? I. Heart II. Stomach III. Lungs IV. Hypothalamus

I and III Thoracic cavity contains the heart and lungs

Which of the following are reported by a provider for beneficiaries in a Medicare Advantage Plan?

I and IV

Retrospective audits should include the following attributes: I. Provider signatures II. Supporting documentation of the patient's diagnoses III. DOS

I, II and III

A PEG Tube is: I. Percutaneous Endoscopic Gastrostomy II. G tube III. Gastrostomy IV. Colostomy

I, II, and III

A patient presents for a routine checkup for his hypertensive heart failure. He is to continue with his current medication and diet. Select the diagnosis code(s).

I11.0, I50.9 Whenever there is a causal relationship between hypertension and heart failure report code I11.0. The heart failure is reported as a second code, because of the instructional note under code I11.0 which indicates to "use additional code to identify type of heart failure (I50.-)."

Patient Name: JS Male. Physician: HO, MD Report Type: HOSPITAL CONSULTATION REPORT Admit Date: 4/26/XX. Discharge Date: 4/30/XX. DATE OF INPATIENT CONSULTATION: 4/27/XX. CHIEF COMPLAINT: Pulmonary emboli. HISTORY OF PRESENT ILLNESS: I am seeing this patient today in Consultation regarding the recurrent pulmonary emboli. The patient is a 42 year-old gentleman who has a history of recurrent pulmonary emboli. He had his first pulmonary emboli in 05/20XX. The patient was on Coumadin when he was involved in an accident on 10/01/XX. He sustained second-degree burns to more than 50 percent of his body. The patient was hospitalized for several months. He did not have any skin grafts. There was a question of him developing a heparin antibody during that admission. The patient has been on Coumadin for the past three months. Over the last several days, he has developed some pain behind his left knee and some chest discomfort. He brought himself to the emergency department where an ultrasound of his leg revealed a clot in the left thigh, a CT angiogram revealed bilateral pulmonary emboli. He has been given Coumadin 10 milligrams and Arixtra 7.5 milligrams SubQ daily. At this time, he is feeling well. He is not complaining of any leg pain or chest pain. He denies any hemoptysis. REVIEW OF SYSTEMS: Significant for the leg pain and chest discomfort. The further review of systems including the general, eyes, ears and throat, cardiac, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, hematological and emotional systems is otherwise negative, except for that stated above. ALLERGIES: The patient has a possible allergy to HEPARIN with a possible heparin antibody. MEDICATIONS: The patient is not on any medications at this time. PAST MEDICAL HISTORY: Significant only for his previous pulmonary emboli and his severe second-degree burn to more than 70 percent of his body. SURGICAL HISTORY: The patient has no prior surgical history. SOCIAL HISTORY: The patient is single, never married. He does not smoke tobacco or drink alcohol. He has his own consulting firm. FAMILY HISTORY: The patient states there is no family history of blood clots. PHYSICAL EXAMINATION: His BP is 133/68, pulse 89, respirations 16, temperature 96.5. The patient is a well-nourished, well-developed white male, in no acute distress, consistent with his stated age of 42. The HEENT examination reveals no oral lesions, no oropharyngeal lesions, no neck masses, no thyromegaly. Heart examination reveals a regular rate and rhythm without murmur or gallop. There are no palpable heaves or thrills. Chest examination is clear to auscultation. There are no wheezes or crackles heard. Abdominal examination reveals positive bowel sounds. The abdomen is soft and non-tender. There is no palpable hepatosplenomegaly, no palpable masses. Lymphatic examination reveals no cervical, axillary, inguinal or epi-trochlear lymph nodes palpable. Skin examination reveals the scars from his burns. There are no nodules or rashes seen. No nodules palpated. Neurologically, his deep tendon reflexes are plus 2/4 in the upper and lower extremities. Motor and sensory are intact. Extremity examination reveals full range of motion in the upper and lower extremities, without cyanosis or edema. The patient is alert and oriented times three and has a normal affect. PERTINENT LABORATORY VALUES: Include hemoglobin of 14.0, WBC of 7.7, platelets of 134,000. Sodium was 139, potassium 4.0, chloride 103, bicarb 29, BUN of 20, creatinine 1.12. The protime is 11.5 seconds and the activated partial thromboplastin time is 30 seconds. CT angiogram reveals bilateral pulmonary emboli. Doppler ultrasound reveals a clot in the left lower extremity. IMPRESSION: 1. Deep venous thrombosis with bilateral pulmonary emboli with a history of a previous pulmonary embolus in 05/2007. 2. Possible heparin antibodies while hospitalized. 3. History of second-degree burns. PLAN: 1 Arixtra 10 milligrams SubQ daily, especially given his possible history of heparin antibody. 2.The patient does require very large doses of Coumadin. He was on 17.5 milligrams alternating with 15 milligrams before he was removed from Coumadin. We will dose him at 17.5 milligrams today. 3. CBC and protime in the morning. 4. The patient will require lifelong anticoagulation as this is his second pulmonary emboli. I appreciate this opportunity to participate in this patient's care. Please do not hesitate to contact me if you have any further question regarding my care of the patient.

I26.99, I82.402, Z86.718, Z79.01 The patient is diagnosed with bilateral pulmonary emboli and deep vein thrombosis. He also has a history of a previous pulmonary embolism and use of Coumadin. From the ICD-10-CM Alphabetic Index, look for Embolism/pulmonary. You are referred to I26.99. From the Alphabetic Index, look for Thrombosis/vein/deep/lower extremity/. You are referred to I82.40-. This code requires a 6th character to identify laterality. The correct code is I82.402. From the Alphabetic Index, look for History/personal (of)/embolism/pulmonary. You are referred to Z86.718. From the Alphabetic Index, look for Long-term (current) (prophylactic) drug therapy (use of)/anticoagulants. You are referred to Z79.01. Refer to all the codes in the Tabular List to verify the code descriptions.

Patient is here for follow up. She was seen in the ER two weeks ago where she had an MRI of the brain which showed significant cerebral arteriosclerosis. She was diagnosed with a TIA. She has been experiencing slight memory loss. Select the correct code(s).

I67.2 Cerebral atherosclerosis is the correct primary ICD-10-CM code. The personal history TIA code Z86.73 is reported as the second code. Memory loss (R41.3) would not be reported as it is a symptom of cerebral arteriosclerosis.

The patient had hip replacement surgery three days ago. The provider documents the patient has had a "iatrogenic cerebrovascular infarction due to recent hip replacement surgery during her current hospital stay." Assign the appropriate ICD-10-CM code for the cardiovascular event.

I97.821 ICD-10-CM guideline I.C.9.c., indicates cerebrovascular infarction that occurs as a result of medical intervention is coded based on whether it was intraoperative or postprocedural. This was postprocedural. Look in the in the ICD-10-CM Alphabetic Index for Stroke/postprocedural/following other sugery referring you to I97.821. The Tabular List for subcategory I97.8 indicates to use an additional code, if applicable, to further specify the disorder. We have not been given further information such the location of the infarct, so no other code is required.

What is the correct ICD-10-CM code for an uncertain gastrointestinal stromal tumor?

In the Alphabetic Index look for Tumor/stromal/gastrointestinal/uncertain behavior. Coders are referred to D48.1.

What is the correct ICD-10-CM code for a patient with COPD exacerbation?

J44.1 To locate the correct code, look in the ICD-10-CM Alphabetic Index for Disease, diseased/pulmonary/chronic obstructive/with/exacerbation.

ANESTHESIA: General. PREOPERATIVE DIAGNOSIS: Ulcer right upper thigh with exposed fat layer. POSTOPERATIVE DIAGNOSIS: Ulcer right upper thigh with exposed fat layer. PROCEDURE: Debridement of ulcer, right upper thigh. INDICATIONS: This 76 year-old female has developed an ulcer on the upper right thigh. She is here for debridement. The patient has a current history of type 2 diabetes and hypertension. DESCRIPTION OF PROCEDURE: Under general laryngeal mask anesthesia, the patient was placed in left lateral decubitus position and the right lateral thigh and hip was appropriately prepped and draped. Sharp Mayo scissor dissection was used to debride skin, subcutaneous tissue and excise the edges of the wound down to the tensor fascia. Some undermining with fat necrosis was also debrided. It was covered with gauze and a dressing. She tolerated the procedure well. Select the diagnosis code(s).

L97.112, E11.622, I10 The indication for the procedure is a skin ulcer with fat layer exposed. The patient also has two chronic diseases, diabetes type 2 and hypertension, which are reported. There is causal relationship between diabetes and the skin ulcer. Look in the ICD-10-CM Alphabetic Index for Diabetes/with/skin ulcer NEC referring you to E11.622

S. Patient returns for follow up of her osteoporosis on anabolic therapy. She continues on TERIPARATIDE shots daily and will complete her two years of that in August of this year. She remains on VITAMIN D reduced to once a week 50,000 units. O: Vital signs are recorded. Despite the above, she seems to be in good spirits today. Moderate kyphotic posture of the thoracic spine noted. Lungs clear, cardiac exam regular rate and rhythm. Vitamin D level was over 40 last time, having been undetectable in March. A: Postmenopausal osteoporosis exacerbated by Vitamin D deficiency and suspected calcium malabsorption. Seems to be stable at this point in that regard. P: 1. CBC, comprehensive metabolic panel. May be able to back off further on her VITAMIN D. 2. When she returns next time in September will obtain DXA to compare with the one she had a year ago. 3. She will complete her two years of TERIPARATIDE injections in August. Select the diagnosis code(s).

M81.0, E55.9 The patient is diagnosed with postmenopausal osteoporosis. In the ICD-10-CM Alphabetic Index, look for Osteoporosis/postmenopausal. Next report the Vitamin D deficiency. Look for Deficiency/vitamin/D. A code for calcium malabsorption is not reported because the condition is documented as suspected. Verify code selection in the Tabular List.

Today a 54 year-old man presents for his routine follow up after renal transplant two years ago. The patient has CKD stage 2 and reports no other complaints. Assign the correct ICD-10-CM code(s).

N18.2, Z94.0 ICD-10-CM guideline I.C.14.a.2, indicates that the presence of CKD after a transplant alone does not constitute a transplant complication. Also, there is an instructional note below code category N18 in the Tabular List indicating to use additional code to report transplant status.

Joey is prescribed Oxycodone for a back injury by his orthopedic surgeon two years ago. The surgeon documents he would like to try another medication to dull the pain. Joey attempts to change to the newer medication but there is breakthrough pain and he goes back to the Oxycodone. Would code from category F11.2 be appropriate?

No, the surgeon did not document that Joey was dependent on the Oxycodone

Diagnoses must be based on face-to face encounters between members and an MD, PA, or NP and status conditions like a below knee amputation, must be assessed and documented in order for payment adjustments to be received. How often should a provider see and assess a patient in a calendar year to validate amputation status?

Once a year

Which type of audit evaluates appropriate risk scores of patients?

RADV

How are resolved conditions coded?

Resolved conditions are reported as history of when appropriate

Type 2 diabetic presents with an insulin pump malfunction. What are the correct codes?

T85.694A, E11.9, Z79.4 ICD-10-CM guideline I.C.4.a.5, indicates insulin pump malfunctions are coded to T85.6-. Insulin pump malfunction can be an under dose or overdose of medication. With documentation that is non-specific such as this, the only known element is pump malfunction.

You are reviewing provider documentation for risk adjusted diagnoses so you can provide feedback to the provider. You are looking to validate diabetic neuropathy using the provider's progress note from an office visit earlier in the year. The provider documented "DM with neuropathy controlled, continue current meds" in the body of the progress note. You should inform the provider:

The diagnostic statement does identify the causal relationship The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The word "with" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order. The physician documentation does not need to provide a link between the diagnoses of diabetes and neuropathy to accurately assign code E11.21. This link can be assumed since neuropathy is listed under the subterm "with." These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated and due to some other underlying cause besides diabetes. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related." (AHA Coding Clinic for ICD-10-CM and PCS, 2016, Second Qtr, Page 36)

01/01/XX S: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are reviewed and consistent with the medications that she was discharged home. O: BP: 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm. A: Chronic atrial fibrillation, currently stable. P: 1. Prothrombin time. 2. Follow up with myself in 1 month, sooner as needed if has any other problems in the meantime. Will also check a creatinine and potassium today as well. Electronically Signed: M, Jones, M.D. Based on the review of the medical record, what discrepancy would a coder identify?

The list of medications was not documented which would affect coding Based on the patient's diagnosis of AF and the ordering of PT, it is likely the patient is being treated with Coumadin. Without the medication list available to validate, a code for long term use of anticoagulants cannot be reported.

01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male is here today for a follow-up visit. The patient's past medical history is notable for diabetes, hypertension, and mixed hyperlipidemia. HPI: Patient presents with type 2 diabetes. Specifically, this is type 2, non-insulin requiring diabetes without complications. Compliance with treatment has been good. In regard to the essential hypertension, benign, this was first diagnosed several years ago. He is tolerating the medication well without side effects. Concerning mixed hyperlipidemia, compliance with treatment has been good; he takes his medication as directed, maintains his low cholesterol diet, follows up as directed, and maintains his exercise regimen. ROS: CONSTITUTIONAL: Negative for chills, fatigue, fever and night sweats. CARDIOVASCULAR: Negative for chest pain, claudication, dizziness, palpitations and pedal edema. RESPIRATORY: Negative for dyspnea, hemoptysis and pleuritic chest pain. GASTROINTESTINAL: Negative for abdominal pain, dysphagia, constipation, diarrhea, heartburn, nausea and vomiting. Past Medical, Family, Social History (PFSH): Past Medical History: Coronary Artery Disease Hyperlipidemia Hypertension Surgical History: Appendectomy: at age 27; Tobacco/Alcohol/Supplements: Tobacco: Currently smokes more than three packs per day. An extensive list of the risks of smoking (and reasons to quit) have been reviewed with the patient; these include increased risk of cancer and increased risk of heart attack. Is unwilling to consider quitting tobacco at this time. Alcohol: Patient has a past history of alcoholism. His last drink was over 10 years ago. Substance Abuse History: NEGATIVE Allergies: Nitroglycerin: chest pain Aspirin: Current Medications: Zocor 80mg Tablet 1 tab(s) po hs, Altace 10mg Capsules 1 cap(s) po qd, Insulin, Lispro (Analog rDNA) 100units/1ml Pen System, Disposable 25-30 U Sq AC meals, Norvasc 10mg Tablet 1 tab(s) po qd, Tenormin 100mg Tablet 1 tab(s) po qd, Heal with Steel Health Center. OBJECTIVE: Vitals: BP: 118/78 mm Hg; P: 46 bpm (regularly irregular); R: 12 bpm. Exams: GENERAL: moderately obese; well groomed; anxious; diaphoretic. EYES: lids and lacrimal system are normal in appearance; conjunctiva and cornea are normal. ENT: Oropharynx: normal dentition and gingiva; normal palate; normal oral mucosa. NECK: thyroid is non-palpable; jugular veins are normal. RESPIRATORY: normal respiratory rate and pattern with no distress; normal breath sounds with no rales, rhonchi, wheezes or rubs. CARDIOVASCULAR: normal rate and rhythm without murmurs; normal S1 and S2 heart sounds with no S3, S4, rubs, or clicks; carotids: 2+ amplitude, no bruits; abdominal aorta appears to be of normal size and is without bruits; femoral pulses: 2+ amplitude, no bruits; 2+ pedal pulses; no edema or significant varicosities. GASTROINTESTINAL: no masses or tenderness; no organomegaly. SKIN: no clubbing, cyanosis, ulcerations, or vascular skin lesions. MUSCULOSKELETAL: spine: no scoliosis, kyphosis, or other abnormal spinal curvatures; normal gait; grossly normal tone and muscle strength. NEUROLOGIC/PSYCHIATRIC: mental status: alert and oriented x 3; Mood/Affect: anxious. ASSESSMENT: E11.9 Type 2 diabetes, I10 Essential hypertension, E78.2 Mixed hyperlipidemia. PLAN: Type 2 diabetes LAB ORDERS: hgbA1C, fasting lipid profile, TSH, urinalysis, urine micro-albumin. MEDICATIONS: Over-the-counter medications recommended include aspirin. RECOMMENDATIONS: instructed in use of glucometer (check glucose before each meal), a daily aspirin, adherence to a 2200 calorie ADA diet, HgbA1C level checked quarterly, urine micro albumin test yearly, daily foot self-inspection, yearly dental exams, annual eye exams, need for yearly flu shots, and pneumovax vaccination every five years. FOLLOW-UP: Schedule a follow-up visit in three months. Orders: Collection of venous blood by venipuncture Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory Glycated hemoglobin Urinalysis, automated, without microscopy Dilated Eye Exam Lipid panel (total cholesterol, HDL, triglycerides) Thyroid stimulating hormone (TSH) Urine micro albumin, quantitative Other Orders: Collection of venous blood by venipuncture today Electrolyte panel (Na, K, Cl, CO2) Electrocardiogram, routine with at least 12 leads; with interpretation and report Electronically Signed: M, Jones, M.D.

There is conflicting information regarding whether the patient is being treated with insulin In the HPI the provider documents the patient has non-insulin requiring diabetes without complications. In the medication list, it is documented that the patient is being treated with insulin. Prior to reporting Z79.4, query the provider.

Patient is here for follow up after her dialysis yesterday. What is the ICD-10-CM code for presence of an AV fistula for dialysis?

Z99.2