CRC Practice Exam B
Which statement is TRUE regarding rule out diagnoses? A. A code for a rule out diagnosis can be coded when coding for HCC B. A code for a rule out diagnosis can be coded in the outpatient setting only C. The provider can document the rule out diagnosis but a code is not selected to report it D. The provider can document the rule out diagnosis and select a secondary code to report it
C A rule out diagnosis cannot be reported for outpatient services. The provider documents the rule out diagnoses in the patient chart to capture the medical decision making but a diagnosis code is not reported.
Patient is being seen in the Outpatient clinic today for liver cancer of a transplanted liver. Select the correct code(s). A. C22.8 B. C22.8, Z94.4 C. T86.49, C80.2, C22.8 D. Z94.4, T86.49, C80.2, C22.8
C According to the ICD-10-CM guideline I.C.19.g.3)(a), code complication of transplanted organ to categoryT86.4, followed by C80.2, Malignant neoplasm associated with transplanted organ; then additional code for specific primary malignancy which is C22.8. Z94.4 is not coded as it is described in T86.49.
05/01/XXEMERGENCY DEPARTMENT VISIT NOTE Mode of arrival: The patient arrived via ambulance. The patient's condition upon arrival was fair. Time seen by clinician: 1558CC. GI bleed HPI: The patient is a 79 year-old female with COPD, CHF, dementia and malnutrition who was transferred from a local nursing home for evaluation of GI bleed. The patient is a poor historian and not able to provide any history. EMS and nursing home staff reported that the patient started with diarrhea today, after having a "explosive" episode of diarrhea had a large amount of bright red blood per rectum. This occurred twice prior to arrival. On arrival to emergency department the patient was noted to have a bleeding external hemorrhoid A Rhino rocket was used to apply pressure to this hemorrhoid and gauze packing with hemostasis. Approximately one hour after initial evaluation the patient then had a more significant approximately 800 cc bowel movement with dark blood and clots. After this large bloody bowel movement, the patient did have transient hypotension which was responsive to IV fluid hydration. Once patient's family arrived they report that the patient has had a prior history of similar GI bleed. Patient's findings were reviewed with her family and her niece who is her designated medical proxy stated the patient should not have any aggressive measurements, GI can be consulted urgently. No emergent endoscopy. The patient appears to agree with this plan. The patient is on no current NSAIDs or anticoagulation. ROS: ALL OTHER SYSTEMS NEGATIVEPMH: As noted, admitted here with aspiration pneumonia and pleural effusion in April. ALLERGIES: NKDAMEDICATIONS' Reviewed, see medication list. SOCIAL HX: Remote history of smoking. FAMILY HX Noncontributory PE VITAL SIGNS: NURSING RECORDS AND DEMOGRAPHICS REVIEWED No respiratory distress.HEENT' PERRLA, EOMI, TMs and Oropharynx within normal limits Airway patent. NECK: Supple, non-tender, no lymphadenopathy. No JVD or carotid bruits. LUNGS: Scattered rhonchi bilaterally, decreased sounds in the bases No rales HEART: RRR, 2/6 diastolic murmur. ABDOMEN: soft, non-tender, hypoactive bowel sounds, moderate distention. Rectal as described. EXTREMITIES No edema or cyanosis noted NEUROLOGICAL: A0x2, CNs intact, motor functions within normal limits No focal deficits. SKIN: No rash. INTERVENTIONS: The patient was given gentle fluid hydration, IV Protonix. Labs: The patient's CBC shows a normal white count of 8000, H&H is 11 and 34. Normal platelet count of 257. Electrolytes show an elevated BUN of 72 and creatinine of 1 9, potassium 5 9"- C02 is 30. Anion gap of five. LFTs are unremarkable. Urinalysis negativeEKG: Normal sinus rhythm, LAFB and right bundle-branch block, no change when compared to EKG from 04/20/2008. No acute Ischemia, interpretation by EDMD. CXR: COPD, no acute infiltrate or free air.19 00- pts care and results reviewed with family, will start blood transfusion when available given significant GI bleed and intermittent hypotension. he is to remain DNR status. BP responsive to fluids/blood products Rectal tube to monitor output/bleeding. Awaiting bleeding scan CONSULTS The patient's findings were reviewed with GI. Patient to have emergent endoscopy otherwise will consult the morning Agrees with bleeding scan. Reviewed with PCP on call at 20:20 CRITICAL CARE TIME: 120 minutes DIAGNOSES: 1 Lower GI bleed2. Transient Hypotension3. Bleeding external hemorrhoid. DISPOSITION. The patient was admitted in guarded condition. Select all current diagnosis codes. A. K92.2, I95.9, K64.4 B. K92.2, R03.1, K64.4 C. K92.2, R03.1, K64.4, J44.9, I50.9, F03.90, E46 D. K92.2, I95.9, J44.9, I50.9, F03.91, E46, J91.8
C All the current conditions are reported. To locate codes in the ICD-10-CM Alphabetic Index look for Bleeding/gastrointestinal; Transient hypotension is not reported with I95.9. Look for Low/blood pressure/reading referring you to R03.1; Hemorrhoid/external; Disease/pulmonary/chronic; Failure/heart,/congestive; Dementia; Malnutrition. The aspiration pneumonia and pulmonary effusion are not reported because they were treated during a previous admission. Verify all code selections in the Tabular List.
Which statements are TRUE regarding retrospective audits?I. Can be performed by internal employeesII. Can be performed by external consultants who sign a business agreementIII. Performed prior to data being submittedIV. Performed after data was submitted A. I and III B. I and IV C. I, II, and IV D. III and IV
C Both internal and external, onshore and offshore resources can perform retrospective chart audits as long as a Business Agreement is signed by the external vendor. Retrospective audits are performed following data submission to validate correct information was submitted and correct any errors in data submitted.
Which one of the following would prevent a chart from being coded for Medicare risk adjustment? A. Patient's DOB is not documented on the medical record B. The patient presented for an acute condition C. Medical record does not include the credentials of the treating provider D. Date of service is past 90 days
C CMS RAPS Participant Guide states that all documentation must be signed by the rendering provider.As stated in CMS' 2008 Call Letter (available on the CMS web site athttp://www.cms.hhs.gov/PrescriptionDrugCovContra/Downloads/CallLetter.pdf):For purposes of risk adjustment data submission and validation, the MA organizations must ensure that the provider of service for face-to-face encounters is appropriately identified on medical records via their signature and physician specialty credentials. (Examples of acceptable physician signatures are: handwritten signature or initials; signature stamp that complies with state regulations; and electronic signature with authentication by the respective provider.) This means that the credentials for the provider of services must be somewhere on the medical record—either next to the provider's signature or pre-printed with the provider's name on the group practice's stationery. If the provider of services is not listed on the stationery, then the credentials must be part of the signature for that provider. In these instances, the coders are able to determine that the beneficiary was evaluated by a physician or an acceptable physician specialty.
The results of a RADV audit are extrapolated across all members of the plan that was audited. What does this mean? A. Financial penalties will be limited to each specific member B. Financial penalties will be averaged over the plan membership C. Financial penalties will be imposed across the plan membership D. Financial penalties will not be imposed until two years post audit
C CMS has stated that HCC risk factors will be spread across all members in that plan. Example: Member A had HCC22 to be validated, the value of that HCC is $2, it could not be validated. The plan membership is 200 members; that one missed HCC cost the company $400 which CMS will take back from the company.
Coders review medical records in their entirety to capture the current diagnosis codes. In which of the following components of the record should the coder NOT capture diagnosis codes? A. Exam B. History C. Nurse notes D. Consultation
C Diagnosis must be documented by the treating provider. The nurse's notes can not be used for documentation to support diagnosis codes.
Nurse Note: Patient here today for a Check-up. Patient is still coughing, might still have fluid in lungs. Patient's daughter thinks patient has depression. Patient is having trouble sleeping. SUBJECTIVECC: Issues as above. Wakes after few hours, some daytime naps. Sometimes gets up at night and sits at table and falls asleep. HPI: Gets frustrated with limitations by poor health and that depresses her. ROS:Constitutional: Denies chills, fatigue, fever and weight change. General health stated as fair. Eyes: Some squinting so going for re exam.CV: Denies chest pain and palpitations. Respiratory: Denies dyspnea and wheezing. Some cough, can't get phlegm up. Gastrointestinal: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena, nausea and vomiting. Genitourinary: Urinary: denies dysuria, frequency, hematuria, incontinence, nocturia and urgency. Musculoskeletal: Denies arthralgia and myalgia. Skin: Denies rashes. Neuro: Denies neurologic symptoms. Psych: Denies symptoms other than depression stated above. Current Meds: Indomethacin 50 mg. Lanoxin 0.125 mg. Iron 325 mg. Lasix 40 ma Glyburide 2.5 mg, Xalatan 0.005 %. Synthroid 125 meg, Lisinopril 40 mg, Mag-Tab SR 84 mg. Ditropan 5 mg, Vitamin B-6 50 mg. Allergies: NKDA PMH: Medical Problems: Hypertension, Atrial Fibrillation, Non-insulin Dependent Diabetes SH: Marital status: widowed. Patient lives alone. There are no pets in the home. Advance directive includes living will. Pt feels safe at home. Personal Habits: Cigarette Use: Never Smoked Cigarettes. Alcohol: Rare consumes alcohol. Drug Use: Denies Drug Use. Daily Caffeine: Consumes on average four cups of coffee per day. Reviewed and updated. Objective BP: 142/70. Pulse: 72. T: 98.5. HT: 63" 5'3." WT: 134lb. Exam: Constitutional: Appears well. No signs of apparent distress present. Elderly, wrinkled w/o bruises. Alert and converses. Slightly HOH.ENMT: Auditory canals normal. Tympanic membranes are intact. Nasal mucosa is pink and moist. Dentition is in good repair. Posterior pharynx shows no exudate, irritation or redness. 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.CV: Rhythm is irregularly irregular. Heart Murmur is still 3/6.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. Musculoskeletal: Uses a cane to ambulate.Skin: Skin is warm and dry. Assessment #1: Atrial FibrillationComments: On digoxin. Not on COUMADIN due to falls.Plan for #1: Med Current: Lanoxin 0.125 mg 1 po q d Assessment #2: Arthritis Climacteric Multiple SitesPlan for #2: Med Current: Indomethacin 50 mg take as needed Assessment #3: Congestive Heart Failure UnspecifiedComments: digoxin, no edema Assessment #4: Insomnia Assessment #5: Adjustment Disorder With Depression Comments: situational, with sleep issues. Med Current: Remeron 15 mg 1 po hs Med New: Remeron 15 mg 1 po hsAssessment #8: CoughComments: Has infiltrates vs CHF on CXR's. CXR next weekPlan for #8: X-ray: Chest, 2 Views What ICD-10-CM coding is reported? A. I48.91, M13.89, I11.0, I50.9, G47.00, F43.21, R05.9, E11.9, Z79.84 B. I48.91, M12.9, I50.9, G47.00, F32.A, E11.9, Z79.4, R05.9 C. I48.91, I50.9, F43.21, G47.00, E11.9, Z79.84 D. I48.91, M12.9, I10, I50.9, G47.00
A All current conditions are reported. To locate the codes, in the ICD-10-CM Alphabetic Index look for Fibrillation/atrial; Arthritis/climacteric which states to see Arthritis/specified form/multiple sites; Hypertension/heart/with heart failure (congestive); Failure/heart/congestive; Insomnia; Disorder/adjustment/depressed mood; Cough; Diabetes/Type 2; Long-term (current) use of/oral/hypoglycemic. On the CRC exam, for each case code all current conditions unless specifically asked to only report diagnoses under the HCC model. Verify all code selection in the Tabular List.
Can a request for recalculation from the plan be requested when inaccurate diagnosis codes are identified after the final risk score is determined? A. Yes, plans can request a recalculation if an inaccurate diagnosis will impact the final payment B. Yes, plans can request a recalculation if found within ten days C. No, plans cannot request a recalculation once a final risk score is calculated D. No, plans request for a recalculation can only occur when notified by CMS
A Once CMS calculates the final risk scores for a payment year, plan sponsors may request a recalculation of payment upon discovering the submission of inaccurate diagnosis codes that CMS used to calculate a final risk score for a previous payment year and that had an impact on the final payment. Plan sponsors must inform CMS immediately upon such a finding. Medicare Managed Care Manual, Chapter 7 - Risk Adjustment
Use the table provided below to answer the question. If the patient is diagnosed with colon cancer and acute leukemia, which HCC is used in the risk calculation? A. HCC 8 B. HCC 11 C. HCC 12 D. HCC 8 and HCC 11
A Payment will always be associated with the HCC in column 1, if a HCC in column 3 also occurs during the same collection period.
Using the information provided. If the patient's diagnoses included K76.6, K74.60, and B18.2, which HCC is used in the risk calculation? Diagnosis Code Description CMS-HCCModel Category V22 B18.0 Chronic viral hepatitis B with delta-agent 29 B18.1 Chronic viral hepatitis B without delta-agent 29 B18.2 Chronic viral hepatitis C 29 B18.8 Other chronic viral hepatitis 29 B18.9 Chronic viral hepatitis, unspecified 29 K74.3 Primary biliary cirrhosis 28 K74.4 Secondary biliary cirrhosis 28 K74.5 Biliary cirrhosis, unspecified 28 K74.60 Unspecified cirrhosis of liver 28 K74.69 Other cirrhosis of liver 28 K76.6 Portal hypertension 27 K76.7 Hepatorenal syndrome 27 K76.81 Hepatopulmonary syndrome 27 Hierarchical Condition Category (HCC)If the HCC Label is listed in this column......Then drop the HCC(s) listed in this column 27Portal Hypertension28, 29, 30 28Cirrhosis of Liver29 29Chronic Hepatitis A. HCC 27 B. HCC 28 C. HCC 29 D. HCC 27, HCC 28, HCC 29
A Payment will always be associated with the HCC in column 1, if a HCC in column 3 also occurs during the same collection period.
RADV/IVA audit submissions typically require: I. Provider printed name II. Two patient identifiers III. Provider's signature IV. Must include specialist consultations V. Must include coordination of care documentation by clinical staff A. II and III B. I, II and IV C. I, III, IV, and V D. I, II, III, IV, and V
A RADV/IVA audits require the provider signature, credentials, and two patient ID's such as patient name and DOB. The printed provider name is only necessary when the signature is illegible and there is a need to identify the provider.
Which risk adjustment model is most commonly used by Medicare? A. HCC B. CDPS C. Blended D. Fee for service
A The Medicare Hierarchal Condition Categories (HCC) model is used by Medicare Advantage plans (Medicare HMOs).
Subjective: Tile patient is a 67-year-old diabetic female who presents today for evaluation and treatment of her painful ingrown toenails. Past treatment has consisted of self-palliative care. The patient is consulting me today for ongoing palliative treatment of these toenails. Examination: Vascular: The pedal pulses are rated as ¼ in both feet. The digital capillary filling time is rated as 3+ seconds. Dermatological: The skin texture, temperature and turgor are normal for the patient's stated age. Closer evaluation of the patient's feet demonstrates onychocryptosis involving all digits of both feet. Neurological: The patient's tactile sensations are grossly intact for the patient's stated age. Assessment: A risk patient with a history of diabetes. The patient requires long-term palliative debridement of her toe nails to prevent possible pedal infection. Treatment: The patient's toenails were debrided manually today with the use of a bone cutter and all dystrophic nail plate thickness was reduced to normal nail plate thickness with the use of an electric rotary nail bur. The patient was rescheduled for follow up evaluation and palliative treatment in 2 months. Signed by: X, DPM 03/01/XX Which codes are recommended to be reported that will affect the HCC risk adjustment value? I. E11.9 II. E11.65 III. L60.0IV. R52 A. I B. II C. I, III, and IV D. II, III, and IV
A The diabetes is the only condition that has an HCC assignment. The diabetes is not documented as uncontrolled. An ingrown toenail is an acute problem. Pain is not assigned an RAF.
Retrospective audits generally include finding additional diagnoses, CMS has stated that the deletion of conditions needs to be part of these audits; why is it so hard for companies to follow CMS directives? I. There is a potential of loss of revenue II. Billing compliance issues might come too light III. All companies follow CMS directives A. I and II B. I C. I and III D. III
A These audits can mandate that insurance companies repay CMS for past revenues which will decrease the bottom line for the stock holders. Billing compliance issues might come into play and a deeper dive might be warranted for specific provider offices which will cause abrasion with the providers.
What is the highest Star Rating that can be achieved? A. 4 B. 5 C. 10 D. 15
B CMS defines the star ratings in the following manner: 5 Stars = Excellent Performance 4 Stars = Above Average Performance 3 Stars = Average Performance 2 Stars = Below Average Performance 1 Star = Poor Performance
What is the function of the spinal cavity? A. Protects the vertebrae B. Enfolds and protects the spinal cord C. Protects the kidneys D. Protects the pleura
B The spinal cavity enfolds and protects the spinal cord.
Which sentence below, best describes the attributes of an Absence seizure (petit mal)? A. Causes stiffening of the muscles and may cause the patient to fall to the ground. B. Characterized by blank staring and subtle body movements that begin and end abruptly. It may cause a brief loss of consciousness. C. Associated with sudden brief jerks or twitches on both sides of the body. D. Characterized by rhythmic, jerking muscle contractions that affect both sides of the body at the same time.
B Absence seizures (petit mal): characterized by blank staring and subtle body movements that begin and end abruptly. It may cause a brief loss of consciousness.
A patient has the diagnosis of diabetes and gangrene and osteomyelitis; which one of the following is most TRUE? A. Conditions listed with a diagnosis of diabetes or in a diabetic patient are usually complications of the diabetes. B. Diabetes can have a causal relationship to these conditions. C. There is an assumption that the gangrene and osteomyelitis are due to secondary diabetes. D. Gangrene is usually associated with type 1 diabetes.
B According to the ICD-10-CM guideline I.A.15.: 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.
If you were using a predictive model and the results were:• The member had an Rx Claim for a beta blocker.• The member had a medical claim which included comprehensive lab panel. Which diagnosis would you predict this member has? A. DM B. Hypertension C. CKD D. Asthma
B Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure.
Admission: The patient is a 68 year-old white female patient. She is a known insulin dependent diabetic who has had a history of having complications of diabetes including ulcers of both feet, eventually resulting in amputation of left leg below the knee. Patient presents with infection on the bottom of her right foot. This had become secondarily infected. She reported the pain as sharp and jabbing and 7/10. She presented to the hospital essentially with cellulitis of her right ankle. Her diabetes is out of control secondary to the infection with a level of 500 on admission. She was placed in the hospital. Social history is negative for tobacco and drugs. She does admit to occasional alcohol. Father had diabetes. Mother had a brain tumor. The patient admits to fevers and chills. She denies headaches, nausea, vomiting, diarrhea, or urinary difficulty. She denies shortness of breath or chest pain. She has had no problems with her eyesight and no problems with hearing. She denies any swelling in her axilla or groin. BP is 150/84, P 84, RR 16, and T 98. Eyes, PERLA. TMs are clear. Heart is regular rate and rhythm. Lungs are clear. Abdomen is soft and obese, with no tenderness. She has swelling in the right foot secondary to osteomyelitis. The patient is oriented to person, place, and time. Cranial nerves 2 thru 12 are intact. Impression: Cellulitis of right ankle, Osteomyelitis of right foot, Insulin-dependent Type 2 diabetes mellitus. Plan: Flagyl 500mg IV q 6 hours, insulin q 6 hours on a sliding scale, Percocet q 4 hours prn pain. Bone scan ordered. Select all current diagnosis codes. A. L03.115, E10.9, M86.9 B. L03.115, E11.69, M86.9, Z89.512, Z79.4 C. L03.119, E11.9, M86.9 D. L03.119, E11.69, M90.871, Z89.512, Z79.4
B Code all current conditions. Cellulitis of the right ankle is reported with L03.115. There is a causal relationship between diabetes and osteomyelitis. Look in the ICD-10-CM Alphabetic Index for Diabetes, diabetic/with/osteomyelitis referring you to E11.69. Report the osteomyelitis code M86.9 according to the instructional note in the Tabular List under code E11.69. Report a code for the amputation status. The patient is insulin dependent.
Patient diagnosed with severe protein calorie malnutrition. What is the appropriate diagnosis coding? A. E41 B. E43 C. E46 D. E43, F50.00
B E43 is the appropriate code as the severe malnutrition is designated as protein calorie.
PATIENT: DTPAIENT ID: 4321 DOB: 05/05/XXXXDOS: 02/02/XX CHIEF COMPLAINT: Cyst on the right upper eyelid. SECOND COMPLAINT: Hypertension. Denies chest pain, shortness of breath, or extremityswelling. Tolerating meds. He is due for labs and refills. THIRD COMPLAINT: Rash on his scalp and forehead. OBJECTIVE: A 72 year-old in no acute distress. Weight and vitals documented. He has a 2- to 3-mm cystic area on the right upper lid laterally. He has some scaliness to the temporal areas and to the scalp. CV: Regular. Lungs are clear. Extremities without significant edema. ASSESSMENT/PLAN 1. Chalazion, right upper eyelid. Refer to Ophthalmology. Follow up here in six months. 2. Hypertension with congestive heart failure, well controlled. 3. Seborrhea. Nystatin and triamcinolone cream as needed. Which code(s) is (are) recommended to be reported that will affect the HCC risk adjustment value? I. H00.11 II. I11.0 III. L21.0 A. I B. II C. I and III D. I, II, and III
B Hypertension with congestive heart failure is the only condition that has an HCC assignment. The cyst and seborrhea are acute conditions that do not have an HCC assigned.
A 45 year-old female patient presents to her primary care office complaining of crying and overall unhappiness and sadness. The physician has seen this patient before for the same condition and has diagnosed the patient with Major Depressive Disorder, Recurrent. Which one of the following ICD-10-CM codes is for Major Depressive Disorder, Recurrent? A. F32.1 B. F33.9 C. F43.21 D. F32.A
B ICD-10-CM Code F33.9, Major Depressive Disorder, Recurrent, unspecified is the correct answer.
What is the proper way to code coronary artery disease with no history of prior coronary artery bypass? A. I25.110 B. I25.10 C. I25.810 D. None of the above
B If the medical record documentation shows no history of prior coronary artery bypass, select the code for the native artery for CAD. If the documentation is unclear concerning prior bypass surgery, query the physician
Patient is seen today for follow up of cirrhosis of the lung found on a thoracic CT. What ICD-10-CM code is reported? A. R91.8 B. J84.10 C. J98.4 D. K74.69
B In the ICD-10-CM Alphabetic Index, look for Cirrhosis/lung.
When providing physician education for documentation, the coder should: A. Focus only on the conditions that have a risk adjustment score B. Instruct the provider to document all diagnoses managed, treated, and monitored C. Instruct the provider to always code using the diabetic manifestation codes D. Focus on the conditions that have been on the list for audit targets
B It is important to remember that documentation is used for more than coding. It is a legal document that supports the services provided and continuity of care. To train providers to document with only coding requirements in mind will cause other compliance issues.
Which of the following is TRUE regarding the past, family, and social histories?I. PFSH contains information regarding a patient's chronic conditionsII. PFSH includes information regarding the patient's history that may put him/her at risk for certain conditionsIII. PFSH should not be used for supporting documentation for diagnosis codes A. I B. I and II C. II D. III
B PFSH can include pertinent information for risk adjustment coding such as tobacco use, chronic conditions the patient is treated for and family histories that put the patient at risk.
Under ICD-10-CM guidelines, a condition exists only when it is stated. Amputation Status are codes that are frequently overlooked by providers. Which Z code series is used to indicate a lower limb amputation status? A. Z99.- B. Z89.- C. Z21 D. Z93.-
B Remember to document permanent diagnoses as often as they are assessed or treated, or when they are a consideration in the patient's care at a minimum, they must be documented annually in order for CMS to consider them as an active condition. See Official Guidelines for Coding and Reporting IV.J. Patients undergoing dialysis (Z99.2) Lower limb amputation status (Z89.-) Asymptomatic HIV status (Z21) Ostomy (specify SITE) (Z93.-)
How are HCCs categorized? A. Type of complication B. Diagnosis groups C. Organ systems D. Age group
B The model takes ICD codes and filters them into Diagnosis Groups (DxGs), then into Condition Categories (CCs), where hierarchies or "families" of conditions are placed to gain an HCC numeric code, which translates to a risk adjustment factor (RAF) value.
What can result from the improper use of cut and paste functions in an EHR to pull in elements of a previous encounter? A. The patient could end up with duplicate claims for the same date of service B. The provider may include diagnoses that are not relevant for the date of service C. The nurse might provide medical care to the wrong patient D. The coder might overlook chronic illnesses that are currently being treated
B The use of cut and paste functions in EHR are discouraged because there is a high error rate in proper use. It allows the provider to bring information forward from a previous encounter that may not be addressed in the current visit.
A 69 year-old male presents for follow up wound care for his bilateral pressure ulcers. His right heel shows a stage one ulcer and left heel shows a stage two ulcer with dark scabbing. The provider orders Betadine painting for both ulcers. Assign the correct ICD-10-CM code(s) for this visit. A. L89.622 B. L89.899 C. L89.622, L89.611 D. L97.409
C In ICD-10-CM pressure ulcers have been made into combination codes that include the location, stage and laterality. As this patient had an ulcer on each foot both of the ulcers would be coded using combination codes.
A patient is diagnosed with VAP. Select the diagnosis code(s). A. J18.9, J95.851 B. J18.9, J95.850 C. J95.851 D. J95.850
C In the Alphabetic Index, look for Pneumonia, ventilator associated. Verify code selection in the Tabular List.
What does the abbreviation MI stand for? A. Missed Intervention B. Minimally Invasive C. Myocardial Infarction D. Mandatory Intervention
C MI is the medical abbreviation for myocardial infarction.
Which provider type(s) is (are) unacceptable data sources under the HCC model? I. Excluded providers II. Children hospitals III. Rural health clinics IV. Independent laboratories A. I B. I and II C. I and IV D. I, II, III, and IV
C Medicare will not pay for items or services rendered to beneficiaries and recipients by an excluded provider or by entities owned or managed by an excluded provider. Therefore, MA organizations should not submit risk adjustment data if it was submitted by an excluded provider. Laboratory services are not submitted to support HCC score. Medicare Managed Care Manual, Chapter 7 - Risk Adjustment
What does the abbreviation RADV indicate? A. Risk adjustment diagnosis values B. Risk adjustment diagnosis voucher C. Risk adjustment data validation D. Reporting adjusted diagnosis values
C RADV indicates Risk Adjustment Data Validation
Are NDC codes helpful in data mining? A. No, NDC codes are not reported. B. No, NDC codes are only evaluated if it is a fee for service plan. C. Yes, the codes indicate medications prescribed which is an indication of the conditions being treated. D. Yes, the codes generate a higher rate of reimbursement.
C The NDC codes help identify the medications the patient is taking. This provides information regarding the condition and severity of the condition.
OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Stage Duke's D colon cancer POSTOPERATIVE DIAGNOSIS: Stage Duke's D colon cancer PROCEDURE: Insertion of an Infusaport ANESTHESIA: Local with IV sedation PROCEDURE: The patient was brought to the operative suite and placed in a supine position. Following IV sedation, she was sterilely prepped and draped in the usual fashion. 1% Xylocaine was used for local anesthesia. A transverse skin incision was made over the left deltoid pectoralis groove and electrocautery used for hemostasis. The incision was then deepened in an attempt to isolate the cephalic vein. The cephalic vein was unable to be identified. Attention was then directed to the left infraumbilical region. The left subclavian vein was then cannulated with 14-gauge needle and guide wire inserted through the needle into the subclavian and advanced into the central venous system. The needle was removed, leaving the guide wire in place. Fluoroscopic visualization was utilized. The guide wire was then delivered subcutaneously to the incision. A subfascial pocket was then created with blunt dissection. Appropriate length of Infusaport catheter was selected. Introducer was inserted over the guide wire and advanced into the left subclavian vein. The introducer and guide wire were removed, leaving the sleeve in place. The Infusaport catheter was inserted through the sleeve into the left subclavian vein and advanced to the superior vena cava. The sleeve was removed, leaving the catheter in place. The Infusaport was then secured to the pectoralis muscle with 3-0 Prolene in the usual fashion.The fascial margins were approximated with 3-0 Vicryl in simple interrupted fashion. The skin margins were approximated with 4-0 Vicryl in simple running intradermal fashion. The system was accessed, aspirated, and flushed with heparinized saline. The system was then clamped and sealed with an op site dressing. The procedure was completed without incident. The patient tolerated the procedure well. All needle and sponge counts were correct and the patient was transported to the recovery room in satisfactory condition with stable vital signs. PATHOLOGY: Preoperatively this 61-year-old patient was evaluated and found to have Duke's D adenocarcinoma of the colon with spread to the abdomen. She wishes to proceed with chemotherapy. At the time of surgery, an Infusaport was inserted through the left subclavian vein as described above. Postprocedure chest X-ray was ordered and will be reviewed. No other pathology at the time of surgery. Select all current diagnosis code(s). A. C18.9 B. C18.9, C76.2 C. C18.9, C79.89 D. C78.5, C79.89
C The patient is having a port placed to begin chemotherapy. The patient has colon cancer which has spread to the abdomen. In the Table of Neoplasms look for Neoplasm, neoplastic/colon/Malignant Primary column. Next look for Neoplasm, neoplastic/abdomen/Malignant Secondary column C79.8-. In the Tabular List complete code is C79.89.
A 67 year-old male is brought in by his daughter for evaluation of two wounds on the legs. The provider exams the skin and finds two skin ulcers. One ulcer is on the right calf and the second ulcer is on the left ankle. The provider orders the nurse to clean both ulcers and for the patient to return in one week. Assign the correct ICD-10-CM codes for this visit. A. L89.509, L89.899 B. L89.529, L89.899 C. L97.219, L97.329 D. L97.209, L97.309
C The provider documented skin ulcers and not pressure ulcers so a code from category L97.219 and L97.329 are correct to report the skin ulcers of calf and ankle.
A 62 year-old female with a long standing history of endocrine disease has noticed numbness in her hands and feet. She sees her physician and after examination, her provider documents the following: A/P: Polyneuropathy, due to endocrine disease. Will get new labs and have patient return in four weeks. Assign the correct ICD-10-CM code(s) for this encounter. A. E34.9 B. G63 C. G63, E34.9 D. E34.9, G63
D Manifestations of endocrine disease are reported as additional diagnosis. See the instruction note in the Tabular List under code G63 indicates to: Code first underlying disease, such as: endocrine disease, except diabetes (E00-E07, E15-E16, E20-E34). In the ICD-10-CM Alphabetic Index look for Polyneuropathy/ in (due to)/endocrine disease NEC E34.9 [G63]. Brackets used in the Alphabetic Index identify manifestation codes. Refer to ICD-10-CM guideline I.A.7. and I.A.13.
How many charts can be submitted to CMS to validate an HCC? A. One B. Three C. Two D. Five
D RADV to permits 5 medical records to be submitted for each HCC to be validated.
Which of the following statements are TRUE regarding problem lists? I. In some EHRs the problem list can be carried over from a previous visit without updating the information II. Problem lists include chronic conditions III. Problem lists can include previously treated conditions. IV. In some EHRs the problem list can include conditions from previous years A. I and II B. I and III C. II, III and IV D. I, II, III, and IV
D All statements regarding problem lists are true.
The patient is seen by her primary care provider. The provider documents the patient has diabetes, CKD stage II and CKD stage III. What should the coder do? A. Report E11.22, N18.2, N18.30 B. Report E11.22, N18.30 C. Query the provider to determine if the diabetes in out of control D. Query the provider to determine the appropriate stage of CKD
D Because two different stages of CKD are documented, query the provider to confirm. If this documentation was during the course of the admission it is possible for a patient to progress from one stage to another but not during the course of an office visit.
Patient has chronic thrombosis and is on blood thinners to combat this. What ICD-10-CM code is reported? A. I82.409 B. Z86.718 C. I82.509 D. I82.91
D Chronic thrombosis stated may be coded as current. Look in the ICD-10-CM Alphabetic Index for Thrombosis/chronic referring you to I82.91.
Which statement(s) is/are TRUE? I. If in the assessment section of an EMR record states "Diabetes- E11.29" then E11.29 should be coded on the claim. II. If in the assessment section of an EMR record states "Diabetes with Diabetic Renal Manifestations E11.29" then E11.29 should be coded on the claim. III. If in the assessment section of an EMR record states "HTN I10 and DM E11.9" then I10 and E11.9 should be coded on the claim. IV. If in the assessment section of an EMR record states "COPD J44.9," "HTN I10," "GERD K21.9," then J44.9, I10, and K21.9 should be coded on the claim. A. I B. I and II C. I, II, and III D. II, III, and IV
D Coders should only report codes for the diagnoses that are written out.
Which ICD-10-CM code(s) is/are reported when the provider diagnoses the patient with adult attention deficit disorder (ADD)? A. I25.10, F90.1 B. F81.0 C. F90.9 D. F98.8
D From the ICD-10-CM Alphabetic Index look for Disorder/attention-deficit without hyperactivity (adolescent) (adult) (child) referring you to F98.8. Verify code selection in the Tabular List.
89 year-old female with history of PE on Coumadin presents to cardiology for follow up. Two years ago the patient had chest pain and a small pulmonary embolus in the right lower lobe was found. The patient reports no symptoms and daughter says she is at baseline. The provider documents "chronic pulmonary embolism, continue with Coumadin". Select the diagnosis code(s). A. I26.09 B. I26.90 C. I27.1 D. I27.82, Z79.01
D In the ICD-10-CM Alphabetic Index look for Embolism/pulmonary/chronic leads us to code I27.82. Below I27.82 is a note saying to use additional code, if applicable for associated long term (current) use of anticoagulants (Z79.01).
Which diagnoses can be coded from a medical record that states a member has the condition, but does not contain supporting documentation? I. COPD II. Croup III. A-FibIV. GERD V. Parkinson's disease VI. MS A. I and II B. III, IV, V and VI C. II, V and VI D. I, III, V, and VI
D The Official Guidelines for Coding and Reporting for Outpatient Services IV.I. and IV.J., state, "Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions(s) and "Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist." This information was previously published in Coding Clinic, Fourth Quarter 2006, pages 236-240.CMS RAPS Participant Manual: Co-existing conditions include chronic, ongoing conditions such as diabetes (250.XX, HCCs 15-19), congestive heart failure (428.0, HCC 80), atrial fibrillation (427.31, HCC 92), chronic obstructive and pulmonary disease (496, HCC 108). These diseases are generally managed by ongoing medication and have the potential for acute exacerbations if not treated properly, particularly if the patient is experiencing other acute conditions. It is likely that these diagnoses would be part of a general overview of the patient's health when treating co-existing conditions for all but the most minor of medical encounters. Co-existing conditions also include ongoing conditions such as multiple sclerosis (340, HCC 72), hemiplegia (342.9X, HCC 100), rheumatoid arthritis (714.0, HCC 38) and Parkinson's disease (332.0, HCC 73). Although they may not impact every minor healthcare episode, it is likely that patients having these conditions would have their general health status evaluated within a data reporting period, and these diagnoses would be documented and reportable at that time.
Which payer type uses HEDIS measures? A. Medicare B. Medicaid C. Private payers D. A variety of payer types
D There are some HEDIS measures captured by Medicare, Medicaid and private payers. HEDIS makes it possible to compare the performance of health plans.
If a medical record has conflicting information documented, how is it resolved? A. The conflicting information is deleted and new documentation is created. B. The conflicting information is only corrected if the revision will result in a higher RAF. C. The provider is queried and if you do not receive a response, delete the conflicting information. D. The provider is queried and an addendum/late entry is created to address the conflicting information.
D Whenever conflicting information is found in a record, the provider should be queried to confirm the accurate information. The provider must document an addendum or late entry to correct the information that was added to the record in error. You cannot delete information from the medical record once the provider has authenticated the note.
