Coding a Note

67. Which of the following sentences below best describes the attributes of an atonic seizure? A. Causes patients to lose muscle tone, so they subsequently collapse. B. Characterized by rhythmic, jerking muscle contractions that affect both sides of the body at the same time. C. Associated with sudden brief jerks or twitches on both sides of the body. D. Most intense type of epilepsy causing loss of consciousness, muscle rigidity, and convulsions.

A. Causes patients to lose muscle tone, so they subsequently collapse.

57. The patient has a history of prostate cancer and is being seen today for placement of palladium-103 seeds for brachytherapy. You: A. Code prostate cancer. B. Code history of prostate cancer. C. Query the provider. D. Code encounter for other prophylactic surgery.

A. Code prostate cancer.

55. Which of the following statements is NOT true when coding peripheral vascular complications of diabetes? A. Diabetic arteriosclerosis with gangrene is coded with E11.52 and E11.59. B. Diabetes with ischemic heart disease and cerebrovascular disease are included in code E11.52. C. Peripheral Vascular Disease is coded with E11.52. D: The condition is coded as a manifestation if a cause and effect relationship is documented.

A. Diabetic arteriosclerosis with gangrene is coded with E11.52 and E11.59.

29. Patient is here for follow up of diabetes and CHF. Under exam, it is noted that his colostomy is intact and a healthy pink color. Select the diagnosis codes. A. E11.9, I50.9, Z93.3 B. E11.9, I50.9 C. E11.69, I50.9, Z93.3 D. E11.69, I50.9

A. E11.9, I50.9, Z93.3 E11.9 - Type 2 diabetes mellitus without complications I50.9 - Heart failure, unspecified Z93.3 - Colostomy status

53. Select the diagnosis code for a patient who is noted to be nutritionally deficient. A. E63.9 B. E44.1 A. E44.0 B. E46

A. E63.9 Nutritional deficiency, unspecified

46. It is noted on the chart that the patient has an ongoing history of smoking 1 pack of cigarettes,.a day for 30 years. You code: A. F17.210 B. Fl7.200 C. Z72.0 D. Z87.891

A. F17.210 F17.210 - Nicotine dependence, cigarettes, uncomplicated F17.200 - Nicotine dependence, unspecified, uncomplicated

40. A patient presents to the ER with a complaint of coughing for two weeks and fatigue. She is diagnose, with COPD with acute bronchitis. Select the diagnosis code(s). A. J44.0 B. J20.9 C. J44.9, J20.9 D. J44.0,J20.9

A. J44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infection

59. Select the appropriate code(s) for a patient diagnosed with aspiration pneumonia from GERD. A. K21.9, J69.0 B. J69.0 C. K21.9, Tl7.808A, J18.9 D. T17.808A, J18.9

A. K21.9, J69.0 K21.9 - Gastro-esophageal reflux disease without esophagitis J69.0 - Pneumonitis due to inhalation of food and vomit

49. Patient being seen for painful, swollen, and hot to touch area on left lower leg. A Doppler study is ordered to rule out DVT (Deep Vein Thrombosis). Select the diagnosis code(s). A. M79.605, M79.89 B. I82.402 C. M79.605, M79.89, I82.402 D. T81.719A

A. M79.605, M79.89 M79.605 - Pain in left leg M79.89 - Other specified soft tissue disorders

27 . A 54-year-old male is admitted into the hospital with a principal diagnosis of surgical site infection secondary to a recent right side below the knee amputation. Patient is a type I diabetic that is uncontrolled with diabetic peripheral vascular disease and congestive heart failure. Select the diagnosis codes. A. T87.43, E10.51, I50.9 B. El0.51, T87.43, I79.8, I50.20 C. Z16.ll, I79.8, I50.9, T87.42 D. T87.41, I50.9, Z16.ll

A. T87.43, E10.51, I50.9 T87.43 - Infection of amputation stump, right lower extremity E10.51 - Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene I50.9 - Heart failure, unspecified

42. Which of the following terms documented by a provider are indexed to I63.50 for the initial encounter I. CVA · II. Stroke III. Cerebral Infarction NOS IV. History of Stroke A. I B. I, II, and III C. II D. IV

B. I, II, and III

35. Patient with long history of chronic CHF, followed monthly, presents today with an acute exacerbation of diastolic heart failure. Select the diagnosis code(s). A. I50.9 B. I50.33, I50.9 C. I50.32, I50.9 D. I50.33

B. I50.33, I50.9 I50.33 - Acute on chronic diastolic (congestive) heart failure I50.9 - Heart failure, unspecified

34. Patient here today with complaints of SOB and has a known history of CHF. She is on Bumex currently. Select the diagnosis code(s). A. R06.02, I50.9 B. I50.9 C. R06.02 D. R06.02, I50.42

B. I50.9 Heart failure, unspecified

69. A pleasant 85-year-old female presents for follow up for chronic venous hypertension with her primary care provider. The provider documents an ulcer of the right calf the assessment and plan is ''A/P skin ulcer of right calf due to chronic venous hypertension, keep wound clean and dry, and return in one week." Select.the diagnosis code(s): A. L97.219 B. I87.311, L97.219 C. I87.311, I89.899 D. I87.311

B. I87.311, L97.219 I87.311 - Chronic venous hypertension (idiopathic) with ulcer of right lower extremity L97.219 - Non-pressure chronic ulcer of right calf with unspecified severity

66. Patient has chronic pulmonary fibrosis following radiation treatment with chronic respiratory failure. Select the diagnosis code(s). A. J96.10 B. J70.1, J96.10 C. J84.10, J96.90 D. J84.10, J96.10

B. J70.1, J96.10 J70.1 - Chronic and other pulmonary manifestations due to radiation J96.10 - Chronic respiratory failure, unspecified whether with hypoxia or hypercapnia

30. Patient with rheumatoid arthritis presents for follow-up of aortic stenosis. Select the diagnosis codes. A. I06.0 B. M06.9, I35.0 C. I06.2 D. M06.9, I06.0

B. M06.9, I35.0 M06.9 - Rheumatoid arthritis, unspecified I35.0 - Nonrheumatic aortic (valve) stenosis

37. An established 84-year-old female patient presents for follow up of chronic kidney disease. She has a long history of severe chronic kidney disease and recent labs show a progression of the disease requiring dialysis. The physician discusses the need for dialysis and documents severe chronic kidney disease resulting in end stage renal disease. Select the diagnosis code(s). A. N18.4, N18.6 B. N18.6 C. N18.6, Z99.2 D. N18.4

B. N18.6 End stage renal disease

62. When a patient has bilateral pressure ulcers at the same site with different stages, how should this be reported? A. Report one code for the site with the deepest stage. B. Report one code for the site to identify the site and stage of each pressure ulcer. C. Report two codes for the site of the pressure ulcers to represent each side, then report one code for the deepest stage of the ulcer. D. Report two codes for the site of the pressure ulcers.

B. Report one code for the site to identify the site and stage of each pressure ulcer.

28. Patient is in the office for dressing changes to his tracheostomy. Select the diagnosis code. A. Z93.0 B. Z43.0 C. Z99.11 D. Z98.89

B. Z43.0 Z43.0 - Encounter for attention to tracheostomy

48. Patient is here today for clearance for surgery. He has a history of DVT (Deep Vein Thrombosis) and is placed on Warfarin to pre- vent a recurrence of DVTs. Select the diagnosis code. A. I82.409 B. Z86.718 C. I82.449 D. I82.91

B. Z86.718 Z86.718 - Personal history of other venous thrombosis and embolismDeep Vein Thrombosis and Pulmonary Embolism (DVT/PE)

64. A patient with an infected central venous catheter develops sepsis and chest pain from a septic pulmonary embolism. You correctly code: A. T81.4, A41.9 B. R65.20, A41.9, I26.90, T80.211 C. A41.9, T80.211, I26.90 D. A41.9, T81.4, I26.90

C. A41.9, T80.211, I26.90 A41.9 - Sepsis, unspecified organism T80.211 - Bloodstream infection due to central venous catheter I26.90 - Septic pulmonary embolism without acute cor pulmonale

47. Select the correct code for major depression with no additional detail documented by the provider. A. F32.3 B. F32.0 C. F32.9 D. F41.9

C. F32.9 F32.9 - Major depressive disorder, single episode, unspecified F32.3 - Major depressive disorder, single episode, severe with psychotic featuresF32.0 - Major depressive disorder, single episode, mildF41.9 - Anxiety disorder, unspecified

44. What are the diagnosis codes for a patient diagnosed with Parkinson's disease with dementia? A. G31.83, F02.81 B. G31.83, F02.80 C. G20, F02.80 D. G20, F03.90

C. G20, F02.80 G20 - Parkinson's disease F02.80 - Dementia in other diseases classified elsewhere without behavioral disturbance

45. What are the correct codes for Alzheimer's dementia? A. G30.9, F03.90 B. G30.9, F06.8 C. G30.9, F02.80 D. G30.9, F02.80, F03.90

C. G30.9, F02.80 G30.9 - Alzheimer's disease, unspecified F02.80 - Dementia in other diseases classified elsewhere without behavioral disturbance

51. Patient presents to her eye doctor for follow up of retinopathy. The physician performs an examination and reviews recent scans. The provider documents "A/P: bilateral hypertensive retinopathy, stable, return in one year." Select the diagnosis code(s). ' A. I10, H35.033 B. H35.039, I10 C. H35.033 D. H35.033, I10

C. H35.033 H35.033 - Hypertensive retinopathy, bilateral

36. A physician sees a 65-year-old male patient in the office for follow up of hypertension. He mentions fatigue and loss of appetite. The physician orders labs that show a GFR of 35 and the physician documents moderate chronic kidney disease and hypertension in the assessment and plan. Select the diagnosis codes. A. N18.3, I10 B. I10, N18.2 C. I12.9, N18.3 D. I12.9, N18.2

C. I12.9, N18.3 I12.9 - Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.31 - Chronic kidney disease, stage 3 (moderate) 30-44 N18.32 - Chronic kidney disease, stage 3 (moderate) 45-59

31. Patient has atherosclerosis of the right lower extremity with an ulceration of the calf that needs debridement for gangrene. Select the diagnosis codes. A. I70.232, I97.219 B. I70.332 . C. I70.261, L97.219 D. I70.261

C. I70.261, L97.219 I70.261 - Atherosclerosis of native arteries of extremities with gangrene, right leg L97.219 - Non-pressure chronic ulcer of right calf with unspecified severity

60. Select the code(s) for a patient diagnosed with staphylococcal pneumonia. A. J18.9, J15.29 B. J18.9, J15.20 C. J15.20 D. J18.9, B95.7

C. J15.20 J15.20 - Pneumonia due to staphylococcus, unspecified

41. Patient has COPD, emphysema and continues to smoke. Select the diagnosis code(s). A. J44.9, F17.200 B. J44.9, J43.8, F17.200 C. J43.8, F17.200 D. J44.9

C. J43.8, F17.200 J43.8 - Other emphysema F17.200 - Nicotine dependence, unspecified, uncomplicated

65. Select the diagnosis code(s) for an essential brown induration of the lung. A. J98.4 B. J84.10 C. J84.03, E83.19 D. E83.19

C. J84.03, E83.19 J84.03 - Idiopathic pulmonary hemosiderosis E83.19 - Other disorders of iron metabolism

61. An 89-year-old female presents for follow up wound care for bilateral pressure ulcers. Her right heel shows a stage one ulcer with a dark scab and left heel shows a stage one ulcer with warm pink skin. The provider orders Betadine painting for both ulcers. Select the diagnosis code(s). · A. L89.612, L89.621 B. L89.601 C. L89.611, L89.621 D. L97.411, L97.921

C. L89.611, L89.621 L89.611 - Pressure ulcer of right heel, stage 1 L89.621 - Pressure ulcer of left heel, stage 1

38. Select the diagnosis codes for a patient with sick sinus syndrome with break through arrhythmia due broken pacemaker lead. A. T82.I10, I49.8 B. T82.120A, I49.6 C. T82.110A, I49.5 D. T82.120A, I49.5

C. T82.110A, I49.5 T82.110A - Breakdown (mechanical) of cardiac electrode, initial encounter I49.5 - Sick sinus syndrome

58. Patient is in to see urology. Follow up of prostate cancer, excised 4 years ago, and no longer on meds. A PSA is drawn today to follow up on his prostate cancer. What diagnosis code(s) should be reported for this encounter? A. C61 B. C61, Z85.46 C. Z85.46 D. 285.46, R97.2

C. Z85.46 Z85.46 - Personal history of malignant neoplasm of prostate

56. What is/are the correct diagnosis code(s) for anxiety? A. F32.9 B. F34.1 C. F41.9, F32.9 D. F41.9

D. F41.9 Anxiety disorder, unspecified

68. A 77-year-old male presents for follow up with his primary care provider. The provider documents a healed pressure ulcer of the right heel and hypertension. The assessment and plan states ''A/P healed skin ulcer of right heel, no further treatment and hypertension." Select the diagnosis code(s). A. I89.619, I10 B. I10, L89.619 C. I97.411, I10 D. I10

D. I10

63. The patient felt sudden sharp chest pain on the left side of his chest and asked his daughter to call an ambulance. The patient was admitted to the hospital and the CT pulmonary angiogram showed a small pulmonary embolus in the left lower lobe. Select the diagnosis code. A. I26.09 B. T80.0XXA C. I26.90 D. I26.99

D. I26.99 I26.99 - Other pulmonary embolism without acute cor pulmonale

50. Patient presents to primary care for follow up on an X-ray. The MA takes the vitals and documents the blood pressure reading of 140/80. After the physician examines the patient he documents "A/P: Elevated BP, should improve with diet, exercise, and weight loss." Select the diagnosis code. A. Z86.79 B. Z09 C. I10 D. R03.0

D. R03.0 Elevated blood-pressure reading, without diagnosis of hypertension

52. Select the diagnosis code(s) for a patient with anorexia who appears cachectic. A. R64 B. R64, F50.00 C. R63.0, R64 D. R63.0

D. R63.0 R63.0 - Anorexia

43. A patient presents to the neurologist for follow up after an emergency room visit. The patient reports a week ago at dinner, the family noticed the patient had facial drooping and called 911. The patient was brought by ambulance to the emergency room and upon arrival the symptoms were noted to be resolved. After review of the radiology report, the emergency provider diagnosed the patient with a TIA. The neurologist performs a neurological exam that is normal. The neurologist documents history of TIA and starts the patient on a daily aspirin. Select the diagnosis code. A. I69.998 B. I63.30 C. G45.9 D. Z86.73

D. Z86.73 Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits I69.998 - Other sequelae following unspecified cerebrovascular disease I63.30 - Cerebral infarction due to thrombosis of unspecified cerebral artery G45.9 - Transient cerebral ischemic attack, unspecified

33. Upon exam, the patient has a patent AV fistula in the left arm for dialysis. Select the diagnosis code. A. T82.898A B. I70.0 C. Z49.31 D. Z99.2

D. Z99.2 Z99.2 - Dependence on renal dialysis