final

In order to establish the adequacy of documentation in the medical record, the following must be reflected:

All health record entries must be legible

A female patient is diagnosed with congestive heart failure. Which of the following will increase the MS-DRG weight if present on admission?

Coronary artery disease

A 62-year-old man comes to the emergency room complaining of chest pain, shortness of breath, and fluid retention. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate?

MI

The physician creates a shunt to form a communicating duct from the lateral ventricles to the peritoneal space, to drain excess CSF. The scalp is incised and retracted posterior to the ear. The physician drills a burr hole and inserts the proximal portion of the shunt toward the lateral ventricles, with or without the aid of an endoscope, until CSF flows through the shunt. The distal end of the shunt is directed and tunneled subcutaneously toward the selected drain site. The two ends are connected and tested. The dura is sutured closed and the scalp is reapproximated and sutured in layers. If an incision is required at the distal end, the incision is sutured in layers. What code should be assigned?

00160J7

The physician inserts a ventilating tube. Under direct visualization with a microscope, the physician makes a small incision in the tympanum (eardrum). Any middle ear fluid is suctioned and may be reserved for analysis. The physician inserts a ventilating tube into the opening in the tympanum. No other treatment is required. What code should be assigned?

099770Z

The physician performs a laparoscopic appendectomy. The physician places a trocar at the umbilicus and insufflates the abdomen. The laparoscope is placed through the umbilical port and additional trocars are placed into the abdominal cavity. The appendix is identified, dissected from surrounding structures and its blood supply divided. The appendix is transected with staples or suture and removed. The trocars are removed and the incisions are closed. What code should be assigned?

0DTJ4ZZ

The physician removes all of a right thyroid lobe, without isthmusectomy. The physician exposes the thyroid via a transverse cervical incision in the skin line. The platysmas are divided and the strap muscles separated in the midline. The thyroid lobe to be excised is isolated and superior and inferior thyroid vessels serving that lobe are ligated. Parathyroid glands are preserved. The thyroid gland is divided in the midline of the isthmus over the anterior trachea. The thyroid lobe is resected. The platysmas and skin are closed. What code should be assigned?

0GTH0ZZ

Within a PCS table, valid codes include all combinations of choices in characters 4 through 7 contained in the same row of the table. Which of the following is not a valid code selection?

0JHW3VZ

Total left hip replacement with cemented ceramic on ceramic bearing prosthesis

0SRB039

The physician performs a laparoscopic surgical removal of one or both ovaries and their accompanying fallopian tubes with the assistance of a fiberoptic laparoscope. The physician may first insert an instrument through the vagina to grasp the cervix and manipulate the uterus during surgery. Next, the physician makes a small incision just below the umbilicus through which a fiberoptic laparoscope is inserted. A second incision is made on the left or right side of the abdomen with additional instruments being placed through these incisions into the abdomen or pelvis. The physician manipulates the tools so that the pelvic organs can be observed, manipulated and removal of one or both ovaries and fallopian tubes can be performed with the laparoscope. The abdomen is deflated, the trocars removed, and the incisions are closed with sutures. Code the ICD-10-PCS procedure code.

0UB74ZZ

Using a laparoscopic approach, both of the fallopian tubes is tied, and a segment of the tube is excised. Excision is the root operation to use when a portion of the fallopian tube is removed. An excision of a ligated portion of the fallopian tubes is also known as a Pomeroy operation. A Pomeroy sterilization technique involves the ligation of a loop of fallopian tube and subsequent resection of the tied loop.

0UB78ZZ

The physician inserts a speculum into the vagina to view the cervix. A tool is used to grasp the cervix and pull it down. A dilator is inserted into the endocervix and through the cervical canal to enlarge the opening. The physician places a curette in the endocervical canal and passes it into the uterus. The endometrial lining of the uterus is scraped on all sides for diagnostic or therapeutic purposes. What code should be assigned?

0UDB7Z8

Reference codes 31360-31368 for laryngectomy. What is the correct code assignment for a laryngectomy with subtotal supraglottic and radical neck dissection?

31368

A patient has metastatic adenocarcinoma of bone. What code should be assigned?

C79.51

The MCE lists each edit code requirement which CMS uses to avoid inappropriate payment on inpatient claims. Updates are made to the MCE on a quarterly basis. CMS publishes a comparison document which lists the quarterly changes made to the MCE manual for the specific year. Chapter 1: Edit code lists includes specific edit code lists used to find errors based on coding. The categories under age conflicts are:

maternity diagnosis 12-55

Claims data provides a comprehensive snapshot of a patient's encounter. This data is valuable in identifying accounts for further review that may be at risk for denials based on current patterns. Key elements of HIM coded claims data include:

patient demographics

A 64-year-old female is admitted to the hospital with nausea, vomiting, and edema. The patient has a history of hypertension and takes Lisinopril as prescribed. On the discharge summary, the final diagnosis of acute renal failure and hypertension are documented. What coding rule applies?

use separate codes for hypertension and acute renal failure

Using a percutaneous endoscopic approach, the physician places a trocar though an incision, and insufflates the abdominal cavity. The laparoscope and additional trocars are placed through small portal incisions. The silicone gastric band is introduced into the peritoneal cavity via a trocar and is placed and secured around the upper stomach to form a smaller stomach pouch with a smaller outlet. A small port is placed under the skin at the time of surgery and connected to the silicone band by tubing to facilitate postoperative adjustments of the outlet size by the addition or removal of saline in the port. The correct code for this procedure is:

0DV64CZ

FNA and CORE biopsies are done on the same lesion, in the same session, on the same day, with the same type of imaging guidance. What codes would be assigned?

10007, 19100-59

The physician removes a biopsy sample of skin, subcutaneous tissue, and/or mucous membrane strictly for the purpose of performing a diagnostic histopathologic study under a microscope. What code(s) should be assigned for this procedure?

11104

A 4-year-old patient has an insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age. What code should be assigned?

36572

Inpatient acute-care PPS hospitals, inpatient rehabilitation facilities (IRFs), long term care hospitals (LTCHs) and inpatient psychiatric facilities (IPFs) may interim bill in at least _____day intervals. Subsequent bills must be in the adjustment bill format. Each bill must include all applicable diagnoses and procedures.

60

The objective of a query is to ensure the reported diagnoses and procedures derived from the health record documentation accurately reflect the patient's episode of care. Compliant query practice should follow these guidelines

Are specific to the patient and episode of care

The objective of a query is to ensure the reported diagnoses and procedures derived from the health record documentation accurately reflect the patient's episode of care. Compliant query practice should follow these guidelines:

Are specific to the patient and episode of care

A patient was admitted to the hospital to with severe left hip pain to rule out a hip fracture. After study, hip fracture was ruled out and the cause of the hip pain was not determined. The patient is discharged home with instructions to follow up with an orthopedic specialist. What coding rule applies?

Assign only the code for the hip pain

A patient was admitted to the hospital to with chest pain, unstable angina and congestive heart failure. The unstable angina is treated with nitrates, and intravenous Lasix is given to manage the heart failure. What coding rule applies?

Assign the codes for the unstable angina and congestive heart failure, sequence either first.

A 27-year-old female presents to the emergency department complaining of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unrelieved following treatment. What diagnosis should be suspected?

Asthma with status asthmaticus

A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?

Asthma with status asthmaticus

A patient has squamous cell carcinoma of the knee. What code should be assigned for this diagnosis?

C44.721 Squamous cell carcinoma of skin of unspecified lower limb, including hip

50-year-old woman is admitted with a diagnosis of metastatic ovarian cancer to the pleura. A thoracoscopic pleurodesis is performed. What codes should be assigned?

C78.2, C56.9, 32650

. A patient is seen in a clinic for a laceration of the elbow. The wound required suturing. On the claim form, which of the following types of codes would be assigned to represent the laceration?

CPT

A patient is admitted because of congestive heart failure (CHF). During the treatment of the CHF, the patient was also found to have elevated liver function tests. The physician worked up the elevated liver function tests but was not able to determine a diagnosis. The following diagnoses should be assigned:

Congestive heart failure and abnormal liver function tests

This female pt. w/ terminal carcinoma of the breast, mets to the liver, brain, and intrahepatic and extrahepatic bile ducts, was admitted w/ dehydration. Pt. rehydrated w/ IVs and discharged, w/ no treatment given to the cancer. What are the codes assigned?

E86.0, C50.919, C78.7, C79.31, C78.89

A patient was admitted with end stage renal disease (ESRD) following kidney transplant. The patient also had angina and chronic obstructive pulmonary disease. The diagnoses would be sequenced as:

End-stage renal disease; status post kidney transplant; chronic obstructive pulmonary disease; angina

The patient was admitted for prostate carcinoma. This was treated with radiation. A member of the medical staff who was not associated with the patient's care requests to see the patient's record. What should the coder do?

Explain that providing the record would violate the privacy policy

A patient is admitted to an acute care facility for detoxification from alcohol and barbiturate intoxication with chronic alcoholism and barbiturate abuse. The patient also has cirrhosis of the liver due to alcoholism. What codes should be assigned?

F10.229, F13.129, K70.30, HZ2ZZZZ

A patient is prescribed Diazepam and reports taking more than the prescribed amount. The patient is admitted to the hospital for complete work up. The final diagnosis is documented as Diazepam use and abuse. How should this be coded?

F13.10

A 55-year old pt. is brought into the operating room for elective decompression of the right median nerve for carpal tunnel syndrome. She is in excellent health otherwise. The surgeon places an Esmarch bandage on the arm, and the arm is exsanguinated. A tourniquet is then placed and the surgeon administers Bier block anesthesia. Tourniquet time was approx. 50 min. Assign the ICD-10-CM dx code and CPT code w/ any applicable modifiers.

G56.01, 64721-47-RT

1. What data entry software do home health agencies use to log patients?

HAVEN (home assessment validation and entry)

A patient admitted with acute abdominal pain is found to have appendicitis and has an appendectomy. The patient has a length of stay of two days. What type of patient encounter is this?

Inpatient

A female patient presents for DUB, for which hysteroscopy with endometrial ablation was undertaken. What codes would be assigned?

N93.8, 58563

The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were miscoded as malignant during the last six months. To address this situation, what work processes could be undertaken?

Obtain the cases of malignant colon tumors from both the cancer registry and the billing system; import both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor registry that are in the billing system. These cases should be manually reviewed to ensure they are not carcinoid tumors

A female patient is admitted for a second-degree cystocele. A repair is performed. In order to code this accurately, what document provides the required additional information?

Operative report

A 70-year-old patient was admitted with pneumonia. The history and physical documented that the patient has a history of diabetes, hypertension, and migraine headache about 10 years ago without recurrence. The patient was administered IV antibiotics, metformin, and Altace during the hospitalization. Which conditions would be reported at the time of discharge?

Pneumonia, diabetes, and hypertension

A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is:

Preventive

A female nursing home patient is admitted for complaints of urinary burning, fever, and chills for the past week. After study, the discharge diagnosis is Proteus Mirabilis, urinary tract infection. Which of the following represents the correct diagnoses and appropriate sequence of those conditions?

Proteus Mirabilis, urinary tract infection

If a patient's discharge summary does not contain a diagnosis that is documented by the specialist in a consultation report and the diagnosis would impact MS-DRG assignment, the coder should:

Query the attending physician regarding the clinical significance of that diagnosis

A 56-year-old woman is admitted to an acute-care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of hospitalization a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should

Query the healthcare provider who performed the procedure to determine if the debridement was excisional

A patient was admitted with redness and blurred vision in the left eye within one week of a corneatransplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following cornea transplant. What action(s) should the coding staff take?

Query the physician

Present on Admission (POA) is defined as being present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department and/or observation services, or outpatient surgery, are considered POA. Coders should not:

Report the POA indicator if a condition is not coded and reported based on Uniform Hospital Discharge Data Set definitions and current "Official Guidelines."

A patient is admitted to the hospital for pain due to displacement of pacemaker electrode. The patient also has hypothyroidism due to partial thyroidectomy seven years ago and a breast cyst. The pacemaker electrode was relocated and Synthroid was given during hospitalization. The diagnostic codes (excluding External Cause codes) that should be assigned are: T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter T82.110D Breakdown (mechanical) of cardiac electrode, subsequent encounter T82.120A Displacement of cardiac electrode, initial encounter T82.120S Displacement of cardiac electrode, sequela N60.09 Solitary cyst of unspecified breast E89.0 Postsurgical hypothyroidism

T82.120A, E89.0

APR-DRGs are a clinical, rather than a statistical model of tracking patient severity of illness and risk of mortality. Which of these is a key a principle of APR-DRGs?

The underlying clinical principle of the APR-DRGs is that the severity of illness and risk of mortality of a patient depends on the patient's underlying comorbidities as well as the reason for admission.

The patient is discharged with hemiplegia and aphasia associated with a cerebral infarction of the left side of the brain due to cerebral artery stenosis. The patient is right-handed and also has a history of hypertension and compensated congestive heart failure (both conditions currently controlled on medication and treated while in the hospital). What code assignment would be appropriate? G81.90 Hemiplegia, unspecified affecting unspecified side G81.91 Hemiplegia, unspecified affecting right dominant side G81.92 Hemiplegia, unspecified affecting left dominant side I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery I66.9 Occlusion and stenosis of unspecified cerebral artery I69.320 Aphasia following cerebral infarction R47.01 Aphasia

Version:1.0 StartHTML:000000246 EndHTML:000149767 StartFragment:000002781 EndFragment:000149735 StartSelection:000003194 EndSelection:000149719 SourceURL:https://sole.hsc.wvu.edu/Exam/4846/Report/StudentOverview/1145328?InstanceID=967229 I63.50, G81.91, R47.01, I50.9, I11.0 your selection - correct answer I66.9, G81.90, R47.01, I11.0 G81.90, R47.01, I50.9, I11.0 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The patient is discharged with hemiplegia and aphasia associated with a cerebral infarction of ... TAGS: None 28. The case-mix index for the information provided above is The case-mix index is the average MS-DRG weight based on the specific patient group and is determined by multiplying the DRG weights by the number of patients and then dividing by the total number of patients MS-DRGMS-DRG WeightNumber of PatientsMS-DRG 193, Simple pneumonia and pleurisy age >17 w/CC3.010MS-DRG 195, Simple pneumonia without MCC or CC2.010MS-DRG 192, Chronic obstructive pulmonary disease w/o CC1.010 Answers: 0.75 2.0 your selection - correct answer 0.679 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The case-mix index for the information provided above is The case-mix index is the aver... TAGS: None 29. Partial removal of right ovary Answers: 0UB04ZZ your selection - incorrect answer 0UB08ZX 0UB00ZZ correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Partial removal of right ovary TAGS: None 30. The physician documented that the patient had a "Biopsy of a right breast lesion. " What root operation is used? Answers: resection diagnostic excision your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The physician documented that the patient had a "Biopsy of a right breast lesion. " What root o... TAGS: None 31. A female patient is admitted for a second-degree cystocele. A repair is performed. In order to code this accurately, what document provides the required additional information? Answers: Operative report correct answer Consultation Discharge summary your selection - incorrect answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A female patient is admitted for a second-degree cystocele. A repair is performed. In order to ... TAGS: None 32. Retention policies for the health information department depend on organizational retention policies that must be in accordance with local, state, and federal laws and regulations. These policies vary from institution to institution. In many instances, healthcare institutions may retain health records longer than the law requires. Which of the following statements best describes how the retention of records should be determined? Answers: Unless state or federal law requires longer periods of time, specific patient health information should be retained for established minimum time periods. your selection - correct answer AHIMA has published specific guidelines for retention of health information and these guidelines should be followed for records retention. The Joint Commission has developed standards for retention of health information which must be followed to maintain accreditation and these standards should be adhered to according to these guidelines with regard to time frames. 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Retention policies for the health information department depend on organizational retention pol... TAGS: None 33. Incision and drainage of external perianal abscess Answers: 0D8QXZZ 0D90XZZ 0D9QXZZ correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Incision and drainage of external perianal abscess TAGS: None 34. This is the first admission for a patient with adenocarcinoma of the right lower lung who was also found with metastasis to the brain. The patient underwent a right lower lung lobectomy via laparotomy. What codes should be assigned? Answers: C34.31, C79.31, 0BTF0ZZ correct answer C34.11, C79.31, 0BTF4ZZ C79.31, C34.31, 0BTF0ZZ Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: This is the first admission for a patient with adenocarcinoma of the right lower lung who was a... TAGS: None 35. A patient has documentation on the discharge summary of urosepsis. The coding staff queries the attending physician about the condition and is provided further information that the patient has septicemia. This is in alignment with the laboratory tests and medication given but the diagnosis of septicemia was not documented by the physician. How should the physician be requested to document the septicemia? Answers: The new information should be squeezed in between lines within the progress notes of the last day. The query sheet will be sufficient to document this information. An addendum to the chart should be written. your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient has documentation on the discharge summary of urosepsis. The coding staff queries the... TAGS: None 36. A patient has nausea and vomiting with abdominal pain due to acute cholecystitis. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. The correct diagnosis code(s) are: Answers: Acute cholecystitis, nausea, vomiting, and abdominal pain your selection - incorrect answer Acute cholecystitis, nausea Acute cholecystitis correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient has nausea and vomiting with abdominal pain due to acute cholecystitis. The physician... TAGS: None 37. Patient with renal tumors received percutaneous cryotherapy ablation of three tumors on the right kidney in the same operative episode at Memorial Hospital. Assign a CPT code for this procedure. 50250Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed50590Lithotripsy, extracorporeal shock wave50592Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency50593Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy Answers: 50593 your selection - correct answer 50590 50592 50250 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Patient with renal tumors received percutaneous cryotherapy ablation of three tumors on the rig... TAGS: None 38. A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient also has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." What is the next step for the coder? Answers: Code sepsis as the principal with a secondary diagnosis of urinary tract infection due to E. coli. your selection - incorrect answer Code urinary tract infection with sepsis as a secondary diagnosis. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms. correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, an... TAGS: None 39. A patient is admitted to the acute care facility with chest pain. The patient was awakened from sleep; this was the patient's first experience with chest pain. The patient was given two nitroglycerin tablets in the emergency department. The chest pain was not relieved, resulting in the diagnosis of new onset unstable angina. Serial CPK was normal. Following a left cardiac catheterization with angiogram of multiple coronary arteries with low osmolar contrast, the patient is found to have arteriosclerotic coronary artery disease. What codes should be assigned? Answers: I25.110, 4A023N7, B2111ZZ correct answer I25.110, 4A023N7, B211Y10 I25.110, 4A023N6, B2111ZZ Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted to the acute care facility with chest pain. The patient was awakened from... TAGS: None 40. Two root operations are similar in that they both involve cutting or separating a body part only.. What root operation is used if the sole objective of the procedure is separating or transecting a body part? Answers: transfer release your selection - incorrect answer division correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Two root operations are similar in that they both involve cutting or separating a body part onl... TAGS: None 41. A 26-day-old baby is admitted with respiratory distress syndrome and a temporary tracheostomy completed. What code(s) should be assigned? Answers: P22.0, 0B113F4 P22.0, 0B110F4 correct answer J80, 0B110F4 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A 26-day-old baby is admitted with respiratory distress syndrome and a temporary tracheostomy c... TAGS: None 42. Poor-quality data collection and reporting can affect: Answers: All of the above your selection - correct answer Patient care, communication, research activities, and public health reporting Use of patient record for legal purposes Patient care, documentation, revenue generation, outcomes evaluation, and public health reporting 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Poor-quality data collection and reporting can affect: TAGS: None 43. The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were miscoded as malignant during the last six months. To address this situation, what work processes could be undertaken? Answers: Obtain the cases of carcinoid colon tumors from the cancer registry, obtain the cases of malignant colon tumors from the billing system, import both lists into a spreadsheet, and compare them. The cases in the cancer registry and not in the billing system are likely malignant and should be manually reviewed. your selection - incorrect answer Compare the cases from the transcription tracking software to the billing system. Identify the cases that are not in the transcription tracking software and are in the billing system. These cases should be manually reviewed to ensure they are not carcinoid tumors. Obtain the cases of malignant colon tumors from both the cancer registry and the billing system; import both lists into a spreadsheet and compare them. Identify the cases that are not in the tumor registry that are in the billing system. These cases should be manually reviewed to ensure they are not carcinoid tumors correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The coding supervisor is concerned that patients diagnosed with carcinoid colon tumors were mis... TAGS: None 44. A 7- Year old patient was admitted to the emergency department for treatment of shortness of breath. The pt. is given epinephrine & nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? Answers: Acute bronchitis Chronic obstructive asthma acute bronchitis w/ COPD Asthma w/ status asthmaticus your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A 7- Year old patient was admitted to the emergency department for treatment of shortness of br... TAGS: None 45. A patient has metastatic adenocarcinoma of bone. What code should be assigned? Answers: C7B.03 C79.51 correct answer C79.52 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient has metastatic adenocarcinoma of bone. What code should be assigned? TAGS: None 46. To correct an entry in the record, the provider should Answers: Draw a single line through the error, and add the correct information in chronological order Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order your selection - correct answer Draw several lines through the error, obliterate the documentation as much as possible, initial and date, add the correct information in chronological order 1.04 / 1.04 CATEGORY: Uncategorized TITLE: To correct an entry in the record, the provider should TAGS: None 47. A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? Answers: Chronic obstructive asthma Asthma with status asthmaticus your selection - correct answer Acute bronchitis 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A 7-year-old patient was admitted to the emergency department for treatment of shortness of bre... TAGS: None 48. A patient presents for cystourethroscopy with removal of two lesions of separate locations in the bladder. One of these is a 1.5-cm bladder tumor in the anterior wall and one is measured as 0.75-cm in the lateral wall. What coding rule applies? Answers: Two CPT codes should be used. Two CPT codes should be used with a modifier -59. your selection - incorrect answer Code only the largest tumor. correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient presents for cystourethroscopy with removal of two lesions of separate locations in t... TAGS: None 49. The CPT manual is published and maintained by the: Answers: Centers for Medicare and Medicaid Services American Medical Association your selection - correct answer American Hospital Association 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The CPT manual is published and maintained by the: TAGS: None 50. The purpose of the POA indicator is: Answers: To differentiate between idiopathic conditions present at admission and idiopathic conditions that develop during an inpatient admission To differentiate between procedures completed before admission and procedures performed during an inpatient admission your selection - incorrect answer To differentiate between conditions present at admission and conditions that develop during an inpatient admission correct answer To differentiate between complications present at admission and complications that develop during an inpatient admission 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The purpose of the POA indicator is: TAGS: None 51. The fourth character in ICD - 10 - PCS depicts the body part. Some body parts are further subdivided into more detailed parts. The lung is divided into nine unique body parts; therefore, if one of these unique body parts (such as right upper lobe of the lung, right middle lobe of the lung right lower lobe of the lung) is removed, what is the appropriate root operation? Answers: partial excision your selection - incorrect answer excision resection correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The fourth character in ICD - 10 - PCS depicts the body part. Some body parts are further subdi... TAGS: None 52. This patient was admitted for chemotherapy due to a primary hepatocellular carcinoma of the transplanted liver. What codes are assigned? Answers: Z51.11, C22.0, C80.2 Z51.11, T86.49, C80.2, C22.0 correct answer Z51.11, C22.0 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: This patient was admitted for chemotherapy due to a primary hepatocellular carcinoma of the tra... TAGS: None 53. A patient is admitted because of congestive heart failure (CHF). During the treatment of the CHF, the patient was also found to have elevated liver function tests. The physician worked up the elevated liver function tests but was not able to determine a diagnosis. The following diagnoses should be assigned: Answers: CHF and abnormal liver function tests your selection - correct answer Abnormal liver function tests CHF 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted because of congestive heart failure (CHF). During the treatment of the CH... TAGS: None 54. A patient is admitted to the acute care facility with chest pain. The patient was awakened from sleep; this was the patient's first experience with chest pain. The patient was given two nitroglycerin tablets in the emergency department. The chest pain was not relieved, resulting in the diagnosis of new onset unstable angina. Serial CPK was normal. Following a left cardiac catheterization with angiogram of multiple coronary arteries with low osmolar contrast, the patient is found to have arteriosclerotic coronary artery disease. What codes should be assigned? Answers: I25.110, 4A023N6, B2111ZZ I25.110, 4A023N7, B211Y10 I25.110, 4A023N7, B2111ZZ correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted to the acute care facility with chest pain. The patient was awakened from... TAGS: None 55. Percutaneous excisional biopsy of the liver Answers: 0FB03ZX correct answer 0FB03ZZ 0FB04ZX Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Percutaneous excisional biopsy of the liver TAGS: None 56. A patient was admitted directly from his primary physician's office due to suspected avian influenza. The admitting physician documentation indicated suspected avian influenza, along with signs and symptoms of avian influenza. The patient left against medical advice (AMA) before confirmatory lab tests could be drawn to identify the virus. The principal diagnosis should be coded from category: Answers: J10, Influenza due to other identified influenza virus J09, Influenza due to certain identified influenza viruses J11, Influenza due to unidentified influenza virus your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient was admitted directly from his primary physician's office due to suspected avian infl... TAGS: None 57. The quality management director is working on physician reappointment reports and needs to focus on all physicians who attended to patients with pneumonia during the last quarter. She asks the coder to get a list of all pneumonia patients who did not have an x-ray done during their stays. To perform this task efficiently, the coder should do the following: (Note: The same time frame applies to all reports.) Answers: Obtain a list of all patients whose DRG was simple pneumonia and pleurisy, retrieve those patient records, and identify documentation of x-ray and physician responsible. Obtain a list of all patients who were diagnosed with pneumonia, retrieve a list of all patients who had an x-ray from the chargemaster, compare both lists, and identify patients who did not have an x-ray along with the physician responsible. correct answer Obtain a list of all patients whose principal diagnosis was pneumonia, retrieve those patient records, and look for documentation of the x-ray. Upon finding, record the patient information and attending physician your selection - incorrect answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The quality management director is working on physician reappointment reports and needs to focu... TAGS: None 58. A female patient is diagnosed with congestive heart failure and also has a stage IV pressure ulcer. Which of the following POA indicators must be present so that the ulcer will be classified as an MCC for this admission? Answers: W U Y your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A female patient is diagnosed with congestive heart failure and also has a stage IV pressure ul... TAGS: None 59. In the Medical and Surgical section, what does the third character of the ICD - 10 - PCS code always represent? Answers: Root operation correct answer Body Key your selection - incorrect answer Body Part 0.00 / 1.04 CATEGORY: Uncategorized TITLE: In the Medical and Surgical section, what does the third character of the ICD - 10 - PCS code a... TAGS: None 60. A patient is admitted with hemoptysis. A bronchoscopy with transbronchial biopsy of the lower lobe was undertaken that revealed squamous cell carcinoma of the right lung. Which conditions should be identified as present on admission? C34.30Malignant neoplasm of lower lobe, unspecified bronchus or lungC34.31Malignant neoplasm of lower lobe, right bronchus or lungP26.9Unspecified pulmonary hemorrhage originating in the perinatal periodR04.2Hemoptysis Answers: C34.31, R04.2 your selection - correct answer C34.30, P26.9, R04.2 C34.30 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted with hemoptysis. A bronchoscopy with transbronchial biopsy of the lower l... TAGS: None 61. 50-year-old woman is admitted with a diagnosis of metastatic ovarian cancer to the pleura. A thoracoscopic pleurodesis is performed. What codes should be assigned? Answers: C56.9, C78.2, 32609 C78.2, C56.9, 32650 correct answer C56.9, C78.2, 32650 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: 50-year-old woman is admitted with a diagnosis of metastatic ovarian cancer to the pleura. A th... TAGS: None 62. A 45-year-old woman underwent a carotid bypass and experienced a significant drop in blood pressure during the surgery. The documentation suggested the patient may have had a myocardial infarction. In accordance with coding guidelines, what should the coding professional do? Answers: Code complication of surgery NOS. your selection - incorrect answer Query the physician to determine if the patient had hypotension. Query the physician to determine if there was a complication of surgery. correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A 45-year-old woman underwent a carotid bypass and experienced a significant drop in blood pres... TAGS: None 63. Reference codes 11200-11201 for removal of skin tags. What is the correct code(s) for removal of 16 skin tags? Answers: 11201 x 16 11200 x 16 11200, 11201 correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Reference codes 11200-11201 for removal of skin tags. What is the correct code(s) for removal o... TAGS: None 64. Pulmonary tuberculosis. Assign the appropriate code __________ Answers: A15.0 a15.0 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Pulmonary tuberculosis. Assign the appropriate code __________ TAGS: None 65. laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code? Answers: 0FB44ZZ 0FB40ZZ 0FT44ZZ correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code? TAGS: None 66. A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of the bladder. The patient's presenting symptom is hematuria. What is the correct code assignment for this procedure? 52000Cystourethroscopy (separate procedure)52204Cystourethroscopy with biopsy(s)−22Increased procedural services Answers: 52204 correct answer 52204-22 your selection - incorrect answer 52000-22 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of t... TAGS: None 67. The blood usage review committee is trying to identify physicians who have ordered blood transfusions without following the predetermined criteria during the last quarter. How can this be done most efficiently? Answers: Obtain a list of all blood transfusions given in the facility during the designated quarter along with the ordering physicians and lab values for RBC. Import the list in a spreadsheet and sort the data by the highest RBC value your selection - incorrect answer Obtain a list of all blood transfusions given in the facility during the designated quarter along with the ordering physicians and lab values for RBC. Import the list into a spreadsheet and filter the data by using the RBC predetermined values or lower in the facility criteria for blood transfusions correct answer Obtain a list of all blood transfusions given in the facility during the quarter along with the ordering physician, manually identify cases with the highest amount of packed cells received, retrieve those patient records, and determine whether the criteria were followed. 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The blood usage review committee is trying to identify physicians who have ordered blood transf... TAGS: None 68. Open cosmetic plastic repair of deformed left ear lobe Answers: 09013ZZ 09010ZZ correct answer 090147Z Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Open cosmetic plastic repair of deformed left ear lobe TAGS: None 69. The information provided shows that: MS-DRGMS-DRG WeightNumber of PatientsMS-DRG 193, Simple pneumonia and pleurisy age >17 w/CC3.010MS-DRG 195, Simple pneumonia without MCC or CC2.010MS-DRG 192, Chronic obstructive pulmonary disease w/o CC1.010 Answers: There is inaccurate coding of pneumonia at this institution There are more patients with pneumonia without MCCs than with MCCs The payment is higher for patients with pneumonia with CCs than without your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The information provided shows that: MS-DRG MS-DRG Weight Number of Pati... TAGS: None 70. Two areas of documentation in the health record that are significant areas of focus of accrediting agencies are: Answers: Incident reports notion in the medical record and attorney's notes Timeliness and legibility of medical documents your selection - correct answer Patient documentation and pastoral counseling 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Two areas of documentation in the health record that are significant areas of focus of accredit... TAGS: None 71. A patient admitted with acute abdominal pain is found to have appendicitis and has an appendectomy. The patient has a length of stay of two days. What type of patient encounter is this? Answers: Long-term care Outpatient Inpatient your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient admitted with acute abdominal pain is found to have appendicitis and has an appendect... TAGS: None 72. The committee responsible for medical record completion reports to which medical staff committee? Answers: Medical Executive Committee your selection - correct answer Chief nursing officer Chief executive officer of the facility Discharge Planning Committee 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The committee responsible for medical record completion reports to which medical staff committee? TAGS: None 73. Removal of two (2) skin tags on chest (0.3 cm and 0.5 cm). What is the correct CPT code(s) assignment Answers: 11200 correct answer 11200, 11201 11305, 11305 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Removal of two (2) skin tags on chest (0.3 cm and 0.5 cm). What is the correct CPT code(s) assi... TAGS: None 74. A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is performed with resection of the joint with implant in the first left toe proximal phalanx. What codes would be assigned? Answers: M20.12, 28291-LT your selection - incorrect answer M20.31, 28291-TA M20.12, 28291-TA correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is perf... TAGS: None 75. A patient is admitted to the hospital during the postpartum period as a result of developing a thromboembolism or pulmonary blood clot leading to respiratory failure. What is the principal diagnosis? Answers: O88.03 O88.23 correct answer O88.22 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient is admitted to the hospital during the postpartum period as a result of developing a ... TAGS: None 76. Per CPT guidelines, a concise statement describing the symptom, problem, condition, dx, or other factor that is the reason for the encounter, usually stated in the pts words, is the definition of the Answers: Admission Dx History of Present illness Cheif Complaint your selection - correct answer Past Hx 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Per CPT guidelines, a concise statement describing the symptom, problem, condition, dx, or othe... TAGS: None 77. Itching due to drug reaction to an antihistamine. What codes should be assigned? L29.9Pruritus, unspecifiedR89.2Abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissuesT50.905AAdverse effect of unspecified drugs, medicaments and biological substances, initial encounterT45.0X1APoisoning by antiallergic and antiemetic drugs, accidental (unintentional), initial encounterT45.0X5AAdverse effect of antiallergic and antiemetic drugs, initial encounter Answers: T50.905A, T45.0X1A L29.9, T45.0X5A your selection - correct answer R89.2, T45.0X1A 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Itching due to drug reaction to an antihistamine. What codes should be assigned? ... TAGS: None 78. A 45-year-old woman was admitted to the inpatient setting for a displacement of a lumbar intervertebral disk. This was treated with a laminectomy and diskectomy. What codes should be assigned? Answers: M51.26, 0SB20ZX M51.36, 0SB24ZX M51.26, 0SB20ZZ correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A 45-year-old woman was admitted to the inpatient setting for a displacement of a lumbar interv... TAGS: None 79. A laparoscopic tubal ligation with Falope ring is completed. What is the correct CPT code assignment 49321Laparoscopy, surgical; with biopsy (single or multiple)58662Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection)58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Answers: 58671 your selection - correct answer 49321, 58662 49321 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A laparoscopic tubal ligation with Falope ring is completed. What is the correct CPT code assig... TAGS: None 80. In the Medical and Surgical section, devices are depicted by which character? Answers: Sixth your selection - correct answer Second First 1.04 / 1.04 CATEGORY: Uncategorized TITLE: In the Medical and Surgical section, devices are depicted by which character? TAGS: None 81. Per CPT Guidelines, a presenting problem of moderate severity is one that Answers: has a low risk of morbidity w/o treatment, little or no risk of mortality w/o treatment, w/ full recovery expected w/o functional impairment runs a definite and prescribed course, is transient in nature and is not likely to permanently alter health status, or has a good prognosis w/ management and compliance may not require the presence of a physician, but for which case is provided under the supervision of a physician has a moderate risk of mobitity w/o treatment, a moderate risk of mortality w/o treatment, uncertain prognosis, or increased probability of functional impairment your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Per CPT Guidelines, a presenting problem of moderate severity is one that TAGS: None 82. Proper discharge planning for inpatients being transferred to another healthcare delivery system must include a complete summary of the patient's history, current status, and future needs to ensure appropriate: Answers: Coding Quality of care Continuity of care your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Proper discharge planning for inpatients being transferred to another healthcare delivery syste... TAGS: None 83. A 45-year-old man with known AIDS is admitted to the hospital for treatment of Pneumocystis carinii pneumonia. What is the principal diagnosis code? Answers: B20 correct answer B59 J18.9 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A 45-year-old man with known AIDS is admitted to the hospital for treatment of Pneumocystis car... TAGS: None 84. The patient was admitted for breast carcinoma in the right breast at two o'clock. This was removed via lumpectomy. The patient was found to have 1 of 7 lymph nodes positive for carcinoma during axillary lymph node dissection. One of the patient's neighbors who is also a coworker at the hospital called the coding department to get the patient's diagnosis because she is a cancer survivor herself. The coder should Answers: Explain that discussing the case would violate the patient's right to privacy your selection - correct answer Discuss the case with the coworker Report the incident to hospital security 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The patient was admitted for breast carcinoma in the right breast at two o'clock. This was remo... TAGS: None 85. A laparoscopic tubal ligation is completed. What is the correct CPT code assignment? 49320Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)58662Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection)58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Answers: 49320, 58662 58670 correct answer 58671 your selection - incorrect answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A laparoscopic tubal ligation is completed. What is the correct CPT code assignment? ... TAGS: None 86. The committee responsible for medical record completion reports to which medical staff committee? Answers: Medical Executive Committee your selection - correct answer Discharge Planning Committee Chief nursing officer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: The committee responsible for medical record completion reports to which medical staff committee? TAGS: None 87. Retention policies for the health information department depend on organizational retention policies that must be in accordance with local, state, and federal laws and regulations. These policies vary from institution to institution. In many instances, healthcare institutions may retain health records longer than the law requires. Which of the following statements best describes how the retention of records should be determined Answers: Health records should be retained according to their use in a facility and the state and federal laws do not apply to the retention of this health information. AHIMA has published specific guidelines for retention of health information and these guidelines should be followed for records retention. Unless state or federal law requires longer periods of time, specific patient health information should be retained for established minimum time periods. your selection - correct answer 1.04 / 1.04 CATEGORY: Uncategorized TITLE: Retention policies for the health information department depend on organizational retention pol... TAGS: None 88. Use the Section IV Outpatient Services Coding Guidelines for ICD-10-CM to answer the following question. For clinic encounters for patients receiving routine laboratory/radiology testing in the absence of any signs, symptoms, or associated diagnosis, what would be assigned? Answers: Encounter for other specified special examinations as first listed code and related signs and symptoms as additional diagnoses correct answer Encounter for other specified special examinations as first listed code and no additional codes Signs and symptoms as first listed code and Encounter for other specified special examinations as additional diagnosis your selection - incorrect answer Signs and symptoms as first listed code and no additional codes 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Use the Section IV Outpatient Services Coding Guidelines for ICD-10-CM to answer the following ... TAGS: None 89. A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior subcapsular mature incipient senile cataract right eye, diabetes mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct? E11.36Type 2 diabetes mellitus with diabetic cataractE11.29Type 2 diabetes mellitus with other diabetic kidney complicationE11.9Type 2 diabetes mellitus without complicationsH25.9Unspecified age-related cataractH25.21Age-related cataract, morgagnian type, right eyeH25.041Posterior subcapsular polar age-related cataract, right eyeI10Essential hypertensionI12.9Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified chronic kidney diseaseN17.9Acute kidney failure, unspecified Answers: H25.21, E11.29, I12.9, N17.9 H25.041, E11.9, I10, N17.9 your selection - correct answer H25.041, E11.9, I12.9 1.04 / 1.04 CATEGORY: Uncategorized TITLE: A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior... TAGS: None 90. Reference 11920-19222 for tattooing. What is the correct code(s) for tattooing of 40 sq cm of skin? Answers: 11920, 11921 11921, 11922 correct answer 11922, 11922 Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Reference 11920-19222 for tattooing. What is the correct code(s) for tattooing of 40 sq cm of skin? TAGS: None 91. A patient has an inpatient discharge with principal diagnosis of either peptic ulcer or cholecystitis documented on the history and physical. Both are equally treated and well documented. A coder should: Answers: Code based on the circumstances of admission and if both are equally treated, code either as principal correct answer Code shoulder pain, peptic ulcer, cholecystitis your selection - incorrect answer Use a code from the Abnormal findings category 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient has an inpatient discharge with principal diagnosis of either peptic ulcer or cholecy... TAGS: None 92. Nonessential modifiers are enclosed in Answers: boxes braces brackets parentheses correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Nonessential modifiers are enclosed in TAGS: None 93. A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of the bladder. The patient's presenting symptom is hematuria. What is the correct code assignment for this procedure? 52000Cystourethroscopy (separate procedure)52204Cystourethroscopy with biopsy(s)−22Increased procedural services Answers: 52000 52204-22 your selection - incorrect answer 52204 correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient presents to the outpatient surgical area for a cystoscopy with multiple biopsies of t... TAGS: None 94. A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct? Answers: Two codes would be used in accordance with CPT code instructions. correct answer Only one code is used and it does not state that it includes endometrial biopsy specifically. Two codes would be used with modifier -59 appended Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct? TAGS: None 95. Percutaneous right foot tenotomy Answers: 0L8V0ZZ 0L8W3ZZ 0L8V3ZZ correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: Percutaneous right foot tenotomy TAGS: None 96. The patient had an esophagoscopy to control a GI bleed. The coder would expect to see the following documentation in the chart for the diagnosis since gastrointestinal bleeding manifests as: Answers: Constipation, which indicates upper or lower gastrointestinal hemorrhage, an indication for procedure code 43255 Petechia, an indication for procedure code 43243 Hematemesis, which indicates acute upper gastrointestinal hemorrhage, an indication for procedure code 43227 correct answer Your answer: Unanswered incorrect 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The patient had an esophagoscopy to control a GI bleed. The coder would expect to see the follo... TAGS: None 97. The best answer to describe how the UHDDS defines a comorbidity is a diagnosis that: Answers: Is not documented Affects the payment rate your selection - incorrect answer a. Affects the payment rate correct answer 0.00 / 1.04 CATEGORY: Uncategorized TITLE: The best answer to describe how the UHDDS defines a comorbidity is a diagnosis that: TAGS: None Note about items on this page Click here to start taking notes Content details Content Type: Exams Close this

Code for the introduction of Ceftazidime-Avibactam Anti-infective into Central Vein, percutaneous approach, New Technology Group 1

XW04321

The ability to limit copy functionality in an EHR system is vital for the accuracy of data. Limitations of copy functionality should include measures such as which of the following

all correct Limiting the ability for data to be copied and pasted from other systems Limiting the ability of one author to copy from another author's documentation Clearly labeling the information as copied from another source

A patient is diagnosed an injury of the nasal mucosa and soft tissue and is admitted for repairs. The correct steps for the coder to take are:

assign a code for both repairs together

A patient fell on his face in the parking lot of the middle school after watching his grandson wrestle. He was bleeding profusely from his nose. The patient drove himself to the ED and due to his age and current medication listing, including Brilinta, that he needed to be admitted. A CT scan of the head was performed. The acute injury to the nose did not resolve bleeding and he received an internal fixation device to repair his nose. The coder should:

assign code for reposition

What standard does a hospital that participates in the Medicare and Medicaid programs have to comply with that hospitals who do not accept Medicare and Medicaid patients do not?

conditions of participation

The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation?

determine the type and volume