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A 12-year-old boy was seen in an ambulatory surgical center for pain in his right arm. The x-ray showed fracture of ulna. Patient underwent closed reduction of fracture right proximal ulna and an elbow-to-finger cast was applied. What diagnostic and procedure codes should be assigned? S52.101AUnspecified fracture of upper end of right radius, initial encounter for closed fracture S52.101BUnspecified fracture of upper end of right radius, initial encounter for open fracture S52.001AUnspecified fracture of upper end of right ulna, initial encounter for closed fracture S52.001BUnspecified fracture of upper end of right ulna, initial encounter for open fracture 0PSH0ZZReposition right radius, open approach 0PSK0ZZReposition right ulna, open approach 24670Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process(es) ); without manipulation 24675Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process(es) ); with manipulation 25560Closed treatment of radial and ulnar shaft fractures; without manipulation 29075Application, cast; elbow to finger (short arm) a. S52.101A, S52.001A, 0PSK0ZZ b. S52.101B, S52.001B, 0PSH0ZZ c. S52.101B, S52.001B, 25560, 29075 d. S52.001A, 24675 Correct Answer: D The patient has a fracture of the right proximal ulna and closed reduction is necessary. In the ICD- 10 - CM Code Book, under Fracture, ulna, proximal, the coder is referred to Fracture, ulna, upper end. The term "manipulation" is used to indicate reduction in CPT. According to CPT guidelines, cast application or strapping (including removal) is only reported as a replacement procedure or when the cast application or strapping is an initial service performed without a restorative treatment or procedure (AMA CPT Professional Edition 2020, 182). (Note: Since this is an ambulatory surgery center case, CPT codes are assigned rather than ICD- 10 - PCS codes.) 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 method 58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320 Correct Answer: B The code that best reports the tubal ligation is 58670 Laparoscopy, surgical; with fulguration of oviducts because there are no clips or excision of lesion completed during the procedure (CPT Assistant Nov. 1999, 29; March 2000, 10). Normal twin delivery at 30 weeks. Both babies were delivered vaginally and were liveborn. What conditions should have codes assigned? O30.003Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.009Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O60.14X0Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified O60.14X1 Preterm labor third trimester with preterm delivery third trimester, fetus 1 O60.14X2Preterm labor third trimester with preterm delivery third trimester, fetus 2O80Encounter for full-term uncomplicated delivery Z3A.3030 weeks gestation of pregnancy Z37.0Single live birth Z37.2Twins, both liveborn a. O80, Z3A.30, Z37. b. O30.003, O60.14X0, Z3A.30, Z37.
d. Use combination code for hypertension and acute renal failure. Correct Answer: C There is not a combination code for acute renal failure and hypertension. Acute kidney failure is not the same as chronic kidney disease (CMS 2020a, Section I.C.9. 2-3, 46-47; Leon-Chisen 2020, 262). 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 cataract E11.29Type 2 diabetes mellitus with other diabetic kidney complication E11.9Type 2 diabetes mellitus without complications H25.9Unspecified age-related cataract H25.21Age-related cataract, morgagnian type, right eye H25.041Posterior subcapsular polar age-related cataract, right eyeI10Essential hypertension I12.9Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified chronic kidney disease N17.9Acute kidney failure, unspecified a. H25.21, E11.29, I12.9, N17. b. E11.36, H25.041, I10, N17. c. H25.9, E11.29, I12.9, N17. d. H25.041, E11.9, I12. Correct Answer: B The patient has posterior subcapsular, mature, incipient, senile cataract right eye, diabetes mellitus, hypertension, acute renal failure. The hypertension and diabetes are not related to the renal failure as it is acute and not chronic. Because of this, no combination code is assigned for hypertension, diabetes and chronic renal failure. However, the diabetes and cataract are related conditions which are coded using a combination code. The classification presumes a relationship between diabetes and cataracts (CMS 2020a, Sections I.A.15, 12 - 13 and I.B.9., 15; AHA Coding Clinic 2016 2nd Quarter, 36 - 37; AHA Coding Clinic 2019 2nd Quarter, 30). 145 Correct Wrong
Unanswered Current Procedural Terminology (CPT) defines a separate procedure as which of the following? a. Procedure considered an integral part of a more major service b. Provision of anesthesia c. Procedure that requires an add-on code d. A surgical procedure performed in conjunction with an E&M visit Correct Answer: A When a procedure is designated as a separate procedure in the CPT code book and it is performed in conjunction with another service, it is considered an integral part of the major service. The CPT code description includes "separate procedure." The intention is not to provide payment for a procedure that is already integral to any given procedure (Smith 2020, 68-69; AMA CPT Professional Edition 2020, 72-73). Documentation from the nursing or other allied health professionals' notes can be used to provide specificity for code assignment for which of the following diagnoses? a. Body mass index (BMI) b. Malnutrition c. Aspiration pneumonia d. Fatigue Correct Answer: A The physician must establish the diagnosis—obesity or morbid obesity—and the additional information can be pulled from ancillary documentation to establish the correct code assignment for body mass index (BMI) (CMS 2020a, Section I.B.14, 17-18). A laparoscopic cholecystectomy was performed. What is the correct ICD- 10 - PCS code? 0FB40ZZExcision of gallbladder, open approach 0FB44ZZExcision of gallbladder, percutaneous endoscopic approach 0FT40ZZResection of gallbladder, open approach 0FT44ZZResection of gallbladder, percutaneous endoscopic approach
The procedure is reported with code 31625, the description of which indicates biopsy of single or multiple sites. When reporting this code, it is not necessary to indicate multiple procedures as the code itself does that (AMA CPT Professional Edition 2020, Appendix A). A patient is admitted with fever and urinary burning. Urosepsis is suspected. The discharge diagnosis is Escherichia coli, urinary tract infection; sepsis ruled out. Which of the following represents the diagnoses to report for this encounter and the appropriate sequencing of the codes for those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli sepsis d. Urinary tract infection, Escherichia coli Correct Answer: D Symptoms are not coded when a related definitive diagnosis is present on discharge. The patient has a discharge diagnosis of urinary tract infection, secondary to E. coli. A secondary code of B96.20 is assigned to identify E. coli as the cause of the infection (CMS 2020a, Section II.A., 108). A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. In addition to gastroenteritis, the final diagnostic statement included angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded and their correct sequence. a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina c. Gastroenteritis, abdominal pain, angina d. Diarrhea, chronic obstructive pulmonary disease, angina Correct Answer: B The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline IV.D for additional information on coding of symptoms, signs, and ill-defined conditions (CMS 2020a, Section IV.D., 113). A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. What diagnostic codes should be used and how should they be sequenced? Z12.11Encounter for screening for malignant neoplasm of colon
D12.6Benign neoplasm of colon, unspecified Z86.010Personal history of colonic polyps a. Z12.11, Z86. b. D12.6, Z12.11, Z86. c. Z12.11, D12. d. D12.6, Z12. Correct Answer: C The circumstances of the encounter are for a screening colonoscopy. Because of this screening, colonoscopy is listed first, followed by a code for the polyps (CMS 2020a, Section I.C.21.c.5, 97 - 98). The patient is admitted for chest pain and is found to have an acute inferior myocardial infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient underwent a CABG ×2 from aorta to the right anterior descending and right obtuse, using the left greater saphenous vein which was harvested via an open approach. Cardiopulmonary bypass was utilized. The appropriate sequencing and ICD codes for the hospitalization would be: I25.10Atherosclerotic heart disease of native coronary artery without angina pectorisI21.19ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wallI22.1Subsequent ST elevation (STEMI) myocardial infarction of inferior wallI21.3ST elevation (STEMI) myocardial infarction, of unspecified siteI22.9Subsequent ST elevation (STEMI) myocardial infarction of unspecified siteI48.91Unspecified atrial fibrillationR07.9Chest pain, unspecified02100AWBypass coronary artery, one artery from aorta with autologous arterial tissue, open approach021109WBypass coronary artery, two arteries from aorta with autologous venous tissue, open approach06BQ0ZZExcision of left saphenous vein, open approach5A1221ZPerformance of cardiac output, continuous a. R07.9, I21.3, I48.91, I22.9, 02100AW, 5A1221Z b. I21.19, I48.91, I22.9, 02100AW c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z d. I22.1, I48.91, I21.19, 021109W Correct Answer: C The patient's hospitalization includes a definitive diagnosis of myocardial infarction of the inferior wall as well as the other diagnoses of coronary artery disease and atrial fibrillation. The chest pain is not coded as it is a symptom of the MI. The patient underwent CABG ×2 with cardiopulmonary bypass and harvesting of the left saphenous vein to be used as graft material. All three procedures are reportable and should be coded (Leon-Chisen 2020, 393-396, 430- 434).
Correct Answer: A Conditions present at birth are considered POA for newborns (CMS 2020a, Appendix I, 117 - 121). A woman is admitted to the hospital for an exacerbation of COPD and mentions a lump she has noticed in her right breast. While she in the hospital, a biopsy is done of the breast lump and a diagnosis of ductal carcinoma is made. What is the POA assignment for the carcinoma? a. Y b. N c. U d. W Correct Answer: A Even though the diagnosis of cancer was made after admission, the patient clearly had the condition when admitted. Therefore, a POA indicator of Y should be assigned (CMS 2020a, Appendix I, 117- 121). The use of the outpatient code editor (OCE) is designed to: a. Correct documentation of home health visits b. Facilitate reporting of adverse drug events c. Reduce the use of computer assisted coding d. Identify incomplete or incorrect claims Correct Answer: D The code editor software reviews many data elements and compares them to what data specifications are required in order to weed out incomplete or incorrect claims (Smith 2020, 314 - 315). Medicare's identification of medically necessary services is outlined in: a. Program transmittals b. Claims processing manual c. Local coverage determinations d. National Correct Coding Initiative Correct Answer: C Local coverage determinations (LCDs) are the mechanism by which Medicare identifies medical necessity for services, procedures, and supplies (Casto 2018, 255).
Medically unlikely edits are used to identify: a. Pairs of procedure codes that should not be billed together b. Maximum units of service for a HCPCS code c. Diagnoses that don't meet medical necessity d. Procedure and gender discrepancies Correct Answer: B Medically unlikely edits are in place to identify the maximum number of units of service for a given HCPCS code for one beneficiary on one date of service (Casto 2018, 256). National Correct Coding Initiative (NCCI) Edits are released how often? a. Monthly b. Quarterly c. Semi-annually d. Annually Correct Answer: B NCCI edits are released on a quarterly basis by Medicare (Casto 2018, 256). In 2000, the Centers for Medicare and Medicaid Services (CMS) issued the final rule on the outpatient prospective payment system (OPPS). The final rule: a. Identified the payment structure for long-term care b. Divided outpatient services into fixed payment groups c. Created less opportunity for health information management professionals d. Facilitated greater use of ICD- 9 - CM procedure codes Correct Answer: B This final rule established APCs by dividing outpatient services into fixed-payment groups (Smith 2020, 315). Diagnostic-related groups (DRGs) and ambulatory patient classifications (APCs) are similar in that they are both:
b. Admit diagnosis c. Discharge disposition d. Discharge diagnosis Correct Answer: C The discharge disposition that is assigned to a patient's record will indicate to the payer whether the patient was discharged or transferred (Casto 2018, 125). When a patient is transferred from an acute-care facility to a skilled nursing facility, what abstracted data element can impact the DRG assignment? a. Admission source b. Patient's blood type c. Discharge disposition d. Patient's age Correct Answer: C The patient's discharge disposition can impact the DRG assignment when a transfer takes place from acute care to skilled care (Casto 2018, 125). For a patient with a principal diagnosis of septicemia, reporting which of the following procedures will have the greatest impact on the MS-DRG? a. Excision of left main bronchus, percutaneous endoscopic approach, diagnostic (0BB74ZX) b. Excision of toe nail, external approach (0HBRXZZ) c. Extraction of perineum skin, external approach (0HD9XZZ) d. Respiratory ventilation, greater than 96 consecutive hours (5A1955Z) Correct Answer: D The ventilator management is the procedure that will impact the MS-DRG to provide appropriate reimbursement. The MS-DRG with the highest weight is 870 (CMS 2019b). Respiratory Ventilation, Greater than 96 Consecutive Hours (5A1955Z). Medicare DRG assigned: 0870, SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS DRG weight = 06.3243. Incorrect answer option explanations provided for clarity: Bronchoscopy with biopsy (0BB74ZX) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect)
Debridement of toenail (0HBRXZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect) Nonexcisional debridement of skin ulcer with abrasion (0HD9XZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect) Which of the following is considered a complication or comorbidity? a. Hypokalemia b. Dehydration c. Hypernatremia d. Fluid overload Correct Answer: C Hypernatremia is a complication or comorbidity (Optum 2019). A patient is admitted for a cerebral infarction. Residual effects at discharge include aphasia and dysphagia. The patient developed acute diastolic congestive heart failure while admitted and was treated with Lasix in addition to being given Betapace for his long-standing hypertension.Which condition is considered a major complication comorbidity? a. Cerebral infarction b. Acute diastolic congestive heart failure c. Hypertension d. Dysphagia Correct Answer: B The acute diastolic congestive heart failure is the major complication in this case since it developed after admission (Schraffenberger and Palkie 2020, 92-93). A patient is admitted for a cerebral infarction. Residual effects at discharge include aphasia and dysphagia. The patient developed acute diastolic congestive heart failure while admitted and was treated with Lasix in addition to being given Betapace for his long-standing hypertension.Which condition meets the definition of comorbidity?
A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it was determined that the patient had an obstruction of the left colon due to adhesions from a prior abdominal surgery. The patient underwent laparotomy with lysis of adhesions. What conditions and procedures should be coded? a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of adhesions b. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, laparotomy, lysis of adhesions c. Abdominal adhesions with obstruction, lysis of adhesions d. Abdominal adhesions, abdominal obstruction, postoperative complications of the digestive system, lysis of adhesions Correct Answer: C The patient has abdominal adhesions with obstruction, and lysis of adhesions was performed. The abdominal pain is not coded as it is a symptom (CMS 2020a, Section I.B.5, 18; Leon- Chisen 2020, 134 - 135). A patient is diagnosed with infertility due to endometriosis and undergoes an outpatient laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter accurately, what steps must the coder take? a. Review the operative report to determine what procedure codes to use. Determine the site or sites of endometriosis so codes with the highest specificity may be assigned. Use infertility as a principal diagnosis. b. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified. Assign a principal diagnosis of infertility. c. Review the operative report to determine where the laser was used in the pelvis so the site or sites of endometriosis can be specified as principal. Assign a secondary diagnosis of infertility. d. Review the operative report to determine what procedure codes to use. Determine the site or sites of endometriosis so codes with the highest specificity may be assigned. Assign endometriosis as the principal diagnosis. Assign infertility as a secondary condition. Correct Answer: D There may be endometrial implants throughout the pelvic cavity that may attach to various anatomic structures, such as the fallopian tube, ovary, and omentum. These locations should be identified so that the appropriate diagnostic codes can be assigned and the appropriate procedure codes can be assigned based on the destruction of the endometrial implants. Therefore, the correct answer is to review the operative report to determine what procedure codes to use and determine
the site or sites of endometriosis so that codes with the highest specificity may be assigned. Also, use the diagnosis of infertility as a secondary condition (Schraffenberger and Palkie 2020, 463 - 465; Leon-Chisen 2020, 270). In order to accurately code a cardiac catheterization, in addition to the approach and the side of the heart into which the catheter was inserted, what else needs to be determined? a. The type of anesthesia used b. If additional procedures were performed c. The duration of the procedure d. Documentation that stents were considered Correct Answer: B In order to code the procedure accurately, the approach and heart chambers must be documented and used to assign the code. Documentation should also be reviewed to determine if any additional procedures are performed (Leon-Chisen 2020, 69, 420). A female patient is admitted for a second-degree cystocele. A repair is performed. Which report provides the documentation necessary to accurately code the repair? a. History and physical b. Discharge summary c. Consultation d. Operative report Correct Answer: D If a procedure is performed, the operative report provides a detailed discussion of what was done (Brickner 2020, 108). To accurately report wound closures with CPT codes, in addition to knowing the site and length of the closure, what other information is necessary? a. If anesthesia was used and what kind
The clinical indicators of RUQ pain, nausea, and vomiting point to cholecystitis, confirmed by x-ray. Since this is an acute episode with the patient having ongoing issues for several months, it is acute on chronic (Schraffenberger and Palkie 2020, 379-380). A patient comes in with right upper quadrant pain, nausea, and vomiting. An x-ray confirms inflammation in the gallbladder. The patient has been dealing with episodes like this for the past six months. The final diagnosis in the discharge statement is appendicitis. What should be one to correct the discrepancy? a. Since the patient came in with pain, it is appropriate to assign the code for acute appendicitis b. A query should be issued to determine the diagnosis as it seems appendicitis is incorrect c. A clinical documentation improvement specialist should be contacted to verify the diagnosis d. There is no discrepancy, code the appendicitis Correct Answer: B A query is necessary to clarify the conflicting documentation (AHIMA 2019c). A resident physician continually documents "CHF" without further clarification in patients' medical records. What is the most likely rationale for this documentation practice? a. No problem exists with this documentation as CHF without further clarification is acceptable. b. The resident is not qualified to make a more definitive determination of the type of CHF. c. The resident lacks knowledge regarding the need for further clarification. d. There is not enough information to determine the type of CHF. Correct Answer: C The resident likely does not recognize the impact that further clarification of the type of CHF would have (Schraffenberger and Palkie 2020, 24). A patient is scheduled for elective surgery for cataract removal of the left eye. The operative report indicates the surgery on the right eye is performed with the use of phacoemulsification and intraocular lens insertion." What discrepancy is noted in this documentation?
a. The use of irrigation and aspiration is not mentioned b. No mention of implantation of intraocular lens c. No indication if general anesthesia was used d. Laterality is not in agreement Correct Answer: D The cataract is first mentioned as being of the left eye, and in the report the procedure is documented as being performed on the right eye (Schraffenberger and Palkie 2020, 40) An inpatient progress note on day two states there is a stage three pressure ulcer of the sacrum that requires debridement. The coding professional composes a query to determine if this condition was present on admission (POA) by asking the physician if the pressure ulcer listed in the progress note of day two was present on admission—yes or no? Is that an acceptable query? Why or why not? a. No. Yes/no queries are not acceptable in any circumstances. b. No. Yes/no queries require clinical indicators. c. Yes. Yes/no queries may be used to established POA status. d. Yes. Yes/no queries are the preferred query format for all queries. Correct Answer: C According to AHIMA's Guidelines for Achieving a Compliant Query Practice, it is acceptable to use the yes/no query format to determine POA status (AHIMA 2019c). Multiple choice queries must supply how many choices in order to be compliant? a. 3 b. 4 c. 5 d. No specific number Correct Answer: D There is no specific number of choices that must be supplied to make a query compliant (AHIMA 2019c).
