Content Area VI: ICD-10-CM Coding – Flashcards

A 32-year-old female patient presents with right arm (dominant) paralysis due to childhood poliomyelitis.

A 65-year-old patient with a history of lung cancer is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department as well as a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case?

A 67-year-old man is admitted with acute dehydration secondary to nausea and vomiting that is due to acute gastroenteritis. He is treated with IV fluids for the dehydration.

A female, 68 years old, was admitted with type 2 diabetes mellitus with a diabetic ulcer of the left heel involving the subcutaneous layer of the skin. The patient will be scheduled for wound care with whirlpool treatments.

A full-term infant born in hospital vaginal delivery was diagnosed with polycystic kidneys.

A full-term newborn vaginal delivery born in the hospital. The birth is complicated by cord compression, which affected the newborn.

A full-term newborn vaginal delivery was born in the hospital to a mother who is addicted to cocaine; however, the infant tested negative.

A male patient is admitted with gastrointestinal hemorrhage resulting in acute blood-loss anemia. A bleeding scan fails to reveal the source of the bleed.

A male patient presents to the ED with acute renal failure. He is also being treated for hypertension.

A newborn infant is born in the hospital vaginal delivery with a unilateral hard cleft palate and cleft lip.

A newborn infant is born in the hospital, delivered vaginally, and sustained a fracture of the clavicle due to birth trauma.

A newborn infant is transferred to Community General Hospital for treatment of an esophageal atresia. What codes should be reported for Community General Hospital?

A newborn is born in the hospital vaginal delivery. Physical examination demonstrates molding of the baby’s scalp, which resolved prior to discharge without treatment.

A one-week-old infant is admitted to the hospital with a diagnosis of urinary tract infection contracted prior to birth. The urine culture is positive for E. coli.

A patient developed a malunion of the medial condyle humeral fracture. The original injury occurred 4 months ago.

A patient had a cholecystectomy 3 days ago and is now readmitted with cellulitis at the site of the operative incision.

A patient has a pathological fracture of the left femur due to metastatic bone cancer. The past medical history is significant for lung cancer.

A patient has aspiration pneumonia with pneumonia due to Staphylococcus aureus.

A patient has diverticulitis of the large bowel with abscess. Patient was treated with IV antibiotics.

A patient has end-stage kidney disease, which resulted from malignant hypertension.

A patient has intractable status epilepticus.

A patient has malignant melanoma of the skin of the back, nose, and scalp. The patient will be scheduled to undergo a radical excision of the melanoma.

A patient is a type 2 diabetic with chronic kidney disease requiring dialysis.

A patient is admited with aplastic anemia secondary to chemotherapy administered for multiple myeloma initial encounter.

A patient is admitted for chemotherapy for treatment of breast cancer with liver metastasis. She had a mastectomy 4 months ago. Chemotherapy is given today. (Do not assign a procedure code for the chemotherapy.)

A patient is admitted for gestational diabetes insulin controlled 28 weeks gestation.

A patient is admitted for control of exacerbation of chronic obstructive lung disease. The patient had stopped taking the prednisone as prescribed due to gaining weight, a known side effect for this drug.

A patient is admitted for infection of the tracheostomy stoma secondary to cellulitis of the neck.

A patient is admitted for intentional overdose of valium and acute respiratory failure with hypoxia.

A patient is admitted for observation for a head injury. The patient was struck while playing football. The patient also suffered a minor laceration to the forehead. Head injury was ruled out.

A patient is admitted for pain control secondary to metastatic carcinoma of the spinal cord.

A patient is admitted for rectal bleeding. The laboratory results reveal chronic blood-loss anemia. The CT and Bleeding Scan results of the abdomen revealed that the rectal bleeding is due to Crohn’s disease of the descending colon.

A patient is admitted for treatment of anemia, neutropenia, and thrombocytopenia.

A patient is admitted for treatment of influenza and pneumonia.

A patient is admitted that has urinary retention secondary to benign prostatic hypertrophy.

A patient is admitted to the hospital for repair of a recurrent incarcerated ventral hernia. The surgery is canceled after the chest x-ray revealed lower lobe pneumonia. The patient is placed on antibiotics for treatment of the pneumonia.

A patient is admitted to the hospital for treatment of dehydration following chemotherapy as treatment for right ovarian cancer.

A patient is admitted who is 39 weeks gestation normal delivery single full-term newborn. During the same episode of care, patient experiences a 36-hour delayed hemorrhage following the delivery.

A patient is admitted with Diabetes Mellitus Type II; diabetic heel ulcer with necrosis of the muscle.

A patient is admitted with a fracture to the L1 vertebrae secondary to postmenopausal senile osteoporosis, initial encounter.

A patient is admitted with a gunshot wound to the right upper quadrant of the abdomen, which involves a moderate laceration to the liver, initial encounter.

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay?

A patient is admitted with a left nondisplaced comminuted patella fracture, a displaced left spiral fracture of the shaft of the fibula, and a displaced comminuted fracture of the shaft of the left tibia, initial encounter.

A patient is admitted with a nondisplaced fracture of the left medial malleolus, initial encounter. The fracture was treated with a cast.

A patient is admitted with a pressure ulcer left buttock stage 2.

A patient is admitted with a stage 1 pressure ulcer of the sacrum. During the hospitalization, the ulcer progressed to a stage 2.

A patient is admitted with a thrombosis of the right middle cerebral artery, with hemiplegia affecting the right dominant side.

A patient is admitted with abdominal pain. A CT and MRI of the abdomen reveal a malignant neoplasm to the head of the pancreas with metastatic disease to the peritoneal cavity.

A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be:

A patient is admitted with acute ST Inferolateral wall myocardial infarction. Several days later during the same episode of care, the patient sustained a subsequent non-ST subendocardial myocardial infarction.

A patient is admitted with acute alcohol intoxication with a blood alcohol level of 113 mg/100 ml.

A patient is admitted with acute exacerbation of chronic obstructive pulmonary disease with a history of tobacco dependence.

A patient is admitted with acute gangrenous cholecystitis with cholelithiasis.

A patient is admitted with acute hemorrhagic cystitis. The patient was treated with IV antibiotics.

A patient is admitted with acute respiratory failure with hypercapnia due to acute asthmatic bronchitis with status asthmaticus. Treatment consisted of IV steroids.

A patient is admitted with acute urinary tract infection due to E. coli.

A patient is admitted with an acute gastric ulcer with hemorrhage and perforation.

A patient is admitted with an anaphylactic reaction due to eating strawberries, initial encounter.

A patient is admitted with an open wound to the left finger with cellulitis due to a dog bite initial encounter. The patient is given IV antibiotics for treatment of the infection.

A patient is admitted with anemia due to end-stage renal disease. The patient is treated for anemia.

A patient is admitted with back pain. A myelogram demonstrated the reason for the back pain is a herniated lumbar intervertebral disc wtih radiculopathy.

A patient is admitted with bleeding esophageal varices with alcoholic liver cirrhosis and portal hypertension. The patient is alcohol dependent.

A patient is admitted with catatonic schizophrenia.

A patient is admitted with cervical spina bifida wtih hydrocephalus.

A patient is admitted with chronic kidney disease stage III due to hypertension and type 1 diabetes mellitus.

A patient is admitted with delirium tremens with alcohol dependence.

A patient is admitted with dermatitis due to prescription topical antibiotic cream used as directed by a physician, initial encounter.

A patient is admitted with dizziness as a result of taking phenobarbital as prescribed, initial encounter.

A patient is admitted with extrinsic asthma with status asthmaticus with bronchospasm.

A patient is admitted with fever and severe headache. The physician’s diagnostic statement at discharge is: Fever and severe headache probably due to viral meningitis.

A patient is admitted with fever due to bacteremia.

A patient is admitted with idiopathic thrombocytopenia and purpura.

A patient is admitted with malignant ascites with widespread metastatic peritoneal lesions, primary site sigmoid colon; sigmoid colon resection six months ago.

A patient is admitted with multiple problems. He has hypertensive kidney disease, CKD stage III, and acute systolic congestive heart failure.

A patient is admitted with obstructed labor due to breech presentation. A single liveborn infant was delivered via Cesarean section. (Do not assign the code for the procedure.)

A patient is admitted with poliovirus meningitis.

A patient is admitted with pregnancy-induced hypertension with severe edema and 24 weeks gestation.

A patient is admitted with pyogenic arthritis of the right hip due to Group A Streptococcus. Treatment consisted of IV antibiotics.

A patient is admitted with right lower quadrant abdominal pain. The discharge diagnosis is listed as abdominal pain due to gastroenteritis or diverticulosis.

A patient is admitted with sensorineural deafness of the left ear. The patient was fitted for a hearing aid.

A patient is admitted with severe protein calorie malnutrition.

A patient is admitted with severe recurrent major depression without psychotic features.

A patient is admitted with sickle cell anemia with crisis.

A patient is admitted with sickle cell pain crisis.

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?

A patient is diagnosed with Alzheimer’s disease and early onset dementia, and frequently wanders away from home.

A patient is diagnosed with psychogenic paroxysmal tachycardia.

A patient is being admitted for chemotherapy for primary lung cancer, left lower lobe.

A patient is readmitted for post-op anemia due to acute blood loss. Patient is 5 days status post-cholecystectomy.

A patient is seen for a cast removal. Six weeks ago, the patient underwent open reduction internal fixation for a displaced fracture left radial styloid process.

A patient is seen in the ED at 22 weeks gestation who is HIV positive.

A patient presents to an OP Clinic with a large growth on the left side of the neck. An MRI is performed and demonstrates metastatic disease to the lymph nodes.

A patient presents to the outpatient department for a chest x-ray. The physician’s order lists the following reasons for the chest x-ray: fever and cough, rule out pneumonia. The radiologist reports that the chest x-ray is positive for double pneumonia.

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case?

A patient was admitted for removal of internal pins from the left ankle. One month ago the patient sustained a displaced bimalleolar fracture to the left ankle.

A patient was admitted with hemoptysis; a CT of the chest revealed a lung mass.

A patient was admitted with severe sepsis due to MRSA with septic shock and acute respiratory failure with hypoxia.

A patient was found at home in a hypoglycemic coma. This patient had never been diagnosed as being diabetic.

A patient with a diagnosis of coronary artery disease with ischemic chest pain. No history of CABG.

A patient with a history of malignant neoplasm of the lung status post lobectomy was admitted after experiencing a violent seizure lasting more than several minutes. During the course of the hospitalization the patient has continued to have seizures. Workup revealed metastatic lesions to the brain. The patient’s seizures were treated with IV Dilantin.

A patient with atherosclerotic peripheral vascular disease of the left lower leg with intermittent claudication. Past surgical history is negative.

A patient with chronic paranoia due to cocaine dependence with intoxication and drug delirium.

A preterm infant 34 weeks gestation is born via Cesarean section and has severe birth asphyxia.

A preterm infant born in the hospital vaginal delivery 36 weeks gestation is treated for neonatal jaundice.

A woman experienced third-degree burns to her thigh and second-degree burns to her right and left foot, initial encounter. She stated that the burns were from hot liquid.

A woman has a Pap smear that detected cervical high-risk human papillomavirus (HPV). The DNA test was positive.

A woman has a vaginal delivery of a full-term liveborn infant after 38 weeks gestation.

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?

The patient presents for a screening examination for lung cancer.

An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents “urosepsis.” How should this case be coded?

According to the UHDDS, which of the following is the definition of “other diagnoses”?

An infant has hypoglycemia and a mother with diabetes.

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?

Patient is admitted with gross hematuria and benign prostatic hypertrophy.

Patient was initially admitted and treated for an amebic abscess of the liver. During the stay the patient developed a “hospital acquired bacterial pneumonia.”

Positive HIV test in a patient who is asymptomatic and has a high-risk lifestyle for HIV infection.

The patient was admitted with AIDS-related Kaposi’s sarcoma of the skin.

The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this code:

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: