Final ICD-10 Exam - Flashcards

question

Status post below the knee amputation (right) is coded as:

answer

Z89.51

question

Open wound codes are used for surgical wounds, nontraumatic wounds, and ulcers.

answer

False

question

An open fracture includes:

answer

compound missile puncture all of the above

question

The most common causes of spinal cord injury are motor vehicle accidents.

answer

True

question

A superficial injury is always coded in addition to any more serious injury at the same site.

answer

False

question

It is appropriate to add codes identifying blood vessel injuries in addition to fractures and dislocations.

answer

True

question

A common cause of a pathologic fracture in female patients is:

answer

osteoporosis

question

If a fracture is not specified as open or closed, it is coded as a(n):

answer

closed fracture

question

Most injuries are diagnosed with the use of

answer

imaging procedures such as x-ray, MRI, CT scan, ultrasound

question

LOC stands for:

answer

loss of consciousness

question

The patient (civilian) has chronic posttraumatic stress syndrome following a terrorist attack, subsequent encounter.

answer

F43.12, Y38.9x2S

question

All of the following are symptoms of fat embolism syndrome EXCEPT ____.

answer

decreased temperature

question

An open fracture occurs when the bone is broken but the skin remains intact.

answer

false

question

In ICD-10-CM, if a fracture is not specified, it is coded to nondisplaced.

answer

true

question

Which of the following is NOT a common site for a laceration?

answer

Stomach

question

External cause codes identify ____.

answer

the activity at the time of the event the cause of an injury the intent or place of occurrence all of the above (all of the above)

question

A ____ is a stretch and/or tear of a ligament.

answer

sprain

question

All of the following are true of external cause codes EXCEPT they capture____.

answer

how to screen patients

question

In ICD-10-CM, there are more Instructional notes for the coder to also code any associated injuries.

answer

True

question

When coding injuries, assign separate codes for each injury unless a combination code is provided.

answer

True

question

Small piece of grass from mowing lawn at a single-family house stuck on right cornea. Grass was removed. Assign injury and procedure codes only.

answer

T15.01xA, 08C8XZZ

question

Patient was seen with an abrasion with laceration of the left knee, initial encounter. Assign only the injury code.

answer

S81.012A

question

The patient was admitted for observation after an accident at work. The patient, who does construction work, fell into a pit but was quickly rescued by co-workers. CT scan and x-rays were taken to evaluate for internal injury. No respiratory issues were noted. On the following morning, the patient had no complaints and was discharged to home. Discharge Diagnosis: Contusion on forehead.

answer

Z04.2, S00.83xA, W17.2xxA, Y92.69, Y99.0

question

The patient was the driver in an ATV rollover. The patient was intoxicated at the time of the accident and was not wearing a helmet. There was no LOC. CT of the head revealed a small subdural hemorrhage. The patient was observed closely for any change in mental status, and neurology was consulted. There was no need for operative intervention at this time. The patient was stable and was given instructions for follow-up.

answer

S06.5x0A, F10.129, V86.59xA

question

In ICD-10-CM, complications of a fracture such as malunion or nonunion are reported with seventh character extensions for subsequent care with nonunion or malunion.

answer

True

question

When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.

answer

True

question

A patient suffered a blowout fracture 1 week ago and is being seen by an orthopedic consultant. Assign only the injury code.

answer

S02.3xxA

question

A ____ fracture is a common fracture in adults in which the lower end of the radius is fractured and the wrist and hand are displaced backward.

answer

Colles'

question

A patient is admitted with a parietal bone fracture and fracture of the left fifth rib. Assign only the injury code.

answer

S02.0xxA, S22.32xA

question

A third-degree burn is defined as:

answer

full-thickness skin loss

question

MVA stands for:

answer

motor vehicle accident

question

An adverse effect is:

answer

a side effect or reaction to a drug that has been taken according to instructions

question

Codes T31 and T32 are used:

answer

when the site of the burn is not specified

question

When coding different degrees of burns of the same site, assign the code or codes that identify:

answer

the highest degree of the burn

question

Examples of poisonings include:

answer

the wrong medication taken the wrong dose of a medication taken too much of a certain medication taken all of the above (correct answer)

question

Debridements can be performed:

answer

at the bedside in the operating room by physical therapists, wound care nurses, and professionals other than physicians all of the above (correct answer)

question

A nonhealing burn is coded as an acute burn.

answer

True

question

A corrosive burn is a thermal burn that is due to a heat source such as fire or a hot appliance.

answer

False

question

The residual effect is usually sequenced first followed by the appropriate sequela (late effect) code.

answer

True

question

When the reason for the admission or encounter is to provide treatment for external multiple burns, sequence first the code that reflects the burn of the highest degree.

answer

True

question

Patient was admitted with second-degree burns of the left hand and first-degree burns of the left forearm. The patient touched a hot steam pipe.

answer

T23.202A, T22.112A, X16.xxxA

question

All of the following are true of the "rule of nines" EXCEPT ____.

answer

the anterior trunk is 9%

question

Debridements must always be done in the OR.

answer

False

question

In a toxic poisoning, the toxic poisoning code (T36-T50) should be sequenced first, followed by the external cause code(s).

answer

True

question

A patient combined prescription Percodan with beer and became stuporous and drowsy.

answer

T40.2x1A, T51.0x1A, R40.1, R40.0

question

The patient was admitted with acute renal failure. The patient had been treated by Home Health with IV gentamicin for Pseudomonas pneumonia. The patient was experiencing some edema and decreased urine output. Blood was drawn, and the physician admitted the patient for IV fluids and investigation of the patient's renal status. Gentamicin was stopped, and another antibiotic was given. The patient's renal function returned to normal. Final Diagnosis: Acute renal failure due to gentamicin. Recent pneumonia.

answer

N17.9, T36.5x5A, J15.1

question

The patient was admitted with hematemesis. The patient has been taking NSAIDs as directed by the physician for arthritis pain. EGD showed that the patient had an acute erosive gastritis, most likely due to NSAIDs, that is the likely cause of the bleeding. Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs. Procedure: EGD with gastric biopsy.

answer

K29.01, T39.395A, M19.90, 0DB68ZX

question

A patient has SIRS due to an accidental burn from the flames from a single-family house fire. The patient has full-thickness skin loss burns of the legs (11%) with second-degree burns of the trunk (4%)

answer

T24.302A, T24.301A, T21.20xA, R65.10, T31.11, X00.0xxA, Y92.019

question

A 2-year-old child was admitted with an accidental electrical burn to the upper lip. The child was at home (single-family) and had bitten on an electrical cord. The mother immediately sought medical attention. The burn was a full-thickness burn. Local wound care was performed. The patient was not having any breathing problems. Further intervention will depend on how the burn heals. Final Diagnosis: Full-thickness burn to upper lip due to electrical current.

answer

T20.32xA, W86.0xxA, Y92.019

question

Debridement is one of the most common procedures performed on burn victims.

answer

True

question

All of the following are to be considered when one is questioning whether a poisoning has occurred EXCEPT whether the ____.

answer

medication was taken 30 minutes after the scheduled time

question

Patient admitted for a suicide attempt with multiple medications, including Naproxen, Keppra, and acetaminophen mixed with beer. Patient was somnolent on arrival in the ER.

answer

T39.312A, T42.6x2A, T39.1x2A, T51.0x2A, R40.0

question

Patient was admitted with cocaine-induced chest pain.

answer

T40.5x1A, R07.9, F14.10

question

Patient was seen in the ER for superficial frostbite, both ears. Patient was exposed to cold weather.

answer

T33.011A, T33.012A, X31.xxxA

question

Patient is being treated with HBOT for decompression sickness when surfacing while scuba diving in the ocean.

answer

T70.3xxA, W94.21xA, Y92.832, Y93.15, 6A150ZZ

question

The patient reported to the ER with nausea/vomiting and weakness. The patient is on OxyContin for chronic pain due to unresectable pancreatic cancer. The patient was in extreme pain and decided to double the OxyContin dosage. When this did not relieve the pain, the patient decided to drink a couple of shots of whiskey. The patient got very weak and called 911. The patient was volume depleted and was treated with IVs; his pain medications were adjusted. Final Diagnosis: Accidental overdose of OxyContin. Pain due to pancreatic cancer.

answer

T40.2x1A, T51.0x1A, C25.9, G89.3, R53.1, R11.2, E86.9

question

A patient was admitted because of an intentional overdose of Valium. The patient is in a coma.

answer

T42.4x2A, R40.20

question

When the patient is admitted for burn injuries and other related conditions such as smoke inhalation, the circumstances of admission govern the selection of the principal or first-listed diagnosis.

answer

True

question

The patient was brought to the ER by her mother. The patient admits to being beaten by her husband. X-rays showed three fractured ribs on the right and a spiral fracture of the right humerus. The humeral fracture was manipulated and was found to be in alignment on follow-up x-rays. The patient was given pain medications and was discharged to the care of her mother. Final Diagnosis: Fracture of three ribs and shaft of humerus due to spousal abuse. Procedure: Closed reduction of fracture right humerus.

answer

T74.11xA, S42.341A, S22.41xA, Y07.01, Y09, 0PSFXZZ

question

When coding infections due to a device, implant, or graft:

answer

also code the specific infection

question

A dehiscence is:

answer

an opening of a surgical wound

question

Iatrogenic means:

answer

a condition is a result of treatment

question

Complication codes should never be used as principal diagnoses.

answer

False

question

If in doubt as to whether a condition occurred as the result of a procedure or medical care, the coder should:

answer

Check to verify that the procedure or illness was within the last 28 days

question

Codes Z94- and T86 are never used together.

answer

True

question

A complication can be coded only if it is in within 1 year of the original surgery.

answer

False

question

Medical conditions that develop after a transplant are not coded as transplant complications unless they affect the transplanted organ.

answer

True

question

If a patient has an illness that affects his or her transplanted kidney, it is:

answer

coded as a transplant complication

question

A mechanical complication is not:

answer

considered "pain"

question

Codes for complications may be located in the chapter for specified body sites.

answer

True

question

Coding complications always implies that poor care has been delivered.

answer

False

question

Patient is admitted for treatment of primary liver cancer. Patient had a liver transplant 2 years ago. Patient has a past medical history of hypertension and COPD and is a former alcoholic. Patient has been sober for 10 years.

answer

T86.49, C80.2, C22.8, I10, J44.9, F10.21, Y83.0

question

Patient with a history of a kidney transplant comes to the ER with gastroenteritis. His history is positive for CKD, stage II, and hypertension.

answer

K52.9, I12.9, N18.2, Z94.0

question

Patient was hospitalized 1 month prior to this admission. During that admit, she was diagnosed with COPD and placed on a ventilator; her sputum was positive for Pseudomonas aeruginosa. She is admitted today with another case of pneumonia.

answer

J18.9, J44.9

question

Leakage of peritoneal dialysis catheter. Patient is on dialysis for end-stage renal disease. Peritoneal catheter was removed. Patient has a history of hypertension and type II diabetes with associated neuropathy.

answer

T85.631A, I12.0, E11.40, Z99.2, Y84.1, 0WPGX0Z

question

Patient admitted with an abscess of abdominal surgical wound, initial encounter. Cultures were positive for Streptococcus. The abscess was incised and drained.

answer

T81.4XXA, B95.5, Y84.8, Y83.9, 0H97XZZ

question

During a posterior lumbar fusion at L4-L5 for spinal stenosis, the surgeon accidentally nicks the dura due to the amount of adhesions present. The fusion was performed via an open posterior procedure on the posterior column using morselized allograft. Patient has a history of asthma for which he takes meds prn.

answer

M48.06, G97.41, J45.909, Y83.8, Y92.234, 0SG0071

question

The term dehiscence means ____.

answer

opening a surgical wound

question

If the documentation is unclear whether the diagnosis was the result of a procedure or condition, a physician query should be initiated.

answer

True

question

Iatrogenic is a term used to signify that a condition is a result of treatment.

answer

True

question

The patient had a postoperative cerebrovascular accident that was embolic in nature. The patient initially had been admitted for treatment of coronary artery arteriosclerosis with CABG (left internal mammary artery and two saphenous vein grafts were used). Cardiopulmonary bypass was used during the surgery.

answer

I25.10, I97.820, I63.40, 021109W, 02100A9, 5A1221Z

question

Complications affect only certain body systems.

answer

False

question

A patient is admitted with a urinary tract infection (UTI) resulting from E. coli. The patient has an indwelling Foley catheter following recent radical prostatectomy for cancer. The coder queries the physician regarding the relationship of the UTI and the Foley, and the physician documents that the UTI is caused by the Foley. The patient is morbidly obese with type II diabetes, controlled with insulin.

answer

T83.51xA, N39.0, B96.20, E66.01, E11.9, Z85.46, Y84.6

question

Patient with decreased visual acuity due to corneal graft rejection. Admitted for cadaver keratoplasty of the left eye.

answer

T86.840, Y83.0, H54.7, 08R93KZ

question

A patient had a kidney transplant 2 years ago but developed ESRD again. The patient has been on dialysis for the past year. The patient is now complaining of SOB and edema and is admitted for fluid overload and hemodialysis. Dialysis is performed multiple times during this stay.

answer

E87.70, N18.6, Z94.0, Z99.2, Y83.0, 5A1D60Z

question

To aspirate means to ____.

answer

breathe in a foreign substance

question

Codes under subcategory T86 are used ____.

answer

for both complications and rejection of transplanted organs

question

There is a time limit to coding complications.

answer

false

question

Patient had an outpatient surgical procedure this morning and was discharged in stable condition. Patient returns because of inability to void. A Foley catheter is inserted. Diagnosis: Postoperative urinary retention.

answer

N99.89, R33.9, Y84.8, Y83.9, 0T9B70Z

question

The only time a coder would not use a code from Chapter 11 is if the physician states that the pregnancy is incidental to the reason for the encounter.

answer

True

question

For initial confirmation of a pregnancy, a woman's blood or urine is tested for _______levels.

answer

hCG

question

When coding a pregnant woman with HIV infection, follow the guidelines for:

answer

pregnancy coding (sequence pregnancy code as principal)

question

For a normal delivery, the diagnosis codes for the mother are:

answer

O80, Z37.0

question

Gestational diabetes:

answer

occurs in a patient who was not diabetic before pregnancy

question

All patients who deliver require at least _____diagnosis code(s).

answer

Two

question

Adverse effects occurring in a pregnant patient are assigned a principal diagnosis code from category T36-T50

answer

False

question

When a fertilized egg is implanted outside of the uterine cavity, it is called a(n):

answer

ectopic pregnancy

question

An episiotomy is considered a complication of delivery, and a O80 diagnosis code cannot be coded on the mother's chart.

answer

False

question

Another term for "before delivery" is:

answer

antepartum

question

The patient is admitted in labor at term. After lab work is completed, it is noted that the patient has a UTI and appears to be preeclamptic. The patient goes on to vaginally deliver a healthy baby boy.

answer

O23.43, O14.93, Z3A.38, Z37.0, 10E0XZZ

question

The patient is admitted to the hospital in preterm labor. She is 27 weeks pregnant. Terbutaline is administered, and the patient remains on bed rest. In the third week of bed rest, her water breaks, and she is taken to the delivery room. She vaginally delivers a baby girl.

answer

O60.13x0, Z37.0, Z3A.27, 10E0XZZ

question

If code O80 is assigned, other codes in the O00-O9A range should also be assigned, if applicable

answer

False

question

A pregnant woman at 39 weeks presents to the hospital for delivery of known quadruplets. She is taken to the operating room for a cesarean section (LTCS). As the babies are delivered, it is discovered that one has died in utero.

answer

O30.203, O36.4xx0, Z3A.39, Z37.62, 1ODOOZ1

question

The patient is 9 weeks pregnant. She is admitted for an elective abortion. The physician performs a vacuum D;C to terminate the pregnancy.

answer

Z33.2, 10A07Z6

question

Ectopic pregnancies occur in 1 in ____ pregnancies.

answer

50

question

A woman is admitted at 22 weeks for insertion of a laminaria for termination of pregnancy. She delivers a liveborn fetus.

answer

O60.12x0, Z3A.22, Z37.0, 10E0XZZ, 10A07ZW

question

A patient at 12 weeks is admitted for a therapeutic abortion due to a chromosome abnormality in the fetus. A D;C is performed, resulting in a complete abortion. Her postoperative course is complicated by shock due to acute blood loss secondary to hemorrhage with resulting anemia.

answer

Z33.2, O04.6, O04.81, D62, O35.1xx0, Z3A.12, 10A07ZZ

question

In ICD-10-CM the final character indicates the episode of care.

answer

False

question

When a vaginal delivery occurs, the principal diagnosis should correspond to the main circumstance or complication of the delivery.

answer

True

question

Which of the following codes are correct when a normal pregnancy is coded?

answer

O80 Normal delivery Z37.0 Single liveborn 10E0XZZ Manually assisted delivery All of the above

question

The patient is admitted in labor at 38 weeks. She labors for 24 hours when it is noted that the baby is in fetal distress. The patient is taken to the OR for an emergency C-section (LTCS). She delivers a healthy baby.

answer

O77.9, Z3A.38, Z37.0, 10D00Z1

question

What drug could be given to inhibit labor?

answer

Terbutaline

question

What drug could be given to induce labor?

answer

Pitocin

question

A patient is an elderly multigravida at 39 weeks who has come in for trial labor following previous cesarean. The patient has been taking iron for iron deficiency anemia and is obese. Labor progresses, but fetal decelerations require repeat LTCS. On day 2, the patient develops a fever and is treated with antibiotics for suspected endometritis.

answer

O76, Z37.0, O34.21, O99.02, D50.9, O99.214, O86.12, O09.523, E66.9, Z3A.39, 10D00ZO

question

In ICD-10-CM there are 7th characters to specify the fetus affected by the obstetric condition.

answer

True

question

When a cesarean delivery is performed, the principal diagnosis should correspond to the reason the cesarean delivery was performed unless the reason for admission was unrelated to the condition resulting in the cesarean delivery.

answer

True

question

Coding a normal pregnancy requires only three diagnostic codes and one or more procedure codes

answer

True

question

A gravid patient at 11 weeks presents for a routine prenatal visit. This patient had preeclampsia in her previous pregnancy and the physician documents high-risk pregnancy. She has blood work done on this visit and is found to be anemic. The physician prescribes an iron supplement.

answer

O09.891, O99.011, D64.9, Z3A.11

question

In ICD-10-CM the diagnosis used for an elective abortion comes from the pregnancy chapter.

answer

False

question

ICD-10-CM does NOT have separate categories for high-risk pregnant individuals.

answer

False

question

In ICD-10-CM there are code extensions to specify the fetus affected by the obstetric condition.

answer

True

question

Prematurity is based on recorded birth weight and gestational age and documentation of prematurity.

answer

True

question

Congenital conditions are always present, well defined, and diagnosed at birth.

answer

False

question

In most cases, pregnancies with chromosomal anomalies end with a natural miscarriage.

answer

True

question

Marfan syndrome:

answer

affects the connective tissue patients have skeletal defects patients have cardiovascular problems all of the above (Correct answer)

question

Treatment for jaundice includes:

answer

phototherapy

question

A congenital anomaly is a condition that is:

answer

present at birth

question

Newborns have their own set of MS-DRGs.

answer

True

question

Down syndrome is also known as:

answer

trisomy 21

question

Apgar score factors are:

answer

heart, breathing, activity and muscle tone, grimace, appearance

question

Meconium is:

answer

fecal matter in an infant's intestine before birth none of the above

question

Tetralogy of Fallot is:

answer

a congenital heart defect

question

All newborn charts must contain the following code:

answer

Z38.-

question

Prematurity can be coded based on the gestational weeks.

answer

False

question

Spina bifida is a curable congenital anomaly because there is a way to repair the damaged nerve tissue.

answer

False

question

TNN (transitory tachypnea of newborn) means the infant ____.

answer

retains lung fluid

question

Bronchopulmonary dysplasia (BPD) is a chronic lung disease that ____. 1. is present immediately at birth 2. develops in the first 4 weeks of life 3. develops in the first year of life 4. happens only in full-term infants 5. is most likely to occur in premature infants 6. is most likely to occur in infants that weigh less than 1500 grams

answer

2, 5, and 6 only

question

When locating infections of the newborn, it is best to look under the main term for the infection and then to look for a subterm of newborn, fetal, or congenital.

answer

True

question

Newborn is delivered vaginally. The baby was premature at 34 weeks and weighed 1842 grams. Meconium staining was noted at delivery.

answer

Z38.00, P07.17, P07.37, P96.83

question

If the baby scores a ____ or higher on the Apgar test 1 minute after birth, he or she is considered to be healthy.

answer

7

question

The child was admitted for repair of cleft lip and cleft soft and hard palate. He is an ex-33-week preemie. A repair of both the hard and soft palate and lip is performed by external approach.

answer

Q37.5, P07.36, 0CQ0XZZ, 0CQ2XZZ

question

An infant is born via vaginal delivery with intrauterine growth retardation. The baby is born at 33 weeks and weighs 1800 grams. Meconium aspiration is noted at delivery. Jaundice is treated with phototherapy.

answer

Z38.00, P07.17, P07.32, P24.00, P59.0, 6A600ZZ Shouldn't code be P07.37

question

The A in the Apgar test given to babies stands for ____.

answer

appearance

question

There is abnormal fetal heart rate or rhythm during labor, and infant is therefore delivered by C-section. Mother was instructed on discharge to put the baby in front of the window in the sun to alleviate the mild jaundice. In addition, a lactation consult was performed during this stay as the baby was having difficulty breast-feeding.

answer

Z38.01, P03.811, P92.5, P59.9

question

There is no cure for Down syndrome, but the risk increases the older the mother is during her pregnancy.

answer

True

question

Child is seen in pediatrician's office. She has a diagnosis of Down syndrome with ADD, sleep apnea, and mild mental retardation. Her medications are reviewed and a suggestion is made to have a sleep study.

answer

Q90.9, F70.0, G47.30, F90.0

question

Which of the following is NOT a congenital condition?

answer

Jackson's syndrome

question

Which of the following makes a condition clinically significant?

answer

The condition requires a clinical evaluation. The condition requires therapeutic treatment. The condition requires an extended hospital stay. **All of the above are correct.

question

Cleft lip occurs in approximately 1 in every 2000 babies.

answer

False

question

Newborn is delivered vaginally and is ruled in for group B strep sepsis.

answer

Z38.00, P36.0

question

An infant is born by cesarean section. On examination, the infant is noted to have neonatal teeth and strawberry nevus on the left leg.

answer

Z38.01, K00.6, Q82.5

question

Spinal fusion is:

answer

the creation of a solid bone bridge between two or more adjacent vertebrae

question

Scoliosis is

answer

a lateral or sideways curvature of the spine

question

A pathologic fracture is a break in a bone that occurs because of:

answer

underlying disorders that weaken the bone

question

ICD-10-CM identifies the following cause(s) for pathologic fractures:

answer

neoplastic disease

question

Percutaneous vertebroplasty is a technique used to treat pain caused by:

answer

compression fracture of the vertebrae

question

Malunion and nonunion are synonymous terms.

answer

False

question

A family history of arthritis:

answer

is coded as Z82.61

question

The etiology of polymyalgia rheumatica is:

answer

unknown

question

Systemic lupus erythematosus (SLE) is a:

answer

chronic, inflammatory autoimmune disease that can damage connective tissue

question

Primary osteoarthritis is related to:

answer

the aging process

question

What drug could be given to treat rheumatoid arthritis?

answer

Celebrex

question

The patient was admitted to the hospital because of severe left hip pain that is often worse during the night. X-rays of the hip were taken in the ER. A preliminary report showed that the patient possibly had Paget's disease of the left femur, which was responsible for the patient's pain. Alkaline phosphatase was elevated, and a bone scan was done to determine the extent of the disease. Final Diagnoses: Severe hip pain due to Paget's disease.

answer

M88.852

question

An 83-year-old woman with severe back pain is admitted. CT shows osteoporosis and possible compression fracture of the lumbar spine. The patient is seen by interventional radiology, and a percutaneous vertebroplasty and reduction of fracture is performed. Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.

answer

M80.08xA, 0QU03JZ, 0QS03ZZ

question

A pediatric patient was admitted with a pathologic fracture of the proximal right humerus. Radiographic evidence suggests that the fracture was caused by a unicameral bone cyst. An orthopedic consult was obtained to see whether this should be treated surgically. It was decided to treat conservatively and monitor healing with serial x-rays. Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.

answer

M84.621A, M85.421

question

____ is an exaggerated inward curvature of the spine that may be caused by increased abdominal girth due to obesity, pregnancy, or abdominal tumors.

answer

Lordosis

question

Osteomyelitis is an infection of the bone that often starts in another part of the body and is spread by the blood.

answer

True

question

What drug could be given to treat osteoporosis?

answer

Fosamax

question

ICD-10-CM has a combination code for osteoporosis with pathologic fracture.

answer

True

question

The patient was admitted from the ER for chest pain to rule out MI. The patient also had some difficulty breathing and pain when taking a deep breath. The patient does have a family history of ischemic heart disease and is positive for the following cardiac risk factors: male, older than age 65, hypertension, smoker, and overweight. After evaluation and monitoring, an MI was ruled out. Cardiology thought the most likely cause for his chest pain was costochondritis. Final Diagnoses: Chest pain due to costochondritis. Hypertension. Smoker, current nicotine dependence (cigarettes). Overweight. Family history of ischemic heart disease.

answer

M94.0, I10, F17.210, E66.3, Z82.49

question

Pathologic fracture of distal left femur due to osteosarcoma of femur.

answer

M84.552A, C40.22

question

____ is when one vertebra slips on another.

answer

Spondylolisthesis

question

Subacute osteomyelitis of sacrum with decubitus sacral ulcer, stage 3. Staphylococcus aureus is the causative organism.

answer

M46.28, L89.153, B95.61

question

A patient is admitted for a total hip replacement with a metal-on-polyethylene prosthesis because of primary osteoarthritis of the right hip. Patient has had a previous left hip replacement.

answer

M16.11, Z96.642, 0SR902Z

question

____ is one of the most common diseases affecting the muscles; it is characterized by widespread muscle pain associated with chronic fatigue.

answer

Fibromyalgia

question

ICD-10-CM has different codes to identify laterality for many musculoskeletal conditions.

answer

True

question

Which of the following make(s) up the musculoskeletal system?

answer

Tendons Cartilage All of the above (correct) Ligaments Bones

question

Patient with a family history of rheumatoid arthritis is being screened for rheumatoid arthritis.

answer

Z13.828, Z82.61

question

A patient is admitted to rule out lupus nephritis. The patient was diagnosed with lupus 5 years ago. A percutaneous left kidney biopsy is performed, and lupus nephritis is confirmed.

answer

M32.14, 0TB13ZX

question

____ are the connective tissues that attach muscle to bones.

answer

Tendons

question

ICD-10-CM uses the sixth character extension when coding pathologic fractures.

answer

False

question

Breast codes are classified only for female patients.

answer

False

question

Acute renal failure cannot be present with chronic renal failure.

answer

False

question

Extracorporeal shock wave lithotripsy is used to treat:

answer

urinary tract calculi

question

ICD-10-CM presumes a cause-and-effect relationship between renal failure and diabetes.

answer

false

question

Cystitis is a lower urinary tract infection that affects the:

answer

none of these

question

ICD-10-CM presumes a cause-and-effect relationship between renal failure and hypertension.

answer

True

question

The term chronic renal failure has been changed to the more precise term of:

answer

Chronic kidney disease

question

According to ICD-10-CM, the term urosepsis classifies to:

answer

see condition

question

Endometriosis can be found in the:

answer

all of the above

question

Different types of incontinence include:

answer

stress urge overflow all of the above

question

A patient is admitted to the hospital for a percutaneous left kidney biopsy, which confirms Berger's disease. Discharge Diagnosis: Berger's disease.

answer

N02.9, 0TB13ZX

question

Patient was seen in the ER with left flank pain. Discharge diagnosis is stone, left kidney.

answer

N20.0

question

ICD-10-CM classifies chronic kidney disease based on severity.

answer

True

question

A patient is admitted to the hospital with fever and chills, flank pain, and burning on urination with increased frequency. CT scan shows stranding around the right kidney consistent with pyelonephritis. Urine culture is positive for Proteus mirabilis. The patient has a long history of obstructive uropathy due to BPH. Final Diagnosis: Fever due to acute pyelonephritis due to Proteus mirabilis. Obstructive uropathy due to benign prostatic hypertrophy.

answer

N10, B96.4, N40.1, N13.8

question

The main parts of the male genital or reproductive tract include the testes, epididymis, vas deferens, seminal vesicles, prostate, and penis.

answer

True

question

In ICD-10-CM there is a code to identify postprocedural renal failure.

answer

True

question

Which of the following is NOT a common genitourinary condition?

answer

Diabetes

question

A patient is admitted to the hospital for fluid overload due to noncompliance with attending renal dialysis sessions. Patient has stage 5 CKD. Multiple sessions of hemodialysis are performed.

answer

E87.70, N18.6, Z91.15, 5A1D60Z

question

A patient is admitted to the hospital with ARF due to dehydration. The patient is treated with IV fluids.

answer

N17.9, E86.0

question

Which of the following can be detected by a urinalysis test

answer

Kidney stones Diabetes Cystitis All of the above (correct answer)

question

Which of the following is/are Z code(s) that may be used with diseases of the genitourinary system?

answer

Z16.21 Resistance to vancomycin Z87.448 Personal history of other diseases of urinary system Z93.59 Artificial opening status, other cystostomy All of the above (correct answer)

question

A patient is admitted with acute pyelonephritis. Blood cultures are negative, but urine cultures are positive for E. coli. The patient is treated with IV fluids and antibiotics. Discharge Diagnosis: Acute pyelonephritis due to E. coli.

answer

N10, B96.20

question

The patient was admitted for treatment of BPH with urinary retention and a history of frequent urinary tract infections. The patient's PSA was normal. A TURP was performed. The patient recovered uneventfully with only minimal hematuria, which had resolved by the time of discharge. Final Diagnosis: Benign prostatic hypertrophy. Procedure: Transurethral resection of prostate.

answer

N40.1, R33.8, Z87.440, 0VB08ZZ

question

Sometimes to assign the correct codes, it is necessary to question the physician to be sure the correct meaning was interpreted and the correct code was assigned, like the term urosepsis.

answer

True

question

A patient is admitted to the hospital for further evaluation of stage 4 kidney disease. The patient is known to have been born with only one kidney, and on routine checkup it was found that the patient's kidney function was markedly abnormal. One year ago, the patient's laboratory tests were relatively normal. The patient's blood pressure was monitored, and it was decided that medications would be necessary to treat the patient's hypertension. The patient was advised about fluid intake and restriction and dietary considerations regarding protein and potassium. Referral was made to a nephrologist because the CKD appears to be progressing rapidly, and arrangements may be necessary for dialysis. Final Diagnosis: Chronic progressive renal failure, stage 4. Hypertension

answer

I12.9, N18.4, Q60.0

question

When the site is known, urinary tract infections are assigned codes based on the site of the infection.

answer

true

question

If causative bacteria are documented by the physician, this code should NEVER be coded in addition to the urinary tract infection.

answer

false

question

A patient was admitted for investigation of microscopic hematuria. The patient plans to donate a kidney to a family member, and any renal disease must be ruled out. The patient had a percutaneous needle biopsy of the left kidney. The patient has a past medical history of GERD, which is treated with Nexium, and had a pneumothorax caused by an MVA several years ago. Final Diagnosis: Kidney donor with microscopic hematuria. Procedure: Diagnostic kidney biopsy.

answer

R31.2, K21.9, 0TB13ZX

question

Patient was admitted to the hospital with acute renal failure due to dehydration. Patient will have to be rehydrated slowly due to CHF. Patient also has diabetic nephropathy.

answer

N17.9, E86.0, I50.9, E11.21

question

____ is a lower urinary tract infection that affects the bladder.

answer

Cystitis

question

Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.

answer

dilation

question

ICD-10-CM assumes a rheumatic etiology when both the mitral and the aortic valves are diseased.

answer

True

question

In ICD-10-CM, when coding coronary artery disease and angina:

answer

one combination code is used

question

A cerebrovascular accident is commonly known as:

answer

stroke

question

An acute myocardial infarction is commonly known as:

answer

heart attack

question

A leaking valve is another name for:

answer

regurgitation incompetence insufficiency all of the above (correct answer)

question

Hypertensive heart disease assumes a cause-and-effect relationship in ICD-10-CM coding.

answer

False

question

The lymph system fights infection by:

answer

filtering out viruses and bacteria

question

The valves in the heart include:

answer

tricuspid, mitral, aortic, pulmonary

question

A diagnostic cardiac catheterization is used to determine the severity of:

answer

coronary artery disease

question

coronary artery disease

answer

epicardium, myocardium, endocardium

question

A patient is admitted with chest pain and is ruled in for an NSTEMI. The patient has a history of a CABG and PTCA with stent placement. Patient is taking medications for hypertension, CAD, and CHF.

answer

I21.4, I10, I25.10, I50.9, Z95.1, Z95.5

question

Patient comes to the hospital with chest pain. A diagnostic left heart cath is performed, and no coronary artery disease is observed. The cardiologist documents the diagnosis as noncardiac chest pain.

answer

R07.89, 4A023N7

question

Patient is admitted through the ER, presenting with acute chest pain. The patient has a history of COPD and pneumonia as well as type II DM with diabetic neuropathy. He has a history of hypertension and gout for which he takes meds. He is currently smoking about one pack per day. After study it is determined that patient has had an acute anterolateral wall infarct. He is taken to the EP lab for a PTCA with the insertion of a drug eluting stent of the LAD.

answer

I21.09, I10, F17.210, M10.9, J44.9, E11.40, 027034Z

question

Deep vein thrombosis (DVT) is a blood clot that forms deep in a vein, usually in the leg or hip.

answer

True

question

Molly has a blood pressure of 150/100. She would be classified as having ____ by her clinician.

answer

hypertension

question

Insertion of pacemakers most often requires five codes.

answer

False, two codes

question

Patient comes to the hospital for repair of an abdominal aortic aneurysm. The repair is performed by percutaneous endoscopic approach.

answer

I71.4, 04V04DZ

question

The time limit for assigning the acute MI in ICD-10-CM is 28 days.

answer

True

question

A patient is admitted with facial droop, left-sided hemiparesis, and nystagmus. Testing reveals occlusion of the left carotid artery with cerebral infarct. The patient has uncontrolled hypertension and atrial fibrillation, which is treated with Coumadin. Before discharge, the patient's nystagmus and facial droop have resolved. The patient is discharged to rehab for continued therapy for left-sided hemiparesis.

answer

I63.232, I69.354, H55.00, I69.392, I10, I48.91, Z79.01

question

Tachycardia is an abnormally high heart rate of more than 100 beats per minute.

answer

True

question

The patient was admitted with left-sided hemiparesis due to a cerebrovascular accident. The patient has a history of previous CVA with residual facial droop.

answer

I63.9, G81.94, I69.392

question

All of the following are tests performed to determine whether a myocardial infarction has occurred EXCEPT ____.

answer

urinalysis

question

Patient is admitted with syncope. After tests are performed, it is determined that the patient has bradycardia due to second degree AV block.

answer

I44.1, R00.1

question

Patient is admitted through the ER with atrial fibrillation and a history of COPD. She is taken to the EPS lab for EPS testing, mapping, and radiofrequency ablation of the left atrium.

answer

I48.91, J44.9, 02573ZZ, 02K83ZZ, 4A023FZ

question

Patient is admitted with chest pain and rules in for an anterolateral MI. There is a family history of CAD.

answer

I21.09, Z82.49

question

The two main types of heart failure are systolic and diastolic.

answer

True

question

Patient comes into the ER after fainting at work. The physician determines that the fainting was caused by elevated blood pressure resulting from extreme stress.

answer

R03.0, F43.0

question

Patient was admitted for treatment of gangrenous cellulitis of left lower leg

answer

I96

question

Patient was admitted to have a drug-eluting stent inserted into the LAD for coronary atherosclerosis. Procedure was performed percutaneously.

answer

I25.10, 027034Z

question

Patient was admitted with acute on chronic systolic and diastolic congestive heart failure.

answer

I25.10, 027034Z

question

Chronic asthmatic bronchitis and chronic bronchitis with emphysema can be classified as chronic obstructive pulmonary disease (COPD).

answer

True

question

Blood that accumulates in the pleural space is called:

answer

hemothorax

question

Pleural effusion is:

answer

fluid that accumulates in the pleural space

question

A personal history of malignant neoplasm of the lung is coded as:

answer

Z85.118

question

It is possible to have an acute infection superimposed on a chronic infection/inflammation.

answer

True

question

Bronchitis can be ______________in origin.

answer

viral or bacterial

question

Respiratory failure is always coded as the principal diagnosis.

answer

False

question

Common treatments for sinusitis include:

answer

decongestants, antibiotics

question

It is possible to have more than one bacterium responsible for pneumonia.

answer

True

question

Mechanical ventilation codes are based on hours.

answer

True

question

A patient is admitted with hypoxemia and acute respiratory failure. The patient has COPD and is being treated for an acute exacerbation. The patient is intubated in the ER and is transferred to ICU and maintained on mechanical ventilation for 24 hours. The patient has a history of chronic diastolic congestive heart failure.

answer

J96.01, J44.1, I50.32, 5A1945Z

question

A diagnostic endoscopic procedure in which a tiny camera on the end of the endoscope is inserted through the nose or mouth into the lungs is called a ____.

answer

bronchoscopy

question

A pneumothorax that occurs as a result of a procedure is a(n) ____ pneumothorax.

answer

iatrogenic

question

Which of the following is NOT categorized with high-risk potential for contracting pneumonia?

answer

Someone who is in his or her early twenties

question

Patient is admitted with acute on chronic respiratory failure due to emphysema. Patient is dependent on oxygen, and has had numerous admissions for pneumonia. Patient is treated with continuous BIPAP for 48 hours and is a DNR/DNI. No infection is identified, and deterioration in respiratory status is thought to be a progression of his emphysema. Patient is discharged to at-home hospice care. Final Diagnoses: End-stage emphysema. Chronic respiratory failure with hypoxia. Procedure: BIPAP.

answer

J96.21, J43.9, Z99.81, Z87.01, Z66, 5A09457

question

Patient arrived at the ER complaining of shortness of breath. Patient was diagnosed and treated for exercise-induced bronchospasm.

answer

J45.990

question

____ is a lower respiratory tract or bronchial tree infection that is characterized by cough, sputum production, and wheezing.

answer

Bronchitis

question

When pleural effusion results from trauma or disease and blood is accumulating in the pleural space, the condition is called ____.

answer

hemothorax

question

A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis due to previous cerebral infarction. Sputum cultures reveal Pseudomonas. Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.

answer

J69.0, J15.1 I69.391, R13.10, I69.359

question

Which of the following is NOT an example of pneumoconiosis (lung disease due to the chronic inhalation of inorganic dust)?

answer

Cyanosis

question

Patient was admitted with flu-like symptoms. The final diagnosis on the discharge summary is possible novel influenza A.

answer

J11.89

question

Asthmatic bronchitis refers to an underlying asthmatic problem in patients in whom asthma has become so persistent that clinically significant chronic airflow obstruction is present despite antiasthmatic therapy.

answer

True

question

A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis of right dominant side due to previous CVA. Sputum cultures reveal Pseudomonas. Patient went into acute respiratory failure after admission. Discharge diagnosis: Pseudomonas pneumonia.

answer

J15.1, J96.00, I69.391, R13.10, I69.351

question

Patient is admitted with shortness of breath and fever that has been present for 2 to 3 weeks and has gotten progressively worse. CT scan showed evidence of bronchiolitis obliterans organizing pneumonia (BOOP). Patient was started on prednisone and discharged when symptoms had resolved. Final Diagnoses: BOOP.

answer

J84.89

question

A patient is admitted for suspected H1N1 influenza.

answer

J11.1

question

Patient was admitted to the hospital in acute respiratory failure due to congestive heart failure. The patient was intubated and placed on mechanical ventilation for 2 days. The patient responded well to IV diuretics.

answer

J96.00, I50.9, 5A1945Z

question

It is inappropriate for coders to assume a causal organism on the basis of laboratory or radiology findings alone.

answer

True

question

Patient is admitted to the hospital and found to have suffered a NSTEMI. After admission the patient went into acute respiratory failure.

answer

I21.4, J96.00

question

Infant was seen in the ER with diagnosis of acute bronchiolitis due to RSV. The infant has been exposed to tobacco smoke.

answer

J21.0, Z77.22

question

Which of the following is a symptom of pneumonia?

answer

Rapid breathing Fever Cough All of the above (correct answer) Chest pain

question

Lysis of adhesions should always be coded if mentioned in the operative report.

answer

False

question

Alcoholism can cause both hepatitis and cirrhosis

answer

True

question

If the appendix ruptures, ___________develops.

answer

peritonitis

question

A peptic ulcer can occur in the:

answer

stomach esophagus duodenum, jejunum, ileum all of the above (correct)

question

Mechanical obstruction of the intestine may be caused by:

answer

neoplasm adhesions herniation all of the above (correct)

question

Hematemesis is defined as:

answer

vomiting of blood

question

Cholelithiasis is a condition of stones in the:

answer

gallbladder

question

If a physician documents both diverticulosis and diverticulitis:

answer

code diverticulitis only

question

A cholecystectomy can be performed by an open approach or laparoscopically.

answer

True

question

An inguinal hernia can be unilateral or bilateral.

answer

True

question

The patient has a diagnosis of upper esophageal stricture and a history of COPD. An EGD with dilatation of the stricture is performed.

answer

K22.2, J44.9, 0D718ZZ

question

The squeezing or movement of food toward the stomach and down the digestive tract is called ____.

answer

peristalsis

question

A patient is admitted for chemotherapy for pancreatic cancer and develops ulcerative mucositis of the mouth due to gemcitabine.

answer

Z51.11, C25.9, K12.31, T45.1X5, 3E03305

question

____ is the abnormal condition of stones in the gallbladder.

answer

Cholelithiasis

question

Patient with known alcoholic cirrhosis of the liver is admitted with ascites and acute bacterial peritonitis due to Staphylococcus aureus. Patient is a recovering alcoholic who has been in remission for 2 years.

answer

K65.0, K70.31, F10.21, B95.61

question

The ER physician documents that the patient is being admitted for hematemesis. The patient has an Hct of 24.3. A transfusion of PRBC is administered, and the patient is taken to the OR for an EGD. The EGD reveals that the patient has an acute perforated duodenal ulcer that is causing the bleed. The ulcer is cauterized. The patient is treated with IV antibiotics, omeprazole, and NG tube. The discharge summary lists an additional diagnosis of acute blood loss anemia.

answer

K26.2, D62, 0D598ZZ, 30233N1

question

Code ____ is coded for personal history of malignant neoplasm of the GI tract, unspecified.

answer

Z85.00

question

Which Z code is associated with family history of digestive disorders

answer

Z83.79

question

Patient presents to the ER with severe abdominal pain. The patient has a history of Crohn's disease. She had asthma as a child and currently appears dehydrated. After study it is determined that the patient has an abscess of the large intestine. Antibiotics are administered, as well as IV fluids with potassium to treat the dehydration and hypokalemia.

answer

K50.914, E87.6, E86.0

question

Patient with malignant neoplasm of the descending colon is admitted for left hemicolectomy and temporary descending colostomy.

answer

C18.6, 0DTG0ZZ, 0D1M0Z4

question

All of the following are functions of the liver EXCEPT that it ____.

answer

stores and releases bile

question

An indirect hernia occurs when the protrusion is through the inguinal ring into the inguinal canal; this is different from a direct hernia.

answer

True

question

Symptoms of gastric ulcers may include pain when eating, vomiting, and tarry bowel movements.

answer

True

question

Ostomies are surgically created openings into the body. Enterostomies and colostomies are created to discharge waste products from the body.

answer

Both statements are true.

question

____ means bright red in the stool.

answer

Hematochezia

question

A patient presents with melena, weakness, and fatigue. A colonoscopy with biopsy of the rectum and colon is performed and reveals multiple diverticula and internal hemorrhoids. The path shows possible inflammatory bowel disease. No source of bleeding is identified. Discharge Diagnosis: GI bleed; chronic blood loss; anemia.

answer

K92.1, D50.0, K57.30, K64.8, 0DBE8ZX, 0DBP8ZX

question

A patient is admitted with Crohn's disease of the large bowel. A right hemicolectomy is performed with temporary ascending colostomy. The patient is malnourished and was dehydrated on admission. Postoperatively, the patient's potassium levels are monitored, and the hypokalemia is treated with K-Dur.

answer

K50.10, E46, E86.0, E87.6, 0DTF0ZZ, 0D1K024

question

What drug could be given to treat GERD?

answer

Prilosec

question

The mouth is where digestion begins.

answer

True

question

Patient comes to the ER with severe abdominal pain and a long history of alcoholism. Physician documents that patient is currently drinking a fifth of liquor a day. Patient is admitted to the hospital with a diagnosis of acute pancreatitis secondary to alcohol use.

answer

K85.9, F10.10

question

Hives and _____________are synonymous terms.

answer

urticaria

question

Decubitus ulcers can progress to ____________if not treated.

answer

osteomyelitis

question

When cellulitis is associated with a skin ulcer, code:

answer

cellulitis and the skin ulcer

question

STSG stands for:

answer

split-thickness skin graft

question

Cellulitis associated with an open wound requires two codes with cellulitis always sequenced as principal.

answer

False

question

An autograft is a graft from:

answer

one area of the body to another in the same individual

question

Decubitus ulcers are coded the same as all other ulcers

answer

False

question

Scrubbing or washing devitalized tissue is known as:

answer

nonexcisional debridement

question

Incision and drainage is coded the same as a debridement.

answer

False

question

Cellulitis is typically treated with

answer

antibiotics

question

Patient has a pressure ulcer of the left ankle on admission, which is documented as a stage I and progresses to a stage III during the course of the stay. The patient is a paraplegic.

answer

L89.523, G82.20

question

In ICD-10-CM decubitus ulcers use a combination code for location and stage.

answer

True

question

Skin grafts can be only full-thickness skin grafts.

answer

False

question

Which layer of the skin is composed of fibrous connective tissue?

answer

Middle Layer

question

A(n) ____ is a skin graft from one person to another.

answer

allograft

question

Patient stepped on a piece of glass and injured his foot 2 days ago. He is now being admitted to the hospital for treatment of cellulitis in the left leg. He has a past history of depression with anxiety for which he takes medicine. He is currently on antibiotics for acute bronchitis.

answer

L03.116, S91.312A, F41.8, J20.9, W25.xxxA

question

Pulse lavage debridement is performed by wound care nurse on a patient with a stage 3 decubitus ulcer of the right ankle. The patient is taking medications for diabetes and for high cholesterol.

answer

L89.513, E11.9, E78.0, 0HDKXZZ

question

The code for the stage of a pressure ulcer should be used as the principal diagnosis.

answer

False

question

A nursing home patient is admitted with an enlarging stage 3 sacral decubitus ulcer for wound care. The patient had a previous CVA with right hemiplegia and aphasia and is on medications for atrial fibrillation and Alzheimer's dementia.

answer

L89.153, I69.351, I69.320, I48.91, G30.9, F02.80

question

The functions of the integumentary system include all of the following EXCEPT ____.

answer

vitamin A synthesis

question

A(n) ____ is a skin graft to an individual from another species, such as a pig.

answer

xenograft

question

Pressure ulcers require two codes.

answer

True

question

Clusters of boils are known as a ____.

answer

carbuncle

question

A patient has a chronic ulcer of the right great toe with skin breakdown only and is admitted for excisional debridement of the skin. The patient has a medical history significant for COPD, asthma, and CAD.

answer

L97.511, J44.9, I25.10, 0HBMXZZ

question

Patient was admitted because of the development of blistering and erosion of skin and mucous membranes. About 5 days ago, the patient had fever, sore throat, and headache and was thought to have influenza. The patient was diagnosed with Stevens-Johnson syndrome.

answer

L51.1, Z86.19

question

On the discharge summary, the provider documents the following discharge diagnoses: exacerbation of COPD, hypertension, hyperlipidemia, and a healing sacral decubitus.

answer

J44.1, I10, E78.5, L89.159

question

Another name for a pressure ulcer is a decubitus ulcer.

answer

True

question

A patient comes to the ER with a crusty, itchy rash. The diagnosis is impetigo of the legs with cellulitis. The patient is admitted to treat the cellulitis.

answer

L03.115, L03.116, L01.00

question

A patient is admitted from the nursing home with suspected aspiration pneumonia. The attending physician documents that the patient has pressure ulcers on both buttocks. The left side has a stage II ulcer and the right side has a stage I ulcer.

answer

J69.0, L89.322, L89.311

question

What are the two most common bacteria associated with skin infections? 1. Streptococcus pyogenes 2. Escherichia coli 3. Staphylococcus aureus 4. Treponema pallidum 5. Pseudomonas aeruginosa

answer

1 and 3

question

An infant is admitted for placement of a ventriculoperitoneal shunt for hydrocephalus. The patient has lumbar spina bifida.

answer

Q05.2, 00160J6

question

A patient with known metastatic cancer to the ribs is admitted for pain control. The patient has a history of lung cancer, which was surgically excised. The patient is administered Fentanyl

answer

G89.3, C79.51, Z85.118

question

A patient is admitted with an acute change in mental status. Patient has a history of CHF, DMII, and prostate cancer. Patient had a prostatectomy 2 years PTA. Upon completion of the lab work, the physician documents metabolic encephalopathy due to urinary tract infection.

answer

G93.41, N39.0, I50.9, E11.9, Z85.46

question

A patient was admitted for acute pain control after falling off a ladder and suffering two broken ribs on the right side. The patient was admitted for pain control.

answer

G89.11, S22.41xA, W11.xxxA

question

Patient is admitted for a spinal fusion at L2-L3. For many years, the patient has suffered from chronic back pain secondary to a herniated disc at L2-L3, which was removed during the fusion. The physician performed an XLIF procedure with the insertion of an interbody fusion device. This procedure was performed percutaneously via an anterior approach to the anterior column.

answer

M51.26, 0SG03A0, 0SB23ZZ

question

Patient came to the ER after falling off her horse at the county fair rodeo. X-rays reveal two fractured ribs on the left. Patient is admitted for acute pain control.

answer

G89.11, S22.42xA, V80.010A, Y92.39, Y93.52

question

A patient is admitted for pain control. The patient has metastatic prostate cancer to the vertebrae and liver. The patient is started on a PCA pump, and pain is more manageable.

answer

G89.3, C61, C78.7, C79.51

question

A disorder of the brain that causes a progressive decline in mental and physical function is called

answer

Alzheimer's disease

question

In ICD-10-CM there are three chapters for the nervous system and sense organs.

answer

True

question

Patient is admitted for a senile cataract in the right eye to be removed by phacoemulsification with IOL replacement via percutaneous approach.

answer

H25.9, 08RJ3JZ, 08DJ3ZZ

question

All of the following are symptoms of meningitis EXCEPT

answer

sensitivity to darkness headache vomiting

question

A patient with trigeminal neuralgia and a history of migraine headaches is admitted for an open rhizotomy. A day after the procedure, the patient develops a severe headache diagnosed as a nonintractable migraine.

answer

G50.0, G43.909, 008K0ZZ

question

Which of the following is the most common diagnostic test for epilepsy?

answer

EEG

question

A patient with intractable epilepsy presents for open implantation of a single array neurostimulator pulse generator with leads. The generator was placed in the chest and the leads were placed in the neck attached to the vagus nerve.

answer

G40.919, 0JH60BZ, 00HE0MZ

question

What drug could be given to treat epilepsy?

answer

Dilantin

question

Patient comes to the ER with high fever and headache. Meningitis is suspected. A lumbar puncture is performed and reveals bacterial meningitis.

answer

G00.9, 009U3ZX

question

What drug could be given to treat Alzheimer's?

answer

Aricept

question

Only the brain is covered by bone; the spinal cord is not

answer

False

question

A college student is admitted with fever, headache, and a stiff neck. Lumbar puncture is performed in the ER, and lab results reveal pneumococcal meningitis. The patient is given IV fluids for volume depletion and high doses of penicillin to treat meningitis.

answer

G00.1, E86.9, 009U3ZX

question

Bacterial Meningitis is

answer

treated with antibiotics

question

Psychosis is defined as:

answer

an impairment of the mental state in which the perception of reality has become distorted

question

Different types of schizophrenia include:

answer

catatonic paranoid disorganized all of the above (Correct Answer)

question

Alcohol withdrawal symptoms include:

answer

shakiness and sweating seizures delirium tremors all of the above (Correct Answer)

question

Dyslexia is defined as a learning disability that affects a child's ability to:

answer

understand or use spoken or written language

question

Panic disorder is defined as:

answer

a terrifying experience that occurs suddenly without warning

question

Alcoholism/dependence is the same as alcohol abuse in ICD-10-CM classification.

answer

False

question

There are several levels of severity that accompany intellectual disability.

answer

True

question

Alteration between mania and depression back and forth very quickly is:

answer

mixed mood disorder

question

Psychosis can be drug induced.

answer

True

question

In ICD-10-CM, the nicotine dependence codes identify the type of nicotine product such as cigarettes, chewing tobacco, or other tobacco product.

answer

True

question

Which of the following is NOT a sign/symptom of alcoholism?

answer

Visual hallucinations Disorganized thinking Paranoia None of the above are correct. (correct answer)

question

Patient was admitted with delirium tremens as a result of alcohol withdrawal. Patient has had a bout of acute gastroenteritis and has not had a drink for a couple of days. Patient was admitted and was started on IV fluids and a banana bag. Patient is hypokalemic with a potassium of 3.0 and is dehydrated. Patient's potassium was repleted with oral medication. Final Diagnoses: Acute gastroenteritis. Alcohol withdrawal. Hypokalemia.

answer

F10.231, K52.9, E87.6, E86.0

question

A patient is admitted following seizure-like activity. It is determined that the patient has a conversion disorder with seizures.

answer

F44.5

question

A 28-year-old man was brought to the ER by a friend who stated that the patient had been acting bizarrely. The patient has been irritable, pacing the apartment, and talking nonstop. He was admitted to the psychiatric unit for management of his manic symptoms. Final Diagnosis: Bipolar affective disease. Severe manic phase. Recurrent episode with psychosis

answer

F32.2

question

Organic psychosis occurs because of deterioration in the brain and is usually progressive and irreversible.

answer

True

question

Stress can be a contributing factor in mental disorders.

answer

True

question

In ICD-10-CM, a past history of drug and alcohol abuse is assigned codes for "in remission."

answer

False

question

Patient was seen in the ER for dizziness, fatigue and difficulty concentrating. Patient was seen for a head injury a couple of weeks ago. Physician documents postconcussional syndrome.

answer

F07.81

question

Severe intellectual disability is classified when the person has an IQ of ____.

answer

20 to 34

question

Patient was admitted to the psychiatric floor for evaluation of mood disorder. After extensive testing and evaluation, it was determined that patient was suffering from major depression that is severe in nature and that some psychotic features are present. Final Diagnosis: Major depressive disorder, severe with psychosis.

answer

F32.3

question

A patient is admitted for treatment of anorexia nervosa. The patient has moderate malnutrition, severe electrolyte imbalance, and nutritional cardiomyopathy.

answer

F50.00, E44.0 E87.8, I43

question

Seizures are a common form of alcohol withdrawal.

answer

True

question

A patient is admitted to the hospital for confusion. According to the family, the patient has been more difficult to manage at home and no longer is able to care for himself. The patient has known Alzheimer's disease. No medical cause could be determined for the patient's increasing confusion, and it is believed that nursing home placement is appropriate. Discharge Diagnosis: Alzheimer's dementia.

answer

G30.9, F02.80

question

Mental disorders are very particular about the body system they affect.

answer

False

question

What drug could be given to treat depression?

answer

Zoloft

question

What drug could be given to treat ADD or ADHD?

answer

Ritalin

question

Patient was admitted because of aggressive behavior and wandering. Neurology diagnosed dementia due to Lewy bodies.

answer

G31.83, F02.81, Z91.83

question

Patient was admitted for psychiatric care for acute posttraumatic stress disorder.

answer

F43.11

question

Graves' disease is the most common form of:

answer

hyperthyroidism

question

An enlarged gland is called:

answer

hyperplasia

question

Type 2 diabetes is much more common than type 1 diabetes

answer

True

question

Bariatrics is the branch of medicine concerned with the management of:

answer

obesity and allied diseases

question

If there is unclear documentation as to whether a patient is a type 1 or type 2 diabetic, the coder should:

answer

code type 2 diabetes

question

Diabetes coding is affected by whether the patient is a type 1 or type 2 diabetic.

answer

True

question

Major endocrine gland(s) include:

answer

pituitary thyroid pancreas all of the above (correct)

question

A cause-and-effect relationship is presumed with all diabetic manifestations.:

answer

False

question

Volume depletion, dehydration, and hypovolemia all classify to the same ICD-10-CM code.

answer

False

question

When a patient is admitted for a complication of cystic fibrosis:

answer

the complication is the principal diagnosis and the cystic fibrosis is secondary

question

The ____ regulate(s) daily patterns of sleep and wakefulness and inhibit(s) hormones that affect ovaries.

answer

pineal gland

question

Adult patient was seen in the clinic for dietary counseling for dysmetabolic syndrome X. Patient is obese with a BMI of 35 and has hypertriglyceridemia and hypertension.

answer

Z71.3, E88.81, E66.9, Z68.35, E78.1, I10

question

Hypothyroidism is an abnormality of the thyroid gland in which secretion of thyroid hormone is usually increased.

answer

False

question

All of the following are possible signs of malnutrition EXCEPT ____.

answer

rapid hair growth

question

Patient with steroid-induced diabetes due to long-term use of prednisone taken for rheumatoid arthritis.

answer

E09.9, T38.0x5S, M06.9

question

Diabetes mellitus without mention of complication would NOT have any additional manifestation codes.

answer

True

question

A patient is admitted for care of a diabetic ulcer on the left midfoot. The patient also has chronic kidney disease, stage 3, resulting from diabetes.

answer

E11.621, L97.429, E11.22, N18.3

question

Gigantism occurs when there is hypersecretion of hGH before puberty and when there is a proportional overgrowth of all body tissues, especially the long bones.

answer

True

question

A patient is admitted because of cystic fibrosis with pulmonary exacerbation. Sputum cultures grew Pseudomonas, and antibiotics are adjusted accordingly. The patient is also treated for hypertonic dehydration.

answer

E84.0, B96.5, E87.0

question

A 15-year-old male patient with cystic fibrosis was diagnosed at the age of 2 and has respiratory and gastrointestinal manifestations. Patient needs a PEG tube to maximize his nutritional status. A percutaneous gastrostomy tube is inserted, and feeds are initiated. The patient's mother is instructed on gastrostomy care and tube feedings. Final Diagnosis: Cystic fibrosis. Moderate malnutrition. Procedure: Percutaneous endoscopic gastrostomy placement.

answer

E84.19, E44.0, E84.0, 0DH63UZ, 3E0G36Z

question

When blood sugar becomes abnormally low, this is called ____.

answer

hypoglycemia

question

In ICD-10-CM there are only two category codes for diabetes mellitus.

answer

False

question

Patient is an elderly gentleman who was admitted from the ER with pain and swelling of his right knee. The pain is throbbing in nature, and the knee feels warm and is very tender to touch. The patient has a knee x-ray, and uric acid levels are elevated. Colchicine is started, and the patient's symptoms are much improved within 48 hours. The patient has diabetes. The patient is advised to limit alcohol consumption and to avoid dietary purines. Final Diagnosis: Gouty arthropathy right knee. Diabetes mellitus, type 2 on insulin.

answer

M10.061, E11.9, Z79.4

question

In ICD-10-CM, if the diabetes is due to an adverse effect of a drug, there is an Instructional note to assign a T36-T50 code as an additional or secondary code.

answer

True

question

Hypopituitarism (low levels of pituitary hormones) can be caused by ____.

answer

tumor stroke head trauma all of the above (correct)

question

Which of the following is NOT a major endocrine gland in the body?

answer

Parotid

question

A patient is admitted because of uncontrolled diabetes resulting from Cushing's syndrome. Patient is on insulin.

answer

E24.9, E08.65, Z79.4

question

The ____ regulates metabolism of glucose in body cells and maintains proper blood glucose

answer

pancreas

question

A patient is admitted with hypokalemia. What drug could be given to treat this condition?

answer

K-Dur

question

A patient is admitted with hyperkalemia. What drug could be given to treat this condition?

answer

Kayexalate

question

Of all oral cancers, 90% are:

answer

squamous cell carcinoma

question

Likely metastatic sites include:

answer

bone brain liver all of the above (correct answer)

question

Malignant growths include

answer

adenocarcinoma leukemia lymphoma all of the above

question

The code for family history of breast cancer is

answer

Z80.3

question

Stage I cancers are cancers that are/have:

answer

diagnosed early and have not spread

question

Leukemias can have metastatic sites

answer

False

question

A neoplasm is:

answer

abnormal growth

question

When a patient is admitted for chemotherapy, code the malignancy as the principal diagnosis.

answer

False

question

Lymphomas that are present in more than one area of the body are considered metastatic.

answer

False

question

All of the following are factors influencing which kind of biopsy will be performed for a patient EXCEPT the ____.

answer

weight of the patient

question

In ICD-10-CM, there is an Instructional note to code the malignancy first even when the encounter is for the management of anemia due to the malignancy.

answer

True

question

A patient is admitted for a wedge resection of metastatic carcinoma to the liver. The patient was diagnosed with small-cell lung carcinoma 3 months ago. What codes are applicable?

answer

C78.7, C34.90, 0FB04ZZ

question

____ is the use of high-energy radiation to treat cancer.

answer

Radiation

question

When admission is for the management of dehydration due to malignancy or therapy and only dehydration is being treated, the dehydration is coded first, followed by the code(s) from the malignancy.

answer

True

question

Pancytopenia due to myelodysplastic syndrome.

answer

D61.818, D46.9 b. D46.9 c. D46.Z

question

The patient is a 30-year-old woman who has multiple intramural fibroids. She has become more symptomatic with menorrhagia, resulting in anemia because of chronic blood loss. The patient would like to maintain fertility, so a myomectomy is performed. Final Diagnosis: Intramural uterine fibroids. Procedure: Myomectomy.

answer

D25.1, N92.0, D50.0, 0UB90ZZ

question

The patient was admitted for chemotherapy for stage IIIA breast (left) cancer. The patient tolerated the chemotherapy regimen with no complications and will return as arranged for cycle 3. Final Diagnosis: Breast cancer, stage IIIA (spread to axillary lymph nodes). Procedure: Chemotherapy via central vein.

answer

Z51.11, C50.912, C77.3, 3E04305

question

What drug could be given to treat anemia due to malignancy?

answer

Epogen

question

Patient is being treated for chemotherapy induced anemia. Patient is receiving chemotherapy for right renal cell carcinoma

answer

C64.1, D64.81, T45.1X5A a. D64.81, T45.1X5A, C64.1 b. D64.89, T45.1X1A, C64.2 c. d. C64.9, D63.0, T45.1X1A

question

In ICD-10-CM, terminology "without mention of remission" is used.

answer

False

question

An example of a sarcoma malignancy is a malignant ____.

answer

tumor in the muscle

question

Patient was seen in the clinic for Burkitt's lymphoma. Patient is HIV positive.

answer

B20, C83.70

question

Carcinomas in situ are malignant cells that remain within the original site with no spread to or invasion of neighboring tissues.

answer

True

question

Patient was admitted with an intestinal obstruction due to peritoneal metastasis from inoperable colorectal cancer.

answer

K56.69, C19, C78.6 b. C19, C78.6 c. C78.6, K56.60 d. C78.6, C19

question

____ carcinoma is primary neoplasm of the liver.

answer

Hepatocellular

question

All of the following are considered by the National Cancer Institute to be the most common sites for cancer in the United States EXCEPT ____.

answer

brain

question

The patient has a history of chronic hepatitis C. On routine ultrasonography, a suspicious mass of the liver was discovered. Biopsy confirmed primary hepatocellular carcinoma, and the patient was admitted for open partial hepatectomy. Final Diagnoses: Chronic hepatitis C. Hepatocellular carcinoma. Procedure: Partial hepatectomy for resection of HCC.

answer

C22.0, B18.9, 0FB00ZZ B18.2, C22.9, 0FB00ZX b. C22.9, B18.2, 0FB00ZX c. d. C22.0, B18.2, 0FB00ZZ

question

What drug could be given to treat neutropenia due to chemotherapy?

answer

Neulasta

question

Smoking is associated with 100% of all oral cancers.

answer

False

question

The excludes 2 note at the very beginning of Chapter 3 pertains to the entire chapter.

answer

True

question

The definition of "idiopathic" is

answer

without any identifiable cause

question

Aplastic anemia is due to:

answer

an impairment or failure of bone marrow function

question

Anemia occurs when the:

answer

hemoglobin decreases

question

Leukocytosis is defined as:

answer

an increase in the number of white blood cells

question

A CBC measures:

answer

hemoglobin, hematocrit, white blood cells, and platelets

question

A bone marrow biopsy is a diagnostic procedure used to

answer

identify types of anemia, cell deficiencies, and leukemia

question

Code D57.3 is assigned for a patient with:

answer

sickle cell trait only

question

The most common type(s) of transfusions is(are):

answer

red blood cells, plasma, and platelets

question

Hemophilia is:

answer

an inherited clotting disorder

question

When looking up anemic conditions in the code book, you should look up

answer

anemia first and then the various subterms

question

____ are medications that are used to prevent venous thrombi.

answer

Anticoagulants

question

____ drugs are used to prevent the clumping of platelets or the formation of arterial thrombi.

answer

Antiplatelet

question

A patient takes Coumadin for chronic atrial fibrillation

answer

I48.2, Z79.01

question

Patient has pancytopenia due to oral methotrexate, which is taken for treatment of rheumatoid arthritis, initial encounter.

answer

D61.811, T45.1x5A, M06.9

question

A patient is admitted with sickle cell thalassemia with vaso-occlusive pain. The patient has a chest x-ray, and acute chest syndrome is ruled out. The patient has had a right hip replacement for avascular necrosis.

answer

D57.419, Z96.641

question

Platelets are also called thrombocytes.

answer

True

question

A patient has anemia due to metastatic bone cancer. The patient has a history of primary left breast cancer that was treated with a mastectomy 4 years ago.

answer

C79.51, D63.0, Z85.3, Z90.12

question

Patient was seen in the clinic for desquamation of skin. He had a bone marrow transplant 2 months ago. The physician is treating him for acute GVHD.

answer

T86.09, D89.810, R23.4

question

The patient was admitted with a deep vein thrombosis. Doppler examination was positive for thrombosis right tibial vein. The patient was treated for DVT a couple of years ago. Because of recurrent thrombosis, the patient was assessed for coagulation disorders and was found to have protein S deficiency. Final Diagnosis: Deep vein thrombosis with edema lower leg. Protein S deficiency. History of previous DVT.

answer

I82.441, D68.59, Z86.718

question

All of the following are symptoms of anemia EXCEPT ____.

answer

hot flashes

question

The patient was admitted to the hospital with usual pain symptoms for sickle cell/Hb-SS disease. The patient did not fill the pain medication prescription, and recent cold weather has brought on a vaso-occlusive crisis. Chest x-ray was performed and revealed evidence of acute chest syndrome. The patient has had right hip replacement for avascular necrosis and is scheduled to have the left hip replaced next month because of avascular necrosis, which is due to the patient's sickle cell disease. Final Diagnosis: Sickle cell crisis with acute chest syndrome. Status post hip replacement.

answer

D57.01, Z96.641

question

Hemophilia ____, also called Christmas disease, is the result of a deficiency of factor IX.

answer

B

question

____ is a common type of hereditary hemolytic anemia that is found more often in the African American population and among people living in Africa, the Mediterranean, Arabia, and South Asia.

answer

Sickle cell anemia

question

The normal red blood cell count for females is ____.

answer

4.0 million to 5.5 million/mm3

question

A patient is admitted with neutropenic fever. The patient has been receiving chemotherapy for AML. No source of infection is identified, and it is thought that the patient's neutropenia is due to chemotherapy. The patient is discharged.

answer

D70.1, R50.81, T45.1x5A, C92.00

question

Anemia due to chronic kidney disease can be used as the principal diagnosis code in ICD-10-CM if the reason for the encounter is to treat the anemia.

answer

False

question

Radiation therapy, drugs that are used for chemotherapy, and other chemicals may result in neutropenia.

answer

True

question

Hemophilia ____ is a common condition that results from a deficiency or abnormality of clotting factor VIII.

answer

A

question

Procedural complications affecting the spleen are included in Chapter 3 of ICD-10-CM.

answer

True

question

C. difficile:

answer

is one of the most common nosocomial infections in the world is characterized by watery diarrhea can be detected by stool specimen all of the above (correct answer)

question

Two codes are always required when coding an organism and disease condition.

answer

False

question

The most serious form of anthrax is one that is:

answer

inhalation

question

MRSA:

answer

stands for methicillin-resistant Staphylococcus aureus

question

HAART stands for

answer

HAART stands for

question

HIV infection can be coded if documented as "possible" or "probable."

answer

false

question

Chronic hepatitis:

answer

can be caused by type B, C, and D hepatitis can last a lifetime is an inflammation of the liver all of the above (correct answer)

question

Tuberculosis can affect which body system?

answer

lung bone kidney all of the above (correct answer)

question

Coding severe sepsis requires:

answer

at least 2 codes

question

Septicemia is:

answer

the presence of bacteria in the blood causing illness

question

Infectious diseases are characterized often by a disease code and an organism code. When this occurs, it is appropriate to use two codes.

answer

True

question

A patient is admitted with pneumonia. The physician suspects sepsis and orders blood cultures. Discharge summary lists principal diagnosis as pneumococcal sepsis.

answer

A40.3, J18.9

question

A homeless man presented to the ER with diabetic ulcers of the right calf of the leg that are infested with maggots.

answer

E11.622, L97.219, B87.1

question

If sepsis is present on admission and meets the definition of principal diagnosis, the systemic infection code should be assigned as the principal diagnosis.

answer

True

question

Clostridium difficile spores can survive up to ____ days.

answer

70

question

Code B20 is NEVER used once a patient develops AIDS.

answer

False

question

Tuberculosis usually occurs in populations with weaker immune systems. This would include all of the following EXCEPT ____.

answer

teenagers

question

A patient is admitted to the hospital with severe diarrhea. Upon examination, the patient is found to be severely dehydrated. She is given IV fluids to correct the hydration. In the assessment, the physician suspects gastroenteritis. After stool cultures, it is determined that the patient has C. difficile colitis.

answer

A04.7, E86.0

question

A patient was admitted to the hospital with fever, cough, and low blood pressure. CXR shows infiltrates, and sputum culture is positive for MRSA. The patient is a known type II diabetic. The discharge summary indicates that the patient was admitted and was given IV antibiotics for MRSA pneumonia.

answer

J15.212, E11.9

question

A patient known to be positive for HIV is admitted to the hospital with high fever, malaise, and cough. PCP pneumonia is suspected. Tests reveal that the patient has infectious mononucleosis.

answer

B27.90, Z21

question

The patient was admitted with septic shock. Blood cultures were positive for coagulase-negative staphylococcus. Patient was also treated for pneumonia. BAL was performed (right middle lobe bronchus).

answer

A41.1, R65.21, J18.9, 0B958ZX or R65.20, A41.1, J18.9, 3E0F8KZ ask instructor

question

How many stages of syphilis are there?

answer

three

question

Another name for a cold sore is herpes simplex type ____.

answer

I

question

Hepatitis ____ is spread through contact with infected blood, through sex with an infected person, or during childbirth. There is a vaccine for this kind of hepatitis.

answer

B

question

Patient has elevated liver function tests and was diagnosed with alcoholic hepatitis. Patient drinks alcohol on a daily basis.

answer

K70.10, F10.20

question

Gonococcal conjunctivitis is coded to:

answer

A54.31

question

Jock itch is coded to ____.

answer

B35.6

question

Of the following medications, which is NOT an antifungal medication?

answer

Zovirax

question

____ is a bacterial infection usually found in wild or domestic animals.

answer

Anthrax

question

When a person carries an infectious disease and shows no ill effects, he or she is known as a(n) ____.

answer

asymptomatic

question

Abnormal findings alone on a report can be coded.

answer

False

question

Z codes can be coded only as principal diagnosis.

answer

False

question

To indicate birth status for a newborn, use a:

answer

code

question

A symptom is:

answer

subjective evidence of a disease or of a patient's condition as perceived by the patient

question

Signs and symptoms that are integral to the disease process:

answer

should not be coded

question

Fever is an example of a sign/symptom.

answer

True

question

Prophylactic means:

answer

medication used to prevent a disease from occurring

question

A Z code is used to indicate a history of a certain condition, even if the patient currently has the condition.

answer

False

question

A screening examination is:

answer

an examination of an asymptomatic individual to detect a given disease

question

Threatened or impending conditions should never be coded as confirmed

answer

False

question

The infant was seen in the ER for fever. Physician documented fever due to vaccination.

answer

R50.83

question

A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease, condition, or injury.

answer

follow-up code

question

Which of the following is a category of Z codes?

answer

a. Contact/exposure b. Inoculations and vaccinations c. Status d. All of the above (correct answer)

question

Patient is admitted to hospice care for treatment of terminal ESRD.

answer

N18.6, Z51.5

question

Which of the following is NOT true of status codes?

answer

a. A status code is informative because the status may affect the course of treatment and its outcome. b. A status code is distinct from a history code. c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code. d. None of the above are correct. (correct answer)

question

Signs and symptoms are not often correlated with a definitive diagnosis in the health record.

answer

True

question

Patient was seen in the clinic. Final diagnosis is RUQ rebound abdominal tenderness.

answer

R10.811

question

Patient has been taking Lipitor for hypercholesterolemia for one year. A hepatic function laboratory test was performed to assess any adverse effects on the patient's liver function. A fasting lipid profile was also done to assess the effectiveness of the Lipitor.

answer

Z51.81, Z79.899, E78.0

question

A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.

answer

True

question

The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer and the patient has severe fibrocystic disease in both breasts, making breast examination difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy. Final Diagnosis: Family history of breast cancer; severe fibrocystic disease. Procedure: Bilateral simple mastectomy.

answer

Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ

question

The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread. Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out. Procedure: Needle core biopsy axillary lymph node.

answer

R59.0, Z85.3, Z90.12, 07B63ZX

question

In ICD-10-CM there are Excludes1 notes that are helpful in determining whether a symptoms code should be assigned.

answer

True

question

A person who has had an allergic episode related to a substance or food in the past should always be considered allergic to the substance.

answer

True

question

The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.

answer

J18.9, E86.0

question

Observation codes are to be used if an injury or illness, or any signs or symptoms related to the suspected condition, are present.

answer

False

question

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.

answer

True

question

A screening code may be listed first if the reason for the visit is specifically a screening exam.

answer

True

question

A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103 and had been started on antibiotics the day before for an acute bilateral otitis media. The patient was discharged to the care of the parents on the following day. Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.

answer

R56.00, H66.93

question

The patient was admitted with abdominal pain in the right upper quadrant. Workup included an EGD that showed some mild gastritis, and abdominal ultrasound was positive for gallstones in the gallbladder. Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis. Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.

answer

K29.70, K80.20, 0DB68ZX

question

The patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting. The patient had a low-grade fever. A diagnosis of acute appendicitis is made, and the patient is taken to the OR for removal of the appendix via open approach.

answer

K35.80, 0DTJ0ZZ

question

Z codes:

answer

indicate a reason for an encounter

question

Canceled procedures should be coded as if they were performed as expected.

answer

False

question

A valid OR procedure is one that:

answer

may affect MS-DRG assignment

question

Cutting out or off, without replacement, a portion of a body part is the definition for which root operation?

answer

excision

question

Which characters are not used in ICD-10-PCS?

answer

the letters I and O

question

A limited coverage procedure should never be coded in any circumstance.

answer

False

question

The root operation identifies the main objective of the procedure performed.

answer

True

question

Which code should be used if a procedure is canceled because of patient smoking?

answer

Z53.01

question

MS-DRGs are broken up into medical and surgical sections.

answer

True

question

A significant procedure is one that:

answer

is surgical in nature carries a procedural risk requires special training all of the above (correct answer)

question

It is a routine part of most surgical procedures to close the operative wound(s), so it is not necessary to code this separately.

answer

True

question

The abbreviation "OR" in the health record stands for "orally related."

answer

False

question

The AMA is responsible for the maintenance of ICD-10-PCS.

answer

False (CMS)

question

Stopping, or attempting to stop, postprocedural bleeding is called ____.

answer

Control

question

Putting back in or on all or a portion of a separated body part to its normal location or other suitable location is reattachment.

answer

True

question

The body site for perirenal is kidney.

answer

True

question

The fifth character value represents the body part in the medical and surgical section.

answer

False

question

Who is responsible for the maintenance of ICD-10-PCS?

answer

CMS

question

It is required that a coder use the Index to assign an ICD-10-PCS code.

answer

False

question

The root operation "replacement" always involves a device.

answer

True

question

ICD-10-PCS is divided into how many sections?

answer

16

question

Any procedure that affects payment or reimbursement must be reported.

answer

True

question

A closed reduction of a fracture is coded to the external approach.

answer

True

question

Temporary postoperative wound drains are not considered devices, and no ICD-10-PCS code is assigned.

answer

True

question

In some instances, a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This would be an example of when a ____ would be coded.

answer

closure

question

The approach for a laparoscopic cholecystectomy is percutaneous endoscopic.

answer

True

question

The body site for perirenal is peritoneum.

answer

False

question

Which of the following is a characteristic of ICD-10-PCS?

answer

There are three to four possible values for a character.

question

The third character of an ICD-10-PCS code represents ____.

answer

root operation

question

Procedures that are performed using an open approach with percutaneous endoscopic assistance are coded to open approach.

answer

True

question

Crisis intervention services are a procedure that can be coded in the Mental Health section.

answer

True

question

The terminology used in ICD-10-PCS is such that multiple meanings can be used for the same term.

answer

False

question

MRI procedures are located in the Nuclear Medicine section.

answer

False

question

The term "products of conception" refers only to the fetus.

answer

False

question

What root operation is assigned for putting material on a body region for protection?

answer

Dressing

question

The approach for chiropractic manipulation is always external.

answer

True

question

What is the section value for radiation oncology?

answer

D

question

The correct PCS code for continuous mechanical ventilation (respiratory) for 36 hours is:

answer

5A1945Z

question

Monitoring is defined as determining the level of physiologic or physical function repetitively over a period of time.

answer

True

question

Procedures from the Obstetric Tables are any procedure performed on a pregnant woman.

answer

False

question

Radionuclide is the fifth character in the nuclear medicine section.

answer

True

question

Detoxification services are a procedure that can be coded in the mental health section.

answer

False

question

In the mental health section, characters five, six, and seven are for qualifiers.

answer

True

question

Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.

answer

False

question

Modality qualifier is the fifth character in the radiation oncology section.

answer

True

question

External is the only root operation that can be used in the osteopathic section.

answer

False

question

In the extracorporeal assistance and performance section, the definition for assistance is completely taking over a physiological function by extracorporeal means.

answer

False

question

The first character value for an imaging procedure is B.

answer

True

question

The first character value for substance abuse treatment is H.

answer

True

question

The fourth character is the body part that is the focus of the radiation therapy.

answer

True

question

The first character value for a mental health procedure is G.

answer

True

question

A bone marrow transplant is coded in the Administration section.

answer

True

question

The approach for an osteopathic treatment is always external.

answer

True

question

Fluoroscopy procedures are located in the imaging section.

answer

True

question

In the Administration section, character "2" is used to identify the substance being introduced.

answer

False

question

Irrigation is a root operation that is found in the placement section.

answer

False

question

According to the guidelines, it is acceptable to assign codes for BMI based on the documentation of a clinician such as a dietitian.

answer

True

question

When coding encounters for rehabilitation, a procedure code should be reported to identify each type of rehabilitation therapy that was performed.

answer

True

question

If a condition is documented as both acute and chronic and there are separate codes at the same indentation level, the chronic condition is sequenced first.

answer

False

question

A sequela is:

answer

the residual effect (condition produced) after the acute phase of an illness or injury has terminated

question

In the inpatient setting, it is acceptable to code diagnoses that have not yet been confirmed but are questionable or suspected at the time of discharge.

answer

False

question

If a condition has been documented as impending and actually occurs, it is acceptable to code the confirmed diagnosis.

answer

True

question

A condition that is present on admission:

answer

is present when a patient is brought to the hospital

question

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.

answer

True

question

Conditions that are routinely associated with a disease should be coded as an additional diagnosis.

answer

False

question

Principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

answer

True

question

Etiology/manifestation convention requires ____ code(s) to fully describe a single condition that affects multiple body systems.

answer

Two

question

When the patient is admitted for a complication due to a surgical procedure, the complication is the principal diagnosis.

answer

True

question

If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists.

answer

True

question

When a coder notices on a laboratory test result that a patient's sodium is below normal, it is acceptable to code hyponatremia.

answer

False

question

If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.

answer

False

question

A(n) ____ is a residual effect (condition produced) after the acute phase of an illness or injury has terminated.

answer

sequela

question

In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.

answer

False

question

The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.

answer

False

question

Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.

answer

True

question

If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.

answer

False

question

Crisis intervention services are a procedure that can be coded in the Mental Health section.

answer

True

question

NEC (not elsewhere classifiable) represents:

answer

unspecified

question

For etiology/manifestation coding, the instructional notes indicate:

answer

the manifestation is coded first, then the etiology

question

An "excludes 1" note means:

answer

not coded here

question

A code category that requires a 7th character must always have this character placed in the 7th character data field.

answer

True

question

The word "__________" in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order.

answer

with

question

The "see" instruction following a main term in the index indicates that:

answer

there is an additional external cause code required

question

The word "and" should be interpreted to mean:

answer

not elsewhere classified

question

Which letter represents a dummy place holder?

answer

X

question

The main terms for procedures are identified in the Alphabetic Index by:

answer

the type of procedure performed.

question

The main term is ____

answer

a term identifying disease conditions or injuries

question

A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.

answer

False

question

The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.

answer

False

question

To be sure you have the correct diagnosis code, it is very important to go to the Alphabetic Index first and then to the Tabular List.

answer

True

question

What is the main term in the procedure "vaginal hysterectomy"?

answer

hysterectomy

question

A query should contain all of the following items EXCEPT ____.

answer

amount of increased reimbursement due to query

question

The AHIMA practice brief says that query forms should do none of the following EXCEPT ____.

answer

contain precise language

question

It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.

answer

True

question

Clinical data in the medical record do not include:

answer

total charges of patient's stay

question

Which is an area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?

answer

Physician orders

question

One of the most important aspects of developing an effective query form is the manner in which the form is worded.

answer

True

question

Principal diagnosis is defined as:

answer

the condition after study to be chiefly responsible for occasioning the admission of the patient for care

question

In some cases a patient is ready to be discharged from the hospital, but at the last minute the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.

answer

develops a fever

question

Conditions that are an integral part of the disease process are coded.

answer

False

question

What does EKG stand for?

answer

Electrocardiogram

question

The medical record serves as a legal document of care and services provided.

answer

True

question

The chief complaint is:

answer

the reason in the patient's own words for presenting to the hospital

question

If the condition of a patient is being clinically evaluated, the coder would expect to see ____.

answer

clinical observations

question

MS-DRGs affect:

answer

reimbursement

question

A "CBC" is an item that would be included in a:

answer

laboratory report

question

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.

answer

False

question

Sometimes ____ will be used to help diagnose a patient's condition.

answer

x-rays

question

Which of these is NOT considered a physician?

answer

Medical student

question

The discharge summary is:

answer

a summary of the patient's hospital stay

question

Always choose the documenting physician's principal diagnosis as the principal diagnosis for coding purposes.

answer

False

question

SOAP format stands for:

answer

subjective, objective, assessment, plan

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