Chapter Five:Professional Review Guide – Flashcards
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Which of the following is a valid ICD-9-CM principal diagnosis code? a. V30.00 single live born, born in hospital b. V27.2 outcome of delivery, twins, both live born c. M9010/0 fibroadenoma, NOS d. E867 accidental poisoning by gas distributed by pipeline
answer
V30.00 single live born, born in hospital
question
A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign a. an unlisted procedure code located in the eye and ocular adnexa section. b. an unlisted Evaluation and Management code from the E/M section. c. an ophthalmologic treatment service code. d. a HCPCS Level Two (alphanumeric) code.
answer
an unlisted procedure code located in the eye and ocular adnexa section.
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A system of preferred terminology for naming disease processes is known as a a. classification system. b. set of categories. c. diagnosis listing. d. medical nomenclature.
answer
medical nomenclature
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Which of the following is NOT included as a part of the minimum data maintained in the MPI? a. patient medical record number b. principal diagnosis c. date of birth d. full name (last, first, and middle)
answer
principal diagnosis
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The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts? a. consultation index b. operation index c. physician's index d. disease index
answer
disease index
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One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued? a. 10 years b. until remission occurs c. 1 year d. for the life of the patient
answer
for the life of the patient
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In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to a. code the record as is. b. confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant. c. code the abnormal potassium level as a complication following surgery. d. code the condition as abnormal blood chemistry.
answer
confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.
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DSM-IV-TR is used most frequently in what type of health care setting? a. ambulatory surgery centers b. behavioral health centers c. nursing homes d. home health agencies
answer
behavioral health centers
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A coder notes that a patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of a. glaucoma. b. arthritis. c. laryngitis. d. bronchitis.
answer
glaucoma
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The patient is diagnosed with congestive heart failure. A drug of choice is a. oxytocin. b. ibuprofen. c. digoxin. d. haloperidol.
answer
digoxin
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ICD-10-CM utilizes a placeholder character. This is used as a 5th character placeholder at certain 6 character codes to allow for future expansion. The placeholder character is a. "O." b. "Z. c. "x." d. "1."
answer
"x."
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The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct a. Standard Nomenclature of Injuries codes. b. CPT code. c. HCPCS Level II codes. d. E-codes and ICD-9-CM codes.
answer
E-codes and ICD-9-CM codes.
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A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is a. abdominal pain. b. alcoholism. c. acute pancreatitis. d. cholecystitis.
answer
acute pancreatitis
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In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when a. a new patient is seen in the office. b. the patient is established. c. the patient is seen for a follow-up inpatient consultation. d. the patient is given subsequent care in the hospital.
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a new patient is seen in the office.
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A direction to "code first underlying disease" should be considered a. a mandatory instruction. b. only when coding inpatient records. c. a suggestion only. d. mandatory dependent on the code selection.
answer
a mandatory instruction.
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Which classification system was developed to standardize terminology and codes for use in clinical laboratories? a. Systematized Nomenclature of Pathology (SNOP) b. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) c. Logical Observation Identifiers, Names and Codes (LOINC) d. Read Codes
answer
Logical Observation Identifiers, Names and Codes (LOINC)
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Which classification system is used to classify neoplasms according to site, morphology, and behavior? a. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) b. International Classification of Diseases for Oncology (ICD-O) c. Current Procedural Terminology (CPT) d. Diagnostic and Statistical Manual of Mental Disorders (DSM)
answer
International Classification of Diseases for Oncology (ICD-O)
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According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a a. significant procedure. b. principal procedure. c. therapeutic procedure. d. operating room procedure.
answer
significant procedure.
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The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the a. National Center for Health Statistics (NCHS). b. Centers for Medicare and Medicaid Services (CMS). c. American Health Information Management Association (AHIMA). d. American Hospital Association (AHA).
answer
National Center for Health Statistics (NCHS).
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An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) a. automated codebook. b. logic-based encoder. c. automatic code assignment. d. grouper.
answer
logic-based encoder.
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Which of the following classification systems was designed with electronic systems in mind and is currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and image d? a. SNDO b. SNOMED CT c. GEM d. ICDPC-2
answer
SNOMED CT
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The Unified Medical Language System (UMLS) is a project sponsored by the a. CMS. b. National Library of Medicine. c. Office of Inspector General. d. World Health Organization.
answer
National Library of Medicine.
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A patient is admitted with shortness of breath and hemoptysis. A chest x-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected. The principal diagnosis is the a. small cell lung carcinoma. b. metastatic brain carcinoma. c. pneumonia. d. hemoptysis.
answer
small cell lung carcinoma.
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Jane Moore was admitted to the ambulatory care unit of the hospital for a planned cholecystectomy for cholelithiasis. Shortly before surgery, Jane developed tachycardia, and the surgery was canceled. After a thorough workup for the tachycardia, Jane was discharged. This outpatient admission should be coded in the following sequence: a. tachycardia, V code for canceled surgery, cholelithiasis b. V code for canceled surgery, tachycardia, cholelithiasis c. cholelithiasis, tachycardia, V code for canceled surgery d. cholelithiasis, V code for canceled surgery
answer
cholelithiasis, tachycardia, V code for canceled surgery
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A 75-year-old female was admitted for repair of a hiatal hernia that was performed on the first day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur, which was surgically reduced. Further complications included severe angina for which a cardiac catheterization and PTCA were performed. The principal procedure is a. herniorrhaphy. b. femur reduction. c. PTCA. d. catheterization.
answer
herniorrhaphy
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Code 402, Hypertensive Heart Disease, would appropriately be used in which of the following situations? REFERENCE: a. congestive heart failure; hypertension b. left heart failure with benign hypertension c. cardiomegaly with hypertension d. hypertensive cardiovascular disease with congestive heart failure
answer
hypertensive cardiovascular disease with congestive heart failure
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A patient is admitted to the hospital 6 weeks post myocardial infarction with severe chest pains. Which is the correct code? a. 410.1x acute MI b. 414.8 chronic MI c. 413.0 angina d. 412 old MI
answer
410.1x acute MI
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Susan Dawn is status post mastectomy (6 weeks) due to carcinoma of the breast. She is admitted to the outpatient clinic for chemotherapy. What is the correct sequencing of the codes? REFERENCE: a. V58.11 chemotherapy; V10.3 personal history of neoplasm of the breast b. V58.11 chemotherapy; 174.9 malignant neoplasm of breast c. V10.3 personal history of neoplasm of the breast; V58.11 chemotherapy d. V67.00 follow-up exam after surgery; V58.11 chemotherapy
answer
V58.11 chemotherapy; 174.9 malignant neoplasm of breast
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Which of the following is coded as an adverse effect in ICD-9-CM? a. rejection of transplanted kidney b. mental retardation due to intracranial abscess c. nonfunctioning pacemaker due to defective soldering d. tinnitus due to allergic reaction after administration of eardrops
answer
tinnitus due to allergic reaction after administration of eardrops
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A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as a. a consultation. b. a referral. c. concurrent care. d. risk factor intervention.
answer
a consultation.
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A patient with leukemia is admitted for chemotherapy 5 weeks after experiencing an acute myocardial infarction. How will the MI be coded? a. acute MI with 5th digit 2—subsequent episode of care b. acute MI with 5th digit 1—initial episode of care c. chronic MI d. history of MI
answer
acute MI with 5th digit 2—subsequent episode of care
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In ICD-9-CM, when an exploratory laparotomy is performed followed by a therapeutic procedure, the coder lists a. exploratory laparotomy, therapeutic procedure, closure of wound. b. therapeutic procedure first, exploratory laparotomy second. c. exploratory laparotomy first, therapeutic procedure second. d. therapeutic procedure only.
answer
therapeutic procedure first, exploratory laparotomy second.
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The most widely discussed and debated unique patient identifier is the a. patient's first and last names. b. patient's date of birth. c. Unique Physician Identification Number (UPIN). d. patient's social security number.
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patient's social security number.
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The Central Office on ICD-9-CM, which publishes Coding Clinic, is maintained by the a. Centers for Medicare and Medicaid Services. b. National Center for Health Statistics. c. American Health Information Management Association. d. American Hospital Association.
answer
American Hospital Association.
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A nomenclature of codes and medical terms that provides standard terminology for reporting physicians' services for third-party reimbursement is a. Current Procedural Terminology (CPT). b. Current Medical Information and Terminology (CMIT). c. Diagnostic and Statistical Manual of Mental Disorders (DSM). d. Systematized Nomenclature of Pathology (SNOP).
answer
Current Procedural Terminology (CPT).
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A cancer program is surveyed for approval by the a. Commission on Cancer of the American College of Surgeons. b. American Cancer Society. c. Joint Commission on Accreditation of Healthcare Organizations. d. State Department of Health.
answer
Commission on Cancer of the American College of Surgeons.
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The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels? a. ABC codes b. READ codes c. LOINC d. SPECIALIST Lexicon
answer
ABC codes
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The Level II (national) codes of the HCPCS coding system are maintained by the a. CPT Editorial Panel. b. American Medical Association. c. Centers for Medicare and Medicaid Services. d. local fiscal intermediary.
answer
Centers for Medicare and Medicaid Services.
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A patient is admitted with alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis? a. chronic alcoholism b. alcoholic withdrawal c. delirium tremens d. cocaine dependence
answer
delirium tremens
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A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia? a. clostridium b. pseudomonas c. listeria d. staphylococcus
answer
pseudomonas
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The Level I (CPT) codes of the HCPCS coding system are maintained by the a. American Hospital Association. b. American Medical Association. c. Centers for Medicare and Medicaid Services. d. local fiscal intermediary.
answer
American Medical Association.
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A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded? a. excision of lesion; full-thickness skin graft to scalp b. full-thickness skin graft to scalp only c. code 15004 for surgical preparation of recipient site; full-thickness skin graft to scalp d. excision of lesion; full-thickness skin graft to scalp; excision of skin from thigh
answer
excision of lesion; full-thickness skin graft to scalp
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A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit. a. -55 b. -25 c. -58 d. -57
answer
-57
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A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued. a. -53 b. -52 c. -74 d. -73
answer
-53
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A barrier to widespread use of automated code assignment is a. poor quality of documentation. b. inadequate technology. c. resistance by HIM professionals. d. resistance by physicians.
answer
poor quality of documentation.
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In assigning E/M codes, three key components are used. These are a. history, examination, time. b. history, examination, counseling. c. history, examination, medical decision making. d. history, nature of presenting problem, time.
answer
history, examination, medical decision making.
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Mrs. Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit. a. -76 b. -58 c. -79 d. -78
answer
-78
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. The primary goal of a hospital-based cancer registry is to a. allocate hospital resources appropriately. b. improve patient care. c. monitor cancer incidence. d. determine the need for professional and public education programs.
answer
improve patient care
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A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus. She has type 1 diabetes and was brought under control and subsequently discharged. The following code was assigned: 648.03 Other current condition in the mother classifiable elsewhere but complicating pregnancy, childbirth of the puerperium, diabetes mellitus Which of the following describes why the coding is in error? a. The condition should have been coded as gestational diabetes because she is pregnant. b. The incorrect fifth digit was used. c. Only the code for the diabetes mellitus should have been used. d. An additional code describing the diabetes mellitus should be used.
answer
An additional code describing the diabetes mellitus should be used.
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A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a a. master patient index. b. disease index. c. admissions register. d. disease registry.
answer
disease registry.
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After reviewing the following excerpt from CPT, code 27646 would be interpreted as 27645 Radical resection of tumor; tibia 27646 fibula 27647 talus or calcaneus a. 27646 radical resection of tumor; fibula. b. 27646 radical resection of tumor; tibia and fibula. c. 27646 radical resection of tumor; fibula, talus or calcaneus. d. 27646 radical resection of tumor; fibula or tibia.
answer
27646 radical resection of tumor; tibia and fibula.
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A patient was admitted to the hospital with hemiplegia and aphasia. The hemiplegia and aphasia were resolved before discharge and the patient was diagnosed with cerebral thrombosis. What is the correct coding and sequencing? a. cerebral thrombosis b. hemiplegia; aphasia c. hemiplegia; cerebral thrombosis; aphasia d. cerebral thrombosis; hemiplegia; aphasia
answer
cerebral thrombosis; hemiplegia; aphasia
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A 36-year-old woman was admitted to the hospital for an obstetrical delivery of her third child. During the admission, a sterilization procedure was performed for contraceptive purposes. The V25.2 code for sterilization would be a. assigned as a secondary diagnosis. b. assigned as a principal diagnosis. c. not assigned because it is the same admission as the delivery. d. not assigned because this was the patient's third child.
answer
assigned as a secondary diagnosis.
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According to ICD-9-CM, which one of the following is NOT a mechanical complication of an internal implant? a. inflammation of urethra due to indwelling catheter b. erosion of skin by pacemaker electrodes c. IUD embedded in uterine wall d. leakage of breast prosthesis
answer
inflammation of urethra due to indwelling catheter
question
A population-based cancer registry that is designed to determine rates and trends in a defined population is a(n) a. cancer control population-based registry. b. incidence-only population-based registry. c. patient care population-based registry. d. research-oriented population-based registry.
answer
incidence-only population-based registry.
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Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)? a. lungs b. axillary lymph nodes c. axillary lymph nodes and lungs d. breast
answer
breast
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When is it appropriate to use category V10, history of malignant neoplasm? a. Primary malignancy has been eradicated and no adjunct treatment is being given at this time. b. Primary malignancy recurred at the original site and adjunct chemotherapy is directed at the site. c. Primary malignancy is eradicated; adjunct treatment is refused by the patient even though there is some remaining malignancy. d. Primary malignancy has been eradicated and the patient is admitted for adjunct chemotherapy to the primary site.
answer
Primary malignancy has been eradicated and no adjunct treatment is being given at this time.
question
According to CPT, in which of the following cases would an established E/M code be used? a. John and his family have just moved to town. John has asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician. b. A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. c. A 78-year-old female with weight loss and progressive agitation over the past 2 months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years. d. Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.
answer
Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.
question
In order to use the inpatient CPT consultation codes, the consulting physician must a. document his findings in the patient's medical record. b. order diagnostic tests. c. use the term "referral" in his report. d. communicate orally his opinion to the attending physician.
answer
document his findings in the patient's medical record.
question
The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits? a. an initial inpatient consult for both visits b. an initial inpatient consult and a follow-up consult c. an initial inpatient consult and initial hospital care d. an initial inpatient consult and a subsequent hospital visit
answer
an initial inpatient consult and a subsequent hospital visit
question
According to the American Medical Association, medical decision making is measured by all of the following except the a. amount and complexity of data reviewed. b. number of diagnoses or management options. c. specialty of the treating physician. d. risk of complications.
answer
. specialty of the treating physician.
question
CPT provides Level I modifiers to explain all of the following situations except a. when one surgeon provides only postoperative services. b. when a service or procedure is partially reduced or eliminated at the physician's discretion. c. when the same laboratory test is repeated multiple times on the same day. d. when a patient sees a surgeon for follow-up care after surgery.
answer
when a patient sees a surgeon for follow-up care after surgery.
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The best place to ascertain the size of an excised lesion for accurate CPT coding is the a. pathology report. b. discharge summary. c. anesthesia record. d. operative report.
answer
operative report.
question
Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement? a. ICD-10-CM b. LOINC c. NANDA d. NDC
answer
ICD-10-CM
question
Case definition is important for all types of registries. Age will certainly be an important criterion for accessing a case in a(n) ________ registry. a. trauma b. implant c. birth defects d. HIV/AID
answer
birth defects
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To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed? a. evaluation and management codes b. ICD-9-CM codes c. CPT codes d. HCPCS Level II Codes
answer
CPT codes
question
The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the a. tickler file. b. disease index. c. suspense file. d. accession register.
answer
accession register.
question
The reference date for a cancer registry is a. the date when data collection began. b. January 1 of the year in which the registry was established. c. the date that the cancer program applies for approval by the American College of Surgeons. d. the date that the Cancer Committee is established.
answer
the date when data collection began.
question
The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses these data for its a. diabetes registry. b. AIDS registry. c. trauma registry. d. implant registry.
answer
trauma registry.
question
In relation to birth defects registries, active surveillance systems a. are commonly used in all 50 states. b. use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs. c. rely on reports submitted by hospitals, clinics, or other sources. d. miss 10% to 30% of all cases.
answer
use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs.
question
In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to a. validity. b. reliability. c. timeliness. d. completeness.
answer
reliability
question
The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the a. Centers for Medicare and Medicaid Services. b. Agency for Healthcare Research and Quality. c. World Health Organization. d. National Library of Medicine.
answer
Agency for Healthcare Research and Quality.
question
The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with a. validity. b. reliability. c. timeliness. d. completeness.
answer
completeness
question
When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding? a. donor site b. recipient site c. type of repair d. size of defect
answer
donor site
question
In CPT, Category III codes include codes a. to measure performance. b. to describe emerging technologies. c. for supplies, drugs, and durable medical equipment. d. for use by nonphysician practitioners.
answer
to describe emerging technologies.
question
The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a a. diabetes registry. b. birth defects registry. c. trauma registry. d. transplant registry.
answer
transplant registry.
question
In the ICD-9-CM classification system, shooting pain in the right eye due to the presence of an intact, correctly positioned permanent contact lens would be coded as a(n) a. late effect. b. current injury. c. abnormal reaction of the body to the presence of an internal prosthetic device. d. mechanical complication of an internal prosthetic device.
answer
abnormal reaction of the body to the presence of an internal prosthetic device.
question
In the ICD-9-CM classification system, severe shock due to third-degree burns sustained in an industrial accident would be coded as a(n) a. late effect. b. current injury. c. abnormal reaction of the body to the presence of an internal prosthetic device. d. mechanical complication of an internal prosthetic device.
answer
current injury.
question
In the ICD-9-CM classification system, a nonfunctioning pacemaker due to the disintegration of the electrodes (leads) would be coded as a(n) a. late effect. b. current injury. c. abnormal reaction of the body to the presence of an internal prosthetic device. d. mechanical complication of an internal prosthetic device.
answer
mechanical complication of an internal prosthetic device.
question
In the ICD-9-CM classification system, an esophageal stricture due to a burn received in a house fire several years ago would be coded as a(n) a. late effect. b. current injury. c. abnormal reaction of the body to the presence of an internal prosthetic device. d. mechanical complication of an internal prosthetic device.
answer
late effect.
question
Dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as a(n) a. adverse reaction to a drug. b. poisoning. c. late effect of an adverse reaction. d. late effect of a poisoning.
answer
poisoning
question
Tachycardia after taking a correct dosage of prescribed Lortab would be reported as a(n) a. adverse reaction to a drug. b. poisoning. c. late effect of an adverse reaction. d. late effect of a poisoning.
answer
adverse reaction to a drug.
question
Blindness due to an allergic reaction to ampicillin administered 6 years ago would be reported as a(n) a. adverse reaction to a drug. b. poisoning. c. late effect of an adverse reaction. d. late effect of a poisoning.
answer
late effect of an adverse reaction.
question
The patient underwent bypass surgery for life-threatening coronary artery disease. With the aid of extracorporeal circulation, the right internal mammary artery was taken down to the left anterior descending artery and saphenous vein grafts were brought from the aorta to the diagonal, the right coronary artery, and the posteriordescending artery. What is the correctICD-9-CM coding for this procedure? a. aortocoronary bypass of three coronary arteries b. single internal mammary artery bypass; aortocoronary artery bypass of three vessels c. single internal mammary artery bypass; aortocoronary bypass of three vessels, extracorporeal circulation d. aortocoronary bypass of four coronary arteries
answer
single internal mammary artery bypass; aortocoronary bypass of three vessels, extracorporeal circulation
question
Patient Jamey Smith has been seen at Oceanside Hospital three times prior to this current encounter. Unfortunately, because of clerical errors, Jamey's information was entered into the MPI incorrectly on the three previous admissions and consequently has three different medical record numbers. The unit numbering system is used at Oceanside Hospital. Jamey's previous entries into the MPI are as follows: 09/03/09 Jamey Smith MR# 10361 03/10/10 Jamey Smith Doe MR# 33998 07/23/11 Jamie Smith Doe MR# 36723 The next available number to be assigned at Oceanside Hospital is 41369. Duplicate entries in the MPI should be scrubbed and all of Jamey's medical records should be filed under medical record number a. 33998. b. 10361. c. 41369. d. 36723.
answer
10361
question
The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type, is the a. benchmarking method. b. record-over-record method. c. focused review method. d. code method.
answer
record-over-record method.
question
The most common type of registry located in hospitals of all sizes and in every region of the country is the a. cancer registry. b. trauma registry. c. birth defects registry. d. AIDS registry.
answer
cancer registry.
question
A radiologist is asked to review a patient's CT scan that was taken at another facility. The modifier -26 attached to the code indicates that the physician is billing for what component of the procedure? a. technical b. professional c. confirmatory d global
answer
professional
question
When coding neoplasms, topography means a. site. b. cell structure and form. c. extent of the spread of the disease. d. variation from normal tissue.
answer
site
question
According to CPT, antepartum care includes all of the following except a. physical examination. b. initial and subsequent history. c. routine chemical urinalysis. d. monthly visits up to 36 weeks.
answer
monthly visits up to 36 weeks.
question
The Cancer Committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of these data is the a. operation index. b. disease index. c. cancer registry abstracts. d. master patient index.
answer
cancer registry abstracts
question
A list or collection of clinical words or phrases with their meanings is a a. language. b. data dictionary. c. clinical vocabulary.
answer
clinical vocabulary.
question
The main difference between concurrent and retrospective coding is a. what classification system is used. b. when the coding is done. c. the involvement of the physician. d. the credentials of the coder.
answer
when the coding is done.
question
A patient was discharged from the acute care hospital with a final diagnosis of bronchial asthma. As the coder reviews the record, she notes that the patient was described as having prolonged and intractable wheezing, airway obstruction that was not relieved by bronchodilators, and the lab values showed decreased respiratory function. The coder queried the physician to determine whether the code for ________ is appropriate to be added to the final diagnoses. a. chronic obstructive pulmonary disease b. acute and chronic bronchitis c. status asthmaticus d. respiratory failure
answer
status asthmaticus
question
A patient is undergoing hemodialysis for end-stage renal disease in the outpatient department of an acute care hospital. The patient develops what is believed to be severe heartburn but is sent to observation for several hours, at which time the patient is admitted to inpatient care for further workup. The cardiologist diagnoses the patient's problem as unstable angina. What is the principal diagnosis for the acute hospital stay? a. heartburn b. complications of hemodialysis c. renal disease d. unstable angina
answer
unstable angina
question
A patient is seen in the emergency room of an acute care hospital with tachycardia and hypotension. The patient had received an injection of tetanus toxoid (correct dosage) earlier at his primary care physician's office. Which of the following is the appropriate sequencing for this encounter? a. unspecified adverse reaction to tetanus toxoid; undetermined cause E code (tetanus toxoid) b. hypotension; tachycardia; accidental poisoning E code (tetanus toxoid) c. poisoning code (tetanus toxoid); hypotension; tachycardia; accidental poisoning E code (tetanus toxoid) d. hypotension; tachycardia; therapeutic use E code (tetanus toxoid)
answer
hypotension; tachycardia; accidental poisoning E code (tetanus toxoid)
question
A rare malignant tumor often associated with AIDS is a. glioblastoma multiforme. b. Kaposi's sarcoma. c. melanoma. d. pheochromocytoma.
answer
Kaposi's sarcoma.
question
A PEG procedure would most likely be done to facilitate a. eating. b. breathing. c. none of these. d. urination.
answer
eating
question
What ICD-9-CM coding scheme is used to show that a therapeutic abortion resulted in a live fetus? a. Code 644.21, early onset of delivery; V27 code (outcome of delivery) b. spontaneous abortion; V30 code to show a newborn birth c. therapeutic abortion d. abortion by type; V27 code (outcome of delivery)
answer
Code 644.21, early onset of delivery; V27 code (outcome of delivery)
question
Prolonged pregnancy is a pregnancy that has advanced beyond ________ completed weeks of gestation. a. 40 b. 39 c. 42 d. 41
answer
42
question
CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10-PCS. The use of these two code sets will be effective on a. October 1, 2013. b. January 1, 2014. c. October 1, 2012. d. January 1, 2014.
answer
October 1, 2013.
question
Mappings between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called a. Medical Mappings. b. GEMS (General Equivalency Mappings). c. ICD Code Maps. d. Code Maps.
answer
GEMS (General Equivalency Mappings).
question
The code structure for ICD-10-CM differs from the code structure of ICD-9-CM. An ICD-10-CM code consists of a. 10 characters. b. five alphanumeric characters. c. seven digits. d. three to seven characters.
answer
three to seven characters
question
The first character for all of the codes assigned in ICD-10-CM is a. a number. b. an alphabet. c. a digit. d. an alphabet or a number.
answer
an alphabet.
question
ICD-10-PCS will be implemented in the United States to code a. physician office procedures. b. hospital inpatient procedures. c. hospital outpatient diagnoses. d. hospital inpatient diagnoses.
answer
hospital inpatient diagnoses.
question
ICD-10-PCS codes have a unique structure. An example of a valid code in the ICD-10-PCS system is a. 013.2. b. L03.311. c. 2W3FX1Z. d. B2151.
answer
2W3FX1Z.
question
ICD-10-PCS utilizes the third character in the Medical and Surgical section to identify the "root operation." The name of the root operation that describes "cutting out or off, without replacing a portion of a body part" is a. extirpation. b. destruction. c. removal. d. excision.
answer
excision
question
In ICD-10-PCS, to code "removal of a thumbnail," the root operation would be a. extraction. b. removal. c. extirpation. d. fragmentation.
answer
extraction
question
In ICD-10-CM, the final character of the code indicates laterality. An unspecified side code is also provided should the site not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct the coder to a. assign separate codes for both the left and right side. b. assign the unspecified side code. c. query the physician. d. not assign a code.
answer
assign the unspecified side code.
question
An example of a valid code in ICD-10-CM is a. Z2358.J. b. 576.212D. c. BJRT23x. d. 329.6677.
answer
576.212D.
