AAPC CPC Chapter 5 – Flashcards

A patient is diagnosed with pressure ulcers on each heel. Each heel displays bone involvement with no evidence of necrosis. Select the diagnosis code(s). A) L97.406 B) L89.619 C) L89.610, L89.620 D) L89.619, L89.629

A patient with age-related osteoporosis suffers a pathologic fracture to her right hip. She is being seen for this new fracture today. Select the diagnosis code(s). A) M81.0, Z87.311 B) S72.091A, M80.851A C) M80.051A D) M80.851A

A 55-year-old female with right hydronephrosis presents for a cystourethroscopy with a retrograde pyelogram. What is the correct diagnosis code? A) Q62.11 B) Q62.0 C) N13.30 D) N13.6

A pregnant female, at 21 weeks, is diagnosed with iron-deficiency anemia and is sent to the clinic for a transfusion. Select the diagnosis code(s). A) O99.012 B) D50.9, Z34.92 C) O99.012, D50.9, Z3A.21 D) D50.9, O99.012

A male newborn, delivered vaginally in the hospital, is born with jaundice. Select the diagnosis code(s) for the newborn's record. A) P59.9, Z38.30 B) R17, O80, Z37.0 C) P59.9 D) Z38.00, P59.9

A 4-year-old male is brought to the hospital by his mother. Today he is going to have surgery to repair his Cheiloschisis. Assign the correct code for his condition. A) Q38.0 B) Q38.5 C) Q36.9 D) Q37.9

Mrs. Bixby, 83, is being admitted for dehydration and anorexia. The probable cause is dementia. She was brought in by her daughter who is visiting from out of town. Her daughter will take her from our office to St. Mary's. The gerontology unit will evaluate her mental condition tomorrow after she is stabilized. How would you code the diagnoses? A) F50.00, E86.0 B) R63.0, E86.0 C) F50.00, E86.0, F02.80 D) R63.0, E86.0, F02.80

A patient was prescribed an anti-depressant. She forgot she had taken her pills for the day and took another pill by accident. She is now complaining of dizziness and excessive sweating. Select the diagnosis codes in the correct sequence. A) R42, R61, T43.201A B) R61, R42, T43.202A C) T43.201A, F45.8, R61 D) T43.201A, R42, R61

The patient was hit in the nose by the ball playing basketball on the varsity team last evening at the gym and woke up with severe epistaxis. The family physician controlled the nasal hemorrhage with cauterization and afterwards packed the nose with nasal packs. What are the correct diagnosis codes? A) R04.0, W21.09XA, Y92.39, Y93.79, Y99.8 B) R04.0, W21.05XA, Y92.39, Y93.67, Y99.8 C) I78.0, W21.05XA, Y92.39, Y93.79, Y99.8 D) I78.0, W21.00XA, Y92.39, Y93.67, Y99.8

The provider orders serum blood tests as part of a pre-employment physical exam. What is the diagnosis? A) Z00.00 B) Z00.01 C) Z02.1 D) Z02.79

A patient complains of a rash that is extremely itchy. It began when she started using a new laundry detergent. She is examined and the provider diagnoses her with dermatitis, due to exposure to the laundry detergent. What is the diagnosis code? A) L23.9 B) L20.89 C) L23.5 D) L24.0

A patient diagnosed with BPH presents with urinary urgency. Select the diagnosis code(s). A) N40.0, R39.15 B) R39.15, N40.1 C) N40.1, R39.15 D) N40.1

A code from categories Q00-Q99 can be used until the patient reaches what age? Refer to ICD-10-CM guideline I.C.17. A) They can be used throughout the life of the patient unless it has been corrected. B) They can be used throughout the life of the patient. C) From birth to the 28th day of life D) From birth until age 18

What is the diagnosis code for an elevated blood pressure reading? A) I10 B) R03.0 C) I15.8 D) I95.9

A patient was sent home with a PICC line for Vancomycin treatment at home. He returns to his physician with an infection due to the PICC Line. The infection is determined to be MRSA. Select the diagnosis code(s) in the correct sequence. A) T80.218A B) A49.02 C) T80.218A, A49.02 D) A49.02, T80.218A

The patient's dense breast tissue made the screening mammogram unreadable, and she is here today for a breast ultrasound. Her mother and sister both have history of breast cancer. What are the correct diagnosis codes? A) N60.01, N60.02, Z80.3 B) Z12.31, N62, Z80.3 C) Z13.89, R92.2, Z80.3 D) Z12.39, R92.2, Z80.3

CASE 1 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes. Cardiovascular: RRR, no MRGs, no edema. Respiratory: Lungs CTA, normal respiratory effort. GI: NABS, no HSM. Skin: Warm and dry, decreased turgor. Psychiatric: A&OX3 with appropriate affect. Labs: BUN = 99, creatinine = 3.6, HCO3 = 14, K = 5.9. IMPRESSION 1. New, acute renal failure, due to dehydration 2. Underlying stage III CKD 3. Mild hypotension (Code the definitive diagnoses documented by the provider.) PLAN 1. Bolus with another liter of NS wide open. 2. Then start D5W with 3 amps of HCO3 at 150 cc/hr. 3. Repeat labs in eight hours. 4. Further diagnostic testing will be ordered if there is no improvement of volume repletion. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3: Dx #4:

CASE 2 PROGRESS NOTE Chief complaint: Multiple ulcers. Subjective: The patient returns, accompanied by her caregiver who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better. Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin.(The ulcers are healing.) There is no cellulitis. The only uncomfortable area seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits which have distorted the bottom of her foot dramatically. To relieve the left foot pain,(Location of the foot pain. Patient had foot pain likely due to tophaceous deposits which are an indication of gout. This is not a definitive diagnosis documented by the provider. Code the symptom.) a sole nerve block posterior to the lateral malleolus is carried out with a 50:50 mixture of 1% lidocaine with epinephrine and .5% marcaine. Following this, she gets good relief from the pain of the lateral posterior part of the foot. The legs are cleansed with Hibiclens and multi-layer compression wraps are reapplied by the PA. Assessment: Ulcers are on the feet.(Location of the ulcers.) Edema is in the lower extremities. Foot pain is (Report the codes for the definitive diagnoses. Procedure performed for foot pain.) treated with a nerve block. Fantastic course to date, thanks to her caregiver Plan: Continue with wound care as before. Return to the office in six to eight weeks; at which time, assuming everything is going well, we could set up an OR time for panniculectomy. She appears to understand and is willing to proceed. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3: Dx #4:

CASE 3 Subjective: The patient presents today after having a cabinet fall on her.(This describes how the injury occurred.) She states the people who put in the cabinet missed the stud by about two inches. The patient complains of cephalgias,(Patient complaint.) primarily occipital, extending up into the bilateral occipital and parietal regions. The patient denies any vision changes, any taste changes or any smell changes. The patient has marked amount of tenderness across the superior trapezius.(Patient complaint.) Objective: Her weight is 188 which is up 5 pounds from last time, blood pressure 144/82, pulse rate 70, respirations are 18. She has full strength in her upper extremities. DTRs in the biceps and triceps are adequate. Grip strength is adequate. Heart is a regular rate. Lungs are clear. Assessment: 1. Cephalgia 2. Thoracic somatic dysfunction (Select codes for definitive diagnosis.) Plan: The plan at this time is to send her for physical therapy, three times a week times four weeks for cervical soft tissue muscle massage, as well as upper dorsal. We'll recheck her in one month. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3:

CASE 4 CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.) MODE OF ARRIVAL: Private vehicle. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain. REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough. All other systems have been reviewed and are negative except as noted. PHYSICAL EXAMINATION: General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance. Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air. HEENT: The head is normocephalic and atraumatic. Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles. Heart: Regular rate and rhythm without murmurs Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand symmetrically. Thorax/Chest Wall: Demonstrates mild tenderness anteriorly and demonstrates distinct tenderness posteriorly along the medial aspect of the scapula. No bruising or ecchymosis is noted on the skin of the chest wall. Patient keeps his right shoulder lowered. There is no deformity noted. There is no tenderness over the right clavicle. No bony deformity is noted there. There is no subcutaneous emphysema of the chest wall. Extremities: Warm and dry without clubbing, cyanosis or edema. Grip strength is 5/5 bilaterally. Patient can flex and extend all fingers without difficulty. He can pronate and supinate at the elbow. He complains of pain in the shoulder when he flexes and extends at the elbow. Normal radial and ulnar pulses are appreciated in the bilateral upper extremities. Capillary refill is brisk. Sensation is normal in all nerve distributions in the bilateral arms. Abdomen: Soft, non-distended. Non-tender. Diagnostics: Two views of the chest, PA and lateral, and three views of the right shoulder were obtained. ED course: The patient received a total of 2 mg of Dilaudid for pain, 1 mg of sublingual Ativan. His arm was placed in a sling This was well tolerated and the patient was discharged home. Medical Decision Making: It appears the patient has an anterior chest wall and a posterior chest wall contusion. The exact reasoning why he has so much difficulty moving the shoulder is unclear at this time, as he is completely neurologically intact from what I can tell. He can adduct and abduct at the shoulder, as I have seen him do it as he was moving around to be examined. X-rays demonstrate no evidence of fracture or dislocation. At this point, I am discharging the patient home, having him use ice packs, doing prescriptions for pain medications and having him return for new or worsening symptoms. IMPRESSION: 1 Anterior and posterior chest wall contusion. 2 Right shoulder injury. (Report codes for the definitive diagnosis.) PLAN: Discharge home. Return for new or worsening symptoms. Sling for comfort. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3: Dx #4: Dx #5:

CASE 5 HPI: 20-year-old female, estimated gestational age 25.3 weeks,(Patient is pregnant.) who presents with red staining after wiping with toilet paper (Patient's complaint.) this afternoon. No abdominal pain. Contractions: Negative. Fetal Movement: Present. ROS: Constitutional: Negative. Headache: Negative. Urinary: Negative. Nausea: Negative. Vomiting: Negative. Past Medical/Family/Social History: Medical History: Negative. Surgical History: Negative. Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies. EXAM: General Appearance: No acute distress. Abdominal: Soft. Non-tender. Vagina: Blood clots size: 1.5 cm and amount 2. Discharge:Pink. No hyphae, BV, or TRICH, and CX not irritated. Cervix: Deferred. Uterus: Fundal height: 24 cm. MDM: Labs: FFN, UA R+M, C+S, GC/chlamydia, CBC, type and RH, DAU. Labs reviewed and WNL. Ultrasound: Negative for placenta previa. NOTES: Patient continues with contractions mildly, but does not feel it. Patient given Celestone I/M. D/C and to return tomorrow for repeat Celestone injection. Diagnosis: Threatened premature labor (Report the definitive diagnosis.) What diagnosis code(s) are reported? Dx #1: Dx #2:

CASE 7 PREOPERATIVE DIAGNOSIS: 1. 2 cm transverse laceration of right forehead. 2. 3 cm stellate laceration of right upper eyelid. 3. 3 cm trap door laceration of right lower eyelid. OPERATIVE DIAGNOSIS: OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm. Anesthesia: Local. PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she was thoroughly evaluated by Dr. Tim and is in the process of getting C-spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is linear, deep, but otherwise uneventful. The upper right eyelid laceration is approximately 3 cm in length and the medial aspect of it is somewhat dusky because it is very thin and devoid of vasculature. The lower eyelid laceration is trap door and somewhat deep. It also becomes very thin at the medial aspect; however, there appears to be no duskiness. It seems to be well vascularized. In any event, we chose to immediately repair these with local anesthesia. DETAILS OF OPERATIVE PROCEDURE: Approximately a total of 6 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the three wounds. They were then thoroughly cleansed with soap, and closure was begun on the upper eyelid. We used 6-0 vicryl subcutaneous sutures to attack the flap back into position, and once this was accomplished, we used individual 6-0 Prolene sutures on the skin to complete the closure. Attention was then turned to the right lower eyelid laceration where essentially an identical procedure was done. The wounds were somewhat similar in that they were flaps pedicled to the lateral towards the medial. Again, we used 6-0 vicryl subcutaneous and 6-0 Prolene individual skin sutures. Finally, attention was turned to the forehead laceration which was similarly closed with these same sutures, 6-0 vicryl subcutaneous and 6-0 Prolene on the skin. The wounds were then dressed with Bacitracin ophthalmic. Patient was instructed to keep them moist at all times and to not let crust form. She was also instructed in the appropriate analgesics to be taken orally and given my office number for a follow-up appointment. At the end of the procedure, she was then sent back to x-ray for CT scan of her C-spine. What diagnosis code(s) are reported? Dx #1: Dx #2: Dx #3:

CASE 8 PREOPERATIVE DIAGNOSIS: Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation. POSTOPERATIVE DIAGNOSIS: Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation. ANESTHESIA: Axillary block with general anesthesia. OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes. DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively. A dorsal/posterior approach to the fracture was performed with a standard recommended incision, location and technique. The interval between the extensor carpi radialis brevis and extensor digitorum communis was developed. The extensor pollicis brevis and the abductor pollicis were gently retracted one way or the other to expose the fracture site, and the fracture was just beneath this area. The radial sensory nerve was identified and protected throughout the procedure. The fracture was exposed with minimal soft tissue stripping. The bone holding forceps were placed on either side of the fracture, the overriding fracture was manipulated with gentle traction, and the fracture reduced. This effectively reduced the distal radioulnar joint. A small fragment, Synthes DCP locking plate was utilized to fix the fracture. Eight holes were utilized. Due to the nature of the fracture and the anatomy, there were three screws distal, four screws proximal, and the last hole was at the area of the fracture. Initially to achieve satisfactory bone to plate contact, three lag screws were required and these were placed initially. This was followed by placement of the remaining screws that were utilized proximal and distal to the fracture site to be locking screws. Intraoperative X-rays utilizing the C-arm were performed throughout the procedure to guide fracture reduction and hardware replacement. Final X-rays demonstrated excellent alignment of the fracture in the distal radioulnar joint. Excellent coaptation of the bony surfaces was obtained. Final irrigation of the wound was performed. The wound was closed in layers in a standard fashion. Splints were applied. Total tourniquet time was approximately 60 minutes. The patient tolerated the procedure well and went to the recovery room in satisfactory condition. Sponge and needle count is correct x2. Estimated blood loss is minimal. What diagnosis code(s) are reported? Dx #1:

CASE 9 PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus. POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus. CLINICAL HISTORY: The patient is a 2-month-old boy who was born and was IUGR. He did well for the first several weeks; however, he then developed a large head. Mom noticed full fontanelle arid in the last week or so, and they have noticed the eyes have decreased mobility. He tends to stare straight and has some trouble looking up and even to the sides bilaterally, so she is reported it to her pediatrician. Pediatrician ordered a CT scan and referred the patient. I saw the patient yesterday in clinic. We ordered an HRI; HRT was done this morning. PIRI shows the congenital hydrocephalus; however, it is not a Dandy-Walker. We had a discussion with the family about risks, benefits, potential complications and also different procedures. We talked about a third ventriculostomy however, given the patient's age and the fact was hydrocephalus, he has elected to go with the shunt, Family is comfortable with this and will bringing him to the OR today for shunting. What diagnosis code(s) are reported? Dx #1:

CASE 10 This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed. Past Medical History: Two vaginal deliveries, one in 1965 and another in 1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband. Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress. HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact. Neck: Thyroid not palpable. No jugular distention. Carotid pulses are present bilaterally. Breasts: Manual breast exam reveals no masses, tenderness or nipple discharge. The breasts are asymmetrical with no nipple discharge. Abdomen: No masses or tenderness noted. No hernias appreciated. No enlargement of the liver or spleen. Pelvic: Vaginal examination reveals no lesions or masses. Discharge is noted and a sample was collected for testing and sent to an outside laboratory for testing. No bleeding noted. Examination of the external genitalia reveals normal pubic hair distribution. The vulva appears to be within normal limits. There are no lesions noted. A speculum is inserted. There is no evidence of prolapse. The cervix appears normal. A cervical smear is obtained and will be sent to pathology. The speculum is removed and a manual pelvic examination is performed. It appears that the uterus is smooth and no masses can be felt. Rectal examination is within normal limits. Screening occult blood is negative. Uterus is not enlarged. Urinary: Urethral meatus is normal. No masses noted for urethra or bladder. Assessment and Plan: Routine Pap and pelvic; vaginal discharge. Patient had Pap and pelvic examination one year ago. Patient was sent to our in-house lab for blood draw today, and she is to follow-up in one week for lab results. What diagnosis code(s) are reported? Dx #1: Dx #2:

What does the abbreviation CKD stand for? A) Chronic Keratoderma B) Chronic Kidney Disease C) Congenital Kidney Disorder D) Chronic Kidney Dysfunction

Where can you find the ICD-10-CM Table of Drugs and Chemicals? A) Index to Procedures of the ICD-10-CM codebook B) CPT® codebook C) The ICD-10-CM codebook D) The ICD-10-CM and CPT codebooks

What does the 7th character A indicate in Chapter 19? A) Initial encounter B) Adverse effect C) Subsequent encounter D) Sequela

What chapter contains codes for diseases and disorders of the nails? A) Chapter 12: Diseases of the Skin and Subcutaneous Tissue B) Chapter 13: Diseases of the Musculoskeletal and Connective Tissue C) Chapter 14: Diseases of the Genitourinary System D) Chapter 16: Certain Conditions Originating in the Perinatal Period

According to the ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A), codes in this range have sequencing priority over what codes? A) All codes including Z33.1 B) Chapter 15 codes do not have sequencing priority over other codes. C) Codes from Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99). D) Codes from all other chapters.

The patient is in for an initial replacement of a leaking dialysis catheter. What ICD-10-CM code is reported? A) T85.611A B) Z49.02 C) T82.43XA D) T82.41XB

A patient is seen in the nursing home for dizziness and a healed stage II pressure ulcer is also noted. What ICD-10-CM code(s) is/are reported? A) R42, L89.90 B) R42, L89.95 C) R42 D) R42, L89.92

A 6 month-old patient is seen at the clinic for a routine well-child visit and vaccinations. During the examination the provider finds that the child has a fever and a diagnosis of acute otitis media in the right ear is documented. Vaccinations are not given at this time. What ICD-10-CM code(s) is/are reported? A) Z00.121 B) Z00.121, H66.91, Z28.01 C) Z00.121, H66.90, Z23 D) H66.90, Z00.01

A 55 year-old has developed a pressure ulcer on her right hip. The base of the ulcer is covered in eschar and the provider documents that the stage of the ulcer cannot be determined. What ICD-10-CM code is reported? A) L89.219 B) L89.210 C) L89.319 D) L89.310

A patient, at 26 weeks' gestation, presents with gestational diabetes controlled with diet and insulin. What ICD-10-CM codes are reported? A) O24.414, Z3A.26 B) O24.414, Z79.4, Z3A.26 C) O24.410, O24.414, Z3A.26 D) E11.9, Z79.4, Z3A.26

Patient is in the facility here today for a screening colonoscopy. During the procedure, a polyp is found and removed with a hot biopsy technique. How would this be reported? A) K63.5, Z12.11 B) Z12.11, K63.5 C) Z12.11 D) K63.5

Patient presents with no menses and positive pregnancy test but an ultrasound reveals no uterine contents. An embryo has implanted on the left ovary and this is treated with laparoscopic oophorectomy. What ICD-10-CM code is reported for this procedure? A) O00.202 B) O00.802 C) O00.09 D) O00.102

A 32 year-old who is 21 weeks pregnant (antepartum) presents with vaginal bleeding. She is admitted to the observation unit to rule out a spontaneous abortion. What ICD-10-CM code(s) is/are reported? A) Z33.1 B) Z34.92, Z3A.21 C) O03.9 D) O46.92, Z3A.21

A 2 month-old is seeing his pediatrician for a routine health check examination. The physician notices a diaper rash and prescribes an ointment to treat it. What ICD-10-CM code(s) is/are reported? A) L22 B) Z00.00 C) Z00.121, L22 D) L22, Z00.129

A pregnant woman in her 40th week has gestational diabetes which is controlled by diet. What ICD-10-CM code(s) is/are reported? A) O24.113, O24.410, Z3A.40 B) O24.913 C) O24.410, Z3A.40 D) O24.410, O24.913

The patient is admitted for radiation therapy for metastatic bone cancer, unknown primary. She developed severe vomiting secondary to the radiation. What ICD-10-CM code(s) is/are reported? A) C79.51, C80.1, R11.10, Z51.0 B) C79.51, C80.1 C) R11.10 D) Z51.0, C79.51, C80.1, R11.10

A patient is coming in for follow up of a second-degree burn on the left forearm. The provider notes the burn is healing well. He is to come back in two weeks for continued care to checkup on the healing of the burn. What ICD-10-CM code is reported? A) T22.219D B) T22.212S C) T22.212D D) T22.212A

A patient had a spontaneous complete abortion three days ago. She returns to the ED and is bleeding. After the ED provider examines her, she still has retained products of conception (POC). What ICD-10-CM code is reported for this encounter? A) O03.6 B) O04.6 C) O02.1 D) O03.1

A 3 year-old is brought to the burn unit after pulling a pot of hot soup off the stove and spilling it on herself. She sustained 18% second degree burns on her legs and 20% third degree burns on her chest and arms. Total body surface area burned is 38%. What ICD-10-CM codes are reported for the burns (do not include external cause codes for the accident)? A) T21.31XA, T22.20XA, T24.209A, T31.32 B) T21.31XA, T22.399A, T24.299A, T31.32 C) T21.31, T22.20, T24.209, T31.32 D) T21.21XA, T22.20XA, T24.209A, T31.23

A patient visits the ED for ringing in the ears, nausea, vomiting and drowsiness. During the history taking, the provider learns the patient has been taking 2 aspirins every hour for the last three days. After examination and performing blood tests the provider diagnoses the patient with aspirin poisoning. What ICD-10-CM codes are reported? A) H93.13, R11.2, R40.0, T39.011A B) T39.011A C) H93.13, R11.2, R40.0 D) T39.011A, H93.13, R11.2, R40.0

The patient has vaginitis three days after she was discharged from the hospital where she had a vaginal delivery of a healthy baby girl. What ICD-10-CM code is reported? A) O86.13 B) N76.0 C) N76.1 D) O23.599

A 7 year-old female patient was seen in the emergency department after being bitten by a dog. The child received treatment for the puncture wounds to her left leg. She also received a rabies vaccine because the dog was known to have rabies. What ICD-10-CM codes are reported? A) S81.812A, A82.9, Z23, W54.0XXA B) S81.852A, Z20.3, Z23, W54.0XXA C) S81.852A, Z23, W54.0XXA D) S81.812A, Z20.3, Z23, W54.0XXA

A 24 year-old woman developed a keloid scar as a result of a third degree burn on the left upper arm. What ICD-10-CM code(s) is/are reported? A) T22.332A, L91.0 B) L91.0 C) L91.0, T22.332S D) T22.332D, L91.0

A child is seen in a hospital based pediatric clinic for active treatment of 10% first and second degree burns to the left calf area and 5% third degree burns on her right hand. What ICD-10-CM codes are reported? A) T23.301A, T24.232A, T24.132A B) T23.291A, T24.202A C) T23.301A, T24.232A D) T24.202A, T23.301A, T24.132A

A patient is prescribed anticonvulsant medication for her seizures. She returns to her doctor three days later with nausea and rash due to taking the anticonvulsant medication. The provider notes that this is a drug reaction to an anticonvulsant and changes the medication. What ICD-10-CM codes are reported? A) R21, R11.0, T42.75XA B) R21, R11.2, T42.71XA C) L27.0, R11.0, T42.75XA D) L27.0, R11.2, T42.71XA

What would be considered an adverse effect? A) Wound infection after surgery. B) Rash developing when taking penicillin. C) Shortness of breath when running. D) Hemorrhaging after a vaginal delivery.

What type of fracture is considered traumatic? A) Spontaneous fracture B) Compound fracture C) Stress fracture D) Pathological fracture

Which statement is TRUE for reporting burn codes? A) The highest degree of burn is reported as the primary code. B) Burn codes are coded by the anatomical site and sequenced from top to bottom of the anatomical body. C) Sunburns are classified with traumatic burns and is the only burn code reported. D) First degree burns involve the epidermis and dermis and should always be sequenced first for multiple degrees of burns.

A child has a splinter under the right middle fingernail. What ICD-10-CM code is reported? A) S61.222A B) S60.452A C) S61.242A D) S61.227A

45 year-old mother of three children is going into surgery to correct an anterior vaginal wall prolapse with an incomplete uterine prolapse. What ICD-10-CM code is reported? A) N81.10 B) N81.4 C) N81.2 D) N81.3

A 4 year-old is brought into the ED crying. He cannot bend his left arm after his older sister pulled it. The provider performs an X-ray and it shows the patient has a dislocated Nursemaid's elbow. The ED provider reduces the elbow successfully. The patient is able to move his arm again. What ICD-10-CM codes are reported? A) S53.095A, Y93.89 B) S53.095S, Y93.89 C) S53.032S, Y93.89 D) S53.032A, Y93.89

The patient has a mass on his forehead; he says it is from a piece of sheet metal from an injury to his forehead months ago. He has an X-ray showing a foreign body is in the mass. After obtaining consent, the metal fragment foreign body is removed from the subcutaneous tissue. What ICD-10-CM code(s) is/are reported? A) Z18.10, S01.82XA B) S01.82XA C) M79.5 D) Z18.10 (S code not reported due to the age of the injury — not acute, so not reported)

The patient has benign prostatic hyperplasia with urinary retention. What ICD-10-CM code(s) is/are reported? A) N40.0 B) Q55.4 C) N40.3, R33.8 D) N40.1, R33.8

What is/are the external cause code(s) for a passenger involved in an MVA that lost control on the highway and hit a guardrail? A) V47.6XXA B) V47.5XXA C) V47.6XXA, Y92.411 D) Y92.411

A patient presents for an initial encounter for swelling, tenderness and erythema at the upper extremity injection site following Hepatitis B vaccination. The patient has a local infection. What ICD-10-CM code is reported? A) T80.29XA B) T88.0XXA C) T50.Z95A D) T80.29XD

A 47 year-old male was treated in the ED after being involved in a fight at a local pub. The patient sustained two lacerations, one to the left cheek and one to the left forearm. Abrasions were also on the left cheek. What ICD-10-CM codes are reported? A) S01.412D, S51.812D, S00.81XD, Y04.0XXD, Y92.29 B) S01.412A, S51.812A, S00.81XA, Y04.0XXA, Y92.29 C) S01.412A, S51.812A, Y04.0XXA, Y92.29 D) S01.412D, S51.812D, Y04.0XXD, Y92.29

Patient is in the ED due to a football hitting his nose when playing tackle football in the park. X-ray shows a displaced nasal fracture. What ICD-10-CM codes are reported? A) S02.2XXA, S03.1XXA, W21.01XA, Y93.61, Y92.830 B) S02.2XXA, W21.01XA, Y93.61, Y92.830 C) S03.1XXA, W21.81XA, Y93.59, Y92.321 D) S02.2XXB, W22.8XXA, Y93.69, Y92.321

After suffering a fracture of the ankle three months ago, a 69 year-old patient presented with what was found to be a malunion fracture. She was treated with additional surgery and discharged. Which injury diagnosis code(s) is/are assigned? A) S82.899A, S82.899P B) S82.899P (Subsequent malunion fractures use 7th character of "P") C) S82.899A, S82.899S D) S82.899A

A 12 month-old receives the following vaccinations: Hepatitis B, Hib, Varicella, and Mumps-measles-rubella. What ICD-10-CM code(s) is/are reported for the vaccinations? A) B19.10, B01.9, B26.9, B05.9, B06.9, Z23 B) B19.10, B01.9, B26.9, B05.9, B06.9 C) Z23, B19.10, B01.9, B26.9, B05.9, B06.9 D) Z23

A 12 month-old receives the following vaccinations: Hepatitis B, Hib, Varicella, and Mumps-measles-rubella. What ICD-10-CM code(s) is/are reported for the vaccinations? A) B19.10, B01.9, B26.9, B05.9, B06.9, Z23 B) B19.10, B01.9, B26.9, B05.9, B06.9 C) Z23, B19.10, B01.9, B26.9, B05.9, B06.9 D) Z23

A 14 year-old male patient was injured while skateboarding. The injuries included a displaced transverse fracture of the right femur shaft with multiple significant abrasions of the right thigh. What ICD-10-CM codes are reported? A) S72.91XA, S70.311A, V00.138A B) S72.321A, V00.138A, Y93.51 C) S72.91XA, S70.311A, Y93.51 D) S72.321A, S70.311A, V00.138A, Y93.51

A 40 year-old woman who is 25 weeks pregnant with her second child, is seeing her obstetrician. She is worried about decreased fetal movement. During the examination the obstetrician detects bradycardia in the fetus. What ICD-10-CM code(s) is/are reported? A) P29.12 B) O76, Z33.1 C) O76, O09.522, Z3A.25 D) O76, Z34.82

Newborn twin girls were delivered in the hospital via cesarean section at 27 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. What ICD-10-CM codes are reported for both twins? A) P07.26, P07.03 B) P07.26, Z38.31 C) Z38.31, P07.03, P07.26 D) P07.03, P07.26, Z38.31

Newborn twin girls were delivered in the hospital via cesarean section at 27 weeks, weighing 850 grams for twin A and 900 grams for twin B. Both were diagnosed with extreme immaturity. What ICD-10-CM codes are reported for both twins? A) P07.26, P07.03 B) P07.26, Z38.31 C) Z38.31, P07.03, P07.26 D) P07.03, P07.26, Z38.31

Ten days following a surgical below the knee amputation, the patient sees her provider. The provider notes that the amputation stump is not healing and is infected. What ICD-10-CM code(s) is/are reported? A) T87.89 B) T87.40 C) T87.43, T87.44 D) S88.119D