question

what coding system is currently in use in the U.S. for inpatient coding?

answer

icd-9-cm

question

What does the cm of icd 9 cm stand for?

answer

clinical modification

question

what payment system does medicare use for facility reimbursement?

answer

ms-drg

question

what nomenclature of disease is used in the U.s.?

answer

snomed systemized nomenclature of medicine

question

what 4 groups constitute the cooperating parties?

answer

AHIMA national center for health statistics CMS AHA

question

Who publishes official coding advice and guidance?

answer

AHA

question

what organizations award coding credentials?

answer

AAPC AHIMA

question

what is another word that is used in the industry for "following the rules"?

answer

compliance

question

true or false? if you were coding a neihbors record it would ok for you to tell your other neighbors the reason the patient was hospitalized.

answer

false

question

true or false? most industrialized countries do not use icd-10.

answer

false

question

true or false? if the discharge summary includes a list of diagnoses, the coder shuld choose the first in the list as the principal diagnosis.

answer

false

question

which report in the record must be on the record within 24 hours?

answer

operative report

question

true or false? the beginning of the patients story is usually the discharge summary.

answer

false. Usually the emergency room admission or the admission H&P

question

true or false? surgery is a form of therapeutic treatment.

answer

true

question

T or F? it is permissible for a coder to use documentation provided by an interventionalist.

answer

true

question

physician queries should have only enough room for a physician to sign and date.

answer

false

question

t or f? it is important that the date and the identify of the physician be included for every note.

answer

true

question

t or f? documentation from a consultant cannot be used to assign codes.

answer

false. it can be used.

question

t or f? an example of a diagnostic procedure is an MRI.

answer

true

question

what term describes a symptom or condition that is the result of a disease/

answer

manisfestation

question

what term describes the cause or origin of a disease or condition?

answer

etiology

question

diagnosis code for stage 3 pressure ulcer of the sacrum.

answer

707.03 (ulcer, sacrum) 707.23 (stage 3)

question

diagnosis code for seizure disorder, recurrent

answer

345.80 (recurrent epilepsy)

question

conditins that are integral to a disease or condition should be coded as additional diagnoses. true or false?

answer

false

question

t or f? when separate codes are used to identify acute and chronic conditions the chronic condition if sequenced first.

answer

false

question

t or f? a patient has right lower quadrant abdominal pain due to acute appendicitis. The abdominal pain should be assigned a code.

answer

false

question

acute and chronic cystitis.

answer

595.0 (acute), 595.2 (chronic)

question

acute on chronic oophoritis

answer

614.0 acute 614.1 chronic

question

constrictive pericarditis due to old tuberculosis infection

answer

423.2 (constrictive pericarditis), 137.4 (old TB infection) Late effect of old TB infection

question

hemiplegia due to previous CVA (not current episode)

answer

438.20 do not code from 430-437 b/c codes in 438 are only used for late effects of CVA. Codes from 430-437 may be assigned IF patient has a CURRENT CVA AND deficits from an old CVA

question

t or f? the approach of the surgical procedure should always be coded.

answer

false

question

t or f? it is not necessary to code closure of a routine surgical incision.

answer

true

question

assign the appropriate procedure code(s) using vol. 3 of the icd 9 cm code book: robotic assisted radical abdominal hysterectomy

answer

68.69 hysterectomy, abdominal, radical 17.41 robotic assisted surgery, open

question

patient was admitted for cardiac ablation for atrial fibrillation. The patient had eaten breakfast so the procedure was cancelled and will be rescheduled for a later date. What procedure code would be assigned?

answer

No code is assigned b/c no procedure was performed.

question

patient has a gastrostomy tube and receives tube feedings.

answer

status, gastrostomy V44.1 insertion, tube, feeding , gastric 96.6

question

absence of kidney due to surgical removal

answer

absence, kidney (acquired) V45.73

question

elevated blood pressure

answer

elevation, blood pressure, reading 796.2 note: the note under category 401 excludes elevated blood presure without diagnosis of hypertension if you looked up hypertension.

question

screening for bladder cancer in patient with gross hematuria

answer

599.71 the guidelines state that we do not use a V code for a screening when there are signs or symptoms or a disease. Instead, if there are signs or symptoms then we are to code the sign/symptom. In this case, you should only code the hematuria and that code is 599.71

question

physical examination to participate in sports

answer

examination, medical (for), sport competition directs you to code V70.3

question

genetic counseling for carrier of cystic fibrosis

answer

V26.33 (counseling, genetic) V83.81 (carrier, cystic fibrosis) the patient is a carrier. this does not mean that the patient has cystic fibrosis so we cannot code a diagnosis as if they have it.

question

acute prostatitis due to E. coli

answer

601.0 (prostate, acute) 041.49 (infection, escherichiacoli)

question

recurrent seizures due to metastasis to brain from lung cancer.

answer

345.80 (seizure, recurrent) 1st listed due to reason for the encounter 198.3 (secondary neoplasm ... metastasis) 162.9 (neoplasm, lung ... primary)

question

malignant neoplasm unknown primary with metastasis to liver.

answer

199.1 neoplasm, unknown primary 197.7 neoplasm, secondary (metastasis)

question

neurofibroma abdominal wall skin

answer

216.5 neurofibroma (see also neoplasm, connective tissue, benign. See note under CT because abdominal wall skin is not listed then code to that site. In this case neoplasm, skin, benign)

question

lung cancer with mets to bone, liver and brain

answer

162.9 neoplasm, lung, primary 198.5 neoplasm, bone, secondary 197.7 neoplasm, liver, secondary 198.3 neoplasm, brain, secondary

question

anemia due to Aids

answer

042 (aids) list as principal/1st listed 285.29 (anemia, in, chronic illness

question

anemia due to colon cancer

answer

285.22 (anemia due to a neoplasm ... The guidelines tell us that if the reason for the treatment is for the anemia, the anemia would be sequenced first) 153.9 colon cancer

question

Diabetes due to prednisone (adverse effect) .. LIST PRINCIPAL DIAGNOSIS ONLY AND NO E CODE.

answer

249.00 (diabetes, secondary directs us to 249. fifth digit 0.

question

chronic kidney disease, stage III, due to diabetic nephropathy; juvenile-onset diabetes

answer

250.41 diabetes, nephropathy 585.3 disease, kidney, chronic, stage III

question

history of alcoholism with 1 year of sobriety

answer

303.93 coded as alcoholism in remission a V code is not used for a recent history of alcoholism

question

psychogenic asthma

answer

316,493.90

question

grief reaction due to son's suicide

answer

309.0 No V code is needed but ok to use V61.07

question

benign essential tremor

answer

333.1

question

hemiplegia of the right side

answer

342.90 hemiplegia 342.9x ... 5th digit of 0 because we are not told whether the dominant or nondominant side is affected...also it does mention anywhere that the hemiplegia was due to a CVA

question

history of seizures

answer

v12.49 disordrs of nervous system and sense organs, other disorders of nervous systema nd sense organs

question

patient with ACS presents to the hospital; patient is taken to the cath lab and following a left cardiac cath and diagnosis of CAD the patient was immedidately taken to surgry, where a 2-vessel CABG is performed (include diagnosis and procedure codes...ASSUM THAT YOU KNOW THIS INCLUDED THE USE OF CARDIOPULMONARY BYPASS)

answer

Diagnosis is CAD ... 414.01 1st listed/principal ACS (acute coronary syndrome) 411.1 2-vessel CABG 36.12 bypass, aortocoronary, two coronary vessels left cardiac cath 37.22 catherization, heart, left cardiopulmo bypass 39.61

question

hypertension secondary to renal artery occlusion

answer

593.81 (occlusion, artery, renal) 405.91 hypertension, secondary, due to, renal, occlusion, unspecified The guidelines tell us to code the principal diagnosis for secondary hypertension according to the reason for the encounter. Normally, the principal diagnosis would be coded to the cause unless it is specified that the encounter is for treatment of the hypertension. This is very hard to ascertain from this diagnostic statement. However, normally the definition of "secondary" indicates it is not primary but rather lesser.

question

hypertension and chronic renal insufficiency

answer

403.90 hypertensive kidney disease category 403 hypertension, renal, unspecified 585.9 NOTE "use additional code" instruction to code the kidney disease. Insufficiency, renal, chronic 585.9

question

old CVA with residual hemiparesis

answer

An "old CVA" is a late effect. See late effect, cerebrovascular disease, with, hemiplegia/hemiparesis, unspecified side 438.20

question

inhalation anthrax with pneumonia

answer

022.1, 484.5 pneumonia, in, anthrax

question

acute and chronic sinusitis

answer

461.9, 473.9 sinusitis (chronic) directs us to code 473.9 sinusitis, acute directs us to code 461.9 acute always listed first

question

congestive heart failure with left pleural effusion that was trreated with thoracentesis at bedside (use diagnosis code(s) and procedure code(s)

answer

428 CHF We only code pleural effusin when treated, and this time it is treated with the thoracentesis to drain off the fluid. However, it would not be listed as principal diagnosis b/c it is "with" or "due to" the CHF. Add code: 511.9 pleural effusion 34.91 thoracentesis

question

a patient is admitted to the hospital with severe GERD and is treated by Nissen fundoplication. (diagnosis and procedure codes)

answer

530.81 (GERD) 44.66 Nissen Operation

question

A patient presents to the ER with hematochezia and hematemesis. The patient is admitted, and it is determined that acute blood loss anemia is caused by diverticulosis.

answer

562.12 diverticulosis with hemorrhage (symptoms do indicate hemorrhage) First listed/principal "after study ..." 285.1 anemia, due to, blood loss, acute Anemia is coded as principal when it is specified or inferred to be the reason for the encounter. In this case, the patient presents for hematochezia and hematemesis which is found after study to be caused by the diveerticulosis with hemorrhage. It is not appropriate to list the anemia as the principal diagnosis.

question

a patient with cholecystitis presents to the ER. ERCP reveals cholelithiasis. The surgeon performs a laparoscopic partial cholecystectomy. (diagnosis and procedure code(s))

answer

574.10 cholelithiasis with cholecystitis with no mention of obstruction 51.24 cholecystectomy 51.10 ERCP

question

a patient with severe malnutrition is admitted to the hospital for endoscopic placement of a gastrostomy tube. (diagnosis and procedure codes)

answer

261 severe malnutrition 43.11 endoscopic gastrostomy, percutaneous

question

gallstone of common bile duct, status post cholecystectomy

answer

574.50 choledocholithiasis with 0 as 5th digit V45.79 absence of gallbladder

question

excision of a pilonidal cyst (diagnosis and procedure)

answer

685.1 86.21 excision, pilonidal

question

ganglion tendon sheath of the right wrist with removal (diagnosis and procedure)

answer

727.42 82.21 excision, ganglion (tendon sheath)

question

arthropathy due to Chrohn's disease

answer

555.9 crohn's disease 713.1 arthritis, due to, enteritis, regional provides codes 555.9, 713.1

question

benign prostatic hypertrophy with urinary obstruction and slight hematuria. History of renal calculi. TURP (endoscopic) performed.

answer

600.01 hypertrophy, prostate, benighn, with, urinary, obstruction 599.69 urinary obstruction (code additinal note with 600.01) V13.01 history of renal calculi 60.29 TURP endoscopic

question

prerenal azotemia

answer

790.6

question

menometrorrhagia with chronic blood loss anemia

answer

626.2 menometrorrhagia 280.0 anemia, blood loss (chronic) Anemia is not the principal diagnosis when it is only specified as "with" another condition. Anemia is only principal diagnosis when it is specified as the reason for the encounter or first listed in the statement, as per guidelines, such as Anemia due to Menometrorrhagia.

question

hematuria with diagnostic cystoscope performed. (diagnosis and procedure)

answer

599.70 hematuria NOS cystoscopy 57.32

question

total abdominal hysterectomy with right salpingo-oophorecectomy for symptomatic uterine fibroids and follicular cyst right ovary. Family history of cervical cancer). (diagnosis and procedure codes)

answer

218.9 fibroid, uterus 620.0 follicular cyst V16.49 family history of cervical cancer 68.49 hysterectomy, abdominal, other (total) 65.49 salpingo-ooperectomy (unilateral for the right) There is no mention that either procedure was done laparascopically.

question

newborn delivered by cesarean section (newborn record)

answer

v30.01 newborn, single, born in hospital, with cesarean delivery

question

baby was born at 2500 grams; physician documented "small for dates"; delivered vaginally (newborn record)

answer

v30.00 newborn, single, born in hospital, w/o mention of c-delivery 764.09 small, fetus or newborn, without mention of malnutrition... can't use 764.1 b/c malnutrition was not mentioned

question

newborn with IURG (intrauterine growth retardation); delivered vaginally. Physician documents light for gestational age. Baby weighed 220 gm at delivery and was born at 37 weeks. (newborn record)

answer

V30.00 newborn, single, born in hospital w/o mention of c-delivery 764.98 retardation, intrauterine growth 765.29 weeks of gestation 37 weeks

question

TTN (transitory tachypnea of the newborn; infant delivered by emergency c-section

answer

V30.01 single liveborn infant, hospital, c-delivery 770.6 tachypnea

question

transfer from community hospital for treatment of interstitial pulmonary fibrosis of prematurity in a newborn

answer

770.7 interstitial pulmonary fibrosis of prematurity in a newborn Fibrosis, pulmonary, interstitial, newborn The newborn is transferred and the baby has already been born. Do not use a V30 infant birth code. Not required to code prematurity unspecified because physicians can use it differently.

question

7 day old infant with infection of the naval cord.

answer

771.4 infection, naval, newborn do not use v20.31 which would be used for a normal wellness visit. This is not a wellness visit.

question

baby delivered by cesarean section in respiratory failure and immeidately transferred to NICU (neonatal intensive care unit)

answer

v30.01 single live birth, hospital, c-section 770.84 failure, respiration/respiratory, newborn

question

newborn delivered vaginally; suspected of having pneumonia;chest xray is performed, revealing no diagnosis. DO NOT CODE THE CHEST XRAY.

answer

v30.00 single live birth, hospital, no c-section v29.2 observation, suspected, newborn, resiratory ... suspected condition, ruled out see also observation, suspected do not code pneumonia because it was not found

question

breech presentation with obstructed labor; delivery by cesarean section (LTCS); single liveborn

answer

660.01 obstructed labor as principal "code first" at 652.21 652.21 delivery, breech V27.0 outcome of delivery (NEVER first) 74.1 LTCS low transverse cesarean section ... cesarean, transperitoneal, low cervical

question

patient delivers 12 lb baby (lga), requirieng an episiotomy

answer

pregnancy, management, large for dates fetus 656.61 outcome of delivery V27.0 episiotomy 73.6 ... the episiotomy also includes the delivery

question

patient with a history of preteerm labor and previous cesarean section is admitted in labor; she has a vaginal birth after cesarean (VBAC) of single liveborn.

answer

pregnancy, management, previous, cesarean dleivery 654.21 outcome of delivery v27.0 manually assisted delivery normal delivery no complications 73.59 history of preterm labor V23.41 NOTE: v13.21 personal history of preterm labor has an excludes note of current pregnancy and directs you to v23.41

question

patient is admitted to the hospital in preterm labor. She is 35 weeks pregnant. 3 days after admission, the patient vaginally delivers a small for gestational age (SGA) baby.

answer

labor, premature 644.21 pregnancy, management affected by, fetal, growth retardation 656.51 outcome of delivery v27.0 vaginal delivery 73.59

question

patient is admitted to the hospital at 33 weeks. She has a twin pregnancy and has a spontaneous vaginal delivery (SVD) of liveborn twins. The evening after delivery, she hemorrhages.

answer

labor, premature 644.21 pregnancy, twin nec 651.01 specify placenta status V91.00 hemorrhage, postpartum 666.12 (postpartum complication "2") outcome of delivery v27.2 delivery manually assisted (spontaneous) 73.59 (normal with no complications)

question

the patient was treated for a sprained wrist. incidentally, the patient is 10 weeks pregnant. (do not code Ecode which would be E928.9)

answer

842.00 sprained wrist V22.2 incidental pregnancy

question

this mother delivered liveborn twins vaginally during her hospital stay. CODE ONLY THE OUTCOME OF DELIVERY.

answer

V27.2 outcome of delivery, twins

question

the patient has a high-risk pregnancy and 2 previous miscarriages.

answer

pregnancy, supervision, previous, abortion V23.2 a pregnancy with previous miscarriages would be a high risk pregnancy.

question

the patient is admitted with HIV and Pneumocystis carinii pneumonia (PCP) and is 35 weeks pregnant.

answer

647.63 pregnancy complicated by AIDS/HIV 042 HIV/AIDS 136.3 PCP

question

the patient delivered a baby 6 days ago. She is now being admitted because of dehiscence of her cesarean wound. The wound was sutured.

answer

dehiscence, cesarean wound 674.14 (fifth digit 4 b/c secondary admission) suture, skin 86.59

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