question

urinary tract infection

answer

Established patient complaining of painful urination and frequency. Patient is a type 2 diabetic. Lab work revealed a urinary tract infection and blood glucose was within normal limits. First listed diagnosis:

question

Crohn's disease

answer

Established patient presented to clinic with exacerbation of Crohn's disease. Patient's rheumatoid arthritis is stable and no medical ion changes were made. First listed diagnosis:

question

sprained knee

answer

Initial office visit for sprained left knee. Patient has a history of hypertension and asthma, both stable at this time. First listed diagnosis

question

COPD or CHF

answer

Initial office visit for patient requiring equal management of COPD and CHF. First listed diagnosis:

question

pneumonia

answer

Established patient seen for cough, fever, and shortness of breath. Chest x-ray confirmed physician's diagnosis of pneumonia and patient was sent home on antibiotics. First listed diagnosis:

question

R10.9 (Pain, abdominal), K92.1 (Blood, in, feces)

answer

Initial office visit for a 28-year old male with persistent abdominal pain and bloody diarrhea. Patient was scheduled for small-bowel x-rays and colonoscopy and will be seen in the office following those outpatient procedures

question

K51.90 (Colitus, ulcerative chronic)

answer

Follow-up office visit for a 28-year old male with recent colonoscopy with biopsy and small bowel x-rays confirmed that the patient had ulcerative colitis and the patient was started on sulfasalazine. Code:

question

R53.83 Fatigue; R17 (Jaundice (yellow))

answer

Initial office visit for 55-year old male with fatigue and jaundice. Laboratory tests were ordered and patient will return in 1 week for the results. Codes:

question

B19.20 (Hepatitis C (viral))

answer

Follow-up visit for 55-year old male with jaundice and fatigue. Diagnostic tests confirm that the patient has hepatitis C. Code:

question

Z23

answer

According to the Guidelines, which category code should you reference to report inoculations and vaccinations:

question

Z20

answer

According to the Guidelines, this category is referenced when reporting suspected exposure to a communicable disease:

question

No

answer

Can Z codes only be used in the outpatient setting?

question

Y92.815 (place of occurrence, train)

answer

Railway accident involving derailment without antecedent collision, injuring a porter. Place of occurrence code:

question

Admission for elective sterilization

answer

A female patient was admitted as an outpatient for elective b ilatateral tubal ligation. The patient was noted to be wheezing during the nurse's assessment. She was seen by her physician and her surgery was canceled because of an exacerbation of her asthma. First listed Diagnosis:

question

Benign prostatic hypertrophy

answer

A male patient was admitted as an outpatient for transurethral prostatic resection for symptomatic benign prostatic hypertrophy. First listed Diagnosis:

question

Hematuria

answer

A patient was admitted as an outpatient for cystoscope for heanmaturia. The procedure was performed without complications. No abnormality or explanation for the hematuria was found. First listed Diagnosis:

question

V48.5XXA (Accident, transport, car occupant, driver, no collision accident [traffic])

answer

Motor vehicle traffic accident due to tire blowout; driver of the car was injured, initial encounter. Injured person code:

question

V86.59XA (Accident, transport, all-terrain vehicle occupant, driver)

answer

Driver of an ATV 9off-road vehicle) is injured when he collides with a fence. Injured person

question

V80.790A (Accident, transport, animal-rider, collision with, non-motor vehicle)

answer

Horse being ridden, rider injured, and non-motor vehicle collision, initial encounter. Injured person code:

question

V91.83XA (Accident, watercraft, causing, injury NEC)

answer

Accident to watercraft causing other injury; occupant of small powered boat injured due to collision, initial encounter. External cause code:

question

Contact, smallpox (laboratory); Z20.89

answer

A person who has been in contact with smallpox. Index location: Code:

question

Immunization, encounter for; Z23

answer

Prophylactic vaccination against smallpox. Index location: Code:

question

History, personal, malignant neoplasm (of), oral cavity, specified site; Z85.818

answer

Personal history of malignant neoplasm of the lip. Index location: Code:

question

Z45.018 (Admission for, adjustment (of), oral cavity, specified site; Z85.818

answer

Admission for cardiac pacemaker adjustment. Code:

question

Z30.018 (Contraception, initial prescription, specified type, NEC)

answer

Initial prescription and insertion of subterm all implantable contraceptive. Code:

question

Z85.46 (History, personal, malignant neoplasm [of], prostate

answer

Personal history of cancer of the prostate. Code:

question

Z23 (Immunization, encounter for)

answer

Baby in for MMR (Measles, mumps, rubella) vaccination. Code:

question

Z12.31 (Mammogram, routine)

answer

Screening mammogram. Code:

question

Z02.1 (Encounter, administrative purposes only, examination for, employment)

answer

Clinic visit for pre-employment physical examination. Code:

question

Z03.810

answer

The I-10 code to report observation for suspected exposure to anthrax, ruled out, is

question

Medical

answer

When reporting the diagnosis for a patient admitted to observation status for a medical condition, assign a code for the ____ condition as the first listed diagnosis.

question

Z04.1; b. S40.811A

answer

The patient fell off his motorcycle when turning too sharply and his his head on the sidewalk. The patient was wearing a helmet. The examination reveals no outward head injury. The only injury noted on examination is abrasion of the right upper arm. The patient is admitted overnight to the obese ration unit to rule out head injury. No head injury was found. A. Hospital observation is located in the index under the main term "Observation," Listed under the main term are the reasons for observation. The subterm is "accident NEC" and subterm "transport." CCheck the code in the Tabular. What is the Z code. Code: The second code is for the abrasion to the right upper arm. When you locate "Abrasion" and subterm "arm (upper)" you are directed to S40.81-0 (the "-" indicates that the Tabular is to be referenced for the additional characters. What is the code for the abrasion? Code:

question

Z04.41

answer

An adult patient is admitted for observation and further evaluation following an alleged rape, ruled out. There is only one code for this case. What is that Z code? Code:

question

Pelvic pain

answer

A 35 year old female patient was admitted to observation of severe nausea and vomitting following diagnostic laparoscopy for pelvic pain. First listed diagnosis:

question

Biliary duct stricture

answer

A male patient was admitted to observation following an endoscopic retrograde cholangiopancreatography (ERCP) for acute pancreatitis. Patient has a biliary duct stricture. First listed diagnosis:

question

Post-menopausal bleeding

answer

Patient was admitted for observation because of urinary retention following a Dilation and Curettage (D&C) for post-menopausal bleeding. First listed diagnosis:

question

Palpitations R00.2, Arthritis, rheumatoid, M06.9

answer

Patient was seen in the office for a consultation for palpitations. Patient also has rheumatoid arthritis. Medications that the patient takes for the arthritis were reviewed to see if they could be the cause of the palpitations. First listed diagnosis: _______ Code: _______ other diagnosis: _______ code: _______

question

Memory loss R41.3, diabetes mellitus, type II E11.9, long-term (current) use of insulin Z79.4

answer

Patient is an established patient with memory loss. Patient also has a long-term (current) use of insulin for diabetes type 2. First listed diagnosis: _______ Code: _______ Other diagnoses: _______ and _______ Codes: _______ and _______

question

Urinary tract infection N39.0, psoriasis L40.0

answer

Patient is a new patient who was seen for flank pain and diagnosed with a urinary tract infection, and antibiotics were prescribed. Patient has psoriasis, which is stable at this time. First listed diagnosis: _______ Code: _______ Other diagnosis: _______ Code: _______

question

Pain, joint, knee M25.561, Stiffness, knee M25.661. Osteoarthritis is not reported because it has not been confirmed and is a "rule out" diagnosis

answer

Patient is seen in the office for pain and stiffness of the right knee. X-rays to rule out osteoarthritis were performed. Reported diagnosis and code: _______ Reported diagnosis and code: _______ Diagnosis not reported: _______

question

Pain, wrist M25.532, numbness R20.0 Carpal tunnel syndrome is not reported because the condition has not been confirmed, rather it is a "probable" condition

answer

Office visit for established patient with left wrist pain and numbness of fingertips. Studies ordered for probable carpel tunnel syndrome. Reported diagnosis and code: _______ Reported diagnosis and code: _______ Diagnosis not reported: _______

question

Amenorrhea N91.2, Galactorrhea not associated with childbirth, N64.3. Pituitary tumor is not coded because it has not been confirmed

answer

Office consultation for a new patient with amenorrhea and Galactorrhea. Studies to rule out pituitary tumor were ordered. Reported diagnosis and code: _______ Reported diagnosis and code: _______ Diagnosis not reported: _______

question

Breast lump N63. Breast cancer is not reported because the condition has not been confirmed

answer

Initial visit for a patient with a breast lump. Working diagnosis is breast cancer. Diagnostic work up has been scheduled Reported diagnosis and code: _______ Diagnosis not reported: _______

question

J44.0 (Bronchitis, acute or subacute, with, chronic obstructive pulmonary disease), F17.210 (Dependence, nicotine, cigarettes)

answer

Harry Drew, a patient with chronic obstructive pulmonary disease, presents for a one-week follow-up for bronchitis. He continues to smoke 1 package of cigarettes per day, against repeated medical advice. Codes: _______, _______

question

J44.9 (disease, airway, obstructive, chronic), F17.210 (Dependence, nicotine, cigarettes)

answer

Harry Drew presents 10 days later for repeated follow-up regarding his bronchitis and to ensure that the infection had responded to the antibiotic prescribed 10 days previously. the physician determined that the bronchitis had responded well and no further bronchitis was identified. The patient's COPD continues to inhibit his activities. He continues to smoke 1 package of cigarettes per day and since his bronchitis has improved he says he is smoking "a bit more" Codes _______, _______

question

Z01.83 (Encounter, blood typing)

answer

David presents for blood typing for his surgery in two days. Code: _______

question

Z00.00 (Examination, annual)

answer

Chris, a 42 year-old male patient, presents for his annual examination. Code: _______

question

Z51.11 (Chemotherapy, neoplasm); C56.2 (Table of Neoplasms, Neoplasm, ovary. Malignant Primary)

answer

The patient presents for a chemotherapy treatment due to primary, malignant ovarian cancer of the left ovary. Codes: _______

question

D52.0 (Anemia, deficiency, folate, dietary)

answer

A patient with dietary folate deficiency anemia presents of a folate injection. Code: _______

question

Z01.82 (Examination, allergy)

answer

A patient presents for allergy testing Code: _______

question

Z01.810

answer

Pre operative cardiovascular examination

question

Z01.811

answer

Pre operative respiratory examination

question

Z01.818

answer

Pre operative examination

question

Z01.811

answer

What Z code would you report for the pre-procedural consultation Code: _______

question

Lung mass

answer

Sam is a 7 year old male patient who is brought to Dr. Well;s office for a pre procedural consultation of a mass on his left lung. Dr. Well reviews the patient's X-rays and MRI taken the previous week and sent from Dr. Gross man, Sam's pediatrician. In addition to the Z code, you would report what diagnosis?

question

Z code

answer

Would the Z code or diagnosis code be first listed?

question

False

answer

When a patient is to have outpatient surgery and the surgery is not performed due to contradiction, the reason the surgery was not performed is the first listed diagnosis

question

True

answer

It is appropriate to code the postoperative diagnosis as it is the most definitive diagnosis for ambulatory surgery

question

True

answer

Chronic diseases that are treated on an ongoing basis should be coded and reported as often as the patient receives treatment and care for the chronic conditions

question

True

answer

In the physician office it is acceptable to report Z codes as a first listed diagnosis

question

False

answer

In the outpatient setting it is unacceptable to have a sign or symptom as the first listed diagnosis

question

False

answer

When coding an encounter for pre operative evaluation, the reason that the patient is having the surgery or procedure performed is the first listed diagnosis

question

True

answer

In the outpatient setting, diagnoses that are documented as "probable," "suspected", "rule out" or "questionable" are reported to the highest degree of certainty, such as symptoms, signs abnormal test results, or other reasons for the visit

question

False

answer

The first listed diagnosis is defined as the diagnosis that is the most serious

question

False

answer

It is acceptable to report a code from Chapter 15 in conjunction with Z34.00 or Z34.80

question

False

answer

It is acceptable to code signs and symptoms even when a definitive diagnosis has been confirmed.

question

First listed diagnosis: diaper rash code: L22

answer

Initial office visit for diaper rash

question

first- listed diagnosis: Congestive Heart failure code i50.9

answer

estalished patient presents with dyspnea and lower extremity edema. the physician determined that the patient's symptoms were due to an exacerbation of congestive hear failure.

question

First listed diagnosis: Vitamin B12 deficiency code: e53.8 Other diagnoses: hypertension Code: I10

answer

established patient seen for management of vitamin b12 deficiency and hypertension

question

first: anterior cruciate ligament tear or left ACL tear code:m23.8x2

answer

patient was admitted as an outpatient for left arthroscopic knee procedure to repair old anterior cruciate ligament

question

first: syncope Code: R55 Other diagnosis: diabetes mellitus Code: E11.9

answer

patient was admitted to observation for syncope, patient has diabetes mellitus. after testing, no cardiac or other cause was found

question

First listed diagnosis: acute post procedural pain Code: G89.18 Other diagnosis: chronic kidney disease Code: N18.4

answer

patient was admitted for pain management following biopsy of the kidney for stage IV chronic kidney disease

question

Encounter for Preprocedural respiratory Examination Code: Z01.811 other: carotid stenosis, emphysema Code: I65.21, J43.9

answer

patient is seen by pulmonologist for surgical clearance for upcoming surgery. patient has emphysema and is scheduled to have an endarterectomy for severe carotid stenosis on the right

question

First listed diagnosis: bladder cancer Code: C67.9

answer

Patient had an outpatient cystoscopy. The preoperative diagnosis is hematuria. Postoperative diagnosis is hematuria due to bladder cancer.

question

Z77.090

answer

Assign the appropriate Z code to: exposure to asbestos.

question

Z86.010

answer

Assign the appropriate Z code to: personal history of colonic polyps.

question

Z94.1

answer

Assign the appropriate Z code to: heart transplant status.

Step-by-Step 2016: Ch 3 (Outpatient Coding and Reporting) – Flashcards

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