Unit 8 – Flashcard Test Questions

This patient is admitted for pulmonary rehabilitation in a setting of advanced COPD. She also has ASHD and type II diabetes mellitus with peripheral neuropathy. She has been -ventilator-dependent at the local acute hospital but was weaned from the ventilator prior to transfer to LTAC. What are the principal diagnosis and secondary diagnoses that the LTAC personnel will report for her stay?

A 69-year-old patient was hit by a car, causing intra-thoracic trauma and hemorrhage. The patient was taken directly from the Emergency Department to the operative suite where the chest was opened and hemorrhage was controlled, but the patient's heart stopped. Open heart massage was performed but the patient expired before the patient could be admitted. Assign the appropriate CPT code(s) and any required modifier(s) to report this service.

The following documentation is from the health record of a 39-year-old female patient. This 39-year-old female was diagnosed with breast cancer 2 years ago. At that time she had a mastectomy performed, with no evidence of metastases to the lymph nodes. About 8 months ago, metastases were found in her liver. The patient was given chemotherapy. She has been losing weight and developing increased fatigue. Patient was referred to hospice care program, with a life expectancy of 4 to 6 months. Progressive weight loss due to loss of appetite led to cachexia and program of home intravenous hyperalimentation. Progressive, unrelenting abdominal pain led to chronic use of analgesics. Patient is awake, alert, and desires to spend more time with family. Progressive weakness and dropping hemoglobin led to the decision to transfuse the patient every 2 weeks with 2 units of packed cells. Patient is stable and more comfortable on this regimen. What are the correct ICD-10-CM/PCS diagnosis codes assigned in this case?

A 55-year-old patient is brought into the operating room for elective decompression of the median nerve for carpal tunnel syndrome. She is in excellent health otherwise. The surgeon places an Esmarch bandage on the arm, and the arm is exsanguinated. A tourniquet is then placed and the surgeon administers Bier block anesthesia. Tourniquet time was approximately 50 minutes. Assign the ICD-10-CM diagnosis code and CPT surgical and anesthesia codes with any applicable modifiers.

Assign the appropriate ICD-10-CM diagnosis code(s) for cataract due to hypoparathyroidism.

The following documentation is from the health record of a patient who received hospital radiology department services. A patient who has had his bladder removed due to carcinoma without recurrence is ordered to have a radiology procedure to evaluate the patency of his ileal conduit, including an ureteropyelography using contract media. The chief complaint and reason for service line in the progress note is blank. The entire procedure is performed in the radiology suite with the radiologist's impression of "normal functioning ileal conduit." Which of the following procedure codes should be reported on the UB-04 in the case? Do not assign PCS procedure codes.

A patient is respirator-dependent and has a tracheostomy in need of revision due to redundant scare tissue formation surrounding the site. Under general anesthesia and after establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using skin flap rotation from the adjacent tissue of the neck. What codes will be used to report this procedure performed in the hospital short-stay surgery area?

An 85-year-old patient of Dr. Smith's was brought to the clinic from her home after her family failed to get her to respond to their phone calls. She was poorly nourished, dehydrated, and confused. Dr. Smith admitted her to the hospital to stabilize her, then discharged her to a nursing facility the next day. Assuming that all documentation guidelines for each level of service have been met, assign the correct CPT codes for Dr. Smith's services to the hospital and nursing home.

This 21-month old male presents to the Emergency Department with nausea and vomiting since 10 pm last night, at least 8 times, which is nonbloody but bilious. Temp of 39.8 since last night. He has a history of Tetralogy of Fallot, s/p repair 2 months ago. He has known immunodeficiency, laryngomalacia, and a gastrostomy tube. After examination, working differential diagnoses are acute gastroenteritis, bacteremia, or possible septicemia. Symptoms similar to episode about 1 month ago that was determined to be bacteremia with G-tube site infection. The patient is treated with Zofran 2 mg IV, followed by Ceftriaxone 600 mg IV. The patient id discharged after resolution of vomiting and fever. Diagnosis listed as acute gastroenteritis. Assign the correct codes for the facility services provided today.

A patient in end-stage renal failure requires outpatient hemodialysis 3 times a week while awaiting kidney transplant. He has an A-V fistula in his left arm for vascular access. Which of the following code combinations is appropriate for reporting physician services for this 55-year-old male for the month of August?

A 69-year-old patient was hit by a car, causing intra-thoracic trauma and hemorrhage. The patient was taken directly from the Emergency Department to the operative suite where the chest was opened and hemorrhage was controlled, but the patient's heart stopped. Open heart massage was performed but the patient expired before the patient could be admitted. Assign the appropriate CPT code(s) and any required modifier(s) to report this service.

A neonatal patient is brought to the operating room for repair of complete transposition of the great arteries under cardiopulmonary bypass. The infant is in critical condition and may not survive. Assign the correct diagnosis codes and CPT codes to report the administration of anesthesia, including physical status, Level I and II modifiers, and qualifying conditions for this procedure.

A 55-year-old patient is brought into the operating room for elective decompression of the median nerve for carpal tunnel syndrome. She is in excellent health otherwise. The surgeon places an Esmarch bandage on the arm, and the arm is exsanguinated. A tourniquet is then placed and the surgeon administers Bier block anesthesia. Tourniquet time was approximately 50 minutes. Assign the ICD-10-CM diagnosis code and CPT surgical and anesthesia codes with any applicable modifiers.

A 48-year-old man came in to the emergency department complaining of vomiting material resembling coffee grounds several times within the past hour. He has abdominal pain and has been unable to eat for the past 24 hours. He is dizzy and lightheaded. Two stools today have been black and tarry. While in the emergency department, he vomited bright-red blood and some material resembling coffee grounds. A nasogastric tube was inserted by the ED physician and attached to suction. An abdominal exam showed a fluid wave consistent with ascites. CBC and clotting studies were drawn. A detailed history and physical exam with high-complexity medical decision making were documented. A GI consultant was called and the patient was taken to the Endoscopy for further evaluation of upper GI bleeding. Diagnosis: Hematemesis, rule out esophageal varices; blood loss anemia, acute; ascites. Which of the follow is the correct diagnosis and CPT procedure assignment for the independent ED physician?

A patient is respirator-dependent and has a tracheostomy in need of revision due to redundant scare tissue formation surrounding the site. Under general anesthesia and after establishing the airway to maintain ventilation, the scar tissue is resected and then repair is accomplished using skin flap rotation from the adjacent tissue of the neck. What codes will be used to report this procedure performed in the hospital short-stay surgery area?

AHIMA DQ model 10 attributes

Quality of Healthcare

Systemic Data Defects

Quality Assurance

Quality Control

The development of a(an) ____ begins when the patient contacts a health care provider's office and schedules an appointment.

The patient ledger is also known as the

A ____ contracts with a third-party payer and accepts whatever the plan pays for procedures or services performed

Physicians generally believe that an application's UI is of no importance.

A non-Medicare patient with carcinoma of the oral cavity and lower lip is receiving daily intramuscular injections of the interferon alfa-2a (3 million units) in the outpatient cancer center. Which of the following will be reported for this service? The payer does accept HCPCS Level II codes for drugs.

This 60-year-old patient was admitted with emphysematous nodules. A thoracoscopic wedge resection was performed in the left lung to remove the lung nodules. A resection was done in the upper and lower lobes. Which of the following answers is correct?

What code(s) is/are assigned for a patient receiving home care after a kidney transplant?

What would be the appropriate ICD-10-CM code for lumbar stenosis?

An elderly patient has an abscess formation around a pacemaker pocket on his chest wall that requires that the device be removed and the pocket reformed in another location. Which of the following code sets is appropriate for this outpatient surgical service?

A hospital-based pediatric clinic is treating a newborn with talipes equinovarus by manipulation and short leg casting. Which of the following code sets is reported for a visit where the condition is evaluated with a -problem-focused history and examination and parents' questions are answered, followed by foot and ankle manipulation and replacement of the plaster cast?

Assign the appropriate ICD-10-CM diagnosis code for aspiration pneumonia due to inhalation of food.

A 32-year old female has recently had surgery for melanoma of the right lower leg, Clark level IV; She had no other signs of metastasis or adenopathy. Under general anesthesia, a sentinel node biopsy of the deep axillary nodes was performed with a gamma counter probe. An injection of isosulfan blue dye was performed and the nodes followed carefully to the single-bright-blue node. This node was excised and sent for frozen section, which proved to be negative for melanoma. Before the procedure, the radiologist performed a lymphoscintigraphy. Which of the following code sets would the surgeon report.

Dr. Smith sent a patient to observation care at the local hospital following his visit to the nursing facility. The patient was admitted for observation to rule out stoke due to a change in mental status. The next morning, Dr. Smith left town, and his partner, Dr., Johnson, admitted the patient to inpatient care because of sudden worsening symptoms. The patient expired later the same day. Assuming documentation guidelines were met, how would E/M services for these two physician be coded?

This 21-month old male presents to the Emergency Department with nausea and vomiting since 10 pm last night, at least 8 times, which is nonbloody but bilious. Temp of 39.8 since last night. He has a history of Tetralogy of Fallot, s/p repair 2 months ago. He has known immunodeficiency, laryngomalacia, and a gastrostomy tube. After examination, working differential diagnoses are acute gastroenteritis, bacteremia, or possible septicemia. Symptoms similar to episode about 1 month ago that was determined to be bacteremia with G-tube site infection. The patient is treated with Zofran 2 mg IV, followed by Ceftriaxone 600 mg IV. The patient is discharged after resolution of vomiting and fever. Diagnosis listed as acute gastroenteritis.

A 20-year-old patient was brought into the emergency department in nearly comatose condition following an evening of drinking beer and vodka with friends. Vital signs were depressed. A blood-alcohol level was measured, which was reported as 0.38. The patient had vomited several times before passing out. There was a 1-cm laceration on the patient's eyebrow. This was treated with a Steri-Strip. The patient was stabilized in the ED for one and a half hours and admitted to intensive care by the Internal Medicine physician on call. Documentation in the ED record supports a level 5 ED visit. Diagnosis was alcohol poisoning, acute alcohol intoxication, and 1-cm laceration, right eyebrow. (Points : 5)

The patient is a four-year-old male with acute lymphocytic leukemia who has had a fever for the last 24 hours. It has been nine days since his last chemotherapy, which was his first. A comprehensive history is documented. On examination, the skin over his Hickman site is extremely red and starting to break down. No other abnormal findings are noted in the comprehensive exam. Labs show that the patient is not neuropenic. The physician lists the diagnoses as : ALL not in remission, infected Hickman. The patient is given 770 mg of Ceptz over 10 minutes through a new peripheral IV site and admitted for continued treatment. Medical decision making is moderate.

The following documentation is from the health record of a 3-year-old child. Parents bring their 3-year-old boy, who was born with hydrocephalus, to the pediatric neurology clinic at Unive3rsity Hospital to have the child evaluated by the pediatric neurologist and have his VP shunt lengthened to accommodate a growth spurt. Their pediatrician requested a consultation to evaluate the shunt and replace the peritoneal catheter if needed. Outpatient surgery had been previously scheduled tentatively pending this evaluation for the afternoon. The catheter used in the shunt was removed and replaced in the outpatient surgery suite following a follow-up consultation, which included a detailed interim history, a detailed examination, and medical decision making of moderate complexity. Findings documented in the consultation include "Assessment: Shunt valve malfunction requiring replacement". The VP shunt valve was replaced along with a new peritoneal catheter in a longer length. Which of the following code sets will be reported for this service?

A 20-year-old patient was brought into the emergency department in nearly comatose condition following an evening of drinking beer and vodka with friends. Vital signs were depressed. A blood-alcohol level was measured, which was reported as 0.38. The patient had vomited several times before passing out. There was a 1-cm laceration on the patient's eyebrow. This was treated with a Steri-Strip. The patient was stabilized in the ED for one and a half hours and admitted to intensive care by the Internal Medicine physician on call. Documentation in the ED record supports a level 5 ED visit. Diagnosis was alcohol poisoning, acute alcohol intoxication, and 1-cm laceration, right eyebrow.

What is the correct ICD-10-PCS code for a total right knee arthroplasty with insertion of total knee prosthesis?

The following documentation is from the health record of a 39-year-old female patient. This 39-year-old female was diagnosed with breast cancer 2 years ago. At that time she had a mastectomy performed, with no evidence of metastases to the lymph nodes. About 8 months ago, metastases were found in her liver. The patient was given chemotherapy. She has been losing weight and developing increased fatigue. Patient was referred to hospice care program, with a life expectancy of 4 to 6 months. Progressive weight loss due to loss of appetite led to cachexia and program of home intravenous hyperalimentation. Progressive, unrelenting abdominal pain led to chronic use of analgesics. Patient is awake, alert, and desires to spend more time with family. Progressive weakness and dropping hemoglobin led to the decision to transfuse the patient every 2 weeks with 2 units of packed cells. Patient is stable and more comfortable on this regimen. What are the correct diagnosis codes assigned in this case?