Ccs 2011 Final Exam

CCS Coding Exam Review 2011: The Certification Step
Final Examination With Answers

PART I 1. The index of the ICD-9-CM indicates the following: Failure, failed renal 586 acute 584.9 chronic 585.9 The medical record states the patient has chronic renal failure and has now been admitted with acute renal failure. Which represents the correct sequence? A. B. C. D. 585.9, 584.9 584.9, 585.9 586, 584.9 Either A or B
CORRECT ANSWER: B. 584.9, 585.9. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., the coder is to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is sequenced first and the chronic condition is to be sequenced second. RATIONALE: A. 585.9 reports the chronic condition sequenced first, and the chronic condition should be sequenced second; 584.9 reports the acute condition, and the acute condition should be sequenced first. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., which directs the coder to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is to be sequenced first and the chronic condition is sequenced second. C. 586 reports renal failure that is not specified as acute or chronic, and the renal failure in this report was specified as acute and chronic. 584.9 correctly reports acute renal failure, but according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., the coder is to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is to be sequenced first and the chronic condition is sequenced second. D. Either A or B. Only B is correct. The acute condition is to be sequenced first and the chronic condition is sequenced second. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., which directs the coder to
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CCS Final Examination With Answers
report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level.
2. A 4-year-old patient presents to the ED with her mother. The patient is an asthmatic with dyspnea and is in obvious distress. The mother states that the childs asthma was in good control until later in the day, when she began to develop problems breathing. For the last 4 hours, the mother had administered the childs albuterol inhalant with no marked improvement. The ED physician directed administration of a nebulizer treatment of albuterol, 3 mL of 0.083%. The documentation indicates asthma with an acute exacerbation. After the initial treatment, the patient began to rapidly improve and was discharged. 493 Asthma The following fifth-digit subclassifications are for use with 493.0-493.2, 493.9: 0 unspecified 1 with status asthmaticus 2 with (acute) exacerbation
493.0 493.1 493.2 493.9 A. B. C. D.
Extrinsic asthma Intrinsic asthma Chronic obstructive asthma Asthma, unspecified
493.01, 99283 493.92, 99284 493.20, 99285 493.12, 99284
CORRECT ANSWER: B. 493.92, 99284. The diagnosis is with acute exacerbation, as documented in the report. The patient received only one nebulizer treatment, as listed in the Level 4, number 6. RATIONALE: A. 493.01, 99283. The level of the ED service is incorrect as there is no nebulizer treatment listed under Level 3. 493.01 reports extrinsic asthma, which is allergic asthma. The diagnostic statements in the report did not indicate this type of asthma. Further, the fifth digit 1 is incorrect, as it indicates status asthmaticus, which is the most severe form of asthma attack and can last for days or weeks; this is not documented in the report. C. 493.20, 99285. 493.20 is assigned to report chronic obstructive asthma, which would be indicated on the report with statements such as asthma with COPD or chronic obstructive asthma, and this report only indicates unspecified asthma. The fifth digit 0 is also incorrect as it indicates an unspecified status,
and this report states that the patient was experiencing an acute exacerbation indicated by a fifth digit, 2. 99285, Level 5, is incorrect as the nebulizer treatment listed under that level (number 3) is for three or more treatments, and this patient received only one treatment. D. 493.12, 99284. 493.12 is incorrect because it reports intrinsic asthma, which is asthma that occurs in patients who have no history of allergy or sensitivities to allergens. The fifth digit 2 is correct to report an acute exacerbation. Level 4 is correct.
3. A patient presents to the emergency department with the chief complaint of nausea and recurrent vomiting with dehydration. The nausea with vomiting is listed first in the final diagnoses section of the report. Upon reviewing the medical record, the coder notes that the patient was described as having dehydration secondary to viral pharyngitis with possible ketoacidosis and received infusion therapy. The patient is a type 1 diabetic who has had no complaints with diabetes for the past 6 years, until perhaps now. The patient also has asthma that is stable at this time. The patient was discharged home. The diagnosis(es) would be:
250.01 250.13 276.50 276.51 462 493.90 493.00 787.01 787.02 787.03 A. B. C. D.
Diabetes mellitus without mention of complication, type I (juvenile type), not stated as uncontrolled Diabetes with ketoacidosis, type I (insulin dependent type) (juvenile type), uncontrolled Volume depletion Dehydration Acute pharyngitis Asthma, unspecified Extrinsic asthma, unspecified Nausea and vomiting Nausea alone Vomiting alone
276.51, 787.01, 462, 250.01, 493.90 276.50, 462, 250.13, 493.90, 787.01 787.02, 787.03, 462, 250.13, 493.90 787.02, 276.50, 462, 250.01, 493.90
CORRECT ANSWER: A. 276.51, 787.01, 462, 250.01, 493.90. 276.51 reports the dehydration, 787.01 reports the nausea with vomiting, 462 reports the pharyngitis, 250.01 reports the type I diabetes, 493.90 reports the asthma. The patients dehydration was the focus on the ER visit so is the first-listed diagnosis. RATIONALE: B. 276.50 reports volume depletion instead of dehydration. The second listed
diagnosis should have been the nausea and vomiting (787.01). 462 is correct to report the pharyngitis, 250.13 is not correct because it reports the ketoacidosisthe report indicates possible, and outpatient coders do not report possible diagnoses. 250.01 should have been assigned instead to report the type I diabetes mellitus. 493.90 correctly reports the asthma as unspecified. C. This choice is incorrect because it reports the nausea alone (787.02) and the vomiting alone (787.03), but there is a combination code (787.01) that reports both nausea and vomiting in one code, and if there is a combination code available, it must be assigned when both are present. 462 correctly reports the pharyngitis, 250.13 is the correct code for ketoacidosis; however, according to ICD-9-CM Official Guidelines for Coding and Reporting, Section IV.I., possible diagnoses are not reported in an outpatient setting. 250.01 should have been assigned instead to report the type I diabetes mellitus. 493.90 correctly reports the asthma as unspecified. The first-listed diagnosis should have been the dehydration, 276.51, and this code is missing from this choice. D. 787.02 is incorrect because it reports nausea alone. Both nausea and vomiting should be reported as 787.01. Code 276.50 indicates volume depletion when the report indicated dehydration and should be coded as 276.51, 462 correctly reports the pharyngitis, 250.01 correctly reports the diabetes, 493.90 correctly reports the asthma as unspecified.
4. A 42-year-old female presents to the emergency room stating that she has significant abdominal discomfort and is supposed to have an upper gastrointestinal series at 8 AM tomorrow morning. She has a gastric ulcer, and the abdominal pain is due to this ulcer. The emergency department physician assesses the patient and orders an abdominal x-ray. The patients physician is in the hospital for rounds and is called to the ED to assume the care of this patient. 789.00 789.07 531.90 531.40 Abdominal pain, unspecified site Abdominal pain, generalized Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage, perforation, or obstruction Gastric ulcer, chronic or unspecified with hemorrhage without mention of obstruction or perforation
A. B. C. D.
99283, 531.90 99282, 531.40 99283, 789.00, 531.40 99284, 789.07, 531.90
CORRECT ANSWER: A. 99283, 531.90. The ED physician assessed the patient and requested an abdominal x-ray, reported with Level 3, number 3, x-ray one area (99283). 531.90 reports a gastric ulcer that was not specified as acute or chronic and had no mention of hemorrhage, perforation, or obstruction.
RATIONALE: B. 99282, 531.40. Level 2 (99282) does not include any x-ray service. The report states that the abdominal pain is due to the ulcer, indicating that the abdominal pain is a symptom of the gastric ulcer and not reported separately per ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.6. and I.B.7. Code 531.40 is incorrect because it reports a gastric ulcer with hemorrhage, and no hemorrhage was indicated in the report. C. 99283, 789.00, 531.40. Level 3 (99283) is correct for an x-ray of one area. 789.00 is incorrect because it reports abdominal pain of unspecified site. The report states that the abdominal pain is due to the ulcer, so the abdominal pain is not reported. 531.40 is incorrect because it reports a chronic gastric ulcer with hemorrhage. The report does not specify acute or chronic and there is no indication of hemorrhage noted in the report. D. 99284, 789.07, 531.90. Level 4 (99284) is incorrect, as it is for x-rays of multiple areas and this x-ray was for a single area (abdomen). 789.07 is incorrect because it reports generalized abdominal pain, but because the report states that the abdominal pain is due to the ulcer, the abdominal pain is not reported. 531.90 correctly reports the gastric ulcer in which it was unspecified as to chronic or acute and without the mention of hemorrhage, perforation, or obstruction.
5. According to the ICD-9-CM Official Guidelines for Coding and Reporting Section I.B.12., regarding reporting late effects indicate that residual is sequenced _________ and the late effect code is sequenced _________. A. B. C. D. second, first first, second first or second, first or second none of the above
CORRECT ANSWER: B. first, second. According to the ICD-9-CM Official Guidelines for Coding and Reporting, the condition or nature of the late effect (the residual) is sequenced first, and the late effect code is sequenced second. RATIONALE: A. second, first. This is an incorrect sequence because according to the ICD-9-CM Official Guidelines for Coding and Reporting, the condition or nature of the late effect (the residual) is sequenced first, and the late effect code is sequenced second. C. first or second, first or second. This is an incorrect sequence because according to the ICD-9-CM Official Guidelines for Coding and Reporting, the condition or nature of the late effect (the residual) is sequenced first, and the late effect code is sequenced second.
D. none of the above. This is incorrect as B is the correct sequence according to the ICD-9-CM Official Guidelines for Coding and Reporting, which state that the condition or nature of the late effect (the residual) is sequenced first, and the late effect code is sequenced second.
6. Hospital outpatient surgery The surgeon performed a split-thickness autograft, both thighs to the abdomen measuring 45 21 cm because of the patients nonhealing surgical wound. Which codes would you use to report the facility services? 15100 15101 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children (except 15050) ; each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Other postoperative infection Non-healing surgical wound Other specified complications of a procedure
998.59 998.83 998.89 A. B. C. D.
15100 10, 998.59 15100, 15101 9, 998.83 15100, 15101 8, 998.83 15100, 998.89
CORRECT ANSWER: B. 15100 is the correct code for the first 100 sq cm or less, and 15101 9 for the remaining 845 sq cm (in this case, 45 21 = 945 sq cm). The code 998.83 describes a nonhealing surgical wound which is the reason for the procedure. RATIONALE: A. 15100 is the correct code to report a split thickness autograft of the trunk for the first 100 sq cm or less (45 sq cm), but is only used for the first 100 sq cm. 15101 9 would be necessary to report the additional 845 sq cm. 998.59 is the incorrect code since the wound is a nonhealing surgical wound. C. 15100 is correct for the first 100 sq cm, but the units listed for code 15101 is wrong. There were 9 additional units, not 8. 998.83 is the correct diagnosis code. D. 15100 is correct for the first 100 sq cm, but 15101 is missing from this choice. 998.89 is the incorrect code since the wound is a nonhealing surgical wound.
7. A 59-year-old female is brought to the ED by ambulance with tachycardia and acute alcohol intoxication. The patient has been seen in the ED on several previous occasions with significant intoxication and has had multiple admissions for acute
intoxication. She is an episodic alcoholic. She has a medical history that includes fairly well controlled hypertension and current tobacco abuse with questionable COPD. The patient is placed on cardiac monitoring. The ED physician assesses the condition of the patient and administers an intravenous solution of 1 liter of 5% dextrose and 0.45% sodium chloride, 2 g of magnesium sulfate, 1 mg of folate, and 100 mg of thiamine. Intramuscular Ativan is also administered. The physician reassesses the patient several times over the next 3 hours. The patients heart rate returns to normal, and the patient is discharged. 303.02 303.00 305.1 401.9 785.0 786.06 V15.82 496 Acute alcoholism, episodic Acute alcoholism Current tobacco abuse Hypertension, unspecified Tachycardia Tachypnea History of tobacco abuse Chronic obstructive pulmonary disease, NOS
A. B. C. D.
99284, 785.0, 303.02, 401.9, 496, V15.82 99291, 303.02, 785.0, 401.9 99285, 303.02, 785.0, 401.9, V15.82 99284, 785.0, 303.02, 401.9, 305.1
CORRECT ANSWER: D. 99284, 785.0, 303.02, 401.9, 305.1. Level 4 is correct as the physician administered several medications (Level 4, number 5), and assessed and reassessed the patient over 3 hours (Level 4, number 4). 785.0 (tachycardia) is the first-listed diagnosis, as it is the primary reason for services that were rendered in the ED (refer to ICD-9-CM Official Guidelines for Coding and Reporting, Section IV, H). The acute alcoholism is reported for the acute alcohol intoxication with 303.02, because although it is a major consideration in the care of this patient, the patient was not brought to the ED because she was intoxicated, but because she was experiencing tachycardia. The fifth digit 2 is reported to indicate that the patient is an episodic alcoholic. The third-listed diagnosis is the fairly well controlled hypertension, reported as unspecified hypertension (401.9) because the hypertension is indicated to be only fairly well controlled, which may be a consideration in the care of a patient with tachycardia. 305.1 reports the current abuse of tobacco. RATIONALE: A. 99284, 785.0, 303.02, 401.9, 496, V15.82. Level 4 ED (99284) correctly reports the ED service. 785.0 correctly reports the first-listed diagnosis as the tachycardia. Acute alcoholism is correctly reported with 303.02 because it is a major consideration in the current care of this patient. 401.9 correctly reports the
unspecified hypertension. 496, COPD, is a questionable diagnosis and is not reported in the outpatient setting, according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section IV.I.V15.82, history of tobacco abuse, is incorrect as this patient currently abuses tobacco and this should be reported with code 305.1. B. 99291, 303.02, 785.0, 401.9. This is not a critical care service, as the physician did not provide any of the services listed on the critical care list. 303.02 is the correct code for the acute alcoholism, but it is not the first-listed diagnosis, as it is not the primary reason for the services provided during this encounter. Rather, tachycardia (785.0) is the primary reason for the service and should be listed first. 401.9 is correct for the unspecified hypertension. 305.1 to report the tobacco abuse is missing from this selection. C. 99285, 303.02, 785.0, 401.9, V15.82. Level 5 ED (99285) is incorrect for this ED service, as none of the services listed in Level 5 were provided for this patient. 303.02, acute alcoholism, was not the primary reason the patient received the service, although it is a major consideration in the care of the patient. Rather, tachycardia (785.0) is the primary reason for the service and should be listed first. 401.9 (hypertension) is reported because it is stated to be only fairly well controlled, and as such could be a significant consideration in the care of the patient. V15.82 (history of tobacco abuse) is not used for a patient who currently abuses tobacco (305.1).
8. The patient presents to the same-day surgery center for cryosurgery of a primary malignant lesion on the genitalia (vulva). The lesion measures 1.6 cm, including margins, and local anesthesia is used.
11602 11420
11622 17272
184.4 184.8 198.82 A. B. C. D.
Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Malignant neoplasm, vulva, unspecified, primary Malignant neoplasm, other sites of female genital organs, primary Malignant neoplasm, genital organs, secondary
17272, 184.4 11602, 198.82 11420, 184.4 11622, 184.8
CORRECT ANSWER: A. 17272 identifies the destruction by cryosurgery of a malignant lesion of the genitalia, lesion diameter 1.1 to 2.0 cm. Code 184.4 is the correct code for malignant neoplasm of the vulva and the reason for the procedure. RATIONALE: B. 11602 is excision of a malignant lesion, but not from the genitalia. Further, the report indicates that the lesion was removed by means of cryosurgery, not excision, as is reported with 11602. Code 198.82 is incorrect; the malignant neoplasm is specified as a primary malignant lesion of the vulva. C. 11420 reports excision of a benign lesion of the genitalia, not a malignant lesion, by excision, not cryosurgery. Code 184.4 is correct. D. 11622 is excision of a malignant lesion from the genitalia, but the report indicates that the lesion was removed by means of cryosurgery, not by excision. Code 184.8 is incorrect since the report states the malignant neoplasm is of the vulva. 9. Carl Ostrick, 21-year-old male, slipped on a patch of ice on his sidewalk while shoveling snow. When he fell, his left hand was wedged under his body and his index finger was dislocated. After manipulating the joint back into normal alignment, the surgeon fixed the dislocation by placing a wire percutaneously through the carpometacarpal joint to maintain alignment. 26608 26650 26706 26676 -LT -RT 833.04 833.14 A. B. C. D. Percutaneous skeletal fixation of metacarpal fracture, each bone Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint Left side Right side Dislocation carpometacarpal, joint, closed Dislocation carpometacarpal, joint, open
26608-RT, 833.14 26650-LT, 833.14 26706-LT, 833.04 26676-LT, 833.04
CORRECT ANSWER: D. 26676-LT reports the percutaneous skeletal fixation of the finger (carpometacarpal) with manipulation. The modifier -LT indicates the left hand. Some payers may require modifier F1, left hand, second digit. The 833.04 describes the closed dislocation and the reason for the procedure.
No E codes are reported according to the guidelines for the AHIMA certification, available on the AHIMA website. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. RATIONALE: A. 26608-RT is percutaneous skeletal fixation of a metacarpal fracture with no mention of manipulation. This code is incorrect because it represents treatment of a fracture injury rather than a dislocation injury and it also identifies a different location than what is stated in this case. -RT indicates the right side and the procedure was on the left side, which is indicated with -LT. Code 833.14 is incorrect because it describes an open dislocation. B. 26650-LT is percutaneous skeletal fixation of a thumb, not an index finger. Code 833.14 is incorrect because it describes an open dislocation. C. 26706-LT is percutaneous skeletal fixation of a metacarpophalangeal dislocation. This is a carpometacarpal joint; therefore code 833.04 is correct.
10. The following appear in the Index of the ICD-9-CM: Complications vaccination 999.9 meningitis 997.09 [321.8] Meningitis infectious NEC 320.9 Meningitis due to preventive immunization, inoculation or vaccination 997.09 [321.8] The patient record indicates a diagnosis of meningitis as a complication of a vaccination. Which would be the correct sequence of codes? A. B. C. D. 320.9, 999.9 997.09, 321.8 321.8, 997.09 999.9, 320.9
CORRECT ANSWER: B. 997.09, 321.8. The use of brackets in the Index identifies manifestations and these are sequenced as secondary diagnoses per ICD-9-CM Official Guidelines for Coding and Reporting, Section I.A.6. RATIONALE: A. 320.9, 999.9 is not sequenced correctly per the ICD-9-CM Official Guidelines for Coding and Reporting. Also, this was not infectious meningitis as reported with
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320.9, but rather meningitis as a complication of a vaccination, 321.8. 999.9 is wrong as well as it represents other and unspecified complications of medical care. C. 321.8, 997.09 is incorrect as it is not the sequence for a complication of meningitis as a result of a vaccination because the display in the Index of the ICD-9-CM indicates the sequence as 997.09 first, followed by 321.8. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.A.6. D. 999.9, 320.9 is incorrect, as 999.9 is an unspecified complication of medical care and in this case, the specific complication is due to vaccination. Also, code 320.9 is incorrect as it reports infectious meningitis but the diagnosis in this case was meningitis due to vaccination and should be reported with 321.8. 11. The surgeon performed a pyeloplasty, gastrojejunal revision and a vagotomy during the same surgical session on this inpatient.
43865
50400
43635 43.99 44.00 44.5 55.87 A. B. C. D.
Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary procedure) Other total gastrectomy Vagotomy, not otherwise specified Revision of gastric anastomosis Correction of ureteropelvic junction
43865 44.5, 43.99 50400, 43635 44.5, 55.87, 44.00
CORRECT ANSWER: D. 44.5, 55.87, 44.00. This choice correctly reports the inpatient procedures of 44.5, gastrojejunal revision, 55.87, pyeloplasty, and 44.00, vagotomy. RATIONALE: A. 43865 reports a revision of a gastrojejunal anastomosis with vagotomy (transection of the vagus nerve) for an outpatient; this was an inpatient and as such, should be reported with Volume 3 codes, not CPT codes. B. 44.5, 43.99. This choice is incorrect, as it does not report the pyeloplasty or vagotomy. C. 50400 is a pyeloplasty and 43635 is an add-on code used to report a vagotomy when performed with a gastrectomy for an outpatient; this was an inpatient and
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as such, should be reported with Volume 3 codes, not CPT codes. 12. Darin was a passenger in an automobile rollover accident and was not wearing a seat belt at the time. He was thrown from the automobile and was pinned under the rear of the overturned automobile. He sustained craniofacial separation that required complicated internal and external fixation using an open approach to repair the extensive damage as an inpatient. A halo device was used to hold the head immobile. 21435 Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (e.g., head cap, halo device, and/or intermaxillary fixation) Application of halo, including removal; cranial Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical approaches, internal fixation, with bone grafting (includes obtaining graft) Insertion or replacement of skull tongs or halo traction device Open reduction of maxillary fracture Open reduction of mandibular fracture Fracture malar and maxillary bones, closed Fracture malar and maxillary bones, open
20661 21432 21436
02.94 76.74 76.76 802.4 802.5 A. B. C. D.
21435, 20661, 802.5 76.74, 76.76, 02.94, 802.4 76.74, 76.76, 802.4 21436, 20661, 802.5
CORRECT ANSWER: B. 802.4, 76.74, 76.76, 02.94 correctly reports the procedures of an open reduction of a maxillary fracture (76.74), open reduction of mandibular fracture (76.76), and insertion of a halo device (02.94). 802.4 is the code for a LeFort III fracture. RATIONALE: A. 21435, 20661, 802.5. This choice is incorrect, as these CPT codes would be used to report the service in an outpatient setting, and this was an inpatient visit. C. 76.74, 76.76, 802.4. This choice is incorrect as it is missing the insertion of a halo device (02.94). D. 21436, 20661, 802.5. This choice is incorrect as these CPT codes would be used to report the service in an outpatient setting, and this was an inpatient visit. 802.5 is also incorrect.
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13. Which codes would you use to report the percutaneous insertion of a permanent dual-chamber pacemaker by means of the subclavian vein in a patient with sick sinus syndrome? 33249 33217 33208 33240 427.1 427.81 427.89 A. B. C. D. Insertion or repositioning of electrode lead(s) for single- or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator Insertion of 2 transvenous electrodes; dual-chamber (two electrodes) permanent pacemaker or pacing cardioverter-defibrillator Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Insertion of single- or dual-chamber pacing cardioverter-defibrillator pulse generator Paroxysmal ventricular tachycardia Sick sinus syndrome Bradycardia
33249, 427.1 33217, 427.81 33208, 427.81 33240, 427.89
CORRECT ANSWER: C. 33208 reports insertion of a permanent dual-chamber pacemaker with transvenous (by means of a vein) electrode placement. Code 427.81, sick sinus syndrome, is the reason for the procedure. RATIONALE: A. 33249 is for insertion of the electrode lead(s) for a single- or dual-chamber pacing cardioverter-defibrillator and the insertion of pulse generator, not insertion of a pacemaker and the electrodes. Code 427.1 is incorrect. B. 33217 is for insertion of the electrodes for a dual-chamber pacemaker, not the insertion of the pacemaker and the electrodes. Code 427.81 is correct. D. 33240 is for insertion of a dual-chamber pacing cardioverter-defibrillator pulse generator, not the pacemaker generator and the electrodes. Code 427.89 is incorrect.
14. The patient is brought to the ED with burns of the back. The notes indicate that the burns were over 10% of the body surface, with 50% of the burns being 3rd degree and the other 50% being 2nd degree. What would be the sequencing of codes to report this burn? A. B. C. D. Code for 2nd degree, code for 3rd degree, code for body area involved. Code for 3rd degree, code for 2nd degree, code for body area involved. Code for body area, code for 3rd degree, code for 2nd degree. Code for 3rd degree, code for body area.
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CORRECT ANSWER: D. Code for 3rd degree, code for body area. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.17.c.2, the code that reflects the highest degree of burn is to be sequenced first, and burns of the same local site but of different degrees are identified by the highest degree of burn recorded. In this case, there was only one area of burn (back, 942.34), and even though there were 2nd and 3rd degree burns, only the 3rd degree burn is reported. No code is reported for the 2nd degree burn. 948.10 is the correct code to report the percentage of body surface that was burned. The code for the body area involved in the burn is sequenced second (ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.17.c.6). In this report, the body area was 10% (948.1X), with 50% of the burn 3rd degree. This means that 5% of the body surface had 3rd degree burn. The fourth digit indicates the percentage of the body surface that was burned, and the fifth digit indicates the percentage of body surface that was 3rd degree burn. RATIONALE: A. Code for 2nd degree, code for 3rd degree, code for body area involved is incorrect, because the highest degree of burn is reported first, and no code is reported for the other degrees of burn if the burn is of the same area. In this case, the burns were all on the back. B. Code for 3rd degree, code for 2nd degree, code for body area involved is incorrect, because the second degree burn is not reported when it is of the same body area as in this casethe back. C. Code for body area, code for 3rd degree, code for 2nd degree is incorrect, because the body area covered by the burn is not sequenced first, and the 2nd degree burn is not reported in addition to the code for the 3rd degree burn when it is of the same body area as in this casethe back.
15. A patient with end-stage renal disease is admitted to the hospital for hemodialysis. V56.31 V56 V56.0 584.9 585.6 585.9 A. B. C. D. Encounter for adequacy testing for hemodialysis Encounter for dialysis and dialysis catheter care Extracorporeal dialysis Acute renal failure End-stage renal disease or chronic kidney disease requiring dialysis Chronic renal failure, NOS
V56.31, 584.9 V56, 584 V56.0, 585.6 585.9, V56.0
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CORRECT ANSWER: C. V56.0 is correct for hemodialysis, and 585.6 is correct for end-stage renal disease requiring dialysis, listed in this order, as the reason for the encounter is the hemodialysis. Encounter for dialysis (V56) is listed in the ICD-9-CM as a first-listed V code. The ICD-9-CM instructs the coder after category V56 to Use additional code to identify the associated condition. Another reference to the correct code sequencing is the V Code Table located in the ICD-9-CM Official Guidelines for Coding and Reporting (following I.C.18.d.15). RATIONALE: A. V56.31 incorrectly reports an encounter for adequacy testing for potential hemodialysis, and this patient is receiving hemodialysis. 584.9 incorrectly reports acute renal failure, and this patient has chronic renal failure. B. V56 and 584 both have a fourth digit and as such are not as specific as possible. You should always code to the highest specificity. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.3. D. The code V56.0 is correct, but the sequence should be as shown in choice C, where the primary reason for the encounter (hemodialysis) is listed first, and the 585.9 code is incorrect.
16. This 52-year-old male has undergone several attempts at extubation, all of which failed. He also has morbid obesity and significant subcutaneous fat in his neck. The patient is now in for a tracheostomy because of upcoming surgery for esophageal cancer. 31.1 31.21 31.29 31.74 150.3 150.5 150.9 278.00 278.01 A. B. C. D. Tracheostomy (temporary) Mediastinal tracheostomy Other permanent tracheostomy Revision of tracheostomy Malignant neoplasm, upper third of esophagus, primary Malignant neoplasm, lower third of esophagus, primary Malignant neoplasm, esophagus, unspecified, primary Obesity Morbid obesity
150.3, 278.00, 31.29 150.5, 31.21 150.9, 278.01, 31.1 150.9, 278.01, 31.74
CORRECT ANSWER: C. 150.9, 278.01, 31.1. The 150.9 esophageal cancer with upcoming surgery is the reason for the trach. Code 278.01 describes this patients morbid obesity and the 31.1 describes the tracheostomy. There is no documentation that
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this is a permanent tracheostomy and a coder cannot assume that it is permanent. RATIONALE: A. 150.3, 278.00, 31.29 reports a permanent tracheostomy and there is no documentation that the tracheostomy is permanent. The codes 150.3 and 278.00 are also incorrect. B. 150.5, 31.21 is a mediastinal tracheostomy that is located lower on the chest and there is no documentation that indicates this was the type of tracheostomy. The diagnosis code 150.5 is incorrect and the code for the obesity is missing. D. 150.9, 278.01, 31.74 is a revision of a previous tracheostomy, and this patient is having an initial placement. The diagnosis codes are correct.
17. Which code would be used to report a 16 sq cm surgical debridement of a nonhealing abdominal surgical wound by a physician, including the subcutaneous tissue? 11000 11010 Debridement of extensive eczematous or infected skin; up to 10% of body surface Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e.g., excisional debridement); skin and subcutaneous tissue Debridement; subcutaneous tissue (includes epidermis and dermis if performed); first 20 sq cm or less Debridement; muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less Other postoperative infections Non-healing surgical wound Other specified complication of a procedure
11042 11043 998.59 998.83 998.89
A. B. C. D.
998.59, 11000 998.89, 11010 998.83, 11043 998.83, 11042
CORRECT ANSWER: D. 998.83, 11042 identifies the debridement of 20 sq cm or less of subcutaneous tissue. Code 998.83 identifies the non-healing surgical wound, which is the reason for the procedure. RATIONALE: A. 998.59, 11000 reports debridement of infected skin, not subcutaneous tissue. Code 998.59 is for infected postoperative wound and there is no mention of any infection.
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B. 998.89, 11010 reports debridement of skin and subcutaneous tissue associated with open fracture or dislocation. Code 998.89 is incorrect. C. 998.83, 11043 reports debridement of the muscle. The report states skin and subcutaneous tissue, it does not state muscle. Code 998.83 is correct.
18. The radiologist, an employee of the hospital, performed preoperative placement of a needle localization wire of a single lesion of the breast for a woman visiting the U.S. from Australia who has a primary malignant lesion of the right breast. Ultrasonic guidance was used, and the radiologist also provided that portion of the service. This service was provided at the hospital, by the hospitals radiologist, using the hospitals equipment. The patient planned to undergo surgery when she returned to her home. Code the hospital service(s). 19290 19125 19295 Preoperative placement of needle localization wire, breast; Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion Image guided placement, metallic localization clip, percutaneous, during breast biopsy/aspiration (List separately in addition to code for primary procedure) Stereotactic localization guidance for biopsy or needle placement; each lesion, radiological supervision and interpretation Ultrasonic guidance for needle placement, imaging supervision and interpretation Neoplasm, breast Neoplasm, breast, malignant, primary Neoplasm, breast, central portion, malignant, primary Neoplasm, breast, malignant, secondary Right Left
77031 76942 174 174.9 174.1 198.81 -RT -LT A. B. C. D.
174.9, 19290-RT, 19125-RT, 77031 174.1, 19125-LT 174.9, 19290-RT, 76942 198.81, 19295-RT
CORRECT ANSWER: C. The diagnosis was primary malignant neoplasm of the breast (174.9). 19290-RT identifies the placement of one wire (marker) preoperatively by a radiologist. Modifier -RT indicates the procedure/ultrasound was performed on the right breast. The radiologist also provided the ultrasonic guidance, reported with 76942. RATIONALE: A. The diagnosis is correct, as primary malignant neoplasm of the breast with 174.9. 19290-RT correctly reports the placement of the wire, but the case did
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not state to code the excision of the lesion with the placement (19125-RT). 77031 is incorrect because it reports stereotactic guidance, but the case stated ultrasound guidance. B. The diagnosis is incorrect, as the central portion of the breast was not specified as the location. 19125 reports removal of a lesion that is identified by a preoperatively placed radiology marker, but only the placement of the wire was to be coded. The placement of the marker was on the right breast (-RT), not the left breast (-LT). D. The diagnosis code 198.81 is incorrect, as the neoplasm was primary not secondary. 19295-RT is the image-guided placement during a breast biopsy/aspiration and is an add-on code that cannot be used alone.
19. The patient presents to the ED with a chief complaint of fever and cough. The ED physician orders a chest x-ray with an indication that this x-ray is for fever and cough. The hospitals radiologist reviews the x-ray and indicates that the diagnosis is pneumonia. Which diagnosis would you report for the radiologists service? A. B. C. D. cough and fever fever and cough pneumonia, cough, and fever pneumonia
CORRECT ANSWER: D. pneumonia. The most definitive diagnosis is to be reported, and that is pneumonia as this is an outpatient service. Signs and symptoms that are secondary to a confirmed diagnosis are not reported separately per the ICD-9-CM Official Guidelines for Coding and Reporting, Section IV, Diagnostic Coding and Reporting Guidelines, L. and Section I.B.6 and I.B.7. Also, according to Coding Clinic 1st Q 2002 page 4, in the outpatient setting it is acceptable to assign codes based on a radiologists interpretation. RATIONALE: A. Reporting cough and fever would be incorrect as these are the symptoms and the diagnosis is known. B. Reporting fever and cough would be incorrect as these are the symptoms and the diagnosis is known. C. Reporting pneumonia, cough, and fever would be incorrect as cough and fever are symptoms of pneumoniasee Section IV, Diagnostic Coding and Reporting Guidelines, paragraph L. and Section I.B.6 and I.B.7.
20. A charge description master is used to determine: A. the fee charged for a specific code or supply
18
B. a description of a service C. a corresponding CPT or HCPCS code and revenue code D. all of the above CORRECT ANSWER: D. All of the above. A charge description master is an inventory of all services, procedures, supplies, and drugs with their corresponding CPT or HCPCS codes, revenue codes, descriptions, and assigned charges billed. It can be used to assist in the analysis of charges and trends within a facility or practice. RATIONALE: A. A charge description master will list the fee charge by code or supply during a specific period of time. B. A charge description master will provide a description of each service or supply corresponding to the CDM number. C. A charge description master will list default and payer-specific CPT and HCPCS codes, if appropriate.
21. A patient presents to the outpatient surgical department for removal of two sigmoid polyps. The surgeon removes the polyps by means of snare technique using a flexible sigmoidoscopy scope. 45320 Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser) Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Neoplasm, colon, benign Neoplasm, rectum, benign Neoplasm, other and unspecified site (digestive system NOS), benign
45383 45309 45338 211.3 211.4 211.9 A. B. C. D.
211.9, 45320 211.3, 45383 211.4, 45309 211.3, 45338
CORRECT ANSWER: D. 211.3, 45338 identifies the flexible sigmoidoscope with the removal of the polyps using snare technique. Code 211.3 identifies the polyp in the sigmoid colon which was the reason for the procedure.
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RATIONALE: A. 211.9, 45320 reports the ablation of polyps that could not be removed by snare technique, but the technique specified in the case was a snare technique. Also, this code represents proctosigmoidoscopy but the procedure was described as a sigmoidoscopy. Code 211.9 is unspecified and the polyp is specified as being located in the sigmoid colon. B. 211.3, 45383 is for colonoscopic ablation of tumors. A colonoscopy was not performed, and the polyps were not ablated. Code 211.3 is correct. C. 211.4, 45309 is for rigid scope, and this was a flexible scope. This code represents proctosigmoidoscopy, but the procedure was described as a sigmoidoscopy. Also, this code is for the removal of a single polyp, and two polyps were removed. Code 211.4 is incorrect as it describes a polyp in the rectum not the sigmoid colon.
22. The delivering physician takes the newborn male, immediately after delivery, to the nursery to perform a clamp circumcision. Report the facility service for the circumcision. 54160 54150 64.0 V50.2 V50.4 V30.00 A. B. C. D. Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) Circumcision, using clamp or other device with regional dorsal penile or ring block Circumcision Routine or ritual circumcision Prophylactic organ removal Single liveborn, born in hospital, without mention of cesarean section
54160, V50.2 54150, V50.4 64.0, V50.2 64.0, V30.00
CORRECT ANSWER: D. 64.0, V30.00. Code identifies the procedure of a circumcision on a male. Since this newborn is still in the hospital, the Volume 3 procedure code is the correct choice of code to report this procedure. V30.00 reports the delivery of a single liveborn that was delivered in the hospital without mention of cesarean delivery. RATIONALE: A. 54160 is a circumcision other than clamp, but this newborn was still in the hospital, so the procedure is reported with a Volume 3 procedure code (64.0). V50.2 is an incorrect diagnosis code for a routine delivery of a newborn as it would be V30.00.
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B. 54150 correctly identifies the clamp circumcision in an outpatient setting, but this service was provided in the hospital; therefore, a Volume 3 procedure code would be reported. V50.4 incorrectly reports the diagnosis because this code reports an encounter for removal of an organ. C. 64.0 is correct to report the circumcision of a male. V50.2 is incorrect because it reports an encounter for circumcision as if the patient was presented for only that purpose, rather than the birth reported with V30.00, which includes the routine circumcision.
23. Indicate the revenue codes for a patient requiring sutures who was treated in the ED. A. B. C. D. 0300 medical nutritional therapies 0560 other medical social services 0450 outpatient emergency services 0361 minor procedures
CORRECT ANSWER: C. 0450 outpatient emergency services is the correct revenue code for a patient requiring sutures who was treated in the ED. RATIONALE: A. 0300 is not the correct revenue code for a minor procedure, rather it is for medical nutritional therapies. B. 0560 is not the correct revenue code for a minor procedure, rather it is for other medical social services. D. 0361 minor procedures reports procedures performed in the operating room suite.
24. A patient is admitted to the hospital to have a cholecystectomy because of acute cholecystitis. The surgeon notes in the medical record that the patient has atrial fibrillation. The patient is not on medication for the condition. The patients primary care physician performs a preoperative physical examination and indicates that the patient is cleared for surgery. The coder would: A. report only the atrial fibrillation B. report the acute cholecystitis as the principal diagnosis, followed by the atrial fibrillation C. not report the atrial fibrillation D. add a complication code for the atrial fibrillation CORRECT ANSWER: B. All diagnoses documented are reportable if they are treated or affect the treatment. The atrial fibrillation would be listed as a secondary diagnosis, following cholecystitis, which is the reason for admission.
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RATIONALE: A. This is an incorrect answer because the atrial fibrillation is not the principal diagnosis. C. This is an incorrect answer because the atrial fibrillation was evaluated; therefore it should have been reported. D. This is an incorrect answer because a complication code is reported only if there is a complication, and no complication was noted for this patient.
25. Congenital hypothyroidism with mild retardation: 243 317 244.9 318.0 A. B. C. D. Congenital hypothyroidism Mild mental retardation Unspecified hypothyroidism Moderate mental retardation
243, 317 244.9, 317 243, 318.0 317, 243
CORRECT ANSWER: A. 243 correctly describes congenital hypothyroidism. Guideline under 243 states use additional code to identify associated mental retardation. 243 is the first-listed diagnosis, and 317 correctly describes mild retardation and is listed second. RATIONALE: B. 244.9 is acquired hypothyroidism, not congenital hypothyroidism, and 317 is correct for mild retardation. C. 243 is correct for congenital hypothyroidism, but 318.0 is for moderate mental retardation, not mild retardation. D. The codes are correct, but the order is incorrect because the first-listed code should be that of the primary condition of hypothyroidism as explained in rationale A above.
26. This inpatient is taken to the operating room for surgery as follows: Left frontal ventricular puncture for implanting catheter, layered repair of 8-cm scalp laceration, and repair of multiple facial and eyelid lacerations with an approximate total length of 12 cm. Report only the facility procedure(s) codes for this case.
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61020 12015 61107
12034 61215 02.2 02.32 86.59 08.81 A. B. C. D.
Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection Simple repair of superficial wounds of face, ears, eyelids, nose, lips, and/or mucous membranes; 7.6 cm to 12.5 cm Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device Layer closure of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm Insertion of subcutaneous reservoir, pump, or continuous infusion system for connection to ventricular catheter Ventriculostomy Ventriculovenostomy Closure of skin and subcutaneous tissue of other sites Repair of eyelid laceration
61020, 12015 02.2, 86.59, 08.81 61215, 12015 02.32, 12034
CORRECT ANSWER: B. The ICD-9-CM procedure codes need to be used for reporting inpatient procedures. 02.2 correctly reports a ventriculostomy, 86.59 is used for closure of the skin lacerations of the scalp and face, and 08.81 for the repair of the eyelid laceration. RATIONALE: A. CPT codes are not used in the inpatient setting. C. CPT codes are not used in the inpatient setting. D. 02.32 reports a ventriculovenostomy, not a ventriculostomy, which was stated in the documentation. 12034 identifies the layered closure of the scalp. This code is not correct because CPT codes are not used in the inpatient setting. Closure of the scalp and face lacerations should be reported with 86.59 and 08.81 for the eyelid.
27. Acute glomerulonephritis due to infectious hepatitis: 580.9 070 580.81 070.9 Acute glomerulonephritis with unspecified pathological lesion in kidney Viral hepatitis Acute glomerulonephritis in diseases classified elsewhere Unspecified viral hepatitis without mention of hepatic coma
A. 580.9, 070
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B. 070, 580.9 C. 580.81, 070.9 D. 070.9, 580.81 CORRECT ANSWER: D. 070.9 describes hepatitis that is unspecified viral hepatitis without mention of hepatic coma, and is the first-listed diagnosis; 580.81, the acute glomerulonephritis, is listed second. This sequencing is correct per ICD-9-CM Official Guidelines for Coding and Reporting, Section I.A.6. RATIONALE: A. 580.9 describes acute glomerulonephritis with an unspecified pathological lesion of the kidney, and 070 is the viral hepatitis category code, but fourth- and fifthdigit codes are available, and a coder must code to the highest specificity possible. B. 070 is the viral hepatitis category code, but fourth- and fifth-digit codes are available, and a coder must code to the highest specificity possible. 580.9 describes acute glomerulonephritis with an unspecified pathological lesion of the kidney. C. These are the correct codes, but in an incorrect order according to Section I.A.6, of the ICD-9-CM Official Guidelines for Coding and Reporting, which states that the underlying condition is to be coded first.
28. A patient was admitted as an outpatient to the hospital for right ear conductive hearing loss. The diagnosis was ear otosclerosis. The operative report indicated that the stapes footplate was significantly thickened. A right ear stapedectomy was performed. During the procedure, the patient experienced atrial fibrillation, and this was documented in the medical record. 387.8 387.9 389.00 427.31 997.1 999 69660 69661 -RT A. B. C. D. Other otosclerosis Otosclerosis, unspecified Conductive hearing loss, unspecified Atrial fibrillation Cardiac complications Complication of medical care, NEC Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without the use of foreign material; with footplate drill out Right
387.8, 389.00, 999, 69660-RT 387.9, 389.00, 997.1, 427.31, 69660-RT 387.9, 997.1, 69661-RT 389.00, 999, 427.31, 69661-RT
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CORRECT ANSWER: B. 387.9, 389.00, 997.1, 427.31, 69660-RT. The diagnoses are 387.9 to report unspecified otosclerosis, 389.00 to report the hearing loss, and 997.1 to report the cardiac complication (atrial fibrillation). Atrial fibrillation is reported additionally with 427.31. A note under category 997 indicates that an additional code is to be used to identify the complication. The procedure was a stapedectomy, without mention of a footplate drill out, reported with 69660. -RT indicates the right ear. RATIONALE: A. 387.8 is incorrect as it reports other otosclerosis. 999 is incorrect as it is missing a 4th digit and it indicates a complication of medical care that was not elsewhere classifiable, and this complication was specifically a cardiac complication. Also missing from this choice is the complication of atrial fibrillation, which is reported with 427.31. A note under category 997 indicates that an additional code is to be used to identify the complication. 69660 correctly reports the stapedectomy, without mention of a footplate drill out. -RT indicates the right ear. 389.00 is the correct code to describe the hearing loss. C. 387.9 is correct. 997.1 correctly reports the cardiac complication. Missing from this choice is the complication of atrial fibrillation, which is reported with 427.31. A note under category 997 indicates that an additional code is to be used to identify the complication. Code 389.00 that describes the type of hearing loss is missing. 69661 reports a stapedectomy with footplate drill out, but no drill out was indicated in the report. -RT indicates the right ear. D. 389.00 reports conductive hearing loss, not otosclerosis as indicated in the documentation. 999 is incorrect as it is missing a 4th digit and it indicates a complication of medical care that was not elsewhere classifiable, and this complication was more specifically a cardiac complication. The atrial fibrillation is correctly reported with 427.31. A note under category 997 indicates that an additional code is to be used to identify the complication. 69661 reports a stapedectomy with footplate drill out, and no drill out was indicated in the report. -RT indicates the right ear.
29. A patient presented to the outpatient surgery department for a procedure in which general anesthesia was to be administered. The patient was prepared and taken to the operating room. Before anesthesia could be administered, the physician decided to cancel the procedure because the patient had a significant upper respiratory infection. What modifier would the hospital append to the procedure code to indicate this situation? A. B. C. D. -59 -73 -74 -77
25
CORRECT ANSWER: B. -73, discontinued outpatient hospital/ambulatory surgery center procedure prior to the administration of anesthesia. This modifier is used to report a procedure that was discontinued because of extenuating circumstances or those that threaten the well-being of the patient. Anesthesia has not been provided when this modifier is reported. RATIONALE: A. -59 is used to report a distinct procedural service. C. -74 is used to report a discontinued outpatient hospital or ambulatory surgery center procedure after administration of anesthesia. D. -77 is used to report a repeat procedure by another physician.
30. This 32-year-old inpatient has a left ectopic (fallopian) pregnancy. The surgeon admits her and performs a laparoscopic salpingectomy. Report the facility services. 59120 59121 59151 58943 Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or oophorectomy, abdominal or vaginal approach ; tubal or ovarian, without salpingectomy and/or oophorectomy Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy Salpingectomy with removal of tubal pregnancy Other partial salpingectomy Unspecified ectopic pregnancy without intrauterine pregnancy Tubal pregnancy (Fallopian) without intrauterine pregnancy Other ectopic pregnancy without intrauterine pregnancy
66.62 66.69 633.90 633.10 633.80
A. B. C. D.
59121, 633.90 59151, 633.10 66.62, 633.10 66.69, 633.80
CORRECT ANSWER: C. 66.62 identifies laparoscopic treatment of an ectopic pregnancy with salpingectomy for the facility. 633.10 is the diagnosis code for a fallopian pregnancy, without intrauterine pregnancy. RATIONALE: A. 59121 reports the physicians or outpatient facilitys services for a surgical treatment of a tubal or ovarian ectopic pregnancy not the facility services (66.62).
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633.90 is an incorrect diagnosis code because it reports an unspecified ectopic pregnancy, but in this report, the site of the ectopic pregnancy was listed as the fallopian tube. B. 59151 is the correct CPT code for reporting the physicians or outpatient facilitys services for a laparoscopic treatment of an ectopic pregnancy. But it is incorrect in this case because the ICD-9-CM procedure codes must be used to report the inpatient facility services (66.62). The diagnosis (633.10) to report a fallopian pregnancy is correct. D. 66.69 identifies a partial salpingectomy and the procedure in this report was treatment of an ectopic pregnancy with salpingectomy. 633.80 reports Other ectopic pregnancy, such as cervical, mesometric, combined, cornual, or intraligamentous, but the report indicated the site of the ectopic pregnancy as the fallopian tube.
31. Open wound of left hand with gravel ground into the wound: 882.0 883.0 882.1 882.2 A. B. C. D. 882.1 883.0 882.0 882.2 Open wound of hand except finger(s) alone without mention of complication Open wound of finger(s) without mention of complication Open wound of hand except finger(s) alone, complicated Open wound of hand except finger(s) alone with tendon involvement
CORRECT ANSWER: A. 882.1 is assigned to an open wound of the hand (except the fingers) with complication because of the gravel that was ground into the wound. The ICD-9-CM defines complicated as delayed healing, delayed treatment, foreign body, or primary infection. This guideline is located in the diagnosis index following the entry for wound, open. RATIONALE: B. 883.0 is an open wound of the finger(s). C. 882.0 is incorrect because it reports an open wound of the hand without mention of complication. This wound did have a complicationthe gravel that was stated to have been ground into the wound. D. 882.2 is for an open wound of the hand with tendon involvement, which was not stated in the question.
32. A patient undergoes a chemotherapy treatment for primary, malignant neoplasm of the bladder in the oncology department of the hospital. During the therapy, she develops tachycardia. The cardiologist is called to the oncology department and
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admits the patient to the hospital for further tests. The medical record indicates that the cardiologists records indicated a diagnosis of nonparoxysmal junctional tachycardia due to acute carditis. What would be the principal diagnosis for the hospital stay? A. B. C. D. primary, malignant neoplasm of the bladder complication of chemotherapy acute carditis nonparoxysmal junctional tachycardia
CORRECT ANSWER: C. Acute carditis. The medical records document that the cardiologist indicated the nonparoxysmal junctional tachycardia is a result of acute carditis. The acute carditis is the cause of the nonproxysmal junctional tachycardia. The nonparoxysmal junctional tachycardia would also be coded because it is not inherent in the disease process but rather is a complication of the disease process. RATIONALE: A. Primary, malignant neoplasm of the bladder is incorrect as it is not the reason the patient was hospitalized, rather hospitalization was due to acute carditis. B. Complication of chemotherapy is incorrect as it is not the reason the patient was hospitalized, rather hospitalization was due to acute carditis. D. Nonparoxysmal junctional tachycardia is not the most definitive diagnosis because the cardiologist indicated the tachycardia was due to acute carditis.
33. Which of the following is true about a device marked with a status indicator H? A. This is included in the OPPS APC payment. B. This is not allowed under the OPPS when the procedure in which the device was used is performed in an outpatient setting. C. This device is paid under OPPS as a cost based pass-through payment. D. This is paid at a reasonable cost and is not subject to deductible or coinsurance. CORRECT ANSWER: C. This device is paid under OPPS on the basis of the cost. See Figure 2-4 in this text, which describes each of the indicators in the OPPS. RATIONALE A. This is included in the OPPS payment. This choice is incorrect. See Figure 2-4 in this text, which describes each of the indicators in the OPPS. B. This is not allowed under the OPPS when the procedure in which the device was used is performed in an outpatient setting. This choice is incorrect. See Figure 2-4 in this text, which describes each of the indicators in the OPPS.
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D. This is paid at a reasonable cost and not subject to deductible or co-insurance. This choice is incorrect. See Figure 2-4 in this text, which describes each of the indicators in the OPPS.
34. This patient is 35 years old at 36 weeks gestation. This is her second pregnancy. She presents in spontaneous labor. Because of her prior cesarean section, she is taken to the operating room to have a repeat low cervical cesarean section performed. The patient also desires sterilization, so a bilateral tubal ligation will also be performed. A single liveborn infant is the outcome of the delivery. Report the facility services for the mother.
59514 58605
58611
58615 59620 644.21 654.21 659.61 669.71 V25.2 V27.0 66.32 74.1
Cesarean delivery only Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (list separately in addition to code for primary procedure) Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach Cesarean delivery only following attempted vaginal delivery after previous cesarean delivery Early onset of delivery, delivered, with or without mention of antepartum condition Previous cesarean delivery, delivered, with or without mention of antepartum condition Elderly multigravida, delivered, with or without mention of antepartum condition Cesarean delivery, without mention of indication; delivered, with or without mention of antepartum condition Sterilization Single liveborn Tubal ligation Low cervical cesarean section
A. B. C. D.
669.71, 654.21, 659.61, V27.0, 74.1 644.21, V27.0, 59620, 58615 644.21, 654.21, V27.0, V25.2, 59514, 58611 654.21, 644.21. 659.61, V27.0, V25.2, 74.1, 66.32
CORRECT ANSWER: D. 654.21, 644.21, 659.61, V27.0, V25.2, 74.1, 66.32. 654.21 reports that the patient has previously delivered by cesarean section. 644.21 reports the
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early onset of delivery (36 weeks). 659.61 reports elderly multigravida. Elderly, as defined by ICD-9-CM, is a woman who is 35 YOA at the time of delivery. Multigravida means a woman who has previously delivered. V27.0 is for single liveborn infant. V25.2 is the diagnosis code for the sterilization (tubal ligation). 74.1 reports the procedure of a low cervical cesarean section. 66.32 reports the tubal ligation. RATIONALE: A. 669.71, 654.21, 659.61, V27.0, 74.1 is incorrect because V25.2 to report the sterilization is missing, and 669.71 is incorrect because the reason for the C-section is knowna repeat C-section. Also missing is the report of the tubal ligation (66.32 procedure code for tubal ligation) and early onset of delivery, 644.21. B. 644.21, V27.0, 59620, 58615. This choice is incorrect because it is to report inpatient procedures; as such, the procedures must be reported with Volume 3 procedure codes (74.1 procedure code for low cervical cesarean section and 66.32 procedure code for tubal ligation), not CPT codes. Missing is the report of the tubal ligation (V25.2). Also missing from this choice are 654.21 (early onset of delivery) and 659.61 (elderly multigravidaolder woman who has delivered previously). C. 644.21, 654.21, V27.0, V25.2, 59514, 58611. This choice is incorrect because it is to report an inpatient procedure; as such, the procedures must be reported with Volume 3 procedure codes (74.1 procedure code for low cervical cesarean section and 66.32 procedure code for tubal ligation), not CPT codes. Also missing from this choice is 659.61 to report elderly multigravida (older woman who has delivered previously). 35. This inpatient presented with an obstructed ventriculoperitoneal shunt. The procedure performed was to be a revision of shunt at the ventricular site. After the shunt system was inspected, the entire cerebrospinal fluid shunt system was removed, and a similar replacement shunt system was placed. Patient has communicating hydrocephalus. Report only the facility services. 996.1 996.2 62180 62258 62256 62190 02.34 02.42 54.95 331.3 331.4 Mechanical complication of other vascular device, implant, and graft Mechanical complication of nervous system device, implant, and graft Ventriculocisternostomy (Torkildsen type operation) Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation Removal of complete cerebrospinal fluid shunt system; without replacement Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular Ventricular shunt to abdominal cavity and organs Revision, removal and irrigation of ventricular shunt site, replacement of ventricular shunt Revision, removal and irrigation of ventriculoperitoneal shunt at peritoneal site Communicating hydrocephalus Obstructive hydrocephalus
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331.5
Normal pressure hydrocephalus
A. B. C. D.
996.1, 331.4, 02.34 996.2, 331.3, 02.42 996.1, 331.5, 62256 996.1, 331.3, 62190
CORRECT ANSWER: B. 996.2, 331.3, 02.42. Code 996.2 is the diagnosis for a mechanical complication of a nervous system device. Code 331.3 is the reason that the patient has the shunt. 02.42 identifies removal and replacement of the entire ventriculoperitoneal shunt. RATIONALE: A. The diagnosis code 996.1 is incorrect. The correct code is 996.2 to report a complication of a mechanical, nervous system device. Also incorrect is 331.4 and 02.34 which reports ventricular shunt to the abdominal cavity/organs and this was a ventriculoperitoneal shunt at the ventricular site (02.42). C. 996.1 is the diagnosis for a mechanical complication of a vascular system device and this was of the nervous system. Code 331.5 is incorrect. This is an inpatient for which Volume 3 codes are used to report procedures, not CPT codes. D. 996.1 is an incorrect diagnosis of a mechanical complication of a vascular system device and this was of the nervous system. This is an inpatient for which Volume 3 codes are used to report procedures, not CPT codes. Code 331.3 is correct.
36. Bloody stool: 578.1 578.0 792.1 772.4 A. B. C. D. 772.4 792.1 578.1 578.0 Melena Hematemesis Abnormal finding in stool (occult blood in stool) Gastrointestinal hemorrhage
CORRECT ANSWER: C. 578.1 correctly describes blood in the stool (melena). RATIONALE: A. 772.4 is gastrointestinal hemorrhage in a fetus or neonate.
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B. 792.1 is occult blood in stool, which is blood that is not visible; rather, it was blood found in stool by means of a lab test. D. 578.0 is hematemesis or vomiting of blood.
37. This 34-year-old female is admitted for total abdominal hysterectomy with bilateral salpingo-oophorectomy. The diagnosis is pelvic peritoneum endometriosis and periovarian adhesions. Report the facility services only.
59.8 65.61 68.49 58150 614.6 617.3
Ureteral catheterization Bilateral salpingo-oophorectomy Total abdominal hysterectomy Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) Pelvic peritoneal adhesions, female (postoperative) (postinfection) Endometriosis of pelvic peritoneum
A. B. C. D.
58150, 617.3, 614.6 68.49, 65.61, 59.8, 617.3 65.61, 617.3, 614.6 617.3, 614.6, 68.49, 65.61
CORRECT ANSWER: D. 617.3, 614.6, 68.49, 65.61. This choice is correct as it reports the inpatient procedure of total abdominal hysterectomy (68.49) and bilateral salpingooophorectomy (65.61). The diagnoses are endometriosis of the pelvic peritoneum (617.3) and pelvic peritoneal adhesions (614.6). RATIONALE: A. 58150, 617.3, 614.6. This choice is incorrect as the inpatient procedures are reported with Volume 3 codes, not CPT codes. B. 68.49, 65.61, 59.8, 617.3. This choice is incorrect as it reports a ureteral catheterization and this procedure was not stated in the report. Also missing is 614.6 to report the pelvic adhesions. C. 65.61, 617.3, 614.6. This choice is incorrect as it does not report the total abdominal hysterectomy.
38. Sarcoidosis with cardiomyopathy:
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135 425.8 517.8 V71.7
Sarcoidosis Cardiomyopathy in other diseases classified elsewhere (code first underlying disease) Lung involvement in other diseases classified elsewhere (code first underlying disease) Observation for suspected cardiovascular disease
Index: Sarcoidosis 135 cardiac 135 [425.8] lung 135 [517.8]
A. B. C. D.
135, 517.8 135, 425.8 425.8, 135 135, 425.8, V71.7
CORRECT ANSWER: B. 135, sarcoidosis, is the first-listed diagnosis, and 425.8, cardiomyopathy, is listed second. You know this because listed in the Index of the ICD-9CM under Sarcoidosis is subterm cardiac 135 [425.8]. You are to list these codes in the order presented in the Index of the ICD-9-CM. Further, when the Tabular List is referenced, a directional note under 425.8, cardiomyopathy, directs the coder to Code first any underlying disease classified elsewhere and includes Sarcoidosis 135 in the list of other diseases. This also directs the coder to list 135 first, followed by 425.8. RATIONALE: A. 135 is correct for the underlying disease of sarcoidosis, but 517.8 is for lung involvement, not cardiac involvement. C. The codes are correct, but the underlying condition (sarcoidosis) is to be listed first and the cardiomyopathy is listed second, as indicated in the directional note with 425.8 in the ICD-9-CM. D. The codes are correct and in the correct order, except V71.7 (observation for suspected cardiovascular disease) is incorrect because there was no indication of evaluation for a suspected condition.
39. A patient is in the hospital being treated for pleural effusion. Which of the following medications would indicate a possible complication or comorbid condition that may affect payment for the DRG? A. Septra B. Naprelan
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C. Captopril D. Ativan CORRECT ANSWER: A. Septra is an antibiotic, which indicates an infection was present and treated and the infection may affect the payment for the DRG. RATIONALE: B. Naprelan is an analgesic and would not indicate a complication or comorbidity that would affect payment for the DRG. C. Captopril is an antihypertensive that would not indicate a complication or comorbidity that would affect payment for the DRG. D. Ativan is an antidepressant and would not indicate a complication or comorbidity that would affect payment for the DRG. If the patient had some significant psychological problem, that problem might be a complication or comorbidity, if the significance of the problem was documented in the medical record.
40. To ensure the accuracy of the data being coded in the department, the supervisor conducts regular reviews of the inpatient coding data. Which code is the only code that can be assigned as a principal diagnosis? A. B. C. D. V15.06 E821 323.71 V71.2 Allergy to insects and arachnids Nontraffic accident involving other off-road motor vehicle Toxic encephalitis and encephalomyelitis Observation for suspected tuberculosis
CORRECT ANSWER: D. V71.2 Observation for suspected tuberculosis. Observation for a suspected condition can be a principal diagnosis if there was no more definitive diagnosis stated. RATIONALE: A. V15.06 Allergy to insects and arachnids (spiders and other eight-legged invertebrates) is not appropriate as a principal diagnosis as it is listed as an additional only V code per the V Code Table in the ICD-9-CM Official Guidelines for Coding and Reporting following Section I.C.18.d.15. B. E821 Nontraffic accident involving other off-road motor vehicle is not appropriate as a principal diagnosis as E codes are never principal diagnoses as noted in the ICD-9-CM Official Guidelines for Coding and Reporting, Section 1.C.19.a.6. C. 323.71 Toxic encephalitis is not appropriate as a principal diagnosis as it is an italicized code, and these are never sequenced first. Furthermore, the instructional note following 323.7 states that the underlying cause is to be coded
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first. 41. A patient is admitted for bariatric surgery and subsequently develops pneumonia. The pneumonia is confirmed by chest x-ray, and the physician initiates a course of antibiotics. This patient also has diet-controlled diabetes but does not take medication for the condition, which is well controlled; the patient is without blood glucose monitoring during the admission, but was on a diabetic bariatric diet. How would you sequence the diagnoses? A. B. C. D. obesity, pneumonia pneumonia, diabetes pneumonia, obesity obesity, pneumonia, diabetes
CORRECT ANSWER: D. Obesity, pneumonia, diabetes is the correct sequence because the principal reason for the admission is the bariatric surgery, which is performed for obesity, followed by the pneumonia, as it is a condition that was diagnosed and treated. Diabetes is a chronic condition and is likely one of the reasons for the patients bariatric surgery. RATIONALE: A. Obesity, pneumonia is incorrect because the diabetes is missing. Diabetes is a chronic condition and in this case it is treated with diet and is likely one of the reasons for the patients bariatric surgery. B. Pneumonia is incorrect as it is not the principal reason the patient is admitted, rather it is a condition that required active intervention during hospitalization. Obesity was the primary reason for admission. C. Pneumonia, obesity is incorrect as the pneumonia is not the principal reason the patient was admitted, rather it is a condition that required active intervention during hospitalization. Obesity was the primary reason for admission.
42. A patient is admitted for acute appendicitis. The procedure began as a laparoscopic procedure but converted to an open procedure. During the procedure, a small serosal tear in the terminal ileum occurred while the cecum was mobilized. What would you report, and what is the correct sequence of codes? A. acute appendicitis, V code to report laparoscopic surgical procedure converted to an open procedure, open appendectomy B. acute appendicitis, complication of surgery by accidental puncture or laceration, internal injury to the ileum, laparoscopic appendectomy C. acute appendicitis, complication of surgery by accidental puncture or laceration, internal injury to the ileum, V code to report laparoscopic surgical procedure converted to an open procedure, open appendectomy D. V code to report laparoscopic surgical procedure converted to an open
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procedure, acute appendicitis, complication of surgery by accidental puncture or laceration, internal injury to the ileum, laparoscopic appendectomy CORRECT ANSWER: C. acute appendicitis, complication of surgery by accidental puncture or laceration, V code to report laparoscopic surgical procedure converted to an open procedure. The reason for the procedure (acute appendicitis) is listed as the principal diagnosis, followed by a complication code (998.2). The V code (V64.41), which indicates that a laparoscopic procedure was converted to an open procedure, is reported last. According to Coding Clinic 3rd Q 1994, it is inappropriate to assign codes from 800-959 as an additional code when reporting an intraoperative laceration or puncture. No E codes are reported according to the guidelines for the AHIMA certification, available on the AHIMA website. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. RATIONALE: A. acute appendicitis, V code to report laparoscopic surgical procedure converted to an open procedure, open appendectomy. The acute appendicitis is correct as the first-listed diagnosis, but missing is a code to report the complication of surgery by accidental puncture, and the V code to indicate that the laparoscopic procedure was converted to an open procedure is reported last. B. acute appendicitis, complication of surgery by accidental puncture or laceration are correct, internal injury to the ileum is incorrect, and there is no V code to report the laparoscopic procedure that was converted to an open procedure. Laparoscopic appendectomy is incorrect because the procedure was converted to an open procedure. D. V code to report laparoscopic surgical procedure converted to an open procedure would not be listed as principal diagnosis; acute appendicitis should be the principal diagnosis. It is incorrect to report injury to ileum. Laparoscopic appendectomy is incorrect because the procedure was converted to an open procedure.
43. In the following display of the ICD-9-CM Index, identify which code is the etiology code and which is the manifestation code: Syndrome Kimmelstiel (-Wilson) (intercapillary glomerulosclerosis) 250.4 [581.81] (Note: A fifth digit would be assigned to 250.4X.) A. B. C. D. 250.4 is the etiology code and 581.81 is the manifestation code. 581.81 is the etiology code and 250.4 is the manifestation code. Both 250.4 and 581.81 can be the etiology or the manifestation code. Neither 250.4 nor 581.81 can be the etiology or the manifestation code.
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CORRECT ANSWER: A. 250.4 is the etiology code and 581.81 is the manifestation code. The etiology (cause) is listed first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. This convention is explained in the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.A.6. RATIONALE: B. 581.81 is the etiology code and 250.4 is the manifestation code is incorrect. The etiology (cause) is listed first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. C. Both 250.4 and 581.81 can be the etiology or the manifestation code is incorrect as only 250.4 can be the etiology, as it is listed first in the Index. When reporting, the etiology (cause) is lists first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. D. Neither 250.4 nor 581.81 can be the etiology or the manifestation code is incorrect because the Index of the ICD-9-CM lists 250.4 (etiology) first and 581.81 (manifestation) second, and you always report the codes in the order they appear in the Index.
44. Which of the following is NOT a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system? A. B. C. D. severity of illness prognosis ABN treatment difficulty
CORRECT ANSWER: C. ABN (advanced beneficiary notice) is a notification of non-coverage to the patient, but not a consideration for the complexity of the hospitals case mix. RATIONALE: A. Severity of illness is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system. B. Prognosis is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system. D. Treatment difficulty is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system.
45. An outcome of delivery (code V27.0-V27.9) should be included on every record when delivery has occurred and should used on subsequent
37
records. A. B. C. D. newborns, not be mothers, not be newborns, be mothers, be
CORRECT ANSWER: B. mothers, not be are the correct responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. RATIONALE: A. newborns, not be are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. C. newborns, be are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. D. mothers, be are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but not used on subsequent records or on the newborn record.
46. The patient presents to the ED with cellulitis of the right small finger due to Staphylococcus aureus. The ED physician prescribed Lorabid p.o. 400 mg q12h 10 d.
681.00 681.9 041.11 041.89
Finger, cellulitis and abscess, unspecified Finger or toe, cellulitis and abscess of unspecified digit Methicillin susceptible Staphylococcus aureus Other specified bacterial infections
A. 99281, 681.9, 041.89 B. 99283, 681.00, 041.11 C. 99282, 681.00, 041.89
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D. 99283, 041.11, 681.00 CORRECT ANSWER: B. 99283, 681.00, 041.11. Level 3 correctly reports the ED service, as prescription medications are listed under this level. 681.00 correctly reports cellulitis of the finger, followed by the code 041.11 to report the cause of the infection as Staphylococcus aureus. These codes are in the correct sequence per the instructional note, following 681, to use an additional code to specify the organism. RATIONALE: A. 99281, Level 1, incorrectly reports this level of service because it is under Level 3 that prescription medications are listed. 681.9 is incorrect because it reports cellulitis of an unspecified digit, and the digit was stated to be the small finger of the right hand. 681.00 is more definitive as it indicates cellulitis of a finger. 041.89 is also incorrect as it is for other specified bacterial infection, and the report indicated the cause of the infection as Staphylococcus aureus. C. 99282, Level 2, is incorrect as prescription medications are listed under Level 3. The cause of the infection is Staphylococcus aureus, not other specified bacterial infection. D. Level 3 is correct for this service as prescription medications are listed under this level. The diagnosis codes are correct but are listed in the wrong sequence. 681.00 should be listed first according to the instructional note, following 681, to use an additional code to specify the organism. 47. A child is seen in the outpatient department at the hospital for a subsequent burn treatment as follows: 2nd degree burn of right forearm, which is 2% burn of body surface; 1st degree burn of right little finger, which is 4% of body surface; 3rd degree burn of right chest wall, which is 5% of body surface. The initial burn occurred when the child pulled a pan of hot water off the stove. 942.32 942.31 943.21 943.22 944.00 944.11 948.10 948.11 Burn of trunk, chest wall excluding breast and nipple, full-thickness skin loss [3rd degree NOS] Burn of trunk, breast, full-thickness skin loss [3rd degree NOS] Burn of upper limb, upper limb, forearm, except wrist and hand, blisters, epidermal loss [2nd degree] Burn of upper limb, elbow, except wrist and hand, blisters, epidermal loss [2nd degree] Burn of wrist(s) and hand(s), single digit other than thumb, [unspecified degree] Burn of wrist(s) and hand(s), single digit other than thumb, erythema [1st degree] Burns classified according to extent of body surface involved, 10%-19% total burn area, less than 10% are 3rd degree burn Burns classified according to extent of body surface involved, 10%-19% total burn area, 10%-19% are 3rd degree burn
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A. B. C. D.
942.32, 943.21, 944.11, 948.11 942.32, 943.21, 944.11, 948.10 942.31, 943.22, 944.00, 948.11 942.31, 943.21, 944.11, 948.10
CORRECT ANSWER: B. 942.32, 943.21, 944.11, 948.10. Burns are sequenced with the highest degree of burn first, followed by the lesser degrees of other areas. If there is a 3rd degree burn and a 2nd degree burn of the same area, only the 3rd degree burn is reported. The burns in this case are reported as 3rd degree burn of chest (942.32), 2nd degree burn of forearm (943.21), and 1st degree burn of finger (944.11). The total body surface code (948.10) is a sum of all the body surfaces involved in the burn (11%, 948.1) with a fifth digit to indicate the total body surface with 3rd degree burn, which in this case was 5% (fifth digit 0). RATIONALE: A. 942.32 correct, 943.21 correct, 944.11 correct, 948.11 incorrect because the total body surface involved in 3rd degree burn was 5%, fifth digit 0 not 1. C. 942.31 incorrect because this reports a burn to the breast and the burn was to the chest wall, 943.22 incorrect because this is for an elbow and the forearm of upper limb was involved, 944.00 is not correct because this code represents unspecified degree of burn and unspecified site of the hand. The correct code for the 1st degree burn of the index finger is 944.11. 948.11 incorrect because the total body surface involved in 3rd degree burn was 5%, fifth digit 0 not 1. D. 942.31 incorrect because this reports a burn to the breast and the burn was to the chest wall, 943.21 correct, 944.11 correct, 948.10 correct.
48. How would you report urticaria due to penicillin that was correctly prescribed and properly administered? A. Code urticaria due to drug followed by an E code to report the causative substance correctly prescribed and properly administered therapeutically. B. Report the E code for the causative substance correctly prescribed and properly administered followed by the code for the allergic urticaria. C. Report only the urticaria as no E codes are reported on the certification examination. D. Report the urticaria as an E code to report both the causative substance and how the adverse effect occurred. CORRECT ANSWER: A. Code urticaria due to drug followed by an E code to report the causative substance properly taken and prescribed therapeutically. According to the AHIMA examination packet, E codes are not assigned, except for those
40
that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered. The E code is never the first-listed diagnosis. In this case, the urticaria is an adverse effect and the E code would be required and assigned on the examination. RATIONALE: B. Report the E code for the causative substance correctly prescribed and properly administered followed by the code for the allergic urticaria is incorrect because an E code is never the first-listed diagnosis as noted in the ICD-9-CM Official Guidelines for Coding and Reporting, Section 1.C.19.a.6. C. Report only the urticaria as no E codes are reported on the certification examination is incorrect because according to the examination packet, E codes are not assigned, except for those that identify the causative substance for an adverse effect of a drug that is correctly prescribed and properly administered. D. Report the urticaria as an E code to report both the causative substance and how the adverse effect occurred is incorrect because the E code only reports the causative agent (i.e., penicillin) and the use of the agent when the adverse effect occurred (i.e., therapeutic use, accidental use, etc). The E code does not report the condition of urticaria. Urticaria due to a drug would be reported with a separate code (708.0) followed by the E code.
49. The payment status indicator that indicates ancillary services, for which payment for services is allowed under OPPS such as x-ray and EKG, is: A. B. C. D. C E F X
CORRECT ANSWER: D. X. This is the correct choice because X is the payment status indicator that indicates ancillary services for which payment for services is allowed under OPPS, such as x-ray and EKG.
RATIONALE: A. C. This is an incorrect choice because C indicates an inpatient service only not payable under OPPS. B. E. This is an incorrect choice because E indicates services for which payment is not allowed under OPPS or is not covered by Medicare. To get paid for these services, an ABN (Advanced Beneficiary Notice) must be signed to bill the patient. C. F. This is an incorrect choice because F indicates corneal tissue acquisition.
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50. In an ambulatory care setting, which of the following would NOT be reported as a secondary diagnosis? A. chronic diseases that are treated on an ongoing basis B. coexisting conditions at the time of the encounter that affect the patients management C. conditions that have been previously treated but no longer are present D. History of that have an effect on the current condition CORRECT ANSWER: C. Conditions that have been previously treated but no longer are present. According to the Ambulatory Care Coding rules presented in the CCS examination information prepared by AHIMA, and the ICD-9-CM Official Guidelines for Coding and Reporting, Section IV. K., conditions that have been previously treated but no longer exist should not be coded. RATIONALE: A. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, J, chronic diseases that are treated on an ongoing basis are to be reported. B. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, K, coexisting conditions at the time of the encounter that affect the patients management are to be reported. D. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services, K, historical conditions that have an impact on current care or influence the patients treatment are to be reported.
51. This 68-year-old female presents with proteinuria present in a recent lab. Patient is admitted for treatment of acute renal failure due to dehydration. 584.9 276.51 791.0 790.99 A. B. C. D. Failure, renal, acute Dehydration Proteinuria Findings, abnormal, other
584.9, 791.0, 584.9, 276.51 790.99
CORRECT ANSWER: C. 584.9, 276.51. This is the correct choice because 584.9 is the correct code for acute renal failure, and 276.51 is the correct diagnosis for dehydration. Proteinuria is a condition that results from acute renal failure; therefore, it is a component of the acute renal failure and is not reported separately.
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RATIONALE: A. 584.9. This choice is incorrect because the diagnosis for the dehydration is missing (276.51). B. 791.0. This choice is incorrect because it is missing a code for acute renal failure, 584.9 and a code to report the dehydration (276.51). The proteinuria is not reported as it is a result of the acute renal failure and as a component of the disease is not reported separately. D. 790.99. This choice is incorrect because missing is a code for the acute renal failure and dehydration. The proteinuria is not reported as it is a result of the acute renal failure and as a component of the disease is not reported separately.
52. A 22-year-old female patient presents to the outpatient department of the hospital for an amniocentesis to assist in the management of her complicated pregnancy. The procedure is being performed by her obstetrician. The medical record indicates 32 weeks gestation, with insulin-dependent, type 1 diabetes, and diabetic nephropathy. Report the department services. 59000 59001 250.41 250.40 583.81 583.89 648.03 Amniocentesis; diagnostic Amniocentesis; therapeutic fluid reduction Diabetes with renal manifestations, type 1 Diabetes with renal manifestations, type 2 Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere Other types of nephropathy or nephritis Diabetes complicating pregnancy, antepartum
A. B. C. D.
59001, 250.41, 648.03, 583.81 59000, 583.81, 250.41, 648.03 59000, 648.03, 583.81, 250.41 59000, 648.03, 250.41, 583.81
CORRECT ANSWER: D. 59000, 648.03, 250.41, 583.81. The service was amniocentesis, reported with 59000. The complication (648.03) is listed first as that is the reason for the procedure. The diabetes (250.41) is listed before the nephropathy (583.81) because the nephropathy code is an italicized code, and also because it stated that it is in diseases classified elsewhere, directing the code to be sequenced after the diabetes. The diagnosis sequencing above is consistent with the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.f. RATIONALE:
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A. 59001 is incorrect as it is for fluid reduction, and 250.41 is correct but should not be the first-listed diagnosis, as the complication (648.03) is the primary reason for the procedure. 583.81 is correct for nephropathy and is sequenced correctly. B. 59000 is correct for amniocentesis, 583.81 is an italicized code that indicates the nephropathy should be sequenced after the diabetes, 250.41 is the correct type of diabetes but should be sequenced before the nephropathy, and 648.03 is the correct code for the complication of pregnancy but should be sequenced first. C. 59000 is correct, 648.03 is correct, but 583.81 should be sequenced after 250.41, because 583.81 is an italicized code.
53. This inpatient was admitted for acute peritonitis (567.29) due to peritoneal dialysis. A review of the medical record indicated that there was a complication of the peritoneal catheter (996.68), which was determined to be peritonitis due to a streptococcal infection (041.09). The patient has hypertensive renal disease with chronic renal failure (403.91) (585.6). What would be the sequence of these codes? A. B. C. D. 567.29, 041.09, 403.91, 996.68 996.68, 567.29, 041.09, 403.91, 585.6 041.09, 567.29, 996.68, 403.91 585.6 996.68, 403.91, 585.9, 567.9, 041.09
CORRECT ANSWER: B. 996.68, 567.29, 041.09, 403.91, 585.6. The complication is sequenced first because it is the reason for the admission. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II.G. and the Coding Clinic, 2nd Qtr 2001, the complication is sequenced first, followed by the peritonitis and infectious organism as the cause of the complication. Hypertensive renal disease with renal failure may be assigned as an additional diagnosis, with instruction to code first the hypertensive chronic kidney disease and use additional code to identify stage of chronic kidney disease. RATIONALE: A. The complication is sequenced first because it is the reason for the admission. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II.G. and the Coding Clinic, 2nd Qtr 2001, the complication is sequenced first, followed by the peritonitis and infectious organism as the cause of the complication. Hypertensive renal disease with renal failure may be assigned as additional diagnoses. C. The complication is sequenced first because it is the reason for the admission. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II.G. and the Coding Clinic, 2nd Qtr 2001, the complication is sequenced first, followed by the peritonitis and infectious organism as the cause of the complication. Hypertensive renal disease with
44
renal failure may be assigned as additional diagnoses. D. The complication is sequenced first because it is the reason for the admission. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section II.G. and the Coding Clinic, 2nd Qtr 2001, the complication is sequenced first, followed by the peritonitis and the infectious organism as the cause of the complication. Hypertensive renal disease with renal failure may be assigned as additional diagnoses.
54. If the gastroenterologist performed a procedure for which there is no code listed in the index of the CPT, the coder should: A. B. C. D. assign an unlisted digestive code hold the report until a CPT update publishes a code for the service assign a code that closely describes the service query the physician as to the code to assign
CORRECT ANSWER: A. Assign an unlisted digestive code. Per CPT guidelines, it is recognized that there may be services or procedures performed by physicians that are not found in the CPT manual. Therefore, a number of specific code numbers have been designated for reporting unlisted procedures. Each of these unlisted procedural code numbers (with the appropriate accompanying topical entry) relates to a specific section of the manual and is presented in the guidelines of that section. This guideline can be found in the introduction section of the CPT manual under the subsection entitled: Instructions for Use of the CPT Codebook. RATIONALE: B. Hold the report until a CPT update publishes a code for the service. This is not an appropriate approach to this situation. C. Assign a code that you think may describe the service correctly. This is not an appropriate approach to this situation. D. Query the physician as to the code to assign. This is not correct, as it is recognized that there are situations where there may not be a code to appropriately identify the service provided. In those instances an unlisted CPT code will be reported. A physician should not recommend a code closely describing a service.
55. INPATIENT PREOPERATIVE DIAGNOSIS: Chronic subdural hematoma, right hemisphere POSTOPERATIVE DIAGNOSIS: Same
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PROCEDURE PERFORMED: Burr hole evacuation of subdural hematoma ANESTHESIA: General PROCEDURE: Under general anesthesia, the patients head was prepped and draped in the usual manner. Incision was made in the frontal and posterior parietal area. Two burr holes were made. The dura was incised and serosanguineous fluid exuded. I then irrigated until I got clots out. I saw the brain beneath. Then, I inserted two Penrose drains and secured them to the skin. I closed the wound with 2-0 Vicryl on the galea and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.
01.24 01.25 01.31 431 432.1 A. B. C. D.
Other craniotomy Other craniectomy Drainage subarachnoid or subdural Intracerebral hemorrhage Nontraumatic subdural hemorrhage
01.25, 432.1 01.31, 432.1 01.25, 431 01.24, 431
CORRECT ANSWER: B. 01.31, 432.1. 01.31 correctly reports this procedure as drainage of subdural hematoma. The code is identified when you reference Incision, hematoma in Volume 3 of the ICD. There is no subterm for cerebral; however, the coder is referred to see also Incision, by site. When referencing Incision, cerebral, there are two subterms, one for epidural or extradural space 01.24 and one for subarachnoid or subdural space 01.31. The Tabular indicates that 01.31 has the subterm subdural empyema, which is a collection of purulent material in the space between the dura mater and the arachnoid mater (subdural). When checking the 01.24, there is no subterm for subdural and although this case was a hematoma, the location of subdural is covered by this term. Therefore, the most descriptive code is 01.31. 432.1 is the correct code to report a nontraumatic subdural hematoma. RATIONALE: A. 01.25, 432.1. This choice is incorrect for the procedure. In the procedure section of this report, a piece of the skull was not removed, rather a hematoma drained along with fluid. Craniectomy is a removal of a piece of the skull. 432.1 is correct for the nontraumatic subdural hematoma. C. 01.25, 431. This choice is incorrect for both the procedure and the diagnosis. In the procedure section of this report, a piece of the skull was not removed, rather
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a hematoma drained along with fluid. Craniectomy is a removal of a piece of the skull. 431 is incorrect as it is for intracerebral hemorrhage which is within the brain. The correct diagnosis code would be 432.1, which specifies a subdural hemorrhage (which is bleeding between the layers that line the brain) and one that was not indicated to be traumatic. D. 01.24, 431. In this choice, 01.24 is incorrect. In the Index of the ICD, Volume 3, when the term Burr holes is referenced, the coder is directed to 01.24. When checking the Tabular, 01.24, Other craniotomy, there is no subterm for subdural, which the procedure in this case was. Also, the burr holes are the approach and the actual procedure was the evacuation for the subdural hematoma. 431 is incorrect as it is for intracerebral hemorrhage which is within the brain. The correct diagnosis code would be 432.1, which specifies a subdural hemorrhage (which is bleeding between the layers that line the brain) and one that was not indicated to be traumatic.
56. The implantation of a permanent dual-chamber pacemaker was performed in the outpatient department of the hospital. The indication was noted to be bradyarrhythmia with fainting. A pacemaker pocket was created in the left infraclavicular area after the area was anesthetized with 0.5 cc of Xylocaine. Atrial and ventricular leads were introduced. Thresholds were obtained adequately. The leads were sutured using 0 silk over their sleeves and secured. The pulse generator was connected. The pacemaker pocket was flushed with antibiotic solution. The pacemaker and leads were placed in the pocket and the pocket closed in two layers. Parameters were satisfactory. 33208 33213 427.89 780.2 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Insertion or replacement of pacemaker pulse generator only; dual chamber Other specified cardiac dysrhythmia Syncope
A. B. C. D.
427.89, 33213 780.2, 33213 427.89, 33208 427.89, 780.2, 33208
CORRECT ANSWER: C. 427.89, 33208. The diagnosis was bradyarrhythmia (427.89). The electrodes were implanted into the atrium and ventricle. The procedure is an initial implantation reported with 33208. Note under 33208 states that subcutaneous insertion of pulse generator is included. RATIONALE: A. 427.89, 33213. The diagnosis code, 427.89, is correct. In this answer, 33213 is
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incorrect as it reports the insertion of a dual-chamber, pulse generator only when the report indicated a permanent pacemaker with placement of electrodes. B. 780.2, 33213. The diagnosis code is incorrect as it reports the fainting, and fainting is a symptom of bradyarrhythmia and should not be reported separately, but rather is included in the bradyarrhythmia code, 427.89. In this answer, 33213 is incorrect as it reports the insertion of a dual-chamber, pulse generator only when the report indicated a permanent pacemaker with placement of electrodes. D. 427.89, 780.2, 33208. In this answer, 33208 and 427.89 are correct; but the fainting should not be reported, as it is a symptom of bradyarrhythmia. The syncope (fainting) should not have been reported separately with 780.2, as fainting is a symptom of bradyarrhythmia.
57. This inpatient is admitted with a fracture of the left shaft of the femur. Under general anesthetic, the patients leg is incised. The area is irrigated with saline. The lateral side of the shaft of the femur both proximally and distally from the fracture site is exposed. The fracture is brought into proper alignment, and a 6-hole plate is placed. Code the facility services and report the diagnosis. 821.01 821.11 79.15 79.35 27502 27507 Fracture of shaft or unspecified part of femur, closed Fracture of shaft or unspecified part of femur, open Closed reduction of fracture with internal fixation, femur Open reduction of fracture with internal fixation, femur Closed treatment of femoral shaft fracture with manipulation, with or without skin or skeletal traction Open treatment of femoral shaft fracture with plate/screws, with or without cerclage
A. B. C. D.
821.01, 79.35 821.11, 79.15 821.11, 27502-LT 821.01, 27507-LT
CORRECT ANSWER: A. 821.01, 79.35. 821.01 reports a closed fracture of the shaft of the femur. The operation was an open procedure as the fracture site was opened to the view of the surgeon. In this procedure, the fracture was closed (no break in the skin), but the procedure was through an incision (open). If a fracture is not stated as open or closed, the coder is to assume the fracture is closed. 79.35 reports an open reduction of a fracture of the femur with internal fixation. No E codes are reported according to the guidelines for the AHIMA certification, available on the AHIMA website. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken.
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RATIONALE: B. 821.11, 79.15. If a fracture is not stated as open or closed, the coder is to assume the fracture is closed. 821.11 is wrong because it reports an open fracture; but the report did not state open fracture; therefore it must be coded as closed using code 821.01. 79.15 reports a closed fracture reduction, and the procedure in this report was performed by means of an incision (an open procedure). C. 821.11, 27502-LT. 821.11 is incorrect also as it reports an open fracture, and this fracture was closed. If a fracture is not stated as open or closed, the coder is to assume the fracture is closed. Inpatient procedures are not reported with CPT codes, but rather with Volume 3 procedure codes. D. 821.01, 27507-LT. The diagnosis was correctly reported with 821.01. If a fracture is not stated as open or closed, the coder is to assume the fracture is closed. Inpatient procedures are not reported with CPT codes, but rather with Volume 3 procedure codes.
58. The 18-year-old patient is brought to the emergency room by ambulance. The diagnosis is pneumothorax. The patient is sedated with Versed and paralyzed with Nimbex. Lidocaine is used to numb the incision area in the midlateral left chest at about nipple level. After the lidocaine, an incision is made and bluntly dissected to the area of the pleural space, making sure the incision is superior to the rib. On entrance to the pleural space, immediate release of air is noted. An 18-gauge chest tube is subsequently placed and sutured to the skin. There are no complications for the procedure, and blood loss is minimal. A follow-up, single-view, chest x-ray shows significant resolution of the pneumothorax, except for a small apical pneumothorax that is noted. Report the service for the emergency room physician, but not the radiology service.
512.0 512.8 32551 32036 71010 71015 A. B. C. D.
Spontaneous tension pneumothorax Other spontaneous pneumothorax Tube thoracostomy includes water seal (e.g., for abscess, hemothorax, emphysema), when performed (separate procedure) Thoracostomy, with open flap drainage Radiologic examination, chest; single view, frontal Radiologic examination, chest; stereo, frontal
99291, 32551, 512.8 99291, 512.8 99285, 32036, 512.0 99291, 32551, 71010, 512.8
CORRECT ANSWER: A. 99291, 32551, 512.8. This service was a critical care service (99291), as
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indicated by point 4 in the Critical Care column, chest tube insertion. Also, the tube insertion (32551) is not included in the critical care service and is reported separately. 512.8 correctly reports pneumothorax as the diagnosis. RATIONALE: B. 99291, 512.8. This selection correctly reports the ED service as critical care and the diagnosis as pneumothorax, but also incorrectly leaves out reporting of the chest tube placement. The placement is not included in the critical care code and is reported separately. C. 99285, 32036, 512.0. Level 5 is the incorrect ED service as this was a chest tube placement (see point 4 in the Critical Care column). 512.0 is incorrect as it reports the diagnosis as spontaneous tension pneumothorax, rather than other spontaneous pneumothorax. D. 99291, 32551, 71010, 512.8. This selection correctly reports the ED service as critical care (99291) and the chest tube placement (32551). The x-ray code (71010) should not have been assigned because the directions indicated not to report the x-ray. The diagnosis of 512.8, pneumothorax, is correct.
59. The patient is brought to the ED by her husband. The patient was sexually assaulted on the way home from work this morning. She is a nurse at a skilled nursing facility in town. According to the patient, she was accosted in the parking lot and was taken to a parked van, where she was assaulted. She received bruises around her head and neck when she was struck repeatedly by her assailant. The ED performed a sexual assault examination. Report the ED service. A. B. C. D. Level 2, 995.83 (sexual assault, adult) Level 3, 995.83 Level 4, 995.83 Level 5, 995.83
CORRECT ANSWER: D. Level 5. Level 5, point 7 indicates sexual assault exam. 995.83 is the code for a sexual assault and verifies the reason for a Level 5 visit. No E codes are reported according to the guidelines for the AHIMA certification, available on the AHIMA website. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. RATIONALE: A. Level 2. There is no indication within this level for a sexual assault exam. See Level 5, point 7. B. Level 3. There is no indication within this level for a sexual assault exam. See Level 5, point 7. C. Level 4. There is no indication within this level for a sexual assault exam. See
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Level 5, point 7.
60. A 19-year-old female is brought to the emergency department by her friend. She sustained a 5-cm laceration on the plantar surface of her right foot when she stepped on a piece of rusty metal at the beach. The wound was L shaped. The wound was cleaned and sutures placed, after which the wound was dressed. The patient was given a tetanus shot and was told to see her physician in 10 days for removal of the stitches. She was given discharge directions for wound care and was discharged. A. B. C. D. Level 2, 892.0 (open wound, foot) Level 3, 892.0 Level 4, 892.0 Level 5, 892.0
CORRECT ANSWER: A. Level 2. This patient received a tetanus booster as indicated in Level 2, point 2. Additionally, this is a simple trauma that did not require an x-ray, Level 2, point 6. No E codes are reported according to the guidelines for the AHIMA certification, available on the AHIMA website. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. RATIONALE: B. Level 3. This choice is incorrect. This patient received a tetanus booster as indicated in Level 2, point 2. Additionally, this is a simple trauma that did not require an x-ray, Level 2, point 6. C. Level 4. This choice is incorrect. This patient received a tetanus booster as indicated in Level 2, point 2. Additionally, this is a simple trauma that did not require an x-ray, Level 2, point 6. D. Level 5. This choice is incorrect. This patient received a tetanus booster as indicated in Level 2, point 2. Additionally, this is a simple trauma that did not require an x-ray, Level 2, point 6.
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PART II With the use of a medical dictionary, CPT, and HCPCS and ICD-9-CM coding manuals, assign codes to the following: 1. CASE 1 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Right ureteral stricture. POSTOPERATIVE DIAGNOSIS: Right ureteral stricture. PROCEDURE PERFORMED: Cystoscopy, right ureteral stent change. LOCATION: Outpatient surgery center. PROCEDURE NOTE: The patient was placed in the lithotomy position after receiving IV sedation. He was prepped and draped in the lithotomy position. The 21-French cystoscope was passed into the bladder, and urine was collected for culture. Inspection of the bladder demonstrated findings consistent with radiation cystitis, which had been previously diagnosed. There was no frank neoplasia. The right ureteral stent was grasped and removed through the urethral meatus; under fluoroscopic control, a guidewire was advanced up the stent, and the stent was exchanged for a 7-French 26-cm stent under fluoroscopic control in the usual fashion. The patient tolerated the procedure well. Code for the outpatient facility services. CORRECT ANSWER AND RATIONALE: 593.3, 595.82, 52332 Diagnosis(es): 593.3 is the diagnosis for ureteral stricture. 595.82 is reported for irradiation cystitis (E code is not reported per ICD-9-CM Official Guidelines for Coding and Reporting for this examination). Procedure(s): 52332-RT identifies ureteral stent insertion and the removal of the existing stent (change of stent) (stent was exchanged.) by cystoscopy. There was no indication that this stent was temporary; therefore, the codes for temporary indwelling bladder catheter would be incorrect. Note that the code for removal of stent (52310) is not assigned because this code is designated as a separate procedure, which means it is part of a more complex or extensive procedure and not coded separately when performed at the same time.
2. CASE 2 OPERATIVE REPORT
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PREOPERATIVE DIAGNOSIS: Fever. PROCEDURE PERFORMED: Lumbar puncture. LOCATION: Emergency department. DESCRIPTION OF PROCEDURE: The patient was placed in the lateral decubitus position with the left side up. The legs and hips were flexed into the fetal position. The lumbosacral area was sterilely prepped. It was then numbed with 1% Xylocaine. I then placed a 22-gauge spinal needle on the first pass into the intrathecal space between the L4 and L5 spinous processes. The fluid was minimally xanthochromic. I sent the fluid for cell count for differential, protein, glucose, Gram stain, and culture. The patient tolerated the procedure well without apparent complication. The needle was removed at the end of the procedure. The area was cleansed, and a Band-Aid was placed. CORRECT ANSWER AND RATIONALE: 780.60, 62270 Diagnosis(es): 780.60 correctly identifies the only diagnosis listed, that of fever. Procedure(s): 62270 indicates aspiration of fluid from the spine (lumbar puncture) for diagnostic rather than therapeutic purposes.
3. CASE 3 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Atelectasis of the left lower lobe. PROCEDURE PERFORMED: Fiberoptic bronchoscopy with brushings and cell washings. LOCATION: ASC. PROCEDURE: The patient was already sedated, on a ventilator, and intubated, so his bronchoscopy was done through the ET tube. It was passed easily down to the carina. About 2 to 2.5 cm above the carina, we could see the trachea, which appeared good, as was the carina. In the right lung, all segments were patent and entered, and no masses were seen. The left lung, however, had petechial ecchymotic areas scattered throughout the airways. The tissue was friable and swollen, but no mucous plugs were noted, and all the airways were open, just somewhat swollen. No abnormal secretions were noted at all. Brushings were taken, as well as washings, including some with Mucomyst to see whether we could get some distal mucous plug, but nothing really significant was returned. The
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specimens were sent to appropriate cytological and bacteriological studies. The patient tolerated the procedure fairly well. Code the outpatient facility services. CORRECT ANSWER AND RATIONALE: 518.0, 31623, 31622-59 Diagnosis(es): 518.0 reports the atelectasis (a condition in which the lung does not completely inflate). Procedure(s): 31622, 31623, 518.0. 31623 identifies the left lung bronchoscopy with washings and brushings. 31622 identifies the diagnostic bronchoscopy of the right lung. Typically, when washings and brushings are performed on the same site (lung), only 31623 would be reported because 31622 is designated as a separate procedure. This means that 31622 is considered a component of a more extensive or comprehensive procedure and is not to be coded additionally. But, in this case since the right and left lungs were scoped, both codes are assigned as described above. The -59 modifier would need to be appended to to 31622 to identify it as being performed at a separate site. Additionally, the bronchoscopy codes are inherently unilateral. 518.0 reports the atelectasis (a condition in which the lung does not completely inflate).
4. CASE 4 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Abscess. PROCEDURE PERFORMED: Incision and drainage of left thigh abscess. LOCATION: Outpatient surgery center. OPERATIVE NOTE: With the patient under general anesthesia, he was placed in the lithotomy position. The area around the anus was carefully inspected, and we saw no evidence of communication with the perirectal space. This appears to have risen in the crease at the top of the leg, extending from the posterior buttocks region up toward the side of the base of the penis. In any event, the area was prepped and draped in a sterile manner. Then, we incised the area in fluctuation. We obtained a lot of very foul-smelling, almost stool-like material (it was not stool, but it was brown and very foul-smelling material). This was not the typical pus one sees with a Staphylococcus aureustype infection. The incision was widened to allow us to probe the cavity fully. Again, I could see no evidence of communication to the rectum, but there was extension down the thigh and extension up into the groin crease. The fascia was darkened from the purulent material. I opened some
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of the fascia to make sure the underlying muscle was viable. This appeared viable. No gas was present. There was nothing to suggest a necrotizing fasciitis. The patient did have a very extensive inflammation within this abscess cavity. The abscess cavity was irrigated with peroxide and saline and was packed with gauze vaginal packing. The patient tolerated the procedure well and was discharged from the operating room in stable condition. CORRECT ANSWER AND RATIONALE: 682.6, 27301 Diagnosis(es): 682.6 abscess of the leg, except the foot. Procedure(s): 27301 indicates an incision and drainage of a deep abscess of the thigh or knee region. The procedure began by inspection of the anus, but the origin was the top of the leg, not the anus. This is considered a deep abscess because it extended to the fascia. In this case the organism is not documented. Clarification should be sought before assigning an organism code in this case. The surgeon said that the material obtained was not the typical pus one sees with a Staphylococcus aureustype infection. This statement could mean that the infection was indeed staph aureus with an atypical odor. Or it could mean that the physician is doubtful that the organism is Staphylococcus aureus because of its atypical odor.
5. CASE 5 EMERGENCY DEPARTMENT SUBJECTIVE: This is a 77-year-old male who presents with a finger laceration. He also has hypertension. He has no known allergies. He presents with a history of sustaining an avulsion laceration to his right third finger yesterday at about 1200 hours, when an air conditioner fell out of a window. OBJECTIVE: He is afebrile with stable vital signs. He states he is up-to-date for tetanus immunization. He last received that 6 years ago. He has a small, avulsed area on the fat pad surface of the distal right third finger. It measures about 3 mm in greatest diameter by about 4 to 5 mm. There is no bleeding currently. This was cleansed with saline and dressed with Bacitracin nonadherent dressing and tube gauze. ASSESSMENT: Avulsion laceration right third finger, as described above. PLAN: Wound care instructions provided. Wound check and dressing change on Monday with his personal physician. CORRECT ANSWER AND RATIONALE: 883.1, 401.9, 99282 883.1 reports laceration of the finger with delayed treatment which codes to
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a complicated open wound, the primary reason for the encounter. The patients injury occurred the day prior to presentation. 401.9 reports unspecified hypertension. No E code is assigned because the only E codes reported on the CCS examination are those that report causative substances for an adverse effect of a drug correctly prescribed and properly administered. 99282 reports the ED services based on the simple trauma that did not require x-ray (Level 2, point 6).
6. CASE 6 LOCATION: Outpatient hospital. EXAMINATION OF: Nephrostogram. CONTRAST: Hand injection of contrast through the nephrostomy tube. CLINICAL SYMPTOMS: Check placement of the nephrostomy tube. NEPHROSTOGRAM HISTORY: This is a 76-year-old male with a history of prostate cancer, left ureteral obstruction, hydronephrosis, needing routine exchange of the nephrostomy tube. FINDINGS PRELEFT NEPHROSTOGRAM: Nephrostogram obtained demonstrates a preexisting 16-French nephrostomy tube within an upper pole calyx. Mild hydronephrosis is seen. No filling defects are identified. Ureteral coils are present. FINDINGS POSTLEFT NEPHROSTOGRAM: Final nephrostogram obtained demonstrates mild hydronephrosis. The new nephrostomy tube is present in the main renal pelvis with the tip of the pigtail into the ureteral pelvic junction. No contrast extravasation of filling defects is seen. Report both the nephrostogram and the radiologic supervision and interpretation of the test, in addition to the diagnosis. CORRECT ANSWER: V55.6, 593.4, 591, V10.46, 50394, 74425 Diagnosis(es): V55.6 attention to a nephrostomy, 593.4 ureteral obstruction, 591 hydronephrosis, V10.46 personal history of prostate cancer. Procedure(s): 50394 reports an injection for nephrostogram. Service(s): 74425 reports the radiologic supervision and interpretation.
7. CASE 7 LOCATION: Outpatient hospital.
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EXAMINATION OF: Right lower extremity ultrasound. CLINICAL SYMPTOMS: Chronic ulcer, right lower extremity (calf). FINDINGS: Ultrasound examination of the deep venous system of the right lower extremity is negative for DVT. The right popliteal, greater saphenous, and femoral veins are patent and negative for thrombus. Unable to evaluate the open wound area. CORRECT ANSWER AND RATIONALE: 707.12, 93971 Diagnosis(es): 707.12 reports an ulcer of the calf. Service(s): 93971, Duplex scan of extremity veins. The unilateral study would be appropriate because it describes an ultrasound for the purpose of evaluating the venous system of the extremity. This can be found in the index under vascular studies, venous studies extremity.
8. CASE 8 HOSPITAL ADMISSION This is an 82-year-old lady who presents with chief complaint of shortness of breath. Reason for admission: COPD, pneumonia, atrial fibrillation with rapid ventricular rate. HISTORY OF PRESENT ILLNESS: This 82-year-old lady with known COPD is steroid-dependent and oxygen-dependent. The patient has had a recent admission and discharge last Friday, when she had a stroke. The patient has known severe, oxygen-requiring COPD. The patient has also been on chronic steroids, on high doses, about 15 mg per day. The patient was in good health until last night when, during the night, she readily developed more and more shortness of breath. The patient was transferred to the emergency department. The patient denies any fever or chills, but does admit to cough, although she says it is a chronic cough, for about a few months now; she says it really has not changed too much lately. She has minimal sputum. She did not have any chest pain, any nasal congestion, or any sore throat. This time, the patient remained alert and oriented. There was no change in mental status. The patient was given nebulizers in the ambulance and in the emergency room, and the saturations somewhat improved. REVIEW OF SYSTEMS: Pulmonary: Shortness of breath, as above. This has developed overnight. Cardiovascular: No chest pain, no feeling of irregular heartbeat or rapid heartbeat. No fever, no chills. GI: No abdominal pain. The patient
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reports no cough with eating or difficulty swallowing. The patients daughters also observed her eating prior and did not note any significant problems with swallowing. Neurologic: The patient had lately been admitted for possible stroke. The symptoms were lethargy, which resolved, and some word-finding difficulties. Psychiatric: No problem reported from the patient or from the patients family. Hematology/Oncology: The patient does have diffuse bruises but no significant bleeding. Endocrine: No polyuria, no polydipsia. There is no mention of diabetes or glucose intolerance, even with steroid use. Extremities: The patient does have chronic lower extremity swelling, which is actually better today, as per patients daughters. PAST MEDICAL HISTORY: 1. The patient has severe, oxygen-requiring COPD. 2. On recent CT, the patient was noted to have about a 2-cm soft tissue density in the left lung base. Prominent diffuse emphysematous changes were also seen. 3. Atrial fibrillation. 4. The patient was judged not to be a good candidate for anti-coagulation. 5. Vitamin B12 deficiency. 6. Crohns disease. 7. Senile osteoporosis. 8. Venous insufficiency. 9. Left frontal region meningioma. 10. Right recent cerebellar stroke. PAST SURGICAL HISTORY: 1. Bowel resection for Crohns disease. 2. Cholecystectomy. 3. Bilateral cataracts. FAMILY HISTORY: Mother had Hodgkins disease. A sister and brother had lung cancer. SOCIAL HISTORY: The patient quit smoking about 30 years ago but was a very heavy smoker. Occasional alcohol use. ALLERGIES: No known allergies. MEDICATIONS: 1. Amitriptyline 25 to 50 mg p.o. q h.s. 2. Augmentin 500 mg 3 times a day. 3. Aspirin 325 mg once a day. 4. Pulmicort 1 puff twice a day. 5. Calcium carbonate with vitamin D; 1 tablet twice a day. 6. Digoxin 0.25 mg once a day. 7. Diltiazem 120 mg once a day. 8. Folic acid 1 mg once a day.
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9. Citrucel t.i.d. p.r.n. 10. DuoNeb nebulizers q 4 hours p.r.n. 11. Oxygen 1 to 4 liters. 12. Vitamin B12 1000 mg/mo. 13. Xalatan eye drops both eyes q h.s., 0.005%. 14. Prednisone 25 mg, then taper to 20 mg p.o. daily. 15. Serevent inhaler 1 puff twice a day. 16. Senokot 1 tablet twice a day. 17. Sulfasalazine 500 mg twice a day. PHYSICAL EXAMINATION: Blood pressure 152/67. Heart rate 105, initial heart rate was in the 140s, the patient then was given Cardizem 15 mg IV; then, heart rates were in the 90s/low 100s. Temperature 36.0. Saturating 89% on 2 liters nasal cannula oxygen. The patient appears in no acute distress, appears actually very comfortable in the bed, joking with me. Psychiatric: Good mood, cooperative. Neurologic: Appears alert and oriented to place and person, can recall prior events; can move all extremities with no significant focal motor or sensory deficit. HEENT: Extraocular movements intact. Oropharynx, dry. Neck: Supple, no JVD, no lymph nodes palpable, no thyromegaly, no carotid bruit. Heart: Irregular S1 and S2. Maybe 1/VI systolic murmur, although blood pressure with the temperature and the irregularity, it is hard to say. Lungs: Bilateral lower area rhonchi. Back: No CVA tenderness. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Lower extremities: bilateral 1+ edema. Skin: Bilateral extremities with superficial bruises. There is one small, about 3 mm in diameter, open wound with about 50% slough formation on the right lower extremity, lateral surface. LABORATORY STUDIES: White blood cell count 12.1, this was 17.4 on the first; hemoglobin 11.0, platelets 270. Prior hemoglobins were 11.5 and 10.6. Differential includes 78% neutrophils. BUN 11, creatinine 0.6, sodium 144, potassium 3.2, chloride 95, bicarb above 41.8, glucose 81, creatinine 0.6. B natriuretic peptide 175. CK MB 0.6, CPK 13. Digoxin 1.1. INR 1.0. Magnesium 14. ABG: pH 7.44, pCO2 69, pO2 83 on nasal cannula oxygen at 5 liters. This equals a saturation of 97%. Troponin I less than 0.04. EKG evaluated by me shows atrial fibrillation with heart rate in 130s with incomplete right bundle branch block. Chest x-ray as evaluated by me shows right lower area atelectasis or infiltrate. This appears new or significantly worsened from the first of January. There is mild blunting of the sulci. The old medical records were reviewed. The case was discussed with the emergency room physician. ASSESSMENT AND PLAN: 1. This lady who has known oxygen-dependent COPD presents with desaturating subjective shortness of breath and new x-ray changes. The patient will be admitted with the admitting diagnosis of pneumonia, COPD exacerbation. I will start the patient on higher dose of steroids. Will try to taper that fast since the patient has a history that she is poorly tolerating the steroids. She is usually awake and hyperactive from that. I will give the patient nebulizers, will continue
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the Serevent and Pulmicort. The patient will be on oxygen. 2. For the pneumonia, I will start patient on Claforan and azithromycin. Will follow for clinical improvement. 3. The patient had atrial fibrillation with rapid ventricular rate. This might be secondary to the pulmonary events and/or nebulizers. The patient was given 50 mg IV Cardizem, which brought down the heart rate to the 90s/low 100s. I will give the patient her Cardizem orally and will observe on telemetry for heart rate. The patient is noted not to be an anticoagulation candidate. 4. Hypokalemia will be replaced. 5. Possible left-sided pulmonary nodule. Follow-up CT will be done in a few months. 6. Crohns disease, appears stable; in fact, patient is somewhat constipated now. Will give Citrucel and Senokot. 7. Osteoporosis, also on chronic steroid. Will give calcium and vitamin D. She might need further treatment as an outpatient for that, including, for example, Fosamax. 8. B12 deficiency. Hemoglobin appears stable since discharge. 9. History of stroke. Patient did not have real problem with word-finding difficulties, also motor functions appear good. There is no report of possible aspiration, although the location of the infiltrate would fit that, but will ask for aspiration precaution. 10. Code status was discussed with the patient; she wished to be code II. This is the same code status used when she was admitted last time as well. RADIOLOGY REPORT EXAMINATION OF: Chest. CLINICAL SYMPTOMS: Respiratory distress CHEST: Findings: This examination is compared with a prior examination dated June 1. Heart size is prominent but unchanged when compared with the prior examination. Pulmonary vascular markings appear at the upper limits of normal. Abnormal focal pulmonary opacity is present within the right lower lung zone, as well as the left mid and left lower lung zones. Findings are most compatible with areas of infiltrate. Possibility of superimposed edematous change or atelectasis cannot be excluded. No pleural effusions are seen. There is atherosclerotic change of the thoracic aorta. Follow-up to document clearing is recommended. PROGRESS NOTE SUBJECTIVE: The patient indicates that her breathing is improved a little today. Daughter is at bedside. The patient indicates that she has a cough; however, it is not productive. The patient denies any chest pain or chest pressure. No fever or chills.
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REVIEW OF SYSTEMS: General: Cardiovascular and respiratory were performed. With the exception noted in the HPI, are negative. VITALS TODAY: Temp is 35.8 with T-max of 37.5. Pulse is 82. Respiratory rate is 16. Blood pressure is 142/78. O2 sat is 98%. Cardiovascular: S1 and S2. No S3, no S4. LUNGS: Bilateral breath sounds, occasional wheeze. Abdomen is soft and nontender. Positive bowel sounds. PSYCH: The patient is alert. IMPRESSION: 1. Pneumonia. 2. COPD exacerbation. PLAN: At this point, continue the patient on current treatments. We will switch the patient to oral steroids, will start tapering dose. I will switch the patient to oral antibiotics. We will pursue discharge planning. DISCHARGE SUMMARY REASON FOR HOSPITALIZATION: The patient is an 82-year-old woman who presents to the emergency department with a complaint of shortness of breath. The patient has known chronic obstructive pulmonary disease. Also, on admission, she was found to have atrial fibrillation with a rapid ventricular rate, as well as right lower lobe pneumonia. The patient has not really had any fevers or chills, but she has been having quite a bit of coughing with minimal sputum production. In the ambulance on the way to the emergency department, the patient was given some nebulizers, and her oxygenation somewhat improved. She is on home O2 and also has been found on a recent CT to have 2-cm soft tissue density in the left lung base. Other medical conditions include: 1. Vitamin B12 deficiency. 2. Crohns disease. 3. Osteoporosis. 4. Venous insufficiency. 5. Left frontal region meningioma. 6. Right recent cerebellar stroke. 7. History of cholecystectomy. 8. History of bilateral cataracts. 9. History of bowel resection for Crohns disease. On admission, the patient was started on Claforan and azithromycin for treatment of her pneumonia. She was also given a bolus of 50 mg IV of Cardizem to bring the
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heart rate back down. The patient was also found to be slightly hypokalemic, with potassium of 3.2 on admission. This was replaced. Over the course of her hospital stay, the patient has done well with improvement in her subjective sense of being short of breath. The patient has continued to have problems with dysphasia. She is status post a recent cerebrovascular accident. The patient was able to be switched to oral antibiotics on June 8. She has remained afebrile on this therapy and has continued to have good oxygen saturations on nasal cannula O2. The patient will be discharged today in stable condition to the nursing home. Follow-up will be with her primary care physician in 1 week. DISCHARGE MEDICATIONS: 1. Amitriptyline 25 mg p.o. q h.s. 2. Aspirin 325 mg once a day. 3. Zithromax 500 mg p.o. daily times 3 additional days. 4. Pulmicort 200 mcg inhaler b.i.d. 5. Calcium carbonate 500 mg p.o. b.i.d. 6. Vantin 200 mg p.o. b.i.d. for 14 additional days. 7. Digoxin 0.25 mg once a day. 8. Diltiazem CD 120 mg p.o. daily. 9. Folic acid 1 mg p.o. daily. 10. Ipratropium bromide inhaler 2.5 mL inhaled treatment. 11. Xalatan eye drops 1 drop in both eyes at bedtime. 12. Prednisone taper beginning at 40 mg p.o. daily for 4 days, then taper down to 30 mg daily for 2 days. Beginning third day, patient will be on 20 mg daily for 5 days. 13. Solu-Medrol Discus 1 puff b.i.d. 14. Senokot 1 tablet p.o. b.i.d. 15. Sulfasalazine enteric 1 500-mg tablet p.o. b.i.d. 16. Ambien 5 mg p.o. q.h.s. p.r.n. 17. Citracal 19-gm packet p.o. b.i.d. p.r.n. for constipation. DISCHARGE DIAGNOSES: 1. Oxygen-dependent chronic obstructive pulmonary disease with chronic obstructive pulmonary disease exacerbation. 2. Community-acquired pneumonia, right lower lobe. 3. Atrial fibrillation with rapid ventricular response, has responded to Cardizem, now rate controlled. 4. Hypokalemia, corrected. 5. Possible left-sided pulmonary nodule, follow-up CT will be needed in a couple of months. 6. Crohns disease, stable. 7. Senile osteoporosis. 8. B12 deficiency. 9. History of cerebrovascular accident with residual dysphasia. 10. Venous insufficiency.
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The patient will be discharged in stable condition to the nursing home. Code for the diagnoses. CORRECT ANSWER AND RATIONALE: 491.21, 486, 427.31, 276.8, 518.89, 555.9, 733.01, 266.2, 438.12, 459.81, V46.2, V58.65 Diagnosis(es): 491.21 reports the COPD exacerbation. Refer to Coding Clinic, 3rd Qtr 2002. 486 Pneumonia, organism unspecified 427.31 atrial fibrillation 276.8 reports the hypokalemia that was treated 518.89 reports the possible pulmonary node 555.9 Crohns disease (Bowel resection, previous) 733.01 senile osteoporosis 266.2 Other B-complex deficiencies (B12) 438.12 reports the late effect of recent cardiovascular accident with dysphasia 459.81 reports the venous insufficiency V46.2 reports oxygen dependence V58.65 reports chronic steroid use As the patient was admitted with both COPD exacerbation and pneumonia and both were treated, either could be assigned as the principal diagnosis. The COPD exacerbation groups to DRG 190 and the pneumonia groups to DRG 194. DRG 190 has a higher relative weight so it is appropriate to assign the COPD exacerbation as the principal diagnosis.
9. CASE 9 OBSERVATION LOCATION: Hospital observation unit. REASON FOR ADMISSION: Exacerbation of COPD. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old male who comes in tonight complaining of progressive shortness of breath over the past 4 days. He had upper respiratory tract symptoms a week ago with nasal discharge and coldlike symptoms. It progressed to shortness of breath over the past 4 days. I was called by a family member of his earlier tonight, and I advised him to come to the Emergency Department, which he did. In the ED, he was wheezy and had oxygen saturation of 92%. He received a nebulizer treatment. A chest x-ray was done, which I reviewed myself; it showed no evidence of infiltrates. He had a large heart. The patient was admitted to the 6th floor. I proceeded by doing ABGs on him. His pH was 7.46, pCO2 94, and bicarb 33.5 on 2 liters per nasal cannula. The patient had some cough with clear phlegm. No fever or chills now. He had some chills a
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week ago. The patient recently had an angiogram for his abdominal aortic aneurysm. He also had a stress test that apparently was positive. The patient is known to have chronic renal failure with a baseline creatinine of 2 to 2.2 with creatinine clearance of 32 mL per minute with a serum creatinine of 2.0 back in December. He does have severe congestive heart failure with ejection fraction less than 20%. PAST MEDICAL HISTORY: 1. Chronic renal failure as mentioned. 2. Coronary artery disease, post two myocardial infarctions. 3. Post AICD placement. 4. Atrial fibrillation with rapid ventricular response, controlled. 5. Congestive heart failure with ejection fraction of less than 20%. 6. Abdominal aortic aneurysm, which is infrarenal measuring 6.2 cm. 7. Bilateral common iliac aneurysm, approximately 3.5 to 3.6 cm. 8. Left internal iliac artery aneurysm, questionably coiled lately. 9. COPD/asthma. 10. History of gouty arthritis with a recent gouty attack in his right first metatarsal phalangeal joint. 11. History of diverticulitis. 12. Hyperlipidemia. 13. Status post cholecystectomy, inguinal hernia repair, appendectomy. 14. Chronic renal failure, post PD catheter placement for peritoneal dialysis. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Nebulizer at home. 2. Bumex 2 mg in the morning and 1 mg in the evening. 3. Coumadin 2 mg on Monday, 1 mg on other days. 4. Digoxin 0.125 mg p.o. b.i.d. 5. Potassium chloride 20 mEq p.o. b.i.d. 6. Zocor 10 mg p.o. q h.s. 7. Coreg 25 mg p.o. b.i.d. 8. Allopurinol 100 mg p.o. daily. 9. Ranitidine 150 mg p.o. q h.s. FAMILY HISTORY: Mother died of pancreatitis. Father died at age 71. Otherwise, family history is noncontributory. SOCIAL HISTORY: Lives here in town with his wife. She was not available today. He quit smoking 16 years ago. REVIEW OF SYSTEMS: Constitutional: No fever, chills, or night sweats. ENT: Resolved upper respiratory tract symptoms. Respiratory: As mentioned. Cardiovascular: Exertional dyspnea. No chest pain. GI: Questionable dark stool but
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no diarrhea, nausea, or vomiting. He had some abdominal discomfort with coughing. Musculoskeletal: History of gouty arthritis that seems to be controlled. Skin: Trace edema. Neuro: Negative. Psychiatric: Negative. PHYSICAL EXAMINATION: The patient was in mild respiratory distress. He was awake, oriented times three without any focal neurological deficits. His heart rate is in the 70s range, blood pressure has been 120s/80s, sats 92% when he came in, 98% on 2 liters per nasal cannula. Slightly increased jugular venous pressure. No cervical lymphadenopathy. Lungs: Good air entry bilaterally but expiratory wheezes bilaterally. No crackles. No sacral edema. Abdomen: Soft and nontender. He has PD catheter in the left lower quadrant. Small hematoma in the right inguinal area from his recent aortogram. Lower extremities: Very trace edema. LABORATORY STUDIES: CBC tonight shows a white count of 8.6 thousand, hemoglobin 12.3, platelets 140,000, BUN 29, sodium 139, potassium 3.6, chloride 98, bicarb 31, creatinine 2.2, calcium 8.5. BNP 536 picogram/mL. INR 1.5 with a pro-time of 14.3. Digoxin 0.6. Troponin-I less than 0.04. His last uric acid level was 7.4. IMPRESSION: 1. Exacerbation of COPD/asthma with wheezes. 2. Abdominal aortic aneurysm. 3. Noncompliance with medications and nebulizer treatments. PLAN: 1. Albuterol MDI 2 puffs t.i.d. 2. Atrovent MDI 2 puffs t.i.d. 3. Azmacort MDI 2 puffs b.i.d. 4. Solu-Medrol 80 mg IV q 8 hours. 5. Continue the current p.o. medications. 6. Zithromax 500 mg IV daily. 7. The patient is code level I. Discussed all of the above with the patient. He seems to understand and agrees with the plan. Will discuss further issues to his abdominal aortic aneurysm and further plans with his positive stress test when the rest of the family is available in the next couple of days. OBSERVATION DISCHARGE SUMMARY LOCATION: Hospital observation unit. DISCHARGE DIAGNOSIS: Exacerbation of COPD. The patient came in with wheezing. Oxygen saturations were 92%. He had no pulmonary edema. He had no infiltrates. Was given steroids, nebulizer therapy. He
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did well. His pO2 was 94 on 2 liters. We walked him the next day. He was doing much better without any major complaints. He was discharged in reasonable general condition. CODE LEVEL: I. DISCHARGE MEDICATIONS: 1. Albuterol inhaler two puffs three times a day p.r.n. 2. Allopurinol 100 mg p.o. daily. 3. Bumex 1 mg in the evening and 2 mg in the morning. 4. Coreg 25 mg p.o. b.i.d. 5. Digoxin 0.125 mg p.o. daily. 6. Zantac 150 mg p.o. daily. 7. Atrovent three times a day. 8. Potassium chloride 20 mEq p.o. b.i.d. 9. Zocor 10 mg p.o. daily. 10. Triamcinolone inhaler (Azmacort) two puffs three times a day. 11. Coumadin 2 mg every Monday and 1 mg on other 6 days of the week. 12. Prednisone 10 mghe will take six pills for three days, then five pills for 3 days. He will go down by 10 mg every 3 days until off. 13. Zithromax 500 mg p.o. daily for 8 more days. DISCHARGE PLAN: The patient will be scheduled in my clinic in 3 weeks with a basic panel, CBC, and Protime/INR. Discussed all of the above with the patient. He seems to understand. I gave him the plan. Issues related to his aneurysm and cardiac status will be discussed in the clinic. CORRECT ANSWER AND RATIONALE: 493.22, 441.4, 428.0, 585.6, 414.01, 412, 427.31, 272.4, 442.2, V45.02, V58.61, V15.81, V45.11, 274.00 Diagnosis(es): 493.22 (Asthma, COPD, exacerbation) 441.4 (Aneurysm, Aortic, Abdominal) 428.0 (congestive heart failure, unspecified) 585.6 (chronic kidney disease, on peritoneal dialysis) 414.01 (coronary atherosclerosis of native coronary artery) 412 (old myocardial infarction) 427.31 (atrial fibrillation) 272.4 (hyperlipidemia) 442.2 (aneurysm, common iliac artery) V45.02 (automatic implantable cardiac defibrillator) V58.61 (long term use of anticoagulants) V15.81 (noncompliance with medical treatment) V45.11 (dialysis, status) 274.00 (gouty arthritis)
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10. CASE 10 INITIAL HOSPITAL SERVICE The patient, Stephen Moore, was brought to the hospital emergency department by air ambulance from Loganville. Stephen was involved in a motor vehicle rollover. Dr. Paul Sutton treated the patient in the emergency department and then contacted Dr. Sanchez, the general surgeon on call, who admitted the patient to the hospital. LOCATION: Inpatient hospital. HISTORY: Mr. Moore is a 25-year-old young man who was involved in a motor vehicle rollover just outside of town. According to the paramedics who brought him down via air ambulance, the patient had arrested three times during the flight. The patient also was reported to be hypothermic with a temperature of 27. The patient is transported with bilateral chest tubes in place. He also has no neck collar in place but is on a backboard with the neck stabilized with straps. There is no family available. The paramedics have no other history at the present time, other than that there is a possibility that after the rollover, he was immersed in cold water for approximately 5 to 10 minutes, but this history is speculative at the present time. ROS, PAST, FAMILY, SOCIAL HISTORY: Unable to obtain because patient is unconscious. PHYSICAL EXAM: The patient is hypotensive. His temperature is 27 with a blood pressure of 60 systolic. He has a tense distended abdomen. His pupils are fixed and dilated. He has no other obvious injuries. ASSESSMENT: 1. Hypotension due to cold water. 2. Distended tight abdomen. 3. Hypothermia. 4. Dilated fixed pupils. 5. Possible major intra-abdominal injuries. PLAN: He is going to be taken immediately to the operating room while we resuscitate him there in a more stable environment. X-ray had been asked previously to place a portable machine in the OR. The patient is critically ill and is at high risk for mortality. The fixed dilated pupils are of concern, but control of his intra-abdominal bleeding and correction of the hypothermia are priorities.
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OPERATIVE REPORT, LAPAROTOMY LOCATION: Inpatient hospital. PREOPERATIVE DIAGNOSIS: Massive thoracic and abdominal injuries. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Damage control laparotomy with suture of a bleeding liver laceration. This young man presented with a temperature of 27 after he was involved in a rollover accident. During the transport down, he apparently arrested three times. The patient has a 60 systolic blood pressure at this stage. He had not had a collar placed during transport but was controlled on the backboard with his head stabilized. Immediately on arrival in the operating room, a cervical collar was placed. The patient had already been intubated. He had bilateral chest tubes in place. Once he was on the operating room table, an attempt was made to get chest x-ray, but radiology could not get a plate under the patient. With good function of the chest tubes and the patients continued severe hypotension, it was elected to proceed with the laparotomy and proceed with further evaluation as the case progressed. As the abdomen was being prepped, anesthesia was giving him fluids and blood and trying to warm him up. All fluids were run in warmers, including the blood that was being infused. Immediately upon having the abdomen prepped and draped, a long midline incision was made; the patient was found to have approximately a liter and one-half of blood present within the abdomen. He was cold. He had an actively bleeding liver tear that was on the dorsum, just lateral to the ligament teres. Several 0 chromic sutures were placed through this in figure-ofeight fashion, and this stopped the bleeding. This was done after we had immediately packed both the left and right upper quadrants, as well as the pelvis. After we were assured that his bleeding was controlled with the packing, anesthesia was continuously warming him and we used warm irrigation in the abdomen. The chest tubes were draining adequately. According to anesthesia, the patient still had fixed dilated pupils. By the end of the procedure, the patients temperature was up to about 30. As the anesthesia was infusing the blood and fluids, and the patients blood pressure was now coming up, we started looking at each of the quadrants. The patient was found to have a non-expanding hematoma involving the pelvis, consistent with a pelvic fracture. This was repacked to make sure there was no active bleeding in this area, but there was no active bleeding. The packs were slowly removed from the left upper quadrant. The spleen was then visualized, and it had what appeared to be a grade one or two laceration; there was no active bleeding, this was repacked. The right side was then evaluated. Most of the blood
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was around the liver. The patient had a laceration at the dome of the liver, just to the right of the ligamentum teres; this was oversewn as noted above. At this point, because of the patients hypothermia and instability, the abdomen was repacked. A Vac-Pac was quickly placed. The patients pupils at this stage were still fixed and dilated. There was a question whether the fixed pupils were due to a primary head injury with an intracranial bleed, or whether this was just a hypoxic issue related to the original injury and the 3 arrests during transport. The patient was taken immediately from the operating room to the CAT scanner, with neurosurgeon available. CAT scan will be done immediately. If the patient does not have anything intracranial that needs to be fixed immediately, he will be taken to the intensive care unit, where we will continue resuscitation with warm fluids and blood as necessary. The patient is in critical condition. At the end of the procedure, the patients blood pressure was up in the 80s systolic. DISCHARGE SUMMARY LOCATION: Inpatient hospital. DIAGNOSES: 1. Intracranial injury with fixed dilated pupils due to rollover car accident. 2. Liver laceration. 3. Hypotension. 4. Hypothermia. 5. Laceration spleen. 6. Cardiac arrest. SUMMARY: The patient was admitted through the emergency department after being involved in a one-car rollover accident. Patient was an unrestrained driver. We took him immediately to surgery, and there we found abdominal bleeding and liver laceration. His abdominal injuries were repaired, and patient was then taken for a CT of his head to try to find cause of his unconscious state and dilation and fixation of his pupils. When I got to the CT room, the patient was not breathing. There was no chance for resuscitation, he just flat-lined immediately. There was nothing we could do for him, and the patient was pronounced dead at 2100 hours. His family was notified, and pastoral services were called in. CORRECT ANSWER AND RATIONALE: 864.05, 854.05, 991.6, 865.00, 458.9, 427.5, 808.8, 50.61 Diagnosis(es): 864.05 reports laceration of the liver 854.05 reports an intracranial injury. The 5th digit of 5 is assigned per the guideline prior to category 850. 991.6 reports accidental hypothermia 865.00 reports spleen laceration 458.9 hypotension 808.8 possible pelvic fracture per OR report
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In this case, cardiac arrest would not be coded as the patient arrested and was resuscitated prior to arriving at the hospital. When the patient arrested in the CT room, no resuscitation took place so it would not be coded. An E code to report the motor vehicle accident is not reported, as on the CCS examination, only medications properly prescribed and properly taken are reported with E codes when the patient has an adverse effect. Procedure(s): 50.61 reports repair of a liver laceration. Do not code exploratory laparotomy when another procedure is done in conjunction with laparotomy. The lacerations of the spleen were not repaired (41.95). Packing was placed; therefore, a repair of the spleen is not coded.
11. CASE 11 ADMISSION HISTORY AND PHYSICAL CHIEF COMPLAINT: A 5-day-old male infant with elevated bilirubin and dehydration. HISTORY OF PRESENT ILLNESS: The patient was born at the hospital 5 days ago by C-section for an occiput posterior presentation. Mom had hypertension during labor and did receive magnesium sulfate. The baby did well following delivery and went home with mom 3 days later. Mom said her milk came in on Saturday, the day they were discharged from the hospital, and she expected baby to really be eating well, but he has not been. She said he typically nurses 20 minutes total and needs quite a bit of stimulation to keep on task. He has been sleepy at home. Today was their scheduled follow-up visit, and bilirubin in the office was 20.4. His birthweight was 9 pounds 3 ounces, and today, he weighed 7 pounds 12 ounces. That is a decrease of 15%. PAST MEDICAL HISTORY: Significant only for receiving hepatitis B vaccine in the hospital. He is not on any medications and has no known drug allergies. SOCIAL HISTORY: Mom, Dad, and baby are all living at home in suburbs currently, as Mom works as a lawyer and Dad is a truck driver. He will be going back on the road sometime next week. There is no tobacco use at home besides Dad's chewing tobacco and no pets at home. FAMILY HISTORY: Mom and Dad are both alive and well. There are no siblings. Maternal grandfather has hypertension. Paternal grandfather has some sort of hypertrophic cardiac disease. REVIEW OF SYSTEMS: Mom says the patient has had two wet diapers today. He has not had a bowel movement since Saturday about noon.
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PHYSICAL EXAMINATION: General: The patient is sleeping with Mom, appears to be in no distress. Temperature has not been taken yet, but heart rate and respiratory rate are both within the normal range. I do not have a blood pressure yet either. HEENT examination: Fontanelle is soft, slightly sunken. Pupils are equal and reactive to light. Red reflexes intact in both eyes. External auditory ear canals and tympanic membranes are normal in appearance bilaterally. Mouth is dry but otherwise unremarkable. Neck is supple. Heart is regular in rate and rhythm with no murmur. Lungs are clear to auscultation bilaterally. Abdomen is soft and nontender. He is nondistended. He has active bowel sounds, and no masses are palpated. Umbilicus appears to be healing well. Extremities: He has 2+ femoral pulses bilaterally. Moves extremities spontaneously times four, although he does require a little stimulation to move very much. Genital examination: He is a circumcised male. Testes are descended bilaterally. Skin has no rashes, although he is very jaundiced in appearance. LABS: Bilirubin was 20.4; this was done in the clinic. ASSESSMENT: 1. Hyperbilirubinemia. 2. Dehydration. PLAN: He will be started on IV fluids, D5 half-normal saline at 20 mL an hour and will be under triple phototherapy. Coombs and basic metabolic panel will both be drawn. Mom can breastfeed ad lib, and a repeat bilirubin will be done at 7 PM this evening. PROGRESS NOTE The patient is a 6-day-old infant. This is hospital day two. He was admitted for dehydration and hyperbilirubinemia. SUBJECTIVE: Mom said that patient's color has definitely improved overnight. He is looking nice and pink this morning. She stated that feedings are still not going well. He will latch on and suck a couple of good sucks but then wants nothing to do with breastfeeding after that, will fuss and push away. She has been pumping and is able to pump 2 ounces every 2 to 3 hours. The baby has still been having several wet diapers and finally had a bowel movement yesterdaythe first since Saturday. OBJECTIVE: Weight today was 3.86 kg. That is up 12 ounces from yesterday. That makes him down 7.7% from birth. He was down 15% on admit. Feedings yesterday: It looks like he breastfed 5, anywhere from 5 minutes to 15 minutes a side. Nursing also had to supplement 92 cc over the night. He received IV fluids, D5, normal saline at 20 cc/hour overnight, also a total of 155 cc of IV fluids since admit. Urine output since admit has been 1.25 cc/kg/hour. Heart rate has ranged
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in the 120s and 130s; respirations 30s and 40s. Blood pressure 91/55. He is maintaining his temperature well in the crib. On PHYSICAL EXAMINATION, head is atraumatic, normocephalic. Fontanelle is flat this morning. Sclerae are still mildly icteric, but skin is otherwise nice and pink. Mouth and throat are moist and pink. Heart is regular in rate and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is soft and nontender, nondistended. No masses are palpated. He has active bowel sounds. Umbilicus is healing well. Femoral pulses are strong bilaterally, circumcised male. Testes are descended bilaterally. He is much more active this morning, moving all four extremities spontaneously, and is wide awake with no tactile stimulation. Bilirubin this morning was 11.3. Basic metabolic panel this morning: Sodium is still elevated at 155, chloride 123. ASSESSMENT: 1. Dehydration. 2. Hyperbilirubinemia. 3. Hypernatremia secondary to #1. PLAN: We will go ahead and discontinue his phototherapy today. Lactation consultants have been consulted for assistance with breastfeeding. IV fluids will be decreased to maintenance at 14 cc/hour and changed to D5 half-normal saline, instead of D5 3/4 normal saline. DISCHARGE SUMMARY REASONS FOR HOSPITALIZATION: Dehydration, hyperbilirubinemia, and hypernatremia. SUMMARY OF HOSPITAL COURSE: The patient was admitted from the clinic at 5 days of age because of difficulty feeding at home, which had led to dehydration and hyperbilirubinemia. His ABO incompatibility test was negative. He was started on triple phototherapy and IV fluids at 1 times maintenance rate. Within 24 hours, his bilirubin had dropped from 20.4 down to 11.3. His sodium had dropped from 158 down to 155 on normal saline. Lactation consultants had been working with the patient and Mom on breastfeeding. He needed to be fed pumped breast milk most of the time because of impatience at the breast, but Mom wanted to keep trying. The patient's bilirubin had dropped to 9.9 after he had been off phototherapy for 24 hours. Sodium was down to 149, and the patient was having frequent wet diapers and stools. The patient was discharged home with instructions to Mom on keeping track of wet diapers and on attempting to breastfeed every 3 hours. They will follow up with Dr. Green in clinic next week. INSTRUCTIONS TO THE PATIENT OR FAMILY: Activity ad lib. Medications: None. Diet: Attempt breastfeeding every 3 hours. If baby does not feed, Mom will feed pumped breast milk. Follow-up appointment will be next Wednesday, with Dr.
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Green in the clinic. CONDITION ON DISCHARGE AS COMPARED TO CONDITION ON ADMISSION: The patient is continuing to improve following an episode of dehydration with hyperbilirubinemia and hypernatremia. DISCHARGE DIAGNOSES: 1. Dehydration. 2. Hyperbilirubinemia secondary to #1. 3. Hypernatremia secondary to #1. 4. Difficulty breastfeeding. CORRECT ANSWER AND RATIONALE: 775.5, 276.0, 774.6, 779.31, 99.83, 99.29 775.5 reports dehydration and 276.0 reports hypernatremia and 774.6 reports the hyperbilirubinemia in a newborn. According to Coding Clinic, 1st Q 2005, page 9, code 775.5 is assigned to indicate a neonatal electrolyte disturbance and assign a 276.0 is assigned to identify the more specific electrolyte disorder, in this case the hypernatremia. 779.31, Feeding problems in newborn. Procedure: 99.29 reports the injection or infusion of therapeutic or prophylactic substance (hydration) and 99.83 reports phototherapy.
12. CASE 12 ADMISSION HISTORY CHIEF COMPLAINT: Chest pain. The patient was transferred from Othertown Hospital because of chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male with past medical history of diabetes mellitus, hypertension, chronic renal insufficiency, and esophageal cancer, status post resection with gastric pull-up. He also has a history of coronary artery disease and had CABG and aortic valve replacement about 7 years ago. He has been in reasonably stable health condition until at about 10 PM last night. He was lying in a recliner when he started having retrosternal chest discomfort. His chest discomfort was described as dull in character with an intensity of 5/10. It initially lasted for about 20 minutes before subsiding but has been waxing and waning since then. This morning at the time of presentation to Othertown Clinic, the intensity of the chest pain was 6/10. The chest pain is non-radiating and is not associated with diaphoresis, nausea, vomiting, shortness of breath, PND, or orthopnea. It was promptly relieved by administration of sublingual nitroglycerin at Othertown Hospital. At this time of evaluation, the patient has been chest pain free. He reports no other complaints. He has never had this type of chest pain over the
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past 7 years, and he does not think it is related to esophageal cancer. His exercise tolerance is less than one block and has been like that for some time. He does not think that it has changed recently with this event. He denies abdominal pain, hematemesis, or melena in stools. No change in urinary habits. His appetite has been good, although he intermittently has nausea. No headache, blurring of vision, or diplopia. He was seen last week at Nearby Clinic, where he had gone for medical follow-up. During that time, he had a CT scan of the chest, which was not different from the CT scan done at the hospital about 2 months ago. He follows with the medical oncology physician. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. CABG. 3. Esophageal cancer. 4. Recent PE. 5. Diabetes mellitus type 2. 6. Hypertension. 7. Chronic renal insufficiency. 8. Chronic hyponatremia. 9. Anemia of chronic disease. 10. Thrombocytopenia. 11. Anticoagulation for mechanical heart valve. 12. Mechanical aortic valve. PAST SURGICAL HISTORY: 1. Aortic valve replacement. 2. Hernia repair. 3. CABG 7 years ago. 4. Recent enteric tube for feeding.
MEDICATIONS: 1. Lopressor 25 mg daily. 2. Digoxin 0.125 mg daily. 3. Folic acid 1 mg daily. 4. Levothyroxine 0.1 mg daily. 5. Pantoprazole 40 mg daily. 6. Potassium chloride 3 mg b.i.d. 7. Sertraline 50 mg daily. 8. Ativan 0.5 mg q 8 hours p.r.n. 9. Ambien 5 mg at bedtime. 10. Lomotil 1 tablet four times daily as needed. 11. Iron 325 mg daily. 12. Multivitamin with mineral 1 tablet daily. 13. Kaopectate.
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ALLERGIES: Penicillin and niacin. SOCIAL HISTORY: He lives with his wife in rural Anytown. He is a retired pharmacist. He smoked about 25 years, two to three packs a day, but quit several years ago. Alcohol is consumed on a social basis. FAMILY HISTORY: His mother had asthma and an enlarged heart. His dad died at the age of 51 with heart disease. Multiple family members have heart disease and diabetes. REVIEW OF SYSTEMS: Cardiovascular, respiratory, GI, and genitourinary systems were reviewed in the HPI, and there are no other pertinent findings. Musculoskeletal: No claudication. No arthritic deformities. Endocrine: He has a history of diabetes and thyroid disease. Psychiatric: No history of depression or any other psychiatric illness. No hallucinations. PHYSICAL EXAMINATION: He is alert and oriented to place, time, and person. He is not in any obvious distress. Vital signs: Blood pressure: 121/73. Pulse: 75 per minute. Respiratory rate: 23 per minute. O2 saturation 97%. Temperature: 36.4. Head: Normocephalic, atraumatic. No cervical lymphadenopathy. Neck is supple. Oropharynx is clear. Trachea is central. General: He is mildly pale, not jaundiced, not cyanosed. No peripheral lymphadenopathy. CVS: First and second heart sounds are normal. He has a metallic sound due to a mechanical aortic valve. No cardiac murmurs appreciated. Chest: Good air entry bilaterally; no crackles, no rhonchi. Breath sounds at the bases are somewhat coarse. Abdomen: He has a feeding tube in place in the left hypochondrium. The point of entrance of the tube is stained with a thin, purulent material. No abdominal tenderness. No guarding. Bowel sounds are present and normal. Genitourinary: Kidneys are not palpable. No costovertebral angle tenderness. No suprapubic tenderness. Musculoskeletal: No finger clubbing. No peripheral cyanosis. No pedal edema. Neurologic: No gross neurologic abnormality noted. Moves all extremities fully. Normal tone and power of all extremities. Psychiatric: He is not depressed. No delusions or hallucinations. EKG: Normal sinus rhythm. No ST/T changes. LABORATORY DATA: Hemoglobin 13.2, WBC 8.6, platelets 220, MCV 92.3. BUN 10, glucose 139, creatinine 0.9, potassium 4.7, sodium 137, chloride 102, bicarbonate 27. ASSESSMENT AND PLAN: 1. Chest pain. The chest pain is of new onset in a patient who has risk factors for coronary artery disease. I will treat this as unstable angina. Will send two more sets of cardiac enzymes and also three sets EKG. Will also obtain a lipid panel. Will send a sample for PT/INR and a comprehensive metabolic panel. The patient has been given aspirin. Will continue with Lovenox 60 mg every 12 hours and continue with beta blocker, Lopressor 25 mg daily. I will maintain the
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2. 3.
4. 5. 6.
7.
patient on intravenous nitroglycerin 5 mcg/minute and oxygen by nasal cannula 2 liters per minute. History of pulmonary embolism. This patient has been on anticoagulation, and that will be continued. Diabetes mellitus. The patient states that his blood sugars have been adequately controlled, and he discontinued hypoglycemic agents himself. Will monitor Accu-Cheks and re-start oral hypoglycemics if indicated. Hypertension. Blood pressure is well controlled at this time. Will administer antihypertensives. Chronic renal insufficiency. His most recent creatinine was 0.9. Will continue to monitor renal function. Mechanical aortic valve. Because of endoscopy that is planned for Friday, the patient has been off Coumadin and is currently on Lovenox. We will continue Lovenox and re-start Coumadin after the procedure. Esophageal cancer. The patient is being followed by the Oncology team. No acute condition is related to the cancer at this time.
Code status was discussed with the patient and family, and he elects to be code I. PROGRESS NOTE SUBJECTIVE: The patient complains of abdominal pain, which has intensity of 5/10. It radiates to the back. He describes it as stabbing in character. He has associated nausea but no vomiting. No change in bowel or urinary habit. Denies chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or orthopnea. Has not been having fever. No hematemesis, melena, or hematochezia. REVIEW OF SYSTEMS: Cardiovascular, respiratory, and neurologic systems were reviewed, and there are no other pertinent findings. OBJECTIVE: He is alert and oriented to place, time, and person. He is not in obvious distress. Vital signs: blood pressure 114/61, pulse 80 per minute, Respiratory rate 20 per minute, O2 saturation 97%, temperature 36.5. Chest: Good air entry bilaterally, no crackles, no rhonchi. Chest: CVS: First and second heart sounds normal. He has a metallic sound due to mechanical aortic valve. No cardiac murmurs are appreciated. Abdomen is soft and nontender, no pulsatile mass noted. No hepatosplenomegaly and no ascites. He has a feeding tube on the left hypochondrium. LABORATORY DATA: Cardiac enzymes negative. Blood sugar ranged from 94 to 235. Albumin is 2.7, creatinine 8.6. Otherwise, the comprehensive metabolic panel is normal. LDL of 83, HDL of 46, triglyceride of 143, cholesterol of 158. INR is 2.7. ASSESSMENT AND PLAN: 1. Abdominal pain: Radiating to the back. Need to rule out aortic dissection. I will
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2.
3. 4. 5. 6. 7. 8.
get a CT scan with contrast. Will continue to monitor the patient hemodynamically. I will increase the patient's Protonix to 40 mg b.i.d. and will start Reglan 5 mg with meals. I will also start the patient on Maalox 10 mL every 6 hours p.r.n. I will send sample for amylase and lipase. Chest pain: The patient has not had chest pain since admission. He is scheduled for noninvasive adenosine Cardiolite this morning. He is currently on Lovenox 15 mg every 12 hours, Lopressor 25 mg, and intravenous nitroglycerin 5 mcg per minute. History of pulmonary embolism. Diabetes mellitus. We will continue with Accu-Cheks and will make adjustments as necessary. Hypertension: Blood pressures have been within acceptable range. Chronic renal insufficiency: The patient seems stable from this standpoint. Mechanical aortic valve. Esophageal cancer.
PHARMACOLOGIC NUCLEAR PERFUSION STRESS TEST INDICATION: Chest pain. PAST MEDICAL HISTORY includes: 1. Aortic valve replacement in 1997. 2. Coronary artery disease, coronary artery bypass grafting surgery, supraventricular tachycardia, hypertension, angina, diabetes mellitus, myocardial infarction in 1997, chronic renal insufficiency, esophageal CA status post resection with pull-through, pulmonary embolism, hypernatremia, anemia of chronic disease, thrombocytopenia. CURRENT MEDICATIONS: 1. Ambien. 2. Atropine. 3. Cardizem CD. 4. Coumadin. 5. Digoxin. 6. Folic acid. 7. K-Dur. 8. Lorazepam. 9. Metoprolol. 10. Protonix. 11. Reglan. 12. Synthroid. 13. Zocor. 14. Zoloft. DISCHARGE SUMMARY
77
REASON FOR HOSPITALIZATION: Chest pain. SUMMARY OF HOSPITAL COURSE: The patient is a 65-year-old man with past medical history of diabetes mellitus, hypertension, chronic renal insufficiency, and advanced esophageal cancer status post resection with gastric pull-through. He also has a history of coronary artery disease and had CABG and aortic valve replacement about seven years ago. He was transferred from Anytown 5 days ago, because of chest pain that started at rest and was associated with nausea and some shortness of breath. The chest pain was relieved by sublingual nitroglycerin. At the time of evaluation in the emergency department, the patient was hemodynamically stable but was having another episode of mild chest pain. He was started on intravenous nitroglycerin, and Lovenox was continued at 60 mg every 12 hours. He had a stress test, which showed predominantly fixed decreased defect in the posterior/inferior wall. There was also suggestion of a possible small amount of reversibility around the basilar aspect of the posterior/inferior wall, which might have been due to technical difficulties. The findings were discussed with Dr. Green, who thought that they were insignificant to warrant any invasive procedures. The patient's chest pain was thought to be due to the advanced esophageal cancer. Because the chest pain was radiating to the back, a CT scan of the chest and abdomen was done, to rule out aortic dissection. In the scan, an incidental finding of soft tissue density in the lung was noted. Oncology consult was requested, and it was thought that the soft tissue densities were most likely due to metastasis from the esophageal cancer. The patient was informed of the findings and was started on analgesics for pain control. His symptoms have improved and he remains hemodynamically stable. Cardiac enzymes were not elevated. Amylase and lipase were normal. The only abnormality noted on comprehensive metabolic panel was albumin of 2.7 and total protein of 5.8. PLAN: The patient is to be discharged home. Appointment will be scheduled with the primary care physician. He also has appointment tomorrow with the gastroenterology physician for an esophagogastroduodenoscopy. FINAL DIAGNOSES: 1. Chest pain due to metastatic esophageal cancer. 2. Unstable angina ruled out. 3. Soft tissue density in the lung thought to be due to metastatic disease from esophageal carcinoma. 4. History of pulmonary embolism. 5. Aortic mechanical valve. 6. Anticoagulation with Lovenox. 7. Diabetes mellitus. 8. Hypertension. 9. Chronic renal insufficiency. 10. Dysphagia. 11. Hypoalbuminemia.
78
DISCHARGE MEDICATIONS: 1. Digoxin 0.125 mg daily. 2. Enoxaparin 18 mg subcutaneously daily. 3. Ferrous sulfate 324 mg daily. 4. Folic acid 1 mg daily. 5. Glyburide 5 mg daily. 6. Kytril. 7. Lovenox 0.1 mg daily. 8. Metoprolol 25 mg daily. 9. Multivitamin 1 tablet daily. 10. Oxycodone 1 tablet every 2-4 hours. 11. Pantoprazole 40 mg three times daily. 12. Potassium chloride 30 mEq twice daily with food. 13. Sertraline (Zoloft) 50 mg daily. 14. Zolpidem 5 mg at bedtime. 15. Lomotil 1 tablet four times a day as needed. 16. Lorazepam 0.5 mg p.r.n. every 8 hours. CONSULTATIONS: 1. Oncology. 2. Telephone consultation with Cardiology. CONDITION ON DISCHARGE: At the time of discharge, patient is hemodynamically stable. Vital signs are blood pressure 103/86. Pulse is 81 per minute. Respiratory rate 20 per minute. Oxygen saturation 94% on room air. Temperature 36.5. His code status at the time of discharge is code I. CORRECT ANSWER AND RATIONALE: 197.0, V10.03, 403.90, 585.9, 273.8, 285.22, 785.0, 414.00, 250.00, 412, V12.51, V43.3, V45.81, V58.61 197.0 the metastatic lung cancer is the principal diagnosis; it was because of the metastasis to the lung that the patient had chest pain. V10.03 is for history of esophageal cancer which has been removed and there is no mention that the patient is still undergoing chemotherapy or other treatment. There is no mention that it has recurred in the esophagus. 403.90 hypertensive chronic kidney disease. The 5th digit of 0 indicates unspecified stage of kidney disease. 585.9 Guidelines under 403 instruct the coder to use additional code to identify the stage of chronic kidney disease. 273.8 hypoalbuminemia 285.22 anemia of neoplastic disease 785.0 reports the unspecified tachycardia 414.00 is coronary atherosclerosis 250.00 diabetes mellitus, type 2 412 old myocardial infarction V12.51 reports a history of pulmonary embolism (not current embolism, 415.9)
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V43.3 reports the mechanical aortic valve V45.81 status of postprocedural aortocoronary bypass V58.61 long-term use of anticoagulants Note: The unstable angina was ruled out during this admission and therefore is not assigned in this case. Patient has a past history of thrombocytopenia, but has a normal platelet count during this admission so would not code. 13. CASE 13 ADMISSION HISTORY PATIENT IDENTIFICATION: The patient is a 4-year-old female with a history of asthma/previous pneumonias in the past who presents with cough, hypoxia, wheezing refractory to home treatment, and inability to intake orals. CHIEF COMPLAINT: Inability to intake orals, cough, hypoxia, and wheezing. HISTORY OF PRESENT ILLNESS: The patient was in her prior normal state of health until approximately 4 AM, 20 hours prior to admission, when she woke up and had some increasing wheezing, refractory to treatment at home, including Pulmicort, Zyrtec, Albuterol, and Singulair. Mother notes that the patient is unable to sit up with this. She has been vomiting all the liquids and oral intakes she has had today. Mom noted that the patient felt feverish and chilled today, but no objective temperatures were taken at home. The patient's mother notes that usually once a year the patient has some episode of either pneumonia/exacerbation of asthma. It seems like she had some allergic component to it with recent allergy test results that showed the patient is allergic to dust, molds, and cats. Of note, the patient was exposed to a cat in her grandmother's home during the night last night. Mother notes cough associated with this, but it is nonproductive in nature since 4 AM, and the wheezing is as described above, refractory to treatment. PAST MEDICAL HISTORY: 1. Past history of asthma/pneumonia. 2. Allergic rhinitis, possible component involved with her asthma. 3. Allergy testing in the past to dust, molds, and cat. 4. The patient was born at full term. No neonatal complications or maternal complications. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Pulmicort. 2. Albuterol. 3. Singulair, 5 mg, she believes.
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4. Zyrtec. 5. Tylenol. FAMILY HISTORY: Father with asthma and both sides of his family having asthma. No noted early deaths due to cardiopulmonary disease. No known cardiopulmonary disease in other family members. SOCIAL HISTORY: The patient lives in Anytown with her mother and mother's roommate. She does attend day care with her grandmother. No noted sick contacts. She does attend school. No smoking around her. No pets, except with her grandmother as above. REVIEW OF SYSTEMS: Fully reviewed and contributory only for decreased urination today, decreased oral intake with vomiting, and a rash that occurred about 5 days ago that did not seem to be pruritic in nature that they treated with Neosporin. PHYSICAL EXAMINATION: Appearance: Four-year-old female in no obvious distress, breathing rapidly, somewhat timid. Temperature is 37, heart rate 160, respiratory rate 40, and O2 sats are 88% on room air. HEENT: HEAD is atraumatic. EYES: EOMS intact and anicteric. PERRLA. Tympanic membranes: Left is clear, as well as right, with some cerumen impaction. No erythema, edema, or exudate. Nose: No obvious rhinitis or rhinorrhea with nasal cannula in. Throat: Oropharynx is clear without erythema, edema, or exudate. Neck: No obvious lymphadenopathy, thyromegaly, or tenderness appreciated. Oropharynx has sticky mucous membranes with little saliva. Lungs: Expiratory wheezes throughout, right greater than left. No crackles or rhonchi. Cardiovascular: Tachy S1 and S2. Regular rate and rhythm. No extra heart sounds, murmurs, rubs, or gallops. Abdomen: Soft. Nontender and nondistended. No organomegaly, pulsatile masses, or obvious tenderness. Bowel sounds are positive. Extremities: Right posterior leg behind the hamstrings: There seem to be some flush-colored domelike papules umbilicated in the center. No peripheral edema. Pulses are positive and symmetric bilaterally in the upper and lower extremities. Neurological: Intact cranial nerves II-XII as best I can tell with the child. INVESTIGATIONS: White cell count 13.56 with 76% neutrophils. Hemoglobin is 15.3, platelets 310, sodium 138, chloride 99, potassium 4.6, bicarb 20.6, BUN 11, creatinine 0.5, calcium 10.5, and glucose 100. Chest x-ray revealed a blunted right heart border with what appears to be some patchy-type infiltrates involving the right lung field. No obvious effusions or cardiomegaly noted. ASSESSMENT AND PLAN: 1. Acute asthma exacerbation. The patient required nebulizers as well as oxygen in the emergency department. We will maintain her on her
81
nebulizers and start steroids. 2. Hypoxia secondary to #1. O2 sats on admission were 88% on room air. 3. Right-sided pneumonia. The patient will be started on antibiotics of Claforan 50 mg per kilogram IV every 6 hours, which is a gram every 6 hours. 4. Dehydration as evidenced by sticky mucous membranes and no oral intake today. We will start IV fluids tonight also. The patient's case, impression, and plan will be discussed with Dr. Green and will be adjusted accordingly. PEDIATRIC CONSULTATION PATIENT IDENTIFICATION: The patient is a 4-year-old female who is hospital day 4 with an acute asthma exacerbation, hypoxia secondary to her asthma exacerbation, right-sided pneumonia, and dehydration. HISTORY OF PRESENT ILLNESS: Mom reports that the patient has a history of asthma and an allergy problem. She does take Singulair 5 mg on a daily basis and has for the better part of 2 years. She has also been taking Zyrtec for the past 6 months, which was recommended by the allergist after her allergy testing. In the past, she has had one to two asthma exacerbations per year. At that time, Mom would give Albuterol and Pulmicort nebs on a p.r.n. basis. Mom said she has not had to use any nebulizers on the patient since sometime last fall, so it has been several months since her last nebulizer. When she started getting ill, Mom gave her three Albuterol nebulizers and two Pulmicort nebulizers at home with no improvement, and that is when she decided that they should come to the emergency department. She was also having coughing spells and would vomit anything that she took orally. The patient also has a history of allergies. She has had allergy testing, it sounds like with the allergist, and tested positive for dust, mold, and cats. The patient was exposed to a cat the day prior to admission at her grandmother's house. PAST MEDICAL HISTORY: Significant for allergic rhinitis with allergy testing positive to dust, mold, and cats, and asthma is currently controlled with Singulair daily and Albuterol and Pulmicort p.r.n. The patient was a full-term delivery with no neonatal or maternal complications. ALLERGIES: She has no known drug allergies. CURRENT MEDICATIONS: While here in the hospital include: 1. Pulmicort nebulizer 0.5 mg b.i.d. 2. Albuterol/Atrovent nebulizers every 4 hours. 3. Albuterol nebulizer every 1 hour p.r.n. 4. Singulair 4 mg at bedtime. 5. Claforan 1 gram every 6 hours. 6. Solu-Medrol 20 mg every 6 hours, which is 1 mg per kilogram.
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FAMILY HISTORY: The patients father has asthma, as do several of her paternal relatives. Her maternal grandmother has allergies and asthma also. Nobody has any history of eczema as far as Mom knows. SOCIAL HISTORY: The patient lives in town. She lives with her mother and her mother's roommate. She goes to Head Start for half days and then goes to her paternal grandmother's house. Her paternal grandmother runs a day care. No one at day care smokes. At home, the mother's roommate does smoke, although not in the presence of the patient. The patient has had no contact with other sick people, and has no exposure to pets, except for at maternal grandmother's house. The maternal grandmother does have a cat. REVIEW OF SYSTEMS is significant for improved appetite and urination since hospitalization. She does have a rash on the back of one leg, which was present on admit, and it has been improving. PHYSICAL EXAMINATION: Appearance: This is a 4-year-old female who is in no distress. She interacts appropriately with me. Temperature is 36.2. T-maximum over the past 24 hours is 37.7. Blood pressure is 121/62 and pulse is 128. The pulse has typically been anywhere in the 1-teens to 140s. Respirations currently are at 32. She has run anywhere from 24 to 42. She is sating 91% on 3 liters; that was this morning. She is currently sating okay on 1 liter. HEENT examination: Head is atraumatic, normocephalic. Eyes: Extraocular movements are intact. Sclera non-icteric. Pupils are equal and reactive to light. Tympanic membranes: She has some cerumen in both external auditory canals, but the tympanic membranes appear normal bilaterally. External auditory ear canals are also normal in appearance bilaterally. Nose: Nasal cannula is in. She does have some nasal discharge that is clear. Throat: Moist and pink without erythema or exudate. Neck: She has no lymph nodes palpable in the anterior or posterior cervical triangles. Neck is nontender. Trachea is midline. Lungs show inspiratory and expiratory wheezes throughout all lung fields. She does have good air movement. There are no crackles or rhonchi. Heart is tachycardic with a normal S1 and S2. Regular rhythm. There is no murmur, rub, or gallop. Abdomen is soft, nontender, and non-distended. No organomegaly. Bowel sounds are active. Extremities: She has no peripheral edema. She has good peripheral pulses. She moves the extremities through a full range of motion times four. She does have a little bit of a rash that seems to be healing well on the back of her right leg. LABORATORY: There has been no lab drawn since the day of admission. IMAGING: She did have a chest x-ray done this morning, which showed a collapsed right upper lobe, as well as some perihilar opacities and opacities extending into the lower lung field medially. No pleural effusions.
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ASSESSMENT AND PLAN: 1. Acute asthma exacerbation, status asthmaticus. The patient seems to be improving. I would recommend continuing the current treatment of Albuterol and Atrovent nebulizers, Pulmicort, and Solu-Medrol. Wean her off oxygen as able. 2. Right-sided pneumonia. The patient is doing well on Claforan right now. I would recommend checking a PPD in order to rule out any tuberculosis. Mom denied any tuberculosis exposure. 3. As long as the patient continues to improve, I would not alter the plan at all. On discharge, she will need to go home on the Pulmicort 0.5 mg nebulizer b.i.d. This may be able to be decreased as an outpatient. The patient was discussed with Dr. Green, and she will see the patient after the clinic today. DISCHARGE SUMMARY REASON FOR HOSPITALIZATION: Exacerbation of asthma with pneumonia. SUMMARY OF HOSPITAL COURSE: The patient was admitted 6 days ago with an asthma exacerbation, known allergic rhinitis, and an acute pneumonia. She was started on IV steroids, IV fluids, nebulizer treatments with Albuterol, Atrovent, and Pulmicort, and IV antibiotics to cover her pneumonia. She was oxygendependent on admit. The patient continued to need oxygen for the first 3 days of her hospitalization up to 3 liters by nasal cannula. Her chest x-ray worsened and did show a collapse of the right upper lung lobe. At that time, pediatrics was consulted. No changes were made in her medications at that time, and the patient seemed to gradually start improving. A PPD test was placed. She was weaned off her oxygen and has been on room air since Friday morning. Medications were switched to oral antibiotics and oral prednisone on Friday morning, and the patient has done well. She is discharged home today, 6 days after admission. INSTRUCTIONS TO PATIENT AND/OR FAMILY: Activity as tolerated. Diet also as tolerated. MEDICATIONS: Include: 1. Albuterol unit dose nebulizer treatments q4h while awake. 2. Pulmicort 0.5 nebulizer treatments b.i.d. 3. Azithromycin 100 mg orally for 3 more days. 4. Prednisolone 15 mg every 12 hours. 5. Singulair 4 mg q h.s. 6. Zyrtec 1 mg daily. FOLLOW-UP APPOINTMENT: Will be made next week. CONDITION ON DISCHARGE AS COMPARED WITH CONDITION ON
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ADMISSION: The patient is doing much better following an acute asthma exacerbation associated with pneumonia. DISCHARGE/FINAL DIAGNOSES include: 1. Acute asthma exacerbation. 2. Allergic rhinitis. 3. Pneumonia with collapse of right upper lung lobe. 4. Hypoxia and dehydration secondary to asthma exacerbation and pneumonia. CORRECT ANSWER AND RATIONALE: 493.01, 486, 799.02, 276.51 493.01 reports asthma with allergic rhinitis, status asthmaticus per pediatric consult 486 reports pneumonia 799.02 reports hypoxia 276.51 reports dehydration (both hypoxia and dehydration are reported, as they are not inherent to the disease process and they were treated). Note that if you coded the allergic rhinitis, the Alphabetic Index under Asthma, with rhinitis, allergic, leads the coder to 493.0X. When you reference 472.0 in the Tabular, the Excludes note indicates allergic rhinitis. When you reference allergic rhinitis 477 in the Tabular, the Excludes note directs you not to code it, if part of allergic asthma, so you do not report the allergic rhinitis.
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CCS Coding Exam Review 2011: The Certification Step

Final Examination With Answers

CCS Final Examination With Answers

493.0 493.1 493.2 493.9 A. B. C. D.

Extrinsic asthma Intrinsic asthma Chronic obstructive asthma Asthma, unspecified

493.01, 99283 493.92, 99284 493.20, 99285 493.12, 99284

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

998.59 998.83 998.89 A. B. C. D.

CCS Final Examination With Answers

CCS Final Examination With Answers

184.4 184.8 198.82 A. B. C. D.

17272, 184.4 11602, 198.82 11420, 184.4 11622, 184.8

CCS Final Examination With Answers

26608-RT, 833.14 26650-LT, 833.14 26706-LT, 833.04 26676-LT, 833.04

CCS Final Examination With Answers

CCS Final Examination With Answers

43635 43.99 44.00 44.5 55.87 A. B. C. D.

43865 44.5, 43.99 50400, 43635 44.5, 55.87, 44.00

CCS Final Examination With Answers

20661 21432 21436

02.94 76.74 76.76 802.4 802.5 A. B. C. D.

CCS Final Examination With Answers

33249, 427.1 33217, 427.81 33208, 427.81 33240, 427.89

CCS Final Examination With Answers

V56.31, 584.9 V56, 584 V56.0, 585.6 585.9, V56.0

CCS Final Examination With Answers

CCS Final Examination With Answers

11042 11043 998.59 998.83 998.89

998.59, 11000 998.89, 11010 998.83, 11043 998.83, 11042

CCS Final Examination With Answers

77031 76942 174 174.9 174.1 198.81 -RT -LT A. B. C. D.

CCS Final Examination With Answers

CCS Final Examination With Answers

45383 45309 45338 211.3 211.4 211.9 A. B. C. D.

211.9, 45320 211.3, 45383 211.4, 45309 211.3, 45338

CCS Final Examination With Answers

54160, V50.2 54150, V50.4 64.0, V50.2 64.0, V30.00

CCS Final Examination With Answers

CCS Final Examination With Answers

243, 317 244.9, 317 243, 318.0 317, 243

CCS Final Examination With Answers

61020 12015 61107

12034 61215 02.2 02.32 86.59 08.81 A. B. C. D.

61020, 12015 02.2, 86.59, 08.81 61215, 12015 02.32, 12034

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

66.62 66.69 633.90 633.10 633.80

59121, 633.90 59151, 633.10 66.62, 633.10 66.69, 633.80

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

CCS Final Examination With Answers

Normal pressure hydrocephalus

CCS Final Examination With Answers

59.8 65.61 68.49 58150 614.6 617.3

38. Sarcoidosis with cardiomyopathy:

CCS Final Examination With Answers

135 425.8 517.8 V71.7