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BADM 361 Human Resources Mgmt Coding Tests (100 OUT OF 100) Questions and Answers. VERIFIED

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Question 1: The ICD-10-CM alphabetic index is composed of which of the following? Select all that apply. A. Index to Diseases and Injuries B. Official Guidelines for Coding and Reporting C. Ta... ble of Neoplasms D. Table of Drugs and Chemicals E. Tabular List of Diseases and Injuries F. Index to External Causes of Injury Your correct answer: A,C,D,F The ICD-10-CM index is composed of the Index to Diseases and Injuries, the Table of Neoplasms, the Table of Drugs and Chemicals, and the Index to External Causes of Injury. Question 2: Which sections of ICD-10-CM are referenced first when researching a diagnosis for code assignment? Select all that apply. A. The Index to Diseases and Injuries B. The Tabular List of Diseases and Injuries C. Table of Neoplasms D. The Table of Drugs and Chemicals E. Official Guidelines for Coding and Reporting F. Index to External Causes of Injury Your correct answer: A,C,D The coder should begin with the Index to Diseases and Injuries, the Table of Neoplasms, or The Table of Drugs and Chemicals when researching a diagnosis for code assignment. Question 3: Which is an accurate characteristic of the 7th character extension? Select all that apply. A. Always follows an X placeholder B. Must always be in the 7th character data field C. Is located in the Index to Diseases and Injuries D. May be preceded by an X placeholder if the code category is five characters or fewer E. May be alpha or numeric F. Is found in all chapters Your correct answer: B,D,E The 7th character extension must always be in the 7th character data field. In order to ensure that it is in the 7th character data field, an X placeholder may be used if the code category is five characters or fewer. The 7th character may be alpha or numeric. Question 4: What are code blocks? A. Builders of codes, as in building blocks B. Sections of codes in each chapter C. Instructions designed to block the coder from making errors D. Categories, subcategories, and valid codes in each chapter Your correct answer: B Blocks are sections of codes in each chapter. Question 5: Which letter in the alphabet is never used as the first character of an ICD- 10-CM code? A. U B. Z C. O D. I Your correct answer: A The letter U is never used as the first character of a code. Question 6: What follows the third character in a four-character code? A. A decimal B. The fourth character C. An X placeholder D. "With" or "Without" Your correct answer: A A decimal follows the third character in a four-character code. Question 7: Which feature in ICD-10-CM provides the ability to assign specific codes for right or left body parts? A. Combination codes B. Exclusion codes C. Laterality D. Inclusion codes Your correct answer: C The word "laterality" describes the feature in ICD-10-CM that provides the ability to assign specific codes for right or left body parts. Question 8: Which of the choices best describes the relationship between the Index to Diseases and Injuries and the Tabular List of Diseases and Injuries? A. The terms listed in each are identical so that codes may be assigned beginning with either the alphabetic index or the tabular list. When a specific code follows a specific category in the alphabetic B. index, the coder understands that it is not necessary to reference the Tabular List of Diseases and Injuries, as it contains the same information. C. The codes following the terms listed in the alphabetic index correspond to the codes and their descriptions in the tabular list. D. The instruction notes and conventions in the Index to Diseases and Injuries and the tabular list are identical and may be transposed. Your correct answer: C The codes following the terms listed in the alphabetic index correspond to the codes and their descriptions in the tabular list. Question 9: Which is a valid ICD-10-CM diagnosis code? Select all that apply. A. C47.1 B. C47.10 C. C47.11 D. C75.0 E. C7A.098 F. C50.129 Your correct answer: B,C,D,E,F ICD-10-CM diagnosis codes can be valid with 3-7 characters. Codes C47.10, C47.11, C75.0, C7A.098, and C50.129 are all valid diagnosis codes. Question 10: When researching terms in the Index to Diseases and Injuries, the system of alphabetization ignores single spaces between words, single hyphens within words, and the final "s" in the possessive form of words. A. True B. False Your correct answer: A Test Results Summary The system of alphabetization in the index ignores single spaces between words, single hyphens within words, and the final "s" in the possessive form of words. Question 1: Refer to your alphabetic index under the main term Pneumonia. Referring to the nonessential modifiers, which diagnostic terms would be coded to J18.9? Select all that apply. A. Acute double pneumonia B. Aspiration pneumonia C. Anthrax pneumonia D. Allergic pneumonia E. Septic pneumonia F. Purulent pneumonia Your correct answer: A,E,F Acute double pneumonia, septic pneumonia, and purulent pneumonia are all coded with J18.9. All of these terms appear in the nonessential modifiers; the others are located by specific subterms under the main term Pneumonia. Question 2: The coder references the main term Cephalitis and finds the index entry "Cephalitis - see Encephalitis." This instruction to "see Encephalitis" must be followed. A. True B. False Your correct answer: A The coding instruction to see another reference in the index must be followed. No code appears with the term Cephalitis, so the coder must look elsewhere as directed. Question 3: Refer to the index entry for Disease. Which diagnostic statement would require the coder to follow the see also instructional note? A. Disease, liver, alcoholic B. Disease, nasal C. Disease, myocardium, primary D. Disease, malignant Your correct answer: D The index entry "Disease, malignant" instructs the coder to "see also Neoplasm, malignant." Question 4: A coder references the diagnostic term Alzheimer's disease by referencing the main term Disease and the subterm Alzheimer's. The corresponding index entry lists the subterm as "Alzheimer's G30.9 [F02.80]." After verifying these codes in the tabular list, how should these codes appear in sequence? A. G30.9 B. G30.9, F02.80 C. F02.80 D. G30.9, F02.80, F05 Your correct answer: B After verifying the codes in the tabular list, the coder would list the code in brackets second. Question 5: When the abbreviation "NEC" appears in a code description, the coder should look for a more specific code if possible. A. True B. False Your correct answer: A When "NEC" appears in a code description, the coder should make sure he or she is using the most specific code possible. Question 6: Refer to the alphabetic index main term Pregnancy, subterms complicated by. Which code examples show appropriate use of the placeholder "X" in the 5th character position, as observed in the index? Select all that apply. A. Subterm, adverse effect anesthesia, local, toxic reaction O29.3X B. Subterm , adverse effect anesthesia, spinal and epidural type NEC O29.5X C. Subterm, antepartum hemorrhage, specified NEC O46.8X D. Subterm, disorders of, amniotic fluid and membranes, specified NEC O41.8X E. Subterm , multiple gestations, specified complication NEC O31.8X F. Subterm, venous disorders, specified NEC O22.8X Your correct answer: A,B,C,D,E,F All appear in the alphabetic index with the placeholder X in the 5th character position. Additional digits will be required to create a valid ICD- 10-CM code. Always refer to the tabular list to verify the code number is correct. Question 7: Refer to the alphabetic index main term Reflux. Which code do the subterms esophageal and gastroesophageal provide as a suggestion? A. K21.0 B. K20.9 C. P78.83 D. K21.9 Your correct answer: D Code K21.9 is suggested for either gastroesophageal reflux or esophageal reflux. Question 8: The diagnosis is fibroadenoma of the left breast. What is the next step to finding a code for this condition? A. Go to the Neoplasm Table, by site, unspecified behavior. B. Refer to the main term Fibroadenoma, follow the instructions to go to specified site NEC —see Neoplasm, benign, by site. C. Go to the main term Fibroma, follow the instructions to see also Neoplasm, connective tissue, benign. D. Refer to the main term Fibroadenosis, breast and then to the suggested code subcategory N60.2- in the Tabular List. Your correct answer: B Since fibroadenoma is a specific type of neoplasm, first refer to the term Fibroadenoma, then follow the instructions and see the Neoplasm, by site, benign. Question 9: Refer to the Tabular List for code G00.8, Other bacterial meningitis. Which of these notes is listed with that code? A. Use additional code to further identify organism (B95.61-B95.8). B. An inclusion note for Purulent meningitis NOS and Pyogenic meningitis NOS. C. Use additional code to further identify organism (B96.-). D. There is no note listed with this code. Your correct answer: C Along with some inclusion notes there is a note to use additional code to further identify organism (B96.-). Question 10: In the Tabular List when referring to the code description for A48.2, Nonpneumonic Legionnaires' disease [Pontiac fever], the term in brackets is another name for this type of Legionnaires' disease. A. True B. False Your correct answer: A Brackets are used to enclose explanatory words or phrases. Test Results Summary Question 1: Which instruction is followed if there is a discrepancy between the conventions and the Official Guidelines for Coding and Reporting? A. The conventions are followed. B. The most recently updated yearly instruction is followed. C. The official guidelines are followed. D. The instruction that is followed depends on the circumstances of admission. Your correct answer: A If there is a discrepancy between the conventions and the Official Guidelines for Coding and Reporting, the conventions take precedence and are followed. Question 2: What does the "X" indicate in the symbol "✓x7th"? A. The "X" must be defined by another number. B. A seventh character is required following the "X." C. A multiple of the 7th power. D. A requirement to check the character before the 7th character. Your correct answer: B The symbol "✓x7th" indicates that the code requires a 7th character after the placeholder "X." Question 3: What convention denotes that a specific diagnosis was documented but there is no corresponding code for that specific diagnosis? A. NOS B. Brackets C. NEC D. Parentheses Your correct answer: C NEC, not elsewhere classified, denotes that a more specific diagnosis was documented, but there is no corresponding specific code. Question 4: A specific diagnosis is not documented. What convention is applied because an available specific code could not be assigned? A. NEC B. Parentheses C. Brackets D. NOS Your correct answer: D NOS, not otherwise specified, denotes that the documentation was not detailed enough to assign a more specific code. Question 5: Which convention or note tells the coder that terms listed under a code category are reported with a code from that category? A. Use additional code B. Excludes2 C. Code also D. Includes Note Your correct answer: D The Includes Note indicates that the terms listed under a code category are coded to, or included in, that code category. Question 6: Refer to your ICD-10-CM codes in the tabular list. Which codes contain an applicable Excludes1 Note? Select all that apply. A. A04.6, Enteritis due to Yersinia enterocolitica B. A06.0, Acute amebic dysentery C. A07.0, Balantidiasis D. B26, Mumps E. B27.00, Gammaherpesviral mononucleosis without complication F. B33.0, Epidemic myalgia Your correct answer: A,B Codes A04.6 and A06.0 contain an applicable Excludes1 Note at the code level or the code category level. Question 7: Which instructions are incorporated into the convention Code first/Use additional code? Select all that apply. A. Manifestation codes are always sequenced following the code for the etiology. B. The code for the etiology is always sequenced following the code for the manifestation. C. Either code may be sequenced first, depending on the circumstances of the admission. D. Two codes are required to fully report the diagnosis. E. A second code is optional. F. The manifestation is the only required code. Your correct answer: A,D The instruction Code first/Use additional code instructs the coder to assign two codes to fully report the diagnosis and instructs the coder to sequence the manifestation code after the etiology code. Question 8: Which phrase applies to the Excludes2 Note? A. "Not included here" B. "Code elsewhere" C. "Not coded here" D. "Code first underlying disease" Your correct answer: A Refer to the definition of Excludes2 in the tabular list. The phrase "Not included here" applies to the Excludes2 Note. It means that it may be appropriate to assign two codes to the diagnostic statement. While trying to learn ICD-10-CM coding, a way to remember the use of the Excludes2 note might be: "2 codes are needed." Question 9: The tabular list instructional note appears with a nonitalicized code to "Code first," followed by an instruction to assign an additional code. When is it correct to comply with this instructional note? A. The additional code is always assigned. B. When there is documentation of the diagnosis pertaining to the additional code. C. It depends on the circumstances of admission. D. When the instruction “Use additional code” is under the additional code. Your correct answer: B The instruction “Code first” in a nonitalicized code indicates that an additional code may be assigned, but only if the diagnosis pertaining to the additional code has been documented. Question 10: Which form of punctuation is used to enclose nonessential modifiers? A. ✓(check mark) B. Brackets C. Parentheses D. Colon Your correct answer: C Parentheses are used to enclose nonessential modifiers. Test Results Summary Question 1: A patient is admitted for treatment of acute diverticulitis. The history and physical report mentions that the patient has mild intermittent asthma. Friends send flowers to the patient's room, bringing on an acute exacerbation of the known asthma. Which POA indicator is assigned to code J45.21, and why? A. POA indicator N is assigned. The acute exacerbation occurred after admission. The guideline pertaining to combination codes is applied. B. POA indicator Y is assigned. The patient was known to have chronic asthma prior to admission, so asthma was present on admission. C. POA indicator N is assigned. An additional code describing the chronic condition is assigned POA indicator Y. D. POA indicator Y is assigned. An additional code describing the chronic condition is assigned POA indicator Y. Your correct answer: A POA indicator N is assigned. The guideline pertaining to combination codes is applied; if the acute exacerbation occurred after admission, N is assigned even though the chronic component of the condition was present on admission. Question 2: A patient previously diagnosed with anorexia nervosa is admitted with abdominal pain. After admission, the patient expresses her dislike of hospital food and refuses to eat. A consulting psychiatrist documents that the anorexia nervosa is exacerbated. Which POA indicator is assigned to code F50.00, and why? A. POA indicator N is assigned. The acute exacerbation occurred after admission. The guideline pertaining to combination codes is applied. POA indicator Y is assigned. When there is no combination code B. available, Y is assigned regardless of when the acute exacerbation of a chronic condition occurred. C. POA indicator N is assigned. An additional code describing the chronic anorexia nervosa is assigned POA indicator Y. D. POA indicator Y is assigned. The patient’s refusal to eat was a symptom of anorexia nervosa, present on admission. Your correct answer: B When there is no single combination code available that describes both the chronic condition and an acute exacerbation, POA indicator Y is assigned regardless of when the acute exacerbation of a chronic condition occurred. Question 3: A patient is admitted for lethargy and muscle aches. A test for Lyme disease is ordered. The patient is discharged home prior to the final test result being available. The result is positive. One week after discharge, the provider documents the final diagnosis as "Lyme disease." Which POA indicator is assigned, and why? POA indicator W is assigned. The provider was clinically unable to A. determine the etiology of the lethargy and muscle aches at the time of discharge. POA indicator U is assigned. Since the laboratory results were not B. available at the time of discharge, there was insufficient documentation to assign a diagnosis code. POA indicator Y is assigned. The timing of the results indicating Lyme C. disease is not relevant. The cause of the symptoms was identified as Lyme disease. D. POA indicator N is assigned. The diagnosis of Lyme disease was not documented at the time of admission. Your correct answer: C POA indicator Y is assigned. The cause of the symptoms was identified as Lyme disease. Results available after discharge may be used when assigning the POA indicator. Question 4: A patient admitted for an emergency appendectomy undergoes preliminary laboratory tests after admission. The pregnancy test is positive, and the surgeon documents "incidental pregnancy" as a secondary diagnosis. The patient states she was not aware she is pregnant. Which POA indicator is assigned for the pregnancy in this case? A. POA indicator N is assigned. The patient had no known history of pregnancy. B. POA indicator U is assigned. Since the patient was not aware of being pregnant, the test results alone are insufficient for diagnosis. C. POA indicator W is assigned. The surgeon can’t tell whether the patient became pregnant before or after admission. D. POA indicator Y is assigned. The patient was pregnant on admission. Your correct answer: D POA indicator Y is assigned. The patient was pregnant on admission, and the surgeon documented the diagnosis as “incidental pregnancy.” It is not likely that that patient became pregnant after admission. Question 5: A patient is admitted with shortness of breath. Results of a thoracotomy with lung biopsy indicate lung cancer. Following the thoracotomy, the patient develops acute pulmonary insufficiency. Which POA indicators are assigned to the diagnoses in this case? A. Assign POA indicator Y to the lung cancer diagnosis and POA indicator N to the acute pulmonary insufficiency diagnosis. B. Assign POA indicator U to the lung cancer diagnosis and POA indicator Y to the acute pulmonary insufficiency diagnosis. C. Assign POA indicator N to the lung cancer diagnosis and POA indicator Y to the acute pulmonary insufficiency diagnosis. D. Assign POA indicator U to the lung cancer diagnosis and POA indicator N to the acute pulmonary insufficiency diagnosis. Your correct answer: A Assign POA indicator Y to the lung cancer diagnosis and POA indicator N to the acute pulmonary insufficiency diagnosis. The lung cancer was present on admission even though it was diagnosed later. The acute pulmonary insufficiency, although an acute condition, was not present on admission, as it occurred following surgery. Question 6: A patient is admitted for an exacerbation of Crohn's disease causing an obstruction of both the duodenum and the ileum. How many diagnosis codes are assigned and with which POA indicator? A. Assign two codes for these diagnoses, both with POA indicator Y. B. Assign one code for these diagnoses, and POA indicator Y. C. Assign three codes for these diagnoses, two with POA indicator Y and one with POA indicator U. D. Assign two codes for these diagnoses, one with POA indicator Y and one with POA indicator U. Your correct answer: B Assign one code, K50.012, Crohn’s disease of small intestine with intestinal obstruction. There are no separate codes for duodenum and ileum. Assign POA indicator Y because both conditions were present on admission. Question 7: What are the characteristics of a HAC? Select all that apply. A. High cost B. High mortality rate C. Occur in high volume D. Are reasonably preventable E. Are pre-existing F. Are present on admission Your correct answer: A,C,D Attributes of HACs include high cost, occur in high volume, and are reasonably preventable. Question 8: Which of the following are exempt from the POA reporting requirement? Select all that apply. A. Fall from the operating table B. Congenital malformations C. Acquired absence of limb D. Outcome of delivery E. Old myocardial infarction F. Striking against sports equipment with subsequent fall Your correct answer: B,C,D,E,F All of the above are exempt from the POA reporting requirement except fall from the operating table. The POA exempt list includes categories that do not represent a current disease or injury or are always present on admission. Question 9: What may be affected if the POA indicator N is assigned to a complication code? A. Reimbursement B. Morbidity and mortality C. The ICD-10-CM code extension D. UHDDS reporting Your correct answer: A A hospital may not be reimbursed for complications that occurred after admission. Question 10: Which POA indicator is assigned to a final diagnosis described as "suspected" based on symptoms that developed after admission? A. Assign POA indicator U. B. Assign POA indicator W. C. Assign POA indicator N. D. Assign POA indicator Y. Your correct answer: C Test Results Summary Assign POA indicator N. Conditions described as possible, probable, suspected, or ruled out that developed after admission are not present on admission. Question 1: Your hospital's finance department staff asks you to change the principal diagnosis code from "chest pain" to "coronary artery disease" in a case in which the cardiac catheterization report states "normal coronary arteries." The final diagnosis listed by the provider is "chest pain." What action would you take? A. Explain to the finance department staff why the assignment of the code for chest pain is correct. Change the principal diagnosis code to the code for coronary artery B. disease because this diagnosis best explains the reason for a cardiac catheterization. C. Query the physician to explain why he or she performed a cardiac catheterization on a patient with normal coronary arteries. D. Contact the patient's insurance company and ask if your hospital will receive reimbursement if the code for chest pain is assigned. Your correct answer: A Explain to the finance department staff why the assignment of the code for "chest pain" is correct. Include a brief explanation of the definition of principal diagnosis and how the diagnosis "chest pain" is supported by documentation in the medical record. Question 2: What action would you take if you were informed that an encounter you coded was rejected for reimbursement because code Z92.4 had been reported as the principal diagnosis? The final diagnosis was Rift Valley fever. A. Explain to the person questioning your coding decision that you, not he, are the professional coder. B. Change the code to A92.4. C. Inform the person questioning you that it is the responsibility of the finance department to follow up with billing problems. D. Request that code Z92.4 be resubmitted because it is a valid code. Your correct answer: B Change the code to A92.4. Remember: Everyone makes mistakes. You made a typographical error. The A and Z keys are closely located. This type of error is not fraudulent because it was not done on purpose. Question 3: What action should the coder take if the chief of surgery instructed that postoperative complication codes never be assigned? A. Never assign codes for postoperative complications. B. Continue to assign codes for postoperative complications except in cases involving the chief of surgery. C. Refuse to inappropriately exclude diagnosis codes in order to misrepresent the quality of care provided. D. Expand the concept of excluding complication codes to include all hospital-acquired conditions. Your correct answer: C Refuse to inappropriately exclude diagnosis codes in order to misrepresent the quality of care provided. Refer to Section 6 in the Standards of Ethical Coding, UHDDS definitions of principal and secondary diagnosis, and ICD-10-CM Official Guidelines for Coding and Reporting. Question 4: Why are codes assigned and reported? Select all that apply. A. Strategic planning B. Obtaining reimbursement C. Mortality statistics D. Local law enforcement reporting E. Building code requirements F. Outcomes measurement Your correct answer: A,B,C,F Codes are assigned and reported for many reasons, including use in strategic planning and outcomes measurement, to obtain reimbursement, and for mortality statistics. Question 5: Which law requires hospitals to adhere to certain standards pertaining to the content and format of electronically submitted data? A. EDI B. UHDDS C. CMS D. HIPAA Your correct answer: D The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires hospitals to adhere to certain standards pertaining to the content and format of electronically submitted data. Question 6: Which regulations are used by the MAC/FI as a basis for coverage determinations? A. NCD B. EDI C. CMS D. MCE Your correct answer: A The MAC/FI bases determinations on national coverage determination (NCD) regulations. Question 7: Who approves the official coding guidelines? A. The U.S. Congress under HIPAA B. The Cooperating Parties C. The Association for the Uniform Hospital Discharge Data Set D. All acute-care, short-term care, long-term care, and psychiatric hospitals Your correct answer: B The Cooperating Parties of the ICD-10-CM—that is, AMA, AHIMA, CMS, and NCHS—approve the official coding guidelines. Question 8: Which organization is the U.S. Clearinghouse for the distribution of official coding advice? A. AHIMA B. CMS C. AHA D. NCHS Your correct answer: C The American Hospital Association's Central Office serves as the official U.S. Clearinghouse on medical coding for the proper use of the ICD-9- CM, ICD-10-CM and ICD-10-PCS systems, and Level I HCPCS (CPT-4 codes) for hospital providers and certain Level II HCPCS codes for hospitals, physicians, and other health professionals. Question 9: A logical process for coding surgical cases should include a search for which main provider report? A. Consultation B. Laboratory report C. Emergency department report D. Operative report Your correct answer: D The coder would logically search for the operative report when coding surgical cases. Question 10: There is a consultation report in the medical record from a dietitian that indicates the patient may be malnourished. The coder could not find further documentation concerning malnourishment from the physician. The coder may assign a code for the malnourishment. A. True B. False Your correct answer: B In this case, the coder should query the physician based on the dietitian’s clinical observations. Question 1: The patient is seen for acute gastroenteritis, nausea with vomiting, and abdominal pain. Which diagnosis or diagnoses should be reported? A. Acute gastroenteritis B. Acute gastroenteritis, vomiting C. Nausea with vomiting, and abdominal pain D. Acute gastroenteritis and abdominal pain Your correct answer: A Assign a code for acute gastroenteritis. The other diagnoses are symptoms associated with acute gastroenteritis and are not assigned codes. Question 2: The patient is seen for acute exacerbation of chronic obstructive pulmonary disease, hemoptysis (cough with hemorrhage), and shortness of breath. Which diagnosis or diagnoses would be reported? A. Acute exacerbation of chronic obstructive pulmonary disease B. Acute exacerbation of chronic obstructive pulmonary disease, hemoptysis C. Hemoptysis, shortness of breath D. Acute exacerbation of chronic obstructive pulmonary disease, hemoptysis, shortness of breath Your correct answer: B Assign a code for acute exacerbation of chronic obstructive pulmonary disease and a code for hemoptysis. Hemoptysis is not routinely associated with acute exacerbation of chronic obstructive pulmonary disease. Shortness of breath is an associated symptom. Question 3: Using your ICD-10-CM code book, how many codes are assigned to the final diagnosis "cellulitis of left toe due to group A streptococcus?" What instruction note is followed for compliance with the guideline? A. One combination code is assigned based on the instruction note "Includes." B. Two codes are assigned based on the instruction note beginning with "Code also..." C. Two codes are assigned based on the instruction note beginning with "Use additional code..." D. One code for both conditions is assigned based on the instructions in the alphabetic index. Your correct answer: C Two codes are assigned based on the instruction note beginning with "Use additional code..." in the tabular list under the main code heading for chapter block L00–L08. Question 4: What general guideline provides sequencing instructions denoted in the tabular list by the instructions "Code, if applicable, any causal condition first" and "Code first?" A. Combination codes B. Signs and symptoms not routinely associated with a disease process C. Impending or threatened condition D. Assigning multiple codes for a single condition Your correct answer: D The general guideline for assigning multiple codes for a single condition provides sequencing instructions denoted in the tabular list by the instructions "Code, if applicable, any causal condition first," and "Code first." Question 5: How many codes are assigned for a condition described as acute (subacute) and chronic if the subterms in the alphabetic index are equally indented? A. Two codes B. One code C. Three codes D. Four codes Your correct answer: A Two codes are assigned if the subterm entries are equally indented. Question 6: A young man attempting to sail solo around the world forgets to bring his vitamins along. After many months at sea, he begins bleeding from his gums. Alarmed, he sails to the nearest port to see a physician. He is diagnosed with vitamin C deficiency, scurvy. Many months later after receiving a complete check up, the patient is diagnosed with a heart arrhythmia caused by his previous bout of scurvy. What is the coding and reporting for this most recent visit? A. I49.9, Cardiac arrhythmia, unspecified B. E54, Ascorbic acid deficiency; E64.2, Sequelae of vitamin C deficiency C. I49.9, Cardiac arrhythmia, unspecified; E64.2, Sequelae of vitamin C deficiency D. E64.2, Sequelae of vitamin C deficiency; I49.9, Cardiac arrhythmia, unspecified Your correct answer: C The tabular list instructs the coder to: Code first condition resulting from (sequela) of malnutrition and other nutritional deficiencies. Then assign code E64.2, Sequelae of vitamin C deficiency for the late effect of the scurvy. Question 7: A person with alcohol dependence goes into withdrawal after the family pours all of the alcohol in the house down the kitchen drain. The final diagnosis is "alcohol dependence with withdrawal, impending delirium tremens." The patient was treated in time to prevent the delirium tremens. What is the coding for this case? A. F10.231, Alcohol dependence with withdrawal delirium B. F10.221, Alcohol dependence with intoxication delirium C. F10.239, Alcohol dependence with withdrawal, unspecified D. F10.921, Alcohol use, unspecified with intoxication delirium Your correct answer: C Assign code F10.239, Alcohol dependence with withdrawal, unspecified. See the alphabetic index, main term Impending, subterm delirium tremens. Because delirium tremens were prevented, only the alcohol dependence with withdrawal is coded. Question 8: You are the coding supervisor. A coder is attempting to assign code K22.11 twice for a patient treated for two bleeding esophageal ulcers, lower and upper. She complains that the computer will allow her to enter the code only once. What is your response? A. Refer her to the general guideline for laterality. B. Override the edit and assign the code twice to show two sites. C. Refer her to the general guideline for reporting the same diagnosis code more than once. D. Tell her to look for a combination code instead. Your correct answer: C The same diagnosis code can be reported only once. Refer her to the general guideline for reporting the same diagnosis code more than once. Question 9: An older patient was admitted to the hospital after becoming unresponsive. The workup revealed that the patient did not have a myocardial infarction, but the etiology of the unresponsiveness could not be determined before the patient expired. The final diagnosis is "Probable cerebral infarct, myocardial infarct ruled out. " What is coded to report this case? A. Unresponsiveness B. Cerebral infarct and myocardial infarction C. Unresponsiveness and myocardial infarction D. Cerebral infarct Your correct answer: D Assign a code for the cerebral infarct because the term "probable" was used, even though the reason for the unresponsiveness was uncertain. Diagnoses that are ruled out are never coded. Question 10: A patient with heroin dependence is admitted for treatment of pneumonia. The provider suspects the patient also has AIDS and orders an HIV test, but the patient leaves AMA before the test can be performed. The final diagnosis is documented as "Pneumonia, suspect AIDS." What steps should the coder take to assign a code or codes? A. Assign only the code for the pneumonia and heroin dependence. B. Assign a code for the pneumonia and heroin dependence. Query the physician for clarification about the diagnosis of AIDS. C. Assign a code for the pneumonia, heroin dependence, and a code for AIDS. D. Refer to the patient's health insurance policy for reporting guidelines. Your incorrect answer: A Summary The coding guidelines instruct the coder to report only confirmed cases of HIV infection/illness. Stating "suspect AIDS" is not a confirmation of the disease. In this case, the HIV test was also never performed so the physician should be queried for more information about why AIDS was suspected and if it should be reported. For example, if the pneumonia can be further specified, it may be an AIDS-related pneumonia. Question 1: Jan was admitted to the hospital complaining of severe abdominal pain of a gnawing, burning nature; fatigue; and a lack of energy. Stools were positive for the presence of blood, and the physician documents "gastric ulcer," which was confirmed by upper GI x-rays. Gastroscopy showed minimal blood oozing from an ulcer crater. Hematocrit was low, and the hematology consultant noted chronic blood loss anemia. Using your ICD- 10-CM alphabetic index and tabular listing, what is the principal diagnosis? A. Abdominal pain B. Chronic blood loss anemia C. Chronic or unspecified gastric ulcer with hemorrhage D. Acute gastric ulcer with hemorrhage Your correct answer: C The principal diagnosis is the reason for admission after study. The ulcer crater was noted to be bleeding. It was not specified as to its current condition, and "unspecified" in the index goes to the chronic or unspecified code. The provider should be queried as to its acute or chronic status. Question 2: The admitting diagnosis is often different from the principal diagnosis. A. True B. False Your correct answer: A The admitting diagnosis is the reason for presenting for care, rather than the reason for admission after study. Question 3: A 75-year-old man presents with progressive shortness of breath over the past 5 days, with increasing orthopnea and paroxysmal nocturnal dyspnea. The patient denies having any chest pain, palpitations, numbness, chest pressure, or weakness. The patient admits to being noncompliant with medications and noncompliant with diet restrictions. He has a history of atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) and is 5 years removed from right ankle surgery to repair a fracture. The patient admits to heavy smoking before he quit 10 years ago. The physician lists a final diagnosis of exacerbation of congestive heart failure (CHF) with COPD. The patient is treated for CHF, COPD, and AF. Which diagnoses would be coded? A. CHF with exacerbation, COPD, AF B. CHF with exacerbation, COPD, AF, history of knee surgery C. CHF with exacerbation, COPD, AF, history of tobacco use D. Shortness of breath, CHF with exacerbation, COPD, AF, history of tobacco use Your correct answer: C The principal diagnosis is the CHF. Other diagnoses to be reported are the COPD, atrial fibrillation, and a history of tobacco use. The past tobacco use is pertinent because it is related to COPD. The tabular listing for "Diseases of the Respiratory System" (Chapter 10) states that the coder should "use an additional code" to report history of tobacco abuse (Z87.891). Question 4: A patient was admitted with a diagnosis of chest pain and left the hospital with a diagnosis of possible acute myocardial infarction. The patient left against medical advice and before his workup could be completed. What is the principal diagnosis? A. Myocardial infarction B. Chest pain C. Angina D. Arteriosclerotic heart disease Your correct answer: A Possible acute myocardial infarction would be coded as if it had occurred. Question 5: If a provider lists a diagnosis in the discharge summary, it should be coded, regardless of whether the record contains supporting documentation. A. True B. False Your correct answer: B A diagnosis listed by the provider should always be supported in the medical record. If it is not, the provider should be asked for clarification. Question 6: Several UHDDS criteria are used to determine whether a condition should be reported as a secondary or other diagnosis. Which criteria are applied? Select all that apply. A. Increased nursing care and/or monitoring was provided. B. A therapeutic procedure was performed for the condition. C. A diagnostic service was performed for the condition. D. The condition was clinically evaluated. E. The condition extended the length of the hospital stay. F. The patient had the condition in the past. Your correct answer: A,B,C,D,E For reporting purposes, the definition of other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring one or more of the following: • Clinical evaluation • Therapeutic treatment • Diagnostic procedures • Extended length of hospital stay • Increase in nursing care or monitoring Conditions that happened in the past must continue to have a bearing on the current treatment of the patient to be included. For example, if a patient was admitted and treated for bronchitis, the fact that he or she had a fractured arm in the past would not be pertinent to the current stay. Question 7: One of the coding guidelines deals with the rare instance in which two or more contrasting or comparative diagnoses are documented as "either/or" (or similar terminology). These diagnoses are coded as if they were confirmed. They are sequenced according to the circumstances of the admission. Either diagnosis may be sequenced first. For example, a patient is admitted with symptoms of abdominal pain with nausea and vomiting determined to be due to pyelonephritis or diverticulitis. The patient has a confirmed diagnosis for both conditions, and both conditions are treated equally. Which UHDDS definition terms are used to describe this situation? A. Coequal diagnoses B. Comparative or contrasting C. Symptom followed by comparative or contrasting D. Original treatment plan not carried out Your correct answer: B This is an example of a comparative or contrasting condition. The patient was admitted with symptoms that can be attributed to either of the patient's conditions. The symptom codes are integral to both conditions, and both conditions were confirmed, so the symptom codes are not reported. Question 8: What term is used to describe the reason a patient seeks medical treatment? A. Chief complaint B. Other diagnosis C. Principal diagnosis D. Secondary diagnosis Your correct answer: A The chief complaint is the reason a patient seeks medical attention. Question 9: A patient presents to the ED with severe abdominal pain, nausea and vomiting, loss of appetite, and a 101⁰F fever. He just returned from a trip abroad. Initially, the physician thought the patient suffered from gastroenteritis. After further examination and blood tests, the patient is diagnosed with appendicitis. What conditions are reported for this scenario? A. Appendicitis B. Gastroenteritis C. Appendicitis and gastroenteritis D. Appendicitis, severe abdominal pain, fever, nausea and vomiting, loss of appetite Your correct answer: A Appendicitis is the principal diagnosis because it is the reason for admission after study. Question 10: A patient is admitted to the hospital with a crushed ankle, contusions, and superficial leg abrasions due to a car accident. The crushed ankle required surgical intervention. The contusions and abrasions were also treated. After his admission, the patient suffered an acute asthma attack. He was treated with albuterol (Proventil) and ipratropium (Atrovent). He has a history of hypertension which was treated with amlodipine (Norvasc). He has a history of migraines but has not had an attack in several years and is on no medication for this. Which conditions are considered other diagnoses for coding purposes? Select all that apply. A. Asthma B. Contusions C. Crushed ankle D. Hypertension E. Migraine F. Superficial leg abrasions Your incorrect answer: B,D Other diagnoses are those conditions that coexist at the time of admission or develop subsequently or affect patient care for the current hospital episode. Asthma, contusions, hypertension and superficial leg abrasions are considered other diagnoses. [Show More]

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