2015 Annual Self-Review

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1 2015 Annual Self-Review CERTIFIED CODING SPECIALIST Gill Sans ahima.org

2 1. A 60-year-old female was admitted for pneumonia and exacerbation of chronic obstructive pulmonary disease. Chart documentation reflects that these two diagnoses equally meet the definition for principal diagnosis. Which of the following statements is true? a. ICD-10-CM code J18.9 must be sequenced as the principal diagnosis code. b. ICD-10-CM code J44.1 must be sequenced as the principal diagnosis code. c. Either ICD-10-CM code J18.9 or ICD-10-CM code J44.1 may be sequenced as the principal diagnosis code. d. A code for the symptom that is integral to both conditions should be sequenced as principal diagnosis followed by the codes for pneumonia and exacerbation of chronic obstructive pulmonary disease. 2. Diagnosis: Comminuted traumatic fracture of right femur shaft, receiving active treatment. What is the correct ICD-10-CM code for this diagnosis? a. S72.301A b. S72.301B c. S72.351A d. S72.351B 3. A 75-year-old male was admitted for pneumonia. A gram stain was positive. There is no physician interpretation of these laboratory findings in the health record. The physician was queried in regards to the clinical findings and the physician indicated that the final diagnosis is pneumonia. What ICD-10-CM code(s) should be assigned for this encounter? a. J15.6 b. J15.8 c. J15.9 d. J year-old male underwent a laparoscopic cholecystectomy for acute cholecystitis with cholelithiasis. The patient also had left knee pain so an x-ray was performed. The x-ray revealed osteoarthritis of the left knee and an old healed fracture of the left tibia. The attending physician noted that the knee pain was due to primary osteoarthritis of the left knee. The documentation in the health record indicates the healed fracture did not affect treatment. What ICD-10-CM diagnosis codes should be assigned for this outpatient encounter? a. K80.00, M b. K80.00, M17.12 c. K80.00, M17.12, Z87.81 d. K80.00, M17.12, S year-old male was admitted for acute systolic heart failure. The patient also has hypertension and stage 2 chronic kidney disease. The patient is status post kidney transplant which was performed two years prior to this admission. What ICD-10-CM codes should be assigned for this admission? a. I50.21, I12.9, N18.2 b. I50.21, I12.9, N18.2, Z94.0 c. I50.21, T86.12, I12.9, N18.2 d. I50.21, T86.12, I12.9, N18.2, Z The physician documented that the patient had a history of a cerebral infarction with residual right-sided weakness. An evaluation by physical therapy and occupational therapy were ordered. What is the appropriate ICD-10-CM code assignment for residual right-sided weakness resulting from an old cerebral infarction? There is no mention of hemiplegia or hemiparesis in the health record. a. I b. I c. I d. I69.398, R A 21-year-old female was admitted at 42 3/7 weeks gestation for induction of labor and delivered the next day. What ICD-10-CM code is assigned to report the weeks of gestation? a. Z3A b. Z3A.00 c. Z3A.42 d. Z3A.49

3 8. Diagnosis: Systolic ejection murmur which originated in the perinatal period was identified on a 14-day-old newborn. The cause of this murmur has not yet been identified. What is the correct ICD-10-CM code assignment for this possible systolic ejection murmur? a. I38 b. P29.89 c. R01.0 d. R This 25-year-old male was seen at the physician s office so that the physician could inspect a laceration of the right cheek which was healing nicely. The patient had previously been treated for this laceration three days earlier by an emergency medicine physician. He accidentally cut himself with the edge of a tin can lid in the kitchen of his single family residence home while cooking dinner. No intervention was required at the physician s office. What is the correct ICD-10-CM code assignment for the wound check at the physician s office? a. S01.41, W45.2, Y93.G3, Y92.010, Y99.8 b. S01.411, W45.2, Y93.G3, Y92.010, Y99.8 c. S01.411A, W45.2XXA, Y93.G3, Y92.010, Y99.8 d. S01.411D, W45.2XXD 10. What is the correct ICD-10-PCS code assignment for non-excisional debridement that was performed on an ulcer of the right thigh? The non-excisional debridement was performed on the fascia of the right thigh using a device that provides concurrent suction and gentle lavage to thoroughly remove debris and contaminants. a. 0J9L0ZZ b. 0JDL0ZZ c. 0JDL0ZZ, 3E10X8Z d. 0JDC0ZZ 11. A 72-year-old female was admitted with a principal diagnosis of congestive heart failure with associated pleural effusion. The patient underwent percutaneous thoracentesis of the right pleural cavity to drain the pleural effusion. While the patient was in the hospital she also had an excisional debridement of the skin of a left heel ulcer. Which of the following ICD-10-PCS procedure codes would be most appropriately reported as principal procedure code for this scenario? a. 0HBNXZZ b. 0HDNXZZ c. 0W993ZZ d. Sequencing of principal procedure code does not matter since neither of the procedures performed were for diagnostic purposes. 12. A patient was admitted to a long-term care hospital from an acute care facility with persistent respiratory failure. The patient was at the long-term care hospital for 97 hours. During this entire time the patient was maintained on continuous positive airway pressure [CPAP] via a tracheostomy, thereby completely taking over the physiological function of ventilation. What is the correct ICD-10-PCS code assignment for CPAP via a tracheostomy for this patient during the long-term care hospitalization? a. 5A19054 b. 5A1955Z c. 5A09557 d. F028GCZ 13. Initial insertion of transvenous implantable defibrillator generator with transvenous leads under fluoroscopy guidance. The generator was placed in a subcutaneous pocket created in an infraclavicular site. Transvenous leads were placed in the right atrium and right ventricle. Additionally, a transvenous lead was placed in the left ventricle for left ventricular pacing. What CPT code(s) should be reported for this procedure? a b , c , d , 33225, 76000

4 14. What is the correct CPT code for destruction of a skin tag lesion on left upper eyelid? a b E1 c d E1 15. Routine electrocardiogram tracing with 12 leads was performed on an outpatient basis at a hospital. What is the correct code for the facility to report on a Medicare patient for this procedure? a b c d A 40-year-old male underwent a diagnostic and surgical right shoulder arthroscopy with decompression of subacromial space. The subacromial decompression involved limited debridement of tissue and bone. What CPT code(s) should be reported for this surgery? a RT, RT, RT b RT, RT c RT, RT d RT 17. What CPT code(s) should be reported for bilateral breast reconstruction with latissimus dorsi flap without implant? a b , c , d , A surgical laparoscopy with bilateral pelvic lymphadenectomy and peri-aortic lymph node sampling was performed. All pelvic lymph nodes were removed with the exception of the internal iliac nodes. What is the correct CPT code for this procedure? a b c d What CPT code should be reported for flexible sigmoidoscopy with ligation of bleeding lesion performed for control of spontaneous bleeding of the lesion? a b c d What CPT code(s) should be reported for endoscopy which was performed through an artificial stoma in the ileum and involved endoscopic examination of the ileum? a b c d What CPT code(s) should be reported for the performance of lumbosacral myelography which includes both the lumbar injection procedure and the radiological supervision and interpretation? a b , c d Which of the following actions is inconsistent with AHIMA Standards of Ethical Coding? a. Assign and report only the codes that are clearly and consistently supported by health record documentation in accordance with applicable code set conventions, rules, and guidelines b. Omit an appropriate code for a surgical complication from the claims submission to improve a healthcare organization s quality profile c. Take adequate measures to discourage, prevent, expose, and correct the unethical conduct of colleagues d. When reviewing health records, coding professionals shall access only that information necessary to perform their duties

5 23. Which HCPCS modifier is appended to a procedure or service code for which you issued an ABN as required? a. GA b. GB c. GY d. GZ 24. Which of the following instances describes a scenario where the documentation is not sufficient for code assignment? a. In assigning a code for heart failure, the coder referred back to a previous encounter to retrieve a more specific diagnosis without physician confirmation b. In assigning a code for a fracture on an inpatient encounter, the coder referred to the radiology report on the inpatient encounter for greater specificity of the site of the fracture than what was documented by the attending physician c. In assigning a code for a pressure ulcer, the coder found that a pressure ulcer of the sacrum was documented numerous times by the attending physician in the current encounter so the coder referenced the nurses notes for information on the stage of this ulcer d. The coder based code assignment on documentation in the current encounter by the physicians involved in the care of the patient 25. What HCPCS modifier should be used on a Medicare claim to identify unused drugs from single use vials or single use packages that are appropriately discarded? a. GZ b. J1 c. JW d. It is never appropriate to report unused drugs on a claim 27.15CCS

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