A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding.
C. Glaucoma
ICD-10-CM utilizes a placeholder character. That is used as a 5th digit character placeholder at certain 6 character codes to allow for future expansion. The placeholder character is?
x
A direction to "code first underlying disease" should be considered
Manditory
The "cooperating party" responsible for maintaining the ICD-9CM disease classification is the
Nation Cernter for Health Stats NCHS
Which of the following classification systems was designed with electronic systems in mind is currently being used for problem list, ICU unity, paitent care assessment, data collection, med research, clinical trail, disease survaellance and image d?
SNOMED-CT
The Unified Medical Language System (UMLS) is a project sponsored by the
National Library of Medicine
Code 402 Hypertensive Heart Disease would be appropriate in which of the following
C. Hypertensive cardiovascular disease with congestive heart failure
A patient is admitted to the hospital 6 weeks post myocardial infarction with server chest pains. Which is correct?
A. 410.1x Acute MI - is considered anything under 8 weeks from initial onset
A patient with Luekemia is admitted for chemo 5 week after experiencing an acute MI How will the MI be coded
Acute MI with 5th digit 2 - subsequent episode of care
The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, and international levels
ABC codes
The Level II codes of HCPCS coding systesm are maintained by the
Centers for Medicare and Medicaid Services
A patient is admitted with alcohol withdraw suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis
C. Delirium tremens
A patient is admitted with pnuemonia. Cultures are requested to determine the infecting organism. Which of the following, if present would alert the coder to ask the physician whether or not they should add gram-negative pneumonia
C. Pseudomonas
Level I (CPT) codes of HCPCS are maintained by the
AMA
A physician excises a 3.1 malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the procedures should codes
excision of lesion; full thickness scalp
A patient is seen by a surgeon who determines the an emergency procedure is necessary. What modifier indicates that the decision to do surgery was made
57
A patient develops difficulty during surgery and it is discontinued; which modifier
53
A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is
disease registry
Is IUD embedded in uterine wall a mechanical complication?
Yes
Is inflammation of urethra due to indwelling catheter a mechanical complication?
NO
A population based cancer registry that is designed to determine rates and trends in a defined population is
incidence-only population-based registry
In regard to quality coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coders refers to
reliability
The method of calculating errors in a coding audit that allows for benchmarking with other hospitals and permits the reviewer to track errors by case types is the
records over records method
The most common type of registry is the
Cancer registry
A patient is seen in the ER with Tachycardia and hypo tension. The patient had received an injection of tetanus toxid correctly earlier.
hypotension, tachycardia, therapeutic use E code tetanus toxid
A PEG procedure would be used to facilitate
Eating
What ICD-9CM coding scheme is used to show that a therapeutic abortion resulted in a live fetus?
code 644.21, early onset of deliver; V27 code (outcome of deliver)
Prolong pregnancy is a pregnancy that has advanced beyond how many weeks
42
The code structure for ICD-10-CM consists of
3 to 7 characters
In ICD-10 to code removal of thumnail the root operation would be
extraction
In ICD-10 if no laterality is identified in the medical record, but it is a bilateral procedure then you
assign separate codes for both the left and right side
