Status post below the knee amputation (right) is coded as:
Z89.51
Open wound codes are used for surgical wounds, nontraumatic wounds, and ulcers.
False
An open fracture includes:
compound
missile
puncture
all of the above
missile
puncture
all of the above
The most common causes of spinal cord injury are motor vehicle accidents.
True
A superficial injury is always coded in addition to any more serious injury at the same site.
False
It is appropriate to add codes identifying blood vessel injuries in addition to fractures and dislocations.
True
A common cause of a pathologic fracture in female patients is:
osteoporosis
If a fracture is not specified as open or closed, it is coded as a(n):
closed fracture
Most injuries are diagnosed with the use of
imaging procedures such as x-ray, MRI, CT scan, ultrasound
LOC stands for:
loss of consciousness
The patient (civilian) has chronic posttraumatic stress syndrome following a terrorist attack, subsequent encounter.
F43.12, Y38.9x2S
All of the following are symptoms of fat embolism syndrome EXCEPT ____.
decreased temperature
An open fracture occurs when the bone is broken but the skin remains intact.
false
In ICD-10-CM, if a fracture is not specified, it is coded to nondisplaced.
true
Which of the following is NOT a common site for a laceration?
Stomach
External cause codes identify ____.
the activity at the time of the event
the cause of an injury
the intent or place of occurrence
all of the above (all of the above)
the cause of an injury
the intent or place of occurrence
all of the above (all of the above)
A ____ is a stretch and/or tear of a ligament.
sprain
All of the following are true of external cause codes EXCEPT they capture____.
how to screen patients
In ICD-10-CM, there are more Instructional notes for the coder to also code any associated injuries.
True
When coding injuries, assign separate codes for each injury unless a combination code is provided.
True
Small piece of grass from mowing lawn at a single-family house stuck on right cornea. Grass was removed. Assign injury and procedure codes only.
T15.01xA, 08C8XZZ
Patient was seen with an abrasion with laceration of the left knee, initial encounter. Assign only the injury code.
S81.012A
The patient was admitted for observation after an accident at work. The patient, who does construction work, fell into a pit but was quickly rescued by co-workers. CT scan and x-rays were taken to evaluate for internal injury. No respiratory issues were noted. On the following morning, the patient had no complaints and was discharged to home.
Discharge Diagnosis: Contusion on forehead.
Discharge Diagnosis: Contusion on forehead.
Z04.2, S00.83xA, W17.2xxA, Y92.69, Y99.0
The patient was the driver in an ATV rollover. The patient was intoxicated at the time of the accident and was not wearing a helmet. There was no LOC. CT of the head revealed a small subdural hemorrhage. The patient was observed closely for any change in mental status, and neurology was consulted. There was no need for operative intervention at this time. The patient was stable and was given instructions for follow-up.
S06.5x0A, F10.129, V86.59xA
In ICD-10-CM, complications of a fracture such as malunion or nonunion are reported with seventh character extensions for subsequent care with nonunion or malunion.
True
When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
True
A patient suffered a blowout fracture 1 week ago and is being seen by an orthopedic consultant. Assign only the injury code.
S02.3xxA
A ____ fracture is a common fracture in adults in which the lower end of the radius is fractured and the wrist and hand are displaced backward.
Colles’
A patient is admitted with a parietal bone fracture and fracture of the left fifth rib. Assign only the injury code.
S02.0xxA, S22.32xA
A third-degree burn is defined as:
full-thickness skin loss
MVA stands for:
motor vehicle accident
An adverse effect is:
a side effect or reaction to a drug that has been taken according to instructions
Codes T31 and T32 are used:
when the site of the burn is not specified
When coding different degrees of burns of the same site, assign the code or codes that identify:
the highest degree of the burn
Examples of poisonings include:
the wrong medication taken
the wrong dose of a medication taken
too much of a certain medication taken
all of the above (correct answer)
the wrong dose of a medication taken
too much of a certain medication taken
all of the above (correct answer)
Debridements can be performed:
at the bedside
in the operating room
by physical therapists, wound care nurses, and professionals other than physicians
all of the above (correct answer)
in the operating room
by physical therapists, wound care nurses, and professionals other than physicians
all of the above (correct answer)
A nonhealing burn is coded as an acute burn.
True
A corrosive burn is a thermal burn that is due to a heat source such as fire or a hot appliance.
False
The residual effect is usually sequenced first followed by the appropriate sequela (late effect) code.
True
When the reason for the admission or encounter is to provide treatment for external multiple burns, sequence first the code that reflects the burn of the highest degree.
True
Patient was admitted with second-degree burns of the left hand and first-degree burns of the left forearm. The patient touched a hot steam pipe.
T23.202A, T22.112A, X16.xxxA
All of the following are true of the “rule of nines” EXCEPT ____.
the anterior trunk is 9%
Debridements must always be done in the OR.
False
In a toxic poisoning, the toxic poisoning code (T36-T50) should be sequenced first, followed by the external cause code(s).
True
A patient combined prescription Percodan with beer and became stuporous and drowsy.
T40.2x1A, T51.0x1A, R40.1, R40.0
The patient was admitted with acute renal failure. The patient had been treated by Home Health with IV gentamicin for Pseudomonas pneumonia. The patient was experiencing some edema and decreased urine output. Blood was drawn, and the physician admitted the patient for IV fluids and investigation of the patient’s renal status. Gentamicin was stopped, and another antibiotic was given. The patient’s renal function returned to normal.
Final Diagnosis: Acute renal failure due to gentamicin.
Recent pneumonia.
Final Diagnosis: Acute renal failure due to gentamicin.
Recent pneumonia.
N17.9, T36.5x5A, J15.1
The patient was admitted with hematemesis. The patient has been taking NSAIDs as directed by the physician for arthritis pain. EGD showed that the patient had an acute erosive gastritis, most likely due to NSAIDs, that is the likely cause of the bleeding.
Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs.
Procedure: EGD with gastric biopsy.
Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs.
Procedure: EGD with gastric biopsy.
K29.01, T39.395A, M19.90, 0DB68ZX
A patient has SIRS due to an accidental burn from the flames from a single-family house fire. The patient has full-thickness skin loss burns of the legs (11%) with second-degree burns of the trunk (4%)
T24.302A, T24.301A, T21.20xA, R65.10, T31.11, X00.0xxA, Y92.019
A 2-year-old child was admitted with an accidental electrical burn to the upper lip. The child was at home (single-family) and had bitten on an electrical cord. The mother immediately sought medical attention. The burn was a full-thickness burn. Local wound care was performed. The patient was not having any breathing problems. Further intervention will depend on how the burn heals.
Final Diagnosis: Full-thickness burn to upper lip due to electrical current.
Final Diagnosis: Full-thickness burn to upper lip due to electrical current.
T20.32xA, W86.0xxA, Y92.019
Debridement is one of the most common procedures performed on burn victims.
True
All of the following are to be considered when one is questioning whether a poisoning has occurred EXCEPT whether the ____.
medication was taken 30 minutes after the scheduled time
Patient admitted for a suicide attempt with multiple medications, including Naproxen, Keppra, and acetaminophen mixed with beer. Patient was somnolent on arrival in the ER.
T39.312A, T42.6x2A, T39.1x2A, T51.0x2A, R40.0
Patient was admitted with cocaine-induced chest pain.
T40.5x1A, R07.9, F14.10
Patient was seen in the ER for superficial frostbite, both ears. Patient was exposed to cold weather.
T33.011A, T33.012A, X31.xxxA
Patient is being treated with HBOT for decompression sickness when surfacing while scuba diving in the ocean.
T70.3xxA, W94.21xA, Y92.832, Y93.15, 6A150ZZ
The patient reported to the ER with nausea/vomiting and weakness. The patient is on OxyContin for chronic pain due to unresectable pancreatic cancer. The patient was in extreme pain and decided to double the OxyContin dosage. When this did not relieve the pain, the patient decided to drink a couple of shots of whiskey. The patient got very weak and called 911. The patient was volume depleted and was treated with IVs; his pain medications were adjusted.
Final Diagnosis: Accidental overdose of OxyContin.
Pain due to pancreatic cancer.
Final Diagnosis: Accidental overdose of OxyContin.
Pain due to pancreatic cancer.
T40.2x1A, T51.0x1A, C25.9, G89.3, R53.1, R11.2, E86.9
A patient was admitted because of an intentional overdose of Valium. The patient is in a coma.
T42.4x2A, R40.20
When the patient is admitted for burn injuries and other related conditions such as smoke inhalation, the circumstances of admission govern the selection of the principal or first-listed diagnosis.
True
The patient was brought to the ER by her mother. The patient admits to being beaten by her husband. X-rays showed three fractured ribs on the right and a spiral fracture of the right humerus. The humeral fracture was manipulated and was found to be in alignment on follow-up x-rays. The patient was given pain medications and was discharged to the care of her mother.
Final Diagnosis: Fracture of three ribs and shaft of humerus due to spousal abuse.
Procedure: Closed reduction of fracture right humerus.
Final Diagnosis: Fracture of three ribs and shaft of humerus due to spousal abuse.
Procedure: Closed reduction of fracture right humerus.
T74.11xA, S42.341A, S22.41xA, Y07.01, Y09, 0PSFXZZ
When coding infections due to a device, implant, or graft:
also code the specific infection
A dehiscence is:
an opening of a surgical wound
Iatrogenic means:
a condition is a result of treatment
Complication codes should never be used as principal diagnoses.
False
If in doubt as to whether a condition occurred as the result of a procedure or medical care, the coder should:
Check to verify that the procedure or illness was within the last 28 days
Codes Z94- and T86 are never used together.
True
A complication can be coded only if it is in within 1 year of the original surgery.
False
Medical conditions that develop after a transplant are not coded as transplant complications unless they affect the transplanted organ.
True
If a patient has an illness that affects his or her transplanted kidney, it is:
coded as a transplant complication
A mechanical complication is not:
considered “pain”
Codes for complications may be located in the chapter for specified body sites.
True
Coding complications always implies that poor care has been delivered.
False
Patient is admitted for treatment of primary liver cancer. Patient had a liver transplant 2 years ago. Patient has a past medical history of hypertension and COPD and is a former alcoholic. Patient has been sober for 10 years.
T86.49, C80.2, C22.8, I10, J44.9, F10.21, Y83.0
Patient with a history of a kidney transplant comes to the ER with gastroenteritis. His history is positive for CKD, stage II, and hypertension.
K52.9, I12.9, N18.2, Z94.0
Patient was hospitalized 1 month prior to this admission. During that admit, she was diagnosed with COPD and placed on a ventilator; her sputum was positive for Pseudomonas aeruginosa. She is admitted today with another case of pneumonia.
J18.9, J44.9
Leakage of peritoneal dialysis catheter. Patient is on dialysis for end-stage renal disease. Peritoneal catheter was removed. Patient has a history of hypertension and type II diabetes with associated neuropathy.
T85.631A, I12.0, E11.40, Z99.2, Y84.1, 0WPGX0Z
Patient admitted with an abscess of abdominal surgical wound, initial encounter. Cultures were positive for Streptococcus. The abscess was incised and drained.
T81.4XXA, B95.5, Y84.8, Y83.9, 0H97XZZ
During a posterior lumbar fusion at L4-L5 for spinal stenosis, the surgeon accidentally nicks the dura due to the amount of adhesions present. The fusion was performed via an open posterior procedure on the posterior column using morselized allograft. Patient has a history of asthma for which he takes meds prn.
M48.06, G97.41, J45.909, Y83.8, Y92.234, 0SG0071
The term dehiscence means ____.
opening a surgical wound
If the documentation is unclear whether the diagnosis was the result of a procedure or condition, a physician query should be initiated.
True
Iatrogenic is a term used to signify that a condition is a result of treatment.
True
The patient had a postoperative cerebrovascular accident that was embolic in nature. The patient initially had been admitted for treatment of coronary artery arteriosclerosis with CABG (left internal mammary artery and two saphenous vein grafts were used). Cardiopulmonary bypass was used during the surgery.
I25.10, I97.820, I63.40, 021109W, 02100A9, 5A1221Z
Complications affect only certain body systems.
False
A patient is admitted with a urinary tract infection (UTI) resulting from E. coli. The patient has an indwelling Foley catheter following recent radical prostatectomy for cancer. The coder queries the physician regarding the relationship of the UTI and the Foley, and the physician documents that the UTI is caused by the Foley. The patient is morbidly obese with type II diabetes, controlled with insulin.
T83.51xA, N39.0, B96.20, E66.01, E11.9, Z85.46, Y84.6
Patient with decreased visual acuity due to corneal graft rejection. Admitted for cadaver keratoplasty of the left eye.
T86.840, Y83.0, H54.7, 08R93KZ
A patient had a kidney transplant 2 years ago but developed ESRD again. The patient has been on dialysis for the past year. The patient is now complaining of SOB and edema and is admitted for fluid overload and hemodialysis. Dialysis is performed multiple times during this stay.
E87.70, N18.6, Z94.0, Z99.2, Y83.0, 5A1D60Z
To aspirate means to ____.
breathe in a foreign substance
Codes under subcategory T86 are used ____.
for both complications and rejection of transplanted organs
There is a time limit to coding complications.
false
Patient had an outpatient surgical procedure this morning and was discharged in stable condition. Patient returns because of inability to void. A Foley catheter is inserted.
Diagnosis: Postoperative urinary retention.
Diagnosis: Postoperative urinary retention.
N99.89, R33.9, Y84.8, Y83.9, 0T9B70Z
The only time a coder would not use a code from Chapter 11 is if the physician states that the pregnancy is incidental to the reason for the encounter.
True
For initial confirmation of a pregnancy, a woman’s blood or urine is tested for _______levels.
hCG
When coding a pregnant woman with HIV infection, follow the guidelines for:
pregnancy coding (sequence pregnancy code as principal)
For a normal delivery, the diagnosis codes for the mother are:
O80, Z37.0
Gestational diabetes:
occurs in a patient who was not diabetic before pregnancy
All patients who deliver require at least _____diagnosis code(s).
Two
Adverse effects occurring in a pregnant patient are assigned a principal diagnosis code from category T36-T50
False
When a fertilized egg is implanted outside of the uterine cavity, it is called a(n):
ectopic pregnancy
An episiotomy is considered a complication of delivery, and a O80 diagnosis code cannot be coded on the mother’s chart.
False
Another term for “before delivery” is:
antepartum
The patient is admitted in labor at term. After lab work is completed, it is noted that the patient has a UTI and appears to be preeclamptic. The patient goes on to vaginally deliver a healthy baby boy.
O23.43, O14.93, Z3A.38, Z37.0, 10E0XZZ
The patient is admitted to the hospital in preterm labor. She is 27 weeks pregnant. Terbutaline is administered, and the patient remains on bed rest. In the third week of bed rest, her water breaks, and she is taken to the delivery room. She vaginally delivers a baby girl.
O60.13×0, Z37.0, Z3A.27, 10E0XZZ
If code O80 is assigned, other codes in the O00-O9A range should also be assigned, if applicable
False
A pregnant woman at 39 weeks presents to the hospital for delivery of known quadruplets. She is taken to the operating room for a cesarean section (LTCS). As the babies are delivered, it is discovered that one has died in utero.
O30.203, O36.4xx0, Z3A.39, Z37.62, 1ODOOZ1
The patient is 9 weeks pregnant. She is admitted for an elective abortion. The physician performs a vacuum D&C to terminate the pregnancy.
Z33.2, 10A07Z6
Ectopic pregnancies occur in 1 in ____ pregnancies.
50
A woman is admitted at 22 weeks for insertion of a laminaria for termination of pregnancy. She delivers a liveborn fetus.
O60.12×0, Z3A.22, Z37.0, 10E0XZZ, 10A07ZW
A patient at 12 weeks is admitted for a therapeutic abortion due to a chromosome abnormality in the fetus. A D&C is performed, resulting in a complete abortion. Her postoperative course is complicated by shock due to acute blood loss secondary to hemorrhage with resulting anemia.
Z33.2, O04.6, O04.81, D62, O35.1xx0, Z3A.12, 10A07ZZ
In ICD-10-CM the final character indicates the episode of care.
False
When a vaginal delivery occurs, the principal diagnosis should correspond to the main circumstance or complication of the delivery.
True
Which of the following codes are correct when a normal pregnancy is coded?
O80 Normal delivery
Z37.0 Single liveborn
10E0XZZ Manually assisted delivery
All of the above
Z37.0 Single liveborn
10E0XZZ Manually assisted delivery
All of the above
The patient is admitted in labor at 38 weeks. She labors for 24 hours when it is noted that the baby is in fetal distress. The patient is taken to the OR for an emergency C-section (LTCS). She delivers a healthy baby.
O77.9, Z3A.38, Z37.0, 10D00Z1
What drug could be given to inhibit labor?
Terbutaline
What drug could be given to induce labor?
Pitocin
A patient is an elderly multigravida at 39 weeks who has come in for trial labor following previous cesarean. The patient has been taking iron for iron deficiency anemia and is obese. Labor progresses, but fetal decelerations require repeat LTCS. On day 2, the patient develops a fever and is treated with antibiotics for suspected endometritis.
O76, Z37.0, O34.21, O99.02, D50.9, O99.214, O86.12, O09.523, E66.9, Z3A.39, 10D00ZO
In ICD-10-CM there are 7th characters to specify the fetus affected by the obstetric condition.
True
When a cesarean delivery is performed, the principal diagnosis should correspond to the reason the cesarean delivery was performed unless the reason for admission was unrelated to the condition resulting in the cesarean delivery.
True
Coding a normal pregnancy requires only three diagnostic codes and one or more procedure codes
True
A gravid patient at 11 weeks presents for a routine prenatal visit. This patient had preeclampsia in her previous pregnancy and the physician documents high-risk pregnancy. She has blood work done on this visit and is found to be anemic. The physician prescribes an iron supplement.
O09.891, O99.011, D64.9, Z3A.11
In ICD-10-CM the diagnosis used for an elective abortion comes from the pregnancy chapter.
False
ICD-10-CM does NOT have separate categories for high-risk pregnant individuals.
False
In ICD-10-CM there are code extensions to specify the fetus affected by the obstetric condition.
True
Prematurity is based on recorded birth weight and gestational age and documentation of prematurity.
True
Congenital conditions are always present, well defined, and diagnosed at birth.
False
In most cases, pregnancies with chromosomal anomalies end with a natural miscarriage.
True
Marfan syndrome:
affects the connective tissue
patients have skeletal defects
patients have cardiovascular problems
all of the above (Correct answer)
patients have skeletal defects
patients have cardiovascular problems
all of the above (Correct answer)
Treatment for jaundice includes:
phototherapy
A congenital anomaly is a condition that is:
present at birth
Newborns have their own set of MS-DRGs.
True
Down syndrome is also known as:
trisomy 21
Apgar score factors are:
heart, breathing, activity and muscle tone, grimace, appearance
Meconium is:
fecal matter in an infant’s intestine before birth
none of the above
none of the above
Tetralogy of Fallot is:
a congenital heart defect
All newborn charts must contain the following code:
Z38.-
Prematurity can be coded based on the gestational weeks.
False
Spina bifida is a curable congenital anomaly because there is a way to repair the damaged nerve tissue.
False
TNN (transitory tachypnea of newborn) means the infant ____.
retains lung fluid
Bronchopulmonary dysplasia (BPD) is a chronic lung disease that ____.
1. is present immediately at birth
2. develops in the first 4 weeks of life
3. develops in the first year of life
4. happens only in full-term infants
5. is most likely to occur in premature infants
6. is most likely to occur in infants that weigh less than 1500 grams
1. is present immediately at birth
2. develops in the first 4 weeks of life
3. develops in the first year of life
4. happens only in full-term infants
5. is most likely to occur in premature infants
6. is most likely to occur in infants that weigh less than 1500 grams
2, 5, and 6 only
When locating infections of the newborn, it is best to look under the main term for the infection and then to look for a subterm of newborn, fetal, or congenital.
True
Newborn is delivered vaginally. The baby was premature at 34 weeks and weighed 1842 grams. Meconium staining was noted at delivery.
Z38.00, P07.17, P07.37, P96.83
If the baby scores a ____ or higher on the Apgar test 1 minute after birth, he or she is considered to be healthy.
7
The child was admitted for repair of cleft lip and cleft soft and hard palate. He is an ex-33-week preemie. A repair of both the hard and soft palate and lip is performed by external approach.
Q37.5, P07.36, 0CQ0XZZ, 0CQ2XZZ
An infant is born via vaginal delivery with intrauterine growth retardation. The baby is born at 33 weeks and weighs 1800 grams. Meconium aspiration is noted at delivery. Jaundice is treated with phototherapy.
Z38.00, P07.17, P07.32, P24.00, P59.0, 6A600ZZ
Shouldn’t code be P07.37
The A in the Apgar test given to babies stands for ____.
appearance
There is abnormal fetal heart rate or rhythm during labor, and infant is therefore delivered by C-section. Mother was instructed on discharge to put the baby in front of the window in the sun to alleviate the mild jaundice. In addition, a lactation consult was performed during this stay as the baby was having difficulty breast-feeding.
Z38.01, P03.811, P92.5, P59.9
There is no cure for Down syndrome, but the risk increases the older the mother is during her pregnancy.
True
Child is seen in pediatrician’s office. She has a diagnosis of Down syndrome with ADD, sleep apnea, and mild mental retardation. Her medications are reviewed and a suggestion is made to have a sleep study.
Q90.9, F70.0, G47.30, F90.0
Which of the following is NOT a congenital condition?
Jackson’s syndrome
Which of the following makes a condition clinically significant?
The condition requires a clinical evaluation.
The condition requires therapeutic treatment.
The condition requires an extended hospital stay.
**All of the above are correct.
The condition requires therapeutic treatment.
The condition requires an extended hospital stay.
**All of the above are correct.
Cleft lip occurs in approximately 1 in every 2000 babies.
False
Newborn is delivered vaginally and is ruled in for group B strep sepsis.
Z38.00, P36.0
An infant is born by cesarean section. On examination, the infant is noted to have neonatal teeth and strawberry nevus on the left leg.
Z38.01, K00.6, Q82.5
Spinal fusion is:
the creation of a solid bone bridge between two or more adjacent vertebrae
Scoliosis is
a lateral or sideways curvature of the spine
A pathologic fracture is a break in a bone that occurs because of:
underlying disorders that weaken the bone
ICD-10-CM identifies the following cause(s) for pathologic fractures:
neoplastic disease
Percutaneous vertebroplasty is a technique used to treat pain caused by:
compression fracture of the vertebrae
Malunion and nonunion are synonymous terms.
False
A family history of arthritis:
is coded as Z82.61
The etiology of polymyalgia rheumatica is:
unknown
Systemic lupus erythematosus (SLE) is a:
chronic, inflammatory autoimmune disease that can damage connective tissue
Primary osteoarthritis is related to:
the aging process
What drug could be given to treat rheumatoid arthritis?
Celebrex
The patient was admitted to the hospital because of severe left hip pain that is often worse during the night. X-rays of the hip were taken in the ER. A preliminary report showed that the patient possibly had Paget’s disease of the left femur, which was responsible for the patient’s pain. Alkaline phosphatase was elevated, and a bone scan was done to determine the extent of the disease.
Final Diagnoses: Severe hip pain due to Paget’s disease.
Final Diagnoses: Severe hip pain due to Paget’s disease.
M88.852
An 83-year-old woman with severe back pain is admitted. CT shows osteoporosis and possible compression fracture of the lumbar spine. The patient is seen by interventional radiology, and a percutaneous vertebroplasty and reduction of fracture is performed.
Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.
Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.
M80.08xA, 0QU03JZ, 0QS03ZZ
A pediatric patient was admitted with a pathologic fracture of the proximal right humerus. Radiographic evidence suggests that the fracture was caused by a unicameral bone cyst. An orthopedic consult was obtained to see whether this should be treated surgically. It was decided to treat conservatively and monitor healing with serial x-rays.
Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.
Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.
M84.621A, M85.421
____ is an exaggerated inward curvature of the spine that may be caused by increased abdominal girth due to obesity, pregnancy, or abdominal tumors.
Lordosis
Osteomyelitis is an infection of the bone that often starts in another part of the body and is spread by the blood.
True
What drug could be given to treat osteoporosis?
Fosamax
ICD-10-CM has a combination code for osteoporosis with pathologic fracture.
True
The patient was admitted from the ER for chest pain to rule out MI. The patient also had some difficulty breathing and pain when taking a deep breath. The patient does have a family history of ischemic heart disease and is positive for the following cardiac risk factors: male, older than age 65, hypertension, smoker, and overweight. After evaluation and monitoring, an MI was ruled out. Cardiology thought the most likely cause for his chest pain was costochondritis.
Final Diagnoses: Chest pain due to costochondritis.
Hypertension.
Smoker, current nicotine dependence (cigarettes).
Overweight.
Family history of ischemic heart disease.
Final Diagnoses: Chest pain due to costochondritis.
Hypertension.
Smoker, current nicotine dependence (cigarettes).
Overweight.
Family history of ischemic heart disease.
M94.0, I10, F17.210, E66.3, Z82.49
Pathologic fracture of distal left femur due to osteosarcoma of femur.
M84.552A, C40.22
____ is when one vertebra slips on another.
Spondylolisthesis
Subacute osteomyelitis of sacrum with decubitus sacral ulcer, stage 3. Staphylococcus aureus is the causative organism.
M46.28, L89.153, B95.61
A patient is admitted for a total hip replacement with a metal-on-polyethylene prosthesis because of primary osteoarthritis of the right hip. Patient has had a previous left hip replacement.
M16.11, Z96.642, 0SR902Z
____ is one of the most common diseases affecting the muscles; it is characterized by widespread muscle pain associated with chronic fatigue.
Fibromyalgia
ICD-10-CM has different codes to identify laterality for many musculoskeletal conditions.
True
Which of the following make(s) up the musculoskeletal system?
Tendons
Cartilage
All of the above (correct)
Ligaments
Bones
Cartilage
All of the above (correct)
Ligaments
Bones
Patient with a family history of rheumatoid arthritis is being screened for rheumatoid arthritis.
Z13.828, Z82.61
A patient is admitted to rule out lupus nephritis. The patient was diagnosed with lupus 5 years ago. A percutaneous left kidney biopsy is performed, and lupus nephritis is confirmed.
M32.14, 0TB13ZX
____ are the connective tissues that attach muscle to bones.
Tendons
ICD-10-CM uses the sixth character extension when coding pathologic fractures.
False
Breast codes are classified only for female patients.
False
Acute renal failure cannot be present with chronic renal failure.
False
Extracorporeal shock wave lithotripsy is used to treat:
urinary tract calculi
ICD-10-CM presumes a cause-and-effect relationship between renal failure and diabetes.
false
Cystitis is a lower urinary tract infection that affects the:
none of these
ICD-10-CM presumes a cause-and-effect relationship between renal failure and hypertension.
True
The term chronic renal failure has been changed to the more precise term of:
Chronic kidney disease
According to ICD-10-CM, the term urosepsis classifies to:
see condition
Endometriosis can be found in the:
all of the above
Different types of incontinence include:
stress
urge
overflow
all of the above
urge
overflow
all of the above
A patient is admitted to the hospital for a percutaneous left kidney biopsy, which confirms Berger’s disease.
Discharge Diagnosis: Berger’s disease.
Discharge Diagnosis: Berger’s disease.
N02.9, 0TB13ZX
Patient was seen in the ER with left flank pain. Discharge diagnosis is stone, left kidney.
N20.0
ICD-10-CM classifies chronic kidney disease based on severity.
True
A patient is admitted to the hospital with fever and chills, flank pain, and burning on urination with increased frequency. CT scan shows stranding around the right kidney consistent with pyelonephritis. Urine culture is positive for Proteus mirabilis. The patient has a long history of obstructive uropathy due to BPH.
Final Diagnosis: Fever due to acute pyelonephritis due to Proteus mirabilis.
Obstructive uropathy due to benign prostatic hypertrophy.
Final Diagnosis: Fever due to acute pyelonephritis due to Proteus mirabilis.
Obstructive uropathy due to benign prostatic hypertrophy.
N10, B96.4, N40.1, N13.8
The main parts of the male genital or reproductive tract include the testes, epididymis, vas deferens, seminal vesicles, prostate, and penis.
True
In ICD-10-CM there is a code to identify postprocedural renal failure.
True
Which of the following is NOT a common genitourinary condition?
Diabetes
A patient is admitted to the hospital for fluid overload due to noncompliance with attending renal dialysis sessions. Patient has stage 5 CKD. Multiple sessions of hemodialysis are performed.
E87.70, N18.6, Z91.15, 5A1D60Z
A patient is admitted to the hospital with ARF due to dehydration. The patient is treated with IV fluids.
N17.9, E86.0
Which of the following can be detected by a urinalysis test
Kidney stones
Diabetes
Cystitis
All of the above (correct answer)
Diabetes
Cystitis
All of the above (correct answer)
Which of the following is/are Z code(s) that may be used with diseases of the genitourinary system?
Z16.21 Resistance to vancomycin
Z87.448 Personal history of other diseases of urinary system
Z93.59 Artificial opening status, other cystostomy
All of the above (correct answer)
Z87.448 Personal history of other diseases of urinary system
Z93.59 Artificial opening status, other cystostomy
All of the above (correct answer)
A patient is admitted with acute pyelonephritis. Blood cultures are negative, but urine cultures are positive for E. coli. The patient is treated with IV fluids and antibiotics.
Discharge Diagnosis: Acute pyelonephritis due to E. coli.
Discharge Diagnosis: Acute pyelonephritis due to E. coli.
N10, B96.20
The patient was admitted for treatment of BPH with urinary retention and a history of frequent urinary tract infections. The patient’s PSA was normal. A TURP was performed. The patient recovered uneventfully with only minimal hematuria, which had resolved by the time of discharge.
Final Diagnosis: Benign prostatic hypertrophy.
Procedure: Transurethral resection of prostate.
Final Diagnosis: Benign prostatic hypertrophy.
Procedure: Transurethral resection of prostate.
N40.1, R33.8, Z87.440, 0VB08ZZ
Sometimes to assign the correct codes, it is necessary to question the physician to be sure the correct meaning was interpreted and the correct code was assigned, like the term urosepsis.
True
A patient is admitted to the hospital for further evaluation of stage 4 kidney disease. The patient is known to have been born with only one kidney, and on routine checkup it was found that the patient’s kidney function was markedly abnormal. One year ago, the patient’s laboratory tests were relatively normal. The patient’s blood pressure was monitored, and it was decided that medications would be necessary to treat the patient’s hypertension. The patient was advised about fluid intake and restriction and dietary considerations regarding protein and potassium. Referral was made to a nephrologist because the CKD appears to be progressing rapidly, and arrangements may be necessary for dialysis.
Final Diagnosis: Chronic progressive renal failure, stage 4. Hypertension
Final Diagnosis: Chronic progressive renal failure, stage 4. Hypertension
I12.9, N18.4, Q60.0
When the site is known, urinary tract infections are assigned codes based on the site of the infection.
true
If causative bacteria are documented by the physician, this code should NEVER be coded in addition to the urinary tract infection.
false
A patient was admitted for investigation of microscopic hematuria. The patient plans to donate a kidney to a family member, and any renal disease must be ruled out. The patient had a percutaneous needle biopsy of the left kidney. The patient has a past medical history of GERD, which is treated with Nexium, and had a pneumothorax caused by an MVA several years ago.
Final Diagnosis: Kidney donor with microscopic hematuria.
Procedure: Diagnostic kidney biopsy.
Final Diagnosis: Kidney donor with microscopic hematuria.
Procedure: Diagnostic kidney biopsy.
R31.2, K21.9, 0TB13ZX
Patient was admitted to the hospital with acute renal failure due to dehydration. Patient will have to be rehydrated slowly due to CHF. Patient also has diabetic nephropathy.
N17.9, E86.0, I50.9, E11.21
____ is a lower urinary tract infection that affects the bladder.
Cystitis
Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.
dilation
ICD-10-CM assumes a rheumatic etiology when both the mitral and the aortic valves are diseased.
True
In ICD-10-CM, when coding coronary artery disease and angina:
one combination code is used
A cerebrovascular accident is commonly known as:
stroke
An acute myocardial infarction is commonly known as:
heart attack
A leaking valve is another name for:
regurgitation
incompetence
insufficiency
all of the above (correct answer)
incompetence
insufficiency
all of the above (correct answer)
Hypertensive heart disease assumes a cause-and-effect relationship in ICD-10-CM coding.
False
The lymph system fights infection by:
filtering out viruses and bacteria
The valves in the heart include:
tricuspid, mitral, aortic, pulmonary
A diagnostic cardiac catheterization is used to determine the severity of:
coronary artery disease
coronary artery disease
epicardium, myocardium, endocardium
A patient is admitted with chest pain and is ruled in for an NSTEMI. The patient has a history of a CABG and PTCA with stent placement. Patient is taking medications for hypertension, CAD, and CHF.
I21.4, I10, I25.10, I50.9, Z95.1, Z95.5
Patient comes to the hospital with chest pain. A diagnostic left heart cath is performed, and no coronary artery disease is observed. The cardiologist documents the diagnosis as noncardiac chest pain.
R07.89, 4A023N7
Patient is admitted through the ER, presenting with acute chest pain. The patient has a history of COPD and pneumonia as well as type II DM with diabetic neuropathy. He has a history of hypertension and gout for which he takes meds. He is currently smoking about one pack per day. After study it is determined that patient has had an acute anterolateral wall infarct. He is taken to the EP lab for a PTCA with the insertion of a drug eluting stent of the LAD.
I21.09, I10, F17.210, M10.9, J44.9, E11.40, 027034Z
Deep vein thrombosis (DVT) is a blood clot that forms deep in a vein, usually in the leg or hip.
True
Molly has a blood pressure of 150/100. She would be classified as having ____ by her clinician.
hypertension
Insertion of pacemakers most often requires five codes.
False, two codes
Patient comes to the hospital for repair of an abdominal aortic aneurysm. The repair is performed by percutaneous endoscopic approach.
I71.4, 04V04DZ
The time limit for assigning the acute MI in ICD-10-CM is 28 days.
True
A patient is admitted with facial droop, left-sided hemiparesis, and nystagmus. Testing reveals occlusion of the left carotid artery with cerebral infarct. The patient has uncontrolled hypertension and atrial fibrillation, which is treated with Coumadin. Before discharge, the patient’s nystagmus and facial droop have resolved. The patient is discharged to rehab for continued therapy for left-sided hemiparesis.
I63.232, I69.354, H55.00, I69.392, I10, I48.91, Z79.01
Tachycardia is an abnormally high heart rate of more than 100 beats per minute.
True
The patient was admitted with left-sided hemiparesis due to a cerebrovascular accident. The patient has a history of previous CVA with residual facial droop.
I63.9, G81.94, I69.392
All of the following are tests performed to determine whether a myocardial infarction has occurred EXCEPT ____.
urinalysis
Patient is admitted with syncope. After tests are performed, it is determined that the patient has bradycardia due to second degree AV block.
I44.1, R00.1
Patient is admitted through the ER with atrial fibrillation and a history of COPD. She is taken to the EPS lab for EPS testing, mapping, and radiofrequency ablation of the left atrium.
I48.91, J44.9, 02573ZZ, 02K83ZZ, 4A023FZ
Patient is admitted with chest pain and rules in for an anterolateral MI. There is a family history of CAD.
I21.09, Z82.49
The two main types of heart failure are systolic and diastolic.
True
Patient comes into the ER after fainting at work. The physician determines that the fainting was caused by elevated blood pressure resulting from extreme stress.
R03.0, F43.0
Patient was admitted for treatment of gangrenous cellulitis of left lower leg
I96
Patient was admitted to have a drug-eluting stent inserted into the LAD for coronary atherosclerosis. Procedure was performed percutaneously.
I25.10, 027034Z
Patient was admitted with acute on chronic systolic and diastolic congestive heart failure.
I25.10, 027034Z
Chronic asthmatic bronchitis and chronic bronchitis with emphysema can be classified as chronic obstructive pulmonary disease (COPD).
True
Blood that accumulates in the pleural space is called:
hemothorax
Pleural effusion is:
fluid that accumulates in the pleural space
A personal history of malignant neoplasm of the lung is coded as:
Z85.118
It is possible to have an acute infection superimposed on a chronic infection/inflammation.
True
Bronchitis can be ______________in origin.
viral or bacterial
Respiratory failure is always coded as the principal diagnosis.
False
Common treatments for sinusitis include:
decongestants, antibiotics
It is possible to have more than one bacterium responsible for pneumonia.
True
Mechanical ventilation codes are based on hours.
True
A patient is admitted with hypoxemia and acute respiratory failure. The patient has COPD and is being treated for an acute exacerbation. The patient is intubated in the ER and is transferred to ICU and maintained on mechanical ventilation for 24 hours. The patient has a history of chronic diastolic congestive heart failure.
J96.01, J44.1, I50.32, 5A1945Z
A diagnostic endoscopic procedure in which a tiny camera on the end of the endoscope is inserted through the nose or mouth into the lungs is called a ____.
bronchoscopy
A pneumothorax that occurs as a result of a procedure is a(n) ____ pneumothorax.
iatrogenic
Which of the following is NOT categorized with high-risk potential for contracting pneumonia?
Someone who is in his or her early twenties
Patient is admitted with acute on chronic respiratory failure due to emphysema. Patient is dependent on oxygen, and has had numerous admissions for pneumonia. Patient is treated with continuous BIPAP for 48 hours and is a DNR/DNI. No infection is identified, and deterioration in respiratory status is thought to be a progression of his emphysema. Patient is discharged to at-home hospice care.
Final Diagnoses: End-stage emphysema.
Chronic respiratory failure with hypoxia.
Procedure: BIPAP.
Final Diagnoses: End-stage emphysema.
Chronic respiratory failure with hypoxia.
Procedure: BIPAP.
J96.21, J43.9, Z99.81, Z87.01, Z66, 5A09457
Patient arrived at the ER complaining of shortness of breath. Patient was diagnosed and treated for exercise-induced bronchospasm.
J45.990
____ is a lower respiratory tract or bronchial tree infection that is characterized by cough, sputum production, and wheezing.
Bronchitis
When pleural effusion results from trauma or disease and blood is accumulating in the pleural space, the condition is called ____.
hemothorax
A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis due to previous cerebral infarction. Sputum cultures reveal Pseudomonas.
Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.
Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.
J69.0, J15.1 I69.391, R13.10, I69.359
Which of the following is NOT an example of pneumoconiosis (lung disease due to the chronic inhalation of inorganic dust)?
Cyanosis
Patient was admitted with flu-like symptoms. The final diagnosis on the discharge summary is possible novel influenza A.
J11.89
Asthmatic bronchitis refers to an underlying asthmatic problem in patients in whom asthma has become so persistent that clinically significant chronic airflow obstruction is present despite antiasthmatic therapy.
True
A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis of right dominant side due to previous CVA. Sputum cultures reveal Pseudomonas. Patient went into acute respiratory failure after admission.
Discharge diagnosis: Pseudomonas pneumonia.
Discharge diagnosis: Pseudomonas pneumonia.
J15.1, J96.00, I69.391, R13.10, I69.351
Patient is admitted with shortness of breath and fever that has been present for 2 to 3 weeks and has gotten progressively worse. CT scan showed evidence of bronchiolitis obliterans organizing pneumonia (BOOP). Patient was started on prednisone and discharged when symptoms had resolved.
Final Diagnoses: BOOP.
Final Diagnoses: BOOP.
J84.89
A patient is admitted for suspected H1N1 influenza.
J11.1
Patient was admitted to the hospital in acute respiratory failure due to congestive heart failure. The patient was intubated and placed on mechanical ventilation for 2 days. The patient responded well to IV diuretics.
J96.00, I50.9, 5A1945Z
It is inappropriate for coders to assume a causal organism on the basis of laboratory or radiology findings alone.
True
Patient is admitted to the hospital and found to have suffered a NSTEMI. After admission the patient went into acute respiratory failure.
I21.4, J96.00
Infant was seen in the ER with diagnosis of acute bronchiolitis due to RSV. The infant has been exposed to tobacco smoke.
J21.0, Z77.22
Which of the following is a symptom of pneumonia?
Rapid breathing
Fever
Cough
All of the above (correct answer)
Chest pain
Fever
Cough
All of the above (correct answer)
Chest pain
Lysis of adhesions should always be coded if mentioned in the operative report.
False
Alcoholism can cause both hepatitis and cirrhosis
True
If the appendix ruptures, ___________develops.
peritonitis
A peptic ulcer can occur in the:
stomach
esophagus
duodenum, jejunum, ileum
all of the above (correct)
esophagus
duodenum, jejunum, ileum
all of the above (correct)
Mechanical obstruction of the intestine may be caused by:
neoplasm
adhesions
herniation
all of the above (correct)
adhesions
herniation
all of the above (correct)
Hematemesis is defined as:
vomiting of blood
Cholelithiasis is a condition of stones in the:
gallbladder
If a physician documents both diverticulosis and diverticulitis:
code diverticulitis only
A cholecystectomy can be performed by an open approach or laparoscopically.
True
An inguinal hernia can be unilateral or bilateral.
True
The patient has a diagnosis of upper esophageal stricture and a history of COPD. An EGD with dilatation of the stricture is performed.
K22.2, J44.9, 0D718ZZ
The squeezing or movement of food toward the stomach and down the digestive tract is called ____.
peristalsis
A patient is admitted for chemotherapy for pancreatic cancer and develops ulcerative mucositis of the mouth due to gemcitabine.
Z51.11, C25.9, K12.31, T45.1X5, 3E03305
____ is the abnormal condition of stones in the gallbladder.
Cholelithiasis
Patient with known alcoholic cirrhosis of the liver is admitted with ascites and acute bacterial peritonitis due to Staphylococcus aureus. Patient is a recovering alcoholic who has been in remission for 2 years.
K65.0, K70.31, F10.21, B95.61
The ER physician documents that the patient is being admitted for hematemesis. The patient has an Hct of 24.3. A transfusion of PRBC is administered, and the patient is taken to the OR for an EGD. The EGD reveals that the patient has an acute perforated duodenal ulcer that is causing the bleed. The ulcer is cauterized. The patient is treated with IV antibiotics, omeprazole, and NG tube. The discharge summary lists an additional diagnosis of acute blood loss anemia.
K26.2, D62, 0D598ZZ, 30233N1
Code ____ is coded for personal history of malignant neoplasm of the GI tract, unspecified.
Z85.00
Which Z code is associated with family history of digestive disorders
Z83.79
Patient presents to the ER with severe abdominal pain. The patient has a history of Crohn’s disease. She had asthma as a child and currently appears dehydrated. After study it is determined that the patient has an abscess of the large intestine. Antibiotics are administered, as well as IV fluids with potassium to treat the dehydration and hypokalemia.
K50.914, E87.6, E86.0
Patient with malignant neoplasm of the descending colon is admitted for left hemicolectomy and temporary descending colostomy.
C18.6, 0DTG0ZZ, 0D1M0Z4
All of the following are functions of the liver EXCEPT that it ____.
stores and releases bile
An indirect hernia occurs when the protrusion is through the inguinal ring into the inguinal canal; this is different from a direct hernia.
True
Symptoms of gastric ulcers may include pain when eating, vomiting, and tarry bowel movements.
True
Ostomies are surgically created openings into the body. Enterostomies and colostomies are created to discharge waste products from the body.
Both statements are true.
____ means bright red in the stool.
Hematochezia
A patient presents with melena, weakness, and fatigue. A colonoscopy with biopsy of the rectum and colon is performed and reveals multiple diverticula and internal hemorrhoids. The path shows possible inflammatory bowel disease. No source of bleeding is identified. Discharge Diagnosis: GI bleed; chronic blood loss; anemia.
K92.1, D50.0, K57.30, K64.8, 0DBE8ZX, 0DBP8ZX
A patient is admitted with Crohn’s disease of the large bowel. A right hemicolectomy is performed with temporary ascending colostomy. The patient is malnourished and was dehydrated on admission. Postoperatively, the patient’s potassium levels are monitored, and the hypokalemia is treated with K-Dur.
K50.10, E46, E86.0, E87.6, 0DTF0ZZ, 0D1K024
What drug could be given to treat GERD?
Prilosec
The mouth is where digestion begins.
True
Patient comes to the ER with severe abdominal pain and a long history of alcoholism. Physician documents that patient is currently drinking a fifth of liquor a day. Patient is admitted to the hospital with a diagnosis of acute pancreatitis secondary to alcohol use.
K85.9, F10.10
Hives and _____________are synonymous terms.
urticaria
Decubitus ulcers can progress to ____________if not treated.
osteomyelitis
When cellulitis is associated with a skin ulcer, code:
cellulitis and the skin ulcer
STSG stands for:
split-thickness skin graft
Cellulitis associated with an open wound requires two codes with cellulitis always sequenced as principal.
False
An autograft is a graft from:
one area of the body to another in the same individual
Decubitus ulcers are coded the same as all other ulcers
False
Scrubbing or washing devitalized tissue is known as:
nonexcisional debridement
Incision and drainage is coded the same as a debridement.
False
Cellulitis is typically treated with
antibiotics
Patient has a pressure ulcer of the left ankle on admission, which is documented as a stage I and progresses to a stage III during the course of the stay. The patient is a paraplegic.
L89.523, G82.20
In ICD-10-CM decubitus ulcers use a combination code for location and stage.
True
Skin grafts can be only full-thickness skin grafts.
False
Which layer of the skin is composed of fibrous connective tissue?
Middle Layer
A(n) ____ is a skin graft from one person to another.
allograft
Patient stepped on a piece of glass and injured his foot 2 days ago. He is now being admitted to the hospital for treatment of cellulitis in the left leg. He has a past history of depression with anxiety for which he takes medicine. He is currently on antibiotics for acute bronchitis.
L03.116, S91.312A, F41.8, J20.9, W25.xxxA
Pulse lavage debridement is performed by wound care nurse on a patient with a stage 3 decubitus ulcer of the right ankle. The patient is taking medications for diabetes and for high cholesterol.
L89.513, E11.9, E78.0, 0HDKXZZ
The code for the stage of a pressure ulcer should be used as the principal diagnosis.
False
A nursing home patient is admitted with an enlarging stage 3 sacral decubitus ulcer for wound care. The patient had a previous CVA with right hemiplegia and aphasia and is on medications for atrial fibrillation and Alzheimer’s dementia.
L89.153, I69.351, I69.320, I48.91, G30.9, F02.80
The functions of the integumentary system include all of the following EXCEPT ____.
vitamin A synthesis
A(n) ____ is a skin graft to an individual from another species, such as a pig.
xenograft
Pressure ulcers require two codes.
True
Clusters of boils are known as a ____.
carbuncle
A patient has a chronic ulcer of the right great toe with skin breakdown only and is admitted for excisional debridement of the skin. The patient has a medical history significant for COPD, asthma, and CAD.
L97.511, J44.9, I25.10, 0HBMXZZ
Patient was admitted because of the development of blistering and erosion of skin and mucous membranes. About 5 days ago, the patient had fever, sore throat, and headache and was thought to have influenza. The patient was diagnosed with Stevens-Johnson syndrome.
L51.1, Z86.19
On the discharge summary, the provider documents the following discharge diagnoses: exacerbation of COPD, hypertension, hyperlipidemia, and a healing sacral decubitus.
J44.1, I10, E78.5, L89.159
Another name for a pressure ulcer is a decubitus ulcer.
True
A patient comes to the ER with a crusty, itchy rash. The diagnosis is impetigo of the legs with cellulitis. The patient is admitted to treat the cellulitis.
L03.115, L03.116, L01.00
A patient is admitted from the nursing home with suspected aspiration pneumonia. The attending physician documents that the patient has pressure ulcers on both buttocks. The left side has a stage II ulcer and the right side has a stage I ulcer.
J69.0, L89.322, L89.311
What are the two most common bacteria associated with skin infections?
1. Streptococcus pyogenes
2. Escherichia coli
3. Staphylococcus aureus
4. Treponema pallidum
5. Pseudomonas aeruginosa
1. Streptococcus pyogenes
2. Escherichia coli
3. Staphylococcus aureus
4. Treponema pallidum
5. Pseudomonas aeruginosa
1 and 3
An infant is admitted for placement of a ventriculoperitoneal shunt for hydrocephalus. The patient has lumbar spina bifida.
Q05.2, 00160J6
A patient with known metastatic cancer to the ribs is admitted for pain control. The patient has a history of lung cancer, which was surgically excised. The patient is administered Fentanyl
G89.3, C79.51, Z85.118
A patient is admitted with an acute change in mental status. Patient has a history of CHF, DMII, and prostate cancer. Patient had a prostatectomy 2 years PTA. Upon completion of the lab work, the physician documents metabolic encephalopathy due to urinary tract infection.
G93.41, N39.0, I50.9, E11.9, Z85.46
A patient was admitted for acute pain control after falling off a ladder and suffering two broken ribs on the right side. The patient was admitted for pain control.
G89.11, S22.41xA, W11.xxxA
Patient is admitted for a spinal fusion at L2-L3. For many years, the patient has suffered from chronic back pain secondary to a herniated disc at L2-L3, which was removed during the fusion. The physician performed an XLIF procedure with the insertion of an interbody fusion device. This procedure was performed percutaneously via an anterior approach to the anterior column.
M51.26, 0SG03A0, 0SB23ZZ
Patient came to the ER after falling off her horse at the county fair rodeo. X-rays reveal two fractured ribs on the left. Patient is admitted for acute pain control.
G89.11, S22.42xA, V80.010A, Y92.39, Y93.52
A patient is admitted for pain control. The patient has metastatic prostate cancer to the vertebrae and liver. The patient is started on a PCA pump, and pain is more manageable.
G89.3, C61, C78.7, C79.51
A disorder of the brain that causes a progressive decline in mental and physical function is called
Alzheimer’s disease
In ICD-10-CM there are three chapters for the nervous system and sense organs.
True
Patient is admitted for a senile cataract in the right eye to be removed by phacoemulsification with IOL replacement via percutaneous approach.
H25.9, 08RJ3JZ, 08DJ3ZZ
All of the following are symptoms of meningitis EXCEPT
sensitivity to darkness
headache
vomiting
headache
vomiting
A patient with trigeminal neuralgia and a history of migraine headaches is admitted for an open rhizotomy. A day after the procedure, the patient develops a severe headache diagnosed as a nonintractable migraine.
G50.0, G43.909, 008K0ZZ
Which of the following is the most common diagnostic test for epilepsy?
EEG
A patient with intractable epilepsy presents for open implantation of a single array neurostimulator pulse generator with leads. The generator was placed in the chest and the leads were placed in the neck attached to the vagus nerve.
G40.919, 0JH60BZ, 00HE0MZ
What drug could be given to treat epilepsy?
Dilantin
Patient comes to the ER with high fever and headache. Meningitis is suspected. A lumbar puncture is performed and reveals bacterial meningitis.
G00.9, 009U3ZX
What drug could be given to treat Alzheimer’s?
Aricept
Only the brain is covered by bone; the spinal cord is not
False
A college student is admitted with fever, headache, and a stiff neck. Lumbar puncture is performed in the ER, and lab results reveal pneumococcal meningitis. The patient is given IV fluids for volume depletion and high doses of penicillin to treat meningitis.
G00.1, E86.9, 009U3ZX
Bacterial Meningitis is
treated with antibiotics
Psychosis is defined as:
an impairment of the mental state in which the perception of reality has become distorted
Different types of schizophrenia include:
catatonic
paranoid
disorganized
all of the above (Correct Answer)
paranoid
disorganized
all of the above (Correct Answer)
Alcohol withdrawal symptoms include:
shakiness and sweating
seizures
delirium tremors
all of the above (Correct Answer)
seizures
delirium tremors
all of the above (Correct Answer)
Dyslexia is defined as a learning disability that affects a child’s ability to:
understand or use spoken or written language
Panic disorder is defined as:
a terrifying experience that occurs suddenly without warning
Alcoholism/dependence is the same as alcohol abuse in ICD-10-CM classification.
False
There are several levels of severity that accompany intellectual disability.
True
Alteration between mania and depression back and forth very quickly is:
mixed mood disorder
Psychosis can be drug induced.
True
In ICD-10-CM, the nicotine dependence codes identify the type of nicotine product such as cigarettes, chewing tobacco, or other tobacco product.
True
Which of the following is NOT a sign/symptom of alcoholism?
Visual hallucinations
Disorganized thinking
Paranoia
None of the above are correct. (correct answer)
Disorganized thinking
Paranoia
None of the above are correct. (correct answer)
Patient was admitted with delirium tremens as a result of alcohol withdrawal. Patient has had a bout of acute gastroenteritis and has not had a drink for a couple of days. Patient was admitted and was started on IV fluids and a banana bag. Patient is hypokalemic with a potassium of 3.0 and is dehydrated. Patient’s potassium was repleted with oral medication.
Final Diagnoses: Acute gastroenteritis.
Alcohol withdrawal.
Hypokalemia.
Final Diagnoses: Acute gastroenteritis.
Alcohol withdrawal.
Hypokalemia.
F10.231, K52.9, E87.6, E86.0
A patient is admitted following seizure-like activity. It is determined that the patient has a conversion disorder with seizures.
F44.5
A 28-year-old man was brought to the ER by a friend who stated that the patient had been acting bizarrely. The patient has been irritable, pacing the apartment, and talking nonstop. He was admitted to the psychiatric unit for management of his manic symptoms.
Final Diagnosis: Bipolar affective disease.
Severe manic phase.
Recurrent episode with psychosis
Final Diagnosis: Bipolar affective disease.
Severe manic phase.
Recurrent episode with psychosis
F32.2
Organic psychosis occurs because of deterioration in the brain and is usually progressive and irreversible.
True
Stress can be a contributing factor in mental disorders.
True
In ICD-10-CM, a past history of drug and alcohol abuse is assigned codes for “in remission.”
False
Patient was seen in the ER for dizziness, fatigue and difficulty concentrating. Patient was seen for a head injury a couple of weeks ago. Physician documents postconcussional syndrome.
F07.81
Severe intellectual disability is classified when the person has an IQ of ____.
20 to 34
Patient was admitted to the psychiatric floor for evaluation of mood disorder. After extensive testing and evaluation, it was determined that patient was suffering from major depression that is severe in nature and that some psychotic features are present.
Final Diagnosis: Major depressive disorder, severe with psychosis.
Final Diagnosis: Major depressive disorder, severe with psychosis.
F32.3
A patient is admitted for treatment of anorexia nervosa. The patient has moderate malnutrition, severe electrolyte imbalance, and nutritional cardiomyopathy.
F50.00, E44.0 E87.8, I43
Seizures are a common form of alcohol withdrawal.
True
A patient is admitted to the hospital for confusion. According to the family, the patient has been more difficult to manage at home and no longer is able to care for himself. The patient has known Alzheimer’s disease. No medical cause could be determined for the patient’s increasing confusion, and it is believed that nursing home placement is appropriate.
Discharge Diagnosis: Alzheimer’s dementia.
Discharge Diagnosis: Alzheimer’s dementia.
G30.9, F02.80
Mental disorders are very particular about the body system they affect.
False
What drug could be given to treat depression?
Zoloft
What drug could be given to treat ADD or ADHD?
Ritalin
Patient was admitted because of aggressive behavior and wandering. Neurology diagnosed dementia due to Lewy bodies.
G31.83, F02.81, Z91.83
Patient was admitted for psychiatric care for acute posttraumatic stress disorder.
F43.11
Graves’ disease is the most common form of:
hyperthyroidism
An enlarged gland is called:
hyperplasia
Type 2 diabetes is much more common than type 1 diabetes
True
Bariatrics is the branch of medicine concerned with the management of:
obesity and allied diseases
If there is unclear documentation as to whether a patient is a type 1 or type 2 diabetic, the coder should:
code type 2 diabetes
Diabetes coding is affected by whether the patient is a type 1 or type 2 diabetic.
True
Major endocrine gland(s) include:
pituitary
thyroid
pancreas
all of the above (correct)
thyroid
pancreas
all of the above (correct)
A cause-and-effect relationship is presumed with all diabetic manifestations.:
False
Volume depletion, dehydration, and hypovolemia all classify to the same ICD-10-CM code.
False
When a patient is admitted for a complication of cystic fibrosis:
the complication is the principal diagnosis and the cystic fibrosis is secondary
The ____ regulate(s) daily patterns of sleep and wakefulness and inhibit(s) hormones that affect ovaries.
pineal gland
Adult patient was seen in the clinic for dietary counseling for dysmetabolic syndrome X. Patient is obese with a BMI of 35 and has hypertriglyceridemia and hypertension.
Z71.3, E88.81, E66.9, Z68.35, E78.1, I10
Hypothyroidism is an abnormality of the thyroid gland in which secretion of thyroid hormone is usually increased.
False
All of the following are possible signs of malnutrition EXCEPT ____.
rapid hair growth
Patient with steroid-induced diabetes due to long-term use of prednisone taken for rheumatoid arthritis.
E09.9, T38.0x5S, M06.9
Diabetes mellitus without mention of complication would NOT have any additional manifestation codes.
True
A patient is admitted for care of a diabetic ulcer on the left midfoot. The patient also has chronic kidney disease, stage 3, resulting from diabetes.
E11.621, L97.429, E11.22, N18.3
Gigantism occurs when there is hypersecretion of hGH before puberty and when there is a proportional overgrowth of all body tissues, especially the long bones.
True
A patient is admitted because of cystic fibrosis with pulmonary exacerbation. Sputum cultures grew Pseudomonas, and antibiotics are adjusted accordingly. The patient is also treated for hypertonic dehydration.
E84.0, B96.5, E87.0
A 15-year-old male patient with cystic fibrosis was diagnosed at the age of 2 and has respiratory and gastrointestinal manifestations. Patient needs a PEG tube to maximize his nutritional status. A percutaneous gastrostomy tube is inserted, and feeds are initiated. The patient’s mother is instructed on gastrostomy care and tube feedings.
Final Diagnosis: Cystic fibrosis.
Moderate malnutrition.
Procedure: Percutaneous endoscopic gastrostomy placement.
Final Diagnosis: Cystic fibrosis.
Moderate malnutrition.
Procedure: Percutaneous endoscopic gastrostomy placement.
E84.19, E44.0, E84.0, 0DH63UZ, 3E0G36Z
When blood sugar becomes abnormally low, this is called ____.
hypoglycemia
In ICD-10-CM there are only two category codes for diabetes mellitus.
False
Patient is an elderly gentleman who was admitted from the ER with pain and swelling of his right knee. The pain is throbbing in nature, and the knee feels warm and is very tender to touch. The patient has a knee x-ray, and uric acid levels are elevated. Colchicine is started, and the patient’s symptoms are much improved within 48 hours. The patient has diabetes. The patient is advised to limit alcohol consumption and to avoid dietary purines.
Final Diagnosis: Gouty arthropathy right knee.
Diabetes mellitus, type 2 on insulin.
Final Diagnosis: Gouty arthropathy right knee.
Diabetes mellitus, type 2 on insulin.
M10.061, E11.9, Z79.4
In ICD-10-CM, if the diabetes is due to an adverse effect of a drug, there is an Instructional note to assign a T36-T50 code as an additional or secondary code.
True
Hypopituitarism (low levels of pituitary hormones) can be caused by ____.
tumor
stroke
head trauma
all of the above (correct)
stroke
head trauma
all of the above (correct)
Which of the following is NOT a major endocrine gland in the body?
Parotid
A patient is admitted because of uncontrolled diabetes resulting from Cushing’s syndrome. Patient is on insulin.
E24.9, E08.65, Z79.4
The ____ regulates metabolism of glucose in body cells and maintains proper blood glucose
pancreas
A patient is admitted with hypokalemia. What drug could be given to treat this condition?
K-Dur
A patient is admitted with hyperkalemia. What drug could be given to treat this condition?
Kayexalate
Of all oral cancers, 90% are:
squamous cell carcinoma
Likely metastatic sites include:
bone
brain
liver
all of the above (correct answer)
brain
liver
all of the above (correct answer)
Malignant growths include
adenocarcinoma
leukemia
lymphoma
all of the above
leukemia
lymphoma
all of the above
The code for family history of breast cancer is
Z80.3
Stage I cancers are cancers that are/have:
diagnosed early and have not spread
Leukemias can have metastatic sites
False
A neoplasm is:
abnormal growth
When a patient is admitted for chemotherapy, code the malignancy as the principal diagnosis.
False
Lymphomas that are present in more than one area of the body are considered metastatic.
False
All of the following are factors influencing which kind of biopsy will be performed for a patient EXCEPT the ____.
weight of the patient
In ICD-10-CM, there is an Instructional note to code the malignancy first even when the encounter is for the management of anemia due to the malignancy.
True
A patient is admitted for a wedge resection of metastatic carcinoma to the liver. The patient was diagnosed with small-cell lung carcinoma 3 months ago. What codes are applicable?
C78.7, C34.90, 0FB04ZZ
____ is the use of high-energy radiation to treat cancer.
Radiation
When admission is for the management of dehydration due to malignancy or therapy and only dehydration is being treated, the dehydration is coded first, followed by the code(s) from the malignancy.
True
Pancytopenia due to myelodysplastic syndrome.
D61.818, D46.9
b. D46.9
c. D46.Z
b. D46.9
c. D46.Z
The patient is a 30-year-old woman who has multiple intramural fibroids. She has become more symptomatic with menorrhagia, resulting in anemia because of chronic blood loss. The patient would like to maintain fertility, so a myomectomy is performed.
Final Diagnosis: Intramural uterine fibroids.
Procedure: Myomectomy.
Final Diagnosis: Intramural uterine fibroids.
Procedure: Myomectomy.
D25.1, N92.0, D50.0, 0UB90ZZ
The patient was admitted for chemotherapy for stage IIIA breast (left) cancer. The patient tolerated the chemotherapy regimen with no complications and will return as arranged for cycle 3.
Final Diagnosis: Breast cancer, stage IIIA (spread to axillary lymph nodes).
Procedure: Chemotherapy via central vein.
Final Diagnosis: Breast cancer, stage IIIA (spread to axillary lymph nodes).
Procedure: Chemotherapy via central vein.
Z51.11, C50.912, C77.3, 3E04305
What drug could be given to treat anemia due to malignancy?
Epogen
Patient is being treated for chemotherapy induced anemia. Patient is receiving chemotherapy for right renal cell carcinoma
C64.1, D64.81, T45.1X5A
a. D64.81, T45.1X5A, C64.1
b. D64.89, T45.1X1A, C64.2
c.
d. C64.9, D63.0, T45.1X1A
In ICD-10-CM, terminology “without mention of remission” is used.
False
An example of a sarcoma malignancy is a malignant ____.
tumor in the muscle
Patient was seen in the clinic for Burkitt’s lymphoma. Patient is HIV positive.
B20, C83.70
Carcinomas in situ are malignant cells that remain within the original site with no spread to or invasion of neighboring tissues.
True
Patient was admitted with an intestinal obstruction due to peritoneal metastasis from inoperable colorectal cancer.
K56.69, C19, C78.6
b. C19, C78.6
c. C78.6, K56.60
d. C78.6, C19
____ carcinoma is primary neoplasm of the liver.
Hepatocellular
All of the following are considered by the National Cancer Institute to be the most common sites for cancer in the United States EXCEPT ____.
brain
The patient has a history of chronic hepatitis C. On routine ultrasonography, a suspicious mass of the liver was discovered. Biopsy confirmed primary hepatocellular carcinoma, and the patient was admitted for open partial hepatectomy.
Final Diagnoses: Chronic hepatitis C. Hepatocellular carcinoma.
Procedure: Partial hepatectomy for resection of HCC.
Final Diagnoses: Chronic hepatitis C. Hepatocellular carcinoma.
Procedure: Partial hepatectomy for resection of HCC.
C22.0, B18.9, 0FB00ZZ
B18.2, C22.9, 0FB00ZX
b. C22.9, B18.2, 0FB00ZX
c.
d. C22.0, B18.2, 0FB00ZZ
What drug could be given to treat neutropenia due to chemotherapy?
Neulasta
Smoking is associated with 100% of all oral cancers.
False
The excludes 2 note at the very beginning of Chapter 3 pertains to the entire chapter.
True
The definition of “idiopathic” is
without any identifiable cause
Aplastic anemia is due to:
an impairment or failure of bone marrow function
Anemia occurs when the:
hemoglobin decreases
Leukocytosis is defined as:
an increase in the number of white blood cells
A CBC measures:
hemoglobin, hematocrit, white blood cells, and platelets
A bone marrow biopsy is a diagnostic procedure used to
identify types of anemia, cell deficiencies, and leukemia
Code D57.3 is assigned for a patient with:
sickle cell trait only
The most common type(s) of transfusions is(are):
red blood cells, plasma, and platelets
Hemophilia is:
an inherited clotting disorder
When looking up anemic conditions in the code book, you should look up
anemia first and then the various subterms
____ are medications that are used to prevent venous thrombi.
Anticoagulants
____ drugs are used to prevent the clumping of platelets or the formation of arterial thrombi.
Antiplatelet
A patient takes Coumadin for chronic atrial fibrillation
I48.2, Z79.01
Patient has pancytopenia due to oral methotrexate, which is taken for treatment of rheumatoid arthritis, initial encounter.
D61.811, T45.1x5A, M06.9
A patient is admitted with sickle cell thalassemia with vaso-occlusive pain. The patient has a chest x-ray, and acute chest syndrome is ruled out. The patient has had a right hip replacement for avascular necrosis.
D57.419, Z96.641
Platelets are also called thrombocytes.
True
A patient has anemia due to metastatic bone cancer. The patient has a history of primary left breast cancer that was treated with a mastectomy 4 years ago.
C79.51, D63.0, Z85.3, Z90.12
Patient was seen in the clinic for desquamation of skin. He had a bone marrow transplant 2 months ago. The physician is treating him for acute GVHD.
T86.09, D89.810, R23.4
The patient was admitted with a deep vein thrombosis. Doppler examination was positive for thrombosis right tibial vein. The patient was treated for DVT a couple of years ago. Because of recurrent thrombosis, the patient was assessed for coagulation disorders and was found to have protein S deficiency.
Final Diagnosis: Deep vein thrombosis with edema lower leg.
Protein S deficiency.
History of previous DVT.
Final Diagnosis: Deep vein thrombosis with edema lower leg.
Protein S deficiency.
History of previous DVT.
I82.441, D68.59, Z86.718
All of the following are symptoms of anemia EXCEPT ____.
hot flashes
The patient was admitted to the hospital with usual pain symptoms for sickle cell/Hb-SS disease. The patient did not fill the pain medication prescription, and recent cold weather has brought on a vaso-occlusive crisis. Chest x-ray was performed and revealed evidence of acute chest syndrome. The patient has had right hip replacement for avascular necrosis and is scheduled to have the left hip replaced next month because of avascular necrosis, which is due to the patient’s sickle cell disease.
Final Diagnosis: Sickle cell crisis with acute chest syndrome.
Status post hip replacement.
Final Diagnosis: Sickle cell crisis with acute chest syndrome.
Status post hip replacement.
D57.01, Z96.641
Hemophilia ____, also called Christmas disease, is the result of a deficiency of factor IX.
B
____ is a common type of hereditary hemolytic anemia that is found more often in the African American population and among people living in Africa, the Mediterranean, Arabia, and South Asia.
Sickle cell anemia
The normal red blood cell count for females is ____.
4.0 million to 5.5 million/mm3
A patient is admitted with neutropenic fever. The patient has been receiving chemotherapy for AML. No source of infection is identified, and it is thought that the patient’s neutropenia is due to chemotherapy. The patient is discharged.
D70.1, R50.81, T45.1x5A, C92.00
Anemia due to chronic kidney disease can be used as the principal diagnosis code in ICD-10-CM if the reason for the encounter is to treat the anemia.
False
Radiation therapy, drugs that are used for chemotherapy, and other chemicals may result in neutropenia.
True
Hemophilia ____ is a common condition that results from a deficiency or abnormality of clotting factor VIII.
A
Procedural complications affecting the spleen are included in Chapter 3 of ICD-10-CM.
True
C. difficile:
is one of the most common nosocomial infections in the world
is characterized by watery diarrheacan be detected by stool specimen
is characterized by watery diarrheacan be detected by stool specimen
all of the above (correct answer)
Two codes are always required when coding an organism and disease condition.
False
The most serious form of anthrax is one that is:
inhalation
MRSA:
stands for methicillin-resistant Staphylococcus aureus
HAART stands for
HAART stands for
HIV infection can be coded if documented as “possible” or “probable.”
false
Chronic hepatitis:
can be caused by type B, C, and D hepatitis
can last a lifetime
is an inflammation of the liver
all of the above (correct answer)
Tuberculosis can affect which body system?
lung
bone
kidney
all of the above (correct answer)
Coding severe sepsis requires:
at least 2 codes
Septicemia is:
the presence of bacteria in the blood causing illness
Infectious diseases are characterized often by a disease code and an organism code. When this occurs, it is appropriate to use two codes.
True
A patient is admitted with pneumonia. The physician suspects sepsis and orders blood cultures. Discharge summary lists principal diagnosis as pneumococcal sepsis.
A40.3, J18.9
A homeless man presented to the ER with diabetic ulcers of the right calf of the leg that are infested with maggots.
E11.622, L97.219, B87.1
If sepsis is present on admission and meets the definition of principal diagnosis, the systemic infection code should be assigned as the principal diagnosis.
True
Clostridium difficile spores can survive up to ____ days.
70
Code B20 is NEVER used once a patient develops AIDS.
False
Tuberculosis usually occurs in populations with weaker immune systems. This would include all of the following EXCEPT ____.
teenagers
A patient is admitted to the hospital with severe diarrhea. Upon examination, the patient is found to be severely dehydrated. She is given IV fluids to correct the hydration. In the assessment, the physician suspects gastroenteritis. After stool cultures, it is determined that the patient has C. difficile colitis.
A04.7, E86.0
A patient was admitted to the hospital with fever, cough, and low blood pressure. CXR shows infiltrates, and sputum culture is positive for MRSA. The patient is a known type II diabetic. The discharge summary indicates that the patient was admitted and was given IV antibiotics for MRSA pneumonia.
J15.212, E11.9
A patient known to be positive for HIV is admitted to the hospital with high fever, malaise, and cough. PCP pneumonia is suspected. Tests reveal that the patient has infectious mononucleosis.
B27.90, Z21
The patient was admitted with septic shock. Blood cultures were positive for coagulase-negative staphylococcus. Patient was also treated for pneumonia. BAL was performed (right middle lobe bronchus).
A41.1, R65.21, J18.9, 0B958ZX
or
R65.20, A41.1, J18.9, 3E0F8KZ
ask instructor
or
R65.20, A41.1, J18.9, 3E0F8KZ
ask instructor
How many stages of syphilis are there?
three
Another name for a cold sore is herpes simplex type ____.
I
Hepatitis ____ is spread through contact with infected blood, through sex with an infected person, or during childbirth. There is a vaccine for this kind of hepatitis.
B
Patient has elevated liver function tests and was diagnosed with alcoholic hepatitis. Patient drinks alcohol on a daily basis.
K70.10, F10.20
Gonococcal conjunctivitis is coded to:
A54.31
Jock itch is coded to ____.
B35.6
Of the following medications, which is NOT an antifungal medication?
Zovirax
____ is a bacterial infection usually found in wild or domestic animals.
Anthrax
When a person carries an infectious disease and shows no ill effects, he or she is known as a(n) ____.
asymptomatic
Abnormal findings alone on a report can be coded.
False
Z codes can be coded only as principal diagnosis.
False
To indicate birth status for a newborn, use a:
code
A symptom is:
subjective evidence of a disease or of a patient’s condition as perceived by the patient
Signs and symptoms that are integral to the disease process:
should not be coded
Fever is an example of a sign/symptom.
True
Prophylactic means:
medication used to prevent a disease from occurring
A Z code is used to indicate a history of a certain condition, even if the patient currently has the condition.
False
A screening examination is:
an examination of an asymptomatic individual to detect a given disease
Threatened or impending conditions should never be coded as confirmed
False
The infant was seen in the ER for fever. Physician documented fever due to vaccination.
R50.83
A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease, condition, or injury.
follow-up code
Which of the following is a category of Z codes?
a. Contact/exposure
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
Patient is admitted to hospice care for treatment of terminal ESRD.
N18.6, Z51.5
Which of the following is NOT true of status codes?
a. A status code is informative because the status may affect the course of treatment and its outcome.
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
Signs and symptoms are not often correlated with a definitive diagnosis in the health record.
True
Patient was seen in the clinic. Final diagnosis is RUQ rebound abdominal tenderness.
R10.811
Patient has been taking Lipitor for hypercholesterolemia for one year. A hepatic function laboratory test was performed to assess any adverse effects on the patient’s liver function. A fasting lipid profile was also done to assess the effectiveness of the Lipitor.
Z51.81, Z79.899, E78.0
A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.
True
The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer and the patient has severe fibrocystic disease in both breasts, making breast examination difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ
The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
R59.0, Z85.3, Z90.12, 07B63ZX
In ICD-10-CM there are Excludes1 notes that are helpful in determining whether a symptoms code should be assigned.
True
A person who has had an allergic episode related to a substance or food in the past should always be considered allergic to the substance.
True
The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.
J18.9, E86.0
Observation codes are to be used if an injury or illness, or any signs or symptoms related to the suspected condition, are present.
False
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
True
A screening code may be listed first if the reason for the visit is specifically a screening exam.
True
A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103 and had been started on antibiotics the day before for an acute bilateral otitis media. The patient was discharged to the care of the parents on the following day.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
R56.00, H66.93
The patient was admitted with abdominal pain in the right upper quadrant. Workup included an EGD that showed some mild gastritis, and abdominal ultrasound was positive for gallstones in the gallbladder.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
K29.70, K80.20, 0DB68ZX
The patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting. The patient had a low-grade fever. A diagnosis of acute appendicitis is made, and the patient is taken to the OR for removal of the appendix via open approach.
K35.80, 0DTJ0ZZ
Z codes:
indicate a reason for an encounter
Canceled procedures should be coded as if they were performed as expected.
False
A valid OR procedure is one that:
may affect MS-DRG assignment
Cutting out or off, without replacement, a portion of a body part is the definition for which root operation?
excision
Which characters are not used in ICD-10-PCS?
the letters I and O
A limited coverage procedure should never be coded in any circumstance.
False
The root operation identifies the main objective of the procedure performed.
True
Which code should be used if a procedure is canceled because of patient smoking?
Z53.01
MS-DRGs are broken up into medical and surgical sections.
True
A significant procedure is one that:
is surgical in nature
carries a procedural risk
requires special training
all of the above (correct answer)
carries a procedural risk
requires special training
all of the above (correct answer)
It is a routine part of most surgical procedures to close the operative wound(s), so it is not necessary to code this separately.
True
The abbreviation “OR” in the health record stands for “orally related.”
False
The AMA is responsible for the maintenance of ICD-10-PCS.
False (CMS)
Stopping, or attempting to stop, postprocedural bleeding is called ____.
Control
Putting back in or on all or a portion of a separated body part to its normal location or other suitable location is reattachment.
True
The body site for perirenal is kidney.
True
The fifth character value represents the body part in the medical and surgical section.
False
Who is responsible for the maintenance of ICD-10-PCS?
CMS
It is required that a coder use the Index to assign an ICD-10-PCS code.
False
The root operation “replacement” always involves a device.
True
ICD-10-PCS is divided into how many sections?
16
Any procedure that affects payment or reimbursement must be reported.
True
A closed reduction of a fracture is coded to the external approach.
True
Temporary postoperative wound drains are not considered devices, and no ICD-10-PCS code is assigned.
True
In some instances, a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This would be an example of when a ____ would be coded.
closure
The approach for a laparoscopic cholecystectomy is percutaneous endoscopic.
True
The body site for perirenal is peritoneum.
False
Which of the following is a characteristic of ICD-10-PCS?
There are three to four possible values for a character.
The third character of an ICD-10-PCS code represents ____.
root operation
Procedures that are performed using an open approach with percutaneous endoscopic assistance are coded to open approach.
True
Crisis intervention services are a procedure that can be coded in the Mental Health section.
True
The terminology used in ICD-10-PCS is such that multiple meanings can be used for the same term.
False
MRI procedures are located in the Nuclear Medicine section.
False
The term “products of conception” refers only to the fetus.
False
What root operation is assigned for putting material on a body region for protection?
Dressing
The approach for chiropractic manipulation is always external.
True
What is the section value for radiation oncology?
D
The correct PCS code for continuous mechanical ventilation (respiratory) for 36 hours is:
5A1945Z
Monitoring is defined as determining the level of physiologic or physical function repetitively over a period of time.
True
Procedures from the Obstetric Tables are any procedure performed on a pregnant woman.
False
Radionuclide is the fifth character in the nuclear medicine section.
True
Detoxification services are a procedure that can be coded in the mental health section.
False
In the mental health section, characters five, six, and seven are for qualifiers.
True
Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
False
Modality qualifier is the fifth character in the radiation oncology section.
True
External is the only root operation that can be used in the osteopathic section.
False
In the extracorporeal assistance and performance section, the definition for assistance is completely taking over a physiological function by extracorporeal means.
False
The first character value for an imaging procedure is B.
True
The first character value for substance abuse treatment is H.
True
The fourth character is the body part that is the focus of the radiation therapy.
True
The first character value for a mental health procedure is G.
True
A bone marrow transplant is coded in the Administration section.
True
The approach for an osteopathic treatment is always external.
True
Fluoroscopy procedures are located in the imaging section.
True
In the Administration section, character “2” is used to identify the substance being introduced.
False
Irrigation is a root operation that is found in the placement section.
False
According to the guidelines, it is acceptable to assign codes for BMI based on the documentation of a clinician such as a dietitian.
True
When coding encounters for rehabilitation, a procedure code should be reported to identify each type of rehabilitation therapy that was performed.
True
If a condition is documented as both acute and chronic and there are separate codes at the same indentation level, the chronic condition is sequenced first.
False
A sequela is:
the residual effect (condition produced) after the acute phase of an illness or injury has terminated
In the inpatient setting, it is acceptable to code diagnoses that have not yet been confirmed but are questionable or suspected at the time of discharge.
False
If a condition has been documented as impending and actually occurs, it is acceptable to code the confirmed diagnosis.
True
A condition that is present on admission:
is present when a patient is brought to the hospital
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
True
Conditions that are routinely associated with a disease should be coded as an additional diagnosis.
False
Principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
True
Etiology/manifestation convention requires ____ code(s) to fully describe a single condition that affects multiple body systems.
Two
When the patient is admitted for a complication due to a surgical procedure, the complication is the principal diagnosis.
True
If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists.
True
When a coder notices on a laboratory test result that a patient’s sodium is below normal, it is acceptable to code hyponatremia.
False
If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.
False
A(n) ____ is a residual effect (condition produced) after the acute phase of an illness or injury has terminated.
sequela
In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
False
The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.
False
Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
True
If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.
False
Crisis intervention services are a procedure that can be coded in the Mental Health section.
True
“Includes” notes:
NEC (not elsewhere classifiable) represents:
unspecified
For etiology/manifestation coding, the instructional notes indicate:
the manifestation is coded first, then the etiology
An “excludes 1” note means:
not coded here
A code category that requires a 7th character must always have this character placed in the 7th character data field.
True
The bolded subterm in the diagnostic statement purulent pneumonia is a(n) ____ modifier.
The bolded subterm in the diagnostic statement cortical cataract is a(n) ____ modifier.
____ is/are used in both the Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code assignment.
A(n) __________ is a term that is enclosed in parentheses following a main term or a subterm and whose presence or absence has no effect on code assignment.
The bolded subterm in the diagnostic statement “bacterial” pneumonia is a(n) ____ modifier.
The word “__________” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order.
with
The code “L20.83 infantile eczema” represents a
The letter “X” in ICD-10-CM can be found in the fifth or sixth character position.
The “see” instruction following a main term in the index indicates that:
there is an additional external cause code required
The word “and” should be interpreted to mean:
not elsewhere classified
Which letter represents a dummy place holder?
X
The main terms for procedures are identified in the Alphabetic Index by:
the type of procedure performed.
The main term is ____
a term identifying disease conditions or injuries
A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.
False
The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.
False
To be sure you have the correct diagnosis code, it is very important to go to the Alphabetic Index first and then to the Tabular List.
True
What is the main term in the procedure “vaginal hysterectomy”?
hysterectomy
A query should contain all of the following items EXCEPT ____.
amount of increased reimbursement due to query
The AHIMA practice brief says that query forms should do none of the following EXCEPT ____.
contain precise language
It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.
True
Clinical data in the medical record do not include:
total charges of patient’s stay
Which is an area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?
Physician orders
One of the most important aspects of developing an effective query form is the manner in which the form is worded.
True
Principal diagnosis is defined as:
the condition after study to be chiefly responsible for occasioning the admission of the patient for care
In some cases a patient is ready to be discharged from the hospital, but at the last minute the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.
develops a fever
Conditions that are an integral part of the disease process are coded.
False
What does EKG stand for?
Electrocardiogram
The medical record serves as a legal document of care and services provided.
True
The chief complaint is:
the reason in the patient’s own words for presenting to the hospital
If the condition of a patient is being clinically evaluated, the coder would expect to see ____.
clinical observations
MS-DRGs affect:
reimbursement
A “CBC” is an item that would be included in a:
laboratory report
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.
False
Sometimes ____ will be used to help diagnose a patient’s condition.
x-rays
Which of these is NOT considered a physician?
Medical student
The discharge summary is:
a summary of the patient’s hospital stay
Always choose the documenting physician’s principal diagnosis as the principal diagnosis for coding purposes.
False
SOAP format stands for:
subjective, objective, assessment, plan
According to the guidelines, it is acceptable to assign codes for BMI based on the documentation of a clinician such as a dietitian.
True
When coding encounters for rehabilitation, a procedure code should be reported to identify each type of rehabilitation therapy that was performed.
True
If a condition is documented as both acute and chronic and there are separate codes at the same indentation level, the chronic condition is sequenced first.
False
A sequela is:
the residual effect (condition produced) after the acute phase of an illness or injury has terminated
In the inpatient setting, it is acceptable to code diagnoses that have not yet been confirmed but are questionable or suspected at the time of discharge.
False
If a condition has been documented as impending and actually occurs, it is acceptable to code the confirmed diagnosis.
True
A condition that is present on admission:
is present when a patient is brought to the hospital
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
True
Conditions that are routinely associated with a disease should be coded as an additional diagnosis.
False
Principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
True
Etiology/manifestation convention requires ____ code(s) to fully describe a single condition that affects multiple body systems.
Two
When the patient is admitted for a complication due to a surgical procedure, the complication is the principal diagnosis.
True
If a diagnosis is documented as possible at the time of discharge from an inpatient stay, code the condition as if it exists.
True
When a coder notices on a laboratory test result that a patient’s sodium is below normal, it is acceptable to code hyponatremia.
False
If a patient is admitted for a complication due to a surgical procedure, the reason for the surgical procedure is the principal diagnosis.
False
A(n) ____ is a residual effect (condition produced) after the acute phase of an illness or injury has terminated.
sequela
In the inpatient setting, it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
False
The selection of codes A00.0 through Z99.89 will NOT be used frequently to describe the reason for the admission/encounter.
False
Principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.
True
If the principal diagnosis was abdominal pain due to acute appendicitis, the abdominal pain would be coded as a secondary diagnosis.
False
Crisis intervention services are a procedure that can be coded in the Mental Health section.
True
Crisis intervention services are a procedure that can be coded in the Mental Health section.
True
The terminology used in ICD-10-PCS is such that multiple meanings can be used for the same term.
False
MRI procedures are located in the Nuclear Medicine section.
False
The term “products of conception” refers only to the fetus.
False
What root operation is assigned for putting material on a body region for protection?
Dressing
The approach for chiropractic manipulation is always external.
True
What is the section value for radiation oncology?
D
The correct PCS code for continuous mechanical ventilation (respiratory) for 36 hours is:
5A1945Z
Monitoring is defined as determining the level of physiologic or physical function repetitively over a period of time.
True
Procedures from the Obstetric Tables are any procedure performed on a pregnant woman.
False
Radionuclide is the fifth character in the nuclear medicine section.
True
Detoxification services are a procedure that can be coded in the mental health section.
False
In the mental health section, characters five, six, and seven are for qualifiers.
True
Root type is the sixth character in the physical rehabilitation and diagnostic audiology section.
False
Modality qualifier is the fifth character in the radiation oncology section.
True
External is the only root operation that can be used in the osteopathic section.
False
In the extracorporeal assistance and performance section, the definition for assistance is completely taking over a physiological function by extracorporeal means.
False
The first character value for an imaging procedure is B.
True
The first character value for substance abuse treatment is H.
True
The fourth character is the body part that is the focus of the radiation therapy.
True
The first character value for a mental health procedure is G.
True
A bone marrow transplant is coded in the Administration section.
True
The approach for an osteopathic treatment is always external.
True
Fluoroscopy procedures are located in the imaging section.
True
In the Administration section, character “2” is used to identify the substance being introduced.
False
Irrigation is a root operation that is found in the placement section.
False
Z codes:
indicate a reason for an encounter
Canceled procedures should be coded as if they were performed as expected.
False
A valid OR procedure is one that:
may affect MS-DRG assignment
Cutting out or off, without replacement, a portion of a body part is the definition for which root operation?
excision
Which characters are not used in ICD-10-PCS?
the letters I and O
A limited coverage procedure should never be coded in any circumstance.
False
The root operation identifies the main objective of the procedure performed.
True
Which code should be used if a procedure is canceled because of patient smoking?
Z53.01
MS-DRGs are broken up into medical and surgical sections.
True
A significant procedure is one that:
is surgical in nature
carries a procedural risk
requires special training
all of the above (correct answer)
carries a procedural risk
requires special training
all of the above (correct answer)
It is a routine part of most surgical procedures to close the operative wound(s), so it is not necessary to code this separately.
True
The abbreviation “OR” in the health record stands for “orally related.”
False
The AMA is responsible for the maintenance of ICD-10-PCS.
False (CMS)
Stopping, or attempting to stop, postprocedural bleeding is called ____.
Control
Putting back in or on all or a portion of a separated body part to its normal location or other suitable location is reattachment.
True
The body site for perirenal is kidney.
True
The fifth character value represents the body part in the medical and surgical section.
False
Who is responsible for the maintenance of ICD-10-PCS?
CMS
It is required that a coder use the Index to assign an ICD-10-PCS code.
False
The root operation “replacement” always involves a device.
True
ICD-10-PCS is divided into how many sections?
16
Any procedure that affects payment or reimbursement must be reported.
True
A closed reduction of a fracture is coded to the external approach.
True
Temporary postoperative wound drains are not considered devices, and no ICD-10-PCS code is assigned.
True
In some instances, a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This would be an example of when a ____ would be coded.
closure
The approach for a laparoscopic cholecystectomy is percutaneous endoscopic.
True
The body site for perirenal is peritoneum.
False
Which of the following is a characteristic of ICD-10-PCS?
There are three to four possible values for a character.
The third character of an ICD-10-PCS code represents ____.
root operation
Procedures that are performed using an open approach with percutaneous endoscopic assistance are coded to open approach.
True
Abnormal findings alone on a report can be coded.
False
Z codes can be coded only as principal diagnosis.
False
To indicate birth status for a newborn, use a:
code
A symptom is:
subjective evidence of a disease or of a patient’s condition as perceived by the patient
Signs and symptoms that are integral to the disease process:
should not be coded
Fever is an example of a sign/symptom.
True
Prophylactic means:
medication used to prevent a disease from occurring
A Z code is used to indicate a history of a certain condition, even if the patient currently has the condition.
False
A screening examination is:
an examination of an asymptomatic individual to detect a given disease
Threatened or impending conditions should never be coded as confirmed
False
The infant was seen in the ER for fever. Physician documented fever due to vaccination.
R50.83
A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease, condition, or injury.
follow-up code
Which of the following is a category of Z codes?
a. Contact/exposure
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
b. Inoculations and vaccinations
c. Status
d. All of the above (correct answer)
Patient is admitted to hospice care for treatment of terminal ESRD.
N18.6, Z51.5
Which of the following is NOT true of status codes?
a. A status code is informative because the status may affect the course of treatment and its outcome.
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
b. A status code is distinct from a history code.
c. A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
d. None of the above are correct. (correct answer)
Signs and symptoms are not often correlated with a definitive diagnosis in the health record.
True
Patient was seen in the clinic. Final diagnosis is RUQ rebound abdominal tenderness.
R10.811
Patient has been taking Lipitor for hypercholesterolemia for one year. A hepatic function laboratory test was performed to assess any adverse effects on the patient’s liver function. A fasting lipid profile was also done to assess the effectiveness of the Lipitor.
Z51.81, Z79.899, E78.0
A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.
True
The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer and the patient has severe fibrocystic disease in both breasts, making breast examination difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Final Diagnosis: Family history of breast cancer; severe fibrocystic disease.
Procedure: Bilateral simple mastectomy.
Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ
The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out.
Procedure: Needle core biopsy axillary lymph node.
R59.0, Z85.3, Z90.12, 07B63ZX
In ICD-10-CM there are Excludes1 notes that are helpful in determining whether a symptoms code should be assigned.
True
A person who has had an allergic episode related to a substance or food in the past should always be considered allergic to the substance.
True
The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.
J18.9, E86.0
Observation codes are to be used if an injury or illness, or any signs or symptoms related to the suspected condition, are present.
False
ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
True
A screening code may be listed first if the reason for the visit is specifically a screening exam.
True
A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103 and had been started on antibiotics the day before for an acute bilateral otitis media. The patient was discharged to the care of the parents on the following day.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
Final Diagnosis: Febrile seizure; fever due to acute bilateral otitis media.
R56.00, H66.93
The patient was admitted with abdominal pain in the right upper quadrant. Workup included an EGD that showed some mild gastritis, and abdominal ultrasound was positive for gallstones in the gallbladder.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis.
Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.
K29.70, K80.20, 0DB68ZX
The patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting. The patient had a low-grade fever. A diagnosis of acute appendicitis is made, and the patient is taken to the OR for removal of the appendix via open approach.
K35.80, 0DTJ0ZZ
C. difficile:
is one of the most common nosocomial infections in the world
is characterized by watery diarrheacan be detected by stool specimen
is characterized by watery diarrheacan be detected by stool specimen
all of the above (correct answer)
Two codes are always required when coding an organism and disease condition.
False
The most serious form of anthrax is one that is:
inhalation
MRSA:
stands for methicillin-resistant Staphylococcus aureus
HAART stands for
HAART stands for
HIV infection can be coded if documented as “possible” or “probable.”
false
Chronic hepatitis:
can be caused by type B, C, and D hepatitis
can last a lifetime
is an inflammation of the liver
all of the above (correct answer)
Tuberculosis can affect which body system?
lung
bone
kidney
all of the above (correct answer)
Coding severe sepsis requires:
at least 2 codes
Septicemia is:
the presence of bacteria in the blood causing illness
Infectious diseases are characterized often by a disease code and an organism code. When this occurs, it is appropriate to use two codes.
True
A patient is admitted with pneumonia. The physician suspects sepsis and orders blood cultures. Discharge summary lists principal diagnosis as pneumococcal sepsis.
A40.3, J18.9
A homeless man presented to the ER with diabetic ulcers of the right calf of the leg that are infested with maggots.
E11.622, L97.219, B87.1
If sepsis is present on admission and meets the definition of principal diagnosis, the systemic infection code should be assigned as the principal diagnosis.
True
Clostridium difficile spores can survive up to ____ days.
70
Code B20 is NEVER used once a patient develops AIDS.
False
Tuberculosis usually occurs in populations with weaker immune systems. This would include all of the following EXCEPT ____.
teenagers
A patient is admitted to the hospital with severe diarrhea. Upon examination, the patient is found to be severely dehydrated. She is given IV fluids to correct the hydration. In the assessment, the physician suspects gastroenteritis. After stool cultures, it is determined that the patient has C. difficile colitis.
A04.7, E86.0
A patient was admitted to the hospital with fever, cough, and low blood pressure. CXR shows infiltrates, and sputum culture is positive for MRSA. The patient is a known type II diabetic. The discharge summary indicates that the patient was admitted and was given IV antibiotics for MRSA pneumonia.
J15.212, E11.9
A patient known to be positive for HIV is admitted to the hospital with high fever, malaise, and cough. PCP pneumonia is suspected. Tests reveal that the patient has infectious mononucleosis.
B27.90, Z21
The patient was admitted with septic shock. Blood cultures were positive for coagulase-negative staphylococcus. Patient was also treated for pneumonia. BAL was performed (right middle lobe bronchus).
A41.1, R65.21, J18.9, 0B958ZX
or
R65.20, A41.1, J18.9, 3E0F8KZ
ask instructor
or
R65.20, A41.1, J18.9, 3E0F8KZ
ask instructor
How many stages of syphilis are there?
three
Another name for a cold sore is herpes simplex type ____.
I
Hepatitis ____ is spread through contact with infected blood, through sex with an infected person, or during childbirth. There is a vaccine for this kind of hepatitis.
B
Patient has elevated liver function tests and was diagnosed with alcoholic hepatitis. Patient drinks alcohol on a daily basis.
K70.10, F10.20
Gonococcal conjunctivitis is coded to:
A54.31
Jock itch is coded to ____.
B35.6
Of the following medications, which is NOT an antifungal medication?
Zovirax
____ is a bacterial infection usually found in wild or domestic animals.
Anthrax
When a person carries an infectious disease and shows no ill effects, he or she is known as a(n) ____.
asymptomatic
“Includes” notes:
NEC (not elsewhere classifiable) represents:
unspecified
For etiology/manifestation coding, the instructional notes indicate:
the manifestation is coded first, then the etiology
An “excludes 1” note means:
not coded here
A code category that requires a 7th character must always have this character placed in the 7th character data field.
True
The bolded subterm in the diagnostic statement purulent pneumonia is a(n) ____ modifier.
The bolded subterm in the diagnostic statement cortical cataract is a(n) ____ modifier.
____ is/are used in both the Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code assignment.
A(n) __________ is a term that is enclosed in parentheses following a main term or a subterm and whose presence or absence has no effect on code assignment.
The bolded subterm in the diagnostic statement “bacterial” pneumonia is a(n) ____ modifier.
The word “__________” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetic order.
with
The code “L20.83 infantile eczema” represents a
The letter “X” in ICD-10-CM can be found in the fifth or sixth character position.
The “see” instruction following a main term in the index indicates that:
there is an additional external cause code required
The word “and” should be interpreted to mean:
not elsewhere classified
Which letter represents a dummy place holder?
X
The main terms for procedures are identified in the Alphabetic Index by:
the type of procedure performed.
The main term is ____
a term identifying disease conditions or injuries
A differential diagnosis is when a patient presents with a symptom that is usually related to only one possible diagnosis.
False
The coder should rely solely on the discharge summary to capture all of the diagnoses and procedures that were treated and performed.
False
To be sure you have the correct diagnosis code, it is very important to go to the Alphabetic Index first and then to the Tabular List.
True
What is the main term in the procedure “vaginal hysterectomy”?
hysterectomy
A query should contain all of the following items EXCEPT ____.
amount of increased reimbursement due to query
The AHIMA practice brief says that query forms should do none of the following EXCEPT ____.
contain precise language
It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.
True
Clinical data in the medical record do not include:
total charges of patient’s stay
Which is an area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?
Physician orders
One of the most important aspects of developing an effective query form is the manner in which the form is worded.
True
Principal diagnosis is defined as:
the condition after study to be chiefly responsible for occasioning the admission of the patient for care
In some cases a patient is ready to be discharged from the hospital, but at the last minute the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.
develops a fever
Conditions that are an integral part of the disease process are coded.
False
What does EKG stand for?
Electrocardiogram
The medical record serves as a legal document of care and services provided.
True
The chief complaint is:
the reason in the patient’s own words for presenting to the hospital
If the condition of a patient is being clinically evaluated, the coder would expect to see ____.
clinical observations
MS-DRGs affect:
reimbursement
A “CBC” is an item that would be included in a:
laboratory report
Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.
False
Sometimes ____ will be used to help diagnose a patient’s condition.
x-rays
Which of these is NOT considered a physician?
Medical student
The discharge summary is:
a summary of the patient’s hospital stay
Always choose the documenting physician’s principal diagnosis as the principal diagnosis for coding purposes.
False
SOAP format stands for:
subjective, objective, assessment, plan
The excludes 2 note at the very beginning of Chapter 3 pertains to the entire chapter.
True
The definition of “idiopathic” is
without any identifiable cause
Aplastic anemia is due to:
an impairment or failure of bone marrow function
Anemia occurs when the:
hemoglobin decreases
Leukocytosis is defined as:
an increase in the number of white blood cells
A CBC measures:
hemoglobin, hematocrit, white blood cells, and platelets
A bone marrow biopsy is a diagnostic procedure used to
identify types of anemia, cell deficiencies, and leukemia
Code D57.3 is assigned for a patient with:
sickle cell trait only
The most common type(s) of transfusions is(are):
red blood cells, plasma, and platelets
Hemophilia is:
an inherited clotting disorder
When looking up anemic conditions in the code book, you should look up
anemia first and then the various subterms
____ are medications that are used to prevent venous thrombi.
Anticoagulants
____ drugs are used to prevent the clumping of platelets or the formation of arterial thrombi.
Antiplatelet
A patient takes Coumadin for chronic atrial fibrillation
I48.2, Z79.01
Patient has pancytopenia due to oral methotrexate, which is taken for treatment of rheumatoid arthritis, initial encounter.
D61.811, T45.1x5A, M06.9
A patient is admitted with sickle cell thalassemia with vaso-occlusive pain. The patient has a chest x-ray, and acute chest syndrome is ruled out. The patient has had a right hip replacement for avascular necrosis.
D57.419, Z96.641
Platelets are also called thrombocytes.
True
A patient has anemia due to metastatic bone cancer. The patient has a history of primary left breast cancer that was treated with a mastectomy 4 years ago.
C79.51, D63.0, Z85.3, Z90.12
Patient was seen in the clinic for desquamation of skin. He had a bone marrow transplant 2 months ago. The physician is treating him for acute GVHD.
T86.09, D89.810, R23.4
The patient was admitted with a deep vein thrombosis. Doppler examination was positive for thrombosis right tibial vein. The patient was treated for DVT a couple of years ago. Because of recurrent thrombosis, the patient was assessed for coagulation disorders and was found to have protein S deficiency.
Final Diagnosis: Deep vein thrombosis with edema lower leg.
Protein S deficiency.
History of previous DVT.
Final Diagnosis: Deep vein thrombosis with edema lower leg.
Protein S deficiency.
History of previous DVT.
I82.441, D68.59, Z86.718
All of the following are symptoms of anemia EXCEPT ____.
hot flashes
The patient was admitted to the hospital with usual pain symptoms for sickle cell/Hb-SS disease. The patient did not fill the pain medication prescription, and recent cold weather has brought on a vaso-occlusive crisis. Chest x-ray was performed and revealed evidence of acute chest syndrome. The patient has had right hip replacement for avascular necrosis and is scheduled to have the left hip replaced next month because of avascular necrosis, which is due to the patient’s sickle cell disease.
Final Diagnosis: Sickle cell crisis with acute chest syndrome.
Status post hip replacement.
Final Diagnosis: Sickle cell crisis with acute chest syndrome.
Status post hip replacement.
D57.01, Z96.641
Hemophilia ____, also called Christmas disease, is the result of a deficiency of factor IX.
B
____ is a common type of hereditary hemolytic anemia that is found more often in the African American population and among people living in Africa, the Mediterranean, Arabia, and South Asia.
Sickle cell anemia
The normal red blood cell count for females is ____.
4.0 million to 5.5 million/mm3
A patient is admitted with neutropenic fever. The patient has been receiving chemotherapy for AML. No source of infection is identified, and it is thought that the patient’s neutropenia is due to chemotherapy. The patient is discharged.
D70.1, R50.81, T45.1x5A, C92.00
Anemia due to chronic kidney disease can be used as the principal diagnosis code in ICD-10-CM if the reason for the encounter is to treat the anemia.
False
Radiation therapy, drugs that are used for chemotherapy, and other chemicals may result in neutropenia.
True
Hemophilia ____ is a common condition that results from a deficiency or abnormality of clotting factor VIII.
A
Procedural complications affecting the spleen are included in Chapter 3 of ICD-10-CM.
True
Of all oral cancers, 90% are:
squamous cell carcinoma
Likely metastatic sites include:
bone
brain
liver
all of the above (correct answer)
brain
liver
all of the above (correct answer)
Malignant growths include
adenocarcinoma
leukemia
lymphoma
all of the above
leukemia
lymphoma
all of the above
The code for family history of breast cancer is
Z80.3
Stage I cancers are cancers that are/have:
diagnosed early and have not spread
Leukemias can have metastatic sites
False
A neoplasm is:
abnormal growth
When a patient is admitted for chemotherapy, code the malignancy as the principal diagnosis.
False
Lymphomas that are present in more than one area of the body are considered metastatic.
False
All of the following are factors influencing which kind of biopsy will be performed for a patient EXCEPT the ____.
weight of the patient
In ICD-10-CM, there is an Instructional note to code the malignancy first even when the encounter is for the management of anemia due to the malignancy.
True
A patient is admitted for a wedge resection of metastatic carcinoma to the liver. The patient was diagnosed with small-cell lung carcinoma 3 months ago. What codes are applicable?
C78.7, C34.90, 0FB04ZZ
____ is the use of high-energy radiation to treat cancer.
Radiation
When admission is for the management of dehydration due to malignancy or therapy and only dehydration is being treated, the dehydration is coded first, followed by the code(s) from the malignancy.
True
Pancytopenia due to myelodysplastic syndrome.
D61.818, D46.9
b. D46.9
c. D46.Z
b. D46.9
c. D46.Z
The patient is a 30-year-old woman who has multiple intramural fibroids. She has become more symptomatic with menorrhagia, resulting in anemia because of chronic blood loss. The patient would like to maintain fertility, so a myomectomy is performed.
Final Diagnosis: Intramural uterine fibroids.
Procedure: Myomectomy.
Final Diagnosis: Intramural uterine fibroids.
Procedure: Myomectomy.
D25.1, N92.0, D50.0, 0UB90ZZ
The patient was admitted for chemotherapy for stage IIIA breast (left) cancer. The patient tolerated the chemotherapy regimen with no complications and will return as arranged for cycle 3.
Final Diagnosis: Breast cancer, stage IIIA (spread to axillary lymph nodes).
Procedure: Chemotherapy via central vein.
Final Diagnosis: Breast cancer, stage IIIA (spread to axillary lymph nodes).
Procedure: Chemotherapy via central vein.
Z51.11, C50.912, C77.3, 3E04305
What drug could be given to treat anemia due to malignancy?
Epogen
Patient is being treated for chemotherapy induced anemia. Patient is receiving chemotherapy for right renal cell carcinoma
C64.1, D64.81, T45.1X5A
a. D64.81, T45.1X5A, C64.1
b. D64.89, T45.1X1A, C64.2
c.
d. C64.9, D63.0, T45.1X1A
In ICD-10-CM, terminology “without mention of remission” is used.
False
An example of a sarcoma malignancy is a malignant ____.
tumor in the muscle
Patient was seen in the clinic for Burkitt’s lymphoma. Patient is HIV positive.
B20, C83.70
Carcinomas in situ are malignant cells that remain within the original site with no spread to or invasion of neighboring tissues.
True
Patient was admitted with an intestinal obstruction due to peritoneal metastasis from inoperable colorectal cancer.
K56.69, C19, C78.6
b. C19, C78.6
c. C78.6, K56.60
d. C78.6, C19
____ carcinoma is primary neoplasm of the liver.
Hepatocellular
All of the following are considered by the National Cancer Institute to be the most common sites for cancer in the United States EXCEPT ____.
brain
The patient has a history of chronic hepatitis C. On routine ultrasonography, a suspicious mass of the liver was discovered. Biopsy confirmed primary hepatocellular carcinoma, and the patient was admitted for open partial hepatectomy.
Final Diagnoses: Chronic hepatitis C. Hepatocellular carcinoma.
Procedure: Partial hepatectomy for resection of HCC.
Final Diagnoses: Chronic hepatitis C. Hepatocellular carcinoma.
Procedure: Partial hepatectomy for resection of HCC.
C22.0, B18.9, 0FB00ZZ
B18.2, C22.9, 0FB00ZX
b. C22.9, B18.2, 0FB00ZX
c.
d. C22.0, B18.2, 0FB00ZZ
What drug could be given to treat neutropenia due to chemotherapy?
Neulasta
Smoking is associated with 100% of all oral cancers.
False
ICD-10-CM assumes a rheumatic etiology when both the mitral and the aortic valves are diseased.
True
In ICD-10-CM, when coding coronary artery disease and angina:
one combination code is used
A cerebrovascular accident is commonly known as:
stroke
An acute myocardial infarction is commonly known as:
heart attack
A leaking valve is another name for:
regurgitation
incompetence
insufficiency
all of the above (correct answer)
incompetence
insufficiency
all of the above (correct answer)
Hypertensive heart disease assumes a cause-and-effect relationship in ICD-10-CM coding.
False
The lymph system fights infection by:
filtering out viruses and bacteria
The valves in the heart include:
tricuspid, mitral, aortic, pulmonary
A diagnostic cardiac catheterization is used to determine the severity of:
coronary artery disease
coronary artery disease
epicardium, myocardium, endocardium
A patient is admitted with chest pain and is ruled in for an NSTEMI. The patient has a history of a CABG and PTCA with stent placement. Patient is taking medications for hypertension, CAD, and CHF.
I21.4, I10, I25.10, I50.9, Z95.1, Z95.5
Patient comes to the hospital with chest pain. A diagnostic left heart cath is performed, and no coronary artery disease is observed. The cardiologist documents the diagnosis as noncardiac chest pain.
R07.89, 4A023N7
Patient is admitted through the ER, presenting with acute chest pain. The patient has a history of COPD and pneumonia as well as type II DM with diabetic neuropathy. He has a history of hypertension and gout for which he takes meds. He is currently smoking about one pack per day. After study it is determined that patient has had an acute anterolateral wall infarct. He is taken to the EP lab for a PTCA with the insertion of a drug eluting stent of the LAD.
I21.09, I10, F17.210, M10.9, J44.9, E11.40, 027034Z
Deep vein thrombosis (DVT) is a blood clot that forms deep in a vein, usually in the leg or hip.
True
Molly has a blood pressure of 150/100. She would be classified as having ____ by her clinician.
hypertension
Insertion of pacemakers most often requires five codes.
False, two codes
Patient comes to the hospital for repair of an abdominal aortic aneurysm. The repair is performed by percutaneous endoscopic approach.
I71.4, 04V04DZ
The time limit for assigning the acute MI in ICD-10-CM is 28 days.
True
A patient is admitted with facial droop, left-sided hemiparesis, and nystagmus. Testing reveals occlusion of the left carotid artery with cerebral infarct. The patient has uncontrolled hypertension and atrial fibrillation, which is treated with Coumadin. Before discharge, the patient’s nystagmus and facial droop have resolved. The patient is discharged to rehab for continued therapy for left-sided hemiparesis.
I63.232, I69.354, H55.00, I69.392, I10, I48.91, Z79.01
Tachycardia is an abnormally high heart rate of more than 100 beats per minute.
True
The patient was admitted with left-sided hemiparesis due to a cerebrovascular accident. The patient has a history of previous CVA with residual facial droop.
I63.9, G81.94, I69.392
All of the following are tests performed to determine whether a myocardial infarction has occurred EXCEPT ____.
urinalysis
Patient is admitted with syncope. After tests are performed, it is determined that the patient has bradycardia due to second degree AV block.
I44.1, R00.1
Patient is admitted through the ER with atrial fibrillation and a history of COPD. She is taken to the EPS lab for EPS testing, mapping, and radiofrequency ablation of the left atrium.
I48.91, J44.9, 02573ZZ, 02K83ZZ, 4A023FZ
Patient is admitted with chest pain and rules in for an anterolateral MI. There is a family history of CAD.
I21.09, Z82.49
The two main types of heart failure are systolic and diastolic.
True
Patient comes into the ER after fainting at work. The physician determines that the fainting was caused by elevated blood pressure resulting from extreme stress.
R03.0, F43.0
Patient was admitted for treatment of gangrenous cellulitis of left lower leg
I96
Patient was admitted to have a drug-eluting stent inserted into the LAD for coronary atherosclerosis. Procedure was performed percutaneously.
I25.10, 027034Z
Patient was admitted with acute on chronic systolic and diastolic congestive heart failure.
I25.10, 027034Z
Chronic asthmatic bronchitis and chronic bronchitis with emphysema can be classified as chronic obstructive pulmonary disease (COPD).
True
Blood that accumulates in the pleural space is called:
hemothorax
Pleural effusion is:
fluid that accumulates in the pleural space
A personal history of malignant neoplasm of the lung is coded as:
Z85.118
It is possible to have an acute infection superimposed on a chronic infection/inflammation.
True
Bronchitis can be ______________in origin.
viral or bacterial
Respiratory failure is always coded as the principal diagnosis.
False
Common treatments for sinusitis include:
decongestants, antibiotics
It is possible to have more than one bacterium responsible for pneumonia.
True
Mechanical ventilation codes are based on hours.
True
A patient is admitted with hypoxemia and acute respiratory failure. The patient has COPD and is being treated for an acute exacerbation. The patient is intubated in the ER and is transferred to ICU and maintained on mechanical ventilation for 24 hours. The patient has a history of chronic diastolic congestive heart failure.
J96.01, J44.1, I50.32, 5A1945Z
A diagnostic endoscopic procedure in which a tiny camera on the end of the endoscope is inserted through the nose or mouth into the lungs is called a ____.
bronchoscopy
A pneumothorax that occurs as a result of a procedure is a(n) ____ pneumothorax.
iatrogenic
Which of the following is NOT categorized with high-risk potential for contracting pneumonia?
Someone who is in his or her early twenties
Patient is admitted with acute on chronic respiratory failure due to emphysema. Patient is dependent on oxygen, and has had numerous admissions for pneumonia. Patient is treated with continuous BIPAP for 48 hours and is a DNR/DNI. No infection is identified, and deterioration in respiratory status is thought to be a progression of his emphysema. Patient is discharged to at-home hospice care.
Final Diagnoses: End-stage emphysema.
Chronic respiratory failure with hypoxia.
Procedure: BIPAP.
Final Diagnoses: End-stage emphysema.
Chronic respiratory failure with hypoxia.
Procedure: BIPAP.
J96.21, J43.9, Z99.81, Z87.01, Z66, 5A09457
Patient arrived at the ER complaining of shortness of breath. Patient was diagnosed and treated for exercise-induced bronchospasm.
J45.990
____ is a lower respiratory tract or bronchial tree infection that is characterized by cough, sputum production, and wheezing.
Bronchitis
When pleural effusion results from trauma or disease and blood is accumulating in the pleural space, the condition is called ____.
hemothorax
A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis due to previous cerebral infarction. Sputum cultures reveal Pseudomonas.
Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.
Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.
J69.0, J15.1 I69.391, R13.10, I69.359
Which of the following is NOT an example of pneumoconiosis (lung disease due to the chronic inhalation of inorganic dust)?
Cyanosis
Patient was admitted with flu-like symptoms. The final diagnosis on the discharge summary is possible novel influenza A.
J11.89
Asthmatic bronchitis refers to an underlying asthmatic problem in patients in whom asthma has become so persistent that clinically significant chronic airflow obstruction is present despite antiasthmatic therapy.
True
A patient is admitted from a nursing home with cough and fever. The patient has a history of dysphagia and hemiparesis of right dominant side due to previous CVA. Sputum cultures reveal Pseudomonas. Patient went into acute respiratory failure after admission.
Discharge diagnosis: Pseudomonas pneumonia.
Discharge diagnosis: Pseudomonas pneumonia.
J15.1, J96.00, I69.391, R13.10, I69.351
Patient is admitted with shortness of breath and fever that has been present for 2 to 3 weeks and has gotten progressively worse. CT scan showed evidence of bronchiolitis obliterans organizing pneumonia (BOOP). Patient was started on prednisone and discharged when symptoms had resolved.
Final Diagnoses: BOOP.
Final Diagnoses: BOOP.
J84.89
A patient is admitted for suspected H1N1 influenza.
J11.1
Patient was admitted to the hospital in acute respiratory failure due to congestive heart failure. The patient was intubated and placed on mechanical ventilation for 2 days. The patient responded well to IV diuretics.
J96.00, I50.9, 5A1945Z
It is inappropriate for coders to assume a causal organism on the basis of laboratory or radiology findings alone.
True
Patient is admitted to the hospital and found to have suffered a NSTEMI. After admission the patient went into acute respiratory failure.
I21.4, J96.00
Infant was seen in the ER with diagnosis of acute bronchiolitis due to RSV. The infant has been exposed to tobacco smoke.
J21.0, Z77.22
Which of the following is a symptom of pneumonia?
Rapid breathing
Fever
Cough
All of the above (correct answer)
Chest pain
Fever
Cough
All of the above (correct answer)
Chest pain
Lysis of adhesions should always be coded if mentioned in the operative report.
False
Alcoholism can cause both hepatitis and cirrhosis
True
If the appendix ruptures, ___________develops.
peritonitis
A peptic ulcer can occur in the:
stomach
esophagus
duodenum, jejunum, ileum
all of the above (correct)
esophagus
duodenum, jejunum, ileum
all of the above (correct)
Mechanical obstruction of the intestine may be caused by:
neoplasm
adhesions
herniation
all of the above (correct)
adhesions
herniation
all of the above (correct)
Hematemesis is defined as:
vomiting of blood
Cholelithiasis is a condition of stones in the:
gallbladder
If a physician documents both diverticulosis and diverticulitis:
code diverticulitis only
A cholecystectomy can be performed by an open approach or laparoscopically.
True
An inguinal hernia can be unilateral or bilateral.
True
The patient has a diagnosis of upper esophageal stricture and a history of COPD. An EGD with dilatation of the stricture is performed.
K22.2, J44.9, 0D718ZZ
The squeezing or movement of food toward the stomach and down the digestive tract is called ____.
peristalsis
A patient is admitted for chemotherapy for pancreatic cancer and develops ulcerative mucositis of the mouth due to gemcitabine.
Z51.11, C25.9, K12.31, T45.1X5, 3E03305
____ is the abnormal condition of stones in the gallbladder.
Cholelithiasis
Patient with known alcoholic cirrhosis of the liver is admitted with ascites and acute bacterial peritonitis due to Staphylococcus aureus. Patient is a recovering alcoholic who has been in remission for 2 years.
K65.0, K70.31, F10.21, B95.61
The ER physician documents that the patient is being admitted for hematemesis. The patient has an Hct of 24.3. A transfusion of PRBC is administered, and the patient is taken to the OR for an EGD. The EGD reveals that the patient has an acute perforated duodenal ulcer that is causing the bleed. The ulcer is cauterized. The patient is treated with IV antibiotics, omeprazole, and NG tube. The discharge summary lists an additional diagnosis of acute blood loss anemia.
K26.2, D62, 0D598ZZ, 30233N1
Code ____ is coded for personal history of malignant neoplasm of the GI tract, unspecified.
Z85.00
Which Z code is associated with family history of digestive disorders
Z83.79
Patient presents to the ER with severe abdominal pain. The patient has a history of Crohn’s disease. She had asthma as a child and currently appears dehydrated. After study it is determined that the patient has an abscess of the large intestine. Antibiotics are administered, as well as IV fluids with potassium to treat the dehydration and hypokalemia.
K50.914, E87.6, E86.0
Patient with malignant neoplasm of the descending colon is admitted for left hemicolectomy and temporary descending colostomy.
C18.6, 0DTG0ZZ, 0D1M0Z4
All of the following are functions of the liver EXCEPT that it ____.
stores and releases bile
An indirect hernia occurs when the protrusion is through the inguinal ring into the inguinal canal; this is different from a direct hernia.
True
Symptoms of gastric ulcers may include pain when eating, vomiting, and tarry bowel movements.
True
Ostomies are surgically created openings into the body. Enterostomies and colostomies are created to discharge waste products from the body.
Both statements are true.
____ means bright red in the stool.
Hematochezia
A patient presents with melena, weakness, and fatigue. A colonoscopy with biopsy of the rectum and colon is performed and reveals multiple diverticula and internal hemorrhoids. The path shows possible inflammatory bowel disease. No source of bleeding is identified. Discharge Diagnosis: GI bleed; chronic blood loss; anemia.
K92.1, D50.0, K57.30, K64.8, 0DBE8ZX, 0DBP8ZX
A patient is admitted with Crohn’s disease of the large bowel. A right hemicolectomy is performed with temporary ascending colostomy. The patient is malnourished and was dehydrated on admission. Postoperatively, the patient’s potassium levels are monitored, and the hypokalemia is treated with K-Dur.
K50.10, E46, E86.0, E87.6, 0DTF0ZZ, 0D1K024
What drug could be given to treat GERD?
Prilosec
The mouth is where digestion begins.
True
Patient comes to the ER with severe abdominal pain and a long history of alcoholism. Physician documents that patient is currently drinking a fifth of liquor a day. Patient is admitted to the hospital with a diagnosis of acute pancreatitis secondary to alcohol use.
K85.9, F10.10
Hives and _____________are synonymous terms.
urticaria
Decubitus ulcers can progress to ____________if not treated.
osteomyelitis
When cellulitis is associated with a skin ulcer, code:
cellulitis and the skin ulcer
STSG stands for:
split-thickness skin graft
Cellulitis associated with an open wound requires two codes with cellulitis always sequenced as principal.
False
An autograft is a graft from:
one area of the body to another in the same individual
Decubitus ulcers are coded the same as all other ulcers
False
Scrubbing or washing devitalized tissue is known as:
nonexcisional debridement
Incision and drainage is coded the same as a debridement.
False
Cellulitis is typically treated with
antibiotics
Patient has a pressure ulcer of the left ankle on admission, which is documented as a stage I and progresses to a stage III during the course of the stay. The patient is a paraplegic.
L89.523, G82.20
In ICD-10-CM decubitus ulcers use a combination code for location and stage.
True
Skin grafts can be only full-thickness skin grafts.
False
Which layer of the skin is composed of fibrous connective tissue?
Middle Layer
A(n) ____ is a skin graft from one person to another.
allograft
Patient stepped on a piece of glass and injured his foot 2 days ago. He is now being admitted to the hospital for treatment of cellulitis in the left leg. He has a past history of depression with anxiety for which he takes medicine. He is currently on antibiotics for acute bronchitis.
L03.116, S91.312A, F41.8, J20.9, W25.xxxA
Pulse lavage debridement is performed by wound care nurse on a patient with a stage 3 decubitus ulcer of the right ankle. The patient is taking medications for diabetes and for high cholesterol.
L89.513, E11.9, E78.0, 0HDKXZZ
The code for the stage of a pressure ulcer should be used as the principal diagnosis.
False
A nursing home patient is admitted with an enlarging stage 3 sacral decubitus ulcer for wound care. The patient had a previous CVA with right hemiplegia and aphasia and is on medications for atrial fibrillation and Alzheimer’s dementia.
L89.153, I69.351, I69.320, I48.91, G30.9, F02.80
The functions of the integumentary system include all of the following EXCEPT ____.
vitamin A synthesis
A(n) ____ is a skin graft to an individual from another species, such as a pig.
xenograft
Pressure ulcers require two codes.
True
Clusters of boils are known as a ____.
carbuncle
A patient has a chronic ulcer of the right great toe with skin breakdown only and is admitted for excisional debridement of the skin. The patient has a medical history significant for COPD, asthma, and CAD.
L97.511, J44.9, I25.10, 0HBMXZZ
Patient was admitted because of the development of blistering and erosion of skin and mucous membranes. About 5 days ago, the patient had fever, sore throat, and headache and was thought to have influenza. The patient was diagnosed with Stevens-Johnson syndrome.
L51.1, Z86.19
On the discharge summary, the provider documents the following discharge diagnoses: exacerbation of COPD, hypertension, hyperlipidemia, and a healing sacral decubitus.
J44.1, I10, E78.5, L89.159
Another name for a pressure ulcer is a decubitus ulcer.
True
A patient comes to the ER with a crusty, itchy rash. The diagnosis is impetigo of the legs with cellulitis. The patient is admitted to treat the cellulitis.
L03.115, L03.116, L01.00
A patient is admitted from the nursing home with suspected aspiration pneumonia. The attending physician documents that the patient has pressure ulcers on both buttocks. The left side has a stage II ulcer and the right side has a stage I ulcer.
J69.0, L89.322, L89.311
What are the two most common bacteria associated with skin infections?
1. Streptococcus pyogenes
2. Escherichia coli
3. Staphylococcus aureus
4. Treponema pallidum
5. Pseudomonas aeruginosa
1. Streptococcus pyogenes
2. Escherichia coli
3. Staphylococcus aureus
4. Treponema pallidum
5. Pseudomonas aeruginosa
1 and 3
An infant is admitted for placement of a ventriculoperitoneal shunt for hydrocephalus. The patient has lumbar spina bifida.
Q05.2, 00160J6
A patient with known metastatic cancer to the ribs is admitted for pain control. The patient has a history of lung cancer, which was surgically excised. The patient is administered Fentanyl
G89.3, C79.51, Z85.118
A patient is admitted with an acute change in mental status. Patient has a history of CHF, DMII, and prostate cancer. Patient had a prostatectomy 2 years PTA. Upon completion of the lab work, the physician documents metabolic encephalopathy due to urinary tract infection.
G93.41, N39.0, I50.9, E11.9, Z85.46
A patient was admitted for acute pain control after falling off a ladder and suffering two broken ribs on the right side. The patient was admitted for pain control.
G89.11, S22.41xA, W11.xxxA
Patient is admitted for a spinal fusion at L2-L3. For many years, the patient has suffered from chronic back pain secondary to a herniated disc at L2-L3, which was removed during the fusion. The physician performed an XLIF procedure with the insertion of an interbody fusion device. This procedure was performed percutaneously via an anterior approach to the anterior column.
M51.26, 0SG03A0, 0SB23ZZ
Patient came to the ER after falling off her horse at the county fair rodeo. X-rays reveal two fractured ribs on the left. Patient is admitted for acute pain control.
G89.11, S22.42xA, V80.010A, Y92.39, Y93.52
A patient is admitted for pain control. The patient has metastatic prostate cancer to the vertebrae and liver. The patient is started on a PCA pump, and pain is more manageable.
G89.3, C61, C78.7, C79.51
A disorder of the brain that causes a progressive decline in mental and physical function is called
Alzheimer’s disease
In ICD-10-CM there are three chapters for the nervous system and sense organs.
True
Patient is admitted for a senile cataract in the right eye to be removed by phacoemulsification with IOL replacement via percutaneous approach.
H25.9, 08RJ3JZ, 08DJ3ZZ
All of the following are symptoms of meningitis EXCEPT
sensitivity to darkness
headache
vomiting
headache
vomiting
A patient with trigeminal neuralgia and a history of migraine headaches is admitted for an open rhizotomy. A day after the procedure, the patient develops a severe headache diagnosed as a nonintractable migraine.
G50.0, G43.909, 008K0ZZ
Which of the following is the most common diagnostic test for epilepsy?
EEG
A patient with intractable epilepsy presents for open implantation of a single array neurostimulator pulse generator with leads. The generator was placed in the chest and the leads were placed in the neck attached to the vagus nerve.
G40.919, 0JH60BZ, 00HE0MZ
What drug could be given to treat epilepsy?
Dilantin
Patient comes to the ER with high fever and headache. Meningitis is suspected. A lumbar puncture is performed and reveals bacterial meningitis.
G00.9, 009U3ZX
What drug could be given to treat Alzheimer’s?
Aricept
Only the brain is covered by bone; the spinal cord is not
False
A college student is admitted with fever, headache, and a stiff neck. Lumbar puncture is performed in the ER, and lab results reveal pneumococcal meningitis. The patient is given IV fluids for volume depletion and high doses of penicillin to treat meningitis.
G00.1, E86.9, 009U3ZX
Bacterial Meningitis is
treated with antibiotics
Psychosis is defined as:
an impairment of the mental state in which the perception of reality has become distorted
Different types of schizophrenia include:
catatonic
paranoid
disorganized
all of the above (Correct Answer)
paranoid
disorganized
all of the above (Correct Answer)
Alcohol withdrawal symptoms include:
shakiness and sweating
seizures
delirium tremors
all of the above (Correct Answer)
seizures
delirium tremors
all of the above (Correct Answer)
Dyslexia is defined as a learning disability that affects a child’s ability to:
understand or use spoken or written language
Panic disorder is defined as:
a terrifying experience that occurs suddenly without warning
Alcoholism/dependence is the same as alcohol abuse in ICD-10-CM classification.
False
There are several levels of severity that accompany intellectual disability.
True
Alteration between mania and depression back and forth very quickly is:
mixed mood disorder
Psychosis can be drug induced.
True
In ICD-10-CM, the nicotine dependence codes identify the type of nicotine product such as cigarettes, chewing tobacco, or other tobacco product.
True
Which of the following is NOT a sign/symptom of alcoholism?
Visual hallucinations
Disorganized thinking
Paranoia
None of the above are correct. (correct answer)
Disorganized thinking
Paranoia
None of the above are correct. (correct answer)
Patient was admitted with delirium tremens as a result of alcohol withdrawal. Patient has had a bout of acute gastroenteritis and has not had a drink for a couple of days. Patient was admitted and was started on IV fluids and a banana bag. Patient is hypokalemic with a potassium of 3.0 and is dehydrated. Patient’s potassium was repleted with oral medication.
Final Diagnoses: Acute gastroenteritis.
Alcohol withdrawal.
Hypokalemia.
Final Diagnoses: Acute gastroenteritis.
Alcohol withdrawal.
Hypokalemia.
F10.231, K52.9, E87.6, E86.0
A patient is admitted following seizure-like activity. It is determined that the patient has a conversion disorder with seizures.
F44.5
A 28-year-old man was brought to the ER by a friend who stated that the patient had been acting bizarrely. The patient has been irritable, pacing the apartment, and talking nonstop. He was admitted to the psychiatric unit for management of his manic symptoms.
Final Diagnosis: Bipolar affective disease.
Severe manic phase.
Recurrent episode with psychosis
Final Diagnosis: Bipolar affective disease.
Severe manic phase.
Recurrent episode with psychosis
F32.2
Organic psychosis occurs because of deterioration in the brain and is usually progressive and irreversible.
True
Stress can be a contributing factor in mental disorders.
True
In ICD-10-CM, a past history of drug and alcohol abuse is assigned codes for “in remission.”
False
Patient was seen in the ER for dizziness, fatigue and difficulty concentrating. Patient was seen for a head injury a couple of weeks ago. Physician documents postconcussional syndrome.
F07.81
Severe intellectual disability is classified when the person has an IQ of ____.
20 to 34
Patient was admitted to the psychiatric floor for evaluation of mood disorder. After extensive testing and evaluation, it was determined that patient was suffering from major depression that is severe in nature and that some psychotic features are present.
Final Diagnosis: Major depressive disorder, severe with psychosis.
Final Diagnosis: Major depressive disorder, severe with psychosis.
F32.3
A patient is admitted for treatment of anorexia nervosa. The patient has moderate malnutrition, severe electrolyte imbalance, and nutritional cardiomyopathy.
F50.00, E44.0 E87.8, I43
Seizures are a common form of alcohol withdrawal.
True
A patient is admitted to the hospital for confusion. According to the family, the patient has been more difficult to manage at home and no longer is able to care for himself. The patient has known Alzheimer’s disease. No medical cause could be determined for the patient’s increasing confusion, and it is believed that nursing home placement is appropriate.
Discharge Diagnosis: Alzheimer’s dementia.
Discharge Diagnosis: Alzheimer’s dementia.
G30.9, F02.80
Mental disorders are very particular about the body system they affect.
False
What drug could be given to treat depression?
Zoloft
What drug could be given to treat ADD or ADHD?
Ritalin
Patient was admitted because of aggressive behavior and wandering. Neurology diagnosed dementia due to Lewy bodies.
G31.83, F02.81, Z91.83
Patient was admitted for psychiatric care for acute posttraumatic stress disorder.
F43.11
Graves’ disease is the most common form of:
hyperthyroidism
An enlarged gland is called:
hyperplasia
Type 2 diabetes is much more common than type 1 diabetes
True
Bariatrics is the branch of medicine concerned with the management of:
obesity and allied diseases
If there is unclear documentation as to whether a patient is a type 1 or type 2 diabetic, the coder should:
code type 2 diabetes
Diabetes coding is affected by whether the patient is a type 1 or type 2 diabetic.
True
Major endocrine gland(s) include:
pituitary
thyroid
pancreas
all of the above (correct)
thyroid
pancreas
all of the above (correct)
A cause-and-effect relationship is presumed with all diabetic manifestations.:
False
Volume depletion, dehydration, and hypovolemia all classify to the same ICD-10-CM code.
False
When a patient is admitted for a complication of cystic fibrosis:
the complication is the principal diagnosis and the cystic fibrosis is secondary
The ____ regulate(s) daily patterns of sleep and wakefulness and inhibit(s) hormones that affect ovaries.
pineal gland
Adult patient was seen in the clinic for dietary counseling for dysmetabolic syndrome X. Patient is obese with a BMI of 35 and has hypertriglyceridemia and hypertension.
Z71.3, E88.81, E66.9, Z68.35, E78.1, I10
Hypothyroidism is an abnormality of the thyroid gland in which secretion of thyroid hormone is usually increased.
False
All of the following are possible signs of malnutrition EXCEPT ____.
rapid hair growth
Patient with steroid-induced diabetes due to long-term use of prednisone taken for rheumatoid arthritis.
E09.9, T38.0x5S, M06.9
Diabetes mellitus without mention of complication would NOT have any additional manifestation codes.
True
A patient is admitted for care of a diabetic ulcer on the left midfoot. The patient also has chronic kidney disease, stage 3, resulting from diabetes.
E11.621, L97.429, E11.22, N18.3
Gigantism occurs when there is hypersecretion of hGH before puberty and when there is a proportional overgrowth of all body tissues, especially the long bones.
True
A patient is admitted because of cystic fibrosis with pulmonary exacerbation. Sputum cultures grew Pseudomonas, and antibiotics are adjusted accordingly. The patient is also treated for hypertonic dehydration.
E84.0, B96.5, E87.0
A 15-year-old male patient with cystic fibrosis was diagnosed at the age of 2 and has respiratory and gastrointestinal manifestations. Patient needs a PEG tube to maximize his nutritional status. A percutaneous gastrostomy tube is inserted, and feeds are initiated. The patient’s mother is instructed on gastrostomy care and tube feedings.
Final Diagnosis: Cystic fibrosis.
Moderate malnutrition.
Procedure: Percutaneous endoscopic gastrostomy placement.
Final Diagnosis: Cystic fibrosis.
Moderate malnutrition.
Procedure: Percutaneous endoscopic gastrostomy placement.
E84.19, E44.0, E84.0, 0DH63UZ, 3E0G36Z
When blood sugar becomes abnormally low, this is called ____.
hypoglycemia
In ICD-10-CM there are only two category codes for diabetes mellitus.
False
Patient is an elderly gentleman who was admitted from the ER with pain and swelling of his right knee. The pain is throbbing in nature, and the knee feels warm and is very tender to touch. The patient has a knee x-ray, and uric acid levels are elevated. Colchicine is started, and the patient’s symptoms are much improved within 48 hours. The patient has diabetes. The patient is advised to limit alcohol consumption and to avoid dietary purines.
Final Diagnosis: Gouty arthropathy right knee.
Diabetes mellitus, type 2 on insulin.
Final Diagnosis: Gouty arthropathy right knee.
Diabetes mellitus, type 2 on insulin.
M10.061, E11.9, Z79.4
In ICD-10-CM, if the diabetes is due to an adverse effect of a drug, there is an Instructional note to assign a T36-T50 code as an additional or secondary code.
True
Hypopituitarism (low levels of pituitary hormones) can be caused by ____.
tumor
stroke
head trauma
all of the above (correct)
stroke
head trauma
all of the above (correct)
Which of the following is NOT a major endocrine gland in the body?
Parotid
A patient is admitted because of uncontrolled diabetes resulting from Cushing’s syndrome. Patient is on insulin.
E24.9, E08.65, Z79.4
The ____ regulates metabolism of glucose in body cells and maintains proper blood glucose
pancreas
A patient is admitted with hypokalemia. What drug could be given to treat this condition?
K-Dur
A patient is admitted with hyperkalemia. What drug could be given to treat this condition?
Kayexalate
Spinal fusion is:
the creation of a solid bone bridge between two or more adjacent vertebrae
Scoliosis is
a lateral or sideways curvature of the spine
A pathologic fracture is a break in a bone that occurs because of:
underlying disorders that weaken the bone
ICD-10-CM identifies the following cause(s) for pathologic fractures:
neoplastic disease
Percutaneous vertebroplasty is a technique used to treat pain caused by:
compression fracture of the vertebrae
Malunion and nonunion are synonymous terms.
False
A family history of arthritis:
is coded as Z82.61
The etiology of polymyalgia rheumatica is:
unknown
Systemic lupus erythematosus (SLE) is a:
chronic, inflammatory autoimmune disease that can damage connective tissue
Primary osteoarthritis is related to:
the aging process
What drug could be given to treat rheumatoid arthritis?
Celebrex
The patient was admitted to the hospital because of severe left hip pain that is often worse during the night. X-rays of the hip were taken in the ER. A preliminary report showed that the patient possibly had Paget’s disease of the left femur, which was responsible for the patient’s pain. Alkaline phosphatase was elevated, and a bone scan was done to determine the extent of the disease.
Final Diagnoses: Severe hip pain due to Paget’s disease.
Final Diagnoses: Severe hip pain due to Paget’s disease.
M88.852
An 83-year-old woman with severe back pain is admitted. CT shows osteoporosis and possible compression fracture of the lumbar spine. The patient is seen by interventional radiology, and a percutaneous vertebroplasty and reduction of fracture is performed.
Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.
Discharge Diagnosis: Pathologic fracture of lumbar vertebra due to senile osteoporosis.
M80.08xA, 0QU03JZ, 0QS03ZZ
A pediatric patient was admitted with a pathologic fracture of the proximal right humerus. Radiographic evidence suggests that the fracture was caused by a unicameral bone cyst. An orthopedic consult was obtained to see whether this should be treated surgically. It was decided to treat conservatively and monitor healing with serial x-rays.
Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.
Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.
M84.621A, M85.421
____ is an exaggerated inward curvature of the spine that may be caused by increased abdominal girth due to obesity, pregnancy, or abdominal tumors.
Lordosis
Osteomyelitis is an infection of the bone that often starts in another part of the body and is spread by the blood.
True
What drug could be given to treat osteoporosis?
Fosamax
ICD-10-CM has a combination code for osteoporosis with pathologic fracture.
True
The patient was admitted from the ER for chest pain to rule out MI. The patient also had some difficulty breathing and pain when taking a deep breath. The patient does have a family history of ischemic heart disease and is positive for the following cardiac risk factors: male, older than age 65, hypertension, smoker, and overweight. After evaluation and monitoring, an MI was ruled out. Cardiology thought the most likely cause for his chest pain was costochondritis.
Final Diagnoses: Chest pain due to costochondritis.
Hypertension.
Smoker, current nicotine dependence (cigarettes).
Overweight.
Family history of ischemic heart disease.
Final Diagnoses: Chest pain due to costochondritis.
Hypertension.
Smoker, current nicotine dependence (cigarettes).
Overweight.
Family history of ischemic heart disease.
M94.0, I10, F17.210, E66.3, Z82.49
Pathologic fracture of distal left femur due to osteosarcoma of femur.
M84.552A, C40.22
____ is when one vertebra slips on another.
Spondylolisthesis
Subacute osteomyelitis of sacrum with decubitus sacral ulcer, stage 3. Staphylococcus aureus is the causative organism.
M46.28, L89.153, B95.61
A patient is admitted for a total hip replacement with a metal-on-polyethylene prosthesis because of primary osteoarthritis of the right hip. Patient has had a previous left hip replacement.
M16.11, Z96.642, 0SR902Z
____ is one of the most common diseases affecting the muscles; it is characterized by widespread muscle pain associated with chronic fatigue.
Fibromyalgia
ICD-10-CM has different codes to identify laterality for many musculoskeletal conditions.
True
Which of the following make(s) up the musculoskeletal system?
Tendons
Cartilage
All of the above (correct)
Ligaments
Bones
Cartilage
All of the above (correct)
Ligaments
Bones
Patient with a family history of rheumatoid arthritis is being screened for rheumatoid arthritis.
Z13.828, Z82.61
A patient is admitted to rule out lupus nephritis. The patient was diagnosed with lupus 5 years ago. A percutaneous left kidney biopsy is performed, and lupus nephritis is confirmed.
M32.14, 0TB13ZX
____ are the connective tissues that attach muscle to bones.
Tendons
ICD-10-CM uses the sixth character extension when coding pathologic fractures.
False
Breast codes are classified only for female patients.
False
Acute renal failure cannot be present with chronic renal failure.
False
Extracorporeal shock wave lithotripsy is used to treat:
urinary tract calculi
ICD-10-CM presumes a cause-and-effect relationship between renal failure and diabetes.
false
Cystitis is a lower urinary tract infection that affects the:
none of these
ICD-10-CM presumes a cause-and-effect relationship between renal failure and hypertension.
True
The term chronic renal failure has been changed to the more precise term of:
Chronic kidney disease
According to ICD-10-CM, the term urosepsis classifies to:
see condition
Endometriosis can be found in the:
all of the above
Different types of incontinence include:
stress
urge
overflow
all of the above
urge
overflow
all of the above
A patient is admitted to the hospital for a percutaneous left kidney biopsy, which confirms Berger’s disease.
Discharge Diagnosis: Berger’s disease.
Discharge Diagnosis: Berger’s disease.
N02.9, 0TB13ZX
Patient was seen in the ER with left flank pain. Discharge diagnosis is stone, left kidney.
N20.0
ICD-10-CM classifies chronic kidney disease based on severity.
True
A patient is admitted to the hospital with fever and chills, flank pain, and burning on urination with increased frequency. CT scan shows stranding around the right kidney consistent with pyelonephritis. Urine culture is positive for Proteus mirabilis. The patient has a long history of obstructive uropathy due to BPH.
Final Diagnosis: Fever due to acute pyelonephritis due to Proteus mirabilis.
Obstructive uropathy due to benign prostatic hypertrophy.
Final Diagnosis: Fever due to acute pyelonephritis due to Proteus mirabilis.
Obstructive uropathy due to benign prostatic hypertrophy.
N10, B96.4, N40.1, N13.8
The main parts of the male genital or reproductive tract include the testes, epididymis, vas deferens, seminal vesicles, prostate, and penis.
True
In ICD-10-CM there is a code to identify postprocedural renal failure.
True
Which of the following is NOT a common genitourinary condition?
Diabetes
A patient is admitted to the hospital for fluid overload due to noncompliance with attending renal dialysis sessions. Patient has stage 5 CKD. Multiple sessions of hemodialysis are performed.
E87.70, N18.6, Z91.15, 5A1D60Z
A patient is admitted to the hospital with ARF due to dehydration. The patient is treated with IV fluids.
N17.9, E86.0
Which of the following can be detected by a urinalysis test
Kidney stones
Diabetes
Cystitis
All of the above (correct answer)
Diabetes
Cystitis
All of the above (correct answer)
Which of the following is/are Z code(s) that may be used with diseases of the genitourinary system?
Z16.21 Resistance to vancomycin
Z87.448 Personal history of other diseases of urinary system
Z93.59 Artificial opening status, other cystostomy
All of the above (correct answer)
Z87.448 Personal history of other diseases of urinary system
Z93.59 Artificial opening status, other cystostomy
All of the above (correct answer)
A patient is admitted with acute pyelonephritis. Blood cultures are negative, but urine cultures are positive for E. coli. The patient is treated with IV fluids and antibiotics.
Discharge Diagnosis: Acute pyelonephritis due to E. coli.
Discharge Diagnosis: Acute pyelonephritis due to E. coli.
N10, B96.20
The patient was admitted for treatment of BPH with urinary retention and a history of frequent urinary tract infections. The patient’s PSA was normal. A TURP was performed. The patient recovered uneventfully with only minimal hematuria, which had resolved by the time of discharge.
Final Diagnosis: Benign prostatic hypertrophy.
Procedure: Transurethral resection of prostate.
Final Diagnosis: Benign prostatic hypertrophy.
Procedure: Transurethral resection of prostate.
N40.1, R33.8, Z87.440, 0VB08ZZ
Sometimes to assign the correct codes, it is necessary to question the physician to be sure the correct meaning was interpreted and the correct code was assigned, like the term urosepsis.
True
A patient is admitted to the hospital for further evaluation of stage 4 kidney disease. The patient is known to have been born with only one kidney, and on routine checkup it was found that the patient’s kidney function was markedly abnormal. One year ago, the patient’s laboratory tests were relatively normal. The patient’s blood pressure was monitored, and it was decided that medications would be necessary to treat the patient’s hypertension. The patient was advised about fluid intake and restriction and dietary considerations regarding protein and potassium. Referral was made to a nephrologist because the CKD appears to be progressing rapidly, and arrangements may be necessary for dialysis.
Final Diagnosis: Chronic progressive renal failure, stage 4. Hypertension
Final Diagnosis: Chronic progressive renal failure, stage 4. Hypertension
I12.9, N18.4, Q60.0
When the site is known, urinary tract infections are assigned codes based on the site of the infection.
true
If causative bacteria are documented by the physician, this code should NEVER be coded in addition to the urinary tract infection.
false
A patient was admitted for investigation of microscopic hematuria. The patient plans to donate a kidney to a family member, and any renal disease must be ruled out. The patient had a percutaneous needle biopsy of the left kidney. The patient has a past medical history of GERD, which is treated with Nexium, and had a pneumothorax caused by an MVA several years ago.
Final Diagnosis: Kidney donor with microscopic hematuria.
Procedure: Diagnostic kidney biopsy.
Final Diagnosis: Kidney donor with microscopic hematuria.
Procedure: Diagnostic kidney biopsy.
R31.2, K21.9, 0TB13ZX
Patient was admitted to the hospital with acute renal failure due to dehydration. Patient will have to be rehydrated slowly due to CHF. Patient also has diabetic nephropathy.
N17.9, E86.0, I50.9, E11.21
____ is a lower urinary tract infection that affects the bladder.
Cystitis
Hydronephrosis is the abnormal ____________________ of the renal pelvis caused by pressure from urine that cannot flow past an obstruction in the urinary tract.
dilation
The only time a coder would not use a code from Chapter 11 is if the physician states that the pregnancy is incidental to the reason for the encounter.
True
For initial confirmation of a pregnancy, a woman’s blood or urine is tested for _______levels.
hCG
When coding a pregnant woman with HIV infection, follow the guidelines for:
pregnancy coding (sequence pregnancy code as principal)
For a normal delivery, the diagnosis codes for the mother are:
O80, Z37.0
Gestational diabetes:
occurs in a patient who was not diabetic before pregnancy
All patients who deliver require at least _____diagnosis code(s).
Two
Adverse effects occurring in a pregnant patient are assigned a principal diagnosis code from category T36-T50
False
When a fertilized egg is implanted outside of the uterine cavity, it is called a(n):
ectopic pregnancy
An episiotomy is considered a complication of delivery, and a O80 diagnosis code cannot be coded on the mother’s chart.
False
Another term for “before delivery” is:
antepartum
The patient is admitted in labor at term. After lab work is completed, it is noted that the patient has a UTI and appears to be preeclamptic. The patient goes on to vaginally deliver a healthy baby boy.
O23.43, O14.93, Z3A.38, Z37.0, 10E0XZZ
The patient is admitted to the hospital in preterm labor. She is 27 weeks pregnant. Terbutaline is administered, and the patient remains on bed rest. In the third week of bed rest, her water breaks, and she is taken to the delivery room. She vaginally delivers a baby girl.
O60.13×0, Z37.0, Z3A.27, 10E0XZZ
If code O80 is assigned, other codes in the O00-O9A range should also be assigned, if applicable
False
A pregnant woman at 39 weeks presents to the hospital for delivery of known quadruplets. She is taken to the operating room for a cesarean section (LTCS). As the babies are delivered, it is discovered that one has died in utero.
O30.203, O36.4xx0, Z3A.39, Z37.62, 1ODOOZ1
The patient is 9 weeks pregnant. She is admitted for an elective abortion. The physician performs a vacuum D&C to terminate the pregnancy.
Z33.2, 10A07Z6
Ectopic pregnancies occur in 1 in ____ pregnancies.
50
A woman is admitted at 22 weeks for insertion of a laminaria for termination of pregnancy. She delivers a liveborn fetus.
O60.12×0, Z3A.22, Z37.0, 10E0XZZ, 10A07ZW
A patient at 12 weeks is admitted for a therapeutic abortion due to a chromosome abnormality in the fetus. A D&C is performed, resulting in a complete abortion. Her postoperative course is complicated by shock due to acute blood loss secondary to hemorrhage with resulting anemia.
Z33.2, O04.6, O04.81, D62, O35.1xx0, Z3A.12, 10A07ZZ
In ICD-10-CM the final character indicates the episode of care.
False
When a vaginal delivery occurs, the principal diagnosis should correspond to the main circumstance or complication of the delivery.
True
Which of the following codes are correct when a normal pregnancy is coded?
O80 Normal delivery
Z37.0 Single liveborn
10E0XZZ Manually assisted delivery
All of the above
Z37.0 Single liveborn
10E0XZZ Manually assisted delivery
All of the above
The patient is admitted in labor at 38 weeks. She labors for 24 hours when it is noted that the baby is in fetal distress. The patient is taken to the OR for an emergency C-section (LTCS). She delivers a healthy baby.
O77.9, Z3A.38, Z37.0, 10D00Z1
What drug could be given to inhibit labor?
Terbutaline
What drug could be given to induce labor?
Pitocin
A patient is an elderly multigravida at 39 weeks who has come in for trial labor following previous cesarean. The patient has been taking iron for iron deficiency anemia and is obese. Labor progresses, but fetal decelerations require repeat LTCS. On day 2, the patient develops a fever and is treated with antibiotics for suspected endometritis.
O76, Z37.0, O34.21, O99.02, D50.9, O99.214, O86.12, O09.523, E66.9, Z3A.39, 10D00ZO
In ICD-10-CM there are 7th characters to specify the fetus affected by the obstetric condition.
True
When a cesarean delivery is performed, the principal diagnosis should correspond to the reason the cesarean delivery was performed unless the reason for admission was unrelated to the condition resulting in the cesarean delivery.
True
Coding a normal pregnancy requires only three diagnostic codes and one or more procedure codes
True
A gravid patient at 11 weeks presents for a routine prenatal visit. This patient had preeclampsia in her previous pregnancy and the physician documents high-risk pregnancy. She has blood work done on this visit and is found to be anemic. The physician prescribes an iron supplement.
O09.891, O99.011, D64.9, Z3A.11
In ICD-10-CM the diagnosis used for an elective abortion comes from the pregnancy chapter.
False
ICD-10-CM does NOT have separate categories for high-risk pregnant individuals.
False
In ICD-10-CM there are code extensions to specify the fetus affected by the obstetric condition.
True
Prematurity is based on recorded birth weight and gestational age and documentation of prematurity.
True
Congenital conditions are always present, well defined, and diagnosed at birth.
False
In most cases, pregnancies with chromosomal anomalies end with a natural miscarriage.
True
Marfan syndrome:
affects the connective tissue
patients have skeletal defects
patients have cardiovascular problems
all of the above (Correct answer)
patients have skeletal defects
patients have cardiovascular problems
all of the above (Correct answer)
Treatment for jaundice includes:
phototherapy
A congenital anomaly is a condition that is:
present at birth
Newborns have their own set of MS-DRGs.
True
Down syndrome is also known as:
trisomy 21
Apgar score factors are:
heart, breathing, activity and muscle tone, grimace, appearance
Meconium is:
fecal matter in an infant’s intestine before birth
none of the above
none of the above
Tetralogy of Fallot is:
a congenital heart defect
All newborn charts must contain the following code:
Z38.-
Prematurity can be coded based on the gestational weeks.
False
Spina bifida is a curable congenital anomaly because there is a way to repair the damaged nerve tissue.
False
TNN (transitory tachypnea of newborn) means the infant ____.
retains lung fluid
Bronchopulmonary dysplasia (BPD) is a chronic lung disease that ____.
1. is present immediately at birth
2. develops in the first 4 weeks of life
3. develops in the first year of life
4. happens only in full-term infants
5. is most likely to occur in premature infants
6. is most likely to occur in infants that weigh less than 1500 grams
1. is present immediately at birth
2. develops in the first 4 weeks of life
3. develops in the first year of life
4. happens only in full-term infants
5. is most likely to occur in premature infants
6. is most likely to occur in infants that weigh less than 1500 grams
2, 5, and 6 only
When locating infections of the newborn, it is best to look under the main term for the infection and then to look for a subterm of newborn, fetal, or congenital.
True
Newborn is delivered vaginally. The baby was premature at 34 weeks and weighed 1842 grams. Meconium staining was noted at delivery.
Z38.00, P07.17, P07.37, P96.83
If the baby scores a ____ or higher on the Apgar test 1 minute after birth, he or she is considered to be healthy.
7
The child was admitted for repair of cleft lip and cleft soft and hard palate. He is an ex-33-week preemie. A repair of both the hard and soft palate and lip is performed by external approach.
Q37.5, P07.36, 0CQ0XZZ, 0CQ2XZZ
An infant is born via vaginal delivery with intrauterine growth retardation. The baby is born at 33 weeks and weighs 1800 grams. Meconium aspiration is noted at delivery. Jaundice is treated with phototherapy.
Z38.00, P07.17, P07.32, P24.00, P59.0, 6A600ZZ
Shouldn’t code be P07.37
The A in the Apgar test given to babies stands for ____.
appearance
There is abnormal fetal heart rate or rhythm during labor, and infant is therefore delivered by C-section. Mother was instructed on discharge to put the baby in front of the window in the sun to alleviate the mild jaundice. In addition, a lactation consult was performed during this stay as the baby was having difficulty breast-feeding.
Z38.01, P03.811, P92.5, P59.9
There is no cure for Down syndrome, but the risk increases the older the mother is during her pregnancy.
True
Child is seen in pediatrician’s office. She has a diagnosis of Down syndrome with ADD, sleep apnea, and mild mental retardation. Her medications are reviewed and a suggestion is made to have a sleep study.
Q90.9, F70.0, G47.30, F90.0
Which of the following is NOT a congenital condition?
Jackson’s syndrome
Which of the following makes a condition clinically significant?
The condition requires a clinical evaluation.
The condition requires therapeutic treatment.
The condition requires an extended hospital stay.
**All of the above are correct.
The condition requires therapeutic treatment.
The condition requires an extended hospital stay.
**All of the above are correct.
Cleft lip occurs in approximately 1 in every 2000 babies.
False
Newborn is delivered vaginally and is ruled in for group B strep sepsis.
Z38.00, P36.0
An infant is born by cesarean section. On examination, the infant is noted to have neonatal teeth and strawberry nevus on the left leg.
Z38.01, K00.6, Q82.5
Status post below the knee amputation (right) is coded as:
Z89.51
Open wound codes are used for surgical wounds, nontraumatic wounds, and ulcers.
False
An open fracture includes:
compound
missile
puncture
all of the above
missile
puncture
all of the above
The most common causes of spinal cord injury are motor vehicle accidents.
True
A superficial injury is always coded in addition to any more serious injury at the same site.
False
It is appropriate to add codes identifying blood vessel injuries in addition to fractures and dislocations.
True
A common cause of a pathologic fracture in female patients is:
osteoporosis
If a fracture is not specified as open or closed, it is coded as a(n):
closed fracture
Most injuries are diagnosed with the use of
imaging procedures such as x-ray, MRI, CT scan, ultrasound
LOC stands for:
loss of consciousness
The patient (civilian) has chronic posttraumatic stress syndrome following a terrorist attack, subsequent encounter.
F43.12, Y38.9x2S
All of the following are symptoms of fat embolism syndrome EXCEPT ____.
decreased temperature
An open fracture occurs when the bone is broken but the skin remains intact.
false
In ICD-10-CM, if a fracture is not specified, it is coded to nondisplaced.
true
Which of the following is NOT a common site for a laceration?
Stomach
External cause codes identify ____.
the activity at the time of the event
the cause of an injury
the intent or place of occurrence
all of the above (all of the above)
the cause of an injury
the intent or place of occurrence
all of the above (all of the above)
A ____ is a stretch and/or tear of a ligament.
sprain
All of the following are true of external cause codes EXCEPT they capture____.
how to screen patients
In ICD-10-CM, there are more Instructional notes for the coder to also code any associated injuries.
True
When coding injuries, assign separate codes for each injury unless a combination code is provided.
True
Small piece of grass from mowing lawn at a single-family house stuck on right cornea. Grass was removed. Assign injury and procedure codes only.
T15.01xA, 08C8XZZ
Patient was seen with an abrasion with laceration of the left knee, initial encounter. Assign only the injury code.
S81.012A
The patient was admitted for observation after an accident at work. The patient, who does construction work, fell into a pit but was quickly rescued by co-workers. CT scan and x-rays were taken to evaluate for internal injury. No respiratory issues were noted. On the following morning, the patient had no complaints and was discharged to home.
Discharge Diagnosis: Contusion on forehead.
Discharge Diagnosis: Contusion on forehead.
Z04.2, S00.83xA, W17.2xxA, Y92.69, Y99.0
The patient was the driver in an ATV rollover. The patient was intoxicated at the time of the accident and was not wearing a helmet. There was no LOC. CT of the head revealed a small subdural hemorrhage. The patient was observed closely for any change in mental status, and neurology was consulted. There was no need for operative intervention at this time. The patient was stable and was given instructions for follow-up.
S06.5x0A, F10.129, V86.59xA
In ICD-10-CM, complications of a fracture such as malunion or nonunion are reported with seventh character extensions for subsequent care with nonunion or malunion.
True
When the primary injury is to the blood vessels or nerves, that injury should be sequenced first.
True
A patient suffered a blowout fracture 1 week ago and is being seen by an orthopedic consultant. Assign only the injury code.
S02.3xxA
A ____ fracture is a common fracture in adults in which the lower end of the radius is fractured and the wrist and hand are displaced backward.
Colles’
A patient is admitted with a parietal bone fracture and fracture of the left fifth rib. Assign only the injury code.
S02.0xxA, S22.32xA
A third-degree burn is defined as:
full-thickness skin loss
MVA stands for:
motor vehicle accident
An adverse effect is:
a side effect or reaction to a drug that has been taken according to instructions
Codes T31 and T32 are used:
when the site of the burn is not specified
When coding different degrees of burns of the same site, assign the code or codes that identify:
the highest degree of the burn
Examples of poisonings include:
the wrong medication taken
the wrong dose of a medication taken
too much of a certain medication taken
all of the above (correct answer)
the wrong dose of a medication taken
too much of a certain medication taken
all of the above (correct answer)
Debridements can be performed:
at the bedside
in the operating room
by physical therapists, wound care nurses, and professionals other than physicians
all of the above (correct answer)
in the operating room
by physical therapists, wound care nurses, and professionals other than physicians
all of the above (correct answer)
A nonhealing burn is coded as an acute burn.
True
A corrosive burn is a thermal burn that is due to a heat source such as fire or a hot appliance.
False
The residual effect is usually sequenced first followed by the appropriate sequela (late effect) code.
True
When the reason for the admission or encounter is to provide treatment for external multiple burns, sequence first the code that reflects the burn of the highest degree.
True
Patient was admitted with second-degree burns of the left hand and first-degree burns of the left forearm. The patient touched a hot steam pipe.
T23.202A, T22.112A, X16.xxxA
All of the following are true of the “rule of nines” EXCEPT ____.
the anterior trunk is 9%
Debridements must always be done in the OR.
False
In a toxic poisoning, the toxic poisoning code (T36-T50) should be sequenced first, followed by the external cause code(s).
True
A patient combined prescription Percodan with beer and became stuporous and drowsy.
T40.2x1A, T51.0x1A, R40.1, R40.0
The patient was admitted with acute renal failure. The patient had been treated by Home Health with IV gentamicin for Pseudomonas pneumonia. The patient was experiencing some edema and decreased urine output. Blood was drawn, and the physician admitted the patient for IV fluids and investigation of the patient’s renal status. Gentamicin was stopped, and another antibiotic was given. The patient’s renal function returned to normal.
Final Diagnosis: Acute renal failure due to gentamicin.
Recent pneumonia.
Final Diagnosis: Acute renal failure due to gentamicin.
Recent pneumonia.
N17.9, T36.5x5A, J15.1
The patient was admitted with hematemesis. The patient has been taking NSAIDs as directed by the physician for arthritis pain. EGD showed that the patient had an acute erosive gastritis, most likely due to NSAIDs, that is the likely cause of the bleeding.
Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs.
Procedure: EGD with gastric biopsy.
Final Diagnosis: Erosive gastritis with hemorrhage due to NSAIDs.
Procedure: EGD with gastric biopsy.
K29.01, T39.395A, M19.90, 0DB68ZX
A patient has SIRS due to an accidental burn from the flames from a single-family house fire. The patient has full-thickness skin loss burns of the legs (11%) with second-degree burns of the trunk (4%)
T24.302A, T24.301A, T21.20xA, R65.10, T31.11, X00.0xxA, Y92.019
A 2-year-old child was admitted with an accidental electrical burn to the upper lip. The child was at home (single-family) and had bitten on an electrical cord. The mother immediately sought medical attention. The burn was a full-thickness burn. Local wound care was performed. The patient was not having any breathing problems. Further intervention will depend on how the burn heals.
Final Diagnosis: Full-thickness burn to upper lip due to electrical current.
Final Diagnosis: Full-thickness burn to upper lip due to electrical current.
T20.32xA, W86.0xxA, Y92.019
Debridement is one of the most common procedures performed on burn victims.
True
All of the following are to be considered when one is questioning whether a poisoning has occurred EXCEPT whether the ____.
medication was taken 30 minutes after the scheduled time
Patient admitted for a suicide attempt with multiple medications, including Naproxen, Keppra, and acetaminophen mixed with beer. Patient was somnolent on arrival in the ER.
T39.312A, T42.6x2A, T39.1x2A, T51.0x2A, R40.0
Patient was admitted with cocaine-induced chest pain.
T40.5x1A, R07.9, F14.10
Patient was seen in the ER for superficial frostbite, both ears. Patient was exposed to cold weather.
T33.011A, T33.012A, X31.xxxA
Patient is being treated with HBOT for decompression sickness when surfacing while scuba diving in the ocean.
T70.3xxA, W94.21xA, Y92.832, Y93.15, 6A150ZZ
The patient reported to the ER with nausea/vomiting and weakness. The patient is on OxyContin for chronic pain due to unresectable pancreatic cancer. The patient was in extreme pain and decided to double the OxyContin dosage. When this did not relieve the pain, the patient decided to drink a couple of shots of whiskey. The patient got very weak and called 911. The patient was volume depleted and was treated with IVs; his pain medications were adjusted.
Final Diagnosis: Accidental overdose of OxyContin.
Pain due to pancreatic cancer.
Final Diagnosis: Accidental overdose of OxyContin.
Pain due to pancreatic cancer.
T40.2x1A, T51.0x1A, C25.9, G89.3, R53.1, R11.2, E86.9
A patient was admitted because of an intentional overdose of Valium. The patient is in a coma.
T42.4x2A, R40.20
When the patient is admitted for burn injuries and other related conditions such as smoke inhalation, the circumstances of admission govern the selection of the principal or first-listed diagnosis.
True
The patient was brought to the ER by her mother. The patient admits to being beaten by her husband. X-rays showed three fractured ribs on the right and a spiral fracture of the right humerus. The humeral fracture was manipulated and was found to be in alignment on follow-up x-rays. The patient was given pain medications and was discharged to the care of her mother.
Final Diagnosis: Fracture of three ribs and shaft of humerus due to spousal abuse.
Procedure: Closed reduction of fracture right humerus.
Final Diagnosis: Fracture of three ribs and shaft of humerus due to spousal abuse.
Procedure: Closed reduction of fracture right humerus.
T74.11xA, S42.341A, S22.41xA, Y07.01, Y09, 0PSFXZZ
When coding infections due to a device, implant, or graft:
also code the specific infection
A dehiscence is:
an opening of a surgical wound
Iatrogenic means:
a condition is a result of treatment
Complication codes should never be used as principal diagnoses.
False
If in doubt as to whether a condition occurred as the result of a procedure or medical care, the coder should:
Check to verify that the procedure or illness was within the last 28 days
Codes Z94- and T86 are never used together.
True
A complication can be coded only if it is in within 1 year of the original surgery.
False
Medical conditions that develop after a transplant are not coded as transplant complications unless they affect the transplanted organ.
True
If a patient has an illness that affects his or her transplanted kidney, it is:
coded as a transplant complication
A mechanical complication is not:
considered “pain”
Codes for complications may be located in the chapter for specified body sites.
True
Coding complications always implies that poor care has been delivered.
False
Patient is admitted for treatment of primary liver cancer. Patient had a liver transplant 2 years ago. Patient has a past medical history of hypertension and COPD and is a former alcoholic. Patient has been sober for 10 years.
T86.49, C80.2, C22.8, I10, J44.9, F10.21, Y83.0
Patient with a history of a kidney transplant comes to the ER with gastroenteritis. His history is positive for CKD, stage II, and hypertension.
K52.9, I12.9, N18.2, Z94.0
Patient was hospitalized 1 month prior to this admission. During that admit, she was diagnosed with COPD and placed on a ventilator; her sputum was positive for Pseudomonas aeruginosa. She is admitted today with another case of pneumonia.
J18.9, J44.9
Leakage of peritoneal dialysis catheter. Patient is on dialysis for end-stage renal disease. Peritoneal catheter was removed. Patient has a history of hypertension and type II diabetes with associated neuropathy.
T85.631A, I12.0, E11.40, Z99.2, Y84.1, 0WPGX0Z
Patient admitted with an abscess of abdominal surgical wound, initial encounter. Cultures were positive for Streptococcus. The abscess was incised and drained.
T81.4XXA, B95.5, Y84.8, Y83.9, 0H97XZZ
During a posterior lumbar fusion at L4-L5 for spinal stenosis, the surgeon accidentally nicks the dura due to the amount of adhesions present. The fusion was performed via an open posterior procedure on the posterior column using morselized allograft. Patient has a history of asthma for which he takes meds prn.
M48.06, G97.41, J45.909, Y83.8, Y92.234, 0SG0071
The term dehiscence means ____.
opening a surgical wound
If the documentation is unclear whether the diagnosis was the result of a procedure or condition, a physician query should be initiated.
True
Iatrogenic is a term used to signify that a condition is a result of treatment.
True
The patient had a postoperative cerebrovascular accident that was embolic in nature. The patient initially had been admitted for treatment of coronary artery arteriosclerosis with CABG (left internal mammary artery and two saphenous vein grafts were used). Cardiopulmonary bypass was used during the surgery.
I25.10, I97.820, I63.40, 021109W, 02100A9, 5A1221Z
Complications affect only certain body systems.
False
A patient is admitted with a urinary tract infection (UTI) resulting from E. coli. The patient has an indwelling Foley catheter following recent radical prostatectomy for cancer. The coder queries the physician regarding the relationship of the UTI and the Foley, and the physician documents that the UTI is caused by the Foley. The patient is morbidly obese with type II diabetes, controlled with insulin.
T83.51xA, N39.0, B96.20, E66.01, E11.9, Z85.46, Y84.6
Patient with decreased visual acuity due to corneal graft rejection. Admitted for cadaver keratoplasty of the left eye.
T86.840, Y83.0, H54.7, 08R93KZ
A patient had a kidney transplant 2 years ago but developed ESRD again. The patient has been on dialysis for the past year. The patient is now complaining of SOB and edema and is admitted for fluid overload and hemodialysis. Dialysis is performed multiple times during this stay.
E87.70, N18.6, Z94.0, Z99.2, Y83.0, 5A1D60Z
To aspirate means to ____.
breathe in a foreign substance
Codes under subcategory T86 are used ____.
for both complications and rejection of transplanted organs
There is a time limit to coding complications.
false
Patient had an outpatient surgical procedure this morning and was discharged in stable condition. Patient returns because of inability to void. A Foley catheter is inserted.
Diagnosis: Postoperative urinary retention.
Diagnosis: Postoperative urinary retention.
N99.89, R33.9, Y84.8, Y83.9, 0T9B70Z