Clinical Classification Systems

Question 1

The following organizations is responsible for updating the procedure classifications of ICD 10 PCS

Answer 1

Centers for Medicare and Medicaid services CMS

Schraffenberger 2015,31

Question 2

Coding accuracy is anticipated to improved due to which ICD 10 CM enhancement?

Answer 2

Expanded codes that capture more detail, in several sections such as injury, diabetes, and postoperative complications. (Sayles 2013, 190)

Question 3

Which character ICD 10 CM diagnosis code provides information regarding encounter care

Answer 3

Seventh character

The seventh character provides information about encounter of care, such as initial encounter,subsequenst encounter, or sequelae

(Sayles 2013, 190)

Question 4

What does the fourth character ICD 10 CM diagnosis code capture?

Answer 4

Etiology

Sayles 2013, 192

Question 5

Define etiology

Answer 5

The cause for manner of causation of a disease or condition

Question 6

ICD 10 CM codes must be a minimum how many characters

Answer 6

(Codes must be at lest 3 characters)

with a decimal point used after the 3rd character. XXX.XXX

(Sayles 2013,192)

Question 7

To which of the following notes appearing under three character code apply

Answer 7

To all codes within category

definition= ICD 10 CM has the same organization thank you notes can instructions as the Icd 9 cm when a note appears under three character code it applies to all codes within that category

(Sayles 2013 p193)

Question 8

Which ICD 10 codes are used for diagnosis only

Answer 8

ICD 10 CM

ICD 10 CM includes diagnoses only
(ICD 10 PCS is for procedure codes) (Sayles 2013,193)

Question 9

Which ICD 10 codes are used for procedures only

Answer 9

ICD 10 PCS inpatient (PCS= procedure code system)

Question 10

Which of the following is a standard terminology used code medical procedures and services

Answer 10

CPT codes Out patient (CPT= out patient diagnostic and therapeutic procedures and medical services)

(Sayles 2013,202)

Question 11

If The patient has an excision I’m a malignant lesion of the skin, the CPT code is determined by the body area from which excision occurs and which of the following

Answer 11

Diameter of the lesion has well As the most narrow margin required to adequately exercise lesion lesion described in The operative report

Question 12

Define excision

Answer 12

The act or procedure of removing by or as if cutting out; especially: surgical removal or resection

Question 13

According to CPT, the repair of the laceration that include retention sutures would be considered what type of closure

Answer 13

(Complex)

Complex closure includes the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures.

Question 14

Define complex closure in regards to medical procedure wound closure

Answer 14

Complex closure includes the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining stints, for retention sutures (AMA,2015,75)

Question 15

A patient is admitted to spotting. She has been treated two weeks previously for miscarriage with sepsis. The sepsis had resolved, and she’s afebrile at this time. She is treated with an aspiration dilution curettage and products of conception are found. What should be the principal diagnosis.

Answer 15

(Miscarriage)

schraffenberger 2015,345

Question 16

Define afebrile

Answer 16

Not feverish

Question 17

Define curettage

Answer 17

he use of a curette, especially on the lining of the uterus.

Question 18

Define curette,

Answer 18

a surgical instrument used to remove material by a scraping action, especially from the uterus.

Question 19

Define Products of conception

Answer 19

abbreviated POC, is a medical term used for the tissue derived from the union of an egg and a sperm. It encompasses anembryonic gestation (blighted ovum) which does not have a viable embryo.

Question 20

an 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of E. coli per CC urine. The attending physician documents “urosepsis”. Township decoder proceeds code this case

a. Code urinary track infection with sepsis as the principal diagnosis
b. code urinary tract infection with with sepsis as the principal diagnosis
c. Query the physician to determine if the patient has sepsis due to the symtomatology
d. query the physician to determine if the patient has septic shock so that this may be used as the principal diagnosis.

Answer 20

Query the physician to determine if the patient has sepsis due to the symptomology

( Schraffenberger 2015, 119)

Question 21

Define oliguria

Answer 21

the production of abnormally small amounts of urine.

Question 22

Define urosepsis

Answer 22

Urosepsis is the acute condition of a systemic infection in the blood that develops secondary to a urinary tract infection (UTI), and then circulates throughout the entire body. A lay term for this critical condition is blood poisoning because an infection is in the bloodstream.

Question 23

A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a close reduction of the fracture in the emergency department and undergoes a complete workout for metastatic sarcoma of the brain the patient is found to have metastatic sarcoma of the loan to and it goes radiation therapy to the brain. What should be the diagnosis.

Answer 23

Metastatic carcinoma of the brain

Schraffenberger 2015,119

Question 24

Define ataxia

Answer 24

the loss of full control of bodily movements.

Question 25

The patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also angina and chronic obstructive pulmonary disease. What would be the correct coding sequence for this case?

Answer 25

Infectious gastroenteritis, chronic obstructive pulmonary disease, angina

Explanation: gastroenteritis is characterized by diarrhea, nausea, and vomiting, and abdominal cramps, codes for symptoms, signs, and ill defined conditions from chapter 18 of the ICD 10 CM codebook are not to be used as principal diagnosis when related definitive diagnosis has been established. Patients can have several chronic conditions coexist at the time of their hospital admission and qualify as additional diagnosis such as COPD and angina

(schraffenberger 2015, 411)

Question 26

Patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prosthetic carcinoma three years ago and it is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. What would be the correct coding sequence for the current hospital stay?

Answer 26

Metastatic carcinoma of the brain, Hx of carcinoma of the prostate

Explanation guideline I.C.2d primary malignancy has been previously excised or eradicated from insight and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, the code for category Z85, personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary sites may be the principal or first listed, with the Z 85 code used as a secondary code

(Schraffenbenerger 2015, 154)

Question 27

Define neoplasm

Answer 27

a new and abnormal growth of tissue in some part of the body, especially as a characteristic of cancer.

Question 28

Define excised

Answer 28

To cut out entirely. For example, a scalpel or laser beam may be used to excise a tumor. The terms excise and resect are not synonymous. Excise implies total removal, whereas resect does not

Question 29

What is the Definition of Etiology?

Answer 29

The cause, or manner of causation of a disease or condition.

Question 30

What does the fifth character ICD 10 CM diagnosis code capture?

Answer 30

Atomic site

Question 31

What does the Sixth character ICD 10 CM diagnosis code capture?

Answer 31

severity

Question 32

According to the UHDDS, which of the following is the definition of “other diagnoses”?

Answer 32

Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring.

( Schraffenberger 2015, 271)

Question 33

A 7 year old patient was admitted to the emergency department for treatment of SHORTNESS OF BREATH. The patient is given EPINEPHRINE AND NEBULIZER treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?

Answer 33

(Asthma with status asthmatics)

A patient in status asthmatics fails to respond to therapy administered during an asthmatic attack. This is a life threatening condition that requires emergency care and likely hospitalization (schraffenberger 2015, 271)

Question 34

A patient is seen in the emergency department for chest pain. After evaluation of the patent it is suspected that the patient may have gastroesphageal reflux disease (GERD). The final diagnosis was “Rule out chest pain versus GERD” the correct ICD 10 CM code is:

Answer 34

(R07.9 Chest pain, unspecified Scharaffenberger 2015,112)

Question 35

which purpose and use goals dose not apply to ICD 10 PCS

Answer 35

(Improved collection of data about nursing care)

Sayles 2013,193

Question 36

Which way is not a way that ICD 10 CM improves coding accuracy?

Answer 36

Increases cross referencing (Sayles 2013, 190)

Question 37

To help clarify terms that currently have overlapping meaning, ICD 10 PCS has defined root operations. What is an example of the root operation of Excision?

Answer 37

(Partial nephrectomy)

Partial nephrectomy is an example of the root procedure Excision. A portion of the body part is cut out or off, without replacement (Sayles 2013, 193)

Question 38

Given the following information, which of the following statements is correct?

Geometric mean Arithmetic mean

4. 1 5.0
5. 3 4.0
6. 4 6.7
7. 4 5.3
8. 5 4.1

Answer 38

(A. in each MS-DRG the geometric mean is lower than the arithmetic mean)

definition:
The geometric mean LOS is defined as the total days of service, excluding any outliers or transfers, divided by the total number of patients. (Sayles 2013,268)

Question 39

If another status T procedure were preformed, how much would the facility receive for the second status T procedure. (Billing # 998324) (CPT/HCPCS 25500) (APC 0044)

Answer 39

(50%)

Definition:
Multiple surgical procedures with payment status indicator T preformed during the same operative session are discounted. The highest weighted produce is fully reimbursed. All other procedures with payment status indicator T are reimbursed at 50%
(Casto and Forrestal 2015, 182)

Question 40

A health information technician is processing payment for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system?

Answer 40

(Radiology examinations)

Radiology procedures are identified under the outpatient perspective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid
(Sayles 2013, 275-276)

Question 41

what setting is the term patient record used in

Answer 41

acute patients (inpatients) Sayles 2013 P.32

Question 42

What setting is the term medical recored used in

Answer 42

Clinics, offices outpatient

Question 43

What is the primary purpose of the health recored

Answer 43

Patient care delivery,Patient care management, patient care support process, financial and other administrative processes, patient self management

Question 44

In what year was health and homeland security added to the secondary purposes of health records

Answer 44

2013

Question 45

how many characters dose procedure codes have PCS

Answer 45

Seven,

Question 46

How many sections is PCS divided into

Answer 46

Sixteen sections

Question 47

What dose the first character in a pcs code stand for

Answer 47

1 the section of the ICD 10 PCS system where the code resides

Question 48

What dose the second character in a PCS code stand for

Answer 48

2# The body system

Question 49

What dose the 3rd character in a PCS code stand for

Answer 49

3# Root operation (such as excision, incision)

Question 50

What dose the 4rth character stand for in PCS coding

Answer 50

4 Specific body part

Question 51

What dose the 5th character stand for in PCS coding

Answer 51

5 Approach used, such as intraluminal or open

Question 52

What dose the 6th Character stand for in PCS coding

Answer 52

6 Devices used to perform the procedure

Question 53

What dose the 7th Character stand for in PCS coding

Answer 53

7 Qualifier to provide additional information about the procedure (for example, diagnostic versus therapeutic)

Question 54

How would the PCS code 097F7DZ be broken down by individual character.

Answer 54

Section Medical and Surgical 0
Body System Ear,Nose, Sinus 9
Root Operation Dilation 7
Body Part Eustachian tube, right F
Approach Via natural or artificial opening 7
Qualifier No Qualifier Z

Question 55

Identify the correct ICD-10-CM diagnosis codes and sequencing for a patient who was admitted for outpatient chemotherapy for treatment of acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications.

a. C91.00, R11.2, Z51.11
b. Z51.11, C91.00, R11.2
c. Z51.11, C91.00
d. C91.Z2, R11.2

Answer 55

b. Z51.11, C91.00, R11.2
Correct Answer: B
When a patient is admitted for the purpose of radiotherapy, chemotherapy, or immunotherapy and develops a complication, such as uncontrolled nausea and vomiting or dehydration, the principal diagnosis is the admission for radiotherapy (Z51.0), the admission for the antineoplastic chemotherapy (Z51.11), or the admission for the antineoplastic immunotherapy (Z51.12). Additional codes would include the cancer and the complication(s) (Hazelwood and Venable 2014, 4, 35–36).

Question 56

Identify the correct ICD-10-CM diagnosis code for a male patient with stress urinary incontinence.

a. N39.46
b. R32
c. N39.3
d. N39.498

Answer 56

N39.3
Correct Answer: C
Urinary incontinence is a loss of urine without warning and may be associated with many conditions. ICD-10-CM classifies stress incontinence to N39.3 for both male and female types. Index Incontinence, stress (female) (male), N39.3. Subcategory N39.4, Other specified urinary incontinence, provides additional specificity that is not documented in this case.
Code N39.46 Mixed incontinence is not correct because it includes urge incontinence in addition to stress. The patient only had stress incontinence. Codes R32 Unspecified urinary incontinence is not correct due to Excludes 1 note which excludes N39.3, Code N39.498 Other specified urinary incontinence is not correct because the type (stress) has a specific code (Hazelwood and Venable 2014, 130).

Question 57

The patient is a 45-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently tripped and subsequently fell. She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. The patient also had a splinter of wood in her elbow from the fall. The patient was admitted and taken to surgery, where an open reduction with internal fixation was accomplished with good alignment of fracture fragments. Post-op course was uneventful and the patient was discharged with daily physical therapy at home. Which of the following would be coded?

a. S82.251A, S06.0XA, S50.359A, W01.198A, Y92.480, Y93.K1, Y99.8, 0QSG04Z
b. S82.252A, S06.0x0A, W01.198A, Y92.481, Y93.K1, Y99.8, 0QSG06Z
c. S82.253A, S06.0x0A, S50.359A, W01.198A, Y92.480, Y93.K1, Y99.8, 0QSGX4Z
d. S82.254A, S06.0x0A, W01.190A, Y92.482, Y93.K1, Y99.8, 0QSH04Z

Answer 57

Correct Answer: A
For S82.251A, the Alphabetic Index main term is Fracture, traumatic, subterms tibia (shaft), comminuted. The Tabular List is consulted to assign the sixth character “1” for displaced right” and seventh character “A” for initial encounter for closed fracture. A fracture not indicated as open or closed is coded closed and a fracture not indicated as displaced or not displaced is coded to displaced (CMS 2016a, I.C.19.c). For S06.0X0A, the Alphabetic Index main term is Concussion. The Tabular List is reviewed to assign sixth character “0” representing without loss of consciousness and seventh character “A” for initial encounter. For S50.359A the Alphabetic Index main term is Splinter, see Foreign body, superficial, by site. For W01.198A, the External Cause Alphabetic Index main term is subterms Fall, due to, slipping, with subsequent striking against object, specified NEC. The Tabular List is consulted to assign seventh character “A” for initial encounter. For Y92.480, the Alphabetic Index main term is Place of occurrence, subterm street or highway, sidewalk. For Y93.K1, the External Cause Alphabetic Index main term is Activity, subterm walking an animal. For Y99.8, the External Cause Alphabetic Index main term is External cause status, subterm specified NEC. Code Y92.480, Y93.K1 and Y99.8 are POA exempt. The other conditions were present on admission. The Alphabetic Index main term is Reposition, subterms tibia, right. Table 0QS is reviewed to assign approach value “0” for open and device value “4” for internal fixation device (AHIMA 2016, 514; CMS 2016b, 58).