ICD-10 Flashcards
1
Q
When coding a visit for pain in neoplastic disease, which code is first?
A
Pain comes 1st when the reason for the encounter is documented as ‘pain control’ or ‘pain management’.
2
Q
Is code Z79.4, long term use of insulin, required for a type 1 diabetic?
A
No, type 1 patients are insulin dependent.
3
Q
What does intractable epilepsy mean?
A
Poorly controlled with medication
4
Q
Can acute respiratory failure be a primary diagnosis with another acute diagnosis if it is clear the respiratory failure was responsible for the patient being admitted?
A
Yes
5
Q
How many codes are used for a transplant complication? (aka a malignant neoplasm of a transplanted organ)
A
- Transplant complication: Assign 1st the appropriate code from category T86.-, Complications of transplanted organs and tissue, followed by code C80.2, Malignant neoplasm associated with transplanted organ. Use an additional code for the specific malignancy.
6
Q
Is there a causal relationship between hypertension and heart and/or kidney involvement?
A
Yes, unless documented as ‘unrelated’, in which case, document as separate.
7
Q
Does NSTEMI get coded as a STEMI?
A
Yes, If a type 1 NSTEMI evolves to STEMI, assign the STEMI code. If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI,
8
Q
When unspecified, what is the side with default dominance for a cerebral infarction?
A
Right
9
Q
When unspecified, what is the default type of diabetes?
A
Type 2
10
Q
Does the use of insulin mean a patient is type 1 diabetic?
A
No
11
Q
Is there a presumed causal relationship between CKD and hypertension?
A
Yes
12
Q
When treatment is directed at secondary cancer, is primary or secondary reported 1st?
A
Secondary
13
Q
Can uncertain diagnosis such as probably, suspected, questionable, rule out or working diagnosis be coded?
A
No
14
Q
When is dehydration sequenced first?
A
When the encounter is for mgmt of dehydration due to the malignancy or therapy, or a combination of both, and only the dehydration is being treated.
15
Q
Unstageable and unspecified pressure ulcers are the same.
A
False. Documentation must state unstageable
16
Q
If a patient is admitted with a pressure ulcer at one stage and it evolves to another, should you utilize the highest stage documented?
A
No, you have to use the code for the stage at admission and another for highest stage documented.
17
Q
Can BMI and Ulcer staging be coded based on ancillary provider documentation?
A
Yes, so long as the associated diagnosis is documented by the patient’s provider.
18
Q
For rheumatoid arthritis at the upper and lower end of the bone, do you code for the bone or the joint?
A
Bone
19
Q
Category M81 is for osteoporosis patients with or without a current pathological fracture?
A
Without a current pathological fracture. Utilize Z code for history of healed osteoporosis fracture.
20
Q
Category Z3A does not apply to which three scenarios?
A
- Abortions
- Elective terminations
- Postpartum conditions
21
Q
True or false, codes for chapter 15 should only be utilized on the mother?
A
Correct. Do not utilize chapter 15 codes on the newborn.
22
Q
When a pregnant patient is admitted with a complication do you code the trimester in which it occurred or current trimester?
A
Trimester it occurred
23
Q
When are codes that describe symptoms and signs appropriate?
A
When a definitive diagnosis has not been established.
24
Q
Lack of ability to move one’s limbs or inability to ambulate due to extreme debility is what type of quadaplegia
A
Functional (R53.2) as opposed to neurologic or injury
25
Code for adverse effect when the prescription was properly taken and administered?
True
26
Code first abuse and neglect?
True
27
Code first poisoning followed by manifestation?
True
28
Should superficial injuries to same site be coded?
No
29
When can ultrasonic guidance be reported more than once?
If two forms of guidance are used
30
How do you choose the appropriate injection CPT code?
Must have the anatomy, site and number of injections, along with the drug and dosage.
31
Can a radiology code be coded in addition to injection with ultrasound guidance?
No
32
Is documenting 'Negative' for PSFH sufficient?
No. There must be a statement of what is negative.
33
Is a modifier needed if the service is outside the 10 day global period?
No
34
The provider documents a brief HPI (location and duration); pertinent ROS (allergies); and complete PFSH (past and social). Expanded problem focused, problem focused complete or; comprehensive
expanded problem focused
35
When a physician is banned from participating in any Federal or State health care program by the OIG under the Exclusion Statute (42 U.S.C. § 1320a-7), what is the minimum term of exclusion that can be applied?
5 Years
36
A Qui Tam Relator may receive what type of award for bringing a case in which the government intervenes?
15-25 percent of the money recovered
37
When utilizing templates to document in a medical record, what documentation must be included in the template?
Elaboration on abnormal findings
38
What program was established by HIPAA to combat fraud and abuse committed against all health plans, both public and private?
Health Care Fraud and Abuse Control Program
39
A way to indicate that a discussion between the patient and the provider took place about a patient’s condition and the treatment options available, to allow the patient an opportunity to ask questions and make an informed choice on his or her plan of treatment.
Informed consent
40
What is appropriate to document in a radiology report for contrast material used in a radiologic study?
The type and amount of contrast used, along with the route of administration is documented.
41
Each provider involved in a surgical case is expected to document the portion of the surgical procedure they performed with the exception of?
Assistant surgeon
42
When a correction is made in an electronic health record, what must exist?
Reliable means to clearly identify the original content and the modified content.
43
True or False, clinical documentation improvement efforts are performed on a prospective basis?
True
44
Which system is given credit for the exam component when a provider documents “no appreciable edema in the ankles?”
Cardiovascular
45
What modifier is appended to indicate a service is provided under the primary care exception without the presence of a teaching physician?
GE
46
True or false, No matter how many tests are ordered/reviewed for labs, radiology and medicine each area only gets 1 point.
True
47
True or false, When an excision (benign or malignant) is performed on the same site as an adjacent tissue transfer, only the adjacent tissue transfer is reported.
True
48
Which modifier begins a new global period for unrelated procedure?
79
49
Risk adjustment models are used to:
Determine projected costs of health care based on the condition(s) of patients.
50
What does the abbreviation CDPS indicate?
Chronic Disability Payment System
51
How often does CMS normalize risk scores and update the list of diagnosis codes for HCC coding?
Yearly
52
Fee schedules for fee-for-service models are determined based on:
RVU's
53
Which components are used to determine RVUs?
Physician work
Practice expense
Malpractice insurance
54
Which status indicator identifies procedures where the global concept does not apply?
XXX
55
Which program was developed by CMS to review claims processing error rates?
CERT
56
When is an ABN required?
When the procedure may not be covered for the patient’s condition.
57
True or false, if STEMI converts to NSTEMI due to
| thrombolytic therapy, it is still coded as STEMI.
True
58
A patient is seen for his hypertension with stage 5 CKD and myocardial disease. The conditions are stable and he is told to continue with his medications. The myocardial disease is unrelated to the hypertension. What ICD-10-CM codes are reported?
I12.0, N18.5, I51.5
Instructional note under I12.0 indicates to use
additional code to identify the stage of the CKD. Code N18.5 is reported for stage 5 CKD. ICD-10-CM guideline, I.C.9.a.1 indicates if the documentation does not have a causal relationship between the hypertension and heart disease the conditions are coded separately. Look in the Alphabetic Index for Disease/myocardium, myocardial referring you to I51.5. Verify code selection in the Tabular List.
59
When non-compliance is identified, what does the OIG recommended?
Take disciplinary action
document the date of the incident
name of reporting party
name of the person responsible for taking action
follow-up action taken
60
When is incidental use and disclosure of PHI permitted?
When the covered entity has reasonable safeguards in place to ensure the information shared is being limited to the minimum necessary.
61
Which one of the following options is a NOT a requirement for financial penalties to be mitigated in a federal False Claims Act case?
The person committing the violation decides to voluntarily opt out of the Medicare program.
62
What is NOT a term used for a radiological view in a radiology report?
Prone
63
What is appropriate to document in a radiology report for contrast material used in a radiologic study?
The type and amount of contrast used, along with the route of administration is documented.
64
What is an action that results in unnecessary costs to a Federal health care program, either directly or indirectly
Abuse
65
Which of the following is NOT supported as a linked condition from a documentation perspective in a medical record?
Diabetes and dermatitis
66
What should the writing style of an audit report be?
Persuasive
67
Which EMR feature is non-compliant with CMS?
Templates that allow the provider to de-select a prepopulated “normal” checkmark when the system is abnormal in the ROS
68
What is NOT considered a purpose of documentation improvement programs?
Increase reimbursements
69
Which is NOT an acceptable cause for query?
Signs and symptoms without a diagnosis
70
The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You:
Code the liver cancer as angiosarcoma, a primary liver cancer, based on the pathologist’s documentation.
71
Patient has a history of a recent myocardial infarct and is admitted today with an ST elevation MI of the anterior wall. The flaw in this documentation from a coding standpoint:
The duration between the recent myocardial infarct and the current myocardial infarct will impact coding, so “recent” is insufficient documentation.
72
Which term or phrase, when used between a manifestation and etiology, does NOT always show a causal relationship?
Likely
73
Which is an example of poor documentation that is especially problematic as there is no “unspecified” code for the condition in ICD-10-CM?
Degenerative disc disease (DDD). Currently, ICD-10-CM does not provide a code for DDD when the site of the disc is not specified.
74
Is it an acceptable practice to use a template that always documents a complete review of systems?
No. The extent of ROS performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).
75
Which type of documentation can be used to report diagnoses under risk adjustment models?
Inpatient Admission Note
76
What type of organization receives reimbursements based on quality metrics and reductions in the total cost of care for an assigned population of patients.
an Accountable Care Organization (ACO)
77
What information should be documented to properly code hypertension in ICD-10-CM?
Level of control (controlled, uncontrolled, malignant)
78
Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code?
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
79
In the 2019 MIPS performance year, what percentage of the provider score will be determined based on the promoting interoperability category?
25%
80
How is the cost category under MIPS going to be determined?
adjudicated claims data.
81
Consider the following final diagnostic statement: Acute renal failure in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication.
ICD-10-CM Guideline I.C.19.g.3 states, “Codes that affect the function of the transplanted kidney, other than CKD, should be assigned a code from subcategory T86.1, Complications of transplanted organ, kidney, and a secondary code that identifies the complication.”
82
Diabetic ulcers are staged by:
skin, fat layer (subcutaneous), muscle, and bone
83
Query the provider, asking if there is a diagnosis to go with the weight loss strategy counseling that was performed.
Query the provider, asking if there is a diagnosis to go with the weight loss strategy counseling that was performed.
84
A pathology report might show:
The histology of a breast biopsy specimen
85
Are views required for a CT order?
No, only for x-rays
86
When are HCC scores normalized by CMS?
Yearly
87
The National Institute of Health identifies in its website conditions that are chronic and incurable, so any “past medical history” of these diseases would translate to a current history of these diseases.
Down syndrome
Parkinson’s disease
schizophrenia
sickle cell anemia
88
Is alcoholic liver disease specific enough to code alcoholic cirrhosis?
Alcoholic liver disease is a nonspecific diagnosis, and correct coding would be K70.9, alcoholic liver disease unspecified. Instructional notes indicate that an additional code should be used to identify the presence or absence of alcohol abuse and dependency.
89
Is it appropriate to assign code Y95, Nosocomial condition, for a documented healthcare acquired condition?
Yes
90
What MIPS measure replaces PQRS?
Quality
91
What is NOT an eligible providers (EPs) for Medicare under the MIPS Quality Payment Program?
Certified social workers
92
When does the performance year begin for the Medicare Quality Payment Program?
January 1 and closes December 31
93
A/P: Diabetic neuropathy, improved. Still having insomnia. Lyrica should help her with the sleeping; we will monitor how her BS responds to this new medicine.
Return to office in 4-5 weeks. For the documentation provided, what is the level of MDM?
Low: Diabetic neuropathy is an established problem to the provider that has improved from the last time the patient was seen and the insomnia is an established problem not stated as stable or uncontrolled (2 points), no data to review (0 points), and the level of risk is moderate for prescription drug management (Lyrica).
94
What statement is TRUE regarding the use of modifier 25 with minor surgeries?
When a significant and separately identifiable E/M is performed on the same date as a minor surgery, modifier 25 can be appended to the E/M code.
95
What documentation is required to support transitional care codes?
I. Communication with the patient within two business days of discharge.
II. Interview with home health agency to assess need for home care.
III. Medical decision making of moderate to high complexity
96
What is adjuvant therapy for cancer?
Additional cancer treatment given after the primary treatment to lower the risk that the cancer will come back. Adjuvant therapy may include chemotherapy, radiation therapy, hormone therapy, targeted therapy, or biological therapy. Adjuvant therapy given before the main treatment is called neoadjuvant therapy.
97
When a patient is diagnosed with multiple pressure ulcers on the same limb that are of different stages, how should this be reported?
Assign as many codes from category L89 as needed to identify all the pressure ulcers the patient has, if applicable.
98
What is MPV (mean platelet volume) on a complete blood count measuring?
Size of platelets
99
What indicators are considered part of the Quick Sepsis-related Organ Failure Assessment (qSOFA) Score:
respiratory rate of 22/min or greater
altered mentation
or systolic blood pressure of 100 mm Hg or less.
100
Which EMR feature is non-compliant with CMS?
1. Templates that allow the provider to de-select a prepopulated “normal” checkmark when the system is abnormal in the ROS
2. EMRs that prepopulate results are not compliant, since the default indicates a system was reviewed when it may not have been.
101
When providing CDI to a provider, does the message change depending on whether you are performing a prospective or retrospective audit?
Yes, because the auditor cannot ask leading questions regarding documentation before a claim is submitted.
102
CDI programs can help with:
Team building
103
The surgeon documents liver cancer, but the pathology report states angiosarcoma of liver. You:
Code the liver cancer as angiosarcoma, a primary liver cancer, based on the pathologist’s documentation.
104
In reviewing the provider’s assessment the documentation states “lab tests reviewed: +K.” You correctly query:
Can you please address the patient’s potassium status in further detail?
105
Which term or phrase, when used between a manifestation and etiology, does NOT always show a causal relationship?
Likely
106
Which is an example of poor documentation that is especially problematic as there is no “unspecified” code for the condition in ICD-10-CM?
Degenerative disc disease (DDD)
107
Which type of documentation can be used to report diagnoses under risk adjustment models?
Inpatient Admission Note
108
Is it an acceptable practice to use a template that always documents a complete review of systems?
No. The extent of ROS performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s).
109
What type of payment does an ACO (Accountable Care Organization) receive?
An ACO receives a payment per member per month (PMPM) to deliver care coordination services.
110
True or false: A patient with a RAF score of 3.09 will likely consume more health care in the coming year than a patient with a RAF score of 1.89.
True
111
What must be documented to properly code hypertension
Level of control (controlled, uncontrolled, malignant)
112
Which statement is TRUE for the use of a sign/symptom code with a definitive diagnosis code?
Codes that describe symptoms and signs are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.
113
When would morbid obesity be considered clinically significant:
When documented by the provider
114
Which code systems are NOT included in HEDIS?
APC
115
What are not HEDIS measures?
1. Melanoma Screening
| 2. Psoriasis Screening
116
In the 2019 MIPS performance year, what percentage of the provider score will be determined based on the promoting interoperability category?
25%
117
In the 2019 MIPS performance year, what percentage of the provider score will be determined based on the improvement category?
15%
118
How is the cost category under MIPS going to be determined?
Adjudicated claims
119
In performing a retrospective review, should you advise this physician that he missed the opportunity to completely code all conditions if patient had a BKA in the past?
status code for the BKA is informative because the status may affect the course of treatment and its outcome.
120
Which of the following would be reported as a history of breast cancer rather than active breast cancer?
1. Breast cancer, post mastectomy, on tamoxifen prophylaxis
2. Breast cancer, post mastectomy, now undergoing prophylactic contralateral mastectomy
3. Breast cancer, post mastectomy, undergoing chemotherapy for secondary bone cancer
121
Consider the following final diagnostic statement: Acute renal failure in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication.
“Codes that affect the function of the transplanted kidney, other than CKD, should be assigned a code from subcategory T86.1, Complications of transplanted organ, kidney, and a secondary code that identifies the complication.”
122
Diabetic ulcers are staged by:
The following on the patient’s leg(s): swelling, pain, tenderness, warm skin, red or discolored skin on the leg, veins you can see, tired legs.
123
Should documentation of “rheumatoid arthritis/osteoarthritis” include whether it is differential or definitive diagnosis?
Yes
124
What does the drug Namenda treat?
Dementia
125
Does the use of an EHR template with macros with multiple choice options for signs and symptoms lead to cloning of the medical record?
No, the use of a template with macro options is permitted as long as the information entered is specific to the patient
126
What information can be pulled forward from a previous encounter if the information is reviewed and updated?
A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information
127
Given the following definitions, which of the following is TRUE related to accurate diagnosis coding in risk adjusted payment models:
Definitions: PMPM = per member per month
MLR = medical loss ratio; the proportion of premium revenues spent on clinical services and quality improvement. MLR = total claims expense (healthcare costs) divided by premiums received (per member per month payments)
The monthly payment is based on a patient’s risk score, which is based on the patient’s overall health status. Health status is determined by the diagnosis codes determined by providers caring for patients. Accurate diagnosis coding is an accurate reflection of patient health status. The sicker the patient, the more healthcare costs are expected, and thus, a higher premium will be paid for the care of that patient
128
True or False: Congestive heart failure can be managed but it cannot be cured.
True
129
Which components are used to determine RVUs?
RVUs are configured using three components:
1. Physician work—time, skill, training, and intensity of service provided
2. Practice expense—reflects the cost of ancillary personnel, supplies, and office overhead
3. Professional liability/malpractice insurance
130
```
Which of the following conditions, if listed under Past Medical History and documented nowhere else in the record, would create a clinical documentation improvement opportunity?
I. ALS
II Hodgkin lymphoma
III Acute bronchitis
IV Chronic bronchitis
V Autism
VI Hypothyroidism
```
1. Hodgkin lymphoma
| 2. Acute bronchitis
131
True or False: aftercare Z codes should not be used for aftercare involving injuries or poisonings.
True
132
Consider the following final diagnostic statement: CKD, Stage III in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication.
ICD-10-CM Coding Guideline I.C.14.a.2 states, “patients who have undergone kidney transplant may still have some form of CKD because the kidney transplant may not fully restore kidney function. Therefore, the presence of CKD alone does not constitute a transplant complication. Guideline I.C.19.g.3 states, “Code T86.1 should not be assigned for post kidney transplant patients who have CKD unless a transplant failure or rejection is documented.”
133
True or False:
Coders cannot assign code F17.218 (nicotine dependence, cigarettes, with other nicotine induced disorders) unless the provider has documented a cause-and-effect relationship.
True
134
Which diagnosis is exempt from reporting Z3A as an additional diagnosis?
Codes in category Z3A, Weeks of gestation are not applicable, and should not be assigned if the pregnancy is outside of the uterus, otherwise nonviable, or with abortive outcomes (categories O00-O08). Refer to ICD-10-CM coding guideline I.C.21.c.11.
135
Which is a benefit for using EHRs?
Greater coordination of care
136
Which MIPS measure replaces meaningful use?
Promoting Interoperability
137
What age range does the HEDIS Breast Cancer Screening measure pertain to?
50-74
138
Quality measure for a biopsy follow up requires:
The description for the biopsy follow up measure states “percentage of new patients whose biopsy results have been reviewed and communicated to the primary care/referring physician and patient by the performing physician.”
139
Which of the following documentation deficiencies has a negative impact on patient outcomes?
Failure to advise the patient instructions for colonoscopy preparation.
140
To protect your organization, when you query the provider you should:
Use your organization’s standardized form to ensure consistency.
141
A: 1. Sleep apnea syndrome. Patient will be scheduled for sleep study.
2. Premenopausal bleeding. Patient does have a referral to a gynecologist.
3. Ptosis of bilateral eyelids. Surgical correction performed 2/14/15.
4. Rheumatoid arthritis/osteoarthritis, erosive, involving bilateral hands and back, doing OK.
Which of the following is an appropriate query for this note?
Can you please provide further clinical information regarding “rheumatoid arthritis/osteoarthritis” in this note? Is this a differential or definitive diagnosis?
142
Drug to treat dementia
Namenda
143
What does history mean from a coding perspective?
Some providers document history of to indicate the patient has the condition for a long period. From a coding perspective, it means the condition has resolved.
144
Does the use of an EHR template with macros with multiple choice options for signs and symptoms lead to cloning of the medical record?
No, the use of a template with macro options is permitted as long as the information entered is specific to the patient.
145
A code from subcategory R65.2 Severe sepsis is NOT assigned unless the documentation specifies either severe sepsis or what other condition?
Associated acute organ dysfunction
146
True or False: Providers treating patients with higher medical costs will receive higher PMPM (per member per month) premium payments if they are accurately coding medical conditions supported in the medical record that account for higher expected medical costs.
True
147
These components are used to determine what?
1. Physician work—time, skill, training, and intensity of service provided
2. Practice expense—reflects the cost of ancillary personnel, supplies, and office overhead
3. Professional liability/malpractice insurance
RVU's
148
True or False: Aftercare Z codes should not be used to report aftercare involving injuries or poisonings.
True
149
True or False: For many etiology and manifestation pairings, use one code that reports both diagnoses.
True
150
True or False: A provider must document the causal link between cigarette dependence and a respiratory condition to report F17.218.
True
151
What advice would you give a provider regarding documentation to support a kidney transplant complication?
The presence of CKD alone does not constitute a transplant complication. Guideline I.C.19.g.3 states, “Code T86.1 should not be assigned for post kidney transplant patients who have CKD unless a transplant failure or rejection is documented.”
152
Which statement is TRUE regarding code F17.218 Nicotine dependence, cigarettes, with other nicotine induced disorders?
A provider must document the causal link between cigarette dependence and a respiratory condition to report F17.218.
153
Is ectopic pregnancy exempt from reporting Z3A as an additional diagnosis?
Yes
154
Which MIPS measure replaces meaningful use?
Promoting Interoperability
155
What age range does the HEDIS Breast Cancer Screening measure pertain to?
50-74 years of age who had a mammogram to screen for breast cancer within the past 27 months.
156
Quality measure for a biopsy follow up requires:
Biopsy results for new patients to be communicated to the patient and the referring provider.
157
Which of the following would be considered sign(s) or symptom(s) for the diagnosis of pulmonary hypertension?
I. Bluish tint to lips
II. Enlarged jugular veins
III. Shortness of breath
All of the above are evidence of pulmonary hypertension. Lack of oxygen can cause a bluish tint to the lips and nail beds and shortness of breath, as blood backs up due to increased pressure, the jugular veins can enlarge.
158
True or False: Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).
True
159
Ture or False; Documentation for BMI, Depth of Non-pressure ulcers, Pressure Ulcer Stages, Coma Scale, and NIH Stroke Scale For the Body Mass Index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH stroke scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis).
True
160
True or False: Aftercare Z codes should not be used to report aftercare involving injuries or poisonings.
True
161
When ordering an CT of the abdomen, what must be documented in the order?
I. Number of views
II. Medically necessary indication for the test
III. With or without contrast
IV. Date the test was ordered
Medically necessary indication for the test
With or without contrast
Date the test was ordered
162
A physician who specializes in elder care undergoes a CDI audit. Fifteen charts are found with the diagnosis of marasmus. Your correct response:
Display in your query the Index entry for marasmus and the codes and descriptions for E41 and R54. Ask for guidance on which to report.
163
According to documentation, A 34-week gestation patient with diabetes delivers twins. Fetus A was delivered without complication, with APGARs of 8 and 8. Fetus B’s delivery was complicated by a knot in the umbilical cord, and his APGARs were 3 and 5. Which query is appropriate?
What type of diabetes did the patient have?
164
The provider states that the patient is hypertensive and is interested in beginning a diet. He discusses weight loss strategies, but does not document that the patient is overweight, obese or morbidly obese. BMI documented in the vitals is 42, blood pressure 145/82. The patient receives a prescription for amlodipine. You:
Query the provider, asking if there is a diagnosis to go with the weight loss strategy counseling that was performed.
165
As the provider was treating actinic keratoses of the patient’s face and neck with cryosurgery, the liquid nitrogen canister misfired, inadvertently burning the patient’s cheek. This wound is treated with ELA-Max. The provider documented that there were “no intraoperative complications.” You correctly:
Ask for clarification of what may be conflicting data.
You cannot report an intraoperative complication unless it is stated by the provider. The correct way to pose a query is to be non-leading. We cannot ask if the provider meant to document something.
166
STARS Ratings are important because they:
Identify top performing health plans.
167
True or False: Trigger point injections are reported based on the number of muscles injected, not the number of injections. Multiple units are not reported for multiple trigger point injections.
True
168
What documentation is required to support transitional care codes?
1. Communication with the patient within two business days of discharge.
2. Medical decision making of moderate to high complexity
169
True or False: Traumatic fractures can be coded for patients with osteoporosis.
The coding guidelines for coding fractures in patients with osteoporosis states “A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.”
170
Acute renal failure in patient with history of renal transplant. What advice would you give to the provider regarding whether this documentation is sufficient to document a kidney transplant complication.
Conditions that affect the function of a transplanted kidney, other than CKD, can be established as kidney transplant complications. Acute renal failure would affect the function of the kidney transplant and it would be appropriate to assign a kidney transplant complication code.
171
True or False: A provider must document the causal link between cigarette dependence and a respiratory condition to report F17.218.
True
172
True or False: A CDI professional can determine services that should be reviewed that are performed by the practice based on services identified for audit in the OIG Workplan.
True
173
A problem pertinent review of systems (ROS) reviews how many systems?
One
174
An extended review of systems (ROS) reviews how many systems?
Two to nine
175
A complete review of systems (ROS) review how many systems?
10 or more
176
What type of Medical Decision Making (MDM) consists of minimal number of diagnosis (dx) or treatment (tx) options, minimal or no data, and minimal risk?
Straightforward
177
What type of Medical Decision Making (MDM) consists of limited number of diagnosis (dx) or treatment (tx) options, limited data, and low risk?
Low
178
What type of Medical Decision Making (MDM) consists of multiple diagnosis (dx) or treatment (tx) options, moderate data, and moderate risk?
Moderate
179
What type of Medical Decision Making (MDM) consists of extensive diagnosis (dx) or treatment (tx) options, extensive data and high level of risk?
High
180
For medical decision making (MDM), two of the three elements must be met. For example, if you have one established stable condition, three data points and low risk, the MDM would be what?
Low
181
A brief HPI is when how many elements are documented?
1-3
182
An extended HPI is when how many elements are documented?
4 or more OR if the patients statements are regarding the status of at least 3 chronic conditions.
183
Modifier for increased procedural services?
22
184
Modifier for Professional Service
26
185
Modifier for Multiple Procedures
51
186
Modifier for Decision for Surgery
57
187
Modifier for Distinct Procedural Service
59
188
True or false: When selecting and E/M based on time, the provider must document the total time spent as well as that more than 50% of that time was spent on counseling or coordinating care. The provider must also include what the physician counseled that patient on or what care was coordinated.
True
189
If lesion removal is not sent for pathologic evaluation can you code for a biopsy?
No
190
If the primary purpose of the procedure is diagnostic, to obtain tissue for histopathology examination and the procedure is intended to remove a lesion or the problematic portion of the lesion, it would be classified as what?
Removal
191
Required documentation elements for a procedure include:
1. H&P and/or laboratory findings that support the medical need for the procedure
2. performance of the procedure by a physician
3. outcome and diagnosis supporting the procedure.
192
Documentation of two days of service contain the exact same ROS, exam findings, and Assessment. Even though the HPI and Plan are separately identifiable, the use of an unaltered template creates what problem(s)
1. Conflicting documentation and unsupported diagnoses.
2. The apparent practice of dropping the active problem list into the assessment section of the note compounds the problem of unsupported diagnoses.
193
If provider documents "smoker" is this considered a nicotine dependence?
Yes. In ICD-10-CM “smoker” refers you to see Dependence, drug, nicotine. F17.210 can be specified if the provider documents “cigarette smoker.”
194
The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) defines cerumen as impacted if one or more of the following conditions are present:
Cerumen impairs the examination of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition;
Extremely hard, dry, irritative cerumen causes symptoms such as pain, itching, hearing loss, etc;
Cerumen is associated with foul odor, infection, or dermatitis; or
Obstructive, copious cerumen cannot be removed without magnification and multiple instrumentations requiring physician skills.
195
What must a provider document to report an E/M code based on time?
The total time of the encounter and that more than 50% of the time was spent counseling or coordinating care.
The provider must include in the documentation the details of the counseling or coordination that was performed.
196
A combination of drug therapies used for HIV treatment is referred to as highly active antiretroviral therapy (HAART). When documentation mentions HAART, but does not indicate a diagnosis of HIV can you code HIV?
No, the provider should be queried.
197
True or False: A patient who is actively using nicotine patches or nicotine gum, or other substance to assist in smoking cessation, is dependent on nicotine.
True
198
What is a disadvantage of the electronic health record with regard to CDI?
Over documentation
CDI is important for many reasons. Errors in the medical record can erode patient/provider trust (or worse). Widespread use of the EHR has allowed "over documentation," cloned medical records, and other compliance failures to flourish. Digitized data and modern computing power allow payers to enforce compliance aggressively using audits, recoupments, and payment denials. You should assume that all clinical documentation will be scrutinized at some point.
199
Compliance is achieved in medical record entries through the use of what?
Internal documentation guidelines
200
What are examples of internal documentation guidelines for medical record entries?
Health risk factors must be identified
Documentation must support CPT and ICD-10 codes
Documentation must be clear why ancillary services are ordered
201
What facility type must have a compliant plan of care from the ordering provider?
Home healthcare entities
Home healthcare entities: Obtaining a compliant plan of care from the ordering provider is vital: without it, services are not justified.
202
A CDI program promotes continuity of care from one provider to another. What affect does this have on patient care?
Improve patient outcomes
Quality patient care is evident only if it is documented in the medical record. CMS documentation guidelines for E/M services include the least expected documentation to support an encounter. CDI promotes complete and accurate documentation that goes beyond coding and billing to include:
-Improve communication and dissemination of info between and across service providers
-Appropriate treatment, interventions and plan of care
-Improve goal setting and evaluation of care outcomes
Improve early detection of problems and changes in health status; and
-Provider "EVIDENCE" of excellent patient care.
203
These are examples of what?
Improve goal setting and evaluation of care outcome
Improve early detection of problems and changes in health status
Provide the appropriate treatment, intervention, and plan of care
promotes complete and accurate documentation
examples of CDI going beyond coding a billing?
204
What is the overarching objective of CDI?
Patient care
205
A CDEO monitors coding and billing risk areas. What risk area would be a subject of an OIG investigation and audit?
Knowing misuse of provider identification numbers, which results in improper billing
Adhering to state, federal , and individual payer mandates is paramount; however, patient care is the overarching objective.
206
What facility must update the patient care plan every 90 days for Medicare patients?
Comprehensive outpatient rehab centers
Comprehensive outpatient rehabilitation centers: The patient care plan must be accurate and updated every 90 days as required for Medicare Patients
207
What is the provider's best defense in any legal situation?
A well documented note
The details in a well-documented note are a provider's best defense in any legal situation. If the record is deficient, there is no "evidence" to support a provider's testimony.
208
What program did HIPAA establish to combat FWA in public and private health plans?
Healthcare Fraud and Abuse Control Program
209
Which forms are commonly found in a medical record?
Release of information
Informed consent
Assignment of Benefits
210
What is an example of a business associate function?
Data analysis
Benefit management
Claims processing
211
Who is responsible to administer and enforce the standards set forth in the Privacy Rule?
OCR
212
Criminal penalties are imposed if a person knowingly obtains or discloses individually identifiable health information in a way that violates the Privacy Rule. Penalties (prior to inflation) begin at:
$50k and up to 1 year imprisonment
213
The Joint Commission published a standard for the appropriate use of medical abbreviations as well as a Do Not Use list. What abbreviation appears on the Do Not Use list?
IU
214
Which level of government establishes Conditions of Participation (CoP) for Medicare?
Federal
215
An operative report generally has four main sections. They are:
Header, indications for surgery, body and findings
216
According to Medicare guidelines, the physician must sign dictated notes________?
Before they are placed in the patient's chart
217
What are the benefits of using a template?
complete collection of information
Customization to fit the patient and the condition
218
According to CMS, which one of the examples below is an instance of fraud?
Billing for services at a higher level than provided or necessary
219
According to COMS, which one of the examples below is an instance of abuse?
Failure to maintain adequate medical or financial records
220
The False Claims Act originated in 1863 under what name?
Lincoln Law
221
The False Claims Act refers to the person bringing a qui tam civil action as a _____.
Relator
222
The common term for a relator is?
Whistleblower
223
Under the Exclusion Statue, there are two types of exclusions. They are:
Mandatory and Permissive
224
How is the OIG Work Plan useful for a CDEO professional?
To evaluate current documentation and provide feedback to providers on services identified as problematic areas in the OIG Work Plan
225
How often is the OIG Workplan updated?
Monthly
226
The OIG developed voluntary compliance plan guidance (CPG) for a variety of healthcare settlings. The CPG for individual and small group practices lists potential benefits of a compliance program. Which is NOT a benefit?
Increase in patient population
227
In reviewing the provider assessment, the documentation states "lab tests reviewed: +k." Which of the following is a compliant query?
Can you please address the patient's potassium status in further detail?
228
A 47-year old patient is seen by her provider for a cervical Pap smear. Her last Pap smear was three year prior. which HEDIS measure is most likely satisfied with this encounter?
Cervical Cancer Screening (CCS)
229
Which of the following is NOT a category of MIPS?
Reimbursement
230
MIPS category Promoting Interoperability continues to highlight the benefits of using EHRs. Which of the following is a benefit of using EHRs?
EHRs improve quality, safety, and efficacy of care.
231
E-prescribing electronically transmits RX to a pharmacy. Which of the following is NOT a benefit of e-prescribing?
Eliminating the need for linking the medication to a disease
232
Which of the following is NOT a HEDIS measure
Chronic Wound Management
233
In risk adjustment, CMS adjusts risk scores to maintain an average risk score of 1.0. What is this called?
Normalization adjustment
234
Which of the following are not taken into consideration in the risk adjustment payment methodology?
Family Medical History
235
Which of the following is a benefit of risk adjustment?
Chronic conditions are likely to be addressed annually
236
Which payment system utilizes RVUs
Fee-for service (FFS)
237
What are NCCI edits
To indicate when a procedure is inclusive to another procedure
238
Why are NCCI edits used?
To indicate when a procedure is inclusive to another procedure
239
Pure risk-adjusted models rely solely on
ICD-10-CM codes
240
The most recognized risk adjustment model is?
Medicare Hierarchal Condition Categories (HCC-C)
241
When an office visit is performed that is separately identifiable from a minor surgery, which modifier is appended to the office visit?
modifier 25
242
What type of information should a documentation specialist look for when modifier 22 is appended to a surgical procedure because the patient is obese?
Documentation should indicate how much longer the procedure took, or what work was above and beyond the normal work because the patient was obese.
243
Modifiers XE, XS, XP and XU were developed to provide greater reporting specificity. These modifiers may be used in place of which modifier?
59
244
A patient presents with acute bronchitis. The conditions listed below have been documented in the past medical history. Which of these conditions should the documentation specialist query the provider to see if they are chronic conditions that affect the current treatment?
COPD and Asthma
245
A patient is admitted whit asymptomatic HIV status and toxoplasmosis. How is this reported?
B20
| B58.9
246
Which of the following is TRUE regarding a final diagnostic statement of cirrhosis of the liver?
The cause of the cirrhosis should be documented for accurate reporting.
247
A patient is seen for a diabetic right foot ulcer, with skin breakdown and muscle necrosis. What codes are reported?
E11.621
| L97.513
248
A patient was given thrombolytic therapy for an acute myocardial infarction (AMI) of the anterolateral wall. What ICD-10-CM codes should be reported?
I21.09
249
A 45 year old female visits her provider after having a biopsy on dense breast tissue. The provider documents evidence of cancer, lower outer quadrant of the right breast. What ICD-10 code is reported?
C50.511
250
A 58 yr old patient sees the provider for confusion and loss of memory. The provider diagnoses the patient with early onset stages of Alzheimer's disease with dementia. What ICD-10 code is reported?
Hypertension and left ventricular failure
251
Mary had DJD of the left knee and has been seeing her physician for several months. She tried physical therapy and NSAIDS without improvement of the pain. The MD recommends a corticosteroid injection for her chronic knee pain. An injection of Kenalog-40 is injected into her left knee. What ICD-10 codes are reported?
G89.29
| M25.562
252
A patient with a history of chronic bronchitis is seen for a productive cough and shortness of breath. The diagnosis is acute bronchitis. What are the ICD-10-CM codes for this condition?
J20.9
| J42
253
ICD-10 guidelines I.C.21.c.4 states, "Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence , and therefore may require continued monitoring." Which of the following conditions, when documented in the past medical history, should a documentation query the provider regarding?
Dementia
Lung Cancer
Diabetes
Heart Failure
254
A 26 yr old gravida 2 para 1 female has been spotting and has been on bed rest. She awoke this morning with severe cramping and bleeding. Her husband brought her to the hospital. After examination, it was determined she has an incomplete early spontaneous abortion. She is in the 12th week of her pregnancy. She was taken to the OR and a D&C was performed. There were no complications from the procedure. She will follow-up with me in the office. She has had four antepartum visits during her pregnancy.
O03.4
255
The National Pressure Ulcer Advisory Panel defines the stages of pressure ulcers. What is a characteristic of a stage 3 pressure ulcer?
The ulcer has a crater-like appearance.
256
A 65 yr old female sees her provider for constant pain in her right upper arm. She reports no trauma but has been cleaning her basement and moving boxes. The patient was previously diagnosed with postmenopausal osteoporosis and the provider is concerned she may have a fracture. The provider sends her to the outpatient radiology department for an x-ray which reveals a fracture of the right humerus. What ICD-10 code is reported?
M80.021A
257
A 10 yr old girl complains of left arm pain after falling while playing on the playground at school. She was taken to Urgent care and the X-ray showed a Type 1 Salter-Harris fracture (physeal) of the lower end of the left humerus. What ICD-10 code is reported for the fracture?
S49.112A
258
The definition and function of a ligament is:
A tough cord that connects bone to bone and provides stability to joints
259
A 70 yr old male sees his provider for type 2 diabetes and chronic kidney disease. The kidney disease progressed to stage 5 last year and he has been on dialysis since then. What IC-10 code would be reported for the patient's visit?
E11.22
N18.6
Z99.2
260
A 35 yr old female patient is given morphine to control postop pain. She complains of nausea and confusion. This is an adverse effect of morphine and her medication is changed with relief of her symptoms. What ICD-10 codes are reported for the adverse effect?
R41.0
R11.0
T40.2X5
261
Which one of the choices is a TRUE statement regarding external cause codes?
Report all external cause codes needed to explain the external causes.
262
A 19 yr old female returns to her physician for her second HPV immunization. She tells the physician she's recovering from bronchopneumonia due to H. influenzae. The physician feels it would be better to wait until she is fully recovered and chooses not to administer the second HPC immunization today. How would you report the immunization not carried out?
Z28.01
263
According to the CMS E/M documentation guidelines for 1997, what exam component includes examination of the abdominal aorta?
Cardiovascular
264
A ROS is an account of body systems obtained through a series of questions seeking to spot signs and/or symptoms that the patient may be experiencing or has experienced. If the provider documented "patient denies indigestion or nausea and vomiting." what system is reviewed?
Gastrointestinal
265
The biggest difference between the 1995 DG and 1997 DG is the:
Exam
266
Using the 1995 DG, what level of exam would be reported for this documentation: History: Patient is being seen for a lingering cough. Exam: constitutional - temperature 97, heart rate 66, BP 128/65: Cardiovascular S1, S2 regular rate and rhythm: Lungs clear to auscultation bilaterally: Abdomen soft, nontender.
Expanded problem focused
267
Medical decision making (MDM) is determined by which three elements?
Number of diagnoses and treatment options, amount and complexity of data, overall risks
268
The patient was admitted to the local hospital with pneumonia. The admitting physician documented a detailed history, comprehensive exam and low MDM,. What E/M code is reported?
99211-AI
269
A physician documents 170 minutes of critical care time. How would this be reported:
99291
| 99292 x 4
270
The codes for removal of lesions are defined by the type of lesion, the anatomical location of the lesion and the lesion diameter. What would be reported for the excision of a 1.5 cm benign lesion of the right arm with simple closure?
11402
271
A patient sees an orthopedist for left hip pain after falling at home. After examination and a review of XX-rays, it is determined the patient has a acetabular fracture of the left hip. The orthopedist admits the patient to the hospital and schedules surgery for the next day. What modifier is used on the E/M office visit code?
57
272
A patient arrives at the ER after tripping and falling while carrying a glass bowl. She has lacerations on both arms. The ER physician performs repairs a 1.5 cm superficial laceration of the right forearm and a 2.0 cm superficial laceration of the left arm. There is also a 3.0 cm laceration of the left hand which is repaired with a layered closure. How are the repairs reported?
12042
| 12002-59
273
The sequencing rules for sepsis or severe sepsis with a noninfectious process are dependent on
whether or not the conditions meet the definition of principal diagnosis. If sepsis or severe sepsis is documented as associated with a noninfectious condition and that condition meets the definition of a principal diagnosis, then you would code the noninfectious condition first followed by the code for the resulting infection.
274
If a sepsis infection meets the definition of principal diagnosis, it should be sequenced
first, followed by the noninfectious condition.
275
When both the associated noninfectious conditions and a sepsis infection meet the definition of principal diagnosis
then either may be assigned as a principal diagnosis. Refer to ICD-10-CM coding guideline I.C.1.d.6. The type of sepsis is not specified in the question reporting code A41.9.
