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Medical Coding

Medical Coding Review Questions

In what part of the medical record would a physician write a note when the chart is already complete or after the procedure is completed? Addendum
What are the 4 organizations that make up the cooperating parties for the ICD-9 CM? AHA, AHIMA, IMCHS, CMS
Reimbursement system for the outpatient APC - Ambulatory Payment Classification
What is ABN? Advance Beneficiary Notice- Also known as "Waiver of Liability". It is a written notice given to the patient prior to the procedure or before receiving services notifying patient that if the insurance denies or does not pay, the patient has to pay.
What software computes the DRG (Diagnosis-Related Group)? Grouper
Treatment for Genital Herpes? Acyclovir or Zovirax
What is Data Structure? Dictionary of Data Elements.
What is coded if they did catheterization of the First, Second & Third order? Third/3rd ONLY
What are the Outliers? Cases requiring more resources than usual or those who stay in the hospital longer than the average LOS (Length of Stay).
How to code incomplete procedure in CPT (Current Procedural Terminology)? Code as done with modifier-52 (reduced services)
What are G codes? Temporary codes for emerging procedure & codes for professional services with no CPT codes yet.
When can you code Late Effect first? When followed by a manifestation code.
Factors affecting DRG Diagnosis, Procedure, Age, Sex, Disposition & Birth-weight of Newborn/Neonate.
What is the definition of Principal Diagnosis? The condition established after study to be the main reason for admission
What are J codes? Codes for medication or a drug code that cannot be self-administered. It is used to identify injectable drugs
What is Serum Hepatitis? Hepatitis B
What is Case Mix Index (CMI)? Represents the Average Diagnosis-Related Group (DRG) relative weight for the hospital
What bones are involved in Epicondylar Fracture? Humerus & Femur
Treatment for Hypothyroidism. Synthroid/ Levothyroxine
Modifier for discontinued outpatient procedure prior to anesthesia administration? modifier-73
Uric Acid is elevated in what condition? Gout
What is EMTALA? Emergency Medical Treatment & Labor Act- All emergency cases must be treated at the ER even if the patient is not financially capable.
What takes precedence in the convention in coding or guidelines? Convention in Coding Books & Instructions.
What are V codes? Codes that are used to document conditions with no actual disease.
Terms Synonymous with Open Fracture. Compound fracture, missile, gunshot, puncture, infected or foreign body.
What is Mutually Exclusive Edit? Submission of two codes (procedures) which are improbable or cannot reasonably be performed at the same session.
Types of Endoscopy 1.) Diagnostic endoscopy- is an insertion of scope for viewing or examination only. 2.) Surgical endoscopy- if they do something else.
What condition is associated with Epstein-Barr virus (EBV)? Infectious Mononucleosis
What is Non-Excisional Debridement? Debridement using water, gauze or a blunt instrument > non-surgical (including sharp debridement
What is Excisional Debridement? Debridement done either by the physician, nurse or therapist using a cutting instrument > surgical removal or cutting away.
What is being treated if a patient is receiving Potassium? Hypokalemia (Low-Potassium/Potassium Deficiency)
Treatment for high LDL cholesterol (Low-density Lipoprotein) & low HDL (High-density Lipoprotein) cholesterol? Pravachol
Types of Skin Grafts 1.) Free Skin Graft 2.) Split Thickness 3.) Full Thickness
Skin graft from another human being (or cadaver) Allograft
In Adverse Effect of drug, what is the principal diagnosis? The Manifestation Code
What agency checks on one day inpatient hospitalization? CMS- Center for Medicare & Medicaid Services
Adjacent tissue transfer (includes excision of the lesion) Z-plasty
What condition is associated with high PSA (Prostate-Specific Antigen)? Cancer of the Prostate (BPH- Benign Prostatic Hyperplasia)
Types of Hernia Inguinal, Umbilical, Femoral, Hiatal or Diaphragmatic Hernia, Incisional or Ventral.
What is Stress Fracture Fracture caused by repetition trauma
What is the principal diagnosis if a patient is admitted for an HIV related condition? 042 AIDS
A screening colonoscopy was performed which showed the presence of diverticulitis. How is this coded? Screening colonoscopy, diverticulosis
When is the 5th digit 0 NOT used Ml & Pregnancy
What is Blood Transfusion Hepatitis Hepatitis C
What is Endoscopy Insertion (the act of implanting or putting in) of scope into natural body passageways.
What condition is associated with SIADH (Syndrome of Inappropriate Antidiuretic Hormone)? Hyponatremia (Low-Sodium/Sodium Deficiency)
Who maintains the CPT book AMA
The 'TERM ENCOUNTER' is applicable to what setting? ALL settings
What is a Complicated Wound is an infected wound with foreign body, delayed healing & delayed treatment.
How to code Incomplete Procedure in ICD-9 Code up to the extent of the procedure
What do you call the series of terms in parenthesis () following the main term Non-essential Modifiers
What condition is associated with elevated HBNP (Human Brain Natriuretic Peptide) CHF (Congestive Heart Failure)
What enzymes are elevated in acute Ml (Myocardial Infarction)? CPK-MB (Creatine Phosphokinase-MB) & Troponin
What are M codes Morphology codes for study of types of cells & behavior of neoplasm.
Organ involved in Ossicular chain reconstruction Middle ear
Symbol for Revised Text Facing Triangle/Bow Tie
What are the KEY factors/components of E & M (Evaluation & Management)? History, Examination & Medical Decision Making
How would you check productivity of the coders Coders ID, number of charts coded, Time Frame
What is a Significant Procedure Define as one that is surgical in nature, carries a procedural/surgical risk or anesthetic risk or requires specialized training
Treatment for CHF (Congestive Heart Failure) Lasix, Lanoxin, Digoxin
What is anemia due to bone marrow failure Aplastic anemia
What bones are involved in trimalleolar fracture Tibia & Fibula (ankle)
What is the principal diagnosis if a patient with AIDS (Acquired Immune Deficiency Syndrome) is admitted for an unrelated condition The unrelated condition
What is the meaning of DRG creep or Up-code (fraud) Coding of diagnosis or procedure which is not present or not documented in order to increase the DRG
What is the meaning of Puerperium Postpartum > after birth extending to 6 weeks
What part of the Medical Record would you find the size of the lesion in excision Operative Report
Test for Syphilis Wassermann or VDRL (Venereal Disease Research Laboratory)
How to code Bilateral Procedure in CPT With modifier-50
What are the 3 Compartments of the Knee Medial, Lateral & Patelo-Femoral
What is Case Mix Complexity of the population of patients or types of patients treated
Physician performs a permanent single chamber pacemaker, how many codes are used 2 codes
What is Benchmarking Process of comparing data to standard, peer group or another organization
What is Audit Trail Chronological list of those who access the EHR (Electronic Health Record) &/or the EMR (Electronic Medical Record)
What is SNOMED Systematic Nomenclature of Medicine-It is a systematic, computer-processable collection of medical terminologies, provides codes, terms, synonyms and definitions
What is OSHPD Office of Statewide Health Planning and Development- Provide the State with an enhanced understanding of the structure and function of its healthcare delivery systems
If a Fracture is NOT stated as Open or Closed, how is the fracture coded Closed
How can access to the network be controlled Identification, Authorization, Authentication
Basis for the HCPCS (Healthcare Common Procedure Coding System) Level II Modifiers Anatomical site
Treatment for gout Allopurinol or Colchicine
Term for Full Thickness removal of skin lesion Excision
Up to when is the Perinatal period Up to 28 days following birth
What disposition will affect the post discharge transfer rule Patient transferred to home health within 3-5 days after discharge
Skin graft from the patient himself Autograft
What is a Separate Procedure Part of a comprehensive procedure
What diagnosis is an indication for EPS (Eiectrophysiological Study) Sinus Node Dysfunction
What type of Hernia Repair requires additional code for the mesh Incisional or Ventral
Patient was admitted for TURP (Transurethral Resection of the Prostate) because of BPH (Benign Prostate Hyperplasia). Patient was found to have pneumonia so surgery was cancelled. Pneumonia was treated. Patient was discharged & rescheduled TURP later. Wha BPH & Pneumonia
Patient underwent tonsillectomy as outpatient. After the procedure, the patient had post-operative hemorrhage & was admitted. Code-in correct sequence Post operative Hemorrhage, Tonsillitis
What condition is associated with elevated ammonia in the blood Alcoholic Encepalopathy
If the physician excised 2 lesions with 1 incision how is this coded 2 Excision codes with modifier-51 on the last
What are E codes Codes used to identify the cause of injury, poisoning and other adverse effects
In poisoning with drug, what is the principal diagnosis The Poisoning Code
Modifier to be used if submitting 2 codes, one of which is a part of the other procedure & is not coded unless done in a separate session or a different excision site. modifier-59 to be used on/with the less significant procedure
What is the correct coding sequence: Patient had cataract surgery in the observation room. Patient had shortness of breath. Patient was admitted Asthma, Cataract
Which procedure will go to a surgical DRG CRTP (Cardiac Resynchronization Therapy Pacemaker)
Test for Hepatitis B Hepatitis B Surface Antigen
How would you code Italicized Codes Secondary
What hospital department is involved in EMTALA Risk management-HIM & Compliance Dept
Test for level of anticoagulant PTT (Prothrombin Time (PT)) & INR (International Normalized Ratio)
What is Surgical Package It includes pre-operative, operative & post operative care services
Treatment for Thrush or Oral Candidiasis/Candida Nystatin/Fungicidin
What is Pathological Fracture Fracture of the bone due to weakness of the bone because of bone disease such as osteoporosis/ or cancer of the bone as in multiple myeloma
What is Spontaneous Fracture This is considered pathological fracture, fragility fracture, compression fracture, or fatigue or insufficiency fracture
What is Principal Procedure Procedure done for definitive treatment (not for diagnostic or exploratory purposes)
What condition has a patient or with a Polydipsia, Polyuria & Polyphagia symptoms Diabetes Mellitus Type II
What is a Skin graft taken from a different species ex. PIG (non-human) Xenograft
What is Unbundling Submission of 2 codes: one of which is a component of the comprehensive code
What is the POA (Present on Admission) if the diagnosis is present on admission Y
How would you improve the function and check the performance of the Medical Records Audit & Monitoring
Up to when is the Postpartum period Six weeks after delivery
What is Debulking Partial excision or surgical removal of tumor, done if cancer is unresectable. It is a surgical removal or part of a malignant tumor which cannot be completely excised, so as to enhance the effectiveness of radiation or chemotherapy
What is called Infectious Hepatitis Hepatitis A
What condition is associated with high TSH (Thyroid-Stimulating Hormone) Hypothyroidism
If they did both diagnostic & surgical endoscopy, which one are you going to code Surgical ONLY
What is the principal diagnosis if a patient with AIDS is admitted for an unrelated condition The unrelated condition
Keyword in the index when you look for TURP Prostatectomy
When is Delivery considered Normal When it is: 1.) Single intrauterine live-born 2.) Vaginal delivery 3.) Full term (37-40 weeks) 4.) Cephalic presentation 5.) Episiotomy or anesthesia 6.) No complication 7.) Artificial Rupture of Membrane (AROM)
In what instances the acute respiratory failure is NOT the principal diagnosis When is it due to: Sepsis, AIDS, Pregnancy, Poisoning, Newborn/Neonate
What is Starred Procedure Code exempted from surgical package & includes only one service or limited services
What is the significance of high TSH (Thyroid-Stimulating Hormone) & lowT4 Hypothyroidism
Patient was admitted with chest pain due to unstable angina & CAD (Coronary Artery Disease)-Code in correct sequence CAD & Unstable Angina
If the physician performs debridement, how will you code it Query the physician whether it is an excision or incision
Modifier that is NOT applicable to hospital outpatient modifier-51
Criteria for reporting additional diagnosis When patient care requires: 1.) Clinical evaluation 2.) Therapeutic treatment 3.) Diagnostic procedure 4.) Extended length of hospital stay 5.) Increased nursing care or monitoring
Symbol for a Revised code Triangle
2 ways of coding Excisional Biopsy 1.) Entire lesion removal = code as excision. 2.) Removal of a part or small piece only = code as biopsy
Treatment for Hypokalemia : K-Dur
In Aspergillosis Pneumonia what is the first listed code Aspergillosis
What is the purpose of a physician query To clarify documentation
Modifier if patient is seen in ER by a cardiologist & a podiatrist modifier-27
CPT code for unlisted procedure Ending in 99
What is required to obtain a copy of the patient's medical record Signed consent of release of medical information
Who allows insurance companies to transfer patient's information to another facility without patient's consent HIPAA (Health Insurance Portability and Accountability Act)
How to code Bilateral Procedures in ICD-9 Code TWICE
Symbol for a New code Bullet
Who investigates coding fraud OIG (Office of Inspector General)
What part of the Tibia is the Tibial Plateau Upper part
What is UHDDS Uniform Hospital Discharge Data Set-Used for reporting inpatient data in acute care, short-term care, and long-term care hospitals
What is the principal diagnosis for a patient admitted for Acute Gastroenteritis & Dehydration Dehydration
What is the principal diagnosis: Pregnancy or Dehydration Pregnancy
What is the treatment for Pneumonia (community acquired) Rocephin or Zithromax
What is the treatment for osteoporosis Fosamax
What is the treatment for DVT (Deep Vein Thrombosis) Heparin or Coumadin
What organism is involved with CLO (Campylobacter-Like Organism) test Helicobacter Pylori
Cholecystectomy without CDE (CholeDochoEnterostomy) & with MCC (Migrating Motor Complex), which will impact the DRG (Diagnosis Related Group) Pneumonia
What is the meaning of Anemia Low red blood cells
What is it called when a coder codes a diagnosis which is not present Up-coding or DRG creep (Example: coder codes urosepsis as sepsis without documentation
When coding Residual & Late Effect, which is coded first Late Effect
How would you code admission for hypertrophy of tonsil, had post operative hemorrhage Post-operative Hemorrhage (principal), Hypertrophy of tonsil
Anemia's white blood cells fight what Infection
What is the definition of Relative Weight An assigned weight intended to reflect the relative resource consumption associated with each DRG
What is the Surgical Hierarchy An order of surgical cases from most to least resource intensive
If patient has appendicitis & had an inadvertent abortion, what is the procedure Appendicitis
Which of the following will go to a DRG CRT-P (Cardiac Resynchronization Therapy Pacemaker)
What is the name of the software that produces the ICD-9 code Encoder
What will simplify HIPAA ruling PPP (Patient Personal Privacy)
Who handles or manages patient's health information records HIM (Health Information Management)
What is the term for Destruction of lesion Ablation, Cutterage, Cautherization
What does excision include Includes anesthesia & simple closure
Which is NOT a minimum data set HIPAA (Health Insurance Portability and Accountability Act)
Name for Central Data Repository Common Data Base
Who administers the coding clinic AHA (American Hospital Association)
Who administers the HCPCS (Healthcare Common Procedure Coding System) Level I AMA (American Medical Association)
Who administers the HCPCS (Healthcare Common Procedure Coding System) level II CMS (Centers for Medicare & Medicaid Services)
In CPT when are you going to add the length of the lesion Same anatomic group & same classification of repair
What is the Hepatitis enzyme Transaminase
What condition is associated with elevated CPK-MM (Creatine PhosphoKinase-Muscle) Musculo-Skeletal Injury (refers to damage of muscular or skeletal systems); Rhabdomyolysis (severe muscle breakdown)
Which will carry the most impact on DRG after 6 days upon discharge of the patient from the hospital Length of Stay
If claim gets rejected what must be done Review & re-code
What do you do with unbilled charts Check if already coded, code if not
A CT (Computed Tomography) scan of the head was requested but the claim was denied, why is this Diagnosis did not match procedure
What is required for a CT (Computed Tomography) scan of the head Diagnosis
What is a Complication A medical problem that occurs during a disease, or after a procedure or treatment or a condition after admission
What is ALOS Arithmetic-mean Average Length of Stay (outlier cases)
What is paid under the APC (Ambulatory Payment Classification) Partial hospitalization
What is NOT paid under the APC Laboratory
What is APG Ambulatory Patient Group- it "consolidates", "packages" and "discounts" a facility's payment for outpatient services, providers may experience decreased reimbursement for the same services when compared with the existing outpatient payment methodologies
What is ATN Acute Tubular Necrosis- is usually caused by a lack of oxygen to the kidney tissues (ischemia of the kidneys). It may also occur if the kidney cells are damaged by a poison or harmful substance
What is Comorbidity A pre-existing condition or co-occurring with a primary disease or disorder
What is HAC Hospital Acquired Condition- is an undesirable situation or condition that affects a patient that arose during a stay in a hospital or medical facility
What is MDC Major Diagnostic Category- is formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas
What is TAH Total Abdominal Hysterectomy- is the removal of the uterus and cervix through an abdominal incision
What is TIA Transient Ischemic Attack- often labeled "mini-stroke," it is more accurately characterized as a "warning stroke/' a warning you should take very seriously. It is caused by a clo
What is EPS Electrophysiological Study- detects the abnormality of the heart rate
What is a Biopsy A removal of specimen that is sent to pathology to see if there are malignant possibilities
What is the name of the biopsy that is performed with a definitive procedure Open biopsy
The patient has no add on his cart, his claim was denied. Why? Not an outlier
Where do slanted brackets // appear In the Alphabetical Index
If they code lumpectomy with lympectomy, which range of codes will you choose Partial
Cardiac Resynchronization Therapy Pacemaker would go to a... Surgical DRG
If you are given several charts/a stack of charts which do you code first High dollar chart/ high paid chart
What are 2 types of Nissen Fundoplasty Laparoscopic & Open
How do you put ethics in your organization Mandatory Compliance Training
What is similar between inpatient & outpatient payment system Both are paid under the Prospective Payment System
What is the name of the inpatient reimbursement system DRG (Diagnosis-Related Group)
How do you code an outpatient rule-out No code (Cannot code possible, likely, or questionable)
What is the principal diagnosis for a patient with respiratory failure due to alcohol intake with medication (Xanax) Poisoning
What is the purpose of the network Allows access to everyone
Which gets coded when concerning a fracture & a dislocation Fracture
Malunion of fracture of femur is considered what Late Effect
When a fracture is caused by a disease, how does this need to be coded Pathological
What causes Hypokalemia Low-Potassium/Potassium Deficeincy
What is Hypoglycemia linked to Low-Calcium
What do you do when you discover a breach in email confidentiality or unauthorized access of medical records Notify immediate Supervisor
What must the coder do to prevent unauthorized access to confidential information Sign in & out
How often do you change the pass-code in the system 90 to 180 days (3-6 months)
How documentation can be improved Feedback
What is the difference between a discharge & a transfer A discharge is a situation where a patient is released from care. A transfer is a situation in which a patient is admitted to another inpatient for related care same day.
Is it an adverse effect or poisoning if the patient developed a reaction after synergistic effect from drug Adverse Effect
TIA (Transient Ischemic Attack) vs. Stroke Both will be coded as primary & symptoms will be coded as secondary
Which of the following is used for external Data storage USB Flash Drive
Controlling factor in the selection of E/M code when counseling and coordination of care dominates more than 50% of time spent by a physician to a patient encounter Face To Face time
How do you code a diabetic patient with Nephropathy Diabetes Mellitus with Renal manifestation
The physician documents Urosepsis due to E. Coli. The coder used this as Septicemia due to E. Coli. What is this called Optimizing
Excision of brain via Craniotomy Lobectomy of the brain
What kind of Mastectomy includes excision/removal of the major pectoral muscles of the breast Radical Mastectomy
Sphincter of body Common bile duct
What is Acute Alcoholism Patient who has hallucinations due to alcohol intake (severe form)
Which of the following will be coded as primary Angina or CKD CKD
How would you code 2 lacerations of the cheek- intermediate & one laceration of the forehead-simple Add cheek & code simply separately (2 codes)
What is CCI CCI stands for National Correct Coding Initiative. In 1994, the Health Care Financing Administration (HCFA) awarded a contract to AdminaStar Federal, the Indiana Medicare carrier, to define correct coding practices that would serve as the basis for nation
What Enzymes are elevated in Acute Pancreatitis Amylase and Lipase
What type of Streptococcus resistant to Vancomycin in Enterococcus Group D
What is considered a flap rotation on skin Adjacent tissue transfer
What is the medication for severe sepsis Xigris
How to clarify medical documentations Query the physician
What is DRG optimization (legal) Coding of diagnosis or procedure which is thoroughly reviewing the documents or query the doctor in order to increase the DRG
What are the 3 factors included in Case Mix Relative Weight, Diagnosis, DRG
What is the first screening test for AIDS ELISA (Enzyme-Linked Immunosorbent Assay)
What organ produces Amylase Pancreas
What is a factor in profit and loss of the hospital Case Resources
What type of contract or agreement does Office of the Inspector General have Federal Compliance Agreement
Sponge was left inside after surgery who to notify Risk Management
What is QIO Quality Improvement Office- provides peer review services within the health care community
What tool is used for monitoring coding compliance PEPPER- Program for Evaluating Payment Patterns Electronic Repor
In the event that the Operative Report is missing on the discharge chart, where do you look next Transcription Report
What CPT Code starts in 99 E&M
What CPT Code starts in 69 Auditory
What is Coding Policies and Procedures Organizational Tools
Medication for Hypertension Lotensin, Lopressor, Norvasec
What is the law that requires no authorization from the patient HIPAA rules
Benign type of Neoplasm/Tumor Lymphoma
Malignant type of Neoplasm/Tumor Carcinoma
Other term for secondary site Metastatic site
What is MDS Minimum Data Set- is a powerful tool for implementing standardized assessment for Medicare and Medicaid (CMS) and for facilitating care management in nursing homes and non-critical access hospital
The 3 words that defines the contrasting diagnosis Versus, Either, Or
Diagnostic Rule Inpatient: Code ALL of this: Ruled out, Probable, confirmed and Un-confirmed Outpatient: ONLY code Confirmed
Treatment for Atrial Fibrillation Digoxin, Atenolol, Verapamil
The source document for coding and reporting diagnoses and procedures Medical Record
An interventional radiology bill for common angioplasty has not been paid by the insurance company. What could be the reason for the denial The coder did not submit the appropriate modifier
APC Encounter Endoscopy Encounter
What Agencies uses UHDDS Medicare and Medicaid
What is the purpose of UHDDS To list and define a set of common, uniform data elements. It provides uniformity and comparability in hospital discharge data
What replaces the function of the book in EHR Encoder Software
What is "Electrocauterization" equivalent to Destruction by Ablation
A code that is enclosed in a Brackets [] in the index is an indication of Manifestation code
3 Components of Hysteroscopy Polypectomy, Myomectomy, and Endometrial Ablation
What kind of infections are Aspergillosis, Candidiasis etc Fungal Infection
A procedure given as bilateral and only 1 side was performed Repeat 1 code (code twice) & modifier-52 (reduced services)
According to AHIMA standards, what of the following is NOT considered a coding-related activity Risk Analysis
DRG & APC groupers are part of an encoding system in w/c of the following settings Acute Care
Which of the following is NOT a factor of CMI LOS -Length of Stay
What is the keyword to find EGD & lleoscopy Small Intestine
What is an Open Incisional Hernia Strangulated
The word "Encounter" according to ICD-9 refers to what Outpatient
What of the following takes precedence if there's an issue to be resolved ICD-9 Official Guidelines for Coding and Reporting
When do you code 650 Episiotomy
The Pt. is admitted with CAD & unstable Angina. Pt. underwent PTCA & insertion of Stent. Which of the following procedure performed would optimize the DRG Stent Replacement
When Stent Insertion is NOT coded When the catheter didn't go through the lesion
What is the code if a Pt. is being seen for testing for HIV and the result is + (positive) Screening
What is the code if a Pt. returns with an HIV test and the result is - (negative) Counseling
Early signs of CHF include Tachycardia Fatigue Dyspnea on exertion Cough Swollen ankles and/or feet Weight gain Intolerance to cold
What are the diagnoses that will impact the DRG for Cholycystectomy UTI
A hospital needs to bill $25,000 to $28,000 in account. Which one will you code first The one that will expire first
According to UHDDS Guideline on ICD-9 codes that are required: If a Pt. has a Lumbar procedure because of lumbar pain, what procedure code that is NOT required for you to code CT-Scan Vertebra
What is the purpose of EHR Provides patient's collection of Medical History and tracks Audit Trails
Bronchodilators for Asthma Proventil or Atrovent
An example of Steroids for COPD & Allergy Prednisone or Medrol
What enzyme is an indicator of Thyroid Disorder TSH
Procedure for flap rotation on skin lesion Full Graft of adjacent tissue
Prospective Payment System (PPS) covers the following facilities Acute Inpatient Hospitals, Home Health Agencies, Hospice, Hospital Outpatient, Inpatient Psychiatric Facilities, Inpatient Rehabilitation Facilities, Long-Term Care Hospitals, and Skilled Nursing Facilities
Modifier that is NOT applicable to hospital outpatient or modifier use when a physician performed a multiple surgeries/services on the same day, during the same surgical session modifier-51
Modifier for discontinued procedure after administration of Anesthesia modifier-74
What are some different types of services documented in medical record Evaluation and Management Operative reports X-Rays
What is an Operative Report A report written to document the details of a surgery or procedure performed on a patient
What are the 2 examples of HIPAA Transaction Code Sets Place of Service codes Relationship codes
When will ICD-10-CM be effective October 1, 2014
Who enforces HIPAA Privacy and Security Rules OCR -Office of Civil Rights
3 volumes of ICD-9 Volume 1: Tabular List of Diagnosis & Injuries; Volume 2: Alphabetical Index of Diagnosis & Injuries; Volume 3: Tabular List & Alphabetic Index of Procedures
What are 2 supplementary classifications in ICD-9 V-codes E-codes
What is an Abortion It is the expulsion or extraction of all or part of the placenta or membrane with or without an identifiable fetus weighing less than 500 grams
Types of Abortion Spontaneous Induced Missed Threatened
4 additional contributory components of an Evaluation and Management code which are Counseling Coordination of care, Time Nature of presenting problem
Code this when there is a decubitus X- ray, diagnostic thoracentesis, or chest-tube drainage Pleural Effusion
What are the Diagnostic Descriptors that are listed in Italics Manifestation code Secondary code
It is the assignment of numbers and sometimes letters to Diagnosis and Procedures. It is also the process of translating or identifying this written or dictated medical record into a series of numeric or alpha-numeric codes Coding
The most common organs affected by Diabetes Mellitus Eyes- Retinopathy Kidney- Nephropathy Nerve- Neuropathy Blood vessels- Angiopathy
Types of Diabetes Type I -Juvenile onset Type II- Adult onset Gestational Diabetes - during Pregnancy Secondary Diabetes - caused by certain Illness or drugs
Classification of Burns First degree (erythema) Second degree (blistering) Third degree (full-thickness involvement)
Types of Infection Nosocomial Infection Cryptogenic Infection Local Infection Systemic Infection
2 Main Conditions that make-up COPD Emphysema Chronic Ashmatic Bronchitis
Common airborne irritants that typically caused COPD Tobacco smoke Dust Chemical fumes Air pollution
Types of CAD Arteriolosclerosis Atherosclerosis Ateriolosclerosis Obliterans Medial calcific sclerosis
Major cause of Ischemia of the Heart, Brain and Extremities Atherosclerosis
Types of Angina Unstable Angina Angina Pectoris
Types of Infarction Transmural Infarctions Subendocardial Infarctions a.k.a. non-Q-wave Ml
Types of CVA Cerebral Infarction Cerebral Hemorrhage Arteriovenous Malformation of Brain
Types of Fracture Treatment Reduction Stabilization
It is an internal fixation device that is NOT necessarily require direct exposure at fracture site, accomplished by gaining access to the bone through an incision Internal fixation with intramedullary nails
What is ICD-9-CM The International Classification of Diseases, Ninth Revision, Clinical Modification- is the official system of assigning codes to diagnoses and procedures associated with hospital utilization. It was designed for statistical reporting and used to code and
In Volume 1: Tabular List Of Diseases and Injuries. It contains major subdivision as follows Classification of Diseases and Injuries Supplementary Classification Appendices
In Volume 2: Alphabetic Index of Diseases. It contains 3 major sections as follows Main Term Subterm Carryover Lines
3 Conditions that are always presumed to be due to Diabetes even without cause and effect relationship unless there is a stated cause Hypoglycemia Osteomyelitis Gangrene
Surgical Procedural Terms commonly use in the treatment of Neoplasm En block Resection Debulking Resection Local Excision
Types of Heart Failure Systolic heart failure Diastolic heart failure
Anti-Anginal Medications Beta Blockers Calcium Channel Blockers Nitrates or Vasodilators
Subendocardial Ml is also known as Non-Q-Wave Non-ST-Elevation Non-transmural
Effects of CHF Increased pressure in the lung Impaired Kidney function Poor circulation throughout the body
What disposition affects MSDRG Skilled Nursing Facility
Pregnant woman admitted with diarrhea, nausea, vomiting Current Condition Affecting Pregnancy
Compressive Fracture of the lumbar spine due to osteoporosis Pathological Fracture - 733.13 & 733.00
How to code induced Abortion resulting in live-born 644.21 - Early onset of delivery
Colonoscopy with biopsy of the transverse colon & polypectomy of the recto-sigmoid with snare 45385 & 45380-59 (2 codes - 2 procedures on different site)
Post-operative Anemia 285.9
What Auxiliary procedure is coded in CABG 39.61 Extracorporeal circulation or Cardio-pulmonary bypass machine
Code for Normal Delivery 650 & V27.0
Auto Immune Hemolytic Anemia (always choose over cold/warm type) 283.0 cold type/warm type
Exploratory laparotomy with appendectomy & drainage of abscess of appendix 47.09
CPT code for TURP (Transurethral Resection of Prostate) 52601
CPT code for PTCA with insertion of coronary stent 92980 = old code (use this instead). 92928 = new code. *always includes angioplasty. (ONE code only- because the code indicates with or without therapeutic intervention which is the PTCA.)
CPT code for PTCA 92920 (92982 - deleted)
What is the code for Decompensated COPD (Chronic Obstructive Pulmonary Disease) 491.21 (decompensated is the same as exacerbation of COPD)
CPT code for Total abdominal hysterectomy with or without salpingo-oophorectomy 58150
Intertrochanteric Fracture of the femur due to multiple myeloma Pathologic fracture: 733.14 & 203.00
Code for anemia due to blood loss 280.0
Code for removal of skin tags 17 lesions 11200 & 11201
How to code renal calculus with Hematuria & Renal Colic 592.0 Code renal calculus only
CPT code for Laparascopic Nissen Fundoplasty or Fundoplication 43280, Laparascopic
CPT code for Bilateral Screening Mammography 77057
Code for Positive Serology for AIDS Adult V08
Exploratory Laparotomy with incidental appendectomy 54.11 & 47.19
Positive Serology for AIDS in a 7 month old baby 795.71 - Inconclusive Positive Serology for AIDS
How to code destruction pre-malignant lesion of skin by cryosurgery or cryotherapy First lesion = 17000. Each additional lesion = 17003 (Repeat code for each additional up to 14) 15 or more lesions = 17004 (Use only 1 code)
CPT code for Hysteroscopy with biopsy of the endometrium or polypectomy with or without DNC (Dilatation & curettage) 58558
CPT code for Colonoscopy with biopsy transverse colon polyp & polypectomy descending colon polyp by snare 45385 & 45380-59
What is the CPT code for angiography of the aortic arch & bilateral common carotid arteries 36217
How to code fracture of the bone due to multiple myeloma or osteoporosis Pathological NEC 733.10 Multiple Myeloma 733.10 203.00 Osteoporosis 733.00
Respiratory failure after ingestion of drugs & alcohol Poisoning code 980.0 & 980.9
How to code EGD (EsophagoGastroDuodenoscopy) up to the ileum 44376 Small intestinal endoscopy
CPT code for Colonoscopy with biopsy of the transverse colon followed by removal of the same polyp by snare 45385 (1 code only = 2 procedures on same (one) site)
CPT code for treatment of non-union fibula 27726
What is the CPT code for recurrent incisional hernia with mesh 49565 & 49568
What is the code for Amphetamine & Heroin dependency Use combination code 304.70 (dependency with combination of drug with opioid)
CPT code for Destruction of pre-malignant lesion by cryotherapy -16 lesions 17004
CPT code for CLO-test also known as EGD with biopsy 43239
CPT code for Destruction of pre-malignant lesion by cryotherapy- 3 lesions 17000, 17003, 17003
What is the code for a seizure on Dilantin Epilepsy 345.90
What is the code for Anemia due to CKD 285.21 (ONE CODE)
What is the code for CKD due to diabetes? 250.40 & 285.9
Female infertility due to Chronic Pelvic Inflammatory Disease 628.8 & 614.4
When a patient is admitted for the purpose of chemotherapy & develops complications such as uncontrolled nausea & vomiting or dehydration, what is the principal diagnosis Admission for Chemotherapy V58.ll
What is the code for BIPAP? (Bi-level Positive Airway Pressure) 93.90
What are the 3 Ethmoidectomy codes 31254, 31255, 31267
What are the 2 CPT codes for colonoscopy Polypectomy 45385 & Biopsy 45380 -59
What add on code must be included with Ventral Incisional Hernia Mesh 49568 (Implantation of material)
What is the difference between codes 303.00 & 303.90 303.00 means that the patient has been admitted intoxicated (drunk) 303.90 means that.... is alcohol dependent
CPT code for Medial And Lateral Miniscectomy 29980
COPD with exacerbation of Asthma 493.22
CPT Code for Bunion Repair, Mitchell Procedure 28296
Admission for drug monitoring of anticoagulant for Coumadin for a patient with Atrial Fibrillation V58.63, V58.61, 427.31
CPT Code for EGD with Percutaneous Gastrostomy 43246
CPT code for Bilateral Hip replacement 81.51, 81.51 (Code TWICE)
Code for Anemia due to blood loss (Acute) 285.1
Code for contusion and laceration of Eyebrow 784.32
CPT code for Repair of Inguinal Hernia with Mesh in a patient with previous Inguinal Hernia Repair 49520
CPT code for Arthroscopy knee with medial meniscectomy and lateral chondroplasty 29881 & 29877-59
CPT code for Excision of scar arm 2X6 cm with closure bt split-thickness graft 15002 & 15110
CPT code for Destruction lumbar nerve by radio frequency ablation L2, L3 & L3 64622 64623 64623
CPT code for Injection steroid transforaminal Cl and C2 64479 64480
Pr code for TURP with incision of bladder neck 60.29 57.19
Code for Sino-Artrial Node Dysfunction 427.89
Pr code for EPS (Electrophysiological Study) 37.26
Code for Encounter for drug monitoring for Coumadin in a patient with Atrial Fibrillation V58.83 V58.61 427.31
Code for Respiratory failure and coma after ingestion of alcohol 980.0 518.81 780.01
Code BPH (Benign Prostatic Hypertropy) with bladder neck obstruction 600.01 596.0
Pr code for TURP and incision of the bladder neck 60.29 57.91
Diagnosis: Code for BPH (Benign Prostatic Hypertrophy) with bladder neck obstruction 600.01 596.0
Procedure: Code for TURP and incisions of the bladder neck 60.29 57.19
Code for Seizure 780.39
Code for Seizure disorder and recurrent 345.90
Procedure Code for Explaratory Laparotomy with Liver biopsy 54.11 50.12 54.12
Patient with ESRD and Diabetes came in for Catheter replacement and underwent Hemodialysis V56.0 585.6 250.00 38.95 39.95
Code for TIA vs Stroke "TIA", it is coded as 435.9; "Stroke", it is coded as 434.91
Code for CHF due to HTN with pleural effusion 402.91 428.0
CPT code for Repair of Incisional hernia with prosthesis 49560 49568
CPT code for treatment of Non-union Fibula 27726
CPT code for Needle or puncture aspiration of cyst in the breast 19000
CPT code for Cystoscopy with fulguration of bladder tumor 52234
CPT code for benign forehead 2X3 cm and excision of benign lesion of the cheek 2X4 cm; both repaired by layered closure I11443 11444 12053 11443 11444 12053
CPT code for Trabeculectomy for glaucoma in a patient with scarring from previous surgery 66172
Code for Interstitial Lung Disease 515
Code for Explaratory Laparotomy with liver biopsy 54.11 51.02
CPT Code for Mastectomy 19303
Created by: hrodil