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Medical Coding
Medical Coding Review Questions
| Question | Answer |
|---|---|
| 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
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