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Medical Coding 2
Another Medical Coding Review Questions
| Question | Answer |
|---|---|
| Symbol for a new code | Bullet |
| Test for Hepatitis B | Hepatitis B surface antigen |
| Treatment for gout | Allopurinol |
| Term for full thickness removal of skin lesion | Excision |
| Key factors in E & M | History, examination, and medical decision making |
| Factors affecting the DRG | Diagnosis, Procedure, age, sex, disposition, birthweight of the newborn |
| Basis of HCPCS modifier II | Anatomical site |
| Treatment for Herpes | Acyclovir (zovirax) |
| Symbol for revised code | triangle |
| Patient with polydipsia and polyuria | Diabetes type 2 |
| Code for induced abortion resulting in a liveborn | Early onset of delivery |
| Code for renal calculus with hematuria | Code renal calculus only 592.0 |
| What are CPT codes ending in 99 | Unlisted procedure |
| Definition of complicated wound | Infected, with foreign body, delayed healing or delayed treatment |
| What is a significant procedure | Surgical in nature, with surgical risk, with anesthetic risk, and requires specialized training |
| What are G codes | Temporary codes for emerging technology and codes for professional service with no CPT code yet |
| Modifier if patient is seen in the ER by a Cardiologist and a Podiatrist | 27 |
| How to code bilateral procedure in ICD-9 | Code twice |
| How to code bilateral procedure in CPT | With modifier -50 |
| How to code incomplete procedure in ICD-9 | Up to the extent of the procedure |
| How to code incomplete procedure in CPT | Code as done with modifier -52 |
| Who maintains the CPT book | AMA |
| CPT code for Clo-test | 43239 |
| How would you code EGD up to the ileum | 44376 |
| What diagnosis is an indication for EPS ( electrophysiological study) | Sinus node dysfunction |
| CPT code for treatment of non-union fibula | 27726 |
| What is case mix INDEX | Average relative weight |
| What is audit trail | Chronological list of those who access the EHR electronic health record or EMR Electronic medical record |
| What is ABN (advanced beneficiary notice) | Notice given to the Patient prior to the procedure telling him that if the insurance does not pay, the patient has to pay |
| What is EMTALA (Emergency medical treatment and labor act) | All emergency cases must be treated at the ER even if not financially capable |
| What Hospital department is involved in Emtala | Risk management and compliance |
| What is APC | Ambulatory payment classification - the reimbursement system for outpatient |
| What id UHDDS | Uniform hospital discharge data set |
| What is OSHPD | Office of the statewide hospital planning and development |
| In what part of the Medical Record would you see the size of the lesion in excision | Operative report |
| In what part of the Medical Record would a Physician write a note when the Chart is already complete | Addendum |
| What is the purpose of Physician Query | To clarify documentation |
| What are M codes | Morphology codes for study of type of cells and behavior of neoplasm |
| Modifier to be used if submitting two codes, one of which is a part of the other procedure and is not coded unless done in a separate session or different excision site | 59 |
| Who allows insurance companies to transfer Patient's info to another facility without Patient's consent | HIPAA |
| What is the meaning of DRG creep | Coding of diagnosis or procedure which is not present or not documented in order to increase the DRG |
| What is debulking | Partial excision or removal of tumor done if Cancer is unresectable |
| What is benchmarking | Process of comparing a data to a standard |
| What is a DATA STRUCTURE | Dictionary of data elements |
| What are J codes | Codes for medications that cannot be self-administered |
| What are the four organizations that make up the Cooperating Parties for the ICD-9-CM | AMA AHIMA NCHS MS |
| Treatment for thrush | Nystatin |
| Test for Syphilis | Wasserman or VDRL |
| What is blood transfusion hepatitis | Hepatitis C |
| What enzymes are elevated in acute MI | CPK-MB & troponin |
| Anemia associated with bone marrow failure | Aplastic anemia |
| What bones are involved in epicondylar fracture | Humerus and femur |
| Positive serology for AIDS in a 7 month old baby | 795.71 Inconclusive positive serology for AIDS |
| What condition is associated with elevated HbNP | CHF |
| When can you code late effect first | When followed by manifestation code |
| In what instance is the manifestation coded | When preceded by late effect code |
| What auxiliary procedure is coded in CABG | 39.61 extra-corporeal circulation or cardio-pulmonary bypass machine |
| How would you control access to the network | Identification, authorization, and authenthication |
| How would you check the productivity of the Coders | Coder ID, number of charts coded and time frame |
| How would you improve the function of the Medical records | Audit and monitoring |
| If they did both Diagnostic and Surgical endoscopy, which are you going to code | Surgical only |
| What is coded if they did catheterization of the first, second, and third order | Third |
| What is being treated if Patient is receiving potassium | Hypokalemia |
| How would you code Italicized codes | Secondary |
| What do you call the series of terms in parenthesis following the main term | Non-essential modifiers |
| What is the POA if the diagnosis is present on admission | Y |
| What is required to obtain a copy of the patient's Medical Record | Signed consent of release of medical information |
| What software computes the DRG | Grouper |
| Test for level of anticoagulant | PTT and INK |
| What is case mix index | Average relative weight |
| What are outliers | Cases requiring more resources than usual or those who stay in the Hospital longer than the average LOS (length of stay) |
| What is SNOMED | Acronym for systematized numenclature of medicine |
| What disposition will affect the Post-discharge transfer rule | Discharge to home health within 3-5 days after discharge |
| The term encounter is applicable to what setting | All setting |
| What is called as infectious hepatitis | Hepatitis A |
| What is blood transfusion hepatitis | Hepatitis C |
| What is serum hepatitis | Hepatits B |
| What is anemia due to bone marrow failure | Aplastic anemia |
| code for anemia due to blood loss | 285.1 |
| Post-operartive anemia | 285.9 |
| Autoimmune hemolytic anemia | 283.0 |
| Female infertility due to chronic PID (pelvic inflammatory disease) | 628.8 614.4 |
| Delivery complicated by Spinal headache | 668.2 349.0 |
| Contusion and laceration of eyebrow | 784.32 |
| What organ is involved in ossicular chain reconstruction | Middle ear |
| What is the definition of principal diagnosis | The condition established AFTER STUDY to be the main reason the patient was admitted |
| What is the principal procedure | The procedure done for definitive treatment rather than the one done for diagnostic or exploratory purposes |
| What is a significant procedure | A procedure that is: a) surgical in nature b) carries a surgical risk or anesthetic risk requires specialized training |
| What are the criteria for reporting additional diagnosis | Code all diagnosis that affect patient care in terms of requiring: a) clinical evaluation b) therapeutic treatment c) diagnostic procedures d) extended length of hospital stay e) increased nursing care or monitoring |
| When is CARDIAC ARREST used as principal diagnosis | If the patient came in cardiac arrest at the ER and died or was admitted and died and there is no cause or etiology of the arrest, the cardiac arrest is the principal diagnosis. If there is a cause, the cause is the principal diagnosis. If the patient wa |
| What condition is associated with elevated uric acid | Gout |
| What condition is associated with elevated ammonia in the blood | Alcoholic encephalopathy |
| CPT for PICA with insertion of coronary stent | 92980 * one code only because the code indicates with or without therapeutic intervention which is the PTCA |
| CPT code for Insertion of one coronary stent | 92980 |
| CPT code PTCA | 92982 |
| What condtition is associated with elevated CPK MM | Musculo-skeletal injury |
| What enzymes are elevated in acute MI | CPK-MB and Troponin |
| What enzymes are elevated in acute pancreatitis | Amylase and lipase |
| What is the meaning of Puerperium | Post-partum |
| Up to when is the newborn period | 28 days |
| In CABG what auxiliary procedure are you going to code | 39.61 |
| Code for CABG with saphenous vein graft to the circumflex and obtuse marginal branch and LIMA (left internal mammary artery to the LAD | 36.12 36.15 |
| What part of the tibia is the tibial plateau | Upper part |
| What bones has epicondyle | Femur and humerus |
| What bones are involved in trimalleolar fracture | Tibia and fibula (ankle) |
| Up to when is the post-partum period | 6 weeks |
| Code for Positive serology for AIDS adult | V08.0 |
| In CPT When are you going to add the length of the lesion | Same anatomic group and same classification of repair |
| What are the factors affecting the DRG | Diagnosis principal and secondary, procedure, sex, age, disposition, birthweight of neonates |
| Positive serology for AIDS newborn | 795.71 non-conclusive serologic test for AIDS |
| Inpatient- Chest pain due to possible angina | Angina 413.9 |
| Anemia associated with bone marrow failure | Aplastic anemia |
| What is the treatment for hypothyroidism | Synthroid |
| What condition is associated with high TSH | Hypothyroidsm |
| What condition is associated with high PSA | BPH or Ca of PROSTATE |
| Colonoscopy with biopsy of the transverse colon and polypectomy of the recto-sigmoid with snare | 453.85 453.80-59 * two codes because biopsy and polypectomy was on different site |
| Colonoscopy with biopsy of the transverse colon polyp followed by removal of the same polyp by snare | 45385 *one code only because biopsy and polypectomy was on the same site |
| What is called serum Hepatitis | Hepatitis B |
| Exploratory laparotomy with incidental appendectomy | 54.11 47.19 |
| Hepatitis associated with blood transfusion | Hepatitis C |
| Exploratory laparotomy with appendectomy and drainage of abscess of appendix | 47.09 |
| What is mutually exclusive edit | Submission of two codes which are improbable to be performed at the same session |
| What is unbundling | Submission of two codes one of which is a component of the comprehensive code |
| What do you call the series of terms in parenthesis following the main term | Non-essential modifier |
| What is a starred procedure | Includes limited services |
| What is a surgical package | Includes pre-operative, operative and post-operative care |
| What is Case mix index | Average relative weight |
| Case mix | The complexity of the population of patients or the types of patients treated |
| What is the term for full thickness removal of skin lesion | Excision which includes local anesthesia and simple closure |
| What is hypokalemia and the treatment for hypokalemia | Low potassium tx- K-dur |
| What condition is associated with SIADH | Hyponatremia (low sodium) |
| Key components of the E & M | History, examination, medical decision making |
| What is a stress fracture | Fracture due to repetitive trauma |
| compression fracture of the lumbar spine due to osteoporosis | Pathological fracture 733.13 733.00 |
| Inter-trochanteric fracture of the femur due to multiple myeloma | Pathological fracture 733.14 203.00 |
| If a fracture is not stated as open or closed, how is the fracture coded | Closed |
| What are the terms synonymous with open fracture | Compound fracture, missile or gunshot or puncture, infected or foreign body |
| Treatment for CHF | Lasix and Digoxin |
| What are M codes | Morphology for histology and behavior of neoplasm |
| complicated wound | Infected, foreign body, delayed healing, delayed treatment |
| Exploratory laparotomy with liver biopsy | 54.11 50.12 54.12 |
| Seizure | 780.39 |
| Seizure disorder | 345.90 |
| Seizure, recurrent | 345.90 |
| Patient with ESRD and diabetes came in for Catheter placement and underwent Hemodialysis | V56.0 585.6 250.00 38.95 39.95 |
| CLO-TEST | 43239 |
| EGD with PEG | 43246 |
| EGD up to the ileum | 44376 |
| Removal of skin tags 16 lesions | 11200 11201 |
| Destruction of pre-malignant lesion of the skin by cryosurgery 17 lesions | 17004 |
| Treatment of non-union of fibula | 27226 |
| Laparoscopic Nissen fundoplasty | 43820 |
| Repair of inguinal hernia with mesh in a patient with previous inguinal hernia repair | 49520 |
| Arthroscopy knee with medial meniscectomy and lateral chondroplasty | 29881 29877-59 |
| Colonoscopy with biopsy of the transverse colon polyp and polypectomy of the ascending colon with snare | 45385 45380-59 |
| Excision of scar arm 2X6 cm with closure by split-thickness graft | 15002 15110 |
| Destruction pre-malignant lesion of skin by cryotherapy 5 lesions | 17000 17003 17003 17003 17003 |
| Destruction lumbar nerve by radiofrequency ablation | L2, L3, & L3 64622 64623 64623 |
| TURP | 52601 |
| PTC A with insertion of stent right coronary artery | 92980 RT |
| Colonoscopy with bx of transverse colon polyp followed by polypectomy of the same polyp by snare. | 45385 45380-59 |
| Injection steroid transforaminal Cl and C2 | 64479 64480 |
| TURP with incision of bladder neck | 60.29 57.19 |
| Bilateral hip replacement | 81.51 81.51 |
| Auto immune hemolytic anemia | 283.0 |
| Encounter for drug monitoring for Coumadin in a patient with atrial fibrillation | V58.83 V58.61 427.31 |
| Female infertility due to chronic PID (pelvic inflammatory disease) | 628.8 614.4 |
| Respiratory failure and coma after ingestion of alcohol | 980.0 518.81 780.00U |
| what is stress fracture | Fracture due to repetitive trauma |
| What is spontaneous fracture | This is considered pathological fracture |
| What is the code for amphetamine and heroin dependency | Use the combination code 304.70 dependency with combination of drug with opiod |
| Is respiratory insufficiency coded separately with COPD | NO. it is part of COPD and asthma. |
| Is bronchospasm coded separately if there is asthma | NO, it is part of asthma, bronchitis, COPD, and asthma |
| What is the code for COPD and acute bronchitis | 491.22 exacerbation is included |
| What is the code for hypertensive cardiovascular disease with chronic renal failure | 404.90+ 585.9 |
| What is non-excisional debridement | Debridement using water, gauze, or blunt instrument |
| What is excisional debridement | Debridement done by either the physician, nurse, or therapist using a cutting instrument. Note: sharp debridement is coded as non-excisional debridement |
| When is delivery considered normal | When there is no complication during the hospital stay; delivery is through the vagina, Full term (37-40 weeks); cephalic presentation (headfirst); baby is single, healthy, no manipilation was done. Episiotomy and anesthesia are part of normal delivery. |
| What is the code for fiberoptic bronchoscopy with biopsy if the specimen showed the alveoli | bronchoscopy with biopsy of lung 33.27 because the alveoli is the lung tissue |
| Abdominal pain due to both gastritis and angina | PDX is either gastritis or angina. |
| Abdominal pain due to gastritis versus angina | PDX is abdominal pain and code both conditions |
| Gastitis and angina | either condition can be PDX. Code both conditions |
| What is the principal diagnosis in the following cases: A 33 yr old male was admitted with abdominal pain. The patient was discharged with the Final diagnosis of; 1. Gastritis versus angina | either condition can be PDX. Code both condition |
| When are you going to code lysis of adhesions | Lysis of adhesion is the freeing of organs from adhesive bands or fibrous tissue. Lysis of adhesions is usually part of a procedure and the only time it is coded is when there is significant or extensive adhesion. Manual or digital lysis of adhesion and l |
| How do you code post-operative ileus | 997.4+560.1 |
| How do you code post-operative pneumonia and post-operative atelectasis | 997.3 + 486 for the pneumonia 997.3 + 518.0 for the atelectasis |
| How do you code post-operative anemia | 285.9 only. Don't' code 998.11 complication code unless the MD documents that It is complicating the procedure. There is always some blood loss in surgery and this is part of the procedure |
| In arthroscopy of the knee, how many codes are needed if lateral and medial meniscectomy with chondroplasty were done, (same compartment) | One only. 29880. There is a combo code for both lateral & medial meniscectomy |
| What are the three compartments of the knee | medial, lateral, and patello-femoral compartments |
| When coding inpatient chart, can you code abnormal findings in the X-ray or lab | NO, unless the physician documents any significance to the finding. However, findings can be use to further clarify a code. Ex: X-ray can be use to code the specific site of the fracture |
| In diverticulosis or diverticulitis of the colon, is perforation part of the code | yes, don't code separately. However the presence of abscess is coded separately (abscess of the intestine) |
| When are you going to use the 5th digits continous, episodic, or in remission inAlcohol and drug abuse and dependency | only when the pattern of use is documented. Otherwise use unspecified 5th digit 0 |
| How do you code cocaine dependency and marijuana dependency | Code with the combination code 304.80 |
| What is the PDX in a pregnant patient with AIDS and pneumocystis carinni pneumonia | The PDX is the pregnancy code. Pregnancy code has a sequencing priority over all other conditions |
| What is the PDX for a patient with AIDS admitted with pneumocystis carinii pneumonia | PDXis AIDS because PCP is AIDS-related disease with an HIV symbol at the tabular |
| In repair of wounds, when do you add the length of the wound repaired | If they are of the same classification( simple, intermediate, or complex) and they are of the same anatomic group |
| In excision of benign or malignant lesions, when do you add the length of the lesion together | Do not add the length of the lesions. Code each lesion separately. Length of lesions are added only if there is only one incision done for all the lesions |
| How many codes do you need for repair of inguinal hernia or umbilical hernia with mesh | ONE only. This includes the repair of the hernia and the use of the mesh. |
| How many codes do you need for repair of incisional or ventral hernia with mesh | TWO one for the repair and one for the mesh or prosthes |
| How do you measure the length in tissue transfer or flap | by sq. cm. To get this, multiply the two dimension to get the sq cm. EX 2 cm X 3 cm = 6 sq cm |
| How many codes are you going to use for tissue transfer or rearrangement (Z-plasty) | one code only. The code for the tissue transfer, the excision code is included |
| What is the code for malignant pleura effusion | 511.81 secondary malignant neoplasm of the pleura |
| What is the code for malignant ascites | 789.51 secondary malignant neoplasm of the peritoneum |
| What is the PDX for a patient with cirrhosis of the liver and was admitted with ascites | PDXis the cirrhosis |
| What is the PDX for a patient with cancer of the breast admitted for chemotherapy | PDXis V58.11 admission for chemo. Code also the cancer of the breast 174.9 |
| What is the principal DX for a patient with cirrhosis of the liver and hepatic encephalopathy | PDXis the hepatic encephalopathy |
| What is the principal DX for a patient with CAD admitted because of unstable angina and was found to have MI (myocardial infarction.) | PDX is the MI. Code also the CAD but don't code the unstable angina |
| What is the principal DX for a patient with CAD admitted for unstable angina | PDXistheCAD. 414.01 Code unstable angina as secondary DX. 411.1 |
| What is the principal diagnosis for a patient admitted to rehabilitation after being treated for acute CVA or infarction | The principal DX is V57.89 and secondary DX are all the residuals of CVA EX 438.82 Do not code 438.XX with V12.59 |
| What is the dominant side of a patient | In a right handed patient, the right is dominant. In a left handed patient, the left is dominant |
| What is the principal DX in poisoning | If a drug was taken incorrectly as in overdose, or taken w/alcohol or with over the counter medication it is poisoning |
| principal DX in adverse effect | If a drug was taken correctly as prescribed it is adverse effect |
| What is the principal DX an a patient admitted with alcohol dependency and withdrawal | The withdrawal is the principal diagnosis EX 291.81 or 291.0 |
| In late effect what is the principal diagnosis, the late effect or the residual | The residual or the manifestation |
| What is the code for decompensated COPD | 491.21 decompensated is the same as exacerbation of COPD |
| What is pathological fracture | Fracture of the bone due to weakness of the bone because of disease of the bone such as Osteoporosis, cancer of the bone as in multiple myeloma |
| When can respiratory/allure be used as principal diagnosis | If the patient came in respiratory failure and the reason for admission is the respiratory Failure, the respiratory failure is the principal diagnosis except if it caused or due to Sepsis Aids Pregnancy Poisoning Newborn |
| What is the difference between radical mastectomy and modified radical mastectomy | In radical mastectomy the major pectoral muscles are removed and in modifiied radical mastectomy only the minor pectoral muscles are removed and the major pectoral is saved |
| What is the difference between 303.00 and 303.90 | In 303.90 there is alcohol dependency w/o acute intoxication In 303.00 there is alcohol dependency and acute intoxication |
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