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Medical Coding 2

Another Medical Coding Review Questions

QuestionAnswer
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
Created by: hrodil