Certified Coding Associate (CCA) Exam Preparation 2022- with rationale c. Edit checks. Questions and answers, Graded A+

Certified Coding Associate (CCA) Exam Preparation 2022- with rationale c. Edit checks Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Rineh ...

Certified Coding Associate (CCA) Exam Preparation 2022- with rationale c. Edit checks Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Rinehart-Thompson 2016a, 265). - ✔✔A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What data quality or data integrity measures should be in place to ensure that only allowable code numbers are entered? a. Access controls b. Audit trail c. Edit checks d. Password controls b. Delinquent record An incomplete record not rectified within a specific number of days as indicated in the medical staff rules and regulations is considered to be delinquent (Sayles 2016, 65). - ✔✔A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record b. Provide an input mask for entering data in the field When several people enter data in an EHR, you can define how users must enter data in specific fields to help maintain consistency. For example, an input mask for a form means that users can only enter the date in a specified format (MacDonald 2010, chapter 4; Carter and Palmer 2016, 506). - ✔✔Which of thefollowing would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)? a. Make admission date a required field b. Provide an input mask for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data a. UHDDS In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (Oachs and Watters 2016, 223). - ✔✔Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is _____. a. UHDDS b. UACDS c. MDS d. ORYX a. Meaning of data Data definition means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent (Sayles 2016, 52). - ✔✔Data definition refers to: a. Meaning of data b. Completeness of data c. Consistency of data d. Detail of dataa. Provide the medical records in paper format The covered entity must provide access to the personal health information in the form or format requested when it is readily producible in such form or format. When it is not readily producible in the form or format requested, it must be produced in a readable hard-copy form or such other form or format agreed upon by the covered entity and the individual (Gordon and Gordon 2016b, 615-616). - ✔✔A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the medical records in paper format. How should the hospital respond? a. Provide the medical records in paper format b. Burn another CD because this is hospital policy c. Provide the patient with both paper and CD copies of the medical record d. Review the CD copies with the patient on a hospital computer b. Objective Objective information may be measured or observed by the healthcare provider (Amatayakul 2016, 294). - ✔✔A notation for a diabetic patient in a physician progress note reads: "FBS 110mg%, urine sugar, no acetone." Which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan d. Query the physician as to the method used. It is not appropriate for the coder to assume the removal was done by either snare or hot biopsy forceps. The ablation code is only assigned when a lesion is completely destroyed and no specimen is retrieved. The coding professional must query the physician to assign the appropriate code (AHIMA 2016, 454). - ✔✔When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? a. Assign the removal by snare technique code. b. Assign the removal by hot biopsy forceps code.c. Assign the ablation code. d. Query the physician as to the method used. d. E-discovery Although e-Discovery is the same pretrial process as discovery, the electronic health record has promoted this concept (Rinehart-Thompson 2016b, 215). - ✔✔The Federal Rules of Civil Procedure (FRCP) incorporated the pre-trial process through the creation of: a. Bench warrants b. Court orders c. Depositions d. E-discovery d. Standards Standards are fixed rules that must be followed, which is different from a guideline that provides general direction (Sayles 2016, 66; Brickner 2016, 82). - ✔✔Statements that define the performance expectations and structures or processes that must be in place are _____. a. Rules b. Policies c. Guidelines d. Standards b. Information access controls An EHR can be viewed by multiple users and from multiple locations at any time, and organizations must have in place appropriate security access control measures to ensure the safety of the data (Sayles 2016, 53; Amatayakul 2016, 285 Kellogg 2016b, 482-483). - ✔✔An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach? a. Audit controlsb. Information access controls c. Facility access controls d. Workstation security c. Major diagnostic categories Diagnosis-related groupings (DRGs) are classified by one of 25 major diagnostic categories (MDCs) (Hazelwood and Venable 2016, 224). - ✔✔Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values b. Is information from which personal characteristics have been stripped Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped (Rinehart-Thompson 2016b, 222). - ✔✔Deidentified information _____. a. Does identify an individual b. Is information from which personal characteristics have been stripped c. Can be later constituted or combined to re-identify an individual d. Pertains to a person that is identified within the information b. History A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Brickner 2016, 90). - ✔✔The ________ may contain information about diseases among relatives in which heredity may play a role. a. Physical examination b. Historyc. Laboratory report d. Administrative data b. Electronic signature authentication Electronic signature authentication systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval (Sayles 2016, 89). - ✔✔This system will require the author to sign onto the system using a user ID and password to complete the entries made. a. Digital dictation b. Electronic signature authentication c. Single sign on technology d. Clinical data repository b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. It is suggested that covered entities use PHI with certain specified direct identifiers removed as a guideline for disclosing only minimum necessary information while providing the amount needed to accomplish the intended purpose (Gordon and Gordon 2016b, 615-616). - ✔✔The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced. b. BeneficenceBeneficence means promoting good (Gordon and Gordon, 2016b, 604, 618). - ✔✔Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence a. American Psychological Association The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance are all acceptable accrediting bodies for behavioral healthcare settings (Fahrenholz and Russo 2013, 624). - ✔✔Which of the following is not an accepted accrediting body for behavioral healthcare organizations? a. American Psychological Association b. Joint Commission c. Commission on Accreditation of Rehabilitation Facilities d. National Committee for Quality Assurance b. Data warehouse A data warehouse is a special type of database that consolidates and stores data from various databases (Oachs and Watters 2016, 998). - ✔✔Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? a. Client-server computer b. Data warehouse c. Local area network d. Internet c. Report of history and physical examinationAccording to the Joint Commission, except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed (Fahrenholz and Russo 2013, 238). - ✔✔According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary a. Postoperative infection Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2017a, Appendix I). - ✔✔A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Postoperative infection b. Appendicitis c. COPD d. Hypertension d. Improved collection of data about nursing care CMS designed ICD-10-PCS with goals to improve coding accuracy, reduce training effort, and improve communication with physicians. It is not used to collect data about nursing care (Giannangelo 2016,124). - ✔✔Which of the following purpose and use goals does not apply to ICD-10-PCS? a. Improved accuracy and efficiency of coding b. Reduced training effort c. Improved communication with physiciansd. Improved collection of data about nursing care a. To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients. For fiscal year 2008, Medicare adopted a severity-adjusted diagnosis-related groups system called Medicare Severity-DRGs (MS-DRGs). This was the most drastic revision to the DRG system in 24 years. The goal of the new MS-DRG system was to significantly improve Medicare's ability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to the sicker patients and decrease payments for treating less severely ill patients (Schraffenberger 2017, 700). - ✔✔What was the goal of the MS-DRG system? a. To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients. b. To improve Medicare's capability to recognize poor quality of care and pay hospitals on an incentive grid that allows hospitals to be paid by performance. c. To improve Medicare's capability to recognize groups of data by patient populations, which will further allow Medicare to adjust the hospitals' wage indexes based on the data. This adjustment will be a system to pay hospitals fairly across all geographic locations. d. To improve Medicare's capability to recognize practice patterns among hospitals that are inappropriately optimizing payments by keeping patients in the hospital longer than the median length of stay. b. Social history Documentation of history of use of drugs, alcohol, and tobacco is considered part of the social history. The review of systems is a part of the history of present illness. See E/M Services Guidelines, instructions for selecting a level of E/M service, in the CPT manual (AMA 2016, 6-10). - ✔✔Documentation in the history of use of drugs, alcohol, and tobacco is considered as part of the _____. a. Past medical history b. Social history c. Systems review d. History of present illnessb. L22 Index Rash, diaper, L22 (Schraffenberger 2017, 394). - ✔✔Identify the ICD-10-CM code for diaper rash in elderly patient. a. L21.9 b. L22 c. R21 d. L74.3 b. Critical access hospitals Critical access hospitals are paid on a cost-based payment system and are not part of the prospective payment system (Kellogg 2016a, 32). - ✔✔Which of the following is not reimbursed according to the Medicare outpatient prospective payment system? a. CMHC partial hospitalization services b. Critical access hospitals c. Hospital outpatient departments d. Vaccines provided by CORFs b. CMS-1450 (UB-04) The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing form (Smith 2016, 13-14). - ✔✔The electronic claim format (837I) replaces which paper billing form? a. CMS-1500 b. CMS-1450 (UB-04) c. UB-92 d. CMS-1400 d. SeventhThe seventh character provides information about encounter of care, such as initial encounter, subsequent encounter, or sequelae (Giannangelo 2016, 123). - ✔✔Which character in an ICD-10-CM diagnosis code provides information regarding encounter of care? a. Fourth b. Fifth c. Sixth d. Seventh a. Value-based insurance design (VBID) VBID calculates both the benefit and the costs of clinical services (Casto and Forrestal 2015, 78). - ✔✔The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost? a. Value-based insurance design (VBID) b. Cost-based reimbursement (CBR) c. Pay for performance design (PPD) d. Prospective payment system (PPS) a. Selective catheterization If the tip of the catheter is manipulated, it is a selective catheterization. In the case of a nonselective catheterization, the tip of the catheter remains in either the aorta or the artery that was originally entered (AHIMA 2016, 451). - ✔✔In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called __________. a. Selective catheterization b. Nonselective catheterization c. Manipulative catheterization d. Radical catheterization d. The identity of the patient's nearest relative and emergency contact numberThe identity of the patient's nearest relative and an emergency contact number are not relative to securing payment from the insurer. The encounter should include the date of the encounter and the identity of the observer (Smith 2016, 9-10). - ✔✔The documentation of each patient encounter should include the following to secure payment from the insurer except _____. a. The reason for the encounter and the patient's relevant history, physical examination, and prior diagnostic test results b. A patient assessment, clinical impression, or diagnosis c. A plan of care d. The identity of the patient's nearest relative and emergency contact number c. Federal and state confidentiality laws Because federal regulations such as HIPAA and state laws govern the release of health record information, HIM department personnel must know what information needs to be included on the authorization for it to be considered valid (Gordon and Gordon 2016, 615-616). - ✔✔The release of information function requires the HIM professional to have knowledge of __________. a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management a. A41.01 Index: Sepsis, Staphylococcus, aureus A41.01. Sepsis is the systemic infection. Because the organism is indicated in the sepsis code, B95.61 is redundant and should not be coded (Schraffenberger 2017, 110, 113-116). - ✔✔Identify the correct ICD-10-CM diagnosis code(s) for a patient with sepsis due to Staphylococcus aureus. a. A41.01 b. A41.2 c. A41.9, B95.61d. A41.9 a. Role-based Role-based access control (RBAC) is a control system in which access decisions are based on the roles of individual users as part of an organization (Brodnik et al. 2012, 304). - ✔✔An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system? a. Role-based b. User-based c. Context-based d. Situation-based b. Monies paid to the healthcare provider cannot exceed charges. The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Hazelwood and Venable 2016, 223-225). - ✔✔A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. The patient receives any monies paid by the insurance companies over and above the charges. b. Monies paid to the healthcare provider cannot exceed charges. c. The decision on which company is primary is based on remittance advice. d. The patient should not have a Medicare supplement. b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency, continuity, and clarity in documentation (Brickner 2016, 82-87). - ✔✔During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?a. Immediately stop the practice of changing transcribed reports. b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. c. Conduct a verification audit. d. Alert hospital legal counsel of the practice. a. Unauthorized access to a system Audit trails can provide tracking information such as who accessed which records and for what purpose (Sandefer 2016, 366). - ✔✔What does an audit trail check for? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup b. Malware Computer viruses and other malware constitute a threat to data security (Rinehart-Thompson, 2016, 256-258). - ✔✔A threat to data security is _____. a. Encryption b. Malware c. Audit trail d. Data quality c. Cost outlier To qualify for a cost outlier, a hospital's charges for a case (adjusted to cost) must exceed the payment rate for the MS-DRG by a specific threshold amount determined by CMS for each fiscal year (Hazelwood and Venable 2016, 225). - ✔✔What is the term used when a Medicare hospital inpatient admission results in exceptionally high costs when compared to other cases in the same DRG? a. Rate increaseb. Charge outlier c. Cost outlier d. Day outlier a. Children's Children's hospitals are excluded from PPS because the PPS diagnosis-related groups do not accurately account for the resource costs for the types of patients treated (Gordon and Gordon 2016a, 440). - ✔✔Which of the following hospitals are excluded from the Medicare acute-care prospective payment system? a. Children's b. Small community c. Tertiary d. Trauma d. To determine whether standards of care are being met Surveyors review the documentation of patient care services to determine whether the standards for care are being met (Brickner 2016, 82-87). - ✔✔How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met d. S79.012D Index Fracture, traumatic, femur, capital epiphyseal. Seventh character is required for further classification of an episode of care and the healing status (Schraffenberger 2017, 565-566). - ✔✔Identify the ICD-10-CM code for a patient with a subsequent encounter for routine healing of a closed traumatic capital epiphyseal fracture of the left femur.a. S79.012A b. S79.019D c. M84.452D d. S79.012D d. K00.6 Index either Neonatal, tooth K00.6, or Eruption, teeth/tooth (Schraffenberger 2017, 364-366). - ✔✔Identify the ICD-10-CM code(s) for neonatal tooth eruption. a. K01.1 b. K00.6, K08.0 c. K01.0 d. K00.6 a. 21012 CPT code 21012 describes excision of a subcutaneous soft tissue tumor of the face or scalp greater than 2 cm and is appropriately coded when the tumor is removed from the subcutaneous tissue rather than subgaleal or intramuscular. Simple and intermediate closure of the wound is included in the procedure for the excision in the musculoskeletal section of CPT (AMA 2016, 111; Kuehn 2017, 108-109). - ✔✔Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0- cm tumor in her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed with interrupted sutures. a. 21012 b. 21012, 12052 c. 21014 d. 21014, 12052 c. 19125Code 19125 describes an excision of a lesion that was identified by preoperative placement of a radiological marker (AMA 2016, 95). - ✔✔Identify CPT code(s) for the following Medicare patient. A 67- year-old female undergoes an excision of a breast lesion identified by preoperative placement of radiological marker. a. 19101 b. 19101, 19125 c. 19125 d. 19125, 19126 a. Alzheimer's disease with early onset Four-digit codes are available to classify Alzheimer's disease with early onset G30.0 (Schraffenberger 2017, 225). - ✔✔Identify the information classified in the fourth digit for the code G30.0. a. Alzheimer's disease with early onset b. Alzheimer's disease with late onset c. Other Alzheimer's disease d. Alzheimer's disease, unspecified d. 0JH606Z, 02H63JZ, 02HK3JZ ICD-10-PCS classifies cardiac pacemakers as Devices, character 6. Root operations of Insertion, removal, and revision always involve a device, such as a pacemaker. In coding initial insertion of a dual chamber permanent pacemaker, three codes are required—one for the pacemaker (0JH606Z) and one for each lead (02H63JZ, 02HK3JZ) (Schraffenberger 2017, 51, 60-62). - ✔✔Identify the ICD-10-PCS code(s) for insertion of dual chamber cardiac pacemaker battery via an incision in the subcutaneous tissue of the chest wall, and percutaneous transvenous insertion of right atrial and right ventricular leads. a. 0JH606Z, 02H73JZ, 02HL3JZ b. 0WH80YZ, 02H63JZ, 02HK3JZ c. 0WH80YZ, 02H73JZ, 02HL3JZ d. 0JH606Z, 02H63JZ, 02HK3JZ a. 0JPT0PZ, 0JH606ZWhen a pacemaker is replaced with another pacemaker, both the removal of the old device and the insertion of the new pacemaker are coded (0JPT0PZ, 0JH606Z). Per ICD-10-PCS Reference Manual, 69- 70, "A procedure to remove a device is coded to Removal if it is not an integral part of another root operation." It is not coded to the root operation Change because this involved cutting the skin. Change is only used for External approaches (CMS 2016). - ✔✔Identify the correct ICD-10-PCS code(s) for replacement of an old dual pacemaker with a new dual pacemaker in the subcutaneous tissue of the chest wall via incisional approach. a. 0JPT0PZ, 0JH606Z b. 0JH606Z c. 0JWT0PZ d. 0JPT3PZ, 0JH634Z b. I44.1 ICD-10-CM classifies both Mobitz type I and type II to I44.1 (Schraffenberger 2017, 312). - ✔✔Identify the appropriate ICD-10-CM code(s) for Mobitz type I and II heart block. a. I44.7, I45.19 b. I44.1 c. I45.0, I45.2 d. I45.10 a. Z45.010, 4B02XSZ Index Checking (of), cardiac pacemaker, pulse generator, Z45.010. The pacemaker check is the root operation Measurement. Index: Measurement, Cardiac, Pacemaker 4B02XSZ (Schraffenberger 2017, 46, 663, 653). - ✔✔Identify the appropriate ICD-10-CM and ICD-10-PCS code(s) for cardiac pacemaker pulse generator check. a. Z45.010, 4B02XSZ b. Z45.018 c. Z45.02 d. Z45.010, 4B02XTZc. I12, Hypertensive chronic kidney disease Coding Guideline I.C.9.a.2 states to assign codes from category I12, when both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present (CMS 2017a). - ✔✔When both hypertension and a condition classifiable to category N18, Chronic kidney disease (CKD), are present, assign codes from category: a. I13, Hypertensive heart and chronic kidney disease. b. I15, Secondary hypertension c. I12, Hypertensive chronic kidney disease d. I27.0, Primary pulmonary hypertension c. 02100Z8, 02100Z9 Index Bypass, Artery, Coronary, One Site. One site is selected since there two different Qualifiers (Character 7). One Qualifier is "8 Internal Mammary, Right," and the other is "9 Internal Mammary, Left." Internal mammary-coronary artery bypass is accomplished by loosening the internal mammary artery from its normal position and using the internal mammary artery to bring blood from the subclavian artery to the occluded coronary artery. Codes are selected based on whether one or both internal mammary arteries are used (Schraffenberger 2017, 67). - ✔✔Identify the appropriate ICD-10- PCS code(s) for a coronary artery bypass of two sites, one using the left internal mammary artery to the left proximal anterior descending artery, and one using the right internal mammary artery to the distal left anterior descending artery, both done via thoracotomy. a. 02104K8, 02104K9 b. 02110A8, 02110A9 c. 02100Z8, 02100Z9 d. 021109W c. Judkins The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material(Schraffenberger 2017, 320). - ✔✔Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery. a. Brachial b. Stones c. Judkins d. Femoral a. Z51.81, Z79.01 Z51.81, Encounter for, Therapeutic drug monitoring, is the correct code to use when a patient visit is for the sole purpose of undergoing a laboratory test to measure the drug level in the patient's blood or urine or to measure a specific function to assess the effectiveness of the drug. Z51.81 may be used alone if the monitoring is for a drug that the patient is on for only a brief period, not long term. However, there is a "code also" note under this code to remind the coder to code for any associated long-term current drug use with codes from category Z79 (Schraffenberger 2017, 680). - ✔✔Identify the correct ICD-10-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's Coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment. a. Z51.81, Z79.01 b. Z51.81, Z79.02 c. Z79.01, R79.1 d. Z79.01 c. 43761, 76000 Code 43761 is assigned to report re-positioning of a nasogastric or orogastric feeding tube through the duodenum. An instructional note guides the coder to report code 76000 when image guidance is performed (AMA 2016, 289). - ✔✔Identify the CPT code(s) for the following patient: A 2-year-old boy presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance. a. 43752 b. 43761c. 43761, 76000 d. 49450 d. 49450 Code 49450 includes replacement of gastrostomy or cecostomy tube, percutaneous, under fluoroscopic guidance including contrast injections(s), image documentation, and report. Therefore, it would not be appropriate to add code 76000 for fluoroscopic guidance, which is already included in the procedure code (AMA 2016, 320). - ✔✔Identify the CPT code(s) for the following patient: A 2-year-old boy presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance. a. 43752 b. 43760 c. 43761, 76000 d. 49450 c. Incomplete abortion An incomplete abortion is one in which some, but not all, of the products of conception are expulsed from the uterus. If the placenta or secundines remain, the abortion is considered incomplete (Schraffenberger 2017, 491). - ✔✔Identify the term ICD-10-CM uses for the following definition: "the expulsion of some, but not all, of the products of conception from the uterus." a. Spontaneous abortion b. Therapeutic abortion c. Incomplete abortion d. Complete abortion b. O20.0, Z3A.15 Index Abortion, threatened O20.0. Hemorrhage is included in the code per the Includes notes under O20.0. Category Z3A, Weeks of gestation, is assigned as an additional code for all pregnancy and childbirth codes per the "use additional code" note at the beginning of Chapter 15 (Schraffenberger2017, 472, 494-495). - ✔✔Identify the ICD-10-CM code(s) for the following: threatened abortion with hemorrhage at 15 weeks; home undelivered. a. O20.0, O20.9 b. O20.0, Z3A.15 c. O20.8 d. O20.8, Z3A.15 a. O62.0, Z3A.40, Z37.0, 10D00Z1 Index Delivery, complicated, by, dilation, cervix incomplete, poor, or slow (O62.0). Outcome of delivery, single, liveborn (Z37.0) is assigned as an additional code. Code Z3A.40, 40 weeks of gestation is assigned as an additional code per the "use additional code" note at the beginning of Chapter 15. Cesarean section, low uterine segment is found in section 1 "Obstetrics" of the Medical and Surgical Related section of the ICD-10-PCS book. The body system is 0, Pregnancy and the body part is products of conception. The qualifier specifies the type of Cesarean (1 low cervical, in this case) (Schraffenberger 2017, 475, 478, 486-487, 497, 502, 654-655, 676). - ✔✔Identify the ICD-10-CM and ICD-10-PCS code(s) for the following: 40-week gestation, term pregnancy with poor cervical dilatation; lower uterine segment cesarean delivery, open approach, with single liveborn female. a. O62.0, Z3A.40, Z37.0, 10D00Z1 b. O62.2, 101D00Z0 c. O62.0, Z3A.40, 10D00Z0 d. O62.2, Z37.0, 10D00Z1 c. According to the condition at time of admission Coding Guideline I.C.12.a.5 notes that pressure ulcers present on admission but healed at the time of discharge are assigned the code for site and stage at time of admission. - ✔✔For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer __________ a. According to the discharge condition. b. According to the nursing progress notes. c. According to the condition at time of admission d. As documented in the Discharge Summary.d. M86.171, B95.8 Index Osteomyelitis, acute, tarsus M86.17-. Refer to Tabular Index for sixth character for laterality of "Right" M86.171. Assign an additional code for Staphylococcus organism B95.8 per the "use additional code (B95-B97) to identify infectious agent" under category M86. Index Infection, staphylococcal unspecified site, as cause of disease classified elsewhere B95.8 (Schraffenberger 2017, 125, 431). - ✔✔Identify the ICD-10-CM code(s) for acute osteomyelitis of tarsus bones of the right ankle due to Staphylococcus. a. M86.161 b. M86.171 c. M86.171, A49.01 d. M86.171, B95.8 b. D61.1, T45.1X5A Index Anemia, aplastic, due to, drugs, D61.1. A coder should always assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic. There is a "use additional code for adverse effect" note at D61.1 to assign an additional code to identify the drug causing the anemia. Utilize the Table of Drugs and Chemicals to locate the term Antineoplastic NEC. Then follow the row across to the Adverse effect column to locate the code. A seventh character of "A" is used to indicate "initial encounter" (Schraffenberger 2017, 140). - ✔✔Identify the ICD-10-CM code(s) for other specified aplastic anemia secondary to adverse effect of chemotherapy, initial encounter. a. D61.1 b. D61.1, T45.1X5A c. D64.9 d. D63.0 c. Z00.129, P07.30 Index Exam, well baby, Z00.129 for the routine well-child examination. Index, Premature, infant—See Preterm, newborn, unspecified weeks of gestation. P07.30 is assigned as an additional code per Guideline I.C.16.e (Schraffenberger 2017, 514, 663-664). - ✔✔Identify the ICD-10-CM code(s) for thefollowing: A 6-month-old child is scheduled for a clinic visit for a routine well-child examination. The physician documents, "well child, born premature." a. Z00.00, P07.30 b. Z00.129 c. Z00.129, P07.30 d. Z00.129, O60.10X0 d. I51.9 Index Dysfunction, ventricular I51.9 (Schraffenberger 2017, 290). - ✔✔Identify the ICD-10-CM code for ventricular diastolic dysfunction. a. I50.1 b. I50.30 c. I50.9 d. I51.9 c. Chapter 14 Diseases of the genitourinary system Certain signs and symptoms of breast disease are included in category N64 Other disorders of breast, which are in Chapter 14 Diseases of the genitourinary system (Schraffenberger 2017, 454). - ✔✔Identify the chapter in which certain signs and symptoms of breast disease, such as mastodynia, induration of breast, and nipple discharge, are included. a. Chapter 2 Neoplasms b. Chapter 12 Diseases of the skin and subcutaneous tissue c. Chapter 14 Diseases of the genitourinary system d. Chapter 18 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified c. 0QBN0ZZ Index Bunionectomy, see Excision, Lower Bones table 0QB. Locate table 0QB. Then select N Metatarsal, right for the Body Part (character 4), and select 0 Open for the Approach (character 5), and select Z NoDevice for Device (character 6), and select Z No Qualifier for the Qualifier (character 7) (CMS 2016, 30; Schraffenberger 2017, 432-436). - ✔✔Which of the following is the correct ICD-10-PCS code for a Mayo operation known as a bunionectomy? An incision was made in the right foot and a portion of the first metatarsal head was removed. a. 0SRP0JZ b. 0STP0ZZ c. 0QBN0ZZ d. 0QTN0ZZ a. Assign two separate codes, one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. Per Coding Guideline I.C.12.a.6, if a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage on admission and a second code for the same site at the highest stage (CMS 2017a). - ✔✔If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, _________. a. Assign two separate codes, one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. b. Assign only the highest stage documented during the stay. c. Assign only the stage of the ulcer on admission. d. Query the attending physician for the appropriate site and stage of the pressure ulcer. d. 0FT44ZZ Index Cholecystectomy, see Resection, Gallbladder, table 0FT4 because gallbladder was removed. The laparoscopy is the approach, and is not coded separately per 2014 ICD-10-PCS Official Guidelines for Coding and Reporting, Guideline B3.11a (page 8) "Inspection of a body part performed in order to achieve the objective of a procedure is not coded separately." To build the code, locate table 0FT and body part 4 Gallbladder, then 4 Percutaneous Endoscopic for the approach, then Z No device for device, and Z No qualifier for the qualifier (Schraffenberger 2017, 76-77). - ✔✔Which of the following is (are) the correct ICD-10-PCS code(s) for laparoscopic cholecystectomy? The entire gallbladder was removed. a. 0FT40ZZ b. 0FT40ZZ, 0FJ44ZZc. 0FT44ZZ, 0FJ44ZZ d. 0FT44ZZ c. 0TBB8ZX Index Excision, Bladder, table 0TBB since a portion of the bladder was removed. The cystoscopy is the approach—via natural or artificial opening, endoscopic. Final code assignment is 0TBB8ZX. The qualifier of "X Diagnostic" is used for biopsies (Schraffenberger 2017, 60-61, 154-155, 174-175, 384). - ✔✔Which of the following is (are) the correct ICD-10-PCS code(s) for cystoscopy with diagnostic biopsy of the bladder? a. 0TBB7ZX b. 0TJB8ZZ, 0TBB8ZX c. 0TBB8ZX d. 0TBB8ZZ b. Encoder An encoder is a computer software program designed to assist coders in assigning appropriate clinical codes and helps ensure accurate reporting of diagnoses and procedures (Sayles and Gordon, 2016, 75). - ✔✔Which of the following software applications would be used to aid in the coding function in a physician's office? a. Grouper b. Encoder c. Pricer d. Diagnosis calculator b. Resource-based relative value scale system The RBRVS system is the federal government's payment system for physicians. It is a system of classifying health services based on the cost of furnishing physicians' services in different settings, the skill and training levels required to perform the services, and the time and risk involved (Casto andForrestal 2015, 6, 10, 149). - ✔✔Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system? a. Diagnosis-related groups b. Resource-based relative value scale system c. Long-term care drugs d. Resource utilization groups c. Tricare Tricare is the healthcare program for active duty members of the military and other qualified family members (Hazelwood and Venable 2016, 213). - ✔✔The health care program for active duty members of the military and other qualified family members is: a. Children's Health Insurance Program (CHIP) b. V.A. Funding Inc. c. Tricare d. Worker's Compensation b. American Medical Association's CPT Assistant newsletter CPT Assistant provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly (AMA 2016, xvi). - ✔✔What is the best reference tool to determine how CPT codes should be assigned? a. Local coverage determination from Medicare b. American Medical Association's CPT Assistant newsletter c. American Hospital Association's Coding Clinic d. CMS website b. UnbundlingUnbundling occurs when a panel code exists, and the individual tests are reported rather than the panel code (AMA 2016, 496; Smith 2016, 257.). - ✔✔An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of: a. Optimizing b. Unbundling c. Sequencing d. Classifying a. Report the remaining tests using individual test codes, according to CPT. Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (Smith 2016, 180). - ✔✔In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel? a. Report the remaining tests using individual test codes, according to CPT. b. Do not report the remaining individual test codes. c. Report only those test codes that are part of a panel. d. Do not report a test code more than once regardless whether the test was performed twice. a. Coding or charging one or two middle levels of service codes exclusively Clustering is coding or charging one or two middle levels of service codes exclusively (Hazelwood and Venable 2014, 231-232). - ✔✔The Office of Inspector General (OIG) has identified risk areas for physician practices. One type of risk is "clustering." Identify its definition. a. Coding or charging one or two middle levels of service codes exclusively b. Billing for a more expensive service than the one actually performed c. Billing for noncovered services as if they are covered d. Assigning additional codes inherent to the main codeb. Claims appeals The front end of the RCM process includes scheduling and registration, insurance verification, preauthorization, financial counseling and pre-encounter services. Claims appeals are a back end process (Malmgren and Solberg 2016, 245). - ✔✔The front end of the revenue cycle process does not include: a. Enterprise wide scheduling system b. Claims appeals c. Order tracking system d. Financial function system c. AHA's Coding Clinic for ICD-10-CM/PCS AHA's Coding Clinic for ICD-10-CM/PCS is a quarterly publication of the Central Office on ICD-10- CM/PCS, which allows coders to submit a request for coding advice through the coding publication. AHA Coding Clinic is the only official publication for ICD-10-CM/PCS coding guidelines and advice provided by the four Cooperating Parties (Hazelwood and Venable 2014, 12). - ✔✔What is the best reference tool for ICD-10-CM/PCS coding advice? a. CMS Inpatient Prospective Payment System (IPPS) b. CMS ICD-10-CM and ICD-10-PCS Coding Guidelines c. AHA's Coding Clinic for ICD-10-CM/PCS d. National Correct Coding Initiative (NCCI) b. HCPCS/CPT codes CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system that pays providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2017c, I-5-I-6). - ✔✔CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set?a. Diagnosis-related groups b. HCPCS/CPT codes c. ICD-10-CM/PCS diagnosis and procedure codes d. Resource utilization groups c. Documenting the charges and services on the itemized bill. The documentation of the charges and itemized bill is not the responsibility of the physician (Smith 2016, 9-10). - ✔✔Several key principles require appropriate physician documentation to secure payment from the insurer. Which answer (listed here) fails to impact payment based on physician responsibility? a. The health record should be complete and legible. b. The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred. c. Documenting the charges and services on the itemized bill. d. The patient's progress and response to treatment and any revision in the treatment plan and diagnoses should be documented. d. The identity of the patient's nearest relative and emergency contact number The identity of the patient's nearest relative and an emergency contact number are not relative to securing payment from the insurer. The encounter should include the date of the encounter and the identity of the observer (Smith 2016, 9-10). - ✔✔The documentation of each pati