Certified Coding Specialist (CCS) Exam Prep Questions -AHIMA 6th Edition

Certified Coding Specialist (CCS) Exam Prep Questions -AHIMA 6th Edition Carcinoma in situ - ✔✔Tumor cells that are undergoing malignant changes but are still confined to the point of origin without invasion of the surrounding normal tissue Examples of carcinoma in situ - ✔✔Intraepithelial infiltrating The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate? a. Unstable angina b. Myocardial infarction c. Congestive heart failure d. Mitral valve stenosis - ✔✔b The CPK elevation with MB enzymes elevated and the EKG ST changes denote a possible Ml (LeonChisen 2013, 386-387). A patient is admitted and diagnosed with fever and urinary burning. The discharge diagnosis· is Escherichia coli, urinary tract infection. Which of the following represents the correct diagnoses and appropriate sequence of those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli, urinary tract infection d. Urinary tract infection, Escherichia coli - ✔✔dSymptoms are not coded when a definitive diagnosis is present on discharge. The patient discharge diagnosis of urinary tract infection. The organism (E. coli) is coded with a seco diagnosis code (B96.20) which is to be added as an additional code to identify the bacterial agent (HHS 2014, Section II.A., 98). A patient was admitted with heart failure within one week of a heart transplant. Due to the timing, the coder thought that it may represent a postoperative transplant rejection following heart transplant. What action(s) should the coding staff take? a. Query the physician. b. Assign the codes for the postoperative transplant rejection. c. Assign only the code for the transplant rejection. d. Assign only the code for heart failure. - ✔✔a When the documentation is not clear regarding a potential complication, it is appropriate query the physician (HHS 2014, Section I.B.16, 16; Leon-Chisen 2013, 43-44). A patient is admitted to a psychiatric unit of an acute-care facility. The patient experienced the following symptoms almost every day for the last month: loss of interest or pleasure in most or all activities, which is a change from her prior level of functioning. She has also gained 15 lbs, has difficulty falling asleep, feels fatigued, and has difficulty making decisions. What potential diagnosis most closely fits the patient's overall symptoms? a. Insomnia b. Major depression c. Reye's syndrome d. Bipolar disorder - ✔✔b The symptoms provided are indicative of a depressive disorder (Leon-Chisen 2013, 175). Inpatient:Admission for inguinal hernia repair. This 30-year-old patient has acquired immunodeficiency syndrome (AIDS) but is not symptomatic at this time due to medication regimen. The procedure performed was a right indirect inguinal herniorrhaphy via open approach. - ✔✔ICD-10-CM: K40.90, B20, ICD-10-PCS: OYQ50ZZ (Schraffenberger 2013, 82-84,252) Inpatient: A 75-year-old male patient was admitted from a nursing home with dehydration and dysphagia due to a previous stroke. During hospitalization the patient was rehydrated and transferred back to the nursing home. - ✔✔ICD-10-CM: E86.0, I69.391 (Schraffenberger 2013, 131, 209-210). Stroke= cerebral infarction Inpatient: A patient is admitted to an acute care facility for detoxification from alcohol and barbiturate intoxication with chronic alcoholism and barbiturate abuse. The patient also has cirrhosis of the liver due to alcoholism. - ✔✔ICD-10-CM: F10.229, F13.129, K70.30, (Schraffenberger 2013, 140-143.) ICD-10-PCS HZ2ZZZZ (Leon-Chisen 2014, 186). Inpatient: A 30-year-old patient was seen in the emergency department for recurrent epileptic seizures. The patient also had tic douloureux. - ✔✔ICD-10-CM: G40.909, G50.0(Schraffenberger 2013,158-159). Inpatient: A patient was admitted to an acute care facility with a temperature of 102 and atrial fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the physician of pneumonia in the progress notes and discharge summary. The patient was treated with oral antiarrhythmia medications and IV antibiotics. - ✔✔ICD-10-CM: J18.9, 148.91- In accordance with the UHDDS, both conditions are not equally treated. The pneumonia was treated with IV antibiotics. This diagnosis had greater utilization of resources of medications and staff time compared with the atrial fibrillation, which was treated with oral medication. Because of this, the pneumonia is sequenced first (HHS 2014, Section II, C). Inpatient: A patient with chronic cholecystitis and gallbladder stones underwent a laparoscopic cholecystectomy in an acute care facility. However, due to extensive gallbladder adhesions the procedure was converted to an open cholecystectomy. - ✔✔ICD-10-CM: K80.10, K82.8 (Schraffenberger 2013, 249-250, 454); HHS 2011, Section I, 18. d, 14), ICD-10-PCS: OFT40ZZ, OFJ44ZZ (Leon-Chisen 2014, 250). Inpatient: A patient is admitted to the inpatient setting with hydronephrosis and a staghorn calculus of the right kidney. The patient underwent an uretetoscopy with placement of bilateral ureteral stents for dilation purposes and removal of calculus of right kidney. - ✔✔ICD-10-CM: N13.2, ICD-10-PCS: OT788DZ, OTC08ZZ (Leon-Chisen 2013, 269). Inpatient:A 77-year-old nursing home patient was admitted to the acute care setting for excisional debridement of decubitus stage 3 ulcer of the right heel via surgical excision in the OR. The patient also has degenerative joint disease of both knees. - ✔✔ICD-10-CM: L89.613, M17.0, ICD-10-PCS: OJBQOZZ (Schraffenberger 2013, 265-266, 278, 282-284). Inpatient: 45-year-old woman was admitted to the inpatient setting for a displacement of a lumbar intervertebral disk. This was treated with a laminectomy and diskectomy. - ✔✔ICD-10-CM: M51.26, ICD-10-PCS: OSB20ZZ, OQBOOZZ (Schraffenberger 2013,279, 282-284). Inpatient: A 34-year-old woman delivered a live born, term baby boy (39 weeks) with macrosomia. She had a hemorrhage following an episiotomy with a low forceps delivery but prior to expulsion of the placenta. - ✔✔ICD-10-CM: 067.9, 033.7, Z37.0, Z3A.39, ICD-10-PCS: 10D07Z3, OW8NXZZThe patient had a hemorrhage that occurred after delivery but before the expulsion of the placenta. This hemorrhage, by definition, occurred in the third stage of labor (Schraffenberger 2013, 270, 278-283, 313). Inpatient: A single, newborn, term live-born baby boy, born in hospital via vaginal delivery. - ✔✔ICD-10-CM: Z38.00(Schraffenberger 2013, 340). Inpatient: Twin newborns, both born prematurely at 32 weeks via cesarean section, 1,002 g was the birth weight of the first twin, whose mate was stillborn. The baby was admitted to the nursery from the delivery room. The baby also was treated for jaundice due to ABO incompatibility. - ✔✔ICD-10-CM: Z38.31, P07.14, P07.35, P55.1 (Schraffenberger 2013, 337). Inpatient: A patient is admitted to the acute care facility with chest pain. The patient was awakened from sleep; this was ;:he patient's first experience with chest pain. The patient was given two nitroglycerin tablets in the emergency department. The chest pain was not relieved, resulting in the diagnosis of new onset unstable angina. Serial CPK was normal. Following a left cardiac catheterization with angiogram of multiple coronary arteries with low osmolar contrast, the patient is found to have arteriosclerotic coronary artery disease. - ✔✔ICD-10-CM: 125.110, ICD-10-PCS: 4A023N7, B2111ZZ (Schraffenberger 2013, 202-204). Inpatient: This is the first admission for a patient with adenocarcinoma of the right lower lung who was also found with metastasis to the brain. The patient underwent a right lower lung lobectomy via laparotomy. - ✔✔ICD-10-CM: C34.31, C79.31, ICD-10-PCS: OBTFOZZ(Schraffenberger 2013, Chapter 5, 99). Inpatient: A patient has metastatic adenocarcinoma of bone. - ✔✔ICD-10-CM: C80.1, C79.51 (Schraffenberger 2013, 99). Inpatient: A patient is admitted with metastatic carcinoma from breast to liver with previous bilateral mastectomy and no reoccurrence at the primary site. - ✔✔ICD-10-CM: C78.7, Z85.3, Z90.13 (Schraffenberger 2013, 478). Inpatient: A young woman was admitted after a car hit her from behind while she waited for a bus on the sidewalk. She sustained a fractured fibula shaft and patella on the left leg with a break in the skin at the midcalf. The patient required an open reduction of the left fibula fracture. - ✔✔ICD-10-CM: S82.402A, S82.002A, T14.8, Y92.480, V03.10XA, ICD-10-PCS: OQSKOZZ (Schraffenberger 2013, 380-381, 443, 428). Inpatient:Syncope; bradycardia ruled out; due to taking Valium as prescribed by a physician. Patient also took an antihistamine as directed on the package without consulting a healthcare provider. - ✔✔ICD-10-CM: T42.4X1A, T45.0X1A, R55-The patient took over-the-counter medications with a prescription medication without consulting the prescribing physician. This is a poisoning