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Medical Coding 1 Final
Test questions from the semester.
126
Medical
12/11/2011

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Term
The supplementary classifications in ICD-9-CM are the:
Definition
E and V codes
Term
What term is used in a code descriptor in the "taburar list of diseases and injuries" that should be interpreted as "and/or" by the coder?
Definition
and
Term
Principal Diagnosis
Definition
The condition established after study to occassion the admission of the patient to the hospital.
Term
The patient is seen in her family physician's office for complaints of dizziness, sweating, and extensive brusing.  The physician documents her impression as "rule out diabetes mellitus" and orders appropriate testing.  How will the encounter be coded?
Definition
dizziness, sweating, extensive brusing
Term
The basic message of which of the following instructional notes, found the "Tabular List of Diseases and Injuries," is "code this condition elsewhere."
Definition
excludes
Term
The discharged inpatient diagnostic statement (Discharge Summary) reads "rule out diabetes mellitus."  Diabetes mellitus should be:
Definition
coded.
Term
Parentheses enclose terms throughout ICD-9-CM that are included int eh code but need not be stated in documentation as they do not affect coe assignment in any way.  These terms which serve as reassurance that the correct code has been selected are referred to as:
Definition
nonessential modifiers
Term
This will always govern the selection of the principal diagnosis for inpatient admission:
Definition
circumstance of admission
Term
When 1 code describes 2 concurrent conditions, you are required to:
Definition
Use the combination code only
Term
A code title in the "Tabular List of Diseases and Injuries" that is listed in an italicized bold font is a:
Definition
Manifestation code
Term

A patient is admitted with chest pain.  The patient has a history of prior gastroesophageal reflux, but he indicates this pain is different.  The patient had been lifting weights earlier int he day.  A coronary etiology is worked up but found to be negative.  The patient was given antacids and pain medication to ease the symptoms.  The physician lists the diagnosis "chest pain due to costochondritis vs. indigestion"

What codes are reported for the above scenario?

536.8 Indigestion
733.6 Costochondritis
786.50 Chest pain, unspecified
Definition
786.50, 733.6, 536.8
Term
Manifestation codes
Definition
In slanted brackets in the alpha index, always sequenced second and must be used with the first code, will either say "in diseases classified elsewhere" or "use additional code"
Term
If the same condition is described as both acute and chronic and separate subentries exist in the ICD-9-CM Alphabetic Index at the same indentation:
Definition
The would both be coded and the acute condition is sequenced first
Term
Codes that contain the abbreviation "NOS" in their description are to be used:
Definition
when the coder lacks sufficient information to assign a more specific code.
Term
The following diagnosit statement was documented by the physician: "acute anterior wall myocardial infarction."  Which of the following is the main term that will need to be referenced int eh "Alphabetic Index to Diseases and Injuries" to locate the appropriate diagnosis code?
Definition
Infarction
Term
Conditions that are not an integral part of a diagnosed disease process:
Definition
Should be reported
Term
These modifiers, known as subterms in the "Alphabetic Index to Diseases and Injuries," are also referred to as which of the following?
Definition
Essential Modifiers
Term
Codes that include the abbreviation NEC, which itself can be found in both the Alphabetic Index and the Tabular List, indicates:
Definition
that ICD-9-CM does not provide a specific code for the patient's condition
Term
The coding of late effects normally requires two codes: one for the residual condition, and one for:
Definition
The cause of the residual condition
Term
Brackets ([]) are used in the Tabular List to enclose:
Definition
synonyms, alternative wording, or explanatory phrases
Term
Tuberculous esophagitis
Definition
017.80
Term
Acute and chronic maxillary sinusitis
Definition
461.0
Term
adenomatous rectal polyp
Definition
211.4
Term
pelvic arthritis due to lyme disease
Definition
088.81, 711.85
Term
pneumonia due to chlamydia
Definition
483.1
Term
According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires specialized training, is defined as a:
Definition
Significant procedure
Term
An E code can be used:
Definition
with both ICD-9-CM diagnosis codes and V codes
Term
ICD-9-CM procedure codes are required to be reported in which of the following settings?
Definition
Hospital inpatient
Term
When an open biopsy is followed by a more extensive definitive procedure, the coder reports:
Definition
the extensive definitive procedure and the open biopsy
Term
E codes are mandatory for adverse reactions due to:
Definition
Drugs, medicinal agents, and biological substances causing adverse effects in therapeutic use.
Term
What is used to surgically divert fluids from one part of the body to another part of the body?
Definition
shunt
Term
E codes are never used as:
Definition
the principal diagnosis
Term
Which instructional note is used to indicate an additional code should be assigned if the referenced procedure is performed?
Definition
code also
Term
E codes are used to report additional information in cases of:
Definition
adverse effects and poisonings, injury due to external cause, transport accidents
Term
A closed biopsy is:
Definition
Needle, Brush (aspiration, endocscopic)
Term
The procedure performed for definitive treatment is referred to as what type of procedure?
Definition
Principal
Term
What V codes can be sequenced as the principal/first-listed diagnosis?
Definition
Outcome of delivery (V30.00 single liveborn; born in hospital, delivered without mention of cesarean delivery) ON THE NEWBORNS CHART ONLY, when patient is in for radiation therapy or chemotherapy, depends on encounter
Term
When only a lesion of an organ is removed, what main term should the coder reference int eh Volume 3 alphabetic index?
Definition
excision
Term
The use of aftercare code V58.0 (encounter for radiotherapy) will require that the coder also reports:
Definition
The type of cancer, and the radiotherapy procedure code.
Term
Where is the E codes tabular list located?
Definition
Following the V codes in Volume 1
Term
What is the sequencing with E codes when several vehicles are involved in an accident?
Definition
Air and space transport accidents, watercraft accidents, motor vehicle traffic and nontraffic accidents, railway accidents, other road vehicle accidents
Term
A patient is admitted to the hospital to receive radiation therapy and chemotherapy for esophageal cancer.  What is the appropriate principal diagnosis?
Definition
Either V58.0 or V58.11
Term
What elements of a surgical procedure would be usually included in the ICD-9-CM procedure code and not reported separately?
Definition
Approach (only code the approach when it is followed by a biopsy), closures, anesthesia
Term
True/False, Different V codes exist for family history of diseases and personal history of diseases?
Definition
True
Term
When an individual is well but seeking health care services for a particular reason, which type of code must be reported as the principal/first-listed diagnosis?
Definition
V code
Term
Patient slipped on an icy sidewalk.
Definition
E885.9
Term
What code would be reported as the first-listed diagnosis when a patient presents to her physician's office for a flu shot?
Definition
V04.81
Term
What is the procedure code for vasectomy with ligation of the vas deferens?
Definition
63.71
Term
What code would be reported when a patient presents to the hospital x-ray department for an outpatient screening examination for lung cancer?
Definition
V76.0
Term
Patient's clothes caught on fire in kitchen fire at home.
Definition
E893.0, E849.0
Term
Sequencing of Late Effect E codes:
Definition
Code residual effect, code late effect, code late effect E code.
Term
Types of E codes:
Definition
cause, intent, place of occurrence
Term
A patient is seen with symptoms of fatigue, fever, and a persistent and productive cough.  Testing reveals HIV-positive status and documented HIV-related pneumonia.  Appropriate medications are prescribed for the pneumonia and the HIV infection.  The proper sequencing and coding with be:
Definition
HIV disease (042); pneumonia (486)
Term
In the diagnostic statment "diabetic foot ulcer," what condition should be assigned as the principal diagnosis?
Definition
The diabetes
Term
A patient is seen with septic shock from generalized septicemia.  The correct coding and sequencing would be:
Definition
Septicemia, SIRS, septic shock
Term
What does insulin do?
Definition
increases glucose metabolism
Term
The patient is admitted through the ER with a omminuted fracture of the left femur.  He had slipped in the bathtub at home.  The patient is HIV positive and is exhibiting AIDS-related lymphadenopathy.  The correct sequencing of these diagnosis is:
Definition
fractured femur, HIV infection, lymphadenopathy
Term
What is gestational diabetes?
Definition
An abnormal glucose tolerance test findings/results in pregnant women without previous history of diabetes.
Term
The term "severe sepsis" is used to indicate sepsis with:
Definition
organ dysfunction
Term
Diabetic foot ulcers may result from:
Definition
diabetic peripheral vascular and/or neurological complications
Term
When acute respiratory failure and acute renal failure are documented as being due to SIRS following trauma, which of the following codes will be listed as the principal diagnosis?
Definition
trauma
Term
A patient with known AIDS is admitted to the hospital as an inpatient with acute appendicitis and undergoes an open appendectomy.  Her AIDS is under treatment and is asymptomatic at the present time.  The appropriate principal diagnosis in this case would be:
Definition
540.9 Acute Appendicitis
Term
A vision related pathology that can frequently be caused by diabetes is:
Definition
reinopathy
Term
In the diagnostic statement "E. coli urosepsis," which of the following will be sequenced as the principal diagnosis?
Definition
urinary tract infection
Term

A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus.  She is Type I diabetic and was brough under control and subsequently discharged.  The following code was assigned:

648.03 Other current condition in the mother classifiable elsewhere but complicating pregnancy, childbirth, or the puerperium, diabetes mellitus, antepartum condition

Describe the coding error:

Definition
An additional code describing the diabetes mellitus should be assigned
Term
Physician documentation of a lab finding of bacteria in the blood will result in the reporting of:
Definition
bacteremia
Term
A 35-year-old patient is seen at his doctor's office with a previous lab test positive for hyperglycemia.  The physician documents a diagnosis of "suspected diabetes mellitus."  The correct diagnosis code(s) for the encounter will report:
Definition
Hyperglycemia
Term
Inpatient encounter for a patient with diabetic intercapillary glorelosclerosis and peripheral angiopathy.  For the past month the patient has been on daily insulin injections.
Definition
250.40, 581.81, 250.70, 443.81, V58.67
Term
Septicemia due to mithicillin resistant staphylococcus aureus.  Patient also had on admission septic shock and a stage 1 decubitus ulcer of the sacrum.  Patient had a centrally placed venous line inserted which will be used for drug infusion.
Definition
038.12, 995.92, 785.52, 707.03, 707.21; 38.93
Term
An HIV positive patient was admitted with skin lesions on the chest and back.  Biopsies were taken, and the pathologic diagnosis was Kaposi's sarcoma.  Hepatosplenomegaly was also noted on physical examination.
Definition
042, 176.0, 571.8; 86.11
Term
68 year old female was admitted wtih Type 1 diabetes mellitus with a diabetic ulcer of the left heel.  Patient was taken to the operating room for excisional debridement of the ulcer.
Definition
250.81, 707.14; 86.22
Term
An elderly patient is seen by his physician for his diabetic polyneuropathy.  He brough the log of his sugar readings for the past month.  The log was reviewed with him and show him to be in good control.  The patient has been a type I diabetic for six years.
Definition
250.61, 357.2
Term
Leukoplakia of the tongue due to HIV infection
Definition
042, 528.6
Term
A 12-year-old female presents to her gastronterolgist's office for a check-up of her celiac disease, which has resulted in the patient developing secondary diabetes, uncomplicated at this point.
Definition
579.0, 249.00
Term
Diabetic proliferative retinopathy in a patient with controlled type I diabetes
Definition
250.51, 362.02
Term
Sepsis due to E. coli infection
Definition
038.42, 995.91
Term
When documentation states that a neoplasm has metastasized, the physician is saying that the neoplasm:
Definition
has spread
Term
Morphology (M) codes are used for:
Definition
describing the kind of neoplasm and its behavior
Term
Richard is admitted for a round of adjunct cancer treatment consisting of chemotherapy for leukemia. The chemotherapy is administered.  What needs to be coded?
Definition
an admission for antineoplastic chemotherapy V code, the leukemia diagnosis code, and a procedure code for chemotherapy administration will be assigned, with the admission for antineoplastic chemotherapy v code sequenced as the principal diagnosis
Term
Given the following diagnosis "carcinoma of lung and axillary lymph nodes, metastatic from breast," what is the primary neoplasm site(s)?
Definition
Breast
Term
When a patient is admitted to the hospital solely for the purpose of treating a complication of a neoplasm, such as dehydration or anemia, the ICD-9-CM diagnosis code for the complication will:
Definition
be sequenced first, followed by the code for the neoplasm
Term
A pathological diagnosis of transitional cell carcinoma of the cervix is made.  The diagnosis will be classified in ICD-9-CM as a neoplasm of the cervix.  Which of the following is the appropriate behavior classification of a transitional cell carcinom?
Definition
in situ
Term
A 72-year-old female patient is admitted to the hospital with excruciating lower back pain.  She has breast cancer with metastasis to the bone, specifically the lumbar vertebrae.  She was treated with rest and alalgesics, then discharged on day two to follow up with her oncologist.  What will be sequenced as the principal diagnosis?
Definition
neoplasm-related pain
Term
When would it be appropriate to report a code from category V10, "personal history of malignant neoplasm," on a patient's chart?
Definition
When the primary malignancy has been removed or irradiated and there is currently no adjunct tratment being given to the patient.
Term
A 65-year-old female was admitted to the hospital with shortness of breath and diagnosed with metastatic adenocarcinoma of the lung, with the primary site listed as the breast.  The patient previously had a lumpectomy (removal of the breast tumor) performed three years ago.  Following surgery she received a round of chemotherapy, after which she had been given a clean bill of health.  What would you sequence as the principal diagnosis?
Definition
Metastatic adenocarcinoma of the lung
Term
The diagnostic phrase "disseminated cancer" is to be interpreted by the coder as:
Definition
widely metastatic
Term
A patient is admitted to the hospital to receive radiation therapy (V58.0) and chemotherapy (V58.11) for esophageal carcinoma (150.5).  What is the appropriate principal diagnosis?
Definition
either V58.0 or V58.11
Term
A patient who had cancer of the descending colon, which was removed one year ago, returns for a follow-up visit.  Colonoscopy revealed a recurrence of cancer.  What would be reported?
Definition
Malignant neoplasm of the colon (153.2)
Term
A patient is admitted with shortness of breath and hemoptysis.  A chest x-ray was inconclusive, revealing patch infiltrates in the left lung.  On the third day of hospitalization, a bronchoscopy with biopsy was performed which revealed a small cell carcinoma of the left upper lobe of the lung, which was determine to be the cause of the SOB and hemoptysis.  A secondary metastatic lesion in the brain was subsequently detected following CT scan.  The principal diagnosis is the:
Definition
small cell lung carcinoma
Term
If a neoplasm is classifed in the pathology report as "in situ," which of the following describes the behavior of the neoplasm?
Definition
Malignant but not yet invasive or metastatic
Term
What ICD-9-CM neoplasms behavior classifications is reported for tumor cells that have the property for invasion of or attachment to adjacent structures, for spread to distant sites, for relentless growth, and for a lethal effect?
Definition
malignant
Term

A patient was diagnosed with adenocarcinoma of the left lower-inner quadrant of the breast with metastases to the axillary lymph nodes which subsequently required a left radical mastectomy.

174.3 Malignant neoplasm of female breast; lower-inner quadrant, primary site
174.5 Malignant neoplasm of female breast; lower-outer quadrant, primary site
196.3 Malignant neoplasm of lymph nodes; axilla and upper limb, secondary site
196.5 Malignant neoplasm of lymph nodes; inguinal region and lower limb, secondary site
196.8

Malignant neoplasm of lymph nodes; multiple secondary sites

Definition
174.3, 196.3
Term

Patient was diagnosed with an adenocarcinoma of the left lower-inner quadrant of the breast with metastases to the axillary lymph nodes who is now 8 weeks status post left radical mastectomy.  The patint presents to oncology clinic today for her first round of chemotherapy.

 

V10.3 Personal history of malignant neoplasm; breast
V58.11 Encounter for antineoplastic chemotherapy
V67.00 Follow-up examination following surgery
174.3 Malignant neoplasm of female breast; lower-inner quadrant, primary site
196.3 Malignant neoplasm of lymph nodes; axilla and upper limb, secondary site
Definition
V58.11, 174.3, 196.3
Term

A patient was admitted to the hospital because colon cancer was suspected.  Exploratory laparatomy was carried out and a significan mass was removed from the descending colon.  In addition, small nodules were seen and bipsied on the liver.

The pathologist report stated: carcinoma of the descending colon metastatic to the liver.

153.2 Malignant neoplasm of the descending colon
153.6 Malignant neoplasm of the ascending colon
153.9 Malignant neoplasm of the colon, unspecified
155.0 Malignant neoplasm of the liver, primary
155.2 Malignant neoplasm of the liver, not specified as primary or secondary
197.7 Malignant neoplasm of the liver, specified as secondary

 

Definition
153.2, 197.7
Term

A patient with a history of malignant neoplasm of the lung, status post resection four years ago without recurrence, is admitted for seizures.  Workup revealed metastatic brain cancer.

162.9 Malignant neoplasm of lung, unspecified site
198.3 Secondary neoplasm of brain and spinal cord
780.39 Seizures
V10.11 Personal history of malignant neoplasm, lung
Definition
198.3, 780.39, V10.11
Term

A patient was admitted to the hospital because of abdominal pain.  Needle biopsy of the liver reveals secondary malignancy of the liver.  Patient then undergoes an exploratory laparotomy to determine the primary site, which is still unknown at the time of discharge.

197.7 Malignant neoplasm of liver, specified as secondary
199.1 Malignant neoplasm without specification of site (primary) (secondary)
789.00 Abdominal pain, unspecified site
50.11 Closed biopsy of liver
50.12 Open biopsy of liver
54.11 Exploratory laparotomy
Definition
197.7, 199.1; 54.11, 50.11
Term
Metastatic carcinoma to the brain
Definition
199.1, 198.3
Term
Multiple myeloma in remission
Definition
203.01
Term
metastatic carcinoma from the trachea
Definition
162.0, 199.1
Term
Intramural leiomyoma of the uterus
Definition
218.1
Term
carcinoma of cervicothoracic esophagus
Definition
150.8
Term

During a coronary artery bypass surgery, the patient underwent the following saphenous vein bypass grafts:  fromt he aorta to the left anterior descending (LAD) brach of the left main coronary artery (LMCA), and from the aorta to the posterior desceding branch of the LMCA.  The patient also had reposistioning of the internal mammary artery to the right coronary artery.

What is the best description of the procedure (how many grafts and what kind performed)

Definition
two aortacoronary grafts and one mammary-coronary graft
Term
When the diagnostic statement lists hypertension and chronic kidney disease, what coding guideline applies?
Definition
A code from subcategory 403.9 (hypertensive chronic kidney disease) is assigned, with an additional code reported to identify the stage of chronic kidney disease
Term
A patient with no previous history of cardiovascular disease is admitted to St. Elegius Hospital with a diagnosis of acute anteroseptal myocardial infarction, and is transferred seventy-two hours later to Chicago Sun Hospital for specialized care and further workup. What is the description of the code (episode and diagnosis)
Definition
Acute MI with a fifth digit of 1 (initial episode of care)
Term
What descriptor of hypertension will require the coder to classify the hypertension as malignant?
Definition
accelerated
Term
A patient was admitted to the hospital with hemiplegia and aphasia.  The patient was diagnosed as having suffered a cerebral thrombosis, which has resolved along with all neurological deficits.  What is the correct coding and sequencing for this patient's inpatient encounter?
Definition
cerebral thrombosis; hemiplegia, aphasia
Term
An elderly patient is admitted to the hospital with unstable anginal symptoms and undergoes cardiovascular workup.  A myocardial infarction is diagnosed.  What should be coded?
Definition
Myocardial infarction only
Term
Concerning Rheumatic Fever and Heart Failure... ICD-9-CM presumes:
Definition

Two mitral valve disorders of unspecified etiology are rheumatic in nature:  stenosis and obstruction

Disorder affecting both the mitral and aortic valves in rheumatic in origin

Term
Category 402
Definition
Hypertensive Heart Disease
Term
A patient with CLL (chronic lymphocytic leukemia) is admitted for chemotherapy 5 weeks after experiencing a heart attack.  How will the MI be coded?
Definition
MI wth 5th digit "2"- subsequent episode of care.
Term
If documentation on the final diagnostic statement reads "uncontrolled hypertension." which nature of hypertension will be reported.
Definition
unspecified.
Term
you have been hired as a coder at an acute care facility that specializes in cardiac procedures, and the very first chart you will code is a PTCA with stent placement.  Confidently you begin to code the chart because you that this type of procedure will require, at a minimum, how many codes?
Definition
4
Term
Coding professional must always assume a cause-and-effect relationship between hypertension and what other condition?
Definition
renal disease
Term
Systolic Heart Failure
Definition
Ability to contract decreases
Term
Diastolic Heart Failure
Definition
When heart has problems relaxing between contractions
Term
When Ed was discharged from the hospital, his physician listed his diagnoses as left heart failure and congestive heart failure with acute pulmonary edema.  You are coding Ed's record and you will report:
Definition
the CHF only
Term

A patient is admitted to the hospital through the emergency room with a diagnosis of CVA.  CT scan of the brain showed a thrombotic infarction.  The patient has a long-standing history of well-controlled hypertension and is continued on medication.  The patient experienced right-sided hemiplegia and aphasia, both of which had resolved at the time of discharge.

342.90 Hemiplegia, unspecified; affecting unspecified side
401.9 Essential hypertension, unspecified
434.00 Occlusion of cerebral arteries, Cerebral thrombosis; without mention of cerebral infarction
434.01 Occlusion of cerebral arteries, Cerebral thrombosis; with cerebral infarction
436 Acute, but ill-defined, cerebrovascular  disease
784.3 Aphasia
Definition
434.01, 342.90, 784.3, 401.9
Term

A PTCA is performed with stent insertion of the left circumflex.  They physician also placed a stent in the obtuse marginal artery and one in the posterior descending artery.

00.42 Procedure on three vessels
00.47 Insertion of three vascular stents
00.66 Percutaneous tranluminal coronary angioplasty (PTCA) or coronary atherectomy
36.06 Insertion of non-drug-eluting coronary artery stent(s)
36.07 Insertion of drug-eluting coronary artery stent(s)
784.3 Aphasia
Definition
00.66, 00.42, 00.47, 36.06
Term

A patient was discharged following an acute inferior wall MI.  The same patient is admitted four days later complaining of substernal chest pressure associated with severy dyspnea.  The physician indicates that the patient had refused CABG surgery during the previous admission and is now being admitted due to acute CHF.  Final discharge diagnoses are CHF and MI.

410.41 Acute myocardial infarction, Of other inferior wall,; initial episode of care
410.42 Acute myocardial infarction, Of other inferior wall,; subsequent episode of care
428.0 Congestive heart failure, unspecified
Definition
428.0, 410.42
Term

A patient is diagnosed with CHF due to hypertensive diastolic heart failure.

401.9 Essential hypertension, unspecified
402.91 Hypertensive heart disease, unspecified, with heart failure
428.0 Congestive heart failure, unspecified
428.30 Diastolic heart failure, unspecified
Definition
402.91, 428.30, 428.0
Term

A patient is admitted with angina secondary to CAD.  There is no past history of CABG surgery.

411.1 Intermediate coronary artery syndrome (unstable angina)
413.9 Other and unspecified angina pectoris (angina NOS)
414.00 Coronary atherosclerosis, Of unspecified type of vessel, native or graft
414.01 Coronary atherosclerosis, Of native coronary artery
Definition
414.01, 413.9
Term
Benign essential hypertension
Definition
401.1
Term
Acute subendocardial infarction of the anterolateral wall of the heart
Definition
410.71
Term
Elevated blood pressure
Definition
796.2
Term
Stenosis of mitral and aortic valve
Definition
396.0
Term
Aortocoronary bypass, left diagonal and left cicumflex arteries with saphenous vein graft; performed with assistance of a cardiopulmonary bypass machine
Definition
36.12, 39.61