Certified Coding Specialist Practice Test COMPLETE SOLUTIONS 2022 A 7-year -old patient was admitted in the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be s uspected? - ✔✔Asthma with status asthmaticus A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending phys ician documents "urosepsis". What is the next step for the coder? - ✔✔Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms During a coronary artery bypass surgery, the patient underwent saphenous bypass grafts; from the aorta to the left anterior descending branch of the left main coronary artery, and the left posterior descending of the left main coronary artery. The patient also underwent a repositioning of the mammary artery. Choose th e best description for this procedure. - ✔✔Two aortocoronary grafts and one mammary -
coronary graft According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a ________________________. - ✔✔Colonoscopy Infusion of Herceptin, a monoclonal antibody used for treatment of breast cancer in patients carrying a certain mutation of the HER2 gene, is classified as ___________________. - ✔✔Molecular targets A patient has findings suggestive of chronic obstructive pu lmonary disease (COPD) on chest x -ray. The attending physician mentions the x -ray. The attending physician mentions the x -ray finding in one progress note but no medication, treatment, or further evaluation is provided. The coder should ___________________ _______________________. - ✔✔Query the attending physician regarding the X -
ray findings If a patient undergoes an inpatient procedure and the final summary diagnosis is different from the diagnosis on the pathology report, the coder should _______________ ______________. - ✔✔Query the attending physician as to the final diagnosis A 56 -year -old woman is admitted to an acute -care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of hospitalizatio n, a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should ____________________________________. - ✔✔Query the healthcare provider who performed the procedure to de termine if the debridement was excisional A 23 -year -old female is admitted for shock following treatment of a miscarriage. The pathology report from the previous admission reveals that the patient had no decidua or products of conception in the tissue rem oved. This encounter would be coded as ___________________________. - ✔✔O08.9, Complication following abortion and ectopic and molar pregnancies Most hospitals require a medical record is completed with ____________________. - ✔✔30 days To correct an ent ry in the medical record, the provider should ________________________________________. - ✔✔Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order After a patient is disc harged from the hospital, the medical record must be reviewed for ___________________________________. - ✔✔Certain basic reports (for example, history and physical, discharge summary, etc.) A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded? - ✔✔Congestive heart failure A 65 -year -old patient is admitted with pain and loosening of a left hip prosthesis. The acetabular component has loosened and become painful. The patient was admitted for open removal and replacement of the acetabular component of the left hip prosthesis. What is the appropriate code(s) for the admission? - ✔✔T84.031A - Mechanical loosening of internal left hip prosthetic joint, initial encounter, 0SPB0JZ - remo val of synthetic substitute from left hip joint, open approach, and 0SRE0JZ - replacement of left hip joint, acetabular surface with synthetic substitute, open approach A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? - ✔✔O48.1 - prolonged pregnancy
coronary graft According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a ________________________. - ✔✔Colonoscopy Infusion of Herceptin, a monoclonal antibody used for treatment of breast cancer in patients carrying a certain mutation of the HER2 gene, is classified as ___________________. - ✔✔Molecular targets A patient has findings suggestive of chronic obstructive pu lmonary disease (COPD) on chest x -ray. The attending physician mentions the x -ray. The attending physician mentions the x -ray finding in one progress note but no medication, treatment, or further evaluation is provided. The coder should ___________________ _______________________. - ✔✔Query the attending physician regarding the X -
ray findings If a patient undergoes an inpatient procedure and the final summary diagnosis is different from the diagnosis on the pathology report, the coder should _______________ ______________. - ✔✔Query the attending physician as to the final diagnosis A 56 -year -old woman is admitted to an acute -care facility from a skilled nursing facility. The patient has multiple sclerosis and hypertension. During the course of hospitalizatio n, a decubitus ulcer is found and debrided at the bedside by a physician. There is no typed operative report and no pathology report. The coder should ____________________________________. - ✔✔Query the healthcare provider who performed the procedure to de termine if the debridement was excisional A 23 -year -old female is admitted for shock following treatment of a miscarriage. The pathology report from the previous admission reveals that the patient had no decidua or products of conception in the tissue rem oved. This encounter would be coded as ___________________________. - ✔✔O08.9, Complication following abortion and ectopic and molar pregnancies Most hospitals require a medical record is completed with ____________________. - ✔✔30 days To correct an ent ry in the medical record, the provider should ________________________________________. - ✔✔Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order After a patient is disc harged from the hospital, the medical record must be reviewed for ___________________________________. - ✔✔Certain basic reports (for example, history and physical, discharge summary, etc.) A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded? - ✔✔Congestive heart failure A 65 -year -old patient is admitted with pain and loosening of a left hip prosthesis. The acetabular component has loosened and become painful. The patient was admitted for open removal and replacement of the acetabular component of the left hip prosthesis. What is the appropriate code(s) for the admission? - ✔✔T84.031A - Mechanical loosening of internal left hip prosthetic joint, initial encounter, 0SPB0JZ - remo val of synthetic substitute from left hip joint, open approach, and 0SRE0JZ - replacement of left hip joint, acetabular surface with synthetic substitute, open approach A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? - ✔✔O48.1 - prolonged pregnancy
