CCS Exam Prep 2024 Latest Update

CCS Exam Prep 2024 Latest Update7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? - ANSWER Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? - ANSWER Since PD is a nonspecific term and has no code in Alpha Index, query phys to determine if pt is being treated for sepsis, highlighting the clinical signs, symptoms During CABG, pt underwent saphenous bypass grafts; from aorta to left ant desc branch of left main coronary artery, and the left post desc of left main coronary artery. Pt also underwent repositioning of the mammary artery to the right coronary artery. What is the best description for this px? - ANSWER 2 aortocoronary grafts and 1 mammary-coronary graft According to CPT, an endoscopy that is undertaken to the level of midtransverse colon would be coded as a: - ANSWER Colonoscopy since this is an examination of entire colon from rectum to cecum that may include terminal ileum Infusion of Herceptin, a monoclonal antibody used for tx of breast cancer in pts carrying a certain mutation of the HER2 gene, is classified as: - ANSWER Molecular Targets which block the growth, spread of cancer by interfering with specific molecules involved in tumor growth, progression Pt has findings suggestive of COPD on chest x-ray and Attending phys mentions x-ray finding in one progress note but no meds, tx, or further eval. The coder should: - ANSWER Query phys regarding clinical significance of findings and request appropriate documentation be provided as this is example of a circumstance where chronic condition must be verified; all secondary conditions must meet the UHDDS definitions although it is not clear if COPD does Pt undergoes inpatient px and final summary dx is difference from dx on path report, the coder should: - ANSWER Query Attending phys as final dx as coding strictly from path report is not appropriate since coder would be assigning dx without Attending phys' corroboration 56 yo woman admitted to acute-care facility from SNF and has multiple sclerosis and hypertension. During course of hospitalization, decubitus ulcer is found and debrided at bedside by phys. There is no typed op report and no path report. The coder should: - ANSWER Query healthcare provider who performed px to determine if debridement was excisional as coders are encouraged to work with physicians, healthcare providers to ensure documentation is very specific and clarified 23 yo female admitted for shock following tx of miscarriage and path report from prev admit reveals pt had no decidua or POC in tissue removed. Encounter would be coded as: - ANSWER O08.9 = complication following abortion and ectopic and molar pregnancies since miscarriage was dealt with in a prior episode of care Most hospitals require a medical record is completed within: - ANSWER 30 days due to Medicare CofP and TJC To correct an entry in the MR, the provider should: - ANSWER Draw single line through the error, add a note explaining the error, initial, date, and add correct info in chronological order After pt is discharged from hospital, the MR must be reviewed for: - ANSWER Certain basic reports such as history and physical, discharge summary, etc. Pt is discharged with diagnosis of acute pulmonary edema due to CHF so what cn(s) should be coded? - ANSWER CHF Pt is admitted for chest pain, was stabilized and discharged. In subsequent adm, pt was admitted an outpt for left heart catheterization, coronary arteriography using 2 catheters, left ventricular angiography, and found to have arteriosclerotic heart disease. Pt has no hx of cardiac surgery. What is the proper sequencing of ICD-10-CM and CPT codes for outpt catheterization? - ANSWER I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris) 93458 (Catheter placement in coronary artery(s) for coronary angiography, incl intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed 65yo pt adm w/pain and loosening of left total hip prosthesis along with the loosening of the acetabular component which has become painful. Pt ad for open removal/replacement of acetabular component of left hip prosthesis, so what is the correct coding for admission? - ANSWER T84.031A (mechanical loosening of int lt hip prosth jt, initial enc 0SPB0JZ (removal synthetic sub fro lt hip jt, open approach 0SRE0JZ (replacement lt hip jt, acetabular surface w/synthetic sub, open approach) Maternity pt adm in labor at 43 wks and has normal delivery with vacuum extraction to facilitate baby's delivery. What is the PD? - ANSWER O48.1 (prolonged pg) With regard to implementation of ICD-10-CM, all of these are correct: - ANSWER ICD-10-CM was developed by NCHS; it was implemented on 10/1/15; was already being used by death certificate coding in US; the process of adopting ICD-10-CM is specified in HIPAA What does NCHS stand for? - ANSWER National Center for Health Statistics 75yo female was adm for AMI and underwent a diagnostic cardiac cath. Following the cath, pt dev a thrombophlebitis documented as due to the catheter in the common femoral artery. The thrombophlebitis would be coded as: - ANSWER T81.718A, complication of other artery following a procedure, NEC, initial enc Pt adm to ED w/chest pain, and dx w/abort MI w/acute myocardial ischemia with no prior cardiac surgery, and normal cardiac enzymes. What is coding for this case? - ANSWER I24.0 (acute coronary thrombosis not resulting in MI) Pts w/acute ischemic heart disease or acute myocardial ischemia do not always indicate an infarction and it is often possible to prevent infarction by means of surgery or use of thrombolytic agents if tx promptly Pt has nausea, vomiting, abdominal pain due to acute cholecystitis. Phys doc the following on DS: Acute cholecystitis, nausea, vomiting, and abdominal pain. What is correct coding? - ANSWER Acute cholecystitis Pt adm bc of CHF, and also found to have elevated liver function tests. Phys worked up ELF test but able to determine dx, so the following dx is assigned: - ANSWER CHF and abnormal liver function tests Pt adm with hypotension due to dobutamine taken and prescribed correctly. How is this coded? - ANSWER I95.2, Hypotension due to drugs T44.5X5A, adverse effects of dobutamine Pt adm 2 wks after laminectomy for spinal stenosis w/headache (headache due to tear in dura accidentally occurred during prior laminectomy surgery). Pt taken to OR for repair of dura. How is this case coded? - ANSWER G97.41, Accidental puncture or laceration of dura during procedure Pt adm w/SOB, CHF, and subsequently dev resp fail. Pt undergoes intubation w/ventilator mgmt. Correct seq of dx would be: - ANSWER CHF and resp failure Pt adm w/pneumococcal pneumonia and pneumococcal sepsis, so the coder should: - ANSWER Assign code for sepsis, pneumonia, and severe sepsis. Pt w/pneumococcal sepsis and pneumococcal pneumonia also has severe sepsis and Guidelines provide info related to coding, seq of sepsis, severe sepsis, and localized infection, such as pneumonia