&Answers 100% Correct
A patient was admitted from the emergency department because of chest pain.
Following blood work, it was determined that the patient had elevated CK-MB enzymes.
The EKG shows nonspecific ST changes. What type of diagnosis might this indicate?
a) mitral valve stenosis
b) unstable angina
c) myocardial infarction
d) congestive heart failure - ANSWER Myocardial infarction
AnswerA patient is admitted to the psychiatric unit of an acute-care facility. Almost every
day for the past month, the patient has experienced loss of interest in most or all
activities, which is a change from her prior level of functioning. She had also gained 15
LBS, difficulty falling asleep, feels fatigued and has difficulty making decision. What
potential diagnosis most closely fits the patients overall symptoms?
a) bipolar disorder
b) insomnia
c) Reye's syndrome
d) major depression - ANSWER Major depression
AnswerA patient is admitted to the hospital complaining of abdominal pain. Following
evaluation, it was determined that the patient had an obstruction of the left colon due to
adhesions from a prior abdominal surgery. The patient underwent laparotomy with lysis
of adhesions. What conditions and procedures should be coded?
a) abdominal pain, abdominal obstruction, laparotomy, lysis of adhesions
b) abdominal adhesions with obstruction, lysis of adhesions
c) abdominal adhesions, abdominal obstruction, postoperative complications of the
digestive system, laparotomy, lysis of adhesions
d) abdominal adhesions, abdominal obstruction, postoperative complications of the
digestive system, lysis of adhesions - ANSWER Abdominal adhesions with obstruction,
lysis of adhesions
AnswerA Patient is diagnosed with infertility due to endometriosis and undergoes an
outpatient laparoscopic laser destruction of pelvic endometriosis. In order to code this
encounter accurately, what steps must the coding professional take?
a) review the operative report to determine what procedure code to use. Determine the
sit or sites of endometriosis so codes with the highest specificity may be assigned. Use
infertility as a principal diagnosis.
b) review the operative report to determine where the laser was used in the pelvis so
the site or sites of endometriosis can be specified. Assign a principal of infertility.
c) receive the operative report to determine where the laser was used in the pelvis so
the site or sites of endometriosis can be specified as principal. Assign a secondary
diagnosis of infertility.
, c) review the operative report to determine what procedures codes to use. Determine
the site or sites of end - ANSWER review the operative report to determine what
procedures codes to use. Determine the site or sites of endometriosis so codes with the
highest specify may be assigned. Assign endometriosis as the principal diagnosis.
Assign infertility as a secondary condition.
AnswerWhen coding a cardiac Catheterization in CPT, in addition to the approach and
the side of the heart into which the catheter was inserted, what else need to be
determined?
a) the type of anesthesia
b) if additional procedures were performed
c) the duration of the procedure
d) documentation that stents were considered - ANSWER If additional procedures were
performed
AnswerA female patient is admitted for a second-degree cystocele. A repair is
performed. Which report provides the documentation necessary to accurately code the
repair?
a) history and physical
b) discharge summary
c) consultation
d) operative report - ANSWER Operative report
AnswerTo accurately report would closures with CPT codes, in addition to knowing the
site and length of the closure, what other information is necessary?
a) if anesthesia was used and what kind
b) the repair type: simple, intermediate or complex
c) the supplies that's were used
d) if exploration of tendons or blood vessels occurred - ANSWER The repair type:
simple, intermediate, or complex
AnswerA 64-year-old female is admitted to the hospital with nausea, vomiting and
edema. Lab values indicate the patient has dehydration. The patient takes lisinopril as
prescribed along with levothyroxine for hypothyroidism. On the discharge summary, 5)3
final diagnoses of acute renal failure, hypothyroidism, and dehydration are documented.
What discrepancy should a coding professional note in this documentation?
a) there is not enough detail in the documentation to assign the dehydration
b) there is no explanation for the patient's vomiting
c) there is no correlating diagnosis for the Lisinopril
d) the nausea, vomiting, and edema are indicative of chronic renal failure not acute -
ANSWER There is no correlating diagnosis for the Lisinopril
AnswerA patient comes in with right upper quadrant pain, nausea, and vomiting. An x-
ray confirms inflammation in the gallbladder. The patient has been dealing with
episodes like this for the past six months. The final diagnosis in the discharge statement
is appendicitis. What discrepancy is muted in this record?