Chp 16 Coding Practice Questions & Answers

Tricia Thornwell, a 68-year-old female, was going walking when she fell down the icy front steps of her house; now she can't bear weight on her right leg. She is brought into the ER by ambulance. After the ER physician completed a thorough exam and reviewed the x-ray, he diagnosed her with a femoral neck base fracture, nondisplaced. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Fracture What type? Traumatic What is the anatomical site? Femur What is the location? Upper end, neck Do any of the following apply to the condition? Nondisplaced What is the laterality? Right Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? No If so does the Code also note apply to the case study? No Code also note Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S72.044A ***Second diagnosis*** Where should you begin to look up the code in the coding manual? External cause of injuries index What is the key term? Fall from What? Stairs Due to? Ice and snow Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • PATIENT: TRUMAN, HERBERT ACCOUNT/EHR #: TRUMHE001 DATE: 07/16/22 Attending Physician: Oscar R. Prader, MD S: Pt is a 47-year-old male brought in by ambulance accompanied by his wife. Wife states he has been confused, dizzy, and vomiting all morning. O: Ht. 5′11″, Wt. 187 lb., R 16. During the physical examination, the patient has a dramatic drop in vital sign measurements and suffers cardiac arrest. The crash team takes over and patient is successfully resuscitated. Blood work reveals overdose of digoxin. After Pt is stabilized, he states he was rushing to get to work this morning and couldn't remember if he had taken his medication, so he took it again. A: Cardiac arrest due to overdose of digoxin, accidental P: Admit for stabilization Oxygenation Hydration IV fluids Monitor electrolyte balance - ANSWERST46.0X1AI46.9 Patricia Neil, a 34-year-old female, presents today with a painful left foot. Patricia accidentally hit her foot on a desk this morning and is concerned she might have broken it. Dr. Dickerson examines Patricia's foot and notes swelling and discoloration. Dr. Dickerson orders an x-ray, which confirms no fractures. Patricia is diagnosed with a contusion, bruise harm score 1. - ANSWERSWhat is the principal diagnosis code? S90.32XA What is the second diagnosis code? W22.03XA Helen Carrizo, an 18-year-old female, presents to the ED with a painful left ankle. Helen is accompanied by her mother. Helen had been rollerblading and tripped, falling on the sidewalk. Helen is unable to flex her ankle, which has begun to swell. Dr. Webber gathered a brief history of the incident that caused the injury, as well as any history relating to her legs and feet. He then performed a limited examination of her left leg, ankle, and foot. The imaging confirmed a sprained calcaneofibular ligament and a sprained anterior tibiofibular ligament. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Sprain What is the anatomical site? Ankle What is the location? Calcaneofibular ligament What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? Yes If so does the Code also note apply to the case study? No Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? No Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S93.412A ***Second diagnosis*** Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Sprain What is the anatomical site? Ankle What is the location? Tibiofibular ligament What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the Billy Ugro, a 7-year-old male, was brought in by his mother. Billy was playing this afternoon in his backyard on the sliding board and fell, scraping his left cheek. Dr. Tucker, his pediatrician, examines the area and cleans and dresses the wound. Billy is diagnosed with a second-degree abrasion. - ANSWERSPrincipal diagnosis Where should you begin to look up the code in the coding manual? Index to Diseases and Injuries What is the key term? Abrasion What is the anatomical site? Cheek What degree Second Do any of the following apply to the condition? None of these What is the laterality? Left Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? Yes If so does the Includes note help to clarify? Yes Is there a Code first notation? No If so does the Code first note apply to the case study? No Code first note Is there a Code also notation? Yes If so does the Code also note apply to the case study? No Is there a Use additional code notation? Yes If so does the Use additional code note apply to the case study? No Is there an Excludes1 notation? Yes If so does the Excludes1 note apply to the case study? No Is there an Excludes2 notation? Yes If so does the Excludes2 note apply to the case study? No Is there a symbol indicating additional characters are required? Yes Do you need to use the placeholder "X"? Yes Did you code to the highest level of specificity? Yes What is the correct diagnosis code? S00.81XA Second diagnosis Where should you begin to look up the code in the coding manual? External cause of injuries index What is the key term? Fall from What? Playground equipment What type? Slide Do any of the following apply to the condition? Initial encounter Begin to code the encounter. Did you verify the code in the Tabular List of Diseases and Injuries? Yes Is there an Includes notation? No If so does the Includes note help to clarify? No Includes note Is there a Code first notation? No If so does the Code first note apply to the case study? No C