CCS PREP EXAM Section 1 Conventions, General coding guidelines and chapt spec guidelines Questions & Answers

How are changes made to ICD-10-PCS? A. Changes are made by 3M. B. Changes are made by the American College of Surgeons. C. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS. D. Changes are made by the World Health Organization. - ANSWERSC. Changes are made through the Coordination and Maintenance Committee process overseen jointly by CMS and NCHS. How is a bilateral condition coded if no bilateral code is provided? - ANSWERSIf no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. When a patient has a bilateral condition and each side is treated during separate encounters, how is it coded when one side is treated first and the second side is treated on a separate encounter? - ANSWERSWhen a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. Which of the following organizations developed ICD-10-PCS? A. World Health Organization B. AHIMA C. 3M under contract to the Centers for Medicare & Medicaid Services D. National Center for Health Statistics - ANSWERS3M under contract to the Centers for Medicare & Medicaid Services What does the second character represent in the ICD-10-PCS code structure in the Medical and Surgical Section? A. Section B. Body system C. Root operation D. Body part - ANSWERSBody system Which of the following statements is NOT one of the conditions that must be met in order for multiple procedures performed during the same operative episode to be coded separately? A. The same root operation is performed on different body parts as defined by distinct values of the body part character. B. The same root operation is repeated in multiple body parts, and those body parts are separate and distinct body parts classified to a single ICD-10-PCS body part value. C. Multiple root operations with the same objectives are performed on the same body part. D. The intended root operation is attempted using one approach but is converted to a different approach. - ANSWERSA. Multiple root operations with the same objectives are performed on the same body part. 5. If a procedure is attempted by a surgeon but is not successful, what should the coding professional do? A. Not code the procedure. B. Code to the root operation performed and if no root operation performed code to inspection. C. Query the surgeon for instructions D. Code the procedure attempted with a qualifier for "attempted." - ANSWERSCode to the root operation performed and if no root operation performed code to inspection. Which of the following root operations is an example of a root operation "to take out some or all of a body part"? A. Extirpation B. Fragmentation C. Division D. Detachment - ANSWERSDetachment Which root operation would be used to indicate the performance of a total mastectomy? A. Excision B. Resection C. Detachment D. Extraction - ANSWERSResection Which of the following root operations has as its objective "moving a body part to normal or other suitable location"? A. Reposition B. Transfer C. Reattachment D. Transplantation - ANSWERSReposition Which of the following is an example of a procedure that should be coded multiple times according to the ICD-10-PCS guidelines for multiple procedures? A. Resection of multiple uterine fibroids B. Destruction of two sigmoid colon polyps C. Extraction of multiple toenails D. All of the above - ANSWERSExtraction of multiple toenails 20. Which of the following statements is true regarding mastectomy followed by breast reconstruction? A. Both resection and replacement of the breast are coded separately. B. Only replacement of the breast is coded C. Only resection of the breast is coded D. Whether to code resection or replacement of the breast is determined by hospital internal policy - ANSWERSBoth resection and replacement of the breast are coded separately. Whats the difference between immunotherapy and chemotherapy - ANSWERSCancer immunotherapy is a treatment that empowers a patient's own immune system to fight cancer. Chemotherapy, often called "chemo," is a treatment with drugs that kill cancer cells directly External cause codes should never be used as a principal or first listed diagnosis. True or false - ANSWERSTRUE Which of the following types of Z codes are used when the initial treatment of a disease has been completed, but the patient requires continued care during the healing or recovery phase? Admission for follow-up examination Admission or encounter for aftercare management Admission for observation and evaluation Screening examinations - ANSWERSAdmission or encounter for aftercare management The aftercare Z codes should be used to report aftercare for injuries. True or False. - ANSWERSFalse. A patient is seen in the outpatient clinic for colonoscopy due to family history of colon cancer. The patient has no personal history of gastrointestinal disease and is currently without signs and symptoms. Colonoscopy was normal. Assign the appropriate code(s) and sequence according to coding guidelines. - ANSWERSZ12.11, Encounter for screening for malignant neoplasm of colon Z80.0, Family history of malignant neoplasm of digestive organs 0DJD8ZZ Inspection of lower intestinal tract, via natural or artificial opening endoscopic A patient had carcinoma of the descending colon, which was resected one year prior to this outpatient encounter. Patient is now seen for colonoscopy to evaluate anastomosis and remaining colon. Colonoscopy showed a normal anastomosis and no evidence of cancer recurrence. Assign the appropriate diagnosis and procedure code(s) and sequence according to coding guidelines. - ANSWERSZ08, Encounter for follow-up examination after completed treatment for malignant neoplasm Z85.038, Personal history of other malignant neoplasm of large intestine Z90.49, Acquired absence of other specified parts of digestive tract Procedure code: 0DJD8ZZ, Inspection of lower intestinal tract, via natural or artificial opening endoscopic Source: Coding Clinic for ICD-9-CM, First Quarter 1995, p. 4. A postmenopausal patient is seen as an outpatient for a bone density study to evaluate for osteoporosis. She has no other signs or symptoms at the present time. What diagnosis code should be used to report this encounter? - ANSWERSZ13.820, Encounter for screening for osteoporosis Z78.0, Asymptomatic menopausal state A woman with no symptoms is referred to the hospital outpatient x-ray department for screening mammogram. The patient is considered high risk for breast cancer secondary to family history of breast malignancy in the mother and sister. How should this encounter be coded? - ANSWERSZ12.31, Encounter for screening mammogram for malignant neoplasm of breast Z80.3, Family history of malignant neoplasm of breast Source: Coding Clinic for ICD-9-CM, Second Quarter 2003, p. 4. Which of the following statements refers to "abnormal findings" for codes describing health examinations with abnormal findings? Condition/diagnosis that is newly found Change in severity of a chronic condition, during a routine physical exam None of the above A and B - ANSWERSA and B A patient is being seen for aftercare treatment of fracture of left radius. How should this encounter be coded? Z51.89 T14.90XD S52.92XD S52.92XA - ANSWERSS52.92XD Codes from chapter 18 are assigned as secondary codes under which of the following circumstances? A.When the symptom or sign is not integral to the underlying condition B.When it affects payment C.When desired D.Never - ANSWERSWhen the symptom or sign is not integral to the underlying condition If the coder notes clinical findings outside the normal range but no related diagnosis is stated, what should the coder do? A. Review the conditions possibly responsible for the abnormal findings and select a code for one of those conditions. B. Code the abnormal finding. C. Review the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned. D. Review the medical record and code the abnormal finding as a "possible, probable" diagnosis. - ANSWERSReview the medical record to determine whether additional tests and/or consultations were carried out related to these findings or whether specific related care was given, and ask the physician whether a code should be assigned.