ADVANCED CODING MODULE 5 EXAM
QUESTIONS AND ANSWERS
Which of the following are permissible to code for SDS diagnoses? - Correct Answers -
past conditions that relate to the current visit
What report is the definitive authority on specimens taken out during surgery? - Correct
Answers -pathology report
When is it appropriate to use non physician notes as a source document for coding? -
Correct Answers -to code BMI for a patient with documented obesity
Which of the following is NOT a characteristic of a critical access hospital? - Correct
Answers -it provides at least 50% critical care services
Which setting uses APCs for Medicare reimbursement? - Correct Answers -same-day
surgery
Outpatient coding conventions state that _________________ diagnoses may NOT be
coded. - Correct Answers -possible
Which condition should be documented as to whether or not the condition is 'reducible'?
- Correct Answers -umbilical hernia
Coagulation and serology tests help determine: - Correct Answers -the amount of time it
takes for bleeding to stop
EGD is a: - Correct Answers -procedure
When does an ER coder report E/M codes? - Correct Answers -when the physician is
employed by the hospital
What report is the official summary of the procedure performed, preoperative and post
operative diagnosis, and step by step details for the actual procedure and or surgery
performed. - Correct Answers -operative report
Where would you expect to find the following statement? "A C-shaped flap was made in
a small fashion below the transverse sinus with the base on the transverse sinus
overlying the cerebellum." - Correct Answers -operative report
, Documentation of EBL 20cc refers to: - Correct Answers -blood loss during a procedure
___________ is a common abbreviation for the oral route of medication administration.
- Correct Answers -PO
_____________ is common abbreviation for no known allergies. - Correct Answers -
NKA
Hospital outpatient coders are typically responsible for coding all outpatient accounts,
which can include _______ services. - Correct Answers -ancillary
A patient who is not formally admitted to the hospital for treatment is known as an
____________. - Correct Answers -outpatient
___________ patients are those who are having surgery as an outpatient. - Correct
Answers -SDS
One step in coding ER visits is to check to see if a __________________ is needed on
the procedure code. - Correct Answers -modifier
NOt every hospital is paid on the _____ system - Correct Answers -APC
The Caldwell-Luc procedure is an eponym for a specific type of: - Correct Answers -
sinusotomy
EMERGENCY ROOM REPORT
CHIEF COMPLAINT: Left hand injury.
HISTORY OF PRESENT ILLNESS: This 25-year-old male was carrying groceries in
plastic bags approximately 10 - 15 pounds in each hand and felt sudden pain in the
dorsum of his left hand. He put down the bag and noticed there was some swelling
along his left fourth MCP on the dorsal side. Patient notes that last week he was
brought to the ER after being in an MVA with question of a hand injury from holding onto
the steering wheel. He was discharged from the ER being told he had a strain. There
were no fractures or ligament damage, this is per patient and no old records are
available. Patient is not having any numbness, tingling, or feeling of weakness right
now.
PAST MEDICAL HISTORY: Unremarkable except for the MVA.
CURRENT MEDICATIONS:Amoxicillin for an earinfection. He occasionally takes
ibuprofen as well.
ALLERGIES: NONE KNOWN.
PHYSICAL EXAM: Patient is a WN, WD - Correct Answers -S63.657A; S63.655A
99282
ICD-9-CM diagnosis code(s): 842.12, E819.0
QUESTIONS AND ANSWERS
Which of the following are permissible to code for SDS diagnoses? - Correct Answers -
past conditions that relate to the current visit
What report is the definitive authority on specimens taken out during surgery? - Correct
Answers -pathology report
When is it appropriate to use non physician notes as a source document for coding? -
Correct Answers -to code BMI for a patient with documented obesity
Which of the following is NOT a characteristic of a critical access hospital? - Correct
Answers -it provides at least 50% critical care services
Which setting uses APCs for Medicare reimbursement? - Correct Answers -same-day
surgery
Outpatient coding conventions state that _________________ diagnoses may NOT be
coded. - Correct Answers -possible
Which condition should be documented as to whether or not the condition is 'reducible'?
- Correct Answers -umbilical hernia
Coagulation and serology tests help determine: - Correct Answers -the amount of time it
takes for bleeding to stop
EGD is a: - Correct Answers -procedure
When does an ER coder report E/M codes? - Correct Answers -when the physician is
employed by the hospital
What report is the official summary of the procedure performed, preoperative and post
operative diagnosis, and step by step details for the actual procedure and or surgery
performed. - Correct Answers -operative report
Where would you expect to find the following statement? "A C-shaped flap was made in
a small fashion below the transverse sinus with the base on the transverse sinus
overlying the cerebellum." - Correct Answers -operative report
, Documentation of EBL 20cc refers to: - Correct Answers -blood loss during a procedure
___________ is a common abbreviation for the oral route of medication administration.
- Correct Answers -PO
_____________ is common abbreviation for no known allergies. - Correct Answers -
NKA
Hospital outpatient coders are typically responsible for coding all outpatient accounts,
which can include _______ services. - Correct Answers -ancillary
A patient who is not formally admitted to the hospital for treatment is known as an
____________. - Correct Answers -outpatient
___________ patients are those who are having surgery as an outpatient. - Correct
Answers -SDS
One step in coding ER visits is to check to see if a __________________ is needed on
the procedure code. - Correct Answers -modifier
NOt every hospital is paid on the _____ system - Correct Answers -APC
The Caldwell-Luc procedure is an eponym for a specific type of: - Correct Answers -
sinusotomy
EMERGENCY ROOM REPORT
CHIEF COMPLAINT: Left hand injury.
HISTORY OF PRESENT ILLNESS: This 25-year-old male was carrying groceries in
plastic bags approximately 10 - 15 pounds in each hand and felt sudden pain in the
dorsum of his left hand. He put down the bag and noticed there was some swelling
along his left fourth MCP on the dorsal side. Patient notes that last week he was
brought to the ER after being in an MVA with question of a hand injury from holding onto
the steering wheel. He was discharged from the ER being told he had a strain. There
were no fractures or ligament damage, this is per patient and no old records are
available. Patient is not having any numbness, tingling, or feeling of weakness right
now.
PAST MEDICAL HISTORY: Unremarkable except for the MVA.
CURRENT MEDICATIONS:Amoxicillin for an earinfection. He occasionally takes
ibuprofen as well.
ALLERGIES: NONE KNOWN.
PHYSICAL EXAM: Patient is a WN, WD - Correct Answers -S63.657A; S63.655A
99282
ICD-9-CM diagnosis code(s): 842.12, E819.0
