CERTIFIED CODING SPECIALIST CCS AHIMA
COMPREHENSIVE QUESTIONS AND ANSWERS SURE
A+
✔✔A patient is admitted to the hospital complaining of abdominal pain. Following
evaluation, it was determined that the patient had an intestinal obstruction of the left
colon due to adhesions from a prior abdominal surgery. The patient underwent an
exploratory laparotomy with lysis of adhesions.
What conditions should be coded?
a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of
adhesions
b. Abdominal adhesions, abdominal obstruction, postoperative complications of the
digestive system, laparotomy, lysis of adhesions
c. Abdominal adhesions with obstruction, lysis of adhesions
d. Abdominal adhesions and abdominal obstruction, postoperative complications of the
digestive system, lysis of adhesions - ✔✔c
The patient has abdominal adhesions with obstruction, and lysis of adhesions was
performed. The abdominal pain is not coded as it is a symptom (HHS 2014, Section
I.B.4, 13; Leon-Chisen 2013,140)
✔✔A patient has a principal diagnosis of pneumonia (118.9) (MS-DRG 195).
Which of the following may legitimately change the coding of the pneumonia in
accordance with the UHDDS and relevant clinical documentation?
a. Sputum culture reflects growth of normal flora.
, b. Patient has a positive gram stain.
c. Patient is found to have dysphagia with aspiration.
d. Patient has nonproductive sputum. - ✔✔c
Patient is found to have dysphagia with aspiration is the correct answer because it
changes the coding to aspiration pneumonia and would result in MS-DRG 179
RESPIRATORY INFECTIONS & INFLAMMATIONS W/0 CC/MCC, which has a weight
of 0.9718 (Medicare Grouper Version Used: 31). This is in comparison to MS-DRG
0195, SIMPLE PNEUMONIA & PLEURISY W/0 CC/MCC MDC: 04 which has a DRG
weight of 0.6978 (Medicare Grouper Version Used: 31).
✔✔A 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 coder take?
a. Review the operative report to determine what procedure codes to use and also to
determine the site or sites of endometriosis so codes with the highest specificity may be
assigned, and 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, and assign a principal diagnosis of
infertility.
c. Review 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, and assign a secondary
diagnosis of infertility.
d. Review the operative report to determine what procedure codes to use and also -
✔✔d
There may be endometrial implants throughout the pelvic cavity which may attach to
various anatomic structures such as the fallopian tube, ovary, and omentum. These
locations should be identified so that the appropriate diagnostic codes can be assigned
and the appropriate procedure codes can be assigned based on the destruction of the
endometrial implants. Therefore, the correct answer is to review the operative report to
determine what procedure codes to use and determine the site or sites of endometriosis
so that codes with the highest specificity may be assigned. Also, use the diagnosis of
infertility as a secondary condition (Schraffenberger 2013, 296; Leon-Chisen 2013, 33,
271).
✔✔In order to establish the adequacy of documentation in the medical record the
following must be reflected:
a. Decisions of patient's caregivers
COMPREHENSIVE QUESTIONS AND ANSWERS SURE
A+
✔✔A patient is admitted to the hospital complaining of abdominal pain. Following
evaluation, it was determined that the patient had an intestinal obstruction of the left
colon due to adhesions from a prior abdominal surgery. The patient underwent an
exploratory laparotomy with lysis of adhesions.
What conditions should be coded?
a. Abdominal pain, abdominal adhesions, abdominal obstruction, laparotomy, lysis of
adhesions
b. Abdominal adhesions, abdominal obstruction, postoperative complications of the
digestive system, laparotomy, lysis of adhesions
c. Abdominal adhesions with obstruction, lysis of adhesions
d. Abdominal adhesions and abdominal obstruction, postoperative complications of the
digestive system, lysis of adhesions - ✔✔c
The patient has abdominal adhesions with obstruction, and lysis of adhesions was
performed. The abdominal pain is not coded as it is a symptom (HHS 2014, Section
I.B.4, 13; Leon-Chisen 2013,140)
✔✔A patient has a principal diagnosis of pneumonia (118.9) (MS-DRG 195).
Which of the following may legitimately change the coding of the pneumonia in
accordance with the UHDDS and relevant clinical documentation?
a. Sputum culture reflects growth of normal flora.
, b. Patient has a positive gram stain.
c. Patient is found to have dysphagia with aspiration.
d. Patient has nonproductive sputum. - ✔✔c
Patient is found to have dysphagia with aspiration is the correct answer because it
changes the coding to aspiration pneumonia and would result in MS-DRG 179
RESPIRATORY INFECTIONS & INFLAMMATIONS W/0 CC/MCC, which has a weight
of 0.9718 (Medicare Grouper Version Used: 31). This is in comparison to MS-DRG
0195, SIMPLE PNEUMONIA & PLEURISY W/0 CC/MCC MDC: 04 which has a DRG
weight of 0.6978 (Medicare Grouper Version Used: 31).
✔✔A 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 coder take?
a. Review the operative report to determine what procedure codes to use and also to
determine the site or sites of endometriosis so codes with the highest specificity may be
assigned, and 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, and assign a principal diagnosis of
infertility.
c. Review 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, and assign a secondary
diagnosis of infertility.
d. Review the operative report to determine what procedure codes to use and also -
✔✔d
There may be endometrial implants throughout the pelvic cavity which may attach to
various anatomic structures such as the fallopian tube, ovary, and omentum. These
locations should be identified so that the appropriate diagnostic codes can be assigned
and the appropriate procedure codes can be assigned based on the destruction of the
endometrial implants. Therefore, the correct answer is to review the operative report to
determine what procedure codes to use and determine the site or sites of endometriosis
so that codes with the highest specificity may be assigned. Also, use the diagnosis of
infertility as a secondary condition (Schraffenberger 2013, 296; Leon-Chisen 2013, 33,
271).
✔✔In order to establish the adequacy of documentation in the medical record the
following must be reflected:
a. Decisions of patient's caregivers
