CCA EXAMS COMPLETE COURSE REVIEW
GUIDE
◉ Identify the appropriate ICD-10-CM diagnosis code for right
cerebral contusion with 15 minute loss of consciousness, initial
encounter for care:
Answer: Contusion, cerebral - see Contusion, brain. Add 6th
character "1" for loss of consciousness of 30 minutes for less, 7th
character for initial encounter = S06.311A
◉ If a patient has en excision of a malignant lesion of the skin, the
CPT code is determined by the body area from which the excision
occurs and which of the following?
Answer: Diameter of the lesion as well as the most narrow margins
required to adequately excise the lesion described in the operative
report
◉ According to CPT, a repair of a laceration that includes retention
sutures would be considered what type of closure?
Answer: Complex closures include the repair of wounds requiring
more that layered closure, namely, scar revision, debridement,
extensive undermining, stents, or retention sutures.
,◉ Patient is admitted with spotting, had been treated two weeks
previously for miscarriage with sepsis. Sepsis resolved, she is
afebrile at this time, treated with an aspiration D&C, and POC are
found. Which of the following should be the PD?
Answer: Miscarriage: Retained POC following an abortion
(Subsequent admissions for retained POC following any type of
abortion are assigned the appropriate code from category O03
[spont. abn.] or O07.4 [failed attempted term. of pg. w/o comp.] and
Z33.2 [encounter for elect. term of pg]. This advice is appropriate
even when the patient was discharged prev. with discharge
diagnosis of complete ab.
◉ An 80-year-old female is admitted with fever, lethargy,
hypotension, tachycardia, oliguria, elevated WBC, and more than
100K organisms of E. coli per cc of urine. Attending physician
documents "urosepsis". How should coder proceed to code?
Answer: Since urosepsis is nonspecific and not codable in ICD-10-
CM, it cannot be considered synonymous with sepsis, and therefore
the physician should be queried.
◉ 65yo patient with history of lung cancer is admitted to healthcare
facility with ataxia, syncope, and a fractured arm as a result from
falling. Pt undergoes closed reduction of fracture in the ED and
undergoes complete workup for metastatic carcinoma of the brain.
Pt is found to have metastatic carcinoma of the lung to brain and
undergoes radiation therapy to brain. Which of the following would
be the PD in this case?
, Answer: If a tx is directed at the malignancy, designate the
malignancy as the PD with the only exception to this guideline being
if the pt admission or encounter is solely for the administration of
chemo, immunotherapy, or radiation, then assign the appropriate
Z51.- code as the first-listed or PD an the diagnosis or problem for
which the service is being performed as a secondary diagnosis.
◉ Pt was admitted for abdominal pain with diarrhea and was
diagnosed with infectious gastroenteritis. Pt also has angina and
COPD. Which of the following would be the correct coding and
sequencing for this case?
Answer: Infectious gastroenteritis; COPD; angina
◉ Pt admitted with hx of prostate cancer and with mental confusion.
Pt completed radiation therapy for prostatic carcinoma 3 years ago
and is status post a radical resection of the prostate. CT scan of brain
during current admission reveals metastasis. Which of the following
is the correct coding and sequencing for the current hospital stay?
Answer: Metastatic carcinoma of the brain; history of carcinoma of
the prostate
◉ According to UHDDS, which of the following is the definition of
"other diagnoses"?
Answer: Receives clinical eval or therapeutic tx or diagnostic
procedures to extends the LOS or increases nursing care and
monitoring
GUIDE
◉ Identify the appropriate ICD-10-CM diagnosis code for right
cerebral contusion with 15 minute loss of consciousness, initial
encounter for care:
Answer: Contusion, cerebral - see Contusion, brain. Add 6th
character "1" for loss of consciousness of 30 minutes for less, 7th
character for initial encounter = S06.311A
◉ If a patient has en excision of a malignant lesion of the skin, the
CPT code is determined by the body area from which the excision
occurs and which of the following?
Answer: Diameter of the lesion as well as the most narrow margins
required to adequately excise the lesion described in the operative
report
◉ According to CPT, a repair of a laceration that includes retention
sutures would be considered what type of closure?
Answer: Complex closures include the repair of wounds requiring
more that layered closure, namely, scar revision, debridement,
extensive undermining, stents, or retention sutures.
,◉ Patient is admitted with spotting, had been treated two weeks
previously for miscarriage with sepsis. Sepsis resolved, she is
afebrile at this time, treated with an aspiration D&C, and POC are
found. Which of the following should be the PD?
Answer: Miscarriage: Retained POC following an abortion
(Subsequent admissions for retained POC following any type of
abortion are assigned the appropriate code from category O03
[spont. abn.] or O07.4 [failed attempted term. of pg. w/o comp.] and
Z33.2 [encounter for elect. term of pg]. This advice is appropriate
even when the patient was discharged prev. with discharge
diagnosis of complete ab.
◉ An 80-year-old female is admitted with fever, lethargy,
hypotension, tachycardia, oliguria, elevated WBC, and more than
100K organisms of E. coli per cc of urine. Attending physician
documents "urosepsis". How should coder proceed to code?
Answer: Since urosepsis is nonspecific and not codable in ICD-10-
CM, it cannot be considered synonymous with sepsis, and therefore
the physician should be queried.
◉ 65yo patient with history of lung cancer is admitted to healthcare
facility with ataxia, syncope, and a fractured arm as a result from
falling. Pt undergoes closed reduction of fracture in the ED and
undergoes complete workup for metastatic carcinoma of the brain.
Pt is found to have metastatic carcinoma of the lung to brain and
undergoes radiation therapy to brain. Which of the following would
be the PD in this case?
, Answer: If a tx is directed at the malignancy, designate the
malignancy as the PD with the only exception to this guideline being
if the pt admission or encounter is solely for the administration of
chemo, immunotherapy, or radiation, then assign the appropriate
Z51.- code as the first-listed or PD an the diagnosis or problem for
which the service is being performed as a secondary diagnosis.
◉ Pt was admitted for abdominal pain with diarrhea and was
diagnosed with infectious gastroenteritis. Pt also has angina and
COPD. Which of the following would be the correct coding and
sequencing for this case?
Answer: Infectious gastroenteritis; COPD; angina
◉ Pt admitted with hx of prostate cancer and with mental confusion.
Pt completed radiation therapy for prostatic carcinoma 3 years ago
and is status post a radical resection of the prostate. CT scan of brain
during current admission reveals metastasis. Which of the following
is the correct coding and sequencing for the current hospital stay?
Answer: Metastatic carcinoma of the brain; history of carcinoma of
the prostate
◉ According to UHDDS, which of the following is the definition of
"other diagnoses"?
Answer: Receives clinical eval or therapeutic tx or diagnostic
procedures to extends the LOS or increases nursing care and
monitoring
