CCS EXAM 2 QUESTIONS WITH COMPLETE SOLUTIONS RATED A+

A 23-year-old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She is afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy c. O03.6, Delayed or excessive hemorrhage following complete or unspecified spontaneous abortion d. O07.1, Delayed or excessive hemorrhage following failed attempted termination of pregnancy - Correct Answer Correct Answer: A A miscarriage is a spontaneous abortion. If the readmission is for the purpose of dealing with retained products of conception, the spontaneous abortion is incomplete; use a code from the O03 category (CMS 2020a, Section I.C.15.q., 68). A 45-year-old woman underwent a carotid bypass and experienced a significant drop in blood pressure during the surgery. The documentation suggested the patient may have had a myocardial infarction. In accordance with coding guidelines, what should the coding professional do? a. Code complication of surgery NOS. b. Query the physician to determine if the patient had hypotension. c. Query the physician to determine if there was a complication of surgery. d. Code preoperative shock. - Correct Answer Correct Answer: C With the documented clinical indicators, it would be appropriate to query the physician regarding the possibility of a complication resulting from surgery. When formulating a query, it is unacceptable to lead a provider to document a particular response. The query should not be directing or probing, and the provider should not be led to make an assumption (AHIMA 2019c; CMS 2020a, Section I.B.16, 18). A 55-year-old patient with AIDS admitted after being struck by car while walking in a parking lot. She has a comminuted, right femoral shaft fracture and a contusion of both hands and right elbow abrasion. The principal diagnosis should be the: a. AIDS b. Fractured femur c. Abrasion elbow d. Contusion hand - Correct Answer Correct Answer: B If a patient with HIV disease is admitted for an unrelated condition (such as a traumatic injury), the code for the unrelated condition (for example, the nature of injury code) should be the principal diagnosis. The most severe injury should be sequenced first. Other diagnoses would be B20 followed by additional diagnosis codes for all reported HIV-related conditions (CMS 2020a, Section I.C.1.a.2.b., 21). A 70-year-old patient was admitted with pneumonia. The history and physical documented that the patient has a history of diabetes, hypertension, and migraine