CCA Mock Exam

A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. - correct answer 45385, 99156, 99157 A code of 45385 should be used for the colonoscopy procedure with the removal of polpys. No additional codes needed for the colonscopy since it included the colonoscopy and removal of polyps. The moderate sedation also needs to be coded. A code of 99156 should be used to code the moderate sedation services provided by a physician for the intial 15 minutes of intraservice time. An additional code of 99157 should be coded for the additional 15 minutes of intraservice time for the moderate sedation since the patient was sedated for a total of 30 minutes. No additional codes needed. The diagnosis is as follows: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast." Given this which are the primary cancer site(s)? - correct answer breast Patient has a year history of mitral valve regurgitation and now presents for a mitral valve replacement with bypass. (Code for physician using CPT procedure codes only.) 33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass 33430 Replacement, mitral valve, with cardiopulmonary bypass 33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass 35231 Repair blood vessel with vein graft; neck - correct answer 33430 You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to - correct answer improve your department's processes Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with - correct answer feedback on specific instances when improved documentation would improve coding Which of the following procedures can be identified as "destruction" of lesions? - correct answer laser removal of condylomata The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as - correct answer upcoding A ________ is a collection of information or data that is organized in such a way that its contents can be queried and relationships created. - correct answer database The use of radioactive sources placed into a tumor-bearing area to generate high-intensity radiation is termed - correct answer brachytherapy Which of the following procedures would NOT be coded to "resection" when using ICD-10-PCS? - correct answer partial resection of upper left lobe During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the code for sterilization, Z30.2, is - correct answer used and sequenced as a secondary diagnosis Some ICD-10-CM codes are exempt from POA reporting because they - correct answer are always present on admission and represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury CMS delegates its daily operations of the Medicare and Medicaid programs to - correct answer Medicare administrative contractor (MAC) Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? - correct answer principal diagnosis As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the - correct answer doctor's admitting progress note The _______________ are the organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claims to detect and correct improper payments. - correct answer recovery audit contractors (RACs) Which of the following could influence a facility's case mix? - correct answer all answers apply (accuracy of coding, changes in DRG weights, changes in the services offered by a facility) The Joint Commission requires that all medical records be completed within ___________ following patient discharge. - correct answer 30 days If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level - correct answer they should both be coded, acute sequenced first What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? - correct answer quid pro quo Staging - correct answer is a system for documenting the extent or spread of cancer Which of these conditions are always considered "present on admission" (POA)? - correct answer congenital conditions Robert Thompson was seen in the outpatient department with a chronic cough and the record states "rule out lung cancer." What should be coded as the patient's diagnosis? - correct answer chronic cough Case-mix index - correct answer relative weight x number of patients for each row sum of all rows total relative weight sums / total number of patients When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only - correct answer the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) - correct answer advance beneficiary notice