CPC Exam 2
A 72-year-old patient presents to the emergency department (ED) with a fever of 100.9, a red swollen
leg, and nausea. The emergency room (ER) doctor documents final diagnoses of cellulitis, sepsis, and
leukocytosis (WBC 15.3). The patient is admitted for treatment of the left calf cellulitis and stays for five
days. The progress note on day two states "possible sepsis." The attending physician's final diagnoses
are left calf cellulitis, hypokalemia, hypertension, and diabetes. Which ICD-10-CM codes should be
reported? - Answer-Query the physician for clarification of sepsis.
A 59-year-old male presents to the emergency room (ER) with coughing, loss of taste and smell, and
generalized weakness. The COVID-19 test is positive. The patient's vital signs in the ER are: Blood
pressure 88/62, heart rate 102, respiratory rate 23, temperature 99.8 F, and SpO2 88 percent on room
air. Haziness and ground-glass opacities are seen on the chest X-ray. After two liters of intravenous
fluids, the patient's blood pressure is 91/65. The patient is started on IV Levophed and antibiotics and
then admitted to the hospital for treatment of septic shock due to COVID-19 pneumonia and acute
respiratory failure. Which ICD-10-CM codes should be reported? - Answer-A41.89, U07.1, J12.82,
R65.21, J96.00
A 78-year-old patient presents to the ED after being called back for two sets of abnormal blood cultures.
The patient was in the ED three days prior for symptoms of vertigo and nausea when cultures were
obtained. The blood culture was positive for Enterococcus faecalis. Antibiotics were given in the ED. The
patient was admitted to determine the infectious source and to administer IV vancomycin. The history
and physical exam stated that the patient was asymptomatic from the Enterococcus faecalis bacteremia.
The CY scan of the abdomen and the transthoracic echocardiogram didn't show a source of infection.
The urine culture was negative. After six days a second set of blood cultures was negative. The patient
was discharged with home antibiotics for eight more days to complete 14 days of treatment. Which ICD-
10-Cm codes should be reported? - Answer-R78.81, 895.2
, A 48-year-old male with a history of alcoholism presents to the emergency department (ED) with severe
stomach cramps and fever after a weekend binge. In the ED, the patient had tachycardia, a temperature
of 101.1 F, a white blood cell count of 15.1, and a lipase level of 485. Abdominal CT showed pancreatic
inflammation and no gallstones or cholecystitis. The patient was admitted for treatment of acute
alcoholic pancreatitis, systemic inflammatory response syndrome (SIRS) versus sepsis, and alcohol
dependence. He was treated with intravenous fluids and pain medication and was kept nothing by
mouth (NPO). He received counseling for his alcohol habit while in the hospital. The final diagnoses on
the discharge summary were SIRS, acute alcoholic pancreatitis, and alcohol abuse. Which codes should
be reported? - Answer-K85.20, F10.20, R65.10
Based on the new evaluation and management E/M changes to determine the level of service, best
practice is for providers to include which of the following in their documentation for every encounter? -
Answer-Time and MDM
With streamlined levels of service viewed by multiple entities, organizations should provide which of the
following? - Answer-Tip sheets, Crosswalks, Provider training resources
What are the three common payment types for drugs? - Answer-ASP(application service provider)
AWP (average wholesale price)
WAC (Wholesale Acquisition Cost)
In the below examples, which is an NDC format that CMS allows? - Answer-50242-0053-06
A physician query should have which one of the following qualities? - Answer-It must be open ended.
The coder's job is to query the physician when which of the following is true? - Answer-Diagnostic data
do not support a documented diagnosis.
There are conflicting opinions between providers for a specific diagnosis.
There is diagnostic data not captured by the provider.
A 72-year-old patient presents to the emergency department (ED) with a fever of 100.9, a red swollen
leg, and nausea. The emergency room (ER) doctor documents final diagnoses of cellulitis, sepsis, and
leukocytosis (WBC 15.3). The patient is admitted for treatment of the left calf cellulitis and stays for five
days. The progress note on day two states "possible sepsis." The attending physician's final diagnoses
are left calf cellulitis, hypokalemia, hypertension, and diabetes. Which ICD-10-CM codes should be
reported? - Answer-Query the physician for clarification of sepsis.
A 59-year-old male presents to the emergency room (ER) with coughing, loss of taste and smell, and
generalized weakness. The COVID-19 test is positive. The patient's vital signs in the ER are: Blood
pressure 88/62, heart rate 102, respiratory rate 23, temperature 99.8 F, and SpO2 88 percent on room
air. Haziness and ground-glass opacities are seen on the chest X-ray. After two liters of intravenous
fluids, the patient's blood pressure is 91/65. The patient is started on IV Levophed and antibiotics and
then admitted to the hospital for treatment of septic shock due to COVID-19 pneumonia and acute
respiratory failure. Which ICD-10-CM codes should be reported? - Answer-A41.89, U07.1, J12.82,
R65.21, J96.00
A 78-year-old patient presents to the ED after being called back for two sets of abnormal blood cultures.
The patient was in the ED three days prior for symptoms of vertigo and nausea when cultures were
obtained. The blood culture was positive for Enterococcus faecalis. Antibiotics were given in the ED. The
patient was admitted to determine the infectious source and to administer IV vancomycin. The history
and physical exam stated that the patient was asymptomatic from the Enterococcus faecalis bacteremia.
The CY scan of the abdomen and the transthoracic echocardiogram didn't show a source of infection.
The urine culture was negative. After six days a second set of blood cultures was negative. The patient
was discharged with home antibiotics for eight more days to complete 14 days of treatment. Which ICD-
10-Cm codes should be reported? - Answer-R78.81, 895.2
, A 48-year-old male with a history of alcoholism presents to the emergency department (ED) with severe
stomach cramps and fever after a weekend binge. In the ED, the patient had tachycardia, a temperature
of 101.1 F, a white blood cell count of 15.1, and a lipase level of 485. Abdominal CT showed pancreatic
inflammation and no gallstones or cholecystitis. The patient was admitted for treatment of acute
alcoholic pancreatitis, systemic inflammatory response syndrome (SIRS) versus sepsis, and alcohol
dependence. He was treated with intravenous fluids and pain medication and was kept nothing by
mouth (NPO). He received counseling for his alcohol habit while in the hospital. The final diagnoses on
the discharge summary were SIRS, acute alcoholic pancreatitis, and alcohol abuse. Which codes should
be reported? - Answer-K85.20, F10.20, R65.10
Based on the new evaluation and management E/M changes to determine the level of service, best
practice is for providers to include which of the following in their documentation for every encounter? -
Answer-Time and MDM
With streamlined levels of service viewed by multiple entities, organizations should provide which of the
following? - Answer-Tip sheets, Crosswalks, Provider training resources
What are the three common payment types for drugs? - Answer-ASP(application service provider)
AWP (average wholesale price)
WAC (Wholesale Acquisition Cost)
In the below examples, which is an NDC format that CMS allows? - Answer-50242-0053-06
A physician query should have which one of the following qualities? - Answer-It must be open ended.
The coder's job is to query the physician when which of the following is true? - Answer-Diagnostic data
do not support a documented diagnosis.
There are conflicting opinions between providers for a specific diagnosis.
There is diagnostic data not captured by the provider.
