Which procedure code describes this bedside procedure?
Diagnosis: Hypotension with sepsis
Consent: Emergent
Procedure: Left femoral arterial line placement for infusion treatment with antibiotics and
vasopressors.
Description: The left groin was cleansed and draped in a sterile fashion. An 18 gauge needle
was then advanced into the left femoral artery. Good blood flow was obtained. Using a
Seldinger technique, a catheter was advanced over the wire into the left femoral artery. It
was sewn in place with 2-0 silk. Good waveform was seen on the monitor. No immediate
complications were noted with this procedure - ANSWER 04HL33Z
Your hospital uses an EHR for all documentation of all services, including coding and billing.
Your town is hit with a tornado and your hospital is badly damaged including the servers,
network connections and computers. How do you provide medical records for patients
transferred to other facilities for their care? - ANSWER You obtain copies from your disas-
ter recovery server
Which of the following describes a violation of HIPAA's privacy rule? - ANSWER A nurse
and an orderly at a state hospital discussed the HIV/AIDS status of a patient in earshot of
other patients
Which of the following diseases is a malignancy of the lymphatic system? - ANSWER
Hodgkin's disease
A drug which ends in the suffix, -pril , is considered a(n): - ANSWER ACE inhibitor
1
, A patient is admitted with neck pain following a collision with another softball player at a
community baseball field. The diagnosis at the time of discharge is right internal carotid ar-
tery dissection likely secondary to trauma. The diagnoses coded for this injury are: - AN-
SWER I77.71, W51.XXXA, Y93.64, Y92.320
How many Major Diagnostic Categories (MDCs) are in the MS-DRG system? - ANSWER 25
What POA indicator would you use for the following scenario?
A 45 year old female presents to the ER with shortness of breath, cough and a high fever.
The ER doctor gets a chest x-ray which indicates pneumonia so he admits the patient.
Shortly after admission the patient deteriorates and develops sepsis. In his discharge sum-
mary the doctor indicates the patient's diagnoses as sepsis secondary to pneumonia, organ-
ism unknown. A query of the physician indicates it is unknown if the patient was septic prior
to admission. What POA indicator would you assign for sepsis? - ANSWER W
What is the correct CMS definition for POA indicator W? - ANSWER Clinically undeter-
mined. Provider unable to clinically determine whether the condition was present at the
time of inpatient admission
The inpatient admission certification form must be signed by whom? - ANSWER The ad-
mitting or attending physician
A 74 year-old Medicare patient is seen in the outpatient cardiac catheterization department
of the hospital for atypical chest pain. The left heart catheterization reveals that the patient
has 3-vessel coronary artery disease. The patient returns to the hospital two days later with
a Non-STEMI and is taken to the operating room for a 3-vessel CABG. Under what Medicare
rule will the left heart catheterization technical component be bundled into the inpatient
stay? - ANSWER Three day payment window
Which type of DRG system uses degrees of Severity of Illness and Risk of Mortality to deter-
mine the DRG? - ANSWER APR-DRG
2
Diagnosis: Hypotension with sepsis
Consent: Emergent
Procedure: Left femoral arterial line placement for infusion treatment with antibiotics and
vasopressors.
Description: The left groin was cleansed and draped in a sterile fashion. An 18 gauge needle
was then advanced into the left femoral artery. Good blood flow was obtained. Using a
Seldinger technique, a catheter was advanced over the wire into the left femoral artery. It
was sewn in place with 2-0 silk. Good waveform was seen on the monitor. No immediate
complications were noted with this procedure - ANSWER 04HL33Z
Your hospital uses an EHR for all documentation of all services, including coding and billing.
Your town is hit with a tornado and your hospital is badly damaged including the servers,
network connections and computers. How do you provide medical records for patients
transferred to other facilities for their care? - ANSWER You obtain copies from your disas-
ter recovery server
Which of the following describes a violation of HIPAA's privacy rule? - ANSWER A nurse
and an orderly at a state hospital discussed the HIV/AIDS status of a patient in earshot of
other patients
Which of the following diseases is a malignancy of the lymphatic system? - ANSWER
Hodgkin's disease
A drug which ends in the suffix, -pril , is considered a(n): - ANSWER ACE inhibitor
1
, A patient is admitted with neck pain following a collision with another softball player at a
community baseball field. The diagnosis at the time of discharge is right internal carotid ar-
tery dissection likely secondary to trauma. The diagnoses coded for this injury are: - AN-
SWER I77.71, W51.XXXA, Y93.64, Y92.320
How many Major Diagnostic Categories (MDCs) are in the MS-DRG system? - ANSWER 25
What POA indicator would you use for the following scenario?
A 45 year old female presents to the ER with shortness of breath, cough and a high fever.
The ER doctor gets a chest x-ray which indicates pneumonia so he admits the patient.
Shortly after admission the patient deteriorates and develops sepsis. In his discharge sum-
mary the doctor indicates the patient's diagnoses as sepsis secondary to pneumonia, organ-
ism unknown. A query of the physician indicates it is unknown if the patient was septic prior
to admission. What POA indicator would you assign for sepsis? - ANSWER W
What is the correct CMS definition for POA indicator W? - ANSWER Clinically undeter-
mined. Provider unable to clinically determine whether the condition was present at the
time of inpatient admission
The inpatient admission certification form must be signed by whom? - ANSWER The ad-
mitting or attending physician
A 74 year-old Medicare patient is seen in the outpatient cardiac catheterization department
of the hospital for atypical chest pain. The left heart catheterization reveals that the patient
has 3-vessel coronary artery disease. The patient returns to the hospital two days later with
a Non-STEMI and is taken to the operating room for a 3-vessel CABG. Under what Medicare
rule will the left heart catheterization technical component be bundled into the inpatient
stay? - ANSWER Three day payment window
Which type of DRG system uses degrees of Severity of Illness and Risk of Mortality to deter-
mine the DRG? - ANSWER APR-DRG
2
