CERTIFIED CODING SPECIALIST COMPREHENSIVE
ANSWERS AND QUESTIONS SET A+
✔✔A patient is admitted with an acute exacerbation of COPD with stage 5 hypertensive
kidney disease. What is the correct diagnostic code assignment?
I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease
I12.9 Hypertensive chronic kidney disease, stage 1 through stage 4, or unspecified with
chronic kidney disease
J44.1 Chronic obstructive pulmonary disease with exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
N18.5 Chronic kidney disease, stage 5
a. J44.9, I12.0
b. J44.1, I12.9
c. J44.9, I12.0
d. J44.1, I12.0, N18.5 - ✔✔d. J44.1, I12.0, N18.5
J44.1 Chronic obstructive pulmonary disease with exacerbation.
I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease.
N18.5 Chronic kidney disease, stage 5
**Acute exacerbation of COPD is coded as J44.1. The hypertension is present with the
chronic renal disease. Because of this, a combination code for hypertension and chronic
renal disease is coded. In addition, the stage of the kidney disease is also coded (HHS
2017, Section I.C.14.a, 53).
✔✔A data map or crosswalk consists of:
a. Terms used to describe paths between classifications and vocabularies
b. A map of time frames for multiple project completion
c. A descriptive list of data names
,d. Normalized data attributes - ✔✔a. Terms used to describe paths between
classifications and vocabularies
**There are several definitions of mapping and crosswalks but an important one in
healthcare is that they are used to describe paths between classifications and
terminologies (Palkie 2016, 164-165).
✔✔The patient was admitted for breast carcinoma in the right breast at two o'clock. This
was removed via lumpectomy. The patient was found to have 1 of 7 lymph nodes
positive for carcinoma during axillary lymph node dissection. One of the patient's
neighbors who is also a coworker at the hospital called the coding department to get the
patient's diagnosis because she is a cancer survivor herself. The coder should:
a. Discuss the case with the coworker
b. Report the incident to hospital security
c. Give the caller false information
d. Explain that discussing the case would violate the patient's right to privacy - ✔✔d.
Explain that discussing the case would violate the patient's right to privacy
** Disclosing information without the patient's written consent violates the patient's right
to privacy (Brodnik 2012, 231, 414; Gordon and Gordon 2016a, 615-616).
✔✔The requirements for documentation and record completion (documents such as
history and physicals, discharge summaries, and consultations) as well as penalties for
non-adherence must be specified in:
a. Hospital rules and regulations
b. Conditions of nonparticipation
c. Medical staff bylaws
d. Nursing staff policies - ✔✔c. Medical staff bylaws
**The medical staff bylaws are required by accreditation and regulatory organizations to
refer to the timeline required for completion (Malmgren and Solberg 2016, 240; Brinda
2016, 166).
✔✔A bronchoscopy with biopsy of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure codes?
a. -50, Bilateral procedure
b. -51, Multiple procedures
c. -LT, Left side
d. No modifiers should be reported. - ✔✔d. No modifiers should be reported.
Because the lungs are paired organs, it may seem as though modifier -50 would be
appropriate. However, a modifier would not be assigned because the bronchus is not a
, paired organ, and the bronchus is the location of the procedure, not the lungs. Similarly,
it might seem as though modifier -LT would be assigned, but again, this would not be
assigned as the bronchus is not a paired organ. In order to assign the correct modifier, it
is important to note that paired organs include ears, eyes, nostrils, kidneys, lungs,
ovaries, and such (CPT Assistant May 2003).
✔✔Using the following evaluation and management map, which answers represent
documentation that should be considered, when assigning an E/M example for hospital
acuity points assignment?
Evaluation and Management Mapping
The following are the points needed to determine the level of CPT code:
Level 1 = 1-20
Level 2 = 21-35
Level 3 = 36-47
Level 4 = 48-60
Level 5 = > 61
Critical Care > 61 with constant physician attendance
CPT Codes
Level 1 = 99281 99281-25 with procedure/laboratory/radiology
Level 2 = 99282 99282-25 with procedure/laboratory/radiology
Level 3 = 99283 99283-25 with procedure/laboratory/radiology
Level 4 = 99284 99284-25 with procedure/laboratory/radiology
Level 5 = 99285 99285-25 with procedure/laboratory/radiology
Emergency Department Acuity Points
5 10 15 20 25
Meds Given 0-2 3-5 6-7 8-9 > 10
Extent of Hx Brief PF EPF Detail Comprehensive
Extent of Exam Brief PF EPF Detail Comprehensive
Number of - ✔✔c. Number of tests ordered
**When an question is asked about an outpatient acuity map, the coder must review the
map and determine the relevant elements that make up the means by which a CPT
code and level is assigned. In the case of this map, and in this question, the number of
tests ordered is the answer.
✔✔Assign the code(s) for chemotherapy for 3 hours' infusion.
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal
anti-neoplastic
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour,
single or initial substance/drug
ANSWERS AND QUESTIONS SET A+
✔✔A patient is admitted with an acute exacerbation of COPD with stage 5 hypertensive
kidney disease. What is the correct diagnostic code assignment?
I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease
I12.9 Hypertensive chronic kidney disease, stage 1 through stage 4, or unspecified with
chronic kidney disease
J44.1 Chronic obstructive pulmonary disease with exacerbation
J44.9 Chronic obstructive pulmonary disease, unspecified
N18.5 Chronic kidney disease, stage 5
a. J44.9, I12.0
b. J44.1, I12.9
c. J44.9, I12.0
d. J44.1, I12.0, N18.5 - ✔✔d. J44.1, I12.0, N18.5
J44.1 Chronic obstructive pulmonary disease with exacerbation.
I12.0 Hypertensive chronic kidney disease with stage 5 or end-stage renal disease.
N18.5 Chronic kidney disease, stage 5
**Acute exacerbation of COPD is coded as J44.1. The hypertension is present with the
chronic renal disease. Because of this, a combination code for hypertension and chronic
renal disease is coded. In addition, the stage of the kidney disease is also coded (HHS
2017, Section I.C.14.a, 53).
✔✔A data map or crosswalk consists of:
a. Terms used to describe paths between classifications and vocabularies
b. A map of time frames for multiple project completion
c. A descriptive list of data names
,d. Normalized data attributes - ✔✔a. Terms used to describe paths between
classifications and vocabularies
**There are several definitions of mapping and crosswalks but an important one in
healthcare is that they are used to describe paths between classifications and
terminologies (Palkie 2016, 164-165).
✔✔The patient was admitted for breast carcinoma in the right breast at two o'clock. This
was removed via lumpectomy. The patient was found to have 1 of 7 lymph nodes
positive for carcinoma during axillary lymph node dissection. One of the patient's
neighbors who is also a coworker at the hospital called the coding department to get the
patient's diagnosis because she is a cancer survivor herself. The coder should:
a. Discuss the case with the coworker
b. Report the incident to hospital security
c. Give the caller false information
d. Explain that discussing the case would violate the patient's right to privacy - ✔✔d.
Explain that discussing the case would violate the patient's right to privacy
** Disclosing information without the patient's written consent violates the patient's right
to privacy (Brodnik 2012, 231, 414; Gordon and Gordon 2016a, 615-616).
✔✔The requirements for documentation and record completion (documents such as
history and physicals, discharge summaries, and consultations) as well as penalties for
non-adherence must be specified in:
a. Hospital rules and regulations
b. Conditions of nonparticipation
c. Medical staff bylaws
d. Nursing staff policies - ✔✔c. Medical staff bylaws
**The medical staff bylaws are required by accreditation and regulatory organizations to
refer to the timeline required for completion (Malmgren and Solberg 2016, 240; Brinda
2016, 166).
✔✔A bronchoscopy with biopsy of the left bronchus was completed and revealed
adenocarcinoma. What, if any, modifier should be added to the procedure codes?
a. -50, Bilateral procedure
b. -51, Multiple procedures
c. -LT, Left side
d. No modifiers should be reported. - ✔✔d. No modifiers should be reported.
Because the lungs are paired organs, it may seem as though modifier -50 would be
appropriate. However, a modifier would not be assigned because the bronchus is not a
, paired organ, and the bronchus is the location of the procedure, not the lungs. Similarly,
it might seem as though modifier -LT would be assigned, but again, this would not be
assigned as the bronchus is not a paired organ. In order to assign the correct modifier, it
is important to note that paired organs include ears, eyes, nostrils, kidneys, lungs,
ovaries, and such (CPT Assistant May 2003).
✔✔Using the following evaluation and management map, which answers represent
documentation that should be considered, when assigning an E/M example for hospital
acuity points assignment?
Evaluation and Management Mapping
The following are the points needed to determine the level of CPT code:
Level 1 = 1-20
Level 2 = 21-35
Level 3 = 36-47
Level 4 = 48-60
Level 5 = > 61
Critical Care > 61 with constant physician attendance
CPT Codes
Level 1 = 99281 99281-25 with procedure/laboratory/radiology
Level 2 = 99282 99282-25 with procedure/laboratory/radiology
Level 3 = 99283 99283-25 with procedure/laboratory/radiology
Level 4 = 99284 99284-25 with procedure/laboratory/radiology
Level 5 = 99285 99285-25 with procedure/laboratory/radiology
Emergency Department Acuity Points
5 10 15 20 25
Meds Given 0-2 3-5 6-7 8-9 > 10
Extent of Hx Brief PF EPF Detail Comprehensive
Extent of Exam Brief PF EPF Detail Comprehensive
Number of - ✔✔c. Number of tests ordered
**When an question is asked about an outpatient acuity map, the coder must review the
map and determine the relevant elements that make up the means by which a CPT
code and level is assigned. In the case of this map, and in this question, the number of
tests ordered is the answer.
✔✔Assign the code(s) for chemotherapy for 3 hours' infusion.
96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal
anti-neoplastic
96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour,
single or initial substance/drug
