CCS Exam Prep 2024 Latest Update!!

7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? - ANSWER Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? - ANSWER Since PD is a nonspecific term and has no code in Alpha Index, query phys to determine if pt is being treated for sepsis, highlighting the clinical signs, symptoms During CABG, pt underwent saphenous bypass grafts; from aorta to left ant desc branch of left main coronary artery, and the left post desc of left main coronary artery. Pt also underwent repositioning of the mammary artery to the right coronary artery. What is the best description for this px? - ANSWER 2 aortocoronary grafts and 1 mammary-coronary graft According to CPT, an endoscopy that is undertaken to the level of midtransverse colon would be coded as a: - ANSWER Colonoscopy since this is an examination of entire colon from rectum to cecum that may include terminal ileum Infusion of Herceptin, a monoclonal antibody used for tx of breast cancer in pts carrying a certain mutation of the HER2 gene, is classified as: - ANSWER Molecular Targets which block the growth, spread of cancer by interfering with specific molecules involved in tumor growth, progression Pt has findings suggestive of COPD on chest x-ray and Attending phys mentions x-ray finding in one progress note but no meds, tx, or further eval. The coder should: - ANSWER Query phys regarding clinical significance of findings and request appropriate documentation be provided as this is example of a circumstance where chronic condition must be verified; all secondary conditions must meet the UHDDS definitions although it is not clear if COPD does Pt undergoes inpatient px and final summary dx is difference from dx on path report, the coder should: - ANSWER Query Attending phys as final dx as coding strictly from path report is not appropriate since coder would be assigning dx without Attending phys' corroboration