CCA Mock Exam (practice)

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. (3 codes) - correct answer 45385, 99156, 99157 The diagnosis is as follows: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast." Given this which are the primary cancer site(s)? a. lungs b. axillary lymph nodes c. breast d. both axillary lymph nodes and lungs - correct answer Breast Patient has a year history of mitral valve regurgitation and now presents for a mitral valve replacement with bypass. (1 code) - correct answer 33430 You are conducting an education session on benchmarking. You tell you audience that the key to benchmarking is to use the comparison to a. compare you department with another b. implement your QI process c. make recommendations for improvement to the other department or organization d. improve your department's prcesses - correct answer d. improve you department 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 A. a copy of the facility coding guidelines, along with written information on improved documentation. B. the UHDDS and information on where each data element is collected and/or verified in your facility. C. regular in-service presentations on documentation, including its importance and tips for improvement. D. feedback on specific instances when improved documentation would improve coding. - correct answer D. feedback on specific instances when improved documentation would improve coding. A patient is diagnosed with early onset Alzheimer's disease with dementia. (2 codes) - correct answer G30.0, F02.80 An established patient was seen by physician in her office for DTaP-IPV. (2 codes) - correct answer 90471, 90698 CPT code for a high-energy ESW of the lateral humeral epicondyle using general anesthesia. (1 code) - correct answer 0102T Which of the following procedures can be identified as "destruction" of lesions? a. paring of hyperkeratotic lesion b. shaving of skin lesion c. removal of skin tags d. laser removal of condylomata - correct answer d. laser removal of condylomata The practice of using a code that results in a higher payment to the provider that the code that more accurately reflects the service provided is known as a. unbundling b. upcoding c. optimizing d. downcoding - correct answer b. 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. a. record b. field c. database d. table - correct answer c. database Single lung transplant without cardiopulmonary bypass. (1 code) - correct answer 32851 Female with 6 months of stress incontinence. Laparoscopic urethral suspension was completed. (1 ICD-9-CM code and 1 CPT code) - correct answer N39.3, 51990 The use of radioactive sources placed into a tumor-bearing area to generate high-intensity radiation is termed. a. brachytherapy b. external beam radiation c. proton beam treatment d. stereotactic radiation treatment - correct answer a. brachytherapy Which of the following procedures would NOT be coded to "resection" when using ICD-10-PCS? a. resection of the upper right lobe b. excision of gallbladder c. partial resection of upper left lobe d. excision of sigmoid colon - correct answer c. 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 A. not used. B. used and sequenced as the principal diagnosis. C. used and sequenced as a secondary diagnosis. D. the only code used. - correct answer C. used and sequenced as a secondary diagnosis. A patient suffered dizziness as a result of taking prescribed phenobarbital. The patient took his medication with beer. (3 codes) - correct answer R42, T42.3X1A, T51.8X1A Some ICD-10-CM codes are exempted from POA reporting because they a. represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury. b. 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. c. are always present on admission. d. represent external cause codes. - correct answer b. 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: A. the office of Inspector General B. the PRO in each state C. the National Center for Vital and Health Statistics D. Medicare administrative contractor (MAC) - correct answer D. Medicare administrative contractor (MAC) Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? a. primary diagnosis b. principal diagnosis c. secondary diagnosis d. admitting diagnosis - correct answer b. principal diagnosis Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radio-frequency thermotherapy. (1 ICD-10-CM code and 1 CPT code) - correct answer N40.0, 53852 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 a. doctor's admitting progress note b. nurse's admit note c. review of systems d. discharge summary - correct answer a. doctor's admitting progress note Lumbar laminectomy (one segment) for decompression of spinal cord. (1 code) - correct answer 63005 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. a. medical outcomes studies b. adjusted clinical groups (ACGs) systems c. recovery audit contractors (RACs) d. Atlas Systems - correct answer c. recovery audit contractors (RACs) Patient has breast carcinoma and is now undergoing complete axillary lymphadenectomy. (1 code) - correct answer 38745 Which of the following could influence a facility's case mix? a. changes in the services offered by a facility b. all answers apply c. accuracy of coding d. changes in DRG weights - correct answer b. all answers apply Excision 2 cm subcutaneous soft tissue lipoma of the back. ( 1 code ICD-10-CM and 1 CPT code) - correct answer D17.1, 21930 The Joint Commission requires that all medical records be completed within ______________ following patients discharge. a. 30 days b. 90 days c. 14 days. d. 7 days - correct answer a. 30 days Patient has a complicated removal of a wrist prosthesis. (1 code) - correct answer 25251 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. A. they should both be coded, acute sequenced first. B. they should both be coded, chronic sequenced first. C. only the acute condition should be coded. D. only the chronic condition should be coded. - correct answer A. they should both be coded, acute sequenced first. Patient presents to the GI lab for a colonoscopy. During the colonoscopy, adenomatous polyps were discovered in the ascending colon and in the transverse colon. Polyps in the ascending colon were removed via hot biopsy forceps, and the polyps in the transverse colon were removed by snare technique. (2 ICD-10-CM codes and 2 CPT codes) - correct answer D12.2, D12.3, 45384, 45385-59 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? a. respondeat superior b. quid pro quo c. qui tam d. res ipsa loquitur - correct answer b. quid pro quo Laparoscopic takedown of the splenic flexure and a partial colectomy with anastomosis. (2 codes) - correct answer 44204, 44213 Define 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)? a. acute conditions b. congenital conditions c. possible, probable, or suspected conditions d. Z codes - correct answer b. congenital conditions Patient came to the hospital ambulatory surgical center for repair of incisional hernia. This is the second time the patient has presented for treatment of this problem. The hernia was repaired with Gore-Tex graft. (1 ICD-10-CM code and 2 CPT codes) - correct answer K40.91, 49565, 49568 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? a. observation and evaluation without need for further medical care b. diagnosis of unknown etiology c. lung cancer d. chronic cough - correct answer d. chronic cough A patient present with dermatitis due to prescription topical antibiotic cream used as directed by physician. (2 ICD-10-CM codes) - correct answer L25.1, T49.0X5A Patient with carpal tunnel comes in for an open carpal tunnel release, right hand. (1 ICD-10-CM code and 1 CPT code) - correct answer G56.01, 64721 When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only. a. code the secondary neoplasm as the principal diagnosis b. code the primary neoplasm as the principal diagnosis c. the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis d. the primary neoplasm is coded as the principal diagnosis and the secondary neoplasm is coded as an additional diagnosis. - correct answer c. 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) a. CMS-1500 claim form b. remittance advice c. explanation of benefits d. advance beneficiary notice - correct answer d. advance beneficiary notice Hysteroscopy with D&C and polypectomy. (1 CPT code) - correct answer B. 58558 Patient has tear of the medical meniscus with loose bodies in the medical compartment of the left knee that was repaired by arthroscopic medial meniscectomy, shaving and trimming of meniscal rim, resection of synovium, and removal of the loose bodies. (1 CPT code) - correct answer 29881-LT A final progress note is appropriate as a discharge summary for a hospitalization in which the patient a. was an obstetric admission with a normal delivery and no complications. b. dies within 24 hours of admission. c. has no comorbidites or complications during this episode of care. d. was admitted within 30 days with the same diagnosis. - correct answer a. was an obstetric admission with a normal delivery and no complications. A patient was sent to the surgeon's office as requested by the patient because the insurance company requires a second option regarding surgery. The patient has been complaining of lower back pain for over a year due to a herniated disk. The patient presents to the surgeon's office where a detailed history and physical examination was performed. Medical records from the primary care physician and the physical therapist were reviewed along with tests performed in the office. Low medical decision making was made. A copy of the surgeon's reports was sent to the insurance company. (1 CPT code) - correct answer 99203-32 Patient was seen today for regular hemodialysis. No problems reported; patients tolerated procedure well. (1 CPT code) - correct answer 90935 When coding multiple wound repairs in CPT,