CCS Exam Prep
Terms in this set (396)
7 yo pt admitted to ED for Asthma with status asthmaticus
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?
Pt admitted with high temp, Since PD is a nonspecific term and has no code in Alpha
lethargy, hypotension, Index, query phys to determine if pt is being treated for
tachycardia, oliguria, sepsis, highlighting the clinical signs, symptoms
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?
During CABG, pt underwent 2 aortocoronary grafts and 1 mammary-coronary graft
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?
,According to CPT, an Colonoscopy since this is an examination of entire colon
endoscopy that is from rectum to cecum that may include terminal ileum
undertaken to the level of
midtransverse colon would
be coded as a:
Infusion of Herceptin, a Molecular Targets which block the growth, spread of
monoclonal antibody used cancer by interfering with specific molecules involved in
for tx of breast cancer in pts tumor growth, progression
carrying a certain mutation
of the HER2 gene, is
classified as:
Pt has findings suggestive Query phys regarding clinical significance of findings
of COPD on chest x-ray and and request appropriate documentation be provided as
Attending phys mentions x- this is example of a circumstance where chronic
ray finding in one progress condition must be verified; all secondary conditions
note but no meds, tx, or must meet the UHDDS definitions although it is not clear
further eval. The coder if COPD does
should:
Pt undergoes inpatient px Query Attending phys as final dx as coding strictly from
and final summary dx is path report is not appropriate since coder would be
difference from dx on path assigning dx without Attending phys' corroboration
report, the coder should:
56 yo woman admitted to Query healthcare provider who performed px to
acute-care facility from SNF determine if debridement was excisional as coders are
and has multiple sclerosis encouraged to work with physicians, healthcare
and hypertension. During providers to ensure documentation is very specific and
course of hospitalization, clarified
decubitus ulcer is found
and debrided at bedside by
phys. There is no typed op
report and no path report.
The coder should:
, 23 yo female admitted for O08.9 = complication following abortion and ectopic
shock following tx of and molar pregnancies since miscarriage was dealt with
miscarriage and path report in a prior episode of care
from prev admit reveals pt
had no decidua or POC in
tissue removed. Encounter
would be coded as:
Most hospitals require a 30 days due to Medicare CofP and TJC
medical record is
completed within:
Draw single line through the error, add a note explaining
To correct an entry in the
the error, initial, date, and add correct info in
MR, the provider should:
chronological order
After pt is discharged from Certain basic reports such as history and physical,
hospital, the MR must be discharge summary, etc.
reviewed for:
Pt is discharged with CHF
diagnosis of acute
pulmonary edema due to
CHF so what cn(s) should
be coded?
Terms in this set (396)
7 yo pt admitted to ED for Asthma with status asthmaticus
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?
Pt admitted with high temp, Since PD is a nonspecific term and has no code in Alpha
lethargy, hypotension, Index, query phys to determine if pt is being treated for
tachycardia, oliguria, sepsis, highlighting the clinical signs, symptoms
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?
During CABG, pt underwent 2 aortocoronary grafts and 1 mammary-coronary graft
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?
,According to CPT, an Colonoscopy since this is an examination of entire colon
endoscopy that is from rectum to cecum that may include terminal ileum
undertaken to the level of
midtransverse colon would
be coded as a:
Infusion of Herceptin, a Molecular Targets which block the growth, spread of
monoclonal antibody used cancer by interfering with specific molecules involved in
for tx of breast cancer in pts tumor growth, progression
carrying a certain mutation
of the HER2 gene, is
classified as:
Pt has findings suggestive Query phys regarding clinical significance of findings
of COPD on chest x-ray and and request appropriate documentation be provided as
Attending phys mentions x- this is example of a circumstance where chronic
ray finding in one progress condition must be verified; all secondary conditions
note but no meds, tx, or must meet the UHDDS definitions although it is not clear
further eval. The coder if COPD does
should:
Pt undergoes inpatient px Query Attending phys as final dx as coding strictly from
and final summary dx is path report is not appropriate since coder would be
difference from dx on path assigning dx without Attending phys' corroboration
report, the coder should:
56 yo woman admitted to Query healthcare provider who performed px to
acute-care facility from SNF determine if debridement was excisional as coders are
and has multiple sclerosis encouraged to work with physicians, healthcare
and hypertension. During providers to ensure documentation is very specific and
course of hospitalization, clarified
decubitus ulcer is found
and debrided at bedside by
phys. There is no typed op
report and no path report.
The coder should:
, 23 yo female admitted for O08.9 = complication following abortion and ectopic
shock following tx of and molar pregnancies since miscarriage was dealt with
miscarriage and path report in a prior episode of care
from prev admit reveals pt
had no decidua or POC in
tissue removed. Encounter
would be coded as:
Most hospitals require a 30 days due to Medicare CofP and TJC
medical record is
completed within:
Draw single line through the error, add a note explaining
To correct an entry in the
the error, initial, date, and add correct info in
MR, the provider should:
chronological order
After pt is discharged from Certain basic reports such as history and physical,
hospital, the MR must be discharge summary, etc.
reviewed for:
Pt is discharged with CHF
diagnosis of acute
pulmonary edema due to
CHF so what cn(s) should
be coded?
