01/01/XX S: Here to follow up on her atrial fibrillation. No new
problems. Feeling well. Medications are reviewed and consistent
with the medications that she was discharged home. O: BP:
110/64. Pulse is regular at 72. Neck is supple. Chest is clear.
Cardiac normal sinus rhythm. A: Chronic atrial fibrillation,
currently stable. P: 1. Prothrombin time. 2. Follow up with
myself in 1 month, sooner as needed if has any other problems
in the meantime. Will also check a creatinine and potassium
today as well. Electronically Signed: M, Jones, M.D. Based on
the review of the medical record, what discrepancy would a
coder identify?
A. The list of medications was not documented which would
affect coding
B. The provider did not document the chief complaint
C. The provider did not properly sign the documentation
D. There are no discrepancies with this documentation Correct
Answers A
Based on the patient's diagnosis of AF and the ordering of PT, it
is likely the patient is being treated with Coumadin. Without the
medication list available to validate, a code for long term use of
anticoagulants cannot be reported.
01/01/XX SUBJECTIVE: CC: This 43 year-old Caucasian male
is here today for a follow-up visit. The patient's past medical
history is notable for diabetes, hypertension, and mixed
hyperlipidemia. HPI: Patient presents with type 2 diabetes.
Specifically, this is type 2, non-insulin requiring diabetes
without complications. Compliance with treatment has been
good. In regard to the essential hypertension, benign, this was
,first diagnosed several years ago. He is tolerating the medication
well without side effects. Concerning mixed hyperlipidemia,
compliance with treatment has been good; he takes his
medication as directed, maintains his low cholesterol diet,
follows up as directed, and maintains his exercise regimen.
ROS: CONSTITUTIONAL: Negative for chills, fatigue, fever
and night sweats. CARDIOVASCULAR: Negative for chest
pain, claudication, dizziness, palpitations and pedal edema.
RESPIRATORY: Negative for dyspnea, he Correct Answers C
In the HPI the provider documents the patient has non-insulin
requiring diabetes without complications. In the medication list,
it is documented that the patient is being treated with insulin.
Prior to reporting Z79.4, query the provider.
A 66 year-old male patient with AIDS presents with new onset
of shortness of breath. Tests confirm the patient has
pneumocystis carinii pneumonia. Select the appropriate
diagnosis code(s).
A. B59
B. B59, B20, R06.02
C. B20, B59
D. B20 Correct Answers C
The Official ICD-10-CM guideline I.C.1.a.2)(a), indicates if a
patient is admitted with an HIV-related condition you first
sequence B20 followed the code for the HIV-related condition.
Shortness of breath is a symptom of the pneumonia and not
reported (ICD-10-CM guideline I.B.5).
A patient presents for a routine checkup for his hypertensive
heart failure. He is to continue with his current medication and
diet. Select the diagnosis code(s).
, A. I50.40, I10
B. I11.0, I50.9
C. I50.9, I10
D. I50.9 Correct Answers B
There is a causal relationship between hypertension and heart
failure report code I11.0. The heart failure is reported as a
second code, because of the instructional note under code I11.0
which indicates to "use additional code to identify type of heart
failure (I50.-)."
A PEG Tube is:
I. Percutaneous Endoscopic Gastrostomy
II. G tube
III. Gastrostomy
IV. Colostomy
A. I
B. I and III
C. I, II, and III
D. IV Correct Answers C
A PEG tube is called by all of these various names except
colostomy.
A Type 2 diabetic presents with an insulin pump malfunction.
What are the correct codes?
A. T85.694A, E11.9
B. T85.694A, E11.620
C. T82.598A, E11.9
D. T82.598A, E11.620 Correct Answers A
ICD-10-CM guideline I.C.4.a.5), indicates insulin pump
malfunctions are coded to T85.6-. Insulin pump malfunction can
be an under dose or overdose of medication. With