CCS PRACTICE EXAM 2

A 23 year old female is admitted for vaginal bleeding following a miscarriage two weeks prior to this admission. She afebrile at this time and is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principle diagnosis? a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion b. O08.1, Delayed or excessive hemorrhage following ectopic and molar pregnancy c. R57.9, Shock, unspecified d. T81.10XA, Postprocedural shock unspecified, initial encounter a. O03.1, Delayed or excessive hemorrhage following incomplete spontaneous abortion A psychiatrist documents that a patient has wide mood swings from excessive happiness to loss of energy and crying. What condition is suspected? a. Bipolar disorder b. Major depression c. Anxiety d. Psychosis A. Bipolar disorder A patient with a cephalic presentation anticipating a vaginal delivery failed to progress. After measurement of the fetal head and a trial of oxytocin, the patient underwent a cesarean section. What condition should the coder suspect and query the physician about? a. Twin pregnancy b. Early delivery c. Eclampsia d. Cephalopelvic disproportion d. Cephalopelvic disproportion A 45 year old woman underwent a carotid bypass and experienced a significant drop in blood pressure during the surgery. The documentation suggested the patient may have had a myocardial infarction. In accordance with coding guidelines, what should the coder do? a. Code complication of surgery NOS. b. Query the physician to determine if the patient had hypotension. c. Query the physician to determine if there was a complication of surgery. d. Code preoperative shock. c. Query the physician to determine if there was a complication of surgery. If a patient's discharge summary does not contain a diagnosis that is documented by the anesthesiologist in a preoperative evaluation and that would impact MS-DRG assignment, the coder should: a. Code only from the discharge diagnosis b. Code the diagnosis reflected on the anesthesia preoperative evaluation c. Code the most severe symptom d. Query the attending physician regarding the clinical significance of that diagnosis d. Query the attending physician regarding the clinical significance of that diagnosis A patient has documentation of esophageal varices. What condition may be related that may affect the coding? a. Arthritis b. Liver disease c. Chronic obstructive pulmonary disease d. Erythema b. Liver disease A patient admitted with acute abdominal pain, is fount to have appendicitis, and has an appendectomy. The patient has a length of stay for 2 days. What type of patient encounter is this? a. Impatient b. Outpatient c. Long term care d. Rehabilitation a. Inpatient A patient was treated in the emergency department for a swollen knee and an aspiration of the joint was performed. The patient was then discharged home. It is important to make sure that which of the following are documented and captured for billing purposes? a. X-ray and other types of radiology examination b. Procedures performed including the aspiration of the joint c. Examination and management in the emergency department d. All services provided including diagnostic