Deck 9: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Question 1

Outpatient Encounter: Patient has been taking Lipitor for hypercholesterolemia for 1 year. A hepatic function lab test was performed to assess any adverse effects on the patient's liver function. A fasting lipid profile was also done to assess the effectiveness of the Lipitor.

A)Z51.81, Z79.899, E78.00
B)E78.1, Z51.81, Z79.899
C)Z51.89, Z79.810, E78.01
D)E78.00, Z79.891

Answer 1

A

Question 2

A(n) ____ code is used to explain continuing surveillance following completed treatment of a disease, condition, or injury.

A)donor
B)aftercare
C)follow-up
D)observation

Answer 2

C

Question 3

The patient was admitted for a takedown of colostomy. The patient underwent a colostomy 3 months ago after colon resection was performed for perforated diverticulitis. The patient was taken to the OR for open colostomy reversal with end-to-end anastomosis. No excision of the colon was performed. The patient still has a few diverticula of the large intestine and should follow a diverticulosis diet.Final Diagnosis: Diverticulosis Procedure: Colostomy takedown

A)K57.32, Z43.3, 0DQE0ZZ, 0WQFXZ2
B)Z43.3, K57.30, 0DQE0ZZ
C)K57.32, 0DQN0ZZ, 0WQFXZ2
D)Z93.3, 0DQH0ZZ, 0WQFXZ2

Answer 3

B

Question 4

On physical exam, the physician noted that the patient had hepatosplenomegaly. Further testing was ordered, and the patient will return in 2 weeks.

A)R16.0
B)R16.1
C)R16.2
D)R16.0, R16.1

Question 5

A 6-month-old infant was admitted with a febrile seizure. The patient had a temperature of 103° F. The patient was discharged to the care of the parents on the following day.Final Diagnosis: Febrile seizure

A)R56.01
B)R56.9
C)R56.00
D)R56.1

Question 6

The patient was admitted to the hospital for monitoring of seizure-like spells. Video electroencephalogram monitoring (external) of these episodes was performed and did not reveal any epileptic activity.Final Diagnosis: Transient alteration of awareness. Seizure disorder ruled out.

A)R40.4, 4A10X4Z
B)R40.4, 4A00X4Z
C)Z13.858, 4A00X4Z
D)R40.4, Z13.858, 4A10X4Z

Question 7

Which of the following is NOT a specific Z code category?

A)Family history
B)Screening
C)Nutrition
D)Observation

Question 8

The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.

A)J18.9, E86.0
B)J18.9, E86.0, R50.9
C)R50.9 J18.9, E86.0
D)J18.9, E86.1, R50.81

Question 9

Patient is admitted to hospice care for treatment of terminal ESRD.

A)N18.6, Z51.5
B)N18.6, Z51.89
C)Z51.5, N18.5
D)Z51.5, N18.6, Z99.2

Question 10

The patient was admitted with abdominal pain in the right upper quadrant. Workup included an EGD that showed some mild gastritis, and abdominal ultrasound was positive for gallstones in the gallbladder.Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis Procedure: Esophagogastroduodenoscopy with biopsy of the stomach

A)R10.11, K29.70, K80.20, 0DB68ZX
B)K29.70, K80.20, 0DB68ZX
C)K80.80, K29.60, 0DB68ZZ
D)K29.60, R10.11, K80.80, 0DT68ZZ

Question 11

The patient was admitted for prophylactic breast removal. The patient has a strong family history of breast cancer, and the patient has severe fibrocystic disease in both breasts, making breast exam difficult. The patient was taken to the OR, and a bilateral simple mastectomy was performed. The patient recovered with no problems. The pathology report showed no evidence of malignancy.Final Diagnosis: Family history of breast cancer; severe fibrocystic disease Procedure: Bilateral simple mastectomy

A)Z40.8, N60.11, N60.12, 0HTV0ZZ
B)Z40.01, Z80.3, N60.11, N60.12, 0HTV0ZZ
C)Z40.01, Z80.3, N60.19, 0HTT0ZZ, 0HTU0ZZ
D)N60.11, N60.12, Z40.01, 0HTT0ZZ, 0HTU0ZZ

Question 12

The patient was admitted from her primary care physician's office for palpitations. The patient has never had an episode like this. The patient does have a family history of coronary artery disease. The patient was monitored by telemetry, but no specific cardiac arrhythmias were identified. The patient was instructed to return for follow-up if palpitations recurred.Final Diagnosis: Palpitations; cardiac arrhythmia ruled out; family history of coronary artery disease

A)R00.1, Z82.49
B)R00.2, Z82.49
C)R00.2, Z82.41
D)R00.1, Z82.41

Question 13

A person who has had an allergic episode related to a substance or food in the past should always be considered allergic to the substance.

Question 14

Which of the following is NOT true of status codes?

A)A status code is informative because the status may affect the course of treatment and its outcome.
B)A status code is distinct from a history code.
C)A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code includes the information provided by the status code.
D)All of the above are correct.

Question 15

Patient was seen in the clinic. Final diagnosis is RUQ rebound abdominal tenderness.

A)R10.11
B)R10.811
C)R10.821
D)R10.829

Question 16

The infant was seen in the ER for fever. Physician documented fever due to vaccination.

A)R50.81
B)R50.82
C)R50.83
D)R50.2

Question 17

ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.

Question 18

Which of the following is a category of Z codes?

A)Contact/exposure
B)Inoculations and vaccinations
C)Status
D)All of the above

Question 19

The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla. The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago. The patient is no longer receiving any therapy for her cancer. A needle biopsy was done. The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.Final Diagnosis: Lymphadenopathy left axilla; metastasis ruled out Procedure: Needle core biopsy axillary lymph node

A)R59.9, Z85.3, Z90.12, 07B63ZX
B)R59.1, Z85.3, Z90.12, 07B63ZZ
C)R59.0, Z85.3, Z90.11, 07B53ZX
D)R59.0, Z85.3, Z90.12, 07B63ZX

Question 20

The patient is admitted to the hospital with right lower quadrant pain and nausea and vomiting. The patient had a low-grade fever. A diagnosis of acute appendicitis is made, and the patient is taken to the OR for removal of the appendix via an open approach.

A)K35.80, R10.31, R11.2, R50.9, 0DTJ4ZZ
B)R10.31, R11.2, R50.9, K35.80, 0DTJ0ZZ
C)K35.80, 0DTJ4ZZ
D)K35.80, 0DTJ0ZZ

Question 21

List one reason why a screening code would not be necessary.

Question 22

Another name for the coma scale is ______________ Coma Scale score.

Question 23

Match each definition to one of the following items.
a.A primary circumstance for using Z codes
b.Symptom
c.Screening exam
d.Is a main term in the Alphabetic Index
e.Sign
Subjective evidence of a disease or of a patient's condition as perceived by the patient

Question 24

Where are Z codes located in the Tabular List of the coding book?

Question 25

Match each definition to one of the following items.
a.A primary circumstance for using Z codes
b.Symptom
c.Screening exam
d.Is a main term in the Alphabetic Index
e.Sign
Done in the absence of any signs or symptoms

Question 26

A(n) ________________ is subjective evidence of a disease or of a patient's condition as perceived by the patient.

Question 27

The NIHSS is a clinical assessment tool used to evaluate and monitor the neurologic status in acute-stroke patients.

Question 28

Match each definition to one of the following items.
a.A primary circumstance for using Z codes
b.Symptom
c.Screening exam
d.Is a main term in the Alphabetic Index
e.Sign
A person who is not currently sick encounters health services for some specific reason, such as to act as an organ donor; to receive prophylactic care, such as inoculations or health screenings; or to receive counseling on health-related issues

Question 29

What is meant by screening exam or test?

Question 30

A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.

Question 31

Match each definition to one of the following items.
a.A primary circumstance for using Z codes
b.Symptom
c.Screening exam
d.Is a main term in the Alphabetic Index
e.Sign
Objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician

Question 32

A(n) ______________ is objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician.

Question 33

What does BMI stand for?

Question 34

Ascites due to cirrhosis of liver: __________

Question 35

Match each definition to one of the following items.
a.A primary circumstance for using Z codes
b.Symptom
c.Screening exam
d.Is a main term in the Alphabetic Index
e.Sign
Vaccination

Question 36

In ICD-10-CM, there are Excludes1 notes that are helpful in determining whether a symptom's code should be assigned.

Question 37

A screening code may be listed first if the reason for the visit is specifically a screening exam.

Question 38

The NIHSS describes the level of consciousness in comatose patients.

Question 39

In the inpatient setting, when a Z code is used as a diagnosis for a given procedure or a reason for the encounter, a procedure code is not necessary to identify that the procedure was performed.

Question 40

Observation codes are to be used if an injury or illness or any signs or symptoms related to the suspected condition is present.

Question 41

Gas pain: __________

Question 42

Patient is admitted to the hospital with the "worst headache" he has ever had. Workup for aneurysm is performed and was negative for aneurysm. There is a strong family history of stroke. No cause for the headache is determined: __________

Question 43

Encounter for admission exam for prisoner: __________

Question 44

Camp physical: __________

Question 45

Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________

Question 46

Patient has a cystostomy: __________

Question 47

Oral phase dysphagia: __________

Question 48

Screening for sickle cell disorder: __________

Question 49

Impending stroke with dizziness and facial weakness: __________

Question 50

Urethral discharge: __________

Question 51

Retained metal fragment: __________

Question 52

Encounter for blood alcohol test: __________

Question 53

Problems with mother-in-law: __________

Question 54

Patient is admitted for workup of normal-pressure hydrocephalus (NPH) because of ataxic gait. NPH is ruled out, and the patient is discharged home: __________

Question 55

Exposure to syphilis: __________

Question 56

Screening for osteoporosis: __________

Question 57

Urinary hesitancy due to enlarged prostate: __________

Question 58

Patient is admitted with an acute cerebrovascular accident. The NIHSS score on admission is 35: _____________________________

Question 59

Counseling on the initiation of contraceptive foam use: __________

Question 60

Positive Mantoux test: __________