Deck 8: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Question 1

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

Answer 1

A

Question 2

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

Answer 2

B

Question 3

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

Answer 3

B

Question 4

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 5

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

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

Question 6

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 examination 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 7

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 8

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 9

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)None of the above are correct

Question 10

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 11

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

Question 12

A 6-month-old infant was admitted with a febrile seizure.The patient had a temperature of 103°F and had been started on antibiotics the day before for an acute bilateral otitis media.The patient was discharged to the care of the parents on the following day.Final Diagnosis: Febrile seizure;fever due to acute bilateral otitis media.

A)R56.01,H66.90
B)R56.9,H66.93
C)R56.00,H66.93
D)R56.00,H66.90

Question 13

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.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,0WQFXZ2
C)K57.32,0DQN0ZZ,0WQFXZ2
D)Z93.3,0DQH0ZZ,0WQFXZ2

Question 14

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 15

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 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 16

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 17

Outpatient Encounter: Patient has been taking Lipitor for hypercholesterolemia for 1 year.A hepatic function laboratory 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,E78.0
B)E78.1,Z51.81,Z79.899
C)Z51.89,Z79.810,E78.0
D)E78.0,Z79.891

Question 18

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 19

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

Question 20

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 21

Match the following terms to the correct definition.
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 22

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

Question 23

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 24

Ascites due to cirrhosis of liver: __________

Question 25

Match the following terms to the correct definition.
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 26

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

Question 27

Match the following terms to the correct definition.
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 28

Impending stroke with dizziness and facial weakness: __________

Question 29

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

Question 30

Signs and symptoms are not often correlated with a definitive diagnosis in the health record.

Question 31

Where can documentation of a patient's medical and surgical history be found?

Question 32

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

Question 33

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 34

What does BMI stand for?

Question 35

Name one problem that can result from lack of documentation.

Question 36

Match the following terms to the correct definition.
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 37

Match the following terms to the correct definition.
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 38

What is meant by screening examination or test?

Question 39

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

Question 40

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

Question 41

Patient has a cystostomy: __________

Question 42

Problems with mother-in-law: __________

Question 43

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

Question 44

Gas pain: __________

Question 45

Retained metal fragment: __________

Question 46

Urethral discharge: __________

Question 47

Urinary hesitancy due to enlarged prostate: __________

Question 48

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

Question 49

Oral phase dysphagia: __________

Question 50

Screening for osteoporosis: __________

Question 51

Encounter for admission examination for prisoner: __________

Question 52

Camp physical: __________

Question 53

Exposure to syphilis: __________

Question 54

Screening for sickle cell disorder: __________

Question 55

Positive Mantoux test: __________

Question 56

Counseling on the initiation of contraceptive foam use: __________

Question 57

Encounter for blood alcohol test: __________