Deck 19: Inpatient Hospital Diagnosis Coding

Question 1

Which of the following is considered the principal diagnosis?

A) The admitting diagnosis
B) The most complicated diagnosis
C) The condition that takes the greatest number of treatments
D) The condition established after study

Answer 1

D

Question 2

In an inpatient setting, if a patient had a condition when he or she was admitted to the hospital, which POA indicator will the coder assign?

A) U
B) W
C) N
D) Y

Answer 2

D

Question 3

In an inpatient setting, if the provider could not determine whether the condition was present upon admission, which POA indicator will the coder assign?

A) U
B) W
C) N
D) Y

Answer 3

B

Question 4

Which of the following is a summary of the patient's hospital stay?

A) Discharge summary
B) Hospital course
C) Discharge instructions
D) Discharge disposition

Question 5

In outpatient coding, which of the following are you permitted to code?

A) Rule out
B) Probable
C) Suspected
D) All of these
E) None of these

Question 6

A patient is seen in the emergency room for nausea and vomiting. Upon work-up, the physician cannot determine the cause. She gives the patient a prescription for Phenergan and instructs her to follow up with her primary care physician if the issue is not resolved. What is the correct code assignment?

A) R11.0
B) R11.1
C) R11.2
D) R11. 11

Question 7

What is the correct code for a patient who was discharged to a nursing home today after a three-day hospital stay due to dementia?

A) F03.90
B) F03.91
C) F10.27
D) F10.97

Question 8

In an inpatient setting, if a patient did not have a condition when he or she was admitted to the hospital, which POA will the coder assign?

A) U
B) W
C) N
D) Y

Question 9

Carolyn Crimson was admitted for acute appendicitis. The day after surgery, she had a hemorrhage and hematoma and was taken back to surgery. Which is the correct POA assignment for this case?

A) K35.80-Y, K91.840-N
B) K35.80-N, K91.841-N
C) K35.80-Y, K91.840-Y
D) K35.80-Y, K91.841-N

Question 10

Which of the following documents does the patient receive a copy of?

A) Discharge summary
B) Hospital course
C) Discharge instructions
D) Discharge disposition

Question 11

Sally Sumpter was brought in today for LLQ abdominal pain. She was admitted to the medical floor and Dr. Jones was called in to examine her. After examination, Dr. Jones determines that Sally has acute cholecystitis. What is the correct code assignment?

A) R10.32, K81.0
B) R10.12, K81.9
C) K81.0
D) K81.9

Question 12

Jamie Jupson was brought in today with a severe headache. An MRI was ordered, and it was determined that Jamie has a glioblastoma in her frontal lobe. What is the correct code assignment?

A) C71.1
B) R51, C71.1
C) G97.1, C71.2
D) R51, C71.2

Question 13

In an inpatient setting, if documentation is insufficient to determine whether the condition was present on admission, which POA indicator will the coder assign?

A) U
B) W
C) N
D) Y

Question 14

Concurrent coding is when the coder:

A) codes from the patient's chart while the patient is still in the hospital.
B) codes from the patient's chart after the patient is discharged.
C) waits until the physician signs all the documents in the charts before coding.
D) sits next to the physician while coding the chart.

Question 15

In inpatient coding, which of the following are you permitted to code?

A) Rule out
B) Probable
C) Suspected
D) All of these
E) None of these

Question 16

Which of the following is signed by the attending physician?

A) Discharge summary
B) Hospital course
C) Discharge instructions
D) Discharge disposition

Question 17

Which of the following contains a transfer order for the patient?

A) Discharge summary
B) Hospital course
C) Discharge instructions
D) Discharge disposition

Question 18

What does the abbreviation POA stand for?

A) Persistent on admission
B) Present on admission
C) Permitted on admission
D) Painful on admission

Question 19

Mary Matthews was found to have a breast lump during a mammogram last month. She is admitted today for a breast biopsy of her left breast. The pathology report returns with infiltrating papillary breast carcinoma of the left breast. Mary's mother had breast cancer in her fifties. What is the correct code assignment?

A) D05.12
B) D05.12, Z80.3
C) C50.312
D) C50.912, Z80.3

Question 20

In an inpatient setting, if a condition is exempt from POA reporting, which POA indicator will the coder assign?

A) 1
B) W
C) N
D) Y

Question 21

A patient is admitted today for anemia. The patient also had hypertension and diabetes mellitus, type 2. What are the correct codes and POA assignments?

A) D64.9-Y, E10.9-Y, I10-Y
B) D64.9-Y, E11.9-Y, I10-Y
C) D64.9-Y, E11.9-N, I10-Y
D) D64.9-Y, E10.9-N, I10-Y

Question 22

Bernard Bunter is seen today for an acute myocardial infarction. Bernard had to have a coronary artery bypass graft surgery performed, which was done without difficulty. Two days later, Bernard developed post-op anemia. Bernard also has hypertension and congestive heart failure. Which of the conditions is a co-morbidity:

A) Acute myocardial infarction
B) Anemia
C) Hypertension
D) Congestive heart failure and hypertension

Question 23

Who typically assigns the DRG for the patient's case?

A) The coder
B) The physician
C) The coding supervisor
D) The DRG grouper

Question 24

Which of the following DRG systems focuses on all-patient refined diagnosis-related group?

A) APR-DRG
B) APS-DRG
C) AP-DRG
D) AMR-DRG

Question 25

What does the abbreviation UHDDS stand for:

A) U.S. Hospital Discharge Data Set
B) Uniform Hospital Discharge Data Set
C) Uniform Hospital Discharge Data Standards
D) U.S. Hospital Discharge Data Standards

Question 26

What does the abbreviation MCC stand for?

A) Major complications
B) Major complications and co-morbidities
C) Major complications and chronic conditions
D) Major chronic conditions

Question 27

Which of the following is included in the DRG system calculation?

A) Labor costs
B) Nonlabor costs
C) Both labor and nonlabor costs
D) Neither labor nor nonlabor costs

Question 28

Sandy Summitt delivered a healthy female live-born infant without any complications. What are the correct codes and POA assignments?

A) O80-1, Z37.0-1
B) O80-Y, Z37.0-Y
C) O82-1, Z37.0-1
D) O82-Y, Z37.0-Y

Question 29

Which of the following is NOT part of the clinical information collected in the UHDDS:

A) Provider information
B) Diagnoses
C) Procedures
D) External causes of injury

Question 30

Which of the following is one of the factors in DRG assignment?

A) Admitting diagnosis
B) Principal diagnosis
C) Present on admission status
D) Type of physician

Question 31

Which of the following is part of the demographic information collected in the UHDDS?

A) Age
B) Gender
C) Ethnicity
D) All of these
E) None of these

Question 32

Which of the following has an effect on the treatment of the patient and makes caring for the patient more complex?

A) Complication
B) Co-morbidity
C) Major complication or co-morbidity
D) Infection

Question 33

What does the abbreviation IPPS stand for?

A) Inpatient patient payment system
B) Inpatient prospective payment system
C) In-hospital prospective payment system
D) In-hospital patient payment system

Question 34

The UHDDS is a collection of specific data gathered about hospital patients:

A) on admission.
B) on discharge.
C) before surgery.
D) postoperatively.

Question 35

Twenty-three-month-old Jamee Hudson was found by his mother to have an empty bottle of naproxen. The mother is unsure whether Jamee took any of the pills or where the pills are. Jamee is brought in for work-up. All the labs come back normal, and the examination does not find any evidence that Jamee swallowed any of the pills. What is/are the correct code(s) and POA assignment(s):

A) Z03.6-1
B) Z03.6-Y
C) T39.311A-Y
D) Z03.6-1, T39.311A-Y

Question 36

Which of the following is a separate condition or illness present in the same patient at the same time as another unrelated condition or illness?

A) Complication
B) Co-morbidity
C) Major complication or co-morbidity
D) Infection

Question 37

Which of the following is an unexpected illness or condition that develops as the result of a procedure?

A) Complication
B) Co-morbidity
C) Major complication or co-morbidity
D) Infection

Question 38

What does the abbreviation DRG stand for?

A) Disease-related groups
B) Diagnosis-related groups
C) Disease resources and groups
D) Diagnosis resources and groups

Question 39

What does the abbreviation CC stand for?

A) Complications
B) Complications and co-morbidities
C) Complications and chronic conditions
D) Chronic conditions

Question 40

Bernard Bunter is seen today for an acute myocardial infarction. Bernard had to have a coronary artery bypass graft surgery performed, which was done without difficulty. Two days later, Bernard developed post-op anemia. Bernard also has hypertension and congestive heart failure. Which of the conditions is a complication?

A) Acute myocardial infarction
B) Anemia
C) Hypertension
D) Congestive heart failure and hypertension

Question 41

Trudy Turnipson is seen today for congenital keratoconus. Upon admission, her blood pressure dropped, and she was diagnosed with hypotension. What are the correct codes and POA assignments?

A) Q13.4-Y, I95.9-N
B) Q13.4-N, I95.9-Y
C) Q13.4-Y, I95.0-N
D) Q13.4-Y, I95.0-1

Question 42

Which of the following is also called a nosocomial condition?

A) Complication
B) Co-morbidity
C) Major complication or co-morbidity
D) Hospital-acquired condition

Question 43

Which of the following claim forms are POA indicators required to be reported on?

A) UB-04
B) 837
C) Both UB-04 and 837
D) Neither UB-04 nor 837

Question 44

Refer to the ICD-10-CM Official Guidelines Section II.H, which states: If the diagnosis documented at the time of ________ is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it ________ or was established.

A) admission, discharge
B) discharge, existed
C) discharge, occurred
D) admission, happened

Question 45

Which of the following will determine how much an acute care facility will be paid?

A) Medicare reimbursement
B) Medicaid reimbursement
C) IPPS
D) OPPS

Question 46

Refer to the ICD-10-CM Official Guidelines Section II, which states: The circumstances of inpatient admission always govern the selection of ________ diagnosis.

A) principal
B) secondary
C) first -listed
D) tertiary

Question 47

What does the abbreviation HAC stand for?

A) Hospital admission criteria
B) Hospital-acquired condition
C) Hospital-acute condition
D) Hospital-associated condition

Question 48

Billy Baker was admitted with pneumococcal sepsis and iron deficiency anemia. What are the correct codes and POA assignments?

A) A40.0-Y, D50.9-Y
B) A40.1-Y, D64.9-Y
C) A40.3-Y, D50.9-Y
D) A40.8-Y, D64.9-Y

Question 49

Trudy Turnipson is seen today for pneumonia resistant to amoxicillin. What are the correct codes and POA assignments?

A) J18.9-Y, Z16.11-Y
B) J18.9-Y, Z16.21-Y
C) J18.9-Y, Z16.20-Y
D) J18.9-Y, Z16.35-Y

Question 50

Refer to the ICD-10-CM Official Guidelines Section III. B, which states: ________ findings (laboratory, x-ray, pathologic, and other diagnostic results) are not coded and reported unless the provider indicates their clinical significance.

A) Normal
B) Abnormal
C) Standard
D) Irregular

Question 51

Which of the following is HAC data used for?

A) Evaluating patient safety directives
B) Limiting payment to a facility for errors
C) Both evaluating patient safety directives and limiting payment to a facility for errors
D) Neither evaluating patient safety directives nor limiting payment to a facility for errors

Question 52

Refer to the ICD-10-CM Official Guidelines Section III. B, which states: If the findings are ________ the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provider whether the abnormal finding should be added.

A) within
B) outside
C) inside
D) exclusive to

Question 53

Which of the following is a special software program?

A) IPPS
B) POA
C) DRG grouper
D) HAC

Question 54

What does the abbreviation LOS stand for?

A) Length of stay
B) Last office stay
C) Length of standards
D) Last outpatient stay