Question 1

When is it appropriate to use category V10, history of malignant neoplasm?

Accepted Answer

Category V10 is used when a primary malignancy has been eradicated and there is no ongoing treatment or evidence of the disease.

Question 2

In the diagnosis "first-, second-, and third-degree burns of the chest wall," a code is required for

Accepted Answer

The answer of In the diagnosis "first-, second-, and third-degree...

Question 3

In order to use the inpatient CPT consultation codes, the consulting physician must

Accepted Answer

To use the inpatient CPT consultation codes, the consulting physician must document his findings in the patient's medical record. While communication with the attending physician and ordering diagnostic tests may occur, these are not specific requirements for using the consultation codes. The term "referral" is also not necessary.

Question 4

A barrier to widespread use of automated code assignment is

Accepted Answer

Poor quality of documentation can lead to inaccurate coding, and automated code assignment relies heavily on accurate documentation. Inadequate technology and resistance by physicians or HIM professionals may also be barriers, but they are not as fundamental or pervasive as poor quality of documentation.

Question 5

In assigning E/M codes, three key components are used. These are

Accepted Answer

The three key components used in assigning Evaluation and Management (E/M) codes are history, examination, and medical decision-making.

Question 6

A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the deciion to do surgery was made on this office visit.

Accepted Answer

Modifier -57 is used to indicate that the decision for surgery was made during the evaluation and management service on the day of or the day before the surgery.

Question 7

The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribe medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient' sresponse to the medication, to review results from the diagnostic test, and to discuss treatment options. What codes should the consultant report for the two visits?

Accepted Answer

The first visit should be reported as an initial inpatient consultation, and the second visit should be reported as a subsequent hospital visit. A follow-up consult is not a code option in the inpatient setting, and reporting both visits as an initial inpatient consult or an initial inpatient consult and initial hospital care would be incorrect, as there was no transfer of care to the consultant for ongoing management of the patient.

Question 8

A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.

Accepted Answer

Modifier -53 is used to indicate that the procedure was discontinued due to extenuating circumstances affecting the patient's condition. This modifier is used when the physician stops the procedure due to risks to the patient's health or safety, and when the physician determines it is in the best interest of the patient to discontinue the procedure.

Question 9

Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)?

Accepted Answer

The term "metastatic from breast" indicates that the cancer has spread from the primary cancer site in the breast to the axillary lymph nodes and lungs. Therefore, the primary cancer site is the breast.

Question 10

According to CPT, in which of the following cases would an established E/M code be used?

Accepted Answer

When a patient is seen by a covering physician (Dr. X) for their regular physician (Dr. Y), and the patient has seen Dr. Y before, it is considered an established patient visit.

Question 11

A patient has major surgery and sees the surgeon 10 days later for an unrelated e/m services. Indicate the modifier that should be attached to the E/M code for the service provided.

Accepted Answer

Modifier -24 is used to indicate that an E/M service was performed during a postoperative period for a reason unrelated to the original procedure.

Question 12

After reviewing the following excerpt from CPT, code 27646 would be interpreted as

Accepted Answer

The CPT excerpt only specifies "tumor, bone" and does not mention any specific bone or bones. Therefore, option B, which includes only "fibula" as the bone being operated on, is the best choice.

Question 13

According to ICD-9-CM, which one of the following is NOT a mechanical complication of an internal implant?

Accepted Answer

Inflammation of urethra due to indwelling catheter is classified as a nonmechanical complication of an internal implant according to ICD-9-CM. The other options are all mechanical complications.

Question 14

A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus. She is a type I diabetic and was brought under control and subsequently discharged. The following code was assigned:  Which of the following describe why the coding is in error?

Accepted Answer

An additional code describing the type I diabetes mellitus should have been used in addition to the code for the admission, as the patient's diabetes is a chronic condition that will require ongoing management beyond the hospitalization. Additionally, the specific type of diabetes should have been documented, rather than leaving it as uncontrolled diabetes mellitus.

Question 15

Mrs. Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit.

Accepted Answer

Modifier -78 is used to indicate a return to the operating room for a related procedure during the postoperative period. The hematoma is a complication of the initial procedure and required surgical intervention, making -78 the appropriate modifier to report. Modifier -58 is used for staged or planned procedures, -76 is used for repeat procedures unrelated to the original procedure, and -79 is used for unrelated procedures during the postoperative period.

Question 16

The primary goal of a hospital-based cancer registry is to

Accepted Answer

The primary goal of a hospital-based cancer registry is to improve patient care by collecting and analyzing data on cancer patients, which helps in evaluating treatment outcomes and planning patient management.

Question 17

A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a

Accepted Answer

A disease registry is a secondary data source that aggregates extensive data about patients with a certain diagnosis. The purpose of a disease registry is typically to track and monitor the incidence and prevalence of a disease, as well as to evaluate and improve the quality and effectiveness of care for patients with that disease. A disease index is similar but is typically limited to information about patient diagnoses and procedures, rather than more extensive patient data. A master patient index and admissions register are not specifically focused on patients with a certain diagnosis.

Question 18

A population-based cancer registry that is designed to determine rates and trends in a defined population is a (an)

Accepted Answer

An incidence-only population-based registry is designed to determine rates and trends in a defined population. It only collects information on newly diagnosed cases of cancer and does not track patients over time. B, C, and D are not accurate descriptions of this type of cancer registry.

Question 19

A 36-year-old woman was admitted to the hospital for an obstetrical delivery of her third child. During the admission, a sterilization procedure was performed for contraceptive purposes. The V25.2 code for sterilization would be

Accepted Answer

The V25.2 code for sterilization would be assigned as a secondary diagnosis, as it is not the reason for admission but rather a concurrent procedure performed during the admission.

Question 20

A patient was admitted to the hospital with hemiplegia and aphasia. The hemiplegia and aphasia were resolved before discharge and the patient was diagnosed with cerebral thrombosis. What is the correct coding and sequencing?

Accepted Answer

The principal diagnosis should be the condition that occasioned the admission, which is cerebral thrombosis. Hemiplegia and aphasia are symptoms that resolved and are not coded separately.

Exam 1: Registered Health Information Administrator