Question 1

Codes from category 655, known or suspected fetal abnormality affecting the mother, should

Accepted Answer

Codes from category 655 should be assigned when the fetal conditions affect the management of the mother, as this is the primary reason for coding these conditions.

Question 2

An established patient was seen in her primary physician's office. The patient fell at home and came to the physician's office for an examination. Due to a possible concussion, the patient was sent to the hospital to be admitted as an observation patient. A detailed history and examination were performed and the medical decision was low complexity. The patient stayed overnight and was discharged the next afternoon.

Accepted Answer

The patient was admitted for observation and discharged the next day, so codes 99218 (initial observation care) and 99217 (observation discharge) are appropriate.

Question 3

The physician explicitly documents that a condition is not present at the time of admission.

Accepted Answer

The correct choice is "N=No" because the physician has explicitly documented that the condition was not present at the time of admission.

Question 4

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made.

Accepted Answer

The correct code is 99324, which is used for new patient visits in a rest home or assisted living facility with a problem-focused history, examination, and straightforward medical decision-making.

Question 5

An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient's last three glucose tests. The patient is still running above normal glucose levels, so the physician decides to adjust the patient's insulin. An expanded history was taken and a physical examination was performed.

Accepted Answer

The correct answer is A because the patient is an established patient, the visit is for follow-up on hypertension and diabetes, the physician takes the blood pressure and references the patient's last three glucose tests, the patient is still running above normal glucose levels, so the physician decides to adjust the patient's insulin, and an expanded history was taken and a physical examination was performed. This all adds up to a level 3 visit, which is 99213.

Question 6

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and ten minutes providing critical care for this patient.

Accepted Answer

The answer of A doctor provides critical care services in...

Question 7

There are a limited number of late effect codes in ICD-9-CM. When coding a residual condition where there is no applicable late effect code, one should code

Accepted Answer

The residual condition is the only code that should be reported.

Question 8

The physician documents that the patient has diabetes that was diagnosed prior to admission.

Accepted Answer

The physician's documentation indicates that the diabetes was present before the patient was admitted, so the correct choice is "Yes" for present on admission (POA).

Question 9

The medical record documentation is unclear as to whether the condition was present on admission.

Accepted Answer

When the medical record documentation is unclear about whether a condition was present on admission, the appropriate choice is "U" for Unknown.

Question 10

Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered x-rays of the ankle, which came back negative for a fracture. A problem-focused history and physical examination were performed and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only.

Accepted Answer

The correct code is 99281 because it is a problem-focused history and physical examination with low complexity medical decision making.

Question 11

When a patient is admitted in respiratory failure due to a chronic nonrespiratory condition,

Accepted Answer

The answer of When a patient is admitted in respiratory...

Question 12

Which of the following are considered late effects regardless of time?

Accepted Answer

Nonunion, malunion, and scarring are all considered late effects regardless of time, as they can occur long after the initial injury or insult. Congenital defects are present at birth and are not considered a late effect, while fractures, burns, and poisoning can be either acute or late effects depending on various factors such as severity and treatment.

Question 13

A diabetic patient is admitted to the hospital with acute gastrointestinal hemorrhage due to ulcer disease. In this case, the diabetes would be

Accepted Answer

Diabetes is a comorbid condition because it is a pre-existing condition that may affect the patient's treatment and recovery, but it is not the primary reason for the hospital admission.

Question 14

A patient is admitted for a total hip replacement because of rheumatoid arthritis. Following admission, but prior to surgery, the patient develops congestive heart failure, which necessitates transfer to ICU. The hip replacement is canceled and the patient is treated for the heart failure. What is the principal diagnosis?

Accepted Answer

The principal diagnosis is the condition that was chiefly responsible for the patient's admission to the hospital. In this case, the patient was admitted for a total hip replacement due to rheumatoid arthritis, making rheumatoid arthritis the principal diagnosis.

Question 15

When Robert was discharged, his physician listed his diagnoses as congestive heart failure with acute pulmonary edema. You're coding Robert's record and you will code

Accepted Answer

The answer of When Robert was discharged, his physician listed...

Question 16

Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple Iife-threatening injuries due to a multiple car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient.

Accepted Answer

The patient received critical care for over 30 minutes, which qualifies for code 99291. Additionally, the patient went into cardiac arrest, which also qualifies for an additional unit of code 99292. Therefore, the best choice is B, 99291 and 99292.

Question 17

Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a comprehensive history and physical examination. The physician ordered lab work to rule out pancreatitis, along with an ultrasound of the gallbladder and abdominal x-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.

Accepted Answer

The comprehensive history, physical examination, ordered lab work, ultrasound and x-ray all suggest that the consultant made a moderate medical decision in determining the best course of treatment for the patient. This level of decision-making is consistent with the requirements for a level 4 consultation according to the documentation guidelines. Therefore, the best choice is C) 99254.

Question 18

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

Accepted Answer

The principal diagnosis should reflect the condition that required the most resources and led to the admission. In this case, both cholecystitis and acute pancreatitis were possible diagnoses, but acute pancreatitis is more severe and requires more resources to treat. The chronic pancreatitis secondary to alcoholism may also have played a role in the patient's presentation, but it is not the principal diagnosis as it is a chronic condition and not the reason for admission. Therefore, the correct principal diagnosis is acute pancreatitis.

Question 19

According to the UHDDS guidelines, the principal procedure is performed for- rather than for

Accepted Answer

The UHDDS guidelines define the principal procedure as the main surgical action performed to achieve definitive treatment rather than for diagnostic or exploratory purposes or to address complications. Therefore, option C is the correct answer as it states the definition provided by UHDDS guidelines.

Question 20

In ICD-9-CM, when an exploratory laparotomy is performed followed by a therapeutic procedure, the coder reports

Accepted Answer

In ICD-9-CM coding, when a therapeutic procedure is performed following an exploratory laparotomy, only the therapeutic procedure is coded, as it encompasses the exploratory aspect.

Exam 1: Registered Health Information Administrator