Question 1

When more than one procedure is performed, the procedure that was performed first is the principal procedure.

Accepted Answer

The principal procedure is determined by the procedure that is most related to the primary diagnosis or main reason for the surgery, not by the order in which the procedures were performed.

Question 2

In some instances, a surgical wound is not closed at the time of a surgical operation and is allowed to heal and will be closed at a later date. This is an example of when a ____ would be coded.
A)closure
B)bilateral procedure
C)biopsy
D)limited coverage

Accepted Answer

The term "closure" refers to the act of suturing or otherwise joining tissues together to close a wound. In this scenario, the wound is left open at the time of the surgical procedure and will be closed at a later date, so the appropriate code to indicate this would be a closure code.

Question 3

Each ____________________ should have its own written policy regarding the assignment of ICD-10-PCS codes.

Accepted Answer

facility

Question 4

When a diagnostic procedure is performed for the principal diagnosis and a procedure for definitive treatment is performed for a secondary diagnosis, the procedure for definitive treatment is the principal procedure.

Accepted Answer

The principal procedure is determined based on the procedure that is most closely related to the principal diagnosis, regardless of whether it is a diagnostic or definitive treatment procedure.

Question 5

An obstetric procedure is any procedure performed on a pregnant woman.

Accepted Answer

The answer of An obstetric procedure is any procedure performed...

Question 6

If a surgical procedure starts out as a laparoscopic approach, it may never be converted to an open procedure.

Accepted Answer

A laparoscopic procedure can be converted to an open procedure if the surgeon encounters complications or determines that a better outcome can be achieved with an open approach.

Question 7

If a surgical procedure was canceled because the patient developed atrial fibrillation before the start of the procedure, which Z code would be assigned?
A)Z53.09 Surgical or other procedure not carried out because of contraindication
B)Z53.20 Surgical or other procedure not carried out because of patient's decision
C)Z53.9 Procedure not carried out for other reasons
D)None of the above

Accepted Answer

Atrial fibrillation is a contraindication for surgical procedures, so the appropriate Z code to assign is Z53.09, which indicates that the procedure was not carried out because of a contraindication.

Question 8

An additional code should always be assigned for closure of the surgical incision.

Accepted Answer

The closure of the surgical incision is typically considered an integral part of the surgical procedure itself and does not usually require an additional code.

Question 9

The Uniform Hospital Discharge Data Set (UHDDS) definitions are used by chronic care, long-term hospitals to report inpatient data elements in a standardized manner.

Accepted Answer

The Uniform Hospital Discharge Data Set (UHDDS) definitions are primarily used for reporting inpatient data elements by acute care, short-term hospitals, not specifically by chronic care, long-term hospitals.

Question 10

When a diagnostic procedure is performed for the principal diagnosis and a procedure for definitive treatment is performed for a secondary diagnosis, the procedure for diagnostic treatment is the principal procedure.

Accepted Answer

The principal procedure is typically the one performed for the principal diagnosis, even if a definitive treatment is performed for a secondary diagnosis.

Question 11

Any procedure that affects payment or reimbursement must be reported.

Accepted Answer

Procedures that affect payment or reimbursement must be reported in order to ensure accurate and ethical billing practices. Failure to report such procedures could result in billing errors, insurance fraud, or other legal and financial repercussions.

Question 12

It is a routine part of most surgical procedures to close the operative wound(s), so it is not necessary to code this separately.

Accepted Answer

It is true that closing the operative wound(s) is a routine part of most surgical procedures, and therefore it is not necessary to code this separately.

Question 13

When a patient shows up to have a procedure performed but the procedure is canceled for whatever reason, the principal diagnosis would be ___________________.

Accepted Answer

The answer of When a patient shows up to have...

Question 14

If a patient's procedure is canceled before he or she shows up at the hospital, what is the correct Z code to assign?
A)Z53.09 Surgical or other procedure not carried out because of contraindication
B)Z53.20 Surgical or other procedure not carried out because of patient's decision
C)Z53.9 Procedure not carried out for other reasons
D)None of the above

Accepted Answer

The answer of If a patient's procedure is canceled before...

Question 15

"Low cervical cesarean section" would be identified by the fifth character approach.

Accepted Answer

"Low cervical cesarean section" refers to the most common type of cesarean section where the incision is made in the lower part of the uterus. The term "fifth character approach" does not specifically apply to the identification or classification of cesarean sections; it is more commonly associated with coding systems like ICD-10, where the fifth character can specify details about a diagnosis or procedure, but not in the context provided.

Question 16

Cutting off all or a portion of the upper or lower extremities is ____.

Accepted Answer

The answer of Cutting off all or a portion of...

Question 17

____________________ is the removal of tissue for pathologic exam to establish a precise diagnosis.

Accepted Answer

The answer of ____________________ is the removal of tissue for...

Question 18

____ identifies procedure codes identified by the Medicare Code Editor as procedures covered under limited circumstances.
A)Bilateral procedure
B)Nonspecific OR procedure
C)Noncovered OR procedure
D)Encoder

Accepted Answer

The Encoder is a tool used to identify procedure codes and determine if they are covered under specific circumstances by Medicare.

Question 19

Taking or letting out fluids and/or gases from a body part is called ____.

Accepted Answer

The answer of Taking or letting out fluids and/or gases...

Question 20

Which of these is a true characteristic of significant procedures?
A)Surgical in nature
B)Carry a procedural risk
C)Carry an anesthetic risk
D)Require specialized training
E)All of the above

Accepted Answer

Significant procedures often are surgical in nature, carry both procedural and anesthetic risks, and require specialized training to perform safely and effectively.

Quiz 8: Coding Medical and Surgical Procedures