Exam 2: Hospital Coding Overview

"V" codes in ICD-9-CM are utilized as primary diagnosis when they are the chief reason for the outpatient encounter.

A "metastatic neoplasm" indicates that the neoplasm is a result of a metabolic imbalance and should be coded from the uncertain behavior column.

When a provider documents the patient has uncontrolled hypertension, this does not qualify the diagnosis as benign or malignant.

When a laparoscopic procedure is converted to an open procedure, both procedures should be assigned an ICD-9 procedure code.

ICD-10-CM and CPT Assign ICD-10-CM diagnostic code and CPT code as appropriate to the following: Phacoemulsification of nuclear sclerotic cataract left eye with intraocular lens placement Patient was brought to the OR and placed in the supine position for ocular surgery. The left eye was administered $0.75\%$ Marcaine to produce topical anesthesia. The eye was then prepped and draped in the usual sterile manner. A 3 mm, half depth, clear corneal incision was made and phacoemulsification was completed. the irrigation aspiration handpiece was utilized to remove cortical remnants. The anterior chamber and capsular bag was then reinflated followed by placement of the intraocular lens. The patient tolerated the procedure well.

ICD-9-CM and CPT Assign ICD-9-CM diagnostic code and CPT code to the following: Repair of right inguinal hernia Patient was brought to the OR and underwent general anesthesia. The right groin was prepped and draped in the usual fashion. Incision was made from the pubic tubercle through anterior superior iliac spine. This was carried down to the subcut tissue to the external oblique fascia. There was noted to be a large inguinal hernia which was dissected out down to the internal ring. A medium Perlix plug was inserted into the defect and then sutured at four points with interrupted 2-0 Prolene. The patient tolerated the procedure well and was taken to recovery in stable condition.

Chart documentation indicating the patient encounter was a result of an adverse effect of a drug and/or chemical would require the coder to consult the:

These codes provide additional information regarding the external cause of the hospital visit in ICD-9-CM diagnostic coding:

Documentation of an elevated blood pressure should be coded as:

Assign the appropriate ICD-9-CM diagnostic code and CPT procedure code for the following scenario: Patient presents to OR for excisional breast biopsy of a suspicious right breast mass. Patient was prepped and draped in the usual sterile manner. An incision was made around the mass, and it was removed in toto. The mass was approximately 2.5 cm $\times$ 0.5 cm, and it was sent to surgical pathology for evaluation. The wound was irrigated and closed with a simple closure.

Modifier 51 is most commonly used for outpatient services.

Diagnoses of the genitourinary system are assigned codes from the 580-629 series of the ICD-9-CM diagnosis codes.

"Use additional codes" indicates an additional code may need to be added in order to correctly assign the diagnostic statement for the chart.

List the severe injury order.

The facility coder must be capable of reviewing chart documentation and determining which contributed to the encounter.

When a physician diagnoses hypertension, the coder must determine if it is benign or malignant.

ICD-10-PCS Assign the appropriate ICD-10-PCS procedure codes for the following: Tonsillectomy with adenoidectomy

Encounters for a maternity delivery require a minimum of how many ICD-9/10 diagnostic codes to be assigned.

Assign CPT code to the following outpatient scenario: Patient presents for right knee arthroscopy after several months of progressive knee pain. Patient was prepped in the usual sterile manner. The arthroscope was introduced and the patellofemoral joint was visualized. It appeared normal as did the lateral compartment. The medial compartment had some synovial tissue that was resected as well as extensive shaving of the medial meniscus.

Neoplasms that have been determined noncancerous in behavior should be coded as __________.