Deck 2: Hospital Coding Overview

Question 1

Facilities use codes on the UB-04 (CMS-1450) to receive reimbursement for services rendered, procedures, and to provide the medical reason for which the services were furnished.

Answer 1

True

Question 2

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

Answer 2

True

Question 3

The facility coder has many responsibilities, which include documenting charts and diagnosing patients' illnesses when the provider does not provide adequate information.

Answer 3

False

Question 4

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

Question 5

When coding a chart for ICD-9/10-CM, the word "and" can be interpreted as "and" or "or."

Question 6

When reviewing chart documentation, brackets [ ] indicate you must consult the physician before assigning a diagnosis code.

Question 7

Parentheses ( ) indicate the diagnostic statement must contain specific words or the coder must seek additional information from the provider.

Question 8

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

Question 9

When the documentation does not specify if a fracture is open or closed, the coder must assign the least significant diagnosis-closed.

Question 10

When a bruise surrounds a laceration, it would be coded as a contusion.

Question 11

ICD-9/10 procedure codes describe what services were performed during the encounter.

Question 12

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

Question 13

When a procedure is performed with topical anesthesia, an ICD-9 procedure code must be assigned.

Question 14

"V" codes and "E" codes in ICD-9-CM are always used in conjunction with one another.

Question 15

There are a number of combination codes on the hypertension table that are used specifically when the provider has provided appropriate documentation to include "crisis" or "uncontrolled."

Question 16

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

Question 17

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

Question 18

When a procedure is started but not completed, assign an ICD-9/10 procedure code for the entire procedure to ensure appropriate reimbursement.

Question 19

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

Question 20

For the purpose of ICD-9-CM/ICD-10-PCS procedural coding, if the procedure is performed on both the left and the right side of the body and documentation supports a bilateral procedure was performed, the service should be coded twice to ensure appropriate reimbursement if there is no code that includes the wording bilateral

Question 21

CPT/HCPCS codes are assigned for the specific services provided in the hospital outpatient setting.

Question 22

The Evaluation and Management section is utilized primarily by professional/physician coders.

Question 23

All CPT codes must also have a modifier code to describe the circumstances.

Question 24

Modifier 51 is most commonly used for outpatient services.

Question 25

The CPT manual and the ICD-9 book are arranged alike to comply with HCPCS rules of coding.

Question 26

Outpatient visit codes utilize the evaluation and management section of the CPT manual.

Question 27

Assignment of anesthesia codes for outpatient facility services is usually not necessary.

Question 28

To ensure timely reimbursement, the outpatient facility coder must be sure not to use a separate anesthesia code if the anesthesia service was included in the procedure code.

Question 29

It is the provider's responsibility to clearly document if the service provided should be coded as an inpatient or outpatient and the coder's responsibility to determine which codes need to be assigned and from what sources those codes should be selected.

Question 30

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

Question 31

The diagnosis that is the chief reason for the admission following performance of all diagnostic services is known as the primary diagnosis.

Question 32

Why is it important to ensure proper assignment of codes?

A) Efficiency
B) Timely reimbursement
C) Prevent malpractice lawsuits
D) All of the above

Question 33

This notation indicates that the underlying condition must be coded first, followed by the underlying disease that caused the manifestation.

A) Parentheses ( )
B) Code first underlying condition
C) Brackets [ ]
D) Code conditionally

Question 34

When the provider specifically states his diagnosis code for the condition, but there is no specific code in ICD-9, which coding convention is utilized?

A) NEC
B) NOS
C) An additional code
D) None of the above

Question 35

Which of the following coding conventions can be used interchangeably?

A) See
B) See also
C) See category
D) None of the above

Question 36

New growths are also referred to as:

A) neoplasms.
B) lacerations.
C) abrasions.
D) lesions.

Question 37

Malignant neoplasms that have spread from their original site can be found under which neoplasm heading?

A) Situ
B) Primary
C) Secondary
D) All of the above

Question 38

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

A) One
B) Two
C) Three
D) Four

Question 39

When hypertension presents prior to pregnancy and is managed during pregnancy, codes from what section should be utilized during the pregnancy?

A) Cardiovascular conditions
B) Hypertension table
C) Pregnancy section
D) All of the above

Question 40

The codes V70-82 in ICD-9-CM are used for patients without reported diagnoses, including patients receiving which services?

A) Physical
B) Gynecological exams
C) Screenings for suspected conditions
D) All of the above

Question 41

Which of the following are examples of external cause codes?

A) All of those listed
B) Accidental falls
C) Submersion accidents
D) Caught in between objects

Question 42

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:

A) table of hypertension.
B) chemical and drug diagnosis locator.
C) table of "E" codes.
D) table of drugs and chemicals.

Question 43

What codes would be utilized when the provider sufficiently documents that the patient attempted to harm herself?

A) Accidental
B) Suicidal attempt
C) Undetermined
D) All of the above

Question 44

Documentation of an elevated blood pressure should be coded as:

A) hypertension.
B) high blood pressure reading without a diagnosis of hypertension.
C) malignant hypertension.
D) none of the above.

Question 45

The acronym HCPCS stands for:

A) Healthcare Cumulative.
B) Healthcare Common Procedure Coding System.
C) Health Care Procedure Coding System.
D) All of the above.

Question 46

The radiology section of the CPT manual is divided into four subsections. Which of the following is not a subsection?

A) Diagnostic x-ray
B) Ultrasound
C) CT scan
D) Nuclear medicine

Question 47

Modifier codes are _____-digit codes that are appended to some CPT codes to describe services for unusual circumstances.

A) one
B) two
C) three
D) four

Question 48

If documentation does not exist to define the neoplasm as benign or malignant, the neoplasm should be coded as __________ __________.

Question 49

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

Question 50

The patient presents with multiple abrasions, fractures, and bruises. What order would the injuries be assigned codes? Explain your answer.

Question 51

List the severe injury order.

Question 52

ICD-9/10 procedure codes should be assigned under what conditions? List four.

Question 53

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

Question 54

Explain what category/look-up of ICD-9/10 procedure code is utilized when a lesion is removed.

Question 55

What are the six major categories or chapters in the CPT book?

Question 56

Explain the "package concept" referred to in the surgery section of the CPT manual.

Question 57

Which procedures are assigned from the surgery section of the CPT manual?

Question 58

Both physicians and facilities utilize evaluation and management codes. Explain the different key components used to assign the codes.

Question 59

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.

Question 60

Assign CPT codes and any appropriate modifiers to the following scenario:

Patient presented for excision of multiple lesions of the trunk, arm, and leg. Excision of a 2-cm lesion from the lower back was performed as well as excisions of lesions of the right upper arm and left lower leg-each were 2 cm in diameter. All wounds were repaired by simple closure.

The surgical path indicated that the back lesion was malignant, whereas both the arm and the leg lesions were benign.

Question 61

Assign ICD-9-CM diagnostic codes for the following:

Patient presented to ED with complaint of a laceration to the wrist as a result of a fall at home in the bathtub.

Question 62

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.

Question 63

Assign the appropriate ICD-9-CM diagnostic code and CPT code for the following scenario:

Patient presents for replacement of pulse generator on her dual-chamber pacemaker due to battery life. The pacemaker only needs replacing. The patient has had satisfactory results with her pacemaker over the past eight years. An incision is made, the pacemaker pocket is entered, and the pulse generator is disconnected from the leads. The pulse generator is changed out, the leads are reconnected, and the pacemaker pocket is closed with sutures.

Question 64

Assign the appropriate ICD-9 procedural code to the following:

Tonsillectomy with adenoidectomy

Question 65

Assign the ICD-9 procedural code to this procedure:

Below the knee amputation, left

Question 66

For the purpose of ICD-10-PCS procedural coding, if the procedure is performed on both the left and the right side of the body and the documentation supports a bilateral procedure was performed, the service should be coded twice to ensure appropriate reimbursement unless code descriptor includes the word "bilateral"

Question 67

ICD-10
Assign the appropriate ICD-10-CM diagnostic code and CPT procedure code for the following scenario:

Patient presents to the 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 $\times$ 0.5cm, and it was sent to surgical pathology for evaluation. The wound was irrigated and closed with simple closure.

Question 68

ICD-10
Assign ICD-10-CM diagnostic codes for the following:

Patient presented to ED with complaint of a laceration to the wrist as a result of a fall at home in the bathtub.

Question 69

ICD-10
Assign the appropriate ICD-10-CM diagnostic code and CPT code for the following scenario:

Patient presents for replacement of pulse generator on her dual-chamber pacemaker due to battery life. The pacemaker only needs replacing. The patient has had satisfactory results with her pacemaker over the past eight years. An incision is made, the pacemaker pocket is entered, and the pulse generator is disconnected from the leads. The pulse generator is changed out, the leads are reconnected, and the pacemaker pocket is closed with sutures.

Question 70

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

Tonsillectomy with adenoidectomy

Question 71

ICD-10-PCS

Assign the ICD-10-PCS procedural code to this procedure:

Below the knee amputation, left

Question 72

ICD-9-CM and CPT

Assign ICD-9-CM diagnostic code and CPT code to the following:
Closed reduction and manipulation of left distal radial and ulnar styloid fracture

After satisfactory anesthesia was accomplished, the patient's left upper extremity was placed in finger trap traction and gentle closed reduction performed using C-Arm visualization. Long arm plaster cast was then applied and alignment was once again checked with C -Arm.

Question 73

ICD-10-CM and CPT

Assign ICD-10-CM diagnostic codes and CPT codes to the following:
Closed reduction and manipulation of left distal radial and ulnar styloid fracture

After satisfactory anesthesia was accomplished, the patient's left upper extremity was placed in finger trap traction and gentle closed reduction performed using C-Arm visualization. Long arm plaster cast was then applied and alignment was once again checked with C -Arm.

Question 74

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.

Question 75

ICD-10-CM and CPT

Assign ICD-10-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.

Question 76

ICD-9-CM and CPT

Assign ICD-9-CM diagnostic code and CPT codes to the following:

The scope was introduced and passed easily to the cecum. There was a small polyp in the ascending colon as well as the distal transverse colon. Both of these were removed with snare polypectomy. An additional polyp was found in the descending colon and this was removed with hot biopsy forceps. The patient tolerated the procedure well and was transferred to the recovery room in good condition.

Question 77

ICD-10-CM and CPT

Assign ICD-10-CM diagnostic codes and CPT codes to the following:

The scope was introduced and passed easily to the cecum. There was a small polyp in the ascending colon as well as the distal transverse colon. Both of these were removed with snare polypectomy. An additional polyp was found in the descending colon and this was removed with hot biopsy forceps. The patient tolerated the procedure well and was transferred to the recovery room in good condition.

Question 78

ICD-9-CM and CPT

Assign ICD-9-CM diagnostic codes and CPT codes 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.

Question 79

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.

Question 80

ICD-9-CM and CPT

Assign ICD-9-CM diagnostic codes and CPT code as appropriate for the following:

Screening colonoscopy for family history of colon cancer
Under IV sedation, video colonoscope was introduced to the cecum. The patient had pockets of retained fecal matter, but a reasonable view of the colon was still able to be performed. There was no blood throughout the lower GI tract; no evidence of polyps or malignancy.

Patient tolerated the procedure well and was stable at the end of the procedure.