Deck 27: Inpatient Coding

Question 1

In the inpatient setting, the physician documents possible aspiration pneumonia in the discharge summary.The aspiration pneumonia is coded as if it exists.

Answer 1

True

Question 2

A significant procedure is one that:

A)carries an anesthetic risk
B)is surgical in nature
C)requires specialized training
D)all of the above

Answer 2

all of the above

Question 3

Patient is admitted following an outpatient procedure because of an exacerbation of the patient's asthma.What is the principal diagnosis?

A)the reason for the patient's outpatient procedure
B)a code for cancellation of the procedure
C)an aftercare V code
D)exacerbation of asthma

Answer 3

exacerbation of asthma

Question 4

The use of a POA indicator is required for all acute-care facilities that are reimbursed under MS-DRGs.

Question 5

Patient is admitted with dysuria due to a severe urinary tract infection.Which diagnoses should be reported?

A)dysuria, urinary tract infection
B)urinary tract infection
C)dysuria
D)urinary tract infection, dysuria

Question 6

The removal of a tooth is an example of an extraction in the ICD-10-PCS system.

Question 7

A principal procedure is one that is performed for definitive treatment rather than for diagnostic or exploratory purposes, or one necessary to take care of a complication.

Question 8

In the inpatient setting, a procedure code from ICD-10-PCS would be assigned to identify a procedure.

Question 9

The Tabular List of ICD-10-PCS contains grids that represent the last four characters of a procedure code.

Question 10

The ICD-10-PCS has a seven-character alphanumeric code structure.

Question 11

The discharge summary states the patient's diagnosis is acute abdominal pain due to peptic ulcer disease or cholecystitis.Which diagnoses should be reported?

A)abdominal pain, peptic ulcer disease, cholecystitis
B)abdominal pain, peptic ulcer disease
C)abdominal pain, cholecystitis
D)abdominal pain

Question 12

The American Hospital Association is responsible for the development of ICD-10-PCS.

Question 13

The Centers for Medicare and Medicaid Services (CMS) is responsible for the development of ICD-10-PCS.

Question 14

In the inpatient setting, a CPT code would be assigned for a procedure code.

Question 15

The discharge summary states the patient's diagnoses are peptic ulcer disease versus chronic cholecystitis.Which diagnoses should be reported?

A)peptic ulcer disease
B)chronic cholecystitis
C)a symptom code
D)both peptic ulcer disease and chronic cholecystitis (either one can be principal)

Question 16

It is unacceptable to assign codes in the inpatient setting to diagnoses that are documented as being "probable," "suspected," or "likely."

Question 17

The principal diagnosis is defined as the most serious condition during a patient's hospital stay.

Question 18

When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.

Question 19

The Official Guidelines for Coding and Reporting are updated every year.

Question 20

In the inpatient setting, the principal diagnosis is also called the "first-listed" diagnosis.

Question 21

The root operation that is defined as cutting out or off, without replacement, all of a body part is:

A)restriction
B)reposition
C)resection
D)revision of device in

Question 22

The root operation that is defined as freeing of a body part is:

A)release
B)repair
C)removal of device from
D)inspection

Question 23

Patient is admitted for a lobectomy for cancer of the lung.The patient was noted to be wheezing so the surgery was canceled because of an exacerbation of the patient's COPD.
ICD-10-CM Code(s): ____________________

Question 24

Patient was discharged with a diagnosis of probable acute myocardial infarction.
ICD-10-CM Code(s): ____________________

Question 25

The root operation that is defined as correcting a portion of a previously performed procedure is:

A)revision of device in
B)replacement
C)reposition
D)transfer

Question 26

The root operation that is defined as taking or letting out of fluids and/or gases in a part of a body is:

A)division
B)dilation
C)creation
D)drainage

Question 27

The acronym UHDDS stands for:

A)Uniform Hospital Doctor Data Set
B)Uniform Hospital Discharge Data Set
C)Uniform Healthcare Discharge Data Set
D)United Hospital Discharge Data Set

Question 28

Patient is admitted with epigastric pain due to acute pancreatitis, without necrosis or infection.
ICD-10-CM Code(s): ____________________

Question 29

Patient was admitted with shortness of breath and edema due to decompensation of congestive heart failure.
ICD-10-CM Code(s): ____________________

Question 30

The root operation that is defined as restoring, to the extent possible, a body part to its natural anatomic structure is:

A)map
B)replacement
C)restriction
D)repair

Question 31

Patient was admitted with severe diarrhea.The physician documents the discharge diagnosis as gastroenteritis versus food poisoning.
ICD-10-CM Code(s): ____________________