Chapter V. Classification Systems and Secondary Data Sources

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Chapter V. Classification Systems and Secondary Data Sources
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Classification Systems
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  1. Which of the following is a valid ICD-9 principal diagnosis code?
    A. V27.2= outcome of delivery, twins, both live born
    B. V30.00= single live born, born in hospital
    C. E867= accidental poisoning by gas distributing by pipeline
    D. M9010/0= fibroadenoma, NOS
    B. V30.00= single live born, born in hospital
  2. A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign
    A. an unlisted Evaluation and Management code from the E/M section.
    B. an unlisted procedure code located in the eye and ocular adnexa section.
    C. a HCPCS Level Two (alphanumeric) code.
    D. an ophthalmologic treatment service code.
    B. an unlisted procedure code located in the eye and ocular adnexa section.
  3. A system of preferred terminology for naming disease processes is known as a 
    A. set of categories.
    B. classification system.
    C. medical nomenclature.
    D. diagnosis listing.
    C. medical nomenclature. 
  4. Which of the following is NOT included as a part of the minimum data maintained in the MPI?
    A. principal diagnosis
    B. patient medical record number
    C. full name (last, first, and middle)
    D. date of birth
    A. principal diagnosis
  5. The Health Information Department recdeives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?
    A. operation index
    B. consultation index
    C. disease index
    D. physician's index
    C. disease index
  6. One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
    A. until remission occurs
    B. 10 years
    C. for the life of the patient
    D. 1 year
    C. for the life of the patient
  7. In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to
    A. confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.
    B. code the record as is.
    C. code the condition as abnormal blood chemistry.
    D. code the abnormal potassium level as a complication following surgery.
    A. confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.
  8. DSM-IV-TR is used most frequently in what type of health care setting?
    A. behavioral health centers
    B. ambulatory surgery centers
    C. home health agencies.
    D. nursing homes.
    A. behavioral health centers
  9. Acoder notes that a patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of
    A. arthritis.
    B. glaucoma.
    C. bronchitis.
    D. laryngitis.
    B. glaucoma.
  10. The patient is diagnosed with congestive heart failure. A drug of choice is
    A. ibuprofen.
    B. oxytocin.
    C. haloperidol.
    D. digoxin.
    D. digoxin.
  11. ICD-10-CM utilizes a placeholder character. This is used as a 5th character placeholder at cdertain 6 character codes to allow for future expansion. The placeholder character is 
    A. "Z"
    B. "O"
    C. "1"
    D. "x"
    D. "x"
  12. The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retreive this data, you will need to have the correct
    A. CPT code.
    B. Standard Nomenclature of Inkuries codes.
    C. E-Codes and ICD-9-CM codes.
    D. HCPCS Level II codes.
    C. E-Codes and ICD-9-CM codes.
  13. 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 
    A. alcoholism
    B. abdominal pain.
    C. cholecystitis
    D. acute pancreatitis.
    D. acute pancreatitis. 
  14. In general, all three key components (history),physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when
    A. the patient is established.
    B. a new patient is seen in the office.
    C. the patient is given subsequent care in the hospital.
    D. the patient is seen for a follow-up inpatient consultation.
    B. A new patient is seen in the office.
  15. A direction to "code first underlying disease" should be considered
    A. only when coding inpatient records.
    B. a mandatory instruction.
    C. mandatory dependent on the code selection.
    D. a suggestion only.
    B. a mandatory instruction.
  16. Which classification system was developed to standardize terminology and codes for use in clinical laboratories?
    A. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED)
    B. Systematized Nomenclature of Pathology (SNOP)
    C. Read Codes
    D. Logical Observation Identifiers, Names, and Codes (LOINC)
    D. Logical Observation Identifiers, Names, and Codes (LOINC)
  17. Which classification system is used to classify neoplasms according to site, morphology, and behavior?
    A. International Classification of Diseases for Oncology (ICD-O)
    B. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED)
    C. Diagnostic and Statistical Manual of Mental Disorders (DSM)
    A. International Classification of Diseases for Oncology (ICD-O)
  18. According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a 
    A. principal procedure.
    B. significant procedure.
    C. operating room procedure.
    D. therapeutic procedure.
    B. significant procedure.
  19. The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the 
    A. Centers for Medicare and Medicaid Services (CMS).
    B. National Center for Health Statistics (NCHS)
    C. American Hospital Association (AHA)
    D. American Health Information Management Association (AHIMA)
    B. National Center for Health Statistic (NCHS).
  20. An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record a (n)
    A. logic-based encoder.
    B. automated codebook.
    C. grouper.
    D. automatic code assignment.
    A. logic-based encoder.
  21. Which of the following classification systems was designed with electronic systems in mind and is currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and imaged?
    A. SNOMED CT
    B. SNDO
    C. ICDPC-2
    D. GEM
    A. SNOMED CT
  22. The Unified Medical Language System (UMLS) is a project sponsored by the 
    A. National Library of Medicine.
    B. CMS.
    C. World Health Organization.
    D. Office of Inspector General.
    A. National Library of Medicine.
  23. A patient is admitted with shortness of breath and hemoptysis. A chest x-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected. The principal diagnosis is the
    A. metastatic brain carcinoma.
    B. small cell lung carcinoma.
    C. hemoptysis.
    D. pneumonia.
    B. small cell lung carcinoma.
  24. Jane Moore was admitted to the ambulatory care unit of the hospital for a planned cholecystectomy for cholelithiasis. Shortly before surgery, Jane developed tachycardia, and the surgery was canceled. After a thorough workup for the tachycardia, Jane was discharged. This outpatient admission should be coded in the following sequence:
    A. V code for canceled surgery, tachycardia, choleithiasis.
    B. tachycardia, V code for canceled surgery, cholelithiasis
    C. cholelithiasis, tachycardia, V code for canceled surgery.
    D. cholelithiasis, tachycardia, V code for canceled surgery.
  25. A 75-year-old female was admitted for repair of a hiatal hernia that was performed on the first day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur, which was surgically reduced. Further complications included severe angina for which a cardiac catherization and PTCA were performed. The principal procedure is
    A. femur reduction
    B. herniorrhaphy.
    C. catheterization.
    D. PTCA.
    B. herniorrhaphy.
  26. Code 402, Hypertensive Heart Disease, would appropriately be used in which of the following situations?
    A. left heart failure with benign hypertension.
    B. congestive heart failure; hypertension.
    C. hypertensive cardiovascular disease with congestive heart failure.
    D. cardiomegaly with hypertension.
    C. hypertensive cardiovascular disease with congestive heart failure.
  27. A patient is admitted to the hospital 6 weeks post myocardial infarction with severe chest pains. Which is the correct code?
    A. 414.8  chronic MI
    B. 410.1x  acute MI
    C. 412  old MI
    D. 413.0  angina
    B. 410.1x  acute MI
  28. Susan Dawn is status post mastectomy (6 weeks) due to carcinoma of the breast. She is admitted to the outpatient clinic for chemotherapy. What is the correct sequencing of the codes?
    A. V58.11 chemotherapy; 174.9 malignant neoplasm of breast
    B. V58.11 chemotherapy; V10.3 personal history of neoplasm of breast.
    C. V67.00 follow-up exam after surgery; V58.11 chemotherapy
    D. V10.3 personal history of neoplasm of the breast; V58.11 chemotherapy
    A. V58.11 chemotherapy; 174.9 malignant neoplasm of breast
  29. which of the following is coded as an adverse effect in ICD-9-CM?
    A. mental retardation due to intracranial abscess
    B. rejection of transplanted kidney
    C. tinnitus due to allergic reaction after administration of eardrops
    D. nonfunctioning pacemaker due to defective soldering.
    C. tinnitus due to allergic reaction after administration of eardrops.
  30. A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as
    A. a referral.
    B. a consultation.
    C. risk factor intervention.
    D. concurrent care.
    B. a consultation.
  31. A patient with leukemia is admitted for chemotherapy 5 weeks after experiencing an acute myocardial infarction. How will the MI be coded?
    A. acute MI with 5th digit 1-initial episode of care
    B. acute MI with 5th digit 2-subsequent episode of care.
    C. history of MI
    D. chronic MI
    B. acute Mi with 5th digit 2-subsequent episode of care.
  32. In ICD-9-CM, when an exploratory laparotomy is performed followed by a therapeutic procedure, the coder lists
    A. therapeutic procedure first, exploratory laparotomy second.
    B. exploratory laparotory , therapeutic procedure, closure of wound.
    C. therapeutic procedure only.
    C. therapeutic procedure only.
  33. The most widely discussed and debated unique patient identifier is the
    A. patient's date of birth.
    B. patient's first and last name. 
    C. patient's social security number.
    D. Unique Physician Identification Number (UPIN)
    C. patient's social security number
  34. The Central Office on ICD-9-CM, which publishes Coding Clinic, is maintained by the 
    A. National Center for Health Statistics.
    B. Centers for Medicare and Medicaid Services.
    C. American Hospital Association.
    D. American Health Information Management Association.
    C. American Hospital Association.
  35. A nomenclature of codes and medical terms that provides standard terminology for reporting physician's services for third-party reimbursement is
    A. Current Medical Information and Terminology (CMIT).
    B. Current Procedural Terminology (CPT)
    C. Systematized Nomenclature of Pathology (SNOP)
    D. Diagnostic and Statistical Manual of Mental Disorders (DSM).
    B. Current Procedural Terminology (CPT)
  36. A cancer program is surveyed for approval by the
    A. American Cancer Society.
    B. Commission on Cancer of the American College of Surgeons
    C. State Department of Health
    D. Joint Commission on Accreditation of Healthcare Organizations.
    B. Commission on Cancer of the American College of Surgeons.
  37. The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, and international levels?
    A. READ codes
    B. ABC codes
    C. SPECIALIST Lexicon
    D. LOINC
    B. ABC codes
  38. The Level II (national) codes of the HCPCS coding system are maintained by the 
    A. American Medical Association
    B. CPT Editorial Panel
    C. local fiscal intermediary
    D. Centers for Medicare and Medicaid Services
    D. Centers for Medicare and Medicaid Services
  39. A patient is admitted with alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis?
    A. alcoholic withdrawal
    B. chronic alcoholism
    C. cocaine dependence
    D. delirium tremens
    D. delirium tremens
  40. A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia?
    A. pseudomonas
    B. clostridium
    C. staphylococcus
    D. listeria
    A. pseudomonas 
  41. The Level I (CPT) codes of the HCPCS coding system are maintained by the 
    A. American Medical Association
    B. American Hospital Association
    C. local fiscal intermediary
    D. Centers for Medicare and Medicaid Services.
    A. American Medical Association
  42. A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?
    A. fill-thickness skin graft to scalp only
    B. excision of lesion; full-thickness skin graft to scalp
    C. excision of lesion; full-thickness skin graft to scalp; excision of skin from thigh
    D. code 15004 for surgical preparation of recipient site; full-thickness skin graft to scalp
    B. excision of lesion; full-thickness skin graft to scalp
  43. A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.
    A. -25
    B. -55
    C. -57
    D. -58
    C. -57
  44. A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.
    A. -52
    B. -53
    C. -73
    D. -74
    B. -53
  45. A barrier to widespread use of automated code assignment is
    A. inadequate technology
    B. poor quality of documentation
    C. resistance by physicians
    D. resistance by HIM professionals
    • B. poor quality of documentation.
  46. In assigning E/M codes, three key components are used. These are
    A. history, examination, counseling
    B. history, examination, time
    C. history, nature of presenting problem, time
    D. history, examination, medical decision making.
    D. history, examination, medical decision making
  47. Mrs. Jones had a appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit.
    A. -58
    B. -76
    C. -78
    D -79
    C. -78

  48. The primary goal of a hospital-based cancer registry is to
    A. improve patient care.
    B. allocate hospital resources appropriately.
    C. determine the need for professional and public education programs.
    D. monitor cancer incidence.
    A. improve patient care.
  49. A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus. she has type 1 diabetes and was brought under control and subsequently discharged. The following code was assigned:
        648.03 Other current condition in the      mother classifiable elsewhere but complicating pregnancy, childbirth of the puerperium, diabetes mellitus

    Which of the following describes why the coding is in error?
    A. The incorrect fifth digit was used.
    B. The condition should have been coded as gestational diabetes because she is pregnant.
    C. An additional code describing the diabetes mellitus should be used.
    D. Only the code for the diabetes mellitus should have been used.
    C. An additional code describing the diabetes mellitus should be used.
  50. A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a 
    A. disease index
    B. master patient index
    C. disease registry
    D. admissions register
    C. disease registry 
  51. After reviewing the following excerpt from CPT,code 27646 would be interpreted
       
      27645  Radical  resection of tumor;tibia and fibula
      27646              fibula
      27647              talus or calcaneus

    A. 27646    radical resection of tumor; tibia and fibula
    B. 27646    radical resection of tumor; fibula
    C. 27646    radical resection of tumor; fibula or tibia
    D. 27646    radical resection of tumor;fibula, talus or calcaneus
    B. 27646   radical resection of tumor; fibula
  52. A patient was admitted to the hospital with hemiplegia and aphasia. The hemiplegia and aphasia were resolved before discharge and the patient was diagnosed with cerebral thrombosis. What is the correct coding and sequencing?
    A. hemiplegia; aphasia
    B. cerebral thrombosis
    C. cerebral thrombosis; hemiplegia; aphasia
    D. hemiplegia; cerebral thrombosis; aphasia
    C. cerebral thrombosis; hemiplegia; aphasia
  53. A 36-year-old woman was admitted to the hospital for an obstetrical delivery of her third child. During the admission, a sterilization procedure was performed for contraceptive purposes. The V25.2 code for sterilization would be
    A. assigned as a principal diagnosis.
    B. assigned as a secondary diagnosis.
    C. not assigned because this was the patient's third child.
    D. not assigned because it is the same admission as the delivery.
    B. assigned as a secondary diagnosis.
  54. According to ICD-9-CM, which one of the following is NOT a mechanical complication of an internal implant?
    A. erosion of skin by pacemaker electrodes
    B. inflammation of urethra due to indwelling catheter
    C. leakage of breast prosthesis
    D. IUD embedded in uterine wall
    B. inflammation of urethra due to indwelling catheter.
  55. A population-based cancer registry that is designed to determine rates and trends in a defined population is a(N)
    A. incidence-only population-based registry
    B. cancer control population-based registry
    C. research-oriented population-based registry
    D. patient care population-based registry.
    A. incidence-only population-based registry
  56. Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)?
    A. axillary lymph nodes
    B. lungs
    C. breast
    D. A and B
    C. breast
  57. When is it appropriate to use category V10, history of malignant neoplasm?
    A. Primary malignancy recurred at the original site and adjunct treatment is being given at this time.
    B. Primary malignancy has been eradicated and no adjunct treatment is being given at this time.
    C. Primary malignancy has been eradicated and the patient is admitted for adjunct chemotherapy to the primary site.
    D. Primary malignancy is eradicated; adjunct treatment is refused by the patient even though there is some remaining malignancy.
    B. Primary malignancy has been eradicated and no adjunct treatment is being given at this time.
  58. According to CPT, in which of the following cases would an established E/M code be used?
    A. A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. 
    B.John and his family have just moved to town. John has asthma and required medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician.
    C. Tom is seen by Dr.X for a sore throat. Dr.X is on call for Tom's regular physician, Dr.Y. The last time that Tom saw Dr. Y was a couple of years ago.
    D. A 78-year-old female with weight loss and progressive agitation over the past 2 months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years.
    C. Tom is seen by Dr.X for a sore throat. Dr.X is on call for Tom's regular physician,Dr. Y. The last time that Tom saw Dr Y was a couple of years.
  59. In order to use the inpatient CPT consultation codes, the consulting physician must
    A. order diagnostic tests.
    B. document his findings in the patient's medical record.
    C. communicate orally his opinion to the attending physician.
    D. use the term "referral" in his report.
    B. document his findings in the patient's medical record. 
  60. The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician . The following day the consultant visits the patient to evaluate the pateint's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits?
    A. an initial inpatient consult and a follow-up consult
    B. an initial inpatient consult for both visits
    C. an initial inpatient consult and a subsequent hospital visit
    D. an initial inpatient consult and an initial hospital care
    C. an initial inpatient consult and a subsequent hospital hospital visit
  61. According to the American Medical Association, medical decision making is measured by all of the following except the
    A. number of diagnoses or management options.
    B. amount and complexity of data reviewed.
    C. risk of complications.
    D. specialty of the treating physician.
    • D. specialty of the treating physician.
  62. CPT provides Level I modifiers to explain all of the following situations except
    A. when a service or procedure is partially reduced  or eliminated at the physician's discretion.
    B. when one surgeon provides only postoperative services.
    C. when a patient sees a surgeon for follow-up care after surgery.
    D. when the same laboratory test is repeated multiple times on the same day.
    C. when a patient sees a surgeon for follow-up care after surgery.
  63. The best place to ascertion the size of an excised lesion for accurate CPT coding is the
    a. discharge summary.
    B. pathology report.
    C. operative report.
    D. anethesia record.
    C. operative report.
  64. Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?
    A. LOINC
    B. ICD-10-CM
    C. NDC
    D. NANDA
    B. ICD-10-CM
  65. Case definition is inportant for all types of registeries. Age will certainly be an important criterion for accessing acase in a(n)__________ registry.
    A. implant
    B. trauma
    C. HIV/AIDS
    D. birth defects
    • D. birth defects
  66. To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?
    A. ICD-9-CM codes
    B. evaluation and management codes
    C. HCPCS Level II Codes
    D. CPT codes
    D. CPT Codes
  67. The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the
    A. disease index.
    B. tickler file.
    C. accession register.
    D. suspense file.
    C. accession register.
  68. The reference date for a cancer registry is
    A. January 1 of the year in which the registry was established.
    B. The date when data collection began.
    C. The date that the Cancer Committee is established.
    D. The date that the cancer program applies for approval by the American College of Surgeons.
    B. the date when data collection began.
  69. The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions;vital signs on admission; procedures and treatment prior to hospitalization;transport modality; and injury severity score. The hospital uses these data for its 
    A. AIDS registry.
    B. diabetes registry.
    C. implant registry.
    D. trauma registry.
    D. trauma registry.
  70. In relation to birth defects registries, active surveillance systems
    A. use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records,indexes, vital records, and hospital logs.
    B. are commonly used in all 50 states.
    C. miss 10% to 30% of all cases.
    D. rely on reports submitted by hospitals, clinics, or other sources.
    A. use trained staff to identify cases in all hospitals,clinic, and other facilities through review of patient records, indexes, vital records, and hospital logs.
  71. In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to
    A. reliability.
    B. validity.
    C. completeness.
    D. timeliness.
    A. reliability.
  72. The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the 
    A. Agency for Healthcare Research and Quality.
    B. Centers for Medicare and Medicaid Services.
    C. National Library of Medicine,
    D. World Health Organization.
    A. Agency of Healthcare Research and Quality.
  73. The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with
    A. reliability.
    B. validity.
    C. completeness.
    D. timeliness.
    C. completeness.
  74. When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding?
    A. recipient site
    B. donor site
    C. size of defect
    D. type of repair
    B. donor site
  75. In CPT, Category III codes include codes
    A. to describe emerging technologies.
    B. to measure performance.
    C. for use by nonphysician practioners.
    D. for supplies, drugs, and durable medical equipment.
    A. to describe emerging technologies.
  76. The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a 
    A. birth defects registry.
    B. diabetes registry.
    C. transplant registry.
    D. trauma registry.
    C. transplant registry.
  77. In the ICD-9-CM classification system, shooting pain in the right eye due to the presence of an intact, correctly positioned permanent contact lens would be coded as a(n)
    A. current injury.
    B. late effect.
    C. mechanical complication of an internal prosthetic device.
    D. abnormal reaction of the body to the presence of an internal prosthetic device.
    D. abnormal reaction of the presence of an internal prosthetic device.
  78. In the ICD-9-CM classification system, severe shock due to third-degree burns sustained in an industrial accident would be coded as a(n)
    A) current injury.
    B) late effect.
    C) mechanical complication of an internal prosthetic device.
    D) abnormal reaction of the body to the presence of an internal prosthetic device.
    A. current injury.
  79. In the ICD-9-CM classification system, a nonfunctioning pacemaker due to the disintegration of the electrodes (leads) would be coded as a(n)
    A) current injury.
    B) late effect.
    C) mechanical complication of an internal prosthetic device.
    D) abnormal reaction of the body to the presence of an internal prosthetic device.
    B. late effect.
  80. In the ICD-9-CM classification system, an esophageal stricture due to a burn received in a house fire several years ago would be coded as a(n)
    A) current injury.
    B) late effect.
    C) mechanical complication of an internal prosthetic device.
    D) abnormal reaction of the body to the presence of an internal prosthetic device.
    B. late effect.
  81. Dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as a(n)
    A) poisoning.
    B) adverse reaction to a drug.
    C) late effect of a poisoning.
    D) late effect of an adverse reaction.
    • A. poisoning.
  82. Tachycardia after taking a correct dosage of prescribed Lortab would be reported as a(n)
    A) poisoning.
    B) adverse reaction to a drug.
    C) late effect of a poisoning.
    D) late effect of an adverse reaction.
    B. Adverse reaction to a drug.
  83. Blindness due to an allergic reaction to ampicillin administered 6 years ago would be reported as a(n)
    A) poisoning.
    B) adverse reaction to a drug.
    C) late effect of a poisoning.
    D) late effect of an adverse reaction.
    D. late effect of an adverse reaction.
  84. The patient underwent bypass surgery for life-threatening coronary artery disease. With the aid of extracorporeal circulation, the right internal mammary artery was taken down to the left anterior descending artery and saphenous vein grafts were brought from the aorta to the diagonal, the right coronary artery, and the posterior descending artery. What is the correct ICD-9-CM coding for this procedure?
    A) single internal mammary artery bypass; aortocoronary artery bypass of three vessels
    B) aortocoronary bypass of four coronary arteries
    C) aortocoronary bypass of four coronary arteries
    D) single internal mammary artery bypass; aortocoronary bypass of three vessels, extracorporeal circulation.
    D. single internal mammary artery bypass; aortocoronary bypass of three vessels, extracorporeal circulation. 
  85. Patient Jamey Smith has been seen at Oceanside Hospital three times prior to this current encounter. Unfortunately, because of clerical errors, Jamey's information was entered into the MPI incorrectly on the three previous admissions and consequently has three different medical record numbers. The unit numbering system is used at Oceanside Hospital. Jamey's previous entries into the MPI are as followed:
         
         09/03/09 Jamey Smith        MR#10361
         03/10/10 Jamey Smith Doe  MR# 33998
         07/23/11 Jamie Smith Doe   MR#36723

    The next available number to be assigned at Oceanside Hospital is 41369. Duplicate entries in the MPI should be scrubbed and all of Jamey's medical records should be filed under medical record number
    A) 10361
    B) 33998
    C) 36723
    D) 41369
    A. 10361
  86. The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type, is the
    A) record-over-record method.
    B) benchmarking method.
    C) code method.
    D) focused review method.
    A. record-over-record method.
  87. The most common type of registry located in hospitals of all sizes and in every region of the country is the
    A) trauma registry.
    B) cancer registry.
    C) AIDS registry.
    D) birth defects registry.
    B. cancer registry.
  88. A radiologist is asked to review a patient's CT scan that was taken at another facility. The modifier -26 attached to the code indicates that the physician is billing for what component of the procedure?
    A) professional.
    B) technical
    C) global
    D) confirmatory
    A. professional
  89. When coding neoplasms, topography means
    A) cell structure and form.
    B) site.
    C) variation from normal tissue.
    D) extent of the spread of the disease.
    B. site.
  90. According to CPT, antepartum care includes all of the following except
    A) initial and subsequent history.
    B) physical examination.
    C) monthly visits up to 36 weeks.
    D) routine chemical urinalysis.
    C. monthly visits up to 36 weeks.
  91. The Cancer Committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of these data is the
    A) disease index.
    B) operation index
    C) master patient index
    D) cancer registry abstracts.
    D. cancer registry abstracts.
  92. A list or collection of clinical words or phrases with their meanings is a 
    A) data dictionary.
    B) language.
    C) medical nomenclature.
    D) clinical vocabulary.
    D. clinical vocabulary.
  93. The main difference between concurrent and retrospective coding is
    A) when the coding is done.
    B) what classification system is used.
    C) the credentials of the coder.
    D) the involvement of the physician.
    A. when the coding is done.
  94. A patient was discharged from the acute care hospital with a final diagnosis of bronchial asthma. As the coder reviews the record, she notes that the patient was described as having prolonged and intractable wheezing, airway obstruction that was not relieved by bronchodilators, and the lab values showed decreased respiratory function. The coder queried the physician to determines whether the coder for _____ is appropriate  to be added to the final diagnoses.
    A) acute and chronic bronchitis
    B) chronic obstructive pulmonary disease
    C) respiratory failure
    D) status asthmaticus
    D. status asthmaticus
  95. A patient is undergoing hemodialysis for end-stage renal disease in the outpatient department of an acute care hospital. The patient develops what is beleived to be severe heartburn but is sent to observation for several hours, at which time the patient is admitted to inpatient care for further workup. The cardiologist diagnoses the patient's problem as unstable angina. What is the principal diagnosis for the acute hospital stay?
    A) complications of hemodialysis
    B) heartburn
    C) unstable angina
    D) renal disease
    C. unstable angina
  96. A patient is seen in the emergency room of an acute care hospital with tachycardia and hypotension. The patient had received an injection of tetanus toxoid (correct dosage) earlier at his primary care physician's office. Which of the following is the appropriate sequencing for this encounter?
    A) hypotension; tachycardia; accidental poisoning E code (tetanus toxoid)
    B) unspecified adverse reaction to tetanus toxoid; undetermined cause E code(tetanus toxoid)
    C) hypotension; tachycardia; therapeutic use E code (tetanus toxoid)
    D) poisoning code (tetanus toxoid); hypotension; tachycardia; accidental poisoning E code (tetanus toxoid)
    C. hypotension; tachycardia; therapeutic use E code (tetanus toxoid)
  97. A rare malignant tumor often associated with AIDS is
    A) Kaposi's sarcoma
    B) glioblastoma multiforme
    C) pheochromocytoma
    D) melanoma
    A. Kaposi's sarcoma.
  98. A PEG procedure would most likely be done to facilitate
    A) breathing.
    B) eating.
    C) urination.
    D) none of the above.
    B. eating.
  99. What ICD-9-CM coding scheme is used to show that a therapeutic abortion resulted in a live fetus?
    A) spontaneous abortion;V30 code to show a newborn birth
    B) Code 644.21, early onset of delivery;V27 code (outcome of delivery)
    C) abortion by type; V27 code (outcome of delivery)
    D) therapeutic abortion
    B. Code 644.21, early onset of delivery;V27 code (outcome of delivery)
  100. Prolonged pregnancy is a pregnancy that has advanced beyond _____ completed weeks of gestation.
    A) 39
    B) 40
    C) 41
    D) 42
    D. 42
  101. CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10-PCS. The use of these two code sets will be effective on 
    A) January 1,2014
    B) October 1,2013
    C) January 1,2014
    D) October 1,2012
    B. October 1,2013
  102. Mappings between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called
    A) GEMS (General Equivalency Mappings)
    B) Medical Mappings
    C)  Code Maps
    D) ICD Code Maps
    A. GEMS (General Equivalency Mappings)
  103. The code structure for ICD-10-CM differs from the code structure of ICD-9-CM. An ICD-10-CM code consists of
    A) five alphanumeric characters.
    B) 10 characters.
    C) three to seven characters.
    D) seven digits.
    C. three to seven characters.
  104. The first character for all of the codes assigned in ICD-10-CM is
    A) an alphabet.
    B) a number.
    C) an alphabet or a number.
    D) a digit.
    A. an alphabet.
  105. ICD-10-PCS will be implemented in the United States to code
    A) hospital inpatient procedures.
    B) physician office procedures.
    C) hospital inpatient diagnoses.
    D) hospital outpatient diagnoses.
    A. hospital inpatient procedures.
  106. ICD-10-PCS codes have a unique structure. An example of a valid code in the ICD-10-PCS system is
    A) L03.311.
    B) 013.2.
    C) B2151.
    D) 2W3FX1Z.
    D. 2W3FX1Z
  107. ICD-10-PCS utilizes the third character in the Medical and Surgical section to identify the "root operation." The name of the root operation that describes "cutting out or off, without replacing a portion of a body part" is
    A) destruction.
    B) extirpation,
    C) excision.
    D) removal.
    C. excision.
  108. In ICD-10-PCS, to code "removal of a thumbnail," the root operation would be
    A) removal.
    B) extraction.
    C) fragmentation.
    D) extirpation.
    B. extraction.
  109. In ICD-10-CM, the final character of the code indicates laterality. An unspecified side code is also provided should the site not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct the coder to 
    A) assign the unspecified side code.
    B) assign separate codes for both the left and right side.
    C) not assign a code.
    D) query the physician.
    B. assign separate codes for both the left and the right side.
  110. An example of  a valid code in ICD-10-CM is
    A) 576.212D
    B) Z2358.J.
    C) 329.6677.
    D) BJRT23x.
    A. 576.212D

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