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2016 Annual Self-Review CERTIFIED CODING SPECIALIST–PHYSICIAN BASED Gill Sans ahima.org 2016 Certified Coding Specialist (CCS-P) Self Review 1. This 12-year-old male patient had a nondisplaced comminuted fracture of the left fibula and had treatment in the ED and then with an orthopod. He followed-up with the orthopod for a recheck at three weeks for cast change. Then the family moved out of state and he now presents at a new orthopod after moving. X-rays were ordered which revealed almost complete healing of the fracture; scheduled for another appointment in two weeks to remove the cast. How is this visit coded? a. S82.45 b. S82.455D c. S82.455S d. Z47.89 2. A 79-year-old male patient was admitted to the hospital for aspiration pneumonia. The patient also has a history of an acute cerebral infarction that resulted in left-sided weakness of his dominant side. What is the code assignment for the residual left-sided weakness? a. I69.352 b. I69.398, R53.1 c. I69.30, R53.1 d. I63.9, R53.1 3. A TMVR was performed with a percutaneous approach for mitral valve repair with a transeptal puncture. An additional device was required to decrease the mitral regurgitation. How is this coded? a. 0345T b. 33418, 33419 c. 33418 d. 33419 4. How is hallux limitus correction (without osteotomy) coded? a. 28288 b. 28289 c. 28290 d. 28292 5. What code is assigned for saccadic eye movement testing with recording? a. 92265 b. 92499 c. 92225 d. 92700 6. A right-sided radiocephalic AV fistula was created, after a right upper extremity ultrasound was performed. How is this coded? a. 36821 b. 36821, 76998 c. 76998 d. 36821, 76998-59 7. Synovectomies of the extensor pollicis longus and extensor digitorum of the wrist were performed. How is this coded? a. 25118 b. 25110 c. 25118, 25118-59 d. 25118--22 8. This 55-year-old male has a contracture with limited range of motion in the right second finger. A tenolysis and capsulotomy was done on the flexor tendon at the IP joint. How is this coded? (Do not assign modifiers in this exercise) a. 26440 b. 26525 c. 26445 d. 26440, 26525 9. A colonoscopy was performed and a small rectal polyp was removed with bipolar cautery. How is this coded? a. 45384 b. 45385 c. 45380 d. 45999 10. An 82-year-old male has a leadless pacemaker system which needs to be replaced. The device is removed and the new pacemaker is inserted. How is this coded? a. 0388T b. 0387T c. 0388T, 0387T d. 33999 11. How is an endoscopic medial maxillectomy coded? a. 30520 b. 31225 c. 21049 d. 31299 All questions were referenced with sources dated March 2016 or earlier 2016 Certified Coding Specialist (CCS-P) Self Review 12. This is described as a paraneoplastic syndrome, also referred to as acral psoriasiform dermatosis and acrokeratosis paraneoplastica. It affects the skin and is usually associated with a malignant neoplasm. a. Bazex syndrome b. Skin necrosis c. Eczema-thrombocytopenia syndrome d. Conn’s syndrome 13. A type 1 diabetic patient was admitted to the hospital because of lethargy. Blood sugar readings were low. The diagnosis was documented as acute encephalopathy secondary to hypoglycemia. How is this coded? a. E10.641 b. E10.641, G93.40 c. E10.641, E10.69, G93.49 d. E10.649, G93.41 14. Which of the following statements is false regarding intrauterine pressure monitoring during labor? a. It refers to a monitoring electrode b. It refers to a pressure gauge c. It provides exact measurements of contractions d. It is inserted into the uterus to evaluate contractions 15. Which of the following syndromes is described as an abnormality in the electrical activity of the heart muscle with disruption of the heart’s normal rhythm, because the heart takes less time than usual to recharge between beats? a. Bernheim’s b. Beau’s c. Short QT d. Sick sinus 16. According to the 2016 HHS OIG Work Plan, the OIG introduced which of the following for review in 2016? a. Physician home visits b. Non-covered services for anesthesia c. Services, supplies, and DME referred/ordered by physicians d. All of the above 17. Which E/M service is introduced in the 2016 HHS OIG Work Plan? a. Consultations b. Prolonged services c. Home health d. Domiciliary 18. When coding in the Biliary Tract of CPT, what is defined as a percutaneously placed device that is positioned within the biliary tree and is completely internal, with no portion extending outside the patient? a. External biliary drainage catheter b. Internal-external biliary drainage catheter c. Stent d. All of the above 19. The patient presents with left flank pain and fever. Diagnosis documented: acute pyelonephritis due to E.coli that is resistant to Cipro. a. N10, B96.20, Z16.23 b. N10, A49.8 c. N10, B96.20 d. N10, B96.20, Z16.11 20. A patient was treated in the ED and has the following diagnosis: septic shock with acute MRSA sepsis. How is this coded? a. R65.21, A41.02 b. A41.02, R65.21, A49.02 c. A41.02 d. A41.02, R65.21 21. This 54-year-old patient has bladder cancer. At the time of diagnosis there were significant metastases, and the patient declined surgical intervention. He has mets to the bones, left lung, brain, and liver. He is being treated for the severe metastases in the femurs; he also has neoplasm related pain in the legs. What code(s) are assigned? a. C79.51, C67.9, C78.7, C79.31, C78.02 b. C79.51, C67.9, C78.7, C79.31, C78.02, G89.3 c. C79.51, C67.9, C78.7, C79.31, C78.02, G89.3, R52 d. C79.51, C67.9, C78.7, C79.31, C78.02, R52 All questions were referenced with sources dated March 2016 or earlier 2016 Certified Coding Specialist (CCS-P) Self Review 22. This female patient is receiving blood transfusions for severe anemia due to carcinoma in the lower-outer quadrant of the left breast. What code(s) are assigned? a. D63.0, C50.512 b. C50.512, D64.9 c. C50.512, D63.0 d. D64.9, C50.511 23. The patient was seen for increasing shortness of breath. He has increased exacerbation of his diastolic heart failure. He was not able to afford his Lasix this month, and has not taken any for 10 days. Diagnosis: acute on chronic diastolic heart failure. a. I50.33 b. I50.33, T50.1X6A c. I50.31 d. I50.33, T50.1X6A, Z91.120 24. An 85-year-old patient has crescendo angina with ASHD. He has no history of CABG. He did have a stroke 2 years ago with residuals of right-side hemiparesis. How is this coded? a. I25.110, I69.351 b. I25.10, I20.0, I69.351 c. I25.118, I69.351 d. I25.119, I69.359 25. The documentation is: nosocomial pneumonia with hemoptysis and acute respiratory failure. How is this coded? a. J15.9, J96.00, Y95 b. J18.8, J96.00, R04.2 c. J18.9, J96.00, R04.2, Y95 d. J18.9, J96.00, Y95 All questions were referenced with sources dated March 2016 or earlier MX1928.16CCS-P