CCA Exam Practice Domain 1: Classification Systems

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Logic-based encoder

An encoder that takes a coder through a series of questions and choices is called a?

33222

CPT code for the following procedure: Revision of the pacemaker skin pocket?

49656

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh.

31623

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:

Asthma with status asthmaticus

A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment: What diagnosis should be suspected?

Hematuria; adverse reaction to Coumadin

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?

214.0

Diagnosis code for lipoma of the face:

280.0, 626.8

A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.

Complication

Which of the following is a condition that arises during hospitalization?

660.11, 653.41, 01967, 01968

An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.)

625.6, 59.5

A female patient is admitted for stress incontinence. A urethral suspension is performed. Assign the correct ICD-9-CM diagnosis and/or procedure code.

Complex

CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?

Volume 1

Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?

296.33

The patient was admitted with major severe, recurrent depression. What is the correct ICD-9-CM diagnosis code assignment for this condition?

V codes

Which of the following ICD-9-CM codes are always alphanumeric?

Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13

A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations?

90966

CPT code for 42-year-old diagnosed with ESRD who requires home dialysis for the month of April.

434.90, 342.90, 784.3, 401.9

A patient was discharged with the following diagnoses: "Cerebral occlusion, hemiparesis, and hypertension. The aphasia resolved before the patient was discharged."

Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring

UHDDS, which of the following is the definition of "other diagnoses"?

Congestive heart failure, respiratory failure, ventilaor management, intubation

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of following would be the correct sequencing and coding of this case?

It can be used to collect data about nursing care

Which of the following statements does not apply to ICD-9-CM?

172.6

Diagnosis code for melanoma of skin of shoulder.

786.50, Chest pain NOS

A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out chest pain versus GERD." ICD-9-CM code is:

Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report.

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?

188.3, 57.49

Patient has carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystocscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment?

Subcategory codes

What are the four-digit ICD-9-CM diagnosis codes referred to as?

Centers for Medicare and Medicaid Services (CMS)

Which organization is responsible for updating the procedure classification of ICD-9-CM?

-55

Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure.

58559

CPT code for hysteroscopy with lysis of intrauterine adhesions?

227.0, 255.12

Diagnosis codes for adenoma of adrenal cortex with Conn's syndrome.

Subclassification level

At which level of the classification system are the most specific ICD-9-CM codes found?

CPT

Standard terminology used to code medical procedure and services?

27810, 12032, 12002

Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0 cm superfiscial laceration of the left arm; 5.0 laceration of the scalp with exposure of the fasica; and a concussion. Patient received the following procedure: X-ray of the ankle which showed a bimalleolar ankle fracture which required closed manipulative reduction and simple suturing of the laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill.

49507

49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?

Identification of the supplies, products, and services provided to patients

Which of the following is not one of the purposes of ICD-9-CM?

291.81, 303.00

A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.

592.0, 59.8

Patient with flank pain was admitted and found to have a calculus of the kidney. A ureteroscopy with placement of ureteral stents was performed. ICD-9-CM diagnosis and procedure codes.

54401

CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence.

Cholecystitis

A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient?

Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis

A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be:

Metastatic carcinoma of the brain; history of carcinoma of the prostate

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay?

808.1, 920, E881.0, E849.0, E000.8, E013.9, 79.25, 78.15, 79.65

Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusions of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied, which is the code assignment?

-24, Unrelated evaluation and management service by the same physician during a postoperative period.

Patient returns during a 90-day postoperative period from a ventral hernia; now complaining of eye pain. What modifer would a physician setting use with the Evaluation and Management code?

Volume 3

Which volume of ICD-9-CM contains the Tabular and Alphabetic Indexes of procedures?

Metastatic carcinoma of the brain

A 65-year-old-patient, with a history of lunch cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case?

Code basal cell carcinoma

A skin lesion is removed from a patient's check in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission?

58720

The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?

Catheter-associated urinary tract infection

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urianry tract infection, COPD and hypertension. Which of following diagnoses should not be tagged as POA?

231.0

Diagnosis code for carcinoma in situ of vocal cord.

038.11, 562.11

A 65-year-old woman was admitted to the hospital. She was diagnosed with septicemia to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?

491.21, 403.91, 585.9

A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.

553.20, 427.89, V64.3, 54.11

A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia, which is the correct code assignment?

Miscarriage

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of following should be the principal diagnosis?

97113; 97113

The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is appropriate treatmente codes and/or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting?

Subclassification codes

What are the five-digit ICD-9-CM diagnosis codes referred to as?

Infectious gastroenteritis; chronic obstructive pulmonary disease; angina

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case?

46930

CPT code assignment for destruction of internal hemmorrhoids with use of infrared coagulation?

851.82

ICD-9-CM diagnosis for cerebral contusion with brief loss of consciousness

Query the physician to ask if the patient has septicemia because of the symptomatology.

An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc or urine. The attending physician documents "urosepsis." How should the coder proceed to code this case?

530.81, 42.24

A 35-year-old male was admitted with esophagel reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure.

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