1. A patient was admitted for vaginal delivery with gestational diabetes.

Following delivery, she

sustained a second-degree perineal laceration. What is the correct Present on Admission (POA)
assignment for both conditions?

A. Gestational Diabetes - POA: Y, Second-degree laceration - POA: N

2. Which of the following major comorbid conditions can significantly impact DRG assignment?

A. Anoxic Encephalopathy

B. Coma

3. A patient was electively admitted for colon cancer screening and later developed atrial fibrillation,
requiring ICU transfer.

Answer: Assign colon cancer screening as the principal diagnosis and atrial fibrillation as a
secondary diagnosis.

4. When a patient is transferred from an acute-care facility to a skilled nursing facility, what
abstracted data element can impact the DRG assignment?

a. Admission source b. Patient’s blood type c. Discharge disposition d. Patient’s age

5. A physician provided moderate MDM and a 45-minute discharge summary E/M service. What is
the correct CPT coding?

99221,99239

99221,99238

99222,99238

99222,99239

6. Which lab test is used to determine CKD stage?

Answer: GFR (Glomerular Filtration Rate)

7. Which of the following scenarios represents a HIPAA violation?

Answer: Discussing HIV test results with a patient in the waiting room

8. What is a covered diagnosis for a patient prescribed Epoetin Alfa?

Answer: N18.6 (ESRD) and D63.1 (Anaemia in CKD)

9. Which statement is correct regarding H&P documentation?

Answer: H&P documentation must be completed within 24 hours of admission.

10. Which government agency provides compliance program guidance for physician practices?

Answer: OIG (Office of Inspector General)

11. A patient was discharged after a biopsy for a mass. Pathology results returned 3 days post-
discharge. What should be done?

Answer: Determine whether a “Yes” or “No” question to the physician is required regarding the
pathology report.

12. A coder notices identical verbiage in all progress notes. What issue does this indicate?

Answer: Cloning (copy and paste)

13. A patient has mononeuropathy with a history of Type 1 Diabetes. How should this be coded?

Answer: E10.41

14. A patient presents with CKD stage 5 and ESRD and is on haemodialysis. How should this be
coded?

Answer: N18.6, Z99.2

15. Which programming language is commonly used in Computer-Assisted Coding (CAC)?

Answer: NLP (Natural Language Processing)

16. How does CAC software impact coders?

Answer: It increases the number of charts coded per day.

17. What is the required time frame for collecting H&P documentation after inpatient admission?

Answer: 24 hours

18. According to Medicare, when must an H&P be completed?

Answer: Within 30 days before or 24 hours after admission or registration, but before surgery

19. A physician documents alcohol use, abuse, and dependence. How should this be coded?

Answer: Code only dependence (F10.20)

20. If there is a discrepancy between the pathology report and attending physician documentation,
what should be done?

Answer: Return the record to the attending physician for review.

21. How should a case of acute on chronic renal failure be coded?

Answer: N17.9 (Acute), N18.9 (Chronic)

22. Which organization collects data for severity of DRG assignment?

Answer: CMS

23. What tool helps identify CC/MCC conditions most accurately?

Answer: Medicare Code Editor (MCE)

24. A patient presents with SOB and pedal oedema and is treated with Lasix. What potential
condition should the coder query?
Answer: CHF
25. A patient presents with SOB and edema, with a history of HTN, CHF, CKD, and Diabetes. Final
diagnosis is exacerbated diastolic CHF. How should this be coded?

Answer: I13.0, I50.33, E11.22, N18.9

26. A patient underwent surgery for a renal mass. Discharge summary indicates renal
adenocarcinoma. How should this be handled?

Answer: Query the attending physician to confirm adenocarcinoma diagnosis.

27. What does APC Status Indicator “N” mean?

Answer: No additional payment is made for services with Status Indicator N.

28. What are symptoms of sepsis?

Answer: Fever, leucocytosis, tachycardia

29. What is the main requirement under HITECH for EHR implementation?

Answer: To demonstrate meaningful use of EHRs

30. A patient presents with two types of cancer. What query should be raised?

Answer: Clarify if one cancer is metastatic to or from the other.

31. A patient treated and discharged from ED falls under which payment system?

Answer: APC (Ambulatory Payment Classification)

32. A patient was admitted for CHF, and a CDI coder queried for specificity. What type of query is
this?
Answer: Concurrent query

33. A patient admitted for elective mastectomy of the right breast had pathology later show
adenocarcinoma in the left breast. Discharge summary includes this finding. What action should be
taken?

Answer: Query the surgeon for laterality

34. Patient admitted to the hospital with a bedsore on the left ankle and documented partial skin
thickness.

Answer: Pressure ulcer on the left ankle (ICD-10-CM Code: L89.522 – Pressure ulcer of left ankle,
stage 2)

35. Patient diagnosed with renal calculus and underwent ESWL (Extracorporeal Shock Wave
Lithotripsy).

Assign appropriate ICD-10-CM and CPT codes.

Answer:

ICD-10-CM: N20.0 – Calculus of kidney

CPT: 50590 – Lithotripsy, extracorporeal shock wave

36. Patient has had bloody stools for 2 weeks. Physician documented haemoglobin of 7 g/dL and
haematocrit of 25%, and a blood transfusion was administered.

Final diagnoses documented:

Gastric ulcer

Anaemia

Facial lesions

What is the appropriate query opportunity?

Answer: The significant clinical findings of haemoglobin 7 and haematocrit 25% along with blood
transfusion may support a more specific type of anaemia diagnosis, such as acute blood loss
anaemia. A query should be sent to the physician to clarify this.

37. In some cases, for proper Medicare Severity Diagnosis Related Group (MS-DRG) assignment,
which of the following needs to be properly documented?

Answer:

Discharge status

Readmission status

38. MS-DRG calculation requires which of the following?

Answer:

Discharge status

40. The patient was admitted to the hospital with shortness of breath (SOB) and is on regular
dialysis. The patient missed a scheduled haemodialysis session, resulting in fluid overload. Clinical
documentation includes congestive heart failure (CHF) and ESRD

What is the appropriate Principal Diagnosis (PDX)?

Answer:

Fluid overload

Congestive heart failure

ESRD

41. Ambulatory surgery centre required documentation as per federal and state policy.

Ans: History and physical note prior to surgery

42. What is the time limit for complete documentation for OPPS (outpatient)?

Ans:

48 hours
32 hours
24 hours

7 hours

42. Patient admitted last 3 weeks for type 2 MI and he is now coming for subsequent type 2 MI.

Coding Ans: I21.A1

43. NCCI edits example:

Ans: Uniform billing

44. Patient admitted with BMI 47.5 documented by dietician and consulting doctor documented
obesity and attending physician documented morbid obesity.

Ans: Query to attending physician for clarification.

45. Patient coming with excisional debridement of tendon, muscle, bone level how you will code

A. tendon level

B. Muscle level

C. Bone level

D. Code all 3 separately

46. if computer assisted coding (CAC) captures unspecified diagnosis and if specificity is mentioned in
the record, then how will you code it.

Ans. Code for the highest level of specificity as per the documentation

47. Physician performed procedure on left hand third digit, left foot third digit what modifier you
will add

Ans: F2, T2

48. An 11 yrs. old boy presented to the hospital with unilateral Tonsillectomy. What modifier you
will assign for this case?

A. 1-50 B.42820-51 C.42825-59 D.42825-52

49. Mr. Jones admitted to the hospital with cellulitis of left axilla and sepsis and also found to have
an additional diagnosis of PNA and UTI. What is the appropriate ICD-10 CM code assignment for this
scenario?

A.A41.9, L03.112, J18.9 and N39.0

B.L03.112, J18.9, A41.9 and N39.0

C.J18.9, L03.112, A41.9 and N39.0

D.N39.0, J18.9, L03.112 and J18.9

50. Patient admitted to the hospital with Colon mass. Physician performed the polypectomy in the
sigmoid colon and biopsy at the descending colon. What modifier will append for this scenario.
A. XU B. XE C. XP D. XS
51. Mr. Kentucky came to the hospital for dysphagia and SOB. Swallow study was performed shows
normal. Chest x-ray ordered and revealed PNA. Clindamycin IV administration was done. In this case,
for what diagnosis you will raise the query for?

A. Query for Infectious pneumonia

B. Query for COVID-19 Pneumonia

C. Query for Aspiration pneumonia

D. Query for Septic shock.

52. How would follow the chart flow process in IP coding, please choose the correct option and
sequence accordingly?

A. Charge Coded, Service, registration, and diagnostic coding

B. Registration, diagnostic coding, services and charge coded

C. Diagnostic coding, registration, service and charge coded

D. Registration, service, charge coded and diagnostic Coding

53. In DRG 637, Diabetes W/MCC, in below options which MCC affects the selection of MS-DRG?

A. Encephalopathy

B. Acute Respiratory failure

C. Crohn’s disease

D. Chronic bacteraemia

54. Patient presented to the hospital with cachexia, nutritionist documented as 35% of muscle
wasting, weight loss and validated as severe protein calorie malnutrition.

A. Query the attending provider for malnutrition

B. Code the severe malnutrition

C. Query the nutritionist for BMI

D. Code malnutrition unspecified as per the report.

55. Patient presented to the hospital with SOB and leg edema and noted to have CHF.
Echocardiography shows 35% of ejection fraction treated with IV diuretics and IV fluids documented
as acute CHF exacerbation. How would you code this scenario?

A. Query the provider for the acuity of CHF requested by ED provider

B Query the provider as diastolic CHF treated during admission to the attending provider

C. Code the congestive heart failure, unspecified

D. Query the provider as systolic CHF treated during admission to the attending provider.

56. Patient admitted to the IP hospital with NSTEMI, noted to have AKI as SDX, which would be
appropriate DRG on this case?

A. DRG 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

B. 281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

C. 282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

D. 284 ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

57. Which organization establish the HITECH rule

Ans: ONC Office of the national coordinator

58. Please provide the hierarchy of coding the below medicine procedure

A. Injection, infusion and IV push

B. Infusion, IV push and Injection

C. Hydration, injection and IV push

D. IV Push, hydration and IV chemo

59. Pt admitted with sepsis and cellulitis at surgical site, previously placed Knee prosthetic joint, at
the surgical site developed cellulitis but it was not crossed skin level and not effected to knee
prosthesis How you will assign code

Ans: Query for relationship of Sepsis and Cellulitis

60. Pt with sepsis and found to have ARF physician didn’t mention relationship how you will code this

Ans: A. Query for Severe sepsis B. Code severe sepsis, ARF

61. Discrepency between pathology and attending physician

A. return the record to the physician for review

B. return the record to pathologist for review

C. Code from both report

D. Code from attending physician report

62. Mrs. Carolyn Vincent, 86 yrs old woman admitted to the hospital with the dehydration, attending
physician confirming that dehydration was treated as primarily and underwent endocrinologist
stated as hyponatremia treated with IV Fluids. What is the appropriate PDX assignment for this
scenario?

A. Dehydration

B. Hyponatremia

C. Dehydration or Hyponatremia

D. Abnormal lab value

63. In reimbursement coding, CPT codes are paid under which payment system in reimbursement
methodology?

A. IPPS-Inpatient prospective payment system

B. APC-Ambulatory payment classification

C. OPPS-Outpatient prospective payment system

D. Hospital outpatient billing.

64. Patient coming with colon cancer and anaemia

, anaemia due to cancer

Ans: C189, D63.0

65. Patient coming osteoarthritis of right hip physician performed THA procedure in I.P settings by
using metal on polyethylene and applied cemented what is the diagnosis and procedure code

Ans: M1611, PCS:0SR9029

66. The Patient has HTN with ESRD. haemodialysis What is ICD codes

Answer: I12.0, N18.6, Z99.2

67. Patient admitted for SOB and elevated troponin and EKG shows abnormalities. Discharge note
documented as NSTEMI, what is ICD code for NSTEMI

Answer- I21.4

68. Patient presented to the hospital for PNA treating with antibiotics and also have respiratory
failure,

treating with BIPAP, Impression 1. Aspiration pneumonia2.Respiratory failure

in this case, for what condition we need to raise the query for?

Answer: Query for acuity of Respiratory failure, to specify acute or chronic or acute on chronic.

69. Patient was admitted for fever, tachycardia, elevated CRP, leucocytosis. Which of the

following is

an example of compliant query?

A. The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas

cultured from the blood. Are you treating for sepsis?

B. In this patient admitted with pneumonia, the admitting history and physical examination

reveals

the following:
WBC 14,000 ; Respiratory rate 24; Temperature 102° F; Heart rate 120; Hypotension; Altered

mental

status; IV antibiotic administration

IV fluid resuscitation. Please document the condition and the causative organism (if known)

in the
medical record

C. The patient has elevated WBCs, tachycardia, and is given an IV antibiotic for Pseudomonas

cultured from the blood. Are you treating for severe sepsis?

D. In this patient admitted with pneumonia, the admitting history and physical examination

reveals

the following:

WBC 14,000; Respiratory rate 24; Temperature 102° F; Heart rate 120; Hypotension; Altered

mental

status; IV antibiotic administration

IV fluid resuscitation. Please document the condition for severe sepsis

70. Patient presented to ED. Which of the following symptom is recorded for the ordering of BNP
test
a. Chest pain
b. Chest pressure
c. SOB
d. Pleurodynia

71. 3 weeks of delivery, vaginal discharge, and foul smell was found and confirmed to have a sepsis
specified as MRSA Puerperal sepsis. How would you report this service?

A.O85, B95.62 B. O85, B95.61 C. O85, B95.3 D. O85, B96.20

72. Patient presented to the hospital with SOB, patient developed Complication and transferred to
the Veterans administration hospital. What is the correct disposition assignment for this report?

A. Transferred to Federal hospital B. Transferred to acute care hospital C. Discharged to home

health D. none of the above

74. Physician performed laparoscopic cholecystectomy in IP hospital. What is the correct ICD-10 PCS
assignment for this case?

A.0FT44ZZ B.0F944ZZ C.0FTG4ZZ D.0F180Z4

75. Patient presented to the hospital with Skin tags removal of 25 lesions, how would you assign the
correct CPT code for this scenario?

A.11200 B.17110 C.11200, 11201 D.10060

76. Patient presented to the hospital with PNA, after admission noted to have UTI due to indwelling
catheter, what is the correct PDX selection for this case?

A.T83.512A, N39.0, J18.9 B. T83.511A, J18.9, N39.0 C. J18.9, T83.511A, N39.0 D. T83.714A

78. Patient admitted for planned cholecystectomy, general anaesthesia administered, patient
developed hypotension, and physician terminated the procedure after administration of
anaesthesia. What is the appropriate CPT modifier you will assign in this case?

A.73 B.74 C.59 D-79

79. Acute Suppurative otitis media in (ASOM) AD coded as

A.H66.002 B.H66.001 C.H66.23 D.H66.43

80. Patient presented to the hospital with ESRD underwent left

kidney transplant transferring kidney from twins. How would you code transferring kidney from
identical twins in this case?

A.0TY10Z1-Identical Twins-Syngeneic B.0TY10Z0-Identical Twins-Allogenic

C.0TY10Z2-Identical twins-Zoo plastic D. None of the above

81. Patient presented to the hospital with Blepharoplasty for right upper eyelid and left upper eyelid
in this case. What is correct modifier for Eyelid in CPT Coding?

A. 2-E1 and 15822-E3 B.15822-50 C. 15822-E2 and 15822-E4 D. All of the above

82. Patient presented to the problem with stroke, hemiparesis, and dysphagia. Hemiparesis is the
main problem and primary focus of treatment. Which condition affects the DRG for this scenario?

A. Hemiparesis B. Post-CVA Complication C. CVA D. All of the Above

83. As per the ICD-10 PCS Coding, F0D belongs to which category?

A. Physical Rehabilitation and diagnostic audiology B. Mental Health C. Administration D. Nuclear

medicine

84. Patient admitted to the hospital with IP admission, after two days of admission patient was
getting discharged. Under what payment system it is get reimbursed?

A. OPPS B. IPPS C.MS-DRG D. Outpatient rehab centre

85. Patient presented to the hospital with left inguinal hernia not as incarcerated and recurrent and
repaired was performed with mesh. How would you code the scenario?

A. 1-LT, K40.90 B.49505-LT, K40.90 C.49565-LT, K40.90 D.49570-LT, K40.92

86. Intercarpal fusion of left hand with bank bone graft- -0RGR0KZ

87. Intercarpal fusion of right hand with bank bone graft- -0RGQ0KZ

88. Patient presented to the hospital with planned chemotherapy for 5 th cycle for lung cancer and
noted to have anaemia, neutropenia and thrombocytopenia on recurrent admission condition also.
In this case, how would you follow this?

A. Code the Pancytopenia due to chemotherapy

B. Code the anaemia, neutropenia and thrombocytopenia

C. Query the provider as pancytopenia due to chemotherapy

D. All of the above.

90. Medically unlikely edits are used to identify:

a. Pairs of procedure codes that should not be billed together

b. Maximum units of service for a HCPCS, CPT code

c. Diagnoses that do not meet medical necessity

d. Procedure and gender discrepancies

91. A 75-year-old patient is admitted for a complex, ventral hernia repair. While in the hospital, the
patient slips and falls, suffering a left hip fracture. Will the hip fracture be identified as part of the
facility’s patient safety indicators (PSI)? Why or why not?

a. No, the hip fracture is the principal diagnosis and will not be part of the PSI

b. Yes, the hip fracture is the principal diagnosis and would still be part of the PSI

c. No, the hip fracture is a secondary diagnosis and therefore, will not be part of the PSI

d. Yes, the hip fracture is a secondary diagnosis and will be part of the PSI

92. Pt has SOB chest pain X-ray chest shows normal but potassium levels elevated for which
condition we can rise query

Ans: Hyperkalaemia

93. Use of encoder software

A. Appointment for treatment

B. medical record document converts in to codes for billing

94. The rule which restricts entity without disclosing pt details

Answer: Privacy rule

96. Pt comes with SOB, wheezing after treatment provider noted pt discharged with

in 24 hours, what kind of visit

Ans: Outpatient visit

97. In report paediatrician mentioned baby is premature 36 weeks but in mother record 38 weeks is
mentioned. How you will code this scenario

Ans. raised query to paediatrician

98. Pt Coming with anyone one diagnosis Provider states POA Indicator Can not determine by me
what is the POA Indicator

Ans. W

99. What is the diagnosis code for Congenital zika virus disease -

Ans. P35.4
100. Patient came with fever leucocytosis WBC 15000 urine culture shows positive physician final
diagnosis mentioned UTI. What is the POA for UTI

Answer Y
101. Patient admitted with CHF decompensated and respiratory failure and COPD exacerbation both
are treated patient has condition has DM type2, HTN, dementia-several episodes of CVA and patient
treated to antibiotics and home O2 In this scenario what condition raise for query

A. respiratory failure
B. COPD

C. CVA

102. Hypertensive urgency ´ acute kidney injury pt is on anti-hypertensive medication

icd codes- I16.0, N17.9, Z79.899

103. Patient admitted with calculus of gallbladder and cholecystitis physician done for
cholecystectomy how will you code this scenario.

A. calculus of gallbladder acute cholecystitis with obstruction

B. calculus of gallbladder with chronic cholecystitis without obstruction

C. Other cholecystitis

104. Level 2 HCPCS comes under

A.RA

B. LD

C. CX

105. HIPAA and HITECH given title

A.Title 1

B. title 2
C. title 3

106. pt admitted for fever (unknow origin) and sepsis, vital signs tem() and bp 90/60 Antibiotics and
iv fluids are given , what would be coder as given

a. Code sepsis

b. query for physician .

c query for lack indicator

d. Unknown origin fever

107. Pt admitted gastric ulcer with bleeding, during stay pt complaint abdominal pain, under
investigation find appendicitis with peritonitis without obstruction What is mcc condition in this case

A. gastric ulcer with bleeding

B, esophageal ulcer

C .appendicitis with peritonitis

108. OB case Obesity and GDM , Oligohydramnios is in ultrasound, admitted for labor ,prolonged
stage of labor to due to malpresentation so planned for c

section what is the PDX

Ans: Oligohydramnios’s-O4100X0 series

109. vaccination code for pneumococcal conjugate vaccine

cpt- 90471 ,90670, : ICD Z23

110. The HIPAA retention requirements are that certain types of documents must be maintained for
six years from the date of their creation or from the date on which they were last in effect,
whichever is later.

Ans: six years

111. physician performed left total knee arthroplasty procedure what is the CPT code

Ans:27447-LT

112. Renal failure documents one physician and renal insufficiency documents other physician what
is coding professional will do

Query to attending physician

113. HITECH is part of which legislative organization?

A. Cms

B. Apc

C. HIPPA

D. Mce

114. Ob pt admitted to hospital at 15 weeks of gestation and has HTN discharge with losartan how
will you code this?

Ans. 010912 and Z3A15

115. Pt have lung cancer and metastatic bone cancer, now present for radiation therapy in this
scenario what Will be the pdx

a) lung cancer

b) bone cancer
c) encounter radiation therapy, lung cancer, bone cancer

d) lung cancer, bone cancer, encounter radiation therapy

116. As per patient history of present illness is collected and pt is having type DM 1, as per physician
note pt having type 2 dm with PVD

Ans: E11.51

117. Physician performed CABG and develops post operative respiratory failure and 3days
mechanical ventilation DRG value

Ans: 233

118. What is the use of RX Norm

Ans: RX Norm is used to provide standardized names and unique identifiers for clinical drugs

119. Pt having sob, wheezing, nausea and moderate persistent asthma

A. J45.40

B. Sob, nausea, wheezing, moderate persistent asthma

C. Sob, nausea, moderate persistent asthma

D. Sob codes

120. Pt having chest pain tachycardia, UTI, proximal a.fib and pt is on eliquis what is the PDX

A. N39.0, i4819

B. I480,N39.0, Z7901

C. I4891

121. Supervisor asking another physician for CHF clarification but pt already left the hospital and
discharged to home what type of query we can rise

Retrospective Query

Concurrent query

122. patient present with cataract surgery with some instrument name & lens. Which book Code
edits come under that

HCPCS

CPT

PCS

125. Pt have renal mass, surgeon done nephrectomy procedure. Pathologist documented renal cell
carcinoma but final assessment documented renal mass what Will be the query need

a) query the pathologist

b) query the attending physician

C) code the renal cell carcinoma

D) code the renal mass

126. Pt has a history of type 1 DM and now came for elevated blood glucose level, physician
documented type 2 DM. And also pt have hx of CKD sage 3

a) type 1 DM hyperglycemia

b) type 2 DM hyperglycemia

c) type 1 DM hyperglycemia, DM+CKD combo code

d) type 2 DM hyperglycemia, DM+CKD combo code E1165, E1122, N1830

127. Physician performed procedure on right middle finger and ring finger modifier you will add

Ans: F7, F8

129. pt coming severe CAD, Pmh documented HTN, DM pt also have arthritis what is the POA for
above conditions

POA-Y for all conditions

130. What is the minimum penalty for HIPPA violations?

A. 100 $

B. 250$

C . 500$

D. 750 $

131. Patient coming for planned colonoscopy

*Elective

*Urgent

132. pt come with hematemesis and found swelling in left lower leg, physician documented
gastritis and cellulitis, physician performed esophagus biopsy with EGD and debridement on
left lower leg subcutaneous level please code sequence

1. Ans:0JBP0ZZ,0DB58ZX
2. 0JBP0ZZ-Excision of Left Lower Leg Subcutaneous Tissue and Fascia, Open Approach

0DB58ZX-Excision of Esophagus, Via Natural or Artificial Opening Endoscopic, Diagnostic

134. Transmit pt health information procedure information for billing purpose is which type
of HIPPA violation

Answer. Accountability
135. Pt admitted for sigmoid colon biopsy, after the procedure, pt was noted to have
bleeding and control of bleeding was performed followed by a total sigmoidectomy
procedure. What are the root operations coded

1. Ans: Excision, Control, Resection; 0DTN0ZZ; 0DBN0ZX

2. 0DTN0ZZ.-Resection of Sigmoid Colon, Open Approach
3. 0DBN0ZX-Excision of Sigmoid Colon, Open Approach, Diagnostic

136. Pt coming with Morbid obesity, BMI 60 what is the ICD Codes

ANS, E66.01, Z68.44

E66.01-Morbid (severe) obesity due to excess calories

Z68.44-Body mass index [BMI] 60.0-69.9, adult

137. Case mix index based on which group

Ans: MS-DRG

138. Pt admitted with the AKI incidentally pt found to have hyponatremia and dehydration so
many sdx are there and haemodialysis procedure done. code the scenario (Same type of
question)

1. Ans: just select the option which is having AKI as PDX

2. 5A1D70Z-hemodialys

139. A patient has findings suggestive of chronic obstructive pulmonary disease (COPD) on
chest x-ray. The attending physician mentions the x-ray finding in one progress note but no
medication, treatment, or further evaluation is provided. The coding professional should:

1. Query the attending physician regarding the x-ray finding

2. b. Code the condition because the documentation reflects it
3. c. Question the radiologist regarding whether to code this condition
4. d. Use a code from abnormal findings to reflect the condition

141. Patient presented to the hospital with atrial fibrillation secondary to noncompliance of
warfarin due to financial problem how would you code the diagnosis for the services?

A.I48.91, T45.7X5A, Z91.19

B.I48.91, T45.516A, Z91.120

C.Z91.19

D.I48.0, T45.7X6A, Z91.120

143. AIDS Pt came to the hospital with fracture coding sequence.?

Answer: Primary code Fracture, Secondary code AIDS

144. Which year HIPPA become law -1996

145. What is the use of CAC software -Code description data

1. Pt. Admitted for labour and delivered an infant, Vacuum was used, due to vacuum infant
sustained Cerebral haemorrhage.

Code the scenario with POA.

(Z38.00 must not list primary in mothers record)

2. Patient admmited for chronic pancrectitis and also has history of DM 2 with retinopathy in both
eyes right greater than left. Code the sequance

PDX – Chronic pancreatitis SDX – E11.319

3. Coder listed 10005 and 76942, NCCI edits stated bundling issue.

- Remove 76942

4. Injection in RT. Paravertebral joints in Lumbar L3 to L5region.

Ans- 64493 - RT

64494 - RT

5. Pt. Has SOB, Wheezing, Rales after having meal at last night, treated with IV Vancomycin,
Query?

Ans: Aspiration pneumonia

7. Sodium Level 120,122, – Hyponatremia

8. Improper/unclear documentation, meant to be.

Ans- Conflicting documentation

9. HITECH rule is meant for

Ans- Incentive for provider for implementation of EHR.

2. What is the HITECH Act of 2009? EHR implementation

3. What should be present in EHR format?

Ans - Electronic signature

4. What actions should be taken if nurse share patient information

Ans: Report to nurse Authorities

5. What are the Goals of the HITECH Act?

Ans - Ensure privacy and security

6. Can Postoperative Respiratory Failure be considered as PSI

ANS: YES Postoperative respiratory failure as part of PSI

7. How many levels of patient severity diagnosis etc

Ans - 4

8. Patient admitted with SOB and diagnosed with COPD exacerbation what action will you take ?

Ans: J44.1

9. What is the revenue code for 42820 cpt code

Ans :0360

10. Patients has diabetes and fatigue, lethargy and labs performed are glucose BS, PTT/PT/iN, K, NA-
find which test does not match with the condition above.

Ans: PTT/PT/IN

11. What type of safeguard includes automatic log-offs and encryption in EHRs?

A. Administrative

B. Physical

C. Technical

D. Legal

Answer: C

12. Which of the following is one resource for determining medical necessity for outpatient services?

a. Medically Unlikely Edits (MUEs)

b. National coverage determinations (NCDs)

c. Clinical validation denials (CVDs)

d. Advanced Beneficiary Notice (ABN)

13. A coder working in work from home in living room friends came to meet the friend while talking
the friends and he doing the work patient health details. The screen is unlocked. The screen is visible
to friends’ what action would be taken?

A. Physical

B. Technical

14. X Hospital recruited a physician for the services on the days of Monday, Wednesday, Thursday.
For remaining days, he works in another location as endocrinologist. He refers the pt from X hospital
to his location hospital. Which type of violation it is?

Ans: Civil Violation, Stark Law

15. Previously performed surgical cholecystectomy, now pt coming with abdominal pain physician
ordered ultrasound and found sponge at surgical site how you will code

Ans: T81590A
 Case Studies

1. Chief Complaint:
Right-sided facial droop, aphasia, and right-sided
weakness.
History of Present Illness (HPI):
The patient presented to the hospital with sudden
onset of right-sided facial droop, difficulty
speaking (aphasia), and right-sided weakness.
Symptoms began approximately [insert time of
onset] prior to arrival.
Past Medical History:
Type 2 Diabetes Mellitus
Hypertension
High cholesterol
Surgical History:
No significant surgical history
Social History:
Non-smoker
Non-alcoholic
Review of Systems (ROS):
Constitutional: No fever or chills

Neurological: Aphasia, right-sided weakness, right

facial droop
Other systems: Unremarkable
Physical Exam:
General: Alert, cooperative
Neurological: Right facial droop, right upper and
lower limb weakness, aphasia
Cardiovascular and Respiratory: Normal
Other systems: Unremarkable
Assessment:
Acute ischemic stroke due to embolic occlusion in
the right MCA (M1 segment)
NIHSS score: 12 on admission
Investigations:
CT Head and Brain: Acute embolic stroke
involving the right MCA, M1 segment

Procedure: Stent Retriever Thrombectomy

Indication:
Acute ischemic stroke due to large vessel
occlusion in the right MCA-M1 segment.

Procedure Details:
The patient was taken to the angiography suite and
positioned supine. Under ultrasound guidance, the
right common femoral artery was accessed using
the Selinger technique and a 6F sheath was
inserted. A 6F guide catheter was advanced into
the right internal carotid artery. Cerebral
angiography confirmed occlusion of the right
MCA at the M1 segment.

A microcatheter and microwire were advanced

through the thrombus. A stent retriever device
(e.g., Solitaire 4x20 mm) was deployed across the
thrombus. After 5 minutes of integration, the
device was withdrawn with simultaneous
aspiration using a large-bore aspiration catheter.

Recanalization was achieved on the first pass with

a TICI score of 2b/3. Post-procedure angiography
showed restored flow in the MCA territory with no
distal embolization. Hemostasis was achieved
using a vascular closure device. The patient
tolerated the procedure well and was shifted to
neurocritical care for observation.

Complications: None intraoperatively.

Discharge Diagnosis:

Acute ischemic embolic stroke, right MCA (M1

segment)
Type 2 Diabetes Mellitus
Hypertension
Hyperlipidemia
Select PDX following one: I63.411
Select SDX following: G81.91, R4701, R29.810,
E11.9, I10, E7800, R29.712
Select PCS following: 03CG3Z7

2. Chief Complaint:
Severe headache associated with nausea and
photophobia.

History of Present Illness (HPI):

The patient presented to the hospital with a sudden
onset of severe headache described as a
"thunderclap headache." The pain reached peak
intensity within one minute and was accompanied
by nausea and sensitivity to light. The patient
reported that this type of headache was unlike any
previous episodes.

Past Medical History:

Hypertension, currently on medication

No other significant medical history
Surgical History:

None
Social History:
Lives with his wife and two children
Employed in the logistics industry
history of smoking and half packets per day 20
years, alcohol, or illicit drug use
Review of Systems:
All systems reviewed and found to be normal
except as noted in HPI:
Neurological: Severe, sudden-onset headache; no
prior similar episodes
Gastrointestinal: Nausea

Eyes: Photophobia

Cardiovascular, Respiratory, Genitourinary,

Musculoskeletal, Dermatological, Endocrine,
Hematologic, Psychiatric: No complaints
Imaging and Diagnosis:
A non-contrast CT head scan revealed evidence of
intracranial haemorrhage. Further evaluation using
CT angiography identified a ruptured aneurysm of
the pre communicating (A1) segment of the
anterior cerebral artery.

Procedure:
The patient was taken to the operating room, and
after sterile preparation and draping, an
endovascular procedure was performed. A catheter
was advanced under fluoroscopic guidance to the
site of the aneurysm. The aneurysm was
successfully treated by deploying coils in the pre
communicating segment of the right posterior
cerebral artery, effectively isolating the aneurysm
from the circulation and preventing further
bleeding.
Discharge Summary:
Diagnosis:
Intracranial haemorrhage due to ruptured artery
aneurysm

Ruptured aneurysm of the pre communicating

segment of the right Posterior cerebral artery
History of hypertension

Procedure Performed:

Endovascular coil embolization of cerebral

aneurysm

Condition at Discharge:

Stable, neurologically intact

Advised follow-up with neurosurgery and

continued antihypertensive therapy

Select PDX following one: I60.31

Select SDX following: I10, F17.210, Z79899

Select PCS following: 03VG3DZ

3. Pt age 96 yrs he was using teeth clips, pt also have advanced dementia
coming with foreign body in left lower bronchus, teeth clip

PDX (T17.598A),
admitted in ED and moved to IP admission procedure performed in IP
setting
Sdx:
Pneumonitis due to solids and liquids-J69.8
PMH Anxiety with depression-F41.8 PMH: Dementia: F03.90, DNR Z66
GERD-K21.9, Z79.899 Long term use of medication
Procedure
Left lower lobe Bronchus FB removal using bronchoscopy, washing of
lung left lower lobe by using bronchoscopy, removal of endobronchial
lesion using forceps and biopsy they perform along with fb removal

OBCB8ZZ-Extirpation
0B9J8ZZ-Drainage
0BDJ8ZX- Extraction

4. Pt have calculus of gallbladder and chronic cholecystitis, physician performed laparoscopic

cholecystectomy with cholangiography,

a. Choose the correct procedure code(s)

47563- Laparoscopy, surgical; cholecystectomy with cholangiography

47562- Laparoscopy, surgical; cholecystectomy

b. Choose the correct principal diagnosis code.

K80.10- Calculus of gallbladder with cholecystitis without obstruction

or

K80.00-Calculus of gallbladder with acute cholecystitis without obstruction

or

K80.20Calculus of gallbladder

c. Choose the correct secondary diagnosis code(s).

Acute pancreatitis-K85.90

Insomnia-G47.00

UTI -N39.0, B95.1

5. PREOP DIAGNOSES:

. Attention to gastrostomy

OPERATIVE DIAGNOSIS: - 1. Attention to gastrostomy and have schizophrenia taking psychiatric

medications on it.

PROCEDURE PERFORMED: Replacement of gastrostomy tube

. INDICATIONS FOR PROCEDURE:

This is a 67year-old male African American male for the attention of gastrostomy and he is
solely. admitted for this purpose only. Suspected infection at the previous gastrostomy site and
patient is schizophrenic and replacement of gastrostomy tube.

DESCRIPTION OF PROCEDURE: After obtaining informed consent and identification of the

patient, the patient was transported to the operating room where monitoring and sedation was
provided by the anaesthesia service. The stomach was distended with air, and the endoscope
advanced through the stomach and pylorus into duodenum and well into the descending
duodenum. The body of the stomach was visualized, and the previous gastrostomy site was
evident and visualized by noting a mucosal opening. A 20 French MIC gastrostomy tube was
placed within the external wound of the previous gastrostomy, and as this was introduced, the
edge of the end of the gastrostomy tube was visible through the hole in the mucosa but seemed
to be slightly off to the side and so would not enter the stomach easily, the gastrostomy tube
was then manipulated, and with some gentle pressure and twisting, the end of the gastrostomy
tube entered the stomach. The balloon on the gastrostomy tube was then inflated and pulled
back to have the flange or the balloon up against the mucosa. No infection at the previous
gastrostomy site. The external flange of the tube was then secured against the skin with the
flange at approximately the 5 cm mark on the tube. Dressing was placed over the gastrostomy
entry site. The patient was then transported to the recovery room in stable condition. 11/02/16
 10:50 Discharged to Home. Impression: Replacement of Gastrostomy tube - Condition is Stable. -
Discharge Instructions: G tube dressings.

1. What is the correct CPT code assignment for this report?

Ans.43762

2. What is the correct PDX code assignment for this report?

Z43.1

1. What is the correct SDX code assignment for this report

schizophrenia (F20.9), CKD-3, HTN.I12.9, N18.30, (Allery to Sulphonamides: Z882,) F41.1-

generalized anxiety

Z87.440 (HX of UTI), F03.90-Dementia

6. Foreign body in Right eye, Corneal - external- got by sticked by wood. Pt using chain saw for
cutting trees
PROCEDURE:
An incision may be required to remove an embedded foreign body (If
so, the physician may cut a V-shaped incision to access the defect
through a flap, or a straight incision may be made. The incision does not
penetrate the cornea. Generally, a slit lamp is used with embedded
foreign body. After the removal, the physician may apply a broad
spectrum antibiotic and a moderate pressure patch over the closed lid
for 24-48 hours.
PMH: HTN, CHF
Social HX: Current every day smoker Cigarette smoking

CPT-65222- Removal of foreign body, external eye corneal, with slit

lamp.
PDX: T15.01XA- Foreign body in cornea, right eye
SDX: W29.3XXA- Contact with powered garden and outdoor hand tools and machinery, initial
encounter
F17.210, I11.0, I50.9, Y92821- forest as the place of occurrence

7. Chin laceration, 1.5 cm with simple repair, physical examination neck tenderness, left shoulder
tenderness, fall external cause, check PMH Dementia, HTN, Migraine, long-term use of medication
code

Gerd on omeprazole in ROS

Pdx: S0181XA
Sdx: M54.2, M25512, F0390, I10, K21.9, G43909, Z79899, W1830XA,
CPT :12011 -Simple repair
/12051- intermediate repair
For intermediate repair check extensive cleaning and heavily contaminated in operative
note
8. Pt coming with acute blood loss anaemia due to chemotherapy,vpt have Liver
to bone metastatic cancer, 2days ago received chemotherapy, physcian
documented pt have dehydration, hyponatremia, physician transfused IV fluids
for dehydration and sodium levels for hyponatremia

Symptom: nausea lethargy blood loss,

Procedure: Physician transfused 2 packs of RBCs, and platelets, through

peripheral vein

PMH: HTN, Hyperlipidaemia

Pdx: D64.81

Sdx: C79.51, C22.8, E87.1, E86.0, I10, E785,

PCS:30233N1-RBC
30233R1-platelets

9. Patient presented to the hospital with

pneumocystis pneumonia due to AIDS, planned
for PICC line placement.
PROCEDURE: PICC Line insertion Reason for
doing the Procedure: pneumocystis Jarocki
pneumonia due to AIDS for Administration of
antibiotics to treat the infection. Other
complications: Dementia due to AIDS, DM and
HTN on medications
the patient was identified by myself on
presentation to the angiography suite. His right
arm was prepped and draped in sterile fashion
from the antecubital fossa up. Under ultrasound
guidance, a #21-gauge needle was placed into his
right cephalic vein. A guidewire was then threaded
through the vein and advanced without difficulty.
An introducer was then placed over the guidewire.
The catheter was cut to 20 cm, then we inserted
back to the introducer. The introducer was
removed. The catheter was secured by two #3-0
silk sutures. Appropriate imaging was then taken.
Sterile dressing was applied. The patient tolerated
the procedure nicely and was discharged from Tip
was confirmed as SVC as per the chest -x ray
report:
1. What is the appropriate PCS code Selection for
this report?
A.02HV33Z,
2. What is the appropriate PDX selection for this
B20
3. What is the appropriate SDX selection for this
report?
B59, E11.9, I10, F02.80,
10. PROCEDURE: Prostatectomy, retro pubic radical, with or without nerve sparing.
INDICATION: Prostate Cancer

PMH HTN, MI

Social hx: former smoker quit few years back

Home medications; Lisinopril, Eliquis

DESCRIPTION OF PROCEDURE: The physician performs a radical prostatectomy (removal of the

prostate gland) through an incision made in the lower abdomen just above the pubic area. In
preparation for removal of the prostate, a catheter is passed into the urethra into the bladder.
Through a lower abdominal incision, with or without care to spare the nerves in the area, the urinary
bladder is exposed and displaced backwards to enter the space behind the pubic bone and expose
the area of the prostate. The gland with the capsule intact and the seminal vesicles and the portions
of the vas deferens in the area are removed by freeing the prostate by blunt dissection and by
transecting the urethra and cutting through the bladder outlet using visi port trocar (Laparoscopic).
The urinary catheter is brought into the operative site and used to create traction for the dissection
by trocar technique. A second catheter is placed in the bladder after the first one is removed along
with the prostate. The transacted urethra is repaired by suturing to the newly created bladder
outlet. A rubber drain is placed in the space between the pubic bone and the bladder and brought
out through a separate stab wound. The dissected tissues and the skin incision are closed in layers
by suturing.

1. Choose the correct procedure code(s)

A.55866- Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic
assistance, when performed

2. Choose the correct principal diagnosis code.

C61- Malignant neoplasm of prostate

3. Choose the correct secondary diagnosis code(s).

HTN I10,

Nicotine dependence quit few years ago: Z87.891.

MI - I25.2

Long term use of anticoagulant pt is on Eliquis: Z79.01

11. pt coming with secondary Lung cancer of left lower lobe lung and GI bleeding, pt also have
Colan cancer, diverticulosis with bleeding

3rd day they did BAL.

4th day bleeding colonoscopy.

And 6th day they just said like pt directed to lung lobectomy. Laparoscopic

And next day discharge

1. Choose the correct principal diagnosis code.

C78.02- Secondary malignant neoplasm of left lung

2. Choose the correct secondary diagnosis code(s).

C18.9- Malignant neoplasm of colon, unspecified

R06.03 Respiratory distress

K57.91- Diverticulosis of intestine, part unspecified, without perforation or abscess with bleeding

R09.02-hypoxemia

3. Choose the correct procedure code(s)

0BTJ4ZZ-Resection of Left Lower Lung Lobe, Percutaneous Endoscopic Approach

0B9J8ZX- Drainage of Left Lower Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic

0DJD8ZZ- Inspection of Lower Intestinal Tract, Via Natural or Artificial Opening Endoscopic

12. Case study (Nephrolithiasis)

Patient admitted with Abdominal pain, Physician ordered diagnostic study ultrasound or CT scan.
Diagnosed with Nephrolithiasis. He will be referred to nephrologist for lithotripsy procedure.

1. Choose the correct principal diagnosis code.

N20.0- Calculus of kidney

2. Choose the correct secondary diagnosis code(s)

None of the above

3. Choose the correct procedure code(s)

None/ No code

13. REASON FOR ADMISSION: Femoral left

intertrochanteric fracture due to Osteoporosis
HISTORY OF PRESENT ILLNESS: The
patient is a 78-year-old male who fell on the day of
admission and sustained a fracture of the neck of
his left femur. The patient was admitted for a
medical evaluation prior to surgical intervention.
PAST MEDICAL HISTORY:
ALLERGIES: None
CHRONIC MEDICATIONS
SOCIAL HISTORY: The patient is widowed
with 3 children and 7 grandchildren. The patient is
a non-drinker and nonsmoker.
REVIEW OF SYSTEMS: The patient has been
in usual health until the day prior to admission
when he fell. There has been no change in bladder
and bowel functioning. Cognitively, he has
dementia.
PHYSICAL EXAMINATION: BP is 170/90,
pulse 80 and regular. The patient is elderly, thin,
somewhat deaf male. His pupils are small and
reactive to light. The pharynx is benign. The
jugular pulse is distended but filled from above.
He has no supraclavicular adenopathy. His chest is
clear. On palpation the pericardium was located in
his anterior axillary line with a palpable thrill. On
auscultation he had a harsh grade III/VI apical
systolic murmur that radiated to the apex and
faintly to the lower left sternal edge. He had a soft
diastolic flow murmur. His abdomen was
somewhat tense without organomegaly. He had
minimal peripheral edema.
DATE: 12/1
PREOPERATIVE DIAGNOSIS: Fracture of left
femoral intertrochanteric due to Osteoporosis
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Open reduction and internal
fixation of fracture left femoral intertrochanteric.
ANESTHESIA: Spinal and general
OPERATIVE INDICATIONS: OPERATIVE
PROCEDURE: The patient was given Ancef 1 g
IV 30 minutes prior to the procedure for
endocarditis/surgical prophylaxis. The patient was
administered a spinal anaesthesia and then placed
on the fracture table in traction. X-rays revealed
satisfactory position and alignment of the fracture
site. The left hip was prepped with Betadine scrub
and Betadine solution and draped in a sterile
fashion. A straight incision was made over the
lateral aspect of the left hip and carried through the
subcutaneous tissue, then tensor fascia Lata and
vastus lateralis muscles so that the fracture could
be reduced and fixation devices utilized. The
lateral shaft of the femur was exposed
subperiosteally. A guide wire was then placed into
the neck and head of the femur and x-rays revealed
a slightly inferior position. The new guide wire
was obtained in satisfactory position. The, and
head of the femur were then drilled to a depth of
85 mm with the drill. An 85-mm, 140-degree and
5-degree compression Gamma nail plate were then
inserted over which a 140-degree angle 4-hole side
plate was then inserted. A compression screw was
then applied after the key was inserted. The side
plate was then fixed to the shaft of the femur with
four screws. X-rays revealed satisfactory position
and alignment of the neck fracture fragments and
the fixation device. The wound was closed with a
continuous #000 Vicryl suture in the vastus
lateralis and tensor fascia lata layers. The
subcutaneous tissue was closed with interrupted
#000 Vicryl sutures and the skin was closed with
staples. A compression dressing was applied. The
patient tolerated the procedure well and there were
no operative complications. Patient was returned
to the recovery room in satisfactory condition.
Choose the correct principal diagnosis code.
a. M80.052A
Choose the correct secondary diagnosis
code(s).

Choose the correct procedure code(s).

0QS706Z

1. Hypertensive urgency-patient
presents with elevated bp-
PDX: I16.0

2. Morbid obesity pdx,

cpt code for gastric bypass robotic assisted
with subcutaneous port
PMH: CKD, DM, HTN
E6601, pdx
Sdx: I12.9, E1122, N18.9, BMI value
CPT:43770
3. DM With Hyperosmolarity with Coma ,pdx,
Procedure: Critical care performed 100
minutes
PDX: E11.01,
Procedure: 99291,99292

4. Gangreneous Appendicitis, PCS laparoscopic

appendectomy
PDX: K35.891, PCS: 0DTJ4ZZ
5. removal of foreign body from foot
patient was tracking on the hill and have for
and got open wound with insertion of wooden
piece into the foot in emergency department the
foreign body was removed from the foot
Puncture wound having foreign body is pdx
S91341A right or S91342A left
SDX: Fall downhill external cause-W1781XA
Forest tackling place of occurance-Y92821
CPT -28190
CPT: removal of F.B-28190 cpt code

6. Patient came with chronic back pain which is

associated with
Pdx: degenerative disc disorder of lumbar
region - M51.360
G8929 -Other chronic pain
Sdx-major depressive disorder F32.9,
homeless Z59.00,
opioid dependence-F11.20
Pcs /cpt- none

7. Left neck lymphadenopathy R59.0

Sdx Validate in document
with excision of
lymphadenectomy cpt code 38500

8. Pt coming with dizziness and headache, G2P2

(pregnancy)
Blood glucose levels high
Pdx: preexisting HTN with Preeclampsia -O11.
series
Z3A.
Sdx: Mental illnesses -O99. 34
Procedure:- lumbar puncture diagnostic 62270

OCT-25
Case studies-1
Pt with left knee osteoarthritis, procedure left knee arthoplasty cemented,
osteoporosis,Hypecalecemia,
Pdx:M17.12
Sdx:,PMH, social HX M81.0,E83.52
PCS; 0SRD069

Case studies-2
Resone for visit: Cellulitis

Hx: I10, B95.62, G47.33, E11.9 (SDX)

Pdx as per laterality left lower or right lower extremity (L03. 115,
L03.116)

CPT: non excisional debridement or non-selective debridement

CPT: 97602
Case studies-3
Patient presented to the hospital with 3 weeks of STEMI and CAD with a past medical history of
History of HTN, DM and hyperlipidemia,hx of tobacco dependence. Physician planned to perform the
CABG for three arteries.
Patient presented to the hospital with CAD and underwent CABG in three arteries from aorta to
coronary arteries –Circumflex artery, marginal artery right Coronary artery and and saphenous vein
harvested from right side-open approach and Cardiopulmonary bypass was instituted. Patient does
not have any complication during the procedures. In this case how would you report this case?
PDX – STEMI OR NSTEMI= PLEASE CHECK THE DOCUMENTS
SDX-CAD HNT, DM, HLD and hx of tobacco dependence.
PPX=== 021209W- CABG in three arteries from aorta to coronary arteries
Primary PCS Code.
 SPX=Harvest of right saphenous vein-06BP0ZZ
SPX-Cardio pulmonary by pass--=5A1221Z-Check the options it is available, if not leave it, asking to
code the

report , option are not available choose no code needed.

Case studies-4

Abdominoplasty case study-

Abdominoplasty at submental fat pad, or Abdomen, pt also have dehydration Hyponatremia

PDX: Z41.1 Encounter for cosmetic surgery

SDX: E86.0, E87.1
CPT:15838 (or) 18530

Case studies-5

Principal diagnosis code: c. I21.19

Acute inferior MI is documented on the 4/20 EKG. This is also evident from the laboratory reports
because the CK-MB is elevated (CMS 2024a, Section I.C.9.e.1, 52).

Secondary diagnosis codes: b. E78.5; c. D62; d. I25.10; e. I44.2; f. K92.0; g. R11.2; h. T41.205A; i.
Z87.891

Procedure codes: a. 021009W; b. 02703DZ; c. 4A023N7; d. B2111ZZ; e. B2151ZZ; f. 0DJ08ZZ; g

06BQ4ZZ; h. 5A1221Z

Case studies-6

Right and left heart catheterization and coronary angiography

PROCEDURE: After obtaining informed consent the patient was taken to the cardiac
catheterization laboratory. The right groin was prepped and draped in the usual fashion and
2% Xylocaine was used to anesthetize. 6-French sheaths were introduced into the right
femoral artery and vein and a 6-French multipurpose catheter was used for the heart
catheterization, coronary angiography, and ventricular angiography. Right heart pressures
and
cardiac outputs were measured. A pigtail catheter was inserted into the left ventricular
cavity
and ventricular pressures obtained. Angiography of the right coronary artery was performed.
Left ventricular angiography and aortic root angiography was performed. The patient
tolerated the procedure well without complications.
DIAGNOSIS: Arteriosclerotic coronary artery disease
Choose the correct first-listed diagnosis code.
a. I25.10
b. I25.110
c. I25.111
d. I25.118
e. I25.119Choose the correct secondary diagnosis code(s).
a. E10.9
b. E78.2
c. E78.5
d. F17.290
e. I10
f. I50.9
g. K21.9
h. K57.30
i. J44.9
j. None apply
Choose the correct procedure code(s).
a. 93451
b. 93452
c. 93453
d. 93454
e. 93456
f. 93460
g. 93563
h. 93564
i. 93565
j. 93567

Case studies-7

INDICATIONS: CAD
PROCDURES PERFORMED: Left heart catheterization, left ventriculography, coronary
angiography, drug-eluting stent to left anterior descending coronary artery
PROCEDURE: After obtaining informed consent the patient was taken to the cardiac
catheterization laboratory. He was prepped and draped in the usual fashion and 2%
Xylocaine
was used to anesthetize the right groin. 6-French sheaths were introduced into the right
femoral artery and vein and a 6-French multipurpose catheter was used for left heart
catheterization, coronary angiography, and left ventricular angiography. I then proceeded to
perform a PTCA with a stent of the LAD. A HTF wire was used to cross the LAD stenosis and a
balloon catheter inserted and inflated for pre stent dilation.
A 4.0 mm Cypher stent was placed in the left anterior descending coronary artery and the
stent deployed by additional balloon angioplasty. Excellent results were obtained. The final
angiogram was obtained and the guiding catheter was removed. The sheaths were securely
sutured and the patient tolerated the procedure well without complications.
FINDINGS:
Left heart catheterization revealed an elevated resting left ventricular end diastolic pressure
of
18 mm Hg.
Left ventriculography: Viewed in the RAO projection with normal systolic wall motion.
The end-diastolic pressure is 18 to 20 mm Hg. There is no gradient detected.
Coronary angiography (using single catheter): The right coronary vessel has dominant
structure with minor luminal irregularities only. The left main is normal with the left anterior
descending coronary artery having a 95% stenosis and the circumflex marginal system with a
10% to 20% plaquing only.
LAD stent underlying: Left anterior descending coronary vessel was easily isolated and the
primary stent intervention was carried out with a 3.0 Cypher drug-eluting stent. Final sizing
was 3.1 mm resulting in 0% residual stenosis and maintenance of TIMI III flow distally in the
LAD system.
CONCLUSION: Critical single-vessel obstructive coronary artery disease involving the LAD
successfully treated with drug-eluting stent technology. The left anterior descending
coronary
artey shows excellent results. Preserved left ventricular systolic wall motion.
Choose the correct first-listed diagnosis code.
a. I25.10b. I25.119
c. I25.720
d. I25.758
e. I25.761
Choose the correct secondary diagnosis code(s).
a. E11.22
b. I10
c. I21.A1
d. I25.119
e. I50.32
f. I73.9
g. N18.6
h. N39.0
i. R33.9
j. None apply
Choose the correct procedure code(s).
a. 92920-RC
b. 92921
c. 92924-RC
d. 92925
e. 92928-LD
f. 92929
g. 92933-LD
h. 93458
i. 93459
j. 93460
.