CCS Coding Exam Review 2011: The Certification Step

PART I 1. The index of the ICD-9-CM indicates the following: Failure, failed renal 586 acute 584.9 chronic 585.9 The medical record states the patient has chronic renal failure and has now been admitted with acute renal failure. Which represents the correct sequence? A. B. C. D. 585.9, 584.9 584.9, 585.9 586, 584.9 Either A or B

CORRECT ANSWER: B. 584.9, 585.9. According to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., the coder is to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is sequenced first and the chronic condition is to be sequenced second. RATIONALE: A. 585.9 reports the chronic condition sequenced first, and the chronic condition should be sequenced second; 584.9 reports the acute condition, and the acute condition should be sequenced first. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., which directs the coder to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is to be sequenced first and the chronic condition is sequenced second. C. 586 reports renal failure that is not specified as acute or chronic, and the renal failure in this report was specified as acute and chronic. 584.9 correctly reports acute renal failure, but according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., the coder is to report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level. The acute condition is to be sequenced first and the chronic condition is sequenced second. D. Either A or B. Only B is correct. The acute condition is to be sequenced first and the chronic condition is sequenced second. See the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.B.10., which directs the coder to
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report both an acute and a chronic condition if there are separate subentries in the Alphabetic Index at the same indentation level.

2. A 4-year-old patient presents to the ED with her mother. The patient is an asthmatic with dyspnea and is in obvious distress. The mother states that the child’s asthma was in good control until later in the day, when she began to develop problems breathing. For the last 4 hours, the mother had administered the child’s albuterol inhalant with no marked improvement. The ED physician directed administration of a nebulizer treatment of albuterol, 3 mL of 0.083%. The documentation indicates asthma with an acute exacerbation. After the initial treatment, the patient began to rapidly improve and was discharged. 493 Asthma The following fifth-digit subclassifications are for use with 493.0-493.2, 493.9: 0 unspecified 1 with status asthmaticus 2 with (acute) exacerbation

493.0 493.1 493.2 493.9 A. B. C. D.

Extrinsic asthma Intrinsic asthma Chronic obstructive asthma Asthma, unspecified

493.01, 99283 493.92, 99284 493.20, 99285 493.12, 99284

CORRECT ANSWER: B. 493.92, 99284. The diagnosis is with acute exacerbation, as documented in the report. The patient received only one nebulizer treatment, as listed in the Level 4, number 6. RATIONALE: A. 493.01, 99283. The level of the ED service is incorrect as there is no nebulizer treatment listed under Level 3. 493.01 reports extrinsic asthma, which is allergic asthma. The diagnostic statements in the report did not indicate this type of asthma. Further, the fifth digit 1 is incorrect, as it indicates status asthmaticus, which is the most severe form of asthma attack and can last for days or weeks; this is not documented in the report. C. 493.20, 99285. 493.20 is assigned to report chronic obstructive asthma, which would be indicated on the report with statements such as “asthma with COPD” or “chronic obstructive asthma,” and this report only indicates unspecified asthma. The fifth digit 0 is also incorrect as it indicates an unspecified status,

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and this report states that the patient was experiencing an acute exacerbation indicated by a fifth digit, 2. 99285, Level 5, is incorrect as the nebulizer treatment listed under that level (number 3) is for three or more treatments, and this patient received only one treatment. D. 493.12, 99284. 493.12 is incorrect because it reports intrinsic asthma, which is asthma that occurs in patients who have no history of allergy or sensitivities to allergens. The fifth digit 2 is correct to report an acute exacerbation. Level 4 is correct.

3. A patient presents to the emergency department with the chief complaint of nausea and recurrent vomiting with dehydration. The nausea with vomiting is listed first in the final diagnoses section of the report. Upon reviewing the medical record, the coder notes that the patient was described as having dehydration secondary to viral pharyngitis with possible ketoacidosis and received infusion therapy. The patient is a type 1 diabetic who has had no complaints with diabetes for the past 6 years, until perhaps now. The patient also has asthma that is stable at this time. The patient was discharged home. The diagnosis(es) would be:

250.01 250.13 276.50 276.51 462 493.90 493.00 787.01 787.02 787.03 A. B. C. D.

Diabetes mellitus without mention of complication, type I (juvenile type), not stated as uncontrolled Diabetes with ketoacidosis, type I (insulin dependent type) (juvenile type), uncontrolled Volume depletion Dehydration Acute pharyngitis Asthma, unspecified Extrinsic asthma, unspecified Nausea and vomiting Nausea alone Vomiting alone

276.51, 787.01, 462, 250.01, 493.90 276.50, 462, 250.13, 493.90, 787.01 787.02, 787.03, 462, 250.13, 493.90 787.02, 276.50, 462, 250.01, 493.90

CORRECT ANSWER: A. 276.51, 787.01, 462, 250.01, 493.90. 276.51 reports the dehydration, 787.01 reports the nausea with vomiting, 462 reports the pharyngitis, 250.01 reports the type I diabetes, 493.90 reports the asthma. The patient’s dehydration was the focus on the ER visit so is the first-listed diagnosis. RATIONALE: B. 276.50 reports volume depletion instead of dehydration. The second listed

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diagnosis should have been the nausea and vomiting (787.01). 462 is correct to report the pharyngitis, 250.13 is not correct because it reports the ketoacidosis—the report indicates “possible,” and outpatient coders do not report possible diagnoses. 250.01 should have been assigned instead to report the type I diabetes mellitus. 493.90 correctly reports the asthma as unspecified. C. This choice is incorrect because it reports the nausea alone (787.02) and the vomiting alone (787.03), but there is a combination code (787.01) that reports both nausea and vomiting in one code, and if there is a combination code available, it must be assigned when both are present. 462 correctly reports the pharyngitis, 250.13 is the correct code for ketoacidosis; however, according to ICD-9-CM Official Guidelines for Coding and Reporting, Section IV.I., “possible” diagnoses are not reported in an outpatient setting. 250.01 should have been assigned instead to report the type I diabetes mellitus. 493.90 correctly reports the asthma as unspecified. The first-listed diagnosis should have been the dehydration, 276.51, and this code is missing from this choice. D. 787.02 is incorrect because it reports nausea alone. Both nausea and vomiting should be reported as 787.01. Code 276.50 indicates volume depletion when the report indicated dehydration and should be coded as 276.51, 462 correctly reports the pharyngitis, 250.01 correctly reports the diabetes, 493.90 correctly reports the asthma as unspecified.

4. A 42-year-old female presents to the emergency room stating that she has significant abdominal discomfort and is supposed to have an upper gastrointestinal series at 8 AM tomorrow morning. She has a gastric ulcer, and the abdominal pain is due to this ulcer. The emergency department physician assesses the patient and orders an abdominal x-ray. The patient’s physician is in the hospital for rounds and is called to the ED to assume the care of this patient. 789.00 789.07 531.90 531.40 Abdominal pain, unspecified site Abdominal pain, generalized Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage, perforation, or obstruction Gastric ulcer, chronic or unspecified with hemorrhage without mention of obstruction or perforation

A. B. C. D.

99283, 531.90 99282, 531.40 99283, 789.00, 531.40 99284, 789.07, 531.90

CORRECT ANSWER: A. 99283, 531.90. The ED physician assessed the patient and requested an abdominal x-ray, reported with Level 3, number 3, x-ray one area (99283). 531.90 reports a gastric ulcer that was not specified as acute or chronic and had no mention of hemorrhage, perforation, or obstruction.

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The report states that the abdominal pain is due to the ulcer. 2010.B.40 is incorrect because it reports a gastric ulcer with hemorrhage. second first or second.CCS Final Examination With Answers RATIONALE: B.07. 2005. C. but because the report states that the abdominal pain is due to the ulcer. first or second none of the above CORRECT ANSWER: B. Section I.40 is incorrect because it reports a chronic gastric ulcer with hemorrhage. According to the ICD-9-CM Official Guidelines for Coding and Reporting Section I. The report states that the abdominal pain is due to the ulcer.B. Elsevier items and derived items © 2011.12.7. 531. as it is for x-rays of multiple areas and this x-ray was for a single area (abdomen). D. 2007. 531. second. indicating that the abdominal pain is a symptom of the gastric ulcer and not reported separately per ICD-9-CM Official Guidelines for Coding and Reporting.. 2009. perforation. A.90 correctly reports the gastric ulcer in which it was unspecified as to chronic or acute and without the mention of hemorrhage. RATIONALE: A. 531. and I. According to the ICD-9-CM Official Guidelines for Coding and Reporting. 99283. 5 . first first. and no hemorrhage was indicated in the report. Level 4 (99284) is incorrect. first or second. the abdominal pain is not reported. 789. 5. the condition or nature of the late effect (the residual) is sequenced first. C.07 is incorrect because it reports generalized abdominal pain. This is an incorrect sequence because according to the ICD-9-CM Official Guidelines for Coding and Reporting. 789. first or second. Code 531. and the late effect code is sequenced second. second.00 is incorrect because it reports abdominal pain of unspecified site. and the late effect code is sequenced second. This is an incorrect sequence because according to the ICD-9-CM Official Guidelines for Coding and Reporting. C. the condition or nature of the late effect (the residual) is sequenced first. 2004 by Saunders. 789.B.40. so the abdominal pain is not reported. 99282. first. 99284. Level 2 (99282) does not include any x-ray service. 531. regarding reporting late effects indicate that residual is sequenced _________ and the late effect code is sequenced _________. B.00.6. D. or obstruction. the condition or nature of the late effect (the residual) is sequenced first. and the late effect code is sequenced second. 531. an imprint Elsevier Inc. 789. first.40.90. 2006. The report does not specify acute or chronic and there is no indication of hemorrhage noted in the report. second. Level 3 (99283) is correct for an x-ray of one area. 2008.

C. 998. but the units listed for code 15101 is wrong. 998. not 8. 15100 is correct for the first 100 sq cm. 15100 is the correct code to report a split thickness autograft of the trunk for the first 100 sq cm or less (45 sq cm). 2007. 998.89 A. 998. B. 15101 × 9.83 998.83 is the correct diagnosis code. 6 . 7.59 998. 15100 × 10. or part thereof (List separately in addition to code for primary procedure) Other postoperative infection Non-healing surgical wound Other specified complications of a procedure 998. Which codes would you use to report the facility services? 15100 15101 Split-thickness autograft. arms. 6. 15100 is the correct code for the first 100 sq cm or less. D. 15100 is correct for the first 100 sq cm. each additional 100 sq cm. A 59-year-old female is brought to the ED by ambulance with tachycardia and acute alcohol intoxication. The patient has been seen in the ED on several previous occasions with significant intoxication and has had multiple admissions for acute Elsevier items and derived items © 2011. and the late effect code is sequenced second. 2009. 998. or each additional one percent of body area of infants and children. 998. but is only used for the first 100 sq cm. Hospital outpatient surgery The surgeon performed a split-thickness autograft. 998. 15101 × 8.CCS Final Examination With Answers D. 2005. both thighs to the abdomen measuring 45 × 21 cm because of the patient’s nonhealing surgical wound. 2010. C. The code 998.89 CORRECT ANSWER: B.59 15100.83 15100.89 is the incorrect code since the wound is a nonhealing surgical wound. which state that the condition or nature of the late effect (the residual) is sequenced first. D. This is incorrect as B is the correct sequence according to the ICD-9-CM Official Guidelines for Coding and Reporting. 15101 × 9 would be necessary to report the additional 845 sq cm.83 15100. 2006. none of the above. 2008. 2004 by Saunders. legs. trunk. an imprint Elsevier Inc.83 describes a nonhealing surgical wound which is the reason for the procedure. 45 × 21 = 945 sq cm). RATIONALE: A. but 15101 is missing from this choice. or one percent of body area of infants and children (except 15050) . first 100 sq cm or less. There were 9 additional units. and 15101 × 9 for the remaining 845 sq cm (in this case.59 is the incorrect code since the wound is a nonhealing surgical wound.

305. number 5).45% sodium chloride.02. H).CCS Final Examination With Answers intoxication. an imprint Elsevier Inc.82 99291. Level 4 ED (99284) correctly reports the ED service. as it is the primary reason for services that were rendered in the ED (refer to ICD-9-CM Official Guidelines for Coding and Reporting.0. 496.82 99284. 401. 303. 2005.0 786. The fifth digit 2 is reported to indicate that the patient is an episodic alcoholic. 785.02. 305. 2006. Intramuscular Ativan is also administered.02. 303. 99284. number 4). RATIONALE: A.0 correctly reports the first-listed diagnosis as the tachycardia. 2010. 2007. She has a medical history that includes fairly well controlled hypertension and current tobacco abuse with questionable COPD. 496. 305. The patient is placed on cardiac monitoring. 2009.9 99285. The ED physician assesses the condition of the patient and administers an intravenous solution of 1 liter of 5% dextrose and 0. She is an episodic alcoholic. 303. V15. 99284.0. 785.9.0 (tachycardia) is the first-listed diagnosis.82 496 Acute alcoholism. 2004 by Saunders. 2 g of magnesium sulfate. The acute alcoholism is reported for the acute alcohol intoxication with 303. Acute alcoholism is correctly reported with 303.9) because the hypertension is indicated to be only fairly well controlled. 785. 303. which may be a consideration in the care of a patient with tachycardia.0. The patient’s heart rate returns to normal. C. The third-listed diagnosis is the “fairly well controlled hypertension.0.82.” reported as unspecified hypertension (401.02 303.0.02. 401. 401.1 401. episodic Acute alcoholism Current tobacco abuse Hypertension. 785. 7 . and assessed and reassessed the patient over 3 hours (Level 4. 303. Level 4 is correct as the physician administered several medications (Level 4. 303. Section IV.02.06 V15. D. the patient was not brought to the ED because she was intoxicated. 785. 401. 401. 401.1.1 reports the current abuse of tobacco. 785. V15. but because she was experiencing tachycardia.1 CORRECT ANSWER: D.9. V15.9. unspecified Tachycardia Tachypnea History of tobacco abuse Chronic obstructive pulmonary disease. 785.02 because it is a major consideration in the current care of this patient.02. 1 mg of folate. because although it is a major consideration in the care of this patient. and 100 mg of thiamine. 303. and the patient is discharged.9 correctly reports the Elsevier items and derived items © 2011.00 305. 785. B.9 785.9. NOS A. 401.02.0.9. 2008. The physician reassesses the patient several times over the next 3 hours. 99284.

02. Excision. excised diameter 0. 401.1). chemosurgery. 2006.0) is the primary reason for the service and should be listed first. and as such could be a significant consideration in the care of the patient. 785. acute alcoholism. 496. 785.0. according to the ICD-9-CM Official Guidelines for Coding and Reporting. 303. arms. except skin tag (unless listed elsewhere). tachycardia (785. 99285. history of tobacco abuse. is a questionable diagnosis and is not reported in the outpatient setting. COPD. 303. Section IV. C. Rather.5 cm or less Excision.9.82 (history of tobacco abuse) is not used for a patient who currently abuses tobacco (305. including margins. 401.82 A.. hands.1 to report the tobacco abuse is missing from this selection. electrosurgery. cryosurgery. an imprint Elsevier Inc. was not the primary reason the patient received the service.8 Elsevier items and derived items © 2011. Rather. 401. V15. malignant lesion including margins.1 to 2. 2010.CCS Final Examination With Answers unspecified hypertension. malignant lesion including margins. 198. 303. B. 8. D. 2009. 2008.82. genitalia.I. 2004 by Saunders.0 cm Destruction. scalp. lesion diameter 1. excised diameter 1. genitalia. hands. scalp.g. surgical curettement). 184. and local anesthesia is used. laser surgery.4 11622.02.0) is the primary reason for the service and should be listed first. but it is not the first-listed diagnosis. 11602 11420 11622 17272 184.1 to 2. 2007. neck. V15. as it is not the primary reason for the services provided during this encounter. excised diameter 1. The patient presents to the same-day surgery center for cryosurgery of a primary malignant lesion on the genitalia (vulva). hands. feet. vulva. 305.0 cm Malignant neoplasm. 184. benign lesion including margins. genital organs. The lesion measures 1. 2005. although it is a major consideration in the care of the patient. Level 5 ED (99285) is incorrect for this ED service. 184.8 198. B.82. tachycardia (785.82 11420. genitalia.9. malignant lesion (e. 8 . This is not a critical care service. other sites of female genital organs.02. 99291. as the physician did not provide any of the services listed on the critical care list. as none of the services listed in Level 5 were provided for this patient. feet. C.V15. neck.4 184. primary Malignant neoplasm.4 11602.6 cm. secondary 17272. or legs.9 is correct for the unspecified hypertension. feet.9 (hypertension) is reported because it is stated to be only fairly well controlled. primary Malignant neoplasm.1.02 is the correct code for the acute alcoholism. 303. neck.0. scalp. is incorrect as this patient currently abuses tobacco and this should be reported with code 305.0 cm Excision. unspecified.1 to 2. trunk. 401.

26608 26650 26706 26676 -LT -RT 833. B. as is reported with 11602. D. C. D. but the report indicates that the lesion was removed by means of cryosurgery. 17272 identifies the destruction by cryosurgery of a malignant lesion of the genitalia. Code 198. thumb (Bennett fracture). closed Dislocation carpometacarpal. Carl Ostrick. with manipulation.4 is the correct code for malignant neoplasm of the vulva and the reason for the procedure. 2010. After manipulating the joint back into normal alignment. Percutaneous skeletal fixation of metacarpal fracture.0 cm. slipped on a patch of ice on his sidewalk while shoveling snow.14 A. not excision. The modifier -LT indicates the left hand. 2006. 2005. joint.04 CORRECT ANSWER: D. C. other than thumb. joint. with manipulation Percutaneous skeletal fixation of metacarpophalangeal dislocation. open 26608-RT. the report indicates that the lesion was removed by means of cryosurgery. 11602 is excision of a malignant lesion.CCS Final Examination With Answers CORRECT ANSWER: A. When he fell. 11622 is excision of a malignant lesion from the genitalia. Some payers may require modifier F1. with manipulation Percutaneous skeletal fixation of carpometacarpal dislocation. 833. 11420 reports excision of a benign lesion of the genitalia. the surgeon fixed the dislocation by placing a wire percutaneously through the carpometacarpal joint to maintain alignment. the malignant neoplasm is specified as a primary malignant lesion of the vulva.1 to 2. not a malignant lesion.82 is incorrect. 21-year-old male. Elsevier items and derived items © 2011. not cryosurgery.04 describes the closed dislocation and the reason for the procedure. single. RATIONALE: B. an imprint Elsevier Inc. second digit. Further. lesion diameter 1. by excision. each bone Percutaneous skeletal fixation of carpometacarpal fracture dislocation.04 833. 833. 2008. left hand. 9 . 26676-LT reports the percutaneous skeletal fixation of the finger (carpometacarpal) with manipulation. but not from the genitalia. The 833. his left hand was wedged under his body and his index finger was dislocated. Code 184.04 26676-LT. not by excision.4 is correct. 833. 2004 by Saunders. 9. Code 184. each joint Left side Right side Dislocation carpometacarpal. 833.8 is incorrect since the report states the malignant neoplasm is of the vulva.14 26650-LT. 2007. 2009. Code 184.14 26706-LT.

10 . 2010.04 is correct. Which would be the correct sequence of codes? A. 997.14 is incorrect because it describes an open dislocation.9 meningitis 997.09 [321. 2005.09 999.09 [321. 320.8. The following appear in the Index of the ICD-9-CM: Complications vaccination 999. therefore code 833.8] Meningitis infectious NEC 320. B. Code 833.9 is not sequenced correctly per the ICD-9-CM Official Guidelines for Coding and Reporting. 997. 2004 by Saunders. This code is incorrect because it represents treatment of a fracture injury rather than a dislocation injury and it also identifies a different location than what is stated in this case. The use of brackets in the Index identifies manifestations and these are sequenced as secondary diagnoses per ICD-9-CM Official Guidelines for Coding and Reporting. 26608-RT is percutaneous skeletal fixation of a metacarpal fracture with no mention of manipulation. inoculation or vaccination 997. 321. 26650-LT is percutaneous skeletal fixation of a thumb.8 321. 26706-LT is percutaneous skeletal fixation of a metacarpophalangeal dislocation. D.9. 2007. Section I. 2006.9 CORRECT ANSWER: B. C.09.14 is incorrect because it describes an open dislocation.8. which is indicated with -LT.09. an imprint Elsevier Inc.CCS Final Examination With Answers No E codes are reported according to the guidelines for the AHIMA certification. C. B.9 997. This is a carpometacarpal joint. Also.8] The patient record indicates a diagnosis of meningitis as a complication of a vaccination.9. 320. 2009. not an index finger. Code 833.6.A.9. available on the AHIMA website. -RT indicates the right side and the procedure was on the left side. RATIONALE: A. 321. 2008. RATIONALE: A. 999. 999.9 Meningitis due to preventive immunization. 320. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. 10. this was not infectious meningitis as reported with Elsevier items and derived items © 2011.

simple Vagotomy when performed with partial distal gastrectomy (List separately in addition to code(s) for primary procedure) Other total gastrectomy Vagotomy. 320.99. not otherwise specified Revision of gastric anastomosis Correction of ureteropelvic junction 43865 44. not CPT codes. 997.87 A. 2009. 11 . 321. should be reported with Volume 3 codes.6. 43865 50400 43635 43.00.8. nephrostomy.5. vagotomy. C. 44. 2010.8. Also. 50400 is a pyeloplasty and 43635 is an add-on code used to report a vagotomy when performed with a gastrectomy for an outpatient. B. but rather meningitis as a complication of a vaccination.5 55.09 first. nephropexy.A. C. as 999. 11.9 is wrong as well as it represents other and unspecified complications of medical care. 44. This choice is incorrect.CCS Final Examination With Answers 320. pyeloplasty. D. an imprint Elsevier Inc.9 is incorrect as it reports infectious meningitis but the diagnosis in this case was meningitis due to vaccination and should be reported with 321.9 is incorrect. gastrojejunal revision. B.87.9.00.8. The surgeon performed a pyeloplasty. the specific complication is due to vaccination. this was an inpatient and as such.87. pyelostomy. this was an inpatient and Elsevier items and derived items © 2011. 55.00 CORRECT ANSWER: D. 2005. as it does not report the pyeloplasty or vagotomy.5. with or without partial gastrectomy or intestine resection. and 44. gastrojejunal revision and a vagotomy during the same surgical session on this inpatient.99 44. code 320. 43635 44.8. 2006. 43865 reports a revision of a gastrojejunal anastomosis with vagotomy (transection of the vagus nerve) for an outpatient. 43.9. Section I. RATIONALE: A. C.5. 321. with or without plastic operation on ureter. See the ICD-9-CM Official Guidelines for Coding and Reporting.9 is an unspecified complication of medical care and in this case. followed by 321.99 50400. 43.5. This choice correctly reports the inpatient procedures of 44. with vagotomy Pyeloplasty (Foley Y-pyeloplasty).09 is incorrect as it is not the sequence for a complication of meningitis as a result of a vaccination because the display in the Index of the ICD-9-CM indicates the sequence as 997. 44. 55. 2007. 2004 by Saunders. 999. Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction.00 44. D. or ureteral splinting.87. 44.5. 55. 999. 2008. plastic operation on renal pelvis.

802. as these CPT codes would be used to report the service in an outpatient setting. 02. 2007. 20661. 12. 2008. closed Fracture malar and maxillary bones. should be reported with Volume 3 codes.74. 802. including removal.76). and/or intermaxillary fixation) Application of halo. 20661. open reduction of mandibular fracture (76. 12 .5 A.g. 802.5 76.76 802. He sustained craniofacial separation that required complicated internal and external fixation using an open approach to repair the extensive damage as an inpatient. cranial Open treatment of craniofacial separation (LeFort III type). B. internal fixation.4.4 is the code for a LeFort III fracture. not CPT codes. This choice is incorrect as it is missing the insertion of a halo device (02. complicated. This choice is incorrect as these CPT codes would be used to report the service in an outpatient setting. D.94). 2006. 20661. utilizing internal and/or external fixation techniques (e. 21435.74.74. 802. Elsevier items and derived items © 2011. 76. head cap. 20661. 2010. 76.76.74.94. open 20661 21432 21436 02.5. 21435 Open treatment of craniofacial separation (LeFort III type). RATIONALE: A. 802. 2004 by Saunders. and this was an inpatient visit. 802.74).4. 21436. complicated. multiple surgical approaches. 76.CCS Final Examination With Answers as such.5.4 802.4 76. He was thrown from the automobile and was pinned under the rear of the overturned automobile. 21435.5 CORRECT ANSWER: B. 802. 76. 802.76.94 76.76.. 76. A halo device was used to hold the head immobile. halo device. an imprint Elsevier Inc. This choice is incorrect. C.74 76. 802. 802. and this was an inpatient visit. 2009. C.94 correctly reports the procedures of an open reduction of a maxillary fracture (76. 2005. 76.94).5 is also incorrect.4 21436. with bone grafting (includes obtaining graft) Insertion or replacement of skull tongs or halo traction device Open reduction of maxillary fracture Open reduction of mandibular fracture Fracture malar and maxillary bones. D. with wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type). and insertion of a halo device (02. 02. Darin was a passenger in an automobile rollover accident and was not wearing a seat belt at the time.76.

2006. The notes indicate that the burns were over 10% of the body surface. B. 33249 is for insertion of the electrode lead(s) for a single. not insertion of a pacemaker and the electrodes. with 50% of the burns being 3rd degree and the other 50% being 2nd degree.81 33208.1 is incorrect. not the insertion of the pacemaker and the electrodes. code for 3rd degree. Code 427. Code for 2nd degree. code for body area involved.81 is correct. B. 427. Insertion or repositioning of electrode lead(s) for single. 2004 by Saunders. 33240 is for insertion of a dual-chamber pacing cardioverter-defibrillator pulse generator. C. atrial and ventricular Insertion of single. not the pacemaker generator and the electrodes. 427. code for 2nd degree. Code 427. code for body area involved. RATIONALE: A. Which codes would you use to report the percutaneous insertion of a permanent dual-chamber pacemaker by means of the subclavian vein in a patient with sick sinus syndrome? 33249 33217 33208 33240 427. Elsevier items and derived items © 2011. 2007.or dual-chamber pacing cardioverter-defibrillator and insertion of pulse generator Insertion of 2 transvenous electrodes. 2005. Code for 3rd degree. sick sinus syndrome. code for 3rd degree. Code for 3rd degree. C.89 A. an imprint Elsevier Inc. Code 427. code for body area. dual-chamber (two electrodes) permanent pacemaker or pacing cardioverter-defibrillator Insertion or replacement of permanent pacemaker with transvenous electrode(s).1 33217. 33217 is for insertion of the electrodes for a dual-chamber pacemaker. 2009. What would be the sequencing of codes to report this burn? A. is the reason for the procedure. 13 .89 CORRECT ANSWER: C. B. Code for body area.81 33240.81 427. 33208 reports insertion of a permanent dual-chamber pacemaker with transvenous (by means of a vein) electrode placement. Code 427. 427. 2008. code for 2nd degree.CCS Final Examination With Answers 13.or dual-chamber pacing cardioverter-defibrillator and the insertion of pulse generator.81. D. D. 427. 2010. 14.or dual-chamber pacing cardioverter-defibrillator pulse generator Paroxysmal ventricular tachycardia Sick sinus syndrome Bradycardia 33249.89 is incorrect.1 427. The patient is brought to the ED with burns of the back. D.

In this report. code for body area involved is incorrect.17. D.9 V56. the burns were all on the back. and no code is reported for the other degrees of burn if the burn is of the same area. code for 2nd degree. 14 .c.2.31. only the 3rd degree burn is reported.9 A. The code for the body area involved in the burn is sequenced second (ICD-9-CM Official Guidelines for Coding and Reporting.31 V56 V56.c. 15. code for body area. and burns of the same local site but of different degrees are identified by the highest degree of burn recorded.6 585.17. In this case. because the body area covered by the burn is not sequenced first. V56. The fourth digit indicates the percentage of the body surface that was burned. C.6).9. and the 2nd degree burn is not reported in addition to the code for the 3rd degree burn when it is of the same body area as in this case—the back. In this case. 2008. NOS V56. A patient with end-stage renal disease is admitted to the hospital for hemodialysis. No code is reported for the 2nd degree burn. 2007. 948. and the fifth digit indicates the percentage of body surface that was 3rd degree burn. 2006. C.C. code for body area involved is incorrect. 584 V56.1X). Encounter for adequacy testing for hemodialysis Encounter for dialysis and dialysis catheter care Extracorporeal dialysis Acute renal failure End-stage renal disease or chronic kidney disease requiring dialysis Chronic renal failure. because the highest degree of burn is reported first. 2009.0 Elsevier items and derived items © 2011. Section I. the body area was 10% (948. B. because the second degree burn is not reported when it is of the same body area as in this case—the back. with 50% of the burn 3rd degree. Section I. Code for 2nd degree. code for 2nd degree is incorrect. code for 3rd degree. 585.C.CCS Final Examination With Answers CORRECT ANSWER: D. 2005.34). the code that reflects the highest degree of burn is to be sequenced first. RATIONALE: A. code for 3rd degree. 2004 by Saunders.0 584. there was only one area of burn (back. Code for 3rd degree. 584.6 585. Code for body area. and even though there were 2nd and 3rd degree burns. an imprint Elsevier Inc. According to the ICD-9-CM Official Guidelines for Coding and Reporting. 942. 2010. This means that 5% of the body surface had 3rd degree burn. B. Code for 3rd degree.9 585.0.10 is the correct code to report the percentage of body surface that was burned. V56.

01.3. primary Malignant neoplasm.5 150.3 150.18. Another reference to the correct code sequencing is the V Code Table located in the ICD-9-CM Official Guidelines for Coding and Reporting (following I.74 150. Section I. 2005. 278. D. as the reason for the encounter is the hemodialysis. 2009. The ICD-9-CM instructs the coder after category V56 to “Use additional code” to identify the associated condition.9 278. Code 278.29 31. 278. The code V56. 150. You should always code to the highest specificity. 31.01 describes this patient’s morbid obesity and the 31. 2006. 584. 2007. upper third of esophagus. all of which failed. 2008.C.5. V56.9.01 A. unspecified.1 150. but the sequence should be as shown in choice C.74 CORRECT ANSWER: C.21 31.00.B. RATIONALE: A. 2010. This 52-year-old male has undergone several attempts at extubation. lower third of esophagus. C. listed in this order. There is no documentation that Elsevier items and derived items © 2011. V56 and 584 both have a fourth digit and as such are not as specific as possible. 31.CCS Final Examination With Answers CORRECT ANSWER: C. D. 31. and 585. primary Obesity Morbid obesity 150. esophagus.9.29 150.9 code is incorrect.01. V56. 31. B.3.1 31.01. 278.0 is correct. Tracheostomy (temporary) Mediastinal tracheostomy Other permanent tracheostomy Revision of tracheostomy Malignant neoplasm. 15 . 2004 by Saunders. 278. 31. where the primary reason for the encounter (hemodialysis) is listed first. See the ICD-9-CM Official Guidelines for Coding and Reporting.1. B.9 incorrectly reports acute renal failure.9. He also has morbid obesity and significant subcutaneous fat in his neck. and this patient is receiving hemodialysis. The 150.00 278.21 150.9 esophageal cancer with upcoming surgery is the reason for the trach. 16.15).0 is correct for hemodialysis. primary Malignant neoplasm. an imprint Elsevier Inc. and the 585.31 incorrectly reports an encounter for adequacy testing for potential hemodialysis.d. and this patient has chronic renal failure. Encounter for dialysis (V56) is listed in the ICD-9-CM as a “first-listed” V code. The patient is now in for a tracheostomy because of upcoming surgery for esophageal cancer.6 is correct for end-stage renal disease requiring dialysis.1 describes the tracheostomy. 31.

11042 identifies the debridement of 20 sq cm or less of subcutaneous tissue. dermis.74 is a revision of a previous tracheostomy.01. 2009.59.CCS Final Examination With Answers this is a permanent tracheostomy and a coder cannot assume that it is permanent.21 is a mediastinal tracheostomy that is located lower on the chest and there is no documentation that indicates this was the type of tracheostomy.83. 150. excisional debridement).5 is incorrect and the code for the obesity is missing. 11000 998. 2005. 31. skin and subcutaneous tissue Debridement. 31. 2008. RATIONALE: A. 2007. muscle and/or fascia (includes epidermis.83.83 998. first 20 sq cm or less Other postoperative infections Non-healing surgical wound Other specified complication of a procedure 11042 11043 998.29 reports a permanent tracheostomy and there is no documentation that the tracheostomy is permanent.5. 16 . and this patient is having an initial placement. D. 998. The diagnosis code 150. D. 11042 CORRECT ANSWER: D. RATIONALE: A.59 is for infected postoperative wound and there is no mention of any infection..3. 150. 278. Which code would be used to report a 16 sq cm surgical debridement of a nonhealing abdominal surgical wound by a physician. including the subcutaneous tissue? 11000 11010 Debridement of extensive eczematous or infected skin. 278. subcutaneous tissue (includes epidermis and dermis if performed).9. if performed). 17. up to 10% of body surface Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (e. not subcutaneous tissue. Code 998. 2010. which is the reason for the procedure. The codes 150. an imprint Elsevier Inc. Code 998.83. first 20 sq cm or less Debridement. 11010 998.59. and subcutaneous tissue.83 identifies the non-healing surgical wound.00 are also incorrect. 2006. C. 31.00.59 998. 150.3 and 278. B. Elsevier items and derived items © 2011.g.89.89 A. 11000 reports debridement of infected skin. 11043 998. The diagnosis codes are correct. 2004 by Saunders. 998. 998. B.

C. C. cough. Reporting fever and cough would be incorrect as these are the symptoms and the diagnosis is known. the fee charged for a specific code or supply Elsevier items and derived items © 2011. Section IV. The ED physician orders a chest x-ray with an indication that this x-ray is for fever and cough. cough and fever fever and cough pneumonia. and fever would be incorrect as cough and fever are symptoms of pneumonia—see Section IV. D. L. B. The diagnosis is incorrect. Which diagnosis would you report for the radiologist’s service? A. 20. B. 19. RATIONALE: A. in the outpatient setting it is acceptable to assign codes based on a radiologist’s interpretation.B.6 and I. and that is pneumonia as this is an outpatient service. but the case stated ultrasound guidance. 2008. Also. 2004 by Saunders. A charge description master is used to determine: A. and fever pneumonia CORRECT ANSWER: D. according to Coding Clinic 1st Q 2002 page 4. 2005. Diagnostic Coding and Reporting Guidelines. not the left breast (-LT). 19295-RT is the image-guided placement during a breast biopsy/aspiration and is an add-on code that cannot be used alone.7.81 is incorrect. Reporting cough and fever would be incorrect as these are the symptoms and the diagnosis is known. The patient presents to the ED with a chief complaint of fever and cough. and Section I. 2010. The diagnosis code 198.B. as the central portion of the breast was not specified as the location. Signs and symptoms that are secondary to a confirmed diagnosis are not reported separately per the ICD-9-CM Official Guidelines for Coding and Reporting. Reporting pneumonia. The placement of the marker was on the right breast (-RT). pneumonia. Diagnostic Coding and Reporting Guidelines. The hospital’s radiologist reviews the x-ray and indicates that the diagnosis is pneumonia. 18 . D. 77031 is incorrect because it reports stereotactic guidance. and Section I.7.B. paragraph L. as the neoplasm was primary not secondary. cough. 2006.6 and I. 2007. 19125 reports removal of a lesion that is identified by a preoperatively placed radiology marker.B.CCS Final Examination With Answers not state to code the excision of the lesion with the placement (19125-RT). The most definitive diagnosis is to be reported. 2009. but only the placement of the wire was to be coded. an imprint Elsevier Inc. B.

polyp(s). A charge description master is an inventory of all services. with removal of single tumor. colon. if appropriate. 45320 211. Code 211. 211. and assigned charges billed. rectum. Elsevier items and derived items © 2011.3. polyp(s). D. procedures.3. polyp. revenue codes. A charge description master will provide a description of each service or supply corresponding to the CDM number. A charge description master will list default and payer-specific CPT and HCPCS codes. with ablation of tumor(s). 45309 211. an imprint Elsevier Inc. with ablation of tumor(s). 2008. and drugs with their corresponding CPT or HCPCS codes. or other lesion(s) not amenable to removal by hot biopsy forceps Proctosigmoidoscopy. C. 21. with removal of tumor(s). 2005. or other lesion(s) by snare technique Neoplasm. 45338 identifies the flexible sigmoidoscope with the removal of the polyps using snare technique. rigid.3 identifies the polyp in the sigmoid colon which was the reason for the procedure. a corresponding CPT or HCPCS code and revenue code D.4. 2007..3. 2010.9. 2006. B.g. It can be used to assist in the analysis of charges and trends within a facility or practice.4 211.3 211. flexible. or other lesion(s) not amenable to removal by hot biopsy forceps. proximal to splenic flexure. all of the above CORRECT ANSWER: D.CCS Final Examination With Answers B. A patient presents to the outpatient surgical department for removal of two sigmoid polyps. or other lesion by snare technique Sigmoidoscopy. RATIONALE: A. All of the above. bipolar cautery or snare technique (e. descriptions. C. A charge description master will list the fee charge by code or supply during a specific period of time.9 A. 45338 CORRECT ANSWER: D. rigid. flexible. benign 45383 45309 45338 211. a description of a service C. polyp(s). 45320 Proctosigmoidoscopy. 2004 by Saunders. benign Neoplasm. 2009. B. The surgeon removes the polyps by means of snare technique using a flexible sigmoidoscopy scope. benign Neoplasm. supplies. laser) Colonoscopy. 211. 45383 211. other and unspecified site (digestive system NOS). 19 .

B. 2008.00 A. B. V50. but the procedure was described as a sigmoidoscopy. Report the facility service for the circumcision. 54160 54150 64. surgical excision other than clamp.9 is unspecified and the polyp is specified as being located in the sigmoid colon.0.00.3. this code represents proctosigmoidoscopy but the procedure was described as a sigmoidoscopy. without mention of cesarean section 54160. Circumcision. 2005. 2004 by Saunders. and the polyps were not ablated. V50.2 64.0. 211.4.4 V30.2 54150.0.2 is an incorrect diagnosis code for a routine delivery of a newborn as it would be V30.4 64. the Volume 3 procedure code is the correct choice of code to report this procedure. using clamp or other device with regional dorsal penile or ring block Circumcision Routine or ritual circumcision Prophylactic organ removal Single liveborn.0). Code 211. device. This code represents proctosigmoidoscopy. Since this newborn is still in the hospital. Code 211.2 V50.00 reports the delivery of a single liveborn that was delivered in the hospital without mention of cesarean delivery. V50. and this was a flexible scope. C. C. Also. 45320 reports the ablation of polyps that could not be removed by snare technique. to the nursery to perform a clamp circumcision. Also. Code identifies the procedure of a circumcision on a male.CCS Final Examination With Answers RATIONALE: A.9.3 is correct. 64. but the technique specified in the case was a snare technique. but this newborn was still in the hospital. 20 . born in hospital.0 V50. V50. an imprint Elsevier Inc. neonate (28 days of age or less) Circumcision. 45383 is for colonoscopic ablation of tumors.4 is incorrect as it describes a polyp in the rectum not the sigmoid colon. 211. 211. or dorsal slit. immediately after delivery. 2009. 2010.00. 2006. V30.00 CORRECT ANSWER: D. so the procedure is reported with a Volume 3 procedure code (64. and two polyps were removed. The delivering physician takes the newborn male. Code 211. 2007. 22. RATIONALE: A. V30. this code is for the removal of a single polyp. D. 45309 is for rigid scope. 54160 is a circumcision other than clamp. V30. Elsevier items and derived items © 2011. A colonoscopy was not performed.

The atrial fibrillation would be listed as a secondary diagnosis. V50. which is the reason for admission. 54150 correctly identifies the clamp circumcision in an outpatient setting. 2008. B. followed by the atrial fibrillation C. Indicate the revenue codes for a patient requiring sutures who was treated in the ED. D. 2007. 0300 medical nutritional therapies 0560 other medical social services 0450 outpatient emergency services 0361 minor procedures CORRECT ANSWER: C. 0300 is not the correct revenue code for a minor procedure. D. which includes the routine circumcision. All diagnoses documented are reportable if they are treated or affect the treatment. The surgeon notes in the medical record that the patient has atrial fibrillation.0 is correct to report the circumcision of a male. 2009. report only the atrial fibrillation B. a Volume 3 procedure code would be reported. Elsevier items and derived items © 2011.2 is incorrect because it reports an encounter for circumcision as if the patient was presented for only that purpose.4 incorrectly reports the diagnosis because this code reports an encounter for removal of an organ. 21 . report the acute cholecystitis as the principal diagnosis. 23. RATIONALE: A. C. following cholecystitis. C.00. 2004 by Saunders. 2010. V50. add a complication code for the atrial fibrillation CORRECT ANSWER: B. A. rather it is for other medical social services. 2006. 0560 is not the correct revenue code for a minor procedure. The patient’s primary care physician performs a preoperative physical examination and indicates that the patient is cleared for surgery. The coder would: A. The patient is not on medication for the condition. not report the atrial fibrillation D. 64. rather than the birth reported with V30. 24. B. an imprint Elsevier Inc. 0450 outpatient emergency services is the correct revenue code for a patient requiring sutures who was treated in the ED. 0361 minor procedures reports procedures performed in the operating room suite. 2005. therefore. but this service was provided in the hospital. A patient is admitted to the hospital to have a cholecystectomy because of acute cholecystitis. rather it is for medical nutritional therapies.CCS Final Examination With Answers B.

Report only the facility procedure(s) codes for this case. 2006. 2010. not congenital hypothyroidism. therefore it should have been reported.0 is for moderate mental retardation. 317 244. 2009. This is an incorrect answer because the atrial fibrillation is not the principal diagnosis.CCS Final Examination With Answers RATIONALE: A. C.9 318. 26. C. 244. C.” 243 is the first-listed diagnosis. 243 correctly describes congenital hypothyroidism. and 317 is correct for mild retardation. 22 . but 318. Congenital hypothyroidism with mild retardation: 243 317 244. and 317 correctly describes mild retardation and is listed second. and no complication was noted for this patient. D.0 317. Congenital hypothyroidism Mild mental retardation Unspecified hypothyroidism Moderate mental retardation 243. 25. 317 243. 2007. RATIONALE: B. This is an incorrect answer because the atrial fibrillation was evaluated. B. and repair of multiple facial and eyelid lacerations with an approximate total length of 12 cm. D. Elsevier items and derived items © 2011.0 A. D. Guideline under 243 states “use additional code to identify associated mental retardation. but the order is incorrect because the first-listed code should be that of the primary condition of hypothyroidism as explained in rationale A above.9. The codes are correct. 243 is correct for congenital hypothyroidism. This is an incorrect answer because a complication code is reported only if there is a complication. not mild retardation. This inpatient is taken to the operating room for surgery as follows: Left frontal ventricular puncture for implanting catheter. 2008. 2004 by Saunders. 2005. 243 CORRECT ANSWER: A. an imprint Elsevier Inc. layered repair of 8-cm scalp laceration. 318.9 is acquired hypothyroidism.

and/or mucous membranes. 23 . D. 2004 by Saunders. 86.2 02.5 cm Insertion of subcutaneous reservoir. CPT codes are not used in the inpatient setting.6 cm to 12. 86.81 for the repair of the eyelid laceration.81 A.6 cm to 12. which was stated in the documentation. 12015 02.2 correctly reports a ventriculostomy. or ventricular puncture. 02. pump. without injection Simple repair of superficial wounds of face.81 for the eyelid. 08. and 08.81 61215. 7.2. or implanted ventricular catheter/reservoir. 12015 02. and/or extremities (excluding hands and feet).9 Acute glomerulonephritis with unspecified pathological lesion in kidney Viral hepatitis Acute glomerulonephritis in diseases classified elsewhere Unspecified viral hepatitis without mention of hepatic coma A. B. lips. 2007. trunk.CCS Final Examination With Answers 61020 12015 61107 12034 61215 02. 2006.59 and 08. nose. for implanting ventricular catheter. Acute glomerulonephritis due to infectious hepatitis: 580. intracerebral.32 86. 2009. C.59. 2005. an imprint Elsevier Inc. 7. pressure recording device.9 070 580. CPT codes are not used in the inpatient setting. or continuous infusion system for connection to ventricular catheter Ventriculostomy Ventriculovenostomy Closure of skin and subcutaneous tissue of other sites Repair of eyelid laceration 61020. suture.59 is used for closure of the skin lacerations of the scalp and face.59 08. Closure of the scalp and face lacerations should be reported with 86. fontanelle. 02. 27. Ventricular puncture through previous burr hole. 12034 CORRECT ANSWER: B. eyelids. or other intracerebral monitoring device Layer closure of wounds of scalp.9.32 reports a ventriculovenostomy. 580. RATIONALE: A.32. 070 Elsevier items and derived items © 2011. 2008. This code is not correct because CPT codes are not used in the inpatient setting.81 070. C. D. 2010. not a ventriculostomy. axillae. 12034 identifies the layered closure of the scalp.5 cm Twist drill hole(s) for subdural. The ICD-9-CM procedure codes need to be used for reporting inpatient procedures. ears.

The diagnosis was ear otosclerosis. 2007. 389. but fourth. 387. 69661-RT Elsevier items and derived items © 2011. B. 580. 580. unspecified Atrial fibrillation Cardiac complications Complication of medical care. 2010. 580.and fifth-digit codes are available. and is the first-listed diagnosis. 2009. RATIONALE: A. with footplate drill out Right 387. Other otosclerosis Otosclerosis. 24 .9.81.1. the patient experienced atrial fibrillation.A. 2004 by Saunders. 999.9 389. 389.CCS Final Examination With Answers B.1.31. but in an incorrect order according to Section I. 2006. and this was documented in the medical record. A patient was admitted as an outpatient to the hospital for right ear conductive hearing loss. 997. and a coder must code to the highest specificity possible. 427.81 CORRECT ANSWER: D. 070.9 describes hepatitis that is unspecified viral hepatitis without mention of hepatic coma. the acute glomerulonephritis. C.31. 070.81. D.9.00.8 387. NEC Stapedectomy or stapedotomy with reestablishment of ossicular continuity. 2008.00 427. of the ICD-9-CM Official Guidelines for Coding and Reporting. 69661-RT 389. 427. This sequencing is correct per ICD-9-CM Official Guidelines for Coding and Reporting.00.6.A. 69660-RT 387.00. 2005. 580.9 describes acute glomerulonephritis with an unspecified pathological lesion of the kidney. The operative report indicated that the stapes footplate was significantly thickened.1 999 69660 69661 -RT A. 070. and a coder must code to the highest specificity possible. 580. which states that the underlying condition is to be coded first. A right ear stapedectomy was performed.6. 997. During the procedure. 69660-RT 387.and fifthdigit codes are available. 999. B. 070.8.9 describes acute glomerulonephritis with an unspecified pathological lesion of the kidney.9 D. Section I. 28.9 C.9. C. unspecified Conductive hearing loss.31 997. is listed second. 580. These are the correct codes. with or without the use of foreign material. an imprint Elsevier Inc. and 070 is the viral hepatitis category code. 070 is the viral hepatitis category code. but fourth.

with para-aortic and pelvic lymph node biopsies. 2005. unilateral or bilateral.62 identifies laparoscopic treatment of an ectopic pregnancy with salpingectomy for the facility. 2006.90 59151. an imprint Elsevier Inc. abdominal or vaginal approach . peritoneal biopsies. 59120 59121 59151 58943 Surgical treatment of ectopic pregnancy.10 66. 30. without intrauterine pregnancy. 633. 2008.69 633. 633. with salpingectomy and/or oophorectomy Oophorectomy. -59 is used to report a distinct procedural service. diaphragmatic assessments. peritoneal washings. tubal or primary peritoneal malignancy. -73. Anesthesia has not been provided when this modifier is reported. without salpingectomy and/or oophorectomy Laparoscopic treatment of ectopic pregnancy.80 A. tubal or ovarian. RATIONALE: A. D. 633. partial or total. RATIONALE: A. tubal or ovarian.10 633. with or without omentectomy Salpingectomy with removal of tubal pregnancy Other partial salpingectomy Unspecified ectopic pregnancy without intrauterine pregnancy Tubal pregnancy (Fallopian) without intrauterine pregnancy Other ectopic pregnancy without intrauterine pregnancy 66. The surgeon admits her and performs a laparoscopic salpingectomy. 66. -74 is used to report a discontinued outpatient hospital or ambulatory surgery center procedure after administration of anesthesia. C. 2004 by Saunders. This modifier is used to report a procedure that was discontinued because of extenuating circumstances or those that threaten the well-being of the patient. discontinued outpatient hospital/ambulatory surgery center procedure prior to the administration of anesthesia. 26 . with or without salpingectomy(s).CCS Final Examination With Answers CORRECT ANSWER: B. Elsevier items and derived items © 2011. 59121 reports the physician’s or outpatient facility’s services for a surgical treatment of a tubal or ovarian ectopic pregnancy not the facility services (66. D. This 32-year-old inpatient has a left ectopic (fallopian) pregnancy.62.62 66. B.10 is the diagnosis code for a fallopian pregnancy. 2010. for ovarian. requiring salpingectomy and/or oophorectomy. 59121. 633.90 633. 633. C. 2009. 2007. -77 is used to report a repeat procedure by another physician.69.62).80 CORRECT ANSWER: C.10 66. Report the facility services.

malignant neoplasm of the bladder in the oncology department of the hospital.0 is incorrect because it reports an open wound of the hand without mention of complication.” RATIONALE: B.0 882. open.0 is an open wound of the finger(s).CCS Final Examination With Answers 633. C. 633. but in this report. The ICD-9-CM defines complicated as “delayed healing.1 882. 32. 2007.90 is an incorrect diagnosis code because it reports an unspecified ectopic pregnancy. This wound did have a complication—the gravel that was stated to have been ground into the wound. The diagnosis (633.0 882. cornual. 882. B.” such as cervical.62).10) to report a fallopian pregnancy is correct. an imprint Elsevier Inc.2 Open wound of hand except finger(s) alone without mention of complication Open wound of finger(s) without mention of complication Open wound of hand except finger(s) alone. 27 .” “delayed treatment. 2005.1 883. or intraligamentous. But it is incorrect in this case because the ICD-9-CM procedure codes must be used to report the inpatient facility services (66.0 883. the site of the ectopic pregnancy was listed as the fallopian tube. 2006. but the report indicated the site of the ectopic pregnancy as the fallopian tube.” “foreign body.69 identifies a partial salpingectomy and the procedure in this report was treatment of an ectopic pregnancy with salpingectomy. 2004 by Saunders. The cardiologist is called to the oncology department and Elsevier items and derived items © 2011. she develops tachycardia.” or “primary infection. D. which was not stated in the question. B. During the therapy. 66.0 882. Open wound of left hand with gravel ground into the wound: 882.2 A. 882. 882. A patient undergoes a chemotherapy treatment for primary. 2008. 59151 is the correct CPT code for reporting the physician’s or outpatient facility’s services for a laparoscopic treatment of an ectopic pregnancy. 883.1 is assigned to an open wound of the hand (except the fingers) with complication because of the gravel that was ground into the wound. mesometric. combined.2 is for an open wound of the hand with tendon involvement.80 reports “Other ectopic pregnancy. D.” This guideline is located in the diagnosis index following the entry for “wound. C. D. complicated Open wound of hand except finger(s) alone with tendon involvement CORRECT ANSWER: A. 2010. 31. 2009. 882.

This is included in the OPPS APC payment. C. This is not allowed under the OPPS when the procedure in which the device was used is performed in an outpatient setting. This is paid at a reasonable cost and is not subject to deductible or coinsurance. What would be the principal diagnosis for the hospital stay? A. RATIONALE: A. primary. D. 2004 by Saunders. 2005. Nonparoxysmal junctional tachycardia is not the most definitive diagnosis because the cardiologist indicated the tachycardia was due to acute carditis. 2006.CCS Final Examination With Answers admits the patient to the hospital for further tests. which describes each of the indicators in the OPPS. 2009. Which of the following is true about a device marked with a status indicator H? A. This choice is incorrect. D. C. B. 2008. D. 33. an imprint Elsevier Inc. rather hospitalization was due to acute carditis. The nonparoxysmal junctional tachycardia would also be coded because it is not inherent in the disease process but rather is a complication of the disease process. The acute carditis is the cause of the nonproxysmal junctional tachycardia. Elsevier items and derived items © 2011. malignant neoplasm of the bladder complication of chemotherapy acute carditis nonparoxysmal junctional tachycardia CORRECT ANSWER: C. This is included in the OPPS payment. malignant neoplasm of the bladder is incorrect as it is not the reason the patient was hospitalized. See Figure 2-4 in this text. B. B. This choice is incorrect. Acute carditis. This is not allowed under the OPPS when the procedure in which the device was used is performed in an outpatient setting. rather hospitalization was due to acute carditis. This device is paid under OPPS as a cost based pass-through payment. The medical records document that the cardiologist indicated the nonparoxysmal junctional tachycardia is a result of acute carditis. See Figure 2-4 in this text. The medical record indicates that the cardiologist’s records indicated a diagnosis of nonparoxysmal junctional tachycardia due to acute carditis. Complication of chemotherapy is incorrect as it is not the reason the patient was hospitalized. which describes each of the indicators in the OPPS. CORRECT ANSWER: C. See Figure 2-4 in this text. 28 . 2010. which describes each of the indicators in the OPPS. B. 2007. RATIONALE A. This device is paid under OPPS on the basis of the cost. Primary.

659. delivered. 2004 by Saunders.21. 58611 654. 2006.0. delivered.21 reports that the patient has previously delivered by cesarean section.CCS Final Examination With Answers D. during same hospitalization (separate procedure) Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra-abdominal surgery (not a separate procedure) (list separately in addition to code for primary procedure) Occlusion of fallopian tube(s) by device (e.32. This is her second pregnancy.g. 2007.0 66. B. V27. 74. 2008.32 CORRECT ANSWER: D. 59514.21. 659. 2005. See Figure 2-4 in this text. an imprint Elsevier Inc. C. with or without mention of antepartum condition Cesarean delivery.1. V27.21. 58615 644. 34. Because of her prior cesarean section. with or without mention of antepartum condition Elderly multigravida.21 reports the Elsevier items and derived items © 2011.0.. 654. band. abdominal or vaginal approach. 644.1 Cesarean delivery only Ligation or transection of fallopian tube(s). so a bilateral tubal ligation will also be performed.21 654.71. 669. 644. 659.2. 654.21. delivered. V27.32 74. The patient also desires sterilization.2 V27.2.21. This patient is 35 years old at 36 weeks’ gestation.2. Falope ring) vaginal or suprapubic approach Cesarean delivery only following attempted vaginal delivery after previous cesarean delivery Early onset of delivery. 644. with or without mention of antepartum condition Sterilization Single liveborn Tubal ligation Low cervical cesarean section A. clip. unilateral or bilateral. V25. 66.1 644.61. delivered. A single liveborn infant is the outcome of the delivery. V27. 66.21. 2010. V27.1. 29 . which describes each of the indicators in the OPPS. 74. V25.21. 654.71 V25. 654.21. 59514 58605 58611 58615 59620 644. This is paid at a reasonable cost and not subject to deductible or co-insurance. with or without mention of antepartum condition Previous cesarean delivery.61. without mention of indication. she is taken to the operating room to have a repeat low cervical cesarean section performed.61. 74.61 669. D. She presents in spontaneous labor. 2009. This choice is incorrect.0.21 659. 59620. Report the facility services for the mother.0.0. V25. postpartum.

implant.2. as defined by ICD-9-CM. 659.0. Also missing from this choice are 654.4 Mechanical complication of other vascular device. removal and irrigation of ventricular shunt site. 2006.95 331. Also missing is the report of the tubal ligation (66. as such. The procedure performed was to be a revision of shunt at the ventricular site. This choice is incorrect because it is to report inpatient procedures.21.0. and graft Ventriculocisternostomy (Torkildsen type operation) Removal of complete cerebrospinal fluid shunt system. and 669. V25. V27. 74. 59620. as such. with replacement by similar or other shunt at same operation Removal of complete cerebrospinal fluid shunt system.CCS Final Examination With Answers early onset of delivery (36 weeks). Also missing from this choice is 659. This choice is incorrect because it is to report an inpatient procedure. removal and irrigation of ventriculoperitoneal shunt at peritoneal site Communicating hydrocephalus Obstructive hydrocephalus Elsevier items and derived items © 2011. V27. -auricular Ventricular shunt to abdominal cavity and organs Revision. Report only the facility services.61 to report elderly multigravida (older woman who has delivered previously). 654.61 reports elderly multigravida. is a woman who is 35 YOA at the time of delivery.3 331. B.2 62180 62258 62256 62190 02. 2004 by Saunders.0 is for single liveborn infant.21. After the shunt system was inspected. 35. the procedures must be reported with Volume 3 procedure codes (74. and graft Mechanical complication of nervous system device. 2010. 644.61.21. 58611.21. C.1 procedure code for low cervical cesarean section and 66.71.21 (early onset of delivery) and 659.21.2 to report the sterilization is missing.0.2 is the diagnosis code for the sterilization (tubal ligation). the entire cerebrospinal fluid shunt system was removed. the procedures must be reported with Volume 3 procedure codes (74. replacement of ventricular shunt Revision. 59514.71 is incorrect because the reason for the C-section is known—a repeat C-section.32 reports the tubal ligation. Elderly. 996. 644. 654.32 procedure code for tubal ligation). 2005. -jugular. 74. subarachnoid/subdural-atrial. 2007. 30 . without replacement Creation of shunt.1 reports the procedure of a low cervical cesarean section. implant. 58615.1 procedure code for low cervical cesarean section and 66. 66.61 (elderly multigravida—older woman who has delivered previously). 2009.2). V27. Missing is the report of the tubal ligation (V25.32 procedure code for tubal ligation) and early onset of delivery. This inpatient presented with an obstructed ventriculoperitoneal shunt.1 996.42 54.32 procedure code for tubal ligation). not CPT codes. 669. 644. RATIONALE: A. Multigravida means a woman who has previously delivered. Patient has communicating hydrocephalus. 2008. V25. 659. not CPT codes.1 is incorrect because V25.34 02. V27. an imprint Elsevier Inc. and a similar replacement shunt system was placed.

0 Melena Hematemesis Abnormal finding in stool (occult blood in stool) Gastrointestinal hemorrhage CORRECT ANSWER: C. This is an inpatient for which Volume 3 codes are used to report procedures. Code 331.1 is an incorrect diagnosis of a mechanical complication of a vascular system device and this was of the nervous system. B. 2006.1.4 792.1 is the diagnosis for a mechanical complication of a vascular system device and this was of the nervous system. C. 02. B.5 Normal pressure hydrocephalus A.1 578. C.2. 31 .3 is the reason that the patient has the shunt.34 996. 331.1 is incorrect.0 792. 36. 62256 996. 996. not CPT codes.3. an imprint Elsevier Inc. 2008.42 identifies removal and replacement of the entire ventriculoperitoneal shunt. 331. 02.3 is correct. 2007. The correct code is 996.CCS Final Examination With Answers 331. RATIONALE: A. D.4. The diagnosis code 996. 2009.3. 331.5. D. 996.1 correctly describes blood in the stool (melena). 2004 by Saunders. 2010. D.1 578.2. 996. RATIONALE: A.1 772. Code 331. 772. 02. This is an inpatient for which Volume 3 codes are used to report procedures.1.42). Also incorrect is 331. nervous system device.4 and 02. Code 331.1 578.42 996. not CPT codes. 772. Bloody stool: 578.42. 2005.2 to report a complication of a mechanical.2 is the diagnosis for a mechanical complication of a nervous system device. Code 996. Elsevier items and derived items © 2011. 996.4 is gastrointestinal hemorrhage in a fetus or neonate.34 which reports ventricular shunt to the abdominal cavity/organs and this was a ventriculoperitoneal shunt at the ventricular site (02.1. 331.4 A. 62190 CORRECT ANSWER: B.3. 331. 578. C.5 is incorrect. 02.

59. rather. Report the facility services only.61).3) and pelvic peritoneal adhesions (614. 614. 2004 by Saunders.49. 65. The diagnoses are endometriosis of the pelvic peritoneum (617. 2006. 38.61. 65. This choice is incorrect as it does not report the total abdominal hysterectomy.61.49. 2007. 65. 68.3.3 Ureteral catheterization Bilateral salpingo-oophorectomy Total abdominal hysterectomy Total abdominal hysterectomy (corpus and cervix).6 68.61. D.3.49 58150 614. 58150. 2008. This 34-year-old female is admitted for total abdominal hysterectomy with bilateral salpingo-oophorectomy.6 617. 65. which is blood that is not visible. 59. This choice is incorrect as the inpatient procedures are reported with Volume 3 codes. 59. The diagnosis is pelvic peritoneum endometriosis and periovarian adhesions. 37. D. 2010. This choice is correct as it reports the inpatient procedure of total abdominal hysterectomy (68.6).3. 617. 792.49) and bilateral salpingooophorectomy (65. 614. 614. 68. 614. B. C.6 to report the pelvic adhesions.8 65. it was blood found in stool by means of a lab test. 617. 58150. 578. This choice is incorrect as it reports a ureteral catheterization and this procedure was not stated in the report. Also missing is 614.3 65. Sarcoidosis with cardiomyopathy: Elsevier items and derived items © 2011. with or without removal of tube(s).3.61. female (postoperative) (postinfection) Endometriosis of pelvic peritoneum A.6.8.3. C. B. 68.6 617. with or without removal of ovary(s) Pelvic peritoneal adhesions. 2009.3. 617. 65.61 68. RATIONALE: A.6. 617.1 is occult blood in stool. 617. 2005.61 CORRECT ANSWER: D. 614.61. 617.6.CCS Final Examination With Answers B.3. not CPT codes. 32 .49. an imprint Elsevier Inc.0 is hematemesis or vomiting of blood.6. 617.49.8. 614.

135 is correct for the underlying disease of sarcoidosis. D. followed by 425. RATIONALE: A. The codes are correct and in the correct order. Septra® B. sarcoidosis. when the Tabular List is referenced. 135. 39. not cardiac involvement. a directional note under 425. Naprelan® Elsevier items and derived items © 2011. 2010.” You are to list these codes in the order presented in the Index of the ICD-9-CM. but 517. B.8 517.8 425. cardiomyopathy. V71.8]. 2009. Which of the following medications would indicate a possible complication or comorbid condition that may affect payment for the DRG? A. 425.8 is for lung involvement. directs the coder to “Code first any underlying disease classified elsewhere” and includes “Sarcoidosis 135” in the list of other diseases. 2004 by Saunders. 2005. You know this because listed in the Index of the ICD-9CM under “Sarcoidosis” is subterm “cardiac 135 [425. C. 135 135. cardiomyopathy.8 135. 517.8.7 CORRECT ANSWER: B.8. Further. 33 . an imprint Elsevier Inc. and 425. The codes are correct. but the underlying condition (sarcoidosis) is to be listed first and the cardiomyopathy is listed second.8] lung 135 [517. 2008. is listed second.8 V71. 135. D. This also directs the coder to list 135 first.8] A.8. 425.CCS Final Examination With Answers 135 425.8.8.7 Sarcoidosis Cardiomyopathy in other diseases classified elsewhere (code first underlying disease) Lung involvement in other diseases classified elsewhere (code first underlying disease) Observation for suspected cardiovascular disease Index: Sarcoidosis 135 cardiac 135 [425.8 in the ICD-9-CM. A patient is in the hospital being treated for pleural effusion. as indicated in the directional note with 425. 2006. 2007. C. except V71. is the first-listed diagnosis.7 (observation for suspected cardiovascular disease) is incorrect because there was no indication of evaluation for a suspected condition.

Observation for a suspected condition can be a principal diagnosis if there was no more definitive diagnosis stated. To ensure the accuracy of the data being coded in the department. Section 1. 2010. C.d.06 Allergy to insects and arachnids (spiders and other eight-legged invertebrates) is not appropriate as a principal diagnosis as it is listed as an “additional only” V code per the V Code Table in the ICD-9-CM Official Guidelines for Coding and Reporting following Section I. If the patient had some significant psychological problem. 2005. the instructional note following 323. if the significance of the problem was documented in the medical record. Ativan CORRECT ANSWER: A. V15.a. V15.C.2 Observation for suspected tuberculosis. Furthermore. Naprelan® is an analgesic and would not indicate a complication or comorbidity that would affect payment for the DRG. C. 40. Captopril® is an antihypertensive that would not indicate a complication or comorbidity that would affect payment for the DRG. and these are never sequenced first. Ativan® is an antidepressant and would not indicate a complication or comorbidity that would affect payment for the DRG. RATIONALE: B.2 Allergy to insects and arachnids Nontraffic accident involving other off-road motor vehicle Toxic encephalitis and encephalomyelitis Observation for suspected tuberculosis CORRECT ANSWER: D. which indicates an infection was present and treated and the infection may affect the payment for the DRG.15.7 states that the underlying cause is to be coded Elsevier items and derived items © 2011.6.71 V71.19. E821 Nontraffic accident involving other off-road motor vehicle is not appropriate as a principal diagnosis as E codes are never principal diagnoses as noted in the ICD-9-CM Official Guidelines for Coding and Reporting.C.CCS Final Examination With Answers C.18. V71. B. Which code is the only code that can be assigned as a principal diagnosis? A. D. 2009. 2008. that problem might be a complication or comorbidity. the supervisor conducts regular reviews of the inpatient coding data. an imprint Elsevier Inc. 34 . 2007. 2004 by Saunders. Captopril® ® D. 323.06 E821 323. B. 2006.71 Toxic encephalitis is not appropriate as a principal diagnosis as it is an italicized code. D. C. Septra® is an antibiotic. RATIONALE: A.

V code to report laparoscopic surgical procedure converted to an open procedure would not be listed as principal diagnosis. Both 250. The acute appendicitis is correct as the first-listed diagnosis. acute appendicitis. followed by a complication code (998. 2005. 2009. acute appendicitis. complication of surgery by accidental puncture or laceration. and the V code to indicate that the laparoscopic procedure was converted to an open procedure is reported last. acute appendicitis. V code to report laparoscopic surgical procedure converted to an open procedure. C. internal injury to the ileum. available on the AHIMA website.81 can be the etiology or the manifestation code. The reason for the procedure (acute appendicitis) is listed as the principal diagnosis. B.4 is the etiology code and 581.81 can be the etiology or the manifestation code. 581. laparoscopic appendectomy CORRECT ANSWER: C. RATIONALE: A. complication of surgery by accidental puncture or laceration are correct. an imprint Elsevier Inc. According to Coding Clinic 3rd Q 1994. 2008.4 and 581. 43. V code to report laparoscopic surgical procedure converted to an open procedure.CCS Final Examination With Answers procedure. is reported last. Laparoscopic appendectomy is incorrect because the procedure was converted to an open procedure. 250. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken.) A.81 is the manifestation code. and there is no V code to report the laparoscopic procedure that was converted to an open procedure.41). In the following display of the ICD-9-CM Index.81 is the etiology code and 250. 2004 by Saunders. identify which code is the etiology code and which is the manifestation code: Syndrome Kimmelstiel (-Wilson) (intercapillary glomerulosclerosis) 250. Neither 250. D. open appendectomy.4 [581. but missing is a code to report the complication of surgery by accidental puncture. Elsevier items and derived items © 2011.2). complication of surgery by accidental puncture or laceration. it is inappropriate to assign codes from 800-959 as an additional code when reporting an intraoperative laceration or puncture.4 nor 581.4X. The V code (V64. It is incorrect to report injury to ileum. Laparoscopic appendectomy is incorrect because the procedure was converted to an open procedure. acute appendicitis should be the principal diagnosis.81] (Note: A fifth digit would be assigned to 250. D. 2007. acute appendicitis. 36 . internal injury to the ileum is incorrect. B. No E codes are reported according to the guidelines for the AHIMA certification. 2006.4 is the manifestation code. 2010. which indicates that a laparoscopic procedure was converted to an open procedure.

CORRECT ANSWER: A. 250.4 is the etiology code and 581.81 is the manifestation code. The etiology (cause) is listed first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. This convention is explained in the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.A.6. RATIONALE: B. 581.81 is the etiology code and 250.4 is the manifestation code is incorrect. The etiology (cause) is listed first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. C. Both 250.4 and 581.81 can be the etiology or the manifestation code is incorrect as only 250.4 can be the etiology, as it is listed first in the Index. When reporting, the etiology (cause) is lists first, followed by the manifestation (symptom) reported in the order displayed in the Index of the ICD-9-CM. D. Neither 250.4 nor 581.81 can be the etiology or the manifestation code is incorrect because the Index of the ICD-9-CM lists 250.4 (etiology) first and 581.81 (manifestation) second, and you always report the codes in the order they appear in the Index.

44. Which of the following is NOT a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system? A. B. C. D. severity of illness prognosis ABN treatment difficulty

CORRECT ANSWER: C. ABN (advanced beneficiary notice) is a notification of non-coverage to the patient, but not a consideration for the complexity of the hospital’s case mix. RATIONALE: A. Severity of illness is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system. B. Prognosis is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system. D. Treatment difficulty is a patient attribute that is part of the concept of the case mix complexity of the MS-DRG system.

45. An outcome of delivery (code V27.0-V27.9) should be included on every record when delivery has occurred and should used on subsequent

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records. A. B. C. D. newborn’s, not be mother’s, not be newborn’s, be mother’s, be

CORRECT ANSWER: B. “mother’s, not be” are the correct responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. RATIONALE: A. “newborn’s, not be” are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. C. “newborn’s, be” are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but should not be used on subsequent records or on the newborn record. D. “mother’s, be” are the incorrect responses according to the ICD-9-CM Official Guidelines for Coding and Reporting, Section I.C.11.b.5., which indicates that the outcome of delivery codes should be included on every maternal record when delivery has occurred but not used on subsequent records or on the newborn record.

46. The patient presents to the ED with cellulitis of the right small finger due to Staphylococcus aureus. The ED physician prescribed Lorabid p.o. 400 mg q12h × 10 d.

681.00 681.9 041.11 041.89

Finger, cellulitis and abscess, unspecified Finger or toe, cellulitis and abscess of unspecified digit Methicillin susceptible Staphylococcus aureus Other specified bacterial infections

A. 99281, 681.9, 041.89 B. 99283, 681.00, 041.11 C. 99282, 681.00, 041.89

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D. 99283, 041.11, 681.00 CORRECT ANSWER: B. 99283, 681.00, 041.11. Level 3 correctly reports the ED service, as prescription medications are listed under this level. 681.00 correctly reports cellulitis of the finger, followed by the code 041.11 to report the cause of the infection as Staphylococcus aureus. These codes are in the correct sequence per the instructional note, following 681, to use an additional code to specify the organism. RATIONALE: A. 99281, Level 1, incorrectly reports this level of service because it is under Level 3 that prescription medications are listed. 681.9 is incorrect because it reports cellulitis of an unspecified digit, and the digit was stated to be the small finger of the right hand. 681.00 is more definitive as it indicates cellulitis of a finger. 041.89 is also incorrect as it is for other specified bacterial infection, and the report indicated the cause of the infection as Staphylococcus aureus. C. 99282, Level 2, is incorrect as prescription medications are listed under Level 3. The cause of the infection is Staphylococcus aureus, not “other specified bacterial infection.” D. Level 3 is correct for this service as prescription medications are listed under this level. The diagnosis codes are correct but are listed in the wrong sequence. 681.00 should be listed first according to the instructional note, following 681, to use an additional code to specify the organism. 47. A child is seen in the outpatient department at the hospital for a subsequent burn treatment as follows: 2nd degree burn of right forearm, which is 2% burn of body surface; 1st degree burn of right little finger, which is 4% of body surface; 3rd degree burn of right chest wall, which is 5% of body surface. The initial burn occurred when the child pulled a pan of hot water off the stove. 942.32 942.31 943.21 943.22 944.00 944.11 948.10 948.11 Burn of trunk, chest wall excluding breast and nipple, full-thickness skin loss [3rd degree NOS] Burn of trunk, breast, full-thickness skin loss [3rd degree NOS] Burn of upper limb, upper limb, forearm, except wrist and hand, blisters, epidermal loss [2nd degree] Burn of upper limb, elbow, except wrist and hand, blisters, epidermal loss [2nd degree] Burn of wrist(s) and hand(s), single digit other than thumb, [unspecified degree] Burn of wrist(s) and hand(s), single digit other than thumb, erythema [1st degree] Burns classified according to extent of body surface involved, 10%-19% total burn area, less than 10% are 3rd degree burn Burns classified according to extent of body surface involved, 10%-19% total burn area, 10%-19% are 3rd degree burn

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A. B. C. D.

942.32, 943.21, 944.11, 948.11 942.32, 943.21, 944.11, 948.10 942.31, 943.22, 944.00, 948.11 942.31, 943.21, 944.11, 948.10

CORRECT ANSWER: B. 942.32, 943.21, 944.11, 948.10. Burns are sequenced with the highest degree of burn first, followed by the lesser degrees of other areas. If there is a 3rd degree burn and a 2nd degree burn of the same area, only the 3rd degree burn is reported. The burns in this case are reported as 3rd degree burn of chest (942.32), 2nd degree burn of forearm (943.21), and 1st degree burn of finger (944.11). The total body surface code (948.10) is a sum of all the body surfaces involved in the burn (11%, 948.1) with a fifth digit to indicate the total body surface with 3rd degree burn, which in this case was 5% (fifth digit 0). RATIONALE: A. 942.32 correct, 943.21 correct, 944.11 correct, 948.11 incorrect because the total body surface involved in 3rd degree burn was 5%, fifth digit “0” not “1.” C. 942.31 incorrect because this reports a burn to the breast and the burn was to the chest wall, 943.22 incorrect because this is for an elbow and the forearm of upper limb was involved, 944.00 is not correct because this code represents unspecified degree of burn and unspecified site of the hand. The correct code for the 1st degree burn of the index finger is 944.11. 948.11 incorrect because the total body surface involved in 3rd degree burn was 5%, fifth digit “0” not “1.” D. 942.31 incorrect because this reports a burn to the breast and the burn was to the chest wall, 943.21 correct, 944.11 correct, 948.10 correct.

48. How would you report urticaria due to penicillin that was correctly prescribed and properly administered? A. Code urticaria due to drug followed by an E code to report the causative substance correctly prescribed and properly administered therapeutically. B. Report the E code for the causative substance correctly prescribed and properly administered followed by the code for the allergic urticaria. C. Report only the urticaria as no E codes are reported on the certification examination. D. Report the urticaria as an E code to report both the causative substance and how the adverse effect occurred. CORRECT ANSWER: A. Code urticaria due to drug followed by an E code to report the causative substance properly taken and prescribed therapeutically. According to the AHIMA examination packet, E codes are not assigned, except for those

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D.51 791. 584. therefore. conditions that have been previously treated but no longer are present D. K. C. 584. conditions that have been previously treated but no longer exist should not be coded.9 276. Conditions that have been previously treated but no longer are present.9. RATIONALE: A. historical conditions that have an impact on current care or influence the patient’s treatment are to be reported. acute Dehydration Proteinuria Findings.99 CORRECT ANSWER: C. 42 . which of the following would NOT be reported as a secondary diagnosis? A. K. This is the correct choice because 584. other 584.51 790.9. 2005. chronic diseases that are treated on an ongoing basis B. 276. 51. This 68-year-old female presents with proteinuria present in a recent lab. 2009. “History of” that have an effect on the current condition CORRECT ANSWER: C. coexisting conditions at the time of the encounter that affect the patient’s management C. Patient is admitted for treatment of acute renal failure due to dehydration. Section IV. 276. chronic diseases that are treated on an ongoing basis are to be reported. Failure. Elsevier items and derived items © 2011.9 is the correct code for acute renal failure. K. coexisting conditions at the time of the encounter that affect the patient’s management are to be reported.51 is the correct diagnosis for dehydration.0 790. B. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services. According to the Ambulatory Care Coding rules presented in the CCS examination information prepared by AHIMA. renal. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services. and the ICD-9-CM Official Guidelines for Coding and Reporting. D.0. it is a component of the acute renal failure and is not reported separately. 584. 2007. According to the Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services.. 2004 by Saunders. 791. abnormal. Proteinuria is a condition that results from acute renal failure.51.99 A. 2006. 2010. B.9. and 276. 2008.CCS Final Examination With Answers 50. J. an imprint Elsevier Inc. In an ambulatory care setting.

583.9.41. type 2 Nephritis and nephropathy.41.99. The procedure is being performed by her obstetrician.11.81.CCS Final Examination With Answers RATIONALE: A. 583.03 59000.81 CORRECT ANSWER: D. 2010. 790. 2009.41 250. an imprint Elsevier Inc. 52. 2007.C.9 and a code to report the dehydration (276. 2006. 648. 2008.03. 250. 2004 by Saunders.f. B.41. type 1 diabetes. Section I. 648.81) because the nephropathy code is an italicized code.81 583. The diagnosis sequencing above is consistent with the ICD-9-CM Official Guidelines for Coding and Reporting.81 59000. 583. 250. 2005.51). D.03.41. and diabetic nephropathy. C.81.03. 250.41 59000. The complication (648. B. 59001. in diseases classified elsewhere Other types of nephropathy or nephritis Diabetes complicating pregnancy. The proteinuria is not reported as it is a result of the acute renal failure and as a component of the disease is not reported separately.0. reported with 59000. This choice is incorrect because the diagnosis for the dehydration is missing (276. 584. RATIONALE: Elsevier items and derived items © 2011. This choice is incorrect because missing is a code for the acute renal failure and dehydration. Report the department services. type 1 Diabetes with renal manifestations.03 Amniocentesis. with insulin-dependent. 648. The service was amniocentesis. 584.03) is listed first as that is the reason for the procedure. antepartum A.03. 59000 59001 250. 59000. 791.40 583. 250. 583. 648. and also because it stated that it is “in diseases classified elsewhere. 648. This choice is incorrect because it is missing a code for acute renal failure.81. diagnostic Amniocentesis. therapeutic fluid reduction Diabetes with renal manifestations. The proteinuria is not reported as it is a result of the acute renal failure and as a component of the disease is not reported separately. 250.” directing the code to be sequenced after the diabetes.41) is listed before the nephropathy (583. D. 43 .89 648. A 22-year-old female patient presents to the outpatient department of the hospital for an amniocentesis to assist in the management of her complicated pregnancy. 583. not specified as acute or chronic.51). The diabetes (250. The medical record indicates 32 weeks’ gestation.

6.03) is the primary reason for the procedure.9.03 is the correct code for the complication of pregnancy but should be sequenced first. 403. 2nd Qtr 2001. 996. 583. 2nd Qtr 2001. Section II. According to the ICD-9-CM Official Guidelines for Coding and Reporting. 2nd Qtr 2001. Section II.29) due to peritoneal dialysis.09.9.09.68. 2008. 585. 2006. and 648. Section II. This inpatient was admitted for acute peritonitis (567. 2005. The patient has hypertensive renal disease with chronic renal failure (403. What would be the sequence of these codes? A. 567.68. 585. the complication is sequenced first. 041.68. C. 59000 is correct. 2010.41. 250. an imprint Elsevier Inc. 53. 567.41 is the correct type of diabetes but should be sequenced before the nephropathy.91. 44 . 996. 996. RATIONALE: A. as the complication (648. and 250. A review of the medical record indicated that there was a complication of the peritoneal catheter (996.6 996. followed by the peritonitis and infectious organism as the cause of the complication. The complication is sequenced first because it is the reason for the admission. 041. followed by the peritonitis and infectious organism as the cause of the complication. 648.G. the complication is sequenced first.G.03 is correct.09 CORRECT ANSWER: B.91) (585. B. C.68). The complication is sequenced first because it is the reason for the admission.91. 2009. but 583.29. with instruction to code first the hypertensive chronic kidney disease and use additional code to identify stage of chronic kidney disease. 403. B. D.29. the complication is sequenced first.81 is an italicized code that indicates the nephropathy should be sequenced after the diabetes.91 585. Hypertensive renal disease with renal failure may be assigned as an additional diagnosis.81 should be sequenced after 250. 2007. 041. 583.41 is correct but should not be the first-listed diagnosis. 59000 is correct for amniocentesis. Hypertensive renal disease with renal failure may be assigned as additional diagnoses. because 583.91. The complication is sequenced first because it is the reason for the admission. 2004 by Saunders.09. According to the ICD-9-CM Official Guidelines for Coding and Reporting.68. and the Coding Clinic. Hypertensive renal disease with Elsevier items and derived items © 2011. and the Coding Clinic.29.91. 403.81 is correct for nephropathy and is sequenced correctly. 567. 59001 is incorrect as it is for fluid reduction. 041. followed by the peritonitis and infectious organism as the cause of the complication. C.29.6). 403. and the Coding Clinic.09.81 is an italicized code. 567.G. 567.09).CCS Final Examination With Answers A. 403. which was determined to be peritonitis due to a streptococcal infection (041.68 996.6 041. 585. According to the ICD-9-CM Official Guidelines for Coding and Reporting.

B. Assign a code that you think may describe the service correctly. The complication is sequenced first because it is the reason for the admission. as it is recognized that there are situations where there may not be a code to appropriately identify the service provided. assign an unlisted digestive code hold the report until a CPT update publishes a code for the service assign a code that closely describes the service query the physician as to the code to assign CORRECT ANSWER: A. right hemisphere POSTOPERATIVE DIAGNOSIS: Same Elsevier items and derived items © 2011. 2008. D. the complication is sequenced first. A physician should not recommend a code “closely describing” a service. C. Per CPT guidelines. 45 . Each of these unlisted procedural code numbers (with the appropriate accompanying topical entry) relates to a specific section of the manual and is presented in the guidelines of that section. D.” This guideline can be found in the “introduction” section of the CPT manual under the subsection entitled: “Instructions for Use of the CPT Codebook. Hold the report until a CPT update publishes a code for the service. This is not an appropriate approach to this situation. According to the ICD-9-CM Official Guidelines for Coding and Reporting. 2009. “it is recognized that there may be services or procedures performed by physicians that are not found in the CPT manual. and the Coding Clinic. INPATIENT PREOPERATIVE DIAGNOSIS: Chronic subdural hematoma. Assign an unlisted digestive code. 2004 by Saunders. In those instances an unlisted CPT code will be reported. Therefore.CCS Final Examination With Answers renal failure may be assigned as additional diagnoses. 2007. 2005. 55. This is not correct. 54. This is not an appropriate approach to this situation.G.” RATIONALE: B. If the gastroenterologist performed a procedure for which there is no code listed in the index of the CPT. 2006. Section II. the coder should: A. followed by the peritonitis and the infectious organism as the cause of the complication. Hypertensive renal disease with renal failure may be assigned as additional diagnoses. D. 2010. 2nd Qtr 2001. C. Query the physician as to the code to assign. an imprint Elsevier Inc. a number of specific code numbers have been designated for reporting unlisted procedures.

however.1. cerebral. 431.1 01. rather Elsevier items and derived items © 2011. I then irrigated until I got clots out. there is no subterm for “subdural” and although this case was a hematoma. In the procedure section of this report. There is no subterm for “cerebral”. 01.25.24.25. 01.24 01. C. one for “epidural or extradural space 01. A dressing was applied. the location of subdural is covered by this term.CCS Final Examination With Answers PROCEDURE PERFORMED: Burr hole evacuation of subdural hematoma ANESTHESIA: General PROCEDURE: Under general anesthesia. rather a hematoma drained along with fluid. the most descriptive code is 01. In the procedure section of this report.31 431 432. the patient’s head was prepped and draped in the usual manner. RATIONALE: A. Other craniotomy Other craniectomy Drainage subarachnoid or subdural Intracerebral hemorrhage Nontraumatic subdural hemorrhage 01. 01.25. 46 . I saw the brain beneath. 432. Two burr holes were made.31. This choice is incorrect for both the procedure and the diagnosis. B. I closed the wound with 2-0 Vicryl on the galea and surgical staples on the skin. the coder is referred to “see also Incision. 432. 01. 2005. 432. 431 CORRECT ANSWER: B. 2007. a piece of the skull was not removed. 432. Craniectomy is a removal of a piece of the skull. a piece of the skull was not removed.1 is the correct code to report a nontraumatic subdural hematoma. 2008. 2006. 2010.25 01.24” and one for “subarachnoid or subdural space 01. 432. The patient was discharged to the recovery room.” The Tabular indicates that 01.31.31.” there are two subterms. 01. The dura was incised and serosanguineous fluid exuded.1 01. Incision was made in the frontal and posterior parietal area. 2004 by Saunders.31. by site. 431 01. an imprint Elsevier Inc. The code is identified when you reference “Incision. C. 2009.” which is a collection of purulent material in the space between the dura mater and the arachnoid mater (subdural). Then.” When referencing “Incision. I inserted two Penrose drains and secured them to the skin.1 is correct for the nontraumatic subdural hematoma.24. Therefore. D. hematoma” in Volume 3 of the ICD. When checking the 01.1 A. 432.1.31 correctly reports this procedure as drainage of subdural hematoma.31 has the subterm “subdural empyema. This choice is incorrect for the procedure.25.

1.2. In the Index of the ICD. The correct diagnosis code would be 432. The procedure is an initial implantation reported with 33208. The implantation of a permanent dual-chamber pacemaker was performed in the outpatient department of the hospital. 33213 427. Atrial and ventricular leads were introduced. 01. 33208 33213 427. The leads were sutured using 0 silk over their sleeves and secured. 33213. 427. which specifies a subdural hemorrhage (which is bleeding between the layers that line the brain) and one that was not indicated to be traumatic. there is no subterm for “subdural. the burr holes are the approach and the actual procedure was the evacuation for the subdural hematoma. 2005. The correct diagnosis code would be 432. 427. is correct. Parameters were satisfactory. 01.5 cc of Xylocaine. 431 is incorrect as it is for intracerebral hemorrhage which is within the brain. 01. 56. 33213 is Elsevier items and derived items © 2011.89 780. In this answer. The indication was noted to be bradyarrhythmia with fainting. B.24.2 Insertion or replacement of permanent pacemaker with transvenous electrode(s). 2008. 2007.2. 2004 by Saunders. D. 427. 33208 CORRECT ANSWER: C. C. Craniectomy is a removal of a piece of the skull. Thresholds were obtained adequately. 33208. 427. In this choice. The pulse generator was connected. dual chamber Other specified cardiac dysrhythmia Syncope A. D. Also. Other craniotomy.89. 47 . The diagnosis was bradyarrhythmia (427. A pacemaker pocket was created in the left infraclavicular area after the area was anesthetized with 0. the coder is directed to 01.CCS Final Examination With Answers a hematoma drained along with fluid. 780. when the term “Burr holes” is referenced. The electrodes were implanted into the atrium and ventricle. The pacemaker pocket was flushed with antibiotic solution. Volume 3.89. 431.” which the procedure in this case was.89. RATIONALE: A. The pacemaker and leads were placed in the pocket and the pocket closed in two layers. 33213 780.89. 431 is incorrect as it is for intracerebral hemorrhage which is within the brain. When checking the Tabular.89.24. 2006.24 is incorrect. The diagnosis code. an imprint Elsevier Inc.24. which specifies a subdural hemorrhage (which is bleeding between the layers that line the brain) and one that was not indicated to be traumatic. 33208 427. atrial and ventricular Insertion or replacement of pacemaker pulse generator only. 2010. Note under 33208 states that subcutaneous insertion of pulse generator is included.89).89.1. 2009.

Code the facility services and report the diagnosis. 79. 821. 2006. C. 821.CCS Final Examination With Answers incorrect as it reports the insertion of a dual-chamber.01. 33208. The fracture is brought into proper alignment. 821. with or without skin or skeletal traction Open treatment of femoral shaft fracture with plate/screws. The diagnosis code is incorrect as it reports the fainting. 27507-LT CORRECT ANSWER: A. with or without cerclage A. 2005. 27502-LT 821. and a 6-hole plate is placed.2. femur Closed treatment of femoral shaft fracture with manipulation. In this procedure.01. 33213. B.35 reports an open reduction of a fracture of the femur with internal fixation. 780.2. pulse generator only when the report indicated a permanent pacemaker with placement of electrodes. open Closed reduction of fracture with internal fixation. In this answer. 48 . but rather is included in the bradyarrhythmia code.89. No E codes are reported according to the guidelines for the AHIMA certification. 2004 by Saunders. The syncope (fainting) should not have been reported separately with 780. an imprint Elsevier Inc. 2009.01 821.11. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken.01. Elsevier items and derived items © 2011.89 are correct.11 79. 79. the coder is to assume the fracture is closed. 821. 2010. 2008. 2007. as fainting is a symptom of bradyarrhythmia. available on the AHIMA website.35 27502 27507 Fracture of shaft or unspecified part of femur. 57.89.35. femur Open reduction of fracture with internal fixation. The area is irrigated with saline.15 79.01 reports a closed fracture of the shaft of the femur. D. In this answer. closed Fracture of shaft or unspecified part of femur.2. 780. the patient’s leg is incised. 33213 is incorrect as it reports the insertion of a dual-chamber. the fracture was closed (no break in the skin). but the fainting should not be reported. as it is a symptom of bradyarrhythmia. 33208 and 427. 427.35 821. If a fracture is not stated as open or closed. The lateral side of the shaft of the femur both proximally and distally from the fracture site is exposed. and fainting is a symptom of bradyarrhythmia and should not be reported separately. This inpatient is admitted with a fracture of the left shaft of the femur.11. Under general anesthetic. The operation was an “open” procedure as the fracture site was opened to the view of the surgeon. 427. B. pulse generator only when the report indicated a permanent pacemaker with placement of electrodes. 79. 79.15 821. but the procedure was through an incision (open). D.

512. but not the radiology service. single-view.11 is incorrect also as it reports an open fracture. An 18-gauge chest tube is subsequently placed and sutured to the skin. frontal Radiologic examination. the coder is to assume the fracture is closed.8. 49 . and blood loss is minimal. and this fracture was closed. The patient is sedated with Versed and paralyzed with Nimbex. 32551. 821. 58.8 99291. Lidocaine is used to numb the incision area in the midlateral left chest at about nipple level. 2010. 2006.8 CORRECT ANSWER: A. 821. chest. 512.11.01. If a fracture is not stated as open or closed. therefore it must be coded as closed using code 821. Spontaneous tension pneumothorax Other spontaneous pneumothorax Tube thoracostomy includes water seal (e. 2004 by Saunders. chest x-ray shows significant resolution of the pneumothorax. 2008. 821.8 32551 32036 71010 71015 A. If a fracture is not stated as open or closed. 821. A follow-up. There are no complications for the procedure. The diagnosis is pneumothorax. 99291. 821.11. C.8 99285. frontal 99291. stereo. D..11 is wrong because it reports an open fracture. when performed (separate procedure) Thoracostomy. and the procedure in this report was performed by means of an incision (an open procedure). but the report did not state “open” fracture.g. 79. 512. but rather with Volume 3 procedure codes. 512.01. The 18-year-old patient is brought to the emergency room by ambulance. B. 32551. making sure the incision is superior to the rib. On entrance to the pleural space. but rather with Volume 3 procedure codes. If a fracture is not stated as open or closed. an imprint Elsevier Inc.0 99291. 27502-LT. The diagnosis was correctly reported with 821. 27507-LT. except for a small apical pneumothorax that is noted. emphysema). 512.CCS Final Examination With Answers RATIONALE: B. D. 512. Inpatient procedures are not reported with CPT codes. Report the service for the emergency room physician. After the lidocaine. 71010.15 reports a closed fracture reduction. as Elsevier items and derived items © 2011.0 512. This service was a critical care service (99291). immediate release of air is noted. an incision is made and bluntly dissected to the area of the pleural space. Inpatient procedures are not reported with CPT codes. chest.15. 2007. 32036. the coder is to assume the fracture is closed. single view. for abscess. 79. with open flap drainage Radiologic examination. 2009. C. 2005. hemothorax. the coder is to assume the fracture is closed.01. 32551.

rather than other spontaneous pneumothorax. 32551. 2008. The patient is brought to the ED by her husband. The diagnosis of 512. 2009. 50 . RATIONALE: B. See Level 5. 59. adult) Level 3.8. Level 4.8. point 7 indicates sexual assault exam. D. She received bruises around her head and neck when she was struck repeatedly by her assailant. 99291. 99291.8 correctly reports pneumothorax as the diagnosis.83 is the code for a sexual assault and verifies the reason for a Level 5 visit.CCS Final Examination With Answers indicated by point 4 in the Critical Care column. 995. Level 5 is the incorrect ED service as this was a chest tube placement (see point 4 in the Critical Care column). This selection correctly reports the ED service as critical care (99291) and the chest tube placement (32551). No E codes are reported according to the guidelines for the AHIMA certification. 995. B. The patient was sexually assaulted on the way home from work this morning.83 (sexual assault. 995. point 7. 71010. RATIONALE: A. the tube insertion (32551) is not included in the critical care service and is reported separately. pneumothorax. This selection correctly reports the ED service as critical care and the diagnosis as pneumothorax. she was accosted in the parking lot and was taken to a parked van. D. Level 5. available on the AHIMA website.83 Level 4. 512. Level 5. See Level 5. but also incorrectly leaves out reporting of the chest tube placement. Level 3. The only E codes reported on the examination are those for medications correctly prescribed and correctly taken. A. is correct. 995. The x-ray code (71010) should not have been assigned because the directions indicated not to report the x-ray. See Elsevier items and derived items © 2011. 512. There is no indication within this level for a sexual assault exam. 512.83 CORRECT ANSWER: D. According to the patient. The placement is not included in the critical care code and is reported separately. where she was assaulted. 2006. an imprint Elsevier Inc.0 is incorrect as it reports the diagnosis as spontaneous tension pneumothorax. Also. There is no indication within this level for a sexual assault exam. 512. The ED performed a sexual assault examination. Level 2. Level 2. 995.83 Level 5. 512. C. 2005. point 7. chest tube insertion.0. She is a nurse at a skilled nursing facility in town. 2004 by Saunders. C. 2010. 32036.8. There is no indication within this level for a sexual assault exam. 99285. 2007. Report the ED service. C. B.

Inspection of the bladder demonstrated findings consistent with radiation cystitis. PROCEDURE PERFORMED: Cystoscopy.”) by cystoscopy. and HCPCS and ICD-9-CM coding manuals. CORRECT ANSWER AND RATIONALE: 593. The 21-French cystoscope was passed into the bladder. which means it is part of a more complex or extensive procedure and not coded separately when performed at the same time. Note that the code for removal of stent (52310) is not assigned because this code is designated as a separate procedure. 52 . 595. Procedure(s): 52332-RT identifies ureteral stent insertion and the removal of the existing stent (change of stent) (“…stent was exchanged…. There was no frank neoplasia.CCS Final Examination With Answers PART II With the use of a medical dictionary. 2010. The right ureteral stent was grasped and removed through the urethral meatus. He was prepped and draped in the lithotomy position.3 is the diagnosis for ureteral stricture. CASE 2 OPERATIVE REPORT Elsevier items and derived items © 2011. 595. 2005. under fluoroscopic control. The patient tolerated the procedure well. 2007. the codes for temporary indwelling bladder catheter would be incorrect. 2006. and urine was collected for culture. right ureteral stent change. 2004 by Saunders. PROCEDURE NOTE: The patient was placed in the lithotomy position after receiving IV sedation. LOCATION: Outpatient surgery center.82. assign codes to the following: 1. an imprint Elsevier Inc. and the stent was exchanged for a 7-French 26-cm stent under fluoroscopic control in the usual fashion. 52332 Diagnosis(es): 593. There was no indication that this stent was temporary. Code for the outpatient facility services.82 is reported for irradiation cystitis (E code is not reported per ICD-9-CM Official Guidelines for Coding and Reporting for this examination). CASE 1 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Right ureteral stricture. 2009. 2008. a guidewire was advanced up the stent.3. POSTOPERATIVE DIAGNOSIS: Right ureteral stricture. CPT. 2. therefore. which had been previously diagnosed.

2005. just somewhat swollen. had petechial ecchymotic areas scattered throughout the airways. It was then numbed with 1% Xylocaine. but nothing really significant was returned. The patient tolerated the procedure well without apparent complication. The left lung. glucose. It was passed easily down to the carina. 2010.60. 2004 by Saunders. DESCRIPTION OF PROCEDURE: The patient was placed in the lateral decubitus position with the left side up. 62270 Diagnosis(es): 780. so his bronchoscopy was done through the ET tube. No abnormal secretions were noted at all. and intubated. The area was cleansed. PROCEDURE: The patient was already sedated. About 2 to 2. protein. The fluid was minimally xanthochromic.5 cm above the carina.60 correctly identifies the only diagnosis listed. PROCEDURE PERFORMED: Lumbar puncture. The tissue was friable and swollen. LOCATION: Emergency department. including some with Mucomyst to see whether we could get some distal mucous plug. Procedure(s): 62270 indicates aspiration of fluid from the spine (lumbar puncture) for diagnostic rather than therapeutic purposes. LOCATION: ASC. all segments were patent and entered. The lumbosacral area was sterilely prepped. that of fever.CCS Final Examination With Answers PREOPERATIVE DIAGNOSIS: Fever. however. which appeared good. an imprint Elsevier Inc. PROCEDURE PERFORMED: Fiberoptic bronchoscopy with brushings and cell washings. and all the airways were open. I then placed a 22-gauge spinal needle on the first pass into the intrathecal space between the L4 and L5 spinous processes. The needle was removed at the end of the procedure. 2008. and a Band-Aid was placed. but no mucous plugs were noted. The Elsevier items and derived items © 2011. 2006. In the right lung. CASE 3 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Atelectasis of the left lower lobe. 2009. as well as washings. and culture. CORRECT ANSWER AND RATIONALE: 780. 3. and no masses were seen. 2007. I sent the fluid for cell count for differential. The legs and hips were flexed into the fetal position. as was the carina. 53 . Brushings were taken. on a ventilator. Gram stain. we could see the trachea.

Additionally. CORRECT ANSWER AND RATIONALE: 518. The -59 modifier would need to be appended to to 31622 to identify it as being performed at a separate site. PROCEDURE PERFORMED: Incision and drainage of left thigh abscess. CASE 4 OPERATIVE REPORT PREOPERATIVE DIAGNOSIS: Abscess. almost stool-like material (it was not stool. extending from the posterior buttocks region up toward the side of the base of the penis. the bronchoscopy codes are inherently unilateral. The patient tolerated the procedure fairly well. 518. and we saw no evidence of communication with the perirectal space. We obtained a lot of very foul-smelling. The incision was widened to allow us to probe the cavity fully. In any event. an imprint Elsevier Inc. 2004 by Saunders. This means that 31622 is considered a component of a more extensive or comprehensive procedure and is not to be coded additionally. but it was brown and very foul-smelling material).0. but there was extension down the thigh and extension up into the groin crease. OPERATIVE NOTE: With the patient under general anesthesia. 2008. LOCATION: Outpatient surgery center. 2006.CCS Final Examination With Answers specimens were sent to appropriate cytological and bacteriological studies. 54 . 31623 identifies the left lung bronchoscopy with washings and brushings. But. Typically. The area around the anus was carefully inspected. when washings and brushings are performed on the same site (lung). 2010.0 reports the atelectasis (a condition in which the lung does not completely inflate). only 31623 would be reported because 31622 is designated as a separate procedure. the area was prepped and draped in a sterile manner. I could see no evidence of communication to the rectum. we incised the area in fluctuation.0 reports the atelectasis (a condition in which the lung does not completely inflate). 31622 identifies the diagnostic bronchoscopy of the right lung. both codes are assigned as described above. 31623. 4. Then. The fascia was darkened from the purulent material. 2009. 31622-59 Diagnosis(es): 518. I opened some Elsevier items and derived items © 2011. This was not the typical pus one sees with a Staphylococcus aureus–type infection. he was placed in the lithotomy position. Again. in this case since the right and left lungs were scoped. Procedure(s): 31622. Code the outpatient facility services. This appears to have risen in the crease at the top of the leg. 31623. 2005. 2007.0. 518.

He also has hypertension. He presents with a history of sustaining an avulsion laceration to his right third finger yesterday at about 1200 hours.9. Wound check and dressing change on Monday with his personal physician. 5.6 abscess of the leg. Procedure(s): 27301 indicates an incision and drainage of a deep abscess of the thigh or knee region. 55 . This is considered a deep abscess because it extended to the fascia. not the anus. 2006. The surgeon said that the material obtained “…was not the typical pus one sees with a Staphylococcus aureus–type infection. It measures about 3 mm in greatest diameter by about 4 to 5 mm. avulsed area on the fat pad surface of the distal right third finger.” This statement could mean that the infection was indeed staph aureus with an atypical odor. He states he is up-to-date for tetanus immunization. The patient did have a very extensive inflammation within this abscess cavity. He has no known allergies.6. CORRECT ANSWER AND RATIONALE: 883. CORRECT ANSWER AND RATIONALE: 682. Or it could mean that the physician is doubtful that the organism is Staphylococcus aureus because of its atypical odor. The abscess cavity was irrigated with peroxide and saline and was packed with gauze vaginal packing.1. 2009. There is no bleeding currently. 27301 Diagnosis(es): 682. except the foot. PLAN: Wound care instructions provided. 2010. 99282 883.CCS Final Examination With Answers of the fascia to make sure the underlying muscle was viable. an imprint Elsevier Inc. The patient tolerated the procedure well and was discharged from the operating room in stable condition. ASSESSMENT: Avulsion laceration right third finger. 2007. but the origin was the top of the leg. 2005. There was nothing to suggest a necrotizing fasciitis. 401.1 reports laceration of the finger with delayed treatment which codes to Elsevier items and derived items © 2011. The procedure began by inspection of the anus. This appeared viable. In this case the organism is not documented. CASE 5 EMERGENCY DEPARTMENT SUBJECTIVE: This is a 77-year-old male who presents with a finger laceration. Clarification should be sought before assigning an organism code in this case. 2008. No gas was present. He last received that 6 years ago. 2004 by Saunders. He has a small. as described above. when an air conditioner fell out of a window. This was cleansed with saline and dressed with Bacitracin nonadherent dressing and tube gauze. OBJECTIVE: He is afebrile with stable vital signs.

4 ureteral obstruction. No filling defects are identified. CLINICAL SYMPTOMS: Check placement of the nephrostomy tube. 2008.6 attention to a nephrostomy. Mild hydronephrosis is seen. an imprint Elsevier Inc. left ureteral obstruction.4. 591 hydronephrosis. CASE 7 LOCATION: Outpatient hospital. 2007. 401. FINDINGS PRE–LEFT NEPHROSTOGRAM: Nephrostogram obtained demonstrates a preexisting 16-French nephrostomy tube within an upper pole calyx.46. 99282 reports the ED services based on the simple trauma that did not require x-ray (Level 2.CCS Final Examination With Answers a complicated open wound. in addition to the diagnosis. 2009. No contrast extravasation of filling defects is seen. The patient’s injury occurred the day prior to presentation. CASE 6 LOCATION: Outpatient hospital. CONTRAST: Hand injection of contrast through the nephrostomy tube. 2005. V10. 2010. EXAMINATION OF: Nephrostogram. Procedure(s): 50394 reports an injection for nephrostogram. 593.9 reports unspecified hypertension. FINDINGS POST–LEFT NEPHROSTOGRAM: Final nephrostogram obtained demonstrates mild hydronephrosis. V10. 2006. Service(s): 74425 reports the radiologic supervision and interpretation. NEPHROSTOGRAM HISTORY: This is a 76-year-old male with a history of prostate cancer. point 6). the primary reason for the encounter. Ureteral coils are present. 56 . 50394.46 personal history of prostate cancer. 593. 2004 by Saunders. hydronephrosis. needing routine exchange of the nephrostomy tube. 74425 Diagnosis(es): V55. 6. 591. Elsevier items and derived items © 2011. CORRECT ANSWER: V55. The new nephrostomy tube is present in the main renal pelvis with the tip of the pigtail into the ureteral pelvic junction. 7.6. No E code is assigned because the only E codes reported on the CCS examination are those that report causative substances for an adverse effect of a drug correctly prescribed and properly administered. Report both the nephrostogram and the radiologic supervision and interpretation of the test.

7. 5. ALLERGIES: No known allergies. and some word-finding difficulties. Hematology/Oncology: The patient does have diffuse bruises but no significant bleeding. 2008. The symptoms were lethargy. There is no mention of diabetes or glucose intolerance. q h. Folic acid 1 mg once a day. Pulmicort 1 puff twice a day. 4. The patient has severe. Bowel resection for Crohn’s disease. 10. A sister and brother had lung cancer. Senile osteoporosis. 9. 1 tablet twice a day. Digoxin 0. Aspirin 325 mg once a day. an imprint Elsevier Inc. 8. Right recent cerebellar stroke. oxygen-requiring COPD. Left frontal region meningioma. the patient was noted to have about a 2-cm soft tissue density in the left lung base. The patient’s daughters also observed her eating prior and did not note any significant problems with swallowing.25 mg once a day. Venous insufficiency. Neurologic: The patient had lately been admitted for possible stroke. Calcium carbonate with vitamin D. 2. Endocrine: No polyuria. 6. Bilateral cataracts. Elsevier items and derived items © 2011. 2006. 7. PAST MEDICAL HISTORY: 1. PAST SURGICAL HISTORY: 1. Prominent diffuse emphysematous changes were also seen. 2007. 3. as per patient’s daughters. 3. 3. SOCIAL HISTORY: The patient quit smoking about 30 years ago but was a very heavy smoker. Atrial fibrillation. no polydipsia. 2004 by Saunders. 2010. Vitamin B12 deficiency. Psychiatric: No problem reported from the patient or from the patient’s family. 4. FAMILY HISTORY: Mother had Hodgkin’s disease. 2. 6. The patient was judged not to be a good candidate for anti-coagulation. 8. 58 . Amitriptyline 25 to 50 mg p.s. Extremities: The patient does have chronic lower extremity swelling.CCS Final Examination With Answers reports no cough with eating or difficulty swallowing. MEDICATIONS: 1. which is actually better today. 2005. even with steroid use. 2. Augmentin 500 mg 3 times a day. Cholecystectomy. Diltiazem 120 mg once a day.o. On recent CT. Crohn’s disease. 2009. which resolved. Occasional alcohol use. 5.

Prior hemoglobins were 11. no carotid bruit. Senokot 1 tablet twice a day.o.6. Vitamin B12 1000 mg/mo. HEENT: Extraocular movements intact. The case was discussed with the emergency room physician. joking with me. sodium 144.0. no lymph nodes palpable.6.r. appears actually very comfortable in the bed. BUN 11. The patient will be admitted with the admitting diagnosis of pneumonia. hemoglobin 11. 2006. ASSESSMENT AND PLAN: 1. pO2 83 on nasal cannula oxygen at 5 liters. COPD exacerbation. cooperative. Chest x-ray as evaluated by me shows right lower area atelectasis or infiltrate. EKG evaluated by me shows atrial fibrillation with heart rate in 130s with incomplete right bundle branch block.r. The old medical records were reviewed. platelets 270. no thyromegaly. bicarb above 41. Oropharynx. although blood pressure with the temperature and the irregularity. CPK 13.6. p. positive bowel sounds. the patient then was given Cardizem 15 mg IV. She is usually awake and hyperactive from that. glucose 81. Back: No CVA tenderness.1. then taper to 20 mg p. nontender. Oxygen 1 to 4 liters. Lungs: Bilateral lower area rhonchi. Lower extremities: bilateral 1+ edema. can recall prior events. creatinine 0. Neurologic: Appears alert and oriented to place and person.005%. Troponin I less than 0. pCO2 69. CK MB 0. 10. Will try to taper that fast since the patient has a history that she is poorly tolerating the steroids.6. it is hard to say. nondistended. an imprint Elsevier Inc. 11. This lady who has known oxygen-dependent COPD presents with desaturating subjective shortness of breath and new x-ray changes. 0.n.0. Serevent inhaler 1 puff twice a day. Skin: Bilateral extremities with superficial bruises. 59 . DuoNeb nebulizers q 4 hours p.n.44. Digoxin 1. I will start the patient on higher dose of steroids. Magnesium 14. open wound with about 50% slough formation on the right lower extremity.8. can move all extremities with no significant focal motor or sensory deficit.0.5 and 10. 2009.4 on the first.s. This appears new or significantly worsened from the first of January. 2004 by Saunders. potassium 3. initial heart rate was in the 140s. Psychiatric: Good mood. Heart: Irregular S1 and S2. then. lateral surface. Saturating 89% on 2 liters nasal cannula oxygen. B natriuretic peptide 175. 16. INR 1. Abdomen: Soft. heart rates were in the 90s/low 100s. Heart rate 105.. this was 17. 2010.1. 12. The patient appears in no acute distress. no JVD. This equals a saturation of 97%. creatinine 0.2. dry.i. 13. Temperature 36. 2005.d. 14. Prednisone 25 mg. chloride 95. Neck: Supple.04. 2007. Maybe 1/VI systolic murmur. will continue Elsevier items and derived items © 2011. There is one small. Sulfasalazine 500 mg twice a day. 17. Xalatan eye drops both eyes q h. LABORATORY STUDIES: White blood cell count 12. PHYSICAL EXAMINATION: Blood pressure 152/67. There is mild blunting of the sulci. daily. ABG: pH 7. Citrucel t. Differential includes 78% neutrophils.CCS Final Examination With Answers 9. I will give the patient nebulizers. about 3 mm in diameter. 15. 2008.

8. CLINICAL SYMPTOMS: Respiratory distress CHEST: Findings: This examination is compared with a prior examination dated June 1. Elsevier items and derived items © 2011. 2. Will give Citrucel and Senokot. 2004 by Saunders. which brought down the heart rate to the 90s/low 100s. There is atherosclerotic change of the thoracic aorta. 9. 2009. Patient did not have real problem with word-finding difficulties. as well as the left mid and left lower lung zones. The patient will be on oxygen. it is not productive. The patient had atrial fibrillation with rapid ventricular rate. Possibility of superimposed edematous change or atelectasis cannot be excluded. Code status was discussed with the patient. Abnormal focal pulmonary opacity is present within the right lower lung zone. 6. 2008. The patient indicates that she has a cough. This might be secondary to the pulmonary events and/or nebulizers. Pulmonary vascular markings appear at the upper limits of normal. Heart size is prominent but unchanged when compared with the prior examination. RADIOLOGY REPORT EXAMINATION OF: Chest. Follow-up CT will be done in a few months. Will give calcium and vitamin D. 4. No pleural effusions are seen. I will start patient on Claforan and azithromycin. The patient is noted not to be an anticoagulation candidate. appears stable. including. B12 deficiency. The patient was given 50 mg IV Cardizem. Hemoglobin appears stable since discharge. Findings are most compatible with areas of infiltrate. 7. 2010. but will ask for aspiration precaution. Follow-up to document clearing is recommended. There is no report of possible aspiration. 10. PROGRESS NOTE SUBJECTIVE: The patient indicates that her breathing is improved a little today. Possible left-sided pulmonary nodule. 3. 2007. patient is somewhat constipated now. in fact. She might need further treatment as an outpatient for that.CCS Final Examination With Answers the Serevent and Pulmicort. also on chronic steroid. 5. Osteoporosis. History of stroke. Hypokalemia will be replaced. I will give the patient her Cardizem orally and will observe on telemetry for heart rate. although the location of the infiltrate would fit that. 2006. she wished to be code II. also motor functions appear good. 2005. This is the same code status used when she was admitted last time as well. Daughter is at bedside. Fosamax. No fever or chills. 60 . an imprint Elsevier Inc. for example. Crohn’s disease. Will follow for clinical improvement. however. For the pneumonia. The patient denies any chest pain or chest pressure.

Vitamin B12 deficiency. the patient was started on Claforan and azithromycin for treatment of her pneumonia.8° with T-max of 37.CCS Final Examination With Answers REVIEW OF SYSTEMS: General: Cardiovascular and respiratory were performed. 2007. but she has been having quite a bit of coughing with minimal sputum production. she was found to have atrial fibrillation with a rapid ventricular rate. 9. With the exception noted in the HPI. PSYCH: The patient is alert. no S4. 61 . History of bowel resection for Crohn’s disease. Respiratory rate is 16. VITALS TODAY: Temp is 35. I will switch the patient to oral antibiotics. We will pursue discharge planning. She was also given a bolus of 50 mg IV of Cardizem to bring the Elsevier items and derived items © 2011. 2008. History of cholecystectomy. Left frontal region meningioma. Other medical conditions include: 1. LUNGS: Bilateral breath sounds. COPD exacerbation. The patient has not really had any fevers or chills. Pneumonia. Osteoporosis. Positive bowel sounds. 2. 2005. She is on home O2 and also has been found on a recent CT to have 2-cm soft tissue density in the left lung base. 2009. 8. The patient has known chronic obstructive pulmonary disease. 2. Abdomen is soft and nontender. DISCHARGE SUMMARY REASON FOR HOSPITALIZATION: The patient is an 82-year-old woman who presents to the emergency department with a complaint of shortness of breath. Venous insufficiency. 4. and her oxygenation somewhat improved. on admission. continue the patient on current treatments. On admission. Pulse is 82. PLAN: At this point. Cardiovascular: S1 and S2. as well as right lower lobe pneumonia. 2010. 3. are negative. occasional wheeze. 6. Blood pressure is 142/78. In the ambulance on the way to the emergency department. 7.5°. Also. IMPRESSION: 1. Crohn’s disease. We will switch the patient to oral steroids. an imprint Elsevier Inc. History of bilateral cataracts. No S3. will start tapering dose. O2 sat is 98%. 2004 by Saunders. 2006. 5. Right recent cerebellar stroke. the patient was given some nebulizers.

patient will be on 20 mg daily for 5 days. b. 2.d. Ambien 5 mg p. Sulfasalazine enteric 1 500-mg tablet p.r. Crohn’s disease. 2006.d. Senokot 1 tablet p. daily.r. 9.d. 9.o. has responded to Cardizem.o. 11. Xalatan eye drops 1 drop in both eyes at bedtime. p.i. for constipation. Follow-up will be with her primary care physician in 1 week. Possible left-sided pulmonary nodule. 2008. 3. This was replaced.h. 2005. 4.s.o. 2. Venous insufficiency. 4. Atrial fibrillation with rapid ventricular response. stable. Pulmicort 200 mcg inhaler b. She is status post a recent cerebrovascular accident.o. then taper down to 30 mg daily for 2 days.d.2 on admission.n. Beginning third day. b.5 mL inhaled treatment. an imprint Elsevier Inc. History of cerebrovascular accident with residual dysphasia. 17.i. Solu-Medrol Discus 1 puff b. Citracal 19-gm packet p.d. 13. 5. daily for 4 days. 6.25 mg once a day. Senile osteoporosis. Diltiazem CD 120 mg p. Prednisone taper beginning at 40 mg p.i. DISCHARGE DIAGNOSES: 1. b. 8.n. Over the course of her hospital stay. q h. b. daily. daily times 3 additional days. the patient has done well with improvement in her subjective sense of being short of breath. DISCHARGE MEDICATIONS: 1. 2009. 2007. Calcium carbonate 500 mg p. 6. Aspirin 325 mg once a day. Folic acid 1 mg p. The patient has continued to have problems with dysphasia. Oxygen-dependent chronic obstructive pulmonary disease with chronic obstructive pulmonary disease exacerbation. 12. right lower lobe. p. Elsevier items and derived items © 2011. 62 . Vantin 200 mg p. for 14 additional days.i.d.i.CCS Final Examination With Answers heart rate back down. q.i. corrected. now rate controlled. Ipratropium bromide inhaler 2.o.s. The patient was also found to be slightly hypokalemic. The patient will be discharged today in stable condition to the nursing home. 2010.o. 10. 14. Community-acquired pneumonia.o. The patient was able to be switched to oral antibiotics on June 8.o.o.d. b. Amitriptyline 25 mg p. Hypokalemia. with potassium of 3. follow-up CT will be needed in a couple of months. 8. 16. She has remained afebrile on this therapy and has continued to have good oxygen saturations on nasal cannula O2. B12 deficiency. 5. 10. 15. 7. 3.i. Digoxin 0.o. 2004 by Saunders.o. 7. Zithromax 500 mg p.

Otherwise. 2006. Hyperlipidemia. questionably coiled lately.0 back in December. 7. q h. 2. q h. The patient is known to have chronic renal failure with a baseline creatinine of 2 to 2. b. 2. Atrial fibrillation with rapid ventricular response. 10. He does have severe congestive heart failure with ejection fraction less than 20%. inguinal hernia repair. 64 . ALLERGIES: No known drug allergies. Allopurinol 100 mg p. appendectomy.s. Status post cholecystectomy. Coreg 25 mg p.o. Zocor 10 mg p.d. Post AICD placement. History of gouty arthritis with a recent gouty attack in his right first metatarsal phalangeal joint. 13. Digoxin 0. Bumex 2 mg in the morning and 1 mg in the evening. 7. which is infrarenal measuring 6. daily. 2009. Potassium chloride 20 mEq p.o.i. FAMILY HISTORY: Mother died of pancreatitis. or night sweats. 8. Bilateral common iliac aneurysm. 2008.CCS Final Examination With Answers week ago. PAST MEDICAL HISTORY: 1. chills.o. family history is noncontributory. No chest pain. 3. 9.i. Father died at age 71. Abdominal aortic aneurysm.5 to 3.o. b.i. History of diverticulitis. 6. Chronic renal failure as mentioned. 4. Respiratory: As mentioned. SOCIAL HISTORY: Lives here in town with his wife. 12. MEDICATIONS: 1. 2004 by Saunders. 1 mg on other days. He quit smoking 16 years ago.s. Chronic renal failure. He also had a stress test that apparently was positive.2 cm. Cardiovascular: Exertional dyspnea. 2010. She was not available today. 5. 11. Coronary artery disease.6 cm. 5. 14. Ranitidine 150 mg p. controlled. 4. an imprint Elsevier Inc. 6. REVIEW OF SYSTEMS: Constitutional: No fever.d. b.2 with creatinine clearance of 32 mL per minute with a serum creatinine of 2. post PD catheter placement for peritoneal dialysis.o. ENT: Resolved upper respiratory tract symptoms. 8. Left internal iliac artery aneurysm. COPD/asthma. post two myocardial infarctions.d. Congestive heart failure with ejection fraction of less than 20%. 2005. 9. approximately 3. GI: Questionable dark stool but Elsevier items and derived items © 2011. The patient recently had an angiogram for his abdominal aortic aneurysm. 3. Nebulizer at home. 2007.125 mg p.o. Coumadin 2 mg on Monday.

4. He had some abdominal discomfort with coughing. creatinine 2. Azmacort MDI 2 puffs b. Lungs: Good air entry bilaterally but expiratory wheezes bilaterally.5 with a pro-time of 14.04. He has PD catheter in the left lower quadrant. Albuterol MDI 2 puffs t. Discussed all of the above with the patient. 2006. Skin: Trace edema. He had no pulmonary edema. Slightly increased jugular venous pressure. IMPRESSION: 1. chloride 98. No cervical lymphadenopathy. Lower extremities: Very trace edema.o. an imprint Elsevier Inc. nebulizer therapy. He Elsevier items and derived items © 2011. Musculoskeletal: History of gouty arthritis that seems to be controlled. His last uric acid level was 7. Small hematoma in the right inguinal area from his recent aortogram.3. Zithromax 500 mg IV daily. 2008. medications. He was awake. Was given steroids. 98% on 2 liters per nasal cannula. 3.i. BNP 536 picogram/mL.2. He seems to understand and agrees with the plan. BUN 29. oriented times three without any focal neurological deficits. 2005. Atrovent MDI 2 puffs t. Abdomen: Soft and nontender.000.3. He had no infiltrates.d. OBSERVATION DISCHARGE SUMMARY LOCATION: Hospital observation unit.CCS Final Examination With Answers no diarrhea. PHYSICAL EXAMINATION: The patient was in mild respiratory distress. 65 . Oxygen saturations were 92%. Digoxin 0. 5. 2004 by Saunders. No sacral edema. 4. potassium 3. Exacerbation of COPD/asthma with wheezes. DISCHARGE DIAGNOSIS: Exacerbation of COPD. Noncompliance with medications and nebulizer treatments. No crackles. Will discuss further issues to his abdominal aortic aneurysm and further plans with his positive stress test when the rest of the family is available in the next couple of days. nausea. 2.i. 2. or vomiting.6 thousand. Continue the current p. 2009. platelets 140. Solu-Medrol 80 mg IV q 8 hours. 7. sats 92% when he came in. blood pressure has been 120s/80s. sodium 139.6. The patient is code level I. 2010. Troponin-I less than 0. hemoglobin 12. Psychiatric: Negative. bicarb 31. PLAN: 1.d. LABORATORY STUDIES: CBC tonight shows a white count of 8.i. The patient came in with wheezing. Abdominal aortic aneurysm. 2007.6. calcium 8. INR 1.d. 3. Neuro: Negative.5. 6. His heart rate is in the 70s range.

DISCHARGE PLAN: The patient will be scheduled in my clinic in 3 weeks with a basic panel. 585.22 (Asthma. Potassium chloride 20 mEq p. 2009. 13. Abdominal) 428. CODE LEVEL: I.n. V45. daily. exacerbation) 441. V45.o.0. b. daily.0 (congestive heart failure. and Protime/INR.d.01. 10. 6.4 (Aneurysm. Allopurinol 100 mg p. 2006.4 (hyperlipidemia) 442. 8. 442. 2010. 66 .02 (automatic implantable cardiac defibrillator) V58. Bumex 1 mg in the evening and 2 mg in the morning. COPD.6. daily. 9.81 (noncompliance with medical treatment) V45. Coreg 25 mg p.2.11.00 Diagnosis(es): 493. 441. V58. His pO2 was 94 on 2 liters. then five pills for 3 days.01 (coronary atherosclerosis of native coronary artery) 412 (old myocardial infarction) 427. Zithromax 500 mg p. on peritoneal dialysis) 414.81. 2005. He was discharged in reasonable general condition. 4. Discussed all of the above with the patient. Aortic. I gave him the plan. He seems to understand.o. 5.r.00 (gouty arthritis) Elsevier items and derived items © 2011. We walked him the next day. 3. 7. status) 274. 2008. 2004 by Saunders. Issues related to his aneurysm and cardiac status will be discussed in the clinic. an imprint Elsevier Inc. 2007. unspecified) 585. 412.o.o. Albuterol inhaler two puffs three times a day p. daily.6 (chronic kidney disease.i.31. CORRECT ANSWER AND RATIONALE: 493.o.02.o. Zocor 10 mg p. Coumadin 2 mg every Monday and 1 mg on other 6 days of the week.11 (dialysis. b. 11. 12. daily for 8 more days. CBC.i.d. DISCHARGE MEDICATIONS: 1. common iliac artery) V45.22. Triamcinolone inhaler (Azmacort) two puffs three times a day. Zantac 150 mg p.31 (atrial fibrillation) 272.4. Digoxin 0.2 (aneurysm. V15. Atrovent three times a day. 272.o. 414.125 mg p. 428.61 (long term use of anticoagulants) V15. 274. He will go down by 10 mg every 3 days until off.61. 2. 427.CCS Final Examination With Answers did well.4. He was doing much better without any major complaints. Prednisone 10 mg—he will take six pills for three days.

but control of his intra-abdominal bleeding and correction of the hypothermia are priorities. He has a tense distended abdomen. LOCATION: Inpatient hospital. ROS. Hypothermia. Possible major intra-abdominal injuries.CCS Final Examination With Answers 10. the general surgeon on call. 2. HISTORY: Mr. 2010. His temperature is 27° with a blood pressure of 60 systolic. FAMILY. 2005. The fixed dilated pupils are of concern. Dilated fixed pupils. an imprint Elsevier Inc. 67 . he was immersed in cold water for approximately 5 to 10 minutes. Distended tight abdomen. Elsevier items and derived items © 2011. The patient also was reported to be hypothermic with a temperature of 27°. According to the paramedics who brought him down via air ambulance. X-ray had been asked previously to place a portable machine in the OR. 2007. other than that there is a possibility that after the rollover. SOCIAL HISTORY: Unable to obtain because patient is unconscious. PAST. CASE 10 INITIAL HOSPITAL SERVICE The patient. There is no family available. PHYSICAL EXAM: The patient is hypotensive. The patient is transported with bilateral chest tubes in place. 2004 by Saunders. who admitted the patient to the hospital. 3. Stephen Moore. 4. but this history is speculative at the present time. Moore is a 25-year-old young man who was involved in a motor vehicle rollover just outside of town. He also has no neck collar in place but is on a backboard with the neck stabilized with straps. 2008. Stephen was involved in a motor vehicle rollover. He has no other obvious injuries. ASSESSMENT: 1. His pupils are fixed and dilated. The paramedics have no other history at the present time. 5. was brought to the hospital emergency department by air ambulance from Loganville. the patient had arrested three times during the flight. Hypotension due to cold water. Sanchez. Dr. 2009. The patient is critically ill and is at high risk for mortality. Paul Sutton treated the patient in the emergency department and then contacted Dr. 2006. PLAN: He is going to be taken immediately to the operating room while we resuscitate him there in a more stable environment.

There was a question whether the fixed pupils were due to a primary head injury with an intracranial bleed. CORRECT ANSWER AND RATIONALE: 864. Liver laceration. he will be taken to the intensive care unit. 2007. The patient is in critical condition. 854.05. His abdominal injuries were repaired. he just flat-lined immediately. 865. 808. just to the right of the ligamentum teres. 2006. 4. and the patient was pronounced dead at 2100 hours. Hypotension. Laceration spleen. 458. The patient had a laceration at the dome of the liver. Hypothermia. CAT scan will be done immediately. where we will continue resuscitation with warm fluids and blood as necessary. 2. Patient was an unrestrained driver. 69 .61 Diagnosis(es): 864. with neurosurgeon available.CCS Final Examination With Answers was around the liver. 2004 by Saunders. When I got to the CT room. Cardiac arrest. this was oversewn as noted above. DIAGNOSES: 1.8.8 possible pelvic fracture per OR report Elsevier items and derived items © 2011. the abdomen was repacked. and pastoral services were called in. The patient’s pupils at this stage were still fixed and dilated. The patient was taken immediately from the operating room to the CAT scanner. His family was notified. 427. 991. At the end of the procedure. 2008.05 reports laceration of the liver 854. Intracranial injury with fixed dilated pupils due to rollover car accident. There was no chance for resuscitation.00 reports spleen laceration 458.9. 50.5.6 reports accidental hypothermia 865. 2009.00. If the patient does not have anything intracranial that needs to be fixed immediately. A Vac-Pac was quickly placed. The 5th digit of 5 is assigned per the guideline prior to category 850. At this point. 2010. and there we found abdominal bleeding and liver laceration. 991. There was nothing we could do for him. 2005. DISCHARGE SUMMARY LOCATION: Inpatient hospital.9 hypotension 808. We took him immediately to surgery. 6. an imprint Elsevier Inc. because of the patient’s hypothermia and instability. 3.6. and patient was then taken for a CT of his head to try to find cause of his unconscious state and dilation and fixation of his pupils. the patient was not breathing. 5. or whether this was just a hypoxic issue related to the original injury and the 3 arrests during transport. SUMMARY: The patient was admitted through the emergency department after being involved in a one-car rollover accident.05 reports an intracranial injury. the patient’s blood pressure was up in the 80s systolic.05.

Genital examination: He is a circumcised male. He was admitted for dehydration and hyperbilirubinemia. Nursing also had to supplement 92 cc over the night. Temperature has not been taken yet.4. LABS: Bilirubin was 20. D5 half-normal saline at 20 mL an hour and will be under triple phototherapy. Moves extremities spontaneously times four. and a repeat bilirubin will be done at 7 PM this evening. anywhere from 5 minutes to 15 minutes a side. Dehydration. I do not have a blood pressure yet either. normal saline at 20 cc/hour overnight. Abdomen is soft and nontender. Testes are descended bilaterally. She has been pumping and is able to pump 2 ounces every 2 to 3 hours. Red reflexes intact in both eyes. HEENT examination: Fontanelle is soft. 2007.25 cc/kg/hour. He is nondistended. The baby has still been having several wet diapers and finally had a bowel movement yesterday—the first since Saturday. SUBJECTIVE: Mom said that patient's color has definitely improved overnight. 2009. Umbilicus appears to be healing well. PROGRESS NOTE The patient is a 6-day-old infant. Feedings yesterday: It looks like he breastfed 5×. Coombs and basic metabolic panel will both be drawn.86 kg. appears to be in no distress. That makes him down 7. He was down 15% on admit. this was done in the clinic. That is up 12 ounces from yesterday. She stated that feedings are still not going well. although he is very jaundiced in appearance. 2008. D5. Urine output since admit has been 1. Skin has no rashes. Mom can breastfeed ad lib. He is looking nice and pink this morning. 2004 by Saunders. and no masses are palpated. 71 . He received IV fluids. PLAN: He will be started on IV fluids. an imprint Elsevier Inc. Lungs are clear to auscultation bilaterally. ASSESSMENT: 1. Mouth is dry but otherwise unremarkable. 2. 2005. Extremities: He has 2+ femoral pulses bilaterally. Neck is supple. This is hospital day two. slightly sunken. 2010. OBJECTIVE: Weight today was 3. will fuss and push away. He has active bowel sounds.7% from birth. but heart rate and respiratory rate are both within the normal range. External auditory ear canals and tympanic membranes are normal in appearance bilaterally. Heart is regular in rate and rhythm with no murmur. although he does require a little stimulation to move very much. 2006. He will latch on and suck a couple of good sucks but then wants nothing to do with breastfeeding after that. Heart rate has ranged Elsevier items and derived items © 2011. also a total of 155 cc of IV fluids since admit. Hyperbilirubinemia.CCS Final Examination With Answers PHYSICAL EXAMINATION: General: The patient is sleeping with Mom. Pupils are equal and reactive to light.

5 mg q 8 hours p. Folic acid 1 mg daily. His exercise tolerance is less than one block and has been like that for some time. 3. 4. His appetite has been good. 3. 5.d. 9. 11. Lopressor 25 mg daily. 8.n. PAST MEDICAL HISTORY: 1. Levothyroxine 0. No headache. During that time.1 mg daily. 9. he had a CT scan of the chest. Sertraline 50 mg daily. 2009. where he had gone for medical follow-up. Esophageal cancer.r. an imprint Elsevier Inc. Pantoprazole 40 mg daily. although he intermittently has nausea. 2008. Anticoagulation for mechanical heart valve. PAST SURGICAL HISTORY: 1. 7.CCS Final Examination With Answers past 7 years. Diabetes mellitus type 2. Iron 325 mg daily. 7. Ativan 0. Recent PE. Coronary artery disease. Chronic renal insufficiency. 3. 2004 by Saunders. CABG 7 years ago. Hernia repair. 10. Lomotil 1 tablet four times daily as needed. Kaopectate. 2006. Recent enteric tube for feeding. 2. Anemia of chronic disease.125 mg daily. 2. 4. Mechanical aortic valve. 12. 8. He follows with the medical oncology physician. CABG. Multivitamin with mineral 1 tablet daily. 13. 6. 6. He was seen last week at Nearby Clinic. Ambien 5 mg at bedtime. MEDICATIONS: 1. Aortic valve replacement. which was not different from the CT scan done at the hospital about 2 months ago. Potassium chloride 3 mg b. 4. No change in urinary habits. 10. 2007. 2005. and he does not think it is related to esophageal cancer. 74 . He does not think that it has changed recently with this event.i. 5. He denies abdominal pain. 12. blurring of vision. Hypertension. 2. or melena in stools. Chronic hyponatremia. Elsevier items and derived items © 2011. or diplopia. Thrombocytopenia. hematemesis. Digoxin 0. 2010. 11.

No peripheral lymphadenopathy. The chest pain is of new onset in a patient who has risk factors for coronary artery disease. Musculoskeletal: No finger clubbing. no crackles. and there are no other pertinent findings. chloride 102. WBC 8. No delusions or hallucinations. Moves all extremities fully. CVS: First and second heart sounds are normal. creatinine 0. an imprint Elsevier Inc. He is a retired pharmacist. Will also obtain a lipid panel. Head: Normocephalic. platelets 220. Endocrine: He has a history of diabetes and thyroid disease. MCV 92. BUN 10. atraumatic. 2007.9. Pulse: 75 per minute. 2006. Vital signs: Blood pressure: 121/73. Temperature: 36. no rhonchi. PHYSICAL EXAMINATION: He is alert and oriented to place. Alcohol is consumed on a social basis.3. No cervical lymphadenopathy. not cyanosed. Chest pain. FAMILY HISTORY: His mother had asthma and an enlarged heart. Psychiatric: He is not depressed. 2004 by Saunders. The patient has been given aspirin. No pedal edema. No guarding. No costovertebral angle tenderness. Breath sounds at the bases are somewhat coarse. Abdomen: He has a feeding tube in place in the left hypochondrium. Will continue with Lovenox 60 mg every 12 hours and continue with beta blocker. Musculoskeletal: No claudication. No suprapubic tenderness. glucose 139. 2008.2. Chest: Good air entry bilaterally.6. GI. He is not in any obvious distress. No hallucinations.CCS Final Examination With Answers ALLERGIES: Penicillin and niacin. 2010. EKG: Normal sinus rhythm. The point of entrance of the tube is stained with a thin. bicarbonate 27. REVIEW OF SYSTEMS: Cardiovascular. Will send a sample for PT/INR and a comprehensive metabolic panel. No cardiac murmurs appreciated. and person. I will treat this as unstable angina.4. not jaundiced. General: He is mildly pale. He smoked about 25 years. LABORATORY DATA: Hemoglobin 13. Genitourinary: Kidneys are not palpable. sodium 137. Multiple family members have heart disease and diabetes. SOCIAL HISTORY: He lives with his wife in rural Anytown. Lopressor 25 mg daily.7. 2009. Will send two more sets of cardiac enzymes and also three sets EKG. O2 saturation 97%. potassium 4. He has a metallic sound due to a mechanical aortic valve. I will maintain the Elsevier items and derived items © 2011. Neurologic: No gross neurologic abnormality noted. 75 . and genitourinary systems were reviewed in the HPI. but quit several years ago. No ST/T changes. No arthritic deformities. respiratory. Respiratory rate: 23 per minute. Psychiatric: No history of depression or any other psychiatric illness. ASSESSMENT AND PLAN: 1. purulent material. Oropharynx is clear. No abdominal tenderness. Neck is supple. 2005. His dad died at the age of 51 with heart disease. time. Trachea is central. two to three packs a day. No peripheral cyanosis. Normal tone and power of all extremities. Bowel sounds are present and normal.

We will continue Lovenox and re-start Coumadin after the procedure. LABORATORY DATA: Cardiac enzymes negative. OBJECTIVE: He is alert and oriented to place.7. and he elects to be code I. He has a feeding tube on the left hypochondrium. Respiratory rate 20 per minute.6. The patient states that his blood sugars have been adequately controlled. creatinine 8. This patient has been on anticoagulation. 2010. Albumin is 2. Denies chest pain. No hepatosplenomegaly and no ascites. He has associated nausea but no vomiting. INR is 2. Blood pressure is well controlled at this time. shortness of breath. Diabetes mellitus. His most recent creatinine was 0. Will administer antihypertensives. Chronic renal insufficiency. 3.CCS Final Examination With Answers 2.9. Will monitor Accu-Cheks and re-start oral hypoglycemics if indicated. melena. Mechanical aortic valve. no rhonchi. History of pulmonary embolism. No change in bowel or urinary habit. 2008. Otherwise. He describes it as stabbing in character. No acute condition is related to the cancer at this time.7. Need to rule out aortic dissection. Hypertension. No cardiac murmurs are appreciated. 76 . Abdomen is soft and nontender. 2007. triglyceride of 143. which has intensity of 5/10. temperature 36. 2005. 2009. PROGRESS NOTE SUBJECTIVE: The patient complains of abdominal pain. He has a metallic sound due to mechanical aortic valve. Chest: CVS: First and second heart sounds normal. O2 saturation 97%. no pulsatile mass noted. Because of endoscopy that is planned for Friday. or hematochezia. Vital signs: blood pressure 114/61. time. and that will be continued. cholesterol of 158. Has not been having fever. and person. pulse 80 per minute. REVIEW OF SYSTEMS: Cardiovascular. and he discontinued hypoglycemic agents himself. 2004 by Saunders. I will Elsevier items and derived items © 2011. Code status was discussed with the patient and family. Chest: Good air entry bilaterally. HDL of 46. LDL of 83. 2006. ASSESSMENT AND PLAN: 1. Will continue to monitor renal function. The patient is being followed by the Oncology team. the patient has been off Coumadin and is currently on Lovenox. 7. No hematemesis. an imprint Elsevier Inc.5. Abdominal pain: Radiating to the back. respiratory. or orthopnea. paroxysmal nocturnal dyspnea. It radiates to the back. patient on intravenous nitroglycerin 5 mcg/minute and oxygen by nasal cannula 2 liters per minute. and there are no other pertinent findings. no crackles. 5. Esophageal cancer. 6. the comprehensive metabolic panel is normal. 4. and neurologic systems were reviewed. He is not in obvious distress. Blood sugar ranged from 94 to 235.

2005. 77 . We will continue with Accu-Cheks and will make adjustments as necessary. Zocor. 4. 2010. PHARMACOLOGIC NUCLEAR PERFUSION STRESS TEST INDICATION: Chest pain. Cardizem CD. 8. Hypertension: Blood pressures have been within acceptable range. PAST MEDICAL HISTORY includes: 1. 14. supraventricular tachycardia. coronary artery bypass grafting surgery. Lopressor 25 mg. 2. Folic acid. diabetes mellitus. Chest pain: The patient has not had chest pain since admission. angina. 3. 8. 3. DISCHARGE SUMMARY Elsevier items and derived items © 2011. I will also start the patient on Maalox 10 mL every 6 hours p. hypertension.n. pulmonary embolism. Aortic valve replacement in 1997. 2008. 9. 2009.d. myocardial infarction in 1997. Digoxin. 4. 11. 2007. 6. Synthroid. hypernatremia. an imprint Elsevier Inc. esophageal CA status post resection with pull-through. Reglan. chronic renal insufficiency. Mechanical aortic valve. 2004 by Saunders. 6. 7. He is scheduled for noninvasive adenosine Cardiolite this morning.CCS Final Examination With Answers 2.r. 2006. Esophageal cancer. 2. 13. Protonix. I will send sample for amylase and lipase. and intravenous nitroglycerin 5 mcg per minute. Coumadin. I will increase the patient's Protonix to 40 mg b. Diabetes mellitus.i. CURRENT MEDICATIONS: 1. 12. History of pulmonary embolism. 5. anemia of chronic disease. Lorazepam. Metoprolol. He is currently on Lovenox 15 mg every 12 hours. 5. Zoloft. Atropine. 7. and will start Reglan 5 mg with meals. Will continue to monitor the patient hemodynamically. Chronic renal insufficiency: The patient seems stable from this standpoint. K-Dur. thrombocytopenia. Coronary artery disease. get a CT scan with contrast. 10. Ambien.

The patient was informed of the findings and was started on analgesics for pain control. Diabetes mellitus. an imprint Elsevier Inc. because of chest pain that started at rest and was associated with nausea and some shortness of breath. 11. who thought that they were insignificant to warrant any invasive procedures. 7. Dysphagia.CCS Final Examination With Answers REASON FOR HOSPITALIZATION: Chest pain. Chronic renal insufficiency. 9. 2007. 5. Oncology consult was requested. The patient's chest pain was thought to be due to the advanced esophageal cancer. The findings were discussed with Dr. and Lovenox was continued at 60 mg every 12 hours. He was transferred from Anytown 5 days ago. 2009. Unstable angina ruled out.7 and total protein of 5. 2010. Hypoalbuminemia. His symptoms have improved and he remains hemodynamically stable. Cardiac enzymes were not elevated. 6. the patient was hemodynamically stable but was having another episode of mild chest pain. and it was thought that the soft tissue densities were most likely due to metastasis from the esophageal cancer. Hypertension. Chest pain due to metastatic esophageal cancer. Because the chest pain was radiating to the back. 2004 by Saunders.8. The chest pain was relieved by sublingual nitroglycerin. 8. 2. Green. hypertension. History of pulmonary embolism. Elsevier items and derived items © 2011. In the scan. which showed predominantly fixed decreased defect in the posterior/inferior wall. Anticoagulation with Lovenox. 2005. PLAN: The patient is to be discharged home. Aortic mechanical valve. 10. 2008. The only abnormality noted on comprehensive metabolic panel was albumin of 2. a CT scan of the chest and abdomen was done. 4. chronic renal insufficiency. which might have been due to technical difficulties. FINAL DIAGNOSES: 1. Appointment will be scheduled with the primary care physician. an incidental finding of soft tissue density in the lung was noted. and advanced esophageal cancer status post resection with gastric pull-through. There was also suggestion of a possible small amount of reversibility around the basilar aspect of the posterior/inferior wall. He also has appointment tomorrow with the gastroenterology physician for an esophagogastroduodenoscopy. Amylase and lipase were normal. At the time of evaluation in the emergency department. He was started on intravenous nitroglycerin. SUMMARY OF HOSPITAL COURSE: The patient is a 65-year-old man with past medical history of diabetes mellitus. He had a stress test. He also has a history of coronary artery disease and had CABG and aortic valve replacement about seven years ago. 78 . Soft tissue density in the lung thought to be due to metastatic disease from esophageal carcinoma. to rule out aortic dissection. 2006. 3.

CCS Final Examination With Answers DISCHARGE MEDICATIONS: 1. Potassium chloride 30 mEq twice daily with food. 285.00.125 mg daily. 785.51 reports a history of pulmonary embolism (not current embolism. Lorazepam 0.03. 2008. Oxygen saturation 94% on room air. The 5th digit of 0 indicates unspecified stage of kidney disease. 2. 2010. 585. 415. 3. CORRECT ANSWER AND RATIONALE: 197. 16.3. 250. 5. 2009. 2. 11. Kytril. Pantoprazole 40 mg three times daily. type 2 412 old myocardial infarction V12. Respiratory rate 20 per minute. Ferrous sulfate 324 mg daily. His code status at the time of discharge is code I.8. Vital signs are blood pressure 103/86. 79 . Temperature 36. Glyburide 5 mg daily. 14.51. 6. Telephone consultation with Cardiology. Zolpidem 5 mg at bedtime.9 Guidelines under 403 instruct the coder to use additional code to identify the stage of chronic kidney disease.00. 10.n. V45. 273. 585. Enoxaparin 18 mg subcutaneously daily. 403. Multivitamin 1 tablet daily.22 anemia of neoplastic disease 785. 7.0. There is no mention that it has recurred in the esophagus.5 mg p. Oncology. 412.9. it was because of the metastasis to the lung that the patient had chest pain. CONDITION ON DISCHARGE: At the time of discharge. 2005.0 the metastatic lung cancer is the principal diagnosis.0.90. 403.9) Elsevier items and derived items © 2011.81. 8. V43. 15. CONSULTATIONS: 1.r. 2006. Lovenox 0. Folic acid 1 mg daily. 9. V10. V12. Digoxin 0. 2004 by Saunders. Oxycodone 1 tablet every 2-4 hours. every 8 hours. V58. 12.03 is for history of esophageal cancer which has been removed and there is no mention that the patient is still undergoing chemotherapy or other treatment.1 mg daily.00 is coronary atherosclerosis 250. 414.8 hypoalbuminemia 285.00 diabetes mellitus. Sertraline (Zoloft) 50 mg daily.90 hypertensive chronic kidney disease. Lomotil 1 tablet four times a day as needed. 4. 2007.0 reports the unspecified tachycardia 414. 13.61 197.22. patient is hemodynamically stable. 273. V10. an imprint Elsevier Inc.5°. Metoprolol 25 mg daily. Pulse is 81 per minute.

2004 by Saunders. Mother notes that the patient is unable to sit up with this. refractory to treatment. It seems like she had some allergic component to it with recent allergy test results that showed the patient is allergic to dust. 2007. Elsevier items and derived items © 2011. but has a normal platelet count during this admission so would not code. an imprint Elsevier Inc. CHIEF COMPLAINT: Inability to intake orals. and inability to intake orals.CCS Final Examination With Answers V43. and Singulair. molds. but no objective temperatures were taken at home. including Pulmicort. but it is nonproductive in nature since 4 AM. 80 . 2005. Albuterol. 2008. and cats. 2010. 3. Mother notes cough associated with this. MEDICATIONS: 1. she believes. possible component involved with her asthma. molds. cough. Singulair. Of note. Zyrtec. HISTORY OF PRESENT ILLNESS: The patient was in her prior normal state of health until approximately 4 AM. 2009. No neonatal complications or maternal complications. ALLERGIES: No known drug allergies. refractory to treatment at home. the patient was exposed to a cat in her grandmother's home during the night last night. PAST MEDICAL HISTORY: 1. wheezing refractory to home treatment. Albuterol.81 status of postprocedural aortocoronary bypass V58. Pulmicort. She has been vomiting all the liquids and oral intakes she has had today.3 reports the mechanical aortic valve V45. CASE 13 ADMISSION HISTORY PATIENT IDENTIFICATION: The patient is a 4-year-old female with a history of asthma/previous pneumonias in the past who presents with cough. 20 hours prior to admission. The patient was born at full term. 2. and the wheezing is as described above. 4. Patient has a past history of thrombocytopenia. hypoxia. 3. and wheezing. Allergic rhinitis. Mom noted that the patient felt feverish and chilled today. 2006. hypoxia. 5 mg. The patient's mother notes that usually once a year the patient has some episode of either pneumonia/exacerbation of asthma. when she woke up and had some increasing wheezing. Past history of asthma/pneumonia. and cat. 13. Allergy testing in the past to dust.61 long-term use of anticoagulants Note: The unstable angina was ruled out during this admission and therefore is not assigned in this case. 2.

or gallops. murmurs. Temperature is 37. PERRLA. calcium 10. and O2 sats are 88% on room air. No organomegaly.5. respiratory rate 40. Nontender and nondistended. HEENT: HEAD is atraumatic. We will maintain her on her Elsevier items and derived items © 2011. REVIEW OF SYSTEMS: Fully reviewed and contributory only for decreased urination today. Hemoglobin is 15. INVESTIGATIONS: White cell count 13. No pets. somewhat timid. or tenderness appreciated. Abdomen: Soft. No smoking around her. pulsatile masses. edema. and glucose 100. Neck: No obvious lymphadenopathy. She does attend school. except with her grandmother as above. Chest x-ray revealed a blunted right heart border with what appears to be some patchy-type infiltrates involving the right lung field. Regular rate and rhythm. 2005. decreased oral intake with vomiting. No erythema. Pulses are positive and symmetric bilaterally in the upper and lower extremities. ASSESSMENT AND PLAN: 1.6. 2010. 81 . Lungs: Expiratory wheezes throughout.CCS Final Examination With Answers 4. breathing rapidly. No extra heart sounds. 5. as well as right. Acute asthma exacerbation. Throat: Oropharynx is clear without erythema. EYES: EOMS intact and anicteric. No noted sick contacts. chloride 99. No peripheral edema. Zyrtec. 2006. No known cardiopulmonary disease in other family members.56 with 76% neutrophils. Tympanic membranes: Left is clear. The patient required nebulizers as well as oxygen in the emergency department. No obvious effusions or cardiomegaly noted. or exudate. rubs. 2008. Tylenol. Extremities: Right posterior leg behind the hamstrings: There seem to be some flush-colored domelike papules umbilicated in the center. PHYSICAL EXAMINATION: Appearance: Four-year-old female in no obvious distress.6. 2009. with some cerumen impaction. 2004 by Saunders. or obvious tenderness. and a rash that occurred about 5 days ago that did not seem to be pruritic in nature that they treated with Neosporin. FAMILY HISTORY: Father with asthma and both sides of his family having asthma. She does attend day care with her grandmother. Oropharynx has sticky mucous membranes with little saliva. potassium 4. 2007. sodium 138.5. Nose: No obvious rhinitis or rhinorrhea with nasal cannula in. bicarb 20.3. Cardiovascular: Tachy S1 and S2. right greater than left. SOCIAL HISTORY: The patient lives in Anytown with her mother and mother's roommate. or exudate. heart rate 160. Bowel sounds are positive. edema. thyromegaly. an imprint Elsevier Inc. BUN 11. Neurological: Intact cranial nerves II-XII as best I can tell with the child. platelets 310. No noted early deaths due to cardiopulmonary disease. creatinine 0. No crackles or rhonchi.

PAST MEDICAL HISTORY: Significant for allergic rhinitis with allergy testing positive to dust. Solu-Medrol 20 mg every 6 hours. Dehydration as evidenced by sticky mucous membranes and no oral intake today. She has also been taking Zyrtec for the past 6 months. so it has been several months since her last nebulizer. The patient also has a history of allergies. mold. and cats. 3. 82 . 4. 4. which was recommended by the allergist after her allergy testing.r. 3. mold. 2004 by Saunders. We will start IV fluids tonight also. 2006. it sounds like with the allergist.5 mg b. impression.CCS Final Examination With Answers nebulizers and start steroids. Hypoxia secondary to #1. In the past. 2010. PEDIATRIC CONSULTATION PATIENT IDENTIFICATION: The patient is a 4-year-old female who is hospital day 4 with an acute asthma exacerbation.r. Singulair 4 mg at bedtime.i. Elsevier items and derived items © 2011.r. and cats. Right-sided pneumonia. Claforan 1 gram every 6 hours. O2 sats on admission were 88% on room air. she has had one to two asthma exacerbations per year. and dehydration.n. 2005.d. She was also having coughing spells and would vomit anything that she took orally. 2008. Mom gave her three Albuterol nebulizers and two Pulmicort nebulizers at home with no improvement. 2007. The patient will be started on antibiotics of Claforan 50 mg per kilogram IV every 6 hours. basis. an imprint Elsevier Inc. At that time. HISTORY OF PRESENT ILLNESS: Mom reports that the patient has a history of asthma and an allergy problem. Green and will be adjusted accordingly. Mom would give Albuterol and Pulmicort nebs on a p. 2. 2.n. 6. She does take Singulair 5 mg on a daily basis and has for the better part of 2 years. CURRENT MEDICATIONS: While here in the hospital include: 1. Mom said she has not had to use any nebulizers on the patient since sometime last fall. When she started getting ill. which is a gram every 6 hours. The patient was exposed to a cat the day prior to admission at her grandmother's house. and that is when she decided that they should come to the emergency department. Pulmicort nebulizer 0. ALLERGIES: She has no known drug allergies. and plan will be discussed with Dr. hypoxia secondary to her asthma exacerbation. She has had allergy testing.n. and asthma is currently controlled with Singulair daily and Albuterol and Pulmicort p. Albuterol nebulizer every 1 hour p. which is 1 mg per kilogram. 2009. Albuterol/Atrovent nebulizers every 4 hours. and tested positive for dust. The patient was a full-term delivery with no neonatal or maternal complications. The patient's case. right-sided pneumonia. 5.

No one at day care smokes. and has no exposure to pets.2. 2009. Elsevier items and derived items © 2011. Temperature is 36. Her maternal grandmother has allergies and asthma also.CCS Final Examination With Answers FAMILY HISTORY: The patient’s father has asthma. nontender. She lives with her mother and her mother's roommate. that was this morning. Regular rhythm. PHYSICAL EXAMINATION: Appearance: This is a 4-year-old female who is in no distress. Nobody has any history of eczema as far as Mom knows. Throat: Moist and pink without erythema or exudate. Neck is nontender. Trachea is midline. Bowel sounds are active. The maternal grandmother does have a cat. At home. an imprint Elsevier Inc. as well as some perihilar opacities and opacities extending into the lower lung field medially. Tympanic membranes: She has some cerumen in both external auditory canals. LABORATORY: There has been no lab drawn since the day of admission. as do several of her paternal relatives. Heart is tachycardic with a normal S1 and S2. There are no crackles or rhonchi. She does have a little bit of a rash that seems to be healing well on the back of her right leg. External auditory ear canals are also normal in appearance bilaterally.7. Blood pressure is 121/62 and pulse is 128. or gallop. 2008. 2005. She moves the extremities through a full range of motion times four. Pupils are equal and reactive to light. There is no murmur. She has good peripheral pulses. 2006. 83 . which was present on admit. but the tympanic membranes appear normal bilaterally. IMAGING: She did have a chest x-ray done this morning. She does have a rash on the back of one leg. No organomegaly. Sclera non-icteric. 2007. Nose: Nasal cannula is in. except for at maternal grandmother's house. and it has been improving. She does have good air movement. Neck: She has no lymph nodes palpable in the anterior or posterior cervical triangles. REVIEW OF SYSTEMS is significant for improved appetite and urination since hospitalization. She goes to Head Start for half days and then goes to her paternal grandmother's house. She does have some nasal discharge that is clear. T-maximum over the past 24 hours is 37. 2004 by Saunders. HEENT examination: Head is atraumatic. 2010. No pleural effusions. SOCIAL HISTORY: The patient lives in town. She is sating 91% on 3 liters. Extremities: She has no peripheral edema. Her paternal grandmother runs a day care. normocephalic. She is currently sating okay on 1 liter. although not in the presence of the patient. Lungs show inspiratory and expiratory wheezes throughout all lung fields. rub. Abdomen is soft. She interacts appropriately with me. Respirations currently are at 32. Eyes: Extraocular movements are intact. The patient has had no contact with other sick people. the mother's roommate does smoke. The pulse has typically been anywhere in the 1-teens to 140s. which showed a collapsed right upper lobe. and non-distended. She has run anywhere from 24 to 42.

and she will see the patient after the clinic today. known allergic rhinitis. Azithromycin 100 mg orally for 3 more days. she will need to go home on the Pulmicort 0. 2007. pediatrics was consulted. 5. She was oxygendependent on admit. This may be able to be decreased as an outpatient. Right-sided pneumonia. She was started on IV steroids. 2.i. 2. 2004 by Saunders. Pulmicort 0. Acute asthma exacerbation.5 mg nebulizer b. and the patient seemed to gradually start improving. At that time. No changes were made in her medications at that time. FOLLOW-UP APPOINTMENT: Will be made next week. I would recommend checking a PPD in order to rule out any tuberculosis. As long as the patient continues to improve. Zyrtec 1 mg daily. status asthmaticus. CONDITION ON DISCHARGE AS COMPARED WITH CONDITION ON Elsevier items and derived items © 2011. Green. and the patient has done well. On discharge. 3. I would recommend continuing the current treatment of Albuterol and Atrovent nebulizers. and an acute pneumonia. and Pulmicort. The patient was discussed with Dr. SUMMARY OF HOSPITAL COURSE: The patient was admitted 6 days ago with an asthma exacerbation. and IV antibiotics to cover her pneumonia. 2005. She is discharged home today. A PPD test was placed. The patient continued to need oxygen for the first 3 days of her hospitalization up to 3 liters by nasal cannula. Pulmicort.d. 4. Singulair 4 mg q h.CCS Final Examination With Answers ASSESSMENT AND PLAN: 1. INSTRUCTIONS TO PATIENT AND/OR FAMILY: Activity as tolerated.d. IV fluids. Prednisolone 15 mg every 12 hours. 3. Atrovent. 84 . The patient is doing well on Claforan right now. 2008.i. 6. 2010. DISCHARGE SUMMARY REASON FOR HOSPITALIZATION: Exacerbation of asthma with pneumonia. 6 days after admission. 2006. I would not alter the plan at all. nebulizer treatments with Albuterol. Wean her off oxygen as able. and Solu-Medrol. MEDICATIONS: Include: 1. 2009. Her chest x-ray worsened and did show a collapse of the right upper lung lobe. an imprint Elsevier Inc. Albuterol unit dose nebulizer treatments q4h while awake. Medications were switched to oral antibiotics and oral prednisone on Friday morning. Mom denied any tuberculosis exposure. Diet also as tolerated. She was weaned off her oxygen and has been on room air since Friday morning.s.5 nebulizer treatments b. The patient seems to be improving.

799. 2004 by Saunders. Hypoxia and dehydration secondary to asthma exacerbation and pneumonia. the Excludes note indicates allergic rhinitis. 2005. 2.02 reports hypoxia 276.01 reports asthma with allergic rhinitis. Acute asthma exacerbation.0 in the Tabular. Pneumonia with collapse of right upper lung lobe. DISCHARGE/FINAL DIAGNOSES include: 1. 2009. CORRECT ANSWER AND RATIONALE: 493. 2008. 276. When you reference allergic rhinitis 477 in the Tabular. Elsevier items and derived items © 2011.02. When you reference 472. the Excludes note directs you not to code it.51 reports dehydration (both hypoxia and dehydration are reported. 2006. 85 . the Alphabetic Index under Asthma. 2010. 4. with rhinitis. leads the coder to 493. Allergic rhinitis. 3. 2007. an imprint Elsevier Inc. 486.CCS Final Examination With Answers ADMISSION: The patient is doing much better following an acute asthma exacerbation associated with pneumonia. status asthmaticus per pediatric consult 486 reports pneumonia 799.51 493. Note that if you coded the allergic rhinitis. so you do not report the allergic rhinitis. if part of allergic asthma. allergic. as they are not inherent to the disease process and they were treated).01.0X.