CCA Prep Exam 1 (100 Questions)

100 Questions  I  By Melodey23
CCA Prep Exam 1 - 100 Questions - Entered 03/12/2012 Domain 1: Health Records and Data Content Domain 2: Health Information Requirements and Standards Domain 3: Clinical Classification Systems Domain 4: Reimbursement Methodologies Domain 5: Information and Communication Technologies Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues

  
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1.  Identify the ICD-9-CM diagnostic code(s) for the following: A 73-year-old female was treated for hemorrhage of the inferior mesenteric artery. She was admitted to the hospital for a transcatheter embolization of the bleeders with polyvinyl alcohol (PVA) microspheres and coils and abdominal angiography.
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2.  Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads.
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B.
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3.  Which of the following four sources of law is also known as judge-made or case law?
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D.
4.  Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to staphylococcus.
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5.  Which term describes the linking of every procedure or service received by a patient to a diagnosis that justifies the need to performing the service?
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D.
6.  Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a braest biopsy.
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7.  Identify the ICD-9-CM diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, ex-preemie".
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8.  Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the:
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D.
9.  A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previouosly treated. According to HIPAA regulations, was this action correct?
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10.  The patient is seen in the physician office with a chief complaint of shortness of breath. In the patient's progress notes, the physician documents the diagnosis of asthma and recommends the patient present to the emergency department of XYZ Hospital immediately. The physician further documents that the patient has severe wheezing and no obvious relief with bronchodilators. Which action will the coder take?
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11.  Which of the following programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards?
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D.
12.  A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____________ .
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13.  Identify the ICD-9-CM diagnostic code for allogeneic donor lymphocyte stem cell infusion.
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D.
14.  CMS developed Medically Unlikely Edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007 and are applied to which code set?
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D.
15.  Where would information on treatment given on a particular encounter be found in the health record?
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D.
16.  Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary-coronary artery bypass.
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D.
17.  Which of the following is not a function of the discharge summary?
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D.
18.  Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers and interrupted sutures.
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19.  The coder might find which of the following on a patient's problem list if the medication list contains the drug Protonix?
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D.
20.  Which of the following is the correct ICD-9-CM procedure code for a Mayo operation known as a bunionectomy?
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D.
21.  What is the best reference tool to determine how CPT codes should be assigned?
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D.
22.  Identify the ICD-9-CM code for diaper rash, elderly patient.
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23.  A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient requests the hospital provide the medical records in paper format. How should the hospital respond?
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24.  Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment Cesarean delivery with single live-born female.
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D.
25.  All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data:
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D.
26.  Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to chemotherapy.
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D.
27.  An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of:
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D.
28.  A family practitioner requests the opinion of a physician specialist in endocrinology who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in which type of report?
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D.
29.  According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?
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30.  A male patient is seen by the physician and diagnosed with pneumonia. The doctor took cultures to try to determine which organism was causing the pneumonia. Which of the following organisms would alert the coder to code it as a gram-negative pneumonia?
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31.  The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is ___________.
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D.
32.  What types of covered entity health records are subject to HIPAA privacy regulations?
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33.  What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed?
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34.  Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician?
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35.  Identify the ICD-9-CM code for acute lymphadenitis.
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36.  While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on __________.
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37.  The release of information function requires the HIM professional to have knowledge of _______________.
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D.
38.  Which of the following statements about a firewall is false?
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D.
39.  Identify the ICD-9-CM code(s) for infected ingrown nail.
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40.  An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?
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41.  What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?
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42.  A software interface is a ___________.
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43.  What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims?
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44.  To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health  record no later than 24 hours after amission.  Which of the following would by the best way to ensure the completeness of health records?
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45.  What does audit trail check for?
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46.  Which of the following is the correct ICD-9-CM code(s) for thoracoscopic lobectomy of left lung?
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D.
47.  Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.
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48.  A health information technician receives a subpoena duces tecum for the records of a discharged patient. To respond to the subpoena, which of the following should the technician do?
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49.  There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further defines removal of foreign body (45379) and bipsy, single or multiple (45380) and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule?
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50.  What type of data is exemplified by the insured party's member identification number?
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51.  Identify the ICD-9-CM diagnostic code for atypical ductal hyperplasia
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52.  Identify the CPT code(s) for the following patient:  A 2-yr-old male presented to the hospital to have his gastrostomy tube changed under flouroscopic guidance.
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53.  The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?
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54.  HIM coding professionals and the orgs that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated?
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55.  Mildred Smith was admitted from an acute hospital to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome".  Underneath the diagnosis was listed her medical information along with her rehabilitation potential. On which form is this information documented.
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56.  An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
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57.  How do accrediation organizations such as the Join Commission use the health record?
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58.  Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system?
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59.  A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM departments. Which of the following electronic systems would fullfill this purpose?
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60.  The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150, Total abdominal hysterectomy, with/without removal of tubes and ovaries 58700, Salpingectomy, complete or partial, unilateral/bilateral (separate procedure) What error has the coder made by using these codes?
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61.  The coder notes that the physician has prescribed Synthroid for the patient. The coder might find which of the following on the patient's problem list?
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D.
62.  The __________ may contain information about diseases among relatives in which heredity may play a role.
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63.  Identify the ICD-9-CM dx code(s) for neonatal tooth eruption
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64.  Identify the code for a patient with a closed transcervical fracture of the epiphysis.
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D.
65.  What is the best source of documentation to determine the size of a removed malignant lesion?
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D.
66.  Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker.
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D.
67.  This document includes a microscopic description of tissue excised during surgery:
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D.
68.  Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip.
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D.
69.  This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with brady-arrhythmias. Prolonged includes insertions of a permament cardiac pacemaker.
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D.
70.  Identify the ICD-9-CM dx code(s) for the following:  threatened abortion with hemorrhage at 15 weeks; home undelivered.
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71.  Identify the ICD-9-CM dx code for blighted ovum
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72.  Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state in which they are located.
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73.  In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporate the greater number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of the panel?
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74.  Identify the ICD-9-CM diagnostic code for diastolic dysfunction
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D.
75.  Which of the following is the correct ICD-9-CM code(s) for laparoscopic cholecystectomy?
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B.
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D.
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76.  Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for reprogramming of a cardiac pacemaker.
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D.
77.  What is the best reference tool to receive ICD-9-CM coding advice?
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78.  Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of __________.
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D.
79.  The sequence of the correct steps when evaluating an ethical problem is:
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D.
80.  Identify the ICD-9-CM procedure code(s) for insertion of tissue expander in breast, post mastectomy.
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D.
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81.  Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation?
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D.
82.  Which of the following software applications would be used to aid in the coding function in a physician's office?
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D.
83.  The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of:
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D.
84.  Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the tachnique using two catheters inserted percutaneously through the femoral artery.
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D.
85.  The HIM director is having difficulty with the on-cal physicians in the emergency services department completing their health records. Currently, three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situations?
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D.
86.  Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format?
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D.
87.  Which of the following definitions best describes the concept for confidentiality?
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D.
88.  Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the option listed here, what is best course of action?
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D.
89.  Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease.
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D.
90.  Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must be facility meet in order to become certified for these programs?
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D.
91.  Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block.
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D.
92.  A 65-year-old white male was aditted to the hospital on 1/15 complaining of abdominal pain. The Attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and ruptured appendix was discovered. The chief complaint was:
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D.
93.  Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given:
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D.
1 comment
94.  Which of the following is the correct ICD-9-CM procedure code(s) for cystoscopy with biopsy?
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D.
95.  The physician orders a chest x-ray for a patient who presents at the office with fever, productive cough, a shortness of breath. The physician indicates in the progress notes: "Ruled out pneumonia" What diagnosis (es) should be coded for the visit when the results have not yet been received?
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D.
96.  Identify the ICD-9-CM diagnosis code for chondromalacia of the patella.
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D.
97.  Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceed the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. To improve compliance, which of the following would be a next step to overcoming noncompliance?
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D.
98.  Identify the CPD code(s) for the following patient: A 2-yr-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance.
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99.  The coder notes that the physician has ordered potassium replacement for the patient. The coder might expect to see a diagnosis of:
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B.
C.
D.
100.  Identify the ICD-9-CM diagnostic code for Paget's disease of the bone (no bone tumor noted)
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B.
C.
D.
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