Ccs General Quiz V
-
A woman underwent a carotid bypass and had a significant drop in blood pressure during the surgery. The documentation suggested the pt may have had a myocardial infarction. In accordance w/ coding guidelines, what should the coder do?
-
Code complication of surgery NOS (not otherwise specified)
-
Query the physician to determine in the pt had hypotension
-
Query the physician to determine if there was a complication of surgery
-
Code preop shock
-
About This Quiz
CCS General Quiz V assesses knowledge in medical coding and clinical documentation. It covers topics such as payment status indicators, procedural complications, and coding for specific medical scenarios. This quiz is essential for professionals aiming to enhance their coding accuracy and compliance.
Quiz Preview
- 2.
Colporrhaphy is a surgery used to fix weaknesses in your vaginal walls.
-
True
-
False
Correct Answer
A. TrueExplanation
Colporrhaphy is indeed a surgery used to repair weaknesses in the vaginal walls. It involves stitching the weakened or damaged tissues in order to provide support and strengthen the vaginal walls. This procedure is commonly performed to treat conditions such as vaginal prolapse or cystocele, where the bladder bulges into the vagina. By repairing the vaginal walls, colporrhaphy helps to alleviate symptoms and improve the overall function and comfort of the vagina.Rate this question:
-
- 3.
Simple surgeries are limited to single areas and only soft tissue. Complicated surgery would require one or more of the following:
-
Multiple incisions
-
Probing to break up loculations
-
Extensive packing
-
Drain placement and wound closure
-
All of the above
Correct Answer
A. All of the aboveExplanation
The correct answer is "All of the above" because the question asks for the requirements of complicated surgery, and all of the options listed (multiple incisions, probing to break up loculations, extensive packing, drain placement, and wound closure) are examples of requirements for complicated surgeries.Rate this question:
-
- 4.
The UHDDS definition of principal procedure indicated that the principal procedure can be assigned for which of the following
-
Addressing complications
-
Exploration
-
Diagnostic
-
Clinical Evaluation
Correct Answer
A. Addressing complicationsExplanation
The principal procedure by UHDDS definition is for definitive treatment or treatment of a complicationRate this question:
-
- 5.
When you’re doing a hepatitis screening test for a non-pregnant ob-gyn patient, you should report Encounter for screening for ______________________________ in the absence of any symptoms.
Correct Answer
other viral diseaseExplanation
if the patient is pregnant, you would use Encounter for antenatal screening of mother because this is part of the antenatal screening.Rate this question:
- 6.
For a patient who has had a tubal ligation but has not made an attempt to have it reversed, the only diagnosis would be __________, tubal ligation.
Correct Answer
statusExplanation
The term "status" refers to the current condition or state of something. In the context of a patient who has had a tubal ligation but has not attempted to reverse it, the only diagnosis that can be given is "status," indicating that the patient's current condition is tubal ligation. This suggests that the patient has not taken any action to reverse the procedure, and their tubes remain tied or blocked.Rate this question:
- 7.
If during a surgery a vascular access device was also implanted, it should be coded. These include peripheral intravenous catheter (PIV), peripherally inserted central catheter (PICC), centrally inserted central catheter (CICC), and implanted venous access port VAP.
-
True
-
False
Correct Answer
A. TrueExplanation
During a surgery, if a vascular access device such as a peripheral intravenous catheter (PIV), peripherally inserted central catheter (PICC), centrally inserted central catheter (CICC), or implanted venous access port (VAP) is implanted, it should be coded. This means that the presence of any of these devices should be documented and recorded for proper medical reporting and billing purposes.Rate this question:
-
- 8.
individual dialectical behavior therapy is a type of __________________, not psychoanalysis
Correct Answer
psychotherapyExplanation
The given correct answer for this question is "psychotherapy." The statement suggests that individual dialectical behavior therapy is a type of psychotherapy, not psychoanalysis. Psychotherapy refers to the treatment of mental disorders or emotional problems through psychological techniques, while psychoanalysis is a specific form of therapy that focuses on exploring unconscious thoughts and feelings. Therefore, individual dialectical behavior therapy falls under the category of psychotherapy rather than psychoanalysis.Rate this question:
- 9.
What are the 5 categories of standards in the HIPAA Security Rule?
-
"Policies, procedures, and documentation", administrative safeguards, organizational safeguards, and physical safeguards
-
Physical safeguards, technical safeguards, administrative safeguards, organizational safeguards, and "policies, procedures, and documentation"
-
Physical safeguards, governing safeguards, technical safeguards, safeguard safeguards, and technical safeguards
-
A and B are correct
Correct Answer
A. Physical safeguards, technical safeguards, administrative safeguards, organizational safeguards, and "policies, procedures, and documentation"Explanation
The correct answer is "Physical safeguards, technical safeguards, administrative safeguards, organizational safeguards, and 'policies, procedures, and documentation'". These categories of standards are outlined in the HIPAA Security Rule, which is designed to protect the confidentiality, integrity, and availability of electronic protected health information (ePHI). Physical safeguards refer to physical measures such as locks and access controls, while technical safeguards involve the use of technology to protect ePHI. Administrative safeguards include policies and procedures for managing the security of ePHI, and organizational safeguards involve the assignment of security responsibilities within an organization. The category of "policies, procedures, and documentation" encompasses the documentation of security policies and procedures that are implemented to protect ePHI.Rate this question:
-
- 10.
When assigned to CPT codes, these indicate whether a service or procedure will be separately reimbursed under the OPPS
-
Ambulatory payment classificatgion
-
Payment status indicators
-
Payment modifiers
-
Diagnosis-related groups
Correct Answer
A. Payment status indicatorsExplanation
A payment status indicator establishes how the service is paid in the hospital OPP (outpatient prospective payment) methodologyRate this question:
-
- 11.
Under HIPPA every organization must have ....
-
Privacy and Security officers
-
Security and Compliance officers
-
Compliance and safety officers
-
Safety and Privacy officers
Correct Answer
A. Privacy and Security officersExplanation
Under HIPAA (Health Insurance Portability and Accountability Act), every organization must have Privacy and Security officers. These officers are responsible for ensuring that the organization complies with HIPAA regulations regarding the protection of patient privacy and the security of their health information. They develop and implement policies and procedures, train employees on privacy and security practices, conduct audits and risk assessments, and handle any breaches or complaints related to patient privacy or data security. Their role is crucial in maintaining the confidentiality and integrity of patient information within the organization.Rate this question:
-
- 12.
A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is _______
Correct Answer
preventativeExplanation
A routine computer back-up procedure is considered a preventative control because it aims to prevent data loss from occurring. By regularly backing up data, the system ensures that even if there is a failure or security breach, the important information can be restored. This proactive approach reduces the risk of data loss and helps maintain the integrity and availability of the data.Rate this question:
- 13.
The OCE has 4 basic purposes: 1. Editing data on the claim for accuracy 2. Specifying the action that the FI (fiscal intermediary) should take if specific edits occur 3. Assigning APCs to the claim (for hospital outpatient services) 4. Determining payment-related conditions that require direct reference to HCPCS codes or modifiers
-
True
-
False
Correct Answer
A. TrueExplanation
The statement is true because the OCE (Outpatient Code Editor) does indeed have 4 basic purposes. These purposes include editing data on the claim for accuracy, specifying the action that the fiscal intermediary should take if specific edits occur, assigning APCs (Ambulatory Payment Classifications) to the claim for hospital outpatient services, and determining payment-related conditions that require direct reference to HCPCS (Healthcare Common Procedure Coding System) codes or modifiers.Rate this question:
-
- 14.
Epidural steroid injections, Corticosteroids, are an _________________ medicine
Correct Answer
anti-inflammatory, anti inflammatoryExplanation
The principal diagnosis is defined as the condition "established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care"Rate this question:
- 15.
If the clinician documents “easy bruising” with no identifiable cause, then you should report R23.3 (Spontaneous _______________)
Correct Answer
ecchymosesExplanation
An ecchymosis is defined as a bruise that is larger than one centimeter.
A bruise that is less than one centimeter, but not less than three millimeters, is called a purpura.
A bruise less than three millimeters is called a petechiae.
R23.3 applies to petechia but not for purpuraRate this question:
- 16.
Immune thrombocytopenia (ITP) is a type of ___________________.
Correct Answer
platelet disorderExplanation
In ITP, your blood does not clot as it should, because you have a low platelet count. Platelets are tiny blood cells that are made in the bone marrow. When you are injured, platelets stick together to form a plug that seals your wound.Rate this question:
- 17.
An aneurysm qualifies as complex either because it is larger than __________or because of the need for extra effort to clip it or prevent further damage to the blood vessels. If documentation is unclear query the physician
Correct Answer
15 mmExplanation
An aneurysm qualifies as complex either because it is larger than 15 mm or because of the need for extra effort to clip it or prevent further damage to the blood vessels. If documentation is unclear, it is important to query the physician for clarification.Rate this question:
- 18.
According to the UHDDS, the definition of a secondary diagnosis is a condition that.........
-
Is recorded in the patient record
-
Receives evaluation and is documented by the physician
-
Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, or increases nursing monitoring and care
-
Is considered to be essential by the physicians involved and is reflected in the record
Correct Answer
A. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, or increases nursing monitoring and careExplanation
Other Diagnosis Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay
Secondary Diagnosis Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, or increases nursing monitoring and careRate this question:
-
- 19.
If the spot of origin in undetermined, all known sites of a neoplasm are coded secondary
-
True
-
False
Correct Answer
A. TrueExplanation
If a primary site of metastatic cancer has not been established, a code for c80.1, primary malignant neoplasm, unspecified may be used, sequenced AFTER codes for the known sitesRate this question:
-
- 20.
If the patient experiences an increase in blood pressure during surgery, the code is indexed as High, blood pressure, _______________ without diagnosis of hypertension
Correct Answer
incidentalExplanation
During surgery, if a patient experiences an increase in blood pressure, it is considered as an incidental finding. This means that the high blood pressure is not a diagnosed condition or a primary focus of the surgery. It is an unexpected and secondary observation made during the procedure. Therefore, the code is indexed as "High, blood pressure, incidental" to accurately document this incidental finding without implying a diagnosis of hypertension.Rate this question:
- 21.
When a pt is admitted and has a discrepancy in their documentation but is still in the unit, the _____________ is responsible for obtaining clarity on the info.
Correct Answer
clinical documentation specialistExplanation
When a patient is admitted to the unit and there is a discrepancy in their documentation, the clinical documentation specialist is responsible for obtaining clarity on the information. They have the expertise to review and analyze the patient's medical records, ensuring that all documentation is accurate and complete. By working closely with the healthcare team, they can identify any discrepancies or missing information and communicate with the necessary parties to resolve the issue. This ensures that the patient's medical records are accurate and up-to-date, promoting quality care and proper billing.Rate this question:
- 22.
A --------- anomaly is an abnormality one was born with
Correct Answer
congenitalExplanation
A congenital anomaly refers to an abnormality that a person is born with. It means that the anomaly was present from birth and is not acquired later in life. This term is used to describe various conditions or physical traits that are present at birth, such as birth defects or genetic disorders. The word "congenital" specifically indicates that the anomaly is inherent and not caused by external factors or events occurring after birth.Rate this question:
- 23.
Pleural effusion can be coded alongside CHF if the patient has a malignant pleural effusion, filariasis, or influenza. Additionally, if a thoracentesis or additional diagnostic testing/evaluation is performed, then a code for (J91.8) (Pleural effusion in other conditions classified elsewhere) should be assigned in addition to the CHF
-
True
-
False
Correct Answer
A. TrueExplanation
It is sinusoidal, not spiked.Rate this question:
-
- 24.
A patient is admitted to the hospital with a high fever, chills, tachycardia, and a respiration rate of 26. Lactic acidosis is noted in the labs. Pneumonia is diagnosed and the patient admitted to ICU where antibiotics are given along with LevoPhed (Norepinephrine, Blood Pressure Support).Due to erratic breathing, mechanical ventilation was initiated. With a final diagnosis of pneumonia, what is the query opportunity?
-
Is this aspiration pneumonia
-
Is this septic shock
-
Is this staphylococcus aureus pneumonia
-
Is this sepsis
Correct Answer
A. Is this septic shockExplanation
Indicators of fever, chills, tachycardia, tachypnea, and lactic acidosis all point to sepsis. The addition of respiratory issues requiring mechanical ventilation and circulatory failure requiring vasopressors, this condition more likely represents septic shock.Rate this question:
-
- 25.
There are two CPT codes for Knee prosthetic insertion. One includes a hinge, a ____________type, the other does not have a hinge
Correct Answer
WALLDIUS, walldiusExplanation
For metastatic cancer, first code the primary site, then any secondary sitesRate this question:
- 26.
If a CT or MRI is performed __________ a procedure, a separate code must be used for the CT or MRI
Correct Answer
beforeExplanation
If a CT or MRI is performed before a procedure, a separate code must be used for the CT or MRI. This suggests that the CT or MRI is being done as a preliminary step or as part of the evaluation process before the actual procedure is carried out. It is important to use a separate code to accurately reflect and bill for the additional service provided.Rate this question:
- 27.
The Anterior Cruciate Ligament (ACL) is __________________
Correct Answer
intra articularExplanation
The Anterior Cruciate Ligament (ACL) is located within the joint, specifically within the articular space. It is an intra-articular ligament, meaning that it is situated inside the joint capsule. This ligament plays a crucial role in stabilizing the knee joint and preventing excessive forward movement of the tibia in relation to the femur.Rate this question:
- 28.
____________ may be needed to treat ectopic pregnancy or infection.
Correct Answer
salpingectomyExplanation
Salpingectomy may be needed to treat ectopic pregnancy or infection. A salpingectomy is a surgical procedure in which one or both fallopian tubes are removed. In the case of an ectopic pregnancy, where the fertilized egg implants outside of the uterus, a salpingectomy may be necessary to remove the affected fallopian tube and prevent further complications. In the case of an infection in the fallopian tubes, such as pelvic inflammatory disease, a salpingectomy may also be performed to remove the infected tissue and prevent the spread of infection.Rate this question:
- 29.
What factors of the APR-DRG system allow for capturing the extent of the patient's conditions and expected loss of life while an inpatient
-
Severity of illness and risk of mortality
-
Severity of diagnosis and risk of morbidity
-
Complications and comorbidities
-
HACs and POA status
Correct Answer
A. Severity of illness and risk of mortalityExplanation
The factors of the APR-DRG system that allow for capturing the extent of the patient's conditions and expected loss of life while an inpatient are severity of illness and risk of mortality. These factors take into account the severity of the patient's illness and the likelihood of mortality associated with their condition. By considering these factors, the APR-DRG system can accurately assess the level of care required and the expected outcomes for the patient. This information is crucial for healthcare providers to appropriately allocate resources and plan for the patient's treatment and recovery.Rate this question:
-
- 30.
If a pregnant patient has been exposed to Parvo but you don’t have the definitive test results back yet, you should use O09.89- Supervision of other high risk pregnancies AND what Z code?
Correct Answer
Z20.828Explanation
Contact with and [suspected] exposure to other viral communicable disease as your secondary code to clarify the high risk nature of the pregnancy at this point.
If Parvo is ruled out, the diagnosis code reverts to
Encounter for supervision of normal first pregnancy OR
Encounter for supervision of other normal pregnancy
If confirmed, your diagnosis would change to O98.51-
Other viral diseases complicating pregnancyRate this question:
- 31.
Dobutamine is a predominantly _______________agonist
Correct Answer
beta-adrenoreceptorExplanation
Dobutamine is a predominantly beta-adrenoreceptor agonist. This means that it primarily stimulates and activates the beta-adrenoreceptors in the body. Beta-adrenoreceptors are a type of receptor found in various tissues, including the heart. When activated, they can increase heart rate, contractility, and cardiac output. Dobutamine specifically targets and activates these receptors, leading to increased cardiac function and improved blood flow.Rate this question:
- 32.
When the ob-gyn DOESN'T get to the patient in time to deliver the baby (it is delivered in the emergency department) but DOES deliver the placenta (59414, Delivery of placenta [separate procedure]), the OB-GYN should report Encounter for care and examination of mother ________________________ because the emergency-department doctor will report O80 (Encounter for full-term uncomplicated delivery), assuming there are no other issues complicating the delivery.
Correct Answer
immediately after deliveryExplanation
The OB-GYN should report Encounter for care and examination of mother immediately after delivery because they provided care and examination to the mother after the baby was delivered in the emergency department.Rate this question:
- 33.
Malignant hydatidiform is reported as a neoplasm of uncertain behavior of the ________________
Correct Answer
placentaExplanation
Malignant hydatidiform is reported as a neoplasm of uncertain behavior of the placenta. This means that it is a tumor-like growth that originates in the placenta, but its behavior and potential for spreading or causing harm are uncertain. It is important to monitor and manage this condition carefully to ensure the best outcome for the patient.Rate this question:
- 34.
Excision of cyst scalp is excision, ____________, ________________
Correct Answer
skin benignExplanation
The correct answer is "skin benign" because the excision of a cyst on the scalp involves the removal of a benign (non-cancerous) growth from the skin.Rate this question:
Quiz Review Timeline (Updated): Mar 1, 2023 +
Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.
-
Current Version
-
Mar 01, 2023Quiz Edited by
ProProfs Editorial Team -
Mar 23, 2017Quiz Created by
Mike
Back to top