Questions and Answers
What must be documented in the medical record regarding care rendered to the patient?
The care rendered to the patient and the patient's response.
What does authentication of health record entries mean?
Where must the requirements for documentation and record completion be specified?
In what order should the diagnoses be coded for a patient with infectious gastroenteritis, angina, and chronic obstructive pulmonary disease?
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What diagnostic codes should be used for a screening colonoscopy where polyps were found?
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When coding benign neoplasm of the skin, which category should be used for benign neoplasm of sweat glands?
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What should be done when coding benign lipomatous neoplasms of skin?
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Which codes are correct for a patient discharged with posterior subcapsular cataract, diabetes, hypertension, and acute renal failure?
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How is acute exacerbation of COPD coded?
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What is carcinoma in situ?
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Examples of carcinoma in situ include _____ infiltrating.
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What type of diagnosis might the patient's symptoms indicate?
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Which of the following represents the correct diagnoses and appropriate sequence of those conditions?
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What action should the coding staff take when documentation is unclear regarding a potential complication?
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What potential diagnosis most closely fits the patient's overall symptoms?
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What is the ICD-10 code for a patient with inguinal hernia repair and AIDS?
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What is the ICD-10 code for a patient admitted for dehydration and dysphagia?
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What is the ICD-10 code for a patient admitted for detoxification from alcohol and barbiturate intoxication?
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What is the ICD-10 code for a patient with recurrent epileptic seizures?
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The patient had a temperature of 102 and atrial fibrillation with documented pneumonia, what is the ICD-10-CM code?
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What is the ICD-10 code for a patient with chronic cholecystitis undergoing laparoscopic cholecystectomy?
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What is the ICD-10 code for hydronephrosis and staghorn calculus of the right kidney?
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What is the ICD-10 code for a patient with decubitus stage 3 ulcer?
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What is the ICD-10 code for a patient who underwent laminectomy and diskectomy for lumbar disk displacement?
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What is the ICD-10-CM code for a patient diagnosed with adenocarcinoma of the right lower lung?
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What actions should be taken for a patient with intestinal obstruction due to adhesions?
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What may legitimately change the coding of pneumonia based on clinical documentation?
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What steps must the coder take for a patient diagnosed with infertility due to endometriosis?
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What must be reflected to establish the adequacy of documentation in the medical record?
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Study Notes
Carcinoma in Situ
- Refers to tumor cells in the initial stage of malignancy, remaining confined to the original site without invading surrounding tissue.
- Common example includes intraepithelial infiltrating.
Patient Cases and Diagnoses
- Elevated CPK and MB enzymes, along with ST changes on an EKG, may indicate a myocardial infarction (MI).
- For urinary tract infections, Escherichia coli is coded as a secondary diagnosis when a definitive diagnosis is provided.
- In cases of post-heart transplant patients with unclear documentation, coders should query the physician for clarity.
- Symptoms like loss of interest, weight gain, fatigued state, and sleep difficulties suggest a diagnosis of major depression.
Inpatient Admission Coding Examples
- A patient with AIDS underwent an inguinal herniorrhaphy; necessary ICD-10 codes include K40.90 for hernia and B20 for AIDS.
- A 75-year-old presented with dehydration post-stroke; codes related to dehydration and I69.391 for stroke should be used.
- Alcohol detoxification with liver cirrhosis would require coding for both conditions, including F10.229 for alcohol dependence.
- For exploratory laparotomy due to intestinal obstruction, only abdominal adhesions with obstruction will be coded, excluding abdominal pain as it is merely a symptom.
Diagnosis and Treatment Procedures
- Pneumonia treated with IV antibiotics takes precedence in coding over atrial fibrillation managed with oral medications.
- Women giving birth may require coding for hemorrhage occurring after delivery but before placenta expulsion.
- For cancer treatments such as lobectomy for lung cancer, both primary and metastatic sites must be accurately coded.
- Documentation of patient care and responses, such as treatment records, must be adequately reflected in medical records.
Outpatient and Ambulatory Coding Examples
- Noncardiac chest pain and tests like esophageal acid reflux require specific ICD-10-CM and CPT codes.
- Annual screening mammograms and excisions of basal cell carcinoma have designated diagnostic and procedural codes for accurate tracking.
- Surgical procedures like hysteroscopy for dysfunctional uterine bleeding must document both the action taken and the associated conditions.
Documentation and Authentication
- Key aspects of medical record adequacy include clear documentation of patient care actions and their responses.
- Authentication of entries serves to verify the authorship and integrity of medical documents, requiring signatures for validation.
- Regulations delineated in medical staff bylaws outline necessary documentation requirements and penalties for noncompliance.
Overall Diagnosis Coding Considerations
- The act of coding for multiple conditions must adhere to guidelines that prioritize definitive diagnoses over mere symptoms.
- Changes in coding based on additional complications (e.g., aspiration pneumonia due to dysphagia) affect health classifications and reimbursement structures.
- Proper coding of treatments and diagnoses involves reviewing operative reports and citing specifics of patient conditions for accuracy and compliance with regulations.### Screening Colonoscopy Coding
- Z12.11: Used for encounters involving screening for malignant neoplasm of the colon.
- D12.6: Represents benign neoplasm of the colon, unspecified.
- Correct coding sequence prioritizes screening colonoscopy (Z12.11) followed by the polyp code (D12.6).
- Option c (Z12.11, D12.6) is the correct coding sequence.
Benign Neoplasms of Skin Coding
- Category D23 includes other benign neoplasms of skin, including those of hair follicles, sebaceous glands, and sweat glands.
- Excludes benign lipomatous neoplasms and melanocytic nevi; these should not be coded under D23.
- Correct code for benign neoplasm of sweat glands is found in category D23, making option a correct.
Coding for Benign Lipomatous Neoplasms
- When coding benign lipomatous neoplasms of the skin, the appropriate range is D17.0-D17.3.
- D23 is not applicable for benign lipomatous neoplasms, thus option b is the correct choice.
Multiple Diagnoses Discharge Coding
- Relevant diagnoses include posterior subcapsular cataract in right eye, diabetes mellitus, hypertension, and mild acute renal failure.
- E11.9: Code for Type 2 diabetes mellitus without complications.
- H25.041: Correct code for posterior subcapsular polar age-related cataract in right eye.
- I10: Represents essential hypertension but does not combine with acute renal failure as it is temporary.
- N17.9: Code for unspecified acute kidney failure.
- Correct combination of codes for this discharge is option b (H25.041, E11.9, I10, N17.9).
Coding Acute Exacerbation of COPD
- Acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) is coded as J44.1.
- Hypertension is documented alongside chronic renal disease, requiring combined coding due to their relationship.
- Stage of chronic kidney disease must also be accounted for in the coding process.
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Description
Test your knowledge on carcinoma in situ, patient diagnoses, and inpatient admission coding examples. This quiz covers critical aspects of medical coding including various conditions and their corresponding ICD-10 codes. Perfect for students and professionals in the medical field.
