CCA Clinical Classification Systems
Coronary arteriography serves as a diagnostic tool in detecting obstruction within the
coronary arteries. Identify the technique using two catheters inserted percutaneously
through the femoral artery. *** The Judkins technique provides x-ray imaging of the
coronary arteries by introducing one catheter into the femoral artery with maneuvering
up into the left coronary artery orifice, followed by a second catheter guided up into the
right coronary artery, and subsequent injection of a contrast material.
Identify the term ICD-10-CM uses for the following definition: "the expulsion of some,
but not all, of the products of conception from the uterus." *** An incomplete abortion
is one in which some, but not all, of the products of conception are expulsed from the
uterus. If the placenta or secundines remain, the abortion is considered incomplete.
For ulcers that were present on admission but healed at the time of discharge, assign
the code for the site and stage of the pressure ulcer __________. *** Coding
Guideline I.C.12.a.5 notes that pressure ulcers present on admission but healed at the
time of discharge are assigned the code for site and stage at time of admission.
Identify the chapter in which certain signs and symptoms of breast disease, such as
mastodynia, induration of breast, and nipple discharge, are included. *** Certain signs
and symptoms of breast disease are included in category N64 Other disorders of
breast, which are in Chapter 14 Diseases of the genitourinary system.
If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher
stage, _________. *** Assign two separate codes, one code for the site and stage of
the ulcer on admission and a second code for the same ulcer site and the highest stage
reported during the stay.
Identify the correct ICD-10-CM sequencing for a patient with disseminated candidiasis
secondary to AIDS-related complex. *** Patients with an HIV-related illness should be
coded to category B20, which includes AIDS, AIDS-like syndrome, AIDS-related
complex, and symptomatic HIV infection. When a patient is seen for an HIV-related
condition, B20 Human immunodeficiency virus is the first listed diagnosis code. Any
HIV-related conditions should be listed as additional diagnosis codes.
The seventh character A is used as long as the patient is receiving active treatment for
the fracture. When the patient is seen by a new or different provider over the course of
treatment for a pathological fracture, assignment of the seventh character is based on
_____. *** Per Coding Guideline I.C.13.c, the seventh character A is used as long as
the patient is receiving active treatment for the fracture. While the patient may be seen
by a new or different provider over the course of treatment for the pathological fracture,
assignment of the seventh character is based on whether the patient is undergoing
active treatment and not whether the provider is seeing the patient for the first time.
, Time may be considered the key or controlling factor to qualify for a particular level of
Evaluation and Management services when __________ percent of the service is
___________. *** Both counseling and coordination of care are contributing factors in
the selection of an E/M level of service. When counseling and coordination of care
constitute more than 50 percent of the face-to-face time, time may be considered the
key or controlling factor.
Category II codes cover all but one of the following topics. What is not addressed by
Category II codes? *** New technology is addressed by the Category III codes.
Per CPT guidelines, a separate procedure is _____. *** Because a separate
procedure is considered a part of, and integral to, another, larger procedure, it is not
coded when performed as part of the more extensive procedure. See Surgery
Guidelines. It may, however, be coded when it is not performed as part of another,
larger service.
CPT was developed and is maintained by ________. *** The AMA developed and
maintains CPT. CMS developed and maintains HCPCS Level II codes.
The codes in the musculoskeletal section of CPT may be used by _____. *** Any
physician may use the codes in any section of CPT.
Observation E/M codes (99218-99220) are used in physician billing when _____. *** A
patient is referred to a designated observation status. See instructional notes preceding
code 99217. In order to report these codes, the admission order must designate
observation status.
Documentation in the history of use of drugs, alcohol, and tobacco is considered as part
of the _____. *** Documentation of history of use of drugs, alcohol, and tobacco is
considered part of the social history. The review of systems is a part of the history of
present illness.
Tissue transplanted from one individual to another of the same species, but different
genotype is called a(n) _____. *** Allograft or allogeneic graft
Mohs micrographic surgery involves the surgeon acting as _____. *** Both surgeon
and pathologist
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in
obtaining acceptable alignment, what type of code should be assigned for the
procedure? *** The "with manipulation" code is used because the fracture was
manipulated, even if the manipulation did not result in clinical anatomic alignment.
In coding arterial catheterizations, when the tip of the catheter is manipulated from the
insertion into the aorta and then out into another artery, this is called __________. ***
If the tip of the catheter is manipulated, it is a selective catheterization.
Coronary arteriography serves as a diagnostic tool in detecting obstruction within the
coronary arteries. Identify the technique using two catheters inserted percutaneously
through the femoral artery. *** The Judkins technique provides x-ray imaging of the
coronary arteries by introducing one catheter into the femoral artery with maneuvering
up into the left coronary artery orifice, followed by a second catheter guided up into the
right coronary artery, and subsequent injection of a contrast material.
Identify the term ICD-10-CM uses for the following definition: "the expulsion of some,
but not all, of the products of conception from the uterus." *** An incomplete abortion
is one in which some, but not all, of the products of conception are expulsed from the
uterus. If the placenta or secundines remain, the abortion is considered incomplete.
For ulcers that were present on admission but healed at the time of discharge, assign
the code for the site and stage of the pressure ulcer __________. *** Coding
Guideline I.C.12.a.5 notes that pressure ulcers present on admission but healed at the
time of discharge are assigned the code for site and stage at time of admission.
Identify the chapter in which certain signs and symptoms of breast disease, such as
mastodynia, induration of breast, and nipple discharge, are included. *** Certain signs
and symptoms of breast disease are included in category N64 Other disorders of
breast, which are in Chapter 14 Diseases of the genitourinary system.
If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher
stage, _________. *** Assign two separate codes, one code for the site and stage of
the ulcer on admission and a second code for the same ulcer site and the highest stage
reported during the stay.
Identify the correct ICD-10-CM sequencing for a patient with disseminated candidiasis
secondary to AIDS-related complex. *** Patients with an HIV-related illness should be
coded to category B20, which includes AIDS, AIDS-like syndrome, AIDS-related
complex, and symptomatic HIV infection. When a patient is seen for an HIV-related
condition, B20 Human immunodeficiency virus is the first listed diagnosis code. Any
HIV-related conditions should be listed as additional diagnosis codes.
The seventh character A is used as long as the patient is receiving active treatment for
the fracture. When the patient is seen by a new or different provider over the course of
treatment for a pathological fracture, assignment of the seventh character is based on
_____. *** Per Coding Guideline I.C.13.c, the seventh character A is used as long as
the patient is receiving active treatment for the fracture. While the patient may be seen
by a new or different provider over the course of treatment for the pathological fracture,
assignment of the seventh character is based on whether the patient is undergoing
active treatment and not whether the provider is seeing the patient for the first time.
, Time may be considered the key or controlling factor to qualify for a particular level of
Evaluation and Management services when __________ percent of the service is
___________. *** Both counseling and coordination of care are contributing factors in
the selection of an E/M level of service. When counseling and coordination of care
constitute more than 50 percent of the face-to-face time, time may be considered the
key or controlling factor.
Category II codes cover all but one of the following topics. What is not addressed by
Category II codes? *** New technology is addressed by the Category III codes.
Per CPT guidelines, a separate procedure is _____. *** Because a separate
procedure is considered a part of, and integral to, another, larger procedure, it is not
coded when performed as part of the more extensive procedure. See Surgery
Guidelines. It may, however, be coded when it is not performed as part of another,
larger service.
CPT was developed and is maintained by ________. *** The AMA developed and
maintains CPT. CMS developed and maintains HCPCS Level II codes.
The codes in the musculoskeletal section of CPT may be used by _____. *** Any
physician may use the codes in any section of CPT.
Observation E/M codes (99218-99220) are used in physician billing when _____. *** A
patient is referred to a designated observation status. See instructional notes preceding
code 99217. In order to report these codes, the admission order must designate
observation status.
Documentation in the history of use of drugs, alcohol, and tobacco is considered as part
of the _____. *** Documentation of history of use of drugs, alcohol, and tobacco is
considered part of the social history. The review of systems is a part of the history of
present illness.
Tissue transplanted from one individual to another of the same species, but different
genotype is called a(n) _____. *** Allograft or allogeneic graft
Mohs micrographic surgery involves the surgeon acting as _____. *** Both surgeon
and pathologist
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in
obtaining acceptable alignment, what type of code should be assigned for the
procedure? *** The "with manipulation" code is used because the fracture was
manipulated, even if the manipulation did not result in clinical anatomic alignment.
In coding arterial catheterizations, when the tip of the catheter is manipulated from the
insertion into the aorta and then out into another artery, this is called __________. ***
If the tip of the catheter is manipulated, it is a selective catheterization.
