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A patient was admitted from the emergency department because of chest pain. Following
blood work, it was determined that the patient had elevated CK-MB enzymes. The EKG shows
nonspecific ST changes. What type of diagnosis might this indicate?
a) mitral valve stenosis
b) unstable angina
c) myocardial infarction
d) congestive heart failure - ANSWER>>Myocardial infarction
A patient is admitted to the psychiatric unit of an acute-care facility. Almost every day for the
past month, the patient has experienced loss of interest in most or all activities, which is a
change from her prior level of functioning. She had also gained 15 LBS, difficulty falling
asleep, feels fatigued and has difficulty making decision. What potential diagnosis most
closely fits the patients overall symptoms?
a) bipolar disorder
b) insomnia
c) Reye's syndrome
d) major depression - ANSWER>>Major depression
A patient is admitted to the hospital complaining of abdominal pain. Following evaluation, it
was determined that the patient had an obstruction of the left colon due to adhesions from a
prior abdominal surgery. The patient underwent laparotomy with lysis of adhesions. What
conditions and procedures should be coded?
a) abdominal pain, abdominal obstruction, laparotomy, lysis of adhesions
b) abdominal adhesions with obstruction, lysis of adhesions
c) abdominal adhesions, abdominal obstruction, postoperative complications of the digestive
system, laparotomy, lysis of adhesions
d) abdominal adhesions, abdominal obstruction, postoperative complications of the digestive
system, lysis of adhesions - ANSWER>>Abdominal adhesions with obstruction, lysis of
adhesions
A Patient is diagnosed with infertility due to endometriosis and undergoes an outpatient
laparoscopic laser destruction of pelvic endometriosis. In order to code this encounter
accurately, what steps must the coding professional take?
, a) review the operative report to determine what procedure code to use. Determine the sit or
sites of endometriosis so codes with the highest specificity may be assigned. Use infertility as
a principal diagnosis.
b) review the operative report to determine where the laser was used in the pelvis so the site
or sites of endometriosis can be specified. Assign a principal of infertility.
c) receive the operative report to determine where the laser was used in the pelvis so the site
or sites of endometriosis can be specified as principal. Assign a secondary diagnosis of
infertility.
c) review the operative report to determine what procedures codes to use. Determine the
site or sites of end - ANSWER>>review the operative report to determine what procedures
codes to use. Determine the site or sites of endometriosis so codes with the highest specify
may be assigned. Assign endometriosis as the principal diagnosis. Assign infertility as a
secondary condition.
When coding a cardiac Catheterization in CPT, in addition to the approach and the side of the
heart into which the catheter was inserted, what else need to be determined?
a) the type of anesthesia
b) if additional procedures were performed
c) the duration of the procedure
d) documentation that stents were considered - ANSWER>>If additional procedures were
performed
A female patient is admitted for a second-degree cystocele. A repair is performed. Which
report provides the documentation necessary to accurately code the repair?
a) history and physical
b) discharge summary
c) consultation
d) operative report - ANSWER>>Operative report
To accurately report would closures with CPT codes, in addition to knowing the site and
length of the closure, what other information is necessary?
a) if anesthesia was used and what kind
b) the repair type: simple, intermediate or complex
c) the supplies that's were used
d) if exploration of tendons or blood vessels occurred - ANSWER>>The repair type: simple,
intermediate, or complex