CCS Exam Prep 2024 with Complete Solutions(GRADED A+)

7 yo pt admitted to ED for tx of shortness of breath and given epinephrine and nebulizer tx. Shortness of breath and wheezing are unabated following tx, so what dx should be suspected? - ANSWER-Asthma with status asthmaticus Pt admitted with high temp, lethargy, hypotension, tachycardia, oliguria, elevated WBC, and has more than 100K organisms of E. coli per cc of urine. Attending phys documents "urosepsis", so what is the next step for the coder? - ANSWER-Since PD is a nonspecific term and has no code in Alpha Index, query phys to determine if pt is being treated for sepsis, highlighting the clinical signs, symptoms During CABG, pt underwent saphenous bypass grafts; from aorta to left ant desc branch of left main coronary artery, and the left post desc of left main coronary artery. Pt also underwent repositioning of the mammary artery to the right coronary artery. What is the best description for this px? - ANSWER-2 aortocoronary grafts and 1 mammary-coronary graft According to CPT, an endoscopy that is undertaken to the level of midtransverse colon would be coded as a: - ANSWER-Colonoscopy since this is an examination of entire colon from rectum to cecum that may include terminal ileum Infusion of Herceptin, a monoclonal antibody used for tx of breast cancer in pts carrying a certain mutation of the HER2 gene, is classified as: - ANSWER-Molecular Targets which block the growth, spread of cancer by interfering with specific molecules involved in tumor growth, progression Pt has findings suggestive of COPD on chest x-ray and Attending phys mentions x-ray finding in one progress note but no meds, tx, or further eval. The coder should: - ANSWER-Query phys regarding clinical significance of findings and request appropriate documentation be provided as this is example of a circumstance where chronic condition must be verified; all secondary conditions must meet the UHDDS definitions although it is not clear if COPD does Pt undergoes inpatient px and final summary dx is difference from dx on path report, the coder should: - ANSWER-Query Attending phys as final dx as coding strictly from path report is not appropriate since coder would be assigning dx without Attending phys' corroboration 56 yo woman admitted to acute-care facility from SNF and has multiple sclerosis and hypertension. During course of hospitalization, decubitus ulcer is found and debrided at bedside by phys. There is no typed op report and no path report. The coder should: - ANSWER-Query healthcare provider who performed px to determine if debridement was excisional as coders are encouraged to work with physicians, healthcare providers to ensure documentation is very specific and clarified 23 yo female admitted for shock following tx of miscarriage and path report from prev admit reveals pt had no decidua or POC in tissue removed. Encounter would be coded as: - ANSWER-O08.9 = complication following abortion and ectopic and molar pregnancies since miscarriage was dealt with in a prior episode of care Most hospitals require a medical record is completed within: - ANSWER-30 days due to Medicare CofP and TJC To correct an entry in the MR, the provider should: - ANSWER-Draw single line through the error, add a note explaining the error, initial, date, and add correct info in chronological order After pt is discharged from hospital, the MR must be reviewed for: - ANSWER-Certain basic reports such as history and physical, discharge summary, etc. Pt is d