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45385, 99156, 99157 A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. breast The diagnosis is as follows: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast." Given this which are the primary cancer site(s)? 33430 Patient has a year history of mitral valve regurgitation and now presents for a mitral valve replacement with bypass. (Code for physician using CPT procedure codes only.) improve your department's processes You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to feedback on specific instances when improved documentation would improve coding Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with G30.0, F02.80 A patient is diagnosed with early onset Alzheimer's disease with dementia. 90471, 90698 (If immunization is the only service that the patient receives, then two codes are used to report the service: the immunization administration code is first and then the code for the vaccine/toxoid.) An established patient was seen by physician in her office for DTaP-IPV/Hib. 0102T CPT code for a high-energy ESW of the lateral humeral epicondyle using general anesthesia. laser removal of condyloma Which of the following procedures can be identified as "destruction" of lesions? upcoding The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as database A ________ is a collection of information or data that is organized in such a way that its contents can be queried and relationships created. 32851 Single lung transplant without cardiopulmonary bypass. (Code for physician using CPT procedure codes only.) N39.3, 51990 Female with 6 months of stress incontinence. Laparoscopic urethral suspension was completed. Choose the appropriate ICD-10-CM and CPT codes. external beam radiation The use of radioactive sources placed into a tumor-bearing area to generate high-intensity radiation is termed partial resection of the upper left lobe Which of the following procedures would NOT be coded to "resection" when using ICD-10-PCS? used and sequenced as a secondary diagnosis During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the code for sterilization, Z30.2, is R42, T42.3x1A, T51.8x1A A patient suffered dizziness as a result of taking prescribed phenobarbital. The patient took his medication with beer. are always present on admission and represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury. Some ICD-10-CM codes are exempt from POA reporting because they Medicare Administrative Contractor (MAC) CMS delegates its daily operations of the Medicare and Medicaid programs to principal diagnosis Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? N40.0, 53852 Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy. (Code ICD-10-CM for diagnoses and CPT for procedures.) doctor's admitting progress note As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the 63005 Lumbar laminectomy (one segment) for decompression of spinal cord. (Code CPT for procedures.) recovery audit contractors (RACs) The _______________ are the organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claims to detect and correct improper payments. 38745 Patient has breast carcinoma and is now undergoing complete axillary lymphadenectomy. (Code for physician using CPT procedure codes only.) all answers apply: changes in the services offered by a facility, changes in DRG weights, and accuracy of coding Which of the following could influence a facility's case mix? D17.1 Excision 2 cm subcutaneous soft tissue lipoma of the back. (Code for diagnoses using ICD-10-CM. Code for procedure using CPT.) 30 days The Joint Commission requires that all medical records be completed within ___________ following patient discharge. 25251 Provide the CPT code for a patient that had a complicated removal of a wrist prosthesis. they should both be coded, acute sequenced first If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level D12.2, D12.3, 45384, 45385-59 Patient presents to the GI lab for a colonoscopy. During the colonoscopy, adenomatous polyps were discovered in the ascending colon and in the transverse colon. Polyps in the ascending colon were removed via hot biopsy forceps, and the polyps in the transverse colon were removed by snare technique. quid pro quo What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? 44204, 44213 (Code 44204 for the laparoscopy, surgical; colectomy, partial, with anastomosis. Code additional code of 44213 for the laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy. (List separately in addition to primary procedure.) CPT code(s) for a laparoscopic takedown of the splenic flexure and a partial colectomy with anastomosis. is a system for documenting the extent or spread of cancer staging congenital disorders Which of these conditions are always considered "present on admission" (POA)?