Case Studies & Practical Application Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Case Studies & Practical Application flashcards as text
A physician performs a colonoscopy with biopsy and removal of two polyps via hot snare. Which CPT coding approach is correct?
Answer: Code only the polypectomy since it is the more complex procedure
When a biopsy and polypectomy are performed at the same site, the polypectomy is the definitive procedure and the biopsy is not coded separately.
A patient with known HIV disease is admitted for Pneumocystis carinii pneumonia. Which sequencing is correct per ICD-10-CM guidelines?
Answer: Code B20 first with B59 as secondary
ICD-10-CM instructs that B20 (HIV disease) is always sequenced first, followed by the specific AIDS-related condition such as B59 (Pneumocystosis).
A 70-year-old patient undergoes a screening colonoscopy and a polyp is found and removed. What is the first-listed diagnosis?
Answer: The screening code, with the polyp as an additional finding
For screening exams, the screening code (Z12.11) is listed first; any findings such as a polyp are coded as additional diagnoses.
A patient is seen in the ED for chest pain. The workup is negative and the physician documents 'chest pain, etiology unclear.' How should this be coded?
Answer: Code the chest pain as documented since no definitive diagnosis was established
In the outpatient/ED setting, suspected or rule-out diagnoses are not coded; only the symptom (chest pain) is coded if no definitive diagnosis is made.
A surgeon performs a laparoscopic appendectomy that is converted to an open procedure. How is this coded?
Answer: Code the open appendectomy only (44950)
When a laparoscopic procedure is converted to open, only the open procedure code is reported; the conversion is not separately billable.
A physician documents 'acute respiratory failure due to COPD exacerbation.' Which is the correct principal diagnosis for an inpatient admission?
Answer: Either may be sequenced first per coding guidelines
ICD-10-CM guidelines allow either acute respiratory failure or the underlying condition to be sequenced first when both are present, based on the circumstances of admission.
A patient is discharged with documentation of 'probable sepsis.' This is an inpatient record. How should this be coded?
Answer: Code sepsis as documented, since inpatient guidelines allow coding of probable diagnoses
For inpatient records, coding guidelines allow coders to code conditions documented as 'probable,' 'suspected,' or 'likely' at discharge.