Understanding Health Insurance - Chapter 10 Coding Compliance Programs, Clinical Documentation Improvement, and Coding for Medical Necessity.

Please check all of my answers for accuracy. If there happen to be any incorrect ones, please let me know. Thank you kindly in advance.

1.) The term medically managed means that even though a diagnosis may not receive direct treatment during an encounter:

it must be considered when determining treatment for other conditions

2.) OCE edits result in one of the following dispositions: rejection, denial, return to provider, or suspension

3.) Policies of the Centers for Medicare and Medicaid Services (CMS) that specify the clinical circumstances under which a service is covered and how it is to be coded are called: local coverage determinations (LCD)

4.) Which is used by MACs and providers to determine whether a procedure is reasonable and necessary for the treatment of an illness or injury? Medicare coverage database

5.) Which involves reviewing patient records and CMS-1500 or UB-04 claims to assess coding accuracy and completeness of documentation? auditing process

6.) Tim Johnson's primary care provider performed a level 3 E/M service in the office on June 1 to evaluate Tim's symptoms of upset stomach and vomiting without nausea. Tim's diabetes mellitus was medically managed during the encounter when venipuncture and a quantitative blood glucose test were performed; test results were within normal limits. The appropriate ICD-10-CM and CPT codes would be K30, R11.11, E11.9, 99213, 36415, 82947

7.) Which code would be supported as a medical necessity for a diagnosis of fracture of the femoral neck? 27230

8.) A patient presents with a sore throat. Upon examination, the physician notes enlarged tonsils and swollen glands in the neck. A rapid strep test is performed and comes back negative. The physician documents acute pharyngitis as the first-listed diagnosis. The appropriate ICD-10-CM and CPT codes would be J02.9, 86403

9.) A patient complains of pain in the left ankle. Upon examination, the nurse practitioner (NP) notes edema around the left lateral malleolus and limited range of motion due to pain. The x-ray is negative for fracture. The NP documents musculoligamentous sprain, left ankle, in the patient's chart. The appropriate ICD-10-CM code would be S93.492A

10.) Which code would be supported as a medical necessity for a diagnosis of osteoporosis? 77081

11.) The correct ICD-10-CM code(s) for benign prostatic hypertrophy (BPH) with urinary retention would be N40.1, R33.8

12.) Which code would be supported as a medical necessity for a male patient with a diagnosis of hypercholesterolemia? 80061

13.) A patient appearing pale, diaphoretic, and in acute distress is assessed. The physician notes limited chest expansion, scattered bilateral wheezes, pulse 112 and regular, and respirations 22 with some shortness of breath. A diagnosis of bacterial endocarditis is given. The appropriate codes would be I33.9, R61, R06.02

14.) A patient complained of pain and swelling in his hand after knocking into a wall. Two x-ray views of the hand revealed a fractured thumb. The appropriate ICD-10-CM and CPT codes are S62.509A, 73120

15.) A patient receives a chest x-ray. Which code would support medical necessity for this procedure? R07.9

16.) The patient was seen in the office for abdominal cramping. A hemoccult test was positive for blood in the stool. The patient underwent proctosigmoidoscopy with biopsy two days later, and carcinoma of the colon was diagnosed. Select the appropriate ICD-10-CM and CPT codes to be reported on the proctoscopy claim. C18.9, 82270, 45305

17.) The patient was treated in the office for urinary frequency with dysuria, sore throat with cough, and headaches. The urinalysis was negative, and the rapid strep test was positive for Streptococcus infection. The patient was placed on antibiotics and was scheduled to be seen in 10 days. The appropriate ICD-10-CM and CPT codes are R35.0, R30.0, B95.5, 81000, 86403

18.) The patient was treated in the office to rule out pneumonia. She had been experiencing wheezing and congestion, and her respirations were labored. The chest x-ray done in the office was positive for pneumonia. The appropriate ICD-10-CM and CPT codes are J18.9, 71045

19.) The doctor treated the patient in the nursing facility for the second time since she was admitted. The patient complained of malaise. It was noted that the patient had a cough as well as a fever of 103F and that her pharynx was red in appearance. The appropriate ICD-10-CMS codes are R53.81, R05, R50.9

20.) A surgeon performs neuroplasty of the median nerve at the carpal tunnel, right hand. Which code would support medical necessity for this procedure? G56.01

21.) The patient was treated in the emergency department for chills and fever. The physician noted left lower abdominal quadrant pain and tenderness. The physician diagnosed acute diverticulitis. The appropriate codes are K57.92, R50.9, R10.814

22.) A patient undergoes a laparoscopic cholecystectomy. Which code would support medical necessity for this procedure? K81.0

23.) A patient with chronic cholecystitis and cholelithiasis without obstruction undergoes laparoscopic cholecystectomy with cholangiography. During the procedure, the surgeon performs a biopsy of a suspicious liver cyst. The appropriate ICD-10-CM and CPT codes are K80.10, K76.89, 47563, 47001-59

24.) The appropriate codes for diagnostic arthroscopy, right knee and open repair, right knee, collateral and cruciate ligaments would be 27409-RT, 29870-RT-59

25.) The nurse practitioner orders a urinalysis. Which code would support medical necessity for this procedure? N15.9

26.) A patient with a displaced supracondylar fracture, left humerus, undergoes closed reduction with manipulation and casting. The appropriate ICD-10-CM and CPT codes would be S42.412A, 29065-LT

27.) A 68-year-old patient stated that "most mornings he wakes up with a headache, has trouble staying awake, and often falls asleep in the middle of the morning." After an unattended minimum sleep study showed several episodes of desaturation and apnea, he was diagnosed with obstructive sleep apnea with hypoxia and ordered to undergo an attended full sleep study. The appropriate ICD and CPT codes would be G47.33, 95801, 95807

28.) A 96-year-old woman was admitted to the emergency room complaining of shortness of breath. She stated, "My legs look like sausages because they are so swollen, and I've gained five pounds in the last couple of days." The physician diagnoses her with congestive heart failure, and the nurse administers 40 mg Lasix via IV push. The appropriate ICD-10-CM and CPT codes would be I50.20, 96374

29.) A 43-year-old man presents to the emergency department complaining of severe pain in his lower back. He states his "back hurt a little bit last night after doing some heavy lifting at work, but this morning the pain was terrible." After a problem-focused history and exam, the physician diagnoses him with lumbar sprain. The appropriate ICD-10-CM and CPT codes are S33.5XXA, 99282

30.) NCCI code pairs (or NCCI edit pairs): list codes that cannot be reported together on any date of service

31.) Which are used to compare units of service (UOS) with CPT and HCPCS level II codes reported on claims and indicate the maximum number of UOS allowable by the same provider for the same beneficiary on the same date of service under most circumstances? MUE 32.) Revenue cycle management includes inpatient DRG coding validation, which is performed by payers to confirm the accuracy of hospital coding and reimbursement

33.) As part of clinical documentation improvement, a patient case review resulted in the determination that a patient's previous hospital discharge was inappropriate because the patient was transported back to the hospital via ambulance and admitted through the emergency department within three days of the previous discharge; this process is called a readmission audit. 34.) Which has become a tool for accurate coding because it is software that uses natural-language processing to locate and analyze diagnoses and procedures in the patient record and assign ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II codes to them? medical abstracting software