What is the FIRST step in physician's office coding?
A. Determine the reason for the visit
B. Locate the correct diagnosis code
C. Determine what procedures and/or services were performed
D. Identify the appropriate setting
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Q. 2) What should coders do when they see an order for an antibiotic?
A. Assign a code for long-term use of antibiotics.
B. Assign a code for unknown infectious disease.
C. Review the record to identify the type of infection.
D. Query the physician regarding why the antibiotic was ordered.
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Q. 3) Coagulation and serology tests help determine:
A. the presence of blood in the urine.
B. the amount of drug present in the blood.
C. the amount of time it takes for bleeding to stop.
D. which antibiotic is most effective against an infectious organism.
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Q. 4) What is the appropriate E/M status and service for an annual nursing facility history and physical and MDS/RAI evaluation for a 92-year-old female resident?
A. Nursing home subsequent visit
B. Domiciliary, rest home, or custodial service, established patient
C. Preventive medicine services
D. Other nursing facility services
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Q. 5) ____ Condition that existed at admission and is thought to increase the length of stay at least one day for approximately 75 of patients.
Fill in the blank with correct word.
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Q. 6) SUBJECTIVE: This 25-year-old male presents with a small laceration to his right distal thigh. He notes he was in a store this evening, when he moved to avoid some people in the aisle, and struck his leg against a metal shelf resulting in this laceration. The patient is not current on his tetanus immunization. He originally was not going to come in for sutures, but the laceration is near his knee and he has to work on his knees a lot as an auto body repairman.
OBJECTIVE: Physical exam reveals a well-developed, well-nourished male. He is alert and oriented and in no acute distress. Vital signs are within normal limits. Exam of his right distal thigh reveals a 2.5 cm linear laceration through the dermis just proximal to the knee. The wound was cleaned, irrigated with normal saline, injected with 1 Xylocaine with epinephrine. It was then sutured with 4-0 interrupted nylon sutures. Neosporin ointment and a dressing were placed over the wound. The patient was also given a DT booster.
ASSESSMENT: Laceration, right distal thigh, sutured.
PLAN: Wound care instructions include suture removal in 10 - 14 days. He is to watch closely for any signs of infection and return to the emergency room should this occur.
ICD-9-CM diagnosis code(s): _____________________
_____________________________
_____________________
ICD-10-CM diagnosis code(s): _____________________
_____________________________
_____________________
CPT code(s) with modifier, if applicable: _____________________
What will be an ideal response?
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Q. 7) A physical examination of the ______ typically includes temperature, turgor, vascularity, color, edema, and lesions.
A. throat
B. vital signs
C. sinuses
D. skin
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Q. 8) The physician's diagnosis and impression regarding current episode of care is found under which component of a SOAP note?
A. S
B. O
C. A
D. P
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Q. 9) The first solid place to find physician information regarding the diagnosis or diagnoses and/or treatment planned for the patient during this episode of care is the _____.
A. face sheet
B. chief complaint
C. physical examination
D. history of present illness
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Q. 10) Which of the following is a comorbidity?
A. Ventilator-associated pneumonia
B. Controlled Type II diabetes mellitus
C. Hypertension
D. Fall from the hospital bed
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