Click here for more sample CPC practice exam questions with Full Rationale Answers

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2016 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

Practice Exam

Click here for more sample CPC practice exam questions and answers with full rationale

Diagnosis Coding and Medical Necessity from Radiology Reports in the ED Facility

I review emergency department charts on the facility side and I often have to review charts from our denials department. I have a case where an MRA of the neck was ordered with a dx of arm numbness and TIA. The nurse is asking if TIA can be added in the Attending’s final impression to support medical necessity for the MRA. The attending reviewed the findings from the radiologist "Diffuse white matter signal abnormalities in the bilateral cerebral cortices, most likely related to chronic microvascular disease. There are no signs of acute ischemia, hemorrhage, or mass." And, the attending documented that the MRA was negative in his progress note and left his final impression of arm numbness.

These are my questions:

1. Can the dx of R93.0, abnormal findings on diagnostic imaging of skull and head, NEC, be reported. Please note: the attending does not address these findings and states the MRA is negative.
2. Can the TIA dx be reported if it is only found on the order? There are no other signs and symptoms in the medical record to support medical necessity for the MRA of the neck.
3. Should I query the provider?

Medical Billing and Coding Forum

Correct Influenza Diagnosis Coding

Does anyone have a concrete answer on how to correctly code for confirmed Influenza diagnosis? Our providers are only documenting Influenza A or B positive. They don’t go beyond that specificity. We have conflicting answers from multiple resources. One telling us we should be using J10.1 and another telling us to use J11.1 as they state Influenza A is unidentified. To me The Influenza is identified as A or B, but not elsewhere classified (J10.1) and the description under this code seems to fit. I’m hoping someone can provide someone insight on this coding conundrum. 😀 Thank you!

Medical Billing and Coding Forum

Capture the Most Specific Diagnosis Codes for Pregnancy

When coding, consider all documented factors such as current and pre-existing conditions, trimester, and age. To capture pregnancy diagnosis codes correctly, documentation must specify the type and trimester of the pregnancy, as well as all related, present co-conditions in the mother. It’s not appropriate to use Z34.00 Encounter for supervision of normal first pregnancy, unspecified […]
AAPC Knowledge Center

documentation qualifying the diagnosis of threatened abortion

Hi,

I have read the threatened abortion needs to have associated symptom like uterine cramps, abdominal pain, bleeding,…I am working in an IVF center (assisted reproducitve technique center) where physicians stated that threatened abortion can clinically be documented and thus coded without the above symptoms such as:
(1) Secondary Infertility where patient had multiple miscarriages and thus if pregnancy occurred, the patient is considered high risk pregnancy with history of infertility along with threatened abortion diagnosis.
Especially in the similar gestation weeks when she was aborted earlier.
(2) Primary Infertility with Multiple failed IVF cycle – Embryo Implantation failure. Thus if pregnancy occurred, the patient is considered high risk pregnancy with history of infertility along with threatened abortion diagnosis.

Another question about threatened abortion, if qualifying symptoms existed, can the physician document threatened abortion on sequential encounters (patient might experiences the symptoms in the first encounter and is under conservative management and not necessarily to have persistent symptoms in her next visit but physician documented in both visits threatened abortion).

Thanks
Jibin zachariah CPC CPMA
01161432

Medical Billing and Coding Forum

Wiki uncontrolled diabetes Diagnosis

Hi,

I have read the coding rule for diabetes poorly controlled, out of control and hyperglycemia and the fact that uncontrolled phrase should not be used anymore but rather specifying the glycemic episode. But i have not seen in all those whether diabetes Mellitus with Hyperglycemia can be always documented by physician without having a hyperglyceminc episode or event whether symptoms level (dryness, urinary problem,…) or blood glucose level (showing elevation despite following diabetic regimen coarse,…) (and thus coded during the overall treatment/management coarse and follow ups). Some physicians have their clinical judgement that diabetes condition by default is out of control (hyperglycemic) and will be better controlled by the medications (oral+/-insulin). If hypoglycemia was the situation, this will certainly need documentation for the hypoglycemic event not like hyperglycemia. Thus, coder will always query the physician about the origin of diagnosis "diabetes with hypoglycemia".

Can you please let me know if query process will be needed when documentation just state poorly controlled without additional info.?

Thanks
Jibin zachariah CPC CPMA
01161432

Medical Billing and Coding Forum

Coding over 12 diagnosis codes for outpatient setting

Hi
While completing outpatient coding uses a CMS 1500 form which will not allow over 12 diagnosis codes. At times my provider gives over 12 dx codes. So I must remove some dx codes listed. I remove the ones in which he gives the dx description as stable or another physician is taking care of the illness. I liked to know is anyone else handling this dilemma the same?

T T

Medical Billing and Coding Forum