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2018 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

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Mini-poll: Which option best describes the type of facility for which you primarily code?

Which option best describes the type of facility for which you primarily code?

  • Large hospital or healthcare system (more than 300 beds)
  • Medium-sized hospital or clinic (100-300 beds)
  • Small hospital or clinic (fewer than 100 beds)
  • Critical access hospital (fewer than 25 beds)
  • Provider-based clinic
  • Physician’s office

Vote here

Last week’s mini-poll 

Does your hospital have an inpatient or outpatient clinical documentation improvement (CDI) program?

  • Yes, we have a CDI program that reviews inpatient records: 66%
  • Yes, we have a CDI program that reviews inpatient and outpatient records: 10%
  • Not applicable, I work in a physician office setting: 12%
  • No, we do not have a CDI program: 13%

Thank you to the readers who participated in last week’s mini-poll!

HCPro.com – JustCoding News: Inpatient

Reporting NSTEMI Type 2 27 days paging mitchellde

Hi everyone,

I have an interesting case needing your opinion.

Patient had knee replacement surgery and post surgery complained of chest pain. Tests revealed elevated troponins which physician classified as NSTEMI. Upon further diagnostic testing, it was revealed it was a Type 2 NSTEMI which medically means as explained to me elevated troponins due to imbalanced oxygen demand and supply, not due to plaque rupture and can be caused by arrhythmia, hypotension, sepsis, etc.

Therefore, hospital stay was coded as I21.4.

Patient came back to the clinic 27 days after initial diagnosis. Coder said that per coding guidelines, within 28 days the NSTEMI must be coded as such and must "follow" and be documented in the clinic post hospital follow up.

The doctor felt that since the NSTEMI is a Type 2 and not caused by CAD, he did not document the NSTEMI. His reason is that it was a transient diagnosis during the hospital stay and not an active diagnosis during office visit. His reluctance to mention NSTEMI is because he said if it is in the documentation, other providers might not understand the complexities of different types of NSTEMI and recommend the patient to have procedures that might harm the patient.

Coder came back insisting that we will be "flagged" and NSTEMI coding is strict. She attended one of your seminars and she wants to hear it from you. I attended several of your seminars and the gist is that as long as the physician is documenting it and able to defend his notes. Her suggestion is for the physician to go back and change his notes to suit the coding guidelines, which no physician would agree to in our group.

I understand that as coders we need to adhere to the coding guidelines but in the real world it is the patient’s wellness and welfare we need to prioritize when it comes down to documentation and communication.

Can somebody please explain to how not coding NSTEMI through all subsequent visits will be flagged. Our notes are very extensive and well supports the diagnosis, compared to other physicians in our small town.

Thanks!

Medical Billing and Coding Forum

HELP NEEDED acute Stanford type A ascending aortic dissection with aneurysm

Postoperative diagnosis:
#1 acute Stanford type A ascending aortic dissection with aneurysm
*
procedure:
#1 emergency replacement of the ascending aorta with hemi-arch using a 34 mm Dacron graft
#2 emergency CABG ×1 with vein graft to the LAD secondary to acute coronary dissection
#3 extensive lysis of pericardial adhesions
#4 right axillary artery cutdown with placement of 8 mm end-to-side Dacron graft for cannulation
#5 ultrasound-guided percutaneous right femoral venous cannulation
#6 placement of left femoral arterial line
#7 cardiopulmonary bypass
#8 deep hypothermic circulatory arrest, 18°C
#9 Cerebral Somanetics monitoring
#10 reinstitution of cardiopulmonary bypass
#11 complex management of coagulopathy, 2 hours
#12 open saphenous vein harvest, left lower extremity, 1 vein segment
#13 TEE with visualization and interpretation ×2
#14 epi-aortic ultrasound with visualization and interpretation

*
Indication:
77-year-old female presenting with acute onset of chest pain radiating to the back. She was evaluated at M B campus in which a CT, PE protocol was performed which revealed an ascending aortic dissection. She was transferred to Center for further care. She’s been taken to the operating suite for emergency repair of ascending aorta.
*
Intraoperative findings:
Pre-bypass TEE showed normal left ventricular function. There was mild concentric left ventricular hypertrophy. There were no regional wall motion abnormalities. Right ventricular function was normal. There was trace to mild mitral regurgitation. The left atrial appendage was free of thrombus. The aortic valve leaflets were coapting appropriately, with no evidence of dilation of the aortic root. There was mild to moderate central aortic insufficiency noted his own of coaptation centrally. The sinotubular junctions were thickened, but not effaced. The aortic dissection could be identified with thrombosis within the false lumen.
*
Initial TEE upon weaning from cardiopulmonary bypass showed preservation of the ventricular function. However, within a few minutes of weaning from bypass, the patient began having hemodynamic instability. The heart was becoming arrhythmia genic. Reevaluation of the TEE revealed that there was severe hypokinesis/akinesis of the anterior wall. This finding prompted the decision to re-heparinize and go emergently back on cardiopulmonary bypass.
*
Once on bypass, epi-aortic ultrasound was actually used to evaluate the LAD territory. At the most proximal portion of the LAD, a dissection flap was identified which explains the severe hypokinesis of the anterior wall. Emergency bypass grafting to the LAD territory was performed using vein graft to the left leg. Once this was completed, final TEE was performed which showed normal ventricular function upon immediate weaning, no alteration in native valvular function. The aortic root was well visualized with no alterations in the native aortic valve function.
*
Upon entering the pericardium, it was evident the patient had a combination of subacute and chronic pericarditis. Exact etiology is unknown. There is no purulent fluid. Extensive lysis of pericardial adhesions had to be performed in order to achieve the operation. Femoral venous cannulation was performed because central venous cannulation could not be performed secondary to the severe displacement of the right atrium relative to the IVC because of the ascending aortic aneurysm. The aneurysm itself was over 6 cm in size. It is incredibly thin walled. The intimal tear was identified on the lesser curvature of the distal ascending aorta. This area was completely resected during the repair. There was no evidence of intimal tear within the aortic arch.
*
Procedure in detail:
The patient had her history and physical updated prior to the procedure. She was transferred to the operating suite and placed on the operating table where she underwent general anesthesia with endotracheal intubation. Monitoring lines and been placed by anesthesia. TEE probe was placed by anesthesia. The patient was prepped and draped in usual sterile fashion using DuraPrep solution. Timeout was used confirm patient identity as well as the surgery to be performed. Antibiotics given prior the incision.
*
A right subclavicular incision was made with a 10 blade scalpel. Soft tissues were divided. The pectoralis muscle was released from its clavicular attachments. The underlying soft tissues were divided to expose the right axillary artery. Great care was taken to preserve the brachial plexus. Right axillary artery was then encircled with Vesseloops proximally and distally for hemostatic control. The patient was given 6000 units of heparin and vascular clamps were placed. A longitudinal arteriotomy was made with a 15 blade scalpel and extended. An 8 mm Dacron graft was then anastomosed to the right axillary artery using 5-0 Prolene. The graft was then de-aired. It was connected to the arterial line for arterial cannulation and bypass.
*
Pre-bypass TEE had been performed by this point in time. Findings are as dictated above.
Sternal incision was made. Soft tissues were identified. Sternotomy was performed in the standard fashion. Sternal retractor was placed. The anterior mediastinal soft tissues were divided. The innominate vein was completely collapsed secondary to the size of the aneurysm placed in the vein on stretch. The pericardium was then opened in which there was extensive pericardial adhesions, some of which were subacute and other show evidence of chronicity. Stay sutures then placed create a pericardial well. Great care was taken to minimize any manipulation the ascending aorta, as it was evident that the wall was extremely thin.
*
The patient was fully heparinized. ACT was found be therapeutic for bypass. Central venous cannulation was attempted multiple times, but the severe angle created by the displacement of the atrium by the aneurysm made routine central cannulation difficult. Decision was then made to perform right femoral venous cannulation. The ultrasound was used to identify the right femoral vein. The vein was compressed and showed no evidence of DVT. Under real-time ultrasound, single anterior wall puncture was performed and the guidewire was placed and confirmed to be across the IVC and SVC under TEE guidance. Serial dilation over wire was performed and the femoral venous cannulation was placed and confirmed in position by TEE. The patient was then placed on full cardiopulmonary bypass and systemically cooled to 18°C.
*
A total of 90 minutes was dedicated purely to lysis of adhesions. This included off-pump lysis of adhesions as well as lysis of adhesions on the patient was on bypass.
*
The innominate artery could not easily be accessed in order to perform selective antegrade cerebral perfusion. Secondary to this, decision made to perform deep hypothermic circulatory arrest. The patient was cooled to 18°C for at least 20 minutes. Once this was completed, the deep hypothermic circulatory arrest was instituted. The bypass pump was turned off. The aorta was opened which revealed a large aneurysm with acute thrombus within the false lumen. The left main coronary artery was evaluated and noted cardioplegia to the left main as well as right coronary ostia was given to achieve complete diastolic cardiac arrest. Left main appeared to be uninvolved in the dissection. The dissection extended to just above the right coronary ostia. This ostomy later be secured with pledgeted 5-0 Prolene sutures.
*
The ascending aorta was then resected with accommodation of Metzenbaum scissors as well as cautery. It was taken to the level of the innominate takeoff and a hemi-arch configuration was constructed. The intimal tear was resected during this portion of the procedure. Using a felt sandwich technique, a felt strip was tacked intraluminally as well as extraluminally and secured with 5-0 Prolene. It was sized to a 34 mm graft. The graft was then anastomosed to the proximal aortic arch using 3-0 Prolene in a running fashion. BioGlue was placed over the anastomosis. The patient was placed in steep Trendelenburg and de-airing maneuvers were performed. After the graft was adequately de-aired, cross-clamp was placed in full antegrade perfusion was reinstituted and the patient was warmed to 32°C.
*
The remainder of the ascending aorta was resected to the level of the sinotubular junction. As stated above, the right coronary artery was widely patent, but the dissection didn’t extend to just above the right coronary artery. The right coronary ostia was slightly higher than the initial attachments. This was secured with pledgeted 5-0 Prolene suture. Once this was completed, a double felt sandwich technique was used to find the proximal anastomosis in a similar fashion as previously described. The patient had been systemically rewarmed. The needle vent was placed and de-airing maneuvers were then performed. Once this was completed, the cross-clamp was removed and the heart was allowed to be reperfused.
*
The heart regained spontaneous rhythm. Pacing wires placed on the right ventricle brought out to the level of the skin. Lungs were ventilated. Anastomoses were found to be hemostatic. The heart was then weaned from bypass without difficulty. Protamine had initially been started and venous cannula was removed. Shortly after this, the patient began having hemodynamic issues with hypotension and the heart was with the genetic. TEE was then used to evaluate the heart. During the TEE evaluation, the left ventricular function was severely depressed and there was severe anterior wall hypokinesis. She was initially treated medically with significant improvement, but quickly deteriorated into the similar situation previously described. Decision was made to re-heparinize and reinstituted cardiopulmonary bypass.
*
Decision was made to bypass the LAD. The LAD was identified and isolated. The vein graft had been harvested from the left lower extremity using an open incision technique by . After was prepped, bleeding heart pump-assisted bypass to the LAD was performed. Arteriotomy was made and extended. The vein grafts beveled and spatulated. It was anastomosed using 7-0 Prolene. The proximal anastomosis was then placed on the ascending aortic graft using a side-biting clamp to achieve hemostasis while creating the anastomosis. The vein graft was de-aired after the clamp was removed.
*
Lungs were ventilated. Pacing wires were placed on the right ventricle. The heart was then weaned from bypass without difficulty. The TEE was reevaluated which showed significant improvement in the anterior wall function with adequate de-airing of the left ventricle. Left ventricular function was found to be normal. Decision was made to give protamine to reverse the effects of heparin. The femoral venous cannula was removed and pressure was held to assist with hemostasis.
*
The next 2 hours were spent administering blood products which include packed red cells, FFP, platelets, cryo-, factor VII in order to achieve hemostasis. As the patient required more and more volume, the hemodynamics were marginal at best. She is being supported by epinephrine drip, milrinone, vasopressin, as well as several doses of bicarbonate for the management of metabolic acidosis, calcium chloride. Once hemostasis was achieved, decision was made to close the chest. The sternum was reapproximated with #7 wires. Prior to closure, a right angle chest tube as well as a 32 French straight mediastinal chest tube were placed in the mediastinum. The superior abdominal fascia was reapproximated with 0 Ethibond. Soft tissues reapproximated with 0 Vicryl. Skin was closed with 4 Monocryl in a running subcuticular manner.
*
Throughout the procedure, the patient was being monitored with cerebral Somanetics. Her initial readings ranged between 40 and 60th percentile. During hypothermic circulatory arrest, readings ranged from 30-45 percentile. She had lower numbers after weaning from bypass, largely related to severe anemia which was being treated with transfusions.
*
Also, during her hemodynamics instability, the left radial arterial line was transducing, but could not be drawn back. Decision was made to place a left femoral arterial line. A percutaneous access left femoral artery and placed the wire. Small stab incision was made. Dilator was placed over wire and a Seldinger technique. The femoral arterial line was placed and secured with 2-0 silk.
*
The right axillary Dacron graft was clipped proximally and then oversewn with 5-0 Prolene. The excess graft was excised and the deep soft tissues were closed with 2-0 Vicryl. Skin was closed with 4 Monocryl running subcuticular manner. Dermabond was placed over the wounds. The patient was then transferred to CVRU in critical condition.

33860 22
33510 51
33508
76998 26 59
93314 26

ARE THESE CORRECT?

Medical Billing and Coding Forum

repair of type I aortic dissection help

Preoperative diagnosis:
#1. Acute type I aortic dissection
#2. Ischemic right leg with absent flow to right iliac artery by CTA
#3. Right renal ischemia-acute due to type I dissection
#4. Abdominal pain-possible malperfusion syndrome
#5. Hyperlipidemia
*
Postoperative diagnosis:
Same
*would this be ?
33860
33866
*
Operation:
#1. Emergency repair of type I aortic dissection
#2. Right axillary artery cannulation
#3. Replacement of ascending aorta from sinotubular junction with hemi-arch repair (26 mm Hemashield graft)
#4. Temporary cardiopulmonary bypass with moderate systemic hypothermia, cold sanguinous antegrade and retrograde cardioplegia, temporary lower body circulatory arrest (26 minutes), unilateral antegrade cerebral perfusion
*
*
Preoperative note:
Patient is a 53 y.o. African-American male with acute type I aortic dissection now being taken the operating room for emergency operative therapy.
*
Operative findings:
#1. TEE independent interpretation-pre bypass: The left ventricular function was normal. The right ventricular size and function was normal. There was trace central mitral valve insufficiency with normal mitral valve leaflets. Aortic valve was a tricuspid valve with minimal incompetence in the long or short axis views. There was an obvious flap in the proximal ascending aortia but it appeared that the sinuses of Valsalva were free of any intimal tear. The atrial septum was intact.
#2. TEE independent interpretation- post bypass: The aortic valve remained unchanged and there was no evidence of any residual flap and the aortic root.
#3. Operative findings: The pericardium was free of any free fluid or blood. There were hemorrhagic changes in the proximal ascending aorta extending up into the arch. On opening the ascending aorta the initial opening (entry point) appeared to be right at the sinotubular junction. Anteriorly the tear started roughly 4 mm distal to the opening of the right coronary artery. The sinuses of Valsalva were free of any tears. Distal able to back the torn intima circumferentially to the medial adventitial portion of the aortic arch without difficulty. There was no evidence of any clot in the false lumen. The right axillary artery was free of any evidence of dissection.
*
Description of operation:
Patient was placed on the operating table in the supine position and adequate general anesthesia was administered monitoring the arterial pressure, bilateral cranial Somanetics, bilateral upper extremity oximetry, pulmonary artery pressure, bladder temperature, and electrocardiogram. A transesophageal echocardiographic probe was placed by anesthesia and findings are described above. The entire chest, abdomen, and legs were prepped in a sterile manner. An incision was made 2 fingerbreadths below and parallel to the right clavicle was deepened down through the soft tissues and the pectoralis major was divided in its fibers. The pectoralis minor muscle was preserved. The right axillary artery was dissected out and encircled proximally and distally with vessel loops and prepared for cannulation. A primary median sternotomy was performed and the pericardium was opened and heparin was administered. The pericardium was marsupialized and pursestring sutures were placed. Following satisfactory heparinization with ACT greater than 450 seconds, right axillary artery and right atrial cannulation were effected and cardiopulmonary bypass was established. Systemic perfusion temperature was dropped to 24°C for approximately 20 minutes. The aorta was crossclamped and cold sanguinous cardioplegia was administered via the aortic root and diastolic arrest promptly ensued. Further myocardial cooling was obtained using topical slush and retrograde cardioplegia. Cardioplegia was administered every 20 minutes throughout the procedure. The aortic root was prepared by removing all dissected tissue leaving normal tissue to subsequently perform the proximal graft anastomosis. After approximately 30 minutes of cooling the patient was placed in steep Trendelenburg position and the head was protected with cooling packs. The innominate artery was occluded and unilateral antegrade cerebral perfusion was initiated. The aortic cross-clamp was released and the ascending aorta was resected up into its junction with the aortic arch. A 26 mm Hemashield graft was selected and sewn in end-to-side manner (hemi-arch technique) to the aortic arch with running 4-0 Prolene in both internally and externally placed Teflon felt strips to reinforce the anastomosis. The total lower body circulatory arrest time was 26 minutes. There was no interruption in cerebral blood flow in the unilateral method. The Hemashield graft was occluded proximal to the arch anastomosis and flow was reestablished to the lower body and rewarming was carried out. The proximal graft was then tailored to appropriate length and angle and sewn in an end-to-end manner to the sinotubular junction running 4-0 Prolene and externally and internally placed Teflon felt strips. A needle vent was placed in the Hemashield graft and rewarming was continued. Volume was infused and the patient and air was evacuated from the left ventricle and ascending aortic graft. Bilateral cranial Somanetics readings were greater than 60 throughout the lower body arrest period. were normal with removal for Volume was infused into the patient and air was evacuated from the left side of the heart and vein graft. The aortic cross-clamp was released and the heart was defibrillated. Following satisfactory rewarming cardiopulmonary bypass was gradually discontinued until satisfactory ejection was occurring and aggressive de-airing maneuvers were carried out in the usual standardized manner under TEE surveillance. Following satisfactory de-airing maneuvers cardiopulmonary bypass was completely discontinued in a gradual manner satisfactory rhythm and hemodynamics ensued. Protamine was administered, decannulation was effected(the axillary artery was repaired with running 7-0 Prolene) and hemostasis was obtained. It did take approximately 1 hour to achieve satisfactory hemostasis. Ultimately this was achieved. Temporary pacemaker wires were placed as well as 3 chest tubes. With satisfactory rhythm, hemodynamics and hemostasis the chest was closed in layers. Sterile dressing was applied, sponge count was correct ×2, and the patient was taken to the CVRU in critical condition.
*

Medical Billing and Coding Forum

substance abuse assessment and type of bill questions for detox and residential

Please help

I am new to the substance abuse field and have a few things I wanted to run by anyone who is willing to help. I switched over from cardiology, integ, and podiatry and am now billing for a detox facility, residential and php facility. I was curious if you could help me with two things.

First where can i find the type of bill code for box 4 required for bc claims? I have been searching all over their website and can’t find anything. I read one thread that said to use 11X but i’m not sure if that’s correct or if it would be 86X since we are not a hospital?

The other question I have is the previous billing company was billing intake assessments with the code H0001 and H0002 and they are all denied from all the insurance companies or reimbursing at a really low rate. Would I be able to use an e/m code such as 99408 or 99409? or is there a better code for an initial assessment and also a discharge assesment?

I would really appreciate the help.
Thank you
Sarah CPC
you can respond on here or feel free to email me at [email protected]

Medical Billing and Coding Forum

detox assessments and type of bill

I am new to the substance abuse field and you seen to have a lot of experience. I switched over from cardiology, integ, and podiatry and am now billing for a detox facility, residential and php facility. I was curious if you could help me with two things.

First where can i find the type of bill code for box 4 required for bc claims? I have been searching all over their website and can’t find anything. I read one thread that said to use 11X but i’m not sure if that’s correct or if it would be 86X since we are not a hospital?

The other question I have is the previous billing company was billing intake assessments with the code H0001 and H0002 and they are all denied from all the insurance companies or reimbursing at a really low rate. Would I be able to use an e/m code such as 99408 or 99409? or is there a better code for an initial assessment and also a discharge assesment?

I would really appreciate the help.
Thank you
Sarah CPC
you can respond on here or feel free to email me at [email protected]

Medical Billing and Coding Forum