Solution Manual for Pearson's Comprehensive Medical Coding, 2nd Edition

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PEARSON’S COMPREHENSIVE MEDICAL CODING: A PATH TO SUCCESS2/ETEXTBOOK ANSWER KEYCHAPTERS 1-24The words in parentheses ( ) following a code provide the Index entries for the Main Term andsubterms of one coding path. Selections for additionalcharacters in the Tabular List are listedafter the subterms.Index entries vary among publishers.To access the navigation panein Word, press Ctrl-F, then click on the left hand tab.CHAPTER 1:YOURCODINGCAREERCODING PRACTICEExercise 1.1 What Is Coding?1. Coding is the process of accurately assigning codes to verbal descriptions of patients’conditions and the healthcare services provided to treat those conditions.2. Diagnosis codes describe patient illnesses, diseases, conditions, injuries, or other reason forseeking healthcare services. Procedure codes describe the services healthcare professionalsprovide to patients.3. Abstract-determine which elements of the visit require codesAssign–determine the codes that describe the patient’s condition and servicesArrange–sequence the codes in proper orderExercise 1.2 Understanding Patient Encounters1. after an encounter is completed2. diagnosis, treatment plan, documentation

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3. history,physicalexamination, testingExercise 1.3 Certification1. Certification is a voluntary achievement which documents that a coder has attained a certainlevel of proficiency by passing a rigorous examination.2. CPC-Certified Professional Coder(physician office coding)COC-Certified Outpatient CoderCPC-P-Certified Professional Coder-Payer3. CCS–Certified Coding Specialist(hospital inpatient and outpatient coding)CCS-P–Certified Coding Specialist-PhysicianCCA–Certified Coding AssociateExercise 1.4 Coding Careers1. Student answers willvary, so any item from Table 1-3 is acceptable.2. Student answers will vary and should include the concept that payment for services frominsurance companies is based a high degree of accuracy and productivity.3. 30 to 40 words per minute (wpm) or 9,000 to 12,000 keystrokes per hour (ksph)4.Coders must be able to identify medical terms, a skill which includes breaking downunfamiliar words into a prefix, root, and suffix to define the meaning. It is not possible to codeaccurately without knowing the definition of medical terms used in clinical documentation.CONCEPT QUIZCompletion1. Diagnosis2. abstract, assign, arrange (answers must be in this order)3.outpatient

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4.inpatient5.ancillary6. attending7. career path8. treatment9. query10.Covered entitiesMultiple Choice1. C2. D3. B4. D5. B6. B7. A8. B9. A10. ACHAPTER 2:CODING AND REIMBURSEMENTCODING PRACTICEExercise 2.1 Healthcare Payers1. most people age 65 and over, people of any age with end stagerenal disease (ESRD), andpeople with disabilities

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2. low income families3. group, self-insured, individualExercise 2.2 Documentation1. establishing the medical need for services2. Student answers will vary and should include three of the following: improve a patient’scondition, evidence-based practice, rendered by appropriate provider, least restrictive setting.3. The medical record is the comprehensive collection of all information on a patient at aparticular facility. Progress notes are the record of a specific patient encounter.Exercise 2.3 Life Cycle Of An Insurance Claim1. It is the time when providers begin collecting insurance information.2. The computer automatically determines which procedure codes are covered and how much theinsurance company is obligated to pay, and then triggers the payment.3. Student answers will vary and should include three of the following: Characters in a code aremistyped, creating an invalid code.Codes have too many or too few characters.Diagnosis does not match the procedure.Codes are sequenced incorrectly.Additional codes required by the Guidelines or Instructional Notes are missing.Patient age or gender does not match the diagnosis or procedure.The services described in one code are included (bundled) into anotherreportedcode.A CPT procedure code requires a modifier in order to be paid.

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Exercise 2.4 Reimbursement Methods1.Negotiated fee scheduleisa fee schedule in which the payerspecifies the percentage of theprovider’s fee schedule it considers to be acceptable.2.Prospective payment systemisareimbursementmethodin which payment is made based on apredetermined, fixed amount per case.3.Capitation isa prospective payment method in which physicians are paid a fixed amount permonth for each member assigned to them, regardless of whether that person requests services.Exercise 2.5 Healthcare Claims1.Version 5010A1isthe current version of the electronic standards for healthcare transactions.2. CMS-1500is used to bill physician services.3. 837Pis the electronic format used to bill physician services.4. UB-04 or CMS-1450is theclaim form used to bill inpatient hospital services5. 837Iis the electronic format used to bill inpatient hospital services.Exercise2.6Federal Compliance1. When providers are overpaid they are legally obligated to report the overpayment toMedicare, to refund the money, and may even have to pay interest on it.2.Overcoding iscoding for a more complex diagnosis or procedure than is documented3. False Claims Act (FCA)Exercise 2.7 Health Information Technology1. Any five of the following are acceptable:Code firstDiagnosis-procedure mismatchInvalid characters (I and O in PCS)

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Manifestation codesMedicare medical necessityMutually exclusive diagnosesMutually exclusive proceduresPatient agePatient genderSeven characters required (PCS)Unacceptable principal diagnosisUse additional codeUse additional digit(s)2.Student answers will vary but should include the concept that coders need to understandwhat information they must give the software in order for it to provide accurate feedback. Anuntrained user can make coding errors with an encoder, just as they would using the physicalmanuals.3.Student answers will vary but should resemble the following examples:A physician can view medications prescribed by other providers to avoid duplication ormedication interactions.An emergency department can access a patient’s medical history to more quickly identify aproblem.A provider can access imaging studies that may help explain the progression of a patient’scondition.4.An encoderrequirespeople to conduct an electronic search for each individual code to beassigned, whereas CAC automatically generates codes based on documentation.

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5.Student answers will vary but should include the concept that technology elevates coders’professionalism and enables them to focus on tasks requiring judgment and critical thinking,while computers assist them with the repetitive tasks.CONCEPT QUIZCompletion1. Part A2. Medigap3. TC (Tricare)4. Family history5.DRG6. RA7. Fraud8. Abuse9. OIG10. complianceMultiple Choice1. A2. B3. D4. A5.A6. C7. A

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8. C9. C10. BCHAPTER3:INTRODUCTION TO ICD-10-CM DIAGNOSIS CODINGCODING PRACTICEExercise3.1Organization ofICD-10-CM1.category2.code3.block4.code (Entries that require a seventh character are referred to as codes, notsubcategories,even though they are not complete without the seventh character.Entries that require afourth, fifth, or sixth character are called subcategories.)5.code6.subcategory7.category8.code9.block10.subcategoryExercise3.2Conventions: Exclusion Notes1.Don’t use together(Instructional note at G43.0 states:Excludes1 chronic migrainewithout aura (G43.7-))

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2.Don’t use together(Instructional note atD56.1states:Excludes1sickle-cell betathalassemia (D57.4-))3.OK4.OK5.Don’t use together(Instructional note at O04 states: Excludes1failed attemptedtermination of pregnancy (O07.-))6.Don’t use together(Instructional note at R22.2 states: Excludes1 intra-abdominal orpelvic mass and lump (R19.0-), intra-abdominal or pelvic swelling (R19.0-))7.OK8.OK9.Don’t use together(Instructional note at S83 states:Excludes1internal derangement ofknee (M23.-))10.Don’t use together(Instructional note at T38.0 states:Excludes1: glucocorticoids,topically used (T49.-))Exercise3.3Conventions: Use Additional Characters, Extensions, and Placeholders1.Correct2.Incorrect, should beE66.013.Incorrect, should beG43.1014.Incorrect, should beI48.915.Incorrect, should beO31.01X16.Correct7.Incorrect, should beS71.151S8.Incorrect, should beS84.22XA

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9.Incorrect, should beS72.022K10.Incorrect, should beT59.6X1DExercise3.4Locatingthe Main Term1.Wound, open, ear2.Deprivation, water3.Infection, urinary4.Chickenpox, see Varicella5.Fever, blackwater6.Infection,gallbladder,see Cholecystitis7.Malaria,quartan,see Malaria, malariae8.Disease, cerebrovascular9.Failure,congestive, see Failure,heart, congestive10.Diabetes, type 1Exercise3.5Abstracting, Assigning, and Arranging Diagnosis Codes1.a.Syndromeb.toxic shockc.A48.3d.noe.Use additional code to identify the organism (B95, B96)f.StreptococcusAg.noh.Includes: diseases generally recognized as communicable or transmissible

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i.noj.B95k.B95.0l.yesm.A48.3n.B95.0CONCEPT QUIZCompletion1.( )2.Excludes13.-4.[ ]5.with6.X7.Excludes28.code first9.use additional code10.seeMultiple Choice1.A2.C3.B4.A

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5.A6.B7.A8.A9.D10.DKEEP ON CODING1.M21.42(Flat, foot, seeDeformity, limb, flat foot, left)2.Z51.12(Encounter, immunotherapyfor neoplasm)3.L89.323(Ulcer, pressure, buttock;Tabular:left,stage 3)4.F10.20(Dependence, alcohol)5.M25.122(Fistula,joint, elbow;Tabular:left)6.Z81.1(History, family, alcohol abuse)7.Z68.38(Body, mass index, adult, 38.0-38.9)8.I10(Hypertension)9.I69.391(Dysphagia, following,cerebrovascular disease, cerebral infarction; Tabular:Useadditional code to identify the type of dysphagia, if known (R13.1-))R13.10(Dysphagia; Tabular:Code first, if applicable, dysphagia following cerebrovasculardisease (I69. with final characters-91))10.R10.824(Pain, abdominal,rebound,see Tenderness, abdominal, rebound, left lowerquadrant)11.R29.6(Repeated falls NEC)12.C4A.11(Carcinoma, Merkel cell, eyelid; Tabular:right)

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13.G89.3(Pain, due to malignancy)14.E11.9(Diabetes, type 2)15.S90.562D(Bite, ankle, superficial, insect; Tabular:left, subsequentencounter)16.T25.711A(Burn, chemical, see corrosion by site;Corrosion, ankle, right, third degree;Tabular:initialencounter)17.Q70.23(Fused, see Fusion, fused;Fusion, toes; Tabular:bilateral)18.N30.21(Cystitis, chronic, with hematuria)19.B59(Pneumonia, pneumocystis)20.D64.9(Anemia)21.Z01.83(Encounter, blood typing)22.J95.851(Pneumonia, ventilator associated)23.B85.0(Lice, head)24.O40.2XX3(Polyhydramnios; Tabular:second trimester, fetus 3)25.H60.501(Otitis, externa,acute; Tabular:right)CODING CHALLENGE1.a.shortness of breathb.Chronic combined systolic and diastolic heart failure; hypertension2.a.yesb.noc.do not code for symptoms that are integral to the condition diagnosedd.hypertension

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3.a.I11.0b.no4.a.Use additional code to identify type of heart failure(I50.-)b.first5.a.Patient is a current and long-term tobacco userb.Use additional code to identify tobacco use (Z72.0).c.no6.a.I50.-b.additional characters required7.a.I50.4b.I50.428.Heart failure due to hypertension (I11.0)9.Z72.010.a.I11.0b.I50.42c.Z72.0

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CHAPTER4: SYMPTOMS, SIGNS, AND ABNORMAL CLINICAL ANDLABORATORY FINDINGS, NOT ELSEWHERE CLASSIFIED (R00-R99)CODING PRACTICEExercise4.1 Symptoms and Signs Refresher1.dys/pnea difficulty breathing, R06.002.noct/uria urination at night, R35.13.a/phag/iaunable to swallow, R13.04.epi/staxis bleeding from above (nosebleed) , R04.05.lymph/adeno/pathy abnormal condition of lymph nodes, R59.16.hyper/emesis excessive vomiting, R11.107.hyp/ox/emia low oxygen in the blood, R09.028.cyan/osis yellow skin, R23.09.glycos/uria sugar in urine, R8110.tachy/card/ia rapid heartbeat, R00.0Exercise4.2 Abstracting Symptoms and Signs1.a.nob.abnormal laboratory testc.abnormal2.a.irregular heartbeat, chest pain, and lightheadednessb.yes

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c.yesd.nonee.atrial fibrillation3.a.nob.seizuresc.seizures4.a.polydipsia, polyuria, difficulty sleeping, hyperglycemiab.yes, type 2 diabetesc.yes, sleep apnead.no, symptoms and signse.polydipsia, polyuria, hyperglycemiaf.difficulty sleepingg.type 2 diabetes, difficulty sleeping5.a.extreme nervousness and irritabilityb.uncertain condition the physician wants toconfirm or eliminate from the finalassessmentc.nod.yes, hyperthyroidisme.nervousness and irritability6.

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a.epigastric painb.noc.acute pancreatitis or cholangitisExercise4.3 Assigning Codes for Symptoms and Signs1.R94.5(Abnormal, function studies, liver)2.I48.91(Fibrillation, atrial)3.R56.9(Seizures)Exercise4.4 Arranging Codes for Symptoms and Signs1.E11.9(Diabetes, type 2)G47.9(Sleep, disorder or disturbance)2.R45.0(Nervousness)R45.4(Irritability)3.K85.90(Pancreatitis, acute)K83.0(Cholangitis)CONCEPT QUIZCompletion1.symptom2.integral3.uncertain4.clinical5.sign6.related7.uncertain

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8.unrelated9.abnormal10.inpatientMultiple Choice1.A2.C3.B4.B5.B6.A7.A8.D9.A10.DKEEP ON CODING1.R10.823(Tenderness, abdominal, rebound, right lower quadrant)2.R93.2(Nonvisualization, gallbladder)3.R12(Heartburn)4.R19.11(Absence, bowel sounds)5.R00.1(Slow, heart)6.R46.3(Overactivity)7.R44.0(Hallucination, auditory)8.R04.0(Nosebleed)

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9.R06.02(Shortness, breath)10.K85.90(Pancreatitis.Instructional note at R65.10: Code first underlyingcondition.R65.10(Syndrome, systemic inflammatory response (SIRS))11.R61(Sweating, excessive)12.R62.0(Late, walker)13.R19.4(Change, bowel habit)14.R01.1(Murmur)15.R40.2123(Coma,with, opening of eyes, in response to, pain)R40.2233(Coma,with, verbal response, inappropriate words)R40.2343(Coma,with, motor response, flexion with withdrawal)R40.2423(Glasgow coma scale, total score, 9-12)16.R78.2(Findings, in blood, cocaine)17.R41.81(Decline, cognitive, age associated)18.R39.198(Urine, stream intermittent)19.R49.0(Hoarseness)20.R79.81(Abnormal, blood-gas level)21.R09.2(Arrest, respiratory)22.R26.81(Unsteadiness on feet)23.R93.2(Abnormal, scan, liver)24.R62.51(Failure, gain,weight)25.R56.00(Seizure, febrile)CODING CHALLENGE1.R92.0(Abnormal mammogram, microcalcifications)

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2.R91.8(Abnormal, diagnostic imaging, lung)3.R75(HIV, laboratory evidence or Test, HIV,nonconclusive)4.R06.7(Sneezing)R09.89(Scratchy throat)R09.82(Drip, postnasal)5.M51.16(Hernia, intervertebral disc, see Displacement, intervertebral disc, lumbarregion, with sciatica)6.R87.614(Abnormal,Papanicolaou (smear),cervix, with cytologic evidence ofmalignancy)7.E88.81(Resistance, insulin)8.R51(Headache, daily chronic)9.I50.9(Failure, heart, congestive)10.E55.9(Deficiency, vitamin, D)CHAPTER 5: NEOPLASMS (C00-D49)CODING PRACTICEExercise 5.1 Neoplasm Refresher1.osteo/sarc/oma malignant neoplasm of bone and connective tissue2.leio/my/oma neoplasm of smooth muscle3.lip/oma neoplasm of fatty tissue4.lipo/sarc/oma malignant neoplasm of fatty tissue5.aden/oma neoplasm of a gland6.adeno/carcin/oma cancerous neoplasm of a gland

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7.oste/oma neoplasm of bone8.melan/oma neoplasm of pigmented cells9.neuro/blast/oma neoplasm of immature nerve cells10.lymph/oma neoplasm of lymph glandsExercise 5.2 Abstracting Diagnoses for Neoplasms1.a.right breast, lower outer quadrantb.yes, brainc.nod.chemotherapy2.a.a therapeutic procedureblocking the flow of bloodb.benign tumor of smooth musclec.uterusd.benign3.a.fundus of thestomachb.the top portion of the curve, the upper part ofthe stomach next to the cardiac.nod.noe.review results of biopsy and CT scan4.a.leftthigh

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b.noc.noned.surgery to remove tumore.femur5.a.classical lymphocyte depleted Hodgkin lymphomab.noc.anemiad.anemia6.a.squamous cellcarcinoma of the lungb.yes, brain stemc.brain stemd.targeted delivery of stereotactic (using 3-D coordinates) radiation to the tumorExercise 5.3 Assigning Codes for Neoplasms1.D25.1(Leiomyoma, uterus, intramural)2.C40.22(Osteosarcoma, see Table of Neoplasms, bone, femur, malignant primary,Tabular List:left)3.C16.1(Adenocarcinoma,see alsoNeoplasm, Malignant, by site; Table of Neoplasms,stomach, fundus, malignant primary)Exercise 5.4 Arranging Codes for Neoplasms1.Z51.11(Chemotherapy, neoplasm)C50.511(Table of Neoplasms, breast, lower outer quadrant, malignant primary,

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Tabular List:right )C79.31(Table of Neoplasms, brain, overlapping lesion, malignant secondary)2.C79.31(Table of Neoplasms, brain, stem, malignant secondary)C34.90(Table of Neoplasms, lung, malignant primary)3.C81.30(Lymphoma, Hodgkin, classical, lymphocyte depleted, unspecified site)D63.0(Anemia, in, neoplastic disease)CONCEPT QUIZCompletion1.topography2.histology3.metastasis or secondary neoplasm4.staging5.adjuvant6.chemotherapy7.CA in situ8.overlapping9.grading10.malignantMultiple Choice1.C2.B3.D4.B

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5.B6.B7.D8.D9.A10.DKEEP ON CODING1.D02.0(Table of Neoplasms, vocal cords, false, CA in situ)2.D10.30(Table of Neoplasms, mouthbenign)3.D3A.093(Tumor, carcinoid, benign, kidney)4.C45.7(Mesothelioma,site classification, lung)5.C79.31(Table of Neoplasms, brain, parietal lobe, malignant secondary)6.D12.6(Polyp, colon, adenomatous)7.D35.1(Adenoma, chief cell)8.B20(Human, immunodeficiency virus disease)C46.4(Kaposi’s, sarcoma, stomach)9.C44.612(Table of Neoplasms, skin, hand, malignant primary,Tabular List:right)10.C43.59(Melanoma, skin, abdominal wall)11.C50.011(Table of Neoplasms, breast, nipple, female,Tabular List:right)12.C82.45(Lymphoma, follicular, grade, IIIb, inguinal region)13.C95.02(Leukemia, unspecified cell type, acute, in relapse)14.C43.62(Melanoma, skin, forearm,Tabular List:left)15.D06.7(Table of Neoplasms, cervix, stump, CA in situ)

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16.Z80.3(History, family, malignant neoplasm, breast)17.Z85.841(History, personal, malignant neoplasm, brain)18.C34.82(Table of Neoplasms, lung, overlapping lesion, malignant primary,TabularList:left)19.Z51.11(Chemotherapy, neoplasm)C56.9(Table of Neoplasms, ovary, malignant primary, unspecified)20.C25.1(Table of Neoplasms, pancreas, body, malignant primary)21.C79.51(Table of Neoplasms, rib, malignant, secondary)22.C69.92(Table of Neoplasms, intraocular, malignant primary,Tabular List:left)D63.0(Anemia, in, neoplastic disease)23.C78.7(Table of Neoplasms, liver, malignant secondary)C80.1(Table of Neoplasms, unknown site or unspecified, malignant primary)24.D39.2(Hydatidiform mole, malignant)25.C07(Table of Neoplasms, parotid, malignant primary)C79.51(Table of Neoplasms, bone, spine, malignant secondary)CODING CHALLENGE1.C90.01(Myeloma, in remission)2.D11.0(Table of Neoplasms, salivary gland, parotid, benign)3.D01.0(Table of Neoplasms, intestine, large, colon, sigmoid, in situ)4.C43.39(Melanoma, skin, forehead)5.D04.5(Table of Neoplasms, skin, breast, in situ)6.Z51.0(Radiation, therapy, encounter for)

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C78.01(Table of Neoplasms, lung, malignant secondary,Tabular List:right)C80.1(Table of Neoplasms, [first row] malignant primary)7.D13.7(Islet cell tumor, pancreas)8.Z12.11(Screening, colonoscopy)Z85.038(History, personal, malignant neoplasm, colon, NEC)9.C25.9(Table of Neoplasms, pancreas, malignant primary)C79.9(Table of Neoplasms, [first row] malignant secondary10.E87.1(Hyponatremia or Dehydration, hypotonic)C56.1(Table of Neoplasms, ovary, malignant primary,Tabular List:right)C56.2(Table of Neoplasms, ovary, malignant primary,Tabular List:left)C79.9(Table of Neoplasms,[first row]malignant secondary)CHAPTER6: FACTORS INFLUENCING HEALTH STATUS AND CONTACT WITHHEALTH SERVICES (Z00-Z99)CODING PRACTICEExercise6.1 Introduction to Z Codes1. Student answers will vary and may include any of the following:aftercarecounselingfollow upimmunizationsobservationobstetrics

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routine or administrative examinations (pre-employment, annual check-up)screening examinations (colonoscopy, mammogram).2. a. OGCR I.C.21.c.1)b. OGCR I.C.21. c.3)c. OGCR I.C.21. c.7)d. OGCR I.C.21. c.13)3. a. Screeningb. Donorc. Non-specificd. HistoryExercise6.2. Abstracting for Z Codes1. a. annual medical examinationb. no2. a. Supervision of normalsecond pregnancy, third trimesterb. no3. a. adjustment of cardiac pacemakerb. no4. a. normal mammogram, both breastsb. noc. personal history of breast cancer5.a. 6-month follow up for malignant neoplasm of prostateb. noc. malignant neoplasm of prostate

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d. personal historye. prostate6. a. angina pectorisb. noc. tobacco useExercise6.3. Assigning Z Codes1.Z00.00(Examination, annual)2.Z34.83(Pregnancy, supervision of, normal, specified NEC, third trimester)Z3A.34(Pregnancy, weeks of gestation, 34 weeks)3.Z45.018(Fitting and adjustment of, pacemaker)Exercise6.4. Arranging Z Codes1.Z12.31(Screening, neoplasm, breast, routine mammogram)Z85.3(History, personal, malignant neoplasm, breast)2.Z08(Examination, following,treatment (for), malignant neoplasm)Z90.79(Absence, prostate)Z85.46(History, personal, malignant neoplasm, prostate)3.I20.0(Angina, unstable)Z72.0(Tobacco, use)CONCEPT QUIZCompletion1. Screening2. Personal history3. Observation

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4.Counseling5. Routine and administrative examinations6. Aftercare7. Family history8. Miscellaneous9. Follow-up10. Obstetrical and reproductiveMultiple Choice1. D2. B3. A4. C5. A6. B7. D8. A9. D10. CKEEP ON CODING1.Z32.02(Encounter, pregnancy, test, result negative)2.Z67.30(Blood, type, AB, Rh positive)3.Z01.20(Examination, dental)4.Z53.20(Canceled procedure, because of, patient’s decision)

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5.Z94.1(Transplant, heart)6.Z99.2(Dialysis, renal, status7.Z45.819(Encounter, removal, breast implant)8.Z53.31(Procedure, converted, laparoscopic to open)9.Z83.3(History, family, diabetes mellitus)10.Z87.891(History, personal,tobacco dependence)11.Z02.81(Encounter,administrative, examination for, paternity testing)12.O09.92(Pregnancy, supervision, high risk, 2nd trimester)Z3A.20(Pregnancy, weeks of gestation, 20)13.Z38.00(Newborn, born in hospital)14.Z72.3(Lack of, physical exercise)15.Z79.1(Long-term, anti-inflammatory, non-steroidal)16.Z91.013(Allergy, food, status, seafood)17.Z98.2(Presence, CSF shunt)18.Z78.1(Status, physical restraint)19.Z66(DNR)20.Z59.0(Homelessness)21.Z33.1(State, pregnant, incidental)22.Z87.442(History, personal, kidney stones)23.Z14.1(Carrier, genetic, cystic fibrosis)24.Z91.412(History, personal, neglect, adult)25.Z00.121(Examination, child, abnormal findings)

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