1. Lucy, a 69-year-old patient, was admitted to a nursing home with cellulitis of the right foot, excluding the toes. She was placed on IV therapy for the cellulitis and is now recovering nicely. She plans to return to her home upon discharge. She has a history of Type I diabetes with no complications. She is being treated for both the cellulitis and the diabetic condition. How would you report these diagnoses?

2. If the type of diabetes mellitus is not documented in the medical record what is the default type you should assign?

3. Cynthia is 28 years old and pregnant. She presents to the emergency room complaining of diarrhea with watery bowel movements with incontinence, cramps, nausea, and vomiting for the past 12 hours. She is unable to keep anything down, including liquids. She has been eating a healthy diet and does not feel this problem is based on something she ate. After testing, she was found to have enteritis due to Clostridium difficile. She was admitted for hydration and further treatment. In what order should you report the diagnoses codes for Cynthia’s condition?

4. A patient is suffering with acute respiratory failure, viral pneumonia, atrial fibrillation, and alcoholic liver cirrhosis. What codes describe these conditions?

5. A 44-year-old male was spraying weeds in his backyard. He accidentally got some of the weed killer in his ice tea. After drinking the ice tea and working for several hours, he told his wife he felt “funny” and started to vomit. She drove him to the emergency room for treatment. How would you report this scenario?

6. Pam’s infant son, who weighs 2,321 grams, is considered underweight for his gestational age without mention of fetal malnutrition. How would you report this case?

7. How would you report a case of a patient with a non-healing burn?

8. Jim lost control of his car while driving on an icy highway and hit a parked car. He was transported to a local emergency room for treatment. He suffered a greenstick fracture of six ribs and atelectasis. How would you report this?

9. Laurie has a malignant secondary tumor of the Bartholin’s gland. Her doctors do not know where this cancer started in Laurie’s system. She is coming in today for radiation of the secondary site. How would you report her diagnoses for today’s treatment?

10. Nancy has been suffering with abdominal cramping pain in the belly area, persistent watery diarrhea, fever, and fatigue. She underwent a colonoscopy and was diagnosed with Crohn’s disease of the large bowel and colon. How would you report the diagnosis from the colonoscopy?

11. Fracture of the right patella with abrasion.

12. Mr. Hallberger is 62 and has multiple problems. I am examining him in the intensive critical care unit. I understand he has fluid overload with acute renal failure and was started on ultrafiltration by the nephrologist on duty. He has an abnormal chest x-ray. He has preexisting type II diabetes mellitus and sepsis. We are left with a patient now who is still sedated and on a ventilator because of respiratory failure. Code the diagnoses only.

13. 27-year-old was frying chicken when an explosion of the oil had occurred and she sustained second-degree burns on her face (3%), third degree burns on both hands (4%), and second degree burns on her lower left arm (3%). There was a total of 10 percent of the body surface that was burned. Select which ICD-9-CM codes should be used.
27-year-old was frying chicken when an explosion of the oil had occurred and she sustained second-degree burns on her face (3%), third degree burns on both hands (4%), and second degree burns on her lower left arm (3%). There was a total of 10 percent of the body surface that was burned. Select which ICD-9-CM codes should be used.

14. A patient that has cirrhosis of the liver just had an endoscopy performed showing hemorrhagic esophageal varices. The ICD-9-CM codes should be reported:

15. 55 year-old-patient had a fracture of his left knee cap six months ago. The fracture has healed but he still has staggering gait in which he will be going to physical therapy. What ICD-9-CM codes should be reported?

16. Which statement is true about V codes:

17. 44-year-old had a history of adenocarcinoma of the cervix on a conization in March 20XX who has been followed with twice-yearly endocervical curettages and Pap smears that were all negative for two years, per the recommendation of a GYN oncologist. Her Pap smear results from the last visit noted atypical glandular cells. In light of this, she underwent a colposcopy and the biopsy of the normal-appearing cervix on colposcopy was benign. The endocervical curettage was benign endocervical glands, and the endometrial sampling was benign endometrium. In light of the fact that she had had previous atypical glandular cells that led to diagnosis of adenocarcinoma and the concerns that this may have recurred, she had been recommended for a cone biopsy and fractional dilatation and curettage, which she is undergoing today. What ICD-9-CM code(s) should be reported?

18. Patient comes into see her primary care physician for a productive cough and shortness of breath. The physician takes a chest x-ray which indicates the patient has congestive pneumonia. Select the ICD-9-CM code(s) for this visit.

19. What is the correct way to code a patient having bradycardia due to Demerol that was correctly prescribed and properly administered?

20. What statement is true when reporting pregnancy codes (630-679):

21. Which of the following is true regarding ICD-9-CM codes with the words “in diseases classified elsewhere” in their descriptions?

22. Which of the following statements is true regarding sequencing of E codes?

23. A patient that has benign hypertension with congestive heart failure is coded:

24. Patient is going back to the OR for a re-exploration L5-S1 laminectomy for a presumed cerebrospinal fluid leak. A small partial laminectomy was slightly extended, however revealed no real evidence of leak. Valsalva maneuver was performed several times, no evidence of leak. There was a pocket of clear serous fluid oozing, which was drained. What ICD-9-CM code(s) should be reported?

25. A four-year-old was seen in the outpatient clinic. The father stated that his son has been very clumsy lately. He also noticed that the child has a waddling gait, is slow when he runs and climbs, and tends to walk on his tip-toes. After examination, documentation of a strong family history of muscular dystrophy was confirmed and a muscle biopsy and electromyography revealed Duchenne’s muscular dystrophy. Physical therapy, splints and braces were ordered for the patient. What ICD-9-CM code(s) would be reported for this encounter?

26. A 24-year-old is taken to the ER by her husband. She s in her 16th week of pregnancy and has been experiencing dizziness and swelling in her hands and feet. The ER physician performs a detailed history and exam. Final assessment is mild preeclampsia with edema. She is instructed to follow-up with her OB physician the next day. What diagnosis code(s) would be reported for this encounter?

27. A 14-year-old male is brought to the emergency room by his parents after injuring his left knee while sliding into base during a tournament baseball game. X-rays reveal a sprain to the knee. The patient is instructed to keep his leg elevated and to keep weight ff of it as much as possible for the next two weeks. What diagnosis code(s) would be reported for this encounter?

28. A patient presented to an ambulatory surgery center with an admitting diagnosis of chest pain. Surgery performed on the patient was a cardiac catheterization. The discharge diagnosis was coronary artery disease, native artery, and unstable angina. What are the correct diagnosis codes for this encounter?

29. A nine year old is brought to the emergency room by his parents. The child has been running a fever for the past 14 hours, with the highest reaching 103.5 degrees. Vomiting is also a complaint. After examination renal x-rays, and lab tests, which were positive for E-coli, the physician documented acute pyelonephritis. The patient was discharged to his parents with a prescription for Bactrim. What are the correct diagnosis codes for this visit?

30. The patient is a 37-year-old female who is seen in the ER with complaints of neck pain, headaches, and nausea with vomiting. There is a possibility of viral meningitis, so a spinal tap was performed. This came back negative. Also, a CT scan of the head was done and came back normal. The discharge diagnosis for the patient is viral syndrome with headaches, A prescription for the headaches was written and the patient was discharged to home. What diagnosis code(s) would be reported for this encounter?

31. A patient is seen in the outpatient cancer center for daily injections of Interferon Alfa-2a, 3 million units. The patient has cancer of the oral cavity and lip. What is (are) the correct diagnosis code(s) for this encounter?

32. A homebound patient with an indwelling catheter is treated in the emergency room for a urinary tract infection due to E.coli caused by the catheter. Aggressive antibiotic therapy was started in the ER. What are the correct diagnosis codes for this encounter?

33. A 54-year-old patient with primary lung cancer of the upper lobe is receiving his first radiation treatment in the oncology clinic. What is the diagnosis code selection for this encounter?

34. A female is treated for a closed fracture of the right hand. The shaft and neck of the metacarpal bones are treated using closed reduction. The fracture was sustained at a baseball field. What are the correct diagnosis codes for this patient’s encounter?

35. Six weeks ago, Terry underwent a biopsy procedure and was diagnosed with secondary metastatic liver carcinoma. His doctors are uncertain about the location of the primary site and have ordered further testing. Today, Terry is undergoing chemotherapy for the liver cancer. How should the diagnosis codes be reported for today’s service?

36. Jodie is 28 weeks pregnant with her second child. During an office visit two weeks ago, she mentioned experiencing some edema and headaches. Dr. Smith noted a higher-than-usual blood pressure for Jodie and asked her to come in for continued blood pressure monitoring and a urine test. Her urine test came back positive for excessive protein. During her visit today, her blood pressure is 140/95, which is consistent with the past abnormal readings. She still has continued abnormal edema but no headache. Dr. Smith tells Jodie she has preeclampsia and wants her to schedule visits more often during the next two months for monitoring. What code(s) should be listed in Jodie’s record for today’s visit?

37. Lynn is a 53-year-old patient who previously received treatment by external fixation for a Grade I right tibial fracture. She suffered the fracture falling from a ladder while cleaning the gutters on her home. Today she underwent an open reduction of the right proximal tibia with bone grafting for non union. What diagnosis codes would Dr. Rennin report for today’s encounter?

38. Dr. Martin completed a diagnostic GI endoscopy on Larry, a 42-year-old patient who complained of diarrhea, blood in his stool, and stomach cramps. Dr. Martin diagnosed Larry with diverticulitis of the colon as the cause of bleeding and other symptoms. How should Dr. Martin report her diagnosis code(s) for this encounter?

39. Dr. Ben admitted Claire for treatment of her acute and chronic pyelonephritis, mild hypertension, and secondary diabetes with associated macular edema. During this encounter, Claire received insulin to temporarily bring her blood sugar under control. How should the diagnosis codes be reported for this admission encounter?

40. Sara is being seen for a spontaneous pathologic fracture of her right hip with additional damage to the intertrochanteric section of the bone. The documentation indicates the patient also has symptomatic HIV disease. Sara has had previous pathologic fractures of the ulna and vertebral segments, which have since healed. How should the diagnosis codes be reported for this encounter?

41. Baby Jones is being treated in the emergency room for shaken baby syndrome with subdural hematoma, concussion with loss of consciousness for 34 minutes, and retinal hemorrhage resulting from the patient’s stepmother not being able to get the baby to stop crying. Baby Jones’ stepmother, who was drunk at the time of the accident, admitted to shaking the patient, but did not mean to harm him. How should the diagnosis codes be reported for this encounter?

42. Jason was burned during a military scuba diving exercise when steam was released from a steam pipe. He suffered second- and deep third-degree burns to the entire anterior side of his right leg, second-degree burns to part of the right palm, and a second- and third-degree burn to his right forearm. The documenta tion indicated 25% of the total body surface area (TBSA) was burned, of which 19% were third-degree burns. How would the diagnosis codes be reported for Jason’s burns?

43. Karen is being treated for widespread rheumatoid arthritis and polyneuropathy in collagen vascular disease. How should you report these diagnosis codes?

44. Ruth was treated for a skin rash, nausea, and vomiting due to an accidental poisoning when she ate wild berries. How should Ruth’s diagnosis codes be reported for this encounter?

45. Cancer of the bladder removed five years ago with no recurrence.

46. A 2 ½-year-old girl has been exposed to hepatitis B, has nasal congestion and is scheduled for MMR and Td immunizations. In view of exposure to Hepatitis B, a prophylactic immunization is given and a common cold is treated. The MMR and Td vaccines are given 3 weeks later. Select the ICD-9-CM codes for both the encounters.

47. What is a late effect?

48. Which of the below situations would require a use of an E code?

49. What is meant by the guideline of coding to the highest level of specificity?

50. The volume II index to diseases lists the disease that includes a code for the chronic and exudative form of angina. What is that code?

51. Identify the range of the codes in Volume I for acute respiratory infections?

52. Provide the appropriate ICD-9-CM code if the primary site of a malignancy is unknown but still exists and is being treated.

53. A 20-year old is seen for third degree burns to the palm and back of the right hand, third degree  burns to the forearm and first degree burns to the back of the left hand. The burns were a result  of hot cooking oil that spilled out of a pan when the patient was frying scones at home.

54. A patient presents to the nephrology clinic suffering from malignant hypertensive heart and  Stage V chronic kidney disease, without heart failure, due to hypertension. What are the  appropriate ICD-9-CM codes?

55. A patient suffers an acute anterolateral wall myocardial infarction (MI) and is admitted to the hospital. The patient is released and readmitted to the hospital five weeks later for a cardiac catheterization due to chest pain. The provider determined that chest pain was from the previous MI. What would be the appropriate ICD-9-CM code for the readmission primary diagnosis?

56. A dog bites a 12- year-old boy on the left ankle while he is delivering newspapers on his morning  paper route. He presents to the ED where the physician cleans the puncture wound and applies dressing. What are the appropriate ICD-9-CM codes for this encounter?

57. A patient has a closed fracture of the left radius shaft and an open fracture of the right radius  shaft after being involved in a motorcycle accident. What are the correct ICD-9-CM codes?

58. A patient with Type I diabetes is seen for an eye checkup. After a thorough examination, the  ophthalmologist determines the patient has diabetic retinal edema.

59. What diagnosis code is used in cases when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode?

60. What are the correct codes for a loss of consciousness caused by inhalation of a hot dog while at  the fair?

61. What is the correct ICD-9-CM code for a patient with chronic spinal meningitis?

62. A patient suffers third degree burns to the full trunk (front and back) and third degree burns to the entire right arm. What are the correct ICD-9-CM codes?

63. A patient was in a serious automobile accident where he was a passenger. He sustained a
closed fracture of the coronoid process of his jaw and an open shaft fracture of the radius with  the ulna of his left wrist. What are the correct ICD-9-CM codes for this patient?

64. If a patient has a test for HIV and there is nonspecific serologic evidence of HIV, which ICD-9- CM code is used?

65. A child is seen in a hospital based pediatric clinic for treatment of first and second degree burns  to the calf area on the left leg. What diagnosis code would be reported for this encounter?

66. A patient was seen in an outpatient clinic. The patient had unprotected intercourse a few
months prior. She recently found out that the individual she was with has HIV. She was seen in order to be tested for this disease. What diagnosis code should be reported?

67. An 18 month old who was born with hypospadias presents to the hospital for hypospadias
correction.  What is the correct diagnosis code for this patient?

68. A 7-year-old female was seen in the emergency department for a dog bite in the leg. The child  received a rabies vaccine since the dog was known to have rabies. What are the correct   diagnosis codes for this encounter?

69. A 32-year-old male was seen in the hospital for removal of two lipomas. One was located on his   back and the other was located on the right forearm. Both involved subcutaneous tissue. What  code selection would be reported for this diagnosis?

70. A 37-year-old female patient was scheduled for surgery in the hospital outpatient surgery
center for carpal tunnel release of the right wrist. What diagnosis code would be reported for a postoperative diagnosis of carpal tunnel syndrome right wrist?

71. A patient with a benign neoplasm found in the duodenum was seen in the hospital for removal of the neoplasm by colonoscopy. What is the correct code for this diagnosis?

72. A 30 year old female was seen in the ER with complaints of diarrhea for the past four days. She was also complaining of lower abdominal pain. After examination the patient was diagnosed with having viral gastroenteritis. She was instructed to drink plenty of fluids and to begin eating solids once the diarrhea has subsided. What diagnosis code would be reported for this encounter?

73. After being involved in a motor vehicle accident, the passenger was treated in the local
emergency room for a fracture of the right proximal end humerus. What are the correct
diagnosis codes for this scenario?

74. A 28 year old male was rushed to the ER after being found unconscious. Information from
family members indicated that the patient had left a suicide note and had taken LSD
(hallucinogenic). What are the correct codes for this diagnosis?

75. A girl was brought to the ER to have a Barbie shoe removed from her throat. The child’s parents explained that their daughter was running around the house with it in her mouth and accidentally swallowed it. What diagnosis code(s) would be used for this encounter?

76. In the emergency department a 10 year old male was seen for having wheezing attacks for the past 3 days. The physician documented the patient as having childhood asthma with acute exacerbation. What correct diagnosis code(s) would be reported for this encounter?

77. A female patient is seen in the outpatient clinic with symptoms of vomiting, nausea and
syncope. After being examined it was determined that the patient had gastrointestinal influenza.  What would be reported for the diagnosis?

78. A 54 year old patient with primary lung cancer of the upper lobe is receiving his first radiation treatment in the oncology clinic. What is the diagnosis code selection for this encounter?

79. A patient with complaints of blurred vision, trouble driving at night and his eyes feeling like there was a film over them, was seen in the outpatient ophthalmology clinic. After a comprehensive ophthalmologic examination it was determined that the patient had bilateral cataracts. Surgery was scheduled for treatment of the cataracts. What ICD-9-CM code(s) would be reported for this diagnosis?

80. A patient was seen in the outpatient dermatology clinic at the local hospital. His complaints were moderate itching, which then became severe (pruritus). He also noticed small blisters, redness and swelling of his lower legs. It was documented that the patient had come in contact with poison ivy. The patient was diagnosed with contact dermatitis due to poison ivy. Hydroxyline HCl 25 mg tablets and Temovate 0.05% cream were prescribed. The patient was instructed to call with any problems. What diagnosis code would be reported for this encounter?

81. A female is treated for a closed fracture of the right hand. The shaft and neck of the metacarpal bones are treated using closed reduction. The fracture was sustained at a baseball field. What are the correct diagnosis codes for the patient encounter?

82. The parents of a six month old male bring their child to the local emergency department.
Symptoms are “seal-like sounding” cough and hoarseness. After work-up it is determined that the child has croup. What diagnosis code(s) would be reported for this condition?

83. A patient presents with a preliminary diagnosis of benign lesion of the gums. The physician excised the lesion and final diagnosis was stated as carcinoma in situ of the hard palate. Assign and if appropriate sequence the diagnosis code(s) for this service.

84. A 26 year old female presents to the emergency department with severe knee pain. The ED
physician takes a history and physical examination. The patient admits to falling while skiing. An x-ray of the knee is ordered and a medial collateral ligament tear is diagnosed. The patient is given a prescription for pain along with instructions to stay off the knee for the next week. What diagnosis codes are appropriate for this encounter?

85. A Medicare patient underwent a breast biopsy in the lower outer quadrant of the breast in the outpatient hospital department because the mammogram and ultrasound showed a lump in the breast. The physician performed the biopsy and sent the specimen to the pathology for examination. The pathologist indicated in the path report that the lump was a malignant neoplasm. What diagnosis code should be reported?

86. A patient presents to the hematology/oncology clinic at the hospital for chemotherapy
treatment for a malignant neoplasm of the liver. The patient has a history of ovarian cancer one year ago and underwent a total hysterectomy with bilateral salpingectomy and oopherectomy bilaterally. One week prior to her visit today she was seen by her oncologist for abdominal pain and mass was discovered on her liver. A liver biopsy was performed and a diagnosis of liver cancer secondary to the ovarian cancer was confirmed. A bone scan was negative for bony metastases. What diagnosis code(s) should be reported for this patient encounter?

87. A 67-year-old patient presents to the catheterization lab at the hospital for a right and left
heart catheterization. He has a history of CAD and a four vessel coronary artery bypass using one mammary artery and three saphenous vein grafts from the patient. The cardiologist discovers 80 percent stenosis in the bypass graft (mammary) artery. What is the correct diagnosis code?

88. A patient who underwent a modified radical mastectomy of the left breast six months earlier because of the carcinoma now has metastasis to the bone. Today, she receives a transfusion of packed cells to treat aplastic anemia, due to her chemotherapy treatment. She will be followed closely on a weekly basis. What diagnosis codes are appropriate to report this patient encounter?

89. A patient with suspected carcinoma of the colon was taken to the surgery unit for a exploratory laparotomy. During the procedure a significant mass was discovered in the sigmoid flexure. A lesion was noted on the liver, and a needle biopsy of the liver was performed during the procedure. The pathology report confirmed adenocarcinoma of the colon sigmoid flexure and metastatic carcinoma of the liver. What is the correct diagnoses code for this service?

90. A patient was admitted through the emergency department following a fall from a ladder while painting his house. He had contusions of the scalp and face and an open intertrochanteric fracture of the femur. The fracture site was debrided and an open reduction with internal fixation was carried out. What diagnosis code should be reported?

91. The patient is seen today for radiation therapy for treatment of breast cancer following a lumpectomy that removed a lesion on the central portion of the right breast. Which of the following diagnosis codes would be listed first for this encounter?

92. The patient is a 75-year-old woman who is here for follow-up after an incident last week in which she had an FB lodged in her throat due to a narrowing in her esophagus. An emergency esophagoscopy was performed and the piece of hamburger meat removed and biopsy performed. She is positive for Barrett’s esophagus. She has a history of GERD and is here today to be evaluated for photodynamic therapy.

93. Three-week-old female with obstructive apnea.

94. Mild retardation due to congenital hypothyroidism.

95. Glomerulonephritis due to infectious hepatitis.

96. Bloody stool

97. A lethargic patient with vomiting and severe cramping ingested five tablets of Tylenol with codeine and half a bottle of whiskey.

98. Admission for hemodialysis because of acute renal failure

99. Sarcoidosis with cardiomyopathy

100. Laceration of left hand.