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Classification Systems, Registries and Indexing

Anita Hazelwood, MLS, RHIA, FAHIMA

Classification Systems, Registries and Indexing

Anita Hazelwood, MLS, RHIA, FAHIMA

1. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer". What should be coded as the patient's diagnosis? A) chronic cough B) observation and evaluation without need for further medical care C) diagnosis of unknown etiology D) lung cancer REFERENCE: Abdelhak, p 241 ICD-9-CM Official Guidelines for Coding and Reporting, 2005 2. Which of the following is a valid ICD-9-CM principal diagnosis code? A) V27.2 Outcome of delivery, twins, both live born B) V30.00 Single live born, born in hospital C) E867 Accidental poisoning by gas distributed by pipeline D) M9010/0 Fibroadenoma, NOS REFERENCE: Brown, p 208, 241, 289, 310-311 3. A physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign A) an unlisted Evaluation and Management code from the E&M section B) an unlisted procedure code located in the eye and ocular adnexa section C) a HCPCS Level Two (alphanumeric) code D) an ophthalmological treatment service code REFERENCE: CPT (2007), p 48-49 Principles of CPT Coding, p 26 Smith, p 22 4. A system of preferred terminology for naming disease processes is known as a A) set of categories B) classification system C) medical nomenclature D) diagnosis listing REFERENCE: Abdelhak, p 230 Johns, 2nd Edition, p 194 LaTour and Eichenwald-Maki, 2nd Edition, p 306, 936 5. A patient who is taking the drug Antivert may be diagnosed with: A) dizziness B) urinary tract infection C) arthritis D) congestive heart failure REFERENCE: Shannon, p 957-958

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6. Which of the following is not included as a part of the minimum data maintained in the MPI? A) principal diagnosis B) patient medical record number C) full name (last, first and middle) D) date of birth REFERENCE: Abdelhak, p 185 Johns, 2nd Edition, p 399 LaTour and Eichenwald-Maki, 2nd Edition, p 207, 289 7. The Health Information department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past six months. Which of the following would be the best source to identify the necessary charts? A) operation index B) consultation index C) disease index D) physician's index REFERENCE: Johns, 2nd Edition, p 400 LaTour and Eichenwald-Maki, 2nd Edition, p 289 8. One of the major functions of the cancer registry is to assure that patients receive regular and continued observation and management. How long should patient follow-up be continued? A) until remission occurs B) ten years C) for the life of the patient D) one year REFERENCE: Abdelhak, p 274-275 Johns, 2nd Edition, p 402-403 LaTour and Eichenwald-Maki, 2nd Edition, p 291 9. In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physicians' orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to A) confer with the physician and ask him/her to list the condition as a final diagnosis if he/she considers the abnormal potassium level to be clinically significant B) code the record as is C) code the condition as an abnormal blood chemistry D) code the abnormal potassium level as a complication following surgery REFERENCE: Abdelhak, p 250-251 Brown, p 24 10. DSM-IV-TR is used most frequently in what type of healthcare setting? A) behavioral health centers B) ambulatory surgery centers C) home health agencies D) nursing homes REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 311-312 Johns, 2nd Edition, p 214-215

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11. A coder notes that a patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are: congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of: A) arthritis B) glaucoma C) bronchitis D) laryngitis REFERENCE: Shannon, p 1257 12. The patient is diagnosed with congestive heart failure. A drug of choice is: A) Ibuprofen B) Oxytocin C) Haloperidol D) Digoxin REFERENCE: Shannon, p 491 13. The following clinical documentation is on the patient's medical record: Physical Examination: Physician notes distended abdomen and excessive weight gain in the last three weeks. Patient appears to be short of breath. Vital signs: T: 98.6 Laboratory results: Show decreased serum albumin level Nurses' Notes: Abdominal girth measured daily; output monitored; daily weight taken. Procedures: Paracentesis x3 Medications: Hydrodiuril Final diagnosis: Cirrhosis of the liver The coder might query the physician to ask if the following condition could be added to the discharge summary: A) acute pericarditis B) lymphoma C) Helicobacter pylori gastritis D) ascites REFERENCE: Rubin, p 425 Shannon, p 765 14. The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct: A) CPT code B) Standard Nomenclature of Injuries codes C) E codes and ICD-9-CM codes D) HCPCS level II codes REFERENCE: Brown, p 310 Schraffenberger (2007), p 247 Principles of ICD-9-CM Coding, p 56

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15. A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is A) alcoholism B) abdominal pain C) cholecystitis D) acute pancreatitis REFERENCE: Coding Clinic, Second Quarter, 1990, p 4 Brown, p 41 16. The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed: A) stereotactic radiation treatment B) proton beam treatment C) brachytherapy D) external beam radiation REFERENCE: Principles of CPT Coding, p 337-339 Buck, p 332, 335 17. In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when A) the patient is established B) a new patient is seen in the office C) the patient is given subsequent care in the hospital D) the patient is seen for a follow-up inpatient consultation REFERENCE: CPT Book (2007), p 7-8 18. A direction to "Code first underlying disease" should be considered A) only when coding inpatient records B) a mandatory instruction C) mandatory dependent upon the code selection D) a suggestion only REFERENCE: Coding Clinic, January - February, 1986, p 9 Brown, p 12-13 Schraffenberger (2007), p 22 Hazelwood and Venable, p 22 Principles of ICD-9-CM Coding, p 19 19. This classification system was developed to standardize terminology and codes for use in clinical laboratories: A) Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) B) Systematized Nomenclature of Pathology (SNOP) C) Read Codes D) Logical Observation Identifiers, Names and Codes (LOINC) REFERENCE: Abdelhak, p 257 Schraffenberger (2005) 2nd Edition, p 108-109 LaTour and Eichenwald-Maki, 2nd Edition, p 325-326

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20. This classification system is used to classify neoplasms according to site, morphology and behavior: A) International Classification of Diseases for Oncology (ICD-O) B) Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) C) Diagnostic and Statistical Manual of Mental Disorders (DSM) D) Current Procedural Terminology (CPT) REFERENCE: Abdelhak, p 257 Johns, 2nd Edition, p 206-207 LaTour and Eichenwald-Maki, 2nd Edition, p 310 Schraffenberger (2005) 2nd Edition, p 110 21. According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk or requires special training is defined as a A) principal procedure B) significant procedure C) operating room procedure D) therapeutic procedure REFERENCE: Brown, p 47 Schraffenberger (2007), p 43, 48 22. The "cooperating party" responsible for maintaining the ICD-9-CM Disease classification is the A) Centers for Medicare and Medicaid Services (CMS) B) National Center for Health Statistics (NCHS) C) American Hospital Association (AHA) D) American Health Information Management Association (AHIMA) REFERENCE: Abdelhak, p 231-232 23. An encoder which prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a (n): A) logic-based encoder B) automated codebook C) grouper D) automatic code assignment REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 318-319 24. A disadvantage of adopting SNOMED for diagnosis coding is that: A) It is too difficult to use as a reimbursement system B) It is not compatible with computer technology C) It would hinder communication among diverse computer systems D) It is not possible to conduct outcomes research with SNOMED REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 324-325 25. The Unified Medical Language System (UMLS) is a project sponsored by the: A) National Library of Medicine B) CMS C) World Health Organization D) Office of Inspector General REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 332-333 Johns, 2nd Edition, p 228-229

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26. A patient is admitted with shortness of breath and hemoptysis. A chest X-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected. The principal diagnosis is the A) metastatic brain carcinoma B) small cell lung carcinoma C) hemoptysis D) pneumonia REFERENCE: Brown, p 19-20 Schraffenberger (2007), p 50-51 27. Jane Moore was admitted to the ambulatory care unit of the hospital for a planned cholecystectomy for cholelithiasis. Shortly before surgery, Jane developed tachycardia, and the surgery was canceled. After a thorough work-up for the tachycardia, Jane was discharged. This outpatient admission should be coded in the following sequence A) V code for canceled surgery, tachycardia, cholelithiasis B) Tachycardia, V code for canceled surgery, cholelithiasis C) Cholelithiasis, V code for canceled surgery D) Cholelithiasis, V code for canceled surgery, tachycardia REFERENCE: Brown, p 54-55 Schraffenberger (2007), p 40 28. A patient has a total abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes: 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s) with or without removal of ovary(s) 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure) This type of coding would be referred to as A) upcoding B) unbundling C) maximizing D) optimization REFERENCE: Buck, p 101, 117 Smith, p 52-53 29. A seventy-five year old female was admitted for repair of a hiatal hernia which was performed on the first day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur which was surgically reduced. Further complications included severe angina for which a cardiac catheterization and PTCA were performed. The principal procedure is A) Femur reduction B) Herniorrhaphy C) Catheterization D) PTCA REFERENCE: Brown, p 48 Schraffenberger (2007), p 43

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30. Code 402, Hypertensive Heart Disease would appropriately be used in which of the following situations? A) Left heart failure with benign hypertension B) Congestive heart failure; hypertension C) Hypertensive cardiovascular disease with congestive heart failure D) Cardiomegaly with hypertension REFERENCE: Brown, p 266-267 Hazelwood and Venable, p 141 Schraffenberger (2007) p113-115 Principles of ICD-9-CM Coding, p 214-219 31. A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. The correct code would be A) 414.8 Chronic MI B) 410.1x Acute MI C) 412 Old MI D) 413.0 Angina REFERENCE: Brown, p 255-256 Hazelwood and Venable, p 144-145 Schraffenberger (2007), p 120 32. Which of the following is classified as a poisoning in ICD-9-CM? A) Syncope due to Contac pills and a three martini lunch B) Digitalis intoxication C) Reaction to dye administered for pyelogram D) Idiosyncratic reaction between various drugs REFERENCE: Brown, p 337-338 Hazelwood and Venable, p 259-260 Schraffenberger (2007), p 236-237 Principles of ICD-9-CM Coding, p 322 33. Susan Dawn is status post mastectomy (six weeks) due to carcinoma of the breast. She is admitted to the outpatient clinic for chemotherapy. What is the correct sequencing of the codes? A) V58.1 chemotherapy; 174.9 malignant neoplasm of breast B) V58.1 chemotherapy; V10.3 personal history of neoplasm of the breast C) V67.00 follow-up exam after surgery; V58.1 chemotherapy D) V10.3 personal history of neoplasm of the breast; V58.1 chemotherapy REFERENCE: Coding Clinic, 2nd Quarter, 1990, p 7 Brown, p 300-301 Hazelwood and Venable, p 86-87 Schraffenberger (2007), p 70-71 34. Which of the following is coded as an adverse effect in ICD-9-CM? A) Mental retardation due to intracranial abscess B) Rejection of transplanted kidney C) Tinnitus due to allergic reaction after administration of ear drops D) Non-functioning pacemaker due to defective soldering REFERENCE: Brown, p 337 Hazelwood and Venable, p 255-256 Schraffenberger (2007), p 231-233

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35. A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as A) a referral B) a consultation C) risk factor intervention D) concurrent care REFERENCE: CPT (2007), p 14 Principles of CPT Coding, p 62-64 Smith, p 187 36. A patient with leukemia is admitted for chemotherapy five weeks after experiencing an acute myocardial infarction. How will the MI be coded? A) MI with 5th digit 1 - initial episode of care B) MI with 5th digit 2 - subsequent episode of care C) History of MI D) Chronic MI REFERENCE: Brown, p 255-256 Hazelwood and Venable, p 144-145 Schraffenberger (2007), p 118-120 37. In ICD-9-CM when an exploratory laparotomy is performed followed by a therapeutic procedure, the coder lists A) therapeutic procedure first, exploratory laparotomy second B) exploratory laparotomy, therapeutic procedure, closure of wound C) therapeutic procedure only D) exploratory laparotomy first, therapeutic procedure second REFERENCE: Brown, p 50 Schraffenberger (2007), p 37-38, 156 38. The most widely-discussed and debated unique patient identifier is the: A) patient's date of birth B) patient's first and last names C) patient's social security number D) Unique Physician Identification Number (UPIN) REFERENCE: Abdelhak, p 81 LaTour and Eichenwald-Maki, 2nd Edition, p 163 39. The Central Office on ICD-9-CM which publishes Coding Clinic is maintained by the A) National Center for Health Statistics B) Centers for Medicare and Medicaid Services C) American Hospital Association D) American Health Information Management Association REFERENCE: Abdelhak, p 232 Schraffenberger (2005), 2nd Edition, p 12 40. This is a listing translating codes from one system to another (i.e.: DSM to ICD-9-CM) A) encoder B) prospective payment system C) crosswalk D) chargemaster REFERENCE: Abdelhak, p 257

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41. A nomenclature of codes and medical terms which provides standard terminology for reporting physicians' services for third party reimbursement is A) Current Medical Information and Terminology (CMIT) B) Current Procedural Terminology (CPT) C) Systematized Nomenclature of Pathology (SNOP) D) Diagnostic and Statistical Manual of Mental Disorders (DSM) REFERENCE: Abdelhak, p 233 Schraffenberger (2005) 2nd Edition, p 7-8 LaTour and Eichenwald-Maki, 2nd Edition, p 310-311 42. A cancer program is surveyed for approval by the A) American Cancer Society B) Commission on Cancer of the American College of Surgeons C) State department of health D) Joint Commission on Accreditation of Healthcare Organizations REFERENCE: Abdelhak, p 264-265 Johns, 2nd Edition, p 403 LaTour and Eichenwald-Maki, 2nd Edition, p 291 43. Abstracting of cancer cases must be completed within ______ months from the date of diagnosis. A) three B) six C) nine D) twelve REFERENCE: Abdelhak, p 269 44. The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national and international levels. A) READ codes B) ABC codes C) SPECIALIST Lexicon D) LOINC REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 315 45. The Level II (national) codes of the HCPCS coding system are maintained by the A) American Medical Association B) CPT Editorial Panel C) local fiscal intermediary D) Centers for Medicare and Medicaid Services REFERENCE: Abdelhak, p 232 Schraffenberger (2005) 2nd Edition, p 8 Johns, 2nd Edition, p 208-210 46. A patient is admitted in alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis? A) alcoholic withdrawal B) chronic alcoholism C) cocaine dependence D) delirium tremens REFERENCE: Brown, p 113 Schraffenberger (2007), p 100

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47. A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia? A) Pseudomonas B) Clostridium C) Staphylococcus D) Listeria REFERENCE: Brown, p 87 48. The Level I (CPT) codes of the HCPCS coding system are maintained by the A) American Medical Association B) American Hospital Association C) local fiscal intermediary D) Centers for Medicare and Medicaid Services REFERENCE: Abdelhak, p 232 Schraffenberger (2005) 2nd Edition, p 7 Johns, 2nd Edition, p 208-210 49. A physician excises a 3.1 cm malignant lesion of the scalp which requires full thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded? A) Full thickness skin graft to scalp only B) Excision of lesion; Full-thickness skin graft to scalp C) Excision of lesion; Full-thickness skin graft to scalp; Excision of skin from thigh D) Code 15000 for surgical preparation of recipient site; Full-thickness skin graft to scalp REFERENCE: CPT Assistant, Vol. 7, #9, September 1997, p 1-3 Smith, p 64-65 50. A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit. A) -25 B) -55 C) -57 D) -58 REFERENCE: CPT (2007), p 437-439 Smith, p 184 51. A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued. A) -52 B) -53 C) -73 D) -74 REFERENCE: CPT (2007), p 437-439 Smith, p 42-43

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52. A patient has major surgery and sees the surgeon 10 days later for an unrelated E&M service. Indicate the modifier that should be attached to the E&M code for the service provided. A) -24 B) -25 C) -59 D) -79 REFERENCE: CPT (2007), p 437-439 Smith, p 182-183 53. A barrier to widespread use of automated code assignment is A) inadequate technology B) poor quality of documentation C) resistance by physicians D) resistance by HIM professionals REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 319 54. In assigning E&M codes, three key components are used. These are A) history, examination, counseling B) history, examination, time C) history, nature of presenting problem, time D) history, examination, medical-decision making REFERENCE: CPT (2007), p 3 Principles of CPT Coding, p 38 Smith, p 169 55. Mrs. Jones has an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit. A) -58 B) -76 C) -78 D) -79 REFERENCE: CPT (2007), p 437-439 Smith, p 45 56. The primary goal of a hospital-based cancer registry is to: A) improve patient care B) allocate hospital resources appropriately C) determine the need for professional and public education programs D) monitor cancer incidence REFERENCE: Abdelhak, p 264-265

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57. A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus. She is a type I diabetic and was brought under control and subsequently discharged. The following code was assigned: 648.03 Other current condition in the mother classifiable elsewhere but complicating pregnancy, childbirth of the puerperium, diabetes mellitus

Which of the following describe why the coding is in error? A) the incorrect 5th digit was used B) the condition should have been coded as gestational diabetes because she is pregnant C) an additional code describing the diabetes mellitus should be used D) only the code for the diabetes mellitus should have been used REFERENCE: Brown, p 214 Schraffenberger (2007), 177-178 Principles of ICD-9-CM Coding, p 154 58. A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a: A) disease index B) master patient index C) disease registry D) admissions register REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 289 59. After reviewing the following excerpt from CPT, code 27646 would be interpreted as: 27645 27646 27647 A) 27646 B) 27646 C) 27646 D) 27646 REFERENCE: radical resection of tumor, bone; tibia fibula talus or calcaneus radical resection of tumor, bone; radical resection of tumor, bone; radical resection of tumor, bone; radical resection of tumor, bone; Smith, p 18-19 Principles of CPT Coding, p 23 tibia and fibula fibula fibula or tibia fibula, talus or calcaneus

60. A patient was admitted to the hospital with hemiplegia and aphasia. The hemiplegia and aphasia were resolved before discharge and the patient was diagnosed with cerebral thrombosis. What is the correct coding and sequencing? A) hemiplegia; aphasia B) cerebral thrombosis C) cerebral thrombosis; hemiplegia; aphasia D) hemiplegia; cerebral thrombosis; aphasia REFERENCE: Brown, p 264 Hazelwood and Venable, p 151 Schraffenberger (2007), p 128

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61. A 36-year old woman was admitted to the hospital for an obstetrical delivery of her third child. During the admission, a sterilization procedure was performed for contraceptive purposes. The V25.2 code for sterilization would be: A) assigned as a principal diagnosis B) assigned as a secondary diagnosis C) not assigned since this was the patient's third child D) not assigned since it is the same admission as the delivery REFERENCE: Brown, p 220 Schraffenberger (2007), p 267-268 62. According to ICD-9-CM, which one of the following is not a mechanical complication of an internal implant? A) erosion of skin by pacemaker electrodes B) inflammation of urethra due to indwelling catheter C) leakage of breast prosthesis D) IUD embedded in uterine wall REFERENCE: Brown, p 348 Hazelwood and Venable, p 272-273 Schraffenberger (2007), p 240 Principles of ICD-9-CM Coding, p 327-328 63. A population-based cancer registry which is designed to determine rates and trends in a defined population is a (an): A) incidence-only population-based registry B) cancer control population-based registry C) research-oriented population-based registry D) patient care population-based registry REFERENCE: Abdelhak, p 265 Johns, 2nd Edition, p 141 LaTour and Eichenwald-Maki, 2nd Edition, p 290 64. Given the following diagnosis: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast". What is the primary cancer site(s)? A) axillary lymph nodes B) lungs C) breast D) both A & B REFERENCE: Brown, p 293 Hazelwood and Venable, p 93 Schraffenberger (2007), p 77 65. In the diagnosis, "first, second, and third degree burns of the chest wall," a code is required for A) the first degree burn only B) the second degree burn only C) the third degree burn only D) for each of the first, second and third degree burns REFERENCE: Brown, p 332 Hazelwood and Venable, p 246 Schraffenberger (2007), p 225-226 Principles of ICD-9-CM Coding, p 316-317

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66. When is it appropriate to use category V10, history of malignant neoplasm? A) primary malignancy recurred at original site and adjunct chemotherapy is directed at the site. B) primary malignancy has been eradicated and no adjunct treatment is being given at this time. C) primary malignancy eradicated and the patient is admitted for adjunct chemotherapy to primary site D) primary malignancy is eradicated; adjunct treatment is refused by patient even through there is some remaining malignancy REFERENCE: Brown, p 465-466 Schraffenberger (2007), p 70-71, 264-265 67. According to CPT, in which of the following cases would an established E&M code be used? A) A home visit with a 45 year old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. B) John and his family have just moved to town. John has asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician. C) Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago. D) A 78 year old female with weight loss and progressive agitation over the past two months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years. REFERENCE: CPT (2007), p 1 Buck, p 29 Principles of CPT Coding, p 39-41 CPT Assistant, Vol 8, #10, October 1998 Smith, p 168 68. The coding system used by AIDS registries is: A) ICD-9-CM B) ICD-0 C) CDC classification D) CPT-4 REFERENCE: Abdelhak, p 291 69. In order to use the inpatient CPT consultation codes, the consulting physician must: A) order diagnostic tests B) document his findings in the patient's medical record C) communicate orally his opinion to the attending physician D) use the term "referral" in his report REFERENCE: CPT (2007), p 14-15 Principles of CPT Coding, p 63 Buck, p 55-57 Smith, p 187

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70. The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination and utilizes moderate medical decision-making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests him and discuss treatment options. What codes should the consultant report for the two visits? A) an initial inpatient consult and a follow-up consult B) an initial inpatient consult for both visits C) an initial inpatient consult and a subsequent hospital visit D) an initial inpatient consult and initial hospital care REFERENCE: Principles of CPT Coding, p 66-67 71. According to the American Medical Association, medical decision-making is measured by all of the following except: A) number of diagnoses/management options B) amount and complexity of data reviewed C) risk of complications D) specialty of the treating physician REFERENCE: CPT (2007), p 7 Principles of CPT Coding, p 49-50 Smith, p 176-177 72. CPT provides Level I modifiers to explain all of the following situations except: A) when face-to-face services provided by a provider are greater than usually required for the highest level of E&M service for a given category B) when one surgeon provides only postoperative services C) when a patient sees a surgeon for follow-up care after surgery D) when the same laboratory test is repeated multiple times on the same day REFERENCE: CPT (2007), p 437-439 Principles of CPT Coding, p 479-499 73. The best place to ascertain the size of an excised lesion for accurate CPT coding is the: A) discharge summary B) pathology report C) operative report D) anesthesia record REFERENCE: Principles of CPT Coding, p 134 Smith, p 54 74. According to guidelines for CPT coding, the major factor to consider when determining whether or not to code lysis of adhesions is A) the type of surgery performed B) the complexity involved in lysing the adhesions C) the anatomical site that is being operated upon D) there is no factor because lysis of adhesions is never coded REFERENCE: Principles of CPT Coding, p 213-214

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75. In relation to bone grafts, an autograft A) refers to donor bone obtained from a bone bank B) is cancellous or bone cortex from the patient's own body C) is made of synthetic material D) is a whole piece of bone cortex from either a bone bank or the patient's own body REFERENCE: Principles of CPT Coding, p 141-142 76. Case definition is important for all types of registries. Age will certainly be an important criteria for accessing a case in a (n) ______________________registry: A) Implant B) Trauma C) HIV/AIDS D) Birth Defects REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 292 77. A patient is diagnosed with colon cancer in 2002 at Cedar Grove Hospital and is newly accessioned into the cancer registry. The medical record indicates a past history of prostate cancer. The accession number used prior to this patient was 02-95. This patient's accession number would be: A) 02-96/00 B) 02-96/01 C) 02-96/02 D) 02-96/01 (colon) and 02-96/02 (prostate) REFERENCE: Abdelhak, p 267-268 78. To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed? A) ICD-9-CM codes B) Evaluation and Management Codes C) HCPCS Level II Codes D) CPT codes REFERENCE: Schraffenberger (2005)2nd Edition, p 7-8 79. The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the: A) disease index B) tickler file C) accession register D) suspense file REFERENCE: Abdelhak, p 267-268 Johns, 2nd Edition, p 401-402 LaTour and Eichenwald-Maki, 2nd Edition, p 290 80. The reference date for a cancer registry is: A) January 1 of the year in which the registry was established B) the date when data collection began C) the date that the Cancer Committee is established D) the date that the cancer program applies for approval by the American College of Surgeons REFERENCE: Abdelhak, p 266

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81. The abstract completed on the patients in your hospital contains the following items: patient demographics; pre-hospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses this data for it's: A) AIDS registry B) diabetes registry C) implant registry D) trauma registry REFERENCE: Abdelhak, p 301-302 Johns, 2nd Edition, p 403-404 LaTour and Eichenwald-Maki, 2nd Edition, p 292 82. In relation to birth defects registries, active surveillance systems A) use trained staff to identify cases in all hospitals, clinics and other facilities through review of patient records, indexes, vital records and hospital logs B) are commonly used in all 50 states C) miss 10 to 30 percent of all cases D) rely on reports submitted by hospitals, clinics or other sources REFERENCE: Abdelhak, p 292 83. This type of registry uses either the CDC classification or the Walter Reed Army Institute of Research system for staging cases A) diabetes B) AIDS C) trauma D) birth defect REFERENCE: Abdelhak, p 291 84. In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to A) reliability B) validity C) completeness D) timeliness REFERENCE: Abdelhak, p 250 LaTour and Eichenwald-Maki, 2nd Edition, p 317 85. The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases which include data on inpatient whose care is paid for by third-party payers. HCUP is an initiative of the: A) Agency for Healthcare Research and Quality B) Centers for Medicare and Medicaid Services C) National Library of Medicine D) World Health Organization REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 299

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86. In regards to quality of coding, the degree to which the codes selected accurately reflect the diagnoses and procedures refer to: A) reliability B) validity C) completeness D) timeliness REFERENCE: Abdelhak, p 250 LaTour and Eichenwald-Maki, 2nd Edition, p 317 87. The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with: A) reliability B) validity C) completeness D) timeliness REFERENCE: Abdelhak, p 250 LaTour and Eichenwald-Maki, 2nd Edition, p 317 88. When coding free skin grafts, which of the following is not an essential item of data needed for accurate coding? A) recipient site B) donor site C) size of defect D) type of repair REFERENCE: Buck, p 147-148 Smith, p 64-66 89. In CPT, Category III codes include A) codes to describe emerging technologies B) codes to measure performance C) codes for use by non-physician practitioners D) codes for supplies, drugs, and durable medical equipment REFERENCE: CPT (2007), p 429 Buck, p 16-17 Smith, p 2-3 90. The information collected for your registry includes patient demographic information, diagnosis codes, functional status and histocompatibility information. This type of registry is a A) Birth Defects registry B) Diabetes registry C) Transplant registry D) Trauma registry REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 294

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91. In the ICD-9-CM classification system, shooting pain in the right eye due to the presence of an intact, correctly positioned permanent contact lens would be coded as: A) a current injury B) a late effect C) a mechanical complication of an internal prosthetic device D) an abnormal reaction of the body to the presence of an internal prosthetic device REFERENCE: Brown, p 348 Hazelwood and Venable, p 273 Schraffenberger (2007), p 241 92. In the ICD-9-CM classification system, severe shock due to third degree burns sustained in an industrial accident would be coded as A) a current injury B) a late effect C) a mechanical complication of an internal prosthetic device D) an abnormal reaction of the body to the presence of an internal prosthetic device REFERENCE: Brown, p 334 93. In the ICD-9-CM classification system, a non-functioning pacemaker due to the disintegration of the electrodes (leads) would be coded as A) a current injury B) a late effect C) a mechanical complication of an internal prosthetic device D) an abnormal reaction of the body to the presence of an internal prosthetic device REFERENCE: Brown, p 348 Hazelwood and Venable, p 272-273 Schraffenberger (2007) p 240 Principles of ICD-9-CM Coding, p 327-328 94. In the ICD-9-CM classification system, an esophageal stricture due to a burn received in a house fire several years ago would be coded as: A) a current injury B) a late effect C) a mechanical complication of an internal prosthetic device D) an abnormal reaction of the body to the presence of an internal prosthetic device REFERENCE: Brown, p 326-327 Hazelwood and Venable, p 50 Schraffenberger (2007), p 255 95. Dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as a (an): A) poisoning B) adverse reaction to a drug C) late effect of a poisoning D) late effect of an adverse reaction REFERENCE: Brown, p 338 Hazelwood and Venable, p 259 Schraffenberger (2007), p 236 Principles of ICD-9-CM Coding, p 322

Classification Systems, Registries and Indexing · 85

96. Tachycardia after taking a correct dosage of prescribed Lortab would be reported as a (an): A) poisoning B) adverse reaction to a drug C) late effect of a poisoning D) late effect of an adverse reaction REFERENCE: Brown, p 337 Hazelwood and Venable, p 255-256 Schraffenberger (2007), p 231-232 97. Blindness due to an allergic reaction to Ampicillin administered six years ago would be reported as a (an): A) poisoning B) adverse reaction to a drug C) late effect of a poisoning D) late effect of an adverse reaction REFERENCE: Brown, p 343 Hazelwood and Venable, p 256-257 Schraffenberger (2007), p 232 98. The patient underwent bypass surgery for life threatening coronary artery disease. With the aid of extracorporeal circulation, the right internal mammary artery was taken down to the left anterior descending artery and saphenous vein grafts were brought from the aorta to the diagonal, the right coronary artery and the posterior descending artery. What is the correct ICD-9-CM coding for this procedure? A) single internal mammary artery bypass; aortocoronary artery bypass of 3 vessels B) aortocoronary bypass of three coronary arteries C) aortocoronary bypass of four coronary arteries D) single internal mammary artery bypass; aortocoronary bypass of 3 vessels, extracorporeal circulation REFERENCE: Brown, p 277-279 Schraffenberger (2007), p 132-133 99. Patient Jamey Smith Doe has been seen at ABC Hospital 3 times prior to this current encounter. Unfortunately, due to clerical errors, Jamey's information was entered into the MPI incorrectly on the three previous admissions and consequently has 3 different medical record numbers. The unit numbering system is used at ABC Hospital. Jamey's previous entries into the MPI are as follows: 09/03/04 03/10/05 07/23/06 Jamey Smith Jamey Smith Doe Jamie Smith Doe MR# 10361 MR# 33998 MR# 36723

The next available number to be assigned at ABC Hospital is 41369. Duplicate entries in the MPI should be scrubbed and all of Jamey's medical records filed under medical record number: A) 10361 B) 33998 C) 36723 D) 41369 REFERENCE: Abdelhak, p 190

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100. The method of calculating errors in a coding audit that allows for benchmarking with other hospitals and permits the reviewer to track errors by case type is the: A) record method B) benchmarking method C) code method D) focused review method REFERENCE: Schraffenberger (2005) 2nd Edition, p 198 101. The most common type of registry located in hospitals of all sizes and in every region of the country is the: A) trauma registry B) cancer registry C) AIDS registry D) birth defects registry REFERENCE: Abdelhak, p 264 102. This code represents a HCPCS Level II National Code: A) W0166 B) 99281 C) J7030 D) 66690 REFERENCE: Abdelhak, p 234 Johns, 2nd Edition, p 208-209 103. A radiologist is asked to review a patient's CT scan that was taken at another facility. The modifier -26 attached to the code indicates that the physician is billing for what component of the procedure? A) professional B) technical C) global D) confirmatory REFERENCE: Buck, p 98, 317 Smith, p 147 104. When coding neoplasms, topography means A) cell structure and form B) site C) variation from normal tissue D) extent of the spread of the disease REFERENCE: Abdelhak, p 269 105. According to CPT, antepartum care includes all of the following except: A) initial and subsequent history B) physical examination C) monthly visits up to 36 weeks D) routine chemical urinalysis REFERENCE: Buck, p 264 Smith, p 124 Principles of CPT Coding, p 243-244

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106. The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of this data is: A) disease index B) operation index C) master patient index D) cancer registry abstracts REFERENCE: Abdelhak, p 264-265 LaTour and Eichenwald-Maki, 2nd Edition, p 290-291 107. A list or collection of clinical words or phrases with their meanings is a: A) data dictionary B) language C) medical nomenclature D) clinical vocabulary REFERENCE: LaTour and Eichenwald-Maki, 2nd Edition, p 306 108. The main difference between concurrent and retrospective coding is: A) when the coding is done B) what classification system is used C) the credentials of the coder D) the involvement of the physician REFERENCE: Schraffenberger (2005) 2nd Edition, p 26 109. A patient was discharged from the acute care hospital with a final diagnosis of bronchial asthma. As the coder reviews the record, she notes that the patient was described as having prolonged and intractable wheezing, airway obstruction which was not relieved by bronchodilators and the lab values showed decreased respiratory function. The coder queried the physician to determine whether the code for ________________ is appropriate to be added to the final diagnoses. A) acute and chronic bronchitis B) chronic obstructive pulmonary disease C) respiratory failure D) status asthmaticus REFERENCE: Schraffenberger (2007), p 143 Hazelwood and Venable, p 163-164 Brown, p 146 110. A patient is undergoing hemodialysis for end stage renal disease in the outpatient department of an acute care hospital. The patient develops what is believed to be severe heartburn but is sent to observation for several hours at which time the patient was admitted to inpatient care for further work-up. The cardiologist diagnosed the patient's problem as unstable angina. What is the principal diagnosis for the acute hospital stay? A) complications of hemodialysis B) heartburn C) unstable angina D) renal disease REFERENCE: Schraffenberger (2007), p 474 Hazelwood and Venable, p 392

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111. A patient is seen in the emergency room of an acute care hospital with tachycardia and hypotension. The patient had received an injection of tetanus toxoid (correct dosage) earlier at his primary care physician's office. Which of the following is the appropriate sequencing for this encounter? A) hypotension; tachycardia; accidental poisoning E code (tetanus toxoid) B) unspecified adverse reaction to tetanus toxoid; undetermined cause E code (tetanus toxoid) C) hypotension; tachycardia; therapeutic use E code (tetanus toxoid) D) poisoning code (tetanus toxoid); hypotension; tachycardia; accidental poisoning E code (tetanus toxoid) REFERENCE: Schraffenberger (2007), p 231-232 Hazelwood and Venable, p 255-257 Brown, p 337-338 112. A rare malignant tumor often associated with AIDS is: A) Kaposi's sarcoma B) glioblastoma multiforme C) pheochromocytoma D) melanoma REFERENCE: Schraffenberger (2007), p 64 Hazelwood and Venable, p 78 113. A PEG procedure would most likely be done to facilitate: A) breathing B) eating C) urination D) none of the above REFERENCE: Schraffenberger (2007), p 155 114. What ICD-9-CM coding scheme is used to show that a therapeutic abortion resulted in a live fetus? A) spontaneous abortion; V30 code to show a newborn birth B) code 644.21, early onset of delivery; V27 code (outcome of delivery) C) abortion by type; V27 code (outcome of delivery) D) therapeutic abortion REFERENCE: Schraffenberger (2007), p 170 Hazelwood and Venable, p 199 Brown, p 229 115. Prolonged pregnancy is a pregnancy that has advanced beyond _____ completed weeks of gestation: A) 39 B) 40 C) 41 D) 42 REFERENCE: Schraffenberger (2007), p 177 Hazelwood and Venable, p 200

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Answer Key for Classification Systems, Registries and Indexing NOTE: Explanations are provided for those questions that require mathematical calculations and questions that are not clearly explained in the references that are sited. 1. 2. A B M codes and E codes are never principal diagnosis codes and, in fact, are optional for coding. V-codes to describe the outcome of delivery are always secondary codes on the mother's chart.

3. 4. 5.

B C A Antivert is used for the management of nausea and dizziness associated with motion sickness and in vertigo associated with diseases affecting the vestibular system.

6. 7. 8. 9.

A C C A A coder should never assign a code on the basis of laboratory results alone. If findings are clearly outside of normal range and the physician has ordered additional testing or treatment, it is appropriate to consult with the physician as to whether a diagnosis should be added or whether the abnormal finding should be listed.

10. 11. 12.

A B D Pilocarpine is used to treat open-angle and angle-closure glaucoma to reduce intraocular pressure Digoxin is used for maintenance therapy in congestive heart failure, atrial fibrillation, atrial flutter and paroxysmal atrial tachycardia. Ibuprofen is an antiinflammatory drug. Oxytocin is used to initiate or improve uterine contractions at term and Haloperidol is used to manage psychotic disorders.

13. 14.

D C HCPCS codes (Levels I and II) would only give the code for any procedures that were performed and would not identify the diagnosis code or cause of the accident. The correct name of the nomenclature for athletic injuries is the Standard Nomenclature of Athletic Injuries and is used to identify sports injuries. It has not been revised since 1976.

15. 16.

D C

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Answer Key for Classification Systems, Registries and Indexing 17. B All three key components (history, physical examination, and medical decision making) are required for new patients and initial visits. At least two of the three key components are required for established patients, subsequent visits, and follow-up consultations.

18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

B D A B B A A A B D There are V codes which indicate various reasons for canceled surgery. Review codes V64.0x, V64.1, V64.2 and V64.3. As usual, the principal diagnosis is always the reason for admission, in this case, the cholelithiasis. The contraindication (the tachycardia) should also be coded.

28. 29.

B B The principal procedure is defined as the procedure performed for definitive treatment (rather than for diagnostic purposes) or one that was necessary to take care of the complication. If two or more procedures meet this definition, the one most related to the principal diagnosis is designated as the principal procedure. In order to use category 402 there must be a cause and effect relationship shown between the hypertension and the heart condition. "With" does not show this relationship nor does the fact that both conditions are listed on the same chart. The term "hypertensive" indicates a cause and effect relationship. An acute MI is considered to be anything under 8 weeks duration from the time of initial onset. A chronic MI is considered anything over 8 weeks with symptoms. An old MI is considered anything over 8 weeks with NO symptoms. A reaction due to mixing drugs and alcohol is coded as a poisoning. The patient is admitted for chemotherapy (V58.11) and since the breast cancer is still actively being treated, it is still coded as current.

30.

C

31.

B

32. 33.

A A

Classification Systems, Registries and Indexing · 91

Answer Key for Classification Systems, Registries and Indexing 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. C B B C C C C B B B B D D A A B C B A B D C A C C Mental retardation is a late effect, rejection of the kidney is a complication, and non-functioning pacemaker is a mechanical complication.

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Answer Key for Classification Systems, Registries and Indexing 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. B B B B A C C B C A B C The first visit would be an inpatient consult. Because the physician continued to treat the patient and participate in his care all subsequent visits are considered as subsequent hospital care and are no longer consults.

71. 72.

D C Modifier -21 may be used when the services that a physician provides are greater than those identified in the highest level of E&M visit. Modifier -55 is used by a physician who only provides postoperative services. Modifier -91 is used when a laboratory test is repeated multiple times on the same day. CPT code 99024 is used to report a follow-up visit after surgery.

73. 74. 75. 76. 77.

C B B D C Every case entered into the cancer registry gets an accession number which includes the year the patient was accessioned and a chronological number. A two digit number is added to indicate the number of primary cancers the patient has had. A patient who has two primaries will have a "02" added for the second primary.

78. 79.

D C

Classification Systems, Registries and Indexing · 93

Answer Key for Classification Systems, Registries and Indexing 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. B D A B A A B C B A C D A C B A B D D The procedure described includes 1 internal mammary artery which is not considered an aortocoronary bypass. There were three aortocoronary bypasses ­ aorta to diagonal, aorta to right coronary artery and aorta to the posterior descending artery. The description states that extracorporeal circulation was used.

99. 100. 101.

A A B

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Answer Key for Classification Systems, Registries and Indexing 102. C HCPCS Level I codes are 5 digit (numeric) codes found in the CPT book. HCPCS Level II National Codes are alphanumeric starting a letter A-V. HCPCS Level III Local Codes are alphanumeric starting with a letter W-Z. Level III codes were eliminated as of December 31, 2003. With CPT radiology codes, there are three components that have to be considered. These are the professional, technical and global components. The professional component describes the services of a physician who supervises the taking of an X-ray film and the interpretation with report of the results. The technical component describes the services of the person who uses the equipment, the film and other supplies. The global component describes the combination of both professional and technical components. If the billing radiologist's services include only the supervision and interpretation component, the radiologist bills the procedure code and adds the modifier -26 to indicate that he did only the professional component of the procedure.

103.

A

104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115.

B C D D A D C D A B B D

Classification Systems, Registries and Indexing · 95

REFERENCE LIST Abdelhak, Mervat; Grostick, Sara; Hanken, Mary Alice; Jacobs, Ellen. Health Information: Management of a Strategic Resource 2nd Edition. W.B. Saunders. Philadelphia, PA., 2004. Brown, Faye. ICD-9-CM Coding Handbook for 2007. American Hospital Association. Chicago, IL. 2006. Buck, Carol J. Step-by-Step Medical Coding 2006 Edition. W. B. Saunders. Philadelphia, PA., 2005. Coding Clinic. American Hospital Association. Chicago, IL. Hazelwood, Anita C. and Venable, Carol A. ICD-9-CM Diagnostic Coding and Reimbursement for Physician Services 2007. American Health Information Management Association. Chicago, IL. . Introduction to the ICD-9-CM Coding Book. Johns, Merida. Health Information Management Technology An Applied Approach, 2nd Edition. American Health Information Management Association. Chicago, IL, 2006. LaTour, Kathleen and Eichenwald-Maki, Shirley. Health Information Management: Concepts, Principles and Practice, 2nd Edition. American Health Information Management Association. Chicago, IL, 2006 Physicians' Current Procedural Terminology: Medical Association. Chicago, IL. 2006. CPT (2007), Professional Edition. American

Principles of CPT Coding, 4th Edition. American Medical Association. Chicago, IL. 2005. Principles of ICD-9-CM Coding 3rd Edition, American Medical Association. Chicago, IL. 2005. Rubin, Emanuel. Essential Pathology. Philadelphia, PA., 2001. 3rd Edition. Lippincott Williams and Wilkins.

Schraffenberger, Lou Ann. Effective Management of Coding Services, 2nd Edition. American Health Information Management Association. Chicago, IL. 2005. Schraffenberger, Lou Ann. Basic ICD-9-CM Coding. Management Association. Chicago, IL, 2006. American Health Information

Shannon, Margaret T. et al. Health Professionals Drug Guide 2004. Prentice Hall. Upper Saddle River, New Jersey, 2004. Smith, Gail. Basic CPT/HCPCS Coding 2006. Association. Chicago, IL. 2006. American Health Information Management

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