Question

134.     Identify the coding ambiguity(ies) in this assessment for a preoperative clearance:

This is a 72-year-old woman here for preoperative and physical prior to abdominal hysterectomy, bilateral salpingo-oophorectomy and tumor debulking surgery for likely ovarian cancer with metastases. It was recommended the patient have hemogram, CA-125, chest X ray, and electrocardiogram prior to the surgery. The ECG showed an atrioventricular bundle branch block, but it has been present without change for years. The other tests were normal.

1. The type of atrioventricular bundle branch block is not documented
2. It is unclear if “likely” describes the cancer, ovarian cancer, or metastases
3. Both A and B
4. Neither A or B

135.     In spina bifida:

1. The vertebra and membranes do not close completely around the spinal cord during development of the fetus
2. The channels in the vertebra through which the spinal cord travels are stenosed
3. The spine has degenerative joint disease and begins to compress
4. None of the above

136.     An embolism is comprised of:

1. Thrombus
2. Air
3. Fat
4. Alny of the above

137.     Which of the following is a risk factor for AAA?

1. Hypertension
2. Prematurity
3. Malnutrition
4. COPD

138.     What is the growth plate for bone called?

1. Basal plate
2. Nail plate
3. Physeal plate
4. Orbital plate

139.     For risk-adjustment purposes, who is responsible for errors in transcription in a medical record?

1. Transcriptionist
2. Author (physician)
3. MAO
4. CMS

140.     According to ICD-10-CM, how is Leigh’s disease classified?

1. Inflammatory disease of nervous system
2. Degenerative disease of nervous system
3. Demyelinating disease of CNS
4. Extrapyramidal and movement disorder

Answer 1

134. C. Both A and B

In ECG the present atrioventricular bundle branch block is present without change for years. So it is not documented. The cancer markers are normal. Hence it is unclear that it is cancer, ovarian cancer, or metastases

135. A. The vertebra and membranes do not close completely around the spinal cord during development of the fetus.

Spina bifida is a birth defect in which there is incomplete closing of the spine and the membranes around the spinal cord during early development in pregnancy. There are three main types: spina bifida occulta, meningocele and myelomeningocele.

136. D. All of the above

Embolism is blockage of blood vessel. The embolus may be a blood clot (thrombus), a fat globule (fat embolism), a bubble of air or other gas (gas embolism), or foreign material.

137. A. Hypertension

The main risk factors are age older than 65 years, male sex, and smoking history. Other risk factors include a family history of abdominal aortic aneurysm, coronary artery disease, hypertension, peripheral artery disease, and previous myocardial infarction.

138. C. Physeal plate

The growth plate, also known as the epiphyseal plate or physis, is the area of growing tissue near the ends of the long bones in children and adolescents.

139. A. Transcriptionist

The transcriptionists are trained professionals, but they are not doctors. Yet it has become standard practice for transcriptionists to correct what they know are errors in transcription

140. B. Degenerative disease of nervous system

Leigh syndrome is a severe neurological disorder that usually becomes apparent in the first year of life.