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Inpatient Coding Assessment

Name: Kimberly C. Clark, RHIT, CCS, CIRCC

Date: October 12, 2010

• Please code by National Coding Guidelines. DO NOT CODE BY YOUR HOSPITAL SPECIFIC
GUIDELINES.
• Please pick up all e-codes, but only use place of occurrence codes if it is included in the coding question.
• Please code both diagnoses and procedures if included in coding question.
• Codes should be sequenced to show principal diagnosis and principal procedure.

1. Patient admitted for sickle cell anemia crisis with acute chest syndrome.

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2. Pregnant female admitted at 39 weeks, GBS (+) carrier, no prenatal care, antepartum.

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3. Patient diagnosed with diabetic retinopathy with type I diabetes, controlled.

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4. Spontaneous abortion, incomplete, with a urinary tract infection.

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5. Patient is diagnosed with acute liver failure due to severe sepsis.

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6. Patient admitted through the ED with an acute anterolateral myocardial infarction and
treated during this hospitalization.

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7. Patient was admitted with unstable angina. Despite being treated with tissue
plasminogen activator (TPA), the angina evolved into an acute inferior myocardial
infarction. A right and left heart catheterization demonstrated 4-vessel coronary
artery disease. A coronary artery bypass graft (CABG) was recommended, which the
patient refused. What are the diagnosis and procedure code assignments?

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8. Premature labor at 22 3/7 weeks with a spontaneous delivery of a stillborn.

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9. Insertion of a biventricular pacer with internal cardiac defibrillator.

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10. Admission for acute renal failure due to benign prostatic hypertrophy with urinary
obstruction.

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11. Combined right and left heart catherization with placement of an Atrial Septal Defect
(ASD) occlusion device (closed technique).

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12. Acute onset of upper GI bleeding from a chronic gastric ulcer.

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13. Patient admitted with cerebral embolism with infarction causing aphasia. Patient has
a history of a previous CVA with the only residual of facial droop.

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14. First pregnancy in a 37 year-old female admitted due to complication of gestational

diabetes. Patient delivered at 39 weeks spontaneously a healthy baby girl. What are
the diagnoses and procedure code assignments?

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15. Patient admitted in congestive heart failure with rheumatic mitral valve and aortic
valve insufficiency.

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16. Hypertensive heart disease with acute systolic congestive heart failure.

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17. Admitted for interstitial seed implant in a patient with prostate cancer.

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18. Sepsis due to an indwelling urinary catheter.

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19. Severe bradycardia due to accidental double dose of digoxin.

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20. Patient with know HIV infection was admitted in acute respiratory failure and after
study it was found that patient’s respiratory failure was due to pneumocystis carinii
pneumonia.

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21. Patient admitted with acute osteomyelitis due to a diabetic calf ulcer, patient has type
II diabetes that is uncontrolled.

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22. Fall from steps resulting in a closed fracture of the head of the femur. Patient had an
open reduction of fracture of femur using a Jewett nail fixation.

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23. Repair of indirect inguinal hernia using a graft.

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24. Drug-eluting stents deployed into two coronary arteries with balloon angioplasty.

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25. Spontaneous delivery of a term, live infant, to a 27-year-old primagravida. Left

occipitoanterior presentation.

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26. Acute appendicitis with a perforated appendix and peritoneal abscess.

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27. Patient admitted for acute respiratory failure due to exacerbation of chronic
obstructive pulmonary disease (COPD), and also was diagnosed with congestive heart
failure and hypertension.

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28. Patient diagnosed with cholelithiasis and acute and chronic cholecystitis. Patient had
a laparoscopic cholecystectomy and intra-operative cholangiogram.

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29. Coronary artery bypass times four using exclusively arterial conduits: left internal
mammary artery to the LAD, in-situ right gastroepiploic artery anastomosis to the
right posterior descending coronary artery, two separate (aortocoronary) grafts using
left radial artery to the obtuse marginal and to the first diagonal arteries.

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30. A 27 year-old male is admitted for laparoscopic biliopancreatic diversion due to

morbid obesity. The patient was also found to have extensive adhesions and also had
lysis of adhesions. What are the diagnosis and procedure code assignments?

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