CHAPTER 1: YOUR CAREER AS A MEDICAL CODER
Answers to Checkpoint Questions
Checkpoint 1.1
In your opinion, is each of the following diagnoses and procedures correctly linked to show medical
necessity? Why or why not?
1. Diagnosis: deviated septum
Procedure: nasal surgery Yes, nasal surgery is ...
chapter 1 your career as a medical coder answers to checkpoint questions checkpoint 11 in your opinion
is each of the following diagnoses and proced
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Conquer Medical Coding 2018
CHAPTER 1: YOUR CAREER AS A MEDICAL CODER
Answers to Checkpoint Questions
Checkpoint 1.1
In your opinion, is each of the following diagnoses and procedures correctly linked to show medical
necessity? Why or why not?
1. Diagnosis: deviated septum
Procedure: nasal surgery Yes, nasal surgery is medically necessary for treating that condition once other
options such as medication have been provided.
2. Diagnosis: mole on a female patient’s cheek, questionable nature
Procedure: surgical removal and biopsy Yes, once a mole is considered of questionable nature it is
medically necessary to biopsy it to determine if it is a malignancy.
3. Diagnosis: male syndrome hair loss
Procedure: implant hair plugs on scalp. No, this would be considered a cosmetic procedure and would
not be covered by insurance.
4. Diagnosis: probable broken wrist
Procedure: comprehensive full-body examination, with complete set of lab tests, chest x-ray, and
ECG No, a probably broken wrist would not require such an extensive workup. The physician would
most likely do an examination and possibly an x-ray of the wrist. The other services would not be
medically necessary.
Checkpoint 1.2
In which type of environment would you prefer to be employed? Why?
The answers will vary, but in a medical school physician group the opportunities for learning all
aspects of coding and reimbursement are available and the potential for advancement to higher
career levels are also available.
Checkpoint 1.3
The following chart note contains typical documentation abbreviations and shortened forms for words.
65-yo female; hx of right breast ca seen in SurgiCenter for bx of breast mass. Frozen
section reported as benign tumor. Bleeding followed the biopsy. Reopened the breast
along site of previous incision with coagulation of bleeders. Wound sutured. Pt adm. for
observation of post-op bleeding. Discharged with no bleeding recurrence.
Final Dx: Benign neoplasm, left breast.
Research each abbreviation using an online resource and record their meanings on the lines provided.
1. yo Year old
2. hx History
3. ca Cancer
4. bx Biopsy
5. Pt Patient
6. adm Admitted
7. op Operative
8. Dx Diagnosis
, Checkpoint 1.4
Consider medical ethics, and answer the questions that follow.
1. Sallie Smith, who works for the Clark Clinic, ordered medical office supplies from her cousin, David
Hand. When the supplies arrived, David came to the office to check on them and to take Sallie out to
lunch.
Is Sallie’s purchase of supplies from her cousin ethical? Why or why not? No.
Rationale: This is a conflict of interest. No attempt was made to find the best price for the supplies,
and there is a personal relationship with the supplier and an implied benefit to the employee.
2. Davon Singh is a medical coder in the practice of Dr. Karen Kline. During the past few weeks,
Dr. Kline has consistently written down codes that stand for 1-hour appointments, but Davon knows that
these visits were all very short, no longer than 15 minutes each. Is it ethical for Davon to code these visits
as hour-long appointments? No.
Rationale: A medical coder would approach the physician or review the documentation to determine
why the physician used those codes. If the visit was 15 minutes and based on time because it was for
a discussion with the patient, the appropriate 15-minute code would be used. If the visit was based on
the key components the coder would review the documentation to determine if the key components
met the criteria for the higher code. This issue is covered in more detail in chapters 13 and 14.
Checkpoint 1.5
1. Visit AHIMA’s website for information about certification (www.ahima.org/certification), and review
the criteria for applying for the CCS versus the CCA examinations. Report on the major differences in
their requirements.
ANS: The CCA candidate requires a U.S. high school diploma or equivalent.
The CCS candidate must have one of the following criteria:
By Credential: RHIA®, RHIT®, or CCS-P®
OR
By Education: Completion of a coding training program that includes anatomy and physiology,
pathophysiology, pharmacology, medical terminology, reimbursement methodology,
intermediate/advanced ICD diagnostic/procedural and CPT coding;
OR
By Experience: Minimum of two (2) years of related coding experience directly applying codes; OR
By Credential With Experience: CCA® plus one (1) year of coding experience directly applying codes;
OR
Other Coding credential from other certifying organization plus one (1) year coding experience
directly applying codes.
2. Visit the AAPC website to learn more about certification (www.aapc.com/certification), and report on
three of the certifications that are offered.
ANS: CPC certified professional coder
CPC-H: certified professional coder—outpatient hospital
CPC-P: certified professional coder—payer
Answers to Review Questions
Matching
A. health information management E. code set
(HIM) F. compliance
B. ethics G. diagnosis code
C. provider H. certification
D. medical necessity I. documentation
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