Praxis II: School Psychologist

Correct: Mitral stenosis is the correct medical term for the narrowing of the mitral valve opening, which is located between the left atrium and the left ventricle. In a coding and audit context, identifying the specific valve and the nature of the pathology (narrowing vs. leaking) is essential for diagnostic accuracy and proper risk adjustment.

Incorrect: Mitral regurgitation refers to a condition where the mitral valve does not close tightly, allowing blood to flow backward into the left atrium, rather than a narrowing of the opening. Aortic stenosis refers to the narrowing of the aortic valve, which is located between the left ventricle and the aorta, not between the atrium and ventricle. Mitral valve prolapse is a condition where the valve’s leaflets bulge into the left atrium during contraction, which is a structural abnormality distinct from the narrowing defined as stenosis.

Takeaway: Internal auditors in healthcare environments must distinguish between specific valvular pathologies, such as stenosis and regurgitation, to ensure the integrity of diagnostic coding and financial reporting.

Correct: According to ICD-10-CM guidelines and instructional notes, when a code for a specific condition (such as a peritoneal abscess under category K65) does not identify the causative organism, a supplemental code from categories B95-B97 must be assigned. The instructional note ‘Use additional code’ specifically directs the coder to identify the bacterial, viral, or fungal agent to provide a complete clinical picture of the digestive system infection.

Incorrect: Reporting the bacterial organism as the principal diagnosis is incorrect because codes from categories B95-B97 are designed to be used as supplementary codes and are never sequenced first. Using a general post-procedural infection code like T81.4 is inappropriate when a more specific site-based code like K65.1 is available. Omitting the organism code is a failure to follow the ‘Use additional code’ instruction, which is mandatory for accurate clinical documentation and billing.

Takeaway: In medical coding for infections, always sequence the clinical manifestation first and use a supplemental code from the B95-B97 range to identify the specific infectious agent as directed by instructional notes.

Correct: Histamine is a vasoactive amine stored in mast cell granules and is one of the first mediators released during an acute inflammatory response. It is primarily responsible for the immediate, transient phase of increased vascular permeability by causing contraction of endothelial cells, which creates gaps in the postcapillary venules.

Incorrect: Prostaglandins are lipid-derived mediators synthesized via the cyclooxygenase pathway that primarily contribute to vasodilation, pain, and fever rather than the immediate increase in permeability. Leukotrienes are also lipid-derived but are generally involved in later stages of inflammation and are potent bronchoconstrictors. Interleukin-1 is a cytokine that mediates systemic effects like fever and the activation of leukocytes and endothelial cells, rather than the immediate vascular changes seen in the earliest moments of inflammation.

Takeaway: Histamine is the primary chemical mediator responsible for the immediate vascular changes, such as vasodilation and increased permeability, in the early stages of acute inflammation.

Correct: According to ICD-10-CM guidelines, when an infection is documented as being resistant to antibiotics, the coder should first assign the code for the infection itself (the condition). A secondary code from category Z16 (Resistance to antimicrobial drugs) is then assigned to identify the resistance, provided there is not a specific combination code that already includes the resistance (such as MRSA). This ensures both the anatomical site and the drug-resistant nature of the pathogen are captured for risk adjustment and clinical tracking.

Incorrect: Sequencing the resistance code as the primary diagnosis is incorrect because the infection itself is the primary reason for the encounter and treatment. While combination codes exist for some specific organisms like MRSA, they are not available for all multi-drug resistant organisms, making the Z16 category the standard supplemental requirement. HCPCS Level II modifiers are used for procedures, supplies, or specific services, and are not used to identify the clinical nature of a pathogen or drug resistance in diagnosis coding.

Takeaway: When coding antibiotic-resistant infections, the infection code is sequenced first, followed by a Z16 category code to specify the drug resistance.

Correct: Logic-based alerts or encoder prompts serve as a robust preventative control by forcing the coder to address instructional notes like “Code also” in real-time. This ensures that the underlying etiology or required secondary manifestations are captured according to ICD-10-CM conventions, thereby reducing the risk of claim denials or compliance audits due to incomplete reporting or incorrect sequencing.

Incorrect: Annual seminars improve general knowledge but do not provide the immediate, case-specific guidance needed to prevent individual coding omissions during the workflow. Manual reconciliation of every tenth patient is a detective control that lacks the coverage and immediacy of automated alerts. Peer-reviewing for typographical errors addresses data entry accuracy but does not specifically target the complex logic required for instructional notes or sequencing instructions.

Takeaway: Real-time automated prompts are the most reliable control for ensuring that coders adhere to specific ICD-10-CM instructional notes and sequencing requirements.

Correct: First-pass metabolism is a critical physiological concept in dosage calculations. When a drug is administered orally, it is absorbed by the digestive system and enters the hepatic portal system, where it is carried to the liver. The liver metabolizes a portion of the drug before it ever reaches the systemic circulation (the cardiovascular system). This necessitates a higher oral dose compared to an intravenous dose, as the latter bypasses the liver’s initial metabolic process, ensuring 100% bioavailability immediately.

Incorrect: Renal clearance refers to the excretion of drugs by the kidneys and does not explain the initial difference in bioavailability between oral and IV routes. The blood-brain barrier is a highly selective semipermeable border that protects the brain, but it does not filter medications in the stomach. Skeletal sequestration is not a standard pharmacological principle used to justify doubling dosages for muscular patients; dosage is typically based on total body weight or surface area rather than bone marrow absorption.

Takeaway: Internal auditors must recognize that first-pass metabolism in the liver is the primary physiological reason why oral and intravenous dosages are not equivalent in concentration.

Correct: Non-selective NSAIDs inhibit the COX-1 enzyme, which is responsible for maintaining the protective mucosal lining of the stomach. Chronic use significantly increases the risk of gastric ulcers and GI bleeding. A control that ensures the concurrent use of gastroprotective agents (like PPIs) for high-risk, long-term users directly mitigates the physiological risk to the digestive system, thereby reducing the bank’s potential liability for health-related disability claims.

Incorrect: Implementing a hard-stop based solely on a skeletal diagnosis is an administrative control that does not address the underlying physiological risk of the medication itself. Quarterly expenditure audits are financial controls that monitor budget adherence but do not mitigate the clinical or health-related risks of the medication. Transitioning patients to opioids is an inappropriate risk response as it replaces GI risks with significantly higher risks of dependency, respiratory depression, and neurological impairment.

Takeaway: Effective risk management for health-related policies requires integrating clinical knowledge of drug-organ interactions with proactive monitoring controls to prevent long-term liability.

Correct: Intramuscular (IM) injections are designed to deliver medication deep into the skeletal muscle tissue. Anatomically, this requires the needle to pass through the epidermis, the dermis, and the hypodermis (subcutaneous adipose tissue) to reach the muscle layer. In medical coding and clinical documentation, the distinction between IM and subcutaneous routes is critical for both clinical efficacy and accurate billing.

Incorrect: Depositing medication into the connective tissue of the dermis describes an intradermal injection, which is typically used for allergy testing or TB screenings. Depositing medication into the subcutaneous adipose tissue describes a subcutaneous injection, which was the specific route the whistleblower alleged was being upcoded. The epidermis is the outermost layer of the skin and does not contain the vascularity or depth required for systemic medication administration via injection.

Takeaway: Accurate coding of injection routes requires a precise understanding of anatomical layers to distinguish between intramuscular, subcutaneous, and intradermal administration for compliance and reimbursement purposes.