CCA prep exam 200 questions

200 Preguntes  I  By Melodey23
CCA prep exam 200 questions
200 Practice questions

  
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1.  From the information provided, how many APCs would this patient have? (See handout if table is not aligned) Billing        Status          CPT/HCPCS     APC Number     Indicator 998323       V                  99285-25          0612 998324       T                  25500                0044 998325       X                  72050                0261 998326       S                  72128                0283 998327       S                  70450                0283  
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2.  Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court?
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3.  If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?
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4.  Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens.
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5.  Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for _________.
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6.  The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds. "In which of the following would this documentation appear?
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7.  Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ________.
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8.  While the focus of inpatient data collection in the UHDDS is on principal diagnosis, the focus of outpatient data collection in the UACDS is on ___________.
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9.  A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations? 410.00     Myocardial infarction of anterolateral wall, episode unspecified 410.01     Myocardial infarction of anterolateral wall, initial episode 410.40     Myocardial infarction of inferior wall, episode unspecified 410.41     Myocardial infarction of inferior wall, initial episode 410.42     Myocardial infarction of inferior wall, subsequent episode 427           Cardiac dysrhythmias 427.3                Atrial fibrillation and flutter 427.31              Atrial fibrillation 786.50     Chest pain, unspecified 36.13        Aortocoronary bypass of three coronary arteries
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10.  A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?
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11.  Identify the correct diagnosis code for lipoma of the face.
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12.  A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease (COPD). Which of the following would be the correct coding and sequencing for this case?
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13.  A statement or guideline that directs decision making or behavior is called a ____________.
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14.  According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
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15.  The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:
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16.  Which of the following dictates how the medical staff operates?
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17.  A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?
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18.  To be in compliance with HIPAA regulations, a hospital would make its membership in a RHIO known to its patients through which of the following?
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19.  Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment?
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20.  In long-term care, the resident's care plan is based on data collected in the _____________.
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21.  In a managed fee-for service agreement, which of the following would be used as a cost-control process for inpatient surgical services?
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22.  An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis". How should the coder proceed to code this case?
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23.  Patient admitted with major depression, recurrent, severe.
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24.  Identify the appropriate CPT code(s) for a routine EKG with 15 leads, with the physician providing only the interpretation and report
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25.  Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
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26.  A female patient is admitted for stress incontinence. A urethral suspension is performed.
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27.  Which of the following is a secondary purpose of the health record?
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28.  In the relational database here the patient table and the visit table are related by _________.                Patient Table Patient#   Last Name     First Name       DOB 021234     Smith              Donna               03/21/1944 022366     Jones             William              04/09/1960 034457     Collins            Mary                   08/21/1977                Visit Table Visit#            Date of Visit      Practitioner#     Patient# 0045678    11/12/2008         456                     021234 0045679    11/12/2008         997                     021234 0045680    11/12/2008         456                     034457  
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29.  Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called _________.
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30.  A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?
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31.  The following is documented in an acute care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear?
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32.  According to the UHDDS, which of the following is the definition of "other diagnoses"?
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33.  A nurse is responsible for which of the following types of acute care documentation?
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34.  The attending physician is responsible for which of the following types of acute care documentations?
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35.  Identify the diagnosis code(s) for benign melanoma of skin of shoulder.
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36.  Employees in the Hospital Busines Office may have legitimate access to patient health information without patient authorization based on what HIPAA standard/principle?
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37.  Which of the following statements is not true abount a business associate agreement?
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38.  Which stage of the litigation process focuses on how strong a case the opposing party has?
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39.  Dr. Williams is on the medical staff of Sutter Hospital and he has asked to see the health record of his wife who was recently hospitalized. Dr. Jones was the patient's physician. Of the options listed here, which is the best course of action?
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40.  Prospective payment systems were developed by the federal government to:
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41.  What are the five-digit ICD-9-CM diagnosis code referred to as?
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42.  Which of the following materials is not documented in an emergency care record?
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43.  The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) and/or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting?
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44.  A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebullizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
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45.  Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
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46.  Which of the following statements is false?
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47.  These codes are used to assign a diagnosis to a patient who is seeking health services, but is not necessarily sick.
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48.  Identify where the following information would be found in the acute care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine".
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49.  The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality elements is mjissing from Mrs. Smith's health record?
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50.  A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
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51.  Fee schedules are updated by third-party payers _____________.
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52.  Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
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53.  Privacy can be defined as the ________.
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54.  Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket:
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55.  Messaging standards for electronic data interchange in healthcare have been developed by ___________.
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56.  Patient with flank pain was admitted and found to have a calculus of the kidney. Ureteroscopy with placement of ureteral stents was performed.
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57.  In designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions is the E1384 standard promulgated by the:
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58.  A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case.
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59.  A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
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60.  The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as carcinoma on the discharge summary. This is an example of a problem with:
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61.  A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
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62.  Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
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63.  Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals?
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64.  Use of the health record to monitor bioterrorism activity is considered a ______________
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65.  Which of the following must be reported to the medical examiner?
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66.  Which of the following statements does not apply to ICD-9-CM?
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67.  The following is documented in an acute care record: "Admit to 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear?
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68.  Diagnosis-related groups are organized into __________.
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69.  Which of the following represents documentation of the patient's current and past health status?
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70.  The patient was admitted with nausea, vomitting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nauea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this case?
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71.  Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ________________ review.
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72.  Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness.
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73.  Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
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74.  Which of the following is a condition that arises during hospitalization?
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75.  Written or spoken permission to proceed with care is classified as ___________.
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76.  A patient was discharged with the following diagnoses: "Cerebral occlusion, hemiparesis, aspasia, and hypertension." Which of the following code assignments would be appropriate for this case? 342.90   Hemiparesis affecting unspecified side 342.91   Hemiparesis affecting dominant side 342.92   Hemiparesis affecting nondominant side 434.90   Cerebral artery occlusion unspecified, without mention of cerebral infarction 434.91   Cerebral artery occlusion unspecified with cerebral infarction 401                   Hypertension 401.0                Malignant hypertension 401.1                Benign hypertension 401.9                Unspecified hypertension 428.0     Congestive heart failure 784.3     Aphasia
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77.  A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
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78.  In conducting a qualitative review the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
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79.  The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the ________.
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80.  A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a POMR progress note would this notation be written?
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81.  Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
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82.  A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastatic. Which of the following is the correct coding and sequencing for the current hospital stay?
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83.  Which of the following provides a set of codes used for collecting data abount substance abuse and mental health disorders?
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84.  The protection measures and tools for safeguarding information and information systems is a definition of:
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85.  Identify where the following information would be found in the acute care record. Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.
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86.  The ______ mandated the development of standards for electronic medical records.
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87.  A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?
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88.  What are four-digit ICD-9-CM diagnosis codes referred to as?
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89.  Which type of patient care record includes documentation of a family bereavement period?
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90.  CPT codes describing endovascular repair of the descending thoracic aorta include all of the following procedures except one. Which procedure is not included in the repair code?
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91.  A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia, which is the correct code assignment?
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92.  Which of the following is not true of notices of privacy practices?
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93.  What is the function of a consultation report?
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94.  Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure
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95.  Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
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96.  The legal health record is a(n) _____________.
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97.  Which of the following would a health record technician use to perform the billing function for a physician's office?
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98.  Which of the following is not a characteristic of high-quality healthcare data?
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99.  If another status T procedure were performed, how much would the facility receive for the second status T procedure? (See handout if table is not aligned) Billing         Status       CPT/HCPCS     APC Number     Indicator 998323       V                  99285-25      0612 998324       T                  25500            0044 998325       X                  72050            0261 998326       S                  72128            0283 998327       S                  70450            0283
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100.  A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?
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101.  Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?
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102.  The folowing is documented in an acute care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear?
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103.  Which of the following contains the physician's findings based on an examination of the patient?
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104.  The HIM department is planning to scan noneelectronic medical record documentation. The project include the scanning of health record documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalizations?
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105.  Law enacted by a legislative body is a(n) _________.
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106.  A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent an intradiscal electrothermal annuloplasy (IDET) in the radiology suite. What ICD-9-CM code should be used?
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107.  CPT Category III code can be used by what groups of providers
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108.  Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?
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109.  Which of the following is a written description of an organization's formal position?
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110.  Which organization originally published ICD-9-CM?
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111.  To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________ days.
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112.  What is it called when accrediting bodies such as the Joint Commission or American Osteopathic Association (AOA) Healthcare Facilities Accreditation Program can survey facilities for compliance with the Medicare Conditions of Participation of Hospitals instead of the government?
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113.  A special Web page that offers secure access to data is called a(n):
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114.  Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2?
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115.  When a provider accepts assignment, this means the __________.
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116.  The __________ notifies physicians that Medicare payments to the facility is partly based on the patient's principal and secondary diagnoses, as well as the major procedures performed, and that falsification of records can lead to fines, imprisonment, or civil penalty under federal laws.
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117.  Which of the following is a standard terminology used to code medical procedures and services?
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118.  Which of the following ICD-9-CM codes are always alphanumeric
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119.  A coding audit shows that an impatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
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120.  Adoption of the Minimum Standards marked the beginning of this modern __________ process for healthcare organizations.
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121.  A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.
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122.  Which of the following tasks may not be performed in an electronic health record system?
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123.  Given the following information, which of the following statements is correct? Given the following information, which of the following statements is correct? (see handout if table is not aligned) MS-DRG    MDC  Type      MS-DRG Title                                 Weight      Discharges      Geometric       Arithmetic                                                                                                                                                               Mean             Mean 191              04      MED     Chronic obstructive                       0.9757          10                          4.1                  5.0                                               pulmonary disease w CC 192              04      MED     Chronic obstructive                       0.7254           20                         3.3                  4.0                                               pulmonary disease                                               w/o CC/MCC 193              04      MED     Simple pneumonia &                    1.4327         10                          5.4                  6.7                                               pleurisy w MCC 194              04      MED     Simple pneumonia &                    1.0056         20                          4.4                  5.3                                                pleurisy w CC 195              04      MED     Simple pneumonia &                    0.7316         10                          3.5                  4.1
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124.  In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation wouild a coder look for to substantiate the diagnosis of aspiration pneumonia (PNA)
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125.  Which of the following elements is not a component of most patient records?
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126.  An encoder that takes a coder through a series of questions and choices is called a(n):
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127.  The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:
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128.  If a patient's total outpatient bill is $500, and the patient's healthcare insurance plan pays 80 percent of the allowable charges, what is the amount the patient is responsible?
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129.  Which of the following is not an element of data quality?
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130.  The key data element for linking data about an individual who is seen in a variety of care settings is the _________.
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131.  The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?
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132.  Which of the following spells out the powers of the three branches of the federal government?
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133.  A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written?
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134.  The sum of a hospital's relative DRG rates for a year was 15,192 and the hospital had 10,471 discharges for the year. Given this information what would be the hospital's case-mix index for that year?
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135.  Data definition refers to _________.
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136.  In which setting may treatment records travel with the patient between treatment centers?
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137.  Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient retruns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment?
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138.  Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
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139.  Accreditation standards and the Medicare Conditions of Participation require that the patient's __________ be documented by the attending physician in the patient's health record no more than 30 days after discharge.
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140.  The following is documented in an acute care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear?
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141.  The goal of coding compliance programs is to prevent _________.
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142.  Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?
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143.  A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient?
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144.  Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
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145.  Identify where the following information would be found in the acute care record:  "CBC; WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93".
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146.  Electronic system used by nurses and physicians to document assessments and findings are called:
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147.  Which of the following is an example of clinical data?
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148.  What is the legal term used to define the protection of health information in a patient-provider relationship?
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149.  What is the term used in reference to the systematic review of sample health records to determine whether health record documentation standards are being met?
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150.  A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.
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151.  Dr. Smith sees his patient, Bob Jones, in the nursing home where he has resided for 11 months. Bob is stable and happy, and Dr. Smith performs an annual physical examination and completes the minimum data set instrument. He performs and documents a detailed interval history, comprehensive examination, and performs medical decision making of low complexity. Assign the appropriate CPT code.
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152.  In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
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153.  What is the defining characteristic of an integrated health record format?
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154.  Attorneys for healthcare organizations use the health record to _________.
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155.  A 35-year-old male was admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure.
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156.  In a problem-oriented medical record, problems are organized ________.
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157.  Use of the health record by a clinician to facilitate quality patient care is considered _____________
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158.  What is the functions of physician's orders?
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