CCA prep exam 200 questions

200 Preguntes  I  By Melodey23
200 Practice questions

  
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1.  Which of the following is not an element of data quality?
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2.  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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3.  Which organization originally published ICD-9-CM?
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4.  Which of the following dictates how the medical staff operates?
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5.  Identify the diagnosis code(s) for benign melanoma of skin of shoulder.
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6.  Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusions of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied, which is the correct code assignment?
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7.  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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8.  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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9.  What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?
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10.  Fee schedules are updated by third-party payers _____________.
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11.  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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12.  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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13.  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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14.  In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following?
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15.  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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16.  What is the function of a consultation report?
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17.  Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called _________.
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18.  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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19.  Privacy can be defined as the ________.
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20.  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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21.  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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22.  Exceptions to the consent requirement include:
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23.  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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24.  The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the __________.
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25.  Community Hospital is launching a clinical documentation improvement initiative because currently clinical documentation does not always adequately reflect the severity of illiness of the patient and does not support optimal HIM coding quality and accuracy. Given the situation, which of the following would be the best action to provide improved documentation for patient care and coding?
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26.  Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?
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27.  Which of the following tasks may not be performed in an electronic health record system?
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28.  A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.
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29.  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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30.  Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket:
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31.  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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32.  Which of the following best describes data completeness?
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33.  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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34.  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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35.  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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36.  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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37.  Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals?
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38.  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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39.  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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40.  In a problem-oriented medical record, problems are organized ________.
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41.  Which of the following federal laws passed in 1996 resulted in new privacy regulations for healthcare organizations?
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42.  Electronic system used by nurses and physicians to document assessments and findings are called:
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43.  Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?
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44.  A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.
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45.  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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46.  What are four-digit ICD-9-CM diagnosis codes referred to as?
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47.  Identify the correct diagnosis code for lipoma of the face.
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48.  A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnose are equally treated. The correct coding and sequencing for this case would be:
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49.  Messaging standards for electronic data interchange in healthcare have been developed by ___________.
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50.  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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51.  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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52.  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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53.  Adoption of the Minimum Standards marked the beginning of this modern __________ process for healthcare organizations.
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54.  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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55.  What are the five-digit ICD-9-CM diagnosis code referred to as?
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56.  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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57.  What is the defining characteristic of an integrated health record format?
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58.  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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59.  What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?
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60.  A statement or guideline that directs decision making or behavior is called a ____________.
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61.  Which of the following ICD-9-CM codes are always alphanumeric
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62.  Use of the health record to monitor bioterrorism activity is considered a ______________
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63.  The ability to electronically send data from one electronic system to a different elctronic system and still retain its meaning is called _____________.  
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64.  A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission?
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65.  A 65-year-old woman is admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?
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66.  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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67.  Diagnosis-related groups are organized into __________.
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68.  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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69.  CPT Category III code can be used by what groups of providers
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70.  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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71.  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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72.  Law enacted by a legislative body is a(n) _________.
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73.  Which of the following must be reported to the medical examiner?
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74.  Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness.
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75.  When coding benign neoplasm of the skin, the section noted here directs the coder to: 216   Benign Neoplasm of Skin                   Includes:                            Blue Nevus                             Dermatofibroma                            Hydrocystoma                            Pigmented Nevus                            Syringoadenoma                            Syringoma                   Excludes:                             Skin of genital organs (221.0-222.9) 216.0   Skin of lip                    Excludes:                              Vermilion border of lip (210.0) 216.1   Eyelid, including canthus                    Excludes:                               Cartilage of eyelid (215.0)
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76.  A patient seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out chest pain versus GERD". The correct ICD-9-CM code is:
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77.  Patient admitted with major depression, recurrent, severe.
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78.  Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?
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79.  Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens.
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80.  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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81.  When a provider accepts assignment, this means the __________.
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82.  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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83.  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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84.  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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85.  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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86.  The attending physician is responsible for which of the following types of acute care documentations?
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87.  Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
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88.  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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89.  Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
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90.  Which type of patient care record includes documentation of a family bereavement period?
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91.  Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedures?
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92.  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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93.  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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94.  Which of the following materials is not documented in an emergency care record?
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95.  A 61-year-old male patient is being assessed for possible colon cancer and treated in the special procdure unit of the hospital. He undergoes a colonoscopy into the ascending colon with biopsy of a suspicious area in the transverse colon using the cold biopsy forceps. In addition, a colonic ultrasound of the area is performed, the transmural bipsy of an area of the mesentery adjacent to the transverse colon. Assign the appropriate CPT codes.
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96.  Which of the following is not a characteristic of high-quality healthcare data?
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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.  Given NCCI edits, if the replacement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for:
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99.  An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.)
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100.  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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101.  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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102.  Patient returns during a 90-day postoperative period from a ventral hernia repair; now complaining of eye pain. What modifier would a physician setting use with the Evaluation and Management code?
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103.  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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104.  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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105.  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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106.  Which of the following is a standard terminology used to code medical procedures and services?
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107.  Which of the following contains the physician's findings based on an examination of the patient?
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108.  Which document directs an individual to bring originals or copies of records to court?
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109.  Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
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110.  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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111.  The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?
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112.  The legal health record is a(n) _____________.
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113.  In long-term care, the resident's care plan is based on data collected in the _____________.
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114.  Which of the following is a condition that arises during hospitalization?
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115.  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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116.  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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117.  The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?
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118.  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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119.  Which of the following spells out the powers of the three branches of the federal government?
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120.  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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121.  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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122.  Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?
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123.  A special Web page that offers secure access to data is called a(n):
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124.  Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
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125.  The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:
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126.  Which of the following is an example of clinical data?
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127.  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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128.  The protection measures and tools for safeguarding information and information systems is a definition of:
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129.  Data definition refers to _________.
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130.  Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0 cm superficial laceration of the left arm; 5.0 laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: X-ray of the ankle which showed a bimalleolar ankle fracture which required closed manipulative reduction and simple suturing of the laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill.
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131.  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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132.  A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.
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133.  Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals?
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134.  The goal of coding compliance programs is to prevent _________.
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135.  Prospective payment systems were developed by the federal government to:
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136.  A 65-year-old patient is admitted with pain and loosening of a previous total hip arthroplasty. The acetabular component has loosened and become painful. The patient was admitted for revision of the hip replacement. The acetabular component uses a metal-on-metal bearing surface. Which of the following codes would be appropriate coding for admission? 996.41   Mechanical loosening of prosthetic joint 996.96   Infection and inflammatory reaction to join prosthesis V43.64   Organ or tissue replaced by other means 00.71   Revision hip replacement, acetabular component 00.74   Revision hip replacement bearing surface, metal on polyethylene 00.75    Revision hip replacement bearing surface, metal on metal 00.76    Revision hip replacement bearing surface, ceramic on ceramic
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137.  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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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.  The following is documented in an acute care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear?
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140.  Which of the following statements does not apply to ICD-9-CM?
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141.  The ______ mandated the development of standards for electronic medical records.
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142.  An encoder that takes a coder through a series of questions and choices is called a(n):
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143.  Which of the following actions would be best to determine if present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement?
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144.  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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145.  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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146.  Attorneys for healthcare organizations use the health record to _________.
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147.  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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148.  Which of the following statements is false?
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149.  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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150.  What is the functions of physician's orders?
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151.  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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152.  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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153.  At which level of classification system are the most specific ICD-9-CM codes found?
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154.  A nurse is responsible for which of the following types of acute care documentation?
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155.  What is the legal term used to define the protection of health information in a patient-provider relationship?
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156.  Which stage of the litigation process focuses on how strong a case the opposing party has?
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157.  The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:
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158.  Which of the following is not true of notices of privacy practices?
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159.  In processing a bill under the Medicare outpatient prospective payment system (OPPS), where a patient had three surgical procedures performed during the same operative session, which of the following would apply?
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160.  Which of the following provides a set of codes used for collecting data abount substance abuse and mental health disorders?
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161.  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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