CCA prep exam 200 questions

200 Preguntes  I  By Melodey23
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200 Practice questions

  
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  • 1. 
    Which of the following elements is not a component of most patient records?
    • A. 

      Patient identification

    • B. 

      Clinical history

    • C. 

      Financial Information

    • D. 

      Test results


  • 2. 
    Which of the following is not a characteristic of high-quality healthcare data?
    • A. 

      Data relevancy

    • B. 

      Data currency

    • C. 

      Data consistency

    • D. 

      Data Accountability


  • 3. 
    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.
    • A. 

      Anesthesia report

    • B. 

      Physician progress notes

    • C. 

      Operative report

    • D. 

      Recovery room record


  • 4. 
    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".
    • A. 

      Medical laboratory report

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Physician orders


  • 5. 
    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".
    • A. 

      Medical laboratory report

    • B. 

      Physical examination

    • C. 

      Physician progress note

    • D. 

      Radiography report


  • 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?
    • A. 

      History

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Operation report


  • 7. 
    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?
    • A. 

      History

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Operation report


  • 8. 
    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?
    • A. 

      Admission order

    • B. 

      History

    • C. 

      Physical examination

    • D. 

      Progress notes


  • 9. 
    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?
    • A. 

      Admission note

    • B. 

      Clinical laboratory

    • C. 

      Newborn record

    • D. 

      Physician order


  • 10. 
    The following is documented in an acute care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?
    • A. 

      Admission order

    • B. 

      Clinical laboratory report

    • C. 

      ECG report

    • D. 

      Radiology report


  • 11. 
    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?
    • A. 

      Admission note

    • B. 

      Consultation report

    • C. 

      Discharge summary

    • D. 

      Nursing progress notes


  • 12. 
    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?
    • A. 

      Admission note

    • B. 

      Nursing note

    • C. 

      Physician progress note

    • D. 

      Social work note


  • 13. 
    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?
    • A. 

      Insomnia

    • B. 

      Hypertension

    • C. 

      Mental or behavior problems

    • D. 

      Rheumatoid arthritis


  • 14. 
    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)
    • A. 

      Diffuse parenchymal lung disease on x-ray

    • B. 

      Patient has history of inhaled food, liquid, or oil

    • C. 

      Positive culture for Pneumocystis carinii

    • D. 

      Positive culture for Streptococcus pneumoniae


  • 15. 
    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?
    • A. 

      Note the condition as present on admission

    • B. 

      Quary the physician to determine if the condition was present on admission

    • C. 

      Note the condition as unknown on admission

    • D. 

      Note the condition as not present on admission


  • 16. 
    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 ________.
    • A. 

      UHDDS

    • B. 

      UACDS

    • C. 

      MDS

    • D. 

      ORYX


  • 17. 
    Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for _________.
    • A. 

      Performance improvement programs

    • B. 

      Billing and claims data processing

    • C. 

      Developing hospital discharge abstracting systems

    • D. 

      Developing individual care plans for residents


  • 18. 
    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 ___________.
    • A. 

      Reason for admission

    • B. 

      Reason for encounter

    • C. 

      Discharge diagnosis

    • D. 

      Activities of daily living


  • 19. 
    In long-term care, the resident's care plan is based on data collected in the _____________.
    • A. 

      UHDDS

    • B. 

      OASIS

    • C. 

      MDS Version 3.0

    • D. 

      HEDIS


  • 20. 
    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?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan


  • 21. 
    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?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan


  • 22. 
    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?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan


  • 23. 
    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?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan


  • 24. 
    Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
    • A. 

      CPT

    • B. 

      HCPCS

    • C. 

      ICD-9-CM

    • D. 

      SNOMED CT


  • 25. 
    Which of the following provides a set of codes used for collecting data abount substance abuse and mental health disorders?
    • A. 

      CPT

    • B. 

      DMS-IV-TR

    • C. 

      HCPCS

    • D. 

      SNOMED CT


  • 26. 
    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?
    • A. 

      Data completeness

    • B. 

      Data relevancy

    • C. 

      Data currencty

    • D. 

      Data precision


  • 27. 
    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?
    • A. 

      Data completeness

    • B. 

      Data consistency

    • C. 

      Data accessibility

    • D. 

      Data comprehensiveness


  • 28. 
    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:
    • A. 

      Data granularity

    • B. 

      Data consistency

    • C. 

      Data precision

    • D. 

      Data relevance


  • 29. 
    Which of the following is an example of clinical data?
    • A. 

      Admitting diagnosis

    • B. 

      Date and time of admission

    • C. 

      Insurance information

    • D. 

      Health record number


  • 30. 
    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?
    • A. 

      Home health

    • B. 

      Behavioral health

    • C. 

      End stage renal disease

    • D. 

      Rehabilitative care


  • 31. 
    Which of the following materials is not documented in an emergency care record?
    • A. 

      Patient's instructions at discharge

    • B. 

      Time and means of the patient's arrival

    • C. 

      Patient's complete medical history

    • D. 

      Emergency care administered before arrival at the facility


  • 32. 
    Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedures?
    • A. 

      Anesthesia report

    • B. 

      Laboratory report

    • C. 

      Operative report

    • D. 

      Pathology report


  • 33. 
    Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
    • A. 

      Emergency

    • B. 

      Newborn

    • C. 

      Obstetric

    • D. 

      Surgical


  • 34. 
    In a problem-oriented medical record, problems are organized ________.
    • A. 

      In alphabetical order

    • B. 

      In numeric order

    • C. 

      In alphabetical order by body system

    • D. 

      By date of onset


  • 35. 
    What is the defining characteristic of an integrated health record format?
    • A. 

      Each section of the record is maintained by the patient care department that provided the care.

    • B. 

      Integrated health records are intended to be used in ambulatory settings.

    • C. 

      Integrated health records include both paper forms and computer printouts.

    • D. 

      Integrated health record components are arranged in strict chronological order.


  • 36. 
    Which of the following represents documentation of the patient's current and past health status?
    • A. 

      Physical exam

    • B. 

      Medical history

    • C. 

      Physician orders

    • D. 

      Patient consent


  • 37. 
    Which of the following contains the physician's findings based on an examination of the patient?
    • A. 

      Physical exam

    • B. 

      Discharge summary

    • C. 

      Medical history

    • D. 

      Patient instructions


  • 38. 
    What is the function of a consultation report?
    • A. 

      Provides a chronological summary of the patient's medical history and illness

    • B. 

      Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

    • C. 

      Concisely summarizes the patient's treatment and stay in the hospital

    • D. 

      Documents the physician's instructions to other parties involved in providing care to a patient


  • 39. 
    What is the functions of physician's orders?
    • A. 

      Provide a chronological summary of the patient's illness and treatment

    • B. 

      Document the patient's current and past health status

    • C. 

      Document the physician's instructions to other parties involved in providing care to a patient

    • D. 

      Document the provider's instructions for follow-up care given to the patient or patient's caregiver


  • 40. 
    Which type of patient care record includes documentation of a family bereavement period?
    • A. 

      Hospice record

    • B. 

      Home health record

    • C. 

      Long-term care record

    • D. 

      Ambulatory care record


  • 41. 
    Which of the following best describes data completeness?
    • A. 

      Data are correct

    • B. 

      Data are easy to obtain

    • C. 

      Data include all required elements

    • D. 

      Data are reliable


  • 42. 
    The attending physician is responsible for which of the following types of acute care documentations?
    • A. 

      Consultation report

    • B. 

      Discharge summary

    • C. 

      Laboratory report

    • D. 

      Pathology report


  • 43. 
    A nurse is responsible for which of the following types of acute care documentation?
    • A. 

      Operative report

    • B. 

      Medication record

    • C. 

      Radiology report

    • D. 

      Therapy assessment


  • 44. 
    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.
    • A. 

      Quantitative

    • B. 

      Qualitative

    • C. 

      Statistical

    • D. 

      Outcomes


  • 45. 
    Which of the following is a secondary purpose of the health record?
    • A. 

      Support for provider reimbursement

    • B. 

      Support for patient self-management activities

    • C. 

      Support for research

    • D. 

      Support for patient care delivery


  • 46. 
    Use of the health record by a clinician to facilitate quality patient care is considered _____________
    • A. 

      A primary purpose of the health record

    • B. 

      Patient care report

    • C. 

      A secondary purpose of the health record

    • D. 

      Policy making and support


  • 47. 
    Use of the health record to monitor bioterrorism activity is considered a ______________
    • A. 

      Primary purpose of the health record

    • B. 

      Secondary purpose of the health record

    • C. 

      Patient use of the health record

    • D. 

      Healthcare licensing agency function


  • 48. 
    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:
    • A. 

      Centers for Medicare and Medicaid Services (CMS)

    • B. 

      American Society for Testing and Measurement (ASTM)

    • C. 

      Joint Commission

    • D. 

      National Centers for Health Statistics (NCHS)


  • 49. 
    The ______ mandated the development of standards for electronic medical records.
    • A. 

      Medicare and Medicaid legislation of 1965

    • B. 

      Prospective Payment Act 1983

    • C. 

      Health Insurance Portability and Accountability Act (HIPAA) of 1996

    • D. 

      Balanced Budget Act of 1997


  • 50. 
    Messaging standards for electronic data interchange in healthcare have been developed by ___________.
    • A. 

      HL7

    • B. 

      IEE

    • C. 

      The Joint Commission

    • D. 

      CMS


  • 51. 
    A statement or guideline that directs decision making or behavior is called a ____________.
    • A. 

      Directive

    • B. 

      Procedure

    • C. 

      Policy

    • D. 

      Process


  • 52. 
    Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2?
    • A. 

      Current Procedural Terminology

    • B. 

      International Classification of Diseases, Ninth Revision, Clinical Modification

    • C. 

      International Classification of Diseases, Tenth Revision

    • D. 

      International Classification of Diseases, Tenth Revision, Clinical Modification


  • 53. 
    Which organization originally published ICD-9-CM?
    • A. 

      American Medical Association

    • B. 

      Centers for Disease Control

    • C. 

      United States federal government

    • D. 

      World Health Organization


  • 54. 
    Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals?
    • A. 

      Current Procedural Terminology

    • B. 

      Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision

    • C. 

      Healthcare Common Procedure Coding System

    • D. 

      International Classification of Diseases, Ninth Revision, Clinical Modification


  • 55. 
    Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals?
    • A. 

      CPT

    • B. 

      HCPCS Level II

    • C. 

      ICD-9-CM

    • D. 

      SNOMED CT


  • 56. 
    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?
    • A. 

      Require all coders to implement this practice

    • B. 

      Report the practice to the OIG

    • C. 

      Counsel the coder and stop the practice immediately

    • D. 

      Put the coder on unpaid leave of absence


  • 57. 
    A health information technician is hired as the chief compliance officer for a large group practice. In evaluating the current program the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audiots in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?
    • A. 

      Compliance program education and training programs for all employees in the organization

    • B. 

      Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation

    • C. 

      Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted

    • D. 

      Establish a corporate compliance committee who report directly to the CFO


  • 58. 
    In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
    • A. 

      Current coding personnel

    • B. 

      Medical staff

    • C. 

      Newly hired coding personnel

    • D. 

      Nursing staff


  • 59. 
    Which of the following isues compliance program guidance?
    • A. 

      AHIMA

    • B. 

      CMS

    • C. 

      Federal Register

    • D. 

      HHS Office of Inspector General


  • 60. 
    Which of the following is a written description of an organization's formal position?
    • A. 

      Hierarchy chart

    • B. 

      Organizational chart

    • C. 

      Policy

    • D. 

      Procedure


  • 61. 
    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?
    • A. 

      Hire clinical documentation specialists to review records prior to coding.

    • B. 

      Ask coders to query physicians more often.

    • C. 

      Provide physicians the opportunity to add addenda to their reports to clarify documentation issues.

    • D. 

      Conduct qualitative analyses of inpatient records while the patient is hospitalized to identify opportunities to improve the documentation in the record.


  • 62. 
    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?
    • A. 

      Ad hoc

    • B. 

      Concurrent

    • C. 

      Retrospective

    • D. 

      Post-discharge


  • 63. 
    The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the __________.
    • A. 

      Ambulatory Care Data Set

    • B. 

      Uniform Hospital Discharge Data Set

    • C. 

      Minimum Data Set for Long-term Care

    • D. 

      Health Plan Employer Data and Information Set


  • 64. 
    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?
    • A. 

      Deemed status

    • B. 

      Judicial decision

    • C. 

      Subpoena

    • D. 

      Credentialing


  • 65. 
    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.
    • A. 

      Principal diagnosis

    • B. 

      Principal procedure

    • C. 

      Comorbidities

    • D. 

      Complications


  • 66. 
    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?
    • A. 

      Qualitative analysis

    • B. 

      Legal record review

    • C. 

      Quantitative analysis

    • D. 

      Ongoing record review


  • 67. 
    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.
    • A. 

      Medicare reimbursement rule

    • B. 

      Physician acknowledgment statement

    • C. 

      Provider agreement

    • D. 

      Diagnosis and procedure validation statement


  • 68. 
    Adoption of the Minimum Standards marked the beginning of this modern __________ process for healthcare organizations.
    • A. 

      Accreditation

    • B. 

      Licensing

    • C. 

      Reform

    • D. 

      Educational


  • 69. 
    Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
    • A. 

      231.0

    • B. 

      161.0

    • C. 

      239.1

    • D. 

      212.1


  • 70. 
    Identify the diagnosis code(s) for benign melanoma of skin of shoulder.
    • A. 

      172.8, 172.6

    • B. 

      172.6

    • C. 

      172.9

    • D. 

      172.8


  • 71. 
    Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?
    • A. 

      Centers for Disease Control (CDC)

    • B. 

      Centers of Medicare and Medicaid Services (CMS)

    • C. 

      National Center for Health Statistics (NCHS)

    • D. 

      World Health Organization (WHO)


  • 72. 
    At which level of classification system are the most specific ICD-9-CM codes found?
    • A. 

      Category level

    • B. 

      Section level

    • C. 

      Subcategory level

    • D. 

      Subclassification level


  • 73. 
    What are the five-digit ICD-9-CM diagnosis code referred to as?
    • A. 

      Category codes

    • B. 

      Section codes

    • C. 

      Subcategory codes

    • D. 

      Subclassification codes


  • 74. 
    What are four-digit ICD-9-CM diagnosis codes referred to as?
    • A. 

      Category codes

    • B. 

      Section codes

    • C. 

      Subcategory codes

    • D. 

      Subclassification codes


  • 75. 
    Which of the following ICD-9-CM codes are always alphanumeric
    • A. 

      Category codes

    • B. 

      E codes

    • C. 

      Subcategory codes

    • D. 

      V codes


  • 76. 
    Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?
    • A. 

      Category codes

    • B. 

      E codes

    • C. 

      Subcategory codes

    • D. 

      V codes


  • 77. 
    Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
    • A. 

      Volume 1

    • B. 

      Volume 2

    • C. 

      Volume 3

    • D. 

      Volume 4


  • 78. 
    Identify the correct diagnosis code for lipoma of the face.
    • A. 

      214.1

    • B. 

      213.0

    • C. 

      214.0

    • D. 

      214.9


  • 79. 
    Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
    • A. 

      227.0, 255.12

    • B. 

      227.0

    • C. 

      255.12

    • D. 

      225.12, 227.8


  • 80. 
    Which of the following is a standard terminology used to code medical procedures and services?
    • A. 

      CPT

    • B. 

      HCPCS

    • C. 

      ICD-9-CM

    • D. 

      SNOMED CT


  • 81. 
    Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness.
    • A. 

      924.9

    • B. 

      851.42

    • C. 

      851.82

    • D. 

      851.81


  • 82. 
    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?
    • A. 

      Length of the lesion as described in the pathology report

    • B. 

      Dimension of the speciment submitted as described in the pathology report

    • C. 

      Width times the length of the lesion as described in the operative report

    • D. 

      Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report


  • 83. 
    According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
    • A. 

      Complex

    • B. 

      Intermediate

    • C. 

      Not specified

    • D. 

      Simple


  • 84. 
    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?
    • A. 

      Acute cholecystitis, nausea, vomiting, abdominal pain

    • B. 

      Abdominal pain, vomiting, nauea, acute cholecystitis

    • C. 

      Nausea, vomiting, abdominal pain

    • D. 

      Acute cholecystitis


  • 85. 
    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?
    • A. 

      Miscarriage

    • B. 

      Complication of spontaneous abortion with sepsis

    • C. 

      Sepsis

    • D. 

      Spontaneous abortion with sepsis


  • 86. 
    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?
    • A. 

      Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis.

    • B. 

      Code urinary tract infection with sepsis as the principal diagnosis.

    • C. 

      Query the physician to ask if the patient has septicemia because of the symptomatology.

    • D. 

      Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.


  • 87. 
    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.
    • A. 

      Ataxia

    • B. 

      Fractured arm

    • C. 

      Metastatic carcinoma of the brain

    • D. 

      Carcinoma of the lung


  • 88. 
    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?
    • A. 

      Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina

    • B. 

      Infectious gastroenteritis; chronic obstructive pulmonary disease; angina

    • C. 

      Gastroenteritis; abdominal pain; angina

    • D. 

      Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina


  • 89. 
    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?
    • A. 

      Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion

    • B. 

      Mental confusion; history of carcinoma of the prostate; admission for chemotherapy

    • C. 

      Metastatic carcinoma of the brain; history of carcinoma of the prostate

    • D. 

      Carcinoma of the prostate; metastatic carcinoma to the brain


  • 90. 
    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:
    • A. 

      Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis

    • B. 

      Pancreatitis; noncalculus cholecystitis; abdominal pain

    • C. 

      Noncalculus cholecystitis; pancreatitis; abdominal pain

    • D. 

      Abdominal pain; pancreatitis; noncalculus cholecystitis


  • 91. 
    According to the UHDDS, which of the following is the definition of "other diagnoses"?
    • A. 

      Is recorded in the patient record

    • B. 

      Is documented by the attending physician

    • C. 

      Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring

    • D. 

      Is documented by at least two physicians and/or the nursing staff


  • 92. 
    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?
    • A. 

      Acute bronchitis

    • B. 

      Acute bronchitis with chronic obstructive pulmonary disease

    • C. 

      Asthma with status asthmaticus

    • D. 

      Chronic obstructive asthma


  • 93. 
    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?
    • A. 

      80.50: Excision or destruction of intervertebral disc, unspecified

    • B. 

      04.2: Destruction of cranial and peripheral nerves

    • C. 

      80.59: Other destruction of intervertebral disc

    • D. 

      05.23: Lumbar sympathectomy


  • 94. 
    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:
    • A. 

      V71.7, Admission for suspected cardiovascular condition

    • B. 

      789.01, Esophageal pain

    • C. 

      530.81, Gastrointestinal reflux

    • D. 

      786.50, Chest pain NOS


  • 95. 
    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?
    • A. 

      Code skin lesion

    • B. 

      Code benign skin lesion

    • C. 

      Code basal cell carcinoma

    • D. 

      Query the dermatologist


  • 96. 
    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.)
    • A. 

      660.11, 653.41, 64475

    • B. 

      660.11, 653.01, 01961

    • C. 

      660.11, 653.41, 01967, 01968

    • D. 

      660.11, 653.91, 01996


  • 97. 
    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.
    • A. 

      99304

    • B. 

      99308

    • C. 

      99318

    • D. 

      99306


  • 98. 
    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.
    • A. 

      45384, 45342

    • B. 

      45380, 45391

    • C. 

      45384, 45392

    • D. 

      45380, 45392


  • 99. 
    Which of the following statements does not apply to ICD-9-CM?
    • A. 

      It can be used as the basis for epidemiological research.

    • B. 

      It can be used in the evaluation of medical care planning for healthcare delivery systems.

    • C. 

      It can be used to facilitate data storage and retrieval

    • D. 

      It can be used to collect data about nursing care.


  • 100. 
    Which of the following is not one of the purpose of ICD-9-CM?
    • A. 

      Classification of morbidity for statistical purposes

    • B. 

      Classification of mortality for statistical purposes

    • C. 

      Reporting of diagnoses by physicians

    • D. 

      Identification of supplies, products, and services provided to patients


  • 101. 
    Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?
    • A. 

      Volume 1

    • B. 

      Volume 2

    • C. 

      Volume 3

    • D. 

      Volume 4


  • 102. 
    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)
    • A. 

      Use category 216 for syringoma

    • B. 

      Use category 216 for malignant melanoma

    • C. 

      Use category 216 for malignant neoplasm of the bone

    • D. 

      Use category 216 for malignant neoplasm of the skin


  • 103. 
    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
    • A. 

      996.41, V43.64, 00.71, 00.75

    • B. 

      996.96, 00.75

    • C. 

      996.41, V43.64, 00.71

    • D. 

      996.96, V43.64, 00.71, 00.75


  • 104. 
    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
    • A. 

      434.91, 342.92, 784.3, 401

    • B. 

      434.90, 342.90, 784.3, 401.9

    • C. 

      434.90, 342.91, 784.3, 401.9

    • D. 

      434.90, 342.90, 784.3, 401.0


  • 105. 
    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?
    • A. 

      Intravascular ultrasound

    • B. 

      Angiographyof the thoracic aorta

    • C. 

      Fluoroscopic guidance in delivery of the endovascular components

    • D. 

      Preprocedure diagnostic imaging


  • 106. 
    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?
    • A. 

      Congestive heart failure, respiratory failure, ventilator management, intubation

    • B. 

      Respiratory failure, intubation, ventilator management

    • C. 

      Respiratory failure, congestive heart failure, intubation, ventilator management

    • D. 

      Shortness of breath, congestive heart failure, respiratory failure, ventilator management


  • 107. 
    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?
    • A. 

      Poisoning due to Coumadin

    • B. 

      Unspecified aderse reaction to Coumadin

    • C. 

      Hematuria; poisoning due to Coumadin

    • D. 

      Hematuria; adverse reaction to Coumadin


  • 108. 
    CPT Category III code can be used by what groups of providers
    • A. 

      Hopital outpatient providers only

    • B. 

      Physicians only

    • C. 

      Hospitals, physicians, insurers, health services researchers

    • D. 

      Medicare-approved providers only


  • 109. 
    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
    • A. 

      Hospital A: 427, 786.50, 427.31, 410.91; Hospital B: 410.92, 36.13

    • B. 

      Hospital A: 410.41, 427, 427.31; Hospital B: 410.42, 36.13

    • C. 

      Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13

    • D. 

      Hospital A: 410.41, 427.31, 786.50; Hospital B: 410.42, 36.13


  • 110. 
    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?
    • A. 

      Abdominal pain

    • B. 

      Cholecystitis

    • C. 

      Hypertension

    • D. 

      Diabetes


  • 111. 
    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?
    • A. 

      Catheter-associated urinary tract infection

    • B. 

      Cerebral vascular accident

    • C. 

      COPD

    • D. 

      Hypertension


  • 112. 
    Which of the following is a condition that arises during hospitalization?
    • A. 

      Case mix

    • B. 

      Complication

    • C. 

      Comorbidity

    • D. 

      Principal diagnosis


  • 113. 
    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?
    • A. 

      038.8, 562.11, 789.00

    • B. 

      038.11, 562.11

    • C. 

      038.8, 562.11, 041.11

    • D. 

      038.9, 562.11


  • 114. 
    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?
    • A. 

      188.3; V10.51; 57.49; 57.32

    • B. 

      198.1; 57.49

    • C. 

      188.3; 57.49

    • D. 

      198.1; 188.3; 57.49


  • 115. 
    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?
    • A. 

      553.20; 427.89; V64.3; 54.11

    • B. 

      553.20; 997.1; 427.89; 54.19

    • C. 

      553.20; 54.11

    • D. 

      553.20; 54.11; V64.3


  • 116. 
    These codes are used to assign a diagnosis to a patient who is seeking health services, but is not necessarily sick.
    • A. 

      E codes

    • B. 

      V codes

    • C. 

      M codes

    • D. 

      C codes


  • 117. 
    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?
    • A. 

      808.1; E881.0; E849.0; 79.25; 78.15

    • B. 

      808.1; 920; E881.0; E849.0; E000.8, E013.9, 79.25; 78.15; 79.65

    • C. 

      808.0; E881.0; E000.8, E013.9, 79.35; 79.65

    • D. 

      808.1; E881.0; E849.0; E013.9, 79.25; 78.15; 79.65


  • 118. 
    Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket:
    • A. 

      33223

    • B. 

      33210

    • C. 

      33212

    • D. 

      33222


  • 119. 
    Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence.
    • A. 

      54401

    • B. 

      54405

    • C. 

      54440

    • D. 

      54400


  • 120. 
    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?
    • A. 

      -79: Unrelated procedure or service by the same physician during the postoperative period

    • B. 

      -25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

    • C. 

      -21: Prolonged evaluation and management services

    • D. 

      -24: Unrelated evaluation and management service by the same physician during a postoperative period


  • 121. 
    A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.
    • A. 

      291.8; 303.00

    • B. 

      303.00

    • C. 

      305.00

    • D. 

      291.81; 303.00


  • 122. 
    A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.
    • A. 

      280.0; 626.8

    • B. 

      285.1; 626.8

    • C. 

      626.8; 280.0

    • D. 

      280.0; 218.9


  • 123. 
    Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens.
    • A. 

      366.10; 250.50; 13.59; 13.71

    • B. 

      250.00; 366.10

    • C. 

      250.00; 366.12

    • D. 

      366.10; 250.00; 13.59; 13.71


  • 124. 
    A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.
    • A. 

      492.8; 496; 403.10, 585.9

    • B. 

      492.8; 585.9; 401.9

    • C. 

      496; 585.9; 401.9

    • D. 

      491.21; 403.91, 585.9


  • 125. 
    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.
    • A. 

      27810, 12032

    • B. 

      27818, 12032

    • C. 

      27810, 12032, 12002

    • D. 

      27810, 12032


  • 126. 
    The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:
    • A. 

      31622, 31640

    • B. 

      31622, 31623

    • C. 

      31623

    • D. 

      31625


  • 127. 
    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
    • A. 

      22

    • B. 

      54

    • C. 

      32

    • D. 

      55


  • 128. 
    What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?
    • A. 

      46255

    • B. 

      46930

    • C. 

      46260

    • D. 

      46945


  • 129. 
    An encoder that takes a coder through a series of questions and choices is called a(n):
    • A. 

      Automated codebook

    • B. 

      Automated code assignment

    • C. 

      Logic-based encoder

    • D. 

      Decision support database


  • 130. 
    Patient admitted with major depression, recurrent, severe.
    • A. 

      296.33

    • B. 

      296.30

    • C. 

      311

    • D. 

      296.89


  • 131. 
    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.
    • A. 

      530.89; 49.29

    • B. 

      530.1; 45.16

    • C. 

      530.81; 42.24

    • D. 

      530.81; 42.23


  • 132. 
    Patient with flank pain was admitted and found to have a calculus of the kidney. Ureteroscopy with placement of ureteral stents was performed.
    • A. 

      592.0; 788.0; 59.8

    • B. 

      788.0; 592.0; 56.0

    • C. 

      594.9; 59.8

    • D. 

      592.0; 59.8


  • 133. 
    A female patient is admitted for stress incontinence. A urethral suspension is performed.
    • A. 

      625.6; 57.32

    • B. 

      788.0; 59.5

    • C. 

      625.6; 59.5

    • D. 

      788.30


  • 134. 
    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?
    • A. 

      49496

    • B. 

      49501

    • C. 

      49507

    • D. 

      49521


  • 135. 
    Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment?
    • A. 

      49565

    • B. 

      49565, 49568

    • C. 

      49656

    • D. 

      49560, 49568


  • 136. 
    What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?
    • A. 

      58555, 58559

    • B. 

      58559

    • C. 

      58559, 58740

    • D. 

      58555, 58559, 58740


  • 137. 
    The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?
    • A. 

      49000, 58940, 58700

    • B. 

      58940, 58720-50

    • C. 

      49000, 58720

    • D. 

      58720


  • 138. 
    Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April.
    • A. 

      90965

    • B. 

      90964

    • C. 

      90966

    • D. 

      90970


  • 139. 
    Identify the appropriate CPT code(s) for a routine EKG with 15 leads, with the physician providing only the interpretation and report
    • A. 

      93010

    • B. 

      93005

    • C. 

      93000

    • D. 

      93000; 93010


  • 140. 
    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?
    • A. 

      97113

    • B. 

      97113-50

    • C. 

      97113; 97113

    • D. 

      97110


  • 141. 
    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
    • A. 

      In each MS-DRG the geometric mean is lower than the arithmetic mean.

    • B. 

      In each MS-DRG the arithmetic mean is lower than the geometric mean.

    • C. 

      The higher the number of patients in each MS-DRG, the greater the geometric means for that MS-DRG.

    • D. 

      The geometric means are lower in MS-DRGs that are associated with a CC or MCC.


  • 142. 
    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
    • A. 

      0 percent

    • B. 

      50 percent

    • C. 

      75 percent

    • D. 

      100 percent


  • 143. 
    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?
    • A. 

      Clinical laboratory tests

    • B. 

      Physician office visits

    • C. 

      Radiology examinations

    • D. 

      Take-home surgical dressings


  • 144. 
    Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
    • A. 

      Children's

    • B. 

      Rural

    • C. 

      State supported

    • D. 

      Tertiary


  • 145. 
    Diagnosis-related groups are organized into __________.
    • A. 

      Case-mix classifications

    • B. 

      Geographic practice cost indices

    • C. 

      Major diagnostic categories

    • D. 

      Resource-based relative values


  • 146. 
    In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following?
    • A. 

      DRGs

    • B. 

      HHRGS

    • C. 

      OASIS

    • D. 

      OPPS


  • 147. 
    Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?
    • A. 

      CMHC partial hospitalization services

    • B. 

      Critical access hospitals

    • C. 

      Hospital outpatient departments

    • D. 

      Vaccines provided by CORFs


  • 148. 
    Fee schedules are updated by third-party payers _____________.
    • A. 

      Annually

    • B. 

      Monthly

    • C. 

      Semiannually

    • D. 

      Weekly


  • 149. 
    Which of the following would a health record technician use to perform the billing function for a physician's office?
    • A. 

      CMS-1500

    • B. 

      UB-04

    • C. 

      UB-92

    • D. 

      CMS 1450


  • 150. 
    When a provider accepts assignment, this means the __________.
    • A. 

      Patient authorizes payment to be made directly to the provider

    • B. 

      The provider agrees to accept the allowed payment amount by the payer as payment in full for the items or service

    • C. 

      Balance filling is allowed on patient accounts, but at a limited rate

    • D. 

      Participating provider receives a fee-for-service reimbursement


  • 151. 
    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?
    • A. 

      Require all coders to implement this practice

    • B. 

      Report the practice to the OIG

    • C. 

      Counsel the coder and stop the practice immediately

    • D. 

      Put the coder on unpaid leave of absence


  • 152. 
    Prospective payment systems were developed by the federal government to:
    • A. 

      Increase healthcare access

    • B. 

      Manage Medicare and Medicaid costs

    • C. 

      Implement managed care programs

    • D. 

      Eliminate fee-for-service programs


  • 153. 
    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:
    • A. 

      The placement of the catheter

    • B. 

      The placement of the catheter and the infusion procedure

    • C. 

      The infusion procedure

    • D. 

      Neither the placement of the catheter nor the infusion procedure


  • 154. 
    The goal of coding compliance programs is to prevent _________.
    • A. 

      Accusations of fraud and abuse

    • B. 

      Delays in claims processing

    • C. 

      Billing errors

    • D. 

      Inaccurate code assignments


  • 155. 
    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?
    • A. 

      Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnosis present on the claim that will lead to higher payment.

    • B. 

      Identify all records for a period that have these indicators for these conditions.

    • C. 

      Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement.

    • D. 

      Take a random sample of records for a period of records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.


  • 156. 
    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  
    • A. 

      1

    • B. 

      4

    • C. 

      5

    • D. 

      3


  • 157. 
    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?
    • A. 

      $10

    • B. 

      $40

    • C. 

      $100

    • D. 

      $400


  • 158. 
    In a managed fee-for service agreement, which of the following would be used as a cost-control process for inpatient surgical services?
    • A. 

      Prospectively precertify the necessity of inpatient services

    • B. 

      Determine what services can be bundled

    • C. 

      Pay only 80 percent of the inpatient bill

    • D. 

      Require the patient to pay 20 percent of the inpatient bill


  • 159. 
    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?
    • A. 

      0.689

    • B. 

      0.689 x 100

    • C. 

      1.45 x 100

    • D. 

      1.45


  • 160. 
    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?
    • A. 

      Bundling of services

    • B. 

      Outlier adjustment

    • C. 

      Pass-through payment

    • D. 

      Discounting of procedures


  • 161. 
    Which of the following is not an element of data quality?
    • A. 

      Accessibility

    • B. 

      Data back up

    • C. 

      Precision

    • D. 

      Relevancy


  • 162. 
    The protection measures and tools for safeguarding information and information systems is a definition of:
    • A. 

      Confidentiality

    • B. 

      Data security

    • C. 

      Informational privacy

    • D. 

      Informational access control


  • 163. 
    Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called _________.
    • A. 

      Natural language processing systems

    • B. 

      Monitoring/audit programs

    • C. 

      Encoders

    • D. 

      Concept, description, and relationship tables


  • 164. 
    A special Web page that offers secure access to data is called a(n):
    • A. 

      Access control

    • B. 

      Home page

    • C. 

      Intranet

    • D. 

      Portal


  • 165. 
    Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
    • A. 

      Clinical data repository

    • B. 

      Picture archiving system

    • C. 

      Electronic document management system

    • D. 

      Speech recognition system


  • 166. 
    Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users?
    • A. 

      Encoded vocabulary

    • B. 

      Controlled vocabulary

    • C. 

      Data exchange standards

    • D. 

      Proprietary standards


  • 167. 
    Which of the following tasks may not be performed in an electronic health record system?
    • A. 

      Document imaging

    • B. 

      Analysis

    • C. 

      Assembly

    • D. 

      Indexing


  • 168. 
    Electronic system used by nurses and physicians to document assessments and findings are called:
    • A. 

      Computerized provider order entry

    • B. 

      Electronic document management systems

    • C. 

      Electronic medication administration record

    • D. 

      Electronic patient care charting


  • 169. 
    Data definition refers to _________.
    • A. 

      Meaning of data

    • B. 

      Completeness of data

    • C. 

      Consistency of data

    • D. 

      Detail of data


  • 170. 
    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  
    • A. 

      Visit number

    • B. 

      Date of visit

    • C. 

      Patient number

    • D. 

      Practitioner number


  • 171. 
    The ability to electronically send data from one electronic system to a different elctronic system and still retain its meaning is called _____________.  
    • A. 

      Data comparability

    • B. 

      National data exchange

    • C. 

      Interoperability

    • D. 

      Data architecture


  • 172. 
    The key data element for linking data about an individual who is seen in a variety of care settings is the _________.
    • A. 

      Facility medical record number

    • B. 

      Facility identification number

    • C. 

      Unique patient identifier

    • D. 

      Patient birth date


  • 173. 
    What is the legal term used to define the protection of health information in a patient-provider relationship?
    • A. 

      Access

    • B. 

      Confidentiality

    • C. 

      Privacy

    • D. 

      Security


  • 174. 
    The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:
    • A. 

      Adult sibling; adult child; spouse; parent

    • B. 

      Parent; spouse; adult child; adult sibling

    • C. 

      Spouse; parent; adult sibling; adult child

    • D. 

      Spouse; adult child; parent; adult sibling


  • 175. 
    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?
    • A. 

      Judicial decision

    • B. 

      Subpoena

    • C. 

      Credential

    • D. 

      Regulation


  • 176. 
    Employees in the Hospital Busines Office may have legitimate access to patient health information without patient authorization based on what HIPAA standard/principle?
    • A. 

      Minimum necessary

    • B. 

      Compound authorization

    • C. 

      Accounting of disclosures

    • D. 

      Preemption


  • 177. 
    Exceptions to the consent requirement include:
    • A. 

      Medical emergencies

    • B. 

      Provider discretion

    • C. 

      Implied consent

    • D. 

      Informed consent


  • 178. 
    Which of the following is required in order to prescribe medications?
    • A. 

      Active medical staff membership

    • B. 

      A drug enforcement agency number

    • C. 

      A position on a medical staff executive committee

    • D. 

      A credential from nationally recognized association


  • 179. 
    Which of the following must be reported to the medical examiner?
    • A. 

      Burns

    • B. 

      Accidental deaths

    • C. 

      Causes of injury

    • D. 

      Morbidity


  • 180. 
    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?
    • A. 

      Refer Dr. Williams to Dr. Jones and release the record if Dr. Jones agrees.

    • B. 

      Inform Dr. Williams that he cannot access his wife's health information unles she authorizes access through a written release of information.

    • C. 

      Requet that Dr. Williams ask the hospital administrator for approval to access his wife's record.

    • D. 

      Inform Dr. Williams that he may review his wife's health record in the presence of the privacy officer.


  • 181. 
    Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity _________.
    • A. 

      Must always provide access

    • B. 

      Can deny access to psychotherapy notes

    • C. 

      Can demand that the individual pay to see his or her record

    • D. 

      Can always deny access


  • 182. 
    The legal health record is a(n) _____________.
    • A. 

      Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information

    • B. 

      Entire set of information created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information

    • C. 

      Set of patient-specific data created or accumulated by a healthcare provider that is defined to be legal by the local, state, or federal authorities

    • D. 

      Set of patient-specific data that is defined to be legal by state or federal statute and that is legally permissible to provide in response to requests for patient information


  • 183. 
    Privacy can be defined as the ________.
    • A. 

      Limitation of the use and disclosure of private information

    • B. 

      Right of an individual to be left alone

    • C. 

      Physical and electronic protection of information

    • D. 

      Protection of information from accidental or intentional disclosure


  • 184. 
    Which of the following statements represents an example of nonmaleficence?
    • A. 

      HITs must ensure that patient-identifiable information is not released to unauthorized parties.

    • B. 

      HITs must apply rules fairly and consistently to every case.

    • C. 

      HITs must ensure that patient-identifiable information is released to the parties who need it to provide services to their patients.

    • D. 

      HITs must ensure that patients themselves, and not other paties, are authorizing access to the patient's individual health information.


  • 185. 
    Attorneys for healthcare organizations use the health record to _________.
    • A. 

      Support claims for medical malpractice

    • B. 

      Protect the legal interests of the facility and its healthcare providers

    • C. 

      Plan and market services

    • D. 

      Locate missing persons


  • 186. 
    Which of the following federal laws passed in 1996 resulted in new privacy regulations for healthcare organizations?
    • A. 

      Health Information Access and Disclosure Act

    • B. 

      Health Insurance Portability and Accountability Act

    • C. 

      Patient Self-Determination Act

    • D. 

      Social Security Act


  • 187. 
    Written or spoken permission to proceed with care is classified as ___________.
    • A. 

      An advanced directive

    • B. 

      Formal consent

    • C. 

      Expressed consent

    • D. 

      Implied consent


  • 188. 
    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?
    • A. 

      Press release

    • B. 

      Notice of Privacy Practices

    • C. 

      Consent form

    • D. 

      Web site notice


  • 189. 
    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 ________.
    • A. 

      Social security number

    • B. 

      Unique physician identification number

    • C. 

      Health record number

    • D. 

      National provider identifier


  • 190. 
    In which setting may treatment records travel with the patient between treatment centers?
    • A. 

      Ambulatory care

    • B. 

      Behavioral healthcare

    • C. 

      Correctional facility care

    • D. 

      Long-term care


  • 191. 
    Which of the following dictates how the medical staff operates?
    • A. 

      Medical staff classification

    • B. 

      Medical staff bylaws

    • C. 

      Medical staff credentialing

    • D. 

      Medical staff committees


  • 192. 
    Law enacted by a legislative body is a(n) _________.
    • A. 

      Administrative law

    • B. 

      Statute

    • C. 

      Regulation

    • D. 

      Rule


  • 193. 
    Which stage of the litigation process focuses on how strong a case the opposing party has?
    • A. 

      Deposition

    • B. 

      Discovery

    • C. 

      Trial

    • D. 

      Verdict


  • 194. 
    Which of the following is not true of notices of privacy practices?
    • A. 

      They must be made available at the site where the individual is treated.

    • B. 

      They must be posted in a prominent place.

    • C. 

      They must contain content that may not be changed.

    • D. 

      They must be prominently posted on the covered entity's Web site when the entity has one.


  • 195. 
    Which of the following spells out the powers of the three branches of the federal government?
    • A. 

      United States Constitution

    • B. 

      Statutes

    • C. 

      Administrative law

    • D. 

      Judicial decisions


  • 196. 
    Which document directs an individual to bring originals or copies of records to court?
    • A. 

      Summons

    • B. 

      Subpoena

    • C. 

      Subpoena duce tecum

    • D. 

      Deposition


  • 197. 
    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.
    • A. 

      10

    • B. 

      20

    • C. 

      30

    • D. 

      60


  • 198. 
    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?
    • A. 

      Minimum Necessary

    • B. 

      Notice of Privacy Practices

    • C. 

      Authorization

    • D. 

      Concent


  • 199. 
    Which of the following statements is false?
    • A. 

      A notice of privacy practices must be written in plain language.

    • B. 

      A consent for use and disclosure of information must be obtained from every patient.

    • C. 

      An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations.

    • D. 

      A notice of privacy practices must give an example of a use or disclosure for healthcare operations.


  • 200. 
    Which of the following statements is not true abount a business associate agreement?
    • A. 

      It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity.

    • B. 

      It allows the business associate to maintain PHI indefinitely.

    • C. 

      It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule.

    • D. 

      It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the Department of Health and Human Services or its agents.


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