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according to CPT non-starred surgical procedures are known as a surgical

package

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

palliative care

Which of the organs listed below has endocrine and exocrine functions?

pancrease

A new strain of influenza, H1N1, is a highly virulent strain that spread all over the world. This type of epidemiological disease pattern is referred to as a(n)

pandemic

A basic concept of office layout and workflow is that the

paper moves to the employee.

Increasing peristalsis of the intestines, increasing salivation, and a slowing heart rate are examples of

parasympathetic nervous system responses.

The progress of a disease, including initiating factors, signs and symptoms, physical manifestations, residual sequela, prognosis, and finally, the end result, is termed

pathogenesis

"Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma"?

pathology report

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

pathology report

pathology report.

in preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

pathology report.

Coinsurance payments are paid by the _______ and determined by a specified percentage.

patient (insured)

An Advance Beneficiary Notice (ABN) is a document signed by the

patient indicating whether he/she wants to receive services that Medicare probably will not pay for.

For health care facility to meet its document destruction needs, the certificate of destruction should include all but which of the following elements?

patient notification

Using the SOAP style of documenting progress notes, choose the "subjective" statement from the following.

patient states low back pain is as severe as it was on admission

The most widely discussed and debated unique patient identifier is the

patient's Social Security number.

One record documentation requirement shared by BOTH acute care and emergency departments is

patient's condition on discharge.

The most widely-discussed and debated unique patient identifier is the:

patient's social security number

A Medicare Summary Notice (MSN) is sent to ________ as their EOB.

patients (beneficiaries)

some services are covered and paid by medicare before medicaid makes payments because medicaid is considered which of the following?

payer of last resort

These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid.

payment status indicator

CMS assigns one _______________ to each APC and each ______________ code.

payment status indicator, HCPCS/CPT

Dr. Smith performed a needle biopsy on Sam's liver. The approach term for the ICD-10-PCS code is:

percutaneous

Laparoscopic cholecysectomy

percutaneous endoscopic

The patient could not breathe on his own, so he was placed on a ventilator.

performance

The muscular contractions that move food through the alimentary canal from the mouth to the anus is referred to as

peristasis

What is the large serous membrane that covers the abdominal organs and lines the abdominal wall?

peritoneum

A 75-year-old patient has a sore tongue with tingling and numbness of the hands and feet. She has headaches and is fatigued. Following diagnostic workup, the doctor orders monthly injections of vitamin B12. This patient most likely has which of the following conditions?

pernicious anemia

Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?

pharmacy consultation

Which of the following anatomical parts is involved in both the respiratory and digestive systems?

pharynx

Before leaving the hospital, all newborns are screened for an autosomal recessive genetic disorder of defective enzymatic conversion in protein metabolism. With early detection and a protein-restricted diet, brain damage is prevented. This disease is

phenylketonuria

"The patient is alert and in no acute distress. Initial vital signs: T 98. P 102 and regular, R 20 and BP 120/69..."

physical exam

According to AHIMA's recommended retention standards, which of the following typed of health information does NOT need to be retained permanently?

physician index

Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are

physician work, practice expense, and malpractice insurance expense.

In a global payment methodology, which is sometimes applied to radiological and similar types of procedures that involve professional and technical components, all of the following are part of the "technical" components EXCEPT

physician's services

The results of a quality improvement study indicated that an informed consent was not obtained for 25% of the surgical procedures performed. The director of the Health Information Department was kept well informed regarding the issue and decided to begin corrective action by providing an in-service. The most important participants who should attend this in-service are

physicians and residents.

Which endocrine gland secretes melatonin, which controls the circadian rhythm of an individual?

pineal

The positive belief in a drug and its ability to cure a patient's illness, even if this drug is an inactive or inert substance, typically positively influences a patient's perception of its outcome. This effect is termed a

placebo effect.

The organizing process determines how the work in a particular department will be divided and accomplished. In order to be in the best position to organize the work effectively, the manager must first engage in which management function?

planning

Which one of the following cells produces antibodies?

plasma cells

A physician prescribes a diuretic for his patient. He could be treating any of the following disorders EXCEPT

pneumonia

Each of the following conditions fall under the category of COPD EXCEPT

pneumonia

The presence of fluid in the alveoli of the lungs is characteristic of

pneumonia

Which one of the following is NOT a data retrieval tool?

point-and-click fields

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

point-of-care documentation.

dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as

poisioning

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data

precision

which of the following groups of healthcare providers contract with a self-insured employer to provide healthcare services

preferred provider organization

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the

prenatal record

prenatal record.

The Centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS-DRG payment for certain conditions that the patient was not admitted with, but were acquired during the hospital stay. Therefore, hospitals are required to report an indicator for each diagnosis. This indicator is referred to as

present on admission.

Installation of a new electronic document management system is scheduled for the HIM department. The department director calls a meeting of the HIM supervisors to coordinate plans for training the HIM staff. What key factors must be taken into consideration as part of the training preparation process?

presentation content and scheduling to accommodate all employee shifts

The condition that is primarily responsible for the patient's admission to the hospital is the ______________ diagnosis.

principal

Which of the following is NOT included as a part of the minimum data maintained in the MPI?

principal diagnosis

Which of the following is NOT a document input device in the electronic document management system?

printer

You have had a problem with duplicate medical record numbers in your facility's MPI. Now you are joining a health information exchange, so you will need to clean up your database and prevent the duplicates from happening again. If you want to find near matches as well as identical matches in your MPI, you should implement a ___________algorithm.

probabilistic

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

problem list

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

problem list.

specific statements related to the course of the patients illness and response to treatment are called

progress notes

which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered?

prospective payment method

A 72-year-old white male patient is on Coumadin therapy. Which of the following tests is commonly ordered to monitor the patient's Coumadin levels?

prothrombin time

The administrator has asked us to develop a patient satisfaction database internally. This database will be used to collect data that can be used to improve our services. He does not want this to be a long, drawn-out process. Which of the following could speed up this process?

prototyping

The organism transmitted by a mosquito bite that causes malaria is a

protozoa

The director of Health Information Services has recently received approval to purchase a new high-speed scanner. The director plans to redesign the department layout to accommodate the equipment and to ensure that the equipment is placed in the most appropriate area of the department. Which of the following tools will best assist the director with this new layout?

proximity chart

A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as Gram-negative pneumonia?

pseudomonas

What field monitors populations as a whole instead of patient specific data?

public health informatics

Maria Giovanni is in the hospital recovering from colon resection surgery. Based on her symptoms, her doctors are concerned about the possibility that she has developed a pulmonary embolism. Which of the following procedures will provide the definitive diagnosis?

pulmonary angiography

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

qualitative review

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization, there was one missed dose of insulin. What type of review is this clerk performing?

qualitative review

Reviewing a medical record to ensure that all diagnosis are justified by documentation throughout the chart is an example of

qualitative review.

Reviewing the record to assure the presence of a discharge summary is referred to as:

quantitative analysis

A health record analyst is reviewing the medical record for authentication of all entries. This process is commonly termed:

quantitative analysis.

a procedure such as computed tomography, nuclear medicine or ultrasonography would be documented in a(n)reports.

radiology/imaging

Which one of the following in NOT an electronic document management system component?

reader-printer

CMS-identified "hospital-acquired conditions" mean that when a particular diagnosis is not "present on admission," CMS determines it to be

reasonably preventable.

Reattachment fourth finger

reattachment

Consider the following situation: The department's working hours are 8:00 AM to 6:00 PM. After 6:00 PM, if a record is needed in the emergency room for a possible readmission, the ER clerk has access to the facility's electronic health record (EHR) in order to retrieve the record. On the occasions when the ER clerk has retrieved a record it appears as if the clerk was viewing records unnecessarily within the EHR. What would be the best training or development method for the ER clerk in order to rectify this situation?

receive training by the Release of Information (ROI) supervisor

The method of calculating errors in a coding audit that allows for benchmarking with other hospitals and permits the reviewer to track errors by case type is the:

record method

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

recorded by persons authorized by hospital regulations and procedures.

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with

recovery audit contractors.

the record in which you would find post-op data on vital signs, status reports of infusion, surgical dressings, tubes, catheters and drains is the:

recovery room record

Most carbon dioxide is carried in the

red blood cells.

As a prerequisite in the implementation of an electronic health record, what process would facilitate automatic indexing?

redesigning forms to include bar codes

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work

reduce clinical denials for medical necessity.

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to

reduce clinical denials for medical necessity.

Though you work in an integrated delivery network, not all systems in your network communicate with one another. As you meet with your partner organizations, you begin to sell them on the concept of an important development intended to support the exchange of health information across the continuum within a geographical community. You are promoting that your organization join a

regional health information organization.

Which of these functions is found in an ambulatory EHR but no in an acute care EHR?

registration

the form in the chart where you would find basic identification and financial data routinely collected on every patient is called the:

registration record

This is the amount collected by the facility for the services it bills.

reimbursement

Which of the following is NOT a factor to consider when developing a record retention program?

reimbursement guidelines

When the third-party payer returns a claim due to missing, inaccurate, or invalid information, this is called a

rejected claim.

Capital Health Center is moving to a new facility in December 2016. The CEO is projecting a conversion to an electronic health record system by then. This new facility will not include space for filing of paper-based health records. Which of the following items would not be considered when planning this conversion?

relationship with the microfilm vendor

You use an information system to create a letter notifying a requester that your facility does not have any records on file for the individual's records requested. What system are you using?

release of information

The HIM supervisor is evaluating software that would utilize electronic logging and monitoring of requests for copies of patient information and develop an accounting of disclosure. What department function is this most useful for?

release of information/disclosure management

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

reliability

In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to

reliability

The _______________ is a statement sent to the provider to explain payments made by third-party payers.

remittance advice

Removal cardiac pacemaker

removal

A complete redo of a knee replacement requiring a new prosthesis is coded to which root operation(s)?

removal; replacement

Mitral valve ring annuloplasty, open

repair

Angioplasty of the right common iliac artery accomplished with an autologous tissue substitute

replacement

Application of free skin graft to the nose status post excision malignant neoplasm

replacement

Dr. Carter performed a hip replacement. The root operation term used for this ICD-10-PCS code is:

replacement

Total left knee replacement

replacement

Which of the following is NOT a mandatory disclosure according to the HIPAA Privacy Rule?

reporting of traffic fatalities

Reduction fracture right femoral shaft

reposition

Accreditation by Joint Commission is a voluntary activity for a facility, and it is

required for reimbursement of certain patient groups

Accreditation by Joint Commission is a voluntary activity for a facility and it is

required for reimbursement of certain patient groups,

gallbladder

resection

Gastric lap band for treatment of morbid obesity

restriction

The leading cause of blindness in the United States is a vision-related pathology caused by diabetes. It is called

retinopathy

Commercial insurance plans usually reimburse health care providers under some type of __________ payment system, whereas the federal Medicare program uses some type of _________ payment system.

retrospective, prospective

A four-digit code that describes a classification of a product or service provided to a patient is a

revenue code

The process by which health care facilities and providers ensure their financial viability by increasing revenue, improving cash flow, and enhancing the patient's experience is called

revenue cycle management.

The typical arrangement of the source-oriented medical record on the nursing unit is what kind of order?

reverse chronological

What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms?

review of systems

Which of the following tasks is the most appropriate for the Health Information Services director to delegate to the supervisor of Record Processing and Statistics?

reviewing monthly statistical reports to verify accuracy

One of your first tasks as the new manager of Health Information Services is to review the department's policy and procedure manual. You have determined that several policy statements do not align with appropriate existing employee practices. Best practice of management processes would require

revising the policy appropriately and documenting the date of the change.

Softening of the bone in children is termed ________.

rickets

Which of the following sequences correctly depicts the flow of blood through the heart to the lungs in order for gas exchange to occur?

right atrium, right Ventricle, pulmonary artery, lungs

A APACHE is a tool used in the insurance industry. What information does this tool provide?

risk of dying

At an integrated delivery system, the hospital and clinic have separate networks. There are times when they need to share information across the network. This can be accomplished with a

router

The childhood viral disease that unvaccinated pregnant women should be prevented from contracting because it may be passed to the fetus, thus causing congenital anomalies such as mental retardation, blindness, and deafness, is

rubella

Concern for health data loss and misuse within the HIM department requires that the health information practitioner evaluate all but which of the followings

salary for the database administrator

What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital?

scanning all 250,000 records for a cost of $195,000

Jessica is the leader of a project team working on the definition of the women's health service line. Several departments are so enthusiastic about the progress that they ask for additions to the project. This is not uncommon, and is known as

scope creep.

The director of a Health Information Department has asked the department supervisors to review and revise all job descriptions. The supervisor over coding and analysis has determined that the job description for the senior coders must be revised. The decision to revise the job description is probably due to a change in the

scope of coding responsibilities.

which of the following would a health record technician use to perform the billing function for a physicians office?

screen 837 or CMS 1500

During the month of May, there were 800 discharge abstracts processed at a cost of $0.90 per abstract for a total of $720.00. In June, 732 discharge abstracts were processed for a total cost of $658.80. This type of cost is known as

semifixed.

Mary Schnering was admitted to Community Hospital on 10/3/15 and assigned a record number of 54-47-53. The patient was later admitted on 1/14/16 and assigned the number 54-88-42. Both records were eventually filed under 54-88-42. What type of numbering /filing system is being used at Community Hospital?

serial-unit

Which procedure will be used to initially diagnose the patient?

serology test

In ______________ anemia, the red blood cells become shaped like elongated crescents in the presence of low oxygen concentration.

sickle cell

An African American couple is undergoing genetic counseling to determine the likelihood of producing children with a recessively genetic blood condition. The genetic tests reveal that the father carries the trait to produce abnormal hemoglobin, HbS, which causes crystallization in RBCs and deforms their shape when O2 is low. This condition causes painful crises and multiple infarcts and is termed

sickle cell anemia

Discharge summary documentation must include

significant findings during hospitalization.

Under APCs, payment status indicator "T" means

significant procedure, multiple procedure reduction applies.

Under APCs, payment status indicator "S" means

significant procedure, multiple procedure reduction does not apply.

According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a

significant procedure.

The final HITECH Omnibus rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to

simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.

When coding neoplasms, topography means

site

The prospective payment system based on resource utilization groups (RUGs) is used for reimbursement to ____________________ for patients with Medicare.

skilled nursing facilities

A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by home health agencies (HHA) and ____.

skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs)

The most fatal type of lung cancer is

small cell cancer.

A patient is admitted with shortness of breath and hemoptysis. A chest X-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected and the patient was started on radiation to the brain. The principal diagnosis is the:

small cell lung carcinoma

Most of the digestion of food and absorption of nutrients occur in the

small intestine.

The healthcare facility has implemented an application that allows patients to support each other. The information system is

social media

Administrative, financial, and other information systems supply the EHR with much of its data. What are these various systems known as?

source system

Sam Spade has been severely injured in an MVA because he was not wearing a seat belt. The organ in his body, situated at the upper left of his abdominal cavity, under the ribs, that is part of his lymphatic system has been ruptured, and he is bleeding internally. Sam needs a surgical procedure known as

splenectomy

The health care providers in an acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should

staff the department with personnel 24 hours a day.

Which of the following is usually the largest expense for a health care facility?

staffing expenses

A patient was discharged from the acute care hospital with a final diagnosis of bronchial asthma. As the coder reviews the record, she notes that the patient was described as having prolonged and tractable wheezing, airway obstruction with was not relieved by bronchodilators and the lab values showed decreased respiratory function. The coder queried the physician to determine whether the code for________is appropriate to be added to the final diagnoses

status asthmaticus

As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system?

stonewall

What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79?

straight numeric

Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital?

straight numeric

Written documents that assist an organization in achieving its objectives and carrying out its mission statement are known as

strategic plans.

Which of the following is not one of the five layers of the epidermis?

stratum fascia

Review the simplistic screen on the screen. This is an example of how__________data can be entered.

structured

Drop boxes, radio buttons, and pick lists are used in

structured data entry.

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document

subjective symptoms that the patient may have forgotten to mention or have may have seemed unimportant.

After a claim has been filed with Medicare, a healthcare organization had late charges posted to a patient's outpatient account that changed the calculation of the APC. What is the best practice for this organization to receive the correct reimbursement from Medicare?

submit an adjusted claims to medicare

Which set of muscles controls the movement of the eye up and down?

superior and inferior rectus

Which type of joint, such as the sutures of the skull, has no movement?

synarthrosis

The interaction of two drugs working together to where each simultaneously helps the other achieve an effect that neither could produce alone is termed a

synergistic effect.

Microbiological lab culture and sensitivity tests were performed on the skin scrapings of a groin lesion on a 27-year-old male patient who presented to a local health department clinic. The results confirm infection with Treponema pallidum. He was given a prescription for penicillin and told to return for a follow-up visit in 2 weeks. His diagnosis is

syphilis

The patient's heart is being monitored while he is at home. This is known as

telaheath

In which brain lobe is the processing of smell and hearing stimuli performed?

temporal

The Assistant Director of Record Processing is evaluating software packages for a chart tracking system in the HIM Department. What is the BEST method to verify that the software will work as marketed?

test the software prior to purchase.

The EHR system implementation team is using simulated patients and simulated patient information to add progress notes, nurses' notes, and so on, to the EHR prior to implementation. Which phase is the team involved in?

testing

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman

the H&P copy is acceptable as long as she documents any interval changes.

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS's website.

the OIG's Work Plan

On an EKG, what signifies the electronic stimulation of the ventricles?

the QRS wave

In your acute care facility it has become critical that up-to-date information regarding patients who are transferred to the oncology patient care unit be immediately sent to an outpatient scheduling system to facilitate outpatient appointments. This transfer of service can be obtained most readily from

the R-ADT system

This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of his family has a financial interest.

the Stark I Law

The director of a Health Information Department has received the quarterly variance budget report. The report indicates the "overtime" category is unfavorable. The director is required to justify this overtime expense. Which of the following would be considered an acceptable explanation for this expenditure? Overtime is unfavorable this quarter due to

the annual purging of inactive files.

The reference date for a cancer registry is

the date when data collection began.

Mary is designing a computer screen that will be used to collect patient demographic information. What input design should be utilized for the state field?

the drop-down menu

what was the result of the Balanced Budget Act of 1997?

the implementation of the APC system

Dr. Smith accesses the EHR in his office to see what patients are ready to be seen and what calls he needs to make. This functionality is called

the in-basket function

standardization came to an end in 1952 and was replaced by accreditation. the organization responsible for accreditation of healthcare facilities is:

the joint commission

In preparing a capital budget request, the first priority will be to document

the need for the new equipment and the return on investment.

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate

the overall quality of documentation in the record.

the best source for obtaining data for job analysis is the:

the person who performs the job

The health car providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding

the presence or absence of such items as preoperative and post operative diagnosis, description of findings, and specimens removed.

The supervisor of release of information in a health information department is preparing a work distribution chart in the hopes of identifying some problem areas. Although the work distribution chart can provide the supervisor with a great deal of information concerning the work performed by her staff, it will not indicate

the solution to a specific problem area.

The nose, mouth, sinuses, pharynx, and larynx make up the

the upper respiratory tract.

A primary focus of screen format design in a health record computer application should be to ensure that

the user is capturing essential data elements.

Diastole occurs when

the ventricles fill.

Under the APC methodology, discounted payments occur when

there are two or more (multiple) procedures that are assigned to status indicator "T."

Necrosis extending down to the underlying fascia is characteristic of a decubitus ulcer in stage

three

A toxic goiter has what distinguishing characteristic?

thyroid hyperfunction

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the

time and means of arrival

A key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record is the

time and means of arrival.

In CPT, Category III codes include codes

to describe emerging technologies.

A transfusion of whole blood was administered to the patient.

transfusion

The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a

transplant registry.

The abstract completed on the patients in your hospital contains the following items: patient demographics, prehospital interventions, vital signs on admission, procedures and treatment prior to hospitalization, transport modality, and injury severity score. The hospital uses these data for its

trauma registry.

A condition that involves the fifth cranial nerve, also known as "tic douloureux," causes intense pain in the eye and forehead; lower lip, the section of the cheek closest to the ear and the outer segment of the tongue; or the upper lip, nose, and cheek.

trigeminal neuralgia

Old age, obesity, and a family history of diabetes are all characteristics of

type 2 diabetes.

The patient was admitted with diabetic nephropathy. She was diagnosed with type II diabetes five years ago and uses oral antidiabetic drugs daily. The ICD-10-CM diagnosis codes should be reported in this sequence.

type II diabetes with nephropathy combination code + control using oral antidiabetic drug code

When engaging the services of a microfilm vendor, all but which one of the following factors should be included in the contract?

type of reader or printer needed to view the microfilm

A patient has a total of abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes: 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s) with or without removal of ovary(s) and 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure)

unbundling

which data set was developed to improve ability to compare data in ambulatory care settings?

uniformed ambulatory care data set

The master patient index must, at a minimum, include sufficient information to

uniquely identify the patient.

Cheryl is the director of the Health Information Services Department, and Suzanne is the assistant director. Cheryl notices one of Suzanne's subordinates leaving the department for an unscheduled break. When the employee returns, Cheryl immediately asks the employee to step into her office and begins discussing the unauthorized break. Which organizational principle is this director violating?

unity of command

a patient is undergoing hemodialysis for end stage renal disease in the outpatient department of an acute care hospital. the patient develops what is believed to be severe heartburn. however she is sent to observation for several hours at which time the patient was admitted to inpatient care for future work-up. the cardiologist diagnosed the patient problem as unstable angina. What is the principal diagnosis for the acute hospital stay?

unstable angina

Early detection programs apply screening guidelines to detect cancers at an early stage, which provides the likelihood of increased survival and decreased morbidity. Which of the following would NOT be a diagnostic or screening test for colorectal cancer?

upper GI X-ray

The patient was brought into the ED with a deep laceration to the ulnar vein. The repair of this is reported from the ______ Body System character of the ICD-10-PCS code.

upper veins

Which structure transports urine from the kidneys to the bladder?

ureter

Common kidney stone treatments that allow small particles to be flushed out of the body through the urinary system include all of the following EXCEPT

ureteroscopy and stone basketing.

You have been asked to develop scenarios that will be used to design and program a new relase of information system. These scenarios will include the processes to be used in detail. What are you designing?

use cases

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the commission's national patient safety goals, the focus has shifted to the

use of prohibited or "dangerous" abbreviations

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the

use of prohibited or "dangerous" abbreviations.

In relation to birth defects registries, active surveillance systems

use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs.

There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by

using established physician query protocols.

Anna Kathryn is attending budget training for new supervisors. The representative from Finance explains that _____ costs will vary in direct proportion to changes in the volume of care provided.

variable

The most realistic approach that could encourage increased productivity in the tedious prepping area is to

vary and rotate the work assigned to each prepper.

Which of the following is a lethal arrhythmia?

ventricular fibrillation

The vendor has provided an update to their software. With this update, the system has new functions. This is known as a

version

all of the following are contained in the medical history report except

vital signs

The information systems manager is testing what the system can handle with regard to passing large amounts of data. This is called

volume testing

Southside Community Hospital utilizes a wide area network to transport data across the Internet. This is done by using a private tunnel. This is a(n)

vpn

A mild, atypical lung infection with inflammation and fluid buildup, usually caused by Mycoplasma pneumoniae or other bacteria, in which the patient is mildly ill but does not require hospitalization and is treated with antibiotics is termed

walking pneumonia

Dr. Smith goes to Hollywood Hospital's Web site and logs in. He sees a list of patients currently in the hospital, test results, and more. Ms. Brown, a patient of Dr. Smith who is having surgery next week, logs onto the same Web site and only sees the date and time of her preoperative visit. This is an example of

web portal

In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded in which of the following cases?

when a new patient is seen in the office

CPT provides Level I modifiers to explain all of the following situations EXCEPT

when a patient sees a surgeon for follow-up care after surgery.

the main difference between concurrent and retrospective coding is:

when the coding is done

The main difference between concurrent and retrospective coding is

when the coding is done.

Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?

when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court

CMS identified Hospital-Acquired Conditions (HACs). Some of these HACs include foreign objects retained after surgery, blood incompatibility, and catheter-associated urinary tract infection. The importance of the HAC payment provision is that the hospital

will not receive additional payment for these conditions when they are not present on admission.

The supervisor over imaging has received frequent complaints from the scanning clerks regarding a prepping clerk's job performance. The scanning clerk's productivity levels have been impacted by the prepping clerk's inability to process the discharge charts in a timely manner. In order to get a clearer understanding of the situation, the supervisor asked the scanning clerks and the prepping clerk to complete a task list for a 2-week period. The supervisor is asking her employees to complete a

work distribution chart.

In explaining the benefits of a document management system, you include:

workflow

The most important consideration in planning the office layout for a Health Information Services department is the

workflow

Joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

yes, prior to surgery

When interviewing a prospective employee, which question would be inappropriate to ask?

"Do you own a home?"

Some services are performed by a nonphysician practitioner (such as a physician assistant). These services are an integral yet incidental component of a physician's treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called

"Incident to" billing.

The supervisor over release of information has requested a meeting with her superior, the director of Health Information Services. She begins the meeting by describing how overwhelmed she is feeling. She is extremely behind in her work and she does not know what she can do to change the situation. In advising the supervisor, the director suggests that perhaps she should begin addressing her problem by attending a management workshop. Which of the following workshop topics is more likely to help the supervisor with her problem?

"The Nature of Delegation"

ICD-10-CM utilizes a placeholder character. This is used as a fifth character placeholder at certain six-character codes to allow for future expansion. The placeholder character is

"x"

Assume the patient has already met his or her deductible and that the physician is a Medicare participating (PAR) provider. The physician's standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?

$ 48.00

The transcription production for February was 225,333 lines. The total work hours for all transcriptionists for the same period were 2,000. The average hourly cost was $13.50. Determine the cost per line for operating this service for this month.

$0.12

If the Medicare non-PAR approved payment amount is $128.00 for a proctoscopy, what is the total Medicare approved payment amount for a doctor who does not accept assignment, applying the limiting charge for this procedure?

$147.20

Under outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20%) or a fixed copayment amount, whichever is less. Mr. Smith, who has paid his deductible for the year, was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case?

$15

If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is

$200.00

If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is

$218.50.

If a participating provider's usual fee for a service is $700.00 and Medicare's allowed amount is $450.00, what amount is written off by the physician?

$250.00

Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's non-PAR fee is $57.00. What is the amount Medicare will pay the beneficiary on this claim?

$45.60

f this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is

$66.50.

The HIM Supervisor conducted a timely performance evaluation for one of her employees and awarded the employee a 4% merit increase. If the employee's hourly salary is presently $7.10, what will the hourly salary be once this merit increase is applied?

$7.38

At Community Hospital the average admission will create a file that will take up 0.25 inch of file space. Each new ER record requires 0.125 inch of file space. Approximately 25,000 new patients are admitted per year and 15,000 ER patients are treated per year. The shelving cost is $1.05 per filing inch. How many money should be allocated for storage space in next year's budget?

$8,531.25

Treatment for chronic conditions at same time preventive medicine is provided.

-25

Consultation required by payer.

-32

Needle core biopsy of right and left breast.

-50

Arthroscopy of right elbow and closed fracture reduction of left wrist.

-51

A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.

-53

Postoperative management of vaginal hysterectomy.

-55

Office consultation as preoperative clearance for surgery.

-56

A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.

-57

Inpatient visit performed by surgeon, with decision to perform surgery tomorrow.

-57

Repeat gallbladder x-ray series, same physician

-76

Mrs. Jones had an appendectomy on November 1. she was taken back to survey on November 2 for evacuation of hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit

-78

Cholecystectomy reported during postoperative period for treatment of leg fracture.

-79

Assistant surgeon reporting patient's cesarean section, delivery only.

-80

According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30?

00-00-31

In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26?

00-06-26

Code anesthesia for decortication of left lung.

00542

Code anesthesia for upper abdominal ventral hernia repair.

00752

Code anesthesia for vaginal hysterectomy.

00944

Code anesthesia for procedures on bony pelvis.

01120

Code anesthesia for total hip replacement.

01214

Code anesthesia for total shoulder replacement.

01638

Code anesthesia for placement of vascular shunt in forearm.

01844

Code anesthesia for cesarean section.

01961

In ICD-10-PCS, percutaneous transposition left radial nerve

01S63ZZ

Place the following in terminal digit order: 01-34-54, 01-35-55, 02-05-49, 02-66-48

02-66-48, 02-05-49, 01-34-54, 01-35-55

Dr. Jones performed an open coronary bypass on two internal mammary arteries, one right, one left. Zooplastic tissue was used. The correct ICD-10-PCS code or codes reported are:

0210088, 0210089

In ICD-10-PCS, heart transplant using porcine heart, open

02YA0Z2

The results of the amniocentesis showed the fetus has Down syndrome. The special care that will be provided to the mother during the rest of her pregnancy will be supported by code:

035.1xx0 Maternal care for (suspected) chromosomal abnormality in fetus

In ICD-10-PCS, percutaneous endoscopic clipping cerebral aneurysm

03VG4CZ

In ICD-10-PCS, percutaneous embolization left uterine artery using coils

04LF3DU

In ICD-10-PCS, percutaneous insertion Greenfield IVC filter

06H03DZ

In ICD-10-PCS, open left neck total lymphadenectomy

07T20ZZ

In ICD-10-PCS, removal FB left cornea

08C9XZZ

In ICD-10-PCS, extraction left intraocular lens without replacement, percutaneous

08DK3ZZ

In ICD-10-PCS, reattachment severed left ear

09M1XZZ

In ICD-10-PCS, percutaneous radiofrequency ablation of the left vocal cord

0C5V3ZZ

In ICD-10-PCS, excision malignant lesion outer upper lip

0CB0XZZ

In ICD-10-PCS, incision and drainage external perianal abscess

0D9QXZZ

In ICD-10-PCS, colonoscopy with sigmoid colon polypectomy

0DBN8ZZ

In ICD-10-PCS, EGD with removal FB from duodenum

0DC98ZZ

In ICD-10-PCS, laparoscopic appendectomy

0DTJ4ZZ

Dr. Woods performed an esophageal transplantation using a section from a cadaver donor.

0DY50Z0

In ICD-10-PCS, report the excision malignant lesion skin of left ear.

0HB3XZZ

In ICD-10-PCS, nonexcisional debridement left heel ulcer

0HDNXZZ

In ICD-10-PCS, a percutaneous fascia transfer to cover defect of the right anterior neck

0JX43ZZ

In ICD-10-PCS, right TRAM pedicle flap reconstruction status post mastectomy, muscle only open

0KXK0Z6

The patient was shot in the right upper femur. He was taken into the operating room so Dr. Smith could remove the bullet from the neck of the femur laparoscopically. The correct ICD-10-PCS code to report is:

0QC64ZZ Extirpation, right upper femur, percutaneous endoscopic

Dr. Smith replaced the patient's L2 vertebra with a prosthetic vertebra during this open procedure. The ICD-10-PCS code to report is:

0QR00JZ

In ICD-10-PCS, open reduction fracture left tibia

0QSH0ZZ

In ICD-10-PCS, left knee arthroscopy with reposition of the anterior horn medial meniscus

0SSC4ZZ

In ICD-10-PCS, routine insertion of indwelling Foley catheter

0T9B70Z

In ICD-10-PCS, transurethral cystoscopy with removal of right ureteral calculus

0TC68ZZ

In ICD-10-PCS, ESWL left ureter wave lithotripsy

0TF7XZZ

In ICD-10-PCS, laparotomy with exploration and adhesiolysis of the left ureter

0TN70ZZ

In ICD-10-PCS, laparoscopy with bilateral occlusion fallopian tubes using external clips

0UL74CZ

At the patient's request, Dr. Jones performed a tubal ligation, bilaterally using an endoscope via vaginal canal. The correct ICD-10-PCS code is:

0UL78ZZ Occlusion, fallopian tubes, bilateral, via natural opening, endoscopic

In ICD-10-PCS, facelift, open

0W020ZZ

Dr. Mason performed a facelift. The ICD-10-PCS code reported is:

0W023ZZ Alteration, face, percutaneous approach

In ICD-10-PCS, thoracentesis right pleural effusion

0W993ZZ

In ICD-10-PCS, percutaneous chest tube placement left pneumothorax

0W9B30Z

The HIM Department maintains 500,000 records and responds to 5,000 requests for records in a given period of time. What is the record usage rate?

As the director of the Health Information Department, you are preparing a request for approval to purchase an encoding system. Because this is considered a capital request, you are required to submit the cost-benefit ratio. The software and license cost is $6,000, hardware maintenance is $1,500, and the training of two employees will cost $500. It is expected that the encoding system will increase reimbursement by $10,000. The cost-benefit ratio is

1.25

The case-mix index (CMI) for the top 10 MS-DRGs above is

1.278.

Of 750 records filed during the week, 75 were not located. What is the filing error rate?

10%

The number of days Medicare will cover SNF inpatient care per benefit period is limited to which of the following?

100

Under ASC PPS, when multiple procedures are performed during the same surgical session, a payment reduction is applied. The procedure in the highest level group is reimbursed at _____ and all remaining procedures are reimbursed at ______.

100%, 50%

Patient presents to the radiology department where a fine-needle aspiration of the breast is performed utilizing computed tomography.

10009

Jason McCall, a 51-year-old male, has a pilonidal cyst. Dr. Bonneti performs an I&D (incision and drainage).

10080

the next available number to assigned a Oceanside Hospital is 41369 D

10361

Lisa was ready to delivery her baby. Due to a diagnosis of placenta previa, Dr. Jones delivered the baby via a low Cesarean section. Lisa's baby girl was born at 11:52 am. Report the delivery with ICD-10-PCS code:

10D00Z1 Extraction, products of conception, open procedure, low incision

In ICD-10-PCS, normal delivery with episiotomy

10E0XZZ, 0W8NXZZ

You are the coding supervisor and wish to know the amount of time spent on coding by eight employees this month. You have the following productivity log. What percentage of time was spent on coding?

11.3%

Patient presents to the hospital for debridement of a diabetic ulcer of the left ankle. The patient has a history of recurrent ulcers. Medication taken by the patient includes Diabeta, and the patient was covered in the hospital with insulin sliding scales. The decubitus ulcer was debrided down to the bone.

11043

Ethan Monahan, a 73-year-old male, came to see Dr. Greenberg for the removal of some skin tags on his left cheek. Dr. Greenberg administered a local anesthetic and then electrosurgically destroyed the nine tags. The tags were sent to pathology for testing.

11200

seventeen skin tags were removed by electrocautherization from the patient back and neck ? what is the correct CPT coding for this procedure

11200,11201

Patient presents to the operating room for excision of three lesions. The 1.5 cm and 2 cm lesions of the back were excised with one excision. The 0.5 cm lesion of the hand was excised. The pathology report identified both back lesions as squamous cell carcinoma. The hand lesion was identified as seborrheic keratosis.

11604, 11420

Denita Tauber found a sore on her neck. The lab test identified it as a malignant lesion, and Dr. Capp excised the lesion, measuring 2.9 cm with margins.

11623

A new Health Information Department had purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number?

Warren Samuels, a 47-year-old male, owns a landscaping business. While he was reviewing some property to write a proposal, the family's toy poodle bit him on the leg. While the 12-cm wound was not severe, Warren wanted Dr. Dawson to check it out. Dr. Dawson performed a simple repair and applied a bandage.

12004

Cletus Jones, a 23-year-old male, was in a fight at a hockey game and was hit in the head with a bottle, which caused some deep lacerations in his scalp. Dr. Fairchild performed a layered closure of the wounds: one 2.0 cm; one 4.5 cm; and two lacerations that were 1.0 cm each in length.

12034

Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5 cm and 2.7 cm. Repair for the wound required the physician to close the epidermal and dermal layers.

12034

Patient presents to the emergency room with lacerations sustained in an automobile accident. Repairs of the 3.3 cm skin laceration of the left leg that involved the fascia, 2.5 cm and 3 cm lacerations of the left arm involving the fascia, and 2.7 cm of the left foot, which required simple sutures, were performed. Sterile dressings were applied.

12034, 12002-59

A HIM Department, currently using 2,540 linear filing inched to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new files shelving units should be purchased?

Patient presents to the operating room where a 3.2 cm malignant lesion of the shoulder was excised and repaired with simple sutures. A 2 cm benign lesion of the cheek was excised and was repaired with a rotation skin graft.

14040, 11604

Patient presents to the operating room for excision of a 4.5 cm malignant melanoma of the left forearm. A 6 cm x 6 cm rotation flap was created for closure.

14301

When all third-party payments have been received and contractual allowances have been written off, the remaining balance is categorized as the patient responsibility. Best practice is to have the patient responsibility amount be less than what percentage of the total balance?

The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the non-PAR fee schedule amount. The limiting charge is

15%

The first patient with cancer seen in your facility on January 1, 2015, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient it

15-0001/00.

Under ASCs, bilateral procedures are reimbursed at ________ of the payment rate for their group.

150

Under ASC PPSs, bilateral procedures are reimbursed at _______ of the payment rate for their group.

150%

Patient presents to the hospital for skin grafts due to previous third-degree burns. The burn eschar of the back was removed. Once the eschar was removed, the defect size measured 10 cm x 10 cm. A skin graft from a donor bank was placed onto the defect and sewn into place as a temporary wound closure.

15002, 15273

A 10 sq cm epidermal autograft to the face from the back

15115

Nonhuman graft for temporary wound closure. Patient has a 5 cm defect on the scalp.

15275

Colleen Sizmauski, a 59-year-old female, came to Dr. Lafferty's office to have an epidermal facial checmical peel performed.

15788

Colleen Sizzle, a 59-year-old female, came to Dr. Kraft's office to have an epidermal facial chemical peel performed.

15788

Facelift utilizing the superficial musculoaponeurotic system (SMAS) flap technique.

15829

Hannah Lopez, a 63-year-old female, is bedridden with two broken legs in traction. Dr. Quinn excised an ischial pressure ulcer with a primary suture.

15940

Jackie Thurman, a 35-year-old female, was seen by her regular physician, Dr. Callman, after she spilled a pot of boiling water on her stomach and legs. Thankfully, her apron and corduroy dress absorbed most of the heat, and she only had first-degree burns. Dr. Callman performed initial local treatment and sent her home.

16000

Ruth Ann Marcelle, a 9-year-old female, had a partial thickness burn on her hand. Dr. Assiss performed a debridement and dressing of the injury.

16020

Ruth Ann Marcelle, a 9-year-old female, had a partial thickness burn on her hand. Dr. Wright performed a debridement and dressing of the injury.

16020

outpatient surgery was performed for the laser removal of the five benign facial lessons. no tissue were sent to pathology. which of the following represents the correct coding and sequencing?

17000,17003,17003,17003,17003

Frank Mulrooney, a 43-year-old male, came to see Dr. Johnston, his podiatrist, for the removal of a benign plantar wart from the sole of his left foot. Dr. Johnston administered a local anesthetic and then destroyed the wart using a chemosurgical technique. A protective bandage was applied to the foot, and Frank was sent home with an appointment to return in one week for a follow-up check.

17110

The first patient with cancer seen in your facility on January 1, 2018 was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is

18-0001/00.

Patient presents to the operating room where the physician performed, using imaging guidance, a percutaneous breast biopsy utilizing a rotating biopsy device.

19081

Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion.

19120-LT

excision of 3 breast lesions with preoperative placement of needle localization wire by the surgeon

19125,19126,19126,19290,19291,19291

Cassandra Twillinger, a 29-year-old female, is postmastectomy and comes in today so Dr. Edwin can perform a breast reconstruction with free flap.

19364

If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate?

2.4%

Under ASC-PPS, the patient is responsible for paying the coinsurance amount based upon ____ of the national median charge for the services rendered.

20%

The patient is financially liable for the coinsurance amount, which is

20%%

Patient is brought to the emergency room following a shark attack. The paramedics have the patient's amputated foot. The patient is taken directly to the operating room to reattach the patient's foot.

20838

Patient presents to the emergency room following an assault. Examination of the patient reveals blunt trauma to the face. Radiology reports that the patient suffers from a fracture to the frontal skull and a blow-out fracture of the orbital floor. Patient is admitted and taken to the operating room where a periorbital approach to the orbital fracture is employed and an implant is inserted.

21390

Open I&D of a deep abscess of the cervical spine

22010

Chronic nontraumatic rotator cuff tear. Arthroscopic procedure of the shoulder with removal of foreign body and open rotator cuff repair

23412, 29819-59

Mr. Jones is a 67-year-old patient who only has Medicare's Part A insurance. Given the information here, if Mr. Jones used 36 lifetime reserve days, how many does the patient have left to be used at a later date?

24 days

You have been appointed as Chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

24 hours after admission or prior to surgery.

Patient presents to the emergency room following a fall from a tree. X-rays were ordered for the left upper arm, which showed a fracture of the humerus shaft. The emergency room physician performed a closed reduction of the fracture and placed the patient in a long arm spica cast. Code the procedures, excluding the X-ray.

24505-LT

how many major diagnostic categories are there in the MS-DRG system?

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day?

25 hours per day

Patient comes into his physician's office complaining of wrist pain. Physician gives the patient an injection and sends the patient to the hospital for an arthrography. Code the complete procedure.

25246, 73115

percutaneous skeleton fixation of distal radial fracture requiring manipu;action with external fixation

25611

Patient presents to the hospital with a right index trigger finger. Release of the trigger finger was performed.

26055-F6

Patient presents with a traumatic partial amputation of the second, third, and fourth fingers on the right hand. Patient was taken to the operating room where completion of the amputation of three fingers was performed with direct closure.

26951-F6, 26951-F7, 26951-F8

Trauma patient was rushed to the operating room with multiple injuries. Open reduction with internal fixation of intertrochanteric femoral fracture and open reduction of the tibial and fibula shaft with internal fixation were performed.

27244, 27758

Patient presents to the emergency room following a fall. X-rays were ordered for the lower leg, and results showed a fracture of the proximal left tibia. The emergency room physician performed a closed manipulation of the fracture with skeletal traction.

27532-LT

After reviewing the following excerpt from CPT, code 27646 would be interpreted as

27646 radical resection of tumor; fibula.

repair secondar achilles tendon

27654

No book:Patient was seen for excision of two interdigital neuromas from the left foot.

28080, 28080

Dr. Torres performed a repair of the secondary tendon flexor in Bobby Morton's right foot. He first performed an open tenotomy and then did the repair with a free graft.

28202

keller procedure

28292

Patient presents to the hospital with ulcer of the right foot. Patient is taken to the operating room where a revision of the right metatarsal head is performed.

28899

diagnostic and surgical arthroscopy of the right knee with lateral meniscectomy

29881

During the month of December, there were 3489 discharges with 134 incomplete records. What was the incomplete record rate for the month?

3.84%

How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained?

Dr. Quartermain performed a rhinoplasty to correct the nasal deformity on Frank Chestnut, a three-year-old male born with a cleft palate. The tip, septum, and osteotomies were all treated

30462

Dr. Quartermain performed a rhinoplasty to correct the nasal deformity on Frank Chestnut, a three-year-old male born with a cleft palate. The tip, septum, and osteotomies were all treated.

30462

Patient with a deviated nasal septum that was repaired by septoplasty

30520

surgical nasal endoscopy with polypectomy

31237

Patient presents to the surgical unit and undergoes unilateral nasal endoscopy, partial ethmoidectomy, and maxillary antrostomy.

31254, 31256-51

Patient has been diagnosed with metastatic laryngeal carcinoma. Patient underwent subtotal supraglottic laryngectomy with radical neck dissection.

31368

Lye burn of the larynx repaired by laryngoplasty

31599

Patient was involved in an accident and has been sent to the hospital. During transport, the patient develops breathing problems and, upon arrival at the hospital, an emergency transtracheal tracheostomy was performed. Following various X-rays, the patient was diagnosed with traumatic pneumothorax. A thoracentesis with insertion of tube was performed.

31603, 32554

Patient with laryngeal cancer has a tracheoesophageal fistula created and has a voicebox inserted.

31611

Tracheostoma revision with flap rotation

31614

Patient has a bronchoscopy with endobronchial biopsies of three sites.

31625

Bronchoscopy with multiple transbronchial right upper and right lower lobe lung biopsy with fluoroscopic guidance

31628, 31632

Patient was admitted with hemoptysis and underwent a bronchoscopy with transbronchial lung biopsy. Following the bronchoscopy, the patient was taken to the operating room where a left lower lobe lobectomy was performed without complications. Pathology reported large cell carcinoma of the left lower lobe.

31628, 32480

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital. Springfield HospitalQuarterly Statistics Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590

32%

thoracentesis with insertion of tube for pneumothorax

32002

Upper lobectomy of the right lung with repair of the bronchus

32480, 32501

Patient has recurrent spontaneous pneumothorax, which has resulted in a chemical pleurodesis by thoracoscopy.

32650

Patient presents to the operating room where a CABG x 3 is performed using the mammary artery and two sections of the saphenous vein.

33533, 33518

Patient undergoes construction of apical-aortic conduit with an insertion of a single-ventricle ventricular assist device.

33975

carotid artery embolectomy

34001

No book: The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision.

34203

Patient complains of recurrent syncope following carotid thromboendarterectomy. Patient returns 2 weeks after initial surgery and undergoes repeat carotid thromboendarterectomy.

35301

Patient has a history of PVD for many years and experiences chest pains. The patient underwent Doppler evaluation, which showed a common femoral DVT. Patient is now admitted for thromboendarterectomy.

35371

Patient returns to the operating room following open-heart bypass for exploration of blood vessel to control postoperative bleeding in the chest.

35820

The physician punctures the left common femoral to examine the right common iliac.

36245

Blood transfusion of three units of packed red blood cells

36430

Eighty-year-old patient has carcinoma and presents to the operating room for placement of a tunneled implantable centrally inserted venous access port.

36561

Patient is admitted with alcohol cirrhosis and has a TIPS procedure performed.

37182

varicoses vein ligation and stripping of long saphenous vein

37720

Trauma patient is rushed to the operating room with multiple injuries. The patient had his spleen removed due to a massive rupture, with repair of the lacerated diaphragm.

38100, 39501

Patient has a bone marrow aspiration of the iliac crest and of the tibia.

38220, 38220-59

Patient has breast carcinoma and is now undergoing sentinel node biopsy. Patient was injected for sentinel node identification and two deep axillary lymph nodes showed up intensely. These two lymph nodes were completely excised. Path report was positive for metastatic carcinoma.

38525, 38792

Patient diagnosed with cystic hygroma of the axilla, which was excised

38550

Laparoscopic retroperitoneal lymph node biopsy

38570

Laparoscopy with multiple biopsies of retroperitoneal lymph nodes

38570

Excision of mediastinal cyst

39200

In ICD-10-PCS, administration of Oxazolidinone, inhaled through the nose

3E09728

The HIM department of a local hospital will experience a 20% increase in the number of discharges processed per day as the result of a merger with a smaller facility. This 20% increase is projected as 120 additional records per day. The standard time for coding a record is 15 minutes. Compute the number of FTEs required to process this increased volume in coding based on an 8-hour day.

In deciding to purchase or lease a new dictation system, the director of Health Information Services calculated the payback period and rate of return on the investment. The hospital's required payback period is 3 years with a required rate of return of 20%. If the equipment costs $32,000 and generates $8,000 per year in savings, what would the payback period for this equipment be?

4 years

Palm Beach Healthcare Center has been in operation fro 13 years. It has 6,000 admissions per year. The facility has expanded and will allow for 200 more admissions per year from now on. There are 2,500 linear feet of filing space available and half is being used. The facility expects a 30% readmission rate. If a unit numbering/filing system is used, how many file folders will be needed for the next year?

4,340

The best practice for a system hold for all charges to be entered into the billing system and all coding to be completed is:

4-days post-discharge or visit

Last month Houston Hospital discharged 517 patient. Each chart is approximately 1.8 inches thick. A shelving unit in the health information department has 7 shelves and each shelf is 36 inches. How many shelving units are needed to store 1 month of discharged records?

4.00

a patient is admitted to your hospital 6 weeks post myocardial infraction with severe chest pains. which is the correct code?

410.1x (acute MI)

prolonged pregnancy is a pregnancy that had advance beyond___completed weeks of gestation

Young child presents with cleft lip and cleft palate. This is the first attempt of repair, which includes major revision of the cleft palate and unilateral cleft lip repair.

42215, 40700

Two-year-old patient returns to the hospital for cleft palate repair where a secondary lengthening procedure takes place.

42220

Injection snoreplasty for treatment of palatal snoring

42299

tonsillectomy on a 6 year old boy

42825

Tonsillectomy on a 14-year-old

42826

Patient presents with a history of upper abdominal pain. Cholangiogram was negative, and patient was sent to the hospital for ERCP. During the procedure, the sphincter was incised and a stent was placed for drainage.

43274

Patient arrives to the hospital and has a Nissen fundoplasty done laparoscopically.

43280

Patient has a history of hiatal hernia for many years, which has progressively gotten worse. The decision to repair the hernia was made, and the patient was sent to the operating room where the repair took place via the thorax and abdomen.

43336

Laparoscopic gastric banding

43770

Morbidly obese patient comes in for vertical banding of the stomach.

43842

Patient presents to the emergency room with right lower abdominal pains. Emergency room physician suspects possible appendicitis. Patient was taken to the operating room where a laparoscopic appendectomy was performed. Pathology report was negative for appendicitis.

44970

laparoscopic adrenalectomy

44970

Patient underwent anoscopy followed by colonoscopy. The physician examined the colon to 60 cm.

45378

colonoscopy with removal of polyps by hot biopsy forceps and by snare technique

45384,45385

Based on the this patient volume, during this time period, the MS-DRG that brings in the highest "total" reimbursement to the hospital is

470

Ultrasonic guidance for the needle biopsy of the liver. Code the complete procedure.

47000, 76942

Patient was admitted for right upper quadrant pain. Workup included various X-rays that showed cholelithiasis. Patient was taken to the operating room where a laparoscopic cholecystectomy was performed. During the procedure, the physician was unable to visualize through the ports, and an open cholecystectomy was elected to be performed. An intraoperative cholangiogram was performed. Pathology report states acute and chronic cholecystitis with cholelithiasis.

47605

No book:A 4-year-old had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition

49501

Laparoscopic repair of umbilical hernia

49652

How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least _____ years unless a longer period is required by state or local laws.

The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period.

Two weeks ago, Dr. Sweetzer perfomed an ureteroneocystostomy with cystoscopy and ureteral stent placement laparoscopically on Patricia Worster. However, today he must perform an open procedure on her to drain a renal abscess that was discovered. Code the drainage of Patricia's renal abscess.

50020

Nephrectomy with resection of half of the ureter

50220

Patient undergoes partial nephrectomy for carcinoma of the kidney.

50240

Removal of nephrostomy tube with fluoroscopic guidance

50389

Patient comes to the hospital with a history of right flank pain. Urine tests are negative. Radiology examination reveals that the patient has renal cysts. Patient is now admitted for laparoscopic ablation of the cysts.

50541

Patient has ovarian vein syndrome and has ureterolysis performed.

50722

Closure of ureterocutaneous fistula

50920

Patient presented to the operating room where an incision was made in the epigastric region for a repair of ureterovisceral fistula.

50930

Ureterolithotomy completed laparoscopically

50945

Patient has extensive bladder cancer. She underwent a complete cystectomy with bilateral pelvic lymphadenectomy and creation of ureteroileal conduit.

51595

Female with 6 months of stress incontinence. Outpatient therapies are not working and the patient decides to have the problem fixed. Laparoscopic urethral suspension was completed.

51990

Patient presents to the operating room for fulguration of bladder tumors. The cystoscope was inserted and entered the urethra, which was normal. Bladder tumors measuring approximately 1.5 cm were removed.

52234

Excision of 2.5 cm bladder tumor with cystoscopy

52235

Litholapaxy, 3 cm calculus

52318

Placement of double-J stent

52332

Patient presents to the hospital with right ureteral calculus. Patient is taken to the operating room where a cystoscopy with ureteroscopy is performed to remove the calculus.

52352-RT

transurethral ballon dilation of prostatic urethra

52510

Excision of Cowper's gland

53250

Male with urinary incontinence. Sling procedure was performed 6 months ago, and now the patient has returned for a revision of the sling procedure.

53442

Male patient has been diagnosed with benign prostatic hypertrophy and undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy.

53852

Laser destruction of penile condylomas

54057

Patient has been diagnosed with prostate cancer. Patient arrived in the operating room where a therapeutic orchiectomy is performed.

54520

Patient undergoes laparoscopic orchiopexy for intra-abdominal testes.

54692

A quarterly review reveals the following data for Springfield Hospital: Springfield Hospital Quarterly Statistics Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 What is the percentage of incomplete records during this quarter?

55%

Scrotal wall abscess drainage

55100

Male presented to operating room for sterilization by bilateral vasectomy

55250

Hydrocelectomy of spermatic cord

55500

Patient has been followed by his primary care physician for elevated PSA. Patient underwent prostate needle biopsy in the physician's office 2 weeks ago, and the final pathology was positive for carcinoma. Patient is admitted for prostatectomy. The frozen section of the prostate and one lymph node is positive for prostate cancer with metastatic disease to the lymph node. Prostatectomy became a radical perineal with bilateral pelvic lymphadenectomy.

55815

Patient has a Bartholin's gland cyst that was marsupialized.

56440

Which set of records filed consecutively on a shelf displays terminal digit filing order?

57-78-00, 57-78-01, 56-78-99

Patient has been diagnosed with carcinoma of the vagina, and she has a radical vaginectomy with complete removal of the vaginal wall.

57111

Patient was admitted with a cystocele and rectocele. An anterior colporrhaphy was performed.

57240

Patient has been diagnosed with uterine fibroids and undergoes a total abdominal hysterectomy with bilateral salpingo-oophorectomy.

58150

Hysteroscopy with D&C and polypectomy

58558

Patient was admitted to the hospital with sharp pelvic pains. A pelvic ultrasound was ordered, and the results showed a possible ovarian cyst. The patient was taken to the operating room where a laparoscopic destruction of two corpus luteum cysts was performed.

58662

Laparoscopic tubal ligation utilizing Endoloop

58671

Patient is at a fertility clinic and undergoes intrauterine embryo transplant.

58974

Amniocentesis

59000

Patient is admitted to the hospital following an ultrasound at 25 weeks, which revealed fetal pleural effusion. A fetal thoracentesis was performed.

59074

Patient is 6 weeks pregnant and complains of left-sided abdominal pains. Patient is suspected of having an ectopic pregnancy. Patient has a laparoscopic salpingectomy with removal of the ectopic tubal pregnancy.

59151

A D&C is performed for postpartum hemorrhage.

59160

A pregnant patient has an incompetent cervix, which was repaired using a vaginal cerclage.

59320

Patient in late stages of labor arrives at the hospital. Her OB physician is not able to make the delivery, and the house physician delivers the baby vaginally. Primary care physician resumes care after delivery. Code the delivery.

59409

Cesarean delivery with antepartum and postpartum care

59510

Attempted vaginal delivery in a previous cesarean section patient, which resulted in a repeat cesarean section

59620

Patient is 24 weeks pregnant and arrives in the emergency room following an automobile accident. No fetal movement or heartbeat noted. Patient is taken to the OB ward where prostaglandin is given to induce abortion.

59855

A HIM Department wants to buy new open-shelf filing units for its file expansion. Each of the shelves in a new 6-shelf unit measures 33 linear filing inches. There will be an estimated 1,000 records to file. The average record is 1-inch thick. How many filing units should be purchased?

Terminally ill patients with life expectancies of ______ may opt to receive hospice services.

6 months or less

Mycobacterium tuberculosis is the organism that causes tuberculosis (TB), typically a respiratory disorder. It is currently experiencing resurgence in the United States and many other countries. What is the average time frame in which all patients with new, previously untreated TB must have daily antibiotic therapy?

6-12 months

If the budgeted payroll expense was $24,300 and the actual payroll expense was $25,800, what is the percentage of cost variance?

6.17%

Your committee is charges with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely check to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is a least every

60 days.

Patient comes in for a percutaneous needle biopsy of the thyroid gland.

60100

Unilateral partial thyroidectomy

60210

On May 1, Dr. Monmouth performed a percutaneous core needle biopsy on Stephan English. Two days later, after reviewing the results of the biopsy, Dr. Monmouth performs a complete thyroidectomy on Stephan. Code both procedures.

60240, 60100

Patient undergoes total thyroidectomy with parathyroid autotransplantation.

60240, 60512

Left carotid artery excision for tumor of carotid body

60605

Laparoscopic adrenalectomy, complete

60650

Patient is admitted to the hospital with facial droop and left-sided paralysis. CT scan of the brain shows subdural hematoma. Burr holes were performed to evacuate the hematoma.

61154

Patient has metastatic brain lesions. Patient undergoes stereotactic radiosurgery gamma knife of two lesions.

61796, 61797

Patient with Parkinson's disease is admitted for insertion of a brain neurostimulator pulse generator with one electrode array.

61885

Patient has rhinorrhea, which requires repair of the CSF leak with craniotomy.

62100

Spinal tap

62270

Patient comes in for steroid injection for lumbar herniated disk. Marcaine and Aristocort were injected into the L2-L3 space.

62322

Laminectomy and excision of intradural lumbar lesion

63272

Patient requires repair of a 6 cm meningocele.

63702

Injection of anesthesia for nerve block of the brachial plexus.

64415

Patient has right sacroiliac joint dysfunction and requires a right S2-S3 paravertebral facet joint anesthetic nerve block with image guidance.

64493

carpal tunnel disease open

64721

Patient comes in through the emergency room with a wound that was caused by an electric saw. Patient is taken to the operating room where two ulna nerves are sutured.

64836, 64837

Patient undergoes enucleation of left eye, and muscles were reattached to an implant.

65105-LT

Aphakia penetrating corneal transplant

65750

Radial keratotomy

65771

Patient undergoes ocular resurfacing construction utilizing stem cell allograft from a cadaver.

65781

Patient returns to the physician's office complaining of obscured vision. Patient has had cataract surgery 6 months prior. Patient requires laser discission of secondary cataract.

66821

Patient suffers from strabismus and requires surgery. Recession of the lateral rectus (horizontal) muscle with adjustable sutures was performed.

67311, 67335

Correction of trichiasis by incision of lid margin

67830

Lagophthalmos correction with implantation using gold weight.

67912

Patient is admitted for a blepharoplasty of the left lower eyelid and a repair for a tarsal strip of the left upper lid.

67917-E1, 15820-E2

Drainage of simple external ear abscess

69000

Patient comes into the office for removal of impacted earwax.

69210

Modified radical mastoidectomy

69505

Patient came in for excision of a middle ear lesion.

69540

Myringoplasty

69620

Patient with a traumatic rupture of the eardrum. Repaired with tympanoplasty with incision of the mastoid. Repair of ossicular chain not required.

69635

Patient with chronic otitis media requiring transtympanic eustachian tube catheterization.

69799

Insertion of cochlear device inner ear

69930

Patient with Bell's palsy requiring a total facial nerve decompression

69955

Decompression internal auditory canal

69960

In ICD-10-PCS, a 1-year-old child was left in a car for 5 hours during a blizzard with extreme drop in temperature. In the hospital, hyperthermia is used to raise the child's body temperature back to normal. One session was completed.

6A3Z0ZZ

Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be

7 years.

The average number of transcribed lines per month at Bent Tree Hospital is 142,500. The daily production standard is 950 lines per day. With 20 workdays in the month, calculate the minimum number of FTEs needed for this volume.

7.5

Given the following file numbers, which are arranged correctly in terminal-digit filing order?

70-41-00 43-42-00 64-55-00 52-43-01

CT scan of the head with contrast

70460

Patient presents to the hospital for a two-view chest X-ray for a cough. The radiology report comes back negative. What would be the correct codes to report to the insurance company?

71046

Patient comes into the outpatient department at the local hospital for an MRI of the cervical spine with contrast. Patient status post automobile accident.

72142

Patient undergoes X-ray of the foot with three views.

73630

Obstetric patient comes in for a pelvimetry with placental placement.

74710

Pregnant female comes in for a complete fetal and maternal evaluation via ultrasound.

76811

Unilateral mammogram with computer-aided detection with further physician review and interpretation.

77065

Patient has carcinoma of the breast and undergoes proton beam delivery of radiation to the breast with a single port.

77520

SPECT bone imaging

78320

Administration of initial oral radionuclide therapy for hyperthyroidism

79005

If the HIM Department has purchased 100 units of 8-shelf files and plans to use the terminal digit filing system, how many shelves should be allocated to each primary number?

Basic metabolic panel (calcium, total) and total bilirubin

80048, 82247

A physician orders a lipid panel on a 54-year-old male with hypercholesterolemia, hypertension, and a family history of heart disease. The lab employee in his office performs and reports the total cholesterol and HDL cholesterol only.

82465, 83718

Creatinine clearance

82575

Vitamin B12

82607

After a work sampling study was completed, it was found that 20 percent of a coder's time was devoted to creating electronic queries to be sent to the physicians' electronic inboxes. How many minutes of a 7-hour day are taken up with this activity?

Clotting factor VII

85230

Partial thromboplastin time utilizing whole blood

85730

Hepatitis C antibody

86803

Chlamydia culture

87110

Pathologist performs a postmortem examination, including the brain, of an adult. Tissue is sent to the lab for microscopic examination.

88025

Cytopathology of cervical Pap smear with automated thin-layer preparation utilizing computer screening and manual rescreening under physician supervision

88175

Pathologist bills for gross and microscopic examination of medial meniscus

88304

What code is used for a culture of embryos less than 4 days old?

89250

Huhner test and semen analysis

89300

What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as cancer program?

90%

An established 3-year-old patient was seen by his pediatrician for a DTaP immunization. The pediatrician also provided documentation for a minimal level office visit in addition to the immunization.

90700, 90471, 99211-25

No book:Patient was seen today for regular hemodialysis. No problems reported, tolerated procedure well.

90935

Caloric vestibular test using air, monothermal

92538

A physician performs a PTCA with drug-eluting stent placement in the left anterior descending artery and angioplasty only in the right coronary artery.

92928-LD, 92920-RC

The patient's physician performed a balloon angioplasty (PTCA) with insertion of drug-eluting stent in the right coronary artery.

92928-RC

Cardioversion of cardiac arrhythmia by external forces

92960

Out of 2,543 records requested from the HIM Department, 2,375 were located. What is the filing accuracy rate?

93.39%

Transesophageal echocardiography (TEE) with probe placement, image, and interpretation and report

93312

Patient presents to the emergency room with chest pains. The patient is admitted as a 23-hour observation. The cardiologist orders cardiac workup, and the patient undergoes left heart catheterization via the left femoral artery with visualization of the coronary arteries and left ventriculography. The physician interprets the report. Code the heart catheterization.

93458

Which code listed below would be used to report an esophageal electrogram during an EPS?

93615

Comprehensive electrophysiologic evaluation (EPS) with induction of arrhythmia

93620

The total number of records filed during the month is 2,500 and, upon completion of a filing accuracy study, 90 records were not found. What is the accuracy rate for filing?

96%

IV push of one antineoplastic drug

96409

One-half hour of IV chemotherapy by infusion followed by IV push of a different chemotherapy

96413, 96411

Osteopathic manipulative treatment to three body regions

98926

Patient with hematochromatosis had a therapeutic phlebotomy performed on an outpatient basis.

99195

The patient is a 52-year-old male from out of state visiting his daughter. He left his medications for his benign hypertension at home and is now here in the clinic in need of a prescription. A problem focused history and examination is performed and a prescription is given to the patient.

99201

The patient is on vacation and presents to a physician's office with a lacerated finger. The physician repairs the laceration and gives a prescription for pain control and has the patient follow up with his primary physician when he returns home. The physician completes problem-focused history and physical examination with straightforward medical decision making. Also checked is a laceration repair for a 1.5 cm finger wound.

99201, 12001

A patient receives individual psychotherapy for 30 minutes. The doctor also provides medical E/M services for this established patient that includes a problem-focused history, a problem-focused examination, and straightforward level of medical decision making

99212, 90833

An established patient returns to the physician's office for follow-up on his hypertension and diabetes. The physician takes the blood pressure and references the patient's last three glucose tests. The patient is still running above-normal glucose levels, so the physician decides to adjust the patient's insulin. An expanded history was taken, and a physical examination was performed.

99213

The patient is a 34-year-old established patient seen in the clinic by her dermatologist. She is followed for extensive psoriasis involving her scalp, trunk, and arms. It has now worsened and spread to her palms, and she is now also complaining of joint pain. The spread to her hands has made it difficult to do many of her day-to-day tasks. A detailed history and examination are performed. The examination includes inspection of the affected areas in addition to bending and rotation of joints. A long discussion took place regarding a change in her medications to try to gain better control of her psoriasis and slow down the systemic progression. Topical and systemic treatment was decided on.

99214

A patient who was on observation status for 48 hours is discharged from the hospital. The patient was being observed after a motor vehicle accident for subdural hematoma, subsequently ruled out. Code only the discharge services and diagnosis.

99217

An established patient was seen in her primary physician's office. The patient fell at home and came to the physician's office for an examination. Due to a possible concussion, the patient was sent to the hospital to be admitted as an observation patient. A detailed history and physical examination were performed, and the medical decision was low complexity. The patient stayed overnight and was discharged the next afternoon.

99218, 99217

Initial observation of a patient was for upper abdominal pain, dizziness, and anemia. A comprehensive history and examination was performed. Moderate complexity decision making was conducted to admit the patient to observation to treat and rule out causes of the patient's anemia.

99219

A 16-year-old female is being admitted by her family practice physician with a 2-week history of fatigue and fever. It has been progressively getting worse. She is suffering from dehydration. The physician performs a comprehensive history to look for explanations for her fatigue, including recent activity level and recent sleep habits. A detailed examination is performed and she is diagnosed with mononucleosis and admitted for treatment.

99221

A 69-year-old established female patient presents to the office with chronic obstructive lung disease, congestive heart failure, and hypertension. The physician conducts a comprehensive history and physical examination and makes a medical decision of moderate complexity. Physician admits the patient from the office to the hospital for acute exacerbation of CHF.

99222

A 56-year-old male with an established history of ASHD of native arteries and past stent placement is admitted through the emergency room with acute onset of chest pain. An EKG was performed and troponin levels taken. Both showed evidence of the patient having an acute inferior wall myocardial infarction. The cardiologist performs a comprehensive history, with the chief complaint, 4 from the history of present illness (HPI), a complete review of systems (ROS), and past, family, and social history (PFSH). The history includes the information that the pain started a week ago but last night worsened. Also on a scale of 1 to 10, he rated the pain an 8. It was also discovered that the patient has not been attending regular appointments in the clinic setting. A comprehensive examination was performed along with high complexity medical decision making (MDM), including management of the patient's acute MI and reviewing data of the medical history of the patient. He was taken immediately to the cardiac catheterization lab to look for the source for the patient's MI.

99223

A 2-year-old boy with bacterial pneumonia is hospitalized and has had 5 days of antibiotic therapy. Today the child developed a fever of 101F with a mild rash on his torso. In a subsequent hospital visit, the attending physician performed a problem focused history and examination. The MDM complexity was low.

99231

This is a follow-up visit on a 28-year-old male who is admitted with the diagnosis of headaches. The patient is subsequently seen because the physician needs to follow up on test results that weren't back yet at the initial consultation. This will help to find a possible cause of headaches and course of treatment. A problem focused history and examination and low-complexity decision making is made after viewing the CT results. The diagnosis of tension headaches was made and treatment options discussed.

99231

The initial consulting physician subsequently sees a 55-year-old patient injured at work when he fell from a house roof and struck his head. The patient had a right frontal parietal craniotomy 6 days previously and is recovering rapidly. The initial consultation was requested regarding a possible drug reaction that produced a rash on the upper torso. The consultant recommended a medication change, but after 48 hours the patient had no improvement. The physicain re-evaluates for other possible causes of the rash. An expanded problem focused interval history and a physcial examination were performed. The MDM complexity was moderate.

99232

a 55 year old male patient is sent to surgeons office for hemorrhoids...

99241

A 44-year-old patient, with chronic mastoiditis, was seen in consultation by the ENT specialist in the office. Her physician was inquiring as to the advantages of surgery versus continued anibiotic treatment when an acute flare comes on. The ENT specialist recommends surgery because of the increasing severity with each acute flare. She is fearful of the surgery because of the need to go under general anesthetic and a fear of permanent hearing loss. The physician performs an expanded problem focused history to include the duration of this problem and how many acute flares a year the patient experiences. An expanded problem focused examination and straightforward decision making is completed. It is determined that with the number of acute flares a year and the increasing severity of each case that surgery is recommended. The patient's fears are laid to rest and the patient decides to go ahead with the surgery.

99242

A 47-year-old female was sent by her family practice physician for an office consultation with a gynecologist. The patient has been suffering with moderate pelvic pain, a heavy sensation in her lower pelvis, and marked discomfort during sexual intercourse. In a detailed history, the gynecologist noted the location, severity, and duration of her pelvic pain and related systems. In the review of systems, the patient had positive findings related to her gastrointestinal, genitourinary, and endocrine body systems. The physician noted that her medical history was noncontributory to the present problem. The detailed physical examination centered on her gastrointestinal and genitourinary systems, with a complete pelvic examination. The physician ordered laboratory tests and a pelvic ultrasound to determine uterine fibroids, endometritis, or other internal gynecological pathology. The MDM complexity was moderate.

99243

A 38-year-old female has severe low back pain due to trauma injury she experienced as a factory worker 4 years ago. The chronic pain has become almost unbearable, and her internal medicine physician cannot go any further with her treatment. An initial outpatient consultation is requested and the patient is sent to see the pain management specialist for suggestions to control the chronic pain. A comprehensive history is taken, including all of the pertinent information regarding her injury. During the comprehensive examination the patient's gait and movement were observe. Moderate-complexity decision making is performed, including different treatment options. A separate note is dictated to show the requesting physician what results were found during the visit and the decision on treamtment of her pain.

99244

An 83-year-old patient is seen at the local nursing home. The patient suffers from severe COPD. Routine labs were drawn on the patient by her primary doctor and her blood sugar came back abnormal. Fasting glucose was then taken and was high. The endocrinologist was asked to render an opinion on a possible diagnosis of diabetes. A problem focused history and examination and straightforward decision making were mad. Diabetes was diagnosed and treatment started. The endocrinologist contacted the primary physician and discussed treatment of the patient. Report services for the endocrinologist only.

99251

A 46-year-old male is admitted to the hospital with a progressive staphylococcal pneumonia that is not responding to treatment. A request is made for the infectious disease physician on staff to render his opinion for treatment. The patient is seen in initial inpatient consultation. An expanded problem focused history and examination are performed. After looking at the sputum cultures, the physician decides on the most effective antibiotic for treatment. The decision making is straightforward.

99252

An inpatient urological consultation is performed for a 32-year-old female who recently had an elective abortion performed on an outpatient basis. The woman has been admitted with a high fever, pelvic pain, and dysuria. During a detailed history, the urologist notes in the the history of present illness that the patient's symptoms began about 2 days after the abortion and progressed to the acute phase, which she is in at the present time. The location of the pain is in the lower abdomen and rated 9 on a scale of 1 to 10. She reports the quality of the pain to be sharp and stabbing. In the review of systems, the physician notes positive responses in 5 of the 12 body systems investigated. The urologist notes a negative medical history related to urinary symptoms other than a mild cystitis about 10 years ago. The detailed physical examination performed by the urologist centers on the genitourinary system and gastrointestinal system in significant detail. The medical decision making is low. Given the patient's past surgical procedure and physical findings at the present, the consultant considers the diagnoses of pyelonephritis, cystitis, pyelitis, and endometritis.

99253

Patient is admitted to the hospital with acute abdominal pain. The attending medical physician requests a surgical consult. The consultant agrees to see the patient and conducts a comprehensive history and physical examination. To rule out pancreatitis, the physician orders lab work, along with an ultrasound of the gallbladder and an abdominal X-ray. Due to the various diagnosis possibilities and the tests reviewed, a moderate medical decision was made.

99254

Services were provided to a patient in the emergency room after the patient twisted her ankle stepping down from a curb. The emergency room physician ordered X-rays of the ankle, which came back negative for a fracture. A problem-focused history and physical examination were performed, and ankle strapping was applied. A prescription for pain was given to the patient. Code the emergency room visit only.

99281

Patient presents to the emergency room complaining of right forearm/elbow pain after racquetball last night. Patient states that he did not fall but overworked his arm. Past medical history is negative and the physical examination reveals the patient is unable to supinate. A four-view X-ray of the right elbow is performed and is negative. The physician signs the patient out with right elbow sprain. Prescription of Motrin is given to the patient.

99281-25, 73080

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and 10 minutes providing critical care for this patient. Code only critical care.

99291

Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life-threatening injuries due to a multiple-car accident. The patient goes into cardiac arrest 10 minutes after arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient. Code only critical care.

99291, 99292

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed, and a straightforward medical decision was made.

99324

A 57-year-old male patient is having his annual physical. Due to a family history of coronary artery disease and his sedentary lifestyle, his doctor orders a total blood cholesterol panel. What is the optimal level of total cholesterol in the blood for adults?

< 200 mg/dL

In an acute care hospital, a complete history and physical may not be required for a new admission when

A legible copy of a current H&P performed in the attending physician's office is available.

Which of the following statements BEST summarizes the current status of cervical cancer?

A new three-shot vaccination series protects against the types of HPV that cause most cervical cancer cases.

Use of the health record by a clinician to facilitate quality patient care is considered:

A primary purpose of the health record

Patient is initially admitted and treated for an amebic abscess of the liver. During the stay the patient developed a "hospital acquired bacterial pneumonia."

A06.4, J15.9, Y95

Patient was initially admitted and treated for an amebic abscess of the liver. During the stay the patient developed a "hospital acquired bacterial pneumonia."

A06.4, J15.9, Y95

Patient was initially admitted and treated for an amoebic abscess of the liver. During the stay, the patient developed a "hospital acquired bacterial pneumonia."

A06.4, J15.9, Y95

A patient was admitted with severe sepsis due to MRSA with septic shock and acute respiratory failure with hypoxia.

A41.02, R65.21, J96.01

The patient was admitted with severe sepsis due to MRSA with septic shock and acute respiratory failure with hypoxia.

A41.02, R65.21, J96.01

A patient is admitted with poliovirus meningitis.

A80.9, G02

A patient is admitted with poliovirus meningitis:

A80.9, G02

A patient is admitted with fever and severe headache. The physician's diagnostic statement at discharge is: Fever and severe headache probably due to viral meningitis.

A87.9

A patient is admitted with fever and severe headache. The physician's diagnostic statement at discharge is: fever and severe headache possibly due to viral meningitis.

A87.9

A patient, who is HIV positive, has raised red or purple lesions that appear on his skin, in his mouth, and almost everywhere on his body. What is the stage of his disease process in today's medical terminology?

AIDS

Health care claims transactions use one of three electronic formats, including which one of those listed below?

ANSI ASC X12N 837 format

The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called

APCs

A data item to include on a qualitative review checklist of newborn inpatient health records that need not be included on adult records would be

APGAR score.

Based on CMS's DRG system, other systems have been developed for payment purposes. The one that classifies the non-Medicare population, such as HIV patients, neonates, and pediatric patients, is known as

APR-DRGs.

As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling

ARRA

Currently, which prospective payment system is used to determine the payment to the "physician" for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient?

ASC PPS

Which of the following is a liver function test?

AST (SGOT)

Your just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?

Abstracting

The "discharged, not final billed" report (also known as "discharged, no final bill" or "accounts not selected for billing") includes what types of accounts?

Accounts that have been discharged and have not been billed for a variety of reasons

Which of the following is an example of clinical data?

Admitting diagnosis

Which of the following statements is FALSE regarding the use of modifiers with the CPT codes?

All modifiers will alter (increase or decrease) the reimbursement of the procedure.

The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems, except:

Alphabetical

The most common etiology of dementia in the United States is

Alzheimer's disease.

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 standardize data definitions are standards promulgated by the:

American Society for Testing and Measurement

How often are the Medicare fee schedule updated?

Annually

Why are there "black box warnings" on antidepressant medications regarding children and adolescents?

Antidepressants increase the risk of suicidal thinking and behavior in some children and adolescents.

Record Delinquency for Second Quarter April May June Percentage incomplete records 70% 88% 79% Percentage delinquent records 51% 43% 61% Percentage delinquent due to missing H&P 3% 1.4% 0.5%

April

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written?

Assessment

Elaine was a diabetic and had a wound that would not heal, so Dr. Smith had her placed in a hyperbaric oxygenation of the wound. The root operation term used in ICD-10-PCS is:

Assistance: taking over a portion of a physiological function by extracorporeal means

In ICD-10-PCS, patient admitted after experiencing seizure. CT of brain, high osmolar contrast taken with and without contrast

B02000Z

The patient was admitted with AIDS-related Kaposi's sarcoma of the skin.

B20, C46.0

The patient was admitted with AIDS-related Kaposi's sarcoma of the skin.

B20, C46.1

Ellis was diagnosed HIV-positive two years ago. He has now been admitted into Cengage Hospital with HIV-related lobar pneumonia. Report this with code or codes:

B20, J18.1

A 32-year-old female patient presents with right arm (dominant) paralysis due to childhood poliomyelitis.

B91, G83.21

A 32-year-old female patient presents with right arm (dominant) paralysis due to childhood poliomyelitis. B91, G83.21 A80.39 A80.39, G83.21 A80.39, G83.3

B91, G83.21

After falling from a balcony, the physician ordered an x-ray of the patient's ribs to see if any fractures were present. The correct ICD-10-PCS code(s) is:

BP0XZZZ, BP0YZZZ Plain radiography, right ribs; Plain radiography, left ribs

Which of the following statements would be found in the laboratory report section of the health record?

BUN reported as 20 mg

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record.

Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016

The federal legislation that focused on healthcare fraud and abuse issues, especially as they relate to penalties, was the:

Balanced Budget Act of 1997

____________ is the most common type of skin cancer, and _________ is the most deadly type of skin cancer.

Basal cell carcinoma, malignant melanoma

A Medicare benefit period is defined as:

Beginning the day the Medicare patient is admitted to the hospital and ending when the patient has been out of the hospital for 60 days in a row, including the day of discharge

Which one of the following would NOT be a strategy when purchasing an electronic health record system?

Broaden the vendor filed and select several vendors of choice.

In ICD-10-PCS, a PET imaging of the myocardium using Rubidium 82

C23GQZZ

A patient is admitted with abdominal pain. A CT and MRI of the abdomen reveal a malignant neoplasm to the head of the pancreas with metastatic disease to the peritoneal cavity.

C25.0, C78.6

a patient is admitted with abdominal pain. A CT and MRI of the abdomen reveal a malignant neoplasm to the head of the pancreas with metastatic disease to the peritoneal cavity

C25.0, C78.6

A patient has malignant melanoma of the skin of the back, nose, and scalp. The patient will be scheduled to undergo a radical excision of the melanoma.

C43.59, C43.31, C43.4

a patient has malignant melanoma of the skin of the back nose and scalp the patient will be scheduled to undergo a radical excision of the melanoma

C43.59, C43.31, C43.4

Dr. Jones performed a left breast biopsy on Anne Smith. The results confirmed a diagnosis of invasive ductal carcinoma, in the lower outer quadrant. This principal diagnosis code is:

C50.512

A patient goes to an OP Clinic with a large growth on the left side of the neck. An MRI is performed and demonstrates metastatic disease to the lymph nodes.

C77.0, C80.1

A patient to an OP Clinic with a large growth on the left side of the neck. An MRI is performed and demonstrates metastatic disease to the lymph nodes.

C77.0, C80.1

A patient is admitted with malignant ascites with widespread metastatic peritoneal lesions, primary site sigmoid colon; sigmoid colon resection 6 months ago.

C78.6, R18.0, Z85.038

Terry is post-mastectomy from breast cancer. Sadly, she has now found out that the cancer has metastasized to her parietal lobe of her brain. Report the brain cancer with code:

C79.31 Secondary malignant neoplasm of brain

A patient with a history of malignant neoplasm of the lung status post lobectomy was admitted after experiencing a violent seizure lasting more than several minutes. During the course of the hospitalization the patient has continued to have seizures. Workup revealed metastatic lesions to the brain. The patient's seizures were treated with IV Dilantin.

C79.31, R56.9, Z85.118

a patient with a history of malignant neoplasm of the lung status post lobectomy was admitted after experiencing a violent seizure lasting more than several minutes...

C79.31, R56.9, Z85.118

A patient with a history of malignant neoplasm of the lung status post lobectomy was admitted after experiencing a violent seizure lasting more than several minutes. During the course of the hospitalization, the patient has continued to have seizures. Workup revealed metastatic lesions to the brain. The patient's seizures were treated with IV Dilantin.

C79.31, Z85.118

A patient presents to an outpatient clinic with a large growth on the left side of the neck. Examination reveals primary malignant neoplasm of lymph nodes. Confirmed diagnosis of nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck.

C81.01

Coronary arteries may become blocked, either partially or totally, due to atherosclerosis and lead to an AMI. Which of the following procedures would be used to improve the coronary blood flow by building an alternate route for the blood to bypass the blockage by inserting a portion of another blood vessel, typically the saphenous vein?

CABG

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking out specific voluntary accreditation standards and guidelines is the

CARF manual.

Improving the clinical specificity of physician reports through a physician query is a goal shared by the coding staff and the

CDI practitioner.

Improving the specificity of clinical reports through the use of a physician query is a documentation goal that may be shared by the coding staff and this specialist:

CDIP

Henry experienced sudden sharp chest pain that he described as heavy and crushing. His pain and past medical history caused Dr. James to suspect that Henry was having an acute myocardial infarction (AMI). Which of the following tests is a more specific marker for an AMI?

CK-MB

the billing form used to report physician services is the

CMS 1500

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets

CMS standards.

When appropriate, under the outpatient PPS, a hospital can use this CPT code in place of, but not in addition to, a code for a medical visit or emergency department service.

CPT Code 99291 (critical care)

To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?

CPT codes

Case finding methods for patients with diabetes include a review of all but which one of the following?

CPT diagnostic codes

Juan has been asked to investigate e-health companies. Which of the following would NOT be included in his investigation?

Cafe Services: a company that provides cafeteria services to the hospital.

AR days have not decreased as expected. The coding supervisor knows that he must initiate change within the coding process to ensure achievement of the goal. Which of the following actions should the coding supervisor take first?

Call a meeting with the coders to discuss the issue.

Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry?

Case-finding

The Level II (national) codes of the HCPCS coding system are maintained by the:

Centers for Medicare and Medicaid Services

The new electronic system recently purchased at your physician practice allows for e-prescribing, exchange of data to a centralized immunization registry, and it allows your physicians to report on key clinical quality measures. In all likelihood, your practice has succeeded in choosing a (an)

Certified EHR.

The unique number that identifies each service or supply in the CDM and links each item to a particular department is known as the:

Charge code

In a typical acute-care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error-fee claims (clean claims) are submitted to third-party payers?

Claims processing

In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?

Claims reconciliation/collections

In CPT, Category III codes include:

Codes to describe emerging technologies

Most chief financial officers view the HIM department's most essential role in the revenue cycle management to be:

Coding of the record

A cancer program is surveyed for approval by the:

Commission on Cancer of the American College of Surgeons

A cancer program is surveyed for approval by the

Commission on Cancer of the American College of Surgeons.

When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT

Communities of Practice requirements.

The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with:

Completeness

The HIM department is planning to scan non-electronic medical record documentation. The project includes the scanning of health record documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?

Concurrent scanning

Community Hospital has launched a clinical documentation improvement (CDI) initiative. Currently, clinical documentation does not always adequately reflect the severity of illness of the patient or support optimal HIM coding accuracy. Given this situation, which of the following would be the best action to validate that the new program is achieving its goals?

Conduct a retrospective review of all query opportunities for the year

A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is:

Continuity of Care Record

which of the following is definition of revenue cycle management?

Coordination of all administrative and clinical functions that contribute to the capture management and collection of patient service revenue

Which of the following is the definition of revenue cycle management?

Coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue

Which term refers to the electronic transmission of information from a provider to a health plan to determine a patient's eligibility for services?

Coordination of benefits transaction

Each of the three dimensions (personal, provider, and community) of information defined by the National Health Information Network (NHIN) contains specific recommendations for:

Core data elements

When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a

Corporate Integrity Agreement.

Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?

Critical access hospital

which of the following is not reimbursed according to the Medicare outpatient prospective payment system

Critical access hospital

A chronic inflammatory bowel disease where affected segments of the bowel may be separated by normal bowel tissue is characteristic of

Crohn's disease.

A nomenclature of codes and medical terms which provides standard terminology for reporting physicians' services for third party reimbursement is:

Current Procedural Terminology (CPT)

A nomenclature of codes and medical terms that provides standard terminology for reporting physicians' services for third-party reimbursement is

Current Procedural Terminology (CPT).

Which code represents an HCPCS Level II National Code?

D0417

A patient is admitted with sickle cell anemia with crisis.

D57.00

A patient is admitted with sickle cell pain crisis.

D57.00

A patient is admitted with sickle cell vaso-occlusive pain crisis.

D57.00

A patient is admitted with aplastic anemia secondary to chemotherapy administered for multiple myeloma initial encounter.

D61.1, T45.1x5A, C90.00

A patient is admitted for treatment of anemia, neutropenia, and thrombocytopenia.

D61.818

A patient is admitted for post-op anemia due to acute blood loss. Patient is 5 days status post-cholecystectomy.

D62

A patient is readmitted for post-op anemia due to acute blood loss. Patient is 5 days status postcholecystectomy.

D62

A patient is readmitted for postoperative anemia due to acute blood loss. Patient is 5 days status postcholecystectomy.

D62, K91.840

A patient is admitted with anemia due to end-stage renal disease. The patient is treated for anemia.

D63.1, N18.6

A patient is admitted for treatment of anemia, neutropenia, and thrombocytopenia.

D64.9, D70.9, D69.6

A patient is admitted with idiopathic thrombocytopenia and purpura.

D69.3

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set

DEEDS

In selecting a messaging standard for use in a picture archival communication system, the BEST choice would be

DICOM

To monitor timely claims processing in a hospital, a summary report of "patient receivables" is generated frequently. Aged receivables can negatively affect a facility's cash flow; therefore, to maintain the facility's fiscal integrity, the HIM manager must routinely analyze this report. Though this report has no standard title, it is often called the

DNFB (discharged, not final billed).

In ICD-10-PCS, beam radiation was administered using electrons for a femoral bone tumor.

DP093ZZ

What is the current name of the Resource Based Relative Value Scale System?

DRG

______ classifies inpatient hospital cases into groups that are expected to consume similar hospital resources.

DRG

HIPAA administrative simplification provisions require all of the following code sets to be used EXCEPT

DSM

Which of the following is not a characteristic of high-quality healthcare data?

Data accountability

Which of the following best describes data accessibility?

Data are easy to obtain

Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?

Data consistency

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?

Data currency

A critical early step in designing an EHR is to develop a(n) __________ in which the characteristics of each data element are defined.

Data dictionary

They provide a complete and exhaustive list of data elements that must be collected.

Data granularity

Which of the following best describes data comprehensiveness?

Data include all required elements

What is the difference between data and information?

Data represent basic facts, whereas information represents meaning.

Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop:

Data sets

All of the following are required elements of a charge description master except:

Date of service

all of the following are required elements of a charge description master except:

Date of service

Which of the following is an example of a government agency that has an interest in the standardization of records and data collection?

Department of Health and Human Services

A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be taken?

Destroy inactive records that exceed the statute of limitations.

Dr. Gastron fulgurated a rectal polyp of the patient. The root operation term used for this ICD-10-PCS code is:

Destruction

Dr. Gastron fulgurated a rectal polyp of the patient. The root operation term used for this ICD-10-PCS code is:

Destruction: physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent

The patient's account balance is displaying a negative balance. What should the healthcare organization do to resolve this situation?

Determine which payer overpaid and return the funds

The phrase "bad debt" refers to accounts that include money owed by the patient and are:

Determined by the facility to be uncollectible

Which of the following services would be included in the 72-hour payment window and included in the inpatient MS-DRG payment to an acute-care hospital?

Diagnostic laboratory testing

______________ is usually the first symptom of benign prostate hyperplasia.

Difficulty in urinating

Which of the following statement is FALSE when addressing characteristics of the legal health record in an electronic document management system?

Direct electronic interfaces from ancillary department system to the document imaging system will not eliminate the need to scan documents and integrate the data from these ancillary systems.

The attending physician is responsible for which of the following types of acute-care documentation?

Discharge summary

You have been asked how to handle versioning of documents in the EMDS. Which of the following should be your response?

Display the second version but identify that a previous version.

Which of the following best describes an integrated health record format?

Documentation from various sources are integrated and arranged in strict chronological order.

What is the function of a consultation report?

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

The amount of money owed a healthcare facility when claims are pending is called:

Dollars in accounts receivable

Dr. Cantu made an error in recording the progress notes in a patient's medical record. What is the first thing he should do to correct the error?

Draw a single line through the error

Which of the following is NOT an advantage of a computerized master patient index?

Duplication of patient registration can never occur.

The local safety council requests statistics on the number of head injuries occurring as a result of bicycle accidents during the last year. To retrieve this data, you will need to have the correct:

E codes and ICD-9-CM codes for this diagnosis

a local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. to retrieve this data you will need to have the correct

E-codes and ICD-9-CM codes

A patient is a type 2 diabetic with chronic kidney disease dependent on dialysis.

E11.22, N18.6, Z99.2

A patient is a type 2 diabetic with chronic kidney disease requiring dialysis.

E11.22, N18.6, Z99.2

A patient is admitted with Diabetes Mellitus Type II; diabetic heel ulcer with necrosis of the muscle.

E11.621, L97.403

A patient is admitted with diabetes mellitus type 2; diabetic heel ulcer with necrosis of the muscle.

E11.621, L97.403

A female, 68 years old, was admitted with type 2 diabetes mellitus with a diabetic ulcer of the left heel involving the subcutaneous layer of the skin. The patient will be scheduled for wound care with whirlpool treatments.

E11.621, L97.421

A female, 68-year old, was admitted with type 2 diabetes mellitus with a diabetic ulcer of the left heel involving the subcutaneous layer of the skin. The patient will be scheduled for wound care with whirlpool treatments.

E11.621, L97.421

A patient was found at home in a hypoglycemic coma. This patient had never been diagnosed as being diabetic.

E15

A patient is admitted with severe protein calorie malnutrition.

E43

Judy does not like outside activities. After the blood test results came back, her physician diagnosed her with Vitamin D deficiency and gave her a prescription.

E55.9 Vitamin D deficiency, unspecified

A patient is admitted to the hospital for treatment of dehydration following chemotherapy as treatment for right ovarian cancer.

E86.0, C56.1

A 67-year-old man is admitted with acute dehydration secondary to lymphocytic colitis previously diagnosed as acute gastroenteritis. He is treated with IV fluids for the dehydration.

E86.0, K52.832

A 67-year-old man is admitted with acute dehydration secondary to nausea and vomiting that is due to acute gastroenteritis. He is treated with IV fluids for the dehydration.

E86.0, K52.9

A patient is admitted to the hospital for treatment of dehydration following chemotherapy as treatment for right ovarian cancer.

E86.01, C56.1

a patient is admitted to the hospital for treatment of dehydration following chemotherapy as treatment for right ovarian cancer

E86.01, C56.1

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?

ECG report

Which of the following pieces of equipment records the electrical activity of the brain?

EEG

On his 12/23/16 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous record number assigned to Mr Robinson during a 9/1/16 admission was 07-10-47. In a serial numbering/filing system, how would those records be filed?

Each admission is filed under its own number.

The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry?

Enhanced databases will provide information for improved clinical care.

CDI staff should revisit cases:

Every 24 to 48 hours

Dr. Thomas performed a tonsillectomy on Peter. The approach, as reported in ICD-10-PCS, is:

External

A thrombus was identified in the patient's leg, so Dr. Common performed a thrombectomy. The root operation term used for this ICD-10-PCS code is:

Extirpation: taking or cutting out solid matter from a body part

The baby was having trouble passing through the vaginal canal, so Dr. Jones use forceps to help him along. Baby Boy was born at 12:57 pm. The root operation term used for this ICD-10-PCS code is:

Extraction: pulling or stripping out or off all or a portion of a body part by the use of force

A patient is admitted with acute alcohol intoxication with a blood alcohol level of 113 mg/100 ml.

F10.120, Y90.5

A patient is admitted with delirium tremens with alcohol dependence.

F10.221

A patient is admitted with withdrawal delirium tremens with alcohol dependence.

F10.231

A patient with chronic paranoia due to cocaine dependence with intoxication and drug delirium.

F14.221

A patient is diagnosed with chronic paranoia due to cocaine dependence with intoxication and drug delirium.

F14.250, F14.221

A patient is admitted with catatonic schizophrenia.

F20.2

A patient is admitted with severe recurrent major depression without psychotic features.

F33.2

Randy has been home from Iraq for three months and comes in to see Dr. Jones for his weekly appointment. He has recurring flashbacks of his time in the war zone, and he is having difficulty sleeping. Dr. Jones is providing therapy for his on-going PTSD. The correct code is:

F43.12 Post-traumatic stress disorder, chronic

Which of the following filing systems would be most affected in the event of a divorce?

Family

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Federal Register

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Federal Register.

Which of the following lists is in correct alphabetical order?

Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip (b)

Which of the following statements describes alphabetical filing?

File the record alphabetically by the last name, followed by alphabetical order of the first name, and then alphabetical order of the middle initial.

A patient is hospitalized for less than 48 hours. Which of the following is permissible in lieu of a discharge summary?

Final progress note

Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare?

Fiscal intermediary/MAC

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?

Focused audit

The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term?

Focused reviews on lower weighted MS-DRGs from triples and pairs

The most recent coding audits has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify an correct these cases in the short term?

Focused reviews on lower weighted MS-DRGs from triples and pairs

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that health care organizations eliminate wrong-site, wrong-patient, and wrong-procedure surgery. In order to accomplish this, which of the following would NOT be considered part of a preoperative verification process?

Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.

One of the Joint Commission National Patient Safety Goals (NSPGs) requires that healthcare organizations eliminate wrong-site, wrong-patient, and wrong-surgery. In order to accomplish this, which of the following would NOT be a considered part of a preoperative verification process?

Follow the daily surgical patient listing for the surgery suite if the patient has been sedated.

Brian is 35 years old and has just been diagnosed with Alzheimer's disease. Report this with:

G30.0 Alzheimer's disease with early onset

A patient is diagnosed with Alzheimer's disease and early onset dementia, and frequently wanders away from home.

G30.0, F02.81, Z91.83

A patient is diagnosed with early onset Alzheimer's disease and early onset dementia and frequently wanders away from home.

G30.0, F02.81, Z91.83

A patient has intractable status epilepticus.

G40.311

A 32-year-old female patient presents with right arm (dominant) paralysis due to childhood poliomyelitis.

G83.21, B91

A patient is admitted for pain control secondary to metastatic carcinoma of the spinal cord.

G89.3, C79.49, C80.1

A patient is admitted for pain control secondary to metastatic carcinoma of the spinal cord. A carcinoid tumor was removed from his lower lobe three years ago for primary lung malignancy, now non-evident.

G89.3, C79.49, Z85.110

In ICD-10-PCS, patient admitted into Behavioral Health Hospital for neuropsychological testing

GZ13ZZZ

The director of the Health Information Services Department is developing a plan to convert their existing filing system to an electronic document management system (EDMS). The tool that is most useful to the director in displaying the steps and completion schedule for each phase of the conversion is a

Gantt chart.

Dr. Smith performed an appendectomy on Douglas Doe. This is reported from the ______ Body System character of the ICD-10-PCS code.

Gastrointestinal System

Mapping between ICD-9 and ICD-10 were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another)

General Equivalency Mappings

Which of the following apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?

Global payments

A patient is admitted with sensorineural deafness of the left ear. No problems with the right ear. The patient was fitted for a hearing aid.

H90.42

A patient is admitted with sensorineural deafness of the left ear. The patient was fitted for a hearing aid.

H90.42

A patient is being cared for in his or her home by a qualified agency participating in Medicare. The data-entry software used to conduct all patient assessments is known as

HAVEN

Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS website or on a CD-ROM.

HAVEN (Home Assessment Validation and Entry)

Which system is used primarily to report services and supplies for reimbursement purposes?

HCPCS

The codes used in a charge description master are:

HCPCS Levels I and II

the codes used in a charge description master are:

HCPCS Levels I and II

This data is used because it provides a uniform system of identifying procedures, services, or supplies. Multiple columns can be available for various financial classes.

HCPCS/CPT code

The term "hard coding" refers to

HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill.

The data set designed to organize data for public release about the outcomes of care is:

HEDIS

what data set is managed by the National Committee for Quality Assurance (NCQA)

HEDIS

The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job Description Summative Report" identified that most Clinical Documentation Improvement Specialists report directly to the

HIM Department.

what legislation resulted in the NPI?

HIPAA

As the compliance officer for a large physician practice group, you are interested in researching the original requirements for meaningful use of certified EHRs for use in an upcoming presentation. You begin by googling

HITECH Act

Messaging standards for electronic data interchange in healthcare have been developed by:

HL7

The vendor that you work for has decided to get into the EHR market. What standard should you suggest using in developing the functions perfomed by the EHR?

HL7 EHR functional model

Genital warts are caused by

HPV

In ICD-10-PCS, during a 90-day residential substance abuse treatment program, the therapist worked one-on-one with the patient performing cognitive behavioral counseling.

HZ32ZZZ

The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of:

Healthcare Integrity and Protection Data Bank

the collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of:

Healthcare Integrity and Protection Data Bank

The patient had a calcification in his common bile duct. The procedure would be reported from the ______ Body System character of the ICD-10-PCS code.

Hepatobiliary system and pancreas

The patient's pathology report revealed the presence of Reed-Sternberg cells. This is indicative of

Hodgkin's disease.

Which disease is a malignancy of the lymphatic system?

Hodgkin's disease.

Carmen, a 78-year-old end-stage renal cancer patient, is in need of palliative care. Which facility would best meet her needs?

Hospice

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

Hospital Bylaws, Rules, and Regulations.

Which of the following is a hereditary disease of the cerebral cortex that includes progressive muscle spasticity and mental impairment leading to dementia?

Huntington's disease

The patient was found to have an obstruction of the aortic value due to rheumatic process. The correct code to report this is:

I06.0 Rheumatic aortic stenosis

A patient has end-stage kidney disease, which resulted from malignant hypertension.

I12.0, N18.6

A patient has end-stage kidney disease, which resulted from malignant hypertension. I12.0, N18.6 I10, N18.6 I13.11, N18.6 I15.1, N18.6

I12.0, N18.6

A patient is admitted with chronic kidney disease stage 3 due to hypertension and type 1 diabetes mellitus.

I12.9, E10.22, N18.3

A patient is admitted with chronic kidney disease stage III due to hypertension and type 1 diabetes mellitus.

I12.9, E10.22, N18.3

A patient is admitted with multiple problems. He has hypertensive kidney disease, CKD stage 3, and acute systolic congestive heart failure.

I13.0, I50.21, N18.3

A patient is admitted with acute ST inferolateral wall myocardial infarction. Several days later during the same episode of care, the patient sustained a subsequent non-ST subendocardial myocardial infarction.

I21.19, I22.2

A patient with a diagnosis of coronary artery disease with ischemic chest pain. No history of CABG.

I25.119

A patient is diagnosed with psychogenic paroxysmal tachycardia.

I47.9, F54

A patient is admitted with a thrombosis of the right middle cerebral artery, with hemiplegia affecting the right dominant side.

I63.311, I69.351

A patient is admitted with a cerebral infarction of the right middle cerebral artery, caused by an embolus, with hemiplegia affecting the right dominant side.

I63.411, I69.351

Darlene had a CVA (cerebrovascular accident) two months ago, and she is still having not able to speak. Dr. Smith diagnosed her with aphasia following a nontraumatic intracerebral hemorrhage. Report this with:

I69.128 Aphasia following nontraumatic intracerebral hemorrhage

After having a cerebrovascular (CVA) accident, Lorraine has been having difficulty in swallowing. The physician diagnosed this as a sequela of the CVA. Report this with code:

I69.991 Dysphagia following unspecified cerebrovascular disease

A patient with atherosclerotic peripheral vascular disease of the left lower leg with intermittent claudication. Past surgical history is negative.

I70.212

Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?

ICD-10-CM

The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve the data, you will need to have the correct

ICD-10-CM codes.

The following coding system(s) is/are utilized in the Inpatient Psychiatric Facilities (IPFs) prospective payment methodology for assignment and proper reimbursement.

ICD-10-CM/ICD-10-PCS codes

The following coding system(s) is/are utilized in the MS-DRG prospective payment methodology for assignment and proper reimbursement.

ICD-10-CM/ICD-10-PCS codes

Which of the following agencies is responsible for providing healthcare services to American Indians and Alaska natives?

IHS

A patient had an appendectomy due to appendicitis. This operative report must be completed when?

Immediately after surgery

A hospital is concerned about the difficulty in retrieving health records for patient care and legal purposes. Some of its data are stored electronically while the remainder are stored on paper. The hospital knows it will be several years before it will be able to implement an entire EHR system and go paperless. Given this information, which of the following would be the best solution for the hospital to ensure that all of the data for a patient data are retrieved when needed?

Implement a document scanning system for the paper records and interface data created in the current EHR with the document scanning system

Administration has asked the clinical provider order-entry task force to select the method of implementation that will reduce risk to the hospital. What method should they choose?

Implement one module in one unit while running the current system in parallel.

what is the main difference between an HMO health plan and POS health plan

In a POS health plan, the enrollee can choose what provider to see for care without the need for a referral or a designated primary care physician

In a problem-oriented health record, problems are organized:

In numeric order

In a paper-based system, the completion of the chart is monitored in a special area of the HIM department called the __________ file.

Incomplete record

How long should the master patient index be maintained?

Indefinitely

Which of the following establish eligibility standards for enrollment in Medicaid?

Individual states

Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered __________ from the database.

Information

Which of the following would the physician include in the discharge summary?

Instructions for future care

Which classification system is used to classify neoplasms according to site, morphology and behavior?

International Classification of Diseases for Oncology (ICD-0)

Which classification system is used to classify neoplasms according to site, morphology, and behavior?

International Classification of Diseases for Oncology (ICD-O)

Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components?

International Classification of Functioning, Disability and Health (ICF)

Based on this patient volume, the MS-DRG that brings in the highest total profit to the hospital is

It cannot be determined from this information.

Which of the following is characteristic of Graves' disease?

It is an autoimmune disease.

Which of the following statements is FALSE in regard to departmental reengineering?

It is intended to make small or minor changes in order to improve a function or process.

The HPV vaccine, Gardasil, is recommended for all children/young adults between the ages of 9 and 26 years. It is a quadrivalent vaccine. What is the definition of quadrivalent?

It prevents infection from the four most prevalent types of HPV that cause cervical cancer.

A patient is admitted for treatment of influenza and pneumonia.

J11.00

A patient presents to the outpatient department for a chest X-ray. The physician's order lists the following reasons for the chest X-ray: fever and cough, rule out pneumonia. The radiologist reports that the chest X-ray is positive for double pneumonia.

J18.9

A patient presents to the outpatient department for a chest x-ray. The physician's order lists the following reasons for the chest x-ray: fever and cough, rule out pneumonia. The radiologist reports that the chest x-ray is positive for double pneumonia.

J18.9

Ralph has been suffering with sinusitis for the last three months. The pain is right between his eyes. He goes to see the doctor, finally, who diagnoses him with chronic sinusitis. Report this with code:

J32.1 Chronic frontal sinusitis

A patient is admitted with acute respiratory failure with hypercapnia due to chronic asthmatic bronchitis with acute exacerbation. Treatment consisted of IV steroids.

J44.1, J96.02

A patient is admitted for control of exacerbation of chronic obstructive lung disease. The patient had stopped taking the prednisone as prescribed due to gaining weight, a known side effect for this drug.

J44.1, T38.0x6A, Z91.14

A patient is admitted with acute exacerbation chronic obstructive pulmonary disease with a history of tobacco dependence.

J44.1, Z87.891

A patient is admitted with extrinsic asthma with status asthmaticus with bronchospasm.

J45.902

A patient is admitted with acute respiratory failure with hypercapnia due to acute asthmatic bronchitis with status asthmaticus. Treatment consisted of IV steroids. term-59

J45.902, J96.02

A patient is admitted with an exercise-induced bronchospasm.

J45.990

A patient has aspiration pneumonia with pneumonia due to Staphylococcus aureus.

J69.0, J15.211

A patient is admitted for infection of the tracheostomy stoma secondary to cellulitis of the neck.

J95.02, L03.221

A patient is admitted with acute gastric ulcer with hemorrhage and perforation.

K25.2

A patient is admitted to the hospital for repair of a recurrent incarcerated ventral hernia. The surgery is canceled after the chest x-ray revealed lower lobe pneumonia. The patient is placed on antibiotics for treatment of the pneumonia.

K43.0, J18.9, Z53.09

A patient is admitted to the hospital for repair of a recurrent incarcerated epigastric hernia. The surgery is canceled after the chest X-ray revealed lower lobe pneumonia. The patient is placed on antibiotics for treatment of the pneumonia.

K43.6, J18.1, Z53.09

A patient is admitted for rectal bleeding. The laboratory results reveal chronic blood-loss anemia. The CT and the Bleeding Scan results of the abdomen revealed that the rectal bleeding is due to Crohn's disease of the descending colon.

K50.111, D50.0

A patient is admitted for rectal bleeding. The laboratory results reveal chronic blood-loss anemia. The CT and the bleeding scan results of the abdomen revealed that the rectal bleeding is due to Crohn's disease of the descending colon.

K50.111, D50.0

A patient has diverticulitis of the large bowel with abscess. Patient was treated with IV antibiotics.

K57.20

No book:Diverticulitis large bowel with ascending colon abscess was the diagnosis for a patient who was admitted with abdominal pain..

K57.20, 0D1K0Z4

A patient is admitted with bleeding esophageal varices with alcoholic liver cirrhosis and portal hypertension. The patient is alcohol dependent.

K70.30, I85.11, K76.6

Dr. Mathews performed surgery on Nathan Weston to remove his gallbladder, after he was diagnosed with cholelithiasis with cholecystitis. Report this condition with:

K80.10 Calculus of gallbladder with chronic cholecystitis without obstruction

No book:Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis.

K80.10, I66.9, Z53.09

A patient is admitted with acute gangrenous cholecystitis with cholelithiasis.

K81.0, K82.A1

A male patient is admitted with gastrointestinal hemorrhage resulting in acute blood-loss anemia. A bleeding scan fails to reveal the source of the bleed.

K92.2, D62

A male patient is admitted with gastrointestinal hemorrhage resulting in acute blood-loss anemia. A bleeding scan fails to reveal the source of the bleeding.

K92.2, D62

a rare malignant tumor often associated with AIDS is

Kaposi's sarcoma

In order to improve efficiency and productivity, which of the following sequence of steps is the most effective?

Know the objective; break down the work into component activities, and the group activities into proper organizational units.

A patient is admitted with a wound open to the left finger with cellulitis due to a dog bite initial encounter. The patient is given IV antibiotics for treatment of the infection.

L03.012, S61.201A

A patient is admitted with an open wound to the left finger with cellulitis due to a dog bite, initial encounter. The patient is given IV antibiotics for treatment of the infection.

L03.012, S61.259A, W54.0xxA

A patient is admitted with dermatitis due to prescription topical antibiotic cream used as directed by a physician, initial encounter.

L25.1, T49.0x5A

A patient is admitted with a stage 1 pressure ulcer of the sacrum. During the hospitalization, the ulcer progressed to a stage 2.

L89.151, L89.152

A patient is admitted with a stage 1 pressure ulcer of the sacrum. During the hospitalization, the ulcer progressed to a stage 2.

L89.152

A patient is admitted with a pressure ulcer left buttock stage 2.

L89.322

A patient is admitted with a pressure ulcer of the left buttock stage 2.

L89.322

This information is published by the Medicare Administrative Contractors (MACs) to describe when and under what circumstances Medicare will cover a service. The ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes are listed in the memoranda.

LCD (Local Coverage Determinations)

Which classification system was developed to standardize terminology and codes for use in clinical laboratories?

Logical Observation Identifiers, Names and Codes (LOINC)

Which of the following types of care is not covered by Medicare?

Long-term nursing care

A patient is admitted with pyogenic arthritis of the right hip due to Group A Streptococcus. Treatment consisted of IV antibiotics.

M00.251

A patient is admitted with pyogenic arthritis of the right hip due to group A streptococcus. Treatment consisted of IV antibiotics.

M00.251, B95.0

A patient is admitted with a back pain. A myelogram demonstrated the reason for the back pain is a herniated lumbar intervertebral disc with radiculopathy.

M51.16

A patient is admitted with a fracture to the L1 vertebrae secondary to postmenopausal senile osteoporosis, initial encounter.

M80.08xA

A patient has a pathological fracture of the left femur due to metastatic bone cancer. The past medical history is significant for lung cancer.

M84.552, C79.51, Z85.118

A patient has a pathological fracture of the left femur due to metastatic bone cancer. The past medical history is significant for lung cancer.

M84.552A, C79.51, Z85.118

A patient has a pathological fracture of the left femur due to metastatic bone cancer. The past medical history is significant for surgical removal of cancer of the lung.

M84.552A, C79.51, Z85.118

Dr. Pedric diagnosed the child with complete physeal arrest of the growth plate of the tibia, right limb, close to the child's ankle. Report this with:

M89.164 Complete physeal arrest, right distal tibia

The patient was diagnosed with anterior spinal artery compression syndrome affecting T10-T12. Report this with code:

M89.164 Complete physeal arrest, right distal tibia

Which of the following is a severe, chronic, two-phased, bacterial respiratory infection that has become increasingly difficult to treat because many antibiotics are no longer effective against it?

MDR-TB

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the

MDS

In long-term care, the resident's care plan is based on data collected in the:

MDS

The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the

MDS

Which of the following is made up of claims data from Medicare claims submitted by acute-care hospitals and skilled nursing facilities?

MEDPAR

Which type of diagnostic test involves the use of electromagnetic waves to produce very detailed images of soft tissue structures of the body?

MRI

In analyzing the reason for changes in hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail?

MS-DRG triples, pairs, and singles

While in the hospital, an external, single read, EKG was performed on the patient. The root operation term used for this ICD-10-PCS code is:

Measurement: determining the level of a physiological or physical function at a point in time

Given the following information, from which payer does the hospital proportionately receive the least amount of payment?

Medicaid

____ is a joint federal and state program that provides health care coverage to low-income populations and certain aged and disabled individuals.

Medicaid

What is the name of the program funded by the federal government to provide medical care to people on low incomes or with limited financial resources?

Medicaid..

Which of the following represents documentation of the patient's current and past health status?

Medical history

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."

Medical laboratory report

Who is responsible for developing bylaws governing physicians' completion of medical records?

Medical staff

This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service.

Medicare Physician Fee Schedule (MPFS)

The ________________________ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider.

Medicare Summary Notice

The______refers to a statement sent to the patient to show how much the provider billed how much Medicare reimbursed the provider and what the patient must pay the provider

Medicare summary notice

______ requires present on admission (POA) indicator to be assigned to the ___________ diagnosis(es) for all claims for __________________admissions.

Medicare, principal and secondary, inpatient

A nurse is responsible for which of the following types of acute-care documentation?

Medication record

Which of the following terms refers to the incidence of death?

Mortality

Which of the following statements describes a method of following a procedure?

Multiple-page discharge summaries are stapled together in the left-hand corner.

A male patient presents to the ED with acute renal failure. He is also being treated for hypertension.

N17.9, I10

A patient is admitted with multiple problems. He has hypertensive kidney disease, CKD stage III, and acute systolic congestive heart failure.

N18.3, I12.9, I50.21

A patient is admitted with anemia due to end-stage renal disease. The patient is treated for anemia.

N18.6, D63.1

A patient is admitted with acute hemorrhagic cystitis. The patient was treated with IV antibiotics.

N30.00

A patient is admitted with acute hemorrhagic cystitis. The patient was treated with IV antibiotics.

N30.01

A patient is admitted with acute urinary tract infection due to E. coli.

N39.0, B96.20

A patient was admitted with gross hematuria and benign prostatic hypertrophy.

N40.0, R31.0

A patient is admitted that has urinary retention secondary to benign prostatic hypertrophy.

N40.1, R33.8

The physician's H&P for admission makes no mention of the patient's UTI. The present on admission indicator is ___.

N=No

all of the following are health care data sets EXCEPT which one?

NCDB

The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the:

National Center for Health Statistics

The Unified Medical Language System (UMLS) is a project sponsored by the

National Library of Medicine

The Unified Medical Language System (UMLS) is a project sponsored by the

National Library of Medicine.

Dr. Gary has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital?

National Practitioner Data Bank

Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credential Committee must query the

National Practitioner Data Bank.

This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms.

National Provider Identifier (NPI)

____ are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients.

Never events or sentinel events

what data cannot be retrieved from the MEDPAR?

Non-Medicare patient data

You have been given a list of data elements that need to be added to the database that you are creating. You notice, that on of the data elements is the patient's full name. Determine how to modify the data element in order to improve search capabilities.

Normalize the data element

When a provider agrees to accept of assignment from Medicare, the provider has agreed to:

Not bill patients for the balance

Janie was brought into the ED with acute lower abdominal pain. Ultrasound showed a left tubal pregnancy. She was taken into the procedure room immediately. Report this condition with:

O00.102 Left tubal pregnancy without intrauterine pregnancy

No book:Incomplete abortion complicated by excessive hemorrhage; dilation and curettage performed.

O03.1, 10D17ZZ

A patient is admitted with pregnancy-induced hypertension with severe edema and proteinuria and 24 weeks gestation.

O14.12, Z3A.24

A patient is admitted with pregnancy-induced hypertension with severe edema and 24 weeks gestation.

O14.12, Z3A24

Gabrielle was 15-weeks pregnant, and Dr. Jones has diagnosed her with diabetes mellitus. They are going to try to control this using a special diet, and she will come back for a follow-up in one month. The correct principal diagnosis code is:

O24.410 Gestational diabetes mellitus, in pregnancy, diet controlled

A patient is admitted for gestational diabetes, insulin-controlled, 28 weeks gestation.

O24.414, Z3A.28

A patient is admitted for gestation diabetes insulin controlled 28 weeks gestation.

O24.414, Z3A28

A patient is admitted with obstructed labor due to breech presentation. A single liveborn infant was delivered via Cesarean section. Do not assign the code for the procedure.

O32.1xx0, Z37.0

A patient is admitted with obstructed labor due to breech presentation. A single live-born infant was delivered via cesarean section. Do not assign the code for the procedure.

O32.1xx1, Z37.0

A patient is admitted who is 39 weeks gestation normal delivery single full-term newborn. During the same episode of care, patient experiences a 36-hour delayed hemorrhage following the delivery.

O72.2, Z3A.39, Z37.0

A patient is admitted who is 39 weeks gestation and has a normal delivery of a single full-term newborn. During the same episode of care, patient experiences a 36-hour delayed hemorrhage due to retained portion of the placenta following the delivery.

O80, Z37.0, O72.2

No book:Vaginal delivery with episiotomy of full-term liveborn infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally.

O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ

A woman has a vaginal delivery of a full-term live-born infant after 38 weeks gestation.

O80, Z37.0, Z3A.38

A woman has a vaginal delivery of a full-term liveborn infant after 38 weeks gestation.

O80, Z37.0, Z3A.38

In the Medical Surgical Section, the seventh character position represents?

O80, Z37.0, Z3A.38

A patient is seen in the ED at 22 weeks gestation who is HIV positive and asymptomatic.

O98.712, Z21, Z3A.22

A patient is seen in the ED at 22 weeks gestation who is HIV positive.

O98.712, Z21, Z3A.22

The home health prospective payment system uses the __________ data set for patient assessments.

OASIS

The prospective payment system used to reimburse home health agencies for patients with Medicare utilizes data from the

OASIS (Outcome and Assessment Information Set).

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in the program. you will need to regularly access the Web site of this governmental agency.

ONC

As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency.

ONC

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

OPPS

in processing a medicare payment for outpatient radiology exams a hospital outpatient services department would receive payment under which of the following?

OPPS

CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10-PCS. The use of these two code sets will be effective on

October 1, 2015

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the

Office for Civil Rights

the division or office of DHHS responsible for investigation cases of alleged fraud and abuse in Medicare and Medicaid programs is:

Office of Inspector General

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."

Operative report

The patient's left inner ear was infected. The diagnosis is:

Otitis interna

Which of the following tools is usually used to track health records that have been removed from their permanent storage locations?

Outguides

Baby boy Jones was born and found to have congenital pneumonia due to chlamydia. Report this condition with:

P23.1 Congenital pneumonia due to Chlamydia

A 1-week-old infant is admitted to the hospital with a diagnosis of urinary tract infection contracted prior to birth. The urine culture is positive for E. coli.

P39.3, A49.8

An infant has hypoglycemia and a mother who had been diagnosed with type 2 diabetes 5 years ago.

P70.1

An infant has hypoglycemia and a mother with diabetes.

P70.1

A "pill-rolling" tremor of the hand is a characteristic symptom of

Parkinson's disease.

A health information technician wants to obtain a chronological list of all patients admitted to the facility during the third quarter with a diagnosis of appendicitis. Which database should the technician utilize?

Patient register

In which department or unit is the health record number typically assigned?

Patient registration

Which of the following materials is not documented in an emergency care record?

Patient's complete medical history

Some services are covered and paid by Medicare before Medicaid makes payments because Medicaid is considered which of the following?

Payer of last resort

Which of the following contains the physician's findings based on an examination of the patient?

Physical exam

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?

Physical examination

Which of the following groups of healthcare providers contracts with a self-insured employer to provide healthcare services?

Preferred provider organization

Dr. Jones performed an amniocentesis on Margaret Smith. The ICD-10-PCS body part character will report:

Products of Conception

Which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered?

Prospective payment method

In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to:

Provide uniform data definitions

When a provider accepts assignment, this means that the:

Provider accepts as payment in full the allowed charge from he fee schedule

When a provider accepts assignment, this means that the:

Provider accepts as payment in full the allowed charge from the fee schedule

A patient is admitted with cervical spina bifida with hydrocephalus.

Q05.0

A newborn infant is transferred to Community General Hospital for treatment of an esophageal atresia. What codes should be reported for Community General Hospital?

Q39.0

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 in 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?

Query the physician to determine if the condition was present on admission.

a surgeon requests the name of a patient he admitted on January 11, 2017. Which of the following would be used to retrieve this information?

R-ADT system

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

R-ADT system.

A patient is admitted with right lower quadrant abdominal pain. The discharge diagnosis is listed as abdominal pain due to gastroenteritis or diverticulosis.

R10.31, K52.9, K57.90

A patient is admitted with malignant ascites with widespread metastatic peritoneal lesions, primary site sigmoid colon; sigmoid colon resection 6 months ago.

R18.0, C78.6, Z85.038

A patient admitted with gross hematuria and benign prostatic hypertrophy.

R31.0, N40.0

A patient is admitted with dizziness as a result of taking phenobarbital as prescribed, initial encounter.

R42, T42.3x5A

A patient is admitted with fever due to bacteremia.

R78.81

A patient is admitted with fever due to bacteremia.

R78.81, R50.9

A woman has a Pap smear that detected cervical high-risk human papillomavirus (HPV). The DNA test was positive.

R87.810

A patient was admitted with hemoptysis; a CT of the chest revealed a lung mass.

R91.8

A patient was admitted with hemoptysis; a CT of the chest revealed a lung mass.

R91.8, R04.2

Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's

RHIO

RIO

what is the abbreviation given to the prospective payment system used for skilled nursing facilities

RUGs

A Medicare patient had two physician office visits, underwent hospital radiology examinations, clinical laboratory tests, and received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?

Radiology examinations

The primary purpose of a minimum data set in healthcare is to:

Recommend common data elements to be collected in health records

There should be four primary percentages that should be calculated and tracked to assess clinical documentation improvement (CDI) programs. These include all of the following except:

Record agreement rate

Which application is best suited for bar coding?

Record tracking/location

This initiative was instituted by the government to eliminate fraud and abuse and recover overpayments, and involves the use of ______________. Charts are audited to identify Medicare overpayments and underpayments. These entities are paid based on a percentage of money they identify and collect on behalf of the government.

Recovery Audit Contractors (RAC)

Two clerks are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking?

Reliability

Johnny was brought into the ED with a 6cm laceration on his left arm. Dr. Singer sutured the laceration. The root operation term used for this ICD-10-PCS code is:

Repair: Restoring to the extent possible, a body part to its normal anatomic structure and function

The charge description master relieves the HIM department of _____ that does not require documentation analysis.

Repetitive coding

Which of the following is a request from a clinical area to check out a health record?

Requisition

The director of the Health Information Services Department has asked that the supervisor of coding institute a method to monitor the accuracy of coding. What method would be the most effective approach?

Review a random sample of each employee's work monthly.

The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions would be most effective in reducing the delay in retrieval of requested records?

Review and possibly reengineer the retrieval process to decrease retrieval time.

A new health information management clerk has been on staff for 2 days. She has thus far analyzed charts incorrectly, sent out confidential information improperly, and used the copy machine inappropriately. Evaluate this situation and determine the best resolution.

Review the job procedure with the clerk and have the analysis supervisor monitor her progress.

The most common rickettsia disease in the United States is

Rocky Mountain spotted fever.

A patient is admitted with a gunshot wound to the right upper quadrant of the abdomen, which involves a moderate laceration to the liver, initial encounter.

S36.115A, S31.600A

A patient developed a malunion of the left medial condyle humeral fracture. The original injury occurred 4 months ago.

S42.462P

A patient developed a malunion of the medical condyle humeral fracture. The original injury occurred 4 months ago.

S42.462P

A patient is seen for a cast removal. Six weeks ago, the patient underwent open reduction internal fixation for a displaced fracture left radial styloid process.

S52.512D

While building a swing set in the backyard, Paul hammered a nail through his left thumb. There was no damage to the nail. His wife drove him to the ED for treatment. Report this condition with:

S61.032A Puncture wound without foreign body of left thumb without damage to the nail, initial encounter

A patient is admitted with a left wrist laceration, with embedded glass that involved the radical nerve, initial encounter.

S61.522A, S64.22xA

After the car accident, Arlene was brought to the ED with a closed oblique fracture of the femur, right side. Report this with:

S72.334A Nondisplaced oblique fracture of shaft of right femur, initial encounter

A patient is admitted with a left nondisplaced comminuted patella fracture, a displaced left spiral fracture of the shaft of the fibula, and a displaced comminuted fracture of the shaft of the left tibia, initial encounter.

S82.045A, S82.442A, S82.252A

A patient is admitted with a nondisplaced fracture of the left medial malleolus, initial encounter. The fracture was treated with a cast.

S82.52xA

A patient is admitted with a nondisplaced fracture of the left medial malleolus, initial encounter. The fracture was treated with a cast.

S82.55xA

A patient was admitted for removal of internal pins from the left ankle. One month ago the patient sustained a displaced bimalleolar fracture to the left ankle.

S82.842D

A patient was admitted for removal of internal pins from the left ankle. One month ago, the patient sustained a traumatic displaced bimalleolar fracture to the left ankle.

S82.842D

This program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children.

SCHIP

Which of the following classification systems was designed with computer systems in mind and is currently being used for medical research studies, clinical trials, disease surveillance, and consumer health information services?

SNOMED CT

A common language used in data definition, and data manipulation is

SQL

Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used?

SQL

The HIM director needs to retrieve data from a database. What might she use?

SQL

Which of the following is used to plot the points for two variables that may be related to each other in some way?

Scatter diagram

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

Screen 837P or CMS 1500

When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow?

Security training is provided to all levels of staff.

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?

Social service note

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 problem-oriented health record progress note would this be written?

Subjective

After a claim has been filed with Medicare, a healthcare organization had late charges posted to a patient's outpatient account that changed the calculation of the APC. What is best practice for this organization to receive the correct reimbursement from Medicare?

Submit an adjusted claim to Medicare

Which of the following is a secondary purpose of the health record?

Support for research

In the master patient index, which is filed by last name, Jill Thomas-Jones would be

T-H-O-M-A-S-J-O-N-E-S, J-I-L-L

In the ED, after the fire at her office, Elaine was found to have third-degree burn on her forearm and a second degree burn on her upper arm, right side. Report this with:

T22.391A Burn of third degree of multiple sites of right shoulder and upper limb, except wrist and hand, initial encounter

During an art project, using acid to etch metal, some acid splashed on the back of her left hand. The burn was severe and she went to the ED where the damage was assessed at third-degree. Report this with:

T23.762A Corrosion of third degree of back of left hand, initial encounter

A woman experienced third-degree burns to her thigh and second-degree burns to her right and left foot, initial encounter. She stated that the burns were from hot liquid.

T24.319A, T25.222A, T25.221A

A patient is admitted for intentional overdose of valium and acute respiratory failure with hypoxia.

T42.4x2A, J96.01

Harold has been getting emetogenic chemotherapy and his physician prescribed Aprepitant (an antiemetic). He took a dose, thinking that he forgot to take it earlier, as scheduled. He actually then, overdosed, causing a bad reaction. At the ED, he was diagnosed with:

T45.0X1A Poisoning by antiallergic and antiemetic drugs, accidental, initial encounter

A patient is admitted with an anaphylactic reaction due to eating strawberries, initial encounter.

T78.04xA

Dr. Freen saw this patient, for the first time, and diagnosed her with a blood stream infection due to a port-a-cath malfunction. The principal diagnosis code is:

T80.211A Bloodstream infection due to central venous catheter, initial encounter

A patient had an intra-abdominal cholecystectomy 3 days ago and is now readmitted with cellulitis at the site of the operative incision.

T81.43xA, L03.311

A patient had a cholecystectomy 3 days ago and is now readmitted with cellulitis at the site of the operative incision.

T81.4xxA, L03.311

Active armed services members and their qualified family members are covered by which of the following healthcare programs?

TRICARE

This program, formerly called CHAMPUS (Civilian Health and Medical Program-Uniformed Services), is a health care program for active members of the military and other qualified family members.

TRICARE

What is the name of the federally funded program that pays the medical bills of the spouses and dependents of persons on active duty in the uniformed services?

TRICARE

Which one of the following actions would NOT be included in the professional obligations of the health information practitioner that lead to responsible handling of patient health information?

Take a compromising position toward optimal interpretation of nonspecific regulations and laws

Incorporating a workflow function in an electronic information system would help support:

Tasks that need to be performed in a specific sequence

Dr. Smith has a practice in Macon, Georgia. He is treating a patient who is physically located in Soperton, Georgia, which is about 70 miles away. What technology is required for Dr. Smith to treat the patient?

Telehealth

Which of the following is FALSE in regard to budget variances?

Temporary budget variances are expected to continue in subsequent months.

Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 36-45-99 37-45-99 38-45-99

Terminal-digit

Which of the following filing methods is considered the most efficient?

Terminal-digit filing

Which of the following is NOT a consideration when implementing a disaster plan?

Test the disaster plan only once.

As the director of health information of a newly established acute-care facility, where would you expect to find directives concerning the minimum health record contents?

The Joint Commission

Most facilities begin counting days in accounts receivable at which of the following times?

The date the bill drops

Review the above organizational chart and determine which of the following statements is FALSE about the relationships of the employees displayed on the chart:

The director has subordinates.

Differentiate between the physical and logical data models.

The logical data model shows what the system should do, and the physical data model shows how the logical data model will be created.

Upon discharge analysis of a patient's record, the analyst does not see a discharge order written by the physician. What can the analyst assume?

The patient left against medical advice.

Indicate the second step in proper sequencing in the MS-DRG logic used to assign a case to a particular MS-DRG.

The principal diagnosis determines the MDC assignment.

Which of the following best describes the situation of a provider who agrees to accept assignment for Medicare Part B services?

The provider cannot bill the patients for the balance between the MPFS amount and the total charges.

One of the coders is out on medical leave unexpectedly. At this facility, electronic workflow is used to distribute work. The supervisor needs the work normally sent to her to be distributed among the other coders. Which of the following statements is true?

The supervisor can change the established criteria.

Which one of the following is an advantage of straight numeric filing over terminal digit filing?

The training period is short.

Which of the following is a disadvantage of terminal digit filing as compared to straight numeric filing?

The training period is slightly longer.

Why must influenza immunizations be developed and administered on an annual basis?

The virus mutates significantly each year.

Which of the following statements best describes the scalar or chain of command principle?

There is a clear flow of authority from superior to subordinate throughout the organization.

Which of the following is NOT an advantage of a centralized filing system?

There is less transportation time and effort when a facility operates from several sites.

The coordination of benefits transaction (C)B) is important so that:

There is no duplication of benefits paid

Which of the following is not a characteristic of the common healthcare data sets such as UHDDS and UACDS?

They provide a complete and exhaustive list of data elements that must be collected.

The EHR utilizes existing source systems to supply data.

This is true because the EHR uses many source systems to populate the data.

Which of the following is coded as an adverse effect in ICD-10-CM?

Tinnitus due to allergic reaction after administration of ear drops

According to CPT, in which of the following cases would an established E/M code be used?

Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.

The information collected for your registry includes patient demographic information, diagnosis codes, functional status and histocompatibility information. This type of registry is a:

Transplant registry

Dr. Delmar performed a heart transplant on Elaine Cardio. The root operation term for the ICD-10-PCS code is:

Transplantation: putting in or on all or a portion of a living body part taken from another individual or animal

Which of the following is a common registration error that will affect the revenue cycle?

Transposed digits in the social security number, date of birth, or policy number

ICD-10-PCS procedure codes are used on which of the following forms to report services provided to a patient?

UB-04

The standard claim form used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the

UB-04.

a health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:

UHDDS

A 37-year-old female goes to her family physician complaining of dysuria, urgency, fever, and malaise. A UA is performed, and upon gross examination is found to be turbid and has an unusual odor. Microscopic examination reveals a rod-shaped microorganism. A 24-hour culture produces a colony count greater than 100,000/mL of Escherichia coli. This would indicate a diagnosis of

UTI

Which of the following is a disadvantage of alphabetical filing?

Uneven expansion of file shelves or cabinets

You are developing a complete data dictionary for your facility. Which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

Uniform Hospital Discharge Data Set

Which system avoids assigning a new number for each patient encounter?

Unit numbering

In which of the following systems are all encounters or patient visits filed or lined together?

Unit numbering system

Dr. Meds manually repaired a fracture to the right metacarpal. This is reported from the ______ Body System character of the ICD-10-PCS code.

Upper bones

Stage I of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage?

Use CPOE for medication orders

Which of the following is a valid ICD-9-CM diagnosis code?

V30.00 Single live born, born in hospital

Admitted 05/04/16 Patty Miller 23-33-56 Admitted 06/05/16 P. J. Miller 25-56-88 Admitted 09/27/16 Patricia Miller 27-12-12

Void the last two numbers and file all admissions under 23-33-56.

A 13-year-old patient is brought to her pediatrician with a 2-week history of fatigue, an occasional low-grade fever, and malaise. The pediatrician indicates it is a possible infection but needs to know what type of infection. She orders a hematology laboratory test to determine the relative number and percentage of each type of leukocytes. This test is referred to as a

WBC diff

A post-anesthesia note is required when?

Within 24 hours of surgery

Which of the following insurance covers healthcare costs and lost income associated with work-related injuries?

Workers' compensation

Patient Accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should:

Write off the failed charges to bad debt and bill Medicare for the clean charges

The patient is admitted in preterm labor. The present on admission indicator is

Y=Yes

The physician's H&P at admission includes that the patient was diagnosed with type 2 diabetes mellitus in 2015. The present on admission indicator is

Y=Yes

joint Commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

Yes, prior to surgery

The patient presents for a screening examination for lung cancer.

Z03.89

A patient is admitted for observation for a head injury. The patient was struck while playing football. The patient also suffered a minor laceration to the forehead. Head injury was ruled out.

Z04.3, S01.81xA

The patient presents for a screening examination for lung cancer.

Z12.2

Positive HIV test in a patient who is asymptomatic and has a high-risk lifestyle for HIV infection.

Z21, Z72.89

A newborn infant is born in the hospital, vaginal delivery. Physical examination demonstrates molding of the baby's scalp, which resolved prior to discharge without treatment.

Z38.00

A newborn is born in the hospital vaginal delivery. Physical examination demonstrates molding of the baby's scalp, which resolved prior to discharge without treatment.

Z38.00

A Newborn infant is born in the hospital vaginal delivery with a unilateral hard cleft palate and cleft lip.

Z38.00, O37.1

A full-term newborn vaginal delivery born in the hospital. The birth is complicated by cord compression, which affected the newborn

Z38.00, P02.5

A full-term newborn vaginal delivery born in the hospital. The birth is complicated by cord compression, which affected the newborn.

Z38.00, P02.5

A full-term newborn, vaginal delivery, is born in the hospital. The birth is complicated by cord compression, which affected the newborn.

Z38.00, P02.5

A newborn infant is born in the hospital, delivered vaginally, and sustained a fracture of the clavicle due to birth trauma.

Z38.00, P13.4

A preterm infant born in the hospital vaginal delivery 36 weeks gestation is treated for neonatal jaundice.

Z38.00, P59.9, P07.39

A preterm infant born in the hospital, vaginal delivery, 36 weeks gestation, is treated for neonatal jaundice.

Z38.00, P59.9, P07.39

A newborn infant is born in the hospital, vaginal delivery, with a unilateral hard cleft palate and cleft lip.

Z38.00, Q37.1

A full-term infant born in the hospital, vaginal delivery, was diagnosed with infantile polycystic kidneys, specifically identifying cystic dilation of the collecting ducts.

Z38.00, Q61.11

A patient is admitted with a fracture to the L1 vertebrae secondary to postmenopausal senile osteoporosis, initial encounter.

Z38.00, Q61.11

A full-term infant born in hospital vaginal delivery was diagnosed with polycystic kidneys.

Z38.00, Q61.19

A full-term newborn vaginal delivery was born in the hospital to a mother who is addicted to cocaine; however, the infant tested negative.

Z38.00, Z03.79

A full-term newborn, vaginal delivery, was born in the hospital to a mother who is addicted to cocaine; however, the infant tested negative.

Z38.00, Z05.2

A preterm infant 34 weeks gestation is born via Cesarean section and has severe birth asphyxia.

Z38.01, P84, P07.37

A preterm infant, 34 weeks gestation, is born via cesarean section and has severe birth asphyxia.

Z38.01, P84, P07.37

A patient is being admitted for chemotherapy for primary lung cancer, left lower lobe.

Z51.11, C34.32

No book:Mary is 6 weeks postmastectomy for carcinoma of the breast. She is admitted for chemotherapy.

Z51.11, C50.911

A patient is admitted for chemotherapy for treatment of breast cancer with liver metastasis. She had a mastectomy 4 months ago. Chemotherapy is given today. (Do not assign a procedure code for chemotherapy.)

Z51.11, C78.7, Z85.3

A patient is admitted for chemotherapy for treatment of liver metastasis from previous breast cancer. She had a mastectomy 4 months ago. Chemotherapy is given today.

Z51.11, C78.7, Z85.3

a patient is admitted for chemotherapy for treatment of breast cancer with liver metastasis. she had a mastectomy 4 months ago. chemotherapy is given today

Z51.11, C78.7, Z85.3

Dr. smith needs something small and lightweight to use for dictating reports and entering data on the go. You suggest he use

a PDA

Which of the following BEST describes tuberculosis?

a chronic, systemic disease whose initial infection is in the lungs

The supervisor of coding and abstracting would like to determine the coders' accuracy. Which type of management tool would provide her with the information she needs?

a coding audit

In the ICD-10-CM classification system, severe shock due to third degree burns sustained in an industrial accident would be coded as:

a current injury

There has been a significant increase in the number of cases and deaths from pertussis. Health care professionals attribute this disease trend to which of the following?

a decrease in the number of people immunized with TDaP

A pharyngeal culture is taken from a 13-year-old male patient presenting to the ER with fever, painful cervical lymph nodes, purulent tonsillar exudate, and difficulty swallowing. A blood agar culture plate shows complete hemolysis around Streptococcus pyogenes bacterial colonies. The patient is given a prescription for erythromycin. The diagnosis in this case is

a group A beta-hemolytic streptococcal throat infection.

what is an IDS?

a group of facilities that provide comprehensive medical care and services

Prevention programs identify risk factors and use strategies to modify attitudes and behaviors to reduce the chance of developing cancers. Which of the following would NOT be an identified risk factor for colorectal cancer?

a high-fiber diet

In an acute care hospital, a complete history and physical may not be required for a new admission when

a legible copy of a current H&P performed in the attending physician's office is available.

A direction to "Code first underlying disease" should be considered:

a mandatory instruction

In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when

a new patient is seen in the office.

All of the following statements are true of MS-DRGs, EXCEPT

a patient claim may have multiple MS-DRGs.

"Qualified employees should be given priority when vacancies within the organization occur" is an example of

a policy of the organization.

the HIM practitioner's duty to retain health information via the archiving and storage of health data includes all but which of the following?

a retention plan for financial data

When the MS-DRG payment received by the hospital is lower than the actual charges for providing the inpatient services for a patient with Medicare, then the hospital

absorbs the loss.

You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?

abstracting

When a provider, knowingly or unknowingly, uses practices that are inconsistent with accepted medical practice and that directly or indirectly result in unnecessary costs to the Medicare program, this is called

abuse

Microfilmed records are considered

acceptable as courtroom evidence.

The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of?

access

When implementing the electronic health record, what is the technical security standard that requires unique user identification, emergency access procedures, automatic log-off, and encryption and decryption of data?

access control

As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use

accession register.

Engaging patients and their families in health care decisions is one of the core objectives for

achieving meaningful use of EHRs

Engaging patients and their families in health care decisions is one of the core objectives for

achieving meaningful use of EHRs.

A patient with leukemia is admitted for chemotherapy 5 weeks after experiencing an acute mycardial infraction. How will the MI be coded?

acute MI with 5th digit 2- subsequent episode of care

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is:

acute pancreatitis

An elevated serum amylase would be characteristic of

acute pancreatitis.

modifier-51

add-on codes

Established 42-year-old patient comes into your office to obtain vaccines required for his trip to Sri Lanka. The nurse injects intramuscularly the following vaccines: hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As the coding specialist, what would you report on the CMS 1500 form?

administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever

Maria has received a request to update a patient's insurance number. She accesses the __________ and updates the system. What system is she using?

admission-discharge-transfer system

For inpatients, the first data item collected of a clinical nature is usually

admitting diagnosis.

Which endocrine gland secretes epinephrine, which activates the "fight or flight" response and increases blood pressure and metabolism?

adrenal medulla

tachycardia after taking a correct dosage of prescribed Lortab would be reported as a(n):

adverse reaction to a drug

Unless state or federal laws require longer time period, AHIMA recommends that patient health information for minors be retained for at least how long?

age of majority plus statute of limitation

You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing?

aggregate data

Of the following, which is a hospital-acquired condition (HAC)?

aire embolism

Dr Smith is entering a medication order in a CPOE. A window pops up with the following message: Patient is on beta-blocker, which is a contraindication for this medication.Do you want to order this medication? Yes or No. This is an example of a(n)

alert

Which of the following conditions is typically treated with the insertion of a pacemaker?

all answers apply

Which of the following issues seems to be the main contributing factor to the rise of antibiotic-resistant bacterial organisms such as methicillin-resistant Staphylococcus aureus?

all answers apply

Children at higher risk for sudden infant death syndrome (SIDS) include those

all answers apply.

U.S. health care providers are concerned about a possible pandemic of avian flu because

all answers apply.

How can Graves' disease be treated?

all answers apply..

A 63-year-old patient with terminal pancreatic cancer has started palliative chemotherapy. Palliative means

alleviating or eliminating distressing symptoms of the disease.

Gas exchange in the lungs takes place at the

alveoli

which of the following organization responsible for the creation of minimum standards for medical records:

american college of surgeons

What is the chief criterion for determining record inactivity?

amount of space available for storage of newer records

A common contraceptive that is implanted in the uterus induces slight endometrial inflammation, which attracts neutrophils to the uterus. These neutrophils are toxic to sperm and prevent the fertilization of the ovum. This contraception is termed

an IUD.

The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits?

an initial inpatient consult and a subsequent hospital visit

A physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign:

an unlisted procedure code located in the eye and ocular adnexa section

a physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician the coder is unable to find a code for the procedure. The coder should assign:

an unlisted procedure code located in the eye and ocular adnexa section

A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign

an unlisted procedure code located in the eye and ocular adnexa section.

A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)

analyst

A clinical documentation specialist performs many duties. These include reviewing the data and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)

analyst

A bee stung little Bobby. He experiences itching, erythema, and respiratory distress caused by laryngeal edema and vascular collapse. In the emergency room where he is given an epinephrine injection, Bobby is diagnosed with

anaphylactic shock.

A severe allergic reaction that can be life-threatening, due to a swollen throat, difficulty breathing, rash, and dizziness that must be treated with injectable epinephrine is termed

anaphylaxis

Under APCs, payment status indicator "X" means

ancillary services.

how often are the medicare fee schedule updated?

annually

The opposing interaction of two drugs in which one decreases or cancels out the effects of the other is termed a

antagonistic effect.

Ingrid Anderson presents with a skin infection that began as a raised, itchy bump, resembling an insect bite. Within 1-2 days, it developed into a vesicle. Now it is a painless ulcer, about 2 cm in diameter, with a black necrotic area in the center. During the history, her doctor learns that she has recently returned from an overseas vacation that included a trip to a sheep farm and becomes concerned that she may have become infected with anthrax. He will prescribe an

antibiotic

One of the most common causes of peptic ulcer disease is the consumption of aspirin and NSAIDs. Another common cause is infection by Helicobacter pylori, and the usual treatment for this condition is use of

antibiotics

University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs?

application service provider model

The project manager is responsible for all of the following functions EXCEPT

approval of the budget for the project.

According to the following table, the most serious record delinquency problem occurred in which of the following months? (70)

april

Under the Patient Self-Determination Act of 1990, evidence of advance directives

are required to be documented in the health record.

Diabetic microvascular disease occurs

as a direct result of elevated serum glucose.

Which one of the following is NOT a step in developing a health record retention schedule?

assigning all records the same retention period

Elaine was a diabetic and had a wound that would not heal, so Dr. Smith had her placed in a hyperbaric oxygenation of the wound. The root operation term used in ICD-10-PCS is:

assistance

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

attending physician.

A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n)

auditor

Choose the appropriate data field types that is best for the data element "health record number".

auto-numbering

When the body's immune system reverses itself and attacks the organs and tissues, this process is called

autoimmunity

Which of the following is NOT a technical security control employed by electronic health record system?

automatic logon

The medical staff wants a speech recognition system where the staff dictates and then the editing of the dictation is done by editors. What type of speech recognition is this?

back-end speech recognition

the federal legislation that focused on healthcare fraud and abuse issues especially as they relate to penalties was the

balanced budget act of 1997

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

bar code placement

Which of the following technologies works best with automated record-tracking systems to speed the data entry process?

bar codes

A 16-year old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would

be filed in the mother's record.

DSM-5 is used most frequently in what type of health care setting?

behavioral health centers

DSM-IV-TR is used most frequently in what type of healthcare setting?

behavioral health centers

Which of the following is a risk factor involved in the etiology of gallstones?

being overweight

THe healthcare facility has decided to purchase all of their information systems from Vendor A so that the information systems will be integrated. This system selection strategy is known as

best of fit

_________indicated that the claim has been release as complete for submission to the insurer for payment

bill drop

Which of the following would be a foreign key in the patient table?

billing number

A health care facility has received a request to participate in a statewide study on cleft lip and cleft palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the

birth defects registry

A pathological diagnosis of transitional cell carcinoma is made. The examined tissue was removed from the

bladder

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is

blood culture before first antibiotic received.

In the Medical Surgical Section of ICD-10-PCS, the fourth character position represents which of the following?

body part

In the Medical Surgical Section of ICD-10-PCS, the second character position represents which of the following?

body system

When a decubitus ulcer has progressed to a stage in which osteomyelitis is present, the ulcer has extended to the

bone

The etiology of aplastic anemia is

bone marrow failure.

Some immunizations, such as tetanus, require a second application to strengthen or "remind" the immune system in response to antigens. The subsequent injections are termed

booster shots

Pain is a symptom of which of the following conditions?

both first-degree burn (superficial) and second-degree burn (partial thickness)

A disease of the inner ear with fluid disruption in the semicircular canal that causes vertigo is

both labyrinthitis and Meniere's disease.

The most common type of vaginitis is

both yeast and protozoan.

O2 is carried in the blood

bound to hemoglobin

The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed:

brachytherapy

All of the following items are "packaged" under the Medicare ASC payments, EXCEPT for

brachytherapy.

Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)?

breast

Recognizing diversity in the workplace

brings awareness to the individual qualities that an employee brings to the organization.

There was an unexpected hardware failure for our EHR. It is expected to be up and operational in 3 hours. Until then, which of the following plans would you need to initiate?

business continuity plan

the principles and policies which govern the medical staff and are approved by the hospital's board of trustees are called the:

bylaws,rules and regulations

Tracheostomy

bypass

When evaluating an outside contract microfilm company, all but which of the following are important factors to rate?

cache memory

Dr. Zambrano ordered a CEA test for Mr. Logan, a 67-year-old African American male patient. Dr. Zambrano may be considering a diagnosis of

cancer

The following type of hospital is considered excluded when it applies for, and receives, a waiver from CMS. This means that the hospital does not participate in the inpatient prospective payment system (IPPS).

cancer hospital

Select the information system where you would find TNM stage.

cancer registry

The most common type of registry located in hospitals of all sizes and in every region of the country is the:

cancer registry

The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of this data is:

cancer registry abstracts

The most common type of registry located in hospitals of all sizes and in every region of the country is the

cancer registry.

What two types of budgets are often prepared by managers of Health Information Management department?

capital budget and operating budget

what is the term used in the insurance industry for the lump sum payment of a set dollar amount for each covered person on a specific health plan?

capitation

The process of cancer development, from exposure through the cellular changes of hyperplasia to neoplasia, is termed

carcinogenesis.

Cancer derived from epithelial tissue is classified as a(n)

carcinoma

The Phalen's wrist flexor test is a noninvasive method for diagnosing

carpal tunnel syndrome.

Diagnostic testing for meningitis usually involves

cerebrospinal fluid analysis.

Henrietta Dawson presents with a chief complaint of pain and weakness in her arms and neck. After an H and P and a review of diagnostic tests that include a myelogram, her doctor diagnoses a herniated nucleus pulposus at the _________ level of her spine.

cervical

Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT

changes in coding productivity.

This process involves the gathering of charge documentation from all departments within the facility that have provided services to patients. The purpose is to make certain that all charges are entered into the billing system.

charge capturing

This information is the numerical identification of the service or supply. Each item has a unique number with a prefix that indicates the department number (the number assigned to a specific ancillary department) and an item number (the number assigned by the accounting department or the business office) for a specific procedure or service represented on the chargemaster.

charge/service code

In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a(n)

chargemaster

This is the amount the facility actually bills for the services it provides.

charges

The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for?

chart tracking

Which of the following types of hospitals are excluded from the Medicare prospective payment system?

children's

Which of the following procedures would be performed for the removal of the gall bladder due to excessive gallstone formation?

cholecystectomy

Accounts receivable (A/R) refers to

claims for which money has not yet come in.

in a typical acute-care setting which revenue cycle are uses an internal auditing system (scrubber) to ensure that error-fee (clean claims) are submitted to third-party payers?

claims processing

Your release of information system has part of the computing on the workstation and part on the file server. What type of technology is being used?

client sever

Under APCs, payment status indicator "V" means

clinic or emergency department visit (medical visits).

The function of a (an) _____is limited to data retrieval.

clinical data repository

The patient has been on medication X for several years. A physician ordered medication Y. The information system immediately sends the physician a message that says that medication Y is contraindicated due to medication X. What technology is being used?

clinical decision support systems

University Hospital had the messaging technology to securely route an alert for a patient's possible drug interaction or abnormal lab result to the appropriate physician's pager number. Which one of the following is the medical staff using?

clinical information system

The permission granted by the governing board to practitioners to provided well-defined patient care services in the granting institution based on licensure education training experience competence health status and judgment is known as

clinical privileges

a list or collection of clinical words or phrases with their meaning is a

clinical vocabulary

a list or collection of clinical words or phrases with their meanings is

clinical vocabulary

This small physician practice does not have the technical staff to manage the EHR. The physicians are looking for someone who can manage the software and hardware for them at a set monthly cost. Their technology support staff is limited, so you want to use a technology where the software and database is stored and maintained remotely. This is called

cloud computing

John Palmer was in a car accident and sustained severe chest trauma resulting in a tension pneumothorax. Manifestations of this disorder include all of the following EXCEPT

clubbing

An 81-year-old male with arteriosclerosis and a long-standing history of taking Coumadin presents to his physician's office for his biweekly prothrombin time (PT) test. The PT test is one of the most common hemostasis tests used as a presurgery screening and monitoring Coumadin (warfarin) therapy. This test evaluates

coagulation of the blood.

A treatment for sensorineural hearing loss is

cochlear implants.

Mary Smith, a 48-year-old patient, is receiving an IV mixture of four different medications to treat stage two invasive ductal breast carcinoma. Each of the medications acts upon a different aspect of the cancer cells. This mixture is typically termed a(n)

cocktail

The correct coding initiative (CCI) edits contain a listing of coders under two columns titled "comprehensive codes" and "component codes". According to the CCI edits when a provider bills medicare for a procedure that appears in both columns for the same beneficiary on the same date of service

code only the comprehensive code

The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled "comprehensive codes" and "component codes." According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service,

code only the comprehensive code.

Most chief financial officers view the HIM department's most essential role in the revenue cycle management to be:

coding of the record

The foundation for communicating all patient care goals in long-term care settings is the

cognitive assessment.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be

cognitive patterns

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be

cognitive patterns.

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data

comprehensiveness

In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to

confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.

In reviewing the medical record of a patient admitted for a left herniorrhaphy the coder discovers an extremely low potassium level on the laboratory report. In examining the physician orders the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to:

confer with the physician and ask him or her to list the condition as a final diagnosis if her or she considers the abnormal potassium level to be clinically significant

In negotiating a contract with a commercial storage company for storage of inactive records, what would be the most important issue to clarify in writing?

confidentiality policies and liability concerns

A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as:

consultation

You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that due to some heart irregularities, he may not be a good surgical risk. Because of your knowledge of COP regulations, you expect that a(n) _________ will be added to his health record.

consultation report

All of the following are examples of direct transmission of a disease EXCEPT

contaminated foods.

I need a snapshot of the patient's condition so I would access the

continuity of care record

Which of the following systems would provide a snapshot of information about the patient's conditon?

continuity of care record

This is the difference between what is charged and what is paid.

contractual allowance

Which of the following is NOT considered a challenge in the adoption of an electronic health record system?

contribution to the quality of patient care

Which of the following is a risky practice in the EHR?

copy and paste

The causative organism for severe acute respiratory syndrome (SARS) is a

coronavirus

This accounting method attributes a dollar figure to every input required to provide a service.

cost accounting

A transcriptionist's productivity level, as determined by line count per day, has dropped significantly over the past 2 weeks. As a result, there is a backlog in transcription of history and physical reports and surgical reports. Several doctors and the operating room supervisor have complained. An appropriate initial course of action for the supervisor of transcription is to

counsel the transcriptionist privately and develop an action plan for improved performance.

There are seven criteria for high-quality clinical documentation. All of these elements are included EXCEPT

covered (by third-party payer).

A surgical procedure that cuts into the skull to drain blood from a subdural hematoma in order to decrease the intracranial pressure is termed a(n)

craniotomy

When a physician orders a liver panel, which of the following tests are NOT included?

creatinine

Creation of arteriovenous graft brachial artery left arm for hemodialysis

creation

A procedure performed with an instrument that freezes and destroys abnormal tissues (including seborrheic keratoses, basal cell carcinomas, and squamous cell carcinomas) is

cryosurgery

A sweat test was done on a patient with the following symptoms: frequent respiratory infections, chronic cough, and foul-smelling bloody stools. Which of the following diseases is probably suspected?

cystic fibrosis

The physician will be called automatically when a lab result is at the panic level. This is an example of a

data -driven rule

The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this case?

data accuracy

As HIM Department Director, you are on the implementation team for the new MPI. You have been assigned the responsibility of looking at every data element stored in the system and establishing criteria for the use of each. An example of what you are doing is shown below. Name: Last name Description: This field is for the paient's last name Number of characters: 30 Alphanumeric Alpha: Acceptable characters a-z Responsible person:HIM Director Used in reports: Admissions list, discharge list, transfer list, health record number list, UB-92, CMS-1500 You are responsible for the

data dictionary

You are interested in some data analysis on patients with cardiac problems. You have downloaded the data that you need on the cardiology patients from the data warehouse into a smaller database that you can work with. You are using a(n)

data mart

You need to identify some patterns in our database. What technology should you use?

data mining

There is a problem with the data dictionary. The drop-down fields do not have all of the options that are needed. This is a problem with

data quality

Identify the information system that collects data from multiple source systems but the data is not collected from these sources systems in real-time.

data warehouse

General Hospital utilizes various related files that include clinical and financial data to generate reports such as MS-DRG case mix reports. What application would be MOST effective for this activity?

database management system

If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to the

date of birth.

Which of the following should NOT be included in the documentation of record destruction?

dates not covered in destruction

It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed?

dates of admission, discharge, and encounters

in which situation could the use of case mix information be helpful?

deciding if a facility should open an urgent care center

In performing a "what if" query to determine if the facility should expand the emergency department, which of the following systems would be used?

decision support system

in August of 2006 what decision was made by the office of Management and Budget that will impact hospital-based billing?

decision to implement UB-04 claim

A supervisor determined that the rate of absenteeism with three of his employees was 15%. This was unacceptable and he researched two possible solutions to the problem. He evaluated these alternatives and thought the best thing to do was to suspend all three employees for 2 days. Once he implemented this solution, he analyzed the consequences. How would you label this process?

decision-making

Which of the following is NOT a benefit of the electronic document management system in the HIM Department?

decreased use of computer technology

the medicare act acknowledges facilities accredited by the joint commission and the American osteopathic association (AOA). it is understood that joint commission and AOA accredited facilities are also in compliance with medicare's regulations. those accredited are said to have:

deemed status

What has been impacted by the correct coding initiative

defining of cases of upcoding and unbundling

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient's health record?

delegated use of computer key by radiology secretary

The supervisor of a Health Information Management department has aspirations of becoming the HIM director. She works very long hours so that she can address all department issues herself rather than relying on her staff to assist her. Which type of management skills is she in need of improving in order to attain her goal of department director?

delegating skills

A patient is admitted in alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principal diagnosis?

delirium tremens

A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?

department staffing

Colon polyp fulguration

destruction

Endometrial ablation of cervical polyps

destruction

Amputation first left toe

detachment

the patient's account balance is displaying a negative balance. what should be the healthcare organization do to resolve this situation?

determine which payer overpaid and return the funds

the phrase "bad debt" refers to accounts that include money owed by the patient and are:

determined bt the facility to be uncollectible

The director of Health Information Services has asked the supervisor over imaging to determine productivity standards for the imaging clerks. In initiating this process, the supervisor has determined that the best way to institute work standards is to

develop standards based on professional standards and industry benchmarks.

Dr. Smith inserted a tracheostomy tube into the patient's trachea. The tube is reported with the ___ character in the ICD-10-PCS code.

device

A serum potassium level of 2.8 would indicate

diabetic ketoacidosis.

the stating of several different diagnoses in the physical exam is referred to as the:

differential diagnosis

The most secure model of signatures used in information systems is

digital signature

A common cardiac glycoside medication that increases the force of the cardiac contraction without increasing the oxygen consumption, thereby increasing the cardiac output is typically given to patients with heart failure. However, there is a very narrow therapeutic window between effectiveness and toxicity, and the patient must be monitored closely. This common cardiac medication is

digoxin

The patient is diagnosed with congestive heart failure. A drug of choice is

digoxin

which of the following terms is used to describe medical schools which sprang up almost overnight in the 1800s and graduated medical students in as little as six months?

diploma mills

The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should

direct the request to the state's office of vital records.

What type of plan is a Joint Commission-accredited facility requried to maintain to protect health information form catastrophes such as fire, flooding, bomb threats, and theft?

disaster

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

discharge order.

"Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKGs remained unchanged. Patient will be discharged and followed as an outpatient."

discharge summary

The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. DNFB is an acronym for _____________.

discharged no final bill

Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record?

discrepancy between post-op diagnosis by the surgeon and pathology diagnosis by the pathologist

Which of the following is least likely to be identified by a retrospective quantitative analysis of a health record?

discrepancy between postoperative diagnosis by the surgeon and pathology diagnosis by the pathologist

As the director of Health Information Services, you manage the department with the assistance of four supervisors. One day you observe a coder coding charts from the face sheet without reviewing the record for additional documentation. The most appropriate course of action would be to

discuss your concerns with the Supervisor of Coding and direct her to address this issue immediately.

Which of the following actions illustrates the use of employee empowerment by upper management?

discussing suggested approaches of improving productivity and performance with employees

A search request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January 2016. Which of the following indices would be the best source in locating the needed records?

disease index

The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?

disease index

Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

disease index

You have been asked to identify every reportable case of cancer from the previous year. A key resource will be the facility's

disease index.

A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a(n)

disease registry.

A patient who is taking the drug Antivert may be diagnosed with:

dizziness

In order to use the inpatient CPT consultation codes, the consulting physician must

document his findings in the patient's medical record.

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

documented in both the progress notes and the discharge summary.

When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding?

donor site

You are the Director of Coding and Billing at a large group practice. The Practice Manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt meaningful use EHR technology. You reply that the incentives began 2011 and ended in 2014. You remind him that by 2015, sanctions for noncompliance began to appear in the form of

downward adjustments to Medicare reimbursement.

Which of the following items is the health information manager primarily concerned with when purchasing file guides?

durability and visibility

The following services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.

durable medical equipment

In the managed care industry, there are specific reimbursement concepts, such as "capitation." All of the following statements are true in regard to the concept of "capitation," EXCEPT

each service is paid based on the actual charges.

A PEG procedure would most likely be done to facilitate:

eating

Impetigo can be

either spread through autoinoculation or caused by Streptococcus pyogenes.

Which of the following tubes conveys sperm from the seminal vesicle to the urethra?

ejaculatory duct

Your department must send information electronically to the state health department every day. Currently this is taking a significant amount of time. What technology can be used to automatically send this information without human intervention?

electronic data interchange

The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called

electronic data interchange (EDI).

Which step of the "chain of infection" is disrupted by eliminating the standing water in old tires, birdbaths, and empty buckets when combatting the Zika virus epidemic?

eliminating the reservoir

Patient care can be improved through the use of technology. Which of the following is an example of how this happens?

elimination of illegible orders

The Director of Health Information Management has been asked by the Board of Trustees to justify support for the use of handheld devices by the medical staff for point-of-service input. Which one of the following reasons would NOT be included in the Director's response?

elimination of the need for expensive desktop computers

The category "Commercial payers" includes private health insurance companies and

employer-based group health insurers.

which of the following documents should be updated at least on an annual basis to incorporate ICD-9-CM and CPT code changes?

encounter form

A major consideration in a hospital or facility closure is to

ensure that authorized parties have access to the information as provided by law.

The hospital is undergoing the development of an information system strategic plan. The part of the process where changes in the community, legislation, and other factors are monitored is called

environmental scanning

Health plans that use ____________ reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient over a specific period of time for a particular reason.

episode of care (EOC)

The chief executive officer (CEO) at a health care facility begins a formal planning cycle at the beginning of each fiscal year. This annual planning process should begin with which of the following?

establishing the annual organizational objectives

under the Home Health Resource group (HHRG) guidelines how often must a patients care be recertified

every 60 days

Joint Commission does not approve auto authentication of entries in a health record. The primary objection to this practice is that

evidence cannot be provided that the physician actually reviewed and approved each report.

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

evidence cannot be provided that the physician actually reviewed and approved each report.

Biopsy of left lower lobe of the lung

excision

Dr. Smith performed a liver biopsy on George Doe. The root operation term for the ICD-10-PCS code is:

excision

Excision descending colon

excision

A physician excises a 3.1 cm malignant lesion of the scalp which requires full thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?

excision of lesion; Full-thickness skin graft to scalp

A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?

excision of lesion; full-thickness skin graft to scalp

The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?

executive information system

Dr. Thomas performed a tonsillectomy on Peter. The approach, as reported in ICD-10-PCS, is:

external

Cesarean section on 27-year-old woman at 38 weeks

extraction

Left common carotid endarterectomy, open

extraction

The baby was having trouble passing through the vaginal canal, so Dr. Jones use forceps to help him along. Baby Boy was born at 12:57 pm. The root operation term used for this ICD-10-PCS code is:

extraction

Uterine dilation and curettage

extraction

Removal deep left vein thrombosis

extripation

As the Chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the

facility's data dictionary.

The first stage of alcoholic liver disease is

fatty liver.

If the department staff are having trouble locating the terminal digit sections quickly, the supervisor could add more

file guides.

Which of the following issues would be of LEAST concern when storing health records in off-site storage

filing order of the records

You need a report that includes only Medicare patients. What operation enables you to generate this report?

filtering

A Medicare patient was seen by Dr. Zachary, who is a nonparticipating physician. The charge for the office visit was $125. The Medicare beneficiary had already met his deductible. The Medicare Fee Schedule amount is $100. Dr. Zachary does not accept assignment. The office manager will apply a practice termed as "balance billing," which means that the patient is

financially liable for charges in excess of the Medicare Fee Schedule, up to a limit.

a patient was seen by DR.Zachary. The charge for the office visit was $125. The Medicare beneficiary had already met his deductible. The medicare fee schedule amount is $100. Dr Zachary does not accept assignment. the office manager will apply a practice termed as "balance billing" which means that the patient is :

financially liable for charges in excess of the Medicare fee schedule

CMS adjusts the Medicare Severity DRGs and the reimbursement rates every

fiscal year beginning October 1.

Two transcriptionists are able to set their own work hours provided the department is covered by one of them during regular office hours. This kind of work arrangement is referred to as

flex time.

Electronic health record built-in tools that can make data capture easier include all but which one of the following?

flow process charts

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?

focused audit

What common vitamin should be taken by pregnant women to substantially reduce the occurrence of neural tube defects, such as spina bifida, in a developing fetus?

folic acid

One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued?

for the life of the patient

Lithotripsy left ureter with removal of fragment

fragmentation; extirpation

____ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist.

fraud

In which brain lobe is the processing of emotions, intellect, and personality performed?

frontal

Spinal fusion cervical C1-C2

fusion

Which one of the following is necessary during the stategic planning process for the EHR?

gauging the user's readiness for the EHR

In the computerization of forms, good screen view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

general appearance as assessed by the physician.

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

geographic practice cost indices.

The CIO has given you a list of critical success factors developed for the EHR that your facility is developing. Which of the following would you expect to see on this list?

get buy-in from the key players

A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of

glaucoma

A coder notes that patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of

glaucoma

A bundled payment that covers all services from immediately prior to a surgical procedure through the appropriate post-procedure care period is known as __________.

global payment

which of the following apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?

global payment

Clinical manifestations of this disease include polydipsia, polyuria, polyphagia, weight loss, and hyperglycemia. Which of the following tests would be ordered to confirm the disease?

glucose tolerance test

What is the name of the protein that gives breads, cereals, baked goods, and pasta their structure but can cause serious gastrointestinal complications when ingested by individuals with celiac disease?

gluten

A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)

grouper

Report generation has four operations: filtering, sorting, calculations, and

grouping

A 68-year-old female patient has no visible bleeding but remains anemic. Her physician is concerned about possible gastrointestinal bleeding. Which of the following tests might be ordered?

guaiac smear test

One of the ways that an EHR is distinguished from a clinical data repository is that the EHR

has clinical decision support capabilities.

Under the HIPAA Privacy Rule, when destruction services are outsourced to a business associate, the contract must provide that the business associate will establish the permitted and required uses and disclosures and include all but which of the following elements?

he hospital's liability insurance in specified amounts

from the following list, identify the health data user whose need is more broad-based than individual patient based.

health care providers

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the

health information manager.

Information found in which of the following would not be considered secondary data?

health record

An example of a primary data source for health care statistics is the

health record.

An example of a primary data source is the

health record.

The patient was brought into the ED with an embolism in her right pulmonary vein. Dr. Rogers brought him into the procedure room to fragment the clot. This is reported from the ______ Body System character of the ICD-10-PCS code.

heart and great vessel

A cardiac condition where there is an abnormality in the way the electricity passes through the sinoatrial (SA) node and the atrioventricular (AV) node to generate a pulse or heartbeat is called

heart block.

Full-blown AIDS sets in as

helper T-cell concentrations decrease.

A 62-year-old female presents to her family doctor complaining of fatigue; constantly feeling cold, especially in her hands and feet; weakness; and pallor. O2 must be transported to the cells and exchanged with CO2, which is then transported back to the lungs to be expelled. A hematology laboratory test that evaluates the oxygen-carrying capacity of blood is referred to as a

hemoglobin determination.

The most common blood-borne infection in the United States is

hepatitis C.

Contributing factors of mental disorders include

heredity, stress, and trauma.

A 75-year-old female was admitted for repair of a hiatal hernia which was performed on the first day of admission. While recovering, the patient fell out of her bed and sustained a fractured femur which was surgically reduced. Further complications included severe angina for which a cardiac catheterization and PTCA were performed. The principal procedure is:

herniorrhaphy

In general, excessive RBC breakdown could result in

high bilirubin levels.

Which item is collected and maintained in the organ transplant registry?

histocompatibility information

In assigning E/M codes, three key components are used. These are

history, examination, and medical decision making.

These are financial protections to ensure that certain types of facilities (e.g., children's hospitals) recoup all of their losses due to the differences in their APC payments and the pre-APC payments.

hold harmless

What prospective payment system reimburses the provider according to determined rates for a 60-day episode of care?

home health resource groups

The state of balance or normality that the human body continuously tries to attain is referred to as

homeostasis

programs which administer palliative supportive series for terminally ill patients and their families are called:

hospice programs

as a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

hospital bylaws, rules, and regulations.

A 28-year-old female presents to her general practitioner with morning nausea and vomiting, weight gain, and two missed menstrual cycles. The physician orders a pregnancy test. What chemical in the urine does this lab test detect?

human chorionic gonadotropin

The facility Hospital Information System team has been researching network topologies and has decided on one that combines the attributes of bus, ring, and star topologies. What topology has the team chosen?

hybrid network

A patient is seen in the emergency room of an acute care hospital with tachycardia and hypotension. The patient had received and injection of tetanus toxoid (correct dosage) earlier at his primary care physician's office. Which for the following is appropriate sequencing for this encounter?

hypotension;tachycardia; therapeutic use E code (tetanus toxoid)

All children will be entered into which of the following registries at birth and thus will continue to be monitored by the registry in their geographic area?

immunization registry

This registry collects data on recipients of heart valves and pacemakers:

implant registry.

The director of the Health Information Services Department has determined that an in-service for department supervisors on developing productivity standards within their respective areas is needed. As an outcome of this in-service, the director would like the supervisors to understand that when setting productivity levels, a supervisor must

implement productivity standards that align with the mission and goals of the organization.

use of a revised CMS-1500 (80/05) claims was required effective April 1, 2007 due to:

implementation of NPI

The Conditions of Participation requires that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered a consultation?

impressions of a cardiologist asked to determine whether patient is a good surgical risk

Which of the following reports would normally be considered a consultation?

impressions of a cardiologist asked to determine whether patient is a good surgical risk

The primary goal of a hospital-based cancer registry is to

improve patient care.

A population-based cancer registry that is designed to determine rates and trends in a defined population is a(n)

incidence-only population-based registry.

A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the

incident report.

A quality control measure that should be established for the filing, storage, and retrieval of health records includes criteria for the

inclusion of late reports.

Mary Mulholland has diabetes. Her physician has told her about some factors that put her more at risk for infections. Which of the following factors would probably NOT be applicable?

increased blood supply

Which of the following is an effect of insulin?

increases glucose metabolism

You recently installed a new computer system and you just learned that the vendor does not have the right to use one portion of the system. Another company owns the rights to the information contained in this portion of the system. What clause in your contract would you review to see if you are protected from being sued by the other company?

indemnification

Strong lateral relationships within a facility are most likely when

individual departments cooperate together to achieve organizational goals.

State Medicaid programs are required to offer medical assistance for

individuals with qualified financial need.

Penicillin is effective in the treatment of all of the following diseases EXCEPT

influenza

What is the business of buying and selling information as a commodity?

information brokering

A work environment that is not ergonomically sound could lead to

injuries

The prospective payment system (PPS) requiring the use of DRGs for inpatient care was implemented in 1983. This PPS is used to manage the costs for

inpatient hospital stays.

Under APCs, payment status indicator "C" means

inpatient procedures/services.

This prospective payment system is for ____________________ and utilizes a Patient Assessment Instrument (PAI) to classify patients into case-mix groups (CMGs).

inpatient rehabilitation facilities

Placement of single-lead cardiac pacemaker

insertion

Cystoscopy

inspection

As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to

install a computerized access control panel.

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

integrated progress notes.

Which of the following tests determines how well new systems being implemented work with existing systems?

integration test

Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a (an)

interfaced system.

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?

intergrity

Joint Commission requires that attending physician to countersign health record documentation that is entered by

interns or medical students.

Joint Commission requires the attending physician to countersign health record documentation that is entered by

interns or medical students.

The hospital utilizes the best of breed model for its information systems. The hospital is able to exchange data between the information systems from the various vendors seamlessly. This concept is

interoperability

With data exchange standards, the ability to transfer data from one system to another system is called

interoperability

a discharge in which the patient was discharged from the inpatient rehabilitation facility and returned within 3 calendar days is called a

interrupted stay

When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n)

interrupted stay.

Which of the following is the most effective method for the prevention of influenza?

intramuscular injection vaccine

The facility has used Internet technology in order to establish an area restricted to employees where policies and procedures, forms, and more can be stored. This is a(n)

intranet

Sex-linked genetic diseases

involve a defect on a chromosome.

A discharge summary:

is not required for a stay of 48 hours or less.

Under APCs, the payment status indicator "N" means that the payment

is packaged into the payment for other services.

all of the following are true about federal government regulation of health care except:

it guarantees access to health care

This information provides a narrative name of the services provided. This information should be presented in a clear and concise manner. When possible, the narratives from the HCPCS/CPT book should be utilized.

item/service description

You are excited about the functionality of your firm's new EHR. Which of the following is an example of that functionality?

its electronic communications

What microform should the HIM practitioner select if the records must be unitized and color-coded for filing purposes?

jacket microfilm

Portal hypertension can contribute to all of the following EXCEPT

kidney failure.

Rheumatoid arthritis typically affects the

knees and small joints of the hands and feet.

You have been asked to give an example of a clinical information system. Which one of the following would you cite?

laboratory information system

To enter the results of a CBC into the computer system, you would use a(n)

laboratory system

The least invasive restrictive gastric surgery used to reduce the size of the stomach to facilitate weight loss in obese patients is

laparoscopic gastric banding

Blindness due to an allergic reaction to ampicillin administered six years ago would be reported as a(n)

late effect of an adverse reaction

Which of the following features should NOT be considered when designing screens to capture quality health data?

left to right and bottom to top formatting

In systemic circulation, which of the following vessels carries oxygenated blood?

left ventricle

As Director of Health information Services, you are negotiating a contract to purchase a new computerized dictation system that will be used across three satellite ambulatory clinics. What element is most critical in the contract negotiation to ensure use of the software in multiple environments?

license grant

Under Medicare, a beneficiary has lifetime reserve days. All of the following statements are true, EXCEPT

lifetime reserve days are paid under Medicare Part B.

Which of the following is NOT a data retrieval tool?

light pen

The hypothalamus and the thalamus are part of the

limbic system.

The drug commonly used to treat bipolar mood swings is

lithium carbonate.

The _____ is the largest solid organ of the body, but the ____ is the largest organ overall.

liver, skin

LCDs and NCDs are review policies that describe the circumstances of coverage for various types of medical treatment. They advise physicians which services Medicare considers reasonable and necessary and may indicate the need for an advance beneficiary notice. They are developed by the Centers for Medicare and Medicaid Services (CMS) and Medicare Administrative Contractors. LCD and NCD are acronyms that stand for

local coverage determinations and national coverage determinations.

An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n)

logic-based encoder.

which of the following types of care is not covered by medicare?

long-term care

Fractures occur in patients with osteoporosis due to

loss of bone mass.

Which one of the following is NOT a pathophysiological factor in anemia?

loss of spleen function

Which of the following conditions is NOT a predisposing risk associated with essential hypertension?

low dietary sodium intake

The key diagnostic finding for typical pneumonia is

lung consolidation on CXR.

Many bacterial diseases are transmitted directly from person to person. Which of the diseases listed next is a bacterial disease transmitted by way of a tick vector?

lyme disease

A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?

magnetic degaussing

Which of the following is NOT a major management challenge in the storage and retention of electronic health record systems?

maintaining the paper-based storage system

In which gender is the urethra significantly longer?

males

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for

marking the surgical site.

Which of the following cells produce histamine in a type I hypersensitivity reaction?

mast cells

Which index is used by the HIM department to link the patient's name and number in relation to access and retention of the patient record?

master patient index

One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with

meaningful use requirements

One of the patients at you physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with

meaningful use requirements.

While in the hospital, an external, single read, EKG was performed on the patient. The root operation term used for this ICD-10-PCS code is:

measurement

Carpal tunnel syndrome is caused by entrapment of the

medial nerve.

Several recent studies suggest that this issue/condition is now the third leading cause of death in the United States, is responsible for at least 10% of all deaths in the United States, and is an underrecognized and therefore underreported cause of death in the United States. This issue/condition is

medical errors

The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is

medical necessity.

A system of preferred terminology for naming disease processes is known as a

medical nomenclature.

You want to review one document in you facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these records standards. Your best resource will be

medical staff rules and regulations.

the form in the acute care patient record which documents the data,time, name or drug, dose and route by which the drug is given in the:

medication sheet

The prevention of illness through vaccination occurs due to the formation of

memory cells.

A 19-year-old college student, who lives on campus in a dormitory, is brought to the ER by his roommates, complaining of a severe headache, nuchal rigidity, fever, and photophobia. The ER physician performs an LP and orders a CSF analysis with a bacterial culture and sensitivity. The young man is admitted to the ICU with a provisional diagnosis of

meningitis due to Neisseria meningitidis-positive cerebrospinal fluid.

Photophobia or visual aura preceding a severe headache is characteristic of

migraines

Your facility has implemented the clinical systems needed to support the EHR. The knowledgebased and decision support systems will be installed next. Your team has a firm plan to indicate the direction you should take and the expected timeframe. This called a

migration path

Cervical cerclage is a procedure used to help prevent

miscarriage

Color coding of record folders is used to assist in the control of

misfiles

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represents the most serious pattern of delinquencies? Fifteen percent of delinquent records show

missing operative reports.

Which valve is between the left atrium and left ventricle?

mitral

In the Radiation Section of ICD-10-PCS, the third character position represents which of the following?

modality

A standard surgical procedure used for the treatment of early-stage breast cancer involves the removal of the cancerous tumor, skin, breast tissue, areola, nipple, and most of the axillary lymph nodes but leaves the underlying chest muscles intact. This procedure is termed a(n)

modified radical mastectomy.

According to CPT, antepartum care includes all of the following except:

monthly visits up to 36 weeks

Fetal monitoring strips are part of the _____ record and should be maintained _____.

mother's; according to the length of time required for a minor's records

Which of the following autoimmune diseases affects tissues of the nervous system?

myasthenia gravis

Which of the following is a congenital condition that is the most severe neural tube defect?

myelomeningocele

Which of the following procedures is typically performed on children to facilitate the drainage of serous exudate behind the tympanic membrane in chronic otitis media?

myringotomy with tympanostomy tubes

The Unified Medical Language System (UMLS) is a project sponsored by the:

national library of medicine

Which application design is used in a computer-assisted coding (CAC)

natural language processing

In creating a new form or computer view, the designer should be most driven by

needs of the users.

Still referring to the information in the table in question 88 and the delinquent record rate shown in the answer for question 89, would the facility be out of compliance with Joint Commission standards?

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates

noncompliance with Joint Commission standards.

Under Medicare Part B, all of the following statements are true and are applicable to nonparticipating physician providers, EXCEPT

nonparticipating providers have a higher fee schedule than that for participating providers.

The steps in developing a record retention program include all but which of the following?

notifying the courts of destruction

The span of control in an organization refers to the

number of people who report to one supervisor.

The best example of point-of-care service and documentation is

nurses using bedside terminals to record vital signs.

The database being implemented must be able to store video, images, and audio. Which of the following database models should be considered?

object oriented

Ligation right fallopian tube

occlusion

One of the major functions of the cancer registry is to assure that patients receive regular and continued observation and management. How long should patient follow-up be continued?

of the life of the patient

what agency oversees the investigation of cases under the false claims act?

office of inspector general

Which of the following relationships does the diagram above demonstrate?

one to one

The MS-DRG (Medicare Severity-Diagnosis Related Group) system was designed to pay:

only one amount (group) of reimbursement per hospitalization

A surgical procedure that is performed to realign and stabilize a fractured femur with a rod and screws is referred to as a(n)

open reduction with internal fixation

The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the health information manager look for this information?

operation index

You have been asked by a peer review committee to print a list of the medical record numbers of all patients who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information?

operation index

"With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin and used for administration of drugs during resuscitation."

operative record

With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin and used for administration of drugs during resuscitation.

operative record

The best place to ascertain the size of an excised lesion for accurate CPT coding is the

operative report.

APCs are groups of services that the OPPS will reimburse. Which one of the following services is not included in APCs?

organ transplantation

The director of a Health Information Department prepared a tool in which the following information could be obtained: job title, reporting line, span of control, and routes of promotion. The document she prepared is a(n)

organizational chart.

The HIM director is not satisfied with performance improvement results of the department. In order for the staff to truly accept the change that has been set into motion, the director must influence the core values and beliefs that are shared by the members of her staff. Which of the following terms is this scenario referring to?

organizational culture

A radiological test for bone mineral density (BMD) is a useful diagnostic tool for diagnosing

osteoporosis

A stapedectomy is a common treatment for

otosclerosis

Which of the following is NOT an alternative storage method for paper-based records?

outguide

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