RHIA Exam Prep
A patient has HIV with disseminated candidiasis. What is the correct code assignment? ------------------------------- B20 Human immunodeficiency virsus [HIV] disease B37.0 Candidal stomatitis Oral thrush B37.7 Candidal sepsis, Disseminated candidiasis, Systemic candidiasis B37.89 Other sites of candidiasis, Candidal osteomyelitis ------------------------------- a. B20, B37.0 b. B37.7, B20 c. B20, B37.7 d. B20, B37.89, B37.7
B20, B37.7 Patients who are admitted for an HIV-relat3ed illness should be assigned a minimum of two codes in the following order: code B20 to identify the HIV disease and additional codes to identify the related diagnosis, which in tis case is disseminated candidiasis code B37.7 (Schraffenberger and Pakie 2019, 126)
The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following? a. Authorship b. Validation c. Integrity d. Identification
a. Authorship Authorship is the origination or creation of recorded information attributed to a specific individual or entity acting at a particular time. In other words, documentation in the EHR or other health record must be credited to the individual who created it. This is typically done through the use of a unique user identifier and a password (Sayles and Kavanaugh-Burke 2018, 23).
To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual
a. Digital The digital signature is similar to the electronic signature except that it uses encryption to provide nonrepudiation to prove the authenticator's identity, which makes it most secure (Sayles and Kavanaugh-Burke 2018, 159).
A computer software program that supports a coder in assigning correct codes is called a(n): a. Encoder b. Grouper c. Automated coder d. Decision support system
a. Encoder An encoder is used to increase the accuracy and efficiency of the coding process. Encoders promote accuracy as well as consistency in the coding of diagnoses and procedures (Amatayakul 2017, 292).
ow do healthcare providers use the administrative data they collect? a. For regulatory, operational, and financial purposes b. For statistical data purposes c. For electronic health record tracking purposes d. For continuity of patient care purposes
a. For regulatory, operational, and financial purposes There are many types of patient-identifiable data elements that are pulled from the patient's healthcare record that are not included in the legal health record or designated record set definitions. Administrative data and derived data and documents are two examples of patientidentifiable data that are used in the healthcare organization. Administrative data are patientidentifiable data used for administrative, regulatory, healthcare operation, and payment (financial) purposes (Fahrenholz 2017a, 56).
What are LOINC codes used for? a. Identifying test results b. Reporting test results c. Identifying tests unique to a specific company d. Reporting a code for reimbursement
a. Identifying test results Logical Observation Identifiers, Names and Codes (LOINC) is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results (Palkie 2016a, 155).
A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? -------------------------------- I97.191 Other postprocedural cardiac functional disturbances following other surgery K43.9 Ventral hernia without obstruction or gangrene R00.1 Bradycardia, unspecified Z53.09 Procedure and treatment not carried out because of other contraindication -------------------------------- Section: Medical & Surgical: 0 Body System: Anatomical Regions, General: W Root Operation: Repair: Q Body Part: Abdominal Wall: F Approach: Open: 0 Device: No Device: Z Qualifier: No Qualifier: Z --------------------------------- Section: Medical & Surgical: 0 Body System: Anatomical Regions, General: W Root Operation: Inspection: J Body Part: Peritoneal Cavity: G Approach: Open: 0 Device: No Device: Z Qualifier: No Qualifier: Z ---------------------------------- a. K43.9, R00.1, Z53.09, 0WJG0ZZ b. K43.9, I97.191, R00.1, 0WJG0ZZ c. K43.9, 0WQF0ZZ d. K43.9, Z53.09, 0WQF0ZZ
a. K43.9, R00.1, Z53.09, 0WJG0ZZ The repair of the hernia is not coded because it was not performed; however, code 0WJG0ZZ is assigned to describe the extent of the procedure, inspection of the peritoneal cavity based on ICD-10-PCS Guideline B3.3. The Z53.09 is also used to indicate the canceled procedure due to the contraindication. The code R00.1 is also added for the bradycardia that the patient developed during the procedure (Kuehn and Jorwic 2019, 41-42; Schraffenberger and Palkie 2019, 689).
Data content standards are used to: a. Share data in the same way the users interpret data b. Share data is a unique way c. Share data between disparate systems d. Modify data
a. Share data in the same way the users interpret data Data standards allow us to share data in a uniform way. Data standards include data content standards and data exchange standards. Data content standards are clear guidelines for the acceptable values for specified data fields. The use of data content standards make it possible to share information so that users are able to interpret data in the same way (Sayles and Kavanaugh-Burke 2018, 31).
Secondary data sources provide information that is ___________ available by looking at individual health records. a. not easily b. easily c. often d. never
a. not easily Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2017c, 128).
A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? ________________________________________ A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus A41.89 Other specified sepsis A41.9 Sepsis, unspecified organism B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding R10.9 Unspecified abdominal pain ------------------------------ a. A41.89, K57.32, R10.9 b. A41.01, K57.32 c. A41.89, K57.32, B95.61 d. A41.9, K57.32
b. A41.01, K57.32 Sepsis is a serious medical condition caused by the body's immune response to an infection. Code A41.01 is for sepsis with methicillin-susceptible Staphylococcus aureus. Because abdominal pain is a symptom of diverticulitis, only the diverticulitis of the colon is coded (Schraffenberger and Palkie 2019, 43, 119).
A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is the correct root operation? a. Destruction b. Extirpation c. Fragmentation d. Release
b. Extirpation The correct root operation is extirpation—taking or cutting out solid matter from a body part. The earlier lithotripsy would have been fragmentation but was not successful in removing the calculus (Kuehn and Jorwic 2019, 85-86).
Regardless of the healthcare setting, accreditation and regulatory standards require a separate healthcare record for each: a. Family b. Individual patient c. Encounter with the facility d. Day of treatment
b. Individual patient Regardless of the healthcare setting, healthcare organizations must meet regulatory and accreditation standards when collecting and storing health information. These standards require a separate health record for each individual patient and address minimum documentation requirements to ensure that these records provide for continuity of patient care among providers (Fahrenholz 2017a, 43).
Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete
b. It provides greater detail Unstructured data is often preferred over structured data because it enables providers to document details and nuance that are usually not available with structured data (Biedermann and Dolezel 2017, 159).
The name of the government agency that has led the development of basic data sets for health records and computer databases is: a. The Centers for Medicare and Medicaid Services b. The National Committee on Vital and Health Statistics c. The American National Standards Institute d. The National Institute of Health
b. The National Committee on Vital and Health Statistics The National Committee on Vital and Health Statistics (NCVHS) has developed the initial efforts toward creating standardized data sets for use in different types of healthcare settings, including acute care, ambulatory care, long-term care, and home care (Fahrenholz 2017a, 62).
It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. a. training sessions b. policies and procedures c. verbally communicated instructions d. a supervisory committee
b. policies and procedures When erroneous entries are made in health records, policies and procedures should have provisions for how corrections are made. Educating clinicians who are authorized to document in the health record on the appropriate way to make corrections will promote consistency and standardization and maintain the integrity of the health record (Jenkins 2017, 161).
Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee co-chaired by representatives from the NCHS and: a. AMA b. OIG c. CMS d. WHO
c. CMS The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Coordination and Maintenance (C&M) Committee is chaired by a representative from the NCHS and a representative from CMS. The committee is responsible for maintaining the United States' clinical modification version of the ICD-10-CM/PCS code sets. The C&M Committee holds two open meetings each year that serve as a public forum for discussing (but not making decisions about) proposed revisions to ICD-10-CM/PCS (Schraffenberger and Palkie 2019, 6). 167 Correct16 Wrong7 Unanswered0 Regi
This functionality can result in confusion from incessant repetition of irrelevant clinical data. a. Change b. Amendment c. Copy and paste d. Deletion
c. Copy and paste The technology used to support the EHR can provide many enhancements over the paper record. Technology also presents the potential for weakening the integrity of the information. One such risk occurs with the copy-and-paste forward functionality present in many operating systems and software programs (Biedermann and Dolezel 2017, 449).
A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code for professional fee reporting? a. -79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period b. -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service c. -59, Distinct procedural service d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period
d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period Modifier -24 is used for unrelated evaluation and management service by the same physician, or other qualified healthcare professional, during a postoperative period (Kuehn 2019, 55).
Which of the following processes is an ancillary function of the health record? a. Admitting and registration information b. Billing and reimbursement c. Patient assessment and care planning d. Biomedical research
d. Biomedical research Biomedical research is considered an ancillary function of the health record (Fahrenholz 2017b, 81-82).
Which of the following is not an appropriate method for destroying paper-based health records? a. Burning b. Shredding c. Pulverizing d. Degaussing
d. Degaussing Because of cost and space limitations, permanently storing paper-based health record documents is not an option for most hospitals. The destruction of patient-identifiable clinical documentation should be carried out in accordance with relevant federal and state regulations and organizational policy. Paper documents can be destroyed by pulverizing, pulping, burning, or shredding as these are acceptable forms of destruction for that medium. Degaussing is an acceptable form of destruction of electronic documents (Fahrenholz 2017b, 107).
Which of the following is the appropriate method for destroying *electronic* data? a. Burning b. Shredding c. Pulverizing d. Degaussing
d. Degaussing The destruction of patient-identifiable clinical documentation should be carried out in accordance with relevant federal and state regulations and organizational policy. Electronic data can be destroyed with magnetic degaussing (demagnetizing) as this is an acceptable destruction methods for paper-based records (Fahrenholz 2017b, 107)
A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? ---------------------------------- E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.8 Type 1 diabetes mellitus with unspecified complications I96 Gangrene, not elsewhere classified --------------------------------- a. E08.52, I96 b. E10.52, I96 c. E10.8 d. E10.52
d. E10.52 The ICD-10-CM index entry for Diabetes, type 1, with gangrene provides E10.52 as the correct code, so the peripheral angiopathy is presumed when gangrene is present (Schraffenberger and Palkie 2019, 43).
A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? a. Outpatient b. Emergency room c. Physician office d. Inpatient
d. Inpatient If the diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "still to be ruled out," or other similar terms indicating uncertainty, code the condition as if it existed or was established for inpatient records (Schraffenberger and Palkie 2019, 98).