AHIMA CCA: Exam

ICD-9-CM are the __________ the patient saw the provider.

"why" - The ICD-9-CM code(s) placed onto a healtcare claim specifically describe the reason(s) the individual has come to see the health care provider on a given day. As a coder, you are only concerned with the diagnosis as determined by the health care provider. The patient's chief complaint is usually a key element in properly coding this explanation.

If a patient's total outpatient bill is $500.00 and the patient's healthcare insurance plan pays 80% of the allowable charges, what is the amount the patient is responsible for?

$100.00 to the patient

50. What was the goal of the MS-DRG system? a. To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients. b. To improve Medicare's capability to recognize poor quality of care and pay hospitals on an incentive grid that allows hospitals to be paid by performance. c. To improve Medicare's capability to recognize groups of data by patient populations, which will further allow Medicare to adjust the hospitals wage indexes based on the data. This adjustment will be a system to pay hospitals fairly across all geographic locations. d. To improve Medicare's capability to recognize practice patterns among hospitals that are inappropriately optimizing payments by keeping patients in the hospital longer than the median length of stay.

**Correct Answer: A For fiscal year 2008, Medicare adopted a severity-adjusted diagnosis-related groups system called Medicare Severity-DRGs (MS-DRGs). This was the most drastic revision to the DRG system in 24 years. The goal of the new MS-DRG system was to significantly improve Medicare's ability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to the sicker patients and decrease payments for treating less severely ill patients (Schraffenberger 2012, 471-473).

18. A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Postoperative infection b. Appendicitis c. COPD d. Hypertension

**Correct Answer: A Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2011c, 97).

44. Which answer FAILS to provide a requirement for assignment of the MS-DRG? a. Diagnoses and procedures (principal and secondary) b. Attending and consulting physicians c. Presence of major or other complications and comorbidities (MCC or CC) d. Discharge disposition or status

**Correct Answer: B Attending and consulting physicians have no bearing on the assignment of the MS-DRG and payment to the hospital (Schraffenberger 2012, 471-473).

98. HIPAA regulations: a. Never preempt state statutes b. Always preempt state statutes c. Preempt less-strict state statutes where they exist d. Preempt stricter state statutes where they exist

**Correct Answer: C HIPAA regulations preempt less strict state statutes where they exist (Johns 2011, 820).

CPT Modifiers (listed)

-24: Unrelated Evaluation & Management Service Same Dr -25: Significant Separate E&M Service -57: Decision for Surgery -22: Increased Procedural Service -52: Reduced Services -53: Discontinued Procedure -73: Discontinued Prior to Anesthesia -74: Discontinued After Anesthesia -54: Surgical Care Only -55 Postoperative Management -56: Preoperative Management -50: Bilateral -59: Distinct Procedural Service -62: Two Surgeons

Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician setting use with the E&M [Evaluation and Management] code?

-24: Unrelated evaluation and management service by the same physician during a postoperative period. NOTE: -79: Unrelated procedure or service by the same physician during the postoperative period... would NOT be used as the question made mention of E&M, not service or procedure.

Identify the 2-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure.

-55: postoperative management only {Modifiers are appended to code the provide more information to alert the payer that payment change is required.

Name the 4 Cooperating Parties for ICD-9-CM

1) AHIMA, 2) AHA-American Hospital Association, 3) CMS-Centers for Medicare and Medicaid, and 4) NCHS-National Center for Health Statistics

What are the 4 reimbursement methods used by OPPS?

1) APC, 2) Fee Schedule, 3) Reasonable Cost, and 4) Average sale of price of Drugs

What are the 3 components of the structure of payment to physicians?

1) RVU (relative value unit-to measure resource) Each RVU has 3 elements (physician work (WORK), physician practice expense (PE), malpractice (MP). Each is adjusted to the local costs. WORK has aspects of intensity (mental, technical, physical effort, stress). PE costs are overhead. 2) geographic adjustment (GPCI-geographic practice cost indexes) 3) CF (conversion factor) which is a constant that applies to the entire RVU.

What are the 4 setting of PAC (Post Acute Care)?

1) SNF- skilled nursing facility, 2) LTCH-long term care hospital, 3) IRF-inpatient rehabilitation facility, 4) HHA-home health agency. EACH PAC has a PPS.

What are the 2 major types of coding edits with respect to NCCI (The National Correct Coding Initiative)?

1) the comprehensive/component edit [pertains to HCPCS codes that should not be used together] and 2) the mutually exclusive edit [applies to improbable or impossible combinations of codes]

What are the required data items of UHDDS?

1- Principal Diagnosis 2- Other Diagnoses that have a significance for the specific hospital episode 3- All significant procedures 4- Age, Sex, Race of patient 5- Expected Payer 5- Hospital's Identification

State the criteria of a "Significant Procedure".

1- Surgical in Nature, 2-Carries a procedural risk, 3- Carries an anesthetic risk, 4- Requires specialized training

Coding Neoplasms:

1-read all notes in table that apply 2-never assign a code form the table 3-report only codes for current status of neoplasm 4-assign a neoplasm code if the tumor has been excised and patient is STILL undergoing radiation or chemo 5-assign a V-Code if the tumor is NO LONGER present OR patient is not receiving treatment only follow-up care 6-the classification documented on a pathology report ovverides the morpholoby classification entry in the Index to Diseases

Burns

1st Degree - erythema 2nd Degree - blistering 3rd Degree - full thickness involvement Extent - percentage of body surface involved Agent - chemical, fire, sun - Assigned an E Code Highest Degree is coded first when more than one burn is present.

To comply with HIPAA, under usual circumstances, a covered entity, must act on a patient's request to review or copy his/her health information with _______ days.

30 days

Patient in the ER for chest pain. Evaluation reveals suspicion of GERD [gastroesophageal reflux disease]. Final diagnosis was "Rule out chest pain versus GERD". What is correct ICD-9-CM code?

786.50, Chest pain NOS: The condition should be coded to the highest degree of certainty - such as the sign or symptom the patient exhibits. In the outpatient setting, the condition [here-GERD] in the statement should NOT BE CODED AS IF it existed. Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "rule out" or other similar terms indicating uncertainty.

What is the electronic format for hospital technical fees?

837I. Effective 10/16/2003, under the Administrative Simplification Compliance section of HIPAA [Health Insurance Portability and Accountability Act of 1996], all healthcare providers must electronically submit claims to Medicare. 837I is for hospitals. 837P is for professional claims. UB-04 are for hospital (technical) claims and 1500 is for clinic (professional) claims.

Which system reimburses hospitals a predetermined amount for each Medicare inpatient admission? A) APR-DRG, B) DRG, C) APC, or D) RUG

A DRG is a predetermined amount of reimbursement for each Medicare inpatient.

What is a combination code?

A combination code is a single code that is used to classify. A) 2 diagnoses or procedures, B) a diagnosis with an associated 2nday process (manifestation), or C) a diagnosis with an associated complication. Example: 574.00 is a combination code: acute cholecystitis and cholelithiasis - 574.0 includes both conditions.

Please define "complication".

A complication is a secondary condition that arises during hospitalization and is thought to increase the LOS-Length of Stay by at least one day for approximately 75% of patients.

What is block grant?

A fixed amount of money given or allocated for a specific purpose, such as a transfer of governmental funds to cover health services.

Which type of patient care record includes documentation of a family bereavement period?

A hospice record.

What is a late effect?

A late effect is the residual condition (long-term condition) that develops after the acute phase of an illness or injury has ended. There is NO TIME LIMIT on when a late effect can be reported.

Describe the NCCI (National Correct Coding Initiative):

A list of coding edits has been developed by CMS in a effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services. NCCI helps CMS to detect inappropriate codes submitted on claims. NCCI edits are included in most encoding computer software packages.

An encoder that takes a coder through a series of questions and choices is called:

A logic-based encoder: prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition and any possible complications or co-morbidities.

Define Capitated Payment/Capitation:

A method of payment for health services in which the 3rd Party Payer reimburses providers a FIXED, per capita (per head/per person) amount. A common phrase is PMPM - per member per month. Capitation is characteristic of HMOs.

Common errors that delay, rather than prevent payment, include all of the following EXCEPT? A) patient name or certificate number, B) Claims out of sequence, C) Illogical demographic data, or D) Inaccurate or deleted codes

A patient name or certificate number is required for filing claims.

Which of the following is NOT an essential data element for a healthcare insurance claim? A) revenue code, B) procedure code, C) Provider name, or D) Procedure name

A procedure name is not a required element on an insurance claim.

What is the AHA Coding Clinic for ICD-9-CM?

A publication issued quarterly by the AHA and approved by CMS to give coding advice and direction for ICD-9-CM.

Which statement is NOT reflective of meeting medical necessity requirements? A) A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease, B) A service or supply provided that is not experimental, investigational, or cosmetic in purpose, C) A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms, or D) A service provided solely for the convenience of the insured, the insured's family, or the provider.

A service provided solely for the convenience of the insured, the insured's family, or the provider.

Patient is admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. Patient was subsequently discharged with a principal diagnosis of cerebral vascular accident and secondary diagnosis of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should NOT be tagged as POA? A) catheter-associated UTI, B) CVA, C) COPD, or D-Hypertension

A) Catheter-Associated UTI: POA-Present on Admission is defined as present at the time the order for inpatient admission occurs. [All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to law or regulation mandating collection of present on admission information.] Conditions that develop during an outpatient encounter, including the ER Department, observation, or outpatient surgery, are considered POA. Any condition that occurs after admission is NOT considered a POA condition.

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? A) prospectively pre-certify the necessity of inpatient services, B) Determine what services can be bundled, C) pay only 80% of the inpatient bill, or D) require the patient to pay 20% of the inpatient bill

A) Pre-certify - managed FFS reimbursement is similar to traditional FFS reimbursement except that managed FFS care plans control costs primarily by managing their members' use of healthcare services.

Which of the following is an example of clinical data? A) Admitting diagnosis, B) Date and time of admission, C) Insurance information, or D) Health record number

A-Admitting Diagnosis: clinical data document the patient's medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided.

A record of all transcations in the computer system that is maintained and reviewed for unauthorized access is called: A) Audit Trail, B) security breach, C) unauthorized access, or D) privacy trail

A-Audit Trail

With regard to training in PHI policies and procedures, the following statement is TRUE: A) every member of the covered entity's workforce must be trained, B) only individuals employed by the covered entity must be trained, C) training only need to occur when there are material changes to the policies and procedures, or D) documentation of training is not required

A-Every member of the covered entity's workforce must be trained.

Which of the following laws created the Healthcare Integrity and Protection Data Bank? A) HIPAA, B) American Recovery and Reinvestment Act, C) Consolidate Omnibus Budget Reconciliation Act, or D) Healthcare Quality Improvement Act

A-HIPAA

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in what type of specialty record? A) Home Health, B) Behavioral Health, C) End Stage renal disease, or D) Rehabilitative Care

A-Home health

Data definition refers to: A) Meaning of Data, B) Completeness of Data, C) Consistency of Data, or D) Detail of Data

A-Meaning of Data: Data Definition means that the data and information documented in the health record are defined; users of the data must understand what the data means and represents

Exceptions to the consent requirement include: A) Medical Emergencies, B) Provider Discretion, C) Implied Consent, or D) Informed Consent

A-Medical Emergencies: the law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or a minor

In a joint effort of the DHHS (Department of Health and Human Services), OIG (Office of Inspector General), CMS (Centers for Medicare and Medicaid Services, and AOA (Administration on Aging, which program was released in 1995 to target fraud and abuse among healthcare providers? A) Operation Restore Trust, B) Medicare Integrity Program, C) Tax Equity and Fiscal Responsibilty Act (TERFA), and D) Medicare and Medicaid Patient and Program Protection Act

A-Operation Restore Trust

What is the incentive to improve the quality of clinicial outcomes using the electronic health record that could result in additional reimbursement or eligibilty for grants or other subsidies to support further HIT efforts? A) Pay for performance and quality, B) Patient referrals, C) Payer of last resort, D) Performance evaluations

A-Pay for performance and quality

Reviewing the health record for missing signatures, missin medical reports, and ensuring that all document belong in the health record is an example of what type of review? A) Quantitative, B) Qualitative, C) Statistical, or D) Outcomes

A-Quantitative Analysis

A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to: A) Request restrictions on certain uses and disclosures of PHI, B) Remove their record from the facility, C) Deny provider changes to their PHI, or D) Delete portions of the record they think are incorrect

A-Request restrictions on certain uses and disclosures: HIPAA provides patients with rights that allow them to have some control over their health information: right of access, right to request amendment of PHI, right to acounting of disclosures, right to request restrictions of PHI, right to request confidential communications, and right to complain of Privacy Rule violations

The number that has bee proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is:

A-Social Security Number

Mary Smith, RHIA, has been charged with the responsibility of designing a data colelction form to be used on admission of a patient to the acute-care hospital in which she works. The first resource she sould use is: A) UHDDS, B) UACDS, C) MDS, or D) ORYX

A-UHDDS (Uniform Hospital Discharge Data Set) - In 1974 the federal government adopted UHDDS as the standard for collecting data for Medicare and Medicaid. The others are: UACDS: Uniform Ambulatory Care Data Set MDS: Minimum Data Set ORYX: performance measurement for healthcare organizations

The following is documented in the acute care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN." In which document would this appear: A) admission order, B) history, C) physical exam, or D) progress notes

A-admission order

Calling out patient names in a physician's office is: A) an incidental disclosure, B) not subject to the "minimum necessary" requirement, C) A disclosure for payment purposes, or D) a HIPAA violation

A-an incidental disclosure occurs as part of the permitted use of disclosure.

Good encoding software should include ______________ to ensure quality: A) edit checks, B) voice recognition, C) reimbursement techonology, or D) passwords

A-edit checks

Identify where the following information would be found in the acute-care record: "CBC: WBC: 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93." A) in the medical lab report, B) in the pathology report, C) in the physical examination, D) in the physicians orders

A-in the medical laboratory report

Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: A) performance-improvement programs, B) billing and claims data processing, C) developing hospital discharge abstracting systems, or D) developing individual care plans for residents

A-performance improvement programs HEDIS-Healthcare Effectiveness Data and Information Set (collects data to measure physician performance) ORYX-collects quality data for hospitals and long term care organizations

Which of the following contains the physician's findings based on an examination of the patient? A) physical examination, B) discharge summary, C) medical history, or D) patient instructions

A-physical examination report represents the attending physician's assessment of the patient's current health status

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 the POMR progress note would this notation be written? A) subjective, B) Objective, C) Assessment, or D) Plan

A-subjective: subjective information includes symptoms and actions reported by the patient and not observed or measured by the healthcare provider.

What are safety net providers?

AKA "Essential Community Providers" and "Providers of Last Resort". These are providers that deliver a significant level of healthcare services either by legal mandate or they adopted an open door policy and a substantal share of their patient mix is uninsured. (rural health clinics, public health department clinics, ER department of public hospitals)

What is included in ASC payment system?

ASC- Ambulatory Surgical Center payment system? End-stage renal disease payment system, safety net provider payments, and hospice services payment system

V Code Terms in the Alphabetic Index:

Absence, Admission for, Aftercare, Attention to, Encounter for, Fitting of, History of, Long-term, Resistance, Status (post), Carrier of, checkup, counseling, dialysis, donot, exposure, newborn, outcome of delivery, removal, vaccination, routine

What is the process that determines how a claim will be reimbursed based on the insurance benefit?

Adjudication is the process that determines reimbursement based on the member's benefits.

ASC

Ambulatory Surgery Center Payment Method ASC Group

What is ASC?

Ambulatory Surgical Center

What is a request for reconsideration of a denied claim for insurance coverage for healthcare services called?

An appeal

What does an encoder do for a coder?

An encoder takes a coder through a series of questions an choices called a logic based encoder. The logic based encoder prompts the user through a variety of questions and choices based on the terminology entered. The coder selects the most accurate colde for a service or condition (and any possible complications or comorbidities).

How is the total weight for each MS-DRG calculated?

An individual MS-DRG case mix can be figured by multiplying the relative weight of each MS-DRG by the #of discharges within that MS-DRG.

Which of the following actions would best to determine whether POA [present on admission] indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? A) Identify all records for a period having these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment B) Identify all records for a period that have these indicators for these conditions, C) Take a random sample of records for a period of time for records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.

Any secondary diagnoses assigned present on admission status will have a negative impact on reimbursement if no other code on the claim is assigned as a complication or co-morbidity or a major complication or co-morbidity.

CPT Appendix

Appendix A - Detailed description of each CPT Modifier Appendix B - Annual CPT Coding changes (added, deleted, revised) Appendix C - Clinical examples for Evaluation and Management Appendix D - Add-on Codes (+ symbol) Appendix E - Codes exempt from Modifier -51 reporting rules

Which statement is NOT one of the outcomes that can occur as part of auto-adjudication? [when clean claims are submitted, they can be adjudicated in many ways through computer software automatically]

Auto-Calculate. Claims that automatically process through computer software either auto-pay, auto-suspend, or auto-deny.

Which of the following statements is NOT true about a business associate agreement? A) It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity, B) It allows the business associate to maintain PHI indefinitely, C) It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule, or D) It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the DHHS (Dept of Health & Human Services) or its agents

B

Which of the following statements is false? A) A notice of privacy practices must be written in plan language, B) Consent for use and disclosure of information must be obtained from every patient, C) An authorization does not have to be obtained for uses and disclosures for treatment, payment and operations, D) A notice of privacy must give an example of a use or disclosure for healthcare operations.

B) Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personally identifiable information for treatment, payment or healthcare operations.

Under the Medicare hospital outpatient perspective payment system (OPPS), services are paid according to: A) fee for service schedule basis that varies according to the MPFS, B) a rate per service basis that varies according to the APC (Ambulatory Payment Classification) group to which the service is assigned C) A cost to charge ratio based on the hospital cost report, or D) a rate pre service basis that varies according to the DRG group

B) a rate per service basis that varies according to the APC

One form of _________________ uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals. A) Integrated workflow processes, B) Computer-Assisted Coding, C) Electronic Document management syste, or D) Speech recognition system

B-Computer Assisted Coding (CAC)

The HIM department is planning to scan nonelectronic 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 of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization? A) Ad hoc, B) Concurrent, C) Retrospective, D) Post discharge

B-Concurrent review occurs on a continuing basis during a patient's stay

What is the legal term used to define the protection of health information in a patient-provider relationship? A) Access, B) Confidentiality, C) Privacy, or D) Security

B-Confidentiality: is a legal ethical concept that establishes the healthcare provider's responsibility for protecting the health records and other personal and private information from unauthorized use or disclosure.

The following is documented in an acute-care record:"I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which document would this appear: A) Admission note, B) Consultation Report, C) Discharge Summary, or D) Nursing Progress Notes

B-Consultation Report

Which of the following is NOT an element of data quality? A) Accessibility, B) Data Backup, C) Precision, or D) Relevancy

B-Data Backup/Data Quality includes the following characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness

The protection measures and tools for safeguarding information and information systems is a definition of: A) Confidentiality, B) Data Security, C) Information privacy or D) Informational access control

B-Data Security

The admitting data of Mrs. White's health record indicated that her birthdate was March 21, 1948. On the discharge summary, her birthdate was recorded as July 21, 1948. Which quality element is missing from Mrs. White's health record? A) Data completeness, B) Data consistency, C) Data accessibility, or D) Data comprehensiveness

B-Data consistency

Deidentified information: A) does identify an individual, B) Is information from which personal characteristics have been stripped, C) Can be later constituted or combined to re-identify an individual, or D) Pertains to a person that is identified within the information

B-De-identified information is information from which personal characteristics have been stripped (doesn't identify the person)

A transition technology used by many hospitals to increase access to medical record content is: A) EHR-Electronic Health Record, B) EDMS-Electronic Document Mangagement System, C) ESA-Electronic Signature Authentication, or D) PACS (Picture Archving and Communication System

B-EDMS-Electronic Document Management System For hospitals that do not have all EHR components, the result is a hybrid record that is part electronic and part paper. Some hospitals overcome hybrid record issues by scanning all paper documents into an EDMS, thereby making everything available online.

This system will require the author to sign onto the system using a user ID and Password to complete the entries made: A) Digitial Dictation, B) Electronic Signature Authentication, C) Single Sign on Technology, or D) Clinical Data Respository

B-Electronic Signature Authentication system requires the AUTHOR to sign onto the system using a USER ID and Password, review the document to be signed, and indicate approval.

A HIT (Health Information Technician) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and porcedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? A) Compliance program education and training programs for all employees in the organization, B) Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation, C) Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted, or D) Establish a corporate compliance committee who report directly to the CFO

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

An encoder that is built using system techniques such as reul-based systems is a: A) encoder interface, B) logic based encoder, C) automated code book encoder, or D) grouper

B-Logic Based Encoder

One form of __________________ computer-assisted coding (CAC) may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation. A) Encoded Vocabulary, B) natural-language processing, C) Data exchange standards, or D) structured reports

B-Natural language processing (NLP) is an artifical intelligence software that reads digital text from online documents and suggests codes to match the documents

What is the program that was unveiled in 1998 by the OIG that encourages healthcare providers to report fradulent conduct affecting Medicare, Medicaid and other federal healthcare programs? A) WHO-World Health Organization, B) Voluntary Disclosure Program, C) Compliance Disclosure Program, or D) Fraud and Abuse Program

B-Voluntary Disclosure Program

The term "minimum necessary" means that healthcare providers and other covered entities must limt use, access, and disclosure to the minimum necessary to: A) satify one's curiosity, B) accomplish the intended purpose, C) treat an individual, or D) perform research

B-accomplish the intended purpose: The Privacy Rule introduced the standard of minimum necessary to limit the amount of PHI (Protected Health Information) used, disclosed, and requested. This mean that healthcare providers and other covered entities must limut uses, disclosures, and requests to only the amount needed to accomplish the intended purposes.

Data Security refers to: A) guaranteeing privacy, B) controlling access, C) using uniformed terminology, or D) transparency

B-controlling access

Which of the following make data entry easier by may harm data quality? A) use of templates, B) copy and paste, C) drop-down boxes, or D) structured data

B-copy and paste

A threat to data security is: A) encryption, B) malware, C) audit trail, or D) data quality

B-malware

Which of the following represents documentation of the patient's current and past health status? A) physical examination, B) medical history, C) physicians orders, or D) patient consent

B-medical history

Notices of privacy practices must be available at the site where the individual is treated and: A) must be posted next to the entrance, B) must be posted in a prominent place where is it reasonable to expect that patients will read them, C) may be posted anywhere at the site, or D) do not have to posted at the site

B-must be posted in a prominent place where is it reasonable to expect that patients will read them

A notation for a diabetic patient in a physican progress note reads: "FBS 110mg%, urine sugar, no acetone". In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

B-objective: objective information is measured or observed by the healthcare provider

The following is documented in an acute care record: Microscopic: Sections are of squamous mucosa with no atypia." In which document would this appear? A) history, B) pathology report, C) physical examination, or D) operation report

B-pathology report

What is the primary use of the case-mix index? A) benchmark of ER room levels, B) Defines how a hosptial compares to peers and whether the facility is at risk, C) Audit of APCS and the comparison to same-size hospitals, or D) a tool for the coding manager to compare coder productivity

B-peer comparison or benchmarking helps a manager to know how his or her team has performed compared to peers.This includes whether the case-mix index level puts the facility at risk.

Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court? A) judicial decision, B) subpoena, C) credential, or D) regulation

B-subpoena

Organisms

Bacteria; Chlamydia; Fungi; Helminth (worm); Mycoplasmas; Protozoans; Rickettsias; Viruses

How is Anesthesia billed?

Base Units and Time Units with CF (conversion factor) for locality.

What is benchmarking?

Benchmarking is the process of comparing performance with a pre-established standard or performance of another facility or group.

Common forms of fraud and abuse include all of the following except: A) Upcoding, B) Unbundling or "exlploding" charges, C) Refiling Claims after denials, or D) Billing for services not furnished to patients

C) Refiling claims after denial is not possible becuase denied claims must be appealed and is not a factor in controlling fraud and abuse

Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion. A) in the anesthesia report, B) in the physician progess notes, C) in the operative report, or D) in the recovery room record

C- in the operative report

Which of the following tasks may NOT be performed in an electronic health record system? A) Document Imaging, B) Analysis, C) Assembly, or D) Indexing

C-Assembly In an EHR, reports are indexed, similar to filing in the paper record, and ensure that the documents are placed in the correct location with the correct record. Record analysis and completion is done via computer. Document imaging converts paper documents into digitized electronic versions.

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missin from the progress notes? A) Data Completeness, B) Data relevancy, C) Data currency, or D) Data precision

C-Data Currency: timeliness - should be recorded near or at the time of the event

The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deivation, left bundle branch block." In which document would this appear? A) Admission order, B) Clinical laboratory report, C) ECG report, or D) Radiology Report

C-ECG report

Computer software programs that assist in the assignment of codes used with diagnostic and procedureal classifications are called: A) natual language processing systems, B) montoring/audit programs, C) encoders, D) concept, description, and relationship tables

C-Encoders

Written or Spoken permission to proceed with care is classified as: A) An Advance Directive, B) Formal Consent, C) Expressed Consent, or D) Implied Consent

C-Expressed Consent (can be written or spoken)

Which of the following is NOT a component of most patient records? A) Patient identification, B) Clinical history, C) Financial Information, or D) Test results

C-Financial Information

Which of the following is a true statement about data stewardship? A) HIM Professionals are not qualified to address data stewardship, B) Data stewardship addresses the needs of the healthcare organization but not the patient, C) HIM professionals have worked with many data stewardship issues for years, or D) Data stewardship does not include privacy issues

C-HIM professionals have worked with many data stewardship issues for years

Which of the following materials is NOT documented in and Emergency Care Record? A) Patient's instruction as discharge, B) time and means of the patient's arrival, C) patient's complete medical history, or D) emergency care administered before arrival at the facility

C-Patient's complete medical history. The emergency care record includes a pertinent history of the illness or injury and physical findings.

Which of the following is NOT true of notices of privacy practices? A) they must be made available at the site where the individual is treated, B) they must be posted in a prominent place, C) they must contain content that may not be changed, or D) they must be prominently posted on the covered entity's website when the entity has one

C-The Notice Of Privacy includes a statment that reserves the right to change the terms of its notice and make the new provisions effective for all PHI that is maintains.

The key data element for linking data about an individual who is seen in a variety of care setting is the: A) facility medical record number, B) facility identification number, C) unique patient identifier, or D) patient date of birth

C-Unique patient identifer which a unique number assigned by a healtcare provider to a patient that distinguishes the patient's medical record from all others

The practice of assigning a diagnosis or procedure code sprcifically for the purpose of obtaining a higher level of payment is called: A) billing, B) Unbundling, C) Upcoding, or D) Unnecessary Service

C-Upcoding

The HIPAA Privacy Rule: A) applies to certain states, B) applies only to healthcare providers operated by the federal government, C) applies nationally to healthcare providers, or D) serves to limt access to an individual's own health information

C-applies nationally to healthcare providers

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

C-assessment: Professional conclusions reached from evaluation of the subjective or objective information make up the assessment.

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? A) Require all coders to use this practice, B) Report the practice to the OIG, C) Counsel the coder and stop the practice immediately, or D) Put the coder or an unpaid leave of absence

C-counsel the coder and stop the practice immediately-perform training

The following is doucmented in an acure-care record: "38 weeks gestation, Apgars 8/9, 6#9.8oz, good cry." In which document would this appear? A) admission note, B) clinical laboratory, C) newborn record, D) physician order

C-newborn record

The following is documented in an acute-care record: "HEENT: Reveals the tympanic membrances, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest counds." In which of the following would this documentation appear? A) History, B) pathology report, C) physical examination, or D) Operation report

C-physical examination

What entity is responsible for updating the MS-DRG?

CMS

CPT Category I

CPT Category 1 Code that represents a procedure or service that is consistent with contemporary medical practice and is performed by many physicians in clinical practice in multiple locations. Category I is 6 Sections: Evaluation and Management Anesthesia Surgery Radiology Pathology and Laboratory Medicine

CPT Modifiers

CPT contain modifiers for use by physicians and other healthcare providers to give additional information needed to process a claim. Common reasons to use modifiers: 1) a service was increased or reduced, 2) only part of a service was performed, 3) a bilateral procedure was performed, 4) an unusual event occurred during a procedure or service. Modifiers also make note of LT-Left Side, RT-Right Side, E1-upper left eyelid, and F1-left hand, second digit

What is the standard terminology used to code medical procedures and services?

CPT is a comprehensive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services.

Under the OPPS (Outpatient Perspective Payment System), on which code set is the APC (Ambulatory Payment Classification) system primarily based for outpatient procedures and services including devices, drugs, and other covered items?

CPT/HCPCS (Healthcare Common Procedural Coding System)

Example of a late effect:

Can be apparent early - i.e. hemiparesis due to CVA, painful scar following a sever burn. OR it may occur months or years later: traumatic arthritis elbow due to prior fracture. The Residual Condition or Nature of the Late Effect is reported FIRST and The Late Effect is reported SECOND. Example:

Name examples of Episode of Care Reimbursement

Capitated Payment Global Payment Prospective Payment

Case Mix Index

Case Mix Index is an average of the sum of the RWs (relative weights) of all patients treated during a specific time period. It is a single number that compares the overall complexity of the healthcare organization's patients with the complexity of the average of all hospitals. Typically, CMI is for a specific period and is derived from the sum of all diagnosis-related group (DRG) weights, divided by the number of Medicare patients.

INPATIENT DISCHARGE SUMMARY DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10 DISCHARGE DIAGNOSIS: Acute pyelonephritis Septicemia, resistant to ampicillin and penicillin ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department. COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient's general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given Zovirax ointment. INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for Zyban to assist smoking cessation. ------------ H&P ADMITTED: 9/8 REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced difficulty about 3 days prior to admission. This was in the form of discomfort in the right side of the lower back and also some dysuria. On the evening of admission, she started experiencing some fever and chills and took some aspirin. This did not help her and she came to the emergency department. HISTORY OF PRESENT ILLNESS: PAST MEDICAL HISTORY: Remarkable only for "walking pneumonia" treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission. ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day. REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period. PHYSICAL EXAMINATION: On admission, significant for temperature of 103 degrees; pulse 120 beats per minute, regular; blood pressure 120/70; respirations 16 VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic. SKIN: Warm to touch HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal. NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter. LUNGS: Clear to auscultation and percussion BACK: Positive pain to palpation and percussion right costovertebral angle HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs. ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal. GENITALIA: Normal female RECTAL: Deferred EXTREMITIES: Femoral pulses normal, no edema NEUROLOGIC: Grossly intact LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable. IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia. PLAN: Hydrate and start IV antibiotics. ---------- PROGRESS NOTES DATE NOTE 9/8 Patient admitted for evaluation of flank pain and fever. She also has a lesion on her lip. This appears to be herpes simplex. Will treat infection process with antibiotics following obtaining cultures. The patient's renal function will be monitored. 9/10 The patient's fever decreasing. Patient comfortable and tolerating antibiotics. Will continue IVs. The importance of stopping cigarette use was discussed with the patient. She is willing to quit and she will be given a prescription for Zyban at discharge. 9/11 Patient is afebrile today. Will discharge when able to obtain transportation. --------- PHYSICIANS ORDERS DATE ORDER 9/8 Admit to floor for evaluation of febrile illness Urinalysis CBC and SMA 16 Urine culture and sensitivity Blood cultures ×2 Chest x-ray Pyelogram D5W 125 cc/h ×3 Strict input and output Zovirax ointment prn to lip Gentamicin 80 mg IV q. 8 H ×3d Cefoxitin 1 g IV q. 8 H ×3 days 9/9 D5W 100 cc/ph 9/10 Discharge patient when transportation is arranged Ciprofloxacin 500 mg p.o. b.i.d. ×12 days Zyban 150 mg p.o. daily ×3 days then b.i.d. Follow up in the office in 1 week. ------------- LAB REPORT HEMATOLOGY DATE: 9/8 Specimen Results Normal Values WBC 15.9 H 4.3-11.0 RBC 5.5 4.5-5.9 HGB 14.0 13.5-17.5 HCT 45 41-52 MCV 90 80-100 MCHC 41 31-57 PLT 251 150-450 CHEMISTRY DATE: 9/8 Specimen Results Normal Values GLUC 100 70-110 BUN 11 8-25 CREAT 1.0 0.5-1.5 NA 143 136-146 K 4.0 3.5-5.5 CL 98 95-110 CO2 30 24-32 CA 9.0 8.4-10.5 PHOS 3.0 2.5-4.4 MG 2.0 1.6-3.0 T BILI 1.0 0.2-1.2 D BILI 0.3 0.0-0.5 PROTEIN 7.0 6.0-8.0 ALBUMIN 5.2 5.0-5.5 AST 25 0-40 ALT 40 30-65 GGT 60 15-85 LD 100-190 ALK PHOS 50-136 URIC ACID 2.2-7.7 CHOL 0-200 TRIG 10-160 URINALYSIS DATE: 9/8 Test Result Ref Range SP GRAVITY 1.03 1.005-1.035 PH 6 5-7 PROT NEG NEG GLUC NEG NEG KETONES NEG NEG BILI NEG NEG BLOOD NEG NEG LEU EST POS NEG NITRATES POS NEG RED SUBS NEG NEG ------------- MICROBIOLOGY 9/10 AMPICILLIN R CEFAZOLIN S CEFOTAXIME S CEFTRIAXONE S CEFUROXIME S CEPHALOTHIN S CIPROFLOXACIN S ERYTHROMYCIN S GENTAMICIN S OXACILLIN S PENICILLIN R PIPERACILLIN TETRACYCLINE TOBRAMYCIN TRIMETH/SULF VANCOMYCIN S = SUSCEPTIBLE R = RESISTANT I = INTERMEDIATE M = MODERATELY SUSCEP ------------ LAB REPORT DATE: 9/11 URINE CULTURE: No growth for 24 hours --------------- MICROBIOLOGY DATE TEST TYPE: 9/8 Culture and Sensitivity #1 SOURCE: Blood SITE: GRAM STAIN RESULTS CULTURE RESULTS: E. coli SUSCEPTIBILITY: 9/10 AMPICILLIN R CEFAZOLIN S CEFOTAXIME S CEFTRIAXONE S CEFUROXIME S CEPHALOTHIN S CIPROFLOXACIN S ERYTHROMYCIN S GENTAMICIN S OXACILLIN S PENICILLIN R PIPERACILLIN TETRACYCLINE TOBRAMYCIN TRIMETH/SULF VANCOMYCIN S = SUSCEPTIBLE R = RESISTANT I = INTERMEDIATE M = MODERATELY SUSCEP -------- DATE TEST TYPE: 9/8 Culture and Sensitivity #2 SOURCE: Blood SITE: GRAM STAIN RESULTS CULTURE RESULTS: E. coli SUSCEPTIBILITY: 9/10 AMPICILLIN R CEFAZOLIN S CEFOTAXIME S CEFTRIAXONE S CEFUROXIME S CEPHALOTHIN S CIPROFLOXACIN S ERYTHROMYCIN S GENTAMICIN S OXACILLIN S PENICILLIN R PIPERACILLIN TETRACYCLINE TOBRAMYCIN TRIMETH/SULF VANCOMYCIN S = SUSCEPTIBLE R = RESISTANT I = INTERMEDIATE M = MODERATELY SUSCEP --------- RAD REPORT DATE: 9/8 CHEST X-RAY: The examination is of a recumbent AP view. Heart size is normal. The aorta is normal and lung fields are free of infiltration. There is no free air and the trachea is midline. DIAGNOSIS: Normal chest x-ray ---------- RAD REPORT DATE: 9/8 PYELOGRAM: The urinary architecture is normal with no hydronephrosis. DIAGNOSIS: Normal pyelogram ------------ Enter five diagnosis codes. PDX DX2 DX3 DX4 DX5

Case Studies PDX 038.42 Septicemia due to Escherichia coli DX2 590.10 Acute pyelonephritis, without lesion of renal medullary necrosis DX3 054.9 Herpes simplex without mention of complication DX4 V09.0 Infection with microorganisms resistant to penicillins DX5 305.1 Tobacco use disorder Notes on Inpatient Practice Case—Patient 4 038.42 E. coli septicemia is documented on the culture and sensitivity as well as in the H & P. SIRS is not used here because septicemia is documented, versus sepsis. (Brown 2012, 109-112). 590.10 Acute pyelonephritis is also coded because this is where the septicemia began. Do not code the organism (Coding Clinic 4th Quarter 1988). It is already reflected in the septicemia code (Brown 2012, 217). 054.9 Herpes simplex is documented on the 9/8 progress notes and is treated (Brown 2012, chapter 10). 305.1 Tobacco abuse is treated and documented in the progress notes, H & P and D/C summary. This code does not require a fifth digit (HHS 2011, Tabular Index; Brown 2012, chapter 12). V09.0 The organism is specified to be resistant to in the discharge summary and therefore designate that in the coding (Brown 2012, 113). Note: The pyelogram performed on 9/8 is not coded because it is an unspecified pyelogram (refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book). A pyelogram is coded only if it is code 87.74 or 87.76 (Retrogrades, urinary systems). Points of Interest on Patient 4 This case illustrates how an infection can begin in one organ system and then become systemic. This is why the same organism is in the urinary tract and the blood. As stated earlier, code both disorders (septicemia and pyelonephritis). The organism causing the infection is resistant to penicillin and ampicillin. Only code resistance to a drug if the resistance is documented by the practitioner in the record. Do not code from the laboratory reports alone. (Garvin 2013, 68--75, 255.)

CASE INSTRUCTIONS: To view this health record: Click on the tabs above. Scroll to the bottom of each document. For your referance, the Coding Guidelines tab includes information from your codebooks. To answer the questions in this case: Enter the appropriate codes in the boxes on the right. Enter a DX code in every box. Any necessary decimal point must be present and correctly placed. Do not include spaces with your answer. ---------- CODING GUIDELINES *Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case. --------- AMBULATORY RECORD PREOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee POSTOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee OPERATION: Left lumbar sympathetic block with C-arm ANESTHESIA: Local INDICATIONS: This 43-year-old female has a 7-month history of left knee pain. She says that even a light touch appears to be exquisitely painful. She has had surgery to clear scar tissue. PROCEDURE DESCRIPTION: The patient was placed on the x-ray lucent gurney in the right lateral decubitus position. The back was prepped with Betadine, and the midline spinous processes were marked. A line was drawn 6 to 7 cm lateral to that midline on the left. L2 was identified using the C-arm and lateral projections, and lidocaine was infiltrated at the skin. The 22-gauge, 6-inch Chiba needle was advanced down to and off the body of L2, and loss of resistance was obtained with a glass syringe. Renografin-60 was injected and showed a good distribution. So 15 cc of bupivacaine 0.5% without epinephrine was injected, plus Depo-Medrol 40 mg. The needle was withdrawn. Then lidocaine was infiltrated on the 6- to 7-cm line at L4. I advanced the 22-gauge, 6-inch needle off the body of L4, but the Renografin-60 distribution appeared not to be adequate. Another wheal was raised at the 13 level, and the needle was advanced down to and off the body of L3. A loss of resistance was obtained with a glass syringe, followed by Renografin-60. This time, the distribution was excellent, and bupivacaine 0.5% without epinephrine =15 cc was injected. She was left on her side for 25 minutes. After 10 minutes, she had a noticeably warmer left foot and ankle. The skin coloration of the left leg was normal. --------- Enter one diagnosis code and two procedure codes. PDX PP1 PR2

Case Studies PDX 337.22 Reflex sympathetic dystrophy of the lower limb PP1 64520-LT Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) PR2 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) Notes for Practice Outpatient Case—Patient 3 337.22 The diagnostic code is needed to establish the medical necessity for the procedure and a pain management code is not appropriate because the underlying condition is being treated (Brown 2012, 163).64520-LT When coding paravertebral spinal nerves and branches, it is appropriate to use the modifiers to note the laterality (CPT Assistant July 1998, 10; April 2005, 13). 77003 Fluoroscopic guidance is not included in the 64520 code; hence, it is therefore appropriate to code a second code (CPT Assistant March 2007, 7; July 2008, 9; February 2010, 12). (Garvin 2013, 55, 251.)

AMBULATORY RECORD DATE: 8/12/20XX SURGERY RECORD: PATIENT HISTORY: This patient is seen today to insert an intrathecal pump for pain management due to ductal carcinoma of the left upper breast metastatic to the spine. She previously underwent modified radical mastectomy with general anesthesia and had no adverse effects. No other surgical history is given. No known allergies, no current medications. Review of systems is normal ASA = 2. Following preoperative evaluation and discussion with the patient, local anesthesia was used to implant an intrathecal programmable pump surgically placed and attached to a previously placed catheter. The patient tolerated the procedure well. There were no adverse effects of anesthesia. ----------- Enter three diagnosis codes and one procedure code. PDX DX2 DX3 PP1

Case Studies PDX 338.3 Neoplasm-related pain (acute) (chronic) DX2 174.8 Malignant neoplasm of female breast, other specified sites DX3 198.5 Secondary malignant neoplasm of bone and bone marrow PP1 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Notes for Practice Outpatient Case—Patient 2 338.3 The patient is admitted for pain management due to metastatic cancer. If the admission is for pain control related to, associated with, or due to, a malignancy, code 338.3 (Brown 2012, 163; Coding Clinic 2nd Quarter 2007, 13-14). 174.8, 198.5 The primary site and metastatic (secondary) sites should be coded (Brown 2012, 378-382). 62362 The reservoir is surgically placed and attached to a previously placed catheter (CPT Assistant March 1997, 11). (Garvin 2013, 54, 250.)

EMERGENCY DEPARTMENT RECORD DATE OF ADMISSION: 8/19 DATE OF DISCHARGE: 8/19 HISTORY (Problem Focused): ADMISSION HISTORY: This is a 13-year-old African-American male. He became short of breath, used his inhaler as described but continued to have wheezing and shortness of breath. ALLERGIES: None CHRONIC MEDICATIONS: Albuterol inhaler FAMILY HISTORY: Noncontributory SOCIAL HISTORY: The patient's father smokes one pack of cigarettes per day, but he does not smoke in the house. REVIEW OF SYSTEMS: His integumentary, musculoskeletal, cardiovascular, genitourinary, and gastrointestinal systems are negative. PHYSICAL EXAMINATION (Extended Problem Focused): GENERAL APPEARANCE: This is an alert, cooperative young male in acute distress. HEENT: PERRLA, extraocular movements are full NECK: Supple CHEST: Lungs reveal wheezes and rales. Heart has normal sinus rhythm. ABDOMEN: Soft and nontender, no organomegaly EXTREMITIES: Examination is normal. LABORATORY DATA: Urinalysis is normal, EKG normal, chest x-ray is normal. CBC and diff show no abnormalities. IMPRESSION: Acute asthma with exacerbation PLAN: Administer epinephrine and intravenous theophylline TREATMENT: Following administration of epinephrine and theophylline, the patient's asthma abated. One venipuncture set and one IV set were used to administer the medication over 30 minutes. DISCHARGE DIAGNOSIS: Asthma with exacerbation DISCHARGE INSTRUCTIONS: The patient was instructed to take his prescribed medications as directed by his primary care physician and to return to the ER if he had any further asthma. ------------ Enter one diagnosis code and two procedure codes. PDX PP1 PR2

Case Studies PDX 493.92 Asthma with (acute) exacerbation PP1 99284-25 E/M code based on mapping scenario provided PR2 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour Notes on Outpatient 6 493.92 This condition brought the patient to the emergency department (Brown 2012, 186-187). 99284-25 This code represents the evaluation and management code for the facility APV and is done according to the mapping scenario as follows; meds given are = 2 = 5 points, the history is problem focused = 10 points, the examination is extended problem focused = 15 points, the number of tests = 4 = 15 points, supplies = one venipuncture set and one intravenous set = 10 points. 55 total points. 96365 The IV infusion is separately reportable and an additional code should be assigned (CPT Changes: An Insider's View 2009). Note: The patient came to the ED because of asthma. The code that represents the most complicated process is the evaluation and management of the patient represented by the E/M code and is sequenced first. The starting of the IV is less complicated and sequenced second. (Garvin 2013, 193, 283.)

*Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case. ________ DISCHARGE SUMMARY DATE OF ADMISSION: 2/3 DATE OF DISCHARGE: 2/5 DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery. _________ H&P ADMITTED: 2/3 REASON FOR ADMISSION: Full-term pregnancy PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Heart disease—father SOCIAL HISTORY: The patient is married and has one other child living with her. REVIEW OF SYSTEMS: SKIN: Normal HEAD-SCALP: Normal EYES: Normal ENT: Normal NECK: Normal BREASTS: Normal THORAX: Normal LUNGS: Normal HEART: Slight midsystolic click with late systolic murmur II/VI ABDOMEN: Normal IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse—asymptomatic. _____________ PROGRESS NOTES DATE NOTE 2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well. Delivered at 1:15 p.m. one full-term male infant. 2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact. 2/5 Will discharge to home ______________ PHYSICIANS ORDER DATE ORDER 2/3 Admit to Labor and Delivery 1,000 cc 5% D/LR May ambulate Type and screen CBC May have ice chips 2/5 Discharge patient to home _________________ DELIVERY RECORD DATE: 2/3 The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby's neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition. ________________ LAB REPORT HEMATOLOGY DATE: 2/3 Specimen Results Normal Values WBC 5.2 4.3-11.0 RBC 4.9 4.5-5.9 HGB 13.8 13.5-17.5 HCT 45 41-52 MCV 93 80-100 MCHC 41 31-57 PLT 255 150-450 ___________ Enter four diagnosis codes and one procedure code. PDX DX2 DX3 DX4 PP1

Case Studies PDX 663.31 Delivery complicated by nuchal cord without compression DX2 V27.0 Single liveborn DX3 648.61 Other cardiovascular diseases in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium DX4 424.0 Mitral valve disorders PP1 73.6 Episiotomy ------ Notes on Inpatient 5 663.31 As per the delivery note, this is a delivery with a nuchal cord wrapped around the baby's neck (Brown 2012, 289). V27.0 Outcome of delivery code (Brown 2012, 270). 648.61, 424.0 These must be coded because they affected the monitoring of the patient and were documented in the medical record. The "use additional code" note at category 648 directs the coder to add another code to identify the condition (Brown 2012, 276-277). 73.6 Episiotomy—the repair of an episiotomy is included in the code (Brown 2012, 282). ------- Points of Interest on Patient 5 In terms of documentation, this case is typical of many delivery charts. Often times, practitioners document the complication of delivery in only one area, such as the delivery note or the operative report. In this case, the baby has a nuchal cord, but it is only mentioned once in the delivery record. This is also an illustration of the three types of codes, at a minimum, that must be on every delivery chart: a diagnostic code from the delivery or pregnancy category, an outcome of birth code (V code), and a procedure code. (Garvin 2013, 124--126, 270.)

INPATIENT RECORD DISCHARGE SUMMARY DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10 DISCHARGE DIAGNOSIS: Acute pyelonephritis Septicemia, resistant to ampicillin and penicillin ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department. COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient's general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given Zovirax ointment. INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for Zyban to assist smoking cessation. _____ H&P ADMITTED: 9/8 REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced difficulty about 3 days prior to admission. This was in the form of discomfort in the right side of the lower back and also some dysuria. On the evening of admission, she started experiencing some fever and chills and took some aspirin. This did not help her and she came to the emergency department. HISTORY OF PRESENT ILLNESS: PAST MEDICAL HISTORY: Remarkable only for "walking pneumonia" treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission. ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day. REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period. PHYSICAL EXAMINATION: On admission, significant for temperature of 103 degrees; pulse 120 beats per minute, regular; blood pressure 120/70; respirations 16 VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic. SKIN: Warm to touch HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal. NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter. LUNGS: Clear to auscultation and percussion BACK: Positive pain to palpation and percussion right costovertebral angle HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs. ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal. GENITALIA: Normal female RECTAL: Deferred EXTREMITIES: Femoral pulses normal, no edema NEUROLOGIC: Grossly intact LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable. IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia. PLAN: Hydrate and start IV antibiotics. ___________ PROGRESS NOTES DATE NOTE 9/8 Patient admitted for evaluation of flank pain and fever. She also has a lesion on her lip. This appears to be herpes simplex. Will treat infection process with antibiotics following obtaining cultures. The patient's renal function will be monitored. 9/10 The patient's fever decreasing. Patient comfortable and tolerating antibiotics. Will continue IVs. The importance of stopping cigarette use was discussed with the patient. She is willing to quit and she will be given a prescription for Zyban at discharge. 9/11 Patient is afebrile today. Will discharge when able to obtain transportation. ______________ PHYSICIAN'S ORDER DATE ORDER 9/8 Admit to floor for evaluation of febrile illness Urinalysis CBC and SMA 16 Urine culture and sensitivity Blood cultures ×2 Chest x-ray Pyelogram D5W 125 cc/h ×3 Strict input and output Zovirax ointment prn to lip Gentamicin 80 mg IV q. 8 H ×3d Cefoxitin 1 g IV q. 8 H ×3 days 9/9 D5W 100 cc/ph 9/10 Discharge patient when transportation is arranged Ciprofloxacin 500 mg p.o. b.i.d. ×12 days Zyban 150 mg p.o. daily ×3 days then b.i.d. Follow up in the office in 1 week. ____________ LAB HEMATOLOGY DATE: 9/8 Specimen Results Normal Values WBC 15.9 H 4.3-11.0 RBC 5.5 4.5-5.9 HGB 14.0 13.5-17.5 HCT 45 41-52 MCV 90 80-100 MCHC 41 31-57 PLT 251 150-450 CHEMISTRY DATE: 9/8 Specimen Results Normal Values GLUC 100 70-110 BUN 11 8-25 CREAT 1.0 0.5-1.5 NA 143 136-146 K 4.0 3.5-5.5 CL 98 95-110 CO2 30 24-32 CA 9.0 8.4-10.5 PHOS 3.0 2.5-4.4 MG 2.0 1.6-3.0 T BILI 1.0 0.2-1.2 D BILI 0.3 0.0-0.5 PROTEIN 7.0 6.0-8.0 ALBUMIN 5.2 5.0-5.5 AST 25 0-40 ALT 40 30-65 GGT 60 15-85 LD 100-190 ALK PHOS 50-136 URIC ACID 2.2-7.7 CHOL 0-200 TRIG 10-160 URINALYSIS DATE: 9/8 Test Result Ref Range SP GRAVITY 1.03 1.005-1.035 PH 6 5-7 PROT NEG NEG GLUC NEG NEG KETONES NEG NEG BILI NEG NEG BLOOD NEG NEG LEU EST POS NEG NITRATES POS NEG RED SUBS NEG NEG __________ MICROBIOLOGY DATE TEST TYPE: Culture and Sensitivity 9/8 SOURCE: Urine SITE: GRAM STAIN RESULTS CULTURE RESULTS: E. coli, 100,000/ml SUSCEPTIBILITY: 9/10 AMPICILLIN R CEFAZOLIN S CEFOTAXIME S CEFTRIAXONE S CEFUROXIME S CEPHALOTHIN S CIPROFLOXACIN S ERYTHROMYCIN S GENTAMICIN S OXACILLIN S PENICILLIN R PIPERACILLIN TETRACYCLINE TOBRAMYCIN TRIMETH/SULF VANCOMYCIN S = SUSCEPTIBLE R = RESISTANT I = INTERMEDIATE M = MODERATELY SUSCEP ____________ LAB DATE: 9/11 URINE CULTURE: No growth for 24 hours ______________ MICROBIOLOGY DATE TEST TYPE: 9/8 Culture and Sensitivity #1 SOURCE: Blood SITE: GRAM STAIN RESULTS CULTURE RESULTS: E. coli SUSCEPTIBILITY: 9/10 AMPICILLIN R CEFAZOLIN S CEFOTAXIME S CEFTRIAXONE S CEFUROXIME S CEPHALOTHIN S CIPROFLOXACIN S ERYTHROMYCIN S GENTAMICIN S OXACILLIN S PENICILLIN R PIPERACILLIN TETRACYCLINE TOBRAMYCIN TRIMETH/SULF VANCOMYCIN S = SUSCEPTIBLE R = RESISTANT I = INTERMEDIATE M = MODERATELY SUSCEP ____________ RADIOLOGY REPORT DATE: 9/8 CHEST X-RAY: The examination is of a recumbent AP view. Heart size is normal. The aorta is normal and lung fields are free of infiltration. There is no free air and the trachea is midline. DIAGNOSIS: Normal chest x-ray _________ RAD REPORT DATE: 9/8 PYELOGRAM: The urinary architecture is normal with no hydronephrosis. DIAGNOSIS: Normal pyelogram nter five diagnosis codes. ____________ PDX DX2 DX3 DX4 DX5

Case Studies PDX 038.42 Septicemia due to Escherichia coli DX2 590.10 Acute pyelonephritis, without lesion of renal medullary necrosis DX3 054.9 Herpes simplex without mention of complication DX4 V09.0 Infection with microorganisms resistant to penicillins DX5 305.1 Tobacco use disorder Notes on Inpatient Practice Case—Patient 4038.42 E. coli septicemia is documented on the culture and sensitivity as well as in the H & P. SIRS is not used here because septicemia is documented, versus sepsis. (Brown 2012, 109-112). 590.10 Acute pyelonephritis is also coded because this is where the septicemia began. Do not code the organism (Coding Clinic 4th Quarter 1988). It is already reflected in the septicemia code (Brown 2012, 217). 054.9 Herpes simplex is documented on the 9/8 progress notes and is treated (Brown 2012, chapter 10). 305.1 Tobacco abuse is treated and documented in the progress notes, H & P and D/C summary. This code does not require a fifth digit (HHS 2011, Tabular Index; Brown 2012, chapter 12). V09.0 The organism is specified to be resistant to in the discharge summary and therefore designate that in the coding (Brown 2012, 113). Note: The pyelogram performed on 9/8 is not coded because it is an unspecified pyelogram (refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book). A pyelogram is coded only if it is code 87.74 or 87.76 (Retrogrades, urinary systems). ____________ Points of Interest on Patient 4 This case illustrates how an infection can begin in one organ system and then become systemic. This is why the same organism is in the urinary tract and the blood. As stated earlier, code both disorders (septicemia and pyelonephritis). The organism causing the infection is resistant to penicillin and ampicillin. Only code resistance to a drug if the resistance is documented by the practitioner in the record. Do not code from the laboratory reports alone. (Garvin 2013, 68--75, 255.)

To view this health record: Click on the tabs above. Scroll to the bottom of each document. For your referance, the Coding Guidelines tab includes information from your codebooks. To answer the questions in this case: Enter the appropriate codes in the boxes on the right. Enter a DX code in every box. Any necessary decimal point must be present and correctly placed. Do not include spaces with your answer. ________________ *Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case. _________ AMBULATORY RECORD PREOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee POSTOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee OPERATION: Left lumbar sympathetic block with C-arm ANESTHESIA: Local INDICATIONS: This 43-year-old female has a 7-month history of left knee pain. She says that even a light touch appears to be exquisitely painful. She has had surgery to clear scar tissue. PROCEDURE DESCRIPTION: The patient was placed on the x-ray lucent gurney in the right lateral decubitus position. The back was prepped with Betadine, and the midline spinous processes were marked. A line was drawn 6 to 7 cm lateral to that midline on the left. L2 was identified using the C-arm and lateral projections, and lidocaine was infiltrated at the skin. The 22-gauge, 6-inch Chiba needle was advanced down to and off the body of L2, and loss of resistance was obtained with a glass syringe. Renografin-60 was injected and showed a good distribution. So 15 cc of bupivacaine 0.5% without epinephrine was injected, plus Depo-Medrol 40 mg. The needle was withdrawn. Then lidocaine was infiltrated on the 6- to 7-cm line at L4. I advanced the 22-gauge, 6-inch needle off the body of L4, but the Renografin-60 distribution appeared not to be adequate. Another wheal was raised at the 13 level, and the needle was advanced down to and off the body of L3. A loss of resistance was obtained with a glass syringe, followed by Renografin-60. This time, the distribution was excellent, and bupivacaine 0.5% without epinephrine =15 cc was injected. She was left on her side for 25 minutes. After 10 minutes, she had a noticeably warmer left foot and ankle. The skin coloration of the left leg was normal. ___________ Enter one diagnosis code and two procedure codes. PDX PP1 PR2

Case Studies PDX 337.22 Reflex sympathetic dystrophy of the lower limb PP1 64520-LT Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) PR2 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid) Notes for Practice Outpatient Case—Patient 3 337.22 The diagnostic code is needed to establish the medical necessity for the procedure and a pain management code is not appropriate because the underlying condition is being treated (Brown 2012, 163). 64520-LT When coding paravertebral spinal nerves and branches, it is appropriate to use the modifiers to note the laterality (CPT Assistant July 1998, 10; April 2005, 13). 77003 Fluoroscopic guidance is not included in the 64520 code; hence, it is therefore appropriate to code a second code (CPT Assistant March 2007, 7; July 2008, 9; February 2010, 12). (Garvin 2013, 55, 251.)

AMBULATORY RECORD To view this health record: Click on the tabs above. Scroll to the bottom of each document. For your referance, the Coding Guidelines tab includes information from your codebooks. To answer the questions in this case: Enter the appropriate codes in the boxes on the right. Enter a DX code in every box. Any necessary decimal point must be present and correctly placed. Do not include spaces with your answer. ______________ *Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case. ______ DATE: 8/12/20XX SURGERY RECORD: PATIENT HISTORY: This patient is seen today to insert an intrathecal pump for pain management due to ductal carcinoma of the left upper breast metastatic to the spine. She previously underwent modified radical mastectomy with general anesthesia and had no adverse effects. No other surgical history is given. No known allergies, no current medications. Review of systems is normal ASA = 2. Following preoperative evaluation and discussion with the patient, local anesthesia was used to implant an intrathecal programmable pump surgically placed and attached to a previously placed catheter. The patient tolerated the procedure well. There were no adverse effects of anesthesia. __________ Enter three diagnosis codes and one procedure code. PDX DX2 DX3 PP1

Case Studies PDX 338.3 Neoplasm-related pain (acute) (chronic) DX2 174.8 Malignant neoplasm of female breast, other specified sites DX3 198.5 Secondary malignant neoplasm of bone and bone marrow PP1 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming Notes for Practice Outpatient Case—Patient 2 338.3 The patient is admitted for pain management due to metastatic cancer. If the admission is for pain control related to, associated with, or due to, a malignancy, code 338.3 (Brown 2012, 163; Coding Clinic 2nd Quarter 2007, 13-14). 174.8, 198.5 The primary site and metastatic (secondary) sites should be coded (Brown 2012, 378-382). 62362 The reservoir is surgically placed and attached to a previously placed catheter (CPT Assistant March 1997, 11). (Garvin 2013, 54, 250.)

EMERGENCY DEPARTMENT RECORD DATE OF ADMISSION: 8/19 DATE OF DISCHARGE: 8/19 HISTORY (Problem Focused): ADMISSION HISTORY: This is a 13-year-old African-American male. He became short of breath, used his inhaler as described but continued to have wheezing and shortness of breath. ALLERGIES: None CHRONIC MEDICATIONS: Albuterol inhaler FAMILY HISTORY: Noncontributory SOCIAL HISTORY: The patient's father smokes one pack of cigarettes per day, but he does not smoke in the house. REVIEW OF SYSTEMS: His integumentary, musculoskeletal, cardiovascular, genitourinary, and gastrointestinal systems are negative. PHYSICAL EXAMINATION (Extended Problem Focused): GENERAL APPEARANCE: This is an alert, cooperative young male in acute distress. HEENT: PERRLA, extraocular movements are full NECK: Supple CHEST: Lungs reveal wheezes and rales. Heart has normal sinus rhythm. ABDOMEN: Soft and nontender, no organomegaly EXTREMITIES: Examination is normal. LABORATORY DATA: Urinalysis is normal, EKG normal, chest x-ray is normal. CBC and diff show no abnormalities. IMPRESSION: Acute asthma with exacerbation PLAN: Administer epinephrine and intravenous theophylline TREATMENT: Following administration of epinephrine and theophylline, the patient's asthma abated. One venipuncture set and one IV set were used to administer the medication over 30 minutes. DISCHARGE DIAGNOSIS: Asthma with exacerbation DISCHARGE INSTRUCTIONS: The patient was instructed to take his prescribed medications as directed by his primary care physician and to return to the ER if he had any further asthma. Enter one diagnosis code and two procedure codes. PDX PP1 PR2

Case Studies PDX 493.92 Asthma with (acute) exacerbation PP1 99284-25 E/M code based on mapping scenario provided PR2 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour Notes on Outpatient 6493.92 This condition brought the patient to the emergency department (Brown 2012, 186-187). 99284-25 This code represents the evaluation and management code for the facility APV and is done according to the mapping scenario as follows; meds given are = 2 = 5 points, the history is problem focused = 10 points, the examination is extended problem focused = 15 points, the number of tests = 4 = 15 points, supplies = one venipuncture set and one intravenous set = 10 points. 55 total points. 96365 The IV infusion is separately reportable and an additional code should be assigned (CPT Changes: An Insider's View 2009). Note: The patient came to the ED because of asthma. The code that represents the most complicated process is the evaluation and management of the patient represented by the E/M code and is sequenced first. The starting of the IV is less complicated and sequenced second. (Garvin 2013, 193, 283.)

AMBULATORY CASE *Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case. ----- FACESHEET DATE OF ADMISSION: 4/5 DATE OF DISCHARGE: 4/5 SEX: Male AGE: 37 DISCHARGE DISPOSITION: Home ADMISSION DIAGNOSIS: Left inguinal hernia DISCHARGE DIAGNOSIS: Same PROCEDURES: Left inguinal herniorrhaphy with excision of lipoma of spermatic cord -------- H&P ADMITTED: 4/5 HISTORY OF PRESENT ILLNESS: The patient has been well until several months ago when he began to have pain when lifting. PAST MEDICAL HISTORY: The patient has no other significant medical or surgical history. SOCIAL HISTORY: Does not use alcohol or tobacco. ALLERGIES: No known allergies MEDICATIONS: None REVIEW OF SYSTEMS: SKIN: Warm and dry, mucous membranes moist HEENT: Essentially normal LUNGS: Clear to percussion and auscultation HEART: Normal, regular rhythm ABDOMEN: Normal GENITALIA: Palpable mass in inguinal canal RECTAL: Normal EXTREMITIES: No edema NEUROLOGIC: Deep tendon reflexes normal IMPRESSION: Left inguinal hernia PLAN: Surgical repair of inguinal hernia -------- PROGRESS NOTES DATE NOTE 4/5 Nursing: Betadine scrub performed, patient anxious to get surgery over; preoperative medications given as ordered. 4/5 Attending MD: Brief op note Dx: Left inguinal hernia Px: Left inguinal herniorrhaphy Anes: Local plus sedation Complications: None 4/5 Attending MD: No bleeding; patient okay for discharge. ___________ OPERATIVE REPORT DATE: 4/5 PREOPERATIVE DIAGNOSIS: Left direct inguinal hernia POSTOPERATIVE DIAGNOSIS: Left direct inguinal hernia OPERATION: Left inguinal herniorrhaphy ANESTHESIA: Local plus sedation OPERATIVE INDICATIONS: A wide mouth direct sac was present in the lower inguinal canal. A lipoma of the cord was present, but no indirect sac. OPERATIVE PROCEDURE: Under local anesthesia consisting of the equivalent of 19 cc of 1% Xylocaine and 8 cc of 0.5% Marcaine, the abdomen was prepared with Betadine and sterilely draped. A left inguinal incision was made and carried down through subcutaneous tissues to the aponeurosis of the external oblique, which was opened from the external ring to a point over the internal ring. Flaps were cleaned in both directions. The nerve was retracted inferiorly. The cord structures were separated from the surrounding at the level of the pubic tubercle and retracted with a Penrose drain. Cremaster over the cord was opened and a search made for an indirect sac. None was found. Lipoma of the cord was dissected free and clamped at its base and excised. The base was ligated with 00 chromic catgut. Additional cremasteric muscles were divided and ligated with 00 chromic catgut. The direct sac was further dissected down to its base and inverted as the defect was closed by approximating transversus to transversus with a running suture of 00 Vicryl. The floor of the canal was then closed by approximating the internal oblique to the shelving portion of the inguinal ligament with multiple sutures of 0 Ethibond. The external oblique aponeurosis was then reclosed with 0 Ethibond, leaving the cord and nerve in the subcutaneous position. Several sutures of 0 Ethibond were also placed above the emergence of the cord at the internal ring. Subcutaneous tissues were then approximated with 3-0 Vicryl and after irrigation skin was closed with skin clips. The patient tolerated the procedure well and was sent to the recovery room in good condition. --------- PATH REPORT DATE SPECIMEN SUBMITTED: 4/5 SPECIMEN: Lipoma of cord CLINICAL DATA: GROSS DESCRIPTION: The specimen is submitted as lipoma of cord. It consists of a single irregularly shaped fragment of fatty tissue that is 8.0 × 4.0 × 1.5 cm. It is covered with a thin membrane. MICROSCOPIC DESCRIPTION: DIAGNOSIS: Lipomatous tissue of left spermatic cord ____________ PHYSICIANS ORDER DATE ORDER 4/5 Attending MD: Admit to same-day surgery Betadine scrub ×3 Preop May take own meds 4/5 Anesthesia note: Continue NPO Demerol 50 mg IM 1½ hr Preop Vistaril 50 mg IM 1½ hr Preop Atropine 0.4 mg IM 1½ hr Preop 4/5 Attending MD: Vital signs q. 15 min until stable Regular diet Darvocet-N-100 q. 4 hrs p.r.n. pain Discharge to home when stable ------------- HEMATOLOGY DATE: 4/5 Specimen Results Normal Values WBC 6.83 4.3-11.0 RBC 4.57 4.5-5.9 HGB 13.7 13.5-17.5 HCT 43 41-52 MCV 87.0 80-100 MCHC 35 31-57 PLT 300 150-400 AUTO DIFFERENTIAL DATE: 4/5 Specimen Results Normal Values NEUT 68.3 40.0-74.0 LYMPH 20 19.0-48.0 MONO 5.6 3.4-9.0 EOS 5.6 0.0-7.0 BASO 0.6 0.0-1.5 LUC 3.8 0.0-4.0 URINALYSIS DATE: 4/5 Test Result Ref Range SP GRAVITY 1.017 1.005-1.035 PH 6 5-7 PROT TRACE NEG GLUC NONE NEG KETONES NONE NEG BILI NONE NEG BLOOD TRACE NEG NITRATES NONE NEG RBCS NONE NEG WBCS NONE NEG ----------- RAD REPORT DATE: 4/5 DIAGNOSIS: Inguinal hernia EXAMINATION: Chest x-ray Heart size and shape are acceptable. The lung fields are clear and the pulmonary vascular pattern is unremarkable. There is no free fluid and the trachea remains midline. ----------- Enter two diagnosis codes and two procedure codes. PDX DX2 PP1 PR2

Case Studies PDX 550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) DX2 214.4 Lipoma of spermatic cord (as per path. and operative reports) PP1 49505-LT Repair initial inguinal hernia, age five years or older; reducible PR2 55520-59 Excision of lesion of spermatic cord (separate procedure) ------------ Notes for Practice Outpatient Case—Patient 1 550.90 The type of hernia is coded (Brown 2012, 208-209). 214.4 The lipoma is also removed and so should be coded (Brown 2012, 377-378). 49505-LT The hernia location is on the left and the laterality is reported (CPT Assistant September 2000, 10). 55520-59 The lipoma requires excision and is therefore coded (CPT Assistant September 2000, 10; October 2001, 8). (Garvin 2013, 48--52, 249.)

FACESHEET AMBULATORY CASE DATE OF ADMISSION: 4/5 DATE OF DISCHARGE: 4/5 SEX: Male AGE: 37 DISCHARGE DISPOSITION: Home ADMISSION DIAGNOSIS: Left inguinal hernia DISCHARGE DIAGNOSIS: Same PROCEDURES: Left inguinal herniorrhaphy with excision of lipoma of spermatic cord ------- H&P ADMITTED: 4/5 HISTORY OF PRESENT ILLNESS: The patient has been well until several months ago when he began to have pain when lifting. PAST MEDICAL HISTORY: The patient has no other significant medical or surgical history. SOCIAL HISTORY: Does not use alcohol or tobacco. ALLERGIES: No known allergies MEDICATIONS: None REVIEW OF SYSTEMS: SKIN: Warm and dry, mucous membranes moist HEENT: Essentially normal LUNGS: Clear to percussion and auscultation HEART: Normal, regular rhythm ABDOMEN: Normal GENITALIA: Palpable mass in inguinal canal RECTAL: Normal EXTREMITIES: No edema NEUROLOGIC: Deep tendon reflexes normal IMPRESSION: Left inguinal hernia PLAN: Surgical repair of inguinal hernia ------------- PROGRESS NOTES DATE NOTE 4/5 Nursing: Betadine scrub performed, patient anxious to get surgery over; preoperative medications given as ordered. 4/5 Attending MD: Brief op note Dx: Left inguinal hernia Px: Left inguinal herniorrhaphy Anes: Local plus sedation Complications: None 4/5 Attending MD: No bleeding; patient okay for discharge ----------- OP REPORT DATE: 4/5 PREOPERATIVE DIAGNOSIS: Left direct inguinal hernia POSTOPERATIVE DIAGNOSIS: Left direct inguinal hernia OPERATION: Left inguinal herniorrhaphy ANESTHESIA: Local plus sedation OPERATIVE INDICATIONS: A wide mouth direct sac was present in the lower inguinal canal. A lipoma of the cord was present, but no indirect sac. OPERATIVE PROCEDURE: Under local anesthesia consisting of the equivalent of 19 cc of 1% Xylocaine and 8 cc of 0.5% Marcaine, the abdomen was prepared with Betadine and sterilely draped. A left inguinal incision was made and carried down through subcutaneous tissues to the aponeurosis of the external oblique, which was opened from the external ring to a point over the internal ring. Flaps were cleaned in both directions. The nerve was retracted inferiorly. The cord structures were separated from the surrounding at the level of the pubic tubercle and retracted with a Penrose drain. Cremaster over the cord was opened and a search made for an indirect sac. None was found. Lipoma of the cord was dissected free and clamped at its base and excised. The base was ligated with 00 chromic catgut. Additional cremasteric muscles were divided and ligated with 00 chromic catgut. The direct sac was further dissected down to its base and inverted as the defect was closed by approximating transversus to transversus with a running suture of 00 Vicryl. The floor of the canal was then closed by approximating the internal oblique to the shelving portion of the inguinal ligament with multiple sutures of 0 Ethibond. The external oblique aponeurosis was then reclosed with 0 Ethibond, leaving the cord and nerve in the subcutaneous position. Several sutures of 0 Ethibond were also placed above the emergence of the cord at the internal ring. Subcutaneous tissues were then approximated with 3-0 Vicryl and after irrigation skin was closed with skin clips. The patient tolerated the procedure well and was sent to the recovery room in good condition. ---------- PATH REPORT DATE SPECIMEN SUBMITTED: 4/5 SPECIMEN: Lipoma of cord CLINICAL DATA: GROSS DESCRIPTION: The specimen is submitted as lipoma of cord. It consists of a single irregularly shaped fragment of fatty tissue that is 8.0 × 4.0 × 1.5 cm. It is covered with a thin membrane. MICROSCOPIC DESCRIPTION: DIAGNOSIS: Lipomatous tissue of left spermatic cord ---------- PHYSICIANS ORDER DATE ORDER 4/5 Attending MD: Admit to same-day surgery Betadine scrub ×3 Preop May take own meds 4/5 Anesthesia note: Continue NPO Demerol 50 mg IM 1½ hr Preop Vistaril 50 mg IM 1½ hr Preop Atropine 0.4 mg IM 1½ hr Preop 4/5 Attending MD: Vital signs q. 15 min until stable Regular diet Darvocet-N-100 q. 4 hrs p.r.n. pain Discharge to home when stable ------------- LAB REPORT HEMATOLOGY DATE: 4/5 Specimen Results Normal Values WBC 6.83 4.3-11.0 RBC 4.57 4.5-5.9 HGB 13.7 13.5-17.5 HCT 43 41-52 MCV 87.0 80-100 MCHC 35 31-57 PLT 300 150-400 AUTO DIFFERENTIAL DATE: 4/5 Specimen Results Normal Values NEUT 68.3 40.0-74.0 LYMPH 20 19.0-48.0 MONO 5.6 3.4-9.0 EOS 5.6 0.0-7.0 BASO 0.6 0.0-1.5 LUC 3.8 0.0-4.0 URINALYSIS DATE: 4/5 Test Result Ref Range SP GRAVITY 1.017 1.005-1.035 PH 6 5-7 PROT TRACE NEG GLUC NONE NEG KETONES NONE NEG BILI NONE NEG BLOOD TRACE NEG NITRATES NONE NEG RBCS NONE NEG WBCS NONE NEG ----------- RAD REPORT ----------- Enter two diagnosis codes and two procedure codes. PDX DX2 PP1 PR2

Case Studies PDX 550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent) DX2 214.4 Lipoma of spermatic cord (as per path. and operative reports) PP1 49505-LT Repair initial inguinal hernia, age five years or older; reducible PR2 55520-59 Excision of lesion of spermatic cord (separate procedure) Notes for Practice Outpatient Case—Patient 1 550.90 The type of hernia is coded (Brown 2012, 208-209). 214.4 The lipoma is also removed and so should be coded (Brown 2012, 377-378). 49505-LT The hernia location is on the left and the laterality is reported (CPT Assistant September 2000, 10). 55520-59 The lipoma requires excision and is therefore coded (CPT Assistant September 2000, 10; October 2001, 8). (Garvin 2013, 48--52, 249.)

INPATIENT RECORD DISCHARGE SUMMARY DATE OF ADMISSION: 2/3 DATE OF DISCHARGE: 2/5 DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery. -------- H&P ADMITTED: 2/3 REASON FOR ADMISSION: Full-term pregnancy PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse ALLERGIES: None known CHRONIC MEDICATIONS: None FAMILY HISTORY: Heart disease—father SOCIAL HISTORY: The patient is married and has one other child living with her. REVIEW OF SYSTEMS: SKIN: Normal HEAD-SCALP: Normal EYES: Normal ENT: Normal NECK: Normal BREASTS: Normal THORAX: Normal LUNGS: Normal HEART: Slight midsystolic click with late systolic murmur II/VI ABDOMEN: Normal IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse—asymptomatic. ------------ PROGRESS NOTES DATE NOTE 2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well. Delivered at 1:15 p.m. one full-term male infant. 2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact. 2/5 Will discharge to home ---------- PHYSICIANS ORDERS DATE ORDER 2/3 Admit to Labor and Delivery 1,000 cc 5% D/LR May ambulate Type and screen CBC May have ice chips 2/5 Discharge patient to home ----------------- DELIVERY RECORD DATE: 2/3 The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby's neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition. ----------- LAB REPORT HEMATOLOGY DATE: 2/3 Specimen Results Normal Values WBC 5.2 4.3-11.0 RBC 4.9 4.5-5.9 HGB 13.8 13.5-17.5 HCT 45 41-52 MCV 93 80-100 MCHC 41 31-57 PLT 255 150-450 ---------- Enter four diagnosis codes and one procedure code. PDX DX2 DX3 DX4 PP1

Case Studies PDX 663.31 Delivery complicated by nuchal cord without compression DX2 V27.0 Single liveborn DX3 648.61 Other cardiovascular diseases in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium DX4 424.0 Mitral valve disorders PP1 73.6 Episiotomy Notes on Inpatient 5 663.31 As per the delivery note, this is a delivery with a nuchal cord wrapped around the baby's neck (Brown 2012, 289). V27.0 Outcome of delivery code (Brown 2012, 270). 648.61, 424.0 These must be coded because they affected the monitoring of the patient and were documented in the medical record. The "use additional code" note at category 648 directs the coder to add another code to identify the condition (Brown 2012, 276-277). 73.6 Episiotomy—the repair of an episiotomy is included in the code (Brown 2012, 282). Points of Interest on Patient 5 In terms of documentation, this case is typical of many delivery charts. Often times, practitioners document the complication of delivery in only one area, such as the delivery note or the operative report. In this case, the baby has a nuchal cord, but it is only mentioned once in the delivery record. This is also an illustration of the three types of codes, at a minimum, that must be on every delivery chart: a diagnostic code from the delivery or pregnancy category, an outcome of birth code (V code), and a procedure code. (Garvin 2013, 124--126, 270.)

CPT Category II

Category II codes represent services and/or test results that contribute to positive health outcomes and quality patient care. This category of codes is a set of optional tracking codes for performance measurement. Use of Category II codes is OPTIONAL and they may NOT be used as substitutes for Category I codes. Category II codes are represented by a 5-digit alphanumeric code with the alpha character F in the last position.

What are the levels of ICD-9-CM codes called?

Category>Subcategory (4-digit)>Sub-classification (5-digit)

Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? A) Children's, B) Rural, C) State Supported, or D) Tertiary (major hospital)

Children's: psychiatric ad rehabilitation hospitals, long-term care hospitals, children's hospitals, cancer hospitals, and critical access hospitals are pain on the basis of reasonable cost, subject to payment limits per discharge under separate PPS ********JOHNS BOOK*********RE-READ this

Patient admitted to the hospital with abdominal pain. Principal diagnosis is cholecystitis. Patient has a history of hypertension and diabetes. In the DRG [Diagnosis Related Group] prospective payment system, which of following determines the MDC [Major Diagnostic Category] assignment for this patient? a-abdominal pain, b-cholecystitis, c-hypertension, or d-diabetes

Cholecystitis - The principal diagnosis determines the MDC.

Timely and correct reimbursement is dependent on: A) Adjudication, B) Clean claims, C) Remittance advice, D) Actual Charge

Clean claims are essential for correct reimbursement.

Normal Delivery

Code 650 is for a normal delivery, which required minimal or no assistance. An episotomy is permitted, but fetal manipulation is NOT (i.e. use of forceps). V27.0 Single Liveborn is the only outcome of delivery code appropriate for use with 650

HIV Rules

Code ONLY CONFIRMED Cases of HIV. When a patient is treated for an HIV-Related Condition, report code 042 first on the health insurance claim and assign diagnosis codes for all documented HIV-related conditions and opportunistic infectins (i.e. candidiasis, Kaposi's sarcoma).

A skin lesion is removed from a patient's cheek in the dermatologist's office. Physician documents "skin lesion" in the health record. Before billing the pathology report returns with a diagnosis of basal cell carcinoma. What actions should the coder take for this claim submission?

Code: Basal Cell Carcinoma: In the OUTPATIENT setting, when diagnostic tests have been interpreted by the physician and the final report is available at the time of coding, code any CONFIRMED or DEFINITIVE diagnosis(es) that are documented in the record. Do NOT code related signs and symptoms as addtional diagnoses. ******NOTE this differs from the coding practive in the hospital inpatient setting regarding abnormal findings on test results. *********

When are codes in slanted brackets listed?

Codes in slanted brackets are always listed as secondary codes because the are manifestations (results) of other conditions.

When are signs and symptoms codes reported?

Codes that describe symptoms and signs are reported when a related definitive diagnosis has not been established (or confirmed) by the provider. ICD-9-CM (Symptoms, Signs and Ill-Defined Conditions 780.0-799.9. **some others can be found in other chapters - i.e. 536.8 stomach pain found in chapter 9, diseases of the digestive system.

Which item is not a purpose of the ICD-9-CM: A)-used in the evaluation of medical care planning for healthcare delivery systems, B)-used in the collection of data about nursing care, C)-used to facilitate data storage and retrieval, or D)-used as the basis of epidemiological research

Collection of data about nursing care is not a purpose of the ICD-9-CM.

Please define "comorbidity".

Comorbidity is a pre-existing condition that because of its presence with a specific diagnosis will likely cause an increase in the patient's length of stay in the hospital.

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

Complex Closure would describe the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures.

What is a condition that arises during hospitalization?

Complication

CC

Complication or Co-Morbidity (refinements of the MS-DRG system)

Describe "grouper":

Computer program that uses specific data elements to assign patients, clients, or residents to groups, categories, or classes.

Explain what is done with signs and symptoms that are NOT an integral part of a disease process?

Conditions that ARE NOT integral should BE coded when present. Example: Patient is seen for follow-up of her controlled hypertension. During encounter she describes insomnia. Dr. prescribes Aluma. Assign 401.9 to the Hypertension, and 780.52 to the insomnia because it is NOT a symptom of hypertension and it was medically managed during the visit.

Explain what is done with signs and symptoms that an integral part of a disease process?

Conditions that are an integral part of a disease process (signs and symptoms) should NOT be assigned as additional codes because they are included in the disease process. Example: Patient in ER complaint of shortness of breath. X-Ray reveals pneumonia. Assign 486 for pnemonia, but DO NOT assigne a code for shortness of breath because it is a symptom of pnemonia.

Patient admitted to the hospital for shortness of breath and congestive heart failure. Patient subsequently develops respiratory failure. Patient undergoes intubation with ventilator management. What is the correct sequencing and coding of this case?

Congestive Heart Failure, Respiratory Failure, Ventilator Management, Intubation: Acute Respiratory Failure [518.81] may be assigned as a principal or secondary diagnosis depending upon the circumstances of the inpatient admission. {chapter specific coding guidelines provide specific sequencing direction-obstetrics, poisoning, HIV, newborn}. Respiratory failure may be listed as a secondary diagnosis. If respiratory failure occurs AFTER admission, it may be listed as a secondary diagnosis.

What is a carve-out?

Contracts that separate out services or populations of patients or clients to decrease risk and costs.

A national dollar amount that Congress designates to convert relative value units into dollars (on an annual basis) is called:

Conversion Factor

Patient has 2 health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? A) Patient receives any monies paid by the insurance companies over and above the charges, B) Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments, C) the decision on which company is primary is based on remittance advice, or D) patient should not have a Medicare supplement

Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments.

55. Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to Staphylococcus aureus septicemia. a. 038.11, 995.91 b. 995.91, 038.11 c. 038.11 d. 038.11, 995.92

Correct Answer: A 038.11, Septicemia, Staphylococcus aureus, and 995.91, Sepsis. The "Code first" note following code 995.91 directs the coder to assign the code for the underlying infection first (Schraffenberger 2012, 80-81).

67. The patient is a 45-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently tripped and subsequently fell. She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. The patient was admitted and taken to surgery, where an open reduction with internal fixation was accomplished with good alignment of fracture fragments. Post-op course was uneventful and the patient was discharged with daily physical therapy at home. Which of the following would be coded? a. 823.20, 850.0, E885.9, E019.0, E849.8, E000.8, 79.36 b. 823.10, 850.0, E885.9, E019.0, E849.8, 79.46 c. 823.20, 850.0, E885.9, E849.5, E000.9, 79.36 d. 823.30, 850.0, E885.9, E019.0, E849.8, E000.9, 79.46

Correct Answer: A A comminuted fracture is considered closed unless specified as open or compound per the note in the Index under Fracture. Four "E" codes are necessary to fully describe the circumstances as instructed by the notes in the Tabular list(AHIMA 2012a, 687).

22. A fee schedule is: a. Developed by third-party payers and includes a list of healthcare services, procedures, and charges associated with each b. Developed by providers and includes a list of healthcare services provided to a patient c. Developed by third-party payers and includes a list of healthcare services provided to a patient d. Developed by providers and lists charge codes

Correct Answer: A A fee schedule is a list of healthcare services and procedures and charges associated with each (Johns 2011, 350).

Which of the following contains the physician's findings based on an examination of the patient? a. Physical exam b. Discharge summary c. Medical history d. Patient instructions

Correct Answer: A A physical examination report represents the attending physician's assessment of the patient's current health status (Johns 2011, 63).

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management, intubation b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management

Correct Answer: A Acute respiratory failure, code 518.81, may be assigned as a principal or secondary diagnosis depending on the circumstances of the inpatient admission. Chapter-specific coding guidelines (obstetrics, poisoning, HIV, newborn) provide specific sequencing direction. Respiratory failure may be listed as a secondary diagnosis. If respiratory failure occurs after admission, it may be listed as a secondary diagnosis (Schraffenberger 2012, 224-226).

52. The patient was admitted with increasing shortness of breath, weakness, and nonproductive cough. Treatment included oxygen therapy. Final diagnoses listed as acute respiratory insufficiency and acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following is the correct ICD-9-CM diagnostic code assignment? a. 491.21 b. 491.21, 518.82 c. 518.81, 491.21 d. 518.82, 491.21

Correct Answer: A Acute respiratory insufficiency is an integral part of COPD and is therefore not coded separately. The patient had acute respiratory insufficiency and not acute respiratory failure (AHIMA 2012a, 682).

63. If a provider believes a service may be denied by Medicare because it could be considered unnecessary, the provider must notify the patient before the treatment begins by using a(n): a. Advance beneficiary notice (ABN) b. Advance notice of coverage (ANC) c. Notice of payment (NOP) d. Consent for payment (CFP)

Correct Answer: A An advance beneficiary notice (ABN) must be given to the patient to sign prior to treatment if any indication presents that may cause the service to be denied by Medicare (Johns 2011, 350).

Calling out patient names in a physician's office is: a. An incidental disclosure b. Not subject to the "minimum necessary" requirement c. A disclosure for payment purposes d. A HIPAA violation

Correct Answer: A An incidental disclosure occurs as part of a permitted use of disclosure (Johns 2011, 847).

39. The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI: a. For as long as it is maintained b. For six years c. Forever d. For 12 months

Correct Answer: A An individual's right extends for as long as the record is maintained (Johns 2011, 827).

29. Which of the following reports includes names of the surgeon and assistants, date, duration and description of the procedure, and any specimens removed? a. Operative report b. Anesthesia report c. Pathology report d. Laboratory report

Correct Answer: A An operative report describes the surgical procedures performed on the patient (Johns 2011, 73).

Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? a. Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment. b. Identify all records for a period that have these indicators for these conditions. c. Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement. d. Take a random sample of records for a period of time for records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.

Correct Answer: A Any secondary diagnoses assigned present on admission status will have a negative impact on reimbursement if no other code on the claim is assigned as a complication or comorbidity or a major complication or comorbidity (Russo 2010, chapter 3).

31. Who may sign an authorization for use and disclosure when the patient is a minor? a. The minor's parent or legal guardian b. The patient c. The physician d. The social worker

Correct Answer: A As a general rule, minors are legally incompetent and unable to make decisions regarding the use and disclosure of their own healthcare information. This authority belongs to the minor's parent(s) or legal guardians(s) unless an exception applies (Brodnik et al. 2009, 243).

25. Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This is called: a. Autoauthentication b. Electronic signature c. Automatic record completion d. Chart tracking

Correct Answer: A Autoauthentication is a policy that allows the physician or provider to state in advance that dictated and transcribed reports should automatically be considered approved and signed when the physician does not make corrections within a certain period of time. Another variation of autoauthentication is that physicians authorize the HIM department to send a weekly list of documents needing signatures. The list is then signed and returned to the HIM department (LaTour and Eichenwald Maki 2010, 213).

56. A patient was admitted for recurrent dislocation of the shoulder. The operation included debridement of the acromion, subacromial bursectomy, division of the coracoacromial ligament, and an abrasion acromioplasty with Mitek suture placement. Which of the following is the correct code assignment? a. 718.31, 81.82 b. 718.31, 81.82, 83.5 c. 831.00, 81.82, 83.5 d. 831.00, 81.82, 83.5, 80.41

Correct Answer: A Bursectomy and division of ligament are included in acromioplasty. Dislocation is not acute; it is stated as recurrent (AHIMA 2012a, 666).

84. In an effort to move toward an episode-of-payment-based payment system, the creation of grouping of APCs were created to allow for multiple services that are typically performed together to be reimbursed by one APC rather than multiple. This methodology is called: a. Composite APC b. Bundling APC c. Discounting APC d. Multiple APC

Correct Answer: A CMS added the concept of composite APCs to the hospital outpatient perspective payment system in CY 2008 in an effort to streamline services that are typically performed together and could be grouped into one payment (Casto and Layman 2011, 181).

5. Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling. a. 82270 b. 82271 c. 82272 d. 82274

Correct Answer: A CPT code 82270 describes a test for occult blood using feces source for the purpose of neoplasm screening with the use of three cards or single triple card for consecutive collection (AMA 2012b, 417).

Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-9-CM d. SNOMED CT

Correct Answer: A CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services (Johns 2011, 255).

24. Which of the following hospitals are excluded from the Medicare acute-care prospective payment system? a. Children's b. Small community c. Tertiary d. Trauma

Correct Answer: A Children's hospitals are excluded from PPS because the PPS diagnosis-related groups do not accurately account for the resource costs for the types of patients treated (Johns 2011, 321).

52. All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered this type of data: a. Clinical b. Identification c. Secondary d. Financial

Correct Answer: A Clinical information is data related to the patient's diagnosis or treatment in a healthcare facility (Odom-Wesley et al. 2009, 55).

42. Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy ruled out. a. 780.39 b. 345.9 c. 780.39, 345.9 d. 345.90

Correct Answer: A Code signs and symptoms when a condition is ruled out, which means the condition has been proven not to exist. The code for seizures (780.39) is assigned when a more specific diagnosis cannot be made even after all the facts bearing on the case have been investigated (Hazelwood and Venable 2012, 68-73).

A national dollar amount that Congress designates to convert relative value units into dollars is called: a. Conversion factor b. Origination fee c. Limitation factor d. National exchange

Correct Answer: A Conversion factor is a national dollar amount that Congress uses to convert relative value units to dollars on an annual basis (Hazelwood and Venable 2012, 331).

54. What should be done when the HIM department's error or accuracy rate is deemed unacceptable? a. A corrective action should be taken. b. The problem should be treated as an isolated incident. c. The formula for determining the rate may need to be adjusted. d. Re-audit the problem area.

Correct Answer: A Corrective action should be taken when error or accuracy rates are deemed to be at an unacceptable rate (Johns 2011, 417).

46. Which dimension of data quality is defined as "data that is free of errors?" a. Accuracy b. Granularity c. Precision d. Currency

Correct Answer: A Data that are free of errors are accurate. Typographical errors in discharge summaries or misspellings of names are examples of inaccurate data (LaTour and Eichenwald Maki 2010, 119).

62. What software will prompt the user through a variety of questions and choices based on the clinical terminology entered to assist the coder in selecting the most appropriate code? a. Logic-based encoder b. Automated code book c. Speech recognition d. Natural-language processing

Correct Answer: A Encoders come in two distinct categories: logic-based and automated codebook formats. A logic-based encoder prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition (and any possible complications or comorbidities). An automated codebook provides screen views that resemble the actual format of the coding system (LaTour and Eichenwald Maki 2010, 269).

With regard to training in PHI policies and procedures, the following statement is true: a. Every member of the covered entity's workforce must be trained. b. Only individuals employed by the covered entity must be trained. c. Training only needs to occur when there are material changes to the policies and procedures. d. Documentation of training is not required.

Correct Answer: A Every member of the covered entity's workforce must be trained in PHI policies and procedures according to the Privacy Rule (Johns 2011, 857).

When coding benign neoplasm of the skin, the section noted here directs the coder to: 216 Benign Neoplasm of Skin Includes: Blue Nevus Dermatofibroma Hydrocystoma Pigmented Nevus Syringoadenoma Syringoma Excludes: Skin of genital organs (221.0-222.9) 216.0 Skin of lip Excludes: Vermilion border of lip (210.0) 216.1 Eyelid, including canthus Excludes: Cartilage of eyelid (215.0) a. Use category 216 for syringoma. b. Use category 216 for malignant melanoma. c. Use category 216 for malignant neoplasm of the bone. d. Use category 216 for malignant neoplasm of the skin.

Correct Answer: A Follow instructions under the main term in the Alphabetic Index. Instructions in the index should be followed when determining which column to use in the neoplasm table. In this example, malignant is not a choice in the Alphabetic Index shown. Benign in category 216 indicates all of the diagnosis codes in this category are benign (Schraffenberger 2012, 95, 100).

92. What is the basic formula for calculating each MS-DRG hospital payment? a. Hospital payment = DRG relative weight × hospital base rate b. Hospital payment = DRG relative weight × hospital base rate − 1 c. Hospital payment = DRG relative weight / hospital base rate + 1 d. Hospital payment = DRG relative weight / hospital base rate

Correct Answer: A For any given patient in a MS-DRG, the hospital knows, in advance, the amount of reimbursement it will receive from Medicare. It is the responsibility of the hospital to ensure that its resource use is in line with the payment (Schraffenberger 2012, 471-473).

Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff? a. Hard coding b. Soft coding c. Encoder coding d. Natural-language processing coding

Correct Answer: A HCPCS codes that are assigned in the charge description master that flow directly to the claim and bypass facility coding staff is a process known as hard coding (Casto and Layman 2011, 250).

Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ______ review. a. Quantitative b. Qualitative c. Statistical d. Outcomes

Correct Answer: A HIM professional analyze medical records for any missing reports, forms, or required signatures and deletions. This is a quantitative analysis of the medical record (Johns 2011, 409-410).

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record? a. Home health b. Behavioral health c. End-stage renal disease d. Rehabilitative care

Correct Answer: A Home health aides may assist the patient with activities of daily living such as bathing and housekeeping, which allows the patient to remain at home. Documentation of this type of intervention is also necessary (Johns 2011, 100).

Which type of patient care record includes documentation of a family bereavement period? a. Hospice record b. Home health record c. Long-term care record d. Ambulatory care record

Correct Answer: A Hospice care is palliative care provided to terminally ill patients and supportive services to patients and their families (Johns 2011, 101).

Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

Correct Answer: A ICD-9-CM Volume 1 is known as the Tabular List and contains the numerical listing of codes that represent diseases and injuries (Johns 2011, 239

67. In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called: a. Selective catheterization b. Nonselective catheterization c. Manipulative catheterization d. Radical catheterization

Correct Answer: A If the tip of the catheter is manipulated, it is a selective catheterization. In the case of a nonselective catheterization, the tip of the catheter remains in either the aorta or the artery that was originally entered (AHIMA 2012a, 604).

In a joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Administration on Aging (AOA), which program was released in 1995 to target fraud and abuse among healthcare providers? a. Operation Restore Trust b. Medicare Integrity Program c. Tax Equity and Fiscal Responsibility Act (TEFRA) d. Medicare and Medicaid Patient and Program Protection Act

Correct Answer: A In a joint effort of the Department of Health and Human Services (HHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Administration on Aging (AOA), Operation Restore Trust was released in 1995 to target fraud and abuse among healthcare providers (Casto and Layman 2011, 36).

A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis b. Pancreatitis; noncalculus cholecystitis; abdominal pain c. Noncalculus cholecystitis; pancreatitis; abdominal pain d. Abdominal pain; pancreatitis; noncalculus cholecystitis

Correct Answer: A In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or the therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction in such cases, any one of the diagnoses may be sequenced first (Schraffenberger 2012, 68-69).

Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome. a. 227.0, 255.12 b. 227.0 c. 255.12 d. 225.12, 227.8

Correct Answer: A Index Adenoma, adrenal (cortex). Index Syndrome, Conn. According to the Index in ICD-9-CM, except where otherwise indicated, the morphological varieties of adenoma should be coded by site as for "Neoplasm, benign" (Schraffenberger 2012, 100).

Identify the diagnosis code(s) for carcinoma in situ of vocal cord. a. 231.0 b. 161.0 c. 239.1 d. 212.1

Correct Answer: A Index Carcinoma, in situ, see also Neoplasm, by site, in situ (Schraffenberger 2012, 94-95.)

56. Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment cesarean delivery with single liveborn female. a. 661.01, V27.0, 74.1 b. 661.21, 74.1 c. 661.01, 74.0 d. 661.21, V27, 74.1

Correct Answer: A Index Delivery, cesarean, poor dilation, cervix (661.0). Refer to the ICD-9-CM Tabular (660-669) for the correct fifth digit of "1," delivered, with or without mention of antepartum condition. Outcome of delivery, single, liveborn. Cesarean section, low uterine segment (Schraffenberger 2012, 282-283).

23. Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for reprogramming of a cardiac pacemaker. a. V53.31 b. 37.85 c. V53.02 d. V53.31, 37.85

Correct Answer: A Index Fitting (of) pacemaker (cardiac). No procedure code exists in ICD-9-CM to describe reprogramming (Schraffenberger 2012, 204-205).

93. Identify the ICD-9-CM code(s) for infected ingrown nail. a. 703.0 b. 703.8, 681.11 c. 681.11 d. 681.9

Correct Answer: A Index Ingrowing, nail (finger) (toe) (infected) (Schraffenberger 2012, 295).

28. Identify the CPT procedure code(s) for extracorporeal sound wave lithotripsy of large kidney stone. a. 50590 b. 52353 c. 43265 d. 28890

Correct Answer: A Index Lithotripsy, kidney, resulting in code 50590 or 52353. Review of the available codes indicates that code 50590 is correct because there is no mention of cystourethroscopy (AHIMA 2012a, 609).

The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the: a. Social security number b. Unique physician identification number c. Health record number d. National provider identifier

Correct Answer: A It is generally agreed that social security numbers (SSNs) should not be used as patient identifiers (Johns 2011, 387).

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? a. Prospectively precertify the necessity of inpatient services b. Determine what services can be bundled c. Pay only 80% of the inpatient bill d. Require the patient to pay 20% of the inpatient bill

Correct Answer: A Managed FFS reimbursement is similar to traditional FFS reimbursement except that managed care plans control costs primarily by managing their members' use of healthcare services (Johns 2011, 287, 316).

60. What is the healthcare expense the patient or insured party is responsible to pay which limited the amount the patient would be responsible for: a. Out-of-pocket expense b. Coinsurance c. Deductible d. Premium

Correct Answer: A Out-of-pocket expenses are the healthcare expenses that the insured party is responsible for paying. Insurance companies introduced this high-benefit-level in major medical plans to limit the amount of out-of-pocket expenses to the insured (Johns 2011, 288).

62. What term is used for retrospective cash payments paid by the patient for services rendered by a provider? a. Fee-for-service b. Deductible c. Retrospective d. Prospective

Correct Answer: A Patient paid cash for services on a retrospective fee-for-service basis, which meant the patient was expected to pay the healthcare provider after a service was rendered (Johns 2011, 291).

What is the incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts? a. Pay for performance and quality b. Patient referrals c. Payer of last resort d. Performance evaluations

Correct Answer: A Pay for performance and pay for quality are types of incentive to improve clinical performance (Johns 2011, 154).

18. A patient is scheduled for a colonoscopy, but due to sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given a general anesthetic prior to the procedure. How should this procedure be coded by the hospital? a. Assign the code for a colonoscopy with modifier -74. b. Assign the code for a colonoscopy with modifier -52. c. Assign an anesthesia code only. d. Do not assign a code because no procedure was performed.

Correct Answer: A Per CPT coding guidelines, when a planned procedure is terminated prior to completion for cause, the intended procedure is coded with a modifier. See instructions for use of modifiers in Appendix A. When a procedure is terminated after the induction of anesthesia, modifier -74 is appended to the intended procedure. See Medicare billing requirements for specific rules for canceled endoscopy procedures (AMA 2012b; AHIMA 2012a, 635).

Which of the following would a health record technician use to perform the billing function for a physician's office? a. CMS-1500 b. UB-04 c. UB-92 d. CMS 1450

Correct Answer: A Physicians submit claims via the electronic format (screen 837P), which takes the place of the CMS-1500 billing form (Johns 2011, 343).

16. The computer abstracting system in a facility has an edit that does not allow coders to assign obstetrical codes to male patients. This edit is called a(n): a. Self-correcting control b. Feedback control c. Presence of a virus d. Audit trail

Correct Answer: A Preventive controls are front-end processes that guide work in such a way that input and process variations are minimized. Simple things such as standard operating procedures, edits on data entered into computer-based systems, and training processes are ways to reduce the potential for error by using preventive controls (also called self-correcting controls) (LaTour and Eichenwald Maki 2010, 696).

84. Which of the following is the concept of the right of an individual to be left alone? a. Privacy b. Bioethics c. Security d. Confidentiality

Correct Answer: A Privacy is the right of an individual to be left alone (Johns 2011, 755).

Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? a. Children's b. Rural c. State supported d. Tertiary

Correct Answer: A Psychiatric and rehabilitation hospitals, long-term care hospitals, children's hospitals, cancer hospitals, and critical access hospitals are paid on the basis of reasonable cost, subject to payment limits per discharge or under separate PPS (Johns 2011, 322).

dentify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93." a. Medical laboratory report b. Pathology report c. Physical examination d. Physician orders

Correct Answer: A Results for lab tests will be included in a medical laboratory report (Johns 2011, 70).

53. What kind of care is covered when a patient requires nursing or rehab services occurring within 30 days of a 3-day stay or longer in an acute care hospital setting and is certified as medically necessary? a. Skilled nursing facility care b. Home health care c. Hospice care d. Acute healthcare

Correct Answer: A Skilled nursing care (SNF) is covered when a patient requires skilled nursing or rehab services within 30 days of a 3-day or longer acute care hospitalization stay (Johns 2011, 295).

A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

Correct Answer: A Subjective information includes symptoms and actions reported by the patient and not observed or measured by the healthcare provider (Johns 2011, 114).

98. An advantage of computer-assisted coding (CAC) is: a. Increased coding productivity b. Complexity, quality and format of health record documentation c. Technological limitations d. User resistance to change

Correct Answer: A The AHIMA e-HIM Workgroup on Computer-Assisted Coding identified advantages and barriers to CAC. The advantages of CAC include increased coding productivity (Sayles and Trawick, 2010, 361).

89. The Health Insurance Portability and Accountability Act (HIPAA): a. Provides a federal floor for healthcare privacy b. Preempts all state laws c. Applies to anyone who collects health information d. Duplicates Joint Commission standards

Correct Answer: A The HIPAA Privacy Rule provides a federal floor on privacy requirements (Johns 2011, 820).

75. Which of the following is NOT an accepted accrediting body for behavioral healthcare organizations? a. American Psychological Association b. Joint Commission c. Commission on Accreditation of Rehabilitation Facilities d. National Committee for Quality Assurance

Correct Answer: A The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance are all acceptable accrediting bodies for behavioral healthcare settings (Odom-Wesley et al. 2009, 447).

Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: a. Performance-improvement programs b. Billing and claims data processing c. Developing hospital discharge abstracting systems d. Developing individual care plans for residents

Correct Answer: A The ORYX Performance Measurement program collects quality data for hospitals and long-term care organizations and HEDIS collects data to measure physician performance (Johns 2011, 141).

2. The HIPAA Privacy Rule requirement that covered entities must limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this an example of? a. Minimum necessary b. Notice of Privacy Practice c. Consent d. Authorization

Correct Answer: A The Privacy Rule introduced the standard of minimum necessary, a "need to know" filter that is applied to limit access to a patient's protected health information (PHI) and to limit the amount of PHI used, disclosed, and requested (Brodnik et al. 2009, 176).

A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. 280.0, 626.8 b. 285.1, 626.8 c. 626.8, 280.0 d. 280.0, 218.9

Correct Answer: A The anemia would be sequenced first based on principal diagnosis guidelines (Schraffenberger 2012, 64).

84. HIM coding professionals and the organizations that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated? a. Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete. b. Follow-up on and monitor identified problems. c. Evaluate and trend diagnoses and procedure code selections. d. Report data quality review results to organizational leadership, compliance staff, and the medical staff.

Correct Answer: A The coder is not following established policies (Johns 2011, 265-267).

36. There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further define removal of foreign body (45379); biopsy, single or multiple (45380); and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule? a. Unbundling b. Optimizing c. Sequencing d. Maximizing

Correct Answer: A The coder should assign the most comprehensive code to describe the entire procedure performed. When a code describes the entire service provided, the coder should not code each component separately. Assigning additional codes inherent to the main code would be a form of unbundling (Hazelwood and Venable 2012, 336).

78. A family practitioner requests the opinion of a physician specialist in endocrinology who reviews the patient's health record and examines the patient. The physician specialist records findings, impressions, and recommendations in which type of report? a. Consultation b. Medical history c. Physical examination d. Progress notes

Correct Answer: A The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record (Johns 2011, 78).

75. A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital provide the medical records in paper format. How should the hospital respond? a. Provide the medical records in paper format b. Burn another CD because this is hospital policy c. Provide the patient with both paper and CD copies of the medical record d. Review the CD copies with the patient on a hospital computer

Correct Answer: A The covered entity must provide access to the personal health information in the form or format requested when it is readily producible in such form for format. When it is not readily producible in the form or format requested, it must be produced in a readable hard-copy form or such other form or format agreed upon by the covered entity and the individual (Johns 2011, 831).

Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the: a. Discharge summary b. Autopsy report c. Incident report d. Consent to treatment

Correct Answer: A The discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged (Johns 2011, 78).

61. Dr. Jones comes into the HIM department and requests the HIM director to pull all of his records from the previous year in which the principal diagnosis of myocardial infarction was indicated. Where would the HIM director begin to pull these records? a. Disease index b. Master patient index c. Operative index d. Physician index

Correct Answer: A The disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each patient's diagnoses are converted from a verbal description to a numerical code, usually using a coding system such as the ICD-9-CM (LaTour and Eichenwald Maki 2010, 331).

Given the following information, which of the following statements is correct? MCD Type MS-DRG Title Weight Discharges Geometric Mean Arithmetic Mean 191 04 MED Chronic obstructive pulmonary disease w CC 0.9757 10 4.1 5.0 192 04 MED Chronic obstructive pulmonary disease w/o CC/MCC 0.7254 20 3.3 4.0 193 04 MED Simple pneumonia & pleurisy w MCC 1.4327 10 5.4 6.7 194 04 MED Simple pneumonia & pleurisy w CC 1.0056 20 4.4 5.3 195 04 MED Simple pneumonia & pleurisy w/o CC/MCC 0.7316 10 3.5 4.1 a. In each MS-DRG the geometric mean is lower than the arithmetic mean. b. In each MS-DRG the arithmetic mean is lower than the geometric mean. c. The higher the number of patients in each MS-DRG, the greater the geometric mean for that MS-DRG. d. The geometric means are lower in MS-DRGs that are associated with a CC or MCC.

Correct Answer: A The geometric mean LOS is defined as the total days of service, excluding any outliers or transfers, divided by the total number of patients (Johns 2011, 323).

The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments

Correct Answer: A The goal of a compliance program is to prevent accusations of fraud and abuse (Johns 2011, 359).

45. Under local anesthesia and ultrasound guidance, a patient underwent radiofrequency ablation of an incompetent greater saphenous vein in the right lower extremity. Assign the appropriate CPT code(s). a. 36475-RT b. 36475-RT, 36000 c. 36478-RT d. 36475-RT, 76942

Correct Answer: A The introduction of the catheter into the vein is included in the procedure code, per the instructional note following code 36476. Code 36478 describes laser ablation of incompetent veins. The scenario for coding specifies radiofrequency ablation, 36475. Per the description of code 36475, the procedure code is inclusive of all imaging guidance and monitoring (AMA 2011b; AHIMA 2012a, 691).

Exceptions to the consent requirement include: a. Medical emergencies b. Provider discretion c. Implied consent d. Informed consent

Correct Answer: A The law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or minor (Brodnik et al. 2009, 99).

66. What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed? a. Operative report b. Tissue report c. Pathology report d. Anesthesia record

Correct Answer: A The operative report describes the surgical procedures performed on the patient (Johns 2011, 73).

45. Who is responsible for writing and signing discharge summaries and discharge instructions? a. Attending physician b. Head nurse c. Primary physician d. Admitting nurse

Correct Answer: A The physician principally responsible for the patient's hospital care writes and signs the discharge summary (Odom-Wesley et al. 2009, 200).

6. A health information technician has been asked to design a problem list for an electronic health record (EHR). Which of the following data elements should be included on the problem list? a. Problem number, problem description, date problem entered b. Problem number, problem name, date of consent for treatment c. Patient identifying information, problem number, examination results d. Problem name, date of onset, physical exam

Correct Answer: A The problem list describes any significant current and past illnesses and conditions as well as the procedures the patient has undergone (Johns 2011, 94).

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? a. Minimum Necessary b. Notice of Privacy Practices c. Authorization d. Consent

Correct Answer: A The standard of minimum necessary means that healthcare providers and other covered entities must limit uses, disclosures, and requests to only the amount needed to accomplish the intended purpose (Johns 2011, 822).

Fee schedules are updated by third-party payers: a. Annually b. Monthly c. Semiannually d. Weekly

Correct Answer: A Third-party payers that reimburse providers on a fee-for-service basis generally update fee schedules on an annual basis (Johns 2011, 350).

35. The inpatient prospective payment system for MS-DRG assignment begins with the: a. Principal diagnosis b. Primary diagnosis c. Secondary diagnosis d. Surgical procedure

Correct Answer: A To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into one of the 25 major diagnostic categories, or MDCs. The principal diagnosis determines the MDC assignment (Johns 2011, 322-323).

99. Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker. a. 37.87 b. 37.85 c. 37.87, 37.89 d. 37.85, 37.89

Correct Answer: A When a pacemaker is replaced with another pacemaker, only the replaced pacemaker is coded (37.85-37.87). Removal of the old pacemaker is not coded (Schraffenberger 2012, 204-205).

63. Identify the CPT procedure code(s) for whole-body PET scan. a. 78813 b. 78816 c. 78806 d. 78804

Correct Answer: A Index Nuclear medicine, tumor imaging, positron emission tomography, resulting in code range 78811-78816. Review of the available codes indicates that 78813 is the correct code (AHIMA 2012a, 624).

29. Which is a feature of managed care? a. Control and reduce the costs of care b. Monitor the activity of physician supervision c. Provide incentive for prospective payment d. Allow the patient to choose several primary physicians

Correct Answer: A The purpose of managed care is to control or reduce the costs of healthcare for which the third-party payer must reimburse the providers and to ensure continuing quality of care (Casto and Layman 2011, 9).

Common errors that delay, rather than prevent, payment, include all of the following except: a. Patient name or certificate number b. Claims out of sequence c. Illogical demographic data d. Inaccurate or deleted codes

Correct Answer: A A patient name or certificate number is required for filing health claims (Casto and Layman 2011, 72).

95. Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation? a. The record is not in compliance because the physical examination must be completed within 24 hours of admission. b. The record is not in compliance because the physical examination must be completed within 48 hours of admission. c. The record is in compliance because the physical examination must be completed within 48 hours. d. The record is in compliance because the physical examination was completed within 72 hours of admission.

Correct Answer: A According to the Joint Commission, the physical examination must be completed within 24 hours of admission (Odom-Wesley et al. 2009, 353).

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension

Correct Answer: A All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to law or regulation mandating collection of present on admission information. Present on admission (POA) is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. Any condition that occurs after admission is not considered a POA condition (Schraffenberger 2012, 66).

79. A(n) ______ is computer software that assists in determining coding accuracy and reliability. a. Encoder b. Interface c. Diagnosis related group d. Record locator service

Correct Answer: A An encoder is computer software that helps the coding professional assign codes (Johns 2011, 269).

5. What does an audit trail check for? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup

Correct Answer: A Audit trails can provide tracking information such as who accessed which records and for what purpose (Johns 2011, 403).

86. Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers with interrupted sutures. a. 21012 b. 21012, 12052 c. 21014 d. 21014, 12052

Correct Answer: A CPT code 21012 describes excision of a subcutaneous soft tissue tumor of the face or scalp greater than 2 cm and is appropriately coded when the tumor is removed from the subcutaneous tissue rather than subgaleal or intramuscular. Simple and intermediate closure of the wound is included in the procedure for the excision in the musculoskeletal section of CPT (AMA 2010a, 28-29; AMA 2012b, 88, 94-95).

Which of the following is an example of clinical data? a. Admitting diagnosis b. Date and time of admission c. Insurance information d. Health record number

Correct Answer: A Clinical data document the patient's medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided (Johns 2011, 61).

Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence. a. 54401 b. 54405 c. 54440 d. 54400

Correct Answer: A Code 54401 is correct because the prosthesis is self-contained (Kuehn 2012, 27, 178).

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? a. Complex b. Intermediate c. Not specified d. Simple

Correct Answer: A Complex closure includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement, extensive undermining, stents or retention sutures (AMA 2012c, 66).

74. Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis. a. 558.9 b. 787.01, 558.9 c. 787.02, 787.03, 558.9 d. 787.01, 558.41

Correct Answer: A Conditions that are integral to the disease process should not be assigned as additional codes. The nausea and vomiting are integral to the disease, gastroenteritis (Hazelwood and Venable 2012, 68).

Data definition refers to: a. Meaning of data b. Completeness of data c. Consistency of data d. Detail of data

Correct Answer: A Data definition means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent (Johns 2011, 48).

33. An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with: a. Data granularity b. Data consistency c. Data comprehensiveness d. Data relevancy

Correct Answer: A Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data (Johns 2011, 48).

88. Which of the following is true about the Joint Commission's "Do Not Use" abbreviation list? a. Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms b. Applies to only medication-related orders c. Applies to all documentation in the health record d. Applies to only preprinted forms

Correct Answer: A For accreditation purposes, the official Do Not Use list applies, at a minimum, to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. This requirement does not currently apply to preprogrammed health information technology systems (for example, electronic medical records or CPOE systems), but remains under consideration for the future. Organizations contemplating introduction or upgrade of such systems should strive to eliminate the use of dangerous abbreviations, acronyms, symbols, and dose designations from the software (Joint Commission 2009).

7. Good encoding software should include ________ to ensure data quality. a. Edit checks b. Voice recognition c. Reimbursement technology d. Passwords

Correct Answer: A Good encoding software should include edit checks to ensure data quality (Johns 2011, 270).

56. An HIM professional's ethical obligations: a. Apply regardless of employment site b. Are limited to the employer c. Apply to only the patient d. Are limited to the employer and patient

Correct Answer: A HIM ethical obligations apply regardless of employment site (Johns 2011, 754).

Messaging standards for electronic data interchange in healthcare have been developed by: a. HL7 b. IEE c. The Joint Commission d. CMS

Correct Answer: A HL7 developed the HL7 Electronic Health Record System (EHR-S) Functional Model. It also includes many standards for data exchange with patient information (Johns 2011, 226).

Which of the following laws created the Healthcare Integrity and Protection Data Bank? a. Health Information Portability and Accountability Act b. American Recovery and Reinvestment Act c. Consolidate Omnibus Budget Reconciliation Act d. Healthcare Quality Improvement Act

Correct Answer: A Health Information Portability and Accountability Act of 1996 (Johns 2011, 692).

35. Health insurance for spouses, children, or both is known as: a. Dependent (family) coverage b. Individual (single) coverage c. Group coverage d. Inclusive coverage

Correct Answer: A Health insurance for spouses, children, or both is known as dependent (family) coverage (Casto and Layman 2011, 5).

50. Which of the following statements is true? a. The higher the relative weight, the higher the payment rates. b. The lower the relative weight, the higher the payment rates. c. The lower the relative weight, the sicker the patient. d. The higher the relative weight, the lesser reimbursement due the facility.

Correct Answer: A Higher relative weights link to higher payment rates (Casto and Layman 2011, 13).

17. Where would a coder who needed to locate the histology of a tissue sample most likely find this information? a. Pathology report b. Progress notes c. Nurse's notes d. Operative report

Correct Answer: A Histology refers to the tissue type of a lesion. The histology of tissue is determined by a pathologist and documented in the pathology report (Johns 2011, 77).

13. A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed? a. Randomly audit EHR documentation for patients readmitted within 30 days b. Survey practitioners to determine if they are following hospital policy c. Institute an in-service program for all hospital personnel d. Observe the documentation practices of all clinical personnel

Correct Answer: A Hospitals must randomly audit EHR documentation to ensure compliance with hospital policy. Readmissions within 30 days serve as a good patient sample for the copy function in the EHR (AHIMA 2012b)

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is: a. UHDDS b. UACDS c. MDS d. ORYX

Correct Answer: A In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (LaTour and Eichenwald Maki 2010, 165).

32. Identify the ICD-9-CM diagnosis code for chondromalacia of the patella. a. 717.7 b. 733.92 c. 748.3 d. 716.86

Correct Answer: A Index Chondromalacia, patella (Schraffenberger 2012, 303-304).

10. Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease. a. 335.20 b. 334.8 c. 335.29 d. 335.2

Correct Answer: A Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is another name for Lou Gehrig's disease. Many diseases carry the name of a person or an eponym. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).

9. Identify the CPT procedure code(s) and correct modifier for a thyroid stimulating hormone (TSH) when medical necessity is not met and the patient signs a required waiver of liability signifying the patient will be responsible for payment if the test is not covered by Medicare. Another name for waiver of liability is Advance Beneficiary Notice (ABN). a. 84443-GA b. 80418-GA c. 84443-GY d. 80418-GY

Correct Answer: A Index Thyroid simulating hormone, 80418, 80438-80440, 84443. Code 84443 is the correct code for a TSH while the rest of the codes are panels including several tests. Modifier -GA is listed in the front cover of the CPT Professional Edition and signifies the patient was given a notice of non-coverage also known as waiver of liability or ABN (AMA 2012b, 427; CMS 2010d; CMS 2010e).

The patient was admitted with major depression severe, recurrent. What is the correct ICD-9-CM diagnosis code assignment for this condition? a. 296.33 b. 296.30 c. 311 d. 296.89

Correct Answer: A Main term: Depression; subterm: recurrent with fifth digit of 3 for severe, without mention of psychotic behavior (Schraffenberger 2012, 143-145).

59. What part of Medicare covers Hospital Insurance that helps cover inpatient hospital, skilled nursing, home health, and hospice care? a. Part A b. Part B c. Part C d. Part D

Correct Answer: A Medicare Part A Hospital Insurance covers inpatient hospital, skilled nursing, home health, and hospice care (Johns 2011, 293).

6. Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of a diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM use them. a. Parentheses ( ) b. Square brackets [ ] c. Slanted brackets [ ] d. Braces { }

Correct Answer: A Parentheses enclose supplementary words or explanatory information that may or may not be present in the statement of a diagnosis or procedure. They do not affect the code number assigned in the case. Terms in parentheses are considered nonessential modifiers, and all three volumes of ICD-9-CM use them. Bronchiectasis (fusiform) (postinfectious) (recurrent) is an example of a diagnosis statement with nonessential modifiers noted with parentheses (Schraffenberger 2012, 26-28).

The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10 mg IV Q 6 PRN." In which of the following would this documentation appear? a. Admission order b. History c. Physical examination d. Progress notes

Correct Answer: A Physician orders are the instructions a physician gives to the other healthcare professionals. Admission and discharge orders should be found for every patient (Johns 2011, 63).

The NCCI editing system used in processing OPPS claims is referred to as: a. Outpatient code editor (OCE) b. Outpatient national editor (ONE) c. Outpatient perspective payment editor (OPPE) d. Outpatient claims editor (OCE)

Correct Answer: A Portions of the NCCI are incorporated into the outpatient code editor (OCE) against which all ambulatory claims are reviewed. The OCE also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services provided (Johns 2011, 348).

11. In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel? a. Report the remaining tests using individual test codes, according to CPT. b. Do not report the remaining individual test codes. c. Report only those test codes that are part of a panel. d. Do not report a test code more than once regardless whether the test was performed twice.

Correct Answer: A Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (AMA 2012b, 402).

80. An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system? a. Role-based b. User-based c. Context-based d. Situation-based

Correct Answer: A Role-based access control (RBAC) is a control system in which access decisions are based on the roles of individual users as part of an organization (Brodnik et al. 2009, 211).

83. Which of the following fails to meet the CMS classification of a hospital-acquired condition? a. Stage I pressure ulcers b. Falls and trauma c. Catheter-associated infection d. Vascular catheter-associated infection

Correct Answer: A Stage I and II pressure ulcers are not considered hospital-acquired conditions but stage III and IV are (Johns 2011, 326).

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis

Correct Answer: A Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from category 634, Spontaneous abortion, or 635, Legally induced abortion, with a fifth digit of "1" (incomplete). This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion (Schraffenberger 2012, 264-266).

8. If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure? a. A "with manipulation" code b. A "without manipulation" code c. An unlisted procedure code d. An E/M code only

Correct Answer: A The "with manipulation" code is used because the fracture was manipulated, even if the manipulation did not result in clinical anatomic alignment. See Musculoskeletal Guidelines, Definitions (AHIMA 2012a, 597).

54. One objective of the Balanced Budget Act (BBA) of 1997 was to: a. Improve program integrity for Medicare by educating beneficiaries to report errors noticed on their explanation of benefits (EOBs) to the Department of Health and Human Services (HHS) b. Improve the quality of care to its beneficiaries by increasing availability to healthcare c. Streamline healthcare costs into one type of payment system for Medicare and Medicaid d. Educate hospital providers how to manage quality care with less reimbursement

Correct Answer: A The Balanced Budget Act of 1997 was incorporated to improve program integrity for Medicare by educating Medicare beneficiaries to be on the watch for errors in billing of services they didn't receive and any other forms of fraudulent activity (Casto and Layman 2011, 37).

A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to: a. Request restrictions on certain uses and disclosures of PHI b. Remove their record from the facility c. Deny provider changes to their PHI d. Delete portions of the record they think are incorrect

Correct Answer: A The HIPAA Privacy Rule provides patients with rights that allow them to have some control over their health information: right of access, right to request amendment of PHI, right to accounting of disclosures, right to request restrictions of PHI, right to request confidential communications, and right to complain of Privacy Rule violations (Johns 2011, 826).

Under the OPPS, on which code set is the APC system primarily based for outpatient procedures and services including devices, drugs, and other covered items? a. CPT/HCPCS b. ICD-9-CM c. CDT d. MS-DRG

Correct Answer: A The Healthcare Common Procedural Coding System (HCPCS) identifies and groups the services within each APC group (Johns 2011, 329).

74. Which of the following provides a complete description to patients about how PHI is used in a healthcare facility? a. Notice of Privacy Practices b. Authorization c. Consent for treatment d. Minimum necessary

Correct Answer: A The NPP explains the patients' rights and the covered entity's legal duties with respect to PHI (Brodnik et al. 2009, 165).

38. The present on admission (POA) indicator is a requirement for a. Inpatient Medicare claims submitted by acute care hospitals b. Inpatient Medicare and Medicaid claims submitted by hospitals c. Medicare claims submitted by all entities d. Inpatient skilled nursing facility Medicare claims

Correct Answer: A The POA indicator applies to diagnosis codes for claims involving inpatient admission to acute-care hospitals or other facilities, as required by law or regulation for public health reporting (Schraffenberger 2012, 58; CMS 2011c, 97-102; Johns 2011, 325).

43. The Privacy Rule applies to: a. All covered entities involved with transmitting or performing any electronic transactions specified in the act b. Healthcare providers only c. Only healthcare providers that receive Medicare reimbursement d. Only entities funded by the federal government

Correct Answer: A The Privacy Rule is applicable to all covered entities involved, either directly or indirectly, with transmitting or performing any electronic transactions specified in the act (Johns 2011, 823).

63. Which of the following is not a function of the discharge summary? a. Providing information about the patient's insurance coverage b. Ensuring the continuity of future care c. Providing information to support the activities of the medical staff review committee d. Providing concise information that can be used to answer information requests

Correct Answer: A The discharge summary provides an overview of the entire medical encounter to ensure the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians, to provide information to support the activities of the medical staff review committee and to provide concise information that can be used to answer information requests from authorized individuals or entities (Johns 2011, 78).

Effective October 16, 2003, under the Administrative Simplification Compliance section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all healthcare providers must electronically submit claims to Medicare. Which is the electronic format for hospital technical fees? a. 837I b. 837P c. UB-04 d. 1500

Correct Answer: A The electronic format for institutional or facility claims is 837I for institutional claims whereas 837P is for professional claims. The UB-04 and the 1500 forms are the paper billing forms for hospital (technical) and clinic (professional) claims, respectively (Casto and Layman 2011, 72).

2. Exceptions to the consent requirement include: a. Medical emergencies b. Provider discretion c. Implied consent d. Informed consent

Correct Answer: A The law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or minor (Brodnik et al. 2009, 99).

17. CCI edit files contain code pairs, called mutually exclusive edits, which prevent payment for: a. Services that cannot reasonably be billed together b. Services that are components of a more comprehensive procedure c. Unnecessary procedures d. Comprehensive procedures

Correct Answer: A The mutually exclusive edit applies to improbable or impossible combinations of codes (Johns 2011, 347).

30. Which of the following is often cited as a reason to implement an electronic health record (EHR)? a. Improve patient safety b. High cost of EHR c. Staff time required to implement the EHR d. Simplicity of implementation changes to workflow

Correct Answer: A The primary benefits of EHRs are quality and patient safety (Johns 2011, 173).

49. Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: "Patient is being admitted for organic brain syndrome." Underneath the diagnosis, her medical information along with her rehabilitation potential were also listed. On which form is this information documented? a. Transfer or referral b. Release of information c. Patient rights acknowledgement d. Admitting physical evaluation

Correct Answer: A The transfer or referral form provides document communication between caregivers in multiple healthcare settings. It is important that a patient's treatment plan be consistent as the patient moves through the healthcare delivery system (Odom-Wesley et al. 2009, 131).

A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. Which is the correct code assignment? a. 553.20, 427.89, V64.3, 54.11 b. 553.20, 997.1, 427.89, 54.19 c. 553.20, 54.11 d. 553.20, 54.11, V64.3

Correct Answer: A The ventral hernia is coded as the primary or first listed diagnosis. The repair of the hernia is not coded because it was not performed; however, code 54.11 is assigned to describe the extent of the procedure, which is an exploratory laparotomy. The V64.3 is coded to indicate the cancelled procedure. Code 427.89 is also used to describe the bradycardia that the patient develops during the procedure (Schraffenberger 2012, 46-47).

87. Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's Coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment. a. V58.83, V58.61 b. V58.83, V58.63 c. V58.61, 790.92 d. V58.61

Correct Answer: A V58.83, Encounter for therapeutic drug monitoring, is the correct code to use when a patient visit is for the sole purpose of undergoing a laboratory test to measure the drug level in the patient's blood or urine or to measure a specific function to assess the effectiveness of the drug. V58.83 may be used alone if the monitoring is for a drug that the patient is on for only a brief period, not long term. However, there is a Use Additional Code note after code V58.83 to remind the coder to use the additional code for any associated long-term drug use with codes V58.61-V58.69 (Schraffenberger 2012, 450-451).

The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost? a. Value-based insurance design (VBID) b. Cost-based reimbursement (CBR) c. Pay for performance design (PPD) d. Prospective payment system (PPS)

Correct Answer: A VBID calculates both the benefit and the costs of clinical services (Casto and Layman 2011, 77).

40. Assignment of benefits is a contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services and to bill the beneficiary only for ________ , and to accept the Medicare payment as payment in full. a. Coinsurance or deductible b. Deductible only c. Coinsurance only d. Balance of charges

Correct Answer: A When a physician accepts assignment of benefits, the physician can only collect any applicable deductible and/or coinsurance from the patient (Casto and Layman 2011, 156).

1. The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which of the following code sets will be reported for this service? a. 600.20, 53852 b. 600.20, 52601 c. 600.00, 53852 d. 222.2, 53850

Correct Answer: A When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20 (AHIMA 2012a, 697).

4. A system that provides alerts and reminders to clinicians is a(n): a. Clinical decision support system b. Electronic data interchange c. Point of care charting system d. Knowledge database

Correct Answer: A Clinical decision support includes providing documentation of clinical findings and procedures, active reminders about medication administration, suggestions for prescribing less expensive but equally effective drugs, protocols for certain health maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-making aids for all stakeholders in the care process (Johns 2011, 138).

44. For coding and billing professionals, being compliant means to perform one's job functions according to the laws, regulations and guidelines with integrity as set forth by Medicare and other third-party payers. This is an example of:: a. Ethics b. Skills c. Behaviors d. Education

Correct Answer: A, Following the AHIMA Standard of Ethical Coding, sets forth guidelines that all coding and billing professionals understand in ethical decision making (Casto and Layman 2011, 34).

What system reimburses hospitals a predetermined amount for each Medicare inpatient admission? a. APR-DRG b. DRG c. APC d. RUG

Correct Answer: B A DRG is a predetermined amount of reimbursement for each Medicare inpatient (Johns 2011, 319).

21. Which of the following threatens the "need-to-know" principle? a. Backdating progress notes b. Blanket authorization c. HIPAA regulations d. Surgical consent

Correct Answer: B A blanket authorization is a common ethical problem when misused. Patients often sign a blanket authorization, which authorizes the release of information from that point forward, without understanding the implications. The problem is the patient is not aware of what information is being accessed (Johns 2011, 778-779).

Which of the following represents documentation of the patient's current and past health status? a. Physical exam b. Medical history c. Physician orders d. Patient consent

Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists his and her past medical, personal, and family history (Johns 2011, 63).

7. Documentation regarding a patient's marital status; dietary, sleep, and exercise patterns; and use of coffee, tobacco, alcohol, and other drugs may be found in the: a. Physical examination record b. History record c. Operative report d. Radiological report

Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists his or her past medical, personal, and family history (Johns 2011, 63).

Which of the following is a condition that arises during hospitalization? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis

Correct Answer: B A complication is a secondary condition that arises during hospitalization and is thought to increase the length of stay by at least one day for approximately 75% of the patients (Johns 2011, 322).

Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court? a. Judicial decision b. Subpoena c. Credential d. Regulation

Correct Answer: B A subpoena is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court (Odom-Wesley et al. 2009, 57).

41. Patient data collection requirements vary according to healthcare setting. One would expect a data element would be collected in the MDS, but would not be collected in the UHDDS. a. Personal identification b. Cognitive patterns c. Procedures and dates d. Principal diagnosis

Correct Answer: B According to UHDDS requirements, answers a, c, and d represent items collected about inpatients. Only answer b represents a data item collected more typically in long-term care settings and required in the MDS (Johns 2011, 98).

1. Data security policies and procedures should be reviewed at least: a. Semi-annually b. Annually c. Every two years d. Quarterly

Correct Answer: B All data security policies and procedures should be reviewed and evaluated at least every year to make sure they are up-to-date and still relevant to the organization (Johns 2011, 995).

99. An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach? a. Audit controls b. Information access controls c. Facility access controls d. Workstation security

Correct Answer: B An EHR can be viewed by multiple users and from multiple locations at any time, and organizations must have in place appropriate security access control measures to ensure the safety of the data (Johns 2011, 435).

A record of all transactions in the computer system that is maintained and reviewed for unauthorized access is called a(n): a. Security breach b. Audit trail c. Unauthorized access d. Privacy trail

Correct Answer: B An audit trail is a record of all transactions in the computer system which is maintained and reviewed for instances of unauthorized access (Johns 2011, 510).

39. Which of the following software applications would be used to aid in the coding function in a physician's office? a. Grouper b. Encoder c. Pricer d. Diagnosis calculator

Correct Answer: B An encoder is a computer software program designed to assist coders assign appropriate clinical codes. An encoder helps ensure accurate reporting of diagnoses and procedures (LaTour and Eichenwald Maki 2010, 318-319).

82. Which of the following software applications would be used to aid in the coding function in a physician ' s office? a. Grouper b. Encoder c. Pricer d. Diagnosis calculator

Correct Answer: B An encoder is a computer software program designed to assist coders in assigning appropriate clinical codes and helps ensure accurate reporting of diagnoses and procedures (LaTour and Eichenwald Maki 2010, 318-319).

8. A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record

Correct Answer: B An incomplete record not rectified within a specific number of days as indicated in the medical staff rules and regulations is considered to be delinquent (Johns 2011, 412).

69. The provider or supplier is prohibited from holding the patient responsible for charges in excess of the Medicare fee schedule. This is called: a. Accept assignment b. Balance billing c. Charge capture d. Inducement

Correct Answer: B Balance billing means the patient cannot be held responsible for charges in excess of the Medicare fee schedule (Johns 2011, 350).

60. Per CPT guidelines, a separate procedure is: a. Coded when it is performed as part of another, larger procedure b. Considered to be an integral part of another, larger service c. Never coded under any circumstance d. Both a and b

Correct Answer: B Because a separate procedure is considered a part of, and integral to, another, larger procedure, it is not coded when performed as part of the more extensive procedure. See Surgery Guidelines. It may, however, be coded when it is not performed as part of another, larger service; therefore, answer "c" is not correct (AHIMA 2012a, 586).

26. Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? a. Unit secretary working on the unit where the patient is located b. Nurse working on the unit where the patient is located c. Health information director d. Admissions registrars

Correct Answer: B Because of the risks associated with miscommunication, verbal orders are discouraged. When a verbal order is necessary, a clinician should sign, give his or her credential (for example, RN, PT, or LPN), and record the date and time the order was received. Verbal orders for medication are usually required to be given to, and to be accepted only by, nursing or pharmacy personnel (Brodnik et al. 2009, 131).

What is the primary use of the case-mix index? a. Benchmark of emergency room levels b. Defines how a hospital compares to peers and whether the facility is at risk c. Audit of APCS and the comparison to same-size hospitals d. A tool for the coding manager to compare coder productivity

Correct Answer: B Benchmarking or peer comparison helps a manager to know how his or her team has performed compared to peers. This includes whether the case-mix index level puts the facility at risk (Casto and Layman 2011, 43).

66. Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

Correct Answer: B Beneficence means promoting good (Johns 2011, 1113).

80. Which of the following situations would be identified by the NCCI edits? a. Determining the MS-DRG b. Billing for two services that are prohibited from being billed on the same day c. Whether data submitted electronically were successfully submitted d. Receiving the remittance advice

Correct Answer: B Billing for two services that are prohibited from being billed on the same day. (Johns 2011, 347).

22. What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims? a. Outpatient Perspective Payment System (OPPS) b. National Correct Coding Initiative (NCCI) c. Ambulatory Payment Classifications (APCs) d. Comprehensive Outpatient Rehab Facilities (CORFs)

Correct Answer: B CMS developed the NCCI to control improper coding practices leading to inappropriate payments in Part B claims (CMS 2012a).

19. What is the best reference tool to determine how CPT codes should be assigned? a. Local coverage determination from Medicare b. American Medical Association's CPT Assistant newsletter c. American Hospital Association's Coding Clinic d. CMS website

Correct Answer: B CPT Assistant provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly (AMA 2012b).

Timely and correct reimbursement is dependent on: a. Adjudication b. Clean claims c. Remittance advice d. Actual charge

Correct Answer: B Clean claims are essential for accurate and timely reimbursement (Casto and Layman 2011, 72).

A patient was discharged with the following diagnoses: "Cerebral occlusion, hemiparesis, and hypertension. The aphasia resolved before the patient was discharged." Which of the following code assignments would be appropriate for this case? 342.90 Hemiparesis affecting unspecified side 342.91 Hemiparesis affecting dominant side 342.92 Hemiparesis affecting nondominant side 434.90 Cerebral artery occlusion unspecified, without mention of cerebral infarction 434.91 Cerebral artery occlusion unspecified with cerebral infarction 401 Hypertension 401.0 Malignant hypertension 401.1 Benign hypertension 401.9 Unspecified hypertension 428.0 Congestive heart failure 784.3 Aphasia a. 434.91, 342.92, 784.3, 401 b. 434.90, 342.90, 784.3, 401.9 c. 434.90, 342.90, 401.9 d. 434.90, 342.90, 784.3, 401.0

Correct Answer: B Code 434.91 is assigned when the diagnosis states stroke, cerebrovascular, or cerebrovascular accident (CVA) without further specification. The health record should be reviewed to make sure nothing more specific is available. Conditions resulting from an acute cerebrovascular disease, such as aphasia or hemiplegia, should be coded as well (Schraffenberger 2012, 198-199).

23. What kind of care offers extensive psychiatric treatment on an outpatient basis with the expectation that the patient's level of functioning will improve so that hospitalization can be avoided? a. Acute hospitalization b. Partial hospitalization c. Outpatient day care d. Short-term care nursing

Correct Answer: B Comprehensive outpatient rehabilitation facility services and mental healthcare provided as part of a partial hospitalization psychiatric program when a physician certifies that inpatient treatment would be required without the partial hospitalization services (Johns 2011, 296).

A threat to data security is: a. Encryption b. Malware c. Audit trail d. Data quality

Correct Answer: B Computer viruses and other malware constitute a threat to data security (Johns 2011, 510).

The HIM department is planning to scan nonelectronic 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 of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization? a. Ad hoc b. Concurrent c. Retrospective d. Post-discharge

Correct Answer: B Concurrent review occurs on a continuing basis during a patient's stay (Johns 2011, 410).

33. Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli. a. 599.0 b. 599.0, 041.49 c. 041.49 d. 041.49, 599.0

Correct Answer: B Connecting words or connecting terms are subterms that indicate a relationship between the main term and an associated condition or etiology in the Alphabetic Index. The connecting term "due to" connects the organism E. coli to the urinary tract infection. The instructional note "Use additional code" is found in the Tabular List of ICD-9-CM. This notation indicates that use of an additional code may provide a more complete picture of the diagnosis or procedure. The additional code should always be assigned if the health record provides supportive documentation. Infection, urinary (tract) Tabular List—use additional code to identify organism. Infection, Escherichia coli (Schraffenberger 2012, 22-23, 79).

The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? a. Data completeness b. Data consistency c. Data accessibility d. Data comprehensiveness

Correct Answer: B Consistent data will be the same each time it is reported or collected (Johns 2011, 47).

Data security refers to: a. Guaranteeing privacy b. Controlling access c. Using uniformed terminology d. Transparency

Correct Answer: B Controlling access—facilities may authorize access to patient data in the facility's computer system to only those who need the access to do their job. This method of control serves the security of the data of patient records (Johns 2011, 510).

A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. Patient receives any monies paid by the insurance companies over and above the charges. b. Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments. c. The decision on which company is primary is based on remittance advice. d. Patient should not have a Medicare supplement.

Correct Answer: B Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments (Johns 2011, 343).

Which of the following is not an element of data quality? a. Accessibility b. Data backup c. Precision d. Relevancy

Correct Answer: B Data quality includes the following characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness (Johns 2011, 43).

The protection measures and tools for safeguarding information and information systems is a definition of: a. Confidentiality b. Data security c. Informational privacy d. Informational access control

Correct Answer: B Data security is the means of ensuring that data are kept safe from corruption and that access to data is suitably controlled (Johns 2011, 919).

93. Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: a. Past medical history b. Social history c. Systems review d. History of present illness

Correct Answer: B Documentation of history of use of drugs, alcohol, and/or tobacco is considered part of the social history. The review of systems is a part of the history of present illness. See E/M Services Guidelines, instructions for selecting a level of E/M service, in the CPT manual (AMA 2011a, 4-7).

95. During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? a. Immediately stop the practice of changing transcribed reports. b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. c. Conduct a verification audit. d. Alert hospital legal counsel of the practice.

Correct Answer: B Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency, continuity, and clarity in documentation (AHIMA 2005).

Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect? a. Category codes b. E codes c. Subcategory codes d. V codes

Correct Answer: B E codes provide a means to describe environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effects (Johns 2011, 242).

This system will require the author to sign onto the system using a user ID and password to complete the entries made. a. Digital dictation b. Electronic signature authentication c. Single sign on technology d. Clinical data repository

Correct Answer: B Electronic signature authentication systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval (Johns 2011, 144).

A health information technician (HIT) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? a. Compliance program education and training programs for all employees in the organization b. Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation c. Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted d. Establish a corporate compliance committee who report directly to the CFO.

Correct Answer: B Establish a process, such as a hotline, to receive complaints and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation (Johns 2011, 259).

A transition technology used by many hospitals to increase access to medical record content is: a. EHR (electronic health record) b. EDMS (electronic document management system) c. ESA (electronic signature authentication) d. PACS (picture archiving and communication system)

Correct Answer: B For hospitals that do not have all EHR components, the result is a hybrid record that is part electronic and part paper. Some hospitals overcome hybrid record issues by scanning all paper documents into an EDMS, thereby making everything available online (Johns 2011, 148).

65. Reimbursement for healthcare services is dependent on patients having a(n): a. Attending physician b. Insurance benefit c. Explanation of benefits d. Qualified provider

Correct Answer: B Generally, reimbursement for healthcare services is dependent on patients having health insurance (Casto and Layman 2011, 3).

34. Each year the OIG develops a work plan that details areas of compliance it will be investigating for that year. What is the expectation of the hospital in relation to the OIG work plan? a. Hospitals are required to follow the same work plan and deploy audits based on that work plan. b. Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan. c. Hospitals must not develop their audits based on the OIG work plan; rather, they must develop their own and look for high-risk areas that need improvement. d. Hospitals must use the plan developed by their state hospital association that is specific to state laws and compliance activities.

Correct Answer: B Hospitals are encouraged but not required to follow the same work plan as the OIG. Hospitals should review the plan carefully and plan their compliance program around the target areas (Johns 2011, 275).

10. What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? a. Vocabulary standard b. Identifier standard c. Structure and content standard d. Security standard

Correct Answer: B Identifier standards establish methods for assigning a unique identifier to individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers (Odom-Wesley et al. 2009, 311).

17. Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to chemotherapy. a. 284.9 b. 284.89 c. 285.9 d. 285.22

Correct Answer: B Index Anemia, aplastic, due to, antineoplastic chemotherapy. A coder should always assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic (Schraffenberger 2012, 133-135 ).

11. Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode. a. 410.11 b. 410.01 c. 410.02 d. 410.12

Correct Answer: B Index Infarction, myocardium, anterolateral (wall) with fifth digit for initial episode (Schraffenberger 2012, 26-28).

What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? a. 58555, 58559 b. 58559 c. 58559, 58740 d. 58555, 58559, 58740

Correct Answer: B Main term of Hysteroscopy; lysis; adhesions (Kuehn 2012, 27, 182-184).

83. What part of Medicare covers physician services, outpatient care and home healthcare? a. Part A b. Part B c. Part C d. Part D

Correct Answer: B Medicare Part B insurance covers physician services, outpatient care, and home healthcare (Johns 2011, 293).

If another status T procedure were performed, how much would the facility receive for the second status T procedure? Billing Number Status Indicator CPT/HCPCS APC 998323 V 99285-25 0612 998324 T 25500 0044 998325 X 72050 0261 998326 S 72128 0283 998327 S 70450 0283 a. 0% b. 50% c. 75% d. 100%

Correct Answer: B Multiple surgical procedures with payment status indicator T performed during the same operative session are discounted. The highest-weighted procedure is fully reimbursed. All other procedures with payment status indicator T are reimbursed at 50% (Casto and Layman 2011, 183).

6. Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? a. Centers for Disease Control (CDC) b. Centers for Medicare and Medicaid Services (CMS) c. National Center for Health Statistics (NCHS) d. World Health Organization (WHO)

Correct Answer: B NCHS is responsible for updating the diagnosis classification (Volumes 1 and 2), and CMS is responsible for updating the procedure classification (Volume 3) (Johns 2011, 239).

2. Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea. a. 780.2 b. 780.2, 787.02 c. 780.2, 787.01 d. 780.4, 787.02

Correct Answer: B Near-syncope and nausea are both signs and symptoms and therefore not integral to the other. Both conditions should be coded (Hazelwood and Venable 2012, 71).

A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

Correct Answer: B Objective information may be measured or observed by the healthcare provider (Johns 2011, 114).

Which of the following make data entry easier, but may harm data quality? a. Use of templates b. Copy and paste c. Drop-down boxes d. Structured data

Correct Answer: B One potential area for poor data quality surrounds the need for making data entry easier. These include "copy and paste," "macros," standard orders, and other techniques that "reuse" data. These techniques can make data entry faster, but care must be taken to ensure appropriate modification to the specific patient (Johns 2011, 182).

40. The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of: a. Confidentiality b. Privacy c. Integrity d. Security

Correct Answer: B Privacy is the right of an individual to be left alone. It includes freedom from observation or intrusion into one's private affairs and the right to maintain control over certain personal and health information (Johns 2011, 755).

83. Mohs micrographic surgery involves the surgeon acting as: a. Both plastic surgeon and general surgeon b. Both surgeon and pathologist c. Both plastic surgeon and dermatologist d. Both dermatologist and pathologist

Correct Answer: B See definitions preceding code 17311 (Mohs micrographic technique) in CPT Professional Edition (AMA 2012b, 79).

A 65-year-old woman was admitted to the hospital. She was diagnosed with septicemia secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? a. 038.8, 562.11, 789.00 b. 038.11, 562.11 c. 038.8, 562.11, 041.11 d. 038.9, 562.11

Correct Answer: B Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms. Code 038.11 is assigned for septicemia with Staphylococcus aureus. Because abdominal pain is a symptom of diverticulosis, only the diverticulitis of the colon (562.11) is coded (Schraffenberger 2012, 80).

Prospective payment systems were developed by the federal government to: a. Increase healthcare access b. Manage Medicare and Medicaid costs c. Implement managed care programs d. Eliminate fee-for-service programs

Correct Answer: B Since 1983, the prospective payment systems have been used to manage the costs of the Medicare and Medicaid programs (Johns 2011, 287, 319).

31. CPT was developed and is maintained by: a. CMS b. AMA c. Cooperating parties d. WHO

Correct Answer: B The AMA developed and maintains CPT. CMS developed and maintains HCPCS Level II codes (AHIMA 2012a, 586).

78. The Joint Commission requires that the medical record delinquency rate quarter averaged from the last four quarterly measurements is not greater than ______ of the average monthly discharge rate. a. 25% b. 50% c. 75% d. 100%

Correct Answer: B The Joint Commission will cite a healthcare organization with a requirement for improvement if the total average health record delinquency exceeds 50 percent of the average monthly discharges in any one quarter (Johns 2011, 609).

91. What is the name of the organization that develops the billing form that hospitals are required to use? a. American Academy of Billing Forms (AABF) b. National Uniform Billing Committee (NUBC) c. National Uniform Claims Committee (NUCC) d. American Billing and Claims Academy (ABCA)

Correct Answer: B The NUBC was established with the goal of developing an acceptable, uniform bill that would consolidate the numerous billing forms hospitals were required to use (Schraffenberger 2012, 65).

The term minimum necessary means that healthcare providers and other covered entities must limit use, access, and disclosure to the minimum necessary to: a. Satisfy one's curiosity b. Accomplish the intended purpose c. Treat an individual d. Perform research

Correct Answer: B The Privacy Rule introduced the standard of minimum necessary to limit the amount of PHI used, disclosed, and requested. This means that healthcare providers and other covered entities must limit uses, disclosures, and requests to only the amount needed to accomplish the intended purpose (Johns 2011, 822).

76. Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system? a. Diagnosis-related groups b. Resource-based relative value scale system c. Long-term care drugs d. Resource utilization groups

Correct Answer: B The RBRVS system is the federal government's payment system for physicians. It is a system of classifying health services based on the cost of furnishing physicians' services in different settings, the skill and training levels required to perform the services, and the time and risk involved (Casto and Layman 2011, 151).

47. Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Reason for encounter c. Discharge diagnosis d. Activities of daily living

Correct Answer: B The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider (LaTour and Eichenwald Maki 2010, 166).

This is a program unveiled in 1998 by the OIG that encourages healthcare providers to report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs. a. World Health Organization b. Voluntary Disclosure Program c. Compliance Disclosure Program d. Fraud and Abuse Program

Correct Answer: B The Voluntary Disclosure program was introduced in 1998 by the OIG to encourage healthcare providers to voluntarily report fraudulent conduct affecting federal payers (Johns 2011, 358).

79. An 8-year-old male hemophiliac is admitted with acute blood loss anemia due to uncontrolled bleeding. He is given clotting factor and six units of whole blood. Which of the following diagnosis and procedure ICD-9-CM codes would be correct? a. 286.0, 99.06, 99.03 b. 285.1, 286.0, 99.06, 99.03 c. 286.0, 285.1, 99.06, 99.03 d. 285.1, 99.06, 99.03

Correct Answer: B The anemia code 285.1 would be coded as the principal diagnosis. In accordance with the UHDDS definition for principal diagnosis, the anemia (not the hemophilia), is the reason for admission and sequenced as the principal diagnosis (CMS 2010c, Section II, 96; AHIMA 2012a, 646).

87. A ventilator-dependent patient (due to chronic obstructive pulmonary disease emphysema) is admitted to the hospital at 10 a.m. on January 1. He is admitted for dehydration and is placed on the hospital's ventilator upon admission. The patient is discharged January 5 at 1 p.m. What is the appropriate code assignment? a. 492.8, 276.51, 96.72 b. 276.51, 492.8, V46.11, 96.72 c. 276.51, 496, V46.11, 96.71 d. 492.8, 276.51, V46.11, 96.72

Correct Answer: B The dehydration is the reason for admission and should be listed as the principal diagnosis. The mechanical ventilation was for 96 continuous hours or more, code 96.72. The code for the ventilator-dependence also should be coded (AHIMA 2012a, 682).

8. Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusions of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied. Which is the correct code assignment? a. 808.1, E881.0, E849.0, 79.25, 78.15 b. 808.1, 920, E881.0, E849.0, E000.8, E013.9, 79.25, 78.15, 79.65 c. 808.0, E881.0, E000.8, E013.9, 79.35, 79.65 d. 808.1, E881.0, E849.0, E013.9, 79.25, 78.15, 79.65

Correct Answer: B The fracture is the principal diagnosis, with the contusions as a secondary diagnosis. The fracture is what required the most treatment. Procedures for the reduction, debridement, and external fixation device would all need to be coded (Schraffenberger 2012, 354-355).

91. Two patients were hospitalized with bacterial pneumonia. One patient was hospitalized for three days and the other patient was hospitalized for 30 days. Both cases result in the same DRG with different lengths of stay. Which answer most closely describes how the hospital will be reimbursed? a. The hospital will receive the same DRG for both patients but additional reimbursement will be allowed for the patient who stayed 30 days because the length of stay was greater than the geometric length of stay for this DRG. b. The hospital will receive the same reimbursement for the same DRG regardless of the length of stay. c. The hospital can appeal the payment for the patient who was in the hospital for 30 days because the cost of care was significantly higher than the average length of stay for the DRG payment. d. The hospital will receive a day outlier for the patient who was hospitalized for 30 days.

Correct Answer: B The hospital will receive the same reimbursement regardless of the length of stay (Casto and Layman 2011, 12).

70. What is the term used for the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business, or payment purposes? a. Minimum data record b. Legal health record c. Mixed-media health record d. Electronic health record

Correct Answer: B The legal health record is the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business, or payment purposes (Odom-Wesley et al. 2009, 24).

12. A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. The patient receives any monies paid by the insurance companies over and above the charges. b. Monies paid to the healthcare provider cannot exceed charges. c. The decision on which company is primary is based on remittance advice. d. The patient should not have a Medicare supplement.

Correct Answer: B The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Johns 2011, 343).

15. This document includes a microscopic description of tissue excised during surgery: a. Recovery room record b. Pathology report c. Operative report d. Discharge summary

Correct Answer: B The pathology report describes specimens examined by the pathologist (Johns 2011, 77).

A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient? a. Abdominal pain b. Cholecystitis c. Hypertension d. Diabetes

Correct Answer: B The principal diagnosis determines the MDC assignment (Johns 2011, 322).

57. The attending physician is responsible for which of the following types of acute care documentation? a. Consultation report b. Discharge summary c. Laboratory report d. Pathology report

Correct Answer: B The results of radiological and pathological procedures require interpretation by specially trained physicians called radiologists and pathologists. These physicians document their findings in written reports. The consultation report documents the clinical opinion of a physician other than the primary or attending physician (Johns 2011, 78).

One form of _______ uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals. a. Integrated workflow processes b. Computer-assisted coding c. Electronic document management system d. Speech recognition system

Correct Answer: B There are several different types of computer-assisted coding (CAC), including software to aid the physicians (Johns 2011, 270).

68. Which of the following is a threat to data security? a. Encryption b. People c. Red flags d. Access controls

Correct Answer: B Threats to data security caused by people can be classified as threats from insiders who make unintentional mistakes, threats from insiders who abuse their access privileges to information, threats from insiders who access information or computer systems for spite or profit, threats from insiders who attempt to access information or steal physical resources, and from vengeful employees or outsiders who mount attacks on the organization's information systems (Johns 2011, 987).

When a provider accepts assignment, this means the: a. Patient authorizes payment to be made directly to the provider b. The provider agrees to accept as payment in full the allowed charge from the fee schedule c. Balance billing is allowed on patient accounts, but at a limited rate d. Participating provider receives a fee-for-service reimbursement

Correct Answer: B To accept assignment means the provider or supplier accepts, as payment in full, the allowed charge from the fee schedule (Johns 2011, 350).

12. An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of: a. Optimizing b. Unbundling c. Sequencing d. Classifying

Correct Answer: B Unbundling occurs when a panel code exists and the individual tests are reported rather than the panel code (AMA 2012b, 402).

Which of the following statements is false? a. A notice of privacy practices must be written in plain language. b. Consent for use and disclosure of information must be obtained from every patient. c. An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations. d. A notice of privacy practices must give an example of a use or disclosure for healthcare operations.

Correct Answer: B Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personally identifiable information for treatment, payment, or healthcare operations (Johns 2011, 838).

24. Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications. a. 204.00, 787.01, V58.11 b. V58.11, 204.00, 787.01 c. V58.11, 204.00 d. 204.22, 787.01

Correct Answer: B When a patient is admitted for the purpose of radiotherapy, chemotherapy, or immunotherapy and develops a complication, such as uncontrolled nausea and vomiting or dehydration, the principal diagnosis is the admission for radiotherapy (V58.0), the admission for the antineoplastic chemotherapy (V58.11), or the admission for the antineoplastic immunotherapy (V58.12). Additional codes would include the cancer and the complication(s) (Hazelwood and Venable 2012, 103).

20. Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)? a. Make admission date a required field b. Provide an input mask for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data

Correct Answer: B When several people enter data in an EHR, you can define how users must enter data in specific fields to help maintain consistency. For example, an input mask for a form means that users can only enter the date in a specified format (MacDonald 2007, chapter 4).

35. The _____ may contain information about diseases among relatives in which heredity may play a role. a. Physical examination b. History c. Laboratory report d. Administrative data

Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Johns 2011, 63).

The following is documented in an acute-care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear? a. Admission note b. Consultation report c. Discharge summary d. Nursing progress notes

Correct Answer: B A consultation report includes the recommendations of a consulting physician who is requested to evaluate a patient (Johns 2011, 78).

57. Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? a. Client-server computer b. Data warehouse c. Local area network d. Internet

Correct Answer: B A data warehouse is a special type of database that consolidates and stores data from various databases (Johns 2011, 909).

92. This is a statement sent by third-party payers to the patient to explain services provided, amounts billed, and payments made by the health plan. a. Coordination of benefits (COB) b. Explanation of benefits (EOB) c. Medicare summary notice (MSN) d. Remittance advice (RA)

Correct Answer: B An EOB is a statement sent by a third-party payer to the patient to explain the services provided (Johns 2011, 343).

51. A coder needs to locate electronic health records for a patient across a health information exchange (HIE). What tool(s) should the coder use? a. Certification b. Identity-matching algorithm and record locator service c. Interoperability and certification d. Meaningful use

Correct Answer: B An HIE organization requires an identity-matching algorithm and record locator service (RLS). An identity-matching algorithm must be used by the HIE to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients. The RLS, then, is a process that seeks information about where a patient may have a health record available to the HIE organization (Johns 2011, 151).

58. How frequently are Category III CPT codes updated? a. Annually b. Semiannually c. Every two years d. Every four months

Correct Answer: B An instructional note has been added to the introductory language under Category III codes in the CPT Professional Edition. "New codes in this section are released semi-annually via the AMA/CPT internet site, to expedite dissemination for reporting. The full set of temporary codes for emerging technology, services, and procedures are published annually in the CPT codebook." (AMA 2012b, 553).

9. What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principal and secondary diagnoses? a. 35 b. 25 c. 18 d. 9

Correct Answer: B As of January 1, 2011, CMS allows a total of 25 ICD-9-CM diagnosis codes (one principal and 24 additional diagnoses) for 837 Institutional claims filing (Schraffenberger 2012, 66).

51. A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended? a. User name and password b. Automatic session terminations c. Cable locks d. Encryption

Correct Answer: B Automatic session termination will help to control access to the computer when unattended by automatically ending the session when not in use, preventing unauthorized access (HHS 2006a).

16. CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set? a. Diagnosis-related groups b. HCPCS/CPT codes c. ICD-9-CM diagnosis and procedure codes d. Resource utilization groups

Correct Answer: B CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system which pays providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2012b).

65. The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for: a. Part A Medicare claims b. Part B Medicare claims c. Medicaid claims d. Medicare and Medicaid claims

Correct Answer: B CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims (Johns 2011, 347).

68. Code 87900, infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics, is used in the management of patients with what disease? a. Cancer patients on toxic chemotherapy agents b. HIV patients on antiretroviral therapy c. Tuberculosis patients on rifampin therapy d. Organ transplant patients on immunosuppressive therapy

Correct Answer: B CPT code 87900 for infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics is used in the management of HIV patients on antiretroviral therapy (AMA 2012b, 442).

32. A 75-year-old male patient was admitted for an acute exacerbation of chronic systolic congestive heart failure and severe mitral regurgitation and aortic stenosis. What would be the correct code assignment for this case? a. 428.23, 396.2 b. 428.23, 428.0, 396.2 c. 428.0, 394.1, 424.1 d. 391.8, 396.2

Correct Answer: B Code 428.23, 428.0 and 396.2 2 would be the correct codes with 428.23 serving as the principal diagnosis. Code 428.23 is described as systolic heart failure in acute and chronic conditions. The code for mitral valve insufficiency and aortic valve stenosis is a combination code of 396.2. Code 428.0 is not an inherent component of diastolic or systolic heart failure and must be coded separately (AHIMA 2012a, 651).

76. After a deductible has been paid, insured and insurer share covered losses according to a specified ratio, and the insured pays a(n) _________ amount. a. Out-of-pocket expense b. Coinsurance c. Deductible d. Premium

Correct Answer: B Coinsurance refers to the amount the insured pays as a requirement of the insurance policy to share covered losses by insurer and insured (Johns 2011, 288).

100. The ______ is a type of coding that is a natural outgrowth of the EHR. a. Automated codebook b. Computer-assisted coding c. Logic based encoder d. Decision support database

Correct Answer: B Computer-assisted coding is defined as the use of computer software that automatically generates a set of medical codes for review, validation, and use based on the documentation from the various providers of healthcare (AHIMA 2010b, 62; LaTour and Eichenwald Maki 2010, 400).

What is the legal term used to define the protection of health information in a patient-provider relationship? a. Access b. Confidentiality c. Privacy d. Security

Correct Answer: B Confidentiality is a legal ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure (Brodnik et al. 2009, 6).

89. What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) program? a. Medicare administrative contractors (MACs) b. Recovery audit contractors (RACs) c. Comprehensive error rate testing (CERT) d. Fiscal intermediaries (FIs)

Correct Answer: B Congress directed HHS to conduct a three-year demonstration project using RACs to detect and correct improper payments in the Medicare traditional fee-for-service program. Congress further required HHS to make the RAC program permanent and nationwide by January 1, 2010 (Schraffenberger 2012, 475).

Which of the following is not reimbursed according to the Medicare outpatient prospective payment system? a. CMHC partial hospitalization services b. Critical access hospitals c. Hospital outpatient departments d. Vaccines provided by CORFs

Correct Answer: B Critical access hospitals are paid on a cost-based payment system and are not part of the prospective payment system (Johns 2011, 330).

71. If a nurse uses the abbreviation CPR to mean cardiopulmonary resuscitation one time and computer-based patient record another time, leading to confusion if the chart were audited would be a concern when applying this dimension of data quality? a. Accuracy b. Granularity c. Precision d. Currency

Correct Answer: B Data quality needs to be consistent. A difference in the use of abbreviations provides a good example of how the lack of consistency can lead to problems (LaTour and Eichenwald Maki 2010, 119).

Deidentified information: a. Does identify an individual b. Is information from which personal characteristics have been stripped c. Can be later constituted or combined to re-identify an individual d. Pertains to a person that is identified within the information

Correct Answer: B Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped (Johns 2011, 826).

78. How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form? a. By requesting the medical record for each service provided b. By reviewing all the diagnosis codes assigned to explain the reasons the services were provided c. By reviewing all physician orders d. By reviewing the discharge summary and history and physical for the patient over the last year

Correct Answer: B Diagnosis codes are often the primary reason for a service to be considered covered or denied by the insurance company. Local and national policies include diagnosis codes that are used in software edits to automatically deny or approve processed claims. Denied services can be appealed and the record can be submitted to support medical necessity if the service fails the automated review (Schraffenberger 2012, 476).

The MS-DRG system creates a hospital's case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of within that MS-DRG. a. Admissions b. Discharges c. CCs d. MCCs

Correct Answer: B Discharges. The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG (Johns 2011, 324).

27. Which of the following statements does not pertain to electronic health records (EHRs)? a. EHR technologies and systems must not intrude on the patient and provider relationship. b. EHRs are filed in paper folders. c. In the United States, a national health information infrastructure is being designed to support EHRs. d. Clinicians may use computer keyboards when documenting in the EHR.

Correct Answer: B EHRs store information in electronic format rather than paper-based media (Johns 2011, 135).

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina c. Gastroenteritis; abdominal pain; angina d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina

Correct Answer: B Gastroenteritis is characterized by diarrhea, nausea, and vomiting, and abdominal cramps. Codes for symptoms, signs, and ill-defined conditions from Chapter 16 of the CPT codebook are not to be used as the principal diagnosis when a related definitive diagnosis has been established. Patients can have several chronic conditions that coexist at the time of their hospital admission and qualify as additional diagnosis such as COPD and angina (Schraffenberger 2012, 66-68, 71-72, 236).

73. Identify the ICD-9-CM diagnostic code(s) for the following: threatened abortion with hemorrhage at 15 weeks; home undelivered. a. 640.01, 640.91 b. 640.03 c. 640.83 d. 640.80

Correct Answer: B Index Abortion, threatened 640.0. Refer to the ICD-9-CM Tabular List (640-649) for the correct fifth digit of 3, antepartum condition, not delivered (Schraffenberger 2012, 274-275).

20. Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block. a. 426.3, 426.4 b. 426.53 c. 426.4, 426.53 d. 426.52

Correct Answer: B Index Block, left, with right bundle branch block. Right and left bundle branch block is inclusive of one code. It is inappropriate to assign a code for right (426.4) and left (426.3) bundle branch block when a combination code includes both the right and left (Schraffenberger 2012, 201-207).

7. Identify the CPT procedure code(s) for an automated CBC with automated differential. a. 85027 b. 85025 c. 85041 d. 85007, 85025

Correct Answer: B Index Blood Cell Count, hemogram, added indices, resulting in code range 85025-85027. The codes for reporting CBCs (complete blood counts) are very specific and should be carefully reviewed. The appropriate code for a CBC with automated white blood cell differential is 85025 (AHIMA 2012a, 628).

43. Identify the CPT procedure code(s) for laparoscopic Nissen fundoplication. a. 43279 b. 43280 c. 43327 d. 43289

Correct Answer: B Index Fundoplasty, esophagogastric, laparoscopic, resulting in code 43280. Indexing the main term Nissen operation results in this cross-reference: see fundoplasty, esophagogastric, laparoscopic, results in code 43280 (AHIMA 2012a, 608).

79. Which of the following is (are) the correct ICD-9-CM code(s) for thoracoscopic lobectomy of left lung? a. 32.30 b. 32.41 c. 32.49 d. 34.02, 32.41

Correct Answer: B Index Lobectomy, lung, segmental (with resection of adjacent lobes), thoracoscopic. Segmental includes the complete excision of a lobe of the lung (Schraffenberger 2012, 227-228).

Identify the diagnosis code(s) for melanoma of skin of shoulder. a. 172.8, 172.6 b. 172.6 c. 172.9 d. 172.8

Correct Answer: B Index Melanoma (malignant), shoulder. Melanoma is considered a malignant neoplasm and is referenced as such in the index of ICD-9-CM. The term "benign neoplasm" is considered a growth that does not invade adjacent structures or spread to distant sites but may displace or exert pressure on adjacent structures (Schraffenberger 2012, 94-95).

51. Identify the appropriate CPT code(s) for 23 minutes of therapeutic exercise. a. 97110 b. 97110, 97110 c. 97110, 97110, 97110 d. 97110-50

Correct Answer: B Index Physical Medicine/Therapy/Occupational Therapy, procedures, therapeutic exercises, resulting in code 97110. Review of the code indicates that it is reported in 15-minute increments. Thus, a 23-minutes session would be reported with code 97110 twice because a unit of time must be at least 8 minutes at a minimum, which the second unit meets the 8-minute minimum (AHIMA 2012a, 633).

72. Identify the ICD-9-CM code for diaper rash, elderly patient. a. 690.10 b. 691.0 c. 782.1 d. 705.1

Correct Answer: B Index Rash, diaper. ICD-9-CM classifies dermatitis to categories 690-694. Atopic dermatitis and related conditions are specific to category 691. Fourth-digit subcategories include diaper or napkin rash and other atopic dermatitis and related conditions (Schraffenberger 2012, 292).

15. Identify the CPT procedure code(s) for ultrasound, pregnant uterus, fetal and maternal evaluation, second trimester, single gestation. a. 76700 b. 76805 c. 76801 d. 76813

Correct Answer: B Index Ultrasound, pregnant uterus, resulting in code range 76801-76817. Review of the available codes indicates that code 76805 is the appropriate code (AHIMA 2012a, 625).

4. What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation? a. 46255 b. 46930 c. 46260 d. 46945

Correct Answer: B Index main term: Destruction, hemorrhoid, thermal. Thermal includes infrared coagulation (Kuehn 2012, 27, 163).

66. The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced.

Correct Answer: B It is suggested that covered entities use PHI with certain specified direct identifiers removed as a guideline for disclosing only minimum necessary information while providing the amount needed to accomplish the intended purpose (Johns 2011, 822).

85. Which of the following would not be found in a medical history? a. Chief complaint b. Vital signs c. Present illness d. Review of systems

Correct Answer: B Medical history documents the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history. The physical examination report represents the attending physician's assessment of the patient's current health status (Johns 2011, 63).

Medicare's newest claims processing payment contract entities are referred to as: a. Recovery audit contractors (RACs) b. Medicare administrative contractors (MACs) c. Fiscal intermediaries (FIs) d. Office of Inspector General contractors (OIGCs)

Correct Answer: B Medicare administrative contractors (MACs) are replacing the claims payment contractors known as FIs and carriers (Casto and Layman 2011, 254).

5. Which statement fails to be true for Medicare coverage? a. Medicare pays for healthcare services provided to Social Security beneficiaries 65 years old and older b. Medicare pays for healthcare services provided to Social Security beneficiaries for new moms 65 years and younger and their newborn babies c. Medicare pays for healthcare services provided to Social Security beneficiaries for people under 65 years old with certain disabilities d. Medicare pays for healthcare services provided to Social Security beneficiaries for people of all ages with end-stage renal disease

Correct Answer: B Medicare does not cover moms and newborn babies unless the mother has a disability. Moms and newborn babies can be covered under the Medicaid program if they meet specific income guidelines (Johns 2011, 293, 301).

One form of _______ computer assisted coding may use, which means that digital text from online documents stored in the information system is read directly by the software which then suggests codes to match the documentation. a. Encoded vocabulary b. Natural-language processing c. Data exchange standards d. Structured reports

Correct Answer: B Natural-language processing (NLP) is an artificial intelligence software that reads digital text from online documents and suggests codes to match the documentation (Johns 2011, 270).

25. Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? a. Patient management b. New technology c. Therapeutic, preventative, or other interventions d. Patient safety

Correct Answer: B New technology is addressed by the Category III codes (AHIMA 2012a, 584).

Notices of privacy practices must be available at the site where the individual is treated and: a. Must be posted next to the entrance b. Must be posted in a prominent place where it is reasonable to expect that patients will read them c. May be posted anywhere at the site d. Do not have to be posted at the site

Correct Answer: B Notices of privacy must be posted in a prominent place where it is reasonable to expect that patients will read them (Johns 2011, 836).

What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of practice, and the risk of malpractice? a. DRGs b. RVUs c. CPT d. SVR

Correct Answer: B Relative value units (RVUs) are assigned to each service to provide a value that correlates to payment (Casto and Layman 2011, 152).

An encoder that is built using expert system techniques such as rule-based systems is a(n): a. Encoder interface b. Logic-based encoder c. Automated code book encoder d. Grouper

Correct Answer: B Some encoders are built using expert system techniques such as rule-based systems, and other encoding software is more simplistic, merely automating a look-up function similar to the manual index in ICD or other coding classifications (Johns 2011, 269).

94. This was passed during the Civil War in order to prohibit contractors of any kind from knowingly filing a false or fraudulent claim, using a false record or statement, or conspiring to defraud the US government. a. American Reinvestment and Recovery Act b. False Claims Act c. False Claims ActBalanced Budget Refinement Act d. Civil Anti-trust Act

Correct Answer: B The False Claims Act was passed during the Civil War in an effort to prevent false use of claims and records from defrauding the US government. Today the federal government can rebuke abusers of the Medicare and Medicaid systems (Casto and Layman 2011, 35).

55. MS-DRG may be split into a maximum of _______ payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC; or no CC. a. Two b. Three c. Four d. Five

Correct Answer: B The Medicare IPPS categorizes diagnosis and procedure codes. The diagnosis codes may qualify for a major complication or comorbidity (MCC), or other complication or comorbidity (CC). A diagnosis code may not qualify for either, allowing diagnosis codes to be grouped into three higher or lower DRG groupings (Schraffenberger 2012, 57; Johns 2011, 322-323).

36. This program was initiated by the Balanced Budget Act of 1997 and allows states to expand existing insurance programs to cover children up to age 19. a. Children's State Medicare Program (CSMP) b. State Children's Health Insurance Program (SCHIP)) c. Children's State Healthcare Alliance (CSHA) d. Children's Aid to Healthcare (CAH)

Correct Answer: B The State Children's Health Insurance Program (SCHIP) (Title XXI of the Social Security Act) provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children (Johns 2011, 304).

Which of the following statements is not true about a business associate agreement? a. It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity. b. It allows the business associate to maintain PHI indefinitely. c. It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule. d. It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the Department of Health and Human Services or its agents.

Correct Answer: B The agreement between the covered entity and business associate should, at termination of the contract, require the business associate to return or destroy all PHI received from the covered entity that it still maintains and prohibit the associate from retaining it (Johns 2011, 824).

74. To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of health records? a. Retrospectively review each patient's medical record to make sure history and physicals are present. b. Review each patient's medical record concurrently to make sure history and physicals are present and meet the accreditation standards. c. Establish a process to review medical records immediately on discharge. d. Do a review of records for all patients discharged in the previous 60 days.

Correct Answer: B The benefit of concurrent review is that content or authentication issues can be identified at the time of patient care and rectified in a timely manner (Johns 2011, 410).

49. When the CCI editor flags that a comprehensive code and a component code are billed together for the same beneficiary on the same date of service, Medicare will pay for: a. The component code but not the comprehensive code b. The comprehensive but not the component code c. The comprehensive and the component codes d. Neither the comprehensive nor the component codes

Correct Answer: B The component code is integral to the comprehensive code and should not be billed separately (CMS 2012a).

What is the function of a consultation report? a. Provides a chronological summary of the patient's medical history and illness b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care c. Concisely summarizes the patient's treatment and stay in the hospital d. Documents the physician's instructions to other parties involved in providing care to a patient

Correct Answer: B The consultation report documents the clinical opinion of a physician other than the primary or attending physician (Johns 2011, 78).

14. The patient presented through the ED with severe abdominal pain, amenorrhea. Serum human chorionic gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient diagnosed with tubal pregnancy. A unilateral salpingectomy with removal of tubal pregnancy was performed. Which of the following is the correct code assignment? a. 633.80, 66.62 b. 633.10, 66.62 c. 633.10, 66.4 d. 633.10, 66.02

Correct Answer: B The ectopic pregnancy was documented as tubal. The salpingectomy was "with removal of tubal pregnancy." The procedure performed was a salpingectomy, not a salpingostomy (AHIMA 2012a, 679).

38. The electronic claim format (837I) replaces which paper billing form? a. CMS-1500 b. CMS-1450 (UB-04) c. UB-92 d. CMS-1400

Correct Answer: B The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing form (Johns 2011, 343).

Under the Medicare hospital outpatient perspective payment system (OPPS), services are paid according to: a. A fee-for-service schedule basis that varies according to the MPFS b. A rate-per-service basis that varies according to the ambulatory payment classification (APC) group to which the service is assigned c. A cost-to-charge ratio based on the hospital cost report d. A rate-per-service basis that varies according to the DRG group

Correct Answer: B The payment varies based on the APC group (Johns 2011, 329).

What is a guarantor? a. The patient who is an inpatient b. The person responsible for the bill, such as a parent c. The person who bills the patient, such as the Medicare biller d. The patient who is an outpatient

Correct Answer: B The person responsible for the bill is the guarantor (Casto and Layman 2011, 8).

4. In an EHR, what is the risk of copying and pasting? a. Reduction in the time required to document b. The system not recording who entered the data c. Quicker overall system response time d. System thinking that the original documenter recorded the note

Correct Answer: B The system not recording who entered the data (Johns 2011, 433).

These codes are used to assign a diagnosis to a patient who is seeking health services, but is not necessarily sick. a. E codes b. V codes c. M codes d. C codes

Correct Answer: B V codes are diagnosis codes and indicate a reason for healthcare encounter (Schraffenberger 2012, 433).

9. A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? a. Chart deficiency system b. Chart tracking system c. Chart abstracting system d. Chart encoder

Correct Answer: B With an automated tracking system, it is easy to track how many records are charged out of the system, their location, and whether they have been returned on the due dates indicated (Johns 2011, 402).

19. In determining the data collection requirements for Medicare patients in a long-term care facility, the health information technician would consult standards from: a. CARF b. CMS c. The Joint Commission d. NCQA

Correct Answer: B The CMS has Conditions of Participation that apply to healthcare organizations that participate in the Medicare program (Johns 2011, 98).

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. a. 31622, 31640 b. 31622, 31623 c. 31623 d. 31625

Correct Answer: C A bronchoscopy with brushings and washings is considered a diagnostic bronchoscopy and not a biopsy. Code 31623 specifies brushings, and code 31622 is selected for washings (Kuehn 2012, 136-137).

To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within _____ days. a. 10 b. 20 c. 30 d. 60

Correct Answer: C A covered entity must act on an individual's request for review of PHI no later than 30 days after the request is made (Johns 2011, 831).

A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus d. Chronic obstructive asthma

Correct Answer: C A patient in status asthmaticus fails to respond to therapy administered during an asthmatic attack. This is a life-threatening condition that requires emergency care and likely hospitalization (Schraffenberger 2012, 222-223).

54. What is the best reference tool for ICD-9-CM coding advice? a. AMA's CPT Assistant b. AHA's Coding Clinic for HCPCS c. AHA's Coding Clinic for ICD-9-CM d. National Correct Coding Initiative (NCCI)

Correct Answer: C AHA's Coding Clinic for ICD-9-CM is a quarterly publication of the Central Office on ICD-9-CM, which allows coders to submit a request for coding advice through the coding publication.

36. In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. The patient, however, was discharged two days later. In this case, what would be the best course of action? a. Request that the physician dictate another discharge summary. b. Have the record analyst note the date discrepancy. c. Request the physician dictate an addendum to the discharge summary. d. File the record as complete because the discharge summary includes all of the pertinent patient information.

Correct Answer: C An addendum may be included in the medical record to update or supplement documentation that has been recorded (AHIMA 2008b, 83-88).

40. An infusion that lasts less than 15 minutes would be reported with a(n): a. Intravenous infusion code b. Intravenous piggyback code c. Intravenous or intra-arterial push code d. Intravenous hydration code

Correct Answer: C An infusion that lasts less than 15 minutes should be reported with an IV push code per the CPT coding guidelines of the CPT Professional Edition based on the instructional notes preceding the hydration notes (AMA 2012b, 518; AHIMA 2012a, 630).

50. The HIM director is having difficulty with the on-call physicians in the emergency services department completing their health records. Currently, three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Routinely send out a fourth notice b. Post the hospital policy in the emergency department c. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices d. Call the Joint Commission

Correct Answer: C As part of the decision making process, the HIM director should analyze the problem and develop alternative solutions (Johns 2011, 410-412).

47. In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ______ systems. a. MIS b. CDS c. ADT d. ABC

Correct Answer: C Automated systems for registering patients and tracking their encounters are commonly known as admission-discharge-transfer (ADT) systems (Johns 2011, 947).

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? a. Require all coders to implement this practice b. Report the practice to the OIG c. Counsel the coder and stop the practice immediately d. Put the coder on unpaid leave of absence

Correct Answer: C Be sure the employees receive appropriate compliance training and continue ongoing training for all employees (Johns 2011, 361-362).

100. The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management

Correct Answer: C Because federal regulations such as HIPAA and state laws govern the release of health record information, HIM department personnel must know what information needs to be included on the authorization for it to be considered valid (Johns 2011, 443).

10. Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? a. 49565 b. 49565, 49568 c. 49656 d. 49560, 49568

Correct Answer: C Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope, and is reducible makes the choice 49656. Notice that the use of mesh is included in the code (Kuehn 2012, 27, 164-166).

30. A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain: a. Moderate rate increases b. Market basket increases c. Budget neutrality d. Sustainable growth rate

Correct Answer: C Budget neutrality must be maintained annually when the RVUs are adjusted (Casto and Layman 2011, 156).

67. CMS identified conditions that are not present on admission and could be "reasonably preventable," and therefore hospitals are not allowed to receive additional payment for these conditions that do present. What are these conditions called? a. a Conditions of Participation b. Present on admission c. Hospital-acquired conditions d. Hospital-acquired infection

Correct Answer: C CMS identified hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals do not receive additional payment for cases in which these cases are present (Johns 2011, 326).

5. What are four-digit ICD-9-CM diagnosis codes referred to as? a. Category codes b. Section codes c. Subcategory codes d. Subclassification codes

Correct Answer: C Categories are divided into subcategories. At this level, four-digit code numbers are used (Johns 2011, 240).

45. Identify the CPT code(s) for the following patient: A 2-year-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance. a. 43752 b. 43761 c. 43761, 76000 d. 49450

Correct Answer: C Code 43761 is assigned to report repositioning of a nasogastric or orogastric feeding tube through the duodenum. An instructional note guides the coder to report code 76000 when image guidance is performed (AMA 2012b, 235).

The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) and/or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting? a. 97113 b. 97113-50 c. 97113, 97113 d. 97110

Correct Answer: C Code 97113, Therapeutic procedure, 1 or more areas, each 15 minutes of aquatic therapy with therapeutic exercises, is billable per 15 minutes of therapy. The patient was treated for 30 minutes; therefore code 97113 should be reported twice. Modifier -50 is not applicable because the service is not a bilateral procedure (Smith 2012, 239).

11. The use of computer software that automatically generates a set of medical codes for review, validation, and use based on clinical documentation provided by healthcare practitioners is the definition of: a. Natural language processing b. Voice recognition c. Computer-assisted coding d. Electronic health record

Correct Answer: C Computer-assisted coding utilizes computer software to generate codes from the data provided (Sayles and Trawick 2010, 360).

28. Which of the following definitions best describes the concept of confidentiality? a. The right of individuals to control access to their personal health information b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

Correct Answer: C Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose (Johns 2011, 49).

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? a. Data completeness b. Data relevancy c. Data currency d. Data precision

Correct Answer: C Data currency and data timeliness refer to the requirement that healthcare data should be up-to-date and recorded at or near the time of the event or observation (Johns 2011, 48).

13. Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition. a. 250.02 b. 250.01, 263.1 c. 250.02, 263.1 d. 250.01, 263.0

Correct Answer: C Diabetes (without complication) with fifth digit of 2 = type II, uncontrolled. 263.1 Malnutrition, mild, not stated as related to diabetes (Schraffenberger 2012, 122-124).

Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values

Correct Answer: C Diagnosis-related groupings (DRGs) are classified by one of 25 major diagnostic categories (MDCs) (Johns 2011, 322).

82. A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in place to minimize this security breach? a. Access controls b. Audit trail c. Edit checks d. Password controls

Correct Answer: C Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Johns 2011, 509).

A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist

Correct Answer: C For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnosis. Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results (Schraffenberger 2012, 340-341).

According to the UHDDS, which of the following is the definition of "other diagnoses"? a. Is recorded in the patient record b. Is documented by the attending physician c. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring d. Is documented by at least two physicians and/or the nursing staff

Correct Answer: C For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care, and/or monitoring (Schraffenberger 2012, 71)

47. An intentional representation that an individual knowingly does to be false and knowing that the act could result in some unauthorized benefit to some other person is an example of: a. Abuse b. Ethical behavior c. Fraud d. Exploding Act

Correct Answer: C Fraud is an intentional representation that an individual knows to be false or does not believe to be true and knowingly misrepresents the act which could result in an unauthorized benefit (Casto and Layman 2011, 34).

Which volume of ICD-9-CM contains the Tabular and Alphabetic Index of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

Correct Answer: C ICD-9-CM Volume 3 contains the Tabular List and Alphabetic Index of procedures (Johns 2011, 243).

A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? a. Ataxia b. Fractured arm c. Metastatic carcinoma of the brain d. Carcinoma of the lung

Correct Answer: C If treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate V code as the first-listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secondary diagnosis (Schraffenberger 2012, 97-98).

75. Which of the following is a prospective payment system implemented for payment of acute hospital inpatient services? a. APC b. DRG c. OPPS d. RBRVS

Correct Answer: C In 1983, CMS implemented a PPS for inpatient hospital care provided to Medicare beneficiaries. The PPS methodology is called diagnosis-related groups (DRGs) (Johns 2011, 319).

86. In which of the following payment systems is the amount of payment determined before the service is delivered? a. Fee-for-service b. Per diem c. Prospective d. Retrospective

Correct Answer: C In a prospective payment system (PPS), the exact amount of the payment is determined before the service is delivered (Johns 2011, 315).

Which of the following tasks may not be performed in an electronic health record system? a. Document imaging b. Analysis c. Assembly d. Indexing

Correct Answer: C In an EHR, reports are indexed, similar to filing in the paper record and ensures the documents are placed in the right location within the right record. Record analysis and completion is done via the computer. Document imaging converts paper documents into digitized electronic versions (Johns 2011, 432).

24. Select the appropriate CPT code(s) to report a therapeutic subcutaneous injection of rabies immune globulin performed under direct physician supervision. a. 96372 b. 90471 c. 90375, 96372 d. 90375, 90473

Correct Answer: C In order to appropriately report administration of vaccines, both the product administered and the method of administration must be reported. An instructional note listed before CPT code 90476 states: "(For immune globulins, see codes 90281-90399, 96365-96368, 96372-96375 for administration of immune globulins)" (AMA 2012b, 459-460).

Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness. a. 924.9 b. 851.42 c. 851.82 d. 851.81

Correct Answer: C Index Contusion, cerebral—see Contusion, brain. Add a fifth digit of "2" for brief loss of consciousness. Cerebral contusions are often caused by a blow to the head. A cerebral contusion is a more severe injury involving a bruise of the brain with bleeding into the brain tissue, but without disruption of the brain's continuity. The loss of consciousness that occurs often lasts longer than that of a concussion. Codes for cerebral laceration and contusion range from 851.0 to 851.9, with fifth digits added to indicate whether a loss of consciousness or concussion occurred (Schraffenberger 2012, 359).

31. Which of the following is (are) the correct ICD-9-CM procedure code(s) for cystoscopy with biopsy? a. 57.34 b. 57.32, 57.33 c. 57.33 d. 57.39

Correct Answer: C Index Cystoscopy (transurethral), with biopsy (Schraffenberger 2012, 251).

55. Identify the ICD-9-CM diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, expreemie." a. V20.1, 765.10 b. V20.2 c. V20.2, 765.10 d. V20.2, 765.19

Correct Answer: C Index Exam, well baby. Premature, infant NEC. Refer to table in Tabular for fifth digit of "0" to note unspecified birth weight (Schraffenberger 2012, 324-328, ).

23. Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence. a. 625.6 b. 788.30 c. 788.32 d. 788.39

Correct Answer: C Index Incontinence, stress, male, NEC 788.32. Category 788.3x indicates incontinence of urine with the fifth digit specific to different types such as urge, stress, mixed, and others (Hazelwood and Venable 2012, 73).

Identify the correct diagnosis code for lipoma of the face. a. 214.1 b. 213.0 c. 214.0 d. 214.9

Correct Answer: C Index Lipoma, face. ICD-9-CM classifies neoplasms by system, organ, or site with the exception of neoplasms of the lymphatic and hematopoietic system, malignant melanomas of the skin, lipomas, common tumors of the bone, uterus, and ovary. Because of these exceptions, the Alphabetic Index must first be checked to determine if a code has been assigned for that specific histology type (Schraffenberger 2012, 99-100).

A 35-year-old male was admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure. a. 530.89, 42.29 b. 530.1, 45.16 c. 530.81, 42.24 d. 530.81, 42.23

Correct Answer: C Main term for procedure: Esophagoscopy; subterm: with closed biopsy (Schraffenberger 2012, 44-45).

64. MS diagnostic-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values

Correct Answer: C Major diagnostic categories (MDCs), of which there are 25. The principal diagnosis determines the MDC assignment (Johns 2011, 322).

10. A Medicare Advantage Plan (like an HMO or PPO) is a health coverage option under what part of Medicare? a. Part A b. Part B c. Part C d. Part E

Correct Answer: C Medicare Part C combines Medicare Part A and Medicare Part B coverage and is operated by private insurance companies that are approved by and under contract with Medicare to form Medicare Advantage Plans (Johns 2011, 293).

If a patient's total outpatient bill is $500, and the patient's healthcare insurance plan pays 80% of the allowable charges, what is the amount for which the patient is responsible? a. $10 b. $40 c. $100 d. $400

Correct Answer: C Out-of-pocket expenses are the healthcare expenses that the insured party is responsible for paying after the insurer has paid its amount. In the example, after the allowed charges of 80%, or $400, are covered by the insurance company, the patient will be responsible for the remaining 20%, or $100 (Johns 2011, 288, 316).

61. Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must the facility meet in order to become certified for these programs? a. Joint Commission Accreditation Standards b. Accreditation Association for Ambulatory Healthcare Standards c. Conditions of Participation d. Outcomes and Assessment Information Set

Correct Answer: C Participating organizations must follow the Medicare Conditions of Participation to receive federal funds from the Medicare program for services rendered (Johns 2011, 61).

From the information provided, how many APCs would this patient have? Billing Number Status Indicator CPT/HCPCS APC 998323 V 99285-25 0612 998324 T 25500 0044 998325 X 72050 0261 998326 S 72128 0283 998327 S 70450 0283 a. 1 b. 4 c. 5 d. 3

Correct Answer: C Payment for separately paid APCs depends on the status indicator assigned to each HCPCS code. This particular example allows separate payment on all five codes based on separately paid status indicator assignment (Johns 2011, 330-332).

What is the function of physician's orders? a. Provide a chronological summary of the patient's illness and treatment b. Document the patient's current and past health status c. Document the physician's instructions to other parties involved in providing care to a patient d. Document the provider's follow-up care instructions given to the patient or patient's caregiver

Correct Answer: C Physician orders are the instructions the physician gives to the other healthcare professionals (Johns 2011, 63).

59. Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough. a. 786.2, 490 b. 486, 786.2 c. 486 d. 481

Correct Answer: C Pneumonia, unspecified, is assigned 486 in the Alphabetic Index. Cough is integral to pneumonia and should not be coded separately (Hazelwood and Venable 2012, 68-73).

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

Correct Answer: C Professional conclusions reached from evaluation of the subjective or objective information make up the assessment (Johns 2011, 114).

21. Where would information on treatment given on a particular encounter be found in the health record? a. Problem list b. Physician's orders c. Progress notes d. Physical examination

Correct Answer: C Progress notes are chronological statements about the patient's response to treatment during his or her stay at the facility (Kuehn 2011, 10).

58. As recommended by AHIMA, HIM compliance policies and procedures should ensure all of the following except: a. Compensation for coders and consultants does not provide any financial incentive to code claims improperly b. The proper selection and sequencing of diagnoses codes c. Proper and timely documentation obtained prior to and after billing d. d The correct application of official coding rules and guidelines

Correct Answer: C Proper and timely documentation of all physician and other professional services must be obtained prior to billing. Facilities should not provide any financial incentive that may tempt a coder to code claims improperly such as upcoding to higher DRGs, which result in higher pay (Johns 20011, 275).

20. A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a: a. Prospective review b. Retrospective review c. Concurrent review d. Peer review

Correct Answer: C Quantitative analysis can occur concurrently while the patient is in the hospital (Johns 2011, 410).

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? a. Require all coders to implement this practice b. Report the practice to the OIG c. Counsel the coder and stop the practice immediately d. Put the coder on unpaid leave of absence

Correct Answer: C Review the elements of the hospital compliance program with the employee (Johns 2011, 361-362).

48. Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? a. Request that the CEO write a memorandum to all hospital staff. b. Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation. c. Include ancillary clinical and medical staff in the process. d. Request a letter from the Joint Commission.

Correct Answer: C Staff participation in the process of developing and implementing a program will contribute to the staff understanding of the importance of the program (Russo 2010, chapter 6).

70. What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals? a. Accreditation organizations b. Certification organizations c. State licensure agencies d. Conditions of participation agencies

Correct Answer: C State licensure agencies have regulations that are modeled after the Medicare Conditions of Participation and Joint Commission standards. States conduct annual surveys to determine the hospital's continued compliance with licensure standards (Odom-Wesley et al. 2009, 287).

Which document directs an individual to bring originals or copies of records to court? a. Summons b. Subpoena c. Subpoena duces tecum d. Deposition

Correct Answer: C Subpoena duces tecum is a written document directing individuals or organizations to furnish relevant documents and records (Johns 2011, 443; AHIMA 2012b, 329).

The HIPAA Privacy Rule: a. Applies to certain states b. Applies only to healthcare providers operated by the federal government c. Applies nationally to healthcare providers d. Serves to limit access to an individual's own health information

Correct Answer: C The HIPAA Privacy Rule applies nationally to healthcare providers (Johns 2011, 801-804).

13. Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery. a. Combined right and left (88.54) b. Stones (88.55) c. Judkins (88.56) d. Other and unspecified (88.57)

Correct Answer: C The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material (Schraffenberger 2012, 206).

81. Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format? a. Problem list as an index b. Initial plan c. SOAP form of progress notes d. Database

Correct Answer: C The Subjective, Objective, Assessment, Plan (SOAP) notes are part of the problem-oriented medical records (POMR) approach most commonly used by physicians and other healthcare professionals. SOAP notes are intended to improve the quality and continuity of client services by enhancing communication among healthcare professionals (Odom-Wesley et al. 2009, 217).

57. A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. Yes; HIPAA only requires that current records be produced for the patient. b. Yes; this is hospital policy over which HIPAA has no control. c. No; the records from the previous hospital are considered part of the designated record set and should be given to the patient. d. No; the records from the previous hospital are not included in the designated record set but should be released anyway.

Correct Answer: C The designated record set includes health records that are used to make decisions about the individual (Johns 2011, 822).

89. Several key principles require appropriate physician documentation to secure payment from the insurer. Which answer (listed here) fails to impact payment based on physician responsibility? a. The health record should be complete and legible. b. The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred. c. Documenting the charges and services on the itemized bill. d. The patient's progress and response to treatment and any revision in the treatment plan and diagnoses should be documented.

Correct Answer: C The documentation of the charges and itemized bill is not the responsibility of the physician (Smith 2012, 7-8).

Which of the following materials is not documented in an emergency care record? a. Patient's instructions at discharge b. Time and means of the patient's arrival c. Patient's complete medical history d. Emergency care administered before arrival at the facility

Correct Answer: C The emergency care record includes a pertinent history of the illness or injury and physical findings (Johns 2011, 93).

73. The number of ligatures, sutures, packs, drains, sponges used, and specimens removed would be found in the: a. Anesthesia report b. Progress notes c. Operative report d. Recovery room report

Correct Answer: C The operative report describes the surgical procedures performed on the patient (Johns 2011, 73).

14. Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago. a. 709.2 b. 906.1 c. 709.2, 906.1 d. 906.1, 709.2

Correct Answer: C The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect (Hazelwood and Venable 2012, 60-61).

97. Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago. a. 787.20, 438.12 b. 784.59, 438.12 c. 438.12 d. 787.20, 438.89

Correct Answer: C The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect. Late effect exceptions occur when the late effect code has been expanded at the fourth- and fifth-digit level to include the manifestations. In this case, only one code is necessary to describe both the residual condition and cause of the late effect (Hazelwood and Venable 2012, 62).

3. An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case? a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. b. Code urinary tract infection with sepsis as the principal diagnosis. c. Query the physician to ask if the patient has septicemia because of the symptomatology. d. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.

Correct Answer: C The term "urosepsis" is a nonspecific term. If that is the only term documented, only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism, if known. Septicemia results from the entry of pathogens into the bloodstream. Symptoms include spiking fever, chills, and skin eruptions in the form of petechiae or purpura. Blood cultures are usually positive; however, a negative culture does not exclude the diagnosis of septicemia. Several other clinical indications and symptomology could indicate the diagnosis of septicemia. Only the physician can diagnose the condition based on clinical indications. Query the physician when the diagnosis is not clear to the coder (Schraffenberger 2012, 79-81, 251).

27. What is the best source of documentation to determine the size of a removed malignant lesion? a. Pathology report b. Post-acute care unit record c. Operative report d. Physical examination

Correct Answer: C The total size of a removed lesion, including margins, is needed for accurate coding. This information is best provided in the operative report. The pathology report typically provides the specimen size rather than the size of the excised lesion. Because the specimen tends to shrink, this is not an accurate measurement (Kuehn 2012, 110-111).

16. Tissue transplanted from one individual to another of the same species but different genotype is called a(n): a. Autograft b. Xenograft c. Allograft or allogeneic graft d. Heterograft

Correct Answer: C Tissue transplanted from one individual to another of the same species but different genotype is called an allograft or allogeneic graft (AHIMA 2012a, 592-593).

94. The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150, Total abdominal hysterectomy, with/without removal of tubes and ovaries 58700, Salpingectomy, complete or partial, unilateral/bilateral (separate procedure) What error has the coder made by using these codes? a. Maximizing b. Upcoding c. Unbundling d. Optimizing

Correct Answer: C Unbundling is the practice of coding services separately that should be coded together as a package because all parts are included within one code and, therefore, one price. Unbundling, done deliberately, could be considered fraud (Kuehn 2012, 347).

168. A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations? 410.00 Myocardial infarction of anterolateral wall, episode unspecified 410.01 Myocardial infarction of anterolateral wall, initial episode 410.40 Myocardial infarction of inferior wall, episode unspecified 410.41 Myocardial infarction of inferior wall, initial episode 410.42 Myocardial infarction of inferior wall, subsequent episode 427 Cardiac dysrhythmias 427.3 Atrial fibrillation and flutter 427.31 Atrial fibrillation 786.50 Chest pain, unspecified 36.13 Aortocoronary bypass of three coronary arteries a. Hospital A: 427, 786.50, 427.31, 410.91; Hospital B: 410.92, 36.13 b. Hospital A: 410.41, 427, 427.31; Hospital B: 410.42, 36.13 c. Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13 d. Hospital A: 410.41, 427.31, 786.50; Hospital B: 410.42, 36.13

Correct Answer: C Use a fifth digit of "1" to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit "1" is assigned regardless of the number of times a patient may be transferred during the initial episode of care (Schraffenberger 2012, 188).

65. Identify ICD-9-CM diagnosis code for atypical ductal hyperplasia. a. 610.1 b. 610.4 c. 610.8 d. 610.9

Correct Answer: C Use this code when the diagnosis is specified as a certain type of "benign mammary dysplasia," and in this case, "ductal" hyperplasia. Index Hyperplasia, breast, ductal, atypical (Schraffenberger 2012, 253).

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay? a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy c. Metastatic carcinoma of the brain; history of carcinoma of the prostate d. Carcinoma of the prostate; metastatic carcinoma to the brain

Correct Answer: C When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal, with the V10 code used as a secondary code (Schraffenberger 2012, 98).

Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment? a. 188.3, V10.51, 57.49, 57.32 b. 198.1, 57.49 c. 188.3, 57.49 d. 198.1, 188.3, 57.49

Correct Answer: C When the primary malignant neoplasm previously removed by surgery or eradicated by radiotherapy or chemotherapy recurs, the primary malignant code for the site is assigned, unless the Alphabetic Index directs otherwise (Schraffenberger 2012, 106).

92. Certain services are not covered by Medicare Part A or Part B and may only be covered by private health plans under the Medicare Advantage program. Which service is covered by Medicare Part A or B? a. Dentures and dental care b. Eyeglasses c. X-rays d. Hearing aids

Correct Answer: C X-rays are covered under Part A or Part B for hospital and physician services. Dentures, eyeglasses, hearing aids, long-term nursing care and custodial care are not covered by Medicare Part A or B (Johns 2011, 297).

30. Which of the following fails to meet the CMS classification of a hospital-acquired condition? a. Foreign object retained after surgery b. Air embolism c. Gram-negative pneumonia d. Blood incompatibility

Correct Answer: C Gram-negative pneumonia (Johns 2011, 326).

8. Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professional

Correct Answer: C The provider is responsible for ensuring the quality of the documentation of the healthcare record (Brodnik et al. 2009, 128).

96. What is a chargemaster? a. Cost-sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met b. A plan that converts the organization's goals and objectives into targets for revenue and spending c. A financial management form that contains information about the organization's charges for the healthcare services it provides to patients d. Charged amounts that are billed as costs by an organization to the current year's activities of operation

Correct Answer: C A chargemaster is a financial management form that contains information about the organization's charges for the healthcare services it provides to patients. Answer "a" is coinsurance. Answer "b" is budget. Answer "d" is expense (Johns 2011, 1116).

81. What is the amount the insured pays before the insurer assumes liability for any remaining costs of covered services? a. Out-of-pocket expense b. Coinsurance c. Deductible d. Premium

Correct Answer: C A deductible is the amount the insured pays before the insurer assumes liability for any remaining costs of covered services (Johns 2011, 288).

An encoder that takes a coder through a series of questions and choices is called a(n): a. Automated codebook b. Automated code assignment c. Logic-based encoder d. Decision support database

Correct Answer: C A logic-based encoder prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition (and any possible complications or comorbidities) (LaTour and Eichenwald Maki 2010, 400).

62. Identify the acute-care record report where the following information would be found: Gross Description: Received fresh designated left lacrimal gland is a single, unoriented, irregular, tan-pink portion of soft tissue measuring 0.8 × 0.6 × 0.1 cm, which is submitted entirely intact in one cassette. a. Medical history b. Medical laboratory report c. Pathology report d. Physical examination

Correct Answer: C A pathology report usually includes descriptions of the tissue from a gross or macroscopic level and representative cells at the microscopic level along with interpretive findings (Johns 2011, 77).

21. A software interface is a: a. Device to enter data b. Protocol for describing data c. Program to exchange data d. Standard vocabulary

Correct Answer: C A software interface is a computer program that allows different applications to communicate and exchange data (Johns 2011, 137).

The key data element for linking data about an individual who is seen in a variety of care settings is the: a. Facility medical record number b. Facility identification number c. Unique patient identifier d. Patient birth date

Correct Answer: C A unique patient identifier is a unique number assigned by a healthcare provider to a patient that distinguishes the patient's medical records from all others (Johns 2011, 1178).

Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for: a. The placement of the catheter b. The placement of the catheter and the infusion procedure c. The infusion procedure d. Neither the placement of the catheter nor the infusion procedure

Correct Answer: C Access to an indwelling IV or insertion of a subcutaneous catheter or port for the purpose of a therapeutic infusion is considered part of the procedure and not separately billed (Smith 2012, 237).

39. According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary

Correct Answer: C According to the Joint Commission, except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed (Odom-Wesley et al. 2009, 150).

What is the process that determines how a claim will be reimbursed based on the insurance benefit? a. Transaction b. Processing c. Adjudication d. Allowance

Correct Answer: C Adjudication is the determination of the reimbursement payment based on the member's insurance benefits (Casto and Layman 2011, 72).

26. The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest? a. Suggest that only hospital clock time be noted in clinical documentation b. Suggest that only electronic documentation have time noted c. Inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated d. Inform the committee that according to the Medicare Conditions of Participation, only medication orders must include date and time

Correct Answer: C All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished (42 CFR 482.24).

The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear? a. Admission order b. Clinical laboratory report c. ECG report d. Radiology report

Correct Answer: C An ECG is a report of an electrocardiogram of the heart (Johns 2011, 70).

9. A request for reconsideration of a denied claim for insurance coverage for healthcare services is called a(n): a. Breach b. Exclusion c. Appeal d. Inclusion

Correct Answer: C An appeal is a request for consideration of denial of coverage for healthcare services of a claim (Casto and Layman 2011, 71).

3. The codes in the musculoskeletal section of CPT may be used by: a. Orthopedic surgeons only b. Orthopedic surgeons and emergency department physicians c. Any physician d. Orthopedic surgeons and neurosurgeons

Correct Answer: C Any physician may use the codes in any section of CPT (AHIMA 2012a, 587).

When clean claims are submitted, they can be adjudicated in many ways through computer software automatically. Which statement is not one of the outcomes that can occur as part of auto-adjudication? a. Auto-pay b. Auto-suspend c. Auto-calculate d. Auto-deny

Correct Answer: C Claims that automatically process through computer software either auto-pay, auto-suspend, or auto-deny (Casto and Layman 2011, 72).

Which of the following elements is not a component of most patient records? a. Patient identification b. Clinical history c. Financial information d. Test results

Correct Answer: C Clinical data document the patient's medical condition, diagnosis, and procedures performed as well as healthcare treatment provided (Johns 2011, 61).

64. Before healthcare organizations can provide services, they usually must obtain by government entities such as the state in which they are located. a. Accreditation b. Certification c. Licensure d. Permission

Correct Answer: C Compliance with state licensing laws is required in order for healthcare organizations to remain in operation (Johns 2011, chapter 61).

1. Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April. a. 90965 b. 90964 c. 90966 d. 90970

Correct Answer: C Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease (ESRD) related services for home dialysis per full month for patients 20 years of age and older (Smith 2012, 227).

What is the process used to transform text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination? a. Distortion b. Extrication c. Encryption d. Encoded

Correct Answer: C Encryption is the process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination (Johns 2011, 510).

Written or spoken permission to proceed with care is classified as: a. An advanced directive b. Formal consent c. Expressed consent d. Implied consent

Correct Answer: C Expressed consent can be spoken or written (Johns 2011, 71).

71. Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a breast biopsy. a. 10022 b. 10022, 19295-LT c. 10022, 19295-LT, 76942 d. 10022, 76942

Correct Answer: C Fine needle aspiration with image guidance is coded with 10022. Instructional note directs coder to assign 19295 for placement of localization clip during a breast biopsy. Add radiology code 76942 for supervision and interpretation of ultrasound guidance for localization clip guidance. See instructional notes following code 10022 (AMA 2012b, 59).

Which of the following is a true statement about data stewardship? a. HIM professionals are not qualified to address data stewardship issues. b. Data stewardship addresses the needs of the healthcare organization but not the patient. c. HIM professionals have worked with many data stewardship issues for years. d. Data stewardship does not include privacy issues.

Correct Answer: C HIM professionals have worked with many data stewardship issues for years (Johns 2011, 508).

The ______ mandated the development of standards for electronic medical records. a. Medicare and Medicaid legislation of 1965 b. Prospective Payment Act of 1983 c. Health Insurance Portability and Accountability Act (HIPAA) of 1996 d. Balanced Budget Act of 1997

Correct Answer: C HIPAA-mandated incorporation of healthcare information standards into all electronic or computer-based health information systems (Johns 2011, 231).

96. Patient admitted with cervical lymphadenopathy. Lymph node biopsy confirmed Hodgkin's sarcoma disease. Megavoltage radiotherapy begun. Which of the following is the correct code set? a. 201.21, 40.40, 92.29 b. 201.91, 40.40, 92.29 c. 201.21, 40.11, 92.24 d. 201.91, 40.11, 92.24

Correct Answer: C Hodgkins sarcoma is assigned to code 201.21. Lymph node biopsy is coded to 40.11. Megavoltage radiotherapy is assigned to a specific code of 92.24 (AHIMA 2012a, 677).

85. Which classification system is in place to reimburse home health agencies? a. MS-DRGs b. RUGs c. HHRGs d. APCs

Correct Answer: C Home health resource groups (HHRGs) represent the classification system established for the prospective reimbursement of covered home care services to Medicare beneficiaries during a 60-day episode of care (Johns 2011, 334).

77. What kind of provider setting manages patients who are terminally ill and often have a life expectancy less than six months? a. Skilled nursing facility b. Home health c. Hospice d. Acute-care, inpatient

Correct Answer: C Hospice care is provided to the terminally ill persons whose life expectancies are certified by their attending physician to be six months or less (Johns 2011, 295).

41. The purpose of a physician query is to: a. Identify the MS-DRG b. Identify the principal diagnosis c. Improve documentation for patient care and proper reimbursement d. Increase reimbursement as form of optimization

Correct Answer: C Improve documentation to support services billed (Johns 2011, 348).

44. Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary-coronary artery bypass. a. 36.15, 36.16 b. 36.15 c. 36.16 d. 36.12, 36.16

Correct Answer: C Index Bypass, internal mammary-coronary artery (single), double vessel (36.16). Internal mammary-coronary artery bypass is accomplished by loosening the internal mammary artery from its normal position and using the internal mammary artery to bring blood from the subclavian artery to the occluded coronary artery. Codes are selected based on whether one or both internal mammary arteries are used, regardless of the number of coronary arteries involved (Schraffenberger 2012, 203-204).

72. Identify the CPT procedure code(s) for a repeat transurethral resection of prostate tissue four years after original procedure. a. 52601 b. 55801 c. 52630 d. 52500

Correct Answer: C Index Excision, prostate regrowth, resulting in code 52630 (AHIMA 2012a, 611).

42. Identify the CPT procedure code(s) and correct modifiers for a basic metabolic panel with ionized calcium and an additional test for carbon dioxide on the same day. Keep in mind that a carbon dioxide test is part of the basic metabolic panel. a. 80047 b. 80047, 82374 c. 80047, 82374-91 d. 80048, 82374-91

Correct Answer: C Index Organ or disease-oriented panel, metabolic, basic to reference codes 80047 and 80048. Code 80047 includes ionized calcium for the correct panel code. Index Carbon Dioxide, blood or urine to arrive at code 82374. Add modifier -91 to the carbon dioxide code to signify the test was performed twice on the same day and is separately reportable. Modifier -91 represents a repeat clinical diagnostic laboratory test, and should be used for a repeat test even when the first test is part of a panel represented by a panel code (AMA 2012b, 402).

33. Identify the ICD-9-CM diagnosis code for blighted ovum. a. 236.1 b. 661.00 c. 631.8 d. 634.90

Correct Answer: C Index Ovum, blighted (Schraffenberger 2012, 282-283).

Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia? a. 49496 b. 49501 c. 49507 d. 49521

Correct Answer: C Index the main term of Hernia repair; inguinal; incarcerated. The age of the patient and the fact that the hernia is not recurrent make the choice 49507. Providing information regarding insurance coverage is not a function of the discharge summary (Kuehn 2012, 27, 164-166).

A female patient is admitted for stress incontinence. A urethral suspension is performed. Assign the correct ICD-9-CM diagnosis and/or procedure code(s). a. 625.6, 57.32 b. 788.0, 59.5 c. 625.6, 59.5 d. 788.30

Correct Answer: C Main term for diagnosis: Incontinence; subterm: stress. Main term for procedure: Suspension; subterm: urethra (Schraffenberger 2012, 10).

Medicaid is a government-sponsored healthcare insurance program that became effective in 1966 as Title 19 of the Social Security Act. Medicaid is administered by: a. The federal government b. The state government c. The federal and state government d. Third-party administrators

Correct Answer: C Medicaid is designed to offer assistance to low-income people and is jointly administered by the federal and state government (Hazelwood and Venable 2012, 327).

61. The ______ uses expert or artificial intelligence software to automatically assign code numbers. a. Functional EHR b. NHIN c. NLP encoding system d. Grouper

Correct Answer: C Natural-language processing (NLP) uses artificial intelligence software to allow digital text from online documents stored in the organization's information system to be read directly by the software, which then suggests codes to match the documentation (Johns 2011, 170).

Denials of outpatient claims are often generated from all of the following edits except: a. NCCI (National Correct Coding Initiative) b. OCE (outpatient code editor) c. OCE (outpatient claims editor) d. National and local policies

Correct Answer: C Outpatient claims editor does not exist. Do not confuse this terminology with outpatient code editor (OCE) (Johns 2011, 348).

A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system? a. Clinical laboratory tests b. Physician office visits c. Radiology examinations d. Take-home surgical dressings

Correct Answer: C Radiology procedures are identified under the outpatient perspective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid (Johns 2011, 329-331).

69. The Medicare Modernization Act (MMA) of 2003 called for CMS to launch a Medicare payment recovery demonstration project. The purpose of the act eventually resulted in the implementation of a group contracted by the government to monitor suspicious and improper activity of Medicare payments including overpayments and underpayments. What is this group? a. Operation Restore Trust b. Payment Error Prevention Program c. Recovery Audit Contractors d. Medicare Administrative Contractors

Correct Answer: C Recovery audit contractors (RACs) would become a cost-effective means of ensuring correct payments to providers under Medicare. The RACs were charged with identifying underpayments and overpayments for claims filed under Medicare (Casto and Layman 2011, 39).

Common forms of fraud and abuse include all of the following except: a. Upcoding b. Unbundling or "exploding" charges c. Refiling claims after denials d. Billing for services not furnished to patients

Correct Answer: C Refiling claims after a denial is not possible because denied claims must be appealed and is not a factor in controlling fraud and abuse (Casto and Layman 2011, 35).

19. A hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should the hospital refer to? a. Explanation of benefits b. Medicare Summary Notice c. Remittance advice d. Coordination of benefits

Correct Answer: C Remittance advice (RA) is sent to the provider to explain payments made by third-party payers (Johns 2011, 346).

The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear? a. History b. Pathology report c. Physical examination d. Operation report

Correct Answer: C Results of the physician's examination of the patient's physical condition is reported in a physical examination report (Johns 2011, 63).

80. Protection of healthcare information from damage, loss, and unauthorized alteration is also known as: a. Privacy b. Results management c. Security d. Data accuracy

Correct Answer: C Security includes physical and electronic protection of the integrity, availability, and confidentiality of computer-based information and the resources used to enter, store, process, and communicate it; and the means to control access and protect information from accidental or intentional disclosure (Johns 2011, 755).

37. Corporate compliance programs were released by the OIG for hospitals to develop and implement their own compliance programs. All of the following except _____ are basic elements of a corporate compliance program. a. Designation of a Chief Compliance Officer b. Implementation of regular and effective education and training programs for all employees c. Medical staff appointee for documentation compliance d. The use of audits or other evaluation techniques to monitor compliance

Correct Answer: C Seven elements are required as part of the basic elements of a corporate compliance program and a medical staff appointee is not one of them (Johns 2011, 274).

73. Which organization developed the first hospital standardization program? a. Joint Commission b. American Osteopathic Association c. American College of Surgeons d. American Association of Medical Colleges

Correct Answer: C The American College of Surgeons started its Hospital Standardization Program in 1918 (Johns 2011, 679).

70. Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceeds the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. To improve compliance, which of the following would be the next step to overcoming noncompliance? a. Discuss the problem with the hospital CEO. b. Call the Joint Commission. c. Contact other hospitals to see what methods they use to ensure compliance. d. Drop the issue because noncompliance is always a problem.

Correct Answer: C The HIM manager may compare organizational data with external data from peer groups to determine best practices (Johns 2011, 609).

52. What healthcare organizations collect UHDDS data? a. All outpatient settings including physician clinics and ambulatory surgical centers b. All outpatient settings including cancer centers, independent testing facilities, and nursing homes c. All non-outpatient settings including acute-care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehabilitation facilities; and nursing homes d. All inpatient settings and outpatient settings with a focus on ambulatory surgical centers

Correct Answer: C The Uniform Hospital Discharge Data Set was promulgated by the US Department of Health, Education, and Welfare in 1974 as a minimum, common core of data on individual acute-care, short-term hospital discharges in Medicare and Medicaid programs. It sought to improve the uniformity and comparability of hospital discharge data. In 1985, the data was expanded to include all nonoutpatient settings (Schraffenberger 2012, 63-65).

Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0-cm superficial laceration of the left arm; 5.0-cm laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: X-ray of the ankle showed a bimalleolar ankle fracture that required closed manipulative reduction, intermediate suturing of the scalp and simple suturing of the arm laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill. a. 27810, 12032 b. 27818, 12032 c. 27810, 12032, 12002 d. 27810, 12032

Correct Answer: C The closed reduction of the fracture is coded first, following principal procedure guidelines. The laceration repair is also coded. When more than one classification of wound repair is performed, all codes are reported, with the code for the most complicated procedure listed first (Kuehn 2012, 30-31, 111-112).

3. An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be correct? a. V30.01, 765.03, 765.24 b. 765.03, 769 c. V30.01, 765.03, 765.24, 769 d. V30.01, 769

Correct Answer: C The codes for prematurity 765.03 and code 765.24 for weeks of gestation meet reporting guidelines as additional diagnoses. A birth code of V30.01 is reported as the principal diagnosis (CMS 2010c, Section I, C, 15b; AHA 2006, 190). See instructional note under 765.0x to "Use Additional Code" for weeks of gestation. A code is also needed for the respiratory distress syndrome, 769 (AHIMA 2012a, 676)

An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.) a. 660.11, 653.41, 64479 b. 660.11, 653.01, 01961 c. 660.11, 653.41, 01967, 01968 d. 660.11, 653.91, 01996

Correct Answer: C The disproportion was specified as cephalopelvic; thus the correct ICD-9-CM code is 653.41. Two codes are required for anesthesia; one for the planned vaginal delivery (01967) and an add-on code (01968) to describe anesthesia for cesarean delivery following planned vaginal delivery converted to cesarean. An instructional note guides the coder to use 01968 with 01967 (Schraffenberger 2012, 272-273; AMA 2012b, 52).

Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion? a. Health Information and Business Office b. Health Information and Materials Management c. Health Information, Business Office, and Cardiac Department d. Health Information and Radiology

Correct Answer: C The health information department along with the business office and cardiac department should be consulted to determine where the breakdown of the charges and assignment of the procedure code occurs. Often one department assumes another department is submitting the code/charge and without auditing and communicating with each other on a regular basis, error can occur for long periods of time with either a financial gain or loss to the facility (Casto and Layman 2011, 258).

Which of the following is not true of notices of privacy practices? a. They must be made available at the site where the individual is treated. b. They must be posted in a prominent place. c. They must contain content that may not be changed. d. They must be prominently posted on the covered entity's website when the entity has one.

Correct Answer: C The notice of privacy includes a statement that the covered entity reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains (Johns 2011, 837).

38. When coding a selective catheterization in CPT, how are codes assigned? a. One code for each vessel entered b. One code for the point of entry vessel c. One code for the final vessel entered d. One code for the vessel of entry and one for the final vessel, with intervening vessels not coded

Correct Answer: C The only vessel coded is the final vessel entered. See instructional note preceding code 36000. Intermediate steps along the way are not reported (AHIMA 2012a, 604).

Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion. a. Anesthesia report b. Physician progress notes c. Operative report d. Recovery room record

Correct Answer: C The operative report includes a description of the procedure performed (Johns 2011, 73).

59. What reimbursement system uses the Medicare fee schedule? a. APCs b. MS-DRGs c. RBRVS d. RUG-III

Correct Answer: C The resource-based relative value scale (RBRVS) system was implemented by CMS in 1992 for physicians' services such as office visits covered under Medicare Part B. The system reimburses physicians according to a fee schedule based on predetermined values assigned to specific services (Johns 2011, 326).

72. Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung. a. 153.9, 162.9 b. 197.0, 153.9 c. 153.9, 197.0 d. 153.9, 239.1

Correct Answer: C The terms metastatic to and direct extension to are used for classifying secondary malignant neoplasms in ICD-9-CM. For example, cancer described as "metastatic to a specific site" is interpreted as a secondary neoplasm of that site. The colon (153.9) is the primary site, and the lung (197.0) is the secondary site (Hazelwood and Venable 2012, 109).

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called: a. Natural-language processing systems b. Monitoring/audit programs c. Encoders d. Concept, description, and relationship tables

Correct Answer: C The type of tool used to aid in the coding process is called an encoder (Johns 2011, 269).

The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear? a. Admission note b. Clinical laboratory c. Newborn record d. Physician order

Correct Answer: C This information is collected by the examination of a newborn and reported on the newborn record (Johns 2011, 97).

34. What is it called when a Medicare hospital inpatient admission results in exceptionally high costs when compared to other cases in the same DRG? a. Rate increase b. Charge outlier c. Cost outlier d. Day outlier

Correct Answer: C To qualify for a cost outlier, a hospital's charges for a case (adjusted to cost) must exceed the payment rate for the MS-DRG by a specific threshold amount determined by CMS for each fiscal year (Johns 2011, 374).

42. An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system? a. DEEDS b. EMEDS c. UACDS d. UHDDS

Correct Answer: C Uniform Ambulatory Care Data Set (Odom-Wesley et al. 2009, 310).

The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment is called: a. Billing b. Unbundling c. Upcoding d. Unnecessary service

Correct Answer: C Upcoding is the practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment (Johns 2011, 358).

41. Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of: a. Transaction standards b. Content and structure standards c. Vocabulary standards d. Security standards

Correct Answer: C Vocabulary standards establish common definitions for medical terms to encourage consistent descriptions of an individual's condition in the health record (Johns 2011, 227).

53. What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard? a. Ignore the state law and follow the HIPAA standard b. Follow the state law and ignore the HIPAA standard c. Comply with both the state law and the HIPAA standard d. Ignore both the state law and the HIPAA standard and follow relevant accreditation standards

Correct Answer: C When a state law is more stringent than a federal law, hospitals must comply with both (Odom-Wesley et al. 2009, 68).

Which of the following is the correct ICD-9-CM procedure code for a Mayo operation known as a bunionectomy? a. 77.54 b. 77.69 c. 77.59 d. 77.51

Correct Answer: C Index Bunionectomy or Mayo operation, bunionectomy. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, operation, or disorder (Schraffenberger 2012, 13).

94. Identify the ICD-9-CM diagnosis code(s) for neutropenic fever. a. 288.00 b. 288.00, 780.60 c. 288.01 d. 288.00, 780.61

Correct Answer: D 288.00, Fever, neutropenic. Instructional note states to use additional code for any associated fever (780.61) (Schraffenberger 2012, 137-139).

This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services: a. General Counsel b. Health Information Director c. Privacy Officer d. Compliance Officer

Correct Answer: D A compliance officer designs, implements, and maintains a compliance program that assures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products and services (Johns 2011, 744).

A special webpage that offers secure access to data is called a(n): a. Access control b. Home page c. Intranet d. Portal

Correct Answer: D A portal is a special application to provide secure remote access to specific applications (Johns 2011, 137).

76. Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea. a. 789.03 b. 789.03, 787.02, 787.03, 787.91 c. 789.03, 787.91 d. 789.03, 787.01, 787.91

Correct Answer: D Abdominal pain includes fifth digits to identify the specific parts of the abdomen affected. Nausea and vomiting is a category common to stomach upset. The fifth digits provide specificity. Nausea and vomiting are coded together with a combination code when both exist. Diarrhea usually is a symptom of some other disorder or of a more severe disease, in which case it should not be coded separately. It is often accompanied by vomiting and various other symptoms that should be coded when present. Because, in this case, a distinct disease is not available, all the symptoms should be coded (Hazelwood and Venable 2012, 73).

Which of the following statements does not apply to ICD-9-CM? a. It can be used as the basis for epidemiological research. b. It can be used in the evaluation of medical care planning for healthcare delivery systems. c. It can be used to facilitate data storage and retrieval. d. It can be used to collect data about nursing care.

Correct Answer: D According to Central Office on ICD-9-CM, ICD-9-CM is not used to collect data about nursing care (Johns 2011, 239).

Which of the following is not one of the purposes of ICD-9-CM? a. Classification of morbidity for statistical purposes b. Classification of mortality for statistical purposes c. Reporting of diagnoses by physicians d. Identification of the supplies, products, and services provided to patients

Correct Answer: D According to Central Office on ICD-9-CM, ICD-9-CM is not used to identify supplies, products, and services used by patients (Johns 2011, 239).

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin

Correct Answer: D Adverse effects can occur in situation in which medication is administered properly and prescribed correctly in both therapeutic and diagnostic procedures. An adverse effect can occur when everything is done correctly. The first-listed diagnosis is the manifestation or the nature of the adverse effect, such as the hematuria. Locate the drug in the Substance column of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E code is mandatory when coding adverse effects (Schraffenberger 2012, 377-378).

The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear? a. Admission note b. Nursing note c. Physician progress note d. Social work note

Correct Answer: D After an initial assessment, documentation by other allied health professionals varies by specialty with appropriate content and frequency of recording (Johns 2011, 70).

Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket. a. 33223 b. 33210 c. 33212 d. 33222

Correct Answer: D Begin with the main term Revision; pacemaker site; chest (Kuehn 2012, 27, 142).

15. Which of the following is the concept responsible for limiting disclosure of private matters including the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual? a. Privacy b. Bioethics c. Security d. Confidentiality

Correct Answer: D Confidentiality is the responsibility for limiting disclosure (Johns 2011, 755).

69. The HIM manager is concerned about whether the data transmitted across the hospital network is altered during the transmission. The concept that concerns the HIM manager is: a. Admissibility b. Disclosures c. Availability d. Data integrity

Correct Answer: D Data integrity services ensure the data are not altered as they are stored or transmitted electronically (Johns 2011, 184).

Using uniform terminology is a way to improve: a. Validity b. Data timeliness c. Audit trails d. Data reliability

Correct Answer: D Data reliability is a method at looking at data quality consistently, sometimes referred to as data reliability. Reliability is frequently checked by having more than one person abstract data for the same case and compare the results for any discrepancies (Johns 2011, 509).

n processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures performed during the same operative session, which of the following would apply? a. Bundling of services b. Outlier adjustment c. Pass-through payment d. Discounting of procedures

Correct Answer: D Discounting applies to multiple surgical procedures furnished during the same operative session. The full rate will be paid to the surgical procedure with the highest rate and the additional procedures will be discounted 50% of their APC rate (Johns 2011, 330).

90. The technology commonly used for automated claims processing (sending bills directly to third-party payers) is: a. Optical character recognition b. Bar coding c. Neural networks d. Electronic data interchange

Correct Answer: D EDI allows the transfer (incoming and outgoing) of information directly from one computer to another by using flexible, standard formats (Johns 2011, 348).

87. What is the maximum number of procedure codes that can appear on a UB-04 institutional claim form via electronic transmission? a. 6 b. 9 c. 15 d. 25

Correct Answer: D Effective January 1, 2011, CMS allows a total of 25 ICD-9-CM procedure codes for 837 Institutional claims filing (Schraffenberger 2012, 66).

53. What type of data is exemplified by the insured party's member identification number? a. Demographic data b. Clinical data c. Certification data d. Financial data

Correct Answer: D Financial data include details about the patient's occupation, employer, and insurance coverage (Odom-Wesley et al. 2009, 42).

88. Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads. a. 37,83, 37.73 b. 37.83, 37.71 c. 37.81, 37.73, 37.71 d. 37.83, 37.72

Correct Answer: D ICD-9-CM classifies cardiac pacemakers to code 37.8: Insertion, replacement, removal, and revision of pacemaker device. In coding initial insertion of a permanent pacemaker, two codes are required—one for the pacemaker (37.80-37.83) and one for the lead (37.70-37.74) (Schraffenberger 2012, 204-205).

A patient is admitted to an acute-care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism. a. 291.8, 303.00 b. 303.00 c. 305.00 d. 291.81, 303.00

Correct Answer: D If the patient is admitted in withdrawal or if withdrawal develops after admission, the withdrawal code is designated as the principal diagnosis. The code for substance abuse/dependence is listed second (Schraffenberger 2012, 148).

86. When correcting erroneous information in a health record, which of the following is NOT appropriate? a. Print "error" above the entry b. Enter the correction in chronological sequence c. Add the reason for the change d. Use black pen to obliterate the entry

Correct Answer: D In a paper-based health record environment, corrections to health record entries are corrected by drawing a single line through the original entry, writing "error" above the entry, and then the practitioner signs, dates, and times the correction (Johns 2011, 413).

Coders will assign codes that have been selected into a computer program called a(n) _____ to assign the patient's case to the correct group based on ICD-9-CM and/or CPT/HCPCS codes. a. Encoder b. Computer-assisted coding c. Natural-language processor d. Grouper

Correct Answer: D In both the MS-DRG and APC groupings, coders enter the codes that have been selected into a computer program called a grouper. The grouper then assigns the patient's case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes (Johns 2011, 272).

22. Identify the CPT procedure code(s) for a SPECT bone scan. a. 78710 b. 78803 c. 78607 d. 78320

Correct Answer: D Index Bone, nuclear medicine, SPECT, resulting in code 78320. The acronym SPECT stand for single photon emission computed tomography and is a more sophisticated form of CT scanning. Unlike basic x-ray CT scanning, SPECT involves injected radionuclides and is considered a form of nuclear medicine. It is being supplanted to some extent now by PET (positron emission tomography) scanning, which is capable of better resolution and sensitivity (AHIMA 2012a, 625).

68. Which of the following is (are) the correct ICD-9-CM code(s) for laparoscopic cholecystectomy? a. 51.21 b. 51.22, 54.21 c. 51.23, 54.21 d. 51.23

Correct Answer: D Index Cholecystectomy (total), laparoscopic (Schraffenberger 2012, 237-238).

26. Identify the code for a patient with a closed transcervical fracture of the epiphysis. a. 820.09 b. 820.02 c. 820.03 d. 820.01

Correct Answer: D Index Fracture, femur, epiphysis, capital. Fifth digits are required for further classification of a specific condition. Many publishers include special symbols and/or color highlighting to identify codes that require a fourth or fifth digit (Schraffenberger 2012, 7).

77. Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa. a. 10060 b. 10140 c. 23030 d. 23031

Correct Answer: D Index Incision and drainage, shoulder, bursa, resulting in code 23031 (AHIMA 2012a, 598).

97. Identify the CPT procedure code(s) and modifier(s) if appropriate, for x-ray of the mandible, five views. a. 70100, 70110 b. 70100-50 c. 70110-50 d. 70110

Correct Answer: D Index Mandible, x-ray, resulting in code range 70100-70110. Review of the available codes indicates that code 70110 is the appropriate code when four or more views are obtained (AHIMA 2012a, 624).

90. Identify the CPT procedure code(s) for partial right-sided thyroid lobectomy with isthmusectomy and subtotal resection of left thyroid. a. 60210 b. 60225 c. 60220 d. 60212

Correct Answer: D Index Thyroidectomy, partial, resulting in code range 60210-60225 or Lobectomy, thyroid gland partial, resulting in code range 60210-60212. Review of the available codes indicates that code 60212 is correct because there is documentation of isthmusectomy and subtotal resection on the opposite (contralateral) side (AHIMA 2012a, 614).

18. When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? a. Assign the removal by snare technique code. b. Assign the removal by hot biopsy forceps code. c. Assign the ablation code. d. Query the physician as to the method used.

Correct Answer: D It is not appropriate for the coder to assume the removal was done by either snare or hot biopsy forceps. The ablation code is only assigned when a lesion is completely destroyed and no specimen is retrieved. The coding professional must query the physician to assign the appropriate code (AHIMA 2012a, 607).

Medicare Part D pays for: a. Physician office visits b. Durable medical equipment c. Inpatient hospital care d. Prescription drugs

Correct Answer: D Medicare Part D pays for prescription drugs for beneficiaries (Hazelwood and Venable 2012, 324).

Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician setting use with the Evaluation and Management code? a. -79, Unrelated procedure or service by the same physician during the postoperative period b. -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service c. -21, Prolonged evaluation and management services d. -24,Unrelated evaluation and management service by the same physician during a postoperative period

Correct Answer: D Modifier -24 is used for unrelated evaluation and management service by the same physician during a postoperative period (Kuehn 2012, 53).

5. Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure. a. -22 b. -54 c. -32 d. -55

Correct Answer: D Modifiers are appended to the code to provide more information or to alert the payer that a payment change is required. Modifier -55 is used to identify the physician provided only postoperative care services for a particular procedure (Kuehn 2012, 292, 295).

95. What technology creates images of handwritten and printed documents that are then stored in health record databases as electronic files? a. Clinical data repository b. Data exchange standards c. Central processor d. Digital scanner

Correct Answer: D Odom-Wesley et al. 2009, 227

90. Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome. a. 042, 112.5, V01.79 b. 112.5, 042 c. 042, 112.5, V08 d. 042, 112.5

Correct Answer: D Only confirmed cases of HIV infection/illness are reported whether inpatient or outpatient. 042, Human immunodeficiency virus [HIV] disease. Patients with HIV-related illness should be coded to category 042, which includes AIDS, AIDS-like syndrome, AIDS-related complex, and symptomatic HIV infection (Hazelwood and Venable 2012, 89-90).

A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension. a. 492.8, 496, 403.10, 585.9 b. 492.8, 585.9, 401.9 c. 496, 585.9, 401.9 d. 491.21, 403.91, 585.9

Correct Answer: D Patient was admitted for COPD, so this is listed as the principal diagnosis. Code 491.21 is used when the medical record includes documentation of COPD with acute exacerbation. ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, code 403.91; however, the code also at category 403 directs the coder to also code the chronic renal failure 585.9 (Schraffenberger 2012, 182-184, 222-223).

25. Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards? a. Internal DRG audits b. Peer review c. Managed care d. Quality improvement

Correct Answer: D Quality improvement (QI) programs have been in place in hospitals for years and have been required by the Medicare/Medicaid programs and accreditation standards. QI programs have covered medical staff as well as nursing and other departments or processes (LaTour and Eichenwald Maki 2010, 33).

Identify where the following information would be found in the acute-care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine." a. Medical laboratory report b. Physical examination c. Physician progress note d. Radiography report

Correct Answer: D Results of an x-ray interpretation by a radiologist are reported in a radiography report (Johns 2011, 70).

32. Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result. a. 796.4 b. 790.6 c. 792.9 d. 790.93

Correct Answer: D Review Tabular List: Findings, abnormal, without diagnosis, prostate specific antigen (PSA), 790.93, or Elevation, prostate specific antigen (PSA), 790.93 (Hazelwood and Venable 2012, 69).

A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out chest pain versus GERD." The correct ICD-9-CM code is: a. V71.7, Admission for suspected cardiovascular condition b. 789.01, Esophageal pain c. 530.81, Gastrointestinal reflux d. 786.50, Chest pain NOS

Correct Answer: D Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "rule out" or other similar terms indicating uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if it existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign or symptom the patient exhibits. In this case, assign the code 786.50, Chest pain NOS (Schraffenberger 2012, 339).

49. Statements that define the performance expectations and/or structures or processes that must be in place are: a. Rules b. Policies c. Guidelines d. Standards

Correct Answer: D Standards are fixed rules that must be followed, which is different from a guideline that provides general direction (Johns 2011, 416).

81. Identify the correct ICD-9-CM diagnosis code(s) for a patient with an abnormal glucose tolerance test. a. 790.29 b. 790.21 c. 790.21, 790.29 d. 790.22

Correct Answer: D The Index may mislead the coder to a nonspecific code. In this example, when the coder references "Abnormal" and subheading "glucose," the coder is directed to code 790.29. The coder should always reference the Tabular List to verify the code. During verification, the coder will see the selection for code 790.22, which accurately describes the specific abnormal finding of glucose tolerance test (Hazelwood and Venable 2012, 74).

What resource can managers use to discover current, hot areas of compliance? a. Policies and Procedures b. National Coverage Determinations c. Official Coding Guidelines d. OIG Workplan

Correct Answer: D The OIG workplan is published every year to provide insight into the directions the OIG is taking, as well as highlights of hot areas of compliance. Coding managers should review this document each year (Casto and Layman 2011, 43).

96. The Medicare Modernization Act of 2003 (MMA) launched a Medicare payment and recovery demonstration project that would later develop into recovery audit contractors (RACs) serving as a means to ensure correct payments under Medicare. During the demonstration program, the contractors were able to identify _____ of dollars in improper payments. a. Hundreds b. Thousands c. Millions d. Billions

Correct Answer: D The RAC demonstration uncovered $1.03 billion of improper payments, of which 96% were overpayments and 4% were underpayments (Casto and Layman 2011, 39).

The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes: a. Adult sibling; adult child; spouse; parent b. Parent; spouse; adult child; adult sibling c. Spouse; parent; adult sibling; adult child d. Spouse; adult child; parent; adult sibling

Correct Answer: D The UHCDA suggests that decision-making priority for an individual's next-of-kin be as follows: Spouse, adult child, parent, adult sibling, or if no one is available who is so related to the individual, authority may be granted to "an adult who exhibited special care and concern for the individual" (Brodnik et al. 2009, 113).

27. How are amendments handled in an EHR? a. Automatically appended to the original note; no additional signature is required. b. Amendments must be entered by the same person as the original note. c. Amendments cannot be entered after 24 hours of the event's occurrence. d. The amendment must have a separate signature, date, and time.

Correct Answer: D The addendum must have a separate signature, date, and time from the original entry (Johns 2011, 437).

93. A 45-year-old man underwent colon resection for carcinoma of the transverse colon. The physician progress note on postoperative day two states anemia. Hemoglobin and hematocrit levels dropped significantly after surgery, and a blood transfusion was ordered. How is the anemia coded? a. 285.1 b. 998.11 c. 998.11, 285.1 d. Unable to code; the physician must be queried.

Correct Answer: D The anemia may be acute blood loss or a complication due to surgery, but it is not stated by the physician. Due to incomplete physician documentation, query the physician (AHA 2004, 4; AHA 2000, 6; AHA 1992, 15-16; AHIMA 2012a, 645).

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report

Correct Answer: D The code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter) (AMA 2012b, 64).

12. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff

Correct Answer: D The cornerstone of accurate coding is physician documentation. Ensuring the accuracy of coded data is a shared responsibility between coding professional and physicians (Johns 2011, 357).

91. The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than ________ hours. a. 30 days/48 hours/24 hours b. 14 days/24 hours/48 hours c. 14 days/48 hours/24 hours d. 30 days/24 hours/48 hours

Correct Answer: D The discharge summary must be completed within 30 days after discharge for most patients but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who are hospitalized for less than 48 hours (Odom-Wesley et al. 2009, 200).

46. Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? a. History and physical reports b. Operative reports c. Consultation reports d. Psychotherapy notes

Correct Answer: D The distinction of psychotherapy notes is important due to HIPAA requirements that these notes may not be released unless specifically specified in an authorization (Odom-Wesley et al. 2009, 440).

97. The documentation of each patient encounter should include the following to secure payment from the insurer except: a. The reason for the encounter and the patient's relevant history, physical exam, and prior diagnostic test results b. A patient assessment, clinical impression, or diagnosis c. A plan of care d. The identity of the patient's nearest relative and emergency contact number

Correct Answer: D The identity of the patient's nearest relative and an emergency contact number are not relative to securing payment from the insurer. The encounter should include the date of the encounter and the identity of the observer (Smith 2012, 8).

At which level of the classification system are the most specific ICD-9-CM codes found? a. Category level b. Section level c. Subcategory level d. Subclassification level

Correct Answer: D The most specific codes in the ICD-9-CM system are found at the subclassification level (Johns 2011, 240).

All of the following should be part of the core areas of a coding compliance plan except: a. Physician query process b. Correct use of encoder software c. Coding diagnoses supported by medical record documentation d. Tracking length of stay

Correct Answer: D Tracking length of stay is part of the hospital utilization review committee function (Casto and Layman 2011, 42 and 46-47).

Which of the following ICD-9-CM codes are always alphanumeric? a. Category codes b. Procedure codes c. Subcategory codes d. V codes

Correct Answer: D V codes are always alphanumeric codes. They are easy to identify because they begin with the alpha character V and follow with numeric digits (Johns 2011, 242).

28. What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm? a. A fine of not more than $10,000 only b. A fine of not more than $10,000, not more than 1 year in jail, or both c. A fine of not more than $5,000 only d. A fine of not more than $250,000, not more than 10 years in jail, or both

Correct Answer: D When a person or entity willfully and knowingly violates the HIPAA Privacy Rule, a fine of not more than $250,000, not more than 10 years in jail, or both may be imposed (LaTour and Eichenwald Maki 2010, 292).

77. Identify the CPT code(s) for the following patient: A 2-year-old male presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance. a. 43752 b. 43760 c. 43761, 76000 d. 49450

Correct Answer: D Code 49450 includes replacement of gastrostomy or cecostomy tube, percutaneous, under fluoroscopic guidance including contrast injections(s), image documentation, and report. Therefore, it would not be appropriate to add code 76000 for fluoroscopic guidance, which is already included in the procedure code (AMA 2012b, 258).

43. Identify the ICD-9-CM diagnostic code for diastolic dysfunction. a. 428.1 b. 428.30 c. 428.9 d. 429.9

Correct Answer: D Index Dysfunction, diastolic (Schraffenberger 2012, 182-183).

In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following? a. DRGs b. HHRGS c. OASIS d. OPPS

Correct Answer: D [outpatient perspective payment system (OPPS)], Radiology procedures performed as outpatients are paid under the Medicare prospective payment system and are identified with a status indicator X for ancillary services (Johns 2011, 329-331).

34. A physician takes the medical records of a group of HIV-positive patients out of the hospital to complete research tasks at home. The physician mistakenly leaves the records in a restaurant, where they are read by a newspaper reporter who publishes an article that identifies the patients. The physician can be sued for: a. Slander b. Willful infliction of mental distress c. Libel d. Invasion of privacy

Correct Answer: D A person's right to privacy is implied in the US Constitution and is "the right to be left alone—the right to be free from unwarranted publicity and exposure to public view, as well as the right to live one's life without having one's name, picture, or private affairs made public against one's will." The right to privacy is also the right to control personal information (Pozgar 2009, 36; LaTour and Eichenwald Maki 2010, 277).

Which of the following is not an essential data element for a healthcare insurance claim? a. Revenue code b. Procedure code c. Provider name d. Procedure name

Correct Answer: D A procedure name is not a required element on a healthcare insurance claim (Casto and Layman 2011, 73).

What statement is not reflective of meeting medical necessity requirements? a. A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease. b. A service or supply provided that is not experimental, investigational, or cosmetic in purpose. c. A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms. d. A service provided solely for the convenience of the insured, the insured's family, or the provider.

Correct Answer: D A service must not be solely for the convenience of the insured, the insured's family, or the provider (Casto and Layman 2011, 99).

71. An HIT using her password can access and change data in the hospital's master patient index. A billing clerk, using his password, cannot perform the same function. Limiting the class of information and functions that can be performed by these two employees is managed by: a. Network controls b. Audit trails c. Administrative controls d. Access controls

Correct Answer: D Access control means being able to identify which employees should have access to what data (Johns 2011, 992).

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff

Correct Answer: D All newly hired coding personnel should receive extensive training on the facility's and HIM department's compliance programs. Education of the medical staff on documentation is likewise important to the success of any compliance program (Johns 2011, 362).

4. Which of the following statements about Category III CPT codes is false? a. They are temporary codes. b. They are updated more frequently than the rest of the CPT codes. c. They are intended to allow for the coding of new technologies, services, and procedures. d. They are tracking codes that can be used for performance measurement.

Correct Answer: D Category II CPT codes are used for performance measurement (AMA 2012b, 535).

99. The computer software program that assigns appropriate DRGs according to information provided for each episode of care is called a: a. Classification b. Database c. Diagnostic decision support (DDS) system d. Grouper

Correct Answer: D Coders enter the codes that have been selected into a computer program called a grouper which assigns the patient's case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes (Johns 2011, 272).

Patient with flank pain was admitted and found to have a calculus of the kidney. A ureteroscopy with placement of ureteral stents was performed. Assign the correct ICD-9-CM diagnosis and procedure codes. a. 592.0, 788.0, 59.8 b. 788.0, 592.0, 56.0 c. 594.9, 59.8 d. 592.0, 59.8

Correct Answer: D Codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related definitive diagnosis has been established. The flank pain would not be coded because it is a symptom of the calculus (Schraffenberger 2012, 67-68).

An accounting of disclosures must include disclosures: a. For use in law enforcement requests b. To any patient family member who makes a request c. To any individual who requested the information d. Made for public health reporting purposes

Correct Answer: D Disclosures for which accounting is not required involve nine exceptions including those in the question (Johns 2011, 833).

Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of the following except: a. Coding conventions defined in the CPT book b. National and local policies and coding edits c. Analysis of standard medical and surgical practice d. Clinical documentation in the discharge summary

Correct Answer: D Editing is not based on the clinical documentation of the discharge summary. Edits are predetermined based on coding conventions defined in the CPT codebooks, national and local policies and coding edits, analysis of standard medical and surgical practice, and review of current coding practices (Johns 2011, 347).

What are five-digit ICD-9-CM diagnosis codes referred to as? a. Category codes b. Section codes c. Subcategory codes d. Subclassification codes

Correct Answer: D Five-digit code numbers represent the subclassification level (Johns 2011, 240).

58. During a review of documentation practices, the HIM director finds that nurses are routinely using the copy-and-paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices? a. Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately. b. Determine how many nurses are involved in this practice. c. Institute an in-service training session on documentation practices. d. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system.

Correct Answer: D In order to thoughtfully and appropriately manage copy functionality, organizations must have sound documentation integrity policies within their organization. HIM professionals should lead their organizations in developing copy policies and procedures that address operational processes, utilization of copy functionality, documentation guidelines, responsibility, and auditing and reporting (AHIMA 2012b, 9-10, 18-21). Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency and continuity and clarity in documentation (AHIMA 2005).

The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure? a. 49000, 58940, 58700 b. 58940, 58720-50 c. 49000, 58720 d. 58720

Correct Answer: D In the abdomen, peritoneum, and omentum subsection, the exploratory laparotomy is a separate procedure and should not be reported when it is part of a larger procedure. The code of 49000 is not reported because laparotomy is the approach to the surgery. The code 58720 includes bilateral so the modifier -50 is not necessary to report (Kuehn 2012, 163-164, 184).

98. Identify the ICD-9-CM diagnosis code(s) for neonatal tooth eruption. a. 525.0 b. 520.6, 525.0 c. 520.9 d. 520.6

Correct Answer: D Index Eruption, teeth/tooth, neonatal. Some main terms are followed by a list of indented subterms (modifiers) that affect the selection of an appropriate code for a given diagnosis. The subterms form individual line entries arranged in alphabetical order and printed in a regular type beginning with a lowercase letter. Subterms are indented on standard indention to the right under the main term. More specific subterms are further indented after the preceding subterm (Schraffenberger 2012, 12).

29. Identify the ICD-9-CM diagnosis code for Paget's disease of the bone (no bone tumor noted). a. 170.9 b. 213.9 c. 238.0 d. 731.0

Correct Answer: D Index Paget's disease, bone. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).

82. CPT procedure codes 96360 and 96361 are used to report infusion of: a. Chemotherapeutic agents b. Sequential drugs of the same drug family c. Hormonal antineoplastics d. Prepackaged fluids and/or electrolytes

Correct Answer: D Instructional notes for hydration state "Codes 96360-96361 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-1/2 normal saline+30mEq KCl/liter), but are not used to report infusion of drugs or other substances." (AMA 2012b, 518-519; AHIMA 2012a, 630).

88. What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? a. Additional payments may be made for locum tenens, increased emergency room services, stays over the average length of stay, and cost outlier cases. b. Additional payments may be made to critical access hospitals, for higher-than-normal volumes, unexpected hospital emergencies, and cost outlier cases. c. Additional payments may be made for increased emergency room services, critical access hospitals, increased labor costs, and cost outlier cases. d. Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases.

Correct Answer: D Medicare provides for additional payment for other factors related to a particular hospital's business. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the MS-DRG adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve these areas. Hospitals that have approved teaching hospitals also receive a percentage add-on payment for each Medicare discharged paid under IPPS, known as the indirect medical education (IME) adjustment. The percentage varies, depending on the ratio of residents to beds. Additional payments are made for new technologies or medical services that have been approved for special add-on payments. Finally, the costs incurred by a hospital for a Medicare beneficiary are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases (Schraffenberger 2012, 471-473).

48. Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Patient Assessment Instrument b. Minimum Data Set for Long-Term Care c. Resident Assessment Protocol d. Outcomes and Assessment Information Set

Correct Answer: D Medicare-certified home healthcare use a standardized patient assessment instrument called the OASIS (Johns 2011, 100).

37. An HIM professional who releases health information that he or she knows will result in genetic discrimination is violating the ethical principle of: a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

Correct Answer: D Nonmaleficence means to do no harm. With regard to the patient and the healthcare team, the HIM professional is obligated to protect health, medical, genetic, social, personal, financial, and adoption information: Clinical information (genetic risk factors) must be protected as well as behavioral information. It is important to protect genetic and social information so that patients will not be vulnerable to the risks of discrimination (LaTour and Eichenwald Maki 2010, 311-312).

85. Identify the acute care record report where the following information would be found: "Set up appointment at the Hypertension Center. Hold potassium supplements. Phenergan p.o. 12.5 mg 1-2 tablets p.o. p.r.n. every 6 hrs." a. Medical laboratory report b. Pathology report c. Physical exam d. Physician order

Correct Answer: D Physician orders are the instructions the physician gives to the other healthcare professionals (Johns 2011, 63).

A denial of a claim is possible for all of the following reasons except: a. Not meeting medical necessity b. Billing too many units of a specific service c. Unbundling d. Approved precertification

Correct Answer: D Prior approval for a service or procedure is called precertification and allows coverage for a specific service (Casto and Layman 2011, 71).

37. Observation E/M codes (99218-99220) are used in physician billing when: a. A patient is admitted and discharged on the same date. b. A patient is admitted for routine nursing care following surgery. c. A patient does not meet admission criteria. d. A patient is referred to a designated observation status.

Correct Answer: D See instructional notes preceding code 99217. In order to report these codes, the admission order must designate observation status. Whether the patient meets admission criteria or is admitted following surgery does not affect the observation code selection. If the patient is admitted and discharged on the same date, codes 99234-99236 are appropriate (AMA 2012b, 13).

12. A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out chest pain versus GERD." The correct ICD-9-CM code is: a. V71.7, Admission for suspected cardiovascular condition b. 789.01, Esophageal pain c. 530.81, Gastrointestinal reflux d. 786.50, Chest pain NOS

Correct Answer: D Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "rule out" or other similar terms indicating uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if it existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign or symptom the patient exhibits. In this case, assign the code 786.50, Chest pain NOS (Schraffenberger 2012, 339).

48. How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met

Correct Answer: D Surveyors review the documentation of patient care services to determine whether the standards for care are being met (Johns 2011, 40).

100. Which of the following does not have to be included in a covered entity's notice of privacy practice? a. Description with one example of disclosures made for treatment, payment, and healthcare operations b. Description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization c. Statement of individual's rights with respect to PHI and how the individual can exercise these rights d. Signature of the patient and date the notice was given to the patient

Correct Answer: D The NPP is a statement mandated by the HIPAA Privacy Rule issued by a healthcare organization that informs individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization, as well as the individual's rights and the organization's legal duties with respect to that information (Brodnik et al. 2009, 249).

Which of the following issues compliance program guidance? a. AHIMA b. CMS c. Federal Register d. HHS Office of Inspector General (OIG)

Correct Answer: D The OIG continues to issue compliance program guidance since 1998 (Johns 2011, 359).

11. The sum of a hospital's total relative DRG weights for a year was 15,192 and the hospital had 10,471 total discharges for the year. Given this information, what would be the hospital's case-mix index for that year? a. 0.689 b. 1.59 c. 1.45 × 100 d. 1.45

Correct Answer: D The case-mix index is 1.45 for the total case-mix index of the hospital. An individual MS-DRG case mix can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG. This provides the total weight for each MS-DRG. The sum of all total weights (15,192) divided by the sum of total patient discharges (10,471) equals the case-mix index (Johns 2011, 324).

What is the defining characteristic of an integrated health record format? a. Each section of the record is maintained by the patient care department that provided the care. b. Integrated health records are intended to be used in ambulatory settings. c. Integrated health records include both paper forms and computer printouts. d. Integrated health record components are arranged in strict chronological order.

Correct Answer: D The integrated health record is arranged so that the documentation from various sources is intermingled and follow strict chronological order (Johns 2011, 114).

Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report

Correct Answer: D The pathology report includes descriptions of the tissue from a gross or macroscopic level and representative cells at the microscopic level (Johns 2011, 77).

Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens. a. 366.10, 250.50, 13.59, 13.71 b. 250.00, 366.10 c. 250.00, 366.12 d. 366.10, 250.00, 13.59, 13.71

Correct Answer: D The patient was admitted for the senile cataract and the procedures were completed for that condition. This follows the UHDDS guidelines for principle diagnosis selection. There is also no causal relationship given between the diabetes and the cataract, so 250.50 would be incorrect (Schraffenberger 2012, 122-123, 164).

64. Identify the acute-care record report where the following information would be found: The patient is a well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair, and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Edema of both legs. a. Discharge summary b. Medical history c. Medical laboratory report d. Physical examination

Correct Answer: D The physical examination report represents the attending physician's assessment of the patient's current health status (Johns 2011, 63).

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

Correct Answer: D The plan includes orders and the roadmap for patient care (Johns 2011, 114).

Electronic systems used by nurses and physicians to document assessments and findings are called: a. Computerized provider order entry b. Electronic document management systems c. Electronic medication administration records d. Electronic patient care charting

Correct Answer: D The primary EHR applications include clinical documentation or patient care charting, computerized provider order entry, electronic medical administration records, and clinical decision support (Johns 2011, 137).

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. What should be done in this case?

Counsel the coder and stop the practice immediately and review the elements of the hospital compliance program with the coder.

Which of the following is NOT reimbursed according to the Medicare outpatient prospective payment system? A) CMHC (community mental health center) partial hospitalization services, B) Critical access hospitals, C) Hospital outpatient departments, or D) Vaccines provided by CORFs (comprehensive outpatient rehabilitation facility)

Critical Access Hospitals are paid on a cost-based payment system and are not part of the prospective payment system. *********JOHNS********RE-READ

CPT

Current Procedural Terminology (CPT-HSPCS LEvel I) CPT reports diagnostic and surgical services and procedures. Created and Published by the AMA. Category I, II and III

CPR

Customary, Prevailing, and Reasonable

Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of following EXCEPT: A) coding conventions defined in the CPT book, B) national and local policies and coding edits, C) analysis of standard medical and surgical procedures, or D) clinical documentation in the discharge summary

D) clinical documentation in the discharge summary. Edits are predetermined based on coding conventions defined in the CPT codebooks, national and local policies and coding edits, analysis of standard medical and surgical practice, and review of current coding practices.

This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services: A) General Counsel, B) Health Information Director, C) Privacy Officer, or D) Compliance Officer

D-Compliance Officer

Electronic systems used by nurses and physicians to doucment assessments and findings are called: A) Computerized provider order entry, B) electronic document management systems, C) electronic medication administration records, or D) electronic patient care charting

D-Electronic Patient Care Charting

Coders will assign codes that have been selected into a computer program called a ______________ to assign the patient's case to the correct group based on ICD-9-CM and/or CPT/HCPCS codes. A) Encoder, B) Computer-Assisted Coding, C) Natural-Language Processor, or D) Grouper

D-Grouper In both the MS-DRG and APC groupings, coders enter the codes that have been selected in a computer program called a grouper. The grouper then assigns the patient' case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes.

Which of the following issues compliance program guidance? A) AHIMA, B) CMS, C) Federal Register, or D) HHS Office of Inspector General (OIG)

D-HHS Office of Inspector General (OIG)

HIT Professionals must have knowledge of: A) Security issues with regard to the management of healthcare reform, B) Laws affecting the physician malpractice insurance, C) AMA's professional ethical principles of practice regarding physician assistants, or D) Laws affecting the use of disclosure of health information

D-Laws affecting the use of disclosure of health information

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? A) Current coding personnel, B) Medical Staff, C) Newly hired coding personnel, or D) Nursing staff

D-Nursing Staff

What resource can managers use to discover current, hot areas of compliance? A) policies and procedures, B) National Coverage Determination, C) Official Coding Guidelines, or D) OIG Workplan

D-OIG Workplan is published every year to provide insight into the directions the OIG is taking, as well as highlights of hot areas of compliance. Coding managers should review this document every year.

A special webpage that offers secure access to data is called a: A) access control, B) Home Page, C) Intranet, or D) Portal

D-Portal: a portal is a special application to provide secure remote access to specific applications

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 document would this appear? A) Admission note, B) Nursing Note, C) Physician Progress Note, or D) Social work note

D-Social work note

The Uniform Health Care Decisions Act ranks the next of kin in the following order for medical decision-making purposes: A) Adult sibling; adult child; spouse; parent, B) Parent; spouse; adult child; adult sibling, C) Spouse; parent; adult sibling; adult child, or D) Spouse; adult child; parent; adult sibling

D-Spouse, Adult Child, Parent, Adult Sibling: UHCDA suggest this order of decision making for an individual's next of kin. If no one is available who is so related to the individual, authority may be granted to "an adult who exhibited special care and concern for the individual"

What is the defining characteristic of an integrated health record format? A) each setion of the record is maintained by the patient care department that provided the care, B) integrated health records are intended to be used in ambulatory settings, C) Integrated health records include both patper and computer printouts, or D) Integrated health record components are arranged in strict chronological order

D-integrated health record components are arranged in strict chronological order

An accounting of disclosures must include disclosures: A) for use in law enforcement requests, B) to any patient family member who makes a request, C) to any individual who requested the information, or D) made for public health reporting purposes

D-made for public health reporting purposes

A notation for a hypertensive patient in a physican ambulatory care progess note reads: "Continue with Diuril, 500mgs once daily. Return in 2 weeks." In which part of the POMR progress note would this notation be written? A) subjective, B) objective, C) assessment, or D) plan

D-plan: the plan lays out a road map for the patient

Identify where the following information would be found in the acute-care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine." A) in the medical lab report, B) in the physical examination, C) in the physician progress notes, or D) in the radiology report

D-the radiology report

All of the following should be part of the core areas of a coding compliance plan EXCEPT: A) physician query process, B) Correct us of encoder software, C) Coding diagnoses supported by medical record documentation, and D) Tracking lenght of stay

D-tracking length of stay

DRG and RW

DRG and RW (Relative Weight): Each DRG is assigned a RW (Relative Weight) that is intended to represent the resource intensity of the clinical group.

How are Diagnosis-related groups organized?

DRG's are organized into MDC's - DRG's are classified by one of 25 major diagnostic categories.

The MS-DRG system creates a hospital's case mix index (type or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of _______________ within the MS-DRG? A) Admissions, B) Discharges, C) CCs, or D) MCCs

Discharges

In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had 3 surgical procedures performed during the same operative session, which of the following would apply? A) bundling of services, B) outlier adjustment, C) pass-through payment, or D) discounting of procedures

Discounting applies to multiple surgical procedures furnished during the same operative session. The full rate will be paid to the surgical procedure with the highest rate and the additional procedures with be discounted 50% of their APC (Ambulatory Payment Classification) rate.

Please describe E Codes.

E Codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect.

Evaluation & Management

E/M services provided in a Dr's office, hospital outpatient department, or another ambulatory care facility Observation Services: furnished in hospital outpatient setting-patient is an outpatient Hosptial Inpatient Services: E/M services provided to hosptial inpatients, including partial hospitalization services Consultations: a consultaiton is an exam of a patient by a provider for the purpose of advising the referring Dr in the E&M Emergency Dept Services Critical Care Services Nursing Facility Services Rest Home Assisted Living Prolonged Services Case Management Newborn Care Preventative Care

What is the process used to transform text into an unintelligible string of characters that can be transmitted via communicaiton media with a high degree of security and then decrypted when it reaches a secure destination?

Encryption

What is ESRD PPS?

End Stage Renal Disease Prospective Payment System

How to code Acute and Chronic Conditions:

Example: Acute Gastritis and Chronic Gastritis are diagnosed. Assign 535.00 and 535.10 in that order. Sequence acute or subacute first.

What is the definition of "other diagnoses"? [according to the UHDDS-Uniform Hospital Discharge Data Set

For reporting purposes "other diagnoses" is interpreted as ADDITIONAL CONDITIONS that affect patient care in terms of requiring: clinical evaluation or therapeutic treatement or diagnostic procedures or extends the length of stay or increases nursing care and monitoring.

Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff? A) Hard Coding, B) Soft Coding, C) Encoder coding, or D) Natural language processing coding

HCPCS codes that are assigned in the charge description master that flow directly to the claim and bypass facility coding staff is a process known as hard coding.

What law mandated the development of standards for electronic medical records? A) Medicare and Medicaid legislation of 1965, B) Prospective Payment Act of 1983, C) HIPAA of 1996, or D) Balanced Budget Act of 1997

HIPAA

Messaging standards for electronic data interchange in healthcare have been developed by: A) HL7, B) IEE, C) The Joint Commission, or D) CMS

HL7-HL7 Electronic Health Record System (EHR-S) Functional Mode.

Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion?

Health Information, Business Office and Cardiac Department

HCPCS

Healthcare Common Procedure Coding System a two-tiered system of procedural codes used primarily for ambulatory care and physician services.

Physician correctly prescribes Coumadin [anticoagulant-blood thinner]. Patient takes the Coumadin as prescribed but develops hematuria [blood in the urine] as a result of taking the medication. What the correct way to code this case?

Hematuria; adverse reaction to Coumadin. An adverse effect can occur when everything is done correctly. Adverse effects can occur in situations where medications are administered properly and prescribed correctly in both therapeutic and diagnostic procedures. The first listed diagnosis is the MANIFESTATION or the nature of the adverse drug effect - in this case HEMATURIA. Locate the drug in the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse effects.

HHPPS

Home Health Prospective Payment System Home Health Agency HHRG - Home Health Resource Group

Are Volume 3 of ICD-9-CM typically for hospital or physician procedures?

Hospital

Neoplams Secondary

Identifies an anatomical site to which the malignant neoplams has spread or metastasized

Neoplams Ca in Site

Indicates the tumor has undergone malignant changes but is still limted to the originating site and has not spread.

Patient admitted for abdominal pain with diarrhea and diagnosed with infectious gastroenteritis. Patient also has angina and chronic obstruction pulmonary disease. What is the correct coding and sequence for this case?

Infectious gastroenteritis; chronic obstructive pulmonary disease; angina - Patients can have several chronic conditions that co-exist at the time of their admision and qualify as additional disgnoses. [the codes for the symptoms "abdominal pain", "diarrhea", "vomiting", or "abdominal cramps" - signs, symptoms, and ill-defined conditions are not to be used as the Principal Diagnosis when a related definitive diagnosis has been established. *Chapter 16 CPT Codebook*

Medicare Part A

Inpatient Hospital Insurance (includes: inpatient hospitalization, long term care hospitalization, skilled nursing, home health, and hospice care)

IPPS

Inpatient Prospective Payment System Inpatient Acute Care Hospital IPPS is the Medicare reimbursement system for inpatient services provided in an acute care setting. Payment to facilities, not payment for professional services. DRG/MS-DRG

IRF PPS

Inpatient Rehabilitation Facility Prospective Payment System Inpatient Rehabilitation Facility CMG: Case-Mix Group

IPF PPS

Inpatient psychiatric facility prospective payment system Inpatient psychiatric facility Per Diem

What is the procedure for locating a DRUG?

Locate the drug in the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse effects.

LTCH PPS

Lont-Term Care Hospital Prospective Payment System Long-Term Care Hospital LTC-DRG MS-LTC-DRG

What are Medicare's newest claims processing payment contract entities referred to as:

MAC's - Medicare Administrative Contractors are replacing the claims payment contractors known as FIs and carriers.

What is Medicare's 4-step methodology for calculating total MS-DRG payment?

MACs (Medicare Administrative Contractors) use grouper and pricer software to calculate the MS-DRG and payment for each hospital encounter. STEPS: 1) the hosptial submits an electronic claim to their designated MAC. MAC performs a claim audit to ensure the claim is a clean claim. Once the claim is clean, the grouper software assigns an MS-DRG based on the demographic and coded data submitted; 2) A base payment rate is established for each Medicare-particpating hospital for each fiscal year (FY). The base payment is a per encounter rate that is based on historic claims data. The RW for MS-DRG 293 (Congestive Heart Failure) is 0.6756. The fully adjusted hospital specific base rate is $7325.00. The RW is multiplied by the hospital base rate to calculate the initial payment rate. ($7235 x 0.6756 = $4948.77); 3) Add-on are added for high cost outliers; 4) Add-on for new medical service or new technology are added at 50%.

What does MC stand for in the ICD-9-CM book?

MC means that this diagnosis code is a major complication of another diagnosis.

Briefly describe MS-DRG

MS-DRG (Medical-Severity-Diagnosis-Related Group). It is system to classsify hospital cases in groups. DRG's are used to determine how much Medicare pays the hospital for each "product" [i.e. "appendectomy"] since patients within each group are clinically similar and are expected to use the same level of hospital resources. Each DRG was a payment weight assigned to it based on the average resources used to treat Medicare patients in that DRG. Payment weights are affected by geographic location (cost of living), number of low income patietns in that location, whether the facility is a teaching facility, and if the case is an outlier case (a particularly costly case). Claim information is gathered: ICD diagnoses, procedures, age, sex, discharge status, and the presence of complication or comorbidities. Examples: Normal Newborn, Psychoses, Major Joint Replacement, Chest Pain, Cesarean Section, Simple pneumonia, Heart Failure. DRG's were developed to monitor quality of care and resource use, cost efficiency, and use the indicators to improve quality. Only ONE DRG can be assigned and reimbursed for a single admission. The payment provided for the DRG is intended to cover the costs of all hospital services performed during the patient's stay. Under the PPS, hospitals are paid a set fee for treating patients in a single DRG category, regardless of the acutal cost of care for the individual.

MCC

Major Complication or Co-Morbidity (refinements of the MS-DRG system)

MDC

Major Diagnostic Category - represents the body systems treated by medicine. (There are 25 MDCs). Examples: 1) diseases and disorders of the nervous system, 2) diseases and disorders of the eye, 3) infectious and parasitic diseases, 4) HIV, 5) endocrine & metabolic disorders, 6) pregnancy, childbirth, and the puerperium, etc...

Hypertension Table; Malignant, Benign, Unspecified

Malignant 5% of all patients (high blood pressure plus swelling of the optic nerve - typically associated with organ damage, such as heart or kidney failure); Benign - 95% of all cases - BUT if record is not specific - code as Unspecified

MCO

Managed Care Organization (Disease management, primary care physician, high quality and affordable care, pre-auth, 2nd opinions, HMOs, EPOs, PPO)

Medicaid is a government-sponsored healthcare insurance program that became effective in 1966 as Title 19 of the Social Security Act. Medicaid is administered by: A) the federal government, B) the state government, C) the federal and state government, or D) third-party administrators

Medicaid is administered by federal and state government and is designed to offer assistance to low income people.

Medicare Part C

Medicare Advantage covers services excluded from Parts A and B. (includes: long-term nursing care, custodial care, dental, vision, routine exams, health and wellness education, acupuncture, hearing aids)

What does Medicare Part D pay for?

Medicare Part D pays for prescription drugs for beneficiaries.

Medigap

Medicare beneficiaries who purchase private insurance to supplement their Part A and Part B

Medicare Part D

Medicare drug benefit

What is the payment to nonparticipating physicians (Medicare)?

Medicare payments to nonparticipating physicians are reduced by 5%. They receive 95% of what participating physicians receive.

Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for:

Medicare will pay for the infusion procedure. Access to an indwelling IV or insertion of a subcutaneous catheter or port for the purpose of a therapeutic infusion is considered part of the procedure and not separately billed. {Physicians often infuse medications such as nitroglycerine during cardiac catheterization procedures. CPT Assistant states that infusion of medication should be considered an intrinsic part of the catheterization procedure.

Memory Tip: C in ECode stands for ___________________

Memory Tip - External Cause: E codes explain HOW an enjury or poisoning happened, and/or WHERE it happened. E Codes are important because the event or element that caused the inhury may require a different insurance company to pay. (i.e. - work/worker's comp, auto/auto insurance, slip at home/homeowner's insurance). In some circumstances you need 2 E codes to tell the whole story - the how and where. An E COde can NEVER be a principal or first-listed code.

Memory Tip: V in VCode stands for _________________

Memory Tip - Prevention: V codes cover screenings, such as mammograms or colonoscopy; preventative medicinces such as vaccines, fertility testing and treatments; prenatal checkups; and well-baby exams. A V Code can be listed as a principal or first-listed code.

Patient admitted with history of prostate cancer and with mental confusion. Patient completed radiation therapy for prostatic carcinoma 3 years prior and is status post a radical resection of the prostate. A CT Scan of the brain during the current admission reveals metastasis. What is the correct coding and sequencing for this case?

Metastastic carcinoma of the brain; History of carcinoma of the prostate - for a FORMER malignancy a code from Category V10, personal history of a malignant neoplasm should be used to indicate the former site of malignancy [when a primary malignancy has been previously excised or eradicated from its site and there is NO further treatment directed to that site & no evidence of any existing primary malignancy]. The mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal, with the V10 code used as a secondary code. (Shcraffenberger)

65-year old patient with history of lung cancer is admitted to a healthcare facility with ataxia (without coordination) and syncope (fainting) and a fractured arm-result of a fall. Treatment is a closed reduction of the fracture in the ER department and undergoes a complete workup for metastatic carcinoma of the brain. Patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. What is the principal diagnosis in this case?

Metastatic carcinoma of the brain. If treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The ONLY EXCEPTION to this guideline is if a patient admission or encounter is SOLELY for the administration of chemotherapy, immunotherapy, or radiation therapy which would prompt the coder to assigne the appropriate V Code as the 1st listed or principal diagnosis and diagnosis or problem for which the service is being peformed as the secondary diagnosis.

MRSA

Methicillin-Resistant Staphylococcus aureus

Patient admitted for spotting. Patient had been treated 2 weeks prior for a miscarriage with sepsis. Sepsis has resolved and she is afrebrile [having no fever] at this time. Patient is treated with an aspiration dilation and curettage. Products of conception are found. What is the principal diagnosis?

Miscarriage: subsequent [later] admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from Catogory 634, spontaneous abortion, or 635, legally induced abortion, with a fifth digit of "1" (incomplete). This advise is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.

What is the 2-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure?

Modifier -55 is used to identify the physician provided ONLY postoperative care services for a particular procedure. [modifiers are appended to the code to provide more information or to alert the payer that a payment change is required.]

Epidural given during labor. Subsequently determined the patient would require a C-section for cephalopelvic disproportion [baby's head too large for mother's pelvis] because of obstructed labor [failure of the fetus to descend through the birth canal]. What it the correct ICD-9-CM diagnostic and the CPT anesthesia codes?

NEED TO LOOK UP THIS ANSWER

80-year old female frebrile, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. Patient has has >100K organisms of Escherichia coli per cc of urine. Attending physician documents: "urosepsis". How should the coder proceed in this case?

NEED TO STUDY THIS BEFORE ADDING THE ANSWER

What is NCCI?

National Correct Coding Initiative

When is the code for an acute phase of an illness or injury that led to the late effect reported?

Never - because the treatment for the acute phase has ended.

Fractures

Newly Diagnosed Fracture 733.1 and subcategories of this may be used while the patient is receiving active treatment for the fracture - surgical treatment, emergency department encounter, evaluation and treatment by a new physician. For Aftercare: V-Codes are used (cast changes or removal; removal of external or internal fixation deivce, medication adjustment, follow-up)

Can a claim be denied for "Approved Pre-certification"?

No

STEMI and NSTEMI

Non-ST elevation myocardial infarction is a less severe, partial block. A NSTEMI can evolve to a STEMI (large portion of heart damage)

Denials of outpatient claims are often generated from all of the following edits EXCEPT: A) NCCI (National Correct Coding Initiative, B) OCE (Outpatient Code Editor, C) OCE (Outpatient Claims Editor, or D) national and local policies

OCE - Outpatient Claims Editor Does Not Exist - the correct terminology is OCE Outpatient Code Editor

The NCCI editing system used in processing OPPS claims is referred to as:

OCE-Outpatient Code Editor: portions of the NCCI are incorporated into the outpatient code editor (OCE) against which all ambulatory claims are reviewed. The OCE, also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services provided.

Define OPPS

OPPS - Hospital Outpatient Prospective Payment System: OPPS requires hospitals/facilities to use Levels 1 and II HCPCS codes. Packaging and bundling concepts are used in OPPS.

In processing a Medicare payment for outpatient radiology examinations, a hospital outpatient services department would receive payment under which of the following? A) DRGs, B) HHRGS, C) OASIS, or D) OPPS

OPPS - Radiology procedures performed as outpatients are paid under the Medicare prospective payment system and are identified with a status indicator X for ancillary services.

What is the AHA Coding Clinic for HSPCS?

Official coding guidance for Healthcare Common Procedure Coding System (HCPCS) Level II procedure, service and supply codes.

What is an underlying condition?

One disease that affects or encourages another condition. (Example: diabetes, hypertension). Foot ulcer due to diabetes - Code Foot ulcer first and then diabetes.

What is OASIS?

Outcome Assessment Information Set: an instrument by which data is collected in a Home Health agency. OASIS data includes: sociodemographic, environment, support status, health status, functional status, and behavioral status. OASIS uses ICD-9-CM codes to represent the health status of patients.

What is an outlier?

Outliers are cases in prosprctive payment systems with unusually long lengths of stay (day outlier) or exceptionally high costs (cost outlier).

OPPS

Outpatient Prospective Payment System Outpatient Hospital Service APC Group - Ambulatory Payment Classification Group

Define POA and when are POA indicators required?

POA is defined as present at the time the order for inpatient admission occurs - conditions that deveopl during an outpatient encounter, including ER, observation, or outpatient surgery, are considered POA. The POA Indicator is required for all claims involving Medicare inpatient admission to general IPPS acute care hospitals or other facilites.

What billing form is used by a health record technician to perform the billing functions for a physician's office?

Physicians submit claims via the electronic format via the CMS-1500 billing form.

Poisoning

Poisoning indicates that the patient's body reacted negatively to a drug or chemical - this is the first code you will use to identify the cause of the poisoning

Provide a description of RCM (revenue cycle management):

Preclaims Submission Activities: patient's responsbile parties, copayments, deductibles Claims Processing Activities: capture of billable services - charge capture; order entry; CDM-charge descrption master>>hard coding. Auditing and Submitting the claim Accounts Receivable: who receives what payments Claims Reconciliation and Collections: reviews, collections, write-offs

Neoplasm Primary

Primary indicates the anatomical site where the neoplasm originated.

Please define "principal diagnosis".

Principal diagnosis is the condition established, after study, to be chiefly responsible for occasioning the admission to the patient for the hospital. The principal diagnosis is NOT the admitting diagnosis, but the diagnosis found after workup, or even after surgery that proves to the be reason for admission.

Is payment for determined by diagnosis or procedure?

Procedure(s) performed. Medical necessity is tied to the procedure.

Why were prospective payment systems developed by the federal government?

Prospective payment systems were developed to manage the costs of Medicare and Medicaid. Since 1983, PPS have been used to manage the costs of the Medicare and Medicaid systems.

What is PHI?

Protected Health Information

What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of the practice and the risk of malpractice?

RVUs - Relative value units are assigned to each service to provide a value that corresponds to payment.

A HIT-Health Information Technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had 2 physician visits, underwent radiology examinations, clinical laboratory test, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system? A) Clinical Laboratory Tests, B) Physician Office Visits, C) Radiology Examinations, or D) Take-Home Surgical Dressings

Radiology Examinations: Radiology procedures are identified under the prospective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid. ******JOHNS BOOK*****RE-READ this

CPT Category III

Represent emerging technologies. 5-digit alphanumeric code ending with T.

Define Clean Claim:

Request for payment that contains only accurate information.

How do you code SIRS, Sepsis, and Severe Sepsis?

Requires a minimum of 2 codes: 1) a code for the underlying cause (such as infection or trauma) and a code from subcategory 995.9 Systemic inflammaatory resonse syndrome (SIRS). The underlying cause is sequenced 1st, then the code from 995.9. [Sepsis and Severe Sepsis require a code for the systemic infection and either code 995.91-Sepsis, or 995.92-Severe Sepsis. If the causal organism is not documented code 038.9, Unspecified septicemia.

What is an RUG?

Resource Utilization Group - Classification for resources used in a nursing home. Patients are classified into 1 of 44 possible RUGs based on data.

RBRVS

Resource-Based Relative Value Scale Physician Offices and practice groups RBRVS - Relative Value Scale

What are RBRVSs?

Resource-Based Relative Value Scale: for physician services, the ambulance fee schedule, and the hospital outpatient payment system. A relative value scale permits comparisons of the resources needed or appropriate prices for various units of service. It takes into account labor, skill, supplies, equipment, space, and other costs for each service or procedure.

Name examples of Fee-For-Service Reimbursement

Self-Pay Traditional retrospective Payment Managed Care

Describe Septicemia:

Septicmia generally refers to a systemic disease associated with the presence of pathological microorganisms ot toxins in the blood, which include bacteria, viruses, fungi.

SNF PPS

Skilled Nursing Facility Prospective Payment System RUG - Resource Utilization Group

What are the AHIMA Standard of Ethical Coding?

Standard developed by the Council on Coding and Classification by the AHIMA (American Health Information Management Association) to give health informtion coding professionals ethical guidelines for performing their coding and grouping tasks.

A 7-year old patient was admitted to ER for treatment of shortness of breath. Patient was give epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? [epineprhine-adrenaline hormone secreted by the medulla of the adrenal glands - when injected treats vasoldilation by increasing blood flow]

Status Asthmaticus: fails to respond to therapy administered during an asthmatic attack. This is a life-threatening conditions that requires emergency care and likely hospitalization. (Schraffenberger)

Steps to Assigning MS-DRG:

Step 1: Pre-MDC Assignment Step 2: Major Diagnostic Category Determination (Principal Diagnosis) Step 3: Medical/Surgical Determination (determine if a procedure was performed) Step 4: Refinement (refinement questions to isolate the correct MS-DRG assignment - Is an MCC present, Is a CC present, what is the patient's sex, birth weight for neonates, patient's discharge disposition (dead, alive)

Medicare Part B

Supplemental Medical Insurance - optional. Covers Physician Services, Medical Services, and Medical Supplies not covered by Medicare Part A. $99.00 per month.

SIRS

Systemic inflammatory response syndrome (SIRS) generally refers to the system response to infectin, trauma/burns, or other insult (such as cancer) with symptoms including fever, tachycardia, tachypnea, and leukocytosis. Sepis generally refers to SIRS due to infection. Severe Sepsis generally refers to sepsis with associated acute organ dysfunction.

Which classification level of ICD-9-CM codes is the most specific?

The "sub-classification" level is the most specific level of coding in ICD-9-CM (5-digit codes).

What is the "two-times rule" under APC (Ambulatory Payment Classification)?

The "two-times rule" states that median cost of the most expensive item or service within a group cannot be more than 2 times greater than the median cost of the least expensive item or service within the same group.

How is the CPT code determined for an excision of a malignant lesion of the skin?

The CPT code for an excision of a malignant lesion of the skin by the body area from which the excision occurs and by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter + the most narrow margins required = the excised diameter).

What is a POA Indicator?

The POA-Present on Admission Indicator is used to differentiate between conditions present at the time of admission and conditions that develop during an inpatient admission. The POA Indicator applies to diagnosis codes for claims involving inpatient admissions to acute care hospitals and other facilities. POA - developed by the Cooperating Parties.

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? A) Minimum Necessary, B) Notice of Privacy Practices, C) Authorization, or D) Consent

The Standard of Minimun Necessary

The sum of a hospital's total relative DRG weights for a year was 15,192 and hospital had 10,471 total discharges for the year. Given this information, what would be the hospital's case mix index for that year? A) 0.689, B) 1.59, C) 1.45 x 100, or D) 1.45

The case-mix index is 1.45 for the total case-mix index of the hospital. The sum all total weights 15,192 divided by the sum of total patient discharges 10,471 = the case mix index.

What is bundling?

The combination of supply and pharmaceutical costs or medical visits with associated procedures or services for 1 lump sum payment.

What is the function of the consulation report?

The consulation report documents opinions about the patient's condition from the perspective of a physician not previously involved in that patient's case

When are multiple codes required?

The etiology/manifestation coding convention requires that 2 codes be reported to completely describe a single condition that affects multiple body systems. Multiple codes may also be needed to report late effects, complications, and obstetrical cases to more fully describe the patient's condition. Example: amyloid neuritis - 277.39 and 357.4

The following is documented in an acute-care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear? a. History b. Pathology report c. Physical examination d. Operation report

The following is documented in an acute-care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear? a. History b. Pathology report c. Physical examination d. Operation report

Describe unbundling:

The fradulent process in which individual component codes are submitted for reimbusement rather than one comprehensive code.

Describe upcoding:

The fradulent process of submiting codes for reimbursement that indicates more complex or higher-paying services than those the patient actually received.

What is the goal of a coding compliance program?

The goal of a coding compliance program is to prevent accusations of fraud and abuse.

Which item is not one of the purposes of ICD-9-CM: A)-reporting of diagnoses by physicians, B)-classification of mortality for statistical purposes, C)-the identification of supplies, products & services provided to patients, or D)-classification of morbidity for statistical purposes

The identification of supplies, products & services provided to patients is NOT on of the purposes of ICD-9-CM.

Perinatal Period

The perinatal period is the interval of time occurring before, during, and up to 28 days following birth. Codes here are NEVER reported on the mother's record - only the infant record. V30-V39 are only coded once - the birth of an infant

What is guarantor?

The person is who responsible for the bill. In the case of a child patient, the parent is the guarantor.

Define Charge Capture:

The process of collecting all services, procedures, and supplies provided during patient care.

Tabular List of Procedures in ICD-9-CM (INPATIENT SETTINGS):

The tablular list of procedures is based on anatomy rather than surgical specialty and it contains numeric codes only. Based on body systems except for 3 chapters - Chapter 00 - procedures and interventions NEC, Chapter 13 - Obstetrical Procedures, or Chapter 16 - Miscellaneous Diagnostic and Therapeutic Procedures.

Describe "hard coding":

The use of the charge description master to code repetitive services.

How many digits are in the Subcategory Level of ICD-9-CM codes?

There are 4 digits at the Subcategory Level of ICD-9-CM codes.

How often are fee schedules updated by third-party payers?

Third-Party Payers who reimburse providers on a fee-for-service basis generally update fee schedules on an annual basis.

E Code Therapeutic Use

This E Code is used when the RIGHT drug is taken in the RIGHT dose by the RIGHT person, but an UNEXPECTED reaction occurred.

E Code Accident

This E Code will be added to the poisoning code to indicate that the adverse reaction was caused by an accidental overdose, an accidental taking of the wrong substance, or an accident that happened during the use of drugs and chemical substances. UNINTENTIONAL ingestion or exposure.

E Code Suicide attempt

This code indicates that the overdose or incorrect substance was taken with the full intent of causing one's own death.

E Code Undetermined`

This code is to be used only when the record does not state what caused the poisoning.

E Code Assault

This code specifies taht one person casued the poisoning on purpose to inflict illness, injury, or death upon another person. This code implies murder.

Describe CDM-Charge description master:

This is the database used by healthcare facilities to house the price list for all services provided to patients.

What does it mean when a provide accepts assignment?

To accept assignment means the provider or supplier accepts, as payment in full, the allowed charge from the fee schedule.

What is the function of the physician's orders?

To document the physician's instructions to other parties involved in providing care to the patient

Coding Pressure Ulcers:

Two codes are needed to completely describe a pressure ulcer: a code from subcategory 707.0, Pressure Ulcer (site) and 707.2 Pressure Ulcer (stage)

What is the UHDDS?

Uniform Hospital Discharge Data Set is a minimum set of items based on standard definitions to provide consistent data for multiple users. UHDDS is required for reporting Medicare and Medicaid patients and many other health care payers also use most of the UHDDS for the uniform billing system.

Patient admitted with abdominal pain. Physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. What is the correct coding and sequencing for this case?

Unusual Instance: Sequence EITHER the pancreatitis OR noncalculus cholecystitis as the principal diagnosis - two or more diagnoses equally meet the criteria for the principal diagnosis as determined by the circumstances of admission, diagnostic workup, and the therapy provided. ALSO the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction. In such cases any one of the diagnoses may be sequenced first.

"Use additional Code"

Use additional code notes are found in the tabular list. Example: Infections in Chapter 1 may be required to identify the bacterail organism causing the infection. UTI due to e Coli - Report: 599.0 and 041.4

UCR

Usual Customary, and Reasonable

What ICD-9-CM codes are always alphanumeric?

V Codes are always alphanumeric.

What codes are used to assign a diagnosis to a patient who is seeking healthcare services but is no necessarily sick?

V Codes are diagnosis codes and indicate a reason for healthcare encounter.

Please describe V Codes.

V Codes are diagnosis codes that indicate a REASON for the healthcare encounter.

Supplemental V Code Classification Factors

V01 - contact with or exposure to communicable disease V02 - carrier or suspected carriers of infectious diseases V03 - V06 - Need for prophylactic vaccination and inoculation against bacterial, viral and single and combination diseases V07 - Need for isolation V08 - asymptomatic HIV infection status V09 - infection with drug-resistant microorganisms

Pregnancy V-Codes

V22.0 - routine outpatient pre-natal no complications present V22.1 - supervision of normal first pregnancy V23 category - supervision of high risk pregnancy V27.0 - V27.9 - outcome of delivery should be included on every maternal record when a delivery has occurred. [do not use on newborn record]

Long Term Insulin Use

V58.67 - long term (current) use of insulin.

What new generation/design of consumer-directed healthcare will be driven by a design where co-payments are set based on the value of the clinical services rather than the traditional practices that focus only on the costs of clinical services [i.e. it will focus on both the benefit and cost]?

VBID - Value Based Insurance Design calculates both the benefit and costs of clinical services.

Please give a brief description of Volume 2 of the ICD-9-CM Volumes.

Volume 2 of the ICD-9-CM contains the ALPHABETIC INDEX to Diseases and Injuries (You should always trust this index).

Please give a brief description of Volume 3 of the ICD-9-CM Volumes.

Volume 3 of the ICD-9-CM contains the TABULAR and ALPHABETIC INDEX to Procedures.

Which volume of ICD-9-CM contains the Tabular and Alphabetic Index of Porcedures?

Volume 3 of the ICD-9-CM contains the Tabluar LIst and Alphabetic Index of Procedures.

What organization is responsible for updating the procedure classification (Volume 3) for ICD-9-CM?

Volume 3 of the ICD-9-CM is updated by CMS-Centers for Medicaid and Medicare.

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

Volume I - the Tablular List contains the numerical listing of codes that represent diseases and injuries.

Please give brief description of Volume I of the ICD-9-CM Volumes.

Volume I of the ICD-9-CM contains the TABULAR INDEX - a numerical listing of codes that represent diseases and injuries.

What organization is responsible for updating the diagnosis classification (Volumes 1 & 2) for ICD-9-CM?

Volumes 1 & 2 of the ICD-9-CM are updated by NCHS-National Center for Health Statistics.

Code First - Underlying condition

When a "code first" note is present and an underlying condition is documented in the patient record, the underlying condition is reported first. Example: Dr. documents rheumatic pneumonia - upon review in ICD-9-CM index and tabular - assign codes 390 and 517.1 for the condition

When are codes for Signs, Symptoms, and Ill-Defined Conditions used?

When there are no other, more specific diagnoses classifiable elsewhere. Codes from this chapter are use to report symptoms, signs, and ill-defined conditions that point with equal suspicion to 2 or more diagnoses or represent important problems in medcal care that may affect management of the patient. Example: patient admitted right lower quad abdominal pain; pelvic ultrasound negative - Assigne code 789.03 - Abdominal pain, right lower quadrant

Can a claim be denied for billing too many units of a specific service?

Yes

Can a claim be denied for not meeting medical necessity?

Yes

Can a claim be denied for unbundling?

Yes

11.** Identify the correct diagnosis code[s] for adenoma of adrenal cortex with Conn's syndrome. a. 227.0, 255.12 b. 227.0 c. 255.12 d. 225.12, 227.8

a. 227.0, 255.12 Index Adenoma, adrenal [cortex]. Index Syndrome, Conn. According to the Index in ICD-9-CM, except where otherwise indicated, the morphological varieties of adenoma should be coded by site as for "Neoplasm, benign".

1. Identify the diagnosis code[s] for carcinoma in situ of vocal cord. a. 231.0 b. 161.0 c. 239.1 d. 212.1

a. 231.0 Index Carcinoma, in situ, see also Neoplasm, by site, in situ.

A 45-year-old is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. 280.0, 626.8 b. 285.1, 626.8 c. 626.8, 280.0 d. 280.0, 218.9

a. 280.0, 626.8 The anemia would be sequenced first based on principal diagnosis guidelines.

The patient was admitted with major depression severe, recurrent. What is the correct ICD-9-CM diagnosis code assignment for this condition? a. 296.33 b. 296.30 c. 311 d. 296.89

a. 296.33 Main term: Depression; subterm: recurrent with fifth digit of 3 for severe, without mention of psychotic behavior.

44. Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence. a. 54401 b. 54405 c. 54440 d. 54400

a. 54401 Code 54401 is correct because the prosthesis is self-contained.

40. A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. Which is the correct code assignment. a. 553.20, 427.89, V64.3, 54.11 b. 553.20, 997.1, 427.89, 54.19 c. 553.20, 54.11 d. 553.20, 54.11, V64.3

a. 553.20, 427.89, V64.3, 54.11 The ventral hernia is coded as the primary or first-listed diagnosis. The repair of the hernia is not coded because it was not performed; however, code 54.11 is assigned to describe the extent of the procedure, which is an exploratory laparotomy. The V64.3 is coded to indicate the cancelled procedure. Code 427.89 is also used to describe the bradycardia that the patient develops during the procedure.

Effective October 16, 2003, under the Administrative Simplification Compliance section of the Health Insurance Portability and Accountability Act of 1996 [HIPAA], all healthcare providers must electronically submit claims to Medicare. Which is the electronic format for hospital technical fees? a. 837I b. 837P c. UB-04 d. 1500

a. 837I -letter "I" as in Ink [NOT number "1"-one] The electronic format for institutional or facility claims is 837I -for INSTITUTIONAL CLAIMS, whereas 837P-is for PROFESSIONAL CLAIMS. The UB-04 and the 1500 forms are the paper billing forms for hospital [technical] and clinic [professional] claims, respectively.

14. The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments

a. Accusations of fraud and abuse The goal of a compliance program is to prevent accusations of fraud and abuse

7. The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN". In which of the following would this documentation appear? a. Admission order b. History c. Physical examination d. Progress Notes

a. Admission order Physician orders are the instructions a physician gives to the other healthcare professionals. Admission and discharge orders should be found for every patient.

21. Which of the following is an example of clinical data? a. Admitting diagnosis b. Date and time of admission c. Insurance information d. Health record number

a. Admitting diagnosis CLINICAL DATA document the patient's medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided.

8. Fee schedules are updated by third-party payers: a. Annually b. Monthly c. Semiannually d. Weekly

a. Annually Third-party payers who reimburse providers on a fee-for-service basis generally update fee schedules on an ANNUAL BASIS.

9. Which of the following would a health record technician use to perform the billing function for a physician's office? a. CMS-1500 b. UB-04 c. UB-92 d. CMS 1450

a. CMS-1500 Physicians submit claims via the electronic format [screen 837P], which take the place of the CMS-1500 billing form.

Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-9-CM d. SNOMED CT

a. CPT CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services.

42. Under the OPPS, on which code set is the APC system primarily based for outpatient procedures and services including devices, drugs, and other covered items? a. CPT/HCPCS b. ICD-9-CM c. CDT d. MS-DRG

a. CPT/HCPCS The Healthcare Common Procedural Coding System [HCPCS] identifies and groups the services within each APC group.

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension

a. Catheter-associated urinary tract infection All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to law or regulation mandating collection of present on admission information . Present on admission [POA] is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. Any condition that occurs after admission is not considered a POA condition.

4. Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? a. Children's b. Rural c. State supported d. Tertiary

a. Children's Psychiatric and rehabilitation hospitals, long-term care hospitals, children's hospitals, cancer hospitals, and critical access hospitals are paid on the basis of reasonable cost, subject to payment limits per discharge or under separate PPS.

15. According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? a. Complex b. Intermediate c. Not specified d. Simple

a. Complex Complex closure includes the repair of wounds requiring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures.

32. A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management, intubation. b. Respiratory failure, intubation, ventilator management. c. Respiratory failure, congestive heart failure, intubation, ventilator management. d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management.

a. Congestive heart failure, respiratory failure, ventilator management, intubation. Acute respiratory failure, code 518.81, may be assigned as a principal or secondary diagnosis depending on the circumstances of the inpatient admission. Chapter-specific coding guidelines [obstetrics, poisoning, HIV, newborn] provide specific sequencing direction. Respiratory failure may be listed as a secondary diagnosis. If respiratory failure occurs after admission, it may be listed as a secondary diagnosis.

39. A national dollar amount that Congress designates to convert relative value units into dollars is called. a. Conversion factor b. Origination fee c. Limitation factor d. National exchange

a. Conversion factor Conversion factor is a national dollar amount that Congress uses to convert relative value units to dollars on an annual basis.

Messaging standards for electronic data interchange in healthcare have been developed by: a. HL7 b. IEE c. The Joint Commission d. CMS

a. HL7 HL7 developed the HLC Electronic Health Record System (EHR-S) Functional Model. It is also includes many standards for data exchange with patient information

Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff? a. Hard coding b. Soft coding c. Encoder coding d. Natural-language processing coding

a. Hard coding HCPCS codes that are assigned in the charge description master that flow directly to the claim and bypass facility coding staff is a process known as HARD CODING.

22. Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record? a. Home health b. Behavioral health c. End-stage renal disease d. Rehabilitative care

a. Home health Home health aids may assist the patient with activities of daily living such as bathing and housekeeping, which allows the patient to remain at home. Documentation of this type of intervention is also necessary.

Which type of patient care record includes documentation of a family bereavement period? a. Hospice record b. Home health record c. Long-term care record d. Ambulatory care record

a. Hospice record HOSPICE CARE is palliative care provided to terminally ill patients and supportive services to patients and their families.

15. Which of the following actions would be best to determine whether present on admission [POA] indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? a. Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment. b. Identify all records for a period that have these indicators for these conditions. c. Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement. d. Take a random sample of records for a period of time for records having these indicators for these conditions and extrapolate the negative impact on Medical reimbursement.

a. Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment. Any secondary diagnoses assigned present on admission status will have a negative impact on reimbursement of no other code on the claim is assigned as a complication or comorbidity or a major complication or comorbidity.

1. Given the following information, which of the following statements is correct? 191, MCD: 04, Type: MED MS-DRG, Title: Chronic obstructive pulmonary disease w/ CC, Weight: 0.9757, Discharges: 10, Geometric Mean: 4.1, Arithmetic Mean: 5.0, 192, MCD: 04, Type: COPD w/o CC/MCC, Weight: 0.7254, Discharges: 20, Geometric Mean: 3.3, Arithmetic Mean: 4.0 193, MCD: 04, Type: MED, Weight: Simple pneumonia & pleurisy w/ MCC, Weight: 1.4327, Discharges: 10, Geometric Mean: 5.4, Arithmetic Mean: 6.7 194, MCD: 04, Type: MED, MS-DRG Title: Simple pneumonia & pleurisy w/ CC, Weight: 1.0056, Discharges: 20, Geometric Mean: 4.4, Arithmetic Mean: 5.3 195, MCD: 04, Type: MED, MS-DRG Title: Simple pneumonia & pleurisy w/o CC/MCC, Weight: 0.7316, Discharges: 10, Geometric Mean: 3.5, Arithmetic Mean: 4.1 a. In each MS-DRG the geometric mean is lower than the arithmetic mean. b. In each MS-DRG the arithmetic mean is lower than the geometric mean. c. The higher the number of patients in each MS-DRG, the greater the geometric mean for that MS-DRG. d. The geometric means are lower in MS-DRGs that are associated with a CC or MCC.

a. In each MS-DRG the geometric mean is lower than the arithmetic mean. The GEOMETRIC MEAN LOS is define as the total days of service, excluding any outliers or transfers, divided by the total number or patients.

3. Identify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBEC 4.65, HGB 14.8, HCT 43.3, MCV 93" a. Medical laboratory report b. Pathology report c. Physical examination d. Physician orders

a. Medical laboratory report Results for lab tests will be included in a medical laboratory report.

16. A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis

a. Miscarriage Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from category 634, spontaneous abortion, or 635, legally induced abortion, with a fifth digit of "1" [incomplete]. This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion.

24. The NCCI editing system used in processing OPPS claims is referred to as: a. Outpatient code editor [OCE] b. Outpatient national editor [ONE] c. Outpatient perspective payment editor [OPPE]. d. Outpatient claims editor [OCE]

a. Outpatient code editor [OCE] Portions of the NCCI are incorporated into the OUTPATIENT CODE EDITOR [OCE] against which all ambulatory claims are reviewed. The COE also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services provided.

27. Common errors that delay, rather than prevent, payment, include all of the following EXCEPT: a. Patient name or certificate number b. Claims out of sequence c. Illogical demographic data. d. Inaccurate or deleted codes.

a. Patient name or certificate number Patient name or certificate number are REQUIRED for filing health claims.

13. Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for: a. Performance-improvement programs b. Billing and claims data processing c. Developing hospital discharge abstracting systems d. Developing individual care plans for residents.

a. Performance-improvement programs The ORYX Performance Measurement program collects quality data for hospitals and long-term care organizations and HEDIS collects data to measure physician performance.

Which of the following contains the physician's findings based on an examination of the patient? a. Physical examination b. Discharge summary c. Medical history d. Patient instructions

a. Physical examination A physical examination report represents the attending physician's assessment of the patient's current health status.

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? a. Prospectively precertify the necessity of inpatient services. b. Determine what services can be bundled. c. Pay only 80% of the inpatient bill d. Require the patient to pay 20% of the inpatient bill.

a. Prospectively precertify the necessity of inpatient services. Managed FFS reimbursement is similar to traditional FFS reimbursement except that managed care plans control costs primary by managing their members' use of healthcare services.

18. ** Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of _____ review. a. Quantitative b. Qualitative c. Statistical d. Outcomes

a. Quantitative HIM professional analyze medical records for any missing reports, forms, or required signatures and deletions. This is a QUANTITATIVE ANALYSIS of the medical record.

21. A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is prancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis b. Pancreatitis; noncalculus cholecystitis; abdominal pain c. Noncalculus cholecystitis; pancreatitis; abdominal pain d. Abdominal pain; pancreatitis; noncalculus cholecystitis

a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis In the unusual instance when two or more diagnoses equally meet the patients for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and the therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction in such as cases, any one of the diagnoses may be sequenced first.

14. **A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet.". In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

a. Subjective Subjective information includes symptoms and actions reported by the patient and not observed or measured by the healthcare provider.

12. Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is: a. UHDDS b. UACDS c. MDS d. ORYX

a. UHDDS In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payments Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups [DRGs]. A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms.

When coding benign neoplasm of the skin, the section noted here directs the coder to: 216 Benign Neoplasm of Skin [Category] Includes: Blue Nevus Dermatofibroma Hydrocystoma Pigmented Nevus Syringoadenoma Syringoma Excludes: Skin of genital organs [221.0-222.9] 216 Skin of lip Excludes Vermilion border of lip [210.0] 216 Eyelid, including canthus Excludes: Cartilage of eyelid [215.0] a. Use category 216 for syringoma b. Use category 216 for malignant melanoma. c. Use category 216 for malignant neoplasm of the bone. d. Use category 216 for malignant neoplasm of the skin.

a. Use category 216 for syringoma Follow instructions under the main term in the Alphabetic Index. Instructions in the index should be followed when determining which column to use in the neoplasm table. In this example, malignant is not a choice in the Alphabetic Index shown. Benign in category 216 indicates all of the diagnosis codes in this category are benign.

29. The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost? a. Value-based insurance design [VBID]. b. Cost-based reimbursement [CBR] c. Pay for performance design [PPD] d. Prospective payment system [PPS]

a. Value-based insurance design [VBID]. Value-based insurance design [VBID] calculates both the benefit and the cost of clinical services.

29. Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries? a. Volume 1 [Tab] b. Volume 2 [Index} c. Volume 3 [Pcs] d. Volume 4

a. Volume 1 ICD-9-CM Volume 1 is known as the Tabular List and contains the numerical listing of codes that represents diseases and injuries.

15. Calling out patient names in a physician's office is: a. an incidental disclosure b. not subject to the "minimum necessary" requirement c. a disclosure for payment purposes d. a HIPAA violation

a. an incidental disclosure [occurs as part of permitted use of disclosures]

Good encoding software should include__ to ensure data quality. a. edit checks b. voice recognition c. reimbursement technology d. passwords

a. edit checks GOOD ENCODING SOFTWARE should include EDIT CHECKS to ensure data quality

With regard to training in PHI policies and procedures, the following statement is true: a. every member of the covered entity's workforce must be trained. b. only individuals employed by the covered entity must be trained. c. training only needs to occur when there are material changes to the policies and procedures. d. documentation of training is not required.

a. every member of the covered entity's workforce must be trained. every member of the covered entity's workforce must be trained in PHI policies and procedures according to the Privacy Rule.

10. Which of the following laws created the Healthcare Integrity and Protection Data Bank? a. health information portability and accountability act b. american recovery and reinvestment act c. consolidate omnibus budget reconciliation act d. healthcare quality improvement act

a. health information portability and accountability act-HIPAA of 1996

Data definition refers to: a. meaning of data b. completeness of data c. consistency of data d. detail of data

a. meaning of data DATA DEFINITION means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent.

Exceptions to the consent requirement include: a. medical emergencies b. provider discretion c. implied consent d. informed consent

a. medical emergencies The LAW permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or a minor.

The HIPAA Privacy Rule requires that covered entities MUST LIMIT USE, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? a. mininum necessary b. notice of privacy practices c. authorization d. consent

a. mininum necessary The standard of MINIMUM NECESSARY means that healthcare providers and other covered entities must limit uses, disclosures, and request to only the amount needed to accomplish the intended purpose.

1. In a joint effort of the Department of Health and Human Services [DHHS], Office of Inspector General [OIG], Centers for Medicare and Medicaid Services [CMS], and Administration on Aging [AOA], which program was released in 1995 to target fraud and abuse among healthcare providers? a. operation restore trust b. medicare integrity program c. tax equity and fiscal responsibility act [TEFRA] d. medicare and medicaid patient and program protection act

a. operation restore trust operation restore trust was released in 1995 to target fraud and abuse among healthcare providers.

What is the incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsides to support further HIT efforts? a. pay for performance and quality b. patient referrals c. payer of last resort d. performance evaluations

a. pay for performance and quality Pay for performance and pay for quality are types of incentive to improve clinical performance

A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to : a. request restrictions on certain uses and disclosures of PHI b. remove their record from the facility c. deny provider changes to their PHI d. delete portions of the record they think are correct.

a. request restrictions on certain uses and disclosures of PHI The HIPAA Privacy Rule provides patients with rights that allow them to have some control over their health information: right of access, right to request amendment of PHI, right to accounting of disclosures, right to request restrictions of PHI, right to request confidential communications, and right to complain of Privacy Rule violations.

The number that has ben proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the: a. social security number b. unique physician identification number c. health record number d. national provider identifier

a. social security number It is generally agreed that social security numbers (SSNs) should be used as patient identifiers.

38. A 65-year-old female was admitted to the hospital. She was diagnosed with septicemia secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? a. 038.8, 562.11, 789.00 b. 038.11, 562 c. 038.9, 562.11. 041.11 d. 039.9, 562.11

b. 038.11, 562 Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms. Code 038.11 is assigned for septicemia with Staphylococcus aureus. Because abdominal pain is a symptom of diverticulosis, only diverticulitis of the colon [562.11] is coded.

2. Identify the diagnosis code[s] for melanoma of skin of shoulder. 1. 172.8, 172.6 b. 172.6 c. 172.9 d. 172.8

b. 172.6 Index Melanoma [malignant], shoulder. Melanoma is considered a malignant neoplasm and is referenced as such in the index of ICD-9-CM. The term "benign neoplasm" is considered a growth that does not invade adjacent structures or spread to distant sties but may displace or exert pressure on adjacent structures .

31. A patient was discharged with the following diagnoses: "Cerebral occlusion, hemiparesis, and hypertension. The aphasia removed before the patient was discharged". Which of the following code assignments would be appropriate for this case? 342.90 Hemiparesis affecting unspecified side. 342.91 Hemiparesis affecting dominant side 342.92 Hemiparesis affecting nondominant side 434.90 Cerebral artery occlusion occlusion unspecified, without mention of cerebral infarction. 434.91 Cerebral artery occlusion unspecified with cerebral infarction 401 Hypertension 401.1 Malignant hypertension 401.9 Unspecified hypertension 428.0 Congestive heart failure. 784.3 Aphasia a. 434.91, 342.92, 784.3, 401 b. 434.90, 342.90, 784.3, 401.9 c. 434.90, 342.90, 401.9 d. 434.90, 342.90, 784.3, 401.0

b. 434.90, 342.90, 784.3, 401.9 Code 434.91 is assigned when the diagnosis states stroke, cerebrovascular, or cerebrovascular accident [CVA] without further specification. The health record should be reviewed to make sure nothing more specific is available. Conditions resulting from an acute cerebrovascular disease, such as aphasia or hemiplegia, should be coded as well.

53. What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation? a. 46255 b. 46930 c. 46260 d. 46945

b. 46930 Index main term: Destruction, hemorrhoid, thermal. Thermal includes infrared coagulation.

2. If another status T procedure were performed, how much would the facility receive for the second status T procedure? 998323-billing#, V-status indicator, 99285-25-CPT/HCPCS, 0612-APC. 998324-billing#, T-status indicator, 25500-CPT/HCPCS, 0044-APC. 998325-billing#, X-status indicator, 72050-CPT/HCPCS, 0261-APC. 998326-billing#, S-status indicator, 70450-CPT/HCPCS, 0283-APC. 998327-billing#, S-status indicator, 70450-CPT/HCPCS, 0283-APC a. 0% b. 50% c. 75% d. 100%

b. 50% Multiple surgical procedures with payment status indicator T performed during the same operative session are discounted. The highest-weighted procedure is fully reimbursed. All other procedures with payment status indicator T are reimbursed at 50%.

61. What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? a. 58555, 58559 b. 58559 c. 58559, 58740 d. 58555, 58559, 58740

b. 58559 Main term of Hysteroscopy; lysis; adhesions.

7. Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip. a. 715.95 b. 715.15 c. 721.90 d. 715.16

b. 715.15 Correct Answer: B Index Osteoarthrosis, localized, primary. For category 715, refer to the table for the fifth digit of 5 for pelvic region and thigh (Schraffenberger 2012, 303-304).

Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusion of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied. Which is the correct code assignment? a. 808.1, E881.0, E849.0, 79.25, 78.15 b. 808.1, 920, E881.0, E849.0, E000.8, E013.9, 79.25, 78.15, 79.65 c. 808.0, E881.0, E000.8, E013.9, 79.35, 79.65 d. 808.1, E881.0, E849.0, E013.9, 79.25, 78.15, 79.65

b. 808.1, 920, E881.0, E849.0, E000.8, E013.9, 79.25, 78.15, 79.65 The fracture is the principal diagnosis, with the contusions as a secondary diagnosis. The fracture is what required in the most treatment. Procedures for the reduction, debridement, and external fixation device would all need to be coded.

41. Under the Medicare hospital outpatient perspective payment system [OPPS], services are paid according to: a. A fee-for-service schedule basis that varies according to the MPFS b. A rate-per-service basis that varies according to the ambulatory payment classification [APC] group to which the service is assigned. c. A cost-to-charge ratio based on the hospital cost report. d. A rate-per-service basis that varies according to the DRG group

b. A rate-per-service basis that varies according to the ambulatory payment classification [APC] group to which the service is assigned. The PAYMENT VARIES based on the APC group.

Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? a. Centers for Disease Control [CDC] b. Centers for Medicare and Medicaid Services [CMS] c. National Center for Health Statistics [NCHS] c. World Health Organization [WHO]

b. Centers for Medicare and Medicaid Services [CMS] NCHS-Natl Center for Health Statistics is responsible for updating the diagnosis classification[Vol 1 & Vol 2], and CMS is responsible for updating the procedure classification [Vol 3].

35. A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient? a. Abdominal pain b. Cholecystitis c. Hypertension d. Diabetes

b. Cholecystitis The principal diagnosis determines the MDC assignment.

26. Timely and correct reimbursement is dependent on: a. Adjudication b. Clean claims c. Remittance advice d. Actual charge

b. Clean claims CLEAN CLAIMS are essential for accurate and timely reimbursement

37. Which of the following is a condition that arises during hospitalization? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis

b. Complication A complication is a secondary condition that arises during hospitalization and is thought to increase the length of stay by at least one day for approximately 75% of the patients.

10. The following is documented in an acute-care record: " I was asked to evaluate this Level 1 trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear? a. Admission note b. Consultation report c. Discharge summary d. Nursing progress notes

b. Consultation report A consultation report includes the recommendations of a consulting physician who is requested to evaluate a patient.

A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. Patient receives any monies paid by the insurance companies over and above the charges. b. Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments. c. The decision on which company is primary is based on remittance advice. d. Patient should not have a Medicare supplement.

b. Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments.

7. Which of the following is NOT reimbursed according to the Medicare outpatient prospective payment system? a. CMHC partial hospitalization services b. Critical access hospitals c. Hospital outpatient departments d. Vaccines provided by CORFs

b. Critical access hospitals CRITICAL ACCESS HOSPITALS are paid on a cost-based payment system and are not part of prospective payment system.

36. What system reimburses hospitals a predetermined amount for each Medicare inpatient admission? a. APR-DRG b. DRG c. APC d. RUG

b. DRG A DRG is a predetermined amount of reimbursement for each Medicare inpatient.

20. The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? a. Data completeness b. Data consistency c. Data accessibility d. Data comprehensiveness.

b. Data consistency Consistency data will be the same each time it is reported or collected.

40. The MS-DRG system creates a hospital's case-mix index [types or categories of patients treated by the hospital] based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of within that MS-DRG. a. Admissions b. Discharges c. CCs d. MCCs

b. Discharges Discharges. The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG.

28. What is the function of a consultation report? a. Provides a chronological summary of the patient's medical history and illness. b. Documents opinions about the patient's condition from the perspective of a physician NOT previously involved in the patient's care. c. Concisely summarizes the patient's treatment and stay in the hospital d. Documents the physician's instructions to other parties involved in providing care to a patient.

b. Documents opinions about the patient's condition from the perspective of a physician NOT previously involved in the patient's care. The consultation report documents the clinical opinion of a physician other than the primary or attending physician.

Which of the following ICD-9-CM codes classify environment events and circumstances as the cause of an injury, poisoning, or other adverse affect? a. Category codes b. E codes c. Subcategory codes d. V codes

b. E codes E codes provide a means to describe environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effects.

A transition technology used by many hospitals to increase access to medical record content is: a. EHR -electronic health record b. EDMS-electronic document management system. c. ESA-electronic signature authentication. d. PACS-picture archiving and communication system.

b. EDMS-electronic document management system. For hospitals that do not have all EHR components, the result is a hybrid record that is part electronic and part paper. Some hospitals overcome hybrid record issues by scanning all paper documents into an EDMS, thereby making everything available online.

19. A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious gastroenteritis, chronic obstructive pulmonary disease; angina b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina c. Gastroenteritis; abdominal pain; angina d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina

b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina Gastroenteritis is characterized by diarrhea, nausea, and vomiting, and abdominal cramps. Codes for symptoms, signs, and ill-defined condition from Chapter 16 of the CPT codebook are not to be used as the principal diagnosis when a related definitive diagnosis has been established. Patients can have several chronic conditions that coexists at the time of their hospital admission and quality as additional diagnosis such as COPD and angina.

12. Prospective payment systems were developed by the federal government to: a. Increase healthcare access b. Manage Medicare and Medicaid costs c. Implement managed care programs d. Element fee-for-service

b. Manage Medicare and Medicaid costs Since 1983, the prospective payment systems have been used to manage the cost of the Medicare and Medicaid programs.

Which of the following represents documentation of the patient's current and past health status? a. Physical examination b. Medical history c. Physician orders d. Patient consent

b. Medical history A complete medical history documents the patient's current complaints and symptoms and lists his and her past medical, personal, and family history.

44. Medicare's newest claims processing payment contract entities are referred to as: a. Recovery audit contractors [RACs]. b. Medicare administrative contractors [MACs]. c. Fiscal intermediaries [FIs] d. Office of Inspector General contractors [OIGCs].

b. Medicare administrative contractors [MACs]. Medicare administrative contractors [MACs] are replacing the claims payment contractors known as FIs and carriers.

15. A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

b. Objective Objective information may be measured or observed by the healthcare provider.

6. The following is documented in an acute-care record: "Microscopic: Sections area of squamous mucosa with no atypia". In whic of the following would this documentation appear? a. History b. Pathology report c. Physical examination d. Operative report

b. Pathology report Pathological examinations of tissue samples and tissues or organs removed during surgical procedures are reported in the pathology report.

33. What system assigns each service a value representing the true resources involved in producing it including the time and intensity of work, the expenses of practice, and the risk of malpractice? a. DRGs b. RVUs c. CPT d. SVR

b. RVUs Relative value units [RVUs] are assigned to each service to provide a value that correlates to payment.

What is a guarantor? a. The patient who is an inpatient b. The person responsible for the bill, such as a parent. c. The person who bills the patient, such as the Medicare Biller. d. The patient who is an outpatient.

b. The person responsible for the bill, such as a parent. The person responsible for the bill is the GUARANTOR.

10. When a provider accepts assignment, this means the: a. Patient authorizes payment to be made directly to the provider b. The provider agrees to accept as payment in full the allowed charge from the fee schedule. c. Balance billing is allowed on patient accounts, but at a limited rate. d. Participating provider receives a fee-for-service reimbursement.

b. The provider agrees to accept as payment in full the allowed charge from the fee schedule. To accept assignment means the provider or supplier accepts, as payment in full, the allowed charge from the fee schedule.

41. These codes are used to assign a diagnosis to a patient who is seeking health services but is not necessarily sick. a. E codes b. V codes c. M codes d. C codes

b. V codes V codes are diagnosis codes and indicate a reason for healthcare encounter.

The term MINIMUM NECESSARY means that healthcare providers and other covered entities must limit use, access, and disclosure to the mininum necessary to: a. satisfy one's security b. accomplish the intended purpose c. treat an individual d. performed research

b. accomplish the intended purpose The Privacy Rule introduced the standard of mininum necessary to limit the amount of PHI used, disclosed, and requested. This means that healthcare providers and other covered entities must limit uses, disclosures, and request to only the amount needed to accomplish the intended purpose.

A record of all transactions in the computer system that is maintained and reviewed for unauthorized access is called a[n]: a. security breach b. audit trail c. unauthorized access d. privacy trail

b. audit trail An audit trail- is a record of all transactions in the computer system, which is maintained and reviewed for instances of unauthorized access.

One form of __ use software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals. a. integrated workflow processes b. computer-assisted coding c. electronic document management system. d. speech recognition system

b. computer-assisted coding There are several different types of computer-assisted coding [CAC], including software to aid the physicians

9. The HIM dept is planning to scan nonelectronic 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 of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization? a. ad hoc b. concurrent c. retrospective d. post discharge

b. concurrent CONCURRENT REVIEW- occurs on a continuing basis during a patient's stay.

What is the legal term used to define the protection of health information in a patient-provider relationship? a. access b. confidentiality c. privacy d. security

b. confidentiality confidentiality is a legal ethical concept that establishes the healthcare provider's responsibility for protecting health records and other personal and private information from unauthorized use or disclosure.

Which of the following statement is False? a. a notice of privacy practices must be written in plain language. b. consent for use and disclosure of information must be obtained from every patient. c. an authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations. d. a notice of privacy practices must give an example of a use or disclosure for healthcare operations.

b. consent for use and disclosure of information must be obtained from every patient. Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personally identifiable information for treatment, payment, or healthcare operations.

Data Security refers to: a. guaranteeing privacy b. controlling access c. using uniformed terminology d. transparency

b. controlling access *** controlling access- facilities may authorize access to patient data in the facility's computer system to only those who need the access to do their job. This method of control serves the security of the data of patient records.

Which of the following make data easier but may harm data quality? a. use of templates b. copy and paste c. drop-down boxes d. structured data

b. copy and paste One potential area for poor data quality surrounds the need for making data entry easier. These include "COPY and PASTE", "MACROS", STANDARD ORDERS, and OTHER TECHNIQUES that "REUSE" data. These techniques can make data entry faster, but care must be taken to ensure appropriate modification to the specific patient.

Which of the following is not an element of data quality? a. accessibility b. data backup c. precision d. relevancy

b. data backup DATA QUALITY includes the following characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness.

4. What is the primary use of the case-mix index? a. benchmark of emergency room levels b. defines how a hospital compares to peers and whether the facility is at risk c. audit of APCS and the comparison to same-size hospitals d. a tool for the coding manager to compare coder productivity

b. defines how a hospital compares to peers and whether the facility is at risk BENCHMARKING or PEER COMPARISON helps a manager to know how his or her team has performed compared to peers. This include whether the case-mix index level puts the facility at risk.

This system will require the author to sign onto the system using user ID and password to complete the entries made. a. digital dictation b. electronic signature authentication-ESA c. single sign on technology d. clinical data repository

b. electronic signature authentication-ESA electronic signature authentication-ESA systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval.

A health information technician (HIT), is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? a. compliance program education and training programs for all employees in the organization b. establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation. c. adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted. d. establish a corporate compliance committee who report directly to the CFO.

b. establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation.

Deidentified information: a. does identify an individual b. is information from which personal characteristics have been stripped c. can be later constituted or combined to re identify an individual d. pertains to a person that is identified within the information.

b. is information from which personal characteristics have been stripped*** Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped.

Which of the following statements is NOT TRUE about business associate agreement? a. It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity. b. it allows the business associate to maintain PHI indefinitely. c. it prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule. d. it requires the business associate to make available all of its books and records relating to PHI use and disclosure to the De

b. it allows the business associate to maintain PHI indefinitely. The agreement between the covered entity and business associate should, at termination of the contract, require the business associate to return or destroy all PHI received from the covered entity that it still maintains and prohibit the associate from retaining it.

An encoder that is built using expert system techniques such as rule-based systems is a[n]. a. encoder interface b. logic-based encoder c. automated code book encoder d. grouper

b. logic-based encoder Some encoders are build using expert system techniques such as rule-based systems, and other encoding software is more simplistic, merely automating a look-up function similar to the manual index in ICD or other coding classification.

A threat to data security is: a. encryption b. malware c. audit trail c. data quality

b. malware Computer viruses and other malware constitute a threat to data security.

14. Notices of privacy practices must be available at the site where the individual is treated and: a. must be posted next to the entrance b. must be posted in prominent place where it is reasonable to expect that patients will read them c. may be posted anywhere at the site d. do not have to be posted at the site

b. must be posted in prominent place where it is reasonable to expect that patients will read them

One form of ___ computer-assisted coding may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation. a. encoded vocabulary b. natural-language processing c. data exchange standards d. structure reports

b. natural-language processing NATURAL-LANGUAGE PROCESSING [NLP] is an artificial intelligence software that reads digital text from online documents and suggests codes to match the documentation.

Which of the following is direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court? a. judicial decision b. subpoena c. credential d. regulation

b. subpoena A subpoena is a direct command that requires an individual or representative of an organization to appear in court or to present an object to the court.

This is a program unveiled in 1998 by the OIG that encourages healthcare providers to report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs. a. world health organization-WHO b. voluntary disclosure program c. compliance disclosure program d. fraud and abuse program

b. voluntary disclosure program The VOLUNTARY DISCLOSURE program was introduced in 1998 by the OIG to encourage healthcare providers to voluntarily report fraudulent conduct affecting federal payers.

17. If a patient's total outpatient bill is $500, and the patient's healthcare insurance plan pays 80% of the allowable charges, what is the amount for which the patient is responsible? a. $10 b. $40 c. $100 d. $400

c. $100 Out-of pocket expenses are the healthcare expenses that the insured party is responsible for paying after the insurer has paid its amount. In the example, after the allowed charges of 80%, or $400, are covered by the insurance company, the patient will be responsible for the remaining 20%, or $100.

39. Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment? a. 188.3, V10.51, 57.49, 57.32 b. 198.1, 57.49 c. 188.3, 57.49 d. 198.1, 188.3, 57.49

c. 188.3, 57.49 When the primary malignant neoplasm previously removed by surgery or eradicated by radiotherapy or chemotherapy recurs, the primary malignant code for the site is assigned, unless the Alphabetic Index directs otherwise.

Identify the correct diagnosis code for lipoma of the face. a. 214.1 b. 213.0 c. 214.0 d. 214.9

c. 214.0 Index Lipoma, face. ICD-9-CM classifies neoplasms by system, organ, or site with the exception of neoplasms of the lymphatic and hematopoietic system, malignant melanomas of the skin, lipomas, common tumors of the bone, uterus, and ovary. Because of these exceptions, the Alphabetic Index must first be checked to determine whether a code has been assigned for that specific histology type.

50. Patient arrived by ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0-cm superficial o fthe left arm: 5.0-cm laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedure: X-ray of the ankle showed a bimalleolar ankle fracture that required closed manipulative reduction, intermediate suturing of the scalp and simple suturing of the arm laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill. a. 27810, 12032 b. 27818, 12032 c. 27810, 12032, 12002 d. 27810, 12032

c. 27810, 12032, 12002 The closed reduction of the fracture is coded first, following principal procedure guidelines. The laceration repair is also coded. When more than one classification of wound repair is performed, all codes are reported, with the code for the most complicated procedure listed first.

To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within __ days. a. 10 b. 20 c. 30 days d. 60

c. 30 days A COVERED ENTITY must act on an individual's request for review of PHI no later than 30 days after the request is made.

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. a. 31622, 31640 b. 31622, 31623 c. 31623 d. 31625

c. 31623 [w/ brushings] A bronchoscopy with brushings and washings is considered a diagnostic bronchoscopy and not a biopsy. Code 31623 specifies brushings, and code 31622 is selected for washings.

59. Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia? a. 49496 b. 49501 c. 49507 d. 49521

c. 49507 Index the main term of Hernia repair; inguinal; incarcerated. The age of the patient and the fact that the hernia is not recurrent make the choice 49507. Providing information regarding insurance coverage is not a function of the discharge summary.

60. Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? a. 49565 b. 49565, 49568 c. 49656 d. 49560, 49568

c. 49656 Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via laparoscope, and is reducible makes the choice 49656. Notice that the use of mesh is included in the code.

From the information provided, how many APCs would this patient have? 998323-billing#, V-status indicator, 99285-25 CPT/HCPCS, 0612-APC. 998324-billing#, T-status indicator, 25500-CPT/HCPCS, 0044-APC. 998325-billing#, X-status indicator, 72050-CPT/HCPCS, 0261-APC. 998326-billing#, S-status indicator, 72128-CPT/HCPCS, 0283-APC. 998327-billing#, S-status indicator, 70450-CPT/HCPCS, 0283-APC. a. 1 b. 4 c. 5 d. 3

c. 5 Payment for separately APCs depends on the status indicator assigned to each HCPCS code. This particular example allows separate payment on all five codes based on separately paid status indicator assignment.

56. A 35-year-old male was admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure. a. 530.89, 42.29 b. 530.1, 45.16 c. 530.81, 42.24 d. 530.81, 42.23

c. 530.81, 42.24 Main term for procedure: Esophagoscopy; subterm: with closed biopsy.

58. A female patient is admitted for stress incontinence. A urethral suspension is performed. Assign the correct ICD-9-CM diagnosis and/or procedure code[s]. a. 625.6, 57.32 b. 788.0, 59.5 c. 625.6, 59.5 d. 788.30

c. 625.6, 59.5 Main term for diagnosis: Incontinence: subterm: stress. Main term for procedure: Suspension: subterm: urethra

26. An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnosis and CPT anesthesia codes. [Modifiers are not used in the example]. a. 660.11, 653.41, 64479 b. 660.11, 653.01, 01961 c. 660.11, 653.41, 01967, 01968 d. 660.11, 653.91, 01996

c. 660.11, 653.41, 01967, 01968 The disproportion was specified as cephalopelvic; thus the correct ICD-9-CM code is 653.41. Two codes are required for anesthesia: one for the planned vaginal delivery [01967] and an add-on code [01968] to describe anesthesia for cesarean delivery following planned vaginal delivery converted to cesarean. An instructional not guides the coder to use 01968 and 01967.

Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness. a. 924.9 b. 851.42 c. 851.82 d. 851.81

c. 851.82 Index Contusion, cerebral-see Contusion, brain. Add a fifth digit of "2" for brief loss of consciousness. Cerebral contusions are often caused by a blow to the head. A cerebral contusion is a more severe injury involving a bruise of the brain with bleeding into the brain tissue, but without disruption of the brain's continuity. The loss of consciousness that occurs often lasts longer than that of a concussion. Codes for cerebral laceration and contusion range from 851.0 to 851.9, with fifth digits added to indicate whether a loss of consciousness or concussion occurred.

63. Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April. a. 90965 b. 90964 c. 90966 d. 90970

c. 90966 Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease [ESRD]-related services for home dialysis per full month for patient 20 years and older.

64.** The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code[s] or modifier for a Medicare patient on physical therapy plan of care in an outpatient setting? a. 97113 b. 97113-50 c. 97113, 97113 d. 97110

c. 97113, 97113 Code 9713, Therapeutic procedure, one or more areas, each 15 min of aquatic therapy with therapeutic exercises, is billable per 15 minutes of therapy. The patient was treated for 30 min; therefore, code 97113 should be reported twice. Modifier -50 is not applicable because the service is not a bilateral procedure.

1. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Ruptured appendix b. Exploratory laparoscopy c. Abdominal pain d. Cholelithiasis

c. Abdominal pain The nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331).

31. What is the process that determines how a claim will be reimbursed based on the insurance benefit? a. Transaction b. Processing c. Adjudication d. Allowance

c. Adjudication ADJUDICATION is the determination of the reimbursement payment based on the member s insurance benefits.

21. A request for reconsideration of a denied claim for insurance coverage for healthcare services is called a[n]: a. Breach b. Exclusion c. Appeal d. Inclusion

c. Appeal An APPEAL is a request for consideration of denial of coverage for healthcare services of a claim.

17. A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled". In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

c. Assessment Professional conclusions reached from evaluation of the subjective or objective information make up the assessment.

23. A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease. c. Asthma with status asthmaticus d. Chronic obstructive asthma

c. Asthma with status asthmaticus A patient in status asthmaticus fails to respond to therapy administered during an asthmatic attack. This is a life-threatening condition that requires emergency care and likely hospitalization.

32. When clean claims are submitted, they can be adjudicated in many ways through computer software automatically. Which statement is NOT of the outcomes that can occur as part of auto adjudication? a. Auto-pay b. Auto-suspend c. Auto-calculate d. Auto-deny

c. Auto-calculate Claims that AUTOMATICALLY PROCESS through computer software either auto-pay, auto-suspend, or auto deny.

25. A skin lesion is removed form a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Before billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should be coding professional do for claim submission? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist

c. Code basal cell carcinoma For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis[es] documented in the interpretation. Do not code related signs and symptoms as additional diagnosis. Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results.

11. A coding audit shows that an inpatient coder is using multiple codes that describes the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? a. Require all coders to implement this practice b. Reports the practice to the OIG c. Counsel the coder and stop the practice immediately. d. Put the coder on unpaid leave of absence.

c. Counsel the coder and stop the practice immediately. Review the elements of the hospital compliance program with the employee.

19. ** Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? a. Data completeness b. Data relevancy c. Data currency d. Data precision

c. Data currency Data currency and data timeliness refer to the requirement that healthcare data should be up-to-date and recorded at or near the time of the event or observation.

29. ** What is the function of physician's orders? a. Provide a chronological summary of the patient's illness and treatment. b. Document the patient's current and past health status c. Document the physician's instructions to other parties involved in providing care to a patient. d. Document the provider's follow-up care instructions given to the patient or patient's caregiver

c. Document the physician's instructions to other parties involved in providing care to a patient. Physician orders are the instructions the physician gives to the other healthcare professionals .

9. The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear? a. Admission order b. Clinical laboratory report c. ECG report d. Radiology report

c. ECG report An ECG is a report of an electrocardiogram of the heart.

1. Which of the following elements is NOT a component of most patients records? a. Patient identification b. Clinical history c. Financial information d. Test results

c. Financial information Clinical data document the patient's medical condition, diagnosis, and procedures performed as well as healthcare treatment provided.

Which of the following is TRUE statement about data stewardship? a. HIM professionals are not qualified to address data stewardship issues. b. Data stewardship addresses the needs of the healthcare organization but not the patient. c. HIM professionals have worked with many data stewardship issues for years. d. Data stewardship does not include privacy issues.

c. HIM professionals have worked with many data stewardship issues for years.

43. Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion? a. Health Information and Business office b. Health Information and Materials Management. c. Health Information, Business Office, and Cardiac Department. d. Health information and Radiology

c. Health Information, Business Office, and Cardiac Department. Health Information, Business Office, and Cardiac Department should be consulted to determine where the breakdown on the charges and assignment of the procedure code occurs. Often one department assumes another department is submitting the code or charge and without auditing and communicating with each other on a regular basis, error can occur for long periods of time with either a financial gain or loss to the facility.

The __ mandated the development of standards for electronics medical records. a. Medicare and Medicaid legislation of 1965 b. Prospective Payment Act of 1983 c. Health Insurance Portability and Accountability Act (HIPAA) of 1996. d. Balanced Budget Act of 1997

c. Health Insurance Portability and Accountability Act (HIPAA) of 1996. HIPAA mandated incorporation of healthcare information standards into all electronic or computer-based health information systems

A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG x3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations? 410.00 Myocardial infarction of anterolateral wall, episode unspecified. 410.01 Myocardial infarction of anterolateral wall, initial episode 410.40 Myocardial infarction of inferior wall, episode unspecified 410.41 Myocardial infarction of inferior wall, initial episode 410.42 Myocardial infarction of inferior wall, subsequent episode 427 -Cardiac dysrhythmias 427.3 --Atrial fibrillation and flutter 427.31 Atrial fibrillation 786.50 Chest pain, unspecified 36.13 Aortocoronary bypass of three coronary arteries a. Hospital A: 427, 786.50, 427.31, 410,91; Hospital B: 410.92, 36.13 b. Hospital A: 410.41, 427, 427.31; Hospital B: 410.42, 36.13 c. Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13 d. Hospital A: 410.41, 427.31, 786.50; Hospital B: 41042, 36.13

c. Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13 Use a fifth digit of "1" to designate the first episode of care [regardless of facility site] for a newly diagnosed myocardial infarction. The fifth digit "1" is assigned regardless of the number of times a patient may be transferred during the initial episode of care.

54. An encoder that takes a coder through a series of questions and choices is called a[n]: a. Automated codebook b. Automated code assignment c. Logic-based encoder d. Decision support database

c. Logic-based encoder A Logic-based encoder prompts the user through a variety of questions and choices based on clinical terminology entered. The coder selects the most accurate code for a service or condition [and any possible complications or comorbidities].

5. Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values

c. Major diagnostic categories Diagnosis-related groupings [DRGs] are classified by one of 25 major diagnostic categories [MDCs].

2. 84. An individual stole and used another person's insurance information to obtain medical care. This action would be considered: a. Violation of bioethics b. Fraud and abuse c. Medical identity theft d. Abuse

c. Medical identity theft Correct Answer: 84. c. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity without the victim's knowledge or consent to obtain medical services or goods (Johns 2011, 773).

A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? a. Ataxia b. Fractured arm c. Metastatic carcinoma of the brain d. Carcinoma of the lung

c. Metastatic carcinoma of the brain If treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this guideline is if a patient admission or encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate V code as the first-listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secondary diagnosis.

20. A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay? a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy c. Metastatic carcinoma of the brain, history of carcinoma of the prostate d. Carcinoma of the prostate; metastatic carcinoma to the brain

c. Metastatic carcinoma of the brain, history of carcinoma of the prostate When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to the site and there is no evidence of any existing primary malignancy, a code from category V10, personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal. with the V10 code used as a secondary code.

8. The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear? a. Admission note b. Clinical laboratory c. Newborn record d. Physician order

c. Newborn record This information is collected by the examination of a newborn and reported on the newborn record.

25. Denials of outpatient claims are often generated from all of the following edits EXCEPT: a. NCCI [National Correct Coding Initiative]. b. OCE [outpatient code editor] c. OCE [outpatient claims editor] d. National and local policies.

c. OCE [outpatient claims editor] Outpatient Claims editor DOES NOT EXIST. DO NOT CONFUSE THIS terminology with Outpatient Code Editor [OCE].

2. Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion. a. Anesthesia report b. Physician progress notes c. Operative report d. Recovery room record

c. Operative report The operative report includes a description of the procedure performed

24. Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? a. Anesthesia report b. Laboratory report c. Operative report c. Pathology report

c. Pathology report The Pathology report includes descriptions of the tissue from a gross or macroscopic level and representative cells at the microscopic level.

23. **Which of the following material is NOT documented in an emergency care record? a. Patient's instructions at discharge b. Time and means of the patient's rival c. Patient's complete medical history d. Emergency care administered before arrival at the facility

c. Patient's complete medical history The emergency care record includes a pertinent history of the illness or injury and physical findings.

5. The following is documented in an acute-case record: "HEET: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds. "In which of the following would this documentation appear." a. History b. Pathology report c. Physical examination d. Operative report

c. Physical examination Results of the physician's examination of the patient's physical condition is reported in a physical examination report.

17. An 80-year-old is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis". How should the coder proceed to code this case? a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. b. Code urinary tract infection with sepsis as the principal diagnosis. c. Query the physician to ask if the patient has septicemia because of the symptomatology. d. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.

c. Query the physician to ask if the patient has septicemia because of the symptomatology. The term "urosepsis" is nonspecific term. If that is the only term documented, only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism, if known. Septicemia results from the entry of pathogens into the bloodstream. Symptoms include spiking fever, chills, and skin eruptions in the form of petechiae or purpura. Blood cultures are usually positive; however, a negative culture does not exclude the diagnosis of septicemia. Several other clinical indications symptomology could indicate the diagnosis of septicemia. Only the physician can diagnose the condition based on clinical indications. Query the physician when the diagnosis is not clear to the coder.

3. A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system? a. Clinical laboratory tests b. Physician office visits c. Radiology examinations d. Take-home surgical dressings

c. Radiology examinations Radiology procedures are identified under the outpatient perspective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid .

According to the UHDDS, which of the following is the definition of "other diagnoses"? a. Is recorded in the patient record b. Is documented by the attending physician c. Receives clinical evaluation of therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring. d. Is documented by at least physicians and the nursing staff.

c. Receives clinical evaluation of therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring. For reporting purposes the definition for "other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care, and monitoring.

What are four-digit ICD-9-CM codes referred to as? a. Category codes b. Section codes c. Subcategory codes d. Subclassification codes

c. Subcategory codes Categories are divided into subcategories. At this level, four-digit code numbers are used.

38.** Medicaid is a government-sponsored healthcare insurance program that became effective in 1966 as Title 19 of the Social Security Act. Medicaid is administered by: a. The federal government b. The state government c. The federal and state government d. Third-party administrators

c. The federal and state government Medicaid is designed to offer assistance to low-income people and is jointly administered by the federal and state government.

13. ** Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for: a. The placement of the catheter b. The placement of the catheter and the infusion procedure c. The infusion procedure d. Neither the placement of the catheter nor the infusion procedure.

c. The infusion procedure Access to indwelling IV or insertion of a subcutaneous catheter or port for the purpose of a therapeutic infusion is considered part of the procedure and not separately billed.

Which volume of ICD-9-CM contains the Tabular and Alphabetic Index of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

c. Volume 3 ICD-9-CM Volume 3 contains the Tabular List and Alphabetic Index of procedures.

12. The HIPAA privacy rule: a. applies to certain states b. applies only to healthcare providers operated by the federal government c. applies nationally to healthcare providers d. serves to limit access to an individual's own health information

c. applies nationally to healthcare providers The HIPAA Privacy Rule-applies nationally to healthcare providers.

Which of the following tasks may not be performed in an electronic health record system? a. document imaging b. analysis c. assembly d. indexing

c. assembly In an EHR, reports are indexed, similar to filing in the paper record, and to ensure that the documents are placed in the right location within the right record. Record analysis and completion is done via computer. Document imaging converts paper documents into digitized electronic versions

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? a. require all coders to implement this practice. b. report the practice to the OIG c. counsel the coder and stop the practice immediately d. put the coder on unpaid leave of absence.

c. counsel the coder and stop the practice immediately Be sure the employees receive appropriate compliance training and continue ongoing training for all employees.

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classification are called: a. natural-language processing systems b. monitoring/audit programs c. encoders d. concept, description, and relationship tables

c. encoders The type of tool used to aid in the encoding process is called an ENCODER.

What is the process used to transform text into an unintelligible string of characters that can be transmitted via communications media with high degree of security and then decrypted when it reaches a secure destination? a. distortion b. extrication c. encryption d. encoded

c. encryption encryption is the process of transforming text into an unintelligible string of characters than can be transmitted via communication media with a hight degree of security and then decrypted when it reaches a secure destination.

Written or spoken permission to proceed with care is classified as: a. an advanced directive b. formal consent c. expressed consent d. implied consent

c. expressed consent expressed consent can be spoken or written.

3. Common forms of fraud and abuse include all of the following except: a. upcoding b. unbundling or "exploding" charges c. refilling claims after denials d. billing for services not furnished to patients

c. refilling claims after denials refilling claims after denial is not possible because denied claims must be appealed and is not a factor in controlling fraud and abuse.

which document directs an individual to bring originals or copies of records to court? a. summons b. subpoena c. subpoena duces tecum c. deposition

c. subpoena duces tecum subpoena duces tecum is a written document directing individuals or organizations to furnish relevant documents and records.

Which of the following is not true of notices of privacy practices? a. they must be available at the site where the individual is treated. b. they must be posted in a prominent place. c. they must contain content that may not be changed d. they must be prominently posted on the covered entity's website when the entity has one.

c. they must contain content that may not be changed The notice of privacy includes a statement that the covered entity reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains.

The key data element for linking data about an individual who is seen in a variety of care settings is the: a. facility medical record number b. facility identification number c. unique patient identifier d. patient birth date

c. unique patient identifier Unique Patient Identifier- is a unique number assigned by a healthcare provider to a patient that distinguishes the patient's medical records from all others.

7. The practice of assigning a diagnosis or procedure codes specifically for the purpose of obtaining a higher level of payment is called: a. billing b. unbundling c. upcoding d. unnecessary service

c. upcoding upcoding-is the practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment.

What does CC stand for in the IDC-9-CM book?

complication/comorbidity - the CC is there to remind you to code the underlying case.....i.e. diabetes with foot ulcer

45. Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician use with the Evaluation and Management code? a. -79, Unrelated procedure or service by the same physician during the postoperative period. b. -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. c. -21, Prolonged evaluation and management services d. -24, Unrelated evaluation and management service by the same physician during a postoperative period.

d. -24, Unrelated evaluation and management service by the same physician during a postoperative period. Modifier -24 is used for unrelated evaluation and management service by the same physician during a postoperative period.

52. Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure. a. -22 b. -54 c. -32 d. -55

d. -55 Modifiers are appended to the code to provide more information or to alert the payer that a payment change is required. Modifier -55 is used to identify the physician provided only postoperative care services for a particular procedure.

The sum of a hospital's total relative DR G weights for a year was 15,192 and the hospital had 10,471 total discharges for the year. Given this information, what would be the hospital's case-mix index for that year? a. 0.689 b. 1.59 c. 1.45 x 100 d. 1.45

d. 1.45 The case-mix index is 1.45 for the total case-mix index of the hospital. An individual MS-DRG case mix ca be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG. This provides the total weight for each MS-DRG. The sum of all total weights [15,192] divided by the sum of total patient discharges [10,471] equals the case-mix index.

A patient is admitted to an acute-care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism. a. 291.8, 303.00 b. 303.00 c. 305.00 d. 291.81, 303.00

d. 291.81, 303.00 If the patient is admitted in withdrawal or if withdrawal develops after admission, the withdrawal code is designated as the principal diagnosis. The code for substance abuse or dependence is listed second.

43. Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket. a. 33223 b. 33210 c. 33212 d. 33222

d. 33222 Begin with the term Revision: pacemaker site; chest.

48. Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens. a. 366.10, 250.50, 13.59, 13.71 b. 250.00, 366.10 c. 250.00, 366.12 d. 366.10, 250.00, 13.59, 13.71

d. 366.10, 250.00, 13.59, 13.71 The patient was admitted for the senile cataract and the procedures were completed for the condition. This follows the UHDDS guidelines for principle diagnosis selection. There is also no causal relationship given between the diabetes and the cataract, so 250.50 would be incorrect.

49. A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension. a. 492.8, 496, 403.10,585.9 b. 492.8, 585.9, 401.9 c. 496, 585.9, 401.9 d. 491.21, 403.91, 585.9

d. 491.21, 403.91, 585.9 Patient was admitted for COPD, so this is listed as the principal diagnosis. Code 491.21 is used when the medical record includes documentation of COPD with acute exacerbation. ICD-9-CM presume a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, code 403.91; however, the code also at category 403 directs the coder to also code the chronic renal failure 585.9.

62. **The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure? a. 49000, 58940, 58700 b. 58940, 58720-50 c. 49000,58720 d. 58720

d. 58720 In the abdomen, peritoneum, and omentum subsection, the exploratory laparotomy is a separate procedure and should not be reported when it is part of a larger procedure. The code of 49000 is not reported because laparotomy is the approach to the surgery. The code 58720 includes bilateral so the modifier -50 is not necessary to report.

57. Patient with flank pain was admitted and found to have a calculus of the kidney. A ureteroscopy with placement of ureteral stents was performed. Assign the correct ICD-9-CM diagnosis and procedures codes. a. 592.0, 788.0, 59.8 b. 788.0, 592.0, 56.0 c. 594.9, 59.8 d. 592.0, 59.8

d. 592.0, 59.8 Codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related diagnosis has been established. The flank pain would not be coded because it is a symptom of the calculus.

3. Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus. a. 730.06 b. 730.07 c. 730.07, 041.1 d. 730.07, 041.10

d. 730.07, 041.10 Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger 2012, 305-306).

24. A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease [GERD]. The final diagnosis was "Rule out chest pain versus GERD". The correct ICD-9-CM code is: a. V71.7, Admission for suspected cardiovascular condition b. 789.01 Esophageal pain c. 530.81 Gastrointestinal reflux d. 786.50 Chest pain NOS

d. 786.50 Chest pain NOS Signs, symptoms, abnormal tests results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "rule out" or other similar terms indicating uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if its existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign or symptom the patient exhibits. In this case, assign the code 786.50, Chest pain NOS.

34. What statement is NOT reflective of meeting medical necessity requirements? a. A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease. b. A service or supply provided that is not experimental, investigational, or cosmetic in purpose. c. A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms. d. A service provided solely for the convenience of the insured, the insured's family, or the provider.

d. A service provided solely for the convenience of the insured, the insured's family, or the provider.

22. A denial of a claim is possible for all of the following reasons EXCEPT: a. Not meeting medical necessity b. Billing too many units of a specific service c. Unbundling d. Approved precertification

d. Approved precertification PRIOR APPROVAL for a service or procedure is called PRECERTIFICATION and allows coverage for a specific service.

23. Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of the following EXCEPT: a. Coding conventions define in the CPT book b. National and local policies and coding edits c. Analysis of standard medical and surgical practice d. Clinical documentation in the discharge summary

d. Clinical documentation in the discharge summary EDITING is NOT based on the clinical documentation of the discharge summary. Edits are predetermined based on coding conventions defined in the CPT codebooks, national and local policies and coding edits, analysis of standard medical and surgical practice, and review of current coding practices.

14. If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report. b. Dimension of the specimen submitted as described in the pathology report. c. Width times the length of the lesion as described in the operative report. d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report.

d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report. The code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision [lesion diameter plus narrow margins required equals the excised diameter].

20. In processing a bill under the Medicare outpatient prospective payment services system [OPPS] in which a patient had three surgical procedures performed during the same operative session, which of the following would apply? a. Bundling of services b. Outlier adjustment c. Pass-through payment d. Discounting of procedures

d. Discounting of procedures DISCOUNTING applies to multiple surgical procedures furnished during the same operative session. The full rate will be paid to the surgical procedure with the highest rate and the additional procedures will be discounted 50% of their APC rate.

6. Which of the following issues compliance program guidance. a. AHIMA b. CMS c. federal register d. HHS Office of Inspector General [OIG]

d. HHS Office of Inspector General [OIG] The OIG continues to issue compliance program guidance since 1998.

33. A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin. c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin.

d. Hematuria; adverse reaction to Coumadin. Adverse affects can occur in situation in which medication is administered properly and prescribed correctly in both therapeutic and diagnostic procedures. An adverse effect can occur when everything is done correctly. The first-listed diagnosis is the manifestations or the nature of the adverse effect, such as the hematuria. Locate the drug in the Substance column of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E code is mandatory when coding adverse effects.

28. Which of the following is not one of the purposes of ICD-9-CM? a. Classification of morbidity for statistical purposes. b. Classification of mortality for statistical purposes c. Reporting of diagnoses by physicians d. Identification of the supplies, products, and services provided to patients.

d. Identification of the supplies, products, and services provided to patients. [HCPCS] According to Central Office on ICD-9-CM, ICD-9-CM is not used to identify supplies, products, and services used by patients.

25. What is the defining characteristic of an integrated health record format? a. Each section of the record in maintained by the patient care department that provided the care. b. Integrated health records are intended to be used in ambulatory settings. c. Integrated health records include both paper forms and computer printouts d. Integrated health record components are arranged in strict chronological order.

d. Integrated health record components are arranged in strict chronological order. The integrated health record is arranged so that the documentation from various sources is intermingled and follow strict chronological order.

27. Which of the following statements does not apply to ICD-9-CM? a. It can be used as the basis for epidemiological research. b. It can be used in the evaluation of medical care planning for healthcare delivery systems. c. It can be used to facilitate data storage and retrieval d. It can be used to collect data about nursing care.

d. It can be used to collect data about nursing care. According to Central Office on ICD-9-CM, ICD-9-CM is not used to collect data about nursing care.

16* What resource can managers use to discover current, hot areas of compliance? a. policies and procedures b. national coverage determination c. official coding guidelines d. OIG workplan

d. OIG workplan The OIG workplan is published every year to provide insight into the directions the OIG is taking, as well as highlights of hot areas of compliance. Coding managers should review this document each year.

6. In processing a Medicare payment for outpatient radiology examinations, a hospital outpatient services department would receive payment under which of the following? a. DRGs b. HHRGs c. OASIS d. OPPS

d. OPPS RADIOLOGY PROCEDURES performed as outpatients are paid under the Medicare prospective payment system and are identified with a status indicator X for ancillary services.

16. A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuri, 500 mgs once daily. Return visit in 2 weeks.". In which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan

d. Plan The plan includes orders and the roadmap for patient care.

37. Medicare Part D pays for: a. Physician office visits b. Durable medical equipment c. Inpatient hospital care d. Prescription drugs

d. Prescription drugs MEDICARE PART D-PAYS FOR PRESCRIPTION DRUGS for beneficiaries.

28. Which of the following is NOT an essential data element for a healthcare insurance claim? a. Revenue code b. Procedure code c. Provider name d. Procedure name.

d. Procedure name. A procedure name IS NOT A REQUIRED element on a healthcare insurance claim.

4. Identify where the following information would be found in the acute-care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine". a. Medical laboratory report b. Pathology report c. Physician progress notes d. Radiography report

d. Radiography report Results of an x-ray interpretation by a radiologist are reported in a radiography report.

6. This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with bradyarrhythmias. Prolonged ambulatory monitoring may be indicated to establish a diagnosis of this condition. Treatment includes insertion of a permanent cardiac pacemaker. a. Atrial fibrillation (427.31) b. Atrial flutter (427.32) c. Paroxysmal supraventricular tachycardia (427.0) d. Sick sinus syndrome (SSS) (427.81)

d. Sick sinus syndrome (SSS) (427.81) Correct Answer: D SSS is the imprecise diagnosis with various characteristics treated with the insertion of a permanent cardiac pacemaker. The other three conditions are treated with cardioversion and different pharmacological therapy (Schraffenberger 2012, 194-195).

11.**The following is documented in an acute-are record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear? a. Admission note b. Nursing note c. Physician progress note d. Social work note

d. Social work note After an initial assessment, documentation by the other allied health professionals varies by specialty with appropriate content and frequency of recording.

5. What are five-digit ICD-9-CM diagnosis codes referred to as? a. Category codes b. Section codes c. Subcategory codes d. Subclassification codes

d. Subclassification codes Five-digit code numbers represent the subclassification level

4. At which level of classification system are the most specific ICD-9-CM codes found? a. Category level b. Section level c. Subcategory level d. Subclassification level

d. Subclassification level The most specific codes in the ICD-9-CM system are found at the subclassification level.

Which of the following ICD-9-CM codes are always alphanumeric? a. Category codes b. Procedure codes c. Subcategory codes d. V codes

d. V codes V codes are always alphanumeric codes. They are easy to identify because they begin with the alpa character V and follow with numeric digits.

8. This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services: a. general counsel b. health information director c. privacy officer d. compliance officer

d. compliance officer A compliance officer- designs, implements, and maintains a compliance program that assures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products and services.

Using uniform terminology is a way to improve: a. validity b. data timeliness c. audit trails. d. data reliability

d. data reliability data reliability is a method at looking at data quality consistently, sometimes referred to as data reliability. Reliability is frequently checked by having more than one person abstract data for the same case and compare the results for any discrepancies.

The protection measures and tools for safeguarding information and information systems is a definition of: a. confidentiality d. data security c. information privacy d. informational access control

d. data security DATA SECURITY is the mean of ensuring that data are kept safe from corruption and that access to data is suitably controled.

Electronic systems used by nurses and physicians to document assessment and findings are called: a. computerized provider order entry b. electronic document management systems-EDMS c. electronic medication administration records d. electronic patient care charting

d. electronic patient care charting The primary EHR applications include clinical documentation or patient care charting, computerized provider order entry, electronic medical administration records, and clinical decision support.

Coders will assign codes that have been selected into a computer program called a[n]__ to assign the patient's case to the correct group based on ICD-9-CM and/or CPT/HCPCS codes. a. encoder b. computer-assisted coding c. natural-language processor d. grouper

d. grouper In both the MS-DRG and APC groupings, coders enter the codes that have been selected in a computer program called a grouper. The grouper then assigns the patient's case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes.

11. HIT professionals must have knowledge of: a. security issues with regard to the management of healthcare reform b. laws affecting the physician malpractice insurance c. AMA's professional ethical principles of practice regarding physician assistants. d. laws affecting the use of disclosure of health information.

d. laws affecting the use of disclosure of health information. An HIT professional must have knowledge of all the points addressed.

13. An accounting of disclosures must include disclosures: a. for use in law enforcement requests b. to any patient family member who makes a request c. to any individual who requested the information d. made for public health reporting purposes

d. made for public health reporting purposes DISCLOSURES for which accounting is not required involve nine exceptions including those in the question.

5. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education. a. current coding personnel b. medical staff c. newly hired coding personnel d. nursing staff

d. nursing staff All newly hired coding personnel should receive an extensive training on the facility's and HIM dept's compliance programs. Education of medical staff on documentation is likewise important to the success of any compliance program.

A special webpage that offers secure access to data is called a[n]: a. access control b. home page c. intranet d. portal

d. portal A PORTAL is a special application to provide secure remote access to specific applications.

The Uniform Health Care Decision Act ranks the next-of-kin in the following order for medical decision-making purposes: a. adult sibling; adult child; spouse; parent b. parent; spouse; adult child; adult sibling c. spouse; parent; adult sibling; adult child d. spouse; adult child; parent; adult sibling

d. spouse; adult child; parent; adult sibling*** The UHCDA suggest that decision-making priority for an individual's next-of-kin be as follows: Spouse, adult child, parent,adult sibling, or if no one is available who is so related to the individual, authority may be granted to "an adult who exhibited special care and concern for the individual".

2. All of the following should be part of the core areas of a coding compliance plan except: a. physician query process b. correct use of encoder software c. coding diagnoses supported by medical record documentation d. tracking length of stay

d. tracking length of stay tracking length of stay is part of the hospital utilization review committee function

Using uniform terminology is a way to improve:

data reliability-a method at looking at data consistency, sometimes referred to as data reliability. Reliability is frequently checked by having more than one person abstract data for the same case and compare the results for any discrepancies.

Code if applicable any causal condition first

indicate that this code may be assigned as a 1st listed diagnosis when the causal condition is unknown or not applicable. If the causal condition IS known, then the it should be reported as the 1st listed diagnosis. Example: Urinary Incontinence and Cogential Ureterocele: Code 753.23 and 788.30

60. The CIA of security includes confidentiality, data integrity, and data _____. a. Accessibility b. Authentication c. Accuracy d. Availability

orrect Answer: D Security measures not only provide for confidentiality, but data integrity and data availability—the CIA of security (Johns 2011, 184).

HIT professionals must have knowledge of: a. Security issues with regard to the management of healthcare reform b. Laws affecting the physician malpractice insurance c. AMA's professional ethical principles of practice regarding physician assistants d. Laws affecting the use of disclosure of health information

orrect Answer: D An HIT professional must have knowledge of all the points addressed (Johns 2011, 801-804)

For OutPatient coding: the coder should not code those conditions described as:

probable, suspected, rule out, or working - this rule changes for inpatient treatments

Name some ancillary services:

radiology, laboratory, or physical therapy

Puerperium - Define

the 6 weeks immediately following childbirth **Complications of Pregnancy, Childbirth, and the Puerperium are NEVER reported on the Baby's record.

What do SLANTED brackets represent: [ ]

these surround additional codes/secondary codes that MUST be included with the initial code.