AHIMA CCA: Exam PDOAN

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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 ).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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.

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).

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).

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).

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).

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, ).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).

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).