Chapter 1 Test

Which is a code set adopted by HIPAA for use by clearinghouses, health plans, and providers?

a. ABC codes✔ b. CMIT c. NDC d. SNOMED

Which classifies dental procedures and services?

a. CPT b. ICD-10-PCS c. CDT✔ d. HCPCS

Which is a secondary purpose of the medical record that does not relate directly to patient care?

a. Clinical research b. Continuity of care c. Discharge note d. Hybrid record

Which is a standard classification of mental disorders used by mental health professionals in the United States?

a. DSM✔ b. ICF c. ABC d. CCC

Which is used to capture paper record images onto storage media?

a. EMR b. Documentation cloning c. EHR d. Scanner✔

Which processes health care claims and performs related business functions for a health plan?

a. Health care clearinghouse b. Third-party payer c. Health care provider d. Third-party administrator✔

Which is documented in the progress note section of the POR to summarize the patient's care, treatment, response to care, and condition on discharge?

a. Medical necessity b. Demographic data c. Discharge note✔ d. Transfer note

Which type of clinical terminologies and clinical vocabularies are used by health care providers to document patient care?

a. Medical nomenclature✔ b. Nosologia Methodica c. Demographic data d. Classification system

Which is the business record for a patient encounter (inpatient or outpatient) that documents health care services provided to a patient?

a. Medical record✔ b. Health care statistics c. Financial record d. Demographic data

A progress note contains diagnoses of muscle strain and weakness. This statement would be located in the __________ portion of the POR progress note.

a. Objective b. Assessment✔ c. Plan d. Subjective

Which is a benefit of joining a professional association?

a. Opportunities to network with other members✔ b. Reduced benefits as compared with nonmembers c. Website-only access to professional journals d. Free certification examination fees

To whom does the student report at the professional practice experience (or internship) site?

a. Physician b. Patient c. Supervisor✔ d. Program faculty

A progress note contains documentation that the patient is to be followed up with in the physician's office two weeks after discharge from the hospital. This statement would be located in the __________ portion of the POR progress note.

a. Plan✔ b. Subjective c. Assessment d. Objective

Which is an electronic database and universal standard used for clinical care and management?

a. READ b. SNOMED c. LOINC✔ d. UMLS

Which is considered to be a small code set according to HIPAA?

a. Race, ethnicity, type of facility, and type of unit ✔ b. Causes of injury, disease, impairment, or other health-related problems c. Actions taken to prevent, diagnose, treat, and manage diseases and injuries d. Diseases, injuries, impairments, and other health-related problems

Which type of medical record format stores documentation in labeled sections?

a. Source-oriented record✔ b. Integrated record c. SOAP notes d. Problem-oriented record

A progress note contains documentation that the EKG showed elevated T-wave changes. This statement would be located in the __________ portion of the POR progress note.

a. Subjective b. Assessment c. Plan d. Objective✔

Which is the standard claim submitted by physicians' offices to third-party payers?

a. UB-04 b. CMS-1450 c. CMS-1500✔ d. UB-92

Hospitals and other health care facilities use automated case abstracting software to:

a. collect and report data for statistical analysis and reimbursement purposes.✔ b. justify diagnostic or therapeutic procedures or services provided to patients. c. submit standard claims to providers for inpatient and outpatient services. d. generate claims data for electronic submission to health care providers.

The primary purpose of the record is __________, which involves documenting patient care services so that others who treat the patient have a source of information on which to base additional care and treatment.

a. continuity of care✔ b. medical necessity c. quality of care d. medicolegal

The requirement that the patient's diagnoses justify diagnostic and/or therapeutic procedures or services provided is called:

a. facilities planning. b. medical necessity.✔ c. policy making. d. continuity of care.

The purpose of adopting standard code sets was to:

a. regulate health care clearinghouses and third-party administrators. b. improve data quality and simplify claims submission for providers.✔ c. establish a medical nomenclature to standardize HIPAA data submissions. d. increase costs associated with processing health insurance claims.

According to HIPAA, health plans that do not accept standard code sets are required to modify their systems to accept all valid codes or to contract with a(n):

a. third-party administrator. b. electronic data interchange. c. insurance company. d. health care clearinghouse.✔

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires __________ types of code sets to be adopted for the purpose of encoding data elements.

a. three b. five c. two ✓ d. four

To provide the maximum benefit to students, internships are typically __________ work experiences that are arranged by academic program faculty.

a. voluntary b. optional c. nonpaid✔ d. elective