AHIMA CCA: Practice Questions
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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.)
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).
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).
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).
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).
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).
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.)
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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)
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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
