Classification systems and secondary data sources

You need to analyze data on the types of care provided to Medicare patients in your geographic area by DRG. Which of the following would be most helpful? a. MEDPAR b. RxNorm c. National practitioner data Bank d. Vital statistics

A. MEDPAR The Medicare provider analysis and review ( MEDPAR) file is made up of acute care hospital, and skilled nursing facility (SNF) Claims data for all Medicare claims. It consists of the following types of data: demographic data on the patient, date on the provider, information on Medicare coverage for the claim, total charges, charger is broken down by specific types of services, ICD - 10 - CM diagnoses and procedure codes, and DRGs. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and analysis by DRG. Limitation of the MEDPAR data for research purposes is that it only contains data about Medicare patients.

According to CPT, antepartum care includes all of the following EXCEPT a. Monthly visits up to 36 weeks b. Routine chemical urinalysis c. Initial and subsequent history d. Physical examination

A. Monthly visits up to 36 weeks antepartum care begins with conception, and ends with delivery, and includes the following: *initial prenatal history and examination subsequent prenatal history and *examinations * documentation of weight, blood pressures, and fetal heart tones * routine, chemical urinalysis * monthly visits up to 28 weeks gestation * biweekly visits to 36 weeks gestation * Weekly visits until delivery

The most widely discussed and debated unique patient identifier is the a. Patients Social Security number b. Patients first and last names c. Patient date of birth d. Unique physician identification number (UPIN)

A. Patients Social Security number The Social Security number has evolved over the years. It is widely used in healthcare as a patient identifier; however, it creates numerous risks for patients, including privacy and security, identity, theft, and identity fraud.

In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders, or on multiple times by the same coder refers to a. Reliability b. Validity c. Timeliness d. Completeness

A. Reliability Coding is the labeling of words or word, group (segments) or images with annotations or skills. To assess reliability, the agreement between and among coders must be checked. validity assesses relevance, completeness, accuracy, and correctness - it measures how well a data collection instrument measures what it should measure. completeness refers to the patient health record being complete, according to the standards, adhere to buy the facility timeliness of documentation is linked to accurate documentation - individual documents in the patient health record must be created in a timely manner, according to the standards used by the facility

According to the American medical association, medical decision making is measured by all of the following, except a. Specialty of the treating physician b. Risk of complications c. Number of diagnoses or management options d. Amount and complexity of data reviewed

A. Specialty of the treating physician medical decision-making involves the complexity of establishing a diagnosis and/or selecting a management, option or treatment plan, as measured by the following: * Number of possible diagnoses and/or management options of treatment plans to be considered * Amount and/or complexity of the data to be obtained, reviewed, and analyzed * risk of significant complications, morbidity, and/or mortality associated with the patients presenting condition, diagnostic procedure(s), and/or the possible management options or treatment plans

A physician instructed his outpatient coder to report multiple codes in order to try and increase reimbursement when a single combination code should normally be reported. What is this called? a. Unbundling b. Jamming c. Overcoating d. Upcoding

A. Unbundling unbundling is reporting multiple codes to increase reimbursement when a single combination code should be reported

ICD - 10 - PCS utilizes the third character in the medical surgical section to identify the root operation. The name of the root operation that describes cutting out or off without replacing a portion of a body part is. a. Destruction b. Excision c. extirpation d. Removal

B. Excision excision is the cutting out or off, without replacement, a portion of a body part

In ICD - 10 - PCS, to code removal of a thumbnail the root operation would be a. Removal b. Extraction c. Fragmentation d. Extirpation

B. Extraction extraction is the pooling, or stripping out or off all or a portion of a body part by the use of force fragmentation is breaking solid matter in a body part into pieces removal is taking out or off a device from a body part by cutting or by use of force Extirpation is taking or cutting out, solid matter from a body part

One of the major functions of the cancer registries to ensure that patient receive regular in, continued observation and management. How long should patient follow up be continued? a. Until remission occurs b. For the life of the patient c. 10 years d. One year

B. For the life of the patient The follow ups for patients for a cancer registry should be continued until the patient's death

Mappings between ICD - nine - CM and ICD - 10 - CM were developed and released by the national center for health statistics (NCHS) to facilitate the transition from one code set to another. They are called. a. ICD code maps b. GEMS (General equivalency mappings) c. Code maps d. Medical mappings

B. GEMS (General equivalency mappings) The national center for health statistics (NCHS) and the CMS annually, publish general equivalence mappings (GEMs) that are translation, dictionary, or crosswalks of codes that can be used to roughly identify ICD - 10 - CM code for the ICD - nine - CM equivalent. GEMs facilitate the location of corresponding diagnosis codes between two code sets.

Which of the following is expected to enable hospitals to collect more specific information for use, and patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement? a. LOINC b. ICD - 10 - CM c. NDC d. NANDA

B. ICD - 10 - CM US government modify the international classification of diseases, 10th revision, clinical modification, ICD - 10 - CM for the reporting of morbidity data and reimbursement in the United States. ICD - 10 codes have the potential to retrieve more about quality of care so that data can be used in a more meaningful way to better understand complications, better, design, clinically, robust, algorithms, and better track the outcomes of care.

A population based cancer registry that is designed to determine rates and trends in a defined population is a(n) a. Patient care population-based registry b. Incidence only population based registry c. Research oriented population-based registry d. Cancer control population base registry

B. Incidence only population base registry in population based cancer, registries, emphasis on identifying trends and changes in the incidents, new cases of cancer within the area, covered by the registry. Most incidents only registries are operated by a government, health agency, and our designer determine cancer rates and trends in a defined population. Monitoring cancer incidence is legislatively mandated in most states.

In ICD - 10 - PCS, to code reduction of a displaced, fracture and application of a cast, the root operation would be: a. Insertion b. Reposition c. Immobilization d. Change

B. Reposition reposition is moving to its normal location or other suitable location all or a portion of a body part. The reduction of a displaced fracture is coded to root operation reposition an application of a cast in conjunction with the reposition. Procedure is not coded separately.

Which of the following classification system was designed with electronic systems in mind, and is currently being used for problem list, ICU monitoring, patient care, assessments, data collection, medical, research, studies, clinical trials, disease, surveillance, and images? a. SNDO b. SNOMED CT c. GEM d. ICPC - 2

B. SNOMED CT One of the greatest strengths of SN O MED is that it was designed with electronic systems in mind. In addition to EHR applications, SNOMED CT is used for problem list, intensive care, unit, monitoring, decision, support, applications, alerts and reminders, patient care, assessments, data collection at the point of care, medical research studies, clinical trials, is Easter, valance, and image indexing. It is used in quality and public health, reporting of infectious diseases, cancer, and bio surveillance. SNOMED CT enables patients and providers to describe individuals, health and care with true fidelity to the clinical status, while maintaining the integrity of the information of both human and machine readability.

According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training, is defined as a a. Operating room procedure b. Significant procedure c. Principal procedure d. Therapeutic procedure

B. Significant procedure A significant procedure is surgical and nature, can carry a procedural and/or anesthetic risk, requires highly trained personnel, and require special facilities or equipment.

The information collected for your registry includes patient, demographic information, diagnosis, codes, functional status, and Histocompatibility information. This type of registry is a a. Birth defects registry b. Transplant registry c. Trauma registry d. Diabetes registry

B. Transplant registry The type of information collected varies according to the type of registry. Pre-transplant data about the recipient include demographics, patient's diagnosis, patient status codes regarding medical urgency, patient's functional status, whether the patient is on life-support, and previous transplantations is included in the transplant registry.

In which registry would you expect to find an injury severity score (ISS)? a. Transplant registry b. Trauma registry c. Birth defects registry d. Cancer registry

B. Trauma registry Trauma registries maintain databases on patients with severe traumatic injuries. The abbreviated injury scale (AIS) reflect the nature of the injury and the severity (threat to life) by body system. The injury severity score (ISS) is an overall severely measurement calculated from the AIS scores for the three most severe injuries of the patient. The AIS and the ISS classifying describe the severity of the injuries and can be used for reporting registry activity.

An example of a valid code in ICE hash 10 - CM is a. 576.212 D b. Z3A.34 c. 32.6677 d. BJRT23x

B. Z3A.34 ICD - 10 - CM codes begin with an alphabetical letter. The second character is always numeric. Characters three through seven can be alpha or numeric. There is a decimal after the third character. Codes can consist of 3 to 7 characters.

The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels? a. SPECIALIST Lexicon b. READ Codes c. ABC codes d. LOINC

C. ABC codes ABC codes consist of five character, alphabetic strings, that identify services, remedies, and/or supplies. Codes are followed by two character code, modifiers, which identify the practitioner type who delivered the care. And healthcare, the combination of ABC codes with older medical code sets allows mini essential, business processes, (such as forecasting, practice management, insurance, billing, claims processing, and third-party reimbursement) to be fully automated. The codes also help digitize information to simplify data collection, analysis, and reporting. It's improve the quality of data and accelerates the speed with which conclusion can be drawn from those data about what works in the US healthcare and why.

The level I (CPT) codes of the HCPCS coding system are maintained by the a. Centers for Medicare and Medicaid services b. American hospital association c. American medical association d. Local fiscal intermediary

C. American medical association HCPCS level I includes the five digit (and some five character) CPT codes developed and published by the American medical association (AMA) The AMA is responsible for the annual update of his coding system and its two digit modifiers.

The cancer committee at your hospital request a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the a. Suspense file b. Disease index c. Ascension register d. Tickler file

C. Ascension register when a case is first entered into the registry, ascension numbers assigned; this number is used to identify the patient. Dissension number consists of the first digits Of the year the patient was seen at the facility, with the remaining digits assigned sequentially throughout the year. The first case in 2020, for example, might be 20-0001. The ascension number may be a sign manually or by automated cancer database used by the organization. And ascension registry of all cases can be kept manually or provided as a report by the database software. This listing of patients in Ascension number order provides a way to monitor that all cases have been entered into the registry.

In ICD - 10 - CM, the final character of the code indicates laterality. An unspecified side code is also provided. Should the site not be identified in the medical record. If no bilateral code is provided, and the condition is bilateral the ICD - 10 - CM official coding guidelines, direct code or to a. Assign the unspecified side code b. Query the physician c. Assign separate codes for both the left and right side d. Not assign a code

C. Assign separate codes for both the left and right side ICD - 10 - CM codes that indicate laterality specifically classified conditions that occur on the left, right, or bilaterally. If a bilateral ICD - 10 - CM code is not provided and the condition is bilateral, the sign separate codes for both the left and right side. If the side is not identified in the patient record, assign a code for unspecified site.

DSM - 5 is used most frequently in what type of healthcare setting? a. Home health agencies b. Ambulatory surgery centers c. Behavioral health centers d. Nursing homes

C. Behavioral health centers The diagnostic and statistical manual of mental disorders, fifth edition (DSM-5) is the handbook used by healthcare professionals as a guide to diagnose mental disorders, and was first published by the American psychiatric association (APA). The DSM - five is most frequently used in behavioral/psychiatric/mental health care, settings.

To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed? a. ICD - 10 - CM codes b. HCPCS level two codes c. CPT codes d. Evaluation and management codes

C. CPT codes CPT is the most widely accepted nomenclature for the reporting a physician procedures, and services under government and private health insurance programs. The purpose of CPT is to provide a uniform language Allows for accurate descriptions of medical, surgical, and diagnostic services. It is designed to communicate consistent information about medical services and procedures among physicians, clinical staff, patient, accreditation organizations, and payers for administrative, financial, and analytical purposes. Descriptions for evaluation and management services such as a new patient office visit, anesthetic services, surgical procedures, radiology services, pathology and laboratory, test, and medical care all found in CPT.

The cancer committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of these data is the a. Master patient index b. Disease index c. Cancer registry abstracts d. Operation index

C. Cancer registry abstracts abstracts organize, summarize and categorize the crucial information of patient's medical record. The cancer registry abstract contains information about each patient from the time of diagnosis and continuing through the patient's life.

The level II (national) codes of the HCPCS coding system, or maintain by the a. Local fiscal intermediary b. CPT editorial panel c. Centers for Medicare and Medicaid services d. American medical association

C. Centers for Medicare and Medicaid services HCPCS was developed by the centers for Medicare and Medicaid (CMS) for the same reasons that the AMA developed CPT: for reporting medical procedures and services. The centers for Medicare and Medicaid services updates HCPCS level II quarterly on January 1, April 1, July 1, and October 1.

Which of the following systems facilitates, capturing standardize data with the electronic document of patient at the point of care? a. Continuity of care document (CCD) b. Clinical documentation architecture (CDA) c. Clinical care classification (CCC) d. Continuity of care record (CCR)

C. Clinical care classification (CCC) The clinical care classification (CCC) System is to interrelated taxonomies: the CCC of nursing diagnoses and outcomes, and the cc of nursing interventions and actions that provide a standardize framework for documenting patient care in hospitals, home health, agencies, ambulatory care, clinics, and other healthcare settings. The CCC system can be used for a number of purposes. Primarily, it facilitates capturing standardized data with electronic documentation of patient care at the point of care.

The coding supervisor notices that the coders are routinely failing to code all possible diagnosis and procedures for a patient encounter. This indicates to supervisor that there is a problem with a. Reliability b. Validity c. Completeness d. Timeliness

C. Completeness

When coding free skin graphs, which of the following is NOT an essential item of data needed for accurate coding? a. Type of repair b. Recipient site c. Donor site d. Size of defect

C. Donor site skin graph codes are categorized by type of graph/repair, body, part, receiving the graft, and size of a defect in square centimeters. The donor site is not needed for coding unless the donor site requires skin grafting or local flaps.

If physician excises, a 3.1 cm malignant lesion of the scalp that requires full thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded? a. Excision of lesion; full thickness skin graft to scalp; excision of skin from thigh b. Surgical preparation of recipient site; full thickness, skin graft to scalp c. Excision of lesion; full thickness skin graft to scalp d. Full thickness, skin graft to scalp only

C. Excision of lesion; full thickness skin graft to scalp when an excision of a lesion requires a skin replacement/substitute graft for repair of the defect, the coding professional is directed to assign a code to identify the excision as well as the graft.

A coder notes that a patient is taking prescription pilocarpine. The final diagnosis on the discharge summary or congestive heart failure and diabetes Mellitus. The coder should query the physician about adding a diagnosis of. a. Bronchitis b. Laryngitis c. Glaucoma d. Arthritis

C. Glaucoma as eyedrops, pilocarpine is used for angle closure glaucoma until surgery can be performed, ocular, hypertension, open angle Glaucoma, and to bring about constriction of the people falling installation. It should also be noted that colors are prohibited from performing assumption, coding, which is the assignment of codes, based on assuming, from a review of clinical evidence in the patient's record, that the patient has a certain diagnosis, a reserve certain procedures/services even though the provider did not specifically document the diagnosis or procedures/services. In this case, coder, should Cory the physician before coding the glaucoma diagnosis.

A patient develops difficulty during surgery and the physician discontinued the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued. a. -74 b. -73 c. -52 d. -53

D. -53 modifier - 53 is appropriate in circumstances where the physician elects to terminate or discontinue a surgical or diagnostic procedure, usually because of a risk to the patient's well-being. This modifier should not be used to report the elective cancellation of procedure prior to the patient surgical preparation, or prior to the induction of anesthesia. modifier - 52 is for reduce services - service/procedure is partially reduced or eliminated at discretion of the physician, or other qualified, healthcare, professional modifier - 73 or -74 does not exist

The physician performed a fiberoptic Broncoscopy with irrigation of the bronchus. In this scenario, what should the coder code? a. Irrigation of bronchus only b. Bronchoscopy only c. Bronchoscopy and irrigation of bronchus d. Unspecified code

A. Irrigation of bronchus only inspection of a body part that is performed to achieve the objective of a procedure is not coded separately. So, in this case, only the irrigation of bronchus would be coded, not the bronchoscopy procedure, which allows for the inspection of the body part.

Miss Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit. a. - 78 b. - 58 c. - 76 d. - 79

A. - 78 modifier - 78 reflect circumstances when it is necessary for patient to return to the operating room (unplanned) during the post operative period. The procedure performed for the subsequent surgery is related to the initial procedure. modifier - 58 is for staged or related procedure or service by the same physician or qualified healthcare, professional during the post operative period modifier - 79 is for an unrelated procedure or service by the same physician or other qualified health, healthcare, professional during the post operative period modifier - 76 is for a repeat procedure or service by the same physician or other qualified, healthcare professional

In ICD- 10 - PCS, how many possible different approaches might be used to reach the site of a procedure? a. 7 b. 6 c. 4 d. 5

A. 7 there are seven different approaches 1. Open 2. Percutaneous 3. Percutaneous endoscopic 4. Via natural or artificial opening 5. Be a natural or artificial opening endoscopic 6. Be a natural or artificial opening endoscopic with percutaneous endoscopic assistance 7. Via external

At the request of one physician, a second physician provides advice regarding the evaluation and management of a specific problem. This is called a. A consultation b. Concurrent care c. Risk factor intervention d. A referral

A. A consultation A consultation is a type of service provided by physician at the request of another physician, or appropriate source to either recommend care for specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient's entire care, or for the care of a specific conditioner problem.

You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called? a. Abstracting b. Case finding c. Nomenclature d. Staging

A. Abstracting abstracting is the compilation, usually an electronic database, of pertinent information extracted from the patient record. The purpose of abstracting is to make information from the patient record readily available for internal and external reporting needs. Abstracting supports the secondary use of patient data for registries, public reporting, research, and other purposes.

A list or Collection of clinical words, or phrases with their meanings is a a. Clinical vocabulary b. Language c. Medical nomenclature d. Data dictionary

A. Clinical vocabulary A clinical vocabulary, list, words, or phrases with their meanings, provides for the proper use of clinical words as names or symbols, and facilitates mapping standardize terms to broader classifications for administrative, regulatory, oversight, and physical requirements.

The health information department receives research request from various committees in the hospital. The medicine committee wishes to review all patients, having a diagnosis of anterolateral myocardial infarction within the past six months. Which of the following would be the best source to identify the necessary charts? a. Disease index b. Operation index c. Consultation index d. physicians index

A. Disease index The disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time.. This is where the medicine committee would look if they wish to review all patients having a diagnosis of Anterolateral my cardio infarction within the past six months.

A PEG procedure would most likely be done to facilitate a. Eating b. None of his answers apply c. Urination d. Breathing

A. Eating percutaneous endoscopic GastroStomy (PEG) is an Endo scopic medical procedure in which a tube (PEG tube) Is passed into a patient stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate.

All children will be entered into which of the following registries at birth, and this will continue to be monitored by the registry in their geographic area? a. Immunization registry b. Cancer registry c. Trauma registry d. Birth defects, registry

A. Immunization registry children are entered into the immunization registry at birth. Immunization registry is usually have the purpose of increasing the number of infants and children who receive proper immunizations at the proper intervals. Information is collected within a geographic area about children and their immunization status.

This registry collects data on recipients of heart valves and pacemakers: a. Implant registry b. Transplant registry c. Hypertension registry d. Cancer registry

A. Implant registry an implant is a material or substance, inserted into the body, such as breast, implants, heart valves, and pacemakers. Implant registries, track the performance of implants, including complications, deaths, and effects resulting from implants, as well as longevity.

Primary goal of a hospital based cancer registry is to a. Improve patient care b. Monitor cancer incidence c. Allocate hospital resources appropriately d. Determine the need for professional and public education programs

A. Improve patient care The national cancer database is a joint program of hospital registries of the commission on cancer and the American cancer society. Its purpose is to share quality Cancer care by providing data to evaluate patient management within hospitals and other treatment centers, make comparisons of cancer occur and outcomes between institutions, and sit standard to help improve quality of cancer care.

ICD 10-10 - CM utilizes a placeholder character. This is used as a fifth character placeholder at certain six character codes to allow for future expansion. The placeholder character is. a. "1" b. "X" c. "O" d. "Z"

B. "X" "X" is used as a placeholder character for ICD - 10 - CM

Patient Jamey Smith has been seen at Oceanside hospital four times prior to this current encounter. Unfortunately, because of clerical errors, Jamey's information was entered into the MPI incorrectly on the four previous admissions, and consequently has four different medical record numbers. The unit numbering system is used at Oceanside hospital. In looking at the entries into the MPI, which medical record number should be used for all visits? Jamey's previous entries into the MPI are as follows: 09/03/15 Jamey Smith MR# 10361 03/10/16 Jamey Smith Doe MR#33998 07/23/17 Jamie Smith Doe MR#36723 11/15/18. Jamey S. Doe. MR#41369 a. 36723 b. 10361 c. 41369 d. 33998

B. 10361 all medical records should be filed and merged under the initial medical record number. That was 10361. The information should not be filed and merged under the subsequent medical record numbers. Most large facilities use a unit numbering system. In this type of system, the patient is assigned a number during the very first encounter with the provider and keeps it for all subsequent encounters. This number may be a sign automatically by a computer program or a sign manually.

In order to use the inpatient CPT consultation codes, the consulting physician must a. Use the term " referral" b. Document his findings in the patient's medical record c. Communicate orally his opinion to the attending physician d. Order diagnostic tests

B. Document his findings in the patient's medical record documentation to support a consultation is essential and should include the request and need for a consultation, the opinion of the consultent, and any services ordered and or performed. All this information should be documented in the health record and communicated by written report to the requesting physician or other appropriate source.

The Attending physician request a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision-making. The cardiologist orders diagnostic test and prescribed medication. He document his findings in the patient's medical record and communicates in writing with the attending physician. The following day, the consult visits the patient to evaluate the patient's response to the medication, to review the results from the diagnostic test, and to discuss treatment options. What codes should the consultant report for the two visits.? a. An initial patient consult for both visits b. Initial patient consult and a subsequent hospital visit c. An initial patient consult and a follow up consult d. An initial patient consult and initial hospital care

B. An initial inpatient consult and a subsequent hospital visit The consultant documented essential information in the medical record during the initial inpatient consult. The consultant then followed up on the patient the next day in the hospital. The consultant should report an initial patient consult and it's subsequent hospital visit.

Physician performed an outpatient surgical procedure on the ill orbit of a patient with Medicare. Upon searching the CPT codes and consulting eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting the physician, the coder is unable to find a code for the procedure. The coder should assign a. And ophthalmologic treatment service code b. An unlisted procedure code located in the eye and ocular adnexa section c. A HCPCS level II (alphanumeric) code d. An unlisted evaluation and management code from the E/M section

B. An unlisted procedure code located in the eye in ocular adNEXA section because of rapid advances in medical research and technology, new services or procedures may be performed before codes have been added to the CPT system to represent them. In these rare instances, and unlisted code should be reported, along with a written report, describing the procedure or service.

Case definition is important for all types of registries. Age will certainly be an important criterion for accessing a case in a(n)__________________ registry. a. Implant b. Birth defects c. Trauma d. HIV/AIDS

B. Birth defects Bertha fixed registries collect information on newborns with birth defects. The registry contains information on children up to a certain age, born with a birth defect.

Given the diagnosis "carcinoma of axillary, lymph nodes, and lungs, metastasis from breast," what is the primary cancer site(s)? a. Axillary lymph nodes b. Breast c. Lungs d. Axillary lymph nodes and lungs

B. Breast The primary malignancy site is the original tumor site. The secondary malignancy, or Matasac cancer is when the tumor has metastasized, or spread, to a secondary site, either adjacent to the primary site or to a remote region of the body.

The committee that is responsible for establishing the quality improvement priorities of the cancer program and for monitoring the effectiveness of quality improvement. Activities is the a. Medical staff committee b. Cancer committee c. Governing board committee d. Quality improvement committee

B. Cancer committee The cancer committee is designated multidisciplinary, body for the administrative oversight, development, and review of cancer care services at a facility. This committee communicates directly with the facilities, medical board, and its activities and recommendations directly impact programs.

Most common type of registry located in hospitals of all sizes, and every region of the country is the a. Trauma registry b. Cancer registry c. AIDS registry d. Birth defects registry

B. Cancer registry The cancer registry is the most common type of registry that is located in all hospitals all over the United States. Cancer registries, maintain data on all patients diagnosed and/or treated for cancer at a particular facility. A cancer registry is a particular type of disease registry, and its major purposes are: *establish maintain a cancer incident reporting system * informational resource for investigation of cancer, and its causes * provide info to assist public health, officials and agencies in the planning an evaluation of cancer prevention and cancer control programs

A cancer program is surveyed for approval by the a. Joint commission on accreditation of healthcare organizations b. Commission on cancer of the American College of surgeons c. American cancer society d. State department of health

B. Commission on cancer of the American College of surgeons The American College of surgeons (ACS) Commission on cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program. The ACS standards are published in the cancer program standards.

In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. Examining the physicians order, the coder notices that intervenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level, or any related condition on the discharge summary. The best course of action for the coder to take is two a. Code the abnormal potassium level as a complication following surgery b. Confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers, abnormal potassium level to be clinically significant c. Code the condition as abnormal blood chemistry d. Code The record as is.

B. Confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant. A coder should never sign a code on the basis of laboratory results alone. Findings are clearly outside the normal range. Patient has ordered additional testing for treatment, it is appropriate to consult with the position as whether a diagnosis should be added, or whether than abnormal findings should be listed.

Which system is a classification of health and health related domains that describe body functions and structures, domains of activities, and participation, and environmental factors interact with all of these components? a. Clinical care classification (CCC) b. International classification of functioning, disability, and health (ICF) c. National drug codes d. International classification of primary care (ICPC-2)

B. International classification of functioning, disability, and health (ICF) The international classification of functioning, disability, and health (ICF). Is a classification developed by the World Health Organization (WHO) of health and health related domains that describe body functions and structures, activities in participation. International classification of primary care (ICPC-2) is a classification system used by practitioners who are coding the details of the encounter, diagnosis, and treatment. clinical care classification (CCC) is to enter related taxonomies(CCCof nursing diagnoses and outcomes and CCC of nursing interventions and actions) they provide a standardized framework for documenting patient care in hospitals, home, health, agencies, ambulatory care, clinics, and other healthcare facilities. National drug codes (NDC) are unique numeric identifier is assigned to each medication, registered under the federal food, drug, and cosmetic act.

Which classification system was developed a standardized, terminology and codes for use in clinical laboratories? a. Systemized nomenclature of human and veterinary medicine international (SNOMED) b. Logical observation, identifiers names, and codes (LOINC) c. Systemized nomenclature of pathology (SNOP) d. Read codes

B. Logical observation, identifiers names, and codes (LOINC ) logical observation, identifiers names, and codes(LOINC) is a clinical terminology that provides a common language for clinical and laboratory observations. Each LOINC name identifies a distinct laboratory observation, and is structured to contain up to six parts

A system of preferred terminology for naming disease processes is known as a a. Set of categories b. Medical nomenclature c. Classification system d. Diagnosis listing

B. Medical nomenclature A medical nomenclature is a vocabulary of clinical and medical terms used by healthcare providers to document patient care. A clinical classification system is a clinical vocabulary, terminologies, or nomenclature that will list words with her definition.

The unified medical language system (UMLS) is a project sponsored by the a. World health organization b. National library of medicine c. Office of inspector general d. CMS

B. National library of medicine The national library of medicine produces two databases of special interest to the HIM professional: MEDLINE and UMLS (unified medical language system).

In ICD - 10 - PCS, when the objective of the procedure is to cut off the blood supply to a vessel, the root operation would be: a. Dilation b. Occlusion c. Restriction d. Bypass

B. Occlusion occlusion is completely closing and orifice or lumen of a tubular body part (i.e. cutting off the blood supply to a vessel) restriction is partially closing in office or lumen of a tubular body dilation is expanding an office or the lumen of a tubular body bypass is altering the root of passage of the contents of a tubular body

You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information? a. National practitioner data Bank (NPDB) b. Physician index c. Healthcare, integrity and protection data bank (HIPDB) d. MEDLINE database

B. Physician index The physician index is a listing of cases in order by physician name or physician identification number. It also includes the patient's health record number and may include other information, such as date of discharge. The physician index enables users to retrieve information about a particular physician, including the number of cases seen during a particular time period.

A radiologist is asked to review a patient CT scan that was taken at another facility. Modifier - 26 attach the code indicates that the physician is billing for what component of the procedure? a. Confirmatory b. Professional c. Global d. Technical

B. Professional modifier - 26 is a professional component and is reported when the provider either interprets test results or operate equipment for a procedure.

In ICD - 10 - PCS, to code, freeing, a vagus nerve root from surrounding scar tissue via open approach, the root operation would be: a. Detachment b. Release c. Division d. Extirpation

B. Release release is freeing a body part from an abnormal physical constraint. When the sole objective of the procedure is to free a body part without cutting into the body part, the root operation assignment should be released.

A patient is seen by surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit. a. -55 b. -25 c. -57 d. -58

C. -57 modifier - 57 can be reported by physicians Along with the appropriate E/M service codes when an E/M service was the result of an initial decision to perform surgery on a patient. modifier - 55 is for post. Operative management only - physician provided only postoperative services for a specific procedure. modifier - 58 is for stage or related procedure or service by the same physician or other qualified healthcare professional during the post operative. modifier - 25 is for a significant, separately, identifiable, evaluation, and management service by the same physician, or other qualified healthcare, professional on the same day of the procedure or other service.

Which system is used primarily to report services and supplies for reimbursement purposes? a. ASTM b. NLM c. HCPCS d. LOINC

C. HCPCS healthcare, common procedure coding system (HCPCS) is used to report services and supplies primarily for reimbursement purposes in the outpatient or ambulatory setting. The code is made up a five character, alpha numeric codes, mainly representing medical supplies, durable, medical goods, and non-physician services. This coding system is also used as an official code set for outpatient hospital, care, chemotherapy, drugs, Medicaid, and other services. The national library of medicine (NLM) is the world's largest medical library operated by the United States federal government. logical observation, identifiers names, and codes (LOINC) is a clinical terminologies that provides a uniform language for clinical and laboratory observations. The American Society for testing in materials (ASTM) is an international standards organization, that publishes and develops technical standards for a wide range of materials, systems, products, and services.

ICD - 10 - PCS was implemented in the United States to code a. Hospital outpatient diagnoses b. Hospital inpatient diagnoses c. Hospital inpatient procedures d. Physician office procedures

C. Hospital inpatient procedures The international classification of diseases, 10th revision, procedure coding system (ICD - 10 - PCS) is an entirely new procedure classification system developed by the centers for Medicare and Medicaid services (CMS) for used in the United States for inpatient hospital settings only.

You have recently been hired as the medical staff coordinator at your local hospital. Which database/registry will you utilize most often? a. LOINC b. MEDPAR c. National practitioner data Bank (NPDB) d. Trauma registry

C. National practitioner data Bank (NPDB) The national practitioner data Bank is a database of medical malpractice payments; adverse licensure actions, including revocations, suspensions, reprimands, censures, probations, and surrenders of licenses for the quality of care, purposes only; and certain professional review actions such as denial of medical staff, privileges taken by healthcare entities, such as hospitals against positions, dentist, and other healthcare providers. Lol requires healthcare facilities to query the NPDB, as part of the credentialing process when I physician initially applied for medical staff privileges and every two years there after.

A coder came across a medical record where a sputum culture indicated bacterial pneumonia but the diagnosis did not indicate the cause of the pneumonia. Documentation in the patient's record, failed to meet, which one of the following criteria: a. Completeness b. Consistency c. Precision d. Clarity

C. Precision precision is when clinical documentation indicates a more specific diagnosis that is documented, such as Speedom culture that indicates bacterial, pneumonia, and diagnosis does not indicate the cause.

A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask position whether or not, they should be coded as gram-negative pneumonia? a. Listeria b. Clostridium c. Pseudomonas d. Staphylococcus

C. Pseudomonas A pseudomonas infection is caused by a very common type of bacteria called pseudomonas aeruginosa. People in the hospital may get this infection. For example, pseudomonas is one of the main causes of pneumonia and patients who are on breathing machines.

The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type is the a. Code method b. Focused review method c. Record over record method d. Benchmarking method

C. Record over record method The record of a record method divides the number of records correctly coded by the total number of records in the sample. It is less labor-intensive, Widely recognized, and focused on statistics. However, it is more subjective in that it does not have a definition of what counts as an error and educational opportunities are not easily identified.

According to CPT, in which of the following cases would an established E/M code be used? a. A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of adult protective services for an assessment of his mental capabilities. b. John and his family have just moved to town. John has asthma and requires medication to control the problem. He has an appointment with Dr. you and will bring his records from the previous physician. c. Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago. d. A 78-year-old female with weight loss and progressive agitation over the past two months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in four years.

C. Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple years ago. an established patient is a patient who has received professional services from the physician or qualified, healthcare, professional ( or another physician or qualified, healthcare, professional of the exact same specialty and subspecialty, who belongs to the same group practice) within the past 3 years.

The abstract completed on the patients in your hospital contains the following items: patient demographics, prehospital interventions, vital signs on admission, procedures, and treatment prior to hospitalization, transport, modality, and injury severity score. The hospital uses data for its a. AIDS registry b. Diabetes registry c. Trauma registry d. Implant registry

C. Trauma registry trauma registries are a potential source of part of the data needed for comprehensive public health surveillance of injuries. Trauma registries are used to collect, store and retrieve data, describing the etiologic factors , Demographic characteristics, diagnoses, treatment, and clinical outcomes of individuals who meet specified case criteria. The injury severity score (ISS) is an overall severity measurement calculated from the abbreviated injury, scale (AIS) scores for the three most severe injuries of the patient, and this information is included in the trauma registry.

After reviewing the following excerpt from CPT, code 27646 would be interpreted as 27645 radical resection of tumor; tibia 27646 fibula 27647 Talus or calcaneus a. 27646 radical resection of tumor; tibia and fibula b. 27646 radical resection of tumor; fibula, talus, or calcaneus c. 27646 radical resection of tumor; fibula, or tibia d. 27646 radical resection of tumor; fibula

D. 27646 radical resection of tumor; fibula The format of the CPT code book is designed to provide descriptions of procedures that can stand alone without additional explanation. To conserve space, many descriptions refer to a common portion of the procedure listed in proceeding entry rather than reporting the procedure and it's entirety. When is The format of the CPT code book is designed to provide descriptions of procedures that can stand alone without additional explanation. To conserve space, many descriptions refer to a common portion of the procedure listed in a proceeding entry, rather than reporting the procedure in its entirety. When this occurs, the incomplete procedural description is indented under the main entry, and the common portion of the main entry is followed by a semicolon. This signifies at the main entry applies to, and is part of all indented entries that follow with their code. Indented entries can you all different kinds of information.

ICD - 10 - PCS codes have unique structure. An example of a valid code in the ICD - 10 - PCS system is a. 013.2 b. L03.311 c. B2151 d. 2W3FX1Z

D. 2W3FX1Z ICD - 10 - PCS codes contain seven characters that can be letters or numbers. Each code is made up of any one of the 10 digits one through nine and any one of the 24 letters a - H, J - N, And P-Z. The letters O and I are not used so that as not to be confused with the numbers zero and one.

The code structure for ICD - 10 - CM differs from the code structure of ICD - nine - CM. An ICD-10-CM code consists of a. 10. Characters. b. Seven digits c. Five. Alpha numeric characters. d. 3 to 7 characters

D. 3 to 7 characters ICD - 10 - CM codes are composed of codes with three, four, five, six, or seven characters. ICD -9-cm codes are composed of codes with three, four, or five characters.

The healthcare cost and utilization project (HCUP) consists of a set of databases that include data on patients, whose care is paid for by third-party payers. HCUP is an initiative of the. a. World health organization b. Centers for Medicare and Medicaid services c. National library of medicine d. Agency for healthcare research and quality

D. Agency for healthcare research and quality it major initiative for the agency for healthcare research and quality (AHRQ) has been the healthcare cost and utilization project (HCUP). HCUP uses data collected at the state level from either claims data from the UB - 04 or discharge abstract data, including UHDDS items reported by individual hospitals, and, in some cases, by freestanding, ambulatory care centers.

You were looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing? a. Patient identifiable data b. MPI data c. Protocol data d. Aggregate data

D. Aggregate data aggregate data include data on groups of people or patients without identifying any particular patient individually. Examples of aggregate, data, or statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis related group (DRG.).

The first character for all of the codes assigned an ICD - 10 - CM is a. An alphabet or a number b. A number c. A digit d. An alphabet

D. An alphabet The appropriate codes are codes from A00.0 through T 88.9, Z00 - Z 99.8 that must be used to identify diagnoses, symptoms, conditions, problems, complaints, or other reasons for encounter/visit. The first character of ICD - 10 - CM is always an alphabet character. The second character is always numeric. Characters three through seven can be alpha or numeric.

A barrier to widespread use of automated code assignment is a. Resistance by physicians b. Inadequate technology c. Resistance by HIM professionals d. Poor quality of documentation

D. Poor quality of documentation computer-assisted coding (CAC) is a tool intended for improved efficiency of the coding and claim submission process. While CAC can be useful in settings were documentation is structured and has a limited vocabulary, it is critical to remember the accurate documentation is underlying source resource for technological advances relating to patient records, medical, coding, and quality improvement. The medical record does not contain reliable and valid documentation, it cannot be coded correctly by an automated system.

A nomenclature of codes in medical terms that provide standard terminologies for reporting physician services for third-party reimbursement is a. Logical observation, identifiers names, and codes (LOINC) b. Diagnostic and statistical manual of mental disorders (DSM) c. Systemized, nonmenclature of pathology (SNOP) d. Current procedural terminology (CPT)

D. Current procedural terminology (CPT) The purpose of the current procedural terminology (CPT) is "to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide, communication among physicians patients, and third parties." CPT has become widely used as a standard for outpatient and ambulatory care, procedural coding in contacts related to reimbursement. systemize nomenclature of pathology (SNOP) consists of logically organized codes for the key terms that describe the pathology case logical observation, identifiers names, and codes ( LOINC) is a clinical terminology that provides a common language for clinical and laboratory observations. Each LOINC name identifies a distinct laboratory observation, and a structure to contain up to six parts. diagnostic and statistical manual of mental disorders (DSM) is a handbook published by the American psychiatric association (APA) that is used by healthcare professionals as a guide to probably diagnose mental disorders

A coder notices that some patient records contain in complete documentation. The Coder brings these records to the attention of the coding supervisor who will implement the next stage of the coding compliance program. What stage of coding compliance is being described in the scenario? a. Prevention b. Verification c. Correction d. Detection

D. Detection detection is the process of identifying potential coding compliance problems correction is based on the review of patient records that contain potential coding compliance problems, during which specific compliance issues are identified in problem-solving methods are used to implement necessary improvement/corrections. prevention involves educating, coders and providers so as to prevent coding complaints problems from reoccurring. verification provides an audit trail, that the detection, correction, and prevention functions of the coding compliance program or being actively performed.

The patient is diagnosed with congestive heart failure. A drug of choice is a. Ibuprofen b. Haloperidol c. Oxytocin d. Digoxin

D. Digoxin digoxin is used for maintenance therapy and congestive heart failure, atrial fibrillation, atrial flutter, and proximal atrial tachycardia.

A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a(n) a. Patient health record b. Master patient index c. Admissions register d. Disease registry

D. Disease registry The health record is a primary data source because it contains information about a patient that has been documented by the professionals who provided care to that patient. Data taken from the primary health record and entered into registries and databases are considered a secondary data source. Secondary data sources consist of facility, specific indexes; registries, either facility or population-based; and other healthcare databases.

An ICD- 10 - PCS, if a resection of tonsils was performed, what approach would it be coded to? a. Via natural or artificial opening b. Open c. Percutaneous d. External

D. External procedures performed with an orfice on structures that are visible without the aid of any instrumentation or coded to the approach external.

The local safety Council requested statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve the data, you will need to have the correct a. CPT code b. HCPCS level two codes c. Standard nomenclature of injuries code d. ICD - 10 - CM codes

D. ICD - 10 - CM codes ICD - 10 - CM chapter 17 includes injury and poisoning codes that classify the following: injuries fractures Burns adverse effects, poisonings, and toxic affects HCPCS codes level one and two are for procedures performed and would not identify the diagnosis code or cause of the accident. CPT codes describe medical, surgical, and a diagnostic services provided to the patient, but wouldn't identify the diagnosis

Which classification system is used to classify neoplasms, according to site, morphology, and behavior? a. Systemized Nomenclature of human in veterinary medicine international (SNOMED) b. Current procedural terminology (CPT) c. Diagnostic and statistical manual of mental disorders (DSM) d. International classification of diseases for oncology (ICD-O)

D. International classification of diseases for oncology (ICD-O) The international classification of diseases for oncology (ICD-O) is used for coding diagnoses of neoplasms in tumor and cancer, registries and in pathology laboratories.

An encoder that prompted the coder to answer a series of questions and choices. Based on the documentation in the medical record is called a(n) a. Grouper b. Automatic code assignment c. Automated code book d. Logic-based encoder

D. Logic-based encoder An encoder, assigns diagnoses and procedure codes. The encoder can query the coder to determine if related code should be assigned. Logic based Encoder and coders are probably the most popular. They asked the code or a series of questions that ultimately lead to code assignment. A grouper is a software program designed to assign the diagnosis related group (DRG) classification.

CMS published a final rule, indicating a compliance date to implement ICD - 10 - CM and I CD - 10 - PCS. The use of these two code sets was effective on. a. January 1, 2015 b. October 1, 2014 c. January 1, 2014 d. October 1, 2015

D. October 1, 2015

The best place to ascertain the size of an excised lesion for accurate CPT coding is the a. Discharge summary b. Anesthesia report c. Pathology report d. Operative report

D. Operative report total size of the excised area, including margins, is needed for accurate coding, and usually this info is provided in the operative report. The physician should make an accurate measurement of the lesion at the time of the incision, and the size of the lesion should be documented in the operative report.

A coding supervisor train the employees that they should code signs and symptoms in addition to the establish diagnosis code. This is an example of: a. Coding b. Jamming c. Unbundling d. Overcoding

D. Overcoding overcoding is reporting codes for signs and symptoms, in addition to the establish diagnosis code

Which of the following is NOT included as part of the minimum data, maintain by the MPI? a. Patient medical record number b. Full name (last, first, and middle name) c. Date of birth d. Principal diagnosis

D. Principal diagnosis The master patient index NPI is a permit database, including every patient ever admitted or treated by the facility. The NPI usually includes the following information: patient's full name, and any other names the patient uses, patient's date of birth, patients complete address, patients phone numbers, patient's health record number, patient's billing or account number, name of attending physician, dates of the patients admission and discharge or the date of the visit or encounter, patient disposition at discharge, or the conclusion of treatment, patient marital status, patient's gender, patient's race, and name of patient emergency contact. The NPI does not contain the patients principal diagnosis. The master patient index NPI is a permit database, including every patient ever admitted or treated by the facility. The NPI usually includes the following information: patient's full name, and any other names the patient uses, patient's date of birth, patients complete address, patients phone numbers, patient's health record number, patient's billing or account number, name of attending physician, dates of the patients admission and discharge or the date of the visit or encounter, patient disposition at discharge, or the conclusion of treatment, patient marital status, patient's gender, patient's race, and name of patient emergency contact. The NPI does not contain the patients principal diagnosis.

Which of the following part of the patient's medical record contains a number to count of the patient's problems, which helps to index documentation throughout the record? a. Review of systems b. Initial plan c. Chief complaint d. Problem list

D. Problem list d. Problem list The problem is serves as a table of contents for the patient record because it is filed at the beginning of the record, and contains a numbered list of the patient's problems, which helps index documentation throughout the record.

The name of the root operation in ICD- 10 - PCS that describes cutting out or off without replacement all of a body part is a. Removal b. Extraction c. Excision d. Resection

D. Resection resection is cutting out or off, without replacement, all of a body part

Which of the following is NOT A function of medical management software? a. Claims processing b. Patient invoicing c. Appointment scheduling d. Statistical reporting

D. Statistical reporting medical management software is a combination of practice management, and medical billing software that automates the daily workflow and procedures of a physicians office or clinic. The software automates the following functions: * appointment scheduling * claims processing * patient invoicing * patient management * Report generation

The reference date for a cancer registry is a. The date that the cancer committee is established b. January 1 of the year and wish the registry was established c. The date that the cancer program applies for approval by the American College of surgeons d. The date, when the data collection began

D. The date, when the data collection began The reference date for the cancer registry is the date the registry began ascensioning cases. The registries policy and procedure manual to find specifically the types of cases to be included

In CPT, category III codes include codes a. To measure performance b. For use by nonphysician practitioners c. For supplies, drugs, and durable medical equipment d. To describe emerging technologies

D. To describe emerging technologies CPT category III includes temporary codes that we would represent emerging medical technologies, services, and procedures that have not yet been approved for general use by the FDA, and are not otherwise covered by CPT codes. It gives physicians and researchers a system for documenting the use of unconventional methods, so that their efficacy and outcomes can be tracked.

In relation to birth defects registries, active surveillance systems a. Miss 10% to 30% of all cases b. Rely on reports submitted by hospitals, clinics, and or other sources c. Are commonly used in all 50 states d. Use trained staff to identify cases in all hospitals, clinics, and other facilities, through review of patient records, indexes, vital records, and hospital logs.

D. Use train staff to identify cases in all hospitals, clinics, and other facilities, through review of patient records, indexes, vital records, and hospital logs. Active case, ascertainment, surveillance systems, identify cases in all hospitals, clinics, or other medical facilities, through systematic review of patient records, surgery, records, disease, indexes, pathology reports, vital records, and hospital logs ( obstetric, newborn nursery, neonatal, intensive care unit, post Mortem) or by interviewing health professionals, who may be knowledgeable about diagnosis codes.

CPT provides level I modifiers to explain all of the following situation's EXCEPT a. When a service or procedure is partially reduced or eliminated at the physicians discretion b. When one surgeon provides only postoperative services c. When the same laboratory test is repeated multiple times on the same day d. When a patient sees a surgeon for follow up care after surgery

D. When a patient sees a surgeon for follow up care after surgery modifier - 52 is for reduced services modifier - 53 is for discontinued procedures modifier - 55 is for post Operative management only modifier - 91 is for repeat clinical diagnostic laboratory test

The main difference between concurrent and retrospective coding is a. The involvement of the physician b. What classification system is used c. The credentials of the coder d. When the coding is done

D. When the coding is done concurrent coding is completed while the patient is still admitted to the facility, whereas retrospective coding is completed after the patient is discharged from the facility.