question

Identify the ICD-10-CM code for a patient with a subsequent encounter for routine healing of a closed traumatic capital epiphyseal fracture of the left femur

answer

S79.012D

question

Identify the ICD-10-CM code(s) for neonatal tooth eruption

answer

K00.6

question

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

answer

21012

question

Identify CPT code(s) for the following Medicare patient. A 67-year old female undergoes an excision of a breast lesion identified by pre-operative placement of radiological marker

answer

19125

question

Identify the information classified in the fourth digit for the code G30.0

answer

Alzheimer's disease with early onset.

question

Identify the ICD-10-PCS code(s) for insertion of dual chamber cardiac pacemaker battery via an incision in the subcutaneous tissue of the chest wall, and percutaneous transvenous insertion of right atrial and right ventricular leads.

answer

0JH606Z, 02H63JZ, 02HK3JZ

question

Identify the correct ICD-10-PCS code(s) for replacement of an old dual pacemaker battery with a new dual pacemaker battery in the subcutaneous tissue f the chest wall via incisional approach.

answer

0JPT0PZ, 0JH606Z

question

Identify the appropriate ICD-10-CM code(s) for Mobitz type I and II heart block

answer

I44.1

question

Identify the appropriate ICD-10-CM and ICD-10-PCS code(s) for cardiac pacemaker pulse generator check

answer

Z45.010, 4B02XSZ

question

This condition has an imprecise diagnosis with various characteristics. the condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. It is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with Brady arrhythmias . Prolonged ambulatory monitoring may be indicated to establish a diagnosis of this condition. Treatment includes insertion of a permanent cardiac pacemaker

answer

Sick sinus syndrome (SSS) (I49.5)

question

Identify the appropriate ICD-10-PCS code(s) for a coronary artery bypass of two sites, one using the left internal mammary artery to the left proximal anterior descending artery, and one using the right internal mammary artery to the distal left anterior descending artery, both done via thoracotomy.

answer

02100Z8, 02100Z9

question

Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery

answer

Judkins

question

Identify the correct ICD-10-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's Coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.

answer

Z51.81, Z79.01

question

Identify the CPT code(s) for the following patient: A 2-year-old-boy presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance

answer

43761, 76000

question

Identify the CPT code(s) for the following patient: A 2-year-old boy presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance

answer

49450

question

Identify the term ICD-10-CM uses for the following definition: "the expulsion of some, but not all, of the products of conception from the uterus."

answer

Incomplete abortion

question

Identify the ICD-10-CM code(s) for the following: threatened abortion with hemorrhage at 15 weeks; home undelivered

answer

O20.0, Z3A.15

question

Identify the ICD-10-CM and ICD-10-PCS code(s) for the following: 40 week gestation, term pregnancy with poor cervical dilation; lower uterine segment cesarean delivery, open approach with single liveborn female.

answer

O62.0, Z3A.40, Z37.0, 10D00Z1

question

Identify the ICD-10-CM code for diaper rash in elderly patient

answer

I.22

question

Identify the ICD-10-CM code(s) for infected ingrown toenail with paronychia of the first toe of the right foot.

answer

L60.0, L03.031

question

Identify the ICD-10-CM code(s) for primary localized osteoarthritis of bilateral hips.

answer

M16.0

question

Identify the ICD-10-CM code for chrondromalacia of the left patella

answer

M22.42

question

Identify the ICD-10-CM code(s) for acute osteomyelitis of the right index finger due to Staphylococcus aureus

answer

M86.141, B95.61

question

Identify the ICD-10-CM code(s) for acute osteomyelitis of tarsus bones of the right ankle due to Staphylococcus.

answer

M86.171, B95.8

question

Identify the ICD-10-CM code(s) for other specified aplastic anemia secondary to adverse effect of chemotherapy, initial encounter

answer

D61.1, T45.1X5A

question

Identify the ICD-10-CM code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well-child examination. The physician documents, "well child, born premature."

answer

Z00.129, P07.30

question

Identify the ICD-10-CM code for ventricular diastolic dysfunction

answer

I51.9

question

Identify the chapter in which certain signs and symptoms of breast disease, such as mastodynia, induration of breast, and nipple discharge, are included

answer

Chapter 14 Diseases of the genitourinary system

question

which of the following is the correct ICD-10-PCS code for a Mayo operation known as a bunionectomy? An incision was made in the right foot and a portion of the first metatarsal head was removed.

answer

0QBN0ZZ

question

Which of the following is not considered an endoscopy?

answer

Fluoroscopy

question

Which of the following is (are) the correct ICD-10-PCS code(s) for laparoscopic cholecystectomy? The entire gallbladder was removed.

answer

0FT44ZZ

question

Which of the following is (are) the correct ICD-10-PCS code(s) for cystoscopy with diagnostic biopsy of the bladder?

answer

0TBB8ZX

question

Which of the following software applications would be used to aid in the coding function in a physician's office?

answer

Encoder

question

Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system?

answer

Resource-based relative value scale system

question

The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150 Total abdominal hysterectomy, with/without removal of tubes and ovaries 58700 Salpingectomy, complete or partial, unilateral/bilateral (separate procedure) What error has the coder made by using these codes?

answer

Unbundling

question

What is the best reference tool to determine how CPT codes should be assigned?

answer

American Medical Association's CPT Assistant news

question

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

answer

Unbundling

question

In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel?

answer

report the remaining tests using individual test codes, according to CPT.

question

The Office of Inspector General (OIG) has identified risk areas for physician practices. One type of risk is "clustering," Identify its definition

answer

Coding or charging one or two middle levels of service codes exclusively

question

What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment for Part B claims?

answer

National Correct Coding Initiative (NCCI)

question

What is the best reference tool for ICD-10-CM/PCS coding advice?

answer

AHA's Coding Clinic for ICD-10-CM/PCS

question

CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007 and are applied to which code set?

answer

HCPCS/CPT codes

question

Several key principles require appropriate physician documentation to secure payment from the insurer. which answer (listed here) fails to impact payment based on physician responsibility?

answer

Documenting the charges and services on the itemized bill.

question

The documentation of each patient encounter should include the following to secure payment from the insurer except:

answer

The identity of the patient's nearest relative and emergency contact number.

question

Two patients were hospitalized with bacterial pneumonia. One patient was hospitalized for three days, and the other patient was hospitalized for 30 days. Both cases result in the same DRG with different lengths of stay. Which answer most closely describes how the hospital will be reimbursed?

answer

the hospital will receive the same reimbursement for the same DRG regardless of the length of stay.

question

Which of the following statements are true?

answer

The higher the relative weight, the higher the payment rates.

question

Which classification system is in place to reimburse home health agencies?

answer

HHRGs

question

What reimbursement system uses the Medicare fee schedule?

answer

RBRVS

question

MS diagnostic-related groups are organized into:

answer

Major diagnostic categories

question

Which of the following hospitals are excluded from the Medicare acuter-care prospective payment system?

answer

Children's

question

CMS identified conditions that are not present on admission and could be "reasonably preventable." Hospitals are not allowed to receive additional payment for these conditions when the condition is present on admission. What are these conditions called?

answer

Hospital-acquired conditions

question

Which of the following fails to meet the CMS classification of a hospital-acquired condition?

answer

Gram-negative pneumonia

question

Which of the following fails to meet the CMS classification of a hospital acquired condition?

answer

Stage I pressure ulcers

question

The electronic claim format (8371) replaces which paper billing form?

answer

CMS-1450 (UB-04)

question

This is a statement sent by third-party payers to the patient to explain services provided, amounts billed, and payments made by the health plan.

answer

Explanation of benefits (EOB)

question

An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?

answer

UACDS

question

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus vagus) is one purpose of:

answer

Vocabulary standards

question

A family practitioner requests the opinion of a physician specialist endocrinology who reviews the patient's health record and examines the patient. The physician specialist records findings, impressions, and recommendations in which type of report?

answer

Consultation

question

Which of the following is not a function of the discharge summary?

answer

Providing information about the patient's insurance coverage.

question

documentation of monitoring to ensure the patient sufficiently recovers from anesthesia, including a post-anesthesia note, vital signs, and intravenous fluids, is a function of the :

answer

Recovery room report

question

A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:

answer

Abdominal pain

question

All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered as this type of data:

answer

Clinical

question

What type of data is exemplified by the insured party's member identification number?

answer

Financial data

question

Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented formula?

answer

SOAP form of progress notes

question

Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on :

answer

Reason for encounter

question

Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: "patient is being admitted for organic brain syndrome." Underneath the diagnosis, her medical information along with her rehabilitation potential was also listed. On which form is this information documented?

answer

Transfer or referral

question

According to the Joint Commission Accreditation Standards, which documentation must be placed in the patient's record before a surgical procedure may be performed?

answer

Report of history and physical examination

question

Bob Smith was admitted to Mercy Hospital on June 21. The physical examination was completed on June 23. According to Medicare Conditions of Participation, which statement applies top this situation?

answer

The record is not in compliance because the physical examination must be completed within 24 hours of admission

question

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n):

answer

Delinquent record

question

The _______________ may contain information about diseases among relatives in which heredity may play a role.

answer

History

question

To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of health records?

answer

Review each patient's medical record concurrently to make sure history and physicals are present and meet the accreditation standards

question

Medical record completion compliance is a problem at Community Hospital. the number of incomplete charts often exceeds the standard set by the Joint commission, risking a type I violation. Previous HIM committee chairperson tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. to improve compliance, which of the following would be the next step to overcome noncompliance?

answer

contact other hospitals to see what methods they use to ensure compliance

question

How do accreditation organizations such as the Joint Commission use the health record?

answer

To determine whether standards of care are being met

question

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must the facility meet in order to become certified for these programs?

answer

Conditions of Participation

question

What is the best source of documentation to determine the size of a removed malignant lesion?

answer

Operative report

question

This document includes a microscopic description of tissue excised during surgery:

answer

Pathology report

question

When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure?

answer

Query the physician as to the method used. and

question

The Medicare Modernization Act of 2003 (MMA) launched a Medicare payment and recovery demonstration project that would later develop into recovery audit contractors (RACs) serving as a means to ensure correct payments under Medicare. During the demonstration program, the contractors were able to identify _____________ of dollars in improper payments.

answer

Billions

question

Corporate compliance programs were released by the OIG for hospitals to develop and implement their own compliance programs. All of the following except__________ are basic elements of a corporate compliance program.

answer

Medical staff appointee for documentation compliance

question

Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards?

answer

Quality improvement

question

Each year the OIG develops a work plan that details area of compliance it will be investigating for that year. what is the expectation of the hospital in relation to the OIG work plan?

answer

Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan.

question

HIM coding professionals and the organizations that employ them have the responsibility to not tolerate behavior that adversely affects data quality. which of the following is an example of behavior that should not be tolerated?

answer

Omit codes that reflect negatively on quality and patient safety measurement.

question

The OIG believes that compliance programs have benefits in addition to submitting accurate claims. this includes al of the following except:

answer

Increased potential for criminal and unethical conduct

question

An individual stole and used another person's insurance information to obtain medical care. This action would be considered:

answer

Medical identity theft

question

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose?

answer

Chart tracking system

question

What does an audit trail check for?

answer

Unauthorized access to a system

question

An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?

answer

Role-based

question

What software will prompt the user through a variety of questions and choices based on the clinical terminology entered to assist the coder in selecting the most appropriate code?

answer

Logic-based encoder

question

The technology commonly used for automated claims processing (sending bills directly to third-party payers) is :

answer

Electronic data interchange

question

What refers to the capacity of health record systems to provide electronic communication linkages and allow exchange of health record data among information systems?

answer

Connectivity

question

a system that provides alerts and reminders to clinicians is a(n):

answer

Clinical decision support system

question

In what form of health information exchange are data centrally located but physically separated?

answer

Consolidated federated

question

A hospital receives a valid request from a patient for copies of his or her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPPA regulations, was this action correct?

answer

No; the records from the previous hospital are considered part of the designated record set and should be given to the patient.

question

A patient request copies of her personal health information on CD. when the patient goes home, she finds that she cannot read the CD on her computer. the patient then requests the hospital to provide the medical records in paper format. How should the hospital respond?

answer

Provide the medical records in paper format.

question

Which of the following definitions best describes the concept of confidentiality?>

answer

the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

question

the release of information function requires the HIM professional to have knowledge of:

answer

Federal and State confidentiality laws

question

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting rom is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

answer

There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice

question

The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of :

answer

Privacy

question

The HIM manager is concerned about whether the data transmitted across the hospital network is altered during the transmission. the concept that concerns the HIM manager is

answer

Data integrity

question

The CIA of security includes confidentiality, data integrity, and data ____________

answer

Availability

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