question

For continuity of care, ambulatory care providers are more likely than providers of ACS to rely on the documentation found in the

answer

Problem list (PCPs, pharmacy consultations and transfer summaries are likely to be found on the records of long-term care patients).

question

All of the following organizations make up the Cooperating Parties for the approval of ICD-9-CM coding guidelines EXCEPT:

answer

Americal Medical Association

question

Define Status asthmaticus

answer

An acute asthmatic attack in which the degree of bronchial obstruction is not relieved by usual treatments such as pinephrine or aminophylline. Only a physician can diagnose status asthmaticus. If te coder suspects the condition based on the symptoms in the record, the coder should query the physician.

question

A data element you would expect to be collected in the MDS but NOT in the UHDDS would be:

answer

Level of cognition

question

Heart system transplant

answer

Is coded with Category III code because no Category I code is available.

question

The physician has ordered potassium replacement for the patient for a diagnosis of:

answer

Hypokalemia (decreased levels of potassium in the blood)

question

When the CPT index and tabular do not contain a code that descrbies an adequately documented procedure that was performed by the physician, what action should the coder take?

answer

Assign the nlisted cde from the orresponding anatomical section

question

One essential item to be captured on the physical exam is the:

answer

Objective survey of body systems (Performed during the PE. This adds objective data to the subjective data provided by the patient. The exam includes all body systems).

question

Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff?

answer

Physician index

question

Accreditation by Joint Commission is a voluntary activity for a facility and it is

answer

required for reimbursement of certain patient groups

question

Joint commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement?

answer

Yes, prior to surgery

question

What would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?

answer

Disease index (contains abstracting patient code numbers into a computer database, allowing a variety of reports to be generated)

question

The lack of a discharge order may indcate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave:

answer

Documented in both the progress notes and the discharge summary.

question

When is an Incident report written?

answer

When there is an account of an unusual event that has an adverse effect on a patient, employee, or facility visitor and it should never be filed with the patient's record.

question

The foundation for communicating all patient care goals in long-term care settings is the

answer

Interdisciplinary patient care plan

question

COP requires a consultation report when

answer

1. Patients that are not a good surgical risk. 2. Those with obscure diagnoses. 3. If a physician has doubts as to the best therapeutic measure to be taken. 4. If there is a question of criminal activity.

question

One distinct advantage of the EHR over paper-based health records is the

answer

accessibility of the record by multiple data users.

question

Problem list

answer

Is a distinct compenent of the problem-oriented record that serves to help index documentation throughout the record.

question

A POMR contains what?

answer

1. H&P 2. Problem list (titles, #'s, dates) 3. Initial plan (diagnostic, therapeutic, pt ed plans) 4. Progress notes All of which is summarized in a discharge summary or transfer note at the end of the stay.

question

R-ADT system contains

answer

Info re patients who are transferred to the oncology unit (or other specialty unit).

question

R-ADT

answer

Registration-admission, discharge, and transfer system

question

What is the best resource for checking out specific accreditation standards and guideleines for a Rehab facility?

answer

CARF manual (Commission on Accreditation of Rehab Facilities)

question

A home health agency does a new patient's certification period every

answer

60 days (recertification can cont. every 62 days until the pt is discharged from home health services)

question

What is a procedural method for protecting the data of a CPR?

answer

Having confidentiality statement signed by all staff utilizing the computer-based patient record.

question

What is a technical method of protecting computerized data?

answer

1. Limiting access of certain screens 2. Auditing capability to track data access 3. Using computer backup systems

question

When is it appropriate to substitute a final progress note for a discharge sumary?

answer

When a pt is hospitalized less than 48 hours with problems of a minor nature, normal newborns, and uncomplicated obstetrical deliveries.

question

Regional health information organization

answer

Are intended to support health information exchange within a geographic region

question

Medical staff rules and regulations

answer

Spells out the documentation requirements for patient records; designates the time frame for completion by he active medical staff; and indicates the penalties for failure to comply with record standards.

question

Antepartum record contains

answer

A comprehensive history and PE on each OB patient visit with particular attention to menstrual and reproductive history.

question

Biometrics-based identifier

answer

Measures a borrower's unique physical characteristics, such as fingerprints or a retinal scan, and compares it to a stored digital template to identify if the person.

question

When can an original health record be physically removed from the hospital?

answer

When the director of health records is acting in response to a subpoena duces tecum and takes the health record to court.

question

Most carbon dioxide is carried in the

answer

Red blood cells

question

A pathological diagnosis of transitional cell carcinoma is made. The examined tissue was removed from the

answer

Bladder

question

All of the following are examples of direct transmission of a disease EXCEPT

answer

contaminated foods

question

Cancer derived from epithelial tissue is classified as a

answer

Carcinoma

question

Full-blown AIDS sets in as

answer

helper T-cell concentration decreases

question

Which of the following anatomical parts is involved in both the respiratory and digestive systems

answer

Phyranx

question

The most fatal type of lung cancer is

answer

small cell cancer

question

Diastole occurs when

answer

the ventricles fill

question

Gas exchange in the lungs takes place at the

answer

alveoli

question

A key diagnostic finding for typical pneumonia is

answer

lung consolidation x-ray

question

John Palmer was in a car accident and sustained severe chest trauma resulting in a tension pneumothorax. Manifestations of this disorder include all of the following EXCEPT

answer

clubbing

question

In order to determine which information should be considered confidential, a health information manager should consider and answer yes to all the following questions EXCEPT:

answer

Is there a need for all health care providers to access the patient information?

question

The medical record is generally accepted as being the property of the

answer

institution

question

With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory?

answer

utilization review

question

The hospital has a policy that states, "Original medical records may be removed from the Medical Record Department jurisdiction only by court order." Which situation would be a violation of the policy?

answer

The physician has been sued and wants to study the original record at home prior to his deposition.

question

Which of the following established legal liability for hospitals in 1965?

answer

Darling v. Charleston Community Memorial Hospital

question

The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality is referred to as

answer

benchmarking

question

Upon retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

answer

qualitative review

question

qualitative review

answer

Quantitative analysis involves checking for the presence or absence of necessary reports or signatures while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record.

question

To comply with ORYX, a nursing home administrator would need to

answer

collect performance measure data that apply to the residents

question

HIM professionals are bound to protect the confidentiality of patient information under the

answer

AHIMA's Code of Ethics

question

HEDIS gathers data in the following area:

answer

measures of quality (e.g. cholesterol screenings)

question

HEDIS

answer

The Health Plan Employer Data and Information Set (HEDIS) is a standardized set of performance measures designed to allow purchasers and consumers to compare the performance of managed care plans. HEDIS defines 3 methods of data collection.

question

The ownership of the information contained in the physical medical/health record is considered to belong to the

answer

patient

question

The effective coordination of utilization review, quality assessment functions, and risk management activities can help eliminate

answer

duplicate record review.

question

The premise that charitable institutions could be held blameless for their negligent acts is known as

answer

doctrine of charitable immunity

question

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

answer

coding compliance program that prevents fraudulent coding and billing

question

Most health care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay.

answer

severity of illness/intensity of service criteria (SI/IS)

question

IS/SI

answer

Definition: Evaluation of need before admission and for continued stay use criteria that are performed are referred to as Intensity of service/severity of illness criteria (IS/SI criteria) reviews. Utilization management uses IS/SI to effectively control resource utilization. HEDIS is Health Plan Employer Data and Information Set.

question

Which of the following is a hereditary disease of the cerebral cortex?

answer

Lou Gehrig Disease

question

The cause of aplastic anemia is

answer

bone marrow failure

question

Which one of the following cells produce antibodies

answer

plasma cells

question

Penicillin is effective in the treatment of all of the following diseases EXCEPT

answer

Lordosis

question

Which of the following autoimmune diseases affects tissues of the nervous system?

answer

myasthenia gravis

question

Dr. Zambrano ordered a CEA test for Mr. Logan. Dr. Zambrano may be considering a diagnosis of:

answer

Cancer

question

Impetigo can

answer

be caused by Streptococcus

question

Each of the following pertains to COPD EXCEPT

answer

pneumonia

question

Which of the following is a lethal arrhythmia?

answer

ventricular fibrillation

question

Portal hypertension can contribute to all of the following EXCEPT

answer

kidney failure

question

The causative organism for Severe Acute Respiratory Syndrome (SARS) is a

answer

coronavirus

question

Before leaving the hospital, all newborns are screened for an autosomal recessive genetic disorder of defective enzymatic conversion in protein metabolism. With early detection and a protein-restricted diet, brain damage is prevented. This disease is

answer

phenylketonuria

question

A serum potassium level of 2.8 would indicate

answer

diabetic ketoacidosis

question

The first stage of alcoholic liver disease is

answer

Fatty liver

question

The patient's pathology report revealed the presence of Reed-Sternberg cells. This is indicative of

answer

Hodgkin's disease

question

Ulcerations of the small intestine are characteristic of

answer

Crohn disease

question

The most common rickettsial disease in the US is

answer

Rocky Mountain spotted fever

question

Common kidney stone treatments that allow small particles to be flushed out of the body through the urinary system include all of the following EXCEPT

answer

ureteroscopy and stone basketing

question

Which of the following is an effect of insulin?

answer

increases glucose metabolism

question

In general, excessive RBC breakdown could result in

answer

high bilirubin levels

question

Most of the digestion of food and absorption of nutrients occurs in the

answer

Small intestine

question

Mary Mulholland has diabetes. Her physician has told her about some factors that put her more at risk for infections. Which of the following factors would probably NOT be applicable?

answer

Increased blood supply

question

Which of the following is a risk factor involved in the etiology of gall stones

answer

being overweight

question

The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled, "comprehensive codes" and "component codes". According to the CCI edits when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service

answer

code only the comprehensive code

question

The hospital outpatient prospective payment system for Medicare applies to all of the following, EXCEPT, for

answer

professional services, such as physician fees

question

If a physician is a non-participating physician who does not accept assignment, he may collect a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount.

answer

Physician can balance bill and collect from the patient the difference between the nonPAR Medicare fee schedule amount and the total charge amount. Therefore, the patient's financial liability is $38.00 + 28.50 =$66.50.

question

If a physician is a non-participating physician who does not accept assignment; he may collect a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount.

answer

In this case, the nonPAR Medicare fee schedule amount is $190.00 and 15% over this amount is $28.50; therefore, the total that he can collect is $218.50.

question

Under the outpatient prospective payment system (OPPS), status indicator "___" is a payment indicator that refers to "significant procedures for which the multiple procedure reduction applies". This means that the reported CPT and/or HCPCS Level II code will be paid a discounted APC reimbursement rate when reported with other procedures on the same claim.

answer

"S"

question

According to the Federal Register, the definition of a "new" patient when assigning a CPT Evaluation and Management (medical visit) code to a Medicare hospital outpatient under the prospective payment system is a patient that has

answer

not already been assigned a medical record number

question

The definition of "new patient" in the CPT Code Book is

answer

"one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years". This definition is used by physicians.

question

What is the definition used by hospitals for a "New patient" under the outpatient prospective payment system (APCs).

answer

In the April 7, 2000 Federal Register (page 18451) CMS defined "new patient as "one who does not already have a medical record number".

question

The _________________ refers to a statement sent to the patient to clarify which services were provided, amount billed and amount of payments made by the health plan.

answer

medicare summary notice

question

"balance billing"

answer

the patient is financially liable for charges in excess of the Medicare fee schedule

question

"PATH" guidelines primarily affect:

answer

Residents and Physicians

question

There are four additional contributory components of an evaluation and management code which are:

answer

Counseling, coordination of care, time and nature of presenting problem

question

Split thickness skin grafts, pinch grafts, allografts and full thickness skin grafts are examples of what types of skin grafts?

answer

Free grafts

question

CPT codes for cast applications cannot be assigned for the initial services performed without restorative treatment for a dislocation, fracture or other injury, when restorative treatment is expected to be performed by another physician.

answer

a) True b) False

question

Which coronary artery has more branches than the others?

answer

Left main coronary artery

question

Which ICD-9-CM procedure code could affect DRG assignment?

answer

a) 44.14 b) 86.11 c) 33.27

question

UHDDS

answer

Collects a minimum set of data about inpatients

question

UACDS

answer

Collects data about ambulatory care patients

question

MDS

answer

Collects data about long-term care residents Develops long-term care resident care plan

question

OASIS

answer

Gathers data about Medicare beneficiaries receiving home care

question

DEEDs data set

answer

Collects data about hospital emergency encounters

question

HEDIS

answer

Set of performance measures used to compare the performance of healthcare plans

question

ORYX

answer

Is associated with JCAHO

question

ONC

answer

Establishes a plan for development of widespread interoperable EHR sysems.

question

What year did standardizing healthcare data begin?

answer

1960s

question

HL7

answer

Provides a foundation for understanding EHR functions

question

SDO

answer

Develops standards

question

CDA

answer

Standards for transmitting clinical documents such as discharge summaries

question

CCR

answer

Best used to create a personal health record

question

UPIN

answer

Identifier standard

question

SSN

answer

Should NOT be used as a unique patient identifier

question

CPT

answer

Clinical representation standard

question

Title XVIII of the SSA Amendment of 1965 is also known as:

answer

Medicare

question

Medicaid eligibility standards are est. by

answer

Individual states

question

Typof payment system where the amount of payment is determined before the service is delivered:

answer

Prospective

question

These payment arrangements are streamlined by the use of chargemasters:

answer

Fee-for-service

question

Payment based on the amount representing reasonable compensation for the service/procedure in a specific area of the country:

answer

UCR

question

Utlilization control most closely assoc. w/ managed fee-for-service reimbursement:

answer

Prospective review

question

Lump-sum payments to providers to compensate them for all healthcare services delivered to a patient for a specific illness and/or over a specific period of time:

answer

EOC

question

Based on per-person premiums or membership fees:

answer

Capitation

question

Prospective payment system implemented in 1983:

answer

DRG

question

Payment system for hospital-based outpatient services and procedures:

answer

OPPS

question

ASC rates are calculated on a:

answer

Prospective basis

question

Congress enacted the first Medicare PPS in:

answer

1983

question

Prior to DRG PPS, Medicare Part A payments to hospitals were based on a

answer

Fee-for-service reimbursement methodology

question

DRG prospective payment rate is based on the ____diagnosis.

answer

Principal

question

DRGs are assigned by

answer

Grouper

question

______ hospitals are excluded from the Medicare acute care pps

answer

Children's

question

DRGs are organized into _____

answer

Case-mix classifications

question

_____ are assoc. with the Medicare fee schedule

answer

RBRVS

question

_____ mandated the implementation of a SNF PPS.

answer

BBA

question

APCs

answer

are assoc. with the outpatient PPS

question

______ are not reimbursed according the OPPS.

answer

Critical access hospitals

question

WHEN MULTIPLE SURGICAL PROCEDURES ARE FURNISHED DURING THE SAME OPERATIVE SESSION, A CONCEPT CALLED ____ IS APPLIED.

answer

Discounting of procedures

question

Home health PPS uses the ____ data set for patient assessments

answer

OASIS

question

A new Medicare payment system for medically necessary transports effective for services provided on or after 1/1/01 was included as part of the ____

answer

BBA

question

A per-discharge PPS for care provided to Medicare beneficiaries by inpatient rehab hospitals and units was phased in on ____

answer

April 1, 2001

question

Fee schedules are updated by third-party payers

answer

Annually

question

To accept assignment means that the

answer

Provider accepts as payment in full whatever the payer reimburses

question

A fee schedule is

answer

developed by third-party payers and includes a list of healthcare services and procedures and charges of each

question

The system in which a health record # is assigned at the first encounter and used for all subsequent encounrters is the

answer

Unit numbering system

question

Reviewing the record for deficiencies after the patient is discharged from the hospital is an example of _____ review

answer

Retrospective

question

The primary guide to locating a record in a numberical filing system is the

answer

Master patient Index

question

If one needed to know the # of C-sections performed by a specific obstetrician the ____ would be used to identify the cases.

answer

Physician index

question

Serves as the MPI function

answer

Patient registration system

question

A chronological listing of data is called a

answer

Register

question

Which of the following indexes is an important source of patient health record numbers?

answer

MPI (Master patient index)

question

After the cases to be included in a registry have been determined, what is the next step in data axcquisition?

answer

Case finding

question

What # is assigned to a case when it is first entered in a cancer registry?

answer

Accession number

question

Which of the following acts mandated est. of the NPI data bank?

answer

Health are Wuality Impovement Act of 1986

question

Which one of the following is NOT part of the NHCS?

answer

The National Immunization Program Survey

question

What two databases produced by the Ntional Library of Medicine are of special interest to HIM professionals?

answer

MEDLINE and UMLS

question

The Darling v. Charleston Memorial Hospital case resulted in

answer

A hospital being found liiable for corporate negligence

question

QIO

answer

Contract with CMS to carry out the HCQIP and other projects and functions assigned in Scopes of Work

question

HCQIP

answer

A quality initiative under CMS and its contracted QI org. to collabroate on clinical QI projects

question

Guidelines for clinical practice can be found on the internet through provisions made by

answer

National Guideline Clearinghouse

question

NCQA directs its evals. of quality to the services performed under the auspices of ___

answer

Managed care plans

question

JCAHO requires hospitals and long-term care facilities to report outcomes for 20% of patients through a mechanism known as ___

answer

ORYX

question

Accreditation oby JCAHO means that the healthcare org. ____

answer

Is considered to have met the Medicare Conditions of Participation

question

Subacute care

answer

Level of skilled care needed by patients with complex medical conditions

question

Ownership of the physical health record rests with the ___

answer

Hospital, facility, or physician who keeps the records of patients

question

The Privacy Rule est. that a patient has the right of access to inspect and obtain a copy of his or her PHI___

answer

for as long as it is maintained

question

The Privacty Rule applies to ___

answer

All covered entities involved, either directly or indirectly, with transmittingor performing any electronic transactions specified in the act

question

Under HIPAA, a patient does not have the right to access his or her___

answer

Psychotherapy notes

question

The Privacy Rule specifies that an individual's request for a copy of their PHI mast be made within ___ days

answer

60

question

Notices of privacy practices must be made available by

answer

Posting it in a prominent place where it is reasonable to expect that the patients will read it.

question

Inmates in correctional institutions ____

answer

Are afforded most privacy protections under HIPAA

question

Consents ____

answer

Are for the purpose of permitting use and disclosure of PHI for treatment, payment, or operations

question

An individual may _

answer

Revoke an authorization in writing

question

Business associate agreements are developed to cover the use of PHI by___

answer

Organizations outisde the covered entity's workforce that uses PHI to perform functions for the covered entity

question

Release of birth and death info to public health authorities ___

answer

Is a "public interest and benefit" disclosure that does not require patiient authorization

question

Patient authorization is required to release ____

answer

PHI to the patient's attorney

question

All infected dialysis catheters are coded as 999.31, Infection due to central venous catheter.

answer

False

question

Code 304.00, Opioid type dependence, unspecified, is the appropriate code assignment for patients who are heroin addicts and are being maintained on methadone.

answer

True

question

It is appropriate to code unrelated incidental findings found on radiology reports during ED encounters.

answer

False

question

Acute kidney failure is an acute exacerbation of chronic kidney failure.

answer

True

question

When the provider documents "hypertensive urgency," it is appropriate to query the provider regarding the specific type of hypertension.

answer

True

question

During the review of 10 records, it was noted that the following data was documented: (1) living arrangements prior to admission to home health care, (2) integumentary status, (3) activities of daily living (ADL) status, and (4) pain status. Which data set is used to capture this type of info?

answer

OASIS

question

Which document would be excluded from the patient record for an elective inpatient surgery admission?

answer

EMT care sheet

question

For a patient with a documented fracture and dislocation at the same anatomical site, which is coded?

answer

fracture only

question

For "extent of burn" ICD-9-CM category code 948, the fifth digit assignment indicates the total amount of the patient's body that experienced:

answer

third-degree burns.

question

A patient presents for treatment of a bullet wound, upper leg, through the femoral shaft. The bullet passed through the skin of the leg and is lodged in bone, resulting in a fracture. This type of fracture is classified as a(n):

answer

missile closed fracture

question

The ED final diagnosis is status post cholecystectomy due to chronic cholelithiasis. The coder should:

answer

Code chronic cholelithiasis as an active condition.

question

Intrathecal drugs are administered into:

answer

CSF

question

Lipomas, fibromas, and adenomas are classified as:

answer

benign

question

1995 E/M coding guidelines for a comprehensive exam requires

answer

8 organ systems and body areas

question

The classification of a patient into a Home Health Resource Group (HHRG) is based on info collected from the _____ data collection tool.

answer

OASIS

question

In the ICD-9-CM coding system, an esophageal stricture due to a burn sustained from a house fire two years ago would be classified as a/an:

answer

late effect

question

Which of the following data sets is used by ambulatory care facilities?

answer

UACDS

question

During the incision and drainage of a deep abscess, the physician documented that the incision penetrated the fascia. To report the appropriate code, review the CPT Surgery subsection.

answer

integumentary

question

The placement of radioactive sources into a tumor-bearing area to generate high-intensity radiation is called:

answer

Brachytherapy

question

ICD-9-CM code category 402 (Hypertensive Heart Disease), is reported for the diagnosis of:

answer

Hypertensive cardiovascular disease with congestive heart failure

question

Which data set was designed to gather data about Medicare beneficiaries who receive home health services?

answer

OASIS

question

Which are the contributory components associated with evaluation and management system CPT codes?

answer

Counseling, Coordination of Care, and the Nature of the Presenting Problem

question

Which is administered to a patient after exposure to a disease to help prevent the patient from becoming infected?

answer

vaccine

question

Wound repair that requires debridement and extensive undermining would be classified as:

answer

intermediate repair

question

To correctly report a skin lesion removal, which information is reviewed in the patient record?

answer

location size of lesion method of removal lesion morphology

question

Which lesion would warrant Mohs Micrographic Surgery?

answer

basal cell carcinoma

question

When discussing CPT category III codes, which statement below is false?

answer

a. Category IIl codes are temporary codes. b. Category III codes are used if applicable instead of an unlisted Category I code. c. Category III codes are used to collect data on performance measurement. d. Category III may not conform to the requirements for Category I codes.

question

Which modifier is not approved for use in ambulatory surgery units (ASU)?

answer

-51

question

Genetic testing code modifiers are located in of the CPT coding manual.

answer

Appendix I

question

Cause of aplastic anemia

answer

Bone marrow failure

question

Most common cause of dementia

answer

Alzheimer's disease

question

CEA test is ordered for

answer

cancer

question

Prevention of illness thru vaccination occurs due to the formation of

answer

memory cells

question

three important plasma proteins

answer

albumins, globulins and fibrinogen

question

blood plasma w/out the clotting factors is called_____.

answer

Serum

question

the three formed elements of the blood are

answer

WBCs, RBCs, and platelets

question

the red pigment in blood cells that carries oxygen is called:

answer

hemoglobin

question

if the body produces an excess of red blood cells, the condition is called:

answer

polycythemia

question

which type os WBCs are the most numerous of the phagocytes?

answer

neutrophils

question

________ found within the lymph nodes, they are phagocytes that destroy bacteria, cancer cells, and other foreign matter in the lymphatic stream

answer

macrophages

question

natural killer cells

answer

A type of white blood cell that can kill tumor cells and virus-infected cells; an important component of innate immunity.

question

histamine

answer

a regulating body substance released in excess during allergic reactions causing swelling and inflammation of tissues

question

prostaglandins

answer

chemicals released from cells that cause smooth muscle contraction and pain. stimulates nerves when something hurts

question

lymph

answer

the fluid that the lymphatic system collects and returns to the bloodstream, the clear fluid that bathes each cell and transfers needed substances and wastes back and forth between the blood and the cells

question

antigen

answer

substance that triggers an immune response, any substance (as a toxin or enzyme) that stimulates the production of antibodies

question

antibody

answer

a substance produced by the body that destroys or inactivates an antigen that has entered the body, protein that helps destroy pathogens

question

Blood Urea Nitrogen (BUN) Creatinine Cystatin C

answer

Kidney Disease

question

Total Protein Albumin Globulins

answer

Liver Disease Kidney Disease Multiple Myeloma Immunodeficiency

question

Total Cholesterol HDL Cholesterol LDL Cholesterol

answer

Triglycerides Heart disease Atherosclerosis

question

Prostate Specific Antigen (PSA), Carcinoembryonic Antigen (CEA), CA-15

answer

Cancer of the prostate, colon, breast

question

PT/INR Ratio

answer

Anticoagulant (Coumadin) therapy

question

Red Blood Cell Count

answer

Anemia

question

White Blood Cell Count

answer

Infection, Leukemia

question

Hemoglobin Hematocrit

answer

Anemia, Hemorrhage

question

pH

answer

Urinary infection, Diabetic Ketoacidosis

question

Specific Gravity

answer

Dehydration, Diabetes

question

Ketones Diabetic Ketoacidosis,

answer

Malnutrition

question

Bilirubin, Urobilinogen

answer

Liver Disease

question

Blood

answer

Kidney trauma or infection; Kidney stones

question

Leukocytes, Nitrites

answer

Bacterial infections of urinary tract (UTI)

question

Protein

answer

Kidney disease

question

Microalbumin

answer

Early stages of kidney disease

question

A toxic goiter has what distinguishing characteristic?

answer

thyroid hyperfunction

question

Which of the following is a congenital condition that is the most severe neural tube defect?

answer

myelominingocele

question

_____________ is usually the first symptom of benign prostate hyperplasia.

answer

difficulty in urinating

question

Which of the following tubes conveys sperm from the seminal vesicle to the urethra

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ejaculatory duct

question

Cervical cerclage is a procedure used to help prevent

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miscarriage

question

Under APCs, payment status indicator "C" means

answer

inpatient only services

question

Under APCs, payment status indicator "V" means

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medical visits

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The term used to describe a diagram depicting grouper logic in assigning MS-DRGs is

answer

decision tree

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This prospective payment system is for __________ and utilizes a patient assessment instrument (PAI) to classify patients into case mix groups (CMGs)

answer

Inpatient rehab facilities

question

Under Medicare Part B, non-participating providers get paid

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5% less than PAR providers

question

If a physician is a non-participating physician who does not accept assignment, he may collect _____

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a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount.

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Balance bill

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Physician can balance bill and collect from the patient the difference between the nonPAR Medicare fee schedule amount and the total charge amount.

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Under the APC methodology, discounted payments occur when

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there are two or more (multiple) procedures that are assigned to status indicator "T" & modifier -73 is used to indicate a procedure is terminated after the patient is prepared but before anesthesia is started.

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The limiting charge is a percentage limit on fees specified by legislation that the nonPAR physician may bill Medicare beneficiaries above the nonPAR fee schedule amount. The limiting charge is

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15%

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Lifetime reserve days are

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applicable for hospital inpatient stays which are payable under Medicare Part A.

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A patient who is taking the drug Antivert may be diagnosed with

answer

dizziness

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The local safety council requests statistics on the number of head injuries occurring as a result of bicycle accidents during the last year. To retrieve this data, you will need to have the correct

answer

E codes and ICD-9-CM codes for this diagnosis

question

Standard Nomenclature of Athletic Injuries

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Used to identify sports injuries. It has not been revised since 1976.

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Code 402, Hypertensive Heart Disease would appropriately be used in which of the following situations?

answer

Hypertensive cardiovascular disease with congestive heart failure

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The term "hypertensive" indicates a

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cause and effect relationship

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Which of the following is a valid ICD-9-CM principal diagnosis code?

answer

V30.00 Single live born, born in hospital

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M codes and E codes

answer

are never principal diagnosis codes and, in fact, are optional for coding.

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A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. The correct code would be

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410.1x Acute MI

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An acute MI is considered

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to be anything under 8 weeks' duration from the time of initial onset.

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A chronic MI is considered

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anything over 8 weeks with symptoms.

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An old MI is considered

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anything over 8 weeks with NO symptoms.

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The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed

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brachytherapy

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A system of preferred terminology for naming disease processes is known as a

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medical nomenclature

question

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

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acute pancreatitis

question

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

answer

significant procedure

question

A data element you would expect to be collected in the MDS, but NOT in the UHDDS, would be

answer

Level of cognition

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In the # "07-0001" listed in a tumor registry accession register, what does the prefix "07" represent?

answer

The year the patient was entered into the database of the registry

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For continuity of care, ambulatory care providers are more likely than providers of ACS to rely on documentation found in the

answer

problem list

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A key item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record

answer

time and means of arrival

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Regional health information organization

answer

is intended to support health information exchange within a geographic region.

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The disease index

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is a listing in diagnostic code number order

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The physician index

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is a listing of cases in order by physician name or number

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MPI

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cross-references the patient name and medical record number.

question

Operation index

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Is a list of the medical record numbers of all patients who had operations performed in the past year at your acute care hospital.

question

The one document in your facility that will spell out the documentation requirements for patient records; designate the time frame for completion by the active medical staff; and indicate the penalties for failure to comply with these record standards is the

answer

medical staff rules and regulations

question

Patient Care Plan

answer

is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved

question

Federal Register

answer

CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register

question

This acute care facility has an approved cancer registry. A patient is readmitted for further treatment of a previously diagnosed cancer. The CTR should

answer

update the follow-up card/file

question

POMR

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database contains the history and physical; the problem list includes titles, numbers, and dates of problems and serves as a table of contents of the record; the initial plan describes diagnostic, therapeutic, and patient education plans; and the progress notes document the progress of the patient throughout the episode of care, summarized in a discharge summary or transfer note at the end of the stay.

question

MDS

answer

designed for use in long-term care facilities

question

COP

answer

set of regulations that health care institutions must follow to receive Medicare reimbursement

question

Federal Register

answer

daily government newspaper for publishing proposed & final rules of federal agencies

question

Uniform Hospital Discharge Data Set

answer

standard definitions for data commonly collected in acute care hospitals

question

The antepartum record

answer

should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history.

question

Health record signatures

answer

should be identified by a minimum of name and discipline, e.g., "J. Smith, P.T." Other types of authentication other than signature (such as written initials or computer entry) must be uniquely identifiable.

question

A qualitative review of surgical records would likely include checking for documentation regarding

answer

the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.

question

Discharge summary documentation must include

answer

significant findings during hospitalization

question

Joint Commission specifies that H&Ps must be completed

answer

within 24 hours

question

The Health Plan Employer Data and Information Set (HEDIS)

answer

Is a standardized set of performance measures designed to allow purchasers and consumers to compare the performance of managed care plans.

question

benchmarking

answer

The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality

question

Quantitative analysis

answer

involves checking for the presence or absence of necessary reports or signatures while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record

question

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the

answer

health information manager

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