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Medical Nomenclature

answer

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

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Acute pancreatitis

answer

13) A pt was admitted with severe abd pain, elevated temp, & nausea. The phys exam indicated possible cholecystitis. Acute & chronic pancreatitis secondary to alcoholism was recorded on the face sheet as the final Dx. The principal Dx is:

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Read codes

answer

16) Which classification system was developed to standardize terminology and codes for use in clinical laboratories?

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Significant procedure

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18) 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:

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National Center for Health Statistics (NCHS)

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19) The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the:

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Logic-based encoder

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20) An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n):

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SNOMED CT

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21) Which of the following classification systems was designed with electronic systems in mind and is currently being used for problem lists, ICU monitoring, pt care assessments, data collection, medical research studies, clinical trials, disease surveillance, and image d?

question

National Library of Medicine

answer

22) The Unified Medical Language System (UMLS) is a project sponsored by the:

question

Small cell lung carcinoma

answer

23) A pt is adm w/ SOB & hemoptysis. A chest XR revealed patchy infiltrates in the L lung & poss pneumonia. On the 3rd day of hospitalization a bronchoscopy w/ biopsy was done which revealed a small cell carcinoma of the LU lobe of the lung. A metastatic lesion in the brain was detected. The principal Dx is the:

question

410.1x acute MI

answer

27) A pt is adm to the hosp 6 wks post myocardial infarction w/ severe chest pains. Which is the correct code?

question

v58.11 chemotherapy; 174.9 malignant neoplasm of breast

answer

28) Pt is status post mastectomy (6 wks) due to carcinoma of the breast. She is adm to the oPt clinic for chemo. What is the correct sequencing of the codes?

question

American Hospital Association

answer

34) The Central Office on ICD-9-CM, which publishes Coding Clinic, is maintained by the:

question

Commission on Cancer of the American College of Surgeons

answer

36) A cancer program is surveyed for approval by the:

question

ABC codes

answer

37) 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?

question

Centers for Medicare and Medicaid Services

answer

38) The Level II (national) codes of the HCPCS coding system are maintained by the:

question

pseudomonas

answer

40) A pt is adm w/ pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia? pseudomonas / clostridium / staphylococcus / listeria

question

American Medical Association

answer

41) The Level I (CPT) codes of the HCPCS coding system are maintained by the:

question

excision of lesion; full-thickness skin graft to flap

answer

42) A 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?

question

-53

answer

44) A pt develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that procedure was discontinued.

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poor quality of documentation

answer

45) A barrier to widespread use of automated code assignment is:

question

Inflammation of urethra due to indwelling catheter

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54) According it ICD-9-CM, which one of the following is NOT mechanical complication of an internal implant? a. erosion of skin by pacemaker electrodes b. Inflammation of urethra due to indwelling catheter c. leakage of breast prosthesis d. IUD embedded in uterine wall

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incidence-only population-based registry

answer

55) A population-based cancer registry that is designed to determine rates and trends in a defined population is a(n):

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document his findings in the patient's medical records

answer

59) In order to sue the inpatient CPT consultation codes, the consulting physician must:

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Birth Defects

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65) Case definition is important for ll types of registries. Age will certainly be an important criterion for accessing a case in a(n) _____ registry.

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the date when the collection began

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68) The reference date for a cancer registry is:

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trauma registry

answer

69) The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions; vital signs on admission; procedures and treatments prior to hospitalization; transport modality;and injury severity score. The hospital uses these data for its:

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use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records and hospital logs.

answer

70) In relation to birth defects registries, active surveillance systems;

question

Agency for Healthcare Research and Quality

answer

72) The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the:

question

donor site

answer

74) When coding free skin rafts, which of the following is NOT an essential item of data needed for accurate coding? recipient site / donor site / size of defect / type of repair

question

to describe emerging technologies

answer

75) In CPT, Category III codes include codes:

question

Transplant registry

answer

76) The information collected for your registry includes patient demographic info, dx codes, functional status, and histocompatibility info. This type of registry is a :

question

abnormal reaction of the body to the presence of an internal prosthetic device

answer

77) In the ICD-9-CM classification system, shooting pain in the right eye due to the presence of an intact, correctly positioned permanent contact lens would be coded as a(n)

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current injury

answer

78) In the ICD-9-CM classification system, severe shock due to third-degree burns sustained in an industrial accident would be coded as a(n)

question

late effect of an adverse reaction

answer

83) Blindness due to an allergic reaction to ampicillin administered 6 years ago would be reported as a(n)

question

single internal mammary artery bypass; aortocoronary bypass of three vessels, extracorporeal circulation

answer

84) The pt underwent bypass surgery for a life-threatening coronary artery disease. W/ the aid of extracorporeal circulation, the r internal mammary artery was taken down to the l anterior descending artery & saphenous vein grafts were brought from the aorta to the daigonal, the R coronary artery & the posterior descending artery. What is the correct ICD-9-CM coding for this procedure?

question

record-over-record method

answer

86) 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:

question

cancer registry

answer

87) The most common type of registry located in hospitals of all sizes and in every region of the country is the

question

site

answer

89) When coding neoplasms, topography means:

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monthly visits up to 36 weeks

answer

90) According to CPT, antepartum care includes all of the following EXCEPT

question

cancer registry abstracts

answer

91) 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:

question

clinical vocabulary

answer

92) A list or collection of clinical words or phrases with their meanings is a:

question

status asthmaticus

answer

94) A pt was disch from the acute care hosp w/ a final dx of bronchial asthma. As the coder reviews the record, she notes that the pt was described as having prolonged & intractable wheezing, airway obstruction that was not relieved by bronchodilators, & the lab values showed decr resp function. The coder queried the physician to determine whether the code for _____ is appropriate to be added to the final dx.

question

eating

answer

98) A PEG procedure wold most likely be done to facilitate:

question

Code 644.21, early onset of delivery; V27 code (outcome of delivery)

answer

99) What ICD-9-CM coding scheme is used to show that a therapeutic abortion resulted in a live fetus?

question

excision

answer

107) ICD-10-PCS utilizes the third character in the Medical and 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:

question

extraction

answer

108) In ICD-10-PCS, to code "removal of a thumbnail," the root operation would be:

question

Percutaneous Endoscopic Gastrostomy (PEG)

answer

A _____ is a safe and effective way to provide food, liquids and medications (when appropriate) directly into the stomach. The procedure is done for patients who are having difficulty swallowing.

RHIT PRG: Classification Systems & Secondary Data Sources Ch5 – Flashcards

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