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22 terms

RHIT Mock Exam Domain 1

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Which volume of ICD-9-C M contains the tabular and alphbetic list of procedures?
Volume 3
In a problem-oriented medical record, problems are organized?
In numeric order
A notation for a hypertensive patient is a physician ambulatory care progress note reads: "blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
Assessment
The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as carcinoma on the discharge summary. This is an example of a problem with?
Data Consistency
Which of the following promotes uniform reporting and statistical collection for medical procedures, supplies, products, and services?
Healthcare Common Procedure coding System
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
Complex
Fee schedules are updated by third-party payers?
Annually
Which of the following ICD-9-C M codes are always alphanumeric?
V Codes
What is the function of physician's orders?
Document the physician's instructions to other parties involved in providing care to a patient
Which of the following best describes data accessibility?
Data are easy to obtain
Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
Home Health
What term is used for retrospective cash payments paid by the patient for services rendered by a provider?
Fee-for-service
Diagnosis-related groups are organized into?
Major diagnostic categories
The National Correct Coding Initiative "NCCI" was developed to control improper coding leading to inappropriate payment for?
Part B Medicare claims
In processing a Medicare payment for outpatient radiology exams a hospital outpatient services department would receive payment under which of the following?
OASIS
A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is?
Continuity of care record
A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be?
Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis
The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?
Data Consistency
Which of the following in Not a characteristic of high-quality healthcare data?
Data accountability
To assign SNF residents to the appropriate resource utilization group data are collected using the?
MDS
Which of the following is a secondary purpose of the health record?
Support for research
The home health prospective payment system uses the OASIS data set for?
Patient Assessments