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CCA PRACTICE QUESTIONS
Terms in this set (200)
Identify the diagnosis code(s) for carcinoma in situ of vocal cord
Identify the diagnosis code(s) for melanoma of skin right shoulder
Which of the following organizations is responsible for updating the procedure classification of ICD-10-PCS?
Centers for Medicare and Medicaid Services (CMS)
Coding accuracy is anticipated to improve due to which ICD-10-CM enhancement?
Expanded codes that capture more detail.
Which character in an ICD-10-CM diagnosis code provides information regarding encounter of care?
What does the fourth character of an ICD-10-CM diagnosis code capture?
ICD-10-CM codes must be a minimum length of how many characters?
To which of the following do notes appearing under a three-character code apply?
To all codes within that category
Which volume of ICD-10-CM contains the Tabular and Alphabetic Index of Procedures?
A. Volume 1, B. Volume 2, C. Volume 3, D. None of the above
None of the above
Identify the correct diagnosis code for lipoma of the face
Identify the correct diagnosis code(s) for adenoma of left adrenal cortex with Conn's syndrome.
Which of the following is a standard terminology used to code medical procedures and services?
Identify the appropriate ICD-10-CM diagnosis code for right cerebral contusion with 15 minute loss of consciousness, initial encounter for care.
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?
Diameter of the lesion as well as the most margins required to adequately excise the lesion described in the operative report
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. the sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage and products of conception are found. Which of the following should be the principal diagnosis?
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case?
Query the physician to determine if the patient has sepsis due to the symptomatology
A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reductionof the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the ling to the brain and undergoes radiant therapy to the brain. which of the following would be the principal diagnosis in this case?
Metastatic carcinoma of the brain
A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case?
Infectious gastroenteritis; chronic obstructive pulmonary disease; angina
A patient I admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay?
Metastatic carcinoma of the brain; history of carcinoma of the prostate
A patient is admitted with abdominal pain. The physician documents the discharge diagnosis as 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
According to the UHDDS, which of the following is the definition of "other diagnoses"?
Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring
A 7-year old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
Asthma with status asthmaticus
A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). the final diagnosis was "Rule out chest pain versus GERD." The correct ICD-10-CM code is :
R07.9 Chest pain, unspecified
A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Before billing, the pathology report returns with a diagnosis of basal cell carcinoma. which of the following actions should the coding professional do for claim submission?
Code basal cell carcinoma
An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-10-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.)
O65.4, 01967, 01968
Which of the following purpose and use goals does not apply to ICD-10-PCS?
Improved collection of data about nursing care
Which of the following is not a way that ICD-10-CM improves coding accuracy?
Increases cross referencing
To help clarify terms that currently have overlapping meaning, ICD-10-PCS has defined root operations. What is an example of the root operation of Excision?
When coding benign neoplasm of the breast, the section noted here directs the coder to:
D24 Benign neoplasm of the breast
Benign neoplasm of tissue of breast
Benign neoplasm of soft parts of breast
Fibroadenoma of breast
Adenofibrosis of breast (N60.2)
Benign cyst of breast (N60.-)
Benign mammary dysplasia (N60.-)
Benign neoplasm of skin of breast (D22.5, D23.5)
Fibrocystic disease of breast (N60.-)
Use category D24 for fibroadenoma of breast
A patient was discharged with the following diagnoses: Cerebral artery occlusion, hemiparesis, and hypertension. The aphasia resolved before the patient was discharged. Which. Of the following code assignments would be appropriate for this case?
G81.90 Hemiparesis affecting unspecified side
G81.91. Hemiparesis affecting right dominant side
G81.92 hemiparesis affecting left dominant side
G81.94. Hemiparesis affecting left nondominant side
I66.9 cerebral artery occlusion unspecified, without mention of cerebral infarction
I50.9. Congestive heart failure
I66.9, G81.90, R47.01, I10
A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure.. The patient undergoes incubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?
Congestive heart failure, respiratory failure, ventilator management
A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?
Hematuria; adverse reaction to Coumadin
A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute ST elevation (STEMI) inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Coumadin therapy and monitoring fort the atrial fibrillation continued at Hospital B. Using the codes listed here, what are the appropriate ICD-10-CM codes and sequencing for both hospitalizations?
I21.09 Myocardial infarction of anterior wall, initial
I21.19 Myocardial infarction of inferior wall, initial
I22.0 Myocardial infarction of anterolateral wall, subsequent
I22.1 Myocardial infarction of inferior wall, subsequent
I48.0 Paroxysmal atrial fibrillation
I48.2 Chronic atrial fibrillation
I48.91 Unspecified atrial fibrillation
R07.9 Chest pain, unspecified
021209W Aortocoronary bypass, Three sites from Aorta with Autologous Venous Tissue, Open Approach
Hospital A: I21.19, I48.91; Hospital B: I21.19, I48.91, 021209W
A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient?
A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
Catheter-associated urinary tract infection
Which of the following is a condition that arises during hospitalization?
A 65-year-old female was admitted to the hospital. She was diagnosed with sepsis secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?
Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment?
A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes an incision in the abdominal wall, and then the patient develops bradycardia. The surgeon does not indicate that it is a complication of the surgery. The operative site is closed without the repair of the hernia. Which is the correct code assignment?
K43.9, R00.1, Z53.09, 0WJF0ZZ
These codes are used to assign a diagnosis to a patient who is seeking health services but is not necessarily sick.
Patient was admitted through the emergency department following a fall from a ladder while painting an interior bathroom in his farmhouse. He had contusions of the scalp and face and a displaced open fracture of the anterior wall of the right acetabulum. the fracture site was excisionally debrided and the fracture was reduced by open procedure with an internal fixation device inserted. Which is the correct code assignment?
S32.411B, S000,3XA, S00.83XA, W11.XXXA, Y92.012, Y93.E9, Y99.8, 0QS404Z, 0QB40ZZ
Assign the correct CPT code for the following procedure: Reposition of the pacemaker electrode
Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an extensive destruction of penile lesion by laser.
Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. what modifier would a physician setting use with the evaluation and management code?
-24. Unrelated evaluation and management service by the same physician during a postoperative period
A patient is admitted to an acute-care hospital for alcohol abuse and uncomplicated alcohol withdrawal syndrome due to chronic alcoholism. His blood alcohol level on admission was 10 mg/100ml.
A 45-year-old female is admitted for blood loss anemia due to dysfunctional uterine bleeding.
Patient admitted with left senile cortical cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of synthetic intraocular lens, via percutaneous approach.
H25.012, E11.9, 08RK3JZ
A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension
J44.1, I12.9, N18.9
Patient arrived by ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle 3.0-cm superficial laceration of the left arm: 5.0-cm laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: X-ray of the ankle showed a bimalleolar ankle fracture that required closed manipulative reduction, intermediate suturing of the scalp, and simple suturing of the arm laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill.
27810, 12032, 12002
The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed.
Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure.
What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?
An encoder that takes a coder through a series of questions and choices is called a (n):
The patient was admitted with major depression current episode seve4e, recurrent. What is the correct ICD-10-CM diagnosis code assignment for this condition?
A 35-year-old male was admitted with heartburn that has not improved with over-the-counter medications. An esophagoscopy and closed esophageal biopsy at the upper esophagus was performed. the physician documented esophageal reflux with esophagitis as the final diagnosis based on pathological examination. Identify the correct diagnosis and procedure codes.
Patient with flank pain was admitted and found to have a calculus of the kidney. A Ureteroscopy with placement of bilateral ureteral stents was performed to expand the lumen so the stone could pass naturally. Assign the correct ICD-10-CM/PCS diagnosis and procedure codes.
A female patient is admitted for stress incontinence. A urethral suspension to reposition the urethra via open approach is performed. Assign the correct ICD-10-CM diagnosis and/or procedure codes.
Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. what is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?
Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code for assignment?
What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?
The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?
Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April.
The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting?
A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system?
Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
Diagnosis-related groups are organized into:
Major diagnostic categories
In processing a Medicare payment for outpatient radiology examinations, a hospital outpatient services department would receive payment under which of the following?
Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?
Critical access hospitals
Fee schedules are updated by third-party payers:
Which of the following would a health record technician use o perform the billing function for a physician's office?
When a provider accepts assignment, this means the:
Provider agrees to accept as payment in full the allowed charge from the fee schedule
A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
Counsel the coder and stop the practice immediately
Prospective payment systems were developed by the federal government to
Manage Medicare and Medicaid costs
Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary. Medicare will pay for:
The infusion procedure
The goal of coding compliance programs is to prevent
Accusations of fraud and abuse
Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement?
Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment.
If a patient's total outpatient bill is $500, and the patient's healthcare insurance plan pays 80% of the allowable charges, what is the amount owed by the patient?
In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services?
Prospectively precertify the necessity of inpatient services
The sum of a hospital's total relative DRG weights for a year was 15,192 and the hospital had 10,471 total discharges for the year. Given this information, what would be the hospital's case-mix index for that year?
In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures performed during the same operative session, which of the following would apply?
Discounting of procedures
A request for reconsideration of a denied claim for insurance coverage for healthcare services is called a(n):
A denial of a claim is possible for all of the following reasons except:
Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of the following except:
Clinical documentation in the discharge summary
The NCCI editing system used in processing OPPS claims is referred to as:
Outpatient code editor (OCE)
Denials of outpatient claims are often generated from all of the following edits except:
OCE (outpatient claims editor)
Timely and correct reimbursement is dependent on :
Solutions to address the problem of dirty claims include all of the following except:
Submitting paper claims
Which of the following is not an essential data element for a healthcare insurance claim?
The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather that the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost?
Value-based insurance design (VBID)benefit?
Effective October 16, 2003, under the Administrative Simplification Compliance section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) all healthcare providers must electronically submit claims to Medicare. Which is the electronic format for hospital technical fees?
What process determines how a claim will be reimbursed based on the insurance benefit?
When clean claims are submitted, they can be adjudicated in many ways through computer software automatically. Which statement is not one of the outcomes that can occur as part of auto-adjudication?
What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of practice, and the risk of malpractice?
What statement is not reflective of meeting medical necessity requirements?
A service provided solely for the convenience of the insured, the insured's family, or the provider
A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true?
Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments.
What system reimburses hospitals a predetermined amount for each Medicare inpatient admission?
Medicare defines fraud as :
Intentional deception or misrepresentation that results in an unauthorized benefit to an individual
Which governmental agency develops an annual work plan that delineates the specific target areas for Medicare that will be monitored in a given year?
Office of Inspector General (OIG)
What is one way that physicians can prevent or minimize potentially abusive or fraudulent activities?
Developing a compliance plan
The MS-DRG system creates a hospital's case mx-index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of ________ within that MS-DRG.
Under the Medicare hospital outpatient perspective payment systems (OPPS), services are paid according to :
A rate-per-service basis that varies according to the ambulatory payment classification (APC) group to which the service is assigned
Under the OPPS, on which code set is the APC system primarily based for outpatient procedures and services including devices, drugs, and other covered items?
Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion?
Health Information, Business Office, and Cardiac Department
Medicare's newest claims processing payment contract entities are referred to as:
Medicare administrative contractors (MACs)
Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff?
What is a guarantor?
The person responsible for the bill, such as a parent.
Which of the following elements is not a component of most patient records?
Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.
Identify where the following information would be found in the acute-care record: "CBC:WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."
Medical laboratory report
Identify where the following information would be found in the acute-care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degener ative changes of the lower thoracic spine."
The following is documented in an acute-care record:"HEENT: Reveals the tympanic membranes, nares and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." Where would this documentation be found?
The following is documented in an acute-care record:"Microscopic: Sections are of squamous mucosa with no atypia." Where would this documentation be found?
The following is documented in an acute-care record: :Admit to 3C. Diet: NPO. Meds: Compazine 10 mg IV Q 6 PRN." Where would this documentation be found?
The following is documented in an acute-care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." Where would this documentation be found?
The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." Where would this documentation be found?
The following is documented in an acute-care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." Where would this documentation be found?
The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." Where would this documentation be found?
Social work note
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is
Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for:
A notation for a diabetic patient in a physician progress note roads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet. "Which part of a POMR progress note would this notation be written?
A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." Which part of a POMR progress note would this notation be written?
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." Which part of a POMR progress note would this notation be written?
A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." Which part of a POMR progress note would this notation be written?
Reviewing the health record for missing signatures, missing medical reports and ensuring that all documents belong in the health record is an example of ____________ review.
Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
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?
Which of the following is an example of clinical data?
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?
Which of the following materials is not documented in an emergency care record?
Patient's complete medical history
Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure?
What is the defining characteristic of an integrated health record format?
Integrated health record components are arranged in strict chronological order
Which of the following represents documentation of the patient's current and past health status?
Which of the following contains the physician's finding based on an examination of the patient?
What is the function of a consultation report?
Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care
What is the function of physician's orders?
Document the physician's instructions to other parties involved in providing care to a patient.
Which type of patient care record includes documentation of a family bereavement period?
In a joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Administration on Aging (AOA), which program was released in 1995 to target fraud and abuse among healthcare providers?
Operation Restore Trust
All of the following should be part of the core areas of a coding compliance plan except:
Tracking length of stay
Common forms of fraud and abuse include all of the following except:
Refiling claims after denials
What is the primary use of the case-mix index?
Defines how a hospital compares to peers and whether the facility is at risk:
What resource can managers use to discover current, hot areas of compliance?
This is a program unveiled in 1998 by the OIG that encourages healthcare providers to report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs:
Voluntary Disclosure Program
What is the process used to transform text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination?
Using uniform terminology is a way to improve:
The __________ mandated the development of standards for electronic medical records.
Health Insurance Portability and Accountability Act (HIPAA) of 1996
Messaging standards for electronic data interchange in healthcare have been developed by:
What is the incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts?
Pay for performance and quality
A threat to data security is
Data security refers to
A record of all transactions in the computer system that is maintained and reviewed for unauthorized access is called a(n)?
Which of the following is a true statement about data stewardship?
HIM professionals have worked with many data stewardship issues for years.
Performance counseling usually begins with which of the following?
Informal counseling or verbal warning
A health information technician (HIT) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?
Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation
In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
Which of the following issues compliance program guidance?
HHS Office of Inspector General
The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment is called:
This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services:
The HIM department is planning to scan medical record documentation. the project includes the scanning of documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?
Which of the following laws created the Healthcare Integrity and Protection Data Bank?
Health Information Portability and Accountability Act
HIT professionals must have knowledge of:
Laws affecting the use of disclosure of health information
The HIPAA Privacy Rule:
Applies nationally to healthcare providers
An accounting of disclosures must include disclosures:
Made for public health reporting purposes
Notices of privacy practices must be available at the site where the individual is treated and:
Must be posted in a prominent place where it is reasonable to expect that patients will read them
Calling out patient names in a physician's office is :
An incidental disclosure
Which of the following is not an element of data quality?
The protection measures and tools for safeguarding information and information systems is a definition of:
Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:
A special webpage that offers secure access to data is called a(n)
One form of _________ uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals
One form of ______________ computer-assisted coding may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation
Which of the following tasks may not be performed in an electronic health record system?
Electronic systems used by nurses and physicians to document assessments and findings are called:
Electronic patient care charting
Data definition refers to:
Meaning of data
An encoder that is built using expert system techniques such as rule-based systems is a(n)
Good encoding software should include _____________ to ensure data quality
The key data element for linking data about an individual who is seen in a variety od care settings is the:
Unique patient identifier
Which of the following make data entry easier but may harm data quality?
Copy and paste
A transition technology used by many hospitals to increase access to medical record content is:
EDMS (electronic document management system)
This system will require the author to sign onto the system using a user ID and password to complete the entries made.
Electronic signature authentication
Coders will assign codes that have been selected into a computer program called a(n)__________________ to assign the patient's case to the correct group based on ICD-10-CM/PCS and/or CPT/HCPCS
What is the legal term used to define the protection of health information in a patient-provider relationship?
The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:
Spouse; adult child; parent; adult sibling
Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court?
Exceptions to the consent requirement include:
The term minimum necessary means that healthcare providers and other covered entities must limit use, access, and disclosure to the minimum necessary to:
Accomplish the intended purpose
A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to :
Request restrictions on certain uses and disclosures of PHI
Written or spoken permission to proceed with care is classified as
The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the:
Social security number
Is information from which personal characteristics have been stripped
Which of the following is not true of notices of privacy practices?
They must contain content that may not be changed
With regard to training in PHI policies and procedures, the following statement is true:
Every member of the covered entity's workforce must be trained
Which document directs an individual to bring originals or copies of records to court?
Subpoena duces tecum
To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within _________ days
The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?
Which of the following statements is false?
Consent for use and disclosure of information must be obtained from every patient.
Which of the following statements is not true about a business agreement?
It allows the business associate to maintain PHI indefinitely.
From the information provided, how many APCs would this patient have?
Billing # Status Indicator CPT APC
998323 V 99285-25 0612
998324 T 25500 0044
998325 X 72050 0261
998326 S 72128 0283
998327 S 70450 0283
If another status T procedure were performed, how much would the facility receive for the second status T procedure?
Billing # Status Indicator CPT APC
998323 V 99285-26 0612
998324 T 25500 0044
998325 X 72050 0261
998326 S 72128 0283
998327 S 70450 0283
Given the following information, which of the following statements is correct?
MCD TYPE MS-DRG title Weight
In each MS-DRG the geometric mean is lower than the arithmetic mean
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