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

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

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

Americal Medical Association

Define Status asthmaticus

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.

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

Level of cognition

Heart system transplant

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

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

(decreased levels of potassium in the blood)

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?

Assign the nlisted cde from the orresponding anatomical section

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

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).

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?

Physician index

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

required for reimbursement of certain patient groups

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?

Yes, prior to surgery

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

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

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:

Documented in both the progress notes and the discharge summary.

When is an Incident report written?

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.

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

Interdisciplinary patient care plan

COP requires a consultation report when

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.

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

accessibility of the record by multiple data users.

Problem list

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

A POMR contains what?

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.

R-ADT system contains

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


Registration-admission, discharge, and transfer system

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

CARF manual
(Commission on Accreditation of Rehab Facilities)

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

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

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

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

What is a technical method of protecting computerized data?

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

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

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

Regional health information organization

Are intended to support health information exchange within a geographic region

Medical staff rules and regulations

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.

Antepartum record contains

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

Biometrics-based identifier

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.

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

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

Most carbon dioxide is carried in the

Red blood cells

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


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

contaminated foods

Cancer derived from epithelial tissue is classified as a


Full-blown AIDS sets in as

helper T-cell concentration decreases

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


The most fatal type of lung cancer is

small cell cancer

Diastole occurs when

the ventricles fill

Gas exchange in the lungs takes place at the


A key diagnostic finding for typical pneumonia is

lung consolidation x-ray

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


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:

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

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


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

utilization review

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?

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

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

Darling v. Charleston Community Memorial Hospital

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


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?

qualitative review

qualitative review

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.

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

collect performance measure data that apply to the residents

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

AHIMA's Code of Ethics

HEDIS gathers data in the following area:

measures of quality (e.g. cholesterol screenings)


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.

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


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

duplicate record review.

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

doctrine of charitable immunity

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

coding compliance program that prevents fraudulent coding and billing

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.

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


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.

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

Lou Gehrig Disease

The cause of aplastic anemia is

bone marrow failure

Which one of the following cells produce antibodies

plasma cells

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


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

myasthenia gravis

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


Impetigo can

be caused by Streptococcus

Each of the following pertains to COPD EXCEPT


Which of the following is a lethal arrhythmia?

ventricular fibrillation

Portal hypertension can contribute to all of the following EXCEPT

kidney failure

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


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


A serum potassium level of 2.8 would indicate

diabetic ketoacidosis

The first stage of alcoholic liver disease is

Fatty liver

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

Hodgkin's disease

Ulcerations of the small intestine are characteristic of

Crohn disease

The most common rickettsial disease in the US is

Rocky Mountain spotted fever

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

ureteroscopy and stone basketing

Which of the following is an effect of insulin?

increases glucose metabolism

In general, excessive RBC breakdown could result in

high bilirubin levels

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

Small intestine

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?

Increased blood supply

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

being overweight

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

code only the comprehensive code

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

professional services, such as physician fees

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.

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.

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.

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.

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.


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

not already been assigned a medical record number

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

"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.

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

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

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.

medicare summary notice

"balance billing"

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

"PATH" guidelines primarily affect:

Residents and Physicians

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

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

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

Free grafts

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.

a) True

b) False

Which coronary artery has more branches than the others?

Left main coronary artery

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

a) 44.14
b) 86.11
c) 33.27


Collects a minimum set of data about inpatients


Collects data about ambulatory care patients


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


Gathers data about Medicare beneficiaries receiving home care

DEEDs data set

Collects data about hospital emergency encounters


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


Is associated with JCAHO


Establishes a plan for development of widespread interoperable EHR sysems.

What year did standardizing healthcare data begin?



Provides a foundation for understanding EHR functions


Develops standards


Standards for transmitting clinical documents such as discharge summaries


Best used to create a personal health record


Identifier standard


Should NOT be used as a unique patient identifier


Clinical representation standard

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


Medicaid eligibility standards are est. by

Individual states

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


These payment arrangements are streamlined by the use of chargemasters:


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


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

Prospective review

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:


Based on per-person premiums or membership fees:


Prospective payment system implemented in 1983:


Payment system for hospital-based outpatient services and procedures:


ASC rates are calculated on a:

Prospective basis

Congress enacted the first Medicare PPS in:


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

Fee-for-service reimbursement methodology

DRG prospective payment rate is based on the ____diagnosis.


DRGs are assigned by


______ hospitals are excluded from the Medicare acute care pps


DRGs are organized into _____

Case-mix classifications

_____ are assoc. with the Medicare fee schedule


_____ mandated the implementation of a SNF PPS.



are assoc. with the outpatient PPS

______ are not reimbursed according the OPPS.

Critical access hospitals


Discounting of procedures

Home health PPS uses the ____ data set for patient assessments


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 ____


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

April 1, 2001

Fee schedules are updated by third-party payers


To accept assignment means that the

Provider accepts as payment in full whatever the payer reimburses

A fee schedule is

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

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

Unit numbering system

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


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

Master patient Index

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

Physician index

Serves as the MPI function

Patient registration system

A chronological listing of data is called a


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