294 terms

CCS-P Review

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
Which of the following indexes is an important source of patient health record numbers?
MPI (Master patient index)
After the cases to be included in a registry have been determined, what is the next step in data axcquisition?
Case finding
What # is assigned to a case when it is first entered in a cancer registry?
Accession number
Which of the following acts mandated est. of the NPI data bank?
Health are Wuality Impovement Act of 1986
Which one of the following is NOT part of the NHCS?
The National Immunization Program Survey
What two databases produced by the Ntional Library of Medicine are of special interest to HIM professionals?
The Darling v. Charleston Memorial Hospital case resulted in
A hospital being found liiable for corporate negligence
Contract with CMS to carry out the HCQIP and other projects and functions assigned in Scopes of Work
A quality initiative under CMS and its contracted QI org. to collabroate on clinical QI projects
Guidelines for clinical practice can be found on the internet through provisions made by
National Guideline Clearinghouse
NCQA directs its evals. of quality to the services performed under the auspices of ___
Managed care plans
JCAHO requires hospitals and long-term care facilities to report outcomes for 20% of patients through a mechanism known as ___
Accreditation oby JCAHO means that the healthcare org. ____
Is considered to have met the Medicare Conditions of Participation
Subacute care
Level of skilled care needed by patients with complex medical conditions
Ownership of the physical health record rests with the ___
Hospital, facility, or physician who keeps the records of patients
The Privacy Rule est. that a patient has the right of access to inspect and obtain a copy of his or her PHI___
for as long as it is maintained
The Privacty Rule applies to ___
All covered entities involved, either directly or indirectly, with transmittingor performing any electronic transactions specified in the act
Under HIPAA, a patient does not have the right to access his or her___
Psychotherapy notes
The Privacy Rule specifies that an individual's request for a copy of their PHI mast be made within ___ days
Notices of privacy practices must be made available by
Posting it in a prominent place where it is reasonable to expect that the patients will read it.
Inmates in correctional institutions ____
Are afforded most privacy protections under HIPAA
Consents ____
Are for the purpose of permitting use and disclosure of PHI for treatment, payment, or operations
An individual may _
Revoke an authorization in writing
Business associate agreements are developed to cover the use of PHI by___
Organizations outisde the covered entity's workforce that uses PHI to perform functions for the covered entity
Release of birth and death info to public health authorities ___
Is a "public interest and benefit" disclosure that does not require patiient authorization
Patient authorization is required to release ____
PHI to the patient's attorney
All infected dialysis catheters are coded as 999.31, Infection due to central venous catheter.
Code 304.00, Opioid type dependence, unspecified, is the appropriate code assignment for patients who are heroin addicts and are being maintained on methadone.
It is appropriate to code unrelated incidental findings found on radiology reports during ED encounters.
Acute kidney failure is an acute exacerbation of chronic kidney failure.
When the provider documents "hypertensive urgency," it is appropriate to query the provider
regarding the specific type of hypertension.
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?
Which document would be excluded from the patient record for an elective inpatient surgery admission?
EMT care sheet
For a patient with a documented fracture and dislocation at the same anatomical site, which is coded?
fracture only
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:
third-degree burns.
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):
missile closed fracture
The ED final diagnosis is status post
cholecystectomy due to chronic cholelithiasis. The coder should:
Code chronic cholelithiasis as an active condition.
Intrathecal drugs are administered into:
Lipomas, fibromas, and adenomas are classified as:
1995 E/M coding guidelines for a comprehensive exam requires
8 organ systems and body areas
The classification of a patient into a Home Health Resource Group (HHRG) is based on info collected from the _____ data collection tool.
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:
late effect
Which of the following data sets is used by ambulatory care facilities?
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.
The placement of radioactive sources into a tumor-bearing area to generate high-intensity radiation is called:
ICD-9-CM code category 402 (Hypertensive Heart Disease), is reported for the diagnosis of:
Hypertensive cardiovascular disease with congestive heart failure
Which data set was designed to gather data about Medicare beneficiaries who receive home health services?
Which are the contributory components associated with evaluation and management system CPT codes?
Counseling, Coordination of Care, and the Nature of the Presenting Problem
Which is administered to a patient after exposure to a disease to help prevent the patient from becoming infected?
Wound repair that requires debridement and extensive undermining would be classified as:
intermediate repair
To correctly report a skin lesion removal, which information is reviewed in the patient record?
size of lesion
method of removal
lesion morphology
Which lesion would warrant Mohs Micrographic Surgery?
basal cell carcinoma
When discussing CPT category III codes, which statement below is false?
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.
Which modifier is not approved for use in ambulatory surgery units (ASU)?
Genetic testing code modifiers are located in of the CPT coding manual.
Appendix I
Cause of aplastic anemia
Bone marrow failure
Most common cause of dementia
Alzheimer's disease
CEA test is ordered for
Prevention of illness thru vaccination occurs due to the formation of
memory cells
three important plasma proteins
albumins, globulins and fibrinogen
blood plasma w/out the clotting factors is called_____.
the three formed elements of the blood are
WBCs, RBCs, and platelets
the red pigment in blood cells that carries oxygen is called:
if the body produces an excess of red blood cells, the condition is called:
which type os WBCs are the most numerous of the phagocytes?
________ found within the lymph nodes, they are phagocytes that destroy bacteria, cancer cells, and other foreign matter in the lymphatic stream
natural killer cells
A type of white blood cell that can kill tumor cells and virus-infected cells; an important component of innate immunity.
a regulating body substance released in excess during allergic reactions causing swelling and inflammation of tissues
chemicals released from cells that cause smooth muscle contraction and pain. stimulates nerves when something hurts
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
substance that triggers an immune response, any substance (as a toxin or enzyme) that stimulates the production of antibodies
a substance produced by the body that destroys or inactivates an antigen that has entered the body, protein that helps destroy pathogens
Blood Urea Nitrogen
Cystatin C
Kidney Disease
Total Protein
Liver Disease
Kidney Disease
Multiple Myeloma
Total Cholesterol
HDL Cholesterol
LDL Cholesterol
Heart disease
Prostate Specific
Antigen (PSA),
Antigen (CEA), CA-15
Cancer of the
prostate, colon,
PT/INR Ratio
(Coumadin) therapy
Red Blood Cell Count
White Blood Cell Count
Urinary infection,
Specific Gravity
Liver Disease
Kidney trauma or
infection; Kidney
Leukocytes, Nitrites
Bacterial infections
of urinary tract (UTI)
Kidney disease
Early stages of
kidney disease
A toxic goiter has what distinguishing characteristic?
thyroid hyperfunction
Which of the following is a congenital condition that is the most severe neural tube defect?
_____________ is usually the first symptom of benign prostate hyperplasia.
difficulty in urinating
Which of the following tubes conveys sperm from the seminal vesicle to the urethra
ejaculatory duct
Cervical cerclage is a procedure used to help prevent
Under APCs, payment status indicator "C" means
inpatient only services
Under APCs, payment status indicator "V" means
medical visits
The term used to describe a diagram depicting grouper logic in assigning MS-DRGs is
decision tree
This prospective payment system is for __________ and utilizes a patient assessment instrument (PAI) to classify patients into case mix groups (CMGs)
Inpatient rehab facilities
Under Medicare Part B, non-participating providers get paid
5% less than PAR providers
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.
Balance bill
Physician can balance bill and collect from the patient the difference between the nonPAR Medicare fee schedule amount and the total charge amount.
Under the APC methodology, discounted payments occur when
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.
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
Lifetime reserve days are
applicable for hospital inpatient stays which are payable under Medicare Part A.
A patient who is taking the drug Antivert may be diagnosed with
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
E codes and ICD-9-CM codes for this diagnosis
Standard Nomenclature of Athletic Injuries
Used to identify sports injuries. It has not been revised since 1976.
Code 402, Hypertensive Heart Disease would appropriately be used in which of the following situations?
Hypertensive cardiovascular disease with congestive heart failure
The term "hypertensive" indicates a
cause and effect relationship
Which of the following is a valid ICD-9-CM principal diagnosis code?
V30.00 Single live born, born in hospital
M codes and E codes
are never principal diagnosis codes and, in fact, are optional for coding.
A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. The correct code would be
410.1x Acute MI
An acute MI is considered
to be anything under 8 weeks' duration from the time of initial onset.
A chronic MI is considered
anything over 8 weeks with symptoms.
An old MI is considered
anything over 8 weeks with NO symptoms.
The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed
A system of preferred terminology for naming disease processes is known as a
medical nomenclature
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
acute pancreatitis
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
significant procedure
A data element you would expect to be collected in the MDS, but NOT in the UHDDS, would be
Level of cognition
In the # "07-0001" listed in a tumor registry accession register, what does the prefix "07" represent?
The year the patient was entered into the database of the registry
For continuity of care, ambulatory care providers are more likely than providers of ACS to rely on documentation found in the
problem list
A key item you would expect to find recorded on an ER record, but would probably NOT see in an acute care record
time and means of arrival
Regional health information organization
is intended to support health information exchange within a geographic region.
The disease index
is a listing in diagnostic code number order
The physician index
is a listing of cases in order by physician name or
cross-references the patient name and medical record number.
Operation index
Is a list of the medical record numbers of all patients who had operations performed in the past year at your acute care hospital.
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
medical staff rules and regulations
Patient Care Plan
is the foundation around which patient care is organized in long-term care facilities because it contains the unique perspective of each discipline involved
Federal Register
CMS publishes both proposed and final rules for the Conditions of Participation for hospitals in the daily Federal Register
This acute care facility has an approved cancer registry. A patient is readmitted for further treatment of a previously
diagnosed cancer. The CTR should
update the follow-up card/file
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.
designed for use in long-term care facilities
set of regulations that health care institutions must follow to receive Medicare reimbursement
Federal Register
daily government newspaper for publishing proposed & final rules of federal agencies
Uniform Hospital Discharge Data Set
standard definitions for data commonly collected in acute care hospitals
The antepartum record
should include a comprehensive history and physical exam on each OB patient visit with particular attention to menstrual and reproductive history.
Health record signatures
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.
A qualitative review of surgical records would likely include checking for documentation regarding
the presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed.
Discharge summary documentation must include
significant findings during hospitalization
Joint Commission specifies that H&Ps must be completed
within 24 hours
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.
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
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
In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper
documentation policies belongs to the
health information manager