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Gravity
Terms in this set (150)
Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions
in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record.
in the discharge summary.
in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record.
on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record.
in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record.
Johnston City was set upon by a swarm of killer bees. All 5,000 residents are at risk of a bee attack. If 25 residents were attacked by the bees, the incidence of bee attacks
is 5 in 5,000.
is 25 in 1,000.
cannot be determined at this time.
is 5 in 1,000.
is 5 in 1,000.
---
Incidence refers to the number of newly reported cases. An incident rate is the number of newly reported cases of a disease in a specified time period divided by the population at that time.
The quotient is then multiplied by a constant such as 1000 or 100,000.
Calculation:
25 / 5000 = 0.005
0.005 x 1000 = 5 per 1,000
RECORD COMPLETION INFORMATION FOR DECEMBER
INCOMPLETE RECORDS 604
-DELINQUENT RECORDS 304
-AVERAGE MONTHLY DISCHARGES
845
AVERAGE MONTHLY OPERATIVE PROCEDURES 526
DELINQUENT OPERATIVE REPORTS 14
Use the information provided in the table above to calculate the delinquent rate. The delinquent rate
is 50%.
is 71%.
is 36%.
cannot be determined.
is 36%
--
Number of Delinquent Records x 100/ Monthly Disharges
Calculation:
(304 / 845) = 0.35976 (x) 100 = 36%
A supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job
process.
detail.
description.
analysis.
description
A piece of objective data collected upon initial assessment of the patient is the
vital signs.
history of present illness.
chief complaint.
review of systems.
vital signs
---
vital signs are objective data that is collected during the initial assessment
Which of the following is considered a late effect regardless of time?
congenital defect
poisoning
nonhealing fracture
nonunion
nonunion
---
See the ICD-10-CM Official Guidelines 2018, Section 1. a. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second.
An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth, or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.
The purpose of CMS's National Correct Coding Initiative is to
teach coders how to unbundle codes.
increase fines and penalties for bundling services into comprehensive CPT codes.
restrict Medicare reimbursement to hospitals for ancillary services.
detect and prevent payment for improperly coded services.
detect and prevent payment for improperly coded services
---
CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims.
Which of the following scenarios identifies a pathologic fracture?
vertebral fracture with cord compression following a car accident
compression fracture of the skull after being hit with a baseball bat
compression fracture of the vertebrae as a result of bone metastasis
greenstick fracture secondary to fall from a bed
compression fracture of the vertebrae as a result of bone metastasis
----
A pathologic fracture is one caused by a diseased condition. In this case, the bone cancer is the underlying cause of the fracture.
The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered
appropriate provided it is limited to a few days.
an underutilization of the hospital's resources
the best utilization of the hospital's resources.
an inappropriate use of hospital resources.
an inappropriate use of hospital resources.
SAMPLE MS-DRG REPORT
MS-DRG IDENTIFIER
A-B-C-D
RELATIVE WEIGHT
1.234-3.122-2.165-5.118
NUMBER OF PATIENTS WITH THIS MS-DRGA
12-10-19-16
Based on the MS-DRG report above, what is the case-mix index for this facility?
0.2042
57
2.9658
11.639
2.9658
----
14.808 + 31.22 + 41.135 + 81.788 = 169.051
12 + 10 + 19 + 16 = 57
169.051 / 57 = 2.9658
--
The case-mix index is calculated by multiplying the volume of patients in each category by the DRG weight (e.g., 1.234 DRG weight x 12 patients) and then dividing the total Medicare Severity-Diagnosis Related Group (MS-DRG) relative weights by the total number of discharges for a group. Calculation:
1.234 x 12 = 14.808
3.122 x 10 = 31.22
2.165 x 19 = 41.135
5.118 x 16 = 81.888
A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of
adjudicus res.
stare decisis.
respondeat superior.
res ipsa loquitur.
respondeat superior
-
Respondeat superior means "let the master answer" for the actions of the servant—the doctrine of the "agency." Under the doctrine of respondeat superior, the courts hold employers responsible for the acts of their employees or agents that are acting within the scope of employment. For example, a hospital can be held responsible for the actions of a physical therapist while they are performing the aspects of their position.
Community Hospital Administration decided to change the number of adult and children beds from 300 to 375 effective on the first day in July. The total number of inpatient service days for adults and children for the year was 111,963. What was the percentage of occupancy rate for adults and children for the entire year?
91.0%
45.4%
90.8%
0.9%
90.8%
---
The percentage of occupancy is the occupancy rate that measures the percentage of beds that are occupied by inpatients in relation to the total number of beds within the facility for a specific period of time.
Occupancy Rate Formula:
Total Inpatient Service Day for a Period (x) 100 /Total Bed Count Days in a Period
Bed Count Days Formula:
Number of beds x Number of days in the period
Since the bed count changes, you must calculate the total bed count days for each period and then add them together.
Calculation:
111,963/(300 x 181) + *375x 184) = 0.98053 x 100 = 90.8%
You supervise five clerical employees who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for
250 square feet of space for your clerical staff.
350 square feet of space for your clerical staff.
200 square feet of space for your clerical staff.
300 square feet of space for your clerical staff.
300 square feet of space for your clerical staff.
---
Generally, allow 60 sq ft per employee. However, as time progresses, less area is being allotted for personal space.
The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that
the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues.
the IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary.
the Ethics Committee reviews ethics complaints, and the IRB focuses on developing policies and procedures.
the IRB focuses on patient care only, and the Ethics Committee addresses both patient care and business practices.
the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues.
---
The Institutional Review Board (IRB) is a committee established to protect the rights and welfare of human subjects involved in research activities. The ethics committee is a committee of the organization tasked with reviewing ethics violations and determining the course of action required to remedy the violations.
You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use
follow-up files.
patient index.
patient abstracts.
accession register.
accession register
--
When a case is first entered into the cancer registry, an accession number is assigned. The unique number is assigned to the patient (not the tumor). The accession number provides a unique identifier for the patient consisting of the year in which the patient was first seen at the reporting facility and the consecutive order in which the patient was abstracted. The first four numbers specify the year, and the last five numbers are the numeric order the patient was entered into the registry database. There is only one accession number per patient, per facility, and per lifetime. A patient's accession number is never reassigned.
Incomplete abortion complicated by excessive hemorrhage; dilation and curettage performed.
Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS.
D62
Acute posthemorrhagic anemia
O03.1
Delayed or excessive hemorrhage following incomplete spontaneous abortion
O03.6
Delayed or excessive hemorrhage following complete or unspecified spontaneous abortion
O03.4
Incomplete spontaneous abortion without complication
10D17ZZ
Extraction, retained products of conception, via natural opening
0UDB7ZZExtraction, endometrium, via natural opening
O03.6, 0UDB7ZZ
O03.1, 10D17ZZ
O03.1, D62, 0UDB7ZZ
O03.4, 10D17ZZ
O03.1, 10D17ZZ
---
O03 is reported for a spontaneous abortion. A spontaneous abortion may be complete or incomplete. The coding manual needs to be referenced for the assigning codes according to the types of complications.
A 4-year-old child had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition.
49496
Repair initial inguinal hernia full-term infant, under age 6 months, or preterm infant over 50 weeks' post conception age and under 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated
49501Repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or strangulated
49521Repair recurrent inguinal hernia, any age; incarcerated or strangulated
49553Repair initial femoral hernia, any age; incarcerated or strangulated
49521
49501
49496
49553
49501
A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section?
confirmatory consultations, new or established patient
office or other outpatient consultations, new or established patient
office and other outpatient services, established patient
office and other outpatient services, new patient
office and other outpatient services, established patient
----
office and other outpatient services, established patient
--
Consultation codes can no longer be coded when the physician has taken an active part in the continued care of the patient. Under a referral, the care of the patient is passed by the referring physician to the provider to whom he or she is referred. In contrast, consultants provide an opinion and then return the patient to the requesting doctor's care.
You are the office manager at a large group practice. One of the physicians at your practice has asked you to research and supply her with information about Medicare's newest payment incentives and how to comply with the quality reporting requirements. You will bring this inquisitive physician facts from CMS regarding
Stage 2 of meaningful use requirements
diagnosis related groups (DRGs)
Merit-based Incentive Payment System (MIPS)
Physician Quality Reporting System (PQRS)
Merit-based Incentive Payment System (MIPS)
---
The Merit-Based Incentive Payment System (MIPS) is one of two tracks under the Quality Payment Program, which moves Medicare Part B providers to a performance-based payment system. MIPS streamlines three historical Medicare programs—the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) Program, and the Medicare Electronic Health Record (EHR) Incentive Program ( Meaningful Use)—into a single payment program. All Medicare Part B providers who meet the definition of a MIPS Eligible Clinician should plan to participate in MIPS in 2017, or they will be subject to a negative 4% payment adjustment on Medicare Part B reimbursements in 2019.
In a research study that includes a patient questionnaire, five of the questions will be answered using the following scale:
1 Strongly disagree
2 Disagree
3 No opinion
4 Agree
5 Strongly agree
The data collected using this scale are commonly referred to as
nominal data.
ordinal data.
continuous data.
cardinal data.
ordinal data.
---
Ordinal data ranks from lowest to highest according to a criterion. Ordinal data can include responses to questionnaires or interviews. The number assigned to each rank does not necessarily indicate an equal difference between each category
A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to
contact the patient's attending physician before complying.
comply with the request immediately.
ignore the request and to advise you if it is repeated.
ask the patient to send the required fee prior to the release.
contact the patient's attending physician before complying
The census taken at midnight on January 1 showed 99 patients remaining in the hospital. On January 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on January 2?
97
95
96
94
97
---
An inpatient service day is a unit of measure denoting the services received by one inpatient in one 24-hour period or any portion of that 24-hour period. The 24-hour period is the time between the census-taking hours on two successive days. One unit of one service day is not usually divided or reported as a fraction of a day. The day of admission is counted as an inpatient service day but the day of discharge is not. Therefore, no patient admitted to an inpatient unit can have a zero-service day stay.
Calculation:
Patients at midnight 8/1
99
Admissions
+4
Discharges
-7
In and out same day
+1
Inpatient service days 8/2
97
You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The system you are likely referencing is
RUGS.
MS-DRG.
IPPS.
RBRVS.
RBRVS
(Resource-Based Relative Value Scale)
---
The resource-based relative value scale (RBRVS) is a scale of national uniform relative values for all physicians' services in outpatient settings.
IPPS: Inpatient Prospective Payment System
MS-DRG: Medicare Severity-Diagnosis Related Group (utilized in acute care settings)
RUGS: Resource Utilization Groups (utilized in skilled nursing facilities)
In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to quality review committees within the hospital. In this case, the PHI is being used as part of the facility's
treatment.
documentation improvement plan.
health care operations.
payment.
health care operations
---
The HIPAA Privacy Rule allows covered entities to use and disclose protected health information for the purpose of treatment, payments, or health care operations.
You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time?
D
A
S
P
P
--
The PDSA cycle is a process for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). It is a four-step cycle that allows you to implement change, solve problems, and continuously improve processes. Its cyclical nature allows it to be utilized in a continuous manner for ongoing improvement. The planning step usually takes the most amount of time.
Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for
Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission.
Jackson, who had no comorbidities or complications during this admission for replacement of a pacemaker battery.
Fieldstone, who was admitted for 5 days following a heart attack for the acute onset of chest pain.
Howard, who died within 24 hours after his admission for a second heart attack in 2 weeks.
Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission.
The coder works 7.5 hours per day. If a time standard is determined from sample observations to be 2.50 minutes per record for coding emergency room records, what is the daily standard for the number of records coded when a 15% fatigue factor is allowed?
180 records per day
200 records per day
192 records per day
153 records per day
153 records per day
---
Calculation:7.5 hours x 60 minutes per hour = 450 minutes per day450 x 15% = 67.5450 − 67.5 = 382.5382.5/2.5 = 153
TYPE OF MATERIAL
NUMBER SCANNED
NUMBER INDEXING ERRORS
CONSULTATION REPORTS 2,879 431
LAB SLIPS 15,242 458
CORRESPONDENCE 1,426 114
OTHER 6,271 313
Referring to the data collected on scanning errors above, if you want to work on the type of material with the highest volume, you will work on problems with
other.
lab slips.
consultation reports.
correspondence.
lab slips
An established patient was seen by the physician in the office for DTaP vaccine and Hib.
90471
Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular injections); one vaccine (single or combination vaccine/toxoid)
90700
Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
90748
Hepatitis B and Hemophilus influenza B vaccine (HepB-Hib), for intramuscular use
99211
Office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
90471, 90748
90700, 90748, 99211
90700
90748, 90471
90471, 90748
--
If the immunization is the only service that the patient receives, then two codes are used to report the service. The immunization administration code is first and then the code for the vaccine/toxoid.
Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA Privacy Rules?
Do not honor because the authorization is invalid.
Contact the patient to get permission to respond.
Honor the authorization since the patient obviously approves of the release.
Contact the attending physician for permission to respond.
Do not honor because the authorization is invalid.
--
Once an expiration date has passed on an authorization, it becomes invalid.
A clerk's work performance has diminished dramatically during the past 2 weeks. The supervisor initiates a discussion with the clerk, during which the clerk reveals that he recently accepted that he has an alcohol addiction. The clerk states an intention to quit drinking completely. The supervisor should
suspend the clerk if alcohol has diminished the clerk's job performance.
give the clerk a leave of absence until these problems can be resolved.
terminate the clerk if it can be proved that alcohol was used on the job.
refer the clerk to the facility's employee assistance program.
refer the clerk to the facility's employee assistance program.
---
An employee assistance program is an employee benefit program that assists employees with personal problems and/or work-related problems that may impact their job performance, health, mental, and emotional well-being.
Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr. Jones approves a two-night leave of absence (LOA). Fred stays one more week before final discharge. How will this affect the hospital's statistics for the period when Fred was hospitalized?
Fred's LOA will positively impact the percentage of bed occupancy for the period.
Fred's LOA will decrease his total discharge days.
Fred's LOA will not negatively impact his total discharge days.
Fred's LOA will increase the daily inpatient census counts.
Fred's LOA will not negatively impact his total discharge days.
--
Leave of absence days are not counted during the concurrent tallies of census or inpatient service days on the dates of the leave; however, the total discharge days will be computed retrospectively from formal admission to formal discharge, disregarding the days when Fred was on leave.
As a new HIM manager, you recognize that employee development is a necessary investment for the long-term survival and growth of the organization. Your goal is to design and implement a staff development program for your employees, so one of your first steps is to
survey the HIM employees to assess their need for new skills or knowledge.
implement training programs that emphasize teamwork.
establish a budget for all hospital employee training.
establish HIPAA training programs hospital-wide.
survey the HIM employees to assess their need for new skills or knowledge
---
The first step in developing a training program is to perform a needs analysis to determine the deficiencies in knowledge and skills between the desired level and the current level of each employee.
A patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of
47 days.
48 days.
46 days.
45 days.
47 days
----
Calculation:
31 (Days in January) - 14 (Day of admission) + 28 (Days in February) + 2 (Days in March) = 47 days
Which of the following is coded as an adverse effect in ICD-10-CM?
nonfunctioning pacemaker due to defective soldering
mental retardation due to intracranial abscess
rejection of transplanted kidney
tinnitus due to allergic reaction after administration of eardrops
tinnitus due to allergic reaction after administration of eardrops
---
An allergic reaction is an adverse effect to medication properly administered.
The file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. There are a total of 4,500 records in the main file. What is the area's accuracy rate?
10.0%
88.9%
8.9%
1.1%
88.9%
---
Formula:
Number of records filed correctly (x) 100 / Number of records filed
Calculation:
400 / 450 = 0.888888 x 100 = 88.9%
An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done?
Both patients can be treated under implied consent.
Nothing, until consent can be obtained from the nearest relative.
The hospital should quickly seek a court-appointed guardian for the child.
The mother can be treated under implied consent but not the child.
Both patients can be treated under implied consent
A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus?
"Y"
"N"
"W"
"U"
"N"
--
Y
Diagnosis was present at time of inpatient admission.
Payment is made for condition when a HAC is present.
N
Diagnosis was not present at time of inpatient admission.
No payment is made for condition when a HAC is present.
U
Documentation insufficient to determine if condition was present at the time of inpatient admission.
No payment is made for condition when a HAC is present.
W
Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission.
Payment is made for condition when a HAC is present.
Sunset Beach Clinic allows patients to communicate by email to ask questions regarding their treatment and request appointment changes. Emails and text messages are
considered proof of patient contact and should be summarized in a progress note in the patient record.
considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters.
generally maintained in a facility's electronic mail system until the next face-to-face patient encounter.
not typically maintained or documented as patient encounters.
considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters.
---
Best practice for handling a patient's email and/or text questions is to treat the information as protected health information and to apply the same security safeguards as other PHI.
You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to
implement your QI process.
improve your department's processes.
compare your department with another.
make recommendations for improvement.
improve your department's processes.
---
Benchmarking involves comparing your department to other departments or organizations known to be excellent in one or more areas. The success of benchmarking involves finding out how the other department functions and then incorporating their ideas into your department.
The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information, you will consult the
hospital's Quality Management Plan.
hospital bylaws, rules, and regulations.
policy and procedure manual.
data dictionary.
hospital bylaws, rules, and regulations
--
Accreditation standards require a hospital's staff bylaws, rules, and regulations to address who is authorized to accept verbal orders.
You are the Director of Coding and Billing at a large group practice. The practice manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt Promoting Interoperability (formerly Meaningful Use) technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that in 2015, sanctions for noncompliance began to appear in the form of
a mandatory action plan for implementing a meaningful use EHR.
withdrawal of permission to treat Medicare and Medicaid patients.
downward adjustments to Medicare reimbursement.
monetary fines up to $100,000.
downward adjustments to Medicare reimbursement
---
EHR incentive program penalties will apply specifically to Medicare eligible professionals (EPs) who do not demonstrate and attest to Promoting Interoperability (formerly Meaningful Use). However, Medicaid EPs who see patients under the Medicare Physician Fee Schedule (PFS) are also subject to a payment reduction.
Which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned?
low forceps
episiotomy
single live-born
occiput presentation
low forceps
Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of stay for the year, can you calculate the annual bed turnover rate? How?
Yes, using the direct method.
No, there is insufficient data to complete the calculation.
Yes, using the indirect method.
Yes, using the basic rate method.
No, there is insufficient data to complete the calculation
--
When a hospital's bed count changes during a period under consideration, the indirect formula for bed turnover rate must be used; however, this formula requires bed occupancy data for the period which is not provided.
A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist.
77263
Therapeutic radiology treatment planning; complex
77290Therapeutic radiology simulation-aided field setting; complex
77315
Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)
77334Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds, or casts)
77334
77290
77263
77315
77263
Office visit for 43-year-old male, new patient, with no complaints. Patient is applying for life insurance and requests a physical examination. A detailed health and family history was obtained and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected.
99381
Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; infant (age under 1 year)
99386
Initial comprehensive preventive medicine evaluation and management of an individual including a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 40-64 years
99396
Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 40-64 years
99450
Basic life and/or disability examination that includes completion of a medical history following a life insurance pro forma
99381
99450
99396
99386
99450
---
The codes in this subsection are used to report evaluations for life or disability insurance baseline information
TYPE OF MATERIAL
NUMBER SCANNED
NUMBER INDEXING ERRORS
CONSULTATION REPORTS
2,879 431
LAB SLIPS 15,242 458
CORRESPONDENCE 1,426 114
OTHER 6,271 313
Referring to the data collected on scanning errors above, if you want to begin with the type of material that has the highest error rate, you will start by working on problems with
correspondence.
other.
lab slips.
consultation reports.
consultation reports.
---
Formula:
The Number of Times the Error Occured (x)100 / The Numer of Times the Error Could Have Occured (Number of Reports)
Calculations:
431 / 2,879 = 0.14970 x 100 = 14.97%
458 / 15,242 = 0.03004855 = 3%
114 / 1,426 = 0.079943 x 100 = 8%
313 / 6,271 = 0.0499122 = 5%
The highest percentage of error is in consultation reports.
A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be
check sheet.
flowchart.
force field analysis.
decision matrix.
check sheet.
-
A checksheet is a data collection tool permitting the recording and compiling of observations or occurrences. It consists of a simple listing of categories, issues, or observations on the left side of the chart and a place on the right for individuals to record checkmarks next to the item when it is observed or counted.
If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level
only the acute condition should be coded.
only the chronic condition should be coded.
they should both be coded, acute sequenced first.
they should both be coded, chronic sequenced first.
they should both be coded, acute sequenced first
As the information security officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. Which of the following would you provide?
proof of organizational firewalls
acceptable policies regarding workstation use and location
audit controls
chain-of-trust partner agreements
acceptable policies regarding workstation use and location
---
The Security Rule defines physical safeguards as "physical measures, policies, and procedures to protect a covered entity's electronic information systems and related buildings and equipment from natural and environmental hazards and unauthorized intrusions.
Physical safeguards include measures that affect facility access control or workstation use such as automatic log offs and the use of privacy screens.
MMBC receives the best reimbursement for well-child visits fromMake Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. Data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below.
Table 1 Well Child Visits.
INSURANCE COMPANY
NUMBER OF WELL CHILD
VISITS
REIMBURSEMENT FROM PAYER
Lifecare 259 $31,196.55
Getwell 786 $100,859.52
SureHealth 462 $54,631.50
BeHealthy 219 $26,991.75
Table 2 Immunizations
INSURANCE COMPANY
NUMBER OF IMMUNIZATIONS
TOTAL REIMBURSEMENT FROM PAYER
Lifecare 412 $2,175.36
Getwell 1,465 $9,053.70
SureHealth 609 $3,580.92
BeHealthy 417 $2,118.36
MMBC receives the best reimbursement for well-child visits from
Getwell.
SureHealth.
Lifecare.
BeHealthy.
Getwell.
Patient was seen for excision of two interdigital neuromas from the left foot.
28080
Excision, interdigital (Morton) neuroma, single, each
64774Excision of neuroma; cutaneous nerve, surgically identifiable
64776Excision of neuroma; digital nerve, one or both, same digit
28080, 28080
64774
28080
64776
28080, 28080
---
Look up in CPT codebook index under foot, neuroma.
Your HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report?
>12 months12-24 months25-37 months38-50 months<51 months
0-2 years3-4 years5 years
0-1 year1-2 years2-3 years3-4 years4-5 years
<12 months12-24 months25-37 months38-50 months51-63 months
<12 months12-24 months25-37 months38-50 months51-63 months
The correspondence section of your department receives an average of 50 requests per day for release of information. It takes an average of 30 minutes to fulfill each request. Using 6.5 productive hours per day as your standard, calculate the staffing needs for the correspondence section
3 FTE
2.5 FTE
4 FTE
3.5 FTE
4 FTE
---
Calculation: 50 x 30 = 1,5001,500/60 = 2525/6.5 = 3.8Round up to 4.
A quantitative drug assay was performed for a patient to determine digoxin level.
80050General health panel80101Drug screen, qualitative; single drug class method (e.g., immunoassay and enzyme assay), each drug class80162Digoxin (therapeutic drug assay, quantitative examination)80166Doxepin (therapeutic drug assay, quantitative examination)
80166
80162
80101
80050
80162
----
A quantitative drug assay was performed for a patient to determine digoxin level would be coded to 80162.
A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records?
the patient's parent or legal guardian
the patient's wife
the patient
either of the patient's parents
the patient
You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM-5 for billing purposes. You find this "theoretically" reasonable because DSM-5
is a widely used system for coding injury in ambulatory care systems.
codes are also valid CPT codes.
codes are also valid ICD-10-CM codes.
is the industry standard for psychiatric billing systems.
codes are also valid ICD-10-CM codes.
---
DSM-5 standardizes the clinician's diagnostic process for patients with mental disorder. The codes incorporated into the classification are ICD-10-CM.
The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training.
This level of involvement is enough to meet Joint Commission standards.
If you can talk him into training his staff, you can let him skip the training.
The Joint Commission only expects involvement from clinical staff.
This will not do because it violates Joint Commission standards and CQI philosophy.
This will not do because it violates Joint Commission standards and CQI philosophy.
The MS-DRG weight in a particular case is 2.0671 and the hospital's payment rate is $3,027. How much would the hospital receive as reimbursement in this case?
$3,027.00
$5,094.10
$960.00
$6,257.11
$6,257.11
---
A Medicare Severity-Diagnosis Related Group (MS-DRG) is a system of classifying a Medicare patient's hospital stay into various groups in order to facilitate payment of services.
Formula:
DRG relative weight x hospital base rate
Calculation:
2.0671 x 3,027 = 6,257.11
The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign
a code for the patient's symptoms.
a code for an impending myocardial infarction.
a code for a myocardial infarction.
no code for this condition.
a code for a myocardial infarction.
---
When a diagnosis is preceded by the phrase "rule out" in the inpatient setting, code the condition as a present diagnosis for that visit.
In preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be
the available options for inactive records.
the average readmission rate for the facility.
the statute of limitations in your state.
best practice standards.
the statute of limitations in your state.
--
Although readmission rates, best practice guidelines, and record archival options may affect the retention period for a facility, the minimum retention period will be mandated by the length of time a patient may bring a lawsuit against the facility.
ORYX is a program that was developed by
CMS to track Medicare costs.
NIH to track communicable diseases.
AMA to allow for rapid CPT updates.
Joint Commission to link patient outcomes to accreditation.
Joint Commission to link patient outcomes to accreditation.
---
ORYX is the Joint Commissions performance measurement and improvement tool. ORYX for hospitals is known as the National Hospital Quality Measures, and requires hospitals to collect and transmit data on key patient care, treatment, and service issues.
Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker.
00530
Anesthesia for permanent transvenous pacemaker insertion
00560
Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator
33202
Insertion of epicardial electrode(s); open incision
33206
Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial
00560
33206, 00560
33202, 00530
00530
00530
As a coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with
the FDA.
the Office for Civil Rights.
the Recovery Audit Contractor.
the Office of the Surgeon General.
the Recovery Audit Contractor.
---
The Recovery Audit Contractor (RAC) program is a government program with a goal of identifying improper payments on claims of health care services already provided to Medicare beneficiaries. The medical reviews consist of the Medicare contractors collecting information and performing a review to determine whether Medicare's coverage, coding, and medical necessity requirements are met.
An HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is
0.9%.
11%.
$265.
$2,655.
11%.
---
A budget variance is the difference between the budgeted amount and the amount actually spent. To determine the percent variance, subtract the budgeted amount from the actual amount and then divide the difference by the budgeted amount.
Calculation:
25,000 - 22,345 = 2,655
2,655 / 25,000 = 0.1062 x 100 = 10.62%, rounds to 11%
Record #
Patient Last Name
Date of Birth
Date of Servics
32-15-65 Smith 02/03/76 -03/20/2016
02-45-77 Cook 09/12/86- 10/21/2016
10-88-48 Baker 01/23/24 -11/14/2016
Which of the following is the unique identifier in the database illustrated in the table above?
record number
patient's last name
date of birth
date of service
record number
CDI programs have been traditionally measured by financial data from DRG shifts and the shift in the organization's case-mix index. As CDI has grown, additional measures of success have been utilized. Which of the following items is not a measure of success for a CDI program?
Claims denials
Reduction of coding queries
Patient safety indicators and hospital-acquired infections
Bed occupancy rate
Bed occupancy rate
---
Trending denial rates and query rates over time is another method of demonstrating the effectiveness of a Clinical Doumentation Improvement (CDI) program. Many CDI programs report a reduction in claims denials and physician queries due to the proactive collaboration of CDI and physicians for accurate and complete documentation. Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality (AHRQ) to reflect quality of care by measuring potentially avoidable in-hospital complications and adverse events. CDI programs need to be on the lookout for certain PSIs that are used to measure a facility's quality scores and help ensure hospital-acquired conditions and their related present on admission (POA) indicators are reported correctly.
A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n)
educator.
reviewer.
ambassador.
analyst.
analyst.
---
The CDS professional may act as a reviewer and educator, but the duties described are most representative of his or her role as an analyst. Ambassador is a distractor. A CDI analyst conduct ongoing analyses of clinical documentation while providing extensive collaboration with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.
Record #
Patient Last Name
Date of Birth
Date of Service
32-15-65 Smith 02/03/76 -03/20/2016
02-45-77 Cook 09/12/86
-10/21/2016
10-88-48 Baker 01/23/24 -11/14/2016
Which means of data modeling is illustrated in the table shown above?
object-oriented model
entity-relationship model
relational data model
data management model
relational data model
Which of these conditions are always considered "present on admission" (POA)?
possible, probable, or suspected conditions
E codes
acute conditions
congenital conditions
congenital conditions
As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee-for-Service program. You will need to develop a professional relationship with
the OIG.
recovery audit contractors.
QIO physicians.
MEDPAR representatives.
recovery audit contractors
---
The recovery audit contractor program is a government program with a goal of identifying improper payments on claims of health care services already provided to Medicare beneficiaries.
All providers, including home health and hospice providers, may be subject to claims review by a RAC. The medical reviews consist of the Medicare contractors collecting information and performing a review to determine whether Medicare's coverage, coding, and medical necessity requirements are met.
A common goal of the Office of the National Coordinator for Health Information Technology, HIEs, and a national infrastructure for information is
transferring health information within a hospital system.
sharing information among providers.
translating images into a digital format.
promoting telemedicine.
sharing information among providers
---
The ONC's mission involves many aspects of health information technology (HIT), including policy coordination, strategic planning for the adoption of health IT and health information exchanges (HIE), establishing governance for the Nationwide Health Information Network, and, above all, promoting a national health IT infrastructure.
Your hospital takes advantage of the 8/80 exemption for health care facilities. Assuming that no employee worked more than 8 hours in a day, which of the employees listed in the table below will be paid overtime this pay period? (it had a chart)
Employees 101, 103, 104, and 105
Employees 101 and 105
Employees 101, 104, and 105
Employees 101, 102, and 105
Employees 101 and 105
---
The 8/80 exception allows employers to pay one and one-half times the employee's regular rate for all hours worked in excess of 8 in a workday and 80 in a 14-day period. Although employees 103 and 104 worked more hours than scheduled, they still did not work overtime using the 8/80 rules.
Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the
Coding Clinic.
Federal Register.
UHDDS.
CMS Coding Guidelines.
UHDDS.
---
The Uniform Hospital Discharge Data Set (UHDDS) is a required data set for acute care facilities. This data set gives specific definitions of principal diagnosis and secondary diagnoses that must be followed when sequencing codes. The purpose of the UHDDS is to improve uniformity and comparability of data.
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes.
I66.9
Occlusion and stenosis of unspecified cerebral artery
K80.10Chronic cholecystitis with chronic cholelithiasis without obstruction
Z53.09
Procedure and treatment not carried out because of other contraindication
I97.821
Postprocedural cerebrovascular infarction during other surgery
0FT40ZZ
Resection of gallbladder, open approach (cholecystectomy)
I97.821, K80.10, 0FT40ZZ
K80.10, I66.9, Z53.09
I97.821, I66.9, Z53.09
I66.9, Z53.09
K80.10, I66.9, Z53.09
A number of key elements for your facility's electronic patient record are still input by clerical staff from handwritten data entry sheets. You are concerned about the transfer of data. If the vital signs stored in the database are not what were originally recorded, the impact on patient care could be severe. You are concerned about the
validity of the data.
stability of the data.
granularity of the data.
timeliness of the data.
validity of the data.
---
Validity refers to the credibility of the data.There is concern of the validity because of the transfer of data.
The Systems Development Life Cycle (SDLC) consists of four primary phases. Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of which phase?
Planning and Analysis
Design
Implementation
Maintenance and Evaluation
Maintenance and Evaluation
--
Maintenance and Evaluation: This phase focuses on responding to identified problems and concerns and the ongoing maintenance of the system.
---
Planning and Analysis: In this phase the organization first defines the goals and scope of the project. The focus on this phase is on defining the organization's business problem and the resources that may be needed to develop the project, along with an in-depth assessment of user needs and functional requirements.
Design: During this phase the system goals, project objectives and scope, determination and prioritization of system requirements, screening for vendors, development of an RFI or RFP, evaluation of vendors, and contract negotiations are completed.
Implementation: Implementation and training occur in this phase.
Annual costs for the only Release of Information Clerk at Jacksonville Beach Healthcare Center (salary and benefits) are $36,429. The monthly cost for the copier used solely for ROI is $89 (supplies and repairs). It costs the department $0.95 on average for ROI mailings (envelopes and postage). There were 687 requests filled for ROI last month. The cost per request for release of information last month was
$4.42.
$5.50.
$4.63.
$4.55.
$5.50
--
Calculations:• $36,429 annual labor costs / 12 = $3,035.75 cost per month• $3,035.75 + $89 copier cost = $3,124.75 monthly costs/687• ROI last month = 4.548 or $4.55 unit cost (not counting mailing)• $4.55 + 0.95 average mailing cost = $5.50 per ROI
An Electronic Document Management Systems (EDMS) allows you to digitize paper patient records so that they can be viewed within the EHR or in a separate viewing platform. Documents are scanned in to the EDMS and indexing is completed through recognitions systems. Which of the following recognition systems utilizes artificial intelligence to allow the system to "learn" the form type through the handwriting or information on the form?
OCR
IWR
ICR
OMR
IWR
---
Intellegent Word Recognition (IWR) allows for the recognition of unconstrained handwritten words.
--
Intelligent Character Recognition (ICR) is an advanced form of OCR in which the system "learns through artificial intelligence or artificial neural networks. Optical Mark Recognition (OMR) is the oldest form of optical recognition and requires pre-printed forms to contain locations for marking specific, limited information that is then read by a scanning system, and the content is incorporated into the EDMS. Optical Character Recognition (OCR) is the scanning of printed or type written text in structured locations on forms into machine-editable text.
The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to
allow school officials to authorize immunization disclosures on behalf of a child attending their school.
allow the minor to authorize the disclosure of the proof of immunization to the school.
simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
require written authorization from a custodial parent before disclosing proof of the child's immunization to the school.
simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.
An effective means of protecting the security of electronic health information would be to
write detailed procedures for the entry of data into the computerized information system.
develop clear policies on data security that are supported by the top management of the facility.
require all facility employees to change their passwords at least once a month.
install a system that would require fingerprint scanning and recognition for data access.
develop clear policies on data security that are supported by the top management of the facility
---
Data security management includes developing, implementing, and enforcing data security policies and procedures.
In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the
flagrant use of specialty-specific abbreviations.
prohibited use of any abbreviations.
use of abbreviations used in the final diagnoses.
use of prohibited or "dangerous" abbreviations.
use of prohibited or "dangerous" abbreviations.
A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have been asked to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on
interrogatories.
depositions.
affidavits.
allocutions.
interrogatories
--
Interrogatories are a list of questions used in the discovery stage of a trial to obtain information from other parties in a lawsuit.
A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that
wages will increase if the union is defeated.
you are opposed to the union.
you need the names of those
involved in union activities.
a strike is inevitable if the union wins.
you are opposed to the union.
A run or line chart would be most useful for collecting data on
a possible relationship between 2 variables.
medication errors and their causes.
waiting time in the Pediatrics Clinic over a 6-month period.
patient satisfaction with the food.
waiting time in the Pediatrics Clinic over a 6-month period
---
Run charts are best used to track data points over time, such as wait time in a Pediatrics Clinic over several months.
Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures.
12002
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.6-7.5 cm
12004
Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 7.6-12.5 cm
12035
Repair, intermediate, of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 12.6-20.0 cm
12045
Repair, intermediate, of wounds of neck, hands, feet, and/or external genitalia; 12.6-20.0 cm
12002, 12004
12004
12035
12045
12035
---
The sizes of the layered wound repairs of the same body area are added together in order to select the correct CPT code.
The special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the
problem list.
interdisciplinary patient care plan.
interval summary.
medical history and review of systems.
interdisciplinary patient care plan
Generally, CMS requires the submission of a claim (CMS 1450) for inpatient services provided to a Medicare beneficiary for inpatient services. An exception to this requirement would be when
attempts are made to charge a beneficiary for a service that is covered by Medicare.
the physician furnishes a covered service to the beneficiary.
the beneficiary refuses to authorize the submission of a bill to Medicare.
an ABN was given to the beneficiary for services unlikely to be covered by Medicare.
the beneficiary refuses to authorize the submission of a bill to Medicare
---
When a beneficiary refuses to authorize the submission of a bill to Medicare, the Medicare provider is not required to submit a claim to Medicare.
Which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but NOT on the job description of chief privacy officer?
Conduct audit trails to monitor inappropriate access to system information.
Monitor the facility's business associate agreements.
Oversee the patient's right to inspect, amend, and restrict access to protected health information.
Cooperate with the Office of Civil Rights in compliance investigations.
Conduct audit trails to monitor inappropriate access to system information.
---
While a privacy officer would likely be involved with facility training in privacy and security standards, a security officer is more likely to be responsible for the technical aspects of monitoring the security of protected health information.
Vaginal delivery with episiotomy of full-term live-born infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally.
Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS.
O80
Encounter for full-term uncomplicated delivery
Z30.2
Encounter for sterilization
Z37.0
Single live-born
0UL74ZZ
Occlusion, bilateral fallopian tubes, percutaneous endoscopic approach, no device
10E0XZZ
Delivery of products of conception, external, no device
0W8NXZZ
Division, perineum, female (episiotomy)
Z37.0, 0W8NXZZ, 0UL74ZZ
O80, Z37.0, 0UL74ZZ
O80, Z37.0, 10E0XZZ, 0UL74ZZ
O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ
O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ
--
Whenever there is a delivery, there must also be an Outcome of Delivery code.
Each of these procedures is reported separately: the delivery, the episiotomy, and the occlusion of the fallopian tubes.
Release of information has increased its use of part-time PRN clerical support in order to respond to increased requests for release of information in a timely manner. For the line item projecting costs for ROI, this quarter's budget variance report will reflect
the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support.
both the increases in revenue and increased costs for clerical support in ROI.
neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports.
the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area.
the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area.
---
Budget variance reflects the difference between projected or budgeted costs and actual costs.
In this case, the budget variance report will compare the costs projected for ROI and the actual cost based on volume
The ER staff has collected the data on the number of visits and corresponding wait times in the ER. The data are displayed on the chart shown above. Based on this information, what kind of correlation do you see between the number of visits (Variable X) and the wait times (Variable Y)?
a conjunctive correlation between Variable X and Variable Y
a causative correlation between Variable X and Variable Y
a positive correlation between Variable X and Variable Y
a negative correlation between Variable X and Variable Y
a positive correlation between Variable X and Variable Y
---
Scatter diagrams display the strength of relationship between two variables. A strong relationship is seen as the data come closer to forming a straight line. When both variables increase and decrease at the same time, and the line progresses from the lower left toward the upper right corner, a positive relationship is demonstrated.
Which of the following statements is true?
A surgical procedure may include one or more surgical operations.
The terms surgical operation and surgical procedure are synonymous.
A surgical operation may include one or more surgical procedures.
The term surgical procedure is an incorrect term and should not be used.
A surgical operation may include one or more surgical procedures.
---
A surgical operation is one or more surgical procedures performed at one time for one patient using a common approach or for a common purpose.
Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gail has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's
CPOE.
RHIO.
expert system.
EDMS system.
RHIO.
---
A RHIO typically oversees the health information exchange among various provider settings, payers, and government agencies. The RHIO is one model toward achieving the proposed National Health Information Network (NHIN).
---
A Regional Health Information Organization (RHIS) is a group of organizations within a specific area that share health information electronically, according to accepted health information technology standards.
Everyone in the health information department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not
salaried nonexempt employees.
salaried exempt employees.
hourly employees.
temporary employees.
salaried exempt employees
---
Salaried exempt employees are paid a set salary per pay period.
In preparation for conversion to an electronic health record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data
dictionary.
reasonableness.
edits.
feasibility.
dictionary.
--
A data dictionary describes all the primitive level data structures and data elements within a system.
Four people were seen in your emergency department yesterday. Which one will be coded as a poisoning?
• Josh was diagnosed with digitalis intoxication.• Ben had an allergic reaction to a dye administered for a pyelogram.• Bryan developed syncope after taking Contac pills with a double scotch.• Matthew had an idiosyncratic reaction between two properly administered prescription drugs.
Matthew
Bryan
Josh
Ben
Bryan
Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with
feedback on specific instances when improved documentation would improve coding.
regular in-service presentations on the importance of accurate clinical documentation and tips for improvement.
the UHDDS and information on where each data element is collected and/or verified in your facility.
a copy of the facility coding guidelines, along with written information on improved documentation.
feedback on specific instances when improved documentation would improve coding.
---
Providing feedback to physicians in concurrent and, as appropriate, retrospective reviews is the purpose of Clinical Documentation Improvement (CDI).
Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be
professional standards.
provider preferences.
space considerations.
statutory requirements.
statutory requirements.
After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because
the results appear to violate the Pareto principle.
you expected the coders to put more emphasis on time pressure.
the rankings show surprising disagreement on the issue.
you thought limited training was the primary reason for the errors.
the results appear to violate the Pareto principle.
--
The Pareto principle states that 20% of the problem are responsible for 80% of the actual problem. This allows for a concentration of vital resources to address a large number of the actual problems.
KEY WEST HOSPITAL FOUR HIGHEST MS-DRGs
MS-DRG A
CMS WEIGHT - 2.023
NUMBER OF PATIENTS WITH MS-DRG A - 323
MS-DRG B
CMS WEIGHT- 0.987
NUMBER OF PATIENTS WITH MS-DRG B - 489
MS-DRG C
CMS WEIGHT - 1.925
NUMBER OF PATIENTS WITH MS-DRG C - 402
MS-DRG D
CMS WEIGHT - 1.243
NUMBER OF PATIENTS WITH MS-DRG D- 386
Key West Hospital collected the data displayed above concerning its four highest earning MS-DRGs. Which MS-DRG generated the most revenue for the hospital?
MS-DRG A
MS-DRG B
MS-DRG D
MS-DRG C
MS-DRG C
---
Calculations:MS-DRG A 2.023 x 323 = 653.43MS-DRG
B 0.987 x 489 = 482.64MS-DRG
C 1.925 x 402 = 773.85MS-DRG
D 1.243 x 386 = 479.80
In your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. When this occurs, who would be expected to authorize the release of the medical information documented in this episode of care?
the custodial parent of the patient
the patient
a court-appointed guardian on behalf of the patient
the patient's doctor on behalf of the patient
the patient
According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is
excisional.
punch.
percutaneous.
incisional.
incisional.
--
incisional biopsy is cutting of breast tissue where a small portion or slice of a lesion is removed.
Now that the EHR has been fully implemented, you are ready to move old records to basement storage. You are ordering shelving for those old paper files. You have 18,000 records. The files average three files per filing inch. The shelf units you have selected have six shelves that will hold 34 inches per shelf. You will have to plan for a 20% expansion rate to accommodate miscellaneous paper records over the next 10 years. How many shelving units should you order?
35
30
36
31
36
---
Calculation:(You can only purchase whole shelf units.)34 x 3 = 102 records per shelf102 x 6 = 612 records per filing unit18,000 x 0.20 = 3,600 records for projected expansion18,000 + 3,600 = 21,600 total records21,600/612 = 35.29 = 36 total filing units needed
You are providing an educational session to new hires at your hospital. You tell the new employees that health records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That is because the hospital medical record
was kept in the regular course of business.
is accurate and complete.
is written rather than spoken.
is impervious to tampering
was kept in the regular course of business
---
A health record kept in the normal course of business is considered an exception to the hearsay rule.
Your facility is engaged in a research project concerning patients newly diagnosed with type 2 diabetes. The researchers notice older patients have a longer length of stay than younger patients. They have seen a
homologous relationship between age and length of stay.
causal relationship between age and length of stay.
negative correlation between age and length of stay.
positive correlation between age and length of stay.
positive correlation between age and length of stay.
--
A patient was treated for meningitis at age 3 (18 years ago). The patient is now 21. The patient's attorney is requesting information on the admission. You tell the clerk the information is
available, and the patient may sign consent to release the information in the record.
available, but the patient's parents will have to sign a consent for you to release it.
no longer available because your facility retains information for 10 years after the last patient visit.
available, but the attorney will have to obtain a court order before you will release it.
available, and the patient may sign consent to release the information in the record.
Employing the SOAP style of progress notes, choose the "assessment" statement from the following:
Patient states low back pain with sciatica is as severe as it was on admission.
Adjust pain medication; begin physical therapy tomorrow.
Sciatica unimproved with hot pack therapy.
Patient moving about very cautiously appears to be in pain.
Sciatica unimproved with hot pack therapy.
--
Progress note elements written in the acronym "SOAP" style are:
S-subjective—records what the patient states is the problem
O-objective—records what the practitioner identifies through history, physical examination, and diagnostic tests
A-assessment—combines the subjective and objective into a conclusion
P-plan—what approach is going to be taken to resolve the problem
Mary is 6 weeks post-mastectomy for carcinoma of the breast. She is admitted for chemotherapy. What is the correct sequencing of the codes?
C50.911
Malignant neoplasm of unspecified site of right female breast
Z85.3
Personal history of malignant neoplasm of breast
Z51.11
Encounter for antineoplastic chemotherapy
Z08
Encounter for follow-up examination after completed treatment for malignant neoplasm
Z85.3
Z08, Z51.11
Z51.11, C50.911
Z51.11, Z85.3
Z51.11, C50.911
--
The cancer is coded as a current condition as long as the patient is receiving adjunct therapy.See the Official Guidelines for Coding and Reporting 2018, Section 1.c.2.d. Primary malignancy previously excised
"When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy."
Postage charges in the health information department have increased during the last quarter. The department director has seen metered envelopes in the mail bin that do not appear to be those used for departmental business. The best course of action for the director would be to
issue employee warnings at the next departmental meeting.
assign responsibility for the postage meter to one employee.
remove the postage meter from the department.
keep a watchful eye on the meter and who uses it.
assign responsibility for the postage meter to one employee
RECORD COMPLETION INFORMATION FOR DECEMBER
INCOMPLETE RECORDS - 604
DELINQUENT RECORDS - 304
AVERAGE MONTHLY DISCHARGES - 845
AVERAGE MONTHLY OPERATIVE PROCEDURES - 526
DELINQUENT OPERATIVE REPORTS - 14
What is the percentage of delinquent missing OP records from operative procedures?
4.6%
1.7%
cannot be determined from the information given
2.7%
2.7%
--
Formula:
Number of Delingquent Operative Reports (x) 100/ Average Monthly Operative Procedures
Calculation:
Calculation: (14 / 526) = 0.02661 x 100 = 2.66%, rounds to 2.7%.
A portion of a deficiency slip is reproduced below. This patient was discharged yesterday. Your greatest concern regarding deficiencies on this record would be the missing
Chart has a X on
x History
xOperative Report
xOperative Report
signature on the discharge summary.
signature on the physical exam.
operative report.
diagnoses and procedures.
operative report.
In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to
compare your facility's outcomes to
nationally known facilities.
facilities within your corporation.
larger facilities.
facilities with superior performance.
facilities with superior performance.
--
Benchmarking occurs when an organization uses comparative data between organizations to judge performance and identify improvements to be successful in other organizations.
A 335-bed hospital opened a new wing on June 1 of a nonleap year, increasing its bed count to 350 beds. The total bed count days for the year at the hospital was
127,750.
122,275.
125,485.
The answer cannot be calculated with the information provided.
125,485.
--
(335 x 151) + (350 x 214) = 125,485
Access to radiologic images has been improved through the use of which of the following?
EDMS
CPOE
LOINC
PACS
PACS
--
Picture Archiving and Communication Systems (PACS) provide a means to store and rapidly access digitized file images.
-An Electronic Document Management System -(EDMS) is a system to store, manage, and retrieve documents. -Computerized Provider Order Entry (-CPOE) refers to the process of providers entering and sending treatment instructions via a computer application.
-Logical Observation Identifiers Names and Codes (-LOINC) is a database that has universal standards for dentifying medical laboratory observaion .
SAINT JOSEPHCODING PRODUCTIVITYWEEK ENDING JANUARY 3, 2018
EMPLOYEE NUMBER
425
425
427
428
INPATIENT
120
48
80
65
OUTPATIENT PROCEDURE
35
89
92
109
EMERGENCY OR OBSERVATION
16
95
4
16
The performance standard for coders is 28-33 workload units per day. Workload units are calculated as follows:Inpatient record = 1 workload unitOutpatient surgical procedure records = 0.75 workload unitsOutpatient observation/emergency records = 0.50 workload unitsOne week's productivity information is shown in the table above. What percentage of the coders is meeting the productivity standards?
100%
75%
50%
25%
100%
---
employee # 425: 120 + (35 × 0.75) + (16 × 0.5) = 154.25154.25/5 = 30.85 average work units per day
employee # 426: 48 + (89 × 0.75) + (95 × 0.5) = 162.25162.25/5 = 32.45 average work units per day
employee # 427: 80 + (92 × 0.75) + (4 × 0.5) = 151151/5 = 30.2 average work units per day
employee # 428: 65 + (109 × 0.75) + (16 × 0.5) = 154.75154.75 = 30.95 average work units per day
The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. This crisis manager is particularly weak in which management function?
organizing
budgeting
controlling
planning
planning
At your meeting with the clerical staff on the stat report concerns, one clerk suggests a possible reason for the delays is a lack of training concerning the nature of stat reports. On the cause and effect diagram, this would most appropriately be listed under
methods.
personnel.
equipment.
materials.
personnel.
The Pharmacy and Therapeutics Committee has asked you to find out more about a computerized order entry system that calculates drug dosages based on patient parameters (weight, age, etc.) and even suggests the best drug given the patient's diagnosis and current treatment. The committee is asking for information on a(n)
practice parameters system.
application system.
clinical decision support system.
ordering system.
clinical decision support system
---
Knowledge-based components of a clinical decision system include: (1) a knowledge-based system that provides facts, or evidence, concerning a domain of knowledge; (2) production rules that are a generic set of "if..then.." structures, or rules that draw from the knowledge base; (3) an inference engine, which is the software that controls how the rules are applied to specific facts about the patient; and (4) the user interface.
The physician has documented the final diagnoses as acute myocardial infarction, COPD, CHF, hypertension, atrial fibrillation, and status post cholecystectomy. The following conditions should be reported:
I10
Essential hypertension
I11.0
Hypertensive, heart disease, with heart failure
I21.3
ST elevation (STEMI) myocardial infarction of unspecified site
I48.91
Unspecified atrial fibrillation
I50.9
Heart failure, unspecified
J44.9
Chronic obstructive pulmonary disease, unspecified
Z90.49
Acquired absence of other specified parts of digestive tract
I21.3, J44.9, I48.91, Z90.49
I11.0, J44.9, I50.9, I10, Z90.49
I11.0, J44.9, I50.9, I10, I48.91, Z90.49
I21.3, J44.9, I50.9, I11.0, I48.91
I21.3, J44.9, I50.9, I11.0, I48.91
---
Category Z90.49, acquired absence of other specified parts of digestive tract, is intended to be used for patient care where the absence of an organ affects treatment.
Based on the information below, what was the net death rate at Seaside Hospital in January?
SEASIDE HOSPITAL SELECTED STATISTICS JANUARY
Admissions - 280
Discharged to Home - 212
Discharge Transfers - 28
Deaths <48 hours - 8
Deaths >48 hours -6
2.4%
2.8%
3.8%
5.8%
2.4%
--
Formula:
Number of Inpatient Deaths-Number of Inpatient Deaths within 48 Hours (x) 100/ Total Number of Discharges Including Deaths - Number of Inpatient Deaths within 48 Hours
Calculation:
14-8/254-8 = 0.02390 x 100 =2.4%
The transcriptionists have collected data on the number and types of problems with the dictation equipment. The best tool to display the data they collected is a
PERT chart.
flowchart.
Pareto chart.
Gantt chart.
Pareto chart
---
Pareto charts are graphs that display bars arranged in descending order to indicate, which issues or problems should be considered first. A Pareto chart would provide the best format for organizing the number and types of problems with the dictation equipment. A flowchart displays a picture of a process. PERT and Gantt charts are project management tools
Community Hospital reported an average LOS in December of 3.7 days with a standard deviation of 23. This information indicates that
patients stay longer at Community than at most hospitals.
there was a small variation in the LOS at Community Hospital.
there was a large variation in the LOS at Community Hospital.
most of the patients at Community Hospital stay 3-4 days.
there was a large variation in the LOS at Community Hospital
---
The standard deviation is the measure of variability often used to show how data are related to the mean. A large standard deviation implies great variability in the data.
Rule 1
Rule 2
Rule 3
Rule 4
Condition 1
Condition 2
Condition 3
Condition 4
Action 1
Action 2
Action 3
Action 4
You stop by the office to meet a friend for lunch. Looking on her desk, you see the grid above. Your friend is trying to
make a decision.
analyze a workflow.
plan a conversion.
design a system.
make a decision.
The electronic system at your physician practice allows for e-prescribing and the exchange of data to a centralized immunization registry, and lets your physicians report on key clinical quality measures. In all likelihood, your practice has succeeded in implementing
a Joint Commission-approved system.
a certified EHR.
an AMA-approved product.
a functional EMR.
a certified EHR.
When checking the census data at South Beach Women's Center, you see that just yesterday, there were four sets of triplets, five sets of twins, and eight single births. Yesterday, South Beach Women's Center had
17 deliveries.
39 deliveries.
25 deliveries.
30 deliveries.
17 deliveries
---
A delivery is defined as the process of delivering a live born infant(s) or dead fetus and placenta by manual, instrumental, or surgical means. A pregnant mother who has one delivery may have multiple births. Multiple births are counted as one delivery for statistical purposes.
Calculation:
4 + 5 + 8 = 17
Most of the children who are seen at MMBC will have a well-child visit and two immunizations. If you add the reimbursement for two immunizations to the reimbursement for each well-child visit, which insurance company benefits MMBC most?
Lifecare
Getwell
BeHealthy
SureHealth
Getwell
You are creating an inventory of all template forms within the electronic health record. You come across an unnamed template in the OB section that includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. The document type you give to this form is
labor record.
postpartum record.
prenatal record.
delivery room record.
postpartum record.
Patient was seen today for regular hemodialysis. No problems reported, tolerated procedure well.
90935
Hemodialysis procedure with single physician evaluation
90937
Hemodialysis procedure requiring repeated evaluations(s) with or without substantial revision of dialysis prescription
90945
Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation
+99354Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient Evaluation and Management service)
99354
90935
90937
90945
90935
Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is
capturing every data item required by UHDDS.
giving each form or view an identifiable name, number, and revision date.
consistent formatting of each page of each form.
providing instructions when necessary for appropriate data fields.
...
How long will it take to complete the project described below?
20 days
17 days
12 days
29 days
20 days
--
start -Order (10 days)
- Install (6 days) - Train Cleks (4days)
During the work sampling of a file clerk's activity, it is noted that the employee is speaking on the telephone during 76 of 300 observations. How much of the employee's time is spent on the phone if the employee works 7 hours a day?
3.28%
3.94 hours
1.77 hours
9.2%
1.77 hours
---
Formula:
Number of Times on the Phone / Number of Total Oberservation
Calculation:
76 / 300 = 0.253
0.253 x 7 hours = 1.77 hours
The state is considering the closure of the Arcadia Hospital. In reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted?
percentage of occupancy
inpatient service days
daily census
average length of stay
percentage of occupancy
---
The inpatient bed occupancy rate measures the percentage of beds that are occupied by inpatients in relation to the total number of beds within the facility for a specific period of time. This metric is used to assess the functionality degree of a hospital and the institution's ability to efficiently manage its resources. Market data on occupancy rates as a key performance indicator shows that 85-90% is the ideal range for bed occupancy. A rate higher than 90% may cause the danger of overcrowding, indicating that hospitals may have to turn away patients and postpone the provision of needed, possibly crucial, health care. If occupancy is below 85%, this might indicate that resources are managed inefficiently and inequitably. An extremely low percentage of occupancy may reflect a duplication of hospital services in a geographic area.
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only
code only the secondary neoplasm as the principal diagnosis.
code only the primary neoplasm as the principal diagnosis.
the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis.
the primary neoplasm is coded as the principal diagnosis, and the secondary neoplasm is coded as an additional diagnosis.
the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis.
---
When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.
The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure
consistent criteria are used to evaluate the alternatives/vendors.
the level of software support will be considered in the decision.
all alternatives/vendors are evaluated subjectively.
the personalities of individual vendors will not influence the decision.
consistent criteria are used to evaluate the alternatives/vendors
---
Example:
Software Capability
PriorityVendor 1
Vendor 2
Vendor 3
Search by code, keyword, or modifier
1 - Y - Y - Y
CCI and MUE alerts for Medicare and Medicaid
1 - Y - Y - Y
Searchable Medicare Physician Fee Schedules 2 - N - Y - Y
As the information security officer at your facility, you have been asked to provide examples of technical security safeguards as required of HIPAA Security Rule. Which of the following would you provide?
evidence of security awareness training
workstation use and location
audit controls
surge protectors
audit controls
--
Under the Security Rule, technical safeguards include automatic log off and unique user identification to protect access and control of ePHI.
Sun City reported 12 cases of chronic heart disease in a population of 8,000 in 2017. In 2018, Sun City reported there were still 12 cases of chronic heart disease, but its population had decreased to 6,000. This represents an increase in the
occurrence of chronic heart disease in Sun City.
reliability of reporting chronic heart disease in Sun City.
prevalence of chronic heart disease in Sun City.
incidence of chronic heart disease in Sun City.
prevalence of chronic heart disease in Sun City
--
Disease incidence rates compare the number of new cases of a specific disease in the population, while a disease prevalence rate is the proportion of people in a population who already have a particular disease (such as chronic heart disease).
The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. Provide correct CPT code for the procedure.
34203
Embolectomy or thrombectomy, with or without catheter; popliteal-tibioperoneal artery, by leg incision
35226
Repair blood vessel, direct; lower extremity
35302
Thromboendarterectomy, including patch graft if performed; superficial femoral artery
37799
Unlisted procedure, vascular surgery
35226
35302
37799
34203
34203
A major drug company wants to promote a fundraiser targeting patients with congestive heart failure. The drug company representative has requested a list of patients treated at your facility. As privacy and security officer, you tell them that
if the fundraising was conducted by a business associate without authorization, and the funds were to benefit your facility (the covered entity), that you could disclose the information.
a prior authorization is required before any PHI can be released.
you will need to confer with the medical director.
they just need to send a written request for the list.
a prior authorization is required before any PHI can be released.
---
The use of patient information for marketing strategies, such as fundraising, requires authorization. There are certain exceptions when marketing services to patients.
A 19-year-old former patient has completed an authorization requesting all of his medical records be released to the army. The release of information clerk should
inform the young man that specific reports must be identified in his request.
send a letter informing him that faxed requests are not accepted.
send the records as requested.
deny the request.
send the records as requested
Diverticulitis large bowel with ascending colon abscess was the diagnosis for a patient who was admitted with abdominal pain. Right hemicolectomy with colostomy performed.
Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS.
K57.20
Diverticulitis of large intestine with perforation and abscess without bleeding
K57.90
Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding
K57.92
Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding
K62.0Anal polyp
0DTK0ZZ
Resection, ascending colon, open approach
0DTL0ZZ
Resection of transverse colon, open approach
0D1K0Z4
Bypass, ascending colon to cutaneous, open approach, no device
K57.92, 0DTK0ZZ, 0D1K0Z4
K57.20, 0D1K0Z4
K57.90, 0DTL0ZZ, 0D1K0Z4
K57.92, K62.0, 0DTL0ZZ
K57.20, 0D1K0Z4
---
See ICD-10-PCS Official Guidelines for Bypass procedures (B3.6a): "Bypass procedures are coded by identifying the body part bypassed 'from' and the body part bypassed 'to.' The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to."
GULFSIDE HEALTHCARE CENTERAVERAGE CLINIC WAITING TIME BY TIME BLOCKDECEMBER 2019
TIME BLOCK
8:00-11:00
11:01-2:00
2:01-5:00
PEDIATRICS
12
8
10
OBSTETRICS
18
10
7
CARDIOLOGY
10
8
7
ORTHOPEDICS
9
14
12
Each month, the staff of the clinic with the lowest overall waiting time is awarded a free dessert in the Gulfside Healthcare Center cafeteria. Take a look at the information listed above. The winner will be selected based on
duplicate thematic data.
objective individual data.
comparative aggregate data.
demonstrative clinical data.
comparative aggregate data.
---
The data displayed is best described as aggregate data, or data extracted from individual health records and then grouped to form de-identified information about a population of patients. Aggregated information can be analyzed and compared in a way that individual health records cannot.
Aggregate data can help care providers see patient data from a completely new angle. While it may not provide specific details needed to treat patients, it can offer crucial insight for strategic planning.
As the director of a Health Information Technology Program, you are reviewing the workforce development forecast for electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of which governmental agency?
CMS
CDC
ONC
OSHA
ONC
---
The Office of the National Coordinator for Health Information Technology (ONC) produced a federal Health IT Strategic Plan that includes three major focus areas with the intent to collect patient-generated data, share information more effectively with patients, and use technology and data to improve population health.
The formula used to calculate the percentage of ambulatory care visits made with same day appointments is
Formula:
Number of Patients Seen with Same Day Appoinments for a Period (x) 100 / Number of Patients Seen in the Same Period
Formula:
Number of Patients Seen with Same Day Appoinments for a Period (x) 100 / Number of Patients Seen in the Same Period
A rate is a fraction that is formulated to express the relationship between the numerator and denominator. The basic rule of thumb for calculating rates is to divide the number of times something actually happened in relation to the number of times it could have happened.
Patient was admitted from the nursing home in acute respiratory failure due to congestive heart failure. Chest x-ray also showed acute pulmonary edema. Patient was intubated and placed on mechanical ventilation for less than 24 hours and expired the day after admission.
Code diagnoses using ICD-10-CM and procedures using ICD-PCS.
I50.9
Heart failure, unspecifiedI50.1Left ventricular failure
J81.0
Acute edema of lung, unspecified
J96.00
Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
J96.20
Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia
0BH17EZ
Insertion of endotrachial device, via natural or artificial opening via trachea
5A1935Z
Ventilation, respiratory system, less than 24 consecutive hours
J96.00, I50.1, 5A1935Z
I50.9, J81.0, 0BH17EZ, 5A1935Z
I50.9, J96.00, J81.0, 0BH17EZ, 5A1935Z
I50.9, J96.20, J81.0, 0BH17EZ, 5A1935Z
J96.00, I50.1, 5A1935Z
--
Acute pulmonary edema is included in the code for congestive heart failure (CHF). Insertion of endotracheal tube is included in the ventilation code.
In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post-surgery. There is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the
lab report.
operative report.
nurses' notes.
pathology report.
lab report
The Quality Payment Program consists of four categories for the measures and activities that providers must report data for the year. Which of the following is not one of the required categories?
Physician satisfaction
Cost measures
Quality measures
Promoting interoperability
Physician satisfaction
---
The Quality Payment Program consists of the following four categories:
Categories
-Quality measures
-Promoting interoperability
-Improvement activities
-Cost measures
Percentage of Total
45%
25%
15%
15%
As a CTR, you know that staging
is a system for documenting the extent or spread of cancer.
refers to the monitoring of incidence and trends associated with a disease.
designates the degree of differentiation of cells.
is continued medical surveillance of a case.
is a system for documenting the extent or spread of cancer.
Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to
decrease medication errors through CPOE systems.
increase patient engagement through patient portals.
report sentinel events to the Joint Commission.
reduce clinical denials for medical necessity.
reduce clinical denials for medical necessity.
----
"Decrease medication errors through CPOE systems" and "report sentinel events to the Joint Commission" are more closely associated with patient safety programs than CDI programs. The answer, "increase patient engagement through patient portals" relates to HITECH goals for physician practices.
Clinical documentation improvement programs are designed to improve clinical documentation specificity, thus supporting the medical necessity requirement for inpatient level care as well as the intensity of service and severity of illness for each inpatient.
Your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model shown above. The team asks if you see anything missing from the model. You tell them they
are missing a step requiring ongoing monitoring and reassessment.
are missing a step requiring reporting to the board of directors.
are missing a step requiring regular employee input into the process.
aren't missing any steps; the model is a good one.
are missing a step requiring ongoing monitoring and reassessment
----
Performance improvement includes evaluating and continuously monitoring performance measures to ensure expectations are being met.
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