AAPC CPC Practice Exam F

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What is the patient's right when it involves making changes in the personal medical record?

A. Patient must work through an attorney to revise any portion of the personal medical information.
B. They should be able to obtain copies of the medical record and request corrections of errors and mistakes.
C. It is a violation of federal health care law to revise a patient medical record.
D. Revision of the patient medical record depends solely on the facility's compliance program policy.

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B. They should be able to obtain copies of the medical record and request corrections of errors and mistakes.

Under HIPAA regulations, patients have the right to receive a copy of their medical record and request that errors are corrected.
https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html

Which modifier is appended to a CPT®, for which the provider had a patient sign an Advance Beneficiary Notice (ABN) form because there is a possibility the service may be denied because the patient's diagnosis might not meet medical necessity for the covered service?

A. GJ
B. GA
C. GB
D. GY

B. GA

An Advance Beneficiary Notice (ABN) is a waiver of liability. When a patient has been informed a service that is otherwise covered by Medicare but might not be covered in a particular instance an ABN is signed by the patient prior to receiving the service. To inform Medicare the ABN has been signed, append modifier GA. If an ABN is signed, the claim is the patient's responsibility if the claim is denied. This modifier is listed in the HCPCS Level II codebook.

Which statement regarding an ICD-10-CM coding conventions is TRUE?

A. If the same condition is described as both acute and chronic and separate subentries exist in the Alphabetic Index at the same indentation level, code only the acute condition.
B. Sequela (Late effect) codes are reported for a current acute phase of the injury or illness
C. An ICD-10-CM code is still valid even if it has not been coded to the full number of characters required for that code.
D. Signs and symptoms that are integral to the disease process should not be assigned as additional codes, unless otherwise instructed.

D. Signs and symptoms that are integral to the disease process should not be assigned as additional codes, unless otherwise instructed.

Multiple choice D is the correct answer, according to the ICD-10-CM Official Coding Guidelines, I.B.5. indicates not to report signs and symptoms that are integral to a definitive diagnosis and are not assigned unless otherwise instructed. When the same condition is diagnosed as acute and chronic and there is a separate code for both, report both codes (I.B.8). Sequela (Late Effect) codes are the residual effect (condition produced) after the acute phase of an illness or injury has terminated (I.B.10). An ICD-10-CM code is not valid unless it is coded to the highest level of specificity. Do not rely solely on the ICD-10-CM Alphabetic Index to Diseases and Injuries to select the correct code.

The term paracentesis found in CPT® code 49082 means:

A. A procedure performed to drain fluid that has accumulated in the abdominal cavity
B. Biopsy of an abdominal mass
C. Removal of tissue samples from the abdominal cavity by an open approach
D. Removal of a cyst located in the abdominal cavity

A. A procedure performed to drain fluid that has accumulated in the abdominal cavity

The term breaks down as follows: prefix par or para refers near, beside or outside and the suffix -centesis refers to puncture or insertion of the insertion of a needle to withdraw fluids. As it relates to code 49082 the surgical procedure is performed by inserting a needle in the abdominal (peritoneal) cavity to drain fluid that has accumulated, or to obtain a fluid sample for testing.

hich term is one who has an overload of sodium?

A. Hyperkalemia
B. Hyperpotassemia
C. Hypernatremia
D. Hypercalcemia

C. Hypernatremia

In the ICD-10-CM Alphabetic Index look for each of the listed terms. Cross reference each code in the Tabular List to note a brief definition. Hypernatremia is the when one has too much sodium in the system. Hypernatremia is indexed to code E87.0.