17 terms


Which of the following is an example of clinical data?

a. Date and time of discharge
b. Health record number
c. Insurance information
d. Final diagnosis
________________ is the index and database that includes patient-identifiable information.

b. Clinical trials database
c. Master patient/population index
Which of the following serves the purpose in standardizing medical terminology to avoid differences in naming various medical conditions and procedures?

a. Transaction standards
b. Content and structure standards
c. Vocabulary standards
d. Security Standards
Physician's orders serve which of the following functions?

a. Provide a chronological summary of the patient's illness and treatment
b. Document the patient's current and past health status
c. Document the physician's instructions to other parties involved in providing care to a patient.
d. Document the provider's instructions for follow-up care given to the patient or patient's caregiver.
Updating the procedure classification of ICD-9-CM is done by which of the following?

a. Centers for Disease Control (CDC)
b. Centers for Medicare and Medicaid Services (CMS)
c. National Center for Health Statistics (NCHS)
d. World Health Organization (WHO)
Two patients were admitted, each with a final diagnosis of fracture of the pelvis. Patient A had a single break in the pelvic ring; patient B had severe multiple fractures of the pelvis and a possible pulmonary embolus. Even though the principal diagnosis is the same what can be used to further recognize the patient who is at higher risk.

a. SNDO codes
b. HCPCS codes
c. Severity of illness system
d. CPT codes
A patient presents to the doctor's office with fever, productive cough and shortness of breath. The physician orders a chest x-ray and indicates in the progress note: "Rule Out pneumonia"
If the results have not yet been received, what should the coder report for the visit?

a. Pneumonia
b. Fever, cough, shortness of breath
c. Cough, shortness of breath
d. Pneumonia, cough, shortness of breath, fever
A patient is admitted after taking his prescribed hypertensive medicine with a cocktail at lunch. The patient had a reaction to the medicine and began vomiting. What is the appropriate coding sequence?

a. Vomiting, hypertension
b. Poisoning hypertensive medication, vomiting, hypertension
c. Vomiting, Adverse effect of hypertensive medication, hypertension
d. Adverse effect of hypertensive medication
What would be the best secondary data source to utilize to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?
Disease Index
Which of the following is a primary purpose of a health record?

a. Assist caregivers in patient care management
b. Aid in billing and reimbursement functions
c. Document patient care delivery
d. Assist in process redesign
C. Document Patient Care Delivery
Clinical data can be shown by which of the following?

a. Admitting diagnosis
b. Date and time of admission
c. Insurance information
d. Health record number
Admitting Diagnosis
Which of the following is a core data set developed by ASTM that communicates a patient's past and current health information as the patient transitions from one care setting to another?

a. Continuity of Care
b. Minimum Data Set
c. Ambulatory Care Data Set
d. Uniform Hospital Discharge Data Set
Continuity of care
The following would be documented in which part of an acute care record:
"I was asked to evaluate this trauma patient with an open right tibia/fibula fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of the open fracture."

a. Admission note
b. Consultation report
c. Discharge summary
d. Nursing progress notes
Consultation report
In which part of a POMR progress note would the following notation be written in?
"Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet."

a. Subjective
a. Objective
b. Assessment
c. Plan
A 60 yo male is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy three years ago is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastatic of the brain. Which of the following is the correct coding and sequencing for the current hospital stay?

a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion
b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy
c. Metastatic carcinoma of the brain; history of carcinoma of the prostate
d. Carcinoma of the prostate; metastatic carcinoma of the prostate
C.Metastatic carcinoma of the brain; carcinoma of teh prostate; mental confusion
What is the purpose of the present on admission (POA) indicator?

a. Differentiate between conditions present on admission and conditions that develop during an inpatient admission.
b. Track principal diagnoses
c. Distinguish between principal and primary diagnoses.
d. Determine principal diagnosis
A.the POA indiciator is used to differientiate between conditions present on admission and conditions that develop during an inpatient admission. Medicare will not pay for any conditions that develop during the hospitalization
The patient was seen for two interdigital neuroma from the left foot
28080 Excision, interdigital (Morton) neuroma, single, each
64774 Excision of neuroma; cutaneous nerve, surgically identifiable
64776 Excision of neuroma; digital nerve, one or both, same digit

a. 64774

b. 64776

c. 28080

d. 28080, 28080
D. Because there was two interdigital neuroma you have to code it twice.