AAPC CIC Questions and Answers 2024: A Guide to Medical Coding, Exams of Nursing

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Chapter 4 AAPC CIC Questions with

Answers 2024

CMS

✔ Centers for Medicare and Medicaid Services CoP ✔ Conditions of Participation CfC ✔ Conditions for Coverage (CMS) JC ✔ The Joint Commission PII ✔ Personally Identifiable Information. Information about individuals that can be used to trace a person's identity, such as a full name, birthdate, biometric data, and identifying numbers such as a Social Security number (SSN). Organizations have an obligation to protect PII and often identify procedures for handling and retaining PII in data policies. Data ✔ objective observations or measurements demographic data ✔ Patient's full name, address, phone number, ethnicity, marital status, date of birth, place of birth, Social Security, and name and contact information of the patient's next of kin serve to confirm the patient's identity and are used by hospitals for research and resource planning UHDDS ✔ Uniform Hospital Discharge Data Set-- 1974 standard for collecting data for Medicare/Medicaid programs MDS ✔ minimum data set (long-term care) SNF ✔ skilled nursing facility (pronounced "sniff") PPS ✔ Prospective Payment System data mining

✔ process to identify trends and patterns in a database. Useful for detecting fraud and abuse and identifying effective treatments and inefficiencies. Face Sheet ✔ also known as the admission form, admitting sheet, data form, or patient information form; a common document in medical facilities that contains demographic information on the patient. H&P ✔ history and physical progress notes ✔ Notes used in the patient chart to track the progress and condition of the patient. Including procedures. Consultations ✔ A professional caregiver (Specialists) giving formal advice to another caregiver Radiology Reports & Operative Reports are documentation entries that will require a coder to code from ____________________. ✔ ICD- 10 PCS Documentation is the recording of pertinent facts and observations about an individual's health history, including past and present illnesses, tests, treatments and outcomes. The medical record chronologically documents patient care to: ✔ 1. Enable the physician and other healthcare professionals to plan and evaluate the patient's immediate treatment and to monitor their healthcare.

2. Enhance communication and promote continuity of care.
3. Facilitate claims review and payments.
4. Assist in utilization review and quality of care evaluations.
5. Reduce complicated medical reviews.
6. Provide clinical data for research and education.
7. Serve as a legal document to verify the services (eg, in defense of an alleged professional liability claim). ASC ✔ ambulatory surgical center CAH ✔ Critical Access Hospital The medical record should be ___________ and ______________ to ensure accurate understanding of a patient's medical condition. ✔ complete, legible Payers define medical necessity as services or supplies that are: (3 things)

✔ In accordance with standards of good medical practice Consistent with the diagnosis The most appropriate level of care provided in the most appropriate setting In regard Xrs, lab tests, and other ancillary services, documentation should include the ______________________ and ________________ of those services in the medical record ✔ reasons for, results each page of the medical record should include ✔ patients name or patient ID number true or false: All Payers employ the same rules concerning coding and reimbursement. ✔ false To monitor reimbursement and coding patterns by provider, payers conduct _____ and _____. ✔ prepayment and post-payment reviews, audits True or False: Rubber stamps for signature authentication are allowed for Medicare claims. ✔ False According to Medicare guidelines, dictated notes must be _____ by the physician before they are placed in the patient's chart. ✔ signed List three CMS requirements for electronic signature in the hospital medical record. ✔ There must be a specific action by the author to indicate that the entry is verified and accurate. Systems that would meet the authentication requirements are as follows: -Computerized systems that require the physician to review the document online and indicate that it has been approved by entering a computer code. -A system in which the physician signs off against a list of entries that must be verified in the individual record. -A mail system in which transcripts are sent to the physician for review, and then he/she signs and returns a postcard identifying the record and verifying the accuracy. True or False: Always code all "history of" diagnoses. ✔ False Which statement is true regarding the report of status codes? a. All status codes documented in the current admission should be reported. b. Only report status codes for conditions that are not mentioned in the body system disease description. c. Only report status of pacemaker codes.

d. If the diagnosis code includes information contained in the status code, report the status code. ✔ Which statement is NOT true about reporting the primary diagnosis code. a. The principle diagnosis code is that condition that is established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. b. Z codes may never be reported as principal diagnosis codes. c. "History of" codes are not reported as principal diagnosis codes. d. A "probable," "suspected," or "likely" code may be reported as the principal diagnosis code. ✔ b