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The nose, mouth, sinuses, pharynx, & larynx make up the? The upper respiratory tract Mary Giovanni is in the hospital recovering from colon resection surgery. Based on her symptoms, her doctors are concerned about the possibility that she has developed a pulmonary embolism. Which of the following procedures will provide the definitive diagnosis? a) Chest X-ray b) Pulmonary angiography c) Lung scan d) None of the above Pulmonary angiography A 32 year old patient has a colonoscopy with removal of 3 polyps by snare. Moderate sedation was used & provided by the physician. The intraservice time was 30 minutes. 45385 - colonoscopy with removal of tumor or polyps or other lesions by snare technique 99156 - initial 15 minutes of intraservice time, patient 5 years or older. 99157 - each additional 15 minutes of intraservice time (list separately in addition to code for primary service) The diagnosis is as follows: "Carcinoma of axillary lymph nodes & Lungs, metastatic from breast" what is the primary cancer site? a) Lungs b) Axillary lymph nodes c) Breast d) Both Axillary lymph nodes & Lungs Breast Patient has a year history of mitral valve regurgitation (mitral insufficiency) and now presents for a mitral valve replacement with bypass (Code for physician using CPT procedure codes only). **(Valvuloplasty is a plastic repair of a valve) 33430 Replacement, mitralvalve, with cardiopulmonary bypass You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to? Improve your departments processes

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Your facility would like to improve physician documentation in order to allow improved coding. As a coding supervisor, you have found it very effective to provide the physicians with? Feedback on specific instances when improved documentation would improve coding. A patient is diagnosed with early onset Alzheimer's disease with dementia, how would this be coded? G30.0-Alzheimer's disease with early onset F02.80-Dementia in other diseases classified elsewhere. Without behavioral disturbance. An established patient was seen by a physician in her office for DTaP-IPV/Hib (DTap=Diphtheria, Tetanus, & Acellular Pertussis) (IPV=Inactivated Polio Vaccine) (Hib=Haemophilus influenzae type B vaccine) 90471 - Immunization administration (includes percutaneous intradermal, subcutaneous, or intramuscular injections) 1 vaccine (single or combination vaccine/toxoid) 90698 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenza type b, & inactivated poliovirus vaccine (DTaP-IPV/Hib) for intramuscular use. What CPT code is used for a high-energy ESW of the lateral humeral epicondyle (tennis elbow) using general anesthesia? 0102T-Extracorporeal shock wave, high energy, performed by a physician , requiring anesthesia other than local, involving lateral humeral epicondyle. Which of the following procedures can be identified as "destruction" of lesions: a) paring of hyperkeratotic lesion b) laser removal of condylomata (wart) c) shaving of skin lesion d) removal of skin tags laser removal of condylomata The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as? Upcoding A is a collection of information or data that is organized in such a way that it's contents can be queried and relationships created Database A single lung transplant without cardiopulmonary bypass. (Code for physician using CPT procedure only) 32851 Lung transplant, single, without cardiopulmonary bypass

A female with 6 months of stress incontinence. Laparoscopic urethral suspension was completed. choose the appropriate ICD- 10 - CM and CPT codes? N39.3- Stress incontinence (female) (male) 51990 - Laparoscopy, surgical; urethral suspension for stress incontinence. The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed? Brachytherapy External Beam Radiation The most common type of radiation therapy used for cancer treatment. A machine is used to aim high- energy rays (or beams) from outside the body into the tumor. (The machine most commonly used is called a linear accelerator or "linac.") What radiation therapy uses several beams of various intensities aimed at different angles to precisely target the tumor. Through the use of CT, MRI or other advanced imaging techniques to precisely map the position of the tumor. The images are used to design a four-dimensional, customized treatment plan that determines beam intensity and positioning. The goal is to deliver the highest possible dose to kill the cancer while minimizing exposure to healthy organs. Stereotactic body radiation therapy (SBRT) or Stereotactic ablative radiotherapy A machine called a synchrotron or cyclotron speeds up protons. The high speed of the protons creates high energy. This energy makes the protons travel to the desired depth in the body. The protons then give the targeted radiation dose in the tumor. There is less radiation dose outside of the tumor which minimizes damage to the surrounding healthy tissues & organs, which helps reduce side effects. Proton Beam Treatment Which of the following procedures would not be coded to "resection" when using ICD- 10 - PCS? a) Excision of sigmoid colon b) Excision of gallbladder c) Resection of the upper right lobe d) Partial resection of upper left lobe. Partial resection of upper left lobe (Partial) During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the code for sterilization, Z30.2, is A. not used. B. used and sequenced as the principal diagnosis. C. used and sequenced as a secondary diagnosis. D. the only code used. Used and sequenced as a secondary diagnosis.

A patient suffered dizziness as a result of taking prescribed phenobarbital. The patient took his medication with beer R42-Dizziness and Giddiness T42.3X1A-Poisoning by barbiturates accidental (unintentional). Initial encounter T51.8X1A-Toxic effect of other alcohols. Accidental (unintentional). Initial encounter Some ICD- 10 - CM codes are exempt from POA reporting because they? Are always present on admission & represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury CMS delegates its daily operations of the Medicare and Medicaid programs to: A. the office of Inspector General B. the PRO in each state C. the National Center for Vital and Health Statistics D. Medicare administrative contractor (MAC) Medicare administrative contractor (MAC) Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? (Uniform Hospital Discharge Data Set) Principal diagnosis Male patient has been diagnosed with benign prostatic hypertrophy & undergoes a transurethral destruction of the prostate by radiofrequency thermotherapy. (Code ICD- 10 - CM for diagnosis & CPT for procedure) N40.0-Benign prostatic hyperplasia without lower urinary tract symptoms 53852 - Transurethral destruction of prostate tissue, by radiofrequency thermotherapy As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the a. doctor's admitting progress note b. nurse's admit note c. review of systems d. discharge summary doctor's admitting progress note Lumbar laminectomy (one segment) for decompression of spinal cord. (Code CPT for procedures) 63005 - Laminectomy, with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy foraminotomy, or discectomy (eg. spinal stenosis), one or two vertebral segments; lumbar except for spondylolisthesis.

Recovery Audit Contractors (RAC's) The are the organizations that contract with medicare to perform reviews of medical records with the corresponding Medicare claims to detect & correct improper payments Patient has a breast carcinoma and is now undergoing complete axillary lymphadenectomy. (Code for physician using CPT procedure codes only) 38745 - Axillary lymphadenectomies; complete Which of the following could influence a facility's case mix? a) Changes in the services offered by a facility b) Accuracy of coding c) Changes in DRG weights d) All answers apply All answers apply Excision 2 cm subcutaneous soft tissue lipoma of the back. (code for diagnoses using ICD- 9 - CM. Code for procedure using CPT.) D17.1-Benign lipomatous neoplasm of skin & subcutaneous tissue of trunk 21930 - Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm The Joint Commission requires that all medical records be completed within following Patient discharge? 30 Days Provide the CPT code for a patient that had a complicated removal of a wrist prosthesis. 25251 - Removal of wrist prosthesis; complicated, including total wrist 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? They should both be coded, acute sequenced first. Patient presents to the GI Lab for a colonoscopy, during the colonoscopy, adenomatous polyps were discovered in the acending colon & the transverse colon. Polyps in the ascending colon were removed via biopsy forceps, & the polyps in the transverse colon were removed by snare technique. D12.2-Benign neoplasm of ascending colon D12.3-Benign neoplasm of the transverse colon 45384 - Colonoscopy with removal of polyps, hot biopsy forceps. 45385 - Colonoscopy with removal of polyps, snare technique.

• 59 Distinct procedural service

What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, & verbal or physical conduct of a sexual nature made in return for job benefits? Quid Pro Quo CPT code(s) for a laparoscopic takedown of the splenic flexure & a partial colectomy with anastomosis? 44204 - Colectomy, partial, with anastomosis. 44213 - Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy is a system for documenting the extent or spread of cancer? Staging Which of these conditions are always considered "present on admission" (POA)? a) Congenital conditions b) Possible, probable, or suspected conditions c) Acute conditions d) Z codes Congenital conditions Patient came to the hospital ambulatory surgical center for repair of incisional inguinal hernia. This is the second time the patient has developed this problem. The hernia was repaired with Gore-Tex graft. Choose the appropriate ICD- 10 - CM and CPT codes? K40.91-Inguinal hernia, without obstruction or gangrene, recurrent. 49565 - Repair recurrent incisional or ventral hernia, reducible (flatens out when you lie down or press it) 49568 - Implantation of mesh or other prosthesis for incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft tissue infection. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." What should be coded as the patient's diagnosis? Chronic cough A patient presents with dermatitis due to prescription topical antibiotic cream used as directed by physician L25.1-Unspecified contact dermatitis due to drugs in contact with skin. T49.0X5A-Adverse effect of local antifungal, anti-infective & anti-inflamatory drugs. Patient with carpal tunnel comes in for an open carpal tunnel release, right hand. (Code ICD- 9 - CM for diagnoses & CPT for procedures.

G56.01-Carpal tunnel syndrome, right upper limb 64721 - Neuroplasty and/or transposition; median nerve at carpal tunnel. MS-Drg Relative # of Patients Identifier Weight with MS- A 1.234 x 12 = 14. B 3.122 x 10 = 31. C 2.165 x 19 = 41. D 5.118 x 16 = 81. total = 169.051/57 = (2.965807) 12+10+19+16= Based on the sample MS-DRG report above, what is the case mix index for this facility.this facility. a) 42. b) 2. c) 2. d) 11. 2.965807 (RW x #PWMS) A thru D =169.051 /57 Total #PWMS When a patient is admitted because of a primary neoplasm with metastasis & treatment is directed toward the secondary neoplasm only how should it be coded? The secondary neoplasm is coded as the principle diagnosis & the primary neoplasm is coded as an additional diagnosis. A 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 A. $2,655. B. 11%. C. $265. D. 0.9%. Calculation: $2,655 × 100 divided by $25,000 = 10.6 = 11% WATERSIDE HOSPITAL CODING PRODUCTIVITY WEEK ENDING JANUARY 2, 2016 EMPLOYEE NUMBER 425,426,427, INPATIENT 120,48,80, OUTPATIENT PROCEDURE 35,89,92, OUTPATIENT OBSERVATION OR EMERGENCY RECORDS 16,95,4, The performance standard for coders is 28 - 33 workload units per day. Workload units are calculated as follows: Inpatient records = 1 workload unit Outpatient surgical procedure records = 0.75 workload units Outpatient observation/Emergency records = 0.50 workload units

One week's productivity information is shown in the preceding table. What percentage of the coders is meeting the productivity standards? A. 100% C. 50% B. 75% D. 25% 100% employee # 425: 120 + (35 × 0.75) + (16 × 0.5) = 154. 154.25/5 = 30.85 average work units per day employee # 426: 48 + (89 × 0.75) + (95 × 0.5) = 162. 162.25/5 = 32.45 average work units per day employee # 427: 80 + (92 × 0.75) + (4 × 0.5) = 151 151/5 = 30.2 average work units per day employee # 428: 65 + (109 × 0.75) + (16 × 0.5) = 154. 154.75/5 = 30.95 average work units per day Hysteroscopy with D&C and polypectomy (Code CPT for procedure). 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D&C A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) a. explaination of benefits b. remittance advice c. advance beneficiary notice d. CMS- 1500 claim form advance beneficiary notice Patient has tear of the medial meniscus with loose bodies in the medial compartment of the left knee that was repaired by arthroscopic medial meniscectomy, shaving and trimming of meniscal rim, resection of synovium, and removal of the loose bodies. (Code using CPT procedure codes). 29881 - LT (left side of body) 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) A final progress note is appropriate as a discharge summary for a hospitalization in which the patient a. dies within 24 hours of admission b. has no comorbidities or complications during this episode of care

c. was admitted within 30 days with the same diagnosis d. was an obstetric admission with a normal delivery and no complications was an obstetric admission with a normal delivery and no complications Patient was seen today for regular hemodialysis. No problems reported; patient tolerated procedure well. 90935 Hemodialysis procedure with single physician evaluation When coding multiple wound repairs in CPT. all wound repairs are coded with the most complex reported first Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker. 00530 Anesthesia for permanent transvenous pacemaker insertion Patient was seen for excision of two interdigital neuroma from the left foot. (a painful growth in the forefoot). 28080 x 2 Excision, interdigital (Morton) neuroma, single, each You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the: a. prenatal record b. labor record c. delivery room record d. postpartum record d. postpartum record Which of the following statements is true? a. A surgical procedure may include one or more surgical operations. b. The terms surgical operation and surgical procedure are synonymous. c. A surgical operation may include one or more surgical procedures. d. The term surgical procedure is an incorrect term and should not be used. A surgical operation may include one or more surgical procedures. A patient has a total abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes:

58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s) with or without removal of ovary(s) 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure) This type of coding is referred to as: a) Optimization b) Upcoding c) Unbundling D) Maximizing Unbundling D&C for missed abortion, first trimester (Code CPT for procedures). 59820 Treatment of missed abortion, completed surgically; first trimester Which of the following contains a list of coding edits developed by CMS in an effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services? a. National Coverage Determination (NCD) b. National Correct Coding Initiative (NCCI) c. CPT Assistant d. Healthcare Common Procedure Coding System (HCPCS) National Correct Coding Initiative (NCCI) The patient presents for a screening examination for lung cancer? Z12.2 Encounter for screening for malignant neoplasm of respiratory organs Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis (Stroke). Surgery is subsequently canceled. Code and sequence the coding from the following codes: K80.10 Calculus of gallbladder with chronic cholecystitis without

obstruction 166.9 Occlusion & stenosis of unspecified cerebral artery Z53.09 Procedure & treatment not carried out because of other contraindication 197.821 Postprocedural cerebrovascular infarction following other surgery OFT40ZZ Resection of gallbbladder, open aproach (Cholecystectomy) a) 197.821, K80.10, OFT40ZZ b) 197.821, 166.9, Z53. c) 166.9, Z53. d) K80.10, 166.9, Z53. K80.10-Calculus of gallbladder with chronic cholecystitis without obstruction 166.9- Occlusion & stenosis of unspecified cerebral artery Z53.09-Procedure & treatment not carried out because of other contraindication Ensuring that data have been modified or accessed only by individuals who are authorized to do so, is a function of data: a) Validity b) Accuracy c) Integrity d) Quality Integrity Which of the following diagnoses or procedures would prevent the normal delivery code, 650, from being assigned? a) occiput presentation b) single liveborn c) episiotomy d) low forceps low forceps An newborn has hypoglycemia with mother diagnosed with type 2 diabetes mellitus 2 years ago?

P70.1 Syndrome of infant of a diabetic mother. Present on Admission (POA) indicators apply to: a) inpatient reporting of diagnosis codes b) outpatient reporting of procedure codes c) inpatient reporting of diagnosis and procedure codes d) outpatient reporting of diagnosis and procedure codes inpatient reporting of diagnosis codes Patient arrives in the emergency room via a medical helicopter. The patient has sustained multiple life- threatening injuries due to a multiple car accidents. The patent goes into cardiac arrest upon arrival. An hour and 30 minutes of critical care time is spent trying to stabilize the patient. 99291 Critical care, evaluation & management of the critically ill or critically injuredpatient: first 30 - 70 minutes. 99292 Each additional 30 minutes (list separately in addition to code for primary service) You have been hired to work with a computer-assisted coding initiative. The technology that you will be working with is: a) electronic data interchange b) intraoperability c) message standards d) natural language processing natural language processing Which of the following is classified as a poisoning in ICD- 9 - CM? a) syncope (loss of consciousness) due to Contac pills and a three martini lunch b) digitalis intoxication c) reaction to dye administered for pyelogram d. idiosyncratic reaction between various drugs syncope due to Contac pills and a three martini lunch A patient presents with cervical spina bifida with hydrocephalus (fluid on the brain).

Q05.0-Cervical spinal bifida with hydrocephalus Which of the following are considered sequela regardless of time? a) Congenital defect b) Nonunion c) Nonhealing fracture d) Poisoning Nonunion A woman has a Pap smear that detected cervical high-risk human papillomavirus (HPV). The DNA test was positive. R87.810 Cervical high risk HPV dna test positve Cesarean delivery with antepartum & postpartum care. 59510 - Routine obstetric care incuding antepartum care, cesarean delivery, & postpartum care. Total transcervical thymectomy (Code CPT for procedure). 60520 - Thymectomy, partial or total; transcervical approach (separate procedures) Which of the following would NOT require HCPCS/CPT codes? a) Hospital inpatient procedure b) Clinic visit c) Hospital ambulatory surgery visit d) Hospital outpatient visit Hospital inpatient procedure Security devices that form barriers between routers of a public network & a private network to protect access by unauthorized users are called: a) Data manipulation engines b) Passwords c) Firewalls d) Data translators Firewalls A patient has end-stage kidney disease, which resulted from malignant hypertension.

I12.0- Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease N18.6-End Stage renal disease Chronic kidney disease requiring chronic dialysis 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. 99450 Basic life and/or disability examination that includes completion of a medical history following a life insurance pro forms CPT code(s) for laryngoscopic submucosal removal of nonneoplastic lesion of the vocal cordwith graft reconstruction. An operating microscope was used: 31546 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion's of vocal cord. Reconstruction with graphs (includes taining autograft) CPT code for a laparoscopic gastric restrictive procedure & placement of an adjustable gastric band. c) 43770 - Laparoscopy surgical, gastric restrictive procedure: Placement of adjustable gastric restrictive device. (eg, gastric band & subcutaneous port components) CPT code(s) for a laparoscopic removal & replacement of both a gastric band & the subcutaneous port components? 43659 - Unlisted laparoscopy procedure, stomach Which of the following is vital for determining why the reimbursement from an insurance company is less than what was expected? a) A CPT codebook b) Talking to the patient c) Knowledge of the individual insurance company's policies. d) The remittance advice The remittance advice The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis, This is called? a) Hard coding b) Soft coding c) Grouping d) Mapping

Hard Coding Patient seen in the emergency department with lacerations on the left arm. Two lacerations, one 7 cm & one 9 cm, were closed with layered sutures 12035 - Repair intermediate 12.6cm to 20.0 cm (the two lacerations are added together) A 4 year old had a repair of an incarcerated inguinal hernia. This is the first time this child has been treated for this condition. a) 49496 b) 49501 c) 49521 d) 49553 49501 - incarcerated or strangulated repair of inguinal hernia age 6 months to under 5 years old) phacoemulsification of left cataract with IOL implant & subconjunctival injection. (Code icd- 10 - cm for diagnosis and CPT for procedure) a) H26.9, 66940 - LT b) H26.9, 66984 - LT c) H26.9, 66983, 68200 d) H26.9, 66984 - LT, 68200 - LT H26.9-Unspecified cataract 66984 - LT-Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure) manual or mechanical technique (eg, irrigation & aspiration or phacoemulsification) Left side Which of the following is NOT related to diagnosing hypothyroidism? a) Elevated liver enzymes & creatine b) A decrease in serum cholesterol & prolactin c) An increase in TSH d) An increase in serum cholesterol & prolactin A decrease in serum cholesterol & prolactin The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. a) 35302 b) 35226 c) 34203 d) 37799 34203 - (Embolectomy/Thrombectomy arterial, with or without catheter). Popliteal-tibio-peronealartery, by leg incision.

A patient is diagnosed with psychogenic paroxysmal tachycardia a) I47.9, F b) I47. c) F d) I47.8, F I47.9-Paroxysmal tachycardia unspecified F54-Psychological & behavioral factors associated with disorders or diseases classified elsewhere. Patient presents with a diabetic ulcer measuring 18 sq cm that needs to be debrided. The patient was taken to the operating room where debridement of the muscle took place. a) 11400 b) 15999 c) 11043 d) 11011 11043 - Debridement, muscle and/or fascia (includes epidermis, dermis, & subcutaneous tissue, if performed) first 20 sq cm or less Patient presents to the hospital and undergoes a posterior L1-L5 spinal fusion for scoliosis with placement of a Harrington rod. Code using CPT. a) 22800, 22842 b) 22800, 22846 c) 22612, 22800, 22841 d) 22800, 22840 22800 - Arthrodesis, posterior, for spinal deformity, with/without cast, up to 6 vertebral segments 22840 - Posterior non-segmental instrumentation (Harrington rod technique, pedicle fixation accross 1 interspace. Using the ICD- 10 - CM code structure, which of the following would be used for "right upper quadrant abdominal tenderness." a) R10. b) R1. c) R108.1 1 d) R10811.

R10.811-Right upper quadrant abdominal tenderness. The has the duty to adjust the MS-DRG's if necessary at the beginning of every fiscal year beginning? a) CMS, January 1 b) CMS, October 1 c) IG, October 1 d) AHA, January 1 CMS (Centers for Medicare & Medicaid Services), October 1 A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist. CPT code? a) 77315 b) 77334 c) 77307 d) 77263 77263 - (Clinical Treatment Planning) Complex The APC payment system is based on what coding system(s)? a) CPT/HCPCS codes b) ICD- 10 - CM diagnosis & procedure codes c) AMA's CPT codes d) CPT & ICD- 10 - CM diagnosis & procedure codes CPT/HCPCS codes Which of the following scenarios identifies a pathologic fracture? a) Greenstick fracture secondary to fall from a bed b) vertebral fracture with cord compression following a car accident c) compression fracture of the vertebrae as a result of bone metastasis d) compression fracture of the skull after being hit with a baseball bat Compression fracture of the vertebrae as a result of bone metastasis Four people were seen in your emergency department yesterday. Which one will be coded as a poisoning?

David for mixing alcohol & perscription drugs All of the following signs/symptoms suggest gram-negative pneumonia EXCEPT? a) Patchy infiltrate b) Fever c) Purulent sputum d) Decreased leukocyte count Decreased leukocyte count A patient is admitted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes? a) "U" b) "N" c) "W" d) "Y" "N" The special form that plays the central roll in planning and providing care at nursing, psychiatric, & rehabilitation facilities is the? a) Problem list b) Interval summary c) Interdisciplinary patient care plan d) Medical history & review of systems Interdisciplinary patient care plan The purpose of the Correct Coding initiative (CCI) is to? a) Teach coders how to unbundle codes b) Increase fines & penalties for bundling services into comprehensive CPT codes. c) Restrict Medicare reimbursement to hospitals for ancillary services. d) Detect & prevent payment for improperly coded services. Detect & prevent payment for improperly coded services. Your organization is sending confidential patient information across the internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called? a) A firewall b) Validity processing

c) Data encryption d) A cell-back process Data encryption In reviewing a medical record for coding purposes, the coder notes that the discharge summary has not yet been transcribed. In its absence, the best place to look for the patient's response to treatment & documentation of any complications that may have developed during this episode of care is in the? a) Doctor's orders b) Doctor's progress note section c) History & physical d) Operative report Doctor's progress note section