Medical Coding and Billing Certification Exam Questions and Answers 2025, Exams of Nursing

Download Medical Coding and Billing Certification Exam Questions and Answers 2025 and more Exams Nursing in PDF only on Docsity! 1 1 | P a g e Medical Coding and Billing Certification Actual Exam Questions and Answers 2025 What symptoms are included in ROS (Review of Systems) for Ear, Nose,Mouth, Throat (Otolaryngologic) Classification - CORRECT ANSWER >>>>- Ears: hearing discharge, tinnitus, dizziness, pain - Nose: head colds, epistaxsis (nosebleed),discharges, obstruction, postnasal drip, sinus pain - Mouth and throat: condition of teeth and gums, last dental examination, soreness, redness, hoarseness, difficulty in swallowing What symptoms are included in ROS (review of Systems) for Cardiovascular Classification - CORRECT ANSWER P a g e 1 | 23 2 2 | P a g e >>>>- Chest pain, rheumatic fever, tachycardia, palpitation, high blood pressure, edema, vertigo, faintness, varicose veins, thrombophlebitis What symptoms are included in ROS for Respiratory Classification - CORRECT ANSWER >>>>- Chest pain, wheezing, cough, dyspnea, sputum, (color and quantity), hemopytsis, asthma, bronchitis, emphysema, pneumonia, tuberculosis, pleuirisy, last chest radiogeraph What symptoms are included in ROS for Gastrointestinal Classification - CORRECT ANSWER >>>>- Appetite, thirst, nausea, vomiting, hematemesis, rectal bleeding, change in bowed habits, diarrhea, constipation, indigestion, food intolerance, flatus, hemorrhiods, jaundice. What symptoms are included in ROS for Urinary Classification - CORRECT ANSWER >>>>- frequent or painful urination, nocturia, pyuria, hematuria, incontinence, urinary infection, What symptoms are included in ROS for Genitoreproductive Classification - CORRECT ANSWER >>>>Male: - veneral disease, sores, discharge from penis, hernias, testicular pain or masses P a g e 2 | 23 5 5 | P a g e - Age-appropriate immunization status - Age-appropriate feeding/dietary status What items are included in the category of Family History - CORRECT ANSWER >>>>Significant information about: - the health status or cause of death of parents, siblings, and children - Specific diseases related to problems identified in the CC, HPI, or ROS What items are included in the category of Social History - CORRECT ANSWER >>>>An age-appropriate review of past and current activities that include significant information about: - Marital status and/or living arrangements - Current employment - Occupational history -Use of drugs, alcohol, and tobacco - Level of education - Sexual history - Other relevant social history How many elements of a history are always included in varying degrees in all patient encounters - CORRECT ANSWER >>>>Three (3); - HPI P a g e 5 | 23 6 6 | P a g e - ROS - PFSH How is the degree, level of HPI, ROS, and PFSH determined - CORRECT ANSWER >>>>They are determined by the CC (Chief complaint) or presenting problem of the patient during the current encounter that is being documented. How many history levels are there, and what are they? - CORRECT ANSWER >>>>There are four levels - Problem focused - Expanded problem focused - Detailed - Comprehensive What are the History levels based on to determine the level? - CORRECT ANSWER >>>>History levels are based on the extent of the history taken and the answered received during that process of the examination. They must be documented in the Medical Records in order to be referenced in the choice of History level. What are the items included in a Problem Focused History level? - CORRECT ANSWER >>>>The Dr. focuses P a g e 6 | 23 7 7 | P a g e on the CC and a brief history of the present problem of a patient. A brief history includes" - A review of the history regarding pertinent information about the present problem or CC. - It centers around the severity, duration, and symptoms of the CC. - Does not have to include PFSH or ROS. What are the items included in a Expanded Problem Focused History level? - CORRECT ANSWER >>>>The Dr. focuses on the CC, obtains a brief history of the present provblem, also performs a problem-pertinent review of systems. This hx includes: - a review of the Organ System (OS) most closely related to the CC - It requires 1 - 3 HPI elements, 1 OS mostly related to the CC, no PSFH What are the items included in a Detailed focused History level? - CORRECT ANSWER >>>>The Dr. focuses on a CC and obtains an extended history of the present problem, and extended ROS, and a pertinent PFSH directly related to the patient's problem. - The extended ROS includes a review of the system directly related to the CC P a g e 7 | 23 10 10 | P a g e - Abdomen - Genitalia, groin, buttocks - Back - Each extremity What are the Organ Systems that could be listed in an examination (OS) - CORRECT ANSWER >>>>- Ophthalmologic (eyes) - Otolaryngologic (ENT) - Cardiovascular - Respiratory - Gastrointestinal - Genitourinary - Musculoskeletal - Integumentary (skin) - Neurologic - Psychiatric - Hematologic/Lympohatic/Immunologic What are the items included in a Problem focused examination - CORRECT ANSWER >>>>It is limited to the affect OS or BA. Includes 1 OS or BA What are the items included in an Expanded problem focused examination - CORRECT ANSWER >>>>It ia a P a g e 10 | 23 11 11 | P a g e limited examination of the affected BA or OS and other related BA's or OS's. It involves a limited examination of 2 - BAs or OSs. What are the items included in a Detailed examination. - CORRECT ANSWER >>>>It is an extended examination of the affected BA's or related Os's It involves an extended examination of 2 - 7 BAs or OSs. What are the items included in a Comprehensive examination. - CORRECT ANSWER >>>>This is the most extensive examination; it includes at least 8 BAs or OSs. What is the difference of the expanded and detailed examination, containing 2 - 7 Ba's or OSs. - CORRECT ANSWER >>>>The difference: - The expanded problem focused examination is limited and is focused on the BA/OS of the CC and the other directly related BAs, OSs. - The detailed examination is extended and covers not only the related BAs/OSs, but also BAs/OSs not directly related to the CC. What does MDM stand for - CORRECT ANSWER >>>>Medical Decision Making P a g e 11 | 23 12 12 | P a g e What are the three elements that MDM are based on - CORRECT ANSWER >>>>1. Number of Dx or management options. They can be minimal, limited, multiple, or extensive 2. Amount or complexity of data to review. The data can be minimal/none. limited, moderate, or extensive. 3. Risk of complications or death, if the condition goes untreated. Risk can be minimal, low, moderate, or high What does the number of Dx or management options the must exist for pertinent documentation to choose the correct level of MDM - CORRECT ANSWER >>>>For each encounter, an assessment, clinical impression, or Dx should be documented. it can be explicitly stated or implied in documented decisions regarding management plans or further evaluation What documentation should be included in the medical records to uphold and determine the level of MDM for a presenting problem (CC) - CORRECT ANSWER >>>>With an established dx: The record should reflect whether the problem is - a improved, well-controlled, resolving, or resolved - inadequately controlled, worsening or failing to respond Without an established dx: The record may be stated as a differential diagnoses or as P a g e 12 | 23 15 15 | P a g e What are some of the basic documentation guidelines for risk of significant complications, morbidity, or mortality? - CORRECT ANSWER >>>>1.Factors that increased the complexity of MDM should be documented - comorbilities -underlying diseases -or other factors 2- If a specific surgical or invasive diagnostic procedure is ordered during the E/M evaluation, document it. 3. If a surgical or invasive diagnostic procedure is performed during the E/M encounter, than document it. 4. If a referral for or decision to perform a surgical or invasive diagnositc procedure is performed on an urgent basis, then document it. What are the levels of risk to determine MDM complexity - CORRECT ANSWER >>>>- Straightforward - Low - Moderate - High What is straightforward decision making? - CORRECT ANSWER >>>>-Minimal diagnosis and/or management options -Minimal/no amount of complexity of data reviewed P a g e 15 | 23 16 16 | P a g e -Minimal risk to the patient of complications/or death if untreated What is low-complexity decision making? - CORRECT ANSWER >>>>-Limited number of diagnoses/or management options -Limited data to be reviewed -Low risk of death/complications to patient if untreated What is Moderate-complexity decision making? - CORRECT ANSWER >>>>-Multiple diagnoses and/or management options -Moderate amount/complexity of data to be reviewed -Moderate risk to the patient of complications or death if untreated. What is High-complexity decision making? - CORRECT ANSWER >>>>-Extensive diagnoses and/or management options -Extensive amount/complexity of data to be reviewed -High risk to the patient for complications or death if the problem is untreated How many elements of a given level of must be met to select a MDM Level? - CORRECT ANSWER >>>>Two to three elements must be met or exceed. P a g e 16 | 23 17 17 | P a g e How many elements of a given level must be met to select a History level? - CORRECT ANSWER >>>>All three elements of the given History level must be met or exceeded. What are contributing factors when choosing a MDM level? - CORRECT ANSWER >>>>There are four: -Counseling -Coordination of care -Nature of the presenting problem -Time What is a definition of contributing factors? - CORRECT ANSWER >>>>Contributing factors are: those conditions that help the physician to determine the extent of history, examination, and decision making (key components) necessary to treat a patient. What is counseling? - CORRECT ANSWER >>>>Counseling is a service that physicians provide to patients and their families. It includes: -Discussion of diagnostic results, impressions, recommended diagnostic studies -prognosis -risks and benefits of treatment P a g e 17 | 23 20 20 | P a g e What is a Moderate severity presenting problem? - CORRECT ANSWER >>>>The risk of complete sickness (morbidity) without treatment is moderate -there is moderate risk of death without treatment -an uncertain prognosis or increased probability of impairment exists. What is a High severity presenting problem? - CORRECT ANSWER >>>>The risk of complete sickness (morbidity) without treatment is high to extreme, -there is a moderate to high risk of death without treatment -a strong probability of severe, prolonged functional imparment Which of the following entities is responsible for implementing the various provisions of HIPAA in Health Care? - CORRECT ANSWER >>>>D. Centers for Medicare and Medicaid Services (CMS) Which of the following is not a key component in selecting a level of Evaluation and Management (E/M) services? - CORRECT ANSWER >>>>B. Date P a g e 20 | 23 21 21 | P a g e When an non-member physician treats an HMO patient, the service rendered is termed: - CORRECT ANSWER >>>>D. Out of Plan or out of Network New Codes in the CPT Manual are represented by: - CORRECT ANSWER >>>>C. A solid circle The Medical Program for dependents of active military personnel is called: - CORRECT ANSWER >>>>B. TRICARE When a code has less than 6 characters and a 7th character applies, it is appropriate to leave a space in the code? - CORRECT ANSWER >>>>False A sequela of an injury is reported with the code that describes the sequela followed by the code for the injury with 7th character 'S'. - CORRECT ANSWER >>>>True Karen has been in a car accident and broke her arm. Which volume will you refer to first to find a code representing her problem? - CORRECT ANSWER >>>>C. Volume 3 - The Alphabetical Index. In which chapter would you find a malignant cancer of the esophagus? - CORRECT ANSWER >>>>Chapter XXI - P a g e 21 | 23 22 22 | P a g e Factors influencing health status and contact with health services (Z00-Z99) In which chapter would you find a malignant cancer of the esophagus? - CORRECT ANSWER >>>>A. Chapter II Neoplasms A veteran's wife needs to go to the doctor. Her husband's leg was cut off due to a explosion in Afghanistan. Which insurance is she likely to have? - CORRECT ANSWER >>>>B. CHAMPVA In the diagnostic statement "eye dryness from insufficient tear production" the primary diagnosis is - CORRECT ANSWER >>>>C. Insufficient tear production Health policies concerning the patient's constitutional right to privacy, confidentiality, and informed consent are a part of: - CORRECT ANSWER >>>>Patient's Bill of Rights Services that are not covered by an insurance plan are referred to as: - CORRECT ANSWER >>>>D. Exclusions P a g e 22 | 23