Medical Coding and Documentation Practices, Exams of Nursing

Download Medical Coding and Documentation Practices and more Exams Nursing in PDF only on Docsity!

AHIMA CCA- Exam

2023 - 2024

A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Ruptured appendix b. Exploratory laparoscopy c. Abdominal pain d. Cholelithiasis - Answer-c. Abdominal pain The nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331).

3. An individual stole and used another person's insurance information to obtain medical care. This action would be considered: a. Violation of bioethics b. Fraud and abuse c. Medical identity theft d. Abuse - Answer-c. Medical identity theft Correct Answer: 84. c. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity without the victim's knowledge or consent to obtain medical services or goods (Johns 2011, 773).

Identify the ICD- 9 - CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus. a. 730. b. 730.

c. 730.07, 041. d. 730.07, 041.10 - Answer-d. 730.07, 041. Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger 2012, 305-306).

A system that provides alerts and reminders to clinicians is a(n): a. Clinical decision support system b. Electronic data interchange c. Point of care charting system d. Knowledge database - Answer-Correct Answer: A Clinical decision support includes providing documentation of clinical findings and procedures, active reminders about medication administration, suggestions for prescribing less expensive but equally effective drugs, protocols for certain health maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-making aids for all stakeholders in the care process (Johns 2011, 138).

What does an audit trail check for? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup - Answer-Correct Answer: A Audit trails can provide tracking information such as who accessed which records and for what purpose (Johns 2011, 403).

This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with bradyarrhythmias. Prolonged ambulatory monitoring may be indicated

to establish a diagnosis of this condition. Treatment includes insertion of a permanent cardiac pacemaker. a. Atrial fibrillation (427.31) b. Atrial flutter (427.32) c. Paroxysmal supraventricular tachycardia (427.0) d. Sick sinus syndrome (SSS) (427.81) - Answer-d. Sick sinus syndrome (SSS) (427.81) Correct Answer: D SSS is the imprecise diagnosis with various characteristics treated with the insertion of a permanent cardiac pacemaker. The other three conditions are treated with cardioversion and different pharmacological therapy (Schraffenberger 2012, 194 - 195).

Identify the ICD- 9 - CM diagnostic code for primary localized osteoarthrosis of the hip. a. 715. b. 715. c. 721. d. 715.16 - Answer-b. 715. Correct Answer: B Index Osteoarthrosis, localized, primary. For category 715, refer to the table for the fifth digit of 5 for pelvic region and thigh (Schraffenberger 2012, 303- 304).

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record - Answer-Correct Answer: B An incomplete record not rectified within a specific number of days as indicated in the medical staff rules and regulations is considered to be delinquent (Johns 2011, 412).

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? a. Chart deficiency system b. Chart tracking system c. Chart abstracting system d. Chart encoder - Answer-Correct Answer: B With an automated tracking system, it is easy to track how many records are charged out of the system, their location, and whether they have been returned on the due dates indicated (Johns 2011, 402).

Identify the appropriate ICD- 9 - CM diagnosis code for Lou Gehrig's disease. a. 335. b. 334. c. 335. d. 335.2 - Answer-Correct Answer: A Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is another name for Lou Gehrig's disease. Many diseases carry the name of a person or an eponym. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).

In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel? a. Report the remaining tests using individual test codes, according to CPT. b. Do not report the remaining individual test codes. c. Report only those test codes that are part of a panel.

d. Do not report a test code more than once regardless whether the test was performed twice. - Answer-Correct Answer: A Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (AMA 2012b, 402).

An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of: a. Optimizing b. Unbundling c. Sequencing d. Classifying - Answer-Correct Answer: B Unbundling occurs when a panel code exists and the individual tests are reported rather than the panel code (AMA 2012b, 402).

Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery. a. Combined right and left (88.54) b. Stones (88.55) c. Judkins (88.56) d. Other and unspecified (88.57) - Answer-Correct Answer: C The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material (Schraffenberger 2012, 206). Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the:

a. Discharge summary b. Autopsy report c. Incident report d. Consent to treatment - Answer-Correct Answer: A The discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged (Johns 2011, 78).

This document includes a microscopic description of tissue excised during surgery: a. Recovery room record b. Pathology report c. Operative report d. Discharge summary - Answer-Correct Answer: B The pathology report describes specimens examined by the pathologist (Johns 2011, 77).

CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set? a. Diagnosis-related groups b. HCPCS/CPT codes c. ICD- 9 - CM diagnosis and procedure codes d. Resource utilization groups - Answer-Correct Answer: B CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system which pays providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2012b).

Identify the ICD- 9 - CM diagnostic code for other specified aplastic anemia secondary to chemotherapy. a. 284. b. 284. c. 285. d. 285.22 - Answer-Correct Answer: B Index Anemia, aplastic, due to, antineoplastic chemotherapy. A coder should always assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic (Schraffenberger 2012, 133-135 ).

When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? a. Assign the removal by snare technique code. b. Assign the removal by hot biopsy forceps code. c. Assign the ablation code. d. Query the physician as to the method used. - Answer-Correct Answer: D It is not appropriate for the coder to assume the removal was done by either snare or hot biopsy forceps. The ablation code is only assigned when a lesion is completely destroyed and no specimen is retrieved. The coding professional must query the physician to assign the appropriate code (AHIMA 2012a, 607).

What is the best reference tool to determine how CPT codes should be assigned? a. Local coverage determination from Medicare b. American Medical Association's CPT Assistant newsletter c. American Hospital Association's Coding Clinic d. CMS website - Answer-Correct Answer: B CPT Assistant provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly (AMA 2012b).

Identify the appropriate ICD- 9 - CM diagnosis code(s) for right and left bundle branch block. a. 426.3, 426. b. 426. c. 426.4, 426. d. 426.52 - Answer-Correct Answer: B Index Block, left, with right bundle branch block. Right and left bundle branch block is inclusive of one code. It is inappropriate to assign a code for right (426.4) and left (426.3) bundle branch block when a combination code includes both the right and left (Schraffenberger 2012, 201-207).

A software interface is a: a. Device to enter data b. Protocol for describing data c. Program to exchange data d. Standard vocabulary - Answer-Correct Answer: C A software interface is a computer program that allows different applications to communicate and exchange data (Johns 2011, 137).

What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims? a. Outpatient Perspective Payment System (OPPS) b. National Correct Coding Initiative (NCCI) c. Ambulatory Payment Classifications (APCs) d. Comprehensive Outpatient Rehab Facilities (CORFs) - Answer-Correct Answer: B

CMS developed the NCCI to control improper coding practices leading to inappropriate payments in Part B claims (CMS 2012a).

Identify the appropriate diagnostic and/or procedure ICD- 9 - CM code(s) for reprogramming of a cardiac pacemaker. a. V53. b. 37. c. V53. d. V53.31, 37.85 - Answer-Correct Answer: A Index Fitting (of) pacemaker (cardiac). No procedure code exists in ICD- 9 - CM to describe reprogramming (Schraffenberger 2012, 204-205).

Which of the following hospitals are excluded from the Medicare acute-care prospective payment system? a. Children's b. Small community c. Tertiary d. Trauma - Answer-Correct Answer: A Children's hospitals are excluded from PPS because the PPS diagnosis-related groups do not accurately account for the resource costs for the types of patients treated (Johns 2011, 321).

Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards? a. Internal DRG audits b. Peer review c. Managed care d. Quality improvement - Answer-Correct Answer: D

Quality improvement (QI) programs have been in place in hospitals for years and have been required by the Medicare/Medicaid programs and accreditation standards. QI programs have covered medical staff as well as nursing and other departments or processes (LaTour and Eichenwald Maki 2010, 33).

Identify the code for a patient with a closed transcervical fracture of the epiphysis. a. 820. b. 820. c. 820. d. 820.01 - Answer-Correct Answer: D Index Fracture, femur, epiphysis, capital. Fifth digits are required for further classification of a specific condition. Many publishers include special symbols and/or color highlighting to identify codes that require a fourth or fifth digit (Schraffenberger 2012, 7).

What is the best source of documentation to determine the size of a removed malignant lesion? a. Pathology report b. Post-acute care unit record c. Operative report d. Physical examination - Answer-Correct Answer: C The total size of a removed lesion, including margins, is needed for accurate coding. This information is best provided in the operative report. The pathology report typically provides the specimen size rather than the size of the excised lesion. Because the specimen tends to shrink, this is not an accurate measurement (Kuehn 2012, 110-111).

Which of the following definitions best describes the concept of confidentiality? a. The right of individuals to control access to their personal health information b. The protection of healthcare information from damage, loss, and unauthorized alteration

c. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information - Answer-Correct Answer: C Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose (Johns 2011, 49).

Identify the ICD- 9 - CM diagnosis code for Paget's disease of the bone (no bone tumor noted). a. 170. b. 213. c. 238. d. 731.0 - Answer-Correct Answer: D Index Paget's disease, bone. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).

Which of the following fails to meet the CMS classification of a hospital-acquired condition? a. Foreign object retained after surgery b. Air embolism c. Gram-negative pneumonia d. Blood incompatibility - Answer-Correct Answer: C Gram-negative pneumonia (Johns 2011, 326).

Which of the following is (are) the correct ICD- 9 - CM procedure code(s) for cystoscopy with biopsy? a. 57.

b. 57.32, 57. c. 57. d. 57.39 - Answer-Correct Answer: C Index Cystoscopy (transurethral), with biopsy (Schraffenberger 2012, 251).

Identify the ICD- 9 - CM diagnosis code for chondromalacia of the patella. a. 717. b. 733. c. 748. d. 716.86 - Answer-Correct Answer: A Index Chondromalacia, patella (Schraffenberger 2012, 303-304).

Identify the ICD- 9 - CM diagnosis code for blighted ovum. a. 236. b. 661. c. 631. d. 634.90 - Answer-Correct Answer: C Index Ovum, blighted (Schraffenberger 2012, 282-283).

Each year the OIG develops a work plan that details areas of compliance it will be investigating for that year. What is the expectation of the hospital in relation to the OIG work plan? a. Hospitals are required to follow the same work plan and deploy audits based on that work plan. b. Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan.

c. Hospitals must not develop their audits based on the OIG work plan; rather, they must develop their own and look for high-risk areas that need improvement. d. Hospitals must use the plan developed by their state hospital association that is specific to state laws and compliance activities. - Answer-Correct Answer: B Hospitals are encouraged but not required to follow the same work plan as the OIG. Hospitals should review the plan carefully and plan their compliance program around the target areas (Johns 2011, 275).

The _____ may contain information about diseases among relatives in which heredity may play a role. a. Physical examination b. History c. Laboratory report d. Administrative data - Answer-Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Johns 2011, 63).

There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further define removal of foreign body (45379); biopsy, single or multiple (45380); and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule? a. Unbundling b. Optimizing c. Sequencing d. Maximizing - Answer-Correct Answer: A The coder should assign the most comprehensive code to describe the entire procedure performed. When a code describes the entire service provided, the coder should not code each component separately. Assigning additional codes inherent to the main code would be a form of unbundling (Hazelwood and Venable 2012, 336).

Corporate compliance programs were released by the OIG for hospitals to develop and implement their own compliance programs. All of the following except _____ are basic elements of a corporate compliance program. a. Designation of a Chief Compliance Officer b. Implementation of regular and effective education and training programs for all employees c. Medical staff appointee for documentation compliance d. The use of audits or other evaluation techniques to monitor compliance - Answer- Correct Answer: C Seven elements are required as part of the basic elements of a corporate compliance program and a medical staff appointee is not one of them (Johns 2011, 274).

The electronic claim format (837I) replaces which paper billing form? a. CMS- 1500 b. CMS-1450 (UB-04) c. UB- 92 d. CMS- 1400 - Answer-Correct Answer: B The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing form (Johns 2011, 343).

According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary - Answer-Correct Answer: C According to the Joint Commission, except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no

more than seven days before the surgery is to be performed (Odom-Wesley et al. 2009, 150).

The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of: a. Confidentiality b. Privacy c. Integrity d. Security - Answer-Correct Answer: B Privacy is the right of an individual to be left alone. It includes freedom from observation or intrusion into one's private affairs and the right to maintain control over certain personal and health information (Johns 2011, 755).

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of: a. Transaction standards b. Content and structure standards c. Vocabulary standards d. Security standards - Answer-Correct Answer: C Vocabulary standards establish common definitions for medical terms to encourage consistent descriptions of an individual's condition in the health record (Johns 2011, 227).

An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system? a. DEEDS b. EMEDS

c. UACDS d. UHDDS - Answer-Correct Answer: C Uniform Ambulatory Care Data Set (Odom-Wesley et al. 2009, 310).

Identify the ICD- 9 - CM diagnostic code for diastolic dysfunction. a. 428. b. 428. c. 428. d. 429.9 - Answer-Correct Answer: D Index Dysfunction, diastolic (Schraffenberger 2012, 182-183).

Identify the appropriate ICD- 9 - CM procedure code(s) for a double internal mammary- coronary artery bypass. a. 36.15, 36. b. 36. c. 36. d. 36.12, 36.16 - Answer-Correct Answer: C Index Bypass, internal mammary-coronary artery (single), double vessel (36.16). Internal mammary-coronary artery bypass is accomplished by loosening the internal mammary artery from its normal position and using the internal mammary artery to bring blood from the subclavian artery to the occluded coronary artery. Codes are selected based on whether one or both internal mammary arteries are used, regardless of the number of coronary arteries involved (Schraffenberger 2012, 203-204).

Identify the CPT code(s) for the following patient: A 2-year-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance. a. 43752 b. 43761

c. 43761, 76000 d. 49450 - Answer-Correct Answer: C Code 43761 is assigned to report repositioning of a nasogastric or orogastric feeding tube through the duodenum. An instructional note guides the coder to report code 76000 when image guidance is performed (AMA 2012b, 235). Which of the following is the correct ICD- 9 - CM procedure code for a Mayo operation known as a bunionectomy? a. 77. b. 77. c. 77. d. 77.51 - Answer-Correct Answer: C Index Bunionectomy or Mayo operation, bunionectomy. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, operation, or disorder (Schraffenberger 2012, 13).

Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Reason for encounter c. Discharge diagnosis d. Activities of daily living - Answer-Correct Answer: B The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider (LaTour and Eichenwald Maki 2010, 166).

How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information

b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met - Answer-Correct Answer: D Surveyors review the documentation of patient care services to determine whether the standards for care are being met (Johns 2011, 40).

Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: "Patient is being admitted for organic brain syndrome." Underneath the diagnosis, her medical information along with her rehabilitation potential were also listed. On which form is this information documented? a. Transfer or referral b. Release of information c. Patient rights acknowledgement d. Admitting physical evaluation - Answer-Correct Answer: A The transfer or referral form provides document communication between caregivers in multiple healthcare settings. It is important that a patient's treatment plan be consistent as the patient moves through the healthcare delivery system (Odom-Wesley et al. 2009, 131).

Which of the following statements is true? a. The higher the relative weight, the higher the payment rates. b. The lower the relative weight, the higher the payment rates. c. The lower the relative weight, the sicker the patient. d. The higher the relative weight, the lesser reimbursement due the facility. - Answer- Correct Answer: A Higher relative weights link to higher payment rates (Casto and Layman 2011, 13).

A coder needs to locate electronic health records for a patient across a health information exchange (HIE). What tool(s) should the coder use?

a. Certification b. Identity-matching algorithm and record locator service c. Interoperability and certification d. Meaningful use - Answer-Correct Answer: B An HIE organization requires an identity-matching algorithm and record locator service (RLS). An identity-matching algorithm must be used by the HIE to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients. The RLS, then, is a process that seeks information about where a patient may have a health record available to the HIE organization (Johns 2011, 151).

All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered this type of data: a. Clinical b. Identification c. Secondary d. Financial - Answer-Correct Answer: A Clinical information is data related to the patient's diagnosis or treatment in a healthcare facility (Odom-Wesley et al. 2009, 55).

What type of data is exemplified by the insured party's member identification number? a. Demographic data b. Clinical data c. Certification data d. Financial data - Answer-Correct Answer: D Financial data include details about the patient's occupation, employer, and insurance coverage (Odom-Wesley et al. 2009, 42).

What is the best reference tool for ICD- 9 - CM coding advice? a. AMA's CPT Assistant b. AHA's Coding Clinic for HCPCS c. AHA's Coding Clinic for ICD- 9 - CM d. National Correct Coding Initiative (NCCI) - Answer-Correct Answer: C AHA's Coding Clinic for ICD- 9 - CM is a quarterly publication of the Central Office on ICD- 9 - CM, which allows coders to submit a request for coding advice through the coding publication.

Identify the ICD- 9 - CM diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, expreemie." a. V20.1, 765. b. V20. c. V20.2, 765. d. V20.2, 765.19 - Answer-Correct Answer: C Index Exam, well baby. Premature, infant NEC. Refer to table in Tabular for fifth digit of "0" to note unspecified birth weight (Schraffenberger 2012, 324-328, ).

Identify the ICD- 9 - CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment cesarean delivery with single liveborn female. a. 661.01, V27.0, 74. b. 661.21, 74. c. 661.01, 74. d. 661.21, V27, 74.1 - Answer-Correct Answer: A Index Delivery, cesarean, poor dilation, cervix (661.0). Refer to the ICD- 9 - CM Tabular (660-669) for the correct fifth digit of "1," delivered, with or without mention of

antepartum condition. Outcome of delivery, single, liveborn. Cesarean section, low uterine segment (Schraffenberger 2012, 282-283).

A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. Yes; HIPAA only requires that current records be produced for the patient. b. Yes; this is hospital policy over which HIPAA has no control. c. No; the records from the previous hospital are considered part of the designated record set and should be given to the patient. d. No; the records from the previous hospital are not included in the designated record set but should be released anyway. - Answer-Correct Answer: C The designated record set includes health records that are used to make decisions about the individual (Johns 2011, 822).

As recommended by AHIMA, HIM compliance policies and procedures should ensure all of the following except: a. Compensation for coders and consultants does not provide any financial incentive to code claims improperly b. The proper selection and sequencing of diagnoses codes c. Proper and timely documentation obtained prior to and after billing d. d The correct application of official coding rules and guidelines - Answer-Correct Answer: C Proper and timely documentation of all physician and other professional services must be obtained prior to billing. Facilities should not provide any financial incentive that may tempt a coder to code claims improperly such as upcoding to higher DRGs, which result in higher pay (Johns 20011, 275).

What reimbursement system uses the Medicare fee schedule? a. APCs

b. MS-DRGs c. RBRVS d. RUG-III - Answer-Correct Answer: C The resource-based relative value scale (RBRVS) system was implemented by CMS in 1992 for physicians' services such as office visits covered under Medicare Part B. The system reimburses physicians according to a fee schedule based on predetermined values assigned to specific services (Johns 2011, 326).

The CIA of security includes confidentiality, data integrity, and data _____. a. Accessibility b. Authentication c. Accuracy d. Availability - Answer-orrect Answer: D Security measures not only provide for confidentiality, but data integrity and data availability—the CIA of security (Johns 2011, 184).

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must the facility meet in order to become certified for these programs? a. Joint Commission Accreditation Standards b. Accreditation Association for Ambulatory Healthcare Standards c. Conditions of Participation d. Outcomes and Assessment Information Set - Answer-Correct Answer: C Participating organizations must follow the Medicare Conditions of Participation to receive federal funds from the Medicare program for services rendered (Johns 2011, 61).

What software will prompt the user through a variety of questions and choices based on the clinical terminology entered to assist the coder in selecting the most appropriate code?

a. Logic-based encoder b. Automated code book c. Speech recognition d. Natural-language processing - Answer-Correct Answer: A Encoders come in two distinct categories: logic-based and automated codebook formats. A logic-based encoder prompts the user through a variety of questions and choices based on the clinical terminology entered. The coder selects the most accurate code for a service or condition (and any possible complications or comorbidities). An automated codebook provides screen views that resemble the actual format of the coding system (LaTour and Eichenwald Maki 2010, 269).

Which of the following is not a function of the discharge summary? a. Providing information about the patient's insurance coverage b. Ensuring the continuity of future care c. Providing information to support the activities of the medical staff review committee d. Providing concise information that can be used to answer information requests - Answer-Correct Answer: A The discharge summary provides an overview of the entire medical encounter to ensure the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians, to provide information to support the activities of the medical staff review committee and to provide concise information that can be used to answer information requests from authorized individuals or entities (Johns 2011, 78).

MS diagnostic-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values - Answer-Correct Answer: C

Major diagnostic categories (MDCs), of which there are 25. The principal diagnosis determines the MDC assignment (Johns 2011, 322).

Identify ICD- 9 - CM diagnosis code for atypical ductal hyperplasia. a. 610.1 b. 610.4 c. 610.8 d. 610.9 - Answer-Correct Answer: C Use this code when the diagnosis is specified as a certain type of "benign mammary dysplasia," and in this case, "ductal" hyperplasia. Index Hyperplasia, breast, ductal, atypical (Schraffenberger 2012, 253).

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced. - Answer-Correct Answer: B It is suggested that covered entities use PHI with certain specified direct identifiers removed as a guideline for disclosing only minimum necessary information while providing the amount needed to accomplish the intended purpose (Johns 2011, 822).

CMS identified conditions that are not present on admission and could be "reasonably preventable," and therefore hospitals are not allowed to receive additional payment for these conditions that do present. What are these conditions called? a. a Conditions of Participation

b. Present on admission c. Hospital-acquired conditions d. Hospital-acquired infection - Answer-Correct Answer: C CMS identified hospital-acquired conditions (not present on admission) as "reasonably preventable," and hospitals do not receive additional payment for cases in which these cases are present (Johns 2011, 326).

Which of the following is (are) the correct ICD- 9 - CM code(s) for laparoscopic cholecystectomy? a. 51.21 b. 51.22, 54.21 c. 51.23, 54.21 d. 51.23 - Answer-Correct Answer: D Index Cholecystectomy (total), laparoscopic (Schraffenberger 2012, 237-238).

The HIM manager is concerned about whether the data transmitted across the hospital network is altered during the transmission. The concept that concerns the HIM manager is: a. Admissibility b. Disclosures c. Availability d. Data integrity - Answer-Correct Answer: D Data integrity services ensure the data are not altered as they are stored or transmitted electronically (Johns 2011, 184).

Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceeds the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking