Medical Coding Questions and Answers, Exams of Nursing

Download Medical Coding Questions and Answers and more Exams Nursing in PDF only on Docsity! 1 1. 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). 2. 84. 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). 3. Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus. a. 730.06 b. 730.07 c. 730.07, 041.1 d. 730.07, 041.10 - Answer d. 730.07, 041.10 2 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). 4. 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). 5. 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). 6. 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) 5 12. 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). 13. 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 6 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). 15. 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). 16. 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). 17. Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to chemotherapy. a. 284.9 b. 284.89 c. 285.9 d. 285.22 - Answer Correct Answer: B 7 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 ). 18. 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). 19. 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). 20. Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block. a. 426.3, 426.4 b. 426.53 c. 426.4, 426.53 10 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). 27. 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). 28. 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). 29. Identify the ICD-9-CM diagnosis code for Paget's disease of the bone (no bone tumor noted). a. 170.9 11 b. 213.9 c. 238.0 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). 30. 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). 31. Which of the following is (are) the correct ICD-9-CM procedure code(s) for cystoscopy with biopsy? a. 57.34 b. 57.32, 57.33 c. 57.33 d. 57.39 - Answer Correct Answer: C Index Cystoscopy (transurethral), with biopsy (Schraffenberger 2012, 251). 32. Identify the ICD-9-CM diagnosis code for chondromalacia of the patella. a. 717.7 b. 733.92 c. 748.3 d. 716.86 - Answer Correct Answer: A 12 Index Chondromalacia, patella (Schraffenberger 2012, 303-304). 33. Identify the ICD-9-CM diagnosis code for blighted ovum. a. 236.1 b. 661.00 c. 631.8 d. 634.90 - Answer Correct Answer: C Index Ovum, blighted (Schraffenberger 2012, 282-283). 34. 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). 35. 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 15 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). 42. 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). 43. Identify the ICD-9-CM diagnostic code for diastolic dysfunction. a. 428.1 b. 428.30 c. 428.9 d. 429.9 - Answer Correct Answer: D Index Dysfunction, diastolic (Schraffenberger 2012, 182-183). 44. Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary- coronary artery bypass. a. 36.15, 36.16 16 b. 36.15 c. 36.16 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). 45. 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. 77.54 b. 77.69 c. 77.59 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). 47. Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: 17 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). 48. 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). 49. 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). 20 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, 74.1 b. 661.21, 74.1 c. 661.01, 74.0 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). 57. 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). 58. 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 21 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). 59. 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). 60. 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). 61. 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 22 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). 62. 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). 63. 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). 64. 25 Data integrity services ensure the data are not altered as they are stored or transmitted electronically (Johns 2011, 184). 70. 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 garage keycard of any physician in poor standing. To improve compliance, which of the following would be the next step to overcoming noncompliance? a. Discuss the problem with the hospital CEO. b. Call the Joint Commission. c. Contact other hospitals to see what methods they use to ensure compliance. d. Drop the issue because noncompliance is always a problem. - Answer Correct Answer: C The HIM manager may compare organizational data with external data from peer groups to determine best practices (Johns 2011, 609). 71. Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a breast biopsy. a. 10022 b. 10022, 19295-LT c. 10022, 19295-LT, 76942 d. 10022, 76942 - Answer Correct Answer: C Fine needle aspiration with image guidance is coded with 10022. Instructional note directs coder to assign 19295 for placement of localization clip during a breast biopsy. Add radiology code 76942 for supervision and interpretation of ultrasound guidance for localization clip guidance. See instructional notes following code 10022 (AMA 2012b, 59). 72. Identify the ICD-9-CM code for diaper rash, elderly patient. a. 690.10 26 b. 691.0 c. 782.1 d. 705.1 - Answer Correct Answer: B Index Rash, diaper. ICD-9-CM classifies dermatitis to categories 690-694. Atopic dermatitis and related conditions are specific to category 691. Fourth-digit subcategories include diaper or napkin rash and other atopic dermatitis and related conditions (Schraffenberger 2012, 292). 73. Identify the ICD-9-CM diagnostic code(s) for the following: threatened abortion with hemorrhage at 15 weeks; home undelivered. a. 640.01, 640.91 b. 640.03 c. 640.83 d. 640.80 - Answer Correct Answer: B Index Abortion, threatened 640.0. Refer to the ICD-9-CM Tabular List (640-649) for the correct fifth digit of 3, antepartum condition, not delivered (Schraffenberger 2012, 274-275). 74. To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of health records? a. Retrospectively review each patient's medical record to make sure history and physicals are present. b. Review each patient's medical record concurrently to make sure history and physicals are present and meet the accreditation standards. c. Establish a process to review medical records immediately on discharge. d. Do a review of records for all patients discharged in the previous 60 days. - Answer Correct Answer: B The benefit of concurrent review is that content or authentication issues can be identified at the time of patient care and rectified in a timely manner (Johns 2011, 410). 27 75. A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital provide the medical records in paper format. How should the hospital respond? a. Provide the medical records in paper format b. Burn another CD because this is hospital policy c. Provide the patient with both paper and CD copies of the medical record d. Review the CD copies with the patient on a hospital computer - Answer Correct Answer: A The covered entity must provide access to the personal health information in the form or format requested when it is readily producible in such form for format. When it is not readily producible in the form or format requested, it must be produced in a readable hard-copy form or such other form or format agreed upon by the covered entity and the individual (Johns 2011, 831). 76. Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system? a. Diagnosis-related groups b. Resource-based relative value scale system c. Long-term care drugs d. Resource utilization groups - Answer Correct Answer: B The RBRVS system is the federal government's payment system for physicians. It is a system of classifying health services based on the cost of furnishing physicians' services in different settings, the skill and training levels required to perform the services, and the time and risk involved (Casto and Layman 2011, 151). 77. Identify the CPT code(s) for the following patient: A 2-year-old male presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance. a. 43752 b. 43760 c. 43761, 76000 30 a. Stage I pressure ulcers b. Falls and trauma c. Catheter-associated infection d. Vascular catheter-associated infection - Answer Correct Answer: A Stage I and II pressure ulcers are not considered hospital-acquired conditions but stage III and IV are (Johns 2011, 326). 84. HIM coding professionals and the organizations that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated? a. Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete. b. Follow-up on and monitor identified problems. c. Evaluate and trend diagnoses and procedure code selections. d. Report data quality review results to organizational leadership, compliance staff, and the medical staff. - Answer Correct Answer: A The coder is not following established policies (Johns 2011, 265-267). 85. Which classification system is in place to reimburse home health agencies? a. MS-DRGs b. RUGs c. HHRGs d. APCs - Answer Correct Answer: C Home health resource groups (HHRGs) represent the classification system established for the prospective reimbursement of covered home care services to Medicare beneficiaries during a 60-day episode of care (Johns 2011, 334). 86. Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers with interrupted sutures. 31 a. 21012 b. 21012, 12052 c. 21014 d. 21014, 12052 - Answer Correct Answer: A CPT code 21012 describes excision of a subcutaneous soft tissue tumor of the face or scalp greater than 2 cm and is appropriately coded when the tumor is removed from the subcutaneous tissue rather than subgaleal or intramuscular. Simple and intermediate closure of the wound is included in the procedure for the excision in the musculoskeletal section of CPT (AMA 2010a, 28-29; AMA 2012b, 88, 94-95). 87. Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's Coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment. a. V58.83, V58.61 b. V58.83, V58.63 c. V58.61, 790.92 d. V58.61 - Answer Correct Answer: A V58.83, Encounter for therapeutic drug monitoring, is the correct code to use when a patient visit is for the sole purpose of undergoing a laboratory test to measure the drug level in the patient's blood or urine or to measure a specific function to assess the effectiveness of the drug. V58.83 may be used alone if the monitoring is for a drug that the patient is on for only a brief period, not long term. However, there is a Use Additional Code note after code V58.83 to remind the coder to use the additional code for any associated long-term drug use with codes V58.61-V58.69 (Schraffenberger 2012, 450-451). 88. Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads. a. 37,83, 37.73 b. 37.83, 37.71 c. 37.81, 37.73, 37.71 32 d. 37.83, 37.72 - Answer Correct Answer: D ICD-9-CM classifies cardiac pacemakers to code 37.8: Insertion, replacement, removal, and revision of pacemaker device. In coding initial insertion of a permanent pacemaker, two codes are required—one for the pacemaker (37.80-37.83) and one for the lead (37.70-37.74) (Schraffenberger 2012, 204-205). 89. Several key principles require appropriate physician documentation to secure payment from the insurer. Which answer (listed here) fails to impact payment based on physician responsibility? a. The health record should be complete and legible. b. The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred. c. Documenting the charges and services on the itemized bill. d. The patient's progress and response to treatment and any revision in the treatment plan and diagnoses should be documented. - Answer Correct Answer: C The documentation of the charges and itemized bill is not the responsibility of the physician (Smith 2012, 7-8). 90. The technology commonly used for automated claims processing (sending bills directly to third-party payers) is: a. Optical character recognition b. Bar coding c. Neural networks d. Electronic data interchange - Answer Correct Answer: D EDI allows the transfer (incoming and outgoing) of information directly from one computer to another by using flexible, standard formats (Johns 2011, 348). 91. Two patients were hospitalized with bacterial pneumonia. One patient was hospitalized for three days and the other patient was hospitalized for 30 days. Both cases result in the same DRG with different lengths of stay. Which answer most closely describes how the hospital will be reimbursed? 35 b. Thousands c. Millions d. Billions - Answer Correct Answer: D The RAC demonstration uncovered $1.03 billion of improper payments, of which 96% were overpayments and 4% were underpayments (Casto and Layman 2011, 39). 97. The documentation of each patient encounter should include the following to secure payment from the insurer except: a. The reason for the encounter and the patient's relevant history, physical exam, and prior diagnostic test results b. A patient assessment, clinical impression, or diagnosis c. A plan of care d. The identity of the patient's nearest relative and emergency contact number - Answer Correct Answer: D The identity of the patient's nearest relative and an emergency contact number are not relative to securing payment from the insurer. The encounter should include the date of the encounter and the identity of the observer (Smith 2012, 8). 98. Identify the ICD-9-CM diagnosis code(s) for neonatal tooth eruption. a. 525.0 b. 520.6, 525.0 c. 520.9 d. 520.6 - Answer Correct Answer: D Index Eruption, teeth/tooth, neonatal. Some main terms are followed by a list of indented subterms (modifiers) that affect the selection of an appropriate code for a given diagnosis. The subterms form individual line entries arranged in alphabetical order and printed in a regular type beginning with a lowercase letter. Subterms are indented on standard indention to the right under the main term. More specific subterms are further indented after the preceding subterm (Schraffenberger 2012, 12). 36 99. Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker. a. 37.87 b. 37.85 c. 37.87, 37.89 d. 37.85, 37.89 - Answer Correct Answer: A When a pacemaker is replaced with another pacemaker, only the replaced pacemaker is coded (37.85-37.87). Removal of the old pacemaker is not coded (Schraffenberger 2012, 204-205). 100. The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management - Answer Correct Answer: C Because federal regulations such as HIPAA and state laws govern the release of health record information, HIM department personnel must know what information needs to be included on the authorization for it to be considered valid (Johns 2011, 443). 1. Data security policies and procedures should be reviewed at least: a. Semi-annually b. Annually c. Every two years d. Quarterly - Answer Correct Answer: B All data security policies and procedures should be reviewed and evaluated at least every year to make sure they are up-to-date and still relevant to the organization (Johns 2011, 995). 37 2. Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea. a. 780.2 b. 780.2, 787.02 c. 780.2, 787.01 d. 780.4, 787.02 - Answer Correct Answer: B Near-syncope and nausea are both signs and symptoms and therefore not integral to the other. Both conditions should be coded (Hazelwood and Venable 2012, 71). 3. The codes in the musculoskeletal section of CPT may be used by: a. Orthopedic surgeons only b. Orthopedic surgeons and emergency department physicians c. Any physician d. Orthopedic surgeons and neurosurgeons - Answer Correct Answer: C Any physician may use the codes in any section of CPT (AHIMA 2012a, 587). 4. In an EHR, what is the risk of copying and pasting? a. Reduction in the time required to document b. The system not recording who entered the data c. Quicker overall system response time d. System thinking that the original documenter recorded the note - Answer Correct Answer: B The system not recording who entered the data (Johns 2011, 433). 5. Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling. 40 d. Security standard - Answer Correct Answer: B Identifier standards establish methods for assigning a unique identifier to individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers (Odom-Wesley et al. 2009, 311). 11. Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode. a. 410.11 b. 410.01 c. 410.02 d. 410.12 - Answer Correct Answer: B Index Infarction, myocardium, anterolateral (wall) with fifth digit for initial episode (Schraffenberger 2012, 26-28). 12. A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. The patient receives any monies paid by the insurance companies over and above the charges. b. Monies paid to the healthcare provider cannot exceed charges. c. The decision on which company is primary is based on remittance advice. d. The patient should not have a Medicare supplement. - Answer Correct Answer: B The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Johns 2011, 343). 13. Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition. a. 250.02 b. 250.01, 263.1 c. 250.02, 263.1 41 d. 250.01, 263.0 - Answer Correct Answer: C Diabetes (without complication) with fifth digit of 2 = type II, uncontrolled. 263.1 Malnutrition, mild, not stated as related to diabetes (Schraffenberger 2012, 122-124). 14. Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago. a. 709.2 b. 906.1 c. 709.2, 906.1 d. 906.1, 709.2 - Answer Correct Answer: C The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect (Hazelwood and Venable 2012, 60-61). 15. Which of the following is the concept responsible for limiting disclosure of private matters including the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual? a. Privacy b. Bioethics c. Security d. Confidentiality - Answer Correct Answer: D Confidentiality is the responsibility for limiting disclosure (Johns 2011, 755). 16. Tissue transplanted from one individual to another of the same species but different genotype is called a(n): a. Autograft b. Xenograft c. Allograft or allogeneic graft d. Heterograft - Answer Correct Answer: C 42 Tissue transplanted from one individual to another of the same species but different genotype is called an allograft or allogeneic graft (AHIMA 2012a, 592-593). 17. Where would a coder who needed to locate the histology of a tissue sample most likely find this information? a. Pathology report b. Progress notes c. Nurse's notes d. Operative report - Answer Correct Answer: A Histology refers to the tissue type of a lesion. The histology of tissue is determined by a pathologist and documented in the pathology report (Johns 2011, 77). 18. A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Postoperative infection b. Appendicitis c. COPD d. Hypertension - Answer **Correct Answer: A Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2011c, 97). 19. A hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should the hospital refer to? a. Explanation of benefits b. Medicare Summary Notice c. Remittance advice d. Coordination of benefits - Answer Correct Answer: C 45 a. Patient management b. New technology c. Therapeutic, preventative, or other interventions d. Patient safety - Answer Correct Answer: B New technology is addressed by the Category III codes (AHIMA 2012a, 584). 26. The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest? a. Suggest that only hospital clock time be noted in clinical documentation b. Suggest that only electronic documentation have time noted c. Inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated d. Inform the committee that according to the Medicare Conditions of Participation, only medication orders must include date and time - Answer Correct Answer: C All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished (42 CFR 482.24). 27. How are amendments handled in an EHR? a. Automatically appended to the original note; no additional signature is required. b. Amendments must be entered by the same person as the original note. c. Amendments cannot be entered after 24 hours of the event's occurrence. d. The amendment must have a separate signature, date, and time. - Answer Correct Answer: D 46 The addendum must have a separate signature, date, and time from the original entry (Johns 2011, 437). 28. What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm? a. A fine of not more than $10,000 only b. A fine of not more than $10,000, not more than 1 year in jail, or both c. A fine of not more than $5,000 only d. A fine of not more than $250,000, not more than 10 years in jail, or both - Answer Correct Answer: D When a person or entity willfully and knowingly violates the HIPAA Privacy Rule, a fine of not more than $250,000, not more than 10 years in jail, or both may be imposed (LaTour and Eichenwald Maki 2010, 292). 29. Which of the following reports includes names of the surgeon and assistants, date, duration and description of the procedure, and any specimens removed? a. Operative report b. Anesthesia report c. Pathology report d. Laboratory report - Answer Correct Answer: A An operative report describes the surgical procedures performed on the patient (Johns 2011, 73). 30. A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain: a. Moderate rate increases b. Market basket increases c. Budget neutrality d. Sustainable growth rate - Answer Correct Answer: C 47 Budget neutrality must be maintained annually when the RVUs are adjusted (Casto and Layman 2011, 156). 31. CPT was developed and is maintained by: a. CMS b. AMA c. Cooperating parties d. WHO - Answer Correct Answer: B The AMA developed and maintains CPT. CMS developed and maintains HCPCS Level II codes (AHIMA 2012a, 586). 32. Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result. a. 796.4 b. 790.6 c. 792.9 d. 790.93 - Answer Correct Answer: D Review Tabular List: Findings, abnormal, without diagnosis, prostate specific antigen (PSA), 790.93, or Elevation, prostate specific antigen (PSA), 790.93 (Hazelwood and Venable 2012, 69). 33. Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli. a. 599.0 b. 599.0, 041.49 c. 041.49 d. 041.49, 599.0 - Answer Correct Answer: B Connecting words or connecting terms are subterms that indicate a relationship between the main term and an associated condition or etiology in the Alphabetic Index. The connecting term "due to" connects the organism E. coli to the urinary tract 50 d. For 12 months - Answer Correct Answer: A An individual's right extends for as long as the record is maintained (Johns 2011, 827). 40. Assignment of benefits is a contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services and to bill the beneficiary only for , and to accept the Medicare payment as payment in full. a. Coinsurance or deductible b. Deductible only c. Coinsurance only d. Balance of charges - Answer Correct Answer: A When a physician accepts assignment of benefits, the physician can only collect any applicable deductible and/or coinsurance from the patient (Casto and Layman 2011, 156). 41. The purpose of a physician query is to: a. Identify the MS-DRG b. Identify the principal diagnosis c. Improve documentation for patient care and proper reimbursement d. Increase reimbursement as form of optimization - Answer Correct Answer: C Improve documentation to support services billed (Johns 2011, 348). 42. Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy ruled out. a. 780.39 b. 345.9 c. 780.39, 345.9 d. 345.90 - Answer Correct Answer: A 51 Code signs and symptoms when a condition is ruled out, which means the condition has been proven not to exist. The code for seizures (780.39) is assigned when a more specific diagnosis cannot be made even after all the facts bearing on the case have been investigated (Hazelwood and Venable 2012, 68-73). 43. The Privacy Rule applies to: a. All covered entities involved with transmitting or performing any electronic transactions specified in the act b. Healthcare providers only c. Only healthcare providers that receive Medicare reimbursement d. Only entities funded by the federal government - Answer Correct Answer: A The Privacy Rule is applicable to all covered entities involved, either directly or indirectly, with transmitting or performing any electronic transactions specified in the act (Johns 2011, 823). 44. Which answer FAILS to provide a requirement for assignment of the MS-DRG? a. Diagnoses and procedures (principal and secondary) b. Attending and consulting physicians c. Presence of major or other complications and comorbidities (MCC or CC) d. Discharge disposition or status - Answer **Correct Answer: B Attending and consulting physicians have no bearing on the assignment of the MS- DRG and payment to the hospital (Schraffenberger 2012, 471-473). 45. Who is responsible for writing and signing discharge summaries and discharge instructions? a. Attending physician b. Head nurse c. Primary physician d. Admitting nurse - Answer Correct Answer: A 52 The physician principally responsible for the patient's hospital care writes and signs the discharge summary (Odom-Wesley et al. 2009, 200). 46. Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? a. History and physical reports b. Operative reports c. Consultation reports d. Psychotherapy notes - Answer Correct Answer: D The distinction of psychotherapy notes is important due to HIPAA requirements that these notes may not be released unless specifically specified in an authorization (Odom-Wesley et al. 2009, 440). 47. In hospitals, automated systems for registering patients and tracking their encounters are commonly known as systems. a. MIS b. CDS c. ADT d. ABC - Answer Correct Answer: C Automated systems for registering patients and tracking their encounters are commonly known as admission-discharge-transfer (ADT) systems (Johns 2011, 947). 48. Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? a. Request that the CEO write a memorandum to all hospital staff. b. Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation. c. Include ancillary clinical and medical staff in the process. 55 c. Comply with both the state law and the HIPAA standard d. Ignore both the state law and the HIPAA standard and follow relevant accreditation standards - Answer Correct Answer: C When a state law is more stringent than a federal law, hospitals must comply with both (Odom-Wesley et al. 2009, 68). 54. What should be done when the HIM department's error or accuracy rate is deemed unacceptable? a. A corrective action should be taken. b. The problem should be treated as an isolated incident. c. The formula for determining the rate may need to be adjusted. d. Re-audit the problem area. - Answer Correct Answer: A Corrective action should be taken when error or accuracy rates are deemed to be at an unacceptable rate (Johns 2011, 417). 55. Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to Staphylococcus aureus septicemia. a. 038.11, 995.91 b. 995.91, 038.11 c. 038.11 d. 038.11, 995.92 - Answer Correct Answer: A 038.11, Septicemia, Staphylococcus aureus, and 995.91, Sepsis. The "Code first" note following code 995.91 directs the coder to assign the code for the underlying infection first (Schraffenberger 2012, 80-81). 56. An HIM professional's ethical obligations: a. Apply regardless of employment site b. Are limited to the employer c. Apply to only the patient 56 d. Are limited to the employer and patient - Answer Correct Answer: A HIM ethical obligations apply regardless of employment site (Johns 2011, 754). 57. Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? a. Client-server computer b. Data warehouse c. Local area network d. Internet - Answer Correct Answer: B A data warehouse is a special type of database that consolidates and stores data from various databases (Johns 2011, 909). 58. During a review of documentation practices, the HIM director finds that nurses are routinely using the copy-and-paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices? a. Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately. b. Determine how many nurses are involved in this practice. c. Institute an in-service training session on documentation practices. d. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. - Answer Correct Answer: D In order to thoughtfully and appropriately manage copy functionality, organizations must have sound documentation integrity policies within their organization. HIM professionals should lead their organizations in developing copy policies and procedures that address operational processes, utilization of copy functionality, documentation guidelines, responsibility, and auditing and reporting (AHIMA 2012b, 9-10, 18-21). Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency and continuity and clarity in documentation (AHIMA 2005). 57 59. Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough. a. 786.2, 490 b. 486, 786.2 c. 486 d. 481 - Answer Correct Answer: C Pneumonia, unspecified, is assigned 486 in the Alphabetic Index. Cough is integral to pneumonia and should not be coded separately (Hazelwood and Venable 2012, 68-73). 60. Per CPT guidelines, a separate procedure is: a. Coded when it is performed as part of another, larger procedure b. Considered to be an integral part of another, larger service c. Never coded under any circumstance d. Both a and b - Answer Correct Answer: B Because a separate procedure is considered a part of, and integral to, another, larger procedure, it is not coded when performed as part of the more extensive procedure. See Surgery Guidelines. It may, however, be coded when it is not performed as part of another, larger service; therefore, answer "c" is not correct (AHIMA 2012a, 586). 61. The uses expert or artificial intelligence software to automatically assign code numbers. a. Functional EHR b. NHIN c. NLP encoding system d. Grouper - Answer Correct Answer: C Natural-language processing (NLP) uses artificial intelligence software to allow digital text from online documents stored in the organization's information system to 60 c. Manipulative catheterization d. Radical catheterization - Answer Correct Answer: A If the tip of the catheter is manipulated, it is a selective catheterization. In the case of a nonselective catheterization, the tip of the catheter remains in either the aorta or the artery that was originally entered (AHIMA 2012a, 604). 68. Which of the following is a threat to data security? a. Encryption b. People c. Red flags d. Access controls - Answer Correct Answer: B Threats to data security caused by people can be classified as threats from insiders who make unintentional mistakes, threats from insiders who abuse their access privileges to information, threats from insiders who access information or computer systems for spite or profit, threats from insiders who attempt to access information or steal physical resources, and from vengeful employees or outsiders who mount attacks on the organization's information systems (Johns 2011, 987). 69. The provider or supplier is prohibited from holding the patient responsible for charges in excess of the Medicare fee schedule. This is called: a. Accept assignment b. Balance billing c. Charge capture d. Inducement - Answer Correct Answer: B Balance billing means the patient cannot be held responsible for charges in excess of the Medicare fee schedule (Johns 2011, 350). 70. What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals? a. Accreditation organizations b. Certification organizations 61 c. State licensure agencies d. Conditions of participation agencies - Answer Correct Answer: C State licensure agencies have regulations that are modeled after the Medicare Conditions of Participation and Joint Commission standards. States conduct annual surveys to determine the hospital's continued compliance with licensure standards (Odom-Wesley et al. 2009, 287). 71. An HIT using her password can access and change data in the hospital's master patient index. A billing clerk, using his password, cannot perform the same function. Limiting the class of information and functions that can be performed by these two employees is managed by: a. Network controls b. Audit trails c. Administrative controls d. Access controls - Answer Correct Answer: D Access control means being able to identify which employees should have access to what data (Johns 2011, 992). 72. Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung. a. 153.9, 162.9 b. 197.0, 153.9 c. 153.9, 197.0 d. 153.9, 239.1 - Answer Correct Answer: C The terms metastatic to and direct extension to are used for classifying secondary malignant neoplasms in ICD-9-CM. For example, cancer described as "metastatic to a specific site" is interpreted as a secondary neoplasm of that site. The colon (153.9) is the primary site, and the lung (197.0) is the secondary site (Hazelwood and Venable 2012, 109). 73. Which organization developed the first hospital standardization program? 62 a. Joint Commission b. American Osteopathic Association c. American College of Surgeons d. American Association of Medical Colleges - Answer Correct Answer: C The American College of Surgeons started its Hospital Standardization Program in 1918 (Johns 2011, 679). 74. Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis. a. 558.9 b. 787.01, 558.9 c. 787.02, 787.03, 558.9 d. 787.01, 558.41 - Answer Correct Answer: A Conditions that are integral to the disease process should not be assigned as additional codes. The nausea and vomiting are integral to the disease, gastroenteritis (Hazelwood and Venable 2012, 68). 75. Which of the following is NOT an accepted accrediting body for behavioral healthcare organizations? a. American Psychological Association b. Joint Commission c. Commission on Accreditation of Rehabilitation Facilities d. National Committee for Quality Assurance - Answer Correct Answer: A The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance are all acceptable accrediting bodies for behavioral healthcare settings (Odom-Wesley et al. 2009, 447). 76. Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea. a. 789.03 65 During verification, the coder will see the selection for code 790.22, which accurately describes the specific abnormal finding of glucose tolerance test (Hazelwood and Venable 2012, 74). 82. A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in place to minimize this security breach? a. Access controls b. Audit trail c. Edit checks d. Password controls - Answer Correct Answer: C Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Johns 2011, 509). 83. Mohs micrographic surgery involves the surgeon acting as: a. Both plastic surgeon and general surgeon b. Both surgeon and pathologist c. Both plastic surgeon and dermatologist d. Both dermatologist and pathologist - Answer Correct Answer: B See definitions preceding code 17311 (Mohs micrographic technique) in CPT Professional Edition (AMA 2012b, 79). 84. Which of the following is the concept of the right of an individual to be left alone? a. Privacy b. Bioethics c. Security d. Confidentiality - Answer Correct Answer: A Privacy is the right of an individual to be left alone (Johns 2011, 755). 85. 66 Which of the following would not be found in a medical history? a. Chief complaint b. Vital signs c. Present illness d. Review of systems - Answer Correct Answer: B Medical history documents the patient's current complaints and symptoms and lists the patient's past medical, personal, and family history. The physical examination report represents the attending physician's assessment of the patient's current health status (Johns 2011, 63). 86. When correcting erroneous information in a health record, which of the following is NOT appropriate? a. Print "error" above the entry b. Enter the correction in chronological sequence c. Add the reason for the change d. Use black pen to obliterate the entry - Answer Correct Answer: D In a paper-based health record environment, corrections to health record entries are corrected by drawing a single line through the original entry, writing "error" above the entry, and then the practitioner signs, dates, and times the correction (Johns 2011, 413). 87. What is the maximum number of procedure codes that can appear on a UB-04 institutional claim form via electronic transmission? a. 6 b. 9 c. 15 d. 25 - Answer Correct Answer: D Effective January 1, 2011, CMS allows a total of 25 ICD-9-CM procedure codes for 837 Institutional claims filing (Schraffenberger 2012, 66). 88. 67 What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? a. Additional payments may be made for locum tenens, increased emergency room services, stays over the average length of stay, and cost outlier cases. b. Additional payments may be made to critical access hospitals, for higher-than- normal volumes, unexpected hospital emergencies, and cost outlier cases. c. Additional payments may be made for increased emergency room services, critical access hospitals, increased labor costs, and cost outlier cases. d. Additional payments may be made to disproportionate share hospitals for indirect medical education, new technologies, and cost outlier cases. - Answer Correct Answer: D Medicare provides for additional payment for other factors related to a particular hospital's business. If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the MS-DRG adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve these areas. Hospitals that have approved teaching hospitals also receive a percentage add-on payment for each Medicare discharged paid under IPPS, known as the indirect medical education (IME) adjustment. The percentage varies, depending on the ratio of residents to beds. Additional payments are made for new technologies or medical services that have been approved for special add-on payments. Finally, the costs incurred by a hospital for a Medicare beneficiary are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases (Schraffenberger 2012, 471-473). 89. What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) program? a. Medicare administrative contractors (MACs) b. Recovery audit contractors (RACs) c. Comprehensive error rate testing (CERT) d. Fiscal intermediaries (FIs) - Answer Correct Answer: B Congress directed HHS to conduct a three-year demonstration project using RACs to detect and correct improper payments in the Medicare traditional fee-for-service program. Congress further required HHS to make the RAC program permanent and nationwide by January 1, 2010 (Schraffenberger 2012, 475). 70 c. Conduct a verification audit. d. Alert hospital legal counsel of the practice. - Answer Correct Answer: B Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency, continuity, and clarity in documentation (AHIMA 2005). 96. What is a chargemaster? a. Cost-sharing in which the policy or certificate holder pays a preestablished percentage of eligible expenses after the deductible has been met b. A plan that converts the organization's goals and objectives into targets for revenue and spending c. A financial management form that contains information about the organization's charges for the healthcare services it provides to patients d. Charged amounts that are billed as costs by an organization to the current year's activities of operation - Answer Correct Answer: C A chargemaster is a financial management form that contains information about the organization's charges for the healthcare services it provides to patients. Answer "a" is coinsurance. Answer "b" is budget. Answer "d" is expense (Johns 2011, 1116). 97. Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago. a. 787.20, 438.12 b. 784.59, 438.12 c. 438.12 d. 787.20, 438.89 - Answer Correct Answer: C The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect. Late effect exceptions occur when the late effect code has been expanded at the fourth- and fifth-digit level to include the manifestations. In this case, only one code is necessary to describe both the residual condition and cause of the late effect (Hazelwood and Venable 2012, 62). 98. HIPAA regulations: 71 a. Never preempt state statutes b. Always preempt state statutes c. Preempt less-strict state statutes where they exist d. Preempt stricter state statutes where they exist - Answer **Correct Answer: C HIPAA regulations preempt less strict state statutes where they exist (Johns 2011, 820). 99. An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach? a. Audit controls b. Information access controls c. Facility access controls d. Workstation security - Answer Correct Answer: B An EHR can be viewed by multiple users and from multiple locations at any time, and organizations must have in place appropriate security access control measures to ensure the safety of the data (Johns 2011, 435). 100. The is a type of coding that is a natural outgrowth of the EHR. a. Automated codebook b. Computer-assisted coding c. Logic based encoder d. Decision support database - Answer Correct Answer: B Computer-assisted coding is defined as the use of computer software that automatically generates a set of medical codes for review, validation, and use based on the documentation from the various providers of healthcare (AHIMA 2010b, 62; LaTour and Eichenwald Maki 2010, 400). 1. The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery suite. The urologist inserts an endoscope in the penile urethra and 72 dilates the structure to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which of the following code sets will be reported for this service? a. 600.20, 53852 b. 600.20, 52601 c. 600.00, 53852 d. 222.2, 53850 - Answer Correct Answer: A When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20 (AHIMA 2012a, 697). 2. The HIPAA Privacy Rule requirement that covered entities must limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this an example of? a. Minimum necessary b. Notice of Privacy Practice c. Consent d. Authorization - Answer Correct Answer: A The Privacy Rule introduced the standard of minimum necessary, a "need to know" filter that is applied to limit access to a patient's protected health information (PHI) and to limit the amount of PHI used, disclosed, and requested (Brodnik et al. 2009, 176). 3. An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be correct? a. V30.01, 765.03, 765.24 b. 765.03, 769 75 not covered by Medicare. Another name for waiver of liability is Advance Beneficiary Notice (ABN). a. 84443-GA b. 80418-GA c. 84443-GY d. 80418-GY - Answer Correct Answer: A Index Thyroid simulating hormone, 80418, 80438-80440, 84443. Code 84443 is the correct code for a TSH while the rest of the codes are panels including several tests. Modifier -GA is listed in the front cover of the CPT Professional Edition and signifies the patient was given a notice of non-coverage also known as waiver of liability or ABN (AMA 2012b, 427; CMS 2010d; CMS 2010e). 10. A Medicare Advantage Plan (like an HMO or PPO) is a health coverage option under what part of Medicare? a. Part A b. Part B c. Part C d. Part E - Answer Correct Answer: C Medicare Part C combines Medicare Part A and Medicare Part B coverage and is operated by private insurance companies that are approved by and under contract with Medicare to form Medicare Advantage Plans (Johns 2011, 293). 11. The use of computer software that automatically generates a set of medical codes for review, validation, and use based on clinical documentation provided by healthcare practitioners is the definition of: a. Natural language processing b. Voice recognition c. Computer-assisted coding d. Electronic health record - Answer Correct Answer: C Computer-assisted coding utilizes computer software to generate codes from the data provided (Sayles and Trawick 2010, 360). 76 12. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff - Answer Correct Answer: D The cornerstone of accurate coding is physician documentation. Ensuring the accuracy of coded data is a shared responsibility between coding professional and physicians (Johns 2011, 357). 13. A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed? a. Randomly audit EHR documentation for patients readmitted within 30 days b. Survey practitioners to determine if they are following hospital policy c. Institute an in-service program for all hospital personnel d. Observe the documentation practices of all clinical personnel - Answer Correct Answer: A Hospitals must randomly audit EHR documentation to ensure compliance with hospital policy. Readmissions within 30 days serve as a good patient sample for the copy function in the EHR (AHIMA 2012b) 14. The patient presented through the ED with severe abdominal pain, amenorrhea. Serum human chorionic gonadotropin (hCG) was lower than normal. There were also endometrial and uterine changes. Patient diagnosed with tubal pregnancy. A unilateral salpingectomy with removal of tubal pregnancy was performed. Which of the following is the correct code assignment? a. 633.80, 66.62 b. 633.10, 66.62 77 c. 633.10, 66.4 d. 633.10, 66.02 - Answer Correct Answer: B The ectopic pregnancy was documented as tubal. The salpingectomy was "with removal of tubal pregnancy." The procedure performed was a salpingectomy, not a salpingostomy (AHIMA 2012a, 679). 15. Identify the CPT procedure code(s) for ultrasound, pregnant uterus, fetal and maternal evaluation, second trimester, single gestation. a. 76700 b. 76805 c. 76801 d. 76813 - Answer Correct Answer: B Index Ultrasound, pregnant uterus, resulting in code range 76801-76817. Review of the available codes indicates that code 76805 is the appropriate code (AHIMA 2012a, 625). 16. The computer abstracting system in a facility has an edit that does not allow coders to assign obstetrical codes to male patients. This edit is called a(n): a. Self-correcting control b. Feedback control c. Presence of a virus d. Audit trail - Answer Correct Answer: A Preventive controls are front-end processes that guide work in such a way that input and process variations are minimized. Simple things such as standard operating procedures, edits on data entered into computer-based systems, and training processes are ways to reduce the potential for error by using preventive controls (also called self-correcting controls) (LaTour and Eichenwald Maki 2010, 696). 17. CCI edit files contain code pairs, called mutually exclusive edits, which prevent payment for: a. Services that cannot reasonably be billed together 80 What kind of care offers extensive psychiatric treatment on an outpatient basis with the expectation that the patient's level of functioning will improve so that hospitalization can be avoided? a. Acute hospitalization b. Partial hospitalization c. Outpatient day care d. Short-term care nursing - Answer Correct Answer: B Comprehensive outpatient rehabilitation facility services and mental healthcare provided as part of a partial hospitalization psychiatric program when a physician certifies that inpatient treatment would be required without the partial hospitalization services (Johns 2011, 296). 24. Select the appropriate CPT code(s) to report a therapeutic subcutaneous injection of rabies immune globulin performed under direct physician supervision. a. 96372 b. 90471 c. 90375, 96372 d. 90375, 90473 - Answer Correct Answer: C In order to appropriately report administration of vaccines, both the product administered and the method of administration must be reported. An instructional note listed before CPT code 90476 states: "(For immune globulins, see codes 90281-90399, 96365-96368, 96372-96375 for administration of immune globulins)" (AMA 2012b, 459-460). 25. Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This is called: a. Autoauthentication b. Electronic signature c. Automatic record completion d. Chart tracking - Answer Correct Answer: A 81 Autoauthentication is a policy that allows the physician or provider to state in advance that dictated and transcribed reports should automatically be considered approved and signed when the physician does not make corrections within a certain period of time. Another variation of autoauthentication is that physicians authorize the HIM department to send a weekly list of documents needing signatures. The list is then signed and returned to the HIM department (LaTour and Eichenwald Maki 2010, 213). 26. Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? a. Unit secretary working on the unit where the patient is located b. Nurse working on the unit where the patient is located c. Health information director d. Admissions registrars - Answer Correct Answer: B Because of the risks associated with miscommunication, verbal orders are discouraged. When a verbal order is necessary, a clinician should sign, give his or her credential (for example, RN, PT, or LPN), and record the date and time the order was received. Verbal orders for medication are usually required to be given to, and to be accepted only by, nursing or pharmacy personnel (Brodnik et al. 2009, 131). 27. Which of the following statements does not pertain to electronic health records (EHRs)? a. EHR technologies and systems must not intrude on the patient and provider relationship. b. EHRs are filed in paper folders. c. In the United States, a national health information infrastructure is being designed to support EHRs. d. Clinicians may use computer keyboards when documenting in the EHR. - Answer Correct Answer: B EHRs store information in electronic format rather than paper-based media (Johns 2011, 135). 28. Identify the CPT procedure code(s) for extracorporeal sound wave lithotripsy of large kidney stone. 82 a. 50590 b. 52353 c. 43265 d. 28890 - Answer Correct Answer: A Index Lithotripsy, kidney, resulting in code 50590 or 52353. Review of the available codes indicates that code 50590 is correct because there is no mention of cystourethroscopy (AHIMA 2012a, 609). 29. Which is a feature of managed care? a. Control and reduce the costs of care b. Monitor the activity of physician supervision c. Provide incentive for prospective payment d. Allow the patient to choose several primary physicians - Answer Correct Answer: A The purpose of managed care is to control or reduce the costs of healthcare for which the third-party payer must reimburse the providers and to ensure continuing quality of care (Casto and Layman 2011, 9). 30. Which of the following is often cited as a reason to implement an electronic health record (EHR)? a. Improve patient safety b. High cost of EHR c. Staff time required to implement the EHR d. Simplicity of implementation changes to workflow - Answer Correct Answer: A The primary benefits of EHRs are quality and patient safety (Johns 2011, 173). 31. Who may sign an authorization for use and disclosure when the patient is a minor? a. The minor's parent or legal guardian b. The patient 85 An HIM professional who releases health information that he or she knows will result in genetic discrimination is violating the ethical principle of: a. Autonomy b. Beneficence c. Justice d. Nonmaleficence - Answer Correct Answer: D Nonmaleficence means to do no harm. With regard to the patient and the healthcare team, the HIM professional is obligated to protect health, medical, genetic, social, personal, financial, and adoption information: Clinical information (genetic risk factors) must be protected as well as behavioral information. It is important to protect genetic and social information so that patients will not be vulnerable to the risks of discrimination (LaTour and Eichenwald Maki 2010, 311-312). 38. The present on admission (POA) indicator is a requirement for a. Inpatient Medicare claims submitted by acute care hospitals b. Inpatient Medicare and Medicaid claims submitted by hospitals c. Medicare claims submitted by all entities d. Inpatient skilled nursing facility Medicare claims - Answer Correct Answer: A The POA indicator applies to diagnosis codes for claims involving inpatient admission to acute-care hospitals or other facilities, as required by law or regulation for public health reporting (Schraffenberger 2012, 58; CMS 2011c, 97-102; Johns 2011, 325). 39. Which of the following software applications would be used to aid in the coding function in a physician's office? a. Grouper b. Encoder c. Pricer d. Diagnosis calculator - Answer Correct Answer: B 86 An encoder is a computer software program designed to assist coders assign appropriate clinical codes. An encoder helps ensure accurate reporting of diagnoses and procedures (LaTour and Eichenwald Maki 2010, 318-319). 40. An infusion that lasts less than 15 minutes would be reported with a(n): a. Intravenous infusion code b. Intravenous piggyback code c. Intravenous or intra-arterial push code d. Intravenous hydration code - Answer Correct Answer: C An infusion that lasts less than 15 minutes should be reported with an IV push code per the CPT coding guidelines of the CPT Professional Edition based on the instructional notes preceding the hydration notes (AMA 2012b, 518; AHIMA 2012a, 630). 41. Patient data collection requirements vary according to healthcare setting. One would expect a data element would be collected in the MDS, but would not be collected in the UHDDS. a. Personal identification b. Cognitive patterns c. Procedures and dates d. Principal diagnosis - Answer Correct Answer: B According to UHDDS requirements, answers a, c, and d represent items collected about inpatients. Only answer b represents a data item collected more typically in long-term care settings and required in the MDS (Johns 2011, 98). 42. Identify the CPT procedure code(s) and correct modifiers for a basic metabolic panel with ionized calcium and an additional test for carbon dioxide on the same day. Keep in mind that a carbon dioxide test is part of the basic metabolic panel. a. 80047 b. 80047, 82374 c. 80047, 82374-91 87 d. 80048, 82374-91 - Answer Correct Answer: C Index Organ or disease-oriented panel, metabolic, basic to reference codes 80047 and 80048. Code 80047 includes ionized calcium for the correct panel code. Index Carbon Dioxide, blood or urine to arrive at code 82374. Add modifier -91 to the carbon dioxide code to signify the test was performed twice on the same day and is separately reportable. Modifier -91 represents a repeat clinical diagnostic laboratory test, and should be used for a repeat test even when the first test is part of a panel represented by a panel code (AMA 2012b, 402). 43. Identify the CPT procedure code(s) for laparoscopic Nissen fundoplication. a. 43279 b. 43280 c. 43327 d. 43289 - Answer Correct Answer: B Index Fundoplasty, esophagogastric, laparoscopic, resulting in code 43280. Indexing the main term Nissen operation results in this cross-reference: see fundoplasty, esophagogastric, laparoscopic, results in code 43280 (AHIMA 2012a, 608). 44. For coding and billing professionals, being compliant means to perform one's job functions according to the laws, regulations and guidelines with integrity as set forth by Medicare and other third-party payers. This is an example of:: a. Ethics b. Skills c. Behaviors d. Education - Answer Correct Answer: A, Following the AHIMA Standard of Ethical Coding, sets forth guidelines that all coding and billing professionals understand in ethical decision making (Casto and Layman 2011, 34). 45. Under local anesthesia and ultrasound guidance, a patient underwent radiofrequency ablation of an incompetent greater saphenous vein in the right lower extremity. Assign the appropriate CPT code(s). a. 36475-RT 90 Identify the appropriate CPT code(s) for 23 minutes of therapeutic exercise. a. 97110 b. 97110, 97110 c. 97110, 97110, 97110 d. 97110-50 - Answer Correct Answer: B Index Physical Medicine/Therapy/Occupational Therapy, procedures, therapeutic exercises, resulting in code 97110. Review of the code indicates that it is reported in 15-minute increments. Thus, a 23-minutes session would be reported with code 97110 twice because a unit of time must be at least 8 minutes at a minimum, which the second unit meets the 8-minute minimum (AHIMA 2012a, 633). 52. The patient was admitted with increasing shortness of breath, weakness, and nonproductive cough. Treatment included oxygen therapy. Final diagnoses listed as acute respiratory insufficiency and acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following is the correct ICD-9-CM diagnostic code assignment? a. 491.21 b. 491.21, 518.82 c. 518.81, 491.21 d. 518.82, 491.21 - Answer Correct Answer: A Acute respiratory insufficiency is an integral part of COPD and is therefore not coded separately. The patient had acute respiratory insufficiency and not acute respiratory failure (AHIMA 2012a, 682). 53. What kind of care is covered when a patient requires nursing or rehab services occurring within 30 days of a 3-day stay or longer in an acute care hospital setting and is certified as medically necessary? a. Skilled nursing facility care b. Home health care c. Hospice care d. Acute healthcare - Answer Correct Answer: A 91 Skilled nursing care (SNF) is covered when a patient requires skilled nursing or rehab services within 30 days of a 3-day or longer acute care hospitalization stay (Johns 2011, 295). 54. One objective of the Balanced Budget Act (BBA) of 1997 was to: a. Improve program integrity for Medicare by educating beneficiaries to report errors noticed on their explanation of benefits (EOBs) to the Department of Health and Human Services (HHS) b. Improve the quality of care to its beneficiaries by increasing availability to healthcare c. Streamline healthcare costs into one type of payment system for Medicare and Medicaid d. Educate hospital providers how to manage quality care with less reimbursement - Answer Correct Answer: A The Balanced Budget Act of 1997 was incorporated to improve program integrity for Medicare by educating Medicare beneficiaries to be on the watch for errors in billing of services they didn't receive and any other forms of fraudulent activity (Casto and Layman 2011, 37). 55. MS-DRG may be split into a maximum of payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC; or no CC. a. Two b. Three c. Four d. Five - Answer Correct Answer: B The Medicare IPPS categorizes diagnosis and procedure codes. The diagnosis codes may qualify for a major complication or comorbidity (MCC), or other complication or comorbidity (CC). A diagnosis code may not qualify for either, allowing diagnosis codes to be grouped into three higher or lower DRG groupings (Schraffenberger 2012, 57; Johns 2011, 322-323). 56. A patient was admitted for recurrent dislocation of the shoulder. The operation included debridement of the acromion, subacromial bursectomy, division of the coracoacromial ligament, and an abrasion acromioplasty with Mitek suture placement. Which of the following is the correct code assignment? 92 a. 718.31, 81.82 b. 718.31, 81.82, 83.5 c. 831.00, 81.82, 83.5 d. 831.00, 81.82, 83.5, 80.41 - Answer Correct Answer: A Bursectomy and division of ligament are included in acromioplasty. Dislocation is not acute; it is stated as recurrent (AHIMA 2012a, 666). 57. The attending physician is responsible for which of the following types of acute care documentation? a. Consultation report b. Discharge summary c. Laboratory report d. Pathology report - Answer Correct Answer: B The results of radiological and pathological procedures require interpretation by specially trained physicians called radiologists and pathologists. These physicians document their findings in written reports. The consultation report documents the clinical opinion of a physician other than the primary or attending physician (Johns 2011, 78). 58. How frequently are Category III CPT codes updated? a. Annually b. Semiannually c. Every two years d. Every four months - Answer Correct Answer: B An instructional note has been added to the introductory language under Category III codes in the CPT Professional Edition. "New codes in this section are released semi- annually via the AMA/CPT internet site, to expedite dissemination for reporting. The full set of temporary codes for emerging technology, services, and procedures are published annually in the CPT codebook." (AMA 2012b, 553). 59. 95 The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for: a. Part A Medicare claims b. Part B Medicare claims c. Medicaid claims d. Medicare and Medicaid claims - Answer Correct Answer: B CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims (Johns 2011, 347). 66. What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed? a. Operative report b. Tissue report c. Pathology report d. Anesthesia record - Answer Correct Answer: A The operative report describes the surgical procedures performed on the patient (Johns 2011, 73). 67. The patient is a 45-year-old female who fell while walking her dog. She was walking on the sidewalk in her neighborhood and accidently tripped and subsequently fell. She sustained a comminuted fracture of the shaft of her right tibia confirmed by x-ray done in the emergency room. She also hit her head on a fire hydrant and suffered a slight concussion but no loss of consciousness. The patient was admitted and taken to surgery, where an open reduction with internal fixation was accomplished with good alignment of fracture fragments. Post-op course was uneventful and the patient was discharged with daily physical therapy at home. Which of the following would be coded? a. 823.20, 850.0, E885.9, E019.0, E849.8, E000.8, 79.36 b. 823.10, 850.0, E885.9, E019.0, E849.8, 79.46 c. 823.20, 850.0, E885.9, E849.5, E000.9, 79.36 96 d. 823.30, 850.0, E885.9, E019.0, E849.8, E000.9, 79.46 - Answer Correct Answer: A A comminuted fracture is considered closed unless specified as open or compound per the note in the Index under Fracture. Four "E" codes are necessary to fully describe the circumstances as instructed by the notes in the Tabular list(AHIMA 2012a, 687). 68. Code 87900, infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics, is used in the management of patients with what disease? a. Cancer patients on toxic chemotherapy agents b. HIV patients on antiretroviral therapy c. Tuberculosis patients on rifampin therapy d. Organ transplant patients on immunosuppressive therapy - Answer Correct Answer: B CPT code 87900 for infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics is used in the management of HIV patients on antiretroviral therapy (AMA 2012b, 442). 69. The Medicare Modernization Act (MMA) of 2003 called for CMS to launch a Medicare payment recovery demonstration project. The purpose of the act eventually resulted in the implementation of a group contracted by the government to monitor suspicious and improper activity of Medicare payments including overpayments and underpayments. What is this group? a. Operation Restore Trust b. Payment Error Prevention Program c. Recovery Audit Contractors d. Medicare Administrative Contractors - Answer Correct Answer: C Recovery audit contractors (RACs) would become a cost-effective means of ensuring correct payments to providers under Medicare. The RACs were charged with identifying underpayments and overpayments for claims filed under Medicare (Casto and Layman 2011, 39). 70. 97 What is the term used for the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business, or payment purposes? a. Minimum data record b. Legal health record c. Mixed-media health record d. Electronic health record - Answer Correct Answer: B The legal health record is the record of care in any health-related setting, used by healthcare professionals while providing patient-care services or for administrative, business, or payment purposes (Odom-Wesley et al. 2009, 24). 71. If a nurse uses the abbreviation CPR to mean cardiopulmonary resuscitation one time and computer-based patient record another time, leading to confusion if the chart were audited would be a concern when applying this dimension of data quality? a. Accuracy b. Granularity c. Precision d. Currency - Answer Correct Answer: B Data quality needs to be consistent. A difference in the use of abbreviations provides a good example of how the lack of consistency can lead to problems (LaTour and Eichenwald Maki 2010, 119). 72. Identify the CPT procedure code(s) for a repeat transurethral resection of prostate tissue four years after original procedure. a. 52601 b. 55801 c. 52630 d. 52500 - Answer Correct Answer: C Index Excision, prostate regrowth, resulting in code 52630 (AHIMA 2012a, 611). 73.