Nurs Exam CCS-P Practice Questions And Answers, Exams of Nursing

Download Nurs Exam CCS-P Practice Questions And Answers and more Exams Nursing in PDF only on Docsity!

Nurs Exam CCS-P Practice Questions And Answers

Graded A 2024

A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates

• compliance with Medicare regulations.
• compliance with Joint Commission standards.
• noncompliance with Joint Commission standards.
• compliance with Joint Commission standards for nonsurgical patients. ICD-10-PCS procedure codes are used on which of the following forms to report services provided to a patient?
• MDC 02
• UB- 04
• CMS- 1500
• CMS-1490S The Unified Medical Language System (UMLS) is a HCPCS sponsored by the
• World Health Organization.
• Office of Inspector General.
• CMS.
• National Library of Medicine. You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?
• case finding
• nomenclature

• abstracting
• staging The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with
• completeness.
• reliability.
• validity.
• timeliness. Patient undergoes enucleation of left eye, and muscles were reattached to an implant.
• 65135-LT
• 65103-LT
• 65105-LT
• 65730-LT There are seven criteria for high-quality clinical documentation. All of these elements are included EXCEPT
• complete.
• consistent.
• covered (by third-party payer).
• precise (accurate) This law prohibits a physician from referring Medicare patients to clinical not limited to lab services where the doctor or a member of his family has a financial interest.

• the Civil Monetary Penalties Act
• the False Claims Act
• the Stark I Law
• the Federal Anti-Kickback Statute This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service.
• Global payment
• Medicare Physician Fee Schedule (MPFS)
• Medicare Severity-Diagnosis Related Groups (MS-DRGs)
• Capitation Which of the following is NOT included as a part of the minimum data maintained in the MPI?
• principal diagnosis
• date of birth
• patient medical record number
• full name (last, first, and middle) Patient comes in through the emergency room with a laceration of the posterior tibial nerve. Patient is taken to the operating room where the nerve requires transposition and suture.
• 64834, 64859, 64872
• 64840, 64874
• 64856
• 64831, 64832, 64876

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing

• concurrent record analysis.
• point-of-care documentation.
• quantitative record review.
• clinical pertinence review. Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of
• qualitative review.
• peer review.
• quantitative review.
• legal analysis. This program, formerly called CHAMPUS (Civilian Health and Medical Program-Uniformed Services), is a health care program for active members of the military and other qualified family members.
• workers' compensation
• TRICARE
• Indian Health Service
• CHAMPVA You are gathering details on electronic health records and how they may benefit the physician's office where you work. Determine which of the following would be credible, antibodywebsite to find this information is:
• Facebook.com.

• REDDIT.com.
• Linkedin.com.
• HealthIT.gov. This registry collects data on recipients of heart valves and pacemakers:
• cancer registry.
• transplant registry.
• implant registry.
• hypertension registry. Excision of thyroid adenoma. 60100 Biopsy thyroid, percutaneous core needle 60200 Excision of cyst or adenoma of thyroid, or transection of isthmus 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy 60280 Excision of thyroglossal duct cyst or sinus
• 60210 Wrong
• 60280
• 60200 Correct
• 60100 The reference date for a cancer registry is
• the date that the cancer program applies for approval by the American College of Surgeons.
• the date when data collection began. Correct
• the date that the Cancer Committee is established.
• January 1 of the year in which the registry was established. Wrong

Closure of traumatic kidney injury. 13100 Repair, complex trunk, 1.1–2.5 cm 50400 Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic operation on ureter, nephropexy, nephrostomy, pyelostomy or ureteral splinting; simple 50500 Nephrorrhaphy, suture of kidney wound or injury 50520 Closure of nephrocutaneous or pyelocutaneous fistula

• 50520
• 13100
• 50400
• 50500 Patient presents to the hospital with ulcer of the right foot. Patient is taken to the operating room where a revision of the right metatarsal head is performed.
• 28111-RT
• 28288-RT
• 28104-RT
• 28899-RT Your supervisor asks you to determine how many patient-records the coders should be completing per hour, on average. You suggest as a place to begin.
• asking each coder what they think
• looking on the Internet
• making up a number
• benchmarking Case definition is important for all types of registries. Age will certainly be an important criterion for accessing a case in a(n) registry.

• birth defects
• trauma
• HIV/AIDS
• implant adenomatap
• 62268
• 64999
• 62272
• 62270 As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as X-rays or medical records are available. They must also develop and use a process for
• including the surgeon in the preanesthesia assessment.
• including the primary caregiver in surgery consults.
• apprising the patient of all complications that might occur.
• marking the surgical site. Patient presents to the emergency room with chest pains. The patient is admitted as a 23-hour observation. The cardiologist orders cardiac workup, and the patient undergoes left heart catheterization via the left femoral artery with visualization of the coronary arteries and left ventriculography. The physician interprets the report. Code the heart catheterization.
• 93458
• 93459

The patient is alert and in no acute distress. Initial vital signs: T98, P 102 and regular, R 20 and BP 120/69…

• 93452, 93455

• 93452, 93458

CMS delegates its daily operations of the Medicare and Medicaid programs to

• the PRO in each state.
• the office of the Inspector General.
• the National Center for Vital and Health Statistics.
• the Medicare administrative contractor (MAC). Based on the following documentation, determine where you would expect this excerpt to appear?
• social history
• physical exam Correct
• past medical history
• chief complaint Wrong Patient presents to the hospital for debridement of a diabetic ulcer of the left ankle. The patient has a history of recurrent ulcers. Medication taken by the patient includes Diabeta, and the patient was covered in the hospital with insulin sliding scales. The decubitus ulcer was debrided down to the bone.
• 11043, +
• 11044, +
• 11043, +
• 11044 The patient presented to his physician’s office due to increasingly severe pain in his right arm, shoulder, and neck for the past 6 weeks. MRI tests showed herniation of the C5–C6 disc. The

M50.02 Cervical disc disorder with myelopathy, mid-cervical region M50.22 Other cervical disc displacement, mid-cervical region M50.122 Cervical disc disorder at C5–C6 level with radiculopathy J43.9 Emphysema, unspecified J44.9 Chronic obstructive pulmonary disease, unspecified I25.10 Coronary atherosclerosis of native coronary artery Z98.61 Atherosclerotic heart disease of native coronary artery without angina pectoris patient is currently being treated for COPD and CAD with a history of a PTCA. (Code the ICD- 10-CM diagnoses.)

• M50.22, J43.9, Z98.
• M50.122, J44.9, I25.10, Z98.
• M50.02, J44.9, I25.10, Z98.
• M50.02, J43. In an acute care hospital, a complete history and physical may not be required for a new admission when
• the patient has an uneventful course in the hospital.
• the patient's stay is less than 24 hours.
• the patient is readmitted for a similar problem within 1 year.
• a legible copy of a current H&P performed in the attending physician's office is available. When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a
• Noncompliance Agreement.
• Recovery Audit Contract.
• Fraud Prevention Memorandum of Understanding.

• Corporate Integrity Agreement. Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data
• timeliness.
• validity. Wrong
• precision. Correct
• reliability. Under Medicare Part B, all of the following Commercial are true and are applicable to nonparticipating physician providers, EXCEPT
• providers must file all Medicare claims.
• fees are restricted to charging no more than the "limiting charge" on nonassigned claims.
• collections are restricted to only the deductible and coinsurance due at the time of service on an assigned claim.
• nonparticipating providers have a higher fee schedule than that for participating providers. In ICD-10-PCS, to code "removal of a thumbnail," the root operation would be
• fragmentation.
• extirpation.
• removal.
• extraction. Assume the patient has already met his or her deductible and that the physician is a Medicare participating (PAR) provider. The physician's standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00. How much reimbursement will the physician receive from Medicare?

• $ 96.

• $ 48.00 Correct
• $ 60.00 Wrong
• $120. An example of a valid code in ICD-10-CM is
• Z3A.34.
• 576.212D.
• 329.6677.
• BJRT23x. The Level I (CPT) codes of the HCPCS coding system are maintained by the
• American Hospital Association.
• local fiscal intermediary.
• Centers for Medicare and Medicaid Services.
• American Medical Association. Hepatitis C antibody
• 86803
• 86804
• 87522
• 87520

An office consultation is performed for a postmenopausal woman who is complaining of spotting in the past 6 months with right lower-quadrant tenderness. A detailed history and physical examination were performed with a low-complexity medical decision.

• 99243
• 99242
• 99253
• 99254 Determine the key data item you would expect to find recorded on an ER record but would probably NOT see in an acute care record
• time and means of arrival. Correct
• lab and diagnostic test results.
• instructions for follow-up care.
• physical findings. Wrong As the chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document
• subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant.
• past and current activities, such as smoking and drinking habits.
• a chronological description of patient's present condition from time of onset to present.
• objective symptoms observed by the physician. A 10 sq cm epidermal autograft to the face from the back
• 15110, 15115

• 15110

• 15115

• 15120

A primary focus of screen format design in a health record computer application should be to ensure that

• paper forms are easily converted to computer forms.
• programmers develop standard screen formats for all hospitals.
• data fields can be randomly accessed.
• the user is capturing essential data elements. Commercial insurance plans usually reimburse health care providers under some type of payment system, whereas the federal Medicare program uses some type of payment system.
• retrospective, concurrent
• prospective, retrospective
• retrospective, prospective
• prospective, concurrent The medical coder’s query stated, “Dr. Jones, I noticed that the patient has had elevated blood pressure during his last three visits. Shouldn’t he be diagnosed with hypertension and prescribed medication?” What do you observe about this query?
• The query should suggest specific diagnoses since the patient had elevated blood pressure for the last 3 visits. Wrong
• The query is leading Dr. Jones to a conclusion. Correct
• The query should state the specific medication.

• The coder correctly suggests the physician prescribe a medication in the query. Patient arrives to the hospital and has a Nissen fundoplasty done laparoscopically.
• 43280
• 43410
• 43502
• 43415 The method of calculating errors in a coding audit that allows for benchmarking with other hospitals, and permits the reviewer to track errors by case type, is the
• record-over-record method.
• code method.
• focused review method.
• benchmarking method. State Medicaid programs are required to offer medical assistance for
• individuals with qualified financial need.
• patients with end-stage renal disease.
• patients with a permanent disability.
• all individuals age 65 and over. Determine which one of the following would be an essential item captured on the physical exam.
• family history as related by the patient.
• general appearance as assessed by the physician.
• chief complaint.

• subjective review of systems. Removal of nephrostomy tube with fluoroscopic guidance
• 99213
• 50387
• 50389
• 99212