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87 Cards in this Set
- Front
- Back
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Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components?
A. International Classification of Primary Care (ICPC-2) B. International Classification on Functioning, Disability, and Health (ICF) C. National Drug Codes D. Clinical Care Classification (CCC) |
B. International Classification on Functioning, Disability, and Health (ICF)
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A physician performed an outpatient surgical procedure on the eye orbit of a patient with Medicare. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign
A. an unlisted Evaluation and Management code from the E/M section. B. an unlisted procedure code located in the eye and ocular adnexa section. C. a HCPCS Level Two (alphanumeric) code. D. an ophthalmologic treatment service code. |
B. an unlisted procedure code located in the eye and ocular adnexa section.
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A system of preferred terminology for naming disease processes is known as a
A. set of categories. B. classification system. C. medical nomenclature. D. diagnosis listing. |
C. medical nomenclature.
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Which of the following is NOT included as a part of the minimum data maintained in the MPI?
A. principal diagnosis B. patient medical record number C. full name (last, first, and middle) D. date of birth |
A. principal diagnosis
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The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?
A. operation index B. consultation index C. disease index D. physician's index |
C. disease index
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One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
A. until remission occurs B. 10 years C. for the life of the patient D. 1 year |
C. for the life of the patient
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In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to
A. confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant. B. code the record as is. C. code the condition as abnormal blood chemistry. D. code the abnormal potassium level as a complication following surgery. |
A. confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant.
A coder should never assign a code on the basis of laboratory results alone. If findings are clearly outside the normal range and the physician has ordered additional testing or treatment, it is appropriate to consult with the physician as to whether a diagnosis should be added or whether the abnormal finding should be listed. |
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DSM-IV-TR is used most frequently in what type of health care setting?
A. behavioral health centers B. ambulatory surgery centers C. home health agencies D. nursing homes |
A. behavioral health centers
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A coder notes that a patient is taking prescription Pilocarpine. The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of
A. arthritis. B. glaucoma. C. bronchitis. D. laryngitis. |
B. glaucoma
Pilocarpine is used to treat open-angle and angle-closure glaucoma to reduce intraocular pressure. |
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The patient is diagnosed with congestive heart failure. A drug of choice is
A. ibuprofen. B. oxytocin. C. haloperidol. D. digoxin. |
D. digoxin.
Digoxin is used for maintenance therapy in congestive heart failure, atrial fibrillation, atrial flutter, and paroxysmal atrial tachycardia. Ibuprofen is an anti-inflammatory drug. Oxytocin is used to initiate or improve uterine contractions at term, and haloperidol is used to manage psychotic disorders. |
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ICD-10-CM utilizes a placeholder character. This is used as a 5th character placeholder at certain 6 character codes to allow for future expansion. The placeholder character is
A. “Z." ”B. “O.” C. “1.” D. “x.” |
D. “x."
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The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct
A. CPT code. B. Standard Nomenclature of Injuries codes. C. E-codes and ICD-9-CM codes. D. HCPCS Level II codes. |
C. E-codes and ICD-9-CM codes.
HCPCS codes (Levels I and II) would only give the code for any procedures that were performed and would not identify the diagnosis code or cause of the accident. The correct name of the nomenclature for athletic injuries is the Standard Nomenclature of Athletic Injuries and is used to identify sports injuries. It has not been revised since 1976. |
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All children will be entered into which of the following registries at birth, and thus will continue to be monitored by the registry in their geographic area?
A. Birth defects registry B. Trauma registry C. Cancer registry D. Immunization registry |
D. Immunization registry
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In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when
A. the patient is established. B. a new patient is seen in the office. C. the patient is given subsequent care in the hospital. D. the patient is seen for a follow-up inpatient consultation. |
B. a new patient is seen in the office. All three key components (history, physical examination, and medical decision making) are required for new patients and initial visits. At least two of the three key components are required for established patients and subsequent visits. |
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This registry collects data on recipients of heart valves and pacemakers.
A. Transplant registry B. Implant registry C. Cancer registry D. Hypertension registry |
B. Implant registry
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Which classification system was developed to standardize terminology and codes for use in clinical laboratories?
A. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) B. Systematized Nomenclature of Pathology (SNOP) C. Read Codes D. Logical Observation Identifiers, Names and Codes (LOINC) |
D. Logical Observation Identifiers, Names and Codes (LOINC)
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Which classification system is used to classify neoplasms according to site, morphology, and behavior?
A. International Classification of Diseases for Oncology (ICD-O) B. Systematized Nomenclature of Human and Veterinary Medicine International (SNOMED) C. Diagnostic and Statistical Manual of Mental Disorders (DSM) D. Current Procedural Terminology (CPT) |
A. International Classification of Diseases for Oncology (ICD-O)
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According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a
A. principal procedure. B. significant procedure. C. operating room procedure. D. therapeutic procedure. |
B. significant procedure.
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You need to analyze data on the types of care provided to Medicare patients in your geographic area by DRG. Which of the following would be most helpful?
A. National Practitioner Data Bank B. MEDPAR C. Vital Statistics D. RxNorm |
B. MEDPAR
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An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n)
A. logic-based encoder. B. automated codebook. C. grouper. D. automatic code assignment. |
A. logic-based encoder.
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Which of the following classification systems was designed with electronic systems in mind and is currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and images?
A. SNOMED CT B. SNDO C. ICDPC-2 D. GEM |
A. SNOMED CT
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The Unified Medical Language System (UMLS) is a project sponsored by the
A. National Library of Medicine. B. CMS. C. World Health Organization. D. Office of Inspector General. |
A. National Library of Medicine.
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You have recently been hired as the Medical Staff Coordinator at your local hospital. Which database/registry will you utilize most often?
A. Trauma Registry B. MEDPAR C. LOINC D. National Practitioner Data Bank (NPDB) |
D. National Practitioner Data Bank (NPDB)
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You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information?
A. Healthcare Integrity and Protection Data Banks (HIPDB) B. Physician Index C. MEDLINE database D. National Practitioner Data Bank (NPDB) |
B. Physician Index
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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?
A. Case finding B. Staging C. Abstracting D. Nomenclature |
C. Abstracting
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Which system is used primarily to report services and supplies for reimbursement purposes?
A. LOINC B. HCPCS C. NLM D. ASTM |
B. HCPCS
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You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing?
A. Aggregate data B. Patient-identifiable data C. MPI data D. Protocol data |
A. Aggregate data
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In which registry would you expect to find an Injury Severity Score (ISS)?
A. Cancer Registry B. Birth Defects Registry C. Trauma Registry D. Transplant Registry |
C. Trauma Registry
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A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as
A. a referral. B. a consultation. C. risk factor intervention. D. concurrent care. |
B. a consultation.
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Which of the following groups maintain healthcare databases in the public and private sectors?
A. Healthcare provider organizations B. Healthcare data organizations C. Healthcare payor organizations D. Healthcare supplier organizations |
B. Healthcare data organizations
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The most widely discussed and debated unique patient identifier is the
A. patient's date of birth. B. patient's first and last names. C. patient's social security number. D. Unique Physician Identification Number (UPIN). |
C. patient's social security number.
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A nomenclature of codes and medical terms that provides standard terminology for reporting physicians' services for third-party reimbursement is
A. Current Medical Information and Terminology (CMIT). B. Current Procedural Terminology (CPT). C. Systematized Nomenclature of Pathology (SNOP). D. Diagnostic and Statistical Manual of Mental Disorders (DSM). |
B. Current Procedural Terminology (CPT).
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A cancer program is surveyed for approval by the
A. American Cancer Society. B. Commission on Cancer of the American College of Surgeons. C. State Department of Health. D. Joint Commission on Accreditation of Healthcare Organizations. |
B. Commission on Cancer of the American College of Surgeons.
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The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels?
A. READ codes B. ABC codes C. SPECIALIST Lexicon D. LOINC |
B. ABC codes
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The Level II (national) codes of the HCPCS coding system are maintained by the
A. American Medical Association. B. CPT Editorial Panel. C. local fiscal intermediary. D. Centers for Medicare and Medicaid Services. |
D. Centers for Medicare and Medicaid Services.
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A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia?
A. pseudomonas B. clostridium C. staphylococcus D. listeria |
A. pseudomonas
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The Level I (CPT) codes of the HCPCS coding system are maintained by the
A. American Medical Association. B. American Hospital Association. C. local fiscal intermediary. D. Centers for Medicare and Medicaid Services. |
A. American Medical Association.
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A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?
A. full-thickness skin graft to scalp only B. excision of lesion; full-thickness skin graft to scalp C. excision of lesion; full-thickness skin graft to scalp; excision of skin from thigh D. code 15004 for surgical preparation of recipient site; full-thickness skin graft to scalp |
B. excision of lesion; full-thickness skin graft to scalp
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A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.
A. −25 B. −55 C. −57 D. −58 |
C. −57
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A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.
A. −52 B. −53 C. −73 D. −74 |
B. −53
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A barrier to widespread use of automated code assignment is
A. inadequate technology. B. poor quality of documentation. C. resistance by physicians. D. resistance by HIM professionals |
B. poor quality of documentation.
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In assigning E/M codes, three key components are used. These are
A. history, examination, counseling. B. history, examination, time. C. history, nature of presenting problem, time. D. history, examination, medical decision making. |
D. history, examination, medical decision making.
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Mrs. Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit.
A. −58 B. −76 C. −78 D. −79 |
C. −78
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The primary goal of a hospital-based cancer registry is to
A. improve patient care. B. allocate hospital resources appropriately. C. determine the need for professional and public education programs. D. monitor cancer incidence. |
A. improve patient care.
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A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a(n)
A. disease index. B. master patient index. C. disease registry. D. admissions register. |
C. disease registry.
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46. In assigning E/M codes, three key components are used. These are
27645 radical resection of tumor; tibia 27646 fibula 27647 talus or calcaneus A. 27646 radical resection of tumor; tibia and fibula. B. 27646 radical resection of tumor; fibula. C. 27646 radical resection of tumor; fibula or tibia. D. 27646 radical resection of tumor; fibula, talus or calcaneus. |
B. 27646 radical resection of tumor; fibula.
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A population-based cancer registry that is designed to determine rates and trends in a defined population is a(n)
A. incidence-only population-based registry. B. cancer control population-based registry. C. research-oriented population-based registry. D. patient care population-based registy |
A. incidence-only population-based registry.
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Given the diagnosis “carcinoma of axillary lymph nodes and lungs, metastatic from breast,” what is the primary cancer site(s)?
A. axillary lymph nodes B. lungs C. breast D. A and B |
C. breast
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According to CPT, in which of the following cases would an established E/M code be used?
A. A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. B. John and his family have just moved to town. John has asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician. C. Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago. D. A 78-year-old female with weight loss and progressive agitation over the past 2 months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years. |
C. Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.
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In order to use the inpatient CPT consultation codes, the consulting physician must
A. order diagnostic tests. B. document his findings in the patient's medical record. C. communicate orally his opinion to the attending physician. D. use the term “referral” in his report. |
B. document his findings in the patient's medical record.
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51. The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits?
A. an initial inpatient consult and a follow-up consult B. an initial inpatient consult for both visits C. an initial inpatient consult and a subsequent hospital visit D. an initial inpatient consult and initial hospital care |
B. an initial inpatient consult for both visits
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According to the American Medical Association, medical decision making is measured by all of the following except the
A. number of diagnoses or management options. B. amount and complexity of data reviewed. C. risk of complications. D. specialty of the treating physician. |
D. specialty of the treating physician.
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CPT provides Level I modifiers to explain all of the following situations EXCEPT
A. when a service or procedure is partially reduced or eliminated at the physician's discretion. B. when one surgeon provides only postoperative services. C. when a patient sees a surgeon for follow-up care after surgery. D. when the same laboratory test is repeated multiple times on the same day. |
C. when a patient sees a surgeon for follow-up care after surgery.
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The best place to ascertain the size of an excised lesion for accurate CPT coding is the
A. discharge summary. B. pathology report. C. operative report. D. anesthesia record. |
C. operative report.
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Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?
A. LOINC B. ICD-10-CM C. NDC D. NANDA |
B. ICD-10-CM
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Case definition is important for all types of registries. Age will certainly be an important criterion for accessing a case in a(n) _____________ registry.
A. implant B. trauma C. HIV/AIDS D. birth defects |
D. birth defects
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To gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?
A. ICD-10-CM codes B. evaluation and management codes C. HCPCS Level II Codes D. CPT codes |
D. CPT codes
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The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the
A. disease index. B. tickler file. C. suspense file. D. accession register. |
D. accession register.
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The reference date for a cancer registry is
A. January 1 of the year in which the registry was established. B. the date when data collection began. C. the date that the Cancer Committee is established. D. the date that the cancer program applies for approval by the American College of Surgeons. |
B. the date when data collection began.
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The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses these data for its
A. AIDS registry. B. diabetes registry. C. implant registry. D. trauma registry. |
D. trauma registry.
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In relation to birth defects registries, active surveillance systems
A. use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs. B. are commonly used in all 50 states. C. miss 10% to 30% of all cases. D. rely on reports submitted by hospitals, clinics, or other sources. |
A. use trained staff to identify cases in all hospitals, clinics, and other facilities through review of patient records, indexes, vital records, and hospital logs.
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In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to
A. reliability. B. validity. C. completeness. D. timeliness. |
A. reliability.
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The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the
A. Agency for Healthcare Research and Quality. B. Centers for Medicare and Medicaid Services. C. National Library of Medicine. D. World Health Organization. |
A. Agency for Healthcare Research and Quality.
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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
A. completeness. B. validity. C. reliability. D. timeliness. |
completeness
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When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding?
A. recipient site B. donor site C. size of defect D. type of repair |
B. donor site
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In CPT, Category III codes include codes
A. to describe emerging technologies. B. to measure performance. C. for use by nonphysician practitioners. D. for supplies, drugs, and durable medical equipment. |
A. to describe emerging technologies.
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The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a
A. birth defects registry. B. diabetes registry. C. transplant registry. D. trauma registry. |
C. transplant registry.
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Patient Jamey Smith has been seen at Oceanside Hospital three times prior to this current encounter. Unfortunately, because of clerical errors, Jamey's information was entered into the MPI incorrectly on the three previous admissions and consequently has three different medical record numbers. The unit numbering system is used at Oceanside Hospital. Jamey's previous entries into the MPI are as follows:
09/03/10Jamey SmithMR# 10361 03/10/11Jamey Smith DoeMR# 339980 7/23/12Jamie Smith DoeMR# 36723 The next available number to be assigned at Oceanside Hospital is 41369. Duplicate entries in the MPI should be scrubbed and all of Jamey's medical records should be filed under medical record number A. 10361. B. 33998. C. 36723. D. 41369. |
A. 10361
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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
A. record-over-record method. B. benchmarking method. C. code method. D. focused review method. |
A. record-over-record method.
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The most common type of registry located in hospitals of all sizes and in every region of the country is the
A. trauma registry. B. cancer registry. C. AIDS registry. D. birth defects registry. |
B. cancer registry.
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A radiologist is asked to review a patient's CT scan that was taken at another facility. The modifier −26 attached to the code indicates that the physician is billing for what component of the procedure?
A. professional B. technical C. global D. confirmatory |
professional
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When coding neoplasms, topography means
A. cell structure and form. B. site. C. variation from normal tissue. D. extent of the spread of the disease. |
B. site.
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According to CPT, antepartum care includes all of the following EXCEPT
A. initial and subsequent history. B. physical examination. C. monthly visits up to 36 weeks. D. routine chemical urinalysis. |
C. monthly visits up to 36 weeks.
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The Cancer Committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of these data is the
A. disease index. B. operation index. C. master patient index. D. cancer registry abstracts. |
D. cancer registry abstracts.
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A list or collection of clinical words or phrases with their meanings is a
A. data dictionary. B. language. C. medical nomenclature. D. clinical vocabulary. |
D. clinical vocabulary.
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The main difference between concurrent and retrospective coding is
A. when the coding is done. B. what classification system is used. C. the credentials of the coder. D. the involvement of the physician. |
A. when the coding is done.
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A PEG procedure would most likely be done to facilitate
A. breathing. B. eating. C. urination. D. none of the above. |
B. eating.
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CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10- PCS. The use of these two code sets will be effective on
A. January 1, 2014. B. October 1, 2014. C. January 1, 2015. D. October 1, 2015. |
B. October 1, 2014.
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Mappings between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called
A. GEMS (General Equivalency Mappings). B. Medical Mappings. C. Code Maps. D. ICD Code Maps. |
A. GEMS (General Equivalency Mappings).
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The code structure for ICD-10-CM differs from the code structure of ICD-9-CM. An ICD-10-CM code consists of
A. five alphanumeric characters. B. 10 characters. C. three to seven characters. D. seven digits. |
C. three to seven characters.
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The first character for all of the codes assigned in ICD-10-CM is
A. an alphabet. B. a number. C. an alphabet or a number. D. a digit. |
A. an alphabet.
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ICD-10-PCS will be implemented in the United States to code
A. hospital inpatient procedures. B. physician office procedures. C. hospital inpatient diagnoses. D. hospital outpatient diagnoses. |
A. hospital inpatient procedures.
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ICD-10-PCS codes have a unique structure. An example of a valid code in the ICD-10-PCS system is
A. L03.311. B. 013.2. C. B2151. D. 2W3FX1Z |
D. 2W3FX1Z
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ICD-10-PCS utilizes the third character in the Medical and Surgical section to identify the “root operation.” The name of the root operation that describes “cutting out or off, without replacing a portion of a body part” is
A. destruction. B. extirpation. C. excision. D. removal. |
C. excision.
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In ICD-10-PCS, to code “removal of a thumbnail,” the root operation would be
A. removal. B. extraction. C. fragmentation. D. extirpation. |
B. extraction.
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In ICD-10-CM, the final character of the code indicates laterality. An unspecified side code is also provided should the site not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, the ICD-10-CM Official Coding Guidelines direct the coder to
A. assign the unspecified side code. B. assign separate codes for both the left and right side. C. not assign a code. D. query the physician. |
B. assign separate codes for both the left and right side.
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An example of a valid code in ICD-10-CM is
A. 576.212D. B. Z3A.34 C. 329.6677. D. BJRT23x. |
B. Z3A.34
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