AHIMA CCA: Practice Questions

1.
Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April.

a. 90965

b. 90964

c. 90966

d. 90970

Correct Answer: C

Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease (ESRD) related services for home dialysis per full month for patients 20 years of age and older (Smith 2012, 227).

2.
Exceptions to the consent requirement include:

a. Medical emergencies

b. Provider discretion

c. Implied consent

d. Informed consent

Correct Answer: A

The law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or minor (Brodnik et al. 2009, 99).

3.
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents “urosepsis.” How should the coder proceed to code this case?

a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis.

b. Code urinary tract infection with sepsis as the principal diagnosis.

c. Query the physician to ask if the patient has septicemia because of the symptomatology.

d. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.

Correct Answer: C

The term “urosepsis” is a nonspecific term. If that is the only term documented, only code 599.0 should be assigned based on the default for the term in the ICD-9-CM index, in addition to the code for the causal organism, if known. Septicemia results from the entry of pathogens into the bloodstream. Symptoms include spiking fever, chills, and skin eruptions in the form of petechiae or purpura. Blood cultures are usually positive; however, a negative culture does not exclude the diagnosis of septicemia. Several other clinical indications and symptomology could indicate the diagnosis of septicemia. Only the physician can diagnose the condition based on clinical indications. Query the physician when the diagnosis is not clear to the coder (Schraffenberger 2012, 79-81, 251).

4.
What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?

a. 46255

b. 46930

c. 46260

d. 46945

Correct Answer: B

Index main term: Destruction, hemorrhoid, thermal. Thermal includes infrared coagulation (Kuehn 2012, 27, 163).

5.
Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure.

a. -22

b. -54

c. -32

d. -55

Correct Answer: D

Modifiers are appended to the code to provide more information or to alert the payer that a payment change is required. Modifier -55 is used to identify the physician provided only postoperative care services for a particular procedure (Kuehn 2012, 292, 295).

6.
Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?

a. Centers for Disease Control (CDC)

b. Centers for Medicare and Medicaid Services (CMS)

c. National Center for Health Statistics (NCHS)

d. World Health Organization (WHO)

Correct Answer: B

NCHS is responsible for updating the diagnosis classification (Volumes 1 and 2), and CMS is responsible for updating the procedure classification (Volume 3) (Johns 2011, 239).

7.
Good encoding software should include ________ to ensure data quality.

a. Edit checks

b. Voice recognition

c. Reimbursement technology

d. Passwords

Correct Answer: A

Good encoding software should include edit checks to ensure data quality (Johns 2011, 270).

8.
Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusions of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied. Which is the correct code assignment?

a. 808.1, E881.0, E849.0, 79.25, 78.15

b. 808.1, 920, E881.0, E849.0, E000.8, E013.9, 79.25, 78.15, 79.65

c. 808.0, E881.0, E000.8, E013.9, 79.35, 79.65

d. 808.1, E881.0, E849.0, E013.9, 79.25, 78.15, 79.65

Correct Answer: B

The fracture is the principal diagnosis, with the contusions as a secondary diagnosis. The fracture is what required the most treatment. Procedures for the reduction, debridement, and external fixation device would all need to be coded (Schraffenberger 2012, 354-355).

9.
A request for reconsideration of a denied claim for insurance coverage for healthcare services is called a(n):

a. Breach

b. Exclusion

c. Appeal

d. Inclusion

Correct Answer: C

An appeal is a request for consideration of denial of coverage for healthcare services of a claim (Casto and Layman 2011, 71).

10.
Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment?

a. 49565

b. 49565, 49568

c. 49656

d. 49560, 49568

Correct Answer: C

Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope, and is reducible makes the choice 49656. Notice that the use of mesh is included in the code (Kuehn 2012, 27, 164-166).

11.
The sum of a hospital’s total relative DRG weights for a year was 15,192 and the hospital had 10,471 total discharges for the year. Given this information, what would be the hospital’s case-mix index for that year?

a. 0.689

b. 1.59

c. 1.45 × 100

d. 1.45

Correct Answer: D

The case-mix index is 1.45 for the total case-mix index of the hospital. An individual MS-DRG case mix can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG. This provides the total weight for each MS-DRG. The sum of all total weights (15,192) divided by the sum of total patient discharges (10,471) equals the case-mix index (Johns 2011, 324).

12.
A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was “Rule out chest pain versus GERD.” The correct ICD-9-CM code is:

a. V71.7, Admission for suspected cardiovascular condition

b. 789.01, Esophageal pain

c. 530.81, Gastrointestinal reflux

d. 786.50, Chest pain NOS

Correct Answer: D

Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as “rule out” or other similar terms indicating uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if it existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign or symptom the patient exhibits. In this case, assign the code 786.50, Chest pain NOS (Schraffenberger 2012, 339).

Identify the correct diagnosis code for lipoma of the face.

a. 214.1

b. 213.0

c. 214.0

d. 214.9

Correct Answer: C

Index Lipoma, face. ICD-9-CM classifies neoplasms by system, organ, or site with the exception of neoplasms of the lymphatic and hematopoietic system, malignant melanomas of the skin, lipomas, common tumors of the bone, uterus, and ovary. Because of these exceptions, the Alphabetic Index must first be checked to determine if a code has been assigned for that specific histology type (Schraffenberger 2012, 99-100).

The term minimum necessary means that healthcare providers and other covered entities must limit use, access, and disclosure to the minimum necessary to:

a. Satisfy one’s curiosity

b. Accomplish the intended purpose

c. Treat an individual

d. Perform research

Correct Answer: B

The Privacy Rule introduced the standard of minimum necessary to limit the amount of PHI used, disclosed, and requested. This means that healthcare providers and other covered entities must limit uses, disclosures, and requests to only the amount needed to accomplish the intended purpose (Johns 2011, 822).

AMBULATORY RECORD

To view this health record:

Click on the tabs above.
Scroll to the bottom of each document.
For your referance, the Coding Guidelines tab includes information from your codebooks.
To answer the questions in this case:

Enter the appropriate codes in the boxes on the right.
Enter a DX code in every box.
Any necessary decimal point must be present and correctly placed.
Do not include spaces with your answer.

______________
*Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.

______
DATE: 8/12/20XX

SURGERY RECORD:

PATIENT HISTORY: This patient is seen today to insert an intrathecal pump for pain management due to ductal carcinoma of the left upper breast metastatic to the spine. She previously underwent modified radical mastectomy with general anesthesia and had no adverse effects. No other surgical history is given. No known allergies, no current medications. Review of systems is normal ASA = 2.

Following preoperative evaluation and discussion with the patient, local anesthesia was used to implant an intrathecal programmable pump surgically placed and attached to a previously placed catheter. The patient tolerated the procedure well. There were no adverse effects of anesthesia.
__________
Enter three diagnosis codes and one procedure code.

PDX

DX2

DX3

PP1

Case Studies
PDX 338.3 Neoplasm-related pain (acute) (chronic)
DX2 174.8 Malignant neoplasm of female breast, other specified sites
DX3 198.5 Secondary malignant neoplasm of bone and bone marrow
PP1 62362 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming

Notes for Practice Outpatient Case—Patient 2

338.3 The patient is admitted for pain management due to metastatic cancer. If the admission is for pain control related to, associated with, or due to, a malignancy, code 338.3 (Brown 2012, 163; Coding Clinic 2nd Quarter 2007, 13-14).
174.8, 198.5 The primary site and metastatic (secondary) sites should be coded (Brown 2012, 378-382).
62362 The reservoir is surgically placed and attached to a previously placed catheter (CPT Assistant March 1997, 11).
(Garvin 2013, 54, 250.)

The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the:

a. Social security number

b. Unique physician identification number

c. Health record number

d. National provider identifier

Correct Answer: A

It is generally agreed that social security numbers (SSNs) should not be used as patient identifiers (Johns 2011, 387).

5.
What are four-digit ICD-9-CM diagnosis codes referred to as?

a. Category codes

b. Section codes

c. Subcategory codes

d. Subclassification codes

Correct Answer: C

Categories are divided into subcategories. At this level, four-digit code numbers are used (Johns 2011, 240).

Identify the diagnosis code(s) for melanoma of skin of shoulder.

a. 172.8, 172.6

b. 172.6

c. 172.9

d. 172.8

Correct Answer: B

Index Melanoma (malignant), shoulder. Melanoma is considered a malignant neoplasm and is referenced as such in the index of ICD-9-CM. The term “benign neoplasm” is considered a growth that does not invade adjacent structures or spread to distant sites but may displace or exert pressure on adjacent structures (Schraffenberger 2012, 94-95).

These codes are used to assign a diagnosis to a patient who is seeking health services, but is not necessarily sick.

a. E codes

b. V codes

c. M codes

d. C codes

Correct Answer: B

V codes are diagnosis codes and indicate a reason for healthcare encounter (Schraffenberger 2012, 433).

A female patient is admitted for stress incontinence. A urethral suspension is performed. Assign the correct ICD-9-CM diagnosis and/or procedure code(s).

a. 625.6, 57.32

b. 788.0, 59.5

c. 625.6, 59.5

d. 788.30

Correct Answer: C

Main term for diagnosis: Incontinence; subterm: stress. Main term for procedure: Suspension; subterm: urethra (Schraffenberger 2012, 10).

Using uniform terminology is a way to improve:

a. Validity

b. Data timeliness

c. Audit trails

d. Data reliability

Correct Answer: D

Data reliability is a method at looking at data quality consistently, sometimes referred to as data reliability. Reliability is frequently checked by having more than one person abstract data for the same case and compare the results for any discrepancies (Johns 2011, 509).

Messaging standards for electronic data interchange in healthcare have been developed by:

a. HL7

b. IEE

c. The Joint Commission

d. CMS

Correct Answer: A

HL7 developed the HL7 Electronic Health Record System (EHR-S) Functional Model. It also includes many standards for data exchange with patient information (Johns 2011, 226).

Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of the following except:

a. Coding conventions defined in the CPT book

b. National and local policies and coding edits

c. Analysis of standard medical and surgical practice

d. Clinical documentation in the discharge summary

Correct Answer: D

Editing is not based on the clinical documentation of the discharge summary. Edits are predetermined based on coding conventions defined in the CPT codebooks, national and local policies and coding edits, analysis of standard medical and surgical practice, and review of current coding practices (Johns 2011, 347).

Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment?

a. 188.3, V10.51, 57.49, 57.32

b. 198.1, 57.49

c. 188.3, 57.49

d. 198.1, 188.3, 57.49

Correct Answer: C

When the primary malignant neoplasm previously removed by surgery or eradicated by radiotherapy or chemotherapy recurs, the primary malignant code for the site is assigned, unless the Alphabetic Index directs otherwise (Schraffenberger 2012, 106).

A health information technician (HIT) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?

a. Compliance program education and training programs for all employees in the organization

b. Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation

c. Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted

d. Establish a corporate compliance committee who report directly to the CFO.

Correct Answer: B

Establish a process, such as a hotline, to receive complaints and the adoption of procedures to protect the anonymity of complainants and to protect whistleblowers from retaliation (Johns 2011, 259).

In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following?

a. DRGs

b. HHRGS

c. OASIS

d. OPPS

Correct Answer: D

[outpatient perspective payment system (OPPS)],

Radiology procedures performed as outpatients are paid under the Medicare prospective payment system and are identified with a status indicator X for ancillary services (Johns 2011, 329-331).

Which document directs an individual to bring originals or copies of records to court?

a. Summons

b. Subpoena

c. Subpoena duces tecum

d. Deposition

Correct Answer: C

Subpoena duces tecum is a written document directing individuals or organizations to furnish relevant documents and records (Johns 2011, 443; AHIMA 2012b, 329).

Under the Medicare hospital outpatient perspective payment system (OPPS), services are paid according to:

a. A fee-for-service schedule basis that varies according to the MPFS

b. A rate-per-service basis that varies according to the ambulatory payment classification (APC) group to which the service is assigned

c. A cost-to-charge ratio based on the hospital cost report

d. A rate-per-service basis that varies according to the DRG group

Correct Answer: B

The payment varies based on the APC group (Johns 2011, 329).

An encoder that takes a coder through a series of questions and choices is called a(n):

a. Automated codebook

b. Automated code assignment

c. Logic-based encoder

d. Decision support database

Correct Answer: C

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) (LaTour and Eichenwald Maki 2010, 400).

Written or spoken permission to proceed with care is classified as:

a. An advanced directive

b. Formal consent

c. Expressed consent

d. Implied consent

Correct Answer: C

Expressed consent can be spoken or written (Johns 2011, 71).

A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to:

a. Request restrictions on certain uses and disclosures of PHI

b. Remove their record from the facility

c. Deny provider changes to their PHI

d. Delete portions of the record they think are incorrect

Correct Answer: A

The HIPAA Privacy Rule provides patients with rights that allow them to have some control over their health information: right of access, right to request amendment of PHI, right to accounting of disclosures, right to request restrictions of PHI, right to request confidential communications, and right to complain of Privacy Rule violations (Johns 2011, 826).

Deidentified information:

a. Does identify an individual

b. Is information from which personal characteristics have been stripped

c. Can be later constituted or combined to re-identify an individual

d. Pertains to a person that is identified within the information

Correct Answer: B

Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped (Johns 2011, 826).

Diagnosis-related groups are organized into:

a. Case-mix classifications

b. Geographic practice cost indices

c. Major diagnostic categories

d. Resource-based relative values

Correct Answer: C

Diagnosis-related groupings (DRGs) are classified by one of 25 major diagnostic categories (MDCs) (Johns 2011, 322).

Identify where the following information would be found in the acute-care record: Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.

a. Anesthesia report

b. Physician progress notes

c. Operative report

d. Recovery room record

Correct Answer: C

The operative report includes a description of the procedure performed (Johns 2011, 73).

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed.

a. 31622, 31640

b. 31622, 31623

c. 31623

d. 31625

Correct Answer: C

A bronchoscopy with brushings and washings is considered a diagnostic bronchoscopy and not a biopsy. Code 31623 specifies brushings, and code 31622 is selected for washings (Kuehn 2012, 136-137).

Which of the following contains the physician’s findings based on an examination of the patient?

a. Physical exam

b. Discharge summary

c. Medical history

d. Patient instructions

Correct Answer: A

A physical examination report represents the attending physician’s assessment of the patient’s current health status (Johns 2011, 63).

Which of the following is a condition that arises during hospitalization?

a. Case mix

b. Complication

c. Comorbidity

d. Principal diagnosis

Correct Answer: B

A complication is a secondary condition that arises during hospitalization and is thought to increase the length of stay by at least one day for approximately 75% of the patients (Johns 2011, 322).

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?

a. Require all coders to implement this practice

b. Report the practice to the OIG

c. Counsel the coder and stop the practice immediately

d. Put the coder on unpaid leave of absence

Correct Answer: C

Be sure the employees receive appropriate compliance training and continue ongoing training for all employees (Johns 2011, 361-362).

n processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures performed during the same operative session, which of the following would apply?

a. Bundling of services

b. Outlier adjustment

c. Pass-through payment

d. Discounting of procedures

Correct Answer: D

Discounting applies to multiple surgical procedures furnished during the same operative session. The full rate will be paid to the surgical procedure with the highest rate and the additional procedures will be discounted 50% of their APC rate (Johns 2011, 330).

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is:

a. UHDDS

b. UACDS

c. MDS

d. ORYX

Correct Answer: A

In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (LaTour and Eichenwald Maki 2010, 165).

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:

a. Natural-language processing systems

b. Monitoring/audit programs

c. Encoders

d. Concept, description, and relationship tables

Correct Answer: C

The type of tool used to aid in the coding process is called an encoder (Johns 2011, 269).

The following is documented in an acute-care record: “Microscopic: Sections are of squamous mucosa with no atypia.” In which of the following would this documentation appear?

a. History

b. Pathology report

c. Physical examination

d. Operation report

The following is documented in an acute-care record: “Microscopic: Sections are of squamous mucosa with no atypia.” In which of the following would this documentation appear?

a. History

b. Pathology report

c. Physical examination

d. Operation report

With regard to training in PHI policies and procedures, the following statement is true:

a. Every member of the covered entity’s workforce must be trained.

b. Only individuals employed by the covered entity must be trained.

c. Training only needs to occur when there are material changes to the policies and procedures.

d. Documentation of training is not required.

Correct Answer: A

Every member of the covered entity’s workforce must be trained in PHI policies and procedures according to the Privacy Rule (Johns 2011, 857).

Identify the diagnosis code(s) for carcinoma in situ of vocal cord.

a. 231.0

b. 161.0

c. 239.1

d. 212.1

Correct Answer: A

Index Carcinoma, in situ, see also Neoplasm, by site, in situ (Schraffenberger 2012, 94-95.)

Data definition refers to:

a. Meaning of data

b. Completeness of data

c. Consistency of data

d. Detail of data

Correct Answer: A

Data definition means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent (Johns 2011, 48).

A 65-year-old woman was admitted to the hospital. She was diagnosed with septicemia secondary to Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?

a. 038.8, 562.11, 789.00

b. 038.11, 562.11

c. 038.8, 562.11, 041.11

d. 038.9, 562.11

Correct Answer: B

Septicemia generally refers to a systemic disease associated with the presence of pathological microorganisms or toxins in the blood, which can include bacteria, viruses, fungi, or other organisms. Code 038.11 is assigned for septicemia with Staphylococcus aureus. Because abdominal pain is a symptom of diverticulosis, only the diverticulitis of the colon (562.11) is coded (Schraffenberger 2012, 80).

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?

a. Length of the lesion as described in the pathology report

b. Dimension of the specimen submitted as described in the pathology report

c. Width times the length of the lesion as described in the operative report

d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report

Correct Answer: D

The code selection is determined by measuring the greatest clinical diameter of the apparent lesion plus that margin required for complete excision (lesion diameter plus the most narrow margins required equals the excised diameter) (AMA 2012b, 64).

The key data element for linking data about an individual who is seen in a variety of care settings is the:

a. Facility medical record number

b. Facility identification number

c. Unique patient identifier

d. Patient birth date

Correct Answer: C

A unique patient identifier is a unique number assigned by a healthcare provider to a patient that distinguishes the patient’s medical records from all others (Johns 2011, 1178).

The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:

a. Adult sibling; adult child; spouse; parent

b. Parent; spouse; adult child; adult sibling

c. Spouse; parent; adult sibling; adult child

d. Spouse; adult child; parent; adult sibling

Correct Answer: D

The UHCDA suggests that decision-making priority for an individual’s next-of-kin be as follows: Spouse, adult child, parent, adult sibling, or if no one is available who is so related to the individual, authority may be granted to “an adult who exhibited special care and concern for the individual” (Brodnik et al. 2009, 113).

A skin lesion is removed from a patient’s cheek in the dermatologist’s office. The dermatologist documents “skin lesion” in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission?

a. Code skin lesion

b. Code benign skin lesion

c. Code basal cell carcinoma

d. Query the dermatologist

Correct Answer: C

For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnosis. Note: This differs from the coding practice in the hospital inpatient setting regarding abnormal findings on test results (Schraffenberger 2012, 340-341).

Exceptions to the consent requirement include:

a. Medical emergencies

b. Provider discretion

c. Implied consent

d. Informed consent

Correct Answer: A

The law permits a presumption of consent during emergency situations, regardless of whether the patient is an adult or minor (Brodnik et al. 2009, 99).

Effective October 16, 2003, under the Administrative Simplification Compliance section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all healthcare providers must electronically submit claims to Medicare. Which is the electronic format for hospital technical fees?

a. 837I

b. 837P

c. UB-04

d. 1500

Correct Answer: A

The electronic format for institutional or facility claims is 837I for institutional claims whereas 837P is for professional claims. The UB-04 and the 1500 forms are the paper billing forms for hospital (technical) and clinic (professional) claims, respectively (Casto and Layman 2011, 72).

Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure?

a. Anesthesia report

b. Laboratory report

c. Operative report

d. Pathology report

Correct Answer: D

The pathology report includes descriptions of the tissue from a gross or macroscopic level and representative cells at the microscopic level (Johns 2011, 77).

The following is documented in an acute-care record: “HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds.” In which of the following would this documentation appear?

a. History

b. Pathology report

c. Physical examination

d. Operation report

Correct Answer: C

Results of the physician’s examination of the patient’s physical condition is reported in a physical examination report (Johns 2011, 63).

If another status T procedure were performed, how much would the facility receive for the second status T procedure?

Billing
Number Status
Indicator CPT/HCPCS APC
998323 V 99285-25 0612
998324 T 25500 0044
998325 X 72050 0261
998326 S 72128 0283
998327 S 70450 0283

a. 0%

b. 50%

c. 75%

d. 100%

Correct Answer: B

Multiple surgical procedures with payment status indicator T performed during the same operative session are discounted. The highest-weighted procedure is fully reimbursed. All other procedures with payment status indicator T are reimbursed at 50% (Casto and Layman 2011, 183).

Dr. Jones entered a progress note in a patient’s health record 24 hours after he visited the patient. Which quality element is missing from the progress note?

a. Data completeness

b. Data relevancy

c. Data currency

d. Data precision

Correct Answer: C

Data currency and data timeliness refer to the requirement that healthcare data should be up-to-date and recorded at or near the time of the event or observation (Johns 2011, 48).

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?

a. Poisoning due to Coumadin

b. Unspecified adverse reaction to Coumadin

c. Hematuria; poisoning due to Coumadin

d. Hematuria; adverse reaction to Coumadin

Correct Answer: D

Adverse effects can occur in situation in which medication is administered properly and prescribed correctly in both therapeutic and diagnostic procedures. An adverse effect can occur when everything is done correctly. The first-listed diagnosis is the manifestation or the nature of the adverse effect, such as the hematuria. Locate the drug in the Substance column of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select the E code for the drug from the Therapeutic Use column of the Table of Drugs and Chemicals. Use of the E code is mandatory when coding adverse effects (Schraffenberger 2012, 377-378).

What is the function of a consultation report?

a. Provides a chronological summary of the patient’s medical history and illness

b. Documents opinions about the patient’s condition from the perspective of a physician not previously involved in the patient’s care

c. Concisely summarizes the patient’s treatment and stay in the hospital

d. Documents the physician’s instructions to other parties involved in providing care to a patient

Correct Answer: B

The consultation report documents the clinical opinion of a physician other than the primary or attending physician (Johns 2011, 78).

The patient was admitted with major depression severe, recurrent. What is the correct ICD-9-CM diagnosis code assignment for this condition?

a. 296.33

b. 296.30

c. 311

d. 296.89

Correct Answer: A

Main term: Depression; subterm: recurrent with fifth digit of 3 for severe, without mention of psychotic behavior (Schraffenberger 2012, 143-145).

A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following services is reimbursed under the outpatient prospective payment system?

a. Clinical laboratory tests

b. Physician office visits

c. Radiology examinations

d. Take-home surgical dressings

Correct Answer: C

Radiology procedures are identified under the outpatient perspective payment system with a status indicator X. Status indicator X identifies ancillary services that are separately paid (Johns 2011, 329-331).

Patient with flank pain was admitted and found to have a calculus of the kidney. A ureteroscopy with placement of ureteral stents was performed. Assign the correct ICD-9-CM diagnosis and procedure codes.

a. 592.0, 788.0, 59.8

b. 788.0, 592.0, 56.0

c. 594.9, 59.8

d. 592.0, 59.8

Correct Answer: D

Codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related definitive diagnosis has been established. The flank pain would not be coded because it is a symptom of the calculus (Schraffenberger 2012, 67-68).

The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) and/or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting?

a. 97113

b. 97113-50

c. 97113, 97113

d. 97110

Correct Answer: C

Code 97113, Therapeutic procedure, 1 or more areas, each 15 minutes of aquatic therapy with therapeutic exercises, is billable per 15 minutes of therapy. The patient was treated for 30 minutes; therefore code 97113 should be reported twice. Modifier -50 is not applicable because the service is not a bilateral procedure (Smith 2012, 239).

Which volume of ICD-9-CM contains the Tabular and Alphabetic Index of procedures?

a. Volume 1

b. Volume 2

c. Volume 3

d. Volume 4

Correct Answer: C

ICD-9-CM Volume 3 contains the Tabular List and Alphabetic Index of procedures (Johns 2011, 243).

Which of the following ICD-9-CM codes are always alphanumeric?

a. Category codes

b. Procedure codes

c. Subcategory codes

d. V codes

Correct Answer: D

V codes are always alphanumeric codes. They are easy to identify because they begin with the alpha character V and follow with numeric digits (Johns 2011, 242).

What is the function of physician’s orders?

a. Provide a chronological summary of the patient’s illness and treatment

b. Document the patient’s current and past health status

c. Document the physician’s instructions to other parties involved in providing care to a patient

d. Document the provider’s follow-up care instructions given to the patient or patient’s caregiver

Correct Answer: C

Physician orders are the instructions the physician gives to the other healthcare professionals (Johns 2011, 63).

The protection measures and tools for safeguarding information and information systems is a definition of:

a. Confidentiality

b. Data security

c. Informational privacy

d. Informational access control

Correct Answer: B

Data security is the means of ensuring that data are kept safe from corruption and that access to data is suitably controlled (Johns 2011, 919).

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services?

a. Prospectively precertify the necessity of inpatient services

b. Determine what services can be bundled

c. Pay only 80% of the inpatient bill

d. Require the patient to pay 20% of the inpatient bill

Correct Answer: A

Managed FFS reimbursement is similar to traditional FFS reimbursement except that managed care plans control costs primarily by managing their members’ use of healthcare services (Johns 2011, 287, 316).

Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ______ review.

a. Quantitative

b. Qualitative

c. Statistical

d. Outcomes

Correct Answer: A

HIM professional analyze medical records for any missing reports, forms, or required signatures and deletions. This is a quantitative analysis of the medical record (Johns 2011, 409-410).

From the information provided, how many APCs would this patient have?

Billing Number Status Indicator CPT/HCPCS APC
998323 V 99285-25 0612
998324 T 25500 0044
998325 X 72050 0261
998326 S 72128 0283
998327 S 70450 0283

a. 1

b. 4

c. 5

d. 3

Correct Answer: C

Payment for separately paid APCs depends on the status indicator assigned to each HCPCS code. This particular example allows separate payment on all five codes based on separately paid status indicator assignment (Johns 2011, 330-332).

In a joint effort of the Department of Health and Human Services (DHHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Administration on Aging (AOA), which program was released in 1995 to target fraud and abuse among healthcare providers?

a. Operation Restore Trust

b. Medicare Integrity Program

c. Tax Equity and Fiscal Responsibility Act (TEFRA)

d. Medicare and Medicaid Patient and Program Protection Act

Correct Answer: A

In a joint effort of the Department of Health and Human Services (HHS), Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS), and Administration on Aging (AOA), Operation Restore Trust was released in 1995 to target fraud and abuse among healthcare providers (Casto and Layman 2011, 36).

A threat to data security is:

a. Encryption

b. Malware

c. Audit trail

d. Data quality

Correct Answer: B

Computer viruses and other malware constitute a threat to data security (Johns 2011, 510).

The HIM department is planning to scan nonelectronic medical record documentation. The project includes the scanning of health record documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient’s hospitalization?

a. Ad hoc

b. Concurrent

c. Retrospective

d. Post-discharge

Correct Answer: B

Concurrent review occurs on a continuing basis during a patient’s stay (Johns 2011, 410).

This is a program unveiled in 1998 by the OIG that encourages healthcare providers to report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs.

a. World Health Organization

b. Voluntary Disclosure Program

c. Compliance Disclosure Program

d. Fraud and Abuse Program

Correct Answer: B

The Voluntary Disclosure program was introduced in 1998 by the OIG to encourage healthcare providers to voluntarily report fraudulent conduct affecting federal payers (Johns 2011, 358).

An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.)

a. 660.11, 653.41, 64479

b. 660.11, 653.01, 01961

c. 660.11, 653.41, 01967, 01968

d. 660.11, 653.91, 01996

Correct Answer: C

The disproportion was specified as cephalopelvic; thus the correct ICD-9-CM code is 653.41. Two codes are required for anesthesia; one for the planned vaginal delivery (01967) and an add-on code (01968) to describe anesthesia for cesarean delivery following planned vaginal delivery converted to cesarean. An instructional note guides the coder to use 01968 with 01967 (Schraffenberger 2012, 272-273; AMA 2012b, 52).

A patient was discharged with the following diagnoses: “Cerebral occlusion, hemiparesis, and hypertension. The aphasia resolved before the patient was discharged.” Which of the following code assignments would be appropriate for this case?
342.90 Hemiparesis affecting unspecified side
342.91 Hemiparesis affecting dominant side
342.92 Hemiparesis affecting nondominant side
434.90 Cerebral artery occlusion unspecified, without mention of cerebral infarction
434.91 Cerebral artery occlusion unspecified with cerebral infarction
401 Hypertension
401.0 Malignant hypertension
401.1 Benign hypertension
401.9 Unspecified hypertension
428.0 Congestive heart failure
784.3 Aphasia

a. 434.91, 342.92, 784.3, 401

b. 434.90, 342.90, 784.3, 401.9

c. 434.90, 342.90, 401.9

d. 434.90, 342.90, 784.3, 401.0

Correct Answer: B

Code 434.91 is assigned when the diagnosis states stroke, cerebrovascular, or cerebrovascular accident (CVA) without further specification. The health record should be reviewed to make sure nothing more specific is available. Conditions resulting from an acute cerebrovascular disease, such as aphasia or hemiplegia, should be coded as well (Schraffenberger 2012, 198-199).

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

Correct Answer: D

All newly hired coding personnel should receive extensive training on the facility’s and HIM department’s compliance programs. Education of the medical staff on documentation is likewise important to the success of any compliance program (Johns 2011, 362).

A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?

a. Acute bronchitis

b. Acute bronchitis with chronic obstructive pulmonary disease

c. Asthma with status asthmaticus

d. Chronic obstructive asthma

Correct Answer: C

A patient in status asthmaticus fails to respond to therapy administered during an asthmatic attack. This is a life-threatening condition that requires emergency care and likely hospitalization (Schraffenberger 2012, 222-223).

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?

a. Minimum Necessary

b. Notice of Privacy Practices

c. Authorization

d. Consent

Correct Answer: A

The standard of minimum necessary means that healthcare providers and other covered entities must limit uses, disclosures, and requests to only the amount needed to accomplish the intended purpose (Johns 2011, 822).

According to the UHDDS, which of the following is the definition of “other diagnoses”?

a. Is recorded in the patient record

b. Is documented by the attending physician

c. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring

d. Is documented by at least two physicians and/or the nursing staff

Correct Answer: C

For reporting purposes the definition for “other diagnoses” is interpreted as additional conditions that affect patient care in terms of requiring: clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay, increased nursing care, and/or monitoring (Schraffenberger 2012, 71)

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay?

a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion

b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy

c. Metastatic carcinoma of the brain; history of carcinoma of the prostate

d. Carcinoma of the prostate; metastatic carcinoma to the brain

Correct Answer: C

When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category V10, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy. Any mention of extension, invasion, or metastatic to another site is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal, with the V10 code used as a secondary code (Schraffenberger 2012, 98).

A 35-year-old male was admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure.

a. 530.89, 42.29

b. 530.1, 45.16

c. 530.81, 42.24

d. 530.81, 42.23

Correct Answer: C

Main term for procedure: Esophagoscopy; subterm: with closed biopsy (Schraffenberger 2012, 44-45).

What system reimburses hospitals a predetermined amount for each Medicare inpatient admission?

a. APR-DRG

b. DRG

c. APC

d. RUG

Correct Answer: B

A DRG is a predetermined amount of reimbursement for each Medicare inpatient (Johns 2011, 319).

A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be:

a. Sequence either the pancreatitis or noncalculus cholecystitis as principal diagnosis

b. Pancreatitis; noncalculus cholecystitis; abdominal pain

c. Noncalculus cholecystitis; pancreatitis; abdominal pain

d. Abdominal pain; pancreatitis; noncalculus cholecystitis

Correct Answer: A

In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or the therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction in such cases, any one of the diagnoses may be sequenced first (Schraffenberger 2012, 68-69).

Which of the following elements is not a component of most patient records?

a. Patient identification

b. Clinical history

c. Financial information

d. Test results

Correct Answer: C

Clinical data document the patient’s medical condition, diagnosis, and procedures performed as well as healthcare treatment provided (Johns 2011, 61).

Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence.

a. 54401

b. 54405

c. 54440

d. 54400

Correct Answer: A

Code 54401 is correct because the prosthesis is self-contained (Kuehn 2012, 27, 178).

Which of the following is not an essential data element for a healthcare insurance claim?

a. Revenue code

b. Procedure code

c. Provider name

d. Procedure name

Correct Answer: D

A procedure name is not a required element on a healthcare insurance claim (Casto and Layman 2011, 73).

When coding benign neoplasm of the skin, the section noted here directs the coder to:
216 Benign Neoplasm of Skin
Includes:
Blue Nevus
Dermatofibroma
Hydrocystoma
Pigmented Nevus
Syringoadenoma
Syringoma
Excludes:
Skin of genital organs (221.0-222.9)
216.0 Skin of lip
Excludes:
Vermilion border of lip (210.0)
216.1 Eyelid, including canthus
Excludes:
Cartilage of eyelid (215.0)

a. Use category 216 for syringoma.

b. Use category 216 for malignant melanoma.

c. Use category 216 for malignant neoplasm of the bone.

d. Use category 216 for malignant neoplasm of the skin.

Correct Answer: A

Follow instructions under the main term in the Alphabetic Index. Instructions in the index should be followed when determining which column to use in the neoplasm table. In this example, malignant is not a choice in the Alphabetic Index shown. Benign in category 216 indicates all of the diagnosis codes in this category are benign (Schraffenberger 2012, 95, 100).

Common errors that delay, rather than prevent, payment, include all of the following except:

a. Patient name or certificate number

b. Claims out of sequence

c. Illogical demographic data

d. Inaccurate or deleted codes

Correct Answer: A

A patient name or certificate number is required for filing health claims (Casto and Layman 2011, 72).

A notation for a hypertensive patient in a physician ambulatory care progress note reads: “Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks.” In which part of a POMR progress note would this notation be written?

a. Subjective

b. Objective

c. Assessment

d. Plan

Correct Answer: D

The plan includes orders and the roadmap for patient care (Johns 2011, 114).

A denial of a claim is possible for all of the following reasons except:

a. Not meeting medical necessity

b. Billing too many units of a specific service

c. Unbundling

d. Approved precertification

Correct Answer: D

Prior approval for a service or procedure is called precertification and allows coverage for a specific service (Casto and Layman 2011, 71).

Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn’s syndrome.

a. 227.0, 255.12

b. 227.0

c. 255.12

d. 225.12, 227.8

Correct Answer: A

Index Adenoma, adrenal (cortex). Index Syndrome, Conn. According to the Index in ICD-9-CM, except where otherwise indicated, the morphological varieties of adenoma should be coded by site as for “Neoplasm, benign” (Schraffenberger 2012, 100).

A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. Which is the correct code assignment?

a. 553.20, 427.89, V64.3, 54.11

b. 553.20, 997.1, 427.89, 54.19

c. 553.20, 54.11

d. 553.20, 54.11, V64.3

Correct Answer: A

The ventral hernia is coded as the primary or first listed diagnosis. The repair of the hernia is not coded because it was not performed; however, code 54.11 is assigned to describe the extent of the procedure, which is an exploratory laparotomy. The V64.3 is coded to indicate the cancelled procedure. Code 427.89 is also used to describe the bradycardia that the patient develops during the procedure (Schraffenberger 2012, 46-47).

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?

a. Require all coders to implement this practice

b. Report the practice to the OIG

c. Counsel the coder and stop the practice immediately

d. Put the coder on unpaid leave of absence

Correct Answer: C

Review the elements of the hospital compliance program with the employee (Johns 2011, 361-362).

Identify the appropriate ICD-9-CM diagnosis code for cerebral contusion with brief loss of consciousness.

a. 924.9

b. 851.42

c. 851.82

d. 851.81

Correct Answer: C

Index Contusion, cerebral—see Contusion, brain. Add a fifth digit of “2” for brief loss of consciousness. Cerebral contusions are often caused by a blow to the head. A cerebral contusion is a more severe injury involving a bruise of the brain with bleeding into the brain tissue, but without disruption of the brain’s continuity. The loss of consciousness that occurs often lasts longer than that of a concussion. Codes for cerebral laceration and contusion range from 851.0 to 851.9, with fifth digits added to indicate whether a loss of consciousness or concussion occurred (Schraffenberger 2012, 359).

Timely and correct reimbursement is dependent on:

a. Adjudication

b. Clean claims

c. Remittance advice

d. Actual charge

Correct Answer: B

Clean claims are essential for accurate and timely reimbursement (Casto and Layman 2011, 72).

The admitting data of Mrs. Smith’s health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith’s birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith’s health record?

a. Data completeness

b. Data consistency

c. Data accessibility

d. Data comprehensiveness

Correct Answer: B

Consistent data will be the same each time it is reported or collected (Johns 2011, 47).

Which of the following is not an element of data quality?

a. Accessibility

b. Data backup

c. Precision

d. Relevancy

Correct Answer: B

Data quality includes the following characteristics: accuracy, accessibility, comprehensiveness, consistency, currency, definition, granularity, precision, relevancy, and timeliness (Johns 2011, 43).

EMERGENCY DEPARTMENT RECORD

DATE OF ADMISSION: 8/19 DATE OF DISCHARGE: 8/19

HISTORY (Problem Focused):

ADMISSION HISTORY: This is a 13-year-old African-American male. He became short of breath, used his inhaler as described but continued to have wheezing and shortness of breath.

ALLERGIES: None

CHRONIC MEDICATIONS: Albuterol inhaler

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient’s father smokes one pack of cigarettes per day, but he does not smoke in the house.

REVIEW OF SYSTEMS: His integumentary, musculoskeletal, cardiovascular, genitourinary, and gastrointestinal systems are negative.

PHYSICAL EXAMINATION (Extended Problem Focused):

GENERAL APPEARANCE: This is an alert, cooperative young male in acute distress.

HEENT: PERRLA, extraocular movements are full

NECK: Supple

CHEST: Lungs reveal wheezes and rales. Heart has normal sinus rhythm.

ABDOMEN: Soft and nontender, no organomegaly

EXTREMITIES: Examination is normal.

LABORATORY DATA: Urinalysis is normal, EKG normal, chest x-ray is normal. CBC and diff show no abnormalities.

IMPRESSION: Acute asthma with exacerbation

PLAN: Administer epinephrine and intravenous theophylline

TREATMENT: Following administration of epinephrine and theophylline, the patient’s asthma abated. One venipuncture set and one IV set were used to administer the medication over 30 minutes.

DISCHARGE DIAGNOSIS: Asthma with exacerbation

DISCHARGE INSTRUCTIONS: The patient was instructed to take his prescribed medications as directed by his primary care physician and to return to the ER if he had any further asthma.
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2

Case Studies
PDX 493.92 Asthma with (acute) exacerbation
PP1 99284-25 E/M code based on mapping scenario provided
PR2 96365 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to one hour

Notes on Outpatient 6493.92 This condition brought the patient to the emergency department (Brown 2012, 186-187).
99284-25 This code represents the evaluation and management code for the facility APV and is done according to the mapping scenario as follows; meds given are = 2 = 5 points, the history is problem focused = 10 points, the examination is extended problem focused = 15 points, the number of tests = 4 = 15 points, supplies = one venipuncture set and one intravenous set = 10 points. 55 total points.
96365 The IV infusion is separately reportable and an additional code should be assigned (CPT Changes: An Insider’s View 2009).
Note: The patient came to the ED because of asthma. The code that represents the most complicated process is the evaluation and management of the patient represented by the E/M code and is sequenced first. The starting of the IV is less complicated and sequenced second.
(Garvin 2013, 193, 283.)

All of the following should be part of the core areas of a coding compliance plan except:

a. Physician query process

b. Correct use of encoder software

c. Coding diagnoses supported by medical record documentation

d. Tracking length of stay

Correct Answer: D

Tracking length of stay is part of the hospital utilization review committee function (Casto and Layman 2011, 42 and 46-47).

Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?

a. Home health

b. Behavioral health

c. End-stage renal disease

d. Rehabilitative care

Correct Answer: A

Home health aides may assist the patient with activities of daily living such as bathing and housekeeping, which allows the patient to remain at home. Documentation of this type of intervention is also necessary (Johns 2011, 100).

The NCCI editing system used in processing OPPS claims is referred to as:

a. Outpatient code editor (OCE)

b. Outpatient national editor (ONE)

c. Outpatient perspective payment editor (OPPE)

d. Outpatient claims editor (OCE)

Correct Answer: A

Portions of the NCCI are incorporated into the outpatient code editor (OCE) against which all ambulatory claims are reviewed. The OCE also applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent services provided (Johns 2011, 348).

Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?

a. 49496

b. 49501

c. 49507

d. 49521

Correct Answer: C

Index the main term of Hernia repair; inguinal; incarcerated. The age of the patient and the fact that the hernia is not recurrent make the choice 49507. Providing information regarding insurance coverage is not a function of the discharge summary (Kuehn 2012, 27, 164-166).

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?

a. Congestive heart failure, respiratory failure, ventilator management, intubation

b. Respiratory failure, intubation, ventilator management

c. Respiratory failure, congestive heart failure, intubation, ventilator management

d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management

Correct Answer: A

Acute respiratory failure, code 518.81, may be assigned as a principal or secondary diagnosis depending on the circumstances of the inpatient admission. Chapter-specific coding guidelines (obstetrics, poisoning, HIV, newborn) provide specific sequencing direction. Respiratory failure may be listed as a secondary diagnosis. If respiratory failure occurs after admission, it may be listed as a secondary diagnosis (Schraffenberger 2012, 224-226).

Common forms of fraud and abuse include all of the following except:

a. Upcoding

b. Unbundling or “exploding” charges

c. Refiling claims after denials

d. Billing for services not furnished to patients

Correct Answer: C

Refiling claims after a denial is not possible because denied claims must be appealed and is not a factor in controlling fraud and abuse (Casto and Layman 2011, 35).

Which of the following is a standard terminology used to code medical procedures and services?

a. CPT

b. HCPCS

c. ICD-9-CM

d. SNOMED CT

Correct Answer: A

CPT is a comprehensive descriptive listing of terms and codes for reporting diagnostic and therapeutic procedures and medical services (Johns 2011, 255).

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?

a. Catheter-associated urinary tract infection

b. Cerebral vascular accident

c. COPD

d. Hypertension

Correct Answer: A

All claims involving inpatient admissions to general acute care hospitals or other facilities that are subject to law or regulation mandating collection of present on admission information. Present on admission (POA) is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA. Any condition that occurs after admission is not considered a POA condition (Schraffenberger 2012, 66).

Which of the following would a health record technician use to perform the billing function for a physician’s office?

a. CMS-1500

b. UB-04

c. UB-92

d. CMS 1450

Correct Answer: A

Physicians submit claims via the electronic format (screen 837P), which takes the place of the CMS-1500 billing form (Johns 2011, 343).

Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?

a. Children’s

b. Rural

c. State supported

d. Tertiary

Correct Answer: A

Psychiatric and rehabilitation hospitals, long-term care hospitals, children’s hospitals, cancer hospitals, and critical access hospitals are paid on the basis of reasonable cost, subject to payment limits per discharge or under separate PPS (Johns 2011, 322).

Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court?

a. Judicial decision

b. Subpoena

c. Credential

d. Regulation

Correct Answer: B

A subpoena is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court (Odom-Wesley et al. 2009, 57).

Both HEDIS and the Joint Commission’s ORYX programs are designed to collect data to be used for:

a. Performance-improvement programs

b. Billing and claims data processing

c. Developing hospital discharge abstracting systems

d. Developing individual care plans for residents

Correct Answer: A

The ORYX Performance Measurement program collects quality data for hospitals and long-term care organizations and HEDIS collects data to measure physician performance (Johns 2011, 141).

Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?

a. CMHC partial hospitalization services

b. Critical access hospitals

c. Hospital outpatient departments

d. Vaccines provided by CORFs

Correct Answer: B

Critical access hospitals are paid on a cost-based payment system and are not part of the prospective payment system (Johns 2011, 330).

Data security refers to:

a. Guaranteeing privacy

b. Controlling access

c. Using uniformed terminology

d. Transparency

Correct Answer: B

Controlling access—facilities may authorize access to patient data in the facility’s computer system to only those who need the access to do their job. This method of control serves the security of the data of patient records (Johns 2011, 510).

One form of _______ uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals.

a. Integrated workflow processes

b. Computer-assisted coding

c. Electronic document management system

d. Speech recognition system

Correct Answer: B

There are several different types of computer-assisted coding (CAC), including software to aid the physicians (Johns 2011, 270).

Fee schedules are updated by third-party payers:

a. Annually

b. Monthly

c. Semiannually

d. Weekly

Correct Answer: A

Third-party payers that reimburse providers on a fee-for-service basis generally update fee schedules on an annual basis (Johns 2011, 350).

What statement is not reflective of meeting medical necessity requirements?

a. A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease.

b. A service or supply provided that is not experimental, investigational, or cosmetic in purpose.

c. A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms.

d. A service provided solely for the convenience of the insured, the insured’s family, or the provider.

Correct Answer: D

A service must not be solely for the convenience of the insured, the insured’s family, or the provider (Casto and Layman 2011, 99).

Which of the following tasks may not be performed in an electronic health record system?

a. Document imaging

b. Analysis

c. Assembly

d. Indexing

Correct Answer: C

In an EHR, reports are indexed, similar to filing in the paper record and ensures the documents are placed in the right location within the right record. Record analysis and completion is done via the computer. Document imaging converts paper documents into digitized electronic versions (Johns 2011, 432).

What is a guarantor?

a. The patient who is an inpatient

b. The person responsible for the bill, such as a parent

c. The person who bills the patient, such as the Medicare biller

d. The patient who is an outpatient

Correct Answer: B

The person responsible for the bill is the guarantor (Casto and Layman 2011, 8).

This system will require the author to sign onto the system using a user ID and password to complete the entries made.

a. Digital dictation

b. Electronic signature authentication

c. Single sign on technology

d. Clinical data repository

Correct Answer: B

Electronic signature authentication systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval (Johns 2011, 144).

A special webpage that offers secure access to data is called a(n):

a. Access control

b. Home page

c. Intranet

d. Portal

Correct Answer: D

A portal is a special application to provide secure remote access to specific applications (Johns 2011, 137).

Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff?

a. Hard coding

b. Soft coding

c. Encoder coding

d. Natural-language processing coding

Correct Answer: A

HCPCS codes that are assigned in the charge description master that flow directly to the claim and bypass facility coding staff is a process known as hard coding (Casto and Layman 2011, 250).

A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient?

a. Abdominal pain

b. Cholecystitis

c. Hypertension

d. Diabetes

Correct Answer: B

The principal diagnosis determines the MDC assignment (Johns 2011, 322).

Which of the following issues compliance program guidance?

a. AHIMA

b. CMS

c. Federal Register

d. HHS Office of Inspector General (OIG)

Correct Answer: D

The OIG continues to issue compliance program guidance since 1998 (Johns 2011, 359).

One form of _______ computer assisted coding may use, which means that digital text from online documents stored in the information system is read directly by the software which then suggests codes to match the documentation.

a. Encoded vocabulary

b. Natural-language processing

c. Data exchange standards

d. Structured reports

Correct Answer: B

Natural-language processing (NLP) is an artificial intelligence software that reads digital text from online documents and suggests codes to match the documentation (Johns 2011, 270).

This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services:

a. General Counsel

b. Health Information Director

c. Privacy Officer

d. Compliance Officer

Correct Answer: D

A compliance officer designs, implements, and maintains a compliance program that assures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products and services (Johns 2011, 744).

Which of the following statements is not true about a business associate agreement?

a. It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity.

b. It allows the business associate to maintain PHI indefinitely.

c. It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule.

d. It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the Department of Health and Human Services or its agents.

Correct Answer: B

The agreement between the covered entity and business associate should, at termination of the contract, require the business associate to return or destroy all PHI received from the covered entity that it still maintains and prohibit the associate from retaining it (Johns 2011, 824).

At which level of the classification system are the most specific ICD-9-CM codes found?

a. Category level

b. Section level

c. Subcategory level

d. Subclassification level

Correct Answer: D

The most specific codes in the ICD-9-CM system are found at the subclassification level (Johns 2011, 240).

Medicaid is a government-sponsored healthcare insurance program that became effective in 1966 as Title 19 of the Social Security Act. Medicaid is administered by:

a. The federal government

b. The state government

c. The federal and state government

d. Third-party administrators

Correct Answer: C

Medicaid is designed to offer assistance to low-income people and is jointly administered by the federal and state government (Hazelwood and Venable 2012, 327).

The following is documented in an acute-care record: “38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry.” In which of the following would this documentation appear?

a. Admission note

b. Clinical laboratory

c. Newborn record

d. Physician order

Correct Answer: C

This information is collected by the examination of a newborn and reported on the newborn record (Johns 2011, 97).

The HIPAA Privacy Rule:

a. Applies to certain states

b. Applies only to healthcare providers operated by the federal government

c. Applies nationally to healthcare providers

d. Serves to limit access to an individual’s own health information

Correct Answer: C

The HIPAA Privacy Rule applies nationally to healthcare providers (Johns 2011, 801-804).

Which of the following is a true statement about data stewardship?

a. HIM professionals are not qualified to address data stewardship issues.

b. Data stewardship addresses the needs of the healthcare organization but not the patient.

c. HIM professionals have worked with many data stewardship issues for years.

d. Data stewardship does not include privacy issues.

Correct Answer: C

HIM professionals have worked with many data stewardship issues for years (Johns 2011, 508).

A notation for a diabetic patient in a physician progress note reads: “Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet.” In which part of a POMR progress note would this notation be written?

a. Subjective

b. Objective

c. Assessment

d. Plan

Correct Answer: A

Subjective information includes symptoms and actions reported by the patient and not observed or measured by the healthcare provider (Johns 2011, 114).

Which of the following represents documentation of the patient’s current and past health status?

a. Physical exam

b. Medical history

c. Physician orders

d. Patient consent

Correct Answer: B

A complete medical history documents the patient’s current complaints and symptoms and lists his and her past medical, personal, and family history (Johns 2011, 63).

Which of the following materials is not documented in an emergency care record?

a. Patient’s instructions at discharge

b. Time and means of the patient’s arrival

c. Patient’s complete medical history

d. Emergency care administered before arrival at the facility

Correct Answer: C

The emergency care record includes a pertinent history of the illness or injury and physical findings (Johns 2011, 93).

The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost?

a. Value-based insurance design (VBID)

b. Cost-based reimbursement (CBR)

c. Pay for performance design (PPD)

d. Prospective payment system (PPS)

Correct Answer: A

VBID calculates both the benefit and the costs of clinical services (Casto and Layman 2011, 77).

An encoder that is built using expert system techniques such as rule-based systems is a(n):

a. Encoder interface

b. Logic-based encoder

c. Automated code book encoder

d. Grouper

Correct Answer: B

Some encoders are built using expert system techniques such as rule-based systems, and other encoding software is more simplistic, merely automating a look-up function similar to the manual index in ICD or other coding classifications (Johns 2011, 269).

A notation for a hypertensive patient in a physician ambulatory care progress note reads: “Blood pressure adequately controlled.” In which part of a POMR progress note would this notation be written?

a. Subjective

b. Objective

c. Assessment

d. Plan

Correct Answer: C

Professional conclusions reached from evaluation of the subjective or objective information make up the assessment (Johns 2011, 114).

An accounting of disclosures must include disclosures:

a. For use in law enforcement requests

b. To any patient family member who makes a request

c. To any individual who requested the information

d. Made for public health reporting purposes

Correct Answer: D

Disclosures for which accounting is not required involve nine exceptions including those in the question (Johns 2011, 833).

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?

a. Miscarriage

b. Complications of spontaneous abortion with sepsis

c. Sepsis

d. Spontaneous abortion with sepsis

Correct Answer: A

Subsequent admissions for retained products of conception following a spontaneous or legally induced abortion are assigned the appropriate code from category 634, Spontaneous abortion, or 635, Legally induced abortion, with a fifth digit of “1” (incomplete). This advice is appropriate even when the patient was discharged previously with a discharge diagnosis of complete abortion (Schraffenberger 2012, 264-266).

Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for:

a. The placement of the catheter

b. The placement of the catheter and the infusion procedure

c. The infusion procedure

d. Neither the placement of the catheter nor the infusion procedure

Correct Answer: C

Access to an indwelling IV or insertion of a subcutaneous catheter or port for the purpose of a therapeutic infusion is considered part of the procedure and not separately billed (Smith 2012, 237).

Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket.

a. 33223

b. 33210

c. 33212

d. 33222

Correct Answer: D

Begin with the main term Revision; pacemaker site; chest (Kuehn 2012, 27, 142).

When clean claims are submitted, they can be adjudicated in many ways through computer software automatically. Which statement is not one of the outcomes that can occur as part of auto-adjudication?

a. Auto-pay

b. Auto-suspend

c. Auto-calculate

d. Auto-deny

Correct Answer: C

Claims that automatically process through computer software either auto-pay, auto-suspend, or auto-deny (Casto and Layman 2011, 72).

The MS-DRG system creates a hospital’s case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of within that MS-DRG.

a. Admissions

b. Discharges

c. CCs

d. MCCs

Correct Answer: B

Discharges. The case-mix index can be figured by multiplying the relative weight of each MS-DRG by the number of discharges within that MS-DRG (Johns 2011, 324).

What is the process used to transform text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination?

a. Distortion

b. Extrication

c. Encryption

d. Encoded

Correct Answer: C

Encryption is the process of transforming text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination (Johns 2011, 510).

Which of the following laws created the Healthcare Integrity and Protection Data Bank?

a. Health Information Portability and Accountability Act

b. American Recovery and Reinvestment Act

c. Consolidate Omnibus Budget Reconciliation Act

d. Healthcare Quality Improvement Act

Correct Answer: A

Health Information Portability and Accountability Act of 1996 (Johns 2011, 692).

A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true?

a. Patient receives any monies paid by the insurance companies over and above the charges.

b. Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments.

c. The decision on which company is primary is based on remittance advice.

d. Patient should not have a Medicare supplement.

Correct Answer: B

Coordination of benefits is necessary to determine which policy is primary and which is secondary so that there is no duplication of payments (Johns 2011, 343).

Medicare’s newest claims processing payment contract entities are referred to as:

a. Recovery audit contractors (RACs)

b. Medicare administrative contractors (MACs)

c. Fiscal intermediaries (FIs)

d. Office of Inspector General contractors (OIGCs)

Correct Answer: B

Medicare administrative contractors (MACs) are replacing the claims payment contractors known as FIs and carriers (Casto and Layman 2011, 254).

Electronic systems used by nurses and physicians to document assessments and findings are called:

a. Computerized provider order entry

b. Electronic document management systems

c. Electronic medication administration records

d. Electronic patient care charting

Correct Answer: D

The primary EHR applications include clinical documentation or patient care charting, computerized provider order entry, electronic medical administration records, and clinical decision support (Johns 2011, 137).

What resource can managers use to discover current, hot areas of compliance?

a. Policies and Procedures

b. National Coverage Determinations

c. Official Coding Guidelines

d. OIG Workplan

Correct Answer: D

The OIG workplan is published every year to provide insight into the directions the OIG is taking, as well as highlights of hot areas of compliance. Coding managers should review this document each year (Casto and Layman 2011, 43).

A record of all transactions in the computer system that is maintained and reviewed for unauthorized access is called a(n):

a. Security breach

b. Audit trail

c. Unauthorized access

d. Privacy trail

Correct Answer: B

An audit trail is a record of all transactions in the computer system which is maintained and reviewed for instances of unauthorized access (Johns 2011, 510).

The ______ mandated the development of standards for electronic medical records.

a. Medicare and Medicaid legislation of 1965

b. Prospective Payment Act of 1983

c. Health Insurance Portability and Accountability Act (HIPAA) of 1996

d. Balanced Budget Act of 1997

Correct Answer: C

HIPAA-mandated incorporation of healthcare information standards into all electronic or computer-based health information systems (Johns 2011, 231).

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case?

a. Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina

b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina

c. Gastroenteritis; abdominal pain; angina

d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina

Correct Answer: B

Gastroenteritis is characterized by diarrhea, nausea, and vomiting, and abdominal cramps. Codes for symptoms, signs, and ill-defined conditions from Chapter 16 of the CPT codebook are not to be used as the principal diagnosis when a related definitive diagnosis has been established. Patients can have several chronic conditions that coexist at the time of their hospital admission and qualify as additional diagnosis such as COPD and angina (Schraffenberger 2012, 66-68, 71-72, 236).

The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?

a. 49000, 58940, 58700

b. 58940, 58720-50

c. 49000, 58720

d. 58720

Correct Answer: D

In the abdomen, peritoneum, and omentum subsection, the exploratory laparotomy is a separate procedure and should not be reported when it is part of a larger procedure. The code of 49000 is not reported because laparotomy is the approach to the surgery. The code 58720 includes bilateral so the modifier -50 is not necessary to report (Kuehn 2012, 163-164, 184).

A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.

a. 492.8, 496, 403.10, 585.9

b. 492.8, 585.9, 401.9

c. 496, 585.9, 401.9

d. 491.21, 403.91, 585.9

Correct Answer: D

Patient was admitted for COPD, so this is listed as the principal diagnosis. Code 491.21 is used when the medical record includes documentation of COPD with acute exacerbation. ICD-9-CM presumes a cause-and-effect relationship and classifies chronic kidney disease with hypertension as hypertensive chronic kidney disease, code 403.91; however, the code also at category 403 directs the coder to also code the chronic renal failure 585.9 (Schraffenberger 2012, 182-184, 222-223).

What is the defining characteristic of an integrated health record format?

a. Each section of the record is maintained by the patient care department that provided the care.

b. Integrated health records are intended to be used in ambulatory settings.

c. Integrated health records include both paper forms and computer printouts.

d. Integrated health record components are arranged in strict chronological order.

Correct Answer: D

The integrated health record is arranged so that the documentation from various sources is intermingled and follow strict chronological order (Johns 2011, 114).

What is the process that determines how a claim will be reimbursed based on the insurance benefit?

a. Transaction

b. Processing

c. Adjudication

d. Allowance

Correct Answer: C

Adjudication is the determination of the reimbursement payment based on the member’s insurance benefits (Casto and Layman 2011, 72).

A national dollar amount that Congress designates to convert relative value units into dollars is called:

a. Conversion factor

b. Origination fee

c. Limitation factor

d. National exchange

Correct Answer: A

Conversion factor is a national dollar amount that Congress uses to convert relative value units to dollars on an annual basis (Hazelwood and Venable 2012, 331).

dentify where the following information would be found in the acute-care record: “CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93.”

a. Medical laboratory report

b. Pathology report

c. Physical examination

d. Physician orders

Correct Answer: A

Results for lab tests will be included in a medical laboratory report (Johns 2011, 70).

Denials of outpatient claims are often generated from all of the following edits except:

a. NCCI (National Correct Coding Initiative)

b. OCE (outpatient code editor)

c. OCE (outpatient claims editor)

d. National and local policies

Correct Answer: C

Outpatient claims editor does not exist. Do not confuse this terminology with outpatient code editor (OCE) (Johns 2011, 348).

A notation for a diabetic patient in a physician progress note reads: “FBS 110 mg%, urine sugar, no acetone.” In which part of a POMR progress note would this notation be written?

a. Subjective

b. Objective

c. Assessment

d. Plan

Correct Answer: B

Objective information may be measured or observed by the healthcare provider (Johns 2011, 114).

Which type of patient care record includes documentation of a family bereavement period?

a. Hospice record

b. Home health record

c. Long-term care record

d. Ambulatory care record

Correct Answer: A

Hospice care is palliative care provided to terminally ill patients and supportive services to patients and their families (Johns 2011, 101).

The goal of coding compliance programs is to prevent:

a. Accusations of fraud and abuse

b. Delays in claims processing

c. Billing errors

d. Inaccurate code assignments

Correct Answer: A

The goal of a compliance program is to prevent accusations of fraud and abuse (Johns 2011, 359).

Calling out patient names in a physician’s office is:

a. An incidental disclosure

b. Not subject to the “minimum necessary” requirement

c. A disclosure for payment purposes

d. A HIPAA violation

Correct Answer: A

An incidental disclosure occurs as part of a permitted use of disclosure (Johns 2011, 847).

A patient is admitted to an acute-care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.

a. 291.8, 303.00

b. 303.00

c. 305.00

d. 291.81, 303.00

Correct Answer: D

If the patient is admitted in withdrawal or if withdrawal develops after admission, the withdrawal code is designated as the principal diagnosis. The code for substance abuse/dependence is listed second (Schraffenberger 2012, 148).

Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion?

a. Health Information and Business Office

b. Health Information and Materials Management

c. Health Information, Business Office, and Cardiac Department

d. Health Information and Radiology

Correct Answer: C

The health information department along with the business office and cardiac department should be consulted to determine where the breakdown of the charges and assignment of the procedure code occurs. Often one department assumes another department is submitting the code/charge and without auditing and communicating with each other on a regular basis, error can occur for long periods of time with either a financial gain or loss to the facility (Casto and Layman 2011, 258).

A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was “Rule out chest pain versus GERD.” The correct ICD-9-CM code is:

a. V71.7, Admission for suspected cardiovascular condition

b. 789.01, Esophageal pain

c. 530.81, Gastrointestinal reflux

d. 786.50, Chest pain NOS

Correct Answer: D

Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as “rule out” or other similar terms indicating uncertainty. In the outpatient setting the condition qualified in that statement should not be coded as if it existed. Rather, the condition should be coded to the highest degree of certainty, such as the sign or symptom the patient exhibits. In this case, assign the code 786.50, Chest pain NOS (Schraffenberger 2012, 339).

A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.

a. 280.0, 626.8

b. 285.1, 626.8

c. 626.8, 280.0

d. 280.0, 218.9

Correct Answer: A

The anemia would be sequenced first based on principal diagnosis guidelines (Schraffenberger 2012, 64).

Which of the following make data entry easier, but may harm data quality?

a. Use of templates

b. Copy and paste

c. Drop-down boxes

d. Structured data

Correct Answer: B

One potential area for poor data quality surrounds the need for making data entry easier. These include “copy and paste,” “macros,” standard orders, and other techniques that “reuse” data. These techniques can make data entry faster, but care must be taken to ensure appropriate modification to the specific patient (Johns 2011, 182).

What is the incentive to improve the quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts?

a. Pay for performance and quality

b. Patient referrals

c. Payer of last resort

d. Performance evaluations

Correct Answer: A

Pay for performance and pay for quality are types of incentive to improve clinical performance (Johns 2011, 154).

Which of the following is not one of the purposes of ICD-9-CM?

a. Classification of morbidity for statistical purposes

b. Classification of mortality for statistical purposes

c. Reporting of diagnoses by physicians

d. Identification of the supplies, products, and services provided to patients

Correct Answer: D

According to Central Office on ICD-9-CM, ICD-9-CM is not used to identify supplies, products, and services used by patients (Johns 2011, 239).

168.
A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations?
410.00 Myocardial infarction of anterolateral wall, episode unspecified
410.01 Myocardial infarction of anterolateral wall, initial episode
410.40 Myocardial infarction of inferior wall, episode unspecified
410.41 Myocardial infarction of inferior wall, initial episode
410.42 Myocardial infarction of inferior wall, subsequent episode
427 Cardiac dysrhythmias
427.3 Atrial fibrillation and flutter
427.31 Atrial fibrillation
786.50 Chest pain, unspecified
36.13 Aortocoronary bypass of three coronary arteries

a. Hospital A: 427, 786.50, 427.31, 410.91; Hospital B: 410.92, 36.13

b. Hospital A: 410.41, 427, 427.31; Hospital B: 410.42, 36.13

c. Hospital A: 410.41, 427.31; Hospital B: 410.41, 36.13

d. Hospital A: 410.41, 427.31, 786.50; Hospital B: 410.42, 36.13

Correct Answer: C

Use a fifth digit of “1” to designate the first episode of care (regardless of facility site) for a newly diagnosed myocardial infarction. The fifth digit “1” is assigned regardless of the number of times a patient may be transferred during the initial episode of care (Schraffenberger 2012, 188).

The following is documented in an acute-care record: “I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture.” In which of the following would this documentation appear?

a. Admission note

b. Consultation report

c. Discharge summary

d. Nursing progress notes

Correct Answer: B

A consultation report includes the recommendations of a consulting physician who is requested to evaluate a patient (Johns 2011, 78).

Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens.

a. 366.10, 250.50, 13.59, 13.71

b. 250.00, 366.10

c. 250.00, 366.12

d. 366.10, 250.00, 13.59, 13.71

Correct Answer: D

The patient was admitted for the senile cataract and the procedures were completed for that condition. This follows the UHDDS guidelines for principle diagnosis selection. There is also no causal relationship given between the diabetes and the cataract, so 250.50 would be incorrect (Schraffenberger 2012, 122-123, 164).

To comply with HIPAA, under usual circumstances, a covered entity must act on a patient’s request to review or copy his or her health information within _____ days.

a. 10

b. 20

c. 30

d. 60

Correct Answer: C

A covered entity must act on an individual’s request for review of PHI no later than 30 days after the request is made (Johns 2011, 831).

To view this health record:

Click on the tabs above.
Scroll to the bottom of each document.
For your referance, the Coding Guidelines tab includes information from your codebooks.
To answer the questions in this case:

Enter the appropriate codes in the boxes on the right.
Enter a DX code in every box.
Any necessary decimal point must be present and correctly placed.
Do not include spaces with your answer.
________________
*Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
_________
AMBULATORY RECORD

PREOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

POSTOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

OPERATION: Left lumbar sympathetic block with C-arm

ANESTHESIA: Local

INDICATIONS:

This 43-year-old female has a 7-month history of left knee pain. She says that even a light touch appears to be exquisitely painful. She has had surgery to clear scar tissue.

PROCEDURE DESCRIPTION:

The patient was placed on the x-ray lucent gurney in the right lateral decubitus position. The back was prepped with Betadine, and the midline spinous processes were marked. A line was drawn 6 to 7 cm lateral to that midline on the left. L2 was identified using the C-arm and lateral projections, and lidocaine was infiltrated at the skin. The 22-gauge, 6-inch Chiba needle was advanced down to and off the body of L2, and loss of resistance was obtained with a glass syringe. Renografin-60 was injected and showed a good distribution. So 15 cc of bupivacaine 0.5% without epinephrine was injected, plus Depo-Medrol 40 mg. The needle was withdrawn.

Then lidocaine was infiltrated on the 6- to 7-cm line at L4. I advanced the 22-gauge, 6-inch needle off the body of L4, but the Renografin-60 distribution appeared not to be adequate. Another wheal was raised at the 13 level, and the needle was
advanced down to and off the body of L3. A loss of resistance was obtained with a glass syringe, followed by Renografin-60. This time, the distribution was excellent, and bupivacaine 0.5% without epinephrine =15 cc was injected. She was left on her side for 25 minutes. After 10 minutes, she had a noticeably warmer left foot and ankle. The skin coloration of the left leg was normal.
___________
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2

Case Studies
PDX 337.22 Reflex sympathetic dystrophy of the lower limb
PP1 64520-LT Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)
PR2 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid)

Notes for Practice Outpatient Case—Patient 3

337.22 The diagnostic code is needed to establish the medical necessity for the procedure and a pain management code is not appropriate because the underlying condition is being treated (Brown 2012, 163).
64520-LT When coding paravertebral spinal nerves and branches, it is appropriate to use the modifiers to note the laterality (CPT Assistant July 1998, 10; April 2005, 13).
77003 Fluoroscopic guidance is not included in the 64520 code; hence, it is therefore appropriate to code a second code (CPT Assistant March 2007, 7; July 2008, 9; February 2010, 12).
(Garvin 2013, 55, 251.)

What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?

a. 58555, 58559

b. 58559

c. 58559, 58740

d. 58555, 58559, 58740

Correct Answer: B

Main term of Hysteroscopy; lysis; adhesions (Kuehn 2012, 27, 182-184).

What is the primary use of the case-mix index?

a. Benchmark of emergency room levels

b. Defines how a hospital compares to peers and whether the facility is at risk

c. Audit of APCS and the comparison to same-size hospitals

d. A tool for the coding manager to compare coder productivity

Correct Answer: B

Benchmarking or peer comparison helps a manager to know how his or her team has performed compared to peers. This includes whether the case-mix index level puts the facility at risk (Casto and Layman 2011, 43).

What is the legal term used to define the protection of health information in a patient-provider relationship?

a. Access

b. Confidentiality

c. Privacy

d. Security

Correct Answer: B

Confidentiality is a legal ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure (Brodnik et al. 2009, 6).

A transition technology used by many hospitals to increase access to medical record content is:

a. EHR (electronic health record)

b. EDMS (electronic document management system)

c. ESA (electronic signature authentication)

d. PACS (picture archiving and communication system)

Correct Answer: B

For hospitals that do not have all EHR components, the result is a hybrid record that is part electronic and part paper. Some hospitals overcome hybrid record issues by scanning all paper documents into an EDMS, thereby making everything available online (Johns 2011, 148).

The following is documented in an acute-care record: “Admit to 3C. Diet: NPO. Meds: Compazine 10 mg IV Q 6 PRN.” In which of the following would this documentation appear?

a. Admission order

b. History

c. Physical examination

d. Progress notes

Correct Answer: A

Physician orders are the instructions a physician gives to the other healthcare professionals. Admission and discharge orders should be found for every patient (Johns 2011, 63).

Which of the following statements is false?

a. A notice of privacy practices must be written in plain language.

b. Consent for use and disclosure of information must be obtained from every patient.

c. An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations.

d. A notice of privacy practices must give an example of a use or disclosure for healthcare operations.

Correct Answer: B

Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personally identifiable information for treatment, payment, or healthcare operations (Johns 2011, 838).

Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0-cm superficial laceration of the left arm; 5.0-cm laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: X-ray of the ankle showed a bimalleolar ankle fracture that required closed manipulative reduction, intermediate suturing of the scalp and simple suturing of the arm laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill.

a. 27810, 12032

b. 27818, 12032

c. 27810, 12032, 12002

d. 27810, 12032

Correct Answer: C

The closed reduction of the fracture is coded first, following principal procedure guidelines. The laceration repair is also coded. When more than one classification of wound repair is performed, all codes are reported, with the code for the most complicated procedure listed first (Kuehn 2012, 30-31, 111-112).

If a patient’s total outpatient bill is $500, and the patient’s healthcare insurance plan pays 80% of the allowable charges, what is the amount for which the patient is responsible?

a. $10

b. $40

c. $100

d. $400

Correct Answer: C

Out-of-pocket expenses are the healthcare expenses that the insured party is responsible for paying after the insurer has paid its amount. In the example, after the allowed charges of 80%, or $400, are covered by the insurance company, the patient will be responsible for the remaining 20%, or $100 (Johns 2011, 288, 316).

The following is documented in an acute-care record: “Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family.” In which of the following would this documentation appear?

a. Admission note

b. Nursing note

c. Physician progress note

d. Social work note

Correct Answer: D

After an initial assessment, documentation by other allied health professionals varies by specialty with appropriate content and frequency of recording (Johns 2011, 70).

INPATIENT RECORD

DISCHARGE SUMMARY
DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10

DISCHARGE DIAGNOSIS:

Acute pyelonephritis
Septicemia, resistant to ampicillin and penicillin
ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department.

COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient’s general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given Zovirax ointment.

INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for Zyban to assist smoking cessation.
_____
H&P
ADMITTED: 9/8

REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced difficulty about 3 days prior to admission. This was in the form of discomfort in the right side of the lower back and also some dysuria. On the evening of admission, she started experiencing some fever and chills and took some aspirin. This did not help her and she came to the emergency department.

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY: Remarkable only for “walking pneumonia” treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission.

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies

SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day.

REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period.

PHYSICAL EXAMINATION: On admission, significant for temperature of 103 degrees; pulse 120 beats per minute, regular; blood pressure 120/70; respirations 16

VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular

GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic.

SKIN: Warm to touch

HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal.

NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter.

LUNGS: Clear to auscultation and percussion

BACK: Positive pain to palpation and percussion right costovertebral angle

HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs.

ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal.

GENITALIA: Normal female

RECTAL: Deferred

EXTREMITIES: Femoral pulses normal, no edema

NEUROLOGIC: Grossly intact

LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable.

IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia.

PLAN: Hydrate and start IV antibiotics.
___________
PROGRESS NOTES

DATE NOTE
9/8 Patient admitted for evaluation of flank pain and fever. She also has a lesion on her lip. This appears to be herpes simplex. Will treat infection process with antibiotics following obtaining cultures. The patient’s renal function will be monitored.
9/10 The patient’s fever decreasing. Patient comfortable and tolerating antibiotics. Will continue IVs. The importance of stopping cigarette use was discussed with the patient. She is willing to quit and she will be given a prescription for Zyban at discharge.
9/11 Patient is afebrile today. Will discharge when able to obtain transportation.
______________
PHYSICIAN’S ORDER

DATE ORDER
9/8 Admit to floor for evaluation of febrile illness
Urinalysis
CBC and SMA 16
Urine culture and sensitivity
Blood cultures ×2
Chest x-ray
Pyelogram
D5W 125 cc/h ×3
Strict input and output
Zovirax ointment prn to lip
Gentamicin 80 mg IV q. 8 H ×3d
Cefoxitin 1 g IV q. 8 H ×3 days
9/9 D5W 100 cc/ph
9/10 Discharge patient when transportation is arranged
Ciprofloxacin 500 mg p.o. b.i.d. ×12 days
Zyban 150 mg p.o. daily ×3 days then b.i.d.
Follow up in the office in 1 week.
____________
LAB
HEMATOLOGY

DATE: 9/8

Specimen Results Normal Values
WBC

15.9 H

4.3-11.0

RBC

5.5

4.5-5.9

HGB

14.0

13.5-17.5

HCT

45

41-52

MCV

90

80-100

MCHC

41

31-57

PLT

251

150-450

CHEMISTRY

DATE: 9/8

Specimen Results Normal Values
GLUC

100

70-110

BUN

11

8-25

CREAT

1.0

0.5-1.5

NA

143

136-146

K

4.0

3.5-5.5

CL

98

95-110

CO2

30

24-32

CA

9.0

8.4-10.5

PHOS

3.0

2.5-4.4

MG

2.0

1.6-3.0

T BILI

1.0

0.2-1.2

D BILI

0.3

0.0-0.5

PROTEIN

7.0

6.0-8.0

ALBUMIN

5.2

5.0-5.5

AST

25

0-40

ALT

40

30-65

GGT

60

15-85

LD

100-190

ALK PHOS

50-136

URIC ACID

2.2-7.7

CHOL

0-200

TRIG

10-160

URINALYSIS

DATE: 9/8

Test Result Ref Range
SP GRAVITY

1.03

1.005-1.035

PH

6

5-7

PROT

NEG

NEG

GLUC

NEG

NEG

KETONES

NEG

NEG

BILI

NEG

NEG

BLOOD

NEG

NEG

LEU EST

POS

NEG

NITRATES

POS

NEG

RED SUBS

NEG

NEG
__________
MICROBIOLOGY

DATE TEST TYPE: Culture and Sensitivity
9/8 SOURCE: Urine
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli, 100,000/ml
SUSCEPTIBILITY:
9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
____________
LAB

DATE: 9/11

URINE CULTURE: No growth for 24 hours
______________
MICROBIOLOGY

DATE TEST TYPE:
9/8 Culture and Sensitivity #1
SOURCE: Blood
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli
SUSCEPTIBILITY:
9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
____________
RADIOLOGY REPORT

DATE: 9/8

CHEST X-RAY: The examination is of a recumbent AP view. Heart size is normal. The aorta is normal and lung fields are free of infiltration. There is no free air and the trachea is midline.

DIAGNOSIS: Normal chest x-ray
_________
RAD REPORT
DATE: 9/8

PYELOGRAM: The urinary architecture is normal with no hydronephrosis.

DIAGNOSIS: Normal pyelogram
nter five diagnosis codes.
____________
PDX

DX2

DX3

DX4

DX5

Case Studies
PDX 038.42 Septicemia due to Escherichia coli
DX2 590.10 Acute pyelonephritis, without lesion of renal medullary necrosis
DX3 054.9 Herpes simplex without mention of complication
DX4 V09.0 Infection with microorganisms resistant to penicillins
DX5 305.1 Tobacco use disorder

Notes on Inpatient Practice Case—Patient 4038.42 E. coli septicemia is documented on the culture and sensitivity as well as in the H & P. SIRS is not used here because septicemia is documented, versus sepsis. (Brown 2012, 109-112).
590.10 Acute pyelonephritis is also coded because this is where the septicemia began. Do not code the organism (Coding Clinic 4th Quarter 1988). It is already reflected in the septicemia code (Brown 2012, 217).
054.9 Herpes simplex is documented on the 9/8 progress notes and is treated (Brown 2012, chapter 10).
305.1 Tobacco abuse is treated and documented in the progress notes, H & P and D/C summary. This code does not require a fifth digit (HHS 2011, Tabular Index; Brown 2012, chapter 12).
V09.0 The organism is specified to be resistant to in the discharge summary and therefore designate that in the coding (Brown 2012, 113).
Note: The pyelogram performed on 9/8 is not coded because it is an unspecified pyelogram (refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book). A pyelogram is coded only if it is code 87.74 or 87.76 (Retrogrades, urinary systems).
____________

Points of Interest on Patient 4

This case illustrates how an infection can begin in one organ system and then become systemic. This is why the same organism is in the urinary tract and the blood. As stated earlier, code both disorders (septicemia and pyelonephritis).
The organism causing the infection is resistant to penicillin and ampicillin. Only code resistance to a drug if the resistance is documented by the practitioner in the record. Do not code from the laboratory reports alone.
(Garvin 2013, 68–75, 255.)

Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?

a. Volume 1

b. Volume 2

c. Volume 3

d. Volume 4

Correct Answer: A

ICD-9-CM Volume 1 is known as the Tabular List and contains the numerical listing of codes that represent diseases and injuries (Johns 2011, 239

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?

a. Complex

b. Intermediate

c. Not specified

d. Simple

Correct Answer: A

Complex closure includes the repair of wounds requiring more than layered closure, viz., scar revision, debridement, extensive undermining, stents or retention sutures (AMA 2012c, 66).

Prospective payment systems were developed by the federal government to:

a. Increase healthcare access

b. Manage Medicare and Medicaid costs

c. Implement managed care programs

d. Eliminate fee-for-service programs

Correct Answer: B

Since 1983, the prospective payment systems have been used to manage the costs of the Medicare and Medicaid programs (Johns 2011, 287, 319).

The following is documented in an acute-care record: “Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block.” In which of the following would this documentation appear?

a. Admission order

b. Clinical laboratory report

c. ECG report

d. Radiology report

Correct Answer: C

An ECG is a report of an electrocardiogram of the heart (Johns 2011, 70).

Identify where the following information would be found in the acute-care record: “PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine.”

a. Medical laboratory report

b. Physical examination

c. Physician progress note

d. Radiography report

Correct Answer: D

Results of an x-ray interpretation by a radiologist are reported in a radiography report (Johns 2011, 70).

What are five-digit ICD-9-CM diagnosis codes referred to as?

a. Category codes

b. Section codes

c. Subcategory codes

d. Subclassification codes

Correct Answer: D

Five-digit code numbers represent the subclassification level (Johns 2011, 240).

Given the following information, which of the following statements is correct?

MCD Type MS-DRG Title Weight Discharges Geometric Mean Arithmetic Mean
191 04 MED Chronic obstructive pulmonary disease w CC 0.9757 10 4.1 5.0
192 04 MED Chronic obstructive pulmonary disease w/o CC/MCC 0.7254 20 3.3 4.0
193 04 MED Simple pneumonia & pleurisy w MCC 1.4327 10 5.4 6.7
194 04 MED Simple pneumonia & pleurisy w CC 1.0056 20 4.4 5.3
195 04 MED Simple pneumonia & pleurisy w/o CC/MCC 0.7316 10 3.5 4.1

a. In each MS-DRG the geometric mean is lower than the arithmetic mean.

b. In each MS-DRG the arithmetic mean is lower than the geometric mean.

c. The higher the number of patients in each MS-DRG, the greater the geometric mean for that MS-DRG.

d. The geometric means are lower in MS-DRGs that are associated with a CC or MCC.

Correct Answer: A

The geometric mean LOS is defined as the total days of service, excluding any outliers or transfers, divided by the total number of patients (Johns 2011, 323).

When a provider accepts assignment, this means the:

a. Patient authorizes payment to be made directly to the provider

b. The provider agrees to accept as payment in full the allowed charge from the fee schedule

c. Balance billing is allowed on patient accounts, but at a limited rate

d. Participating provider receives a fee-for-service reimbursement

Correct Answer: B

To accept assignment means the provider or supplier accepts, as payment in full, the allowed charge from the fee schedule (Johns 2011, 350).

Which of the following is not true of notices of privacy practices?

a. They must be made available at the site where the individual is treated.

b. They must be posted in a prominent place.

c. They must contain content that may not be changed.

d. They must be prominently posted on the covered entity’s website when the entity has one.

Correct Answer: C

The notice of privacy includes a statement that the covered entity reserves the right to change the terms of its notice and to make the new notice provisions effective for all PHI that it maintains (Johns 2011, 837).

What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of practice, and the risk of malpractice?

a. DRGs

b. RVUs

c. CPT

d. SVR

Correct Answer: B

Relative value units (RVUs) are assigned to each service to provide a value that correlates to payment (Casto and Layman 2011, 152).

HIT professionals must have knowledge of:

a. Security issues with regard to the management of healthcare reform

b. Laws affecting the physician malpractice insurance

c. AMA’s professional ethical principles of practice regarding physician assistants

d. Laws affecting the use of disclosure of health information

orrect Answer: D

An HIT professional must have knowledge of all the points addressed (Johns 2011, 801-804)

Which of the following statements does not apply to ICD-9-CM?

a. It can be used as the basis for epidemiological research.

b. It can be used in the evaluation of medical care planning for healthcare delivery systems.

c. It can be used to facilitate data storage and retrieval.

d. It can be used to collect data about nursing care.

Correct Answer: D

According to Central Office on ICD-9-CM, ICD-9-CM is not used to collect data about nursing care (Johns 2011, 239).

Which of the following is an example of clinical data?

a. Admitting diagnosis

b. Date and time of admission

c. Insurance information

d. Health record number

Correct Answer: A

Clinical data document the patient’s medical condition, diagnosis, and procedures performed as well as the healthcare treatment provided (Johns 2011, 61).

Under the OPPS, on which code set is the APC system primarily based for outpatient procedures and services including devices, drugs, and other covered items?

a. CPT/HCPCS

b. ICD-9-CM

c. CDT

d. MS-DRG

Correct Answer: A

The Healthcare Common Procedural Coding System (HCPCS) identifies and groups the services within each APC group (Johns 2011, 329).

Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?

a. Category codes

b. E codes

c. Subcategory codes

d. V codes

Correct Answer: B

E codes provide a means to describe environmental events, circumstances, and conditions as the cause of injury, poisoning, and other adverse effects (Johns 2011, 242).

Medicare Part D pays for:

a. Physician office visits

b. Durable medical equipment

c. Inpatient hospital care

d. Prescription drugs

Correct Answer: D

Medicare Part D pays for prescription drugs for beneficiaries (Hazelwood and Venable 2012, 324).

Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician setting use with the Evaluation and Management code?

a. -79, Unrelated procedure or service by the same physician during the postoperative period

b. -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

c. -21, Prolonged evaluation and management services

d. -24,Unrelated evaluation and management service by the same physician during a postoperative period

Correct Answer: D

Modifier -24 is used for unrelated evaluation and management service by the same physician during a postoperative period (Kuehn 2012, 53).

Notices of privacy practices must be available at the site where the individual is treated and:

a. Must be posted next to the entrance

b. Must be posted in a prominent place where it is reasonable to expect that patients will read them

c. May be posted anywhere at the site

d. Do not have to be posted at the site

Correct Answer: B

Notices of privacy must be posted in a prominent place where it is reasonable to expect that patients will read them (Johns 2011, 836).

Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital’s Medicare reimbursement?

a. Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnoses present on the claim that will lead to higher payment.

b. Identify all records for a period that have these indicators for these conditions.

c. Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement.

d. Take a random sample of records for a period of time for records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.

Correct Answer: A

Any secondary diagnoses assigned present on admission status will have a negative impact on reimbursement if no other code on the claim is assigned as a complication or comorbidity or a major complication or comorbidity (Russo 2010, chapter 3).

The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment is called:

a. Billing

b. Unbundling

c. Upcoding

d. Unnecessary service

Correct Answer: C

Upcoding is the practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment (Johns 2011, 358).

*Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
________
DISCHARGE SUMMARY

DATE OF ADMISSION: 2/3
DATE OF DISCHARGE: 2/5

DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant

Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery.
_________
H&P

ADMITTED: 2/3

REASON FOR ADMISSION: Full-term pregnancy

PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Heart disease—father

SOCIAL HISTORY: The patient is married and has one other child living with her.

REVIEW OF SYSTEMS:

SKIN: Normal

HEAD-SCALP: Normal

EYES: Normal

ENT: Normal

NECK: Normal

BREASTS: Normal

THORAX: Normal

LUNGS: Normal

HEART: Slight midsystolic click with late systolic murmur II/VI

ABDOMEN: Normal

IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse—asymptomatic.
_____________
PROGRESS NOTES

DATE NOTE
2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well.
Delivered at 1:15 p.m. one full-term male infant.
2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact.
2/5 Will discharge to home
______________
PHYSICIANS ORDER

DATE ORDER
2/3 Admit to Labor and Delivery
1,000 cc 5% D/LR
May ambulate
Type and screen
CBC
May have ice chips
2/5 Discharge patient to home
_________________
DELIVERY RECORD

DATE: 2/3

The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby’s neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition.
________________
LAB REPORT

HEMATOLOGY

DATE: 2/3

Specimen Results Normal Values
WBC

5.2

4.3-11.0

RBC

4.9

4.5-5.9

HGB

13.8

13.5-17.5

HCT

45

41-52

MCV

93

80-100

MCHC

41

31-57

PLT

255

150-450
___________
Enter four diagnosis codes and one procedure code.

PDX

DX2

DX3

DX4

PP1

Case Studies

PDX 663.31 Delivery complicated by nuchal cord without compression
DX2 V27.0 Single liveborn
DX3 648.61 Other cardiovascular diseases in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium
DX4 424.0 Mitral valve disorders
PP1 73.6 Episiotomy

——
Notes on Inpatient 5

663.31 As per the delivery note, this is a delivery with a nuchal cord wrapped around the baby’s neck (Brown 2012, 289).
V27.0 Outcome of delivery code (Brown 2012, 270).
648.61, 424.0 These must be coded because they affected the monitoring of the patient and were documented in the medical record. The “use additional code” note at category 648 directs the coder to add another code to identify the condition (Brown 2012, 276-277).
73.6 Episiotomy—the repair of an episiotomy is included in the code (Brown 2012, 282).

——-
Points of Interest on Patient 5

In terms of documentation, this case is typical of many delivery charts. Often times, practitioners document the complication of delivery in only one area, such as the delivery note or the operative report. In this case, the baby has a nuchal cord, but it is only mentioned once in the delivery record.
This is also an illustration of the three types of codes, at a minimum, that must be on every delivery chart: a diagnostic code from the delivery or pregnancy category, an outcome of birth code (V code), and a procedure code.
(Garvin 2013, 124–126, 270.)

A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case?

a. Ataxia

b. Fractured arm

c. Metastatic carcinoma of the brain

d. Carcinoma of the lung

Correct Answer: C

If treatment is directed at the malignancy, designate the malignancy as the principal diagnosis. The only exception to this guideline is if a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy, or radiation therapy, assign the appropriate V code as the first-listed or principal diagnosis and the diagnosis or problem for which the service is being performed as a secondary diagnosis (Schraffenberger 2012, 97-98).

Coders will assign codes that have been selected into a computer program called a(n) _____ to assign the patient’s case to the correct group based on ICD-9-CM and/or CPT/HCPCS codes.

a. Encoder

b. Computer-assisted coding

c. Natural-language processor

d. Grouper

Correct Answer: D

In both the MS-DRG and APC groupings, coders enter the codes that have been selected into a computer program called a grouper. The grouper then assigns the patient’s case to the correct group based on the ICD-9-CM and/or CPT/HCPCS codes (Johns 2011, 272).

AMBULATORY CASE

*Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. *If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
—–
FACESHEET
DATE OF ADMISSION: 4/5 DATE OF DISCHARGE: 4/5

SEX: Male AGE: 37 DISCHARGE DISPOSITION: Home

ADMISSION DIAGNOSIS: Left inguinal hernia

DISCHARGE DIAGNOSIS: Same

PROCEDURES: Left inguinal herniorrhaphy with excision of lipoma of spermatic cord
——–
H&P
ADMITTED: 4/5

HISTORY OF PRESENT ILLNESS: The patient has been well until several months ago when he began to have pain when lifting.

PAST MEDICAL HISTORY: The patient has no other significant medical or surgical history.

SOCIAL HISTORY: Does not use alcohol or tobacco.

ALLERGIES: No known allergies

MEDICATIONS: None

REVIEW OF SYSTEMS:

SKIN: Warm and dry, mucous membranes moist

HEENT: Essentially normal

LUNGS: Clear to percussion and auscultation

HEART: Normal, regular rhythm

ABDOMEN: Normal

GENITALIA: Palpable mass in inguinal canal

RECTAL: Normal

EXTREMITIES: No edema

NEUROLOGIC: Deep tendon reflexes normal

IMPRESSION: Left inguinal hernia

PLAN: Surgical repair of inguinal hernia
——–
PROGRESS NOTES

DATE NOTE
4/5 Nursing:
Betadine scrub performed, patient anxious to get surgery over; preoperative medications given as ordered.
4/5 Attending MD:
Brief op note
Dx: Left inguinal hernia
Px: Left inguinal herniorrhaphy
Anes: Local plus sedation
Complications: None
4/5 Attending MD:
No bleeding; patient okay for discharge.
___________
OPERATIVE REPORT

DATE: 4/5

PREOPERATIVE DIAGNOSIS: Left direct inguinal hernia

POSTOPERATIVE DIAGNOSIS: Left direct inguinal hernia

OPERATION: Left inguinal herniorrhaphy

ANESTHESIA: Local plus sedation

OPERATIVE INDICATIONS: A wide mouth direct sac was present in the lower inguinal canal. A lipoma of the cord was present, but no indirect sac.

OPERATIVE PROCEDURE: Under local anesthesia consisting of the equivalent of 19 cc of 1% Xylocaine and 8 cc of 0.5% Marcaine, the abdomen was prepared with Betadine and sterilely draped. A left inguinal incision was made and carried down through subcutaneous tissues to the aponeurosis of the external oblique, which was opened from the external ring to a point over the internal ring. Flaps were cleaned in both directions. The nerve was retracted inferiorly. The cord structures were separated from the surrounding at the level of the pubic tubercle and retracted with a Penrose drain. Cremaster over the cord was opened and a search made for an indirect sac. None was found. Lipoma of the cord was dissected free and clamped at its base and excised. The base was ligated with 00 chromic catgut. Additional cremasteric muscles were divided and ligated with 00 chromic catgut. The direct sac was further dissected down to its base and inverted as the defect was closed by approximating transversus to transversus with a running suture of 00 Vicryl. The floor of the canal was then closed by approximating the internal oblique to the shelving portion of the inguinal ligament with multiple sutures of 0 Ethibond. The external oblique aponeurosis was then reclosed with 0 Ethibond, leaving the cord and nerve in the subcutaneous position. Several sutures of 0 Ethibond were also placed above the emergence of the cord at the internal ring. Subcutaneous tissues were then approximated with 3-0 Vicryl and after irrigation skin was closed with skin clips. The patient tolerated the procedure well and was sent to the recovery room in good condition.
———
PATH REPORT

DATE SPECIMEN SUBMITTED: 4/5

SPECIMEN: Lipoma of cord

CLINICAL DATA:

GROSS DESCRIPTION: The specimen is submitted as lipoma of cord. It consists of a single irregularly shaped fragment of fatty tissue that is 8.0 × 4.0 × 1.5 cm. It is covered with a thin membrane.

MICROSCOPIC DESCRIPTION:

DIAGNOSIS: Lipomatous tissue of left spermatic cord
____________
PHYSICIANS ORDER

DATE ORDER
4/5 Attending MD:
Admit to same-day surgery
Betadine scrub ×3 Preop
May take own meds
4/5 Anesthesia note:
Continue NPO
Demerol 50 mg IM 1½ hr Preop
Vistaril 50 mg IM 1½ hr Preop
Atropine 0.4 mg IM 1½ hr Preop
4/5 Attending MD:
Vital signs q. 15 min until stable
Regular diet
Darvocet-N-100 q. 4 hrs p.r.n. pain
Discharge to home when stable
————-
HEMATOLOGY

DATE: 4/5

Specimen Results Normal Values
WBC

6.83

4.3-11.0

RBC

4.57

4.5-5.9

HGB

13.7

13.5-17.5

HCT

43

41-52

MCV

87.0

80-100

MCHC

35

31-57

PLT

300

150-400

AUTO DIFFERENTIAL

DATE: 4/5

Specimen Results Normal Values
NEUT

68.3

40.0-74.0

LYMPH

20

19.0-48.0

MONO

5.6

3.4-9.0

EOS

5.6

0.0-7.0

BASO

0.6

0.0-1.5

LUC

3.8

0.0-4.0

URINALYSIS

DATE: 4/5

Test Result Ref Range
SP GRAVITY

1.017

1.005-1.035

PH

6

5-7

PROT

TRACE

NEG

GLUC

NONE

NEG

KETONES

NONE

NEG

BILI

NONE

NEG

BLOOD

TRACE

NEG

NITRATES

NONE

NEG

RBCS

NONE

NEG

WBCS

NONE

NEG
———–
RAD REPORT

DATE: 4/5

DIAGNOSIS: Inguinal hernia

EXAMINATION: Chest x-ray

Heart size and shape are acceptable. The lung fields are clear and the pulmonary vascular pattern is unremarkable. There is no free fluid and the trachea remains midline.
———–
Enter two diagnosis codes and two procedure codes.

PDX

DX2

PP1

PR2

Case Studies
PDX 550.90 Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent)
DX2 214.4 Lipoma of spermatic cord (as per path. and operative reports)
PP1 49505-LT Repair initial inguinal hernia, age five years or older; reducible
PR2 55520-59 Excision of lesion of spermatic cord (separate procedure)
————
Notes for Practice Outpatient Case—Patient 1

550.90 The type of hernia is coded (Brown 2012, 208-209).
214.4 The lipoma is also removed and so should be coded (Brown 2012, 377-378).
49505-LT The hernia location is on the left and the laterality is reported (CPT Assistant September 2000, 10).
55520-59 The lipoma requires excision and is therefore coded (CPT Assistant September 2000, 10; October 2001, 8).
(Garvin 2013, 48–52, 249.)

Q 54.1: A 70-year-old man, with a history of pulmonary hypertension and obstructive sleep apnea, presents with complaints of increasing dyspnea while walking his dog. He has also recently noted increased lower extremity edema. On physical examination, jugular venous distension …

Pathology/Laboratory Chapter Topics Format Organ or Disease-Oriented Panels Drug Testing Therapeutic Drug Assays Evocative/Suppression Testing Consultations (Clinical Pathology) Urinalysis, Molecular Pathology, and Chemistry Molecular Pathology Hematology and Coagulation Immunology Transfusion Medicine Microbiology Anatomic Pathology Cytopathology and Cytogenic Studies Surgical Pathology …

Integumentary System Chapter Topics Integumentary System Format Skin, Subcutaneous, and Accessory Structures Nails, Pilonidal Cyst and Introduction Repair (Closure) Burns Destruction Breast Procedures Learning Objectives After completing this chapter you should be able to 1 Describe the format of the …

Integumentary System Chapter Topics Integumentary System Format Skin, Subcutaneous, and Accessory Structures Nails, Pilonidal Cyst and Introduction Repair (Closure) Burns Destruction Breast Procedures Learning Objectives After completing this chapter you should be able to 1 Describe the format of the …

David from ajethno:

Hi there, would you like to get such a paper? How about receiving a customized one? Check it out https://goo.gl/chNgQy