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a significant procedure may not be coded in addition to the principal diagnosis
a diagnosis cannot be coded if there is no documentation in the report
when codes are listed in brackets in the alphabetical index it indicates that both codes must be listed in the specified order
review of systems would be located in which medical report history and physical
CMS means Center for Medicare and Medicaid Services
DMEPOS is Durable Medical Equipment Prosthetics Orthotics and Supplies
abuse is downcoding
an EOB
presence of possible lung cancer as evidenced by presence of masses radiology
family history is a standard element in what type of medical report history and physical exam
IPA is
JCAHO is Joint Commission on Accreditation of Hospital Organizations
medigap insurance coverage to cover the costs of deductibles
UHDDS Uniform Hospital Discharge Data Set
SOAP Subjective, Objective, Assessment, Plan
staff model HMO is a group of physicians who are employees of an organization that provide health care
PID caused by gonorrhea and chlamydial infection
synapse the space between two neurons
sympathetic nerves are autonomic
appendicular skeleton includes the arms
accommodation is ophthalmic adjustment
TURP is Transurethral Resection of Prostate
which of the following is not a part of the heart carotid
pleural effusion is often characterized by empyema
grading of neoplasm is useful in determining prognosis for patient
tomography is series of pictures
arthrocentesis is a surgical puncture of a joint remove fluid
postural problems do not include spondylosis
part of the small intestine do not include cecum
planes of the body do not include caudal
which of the following is not an endocrine gland spleen
cellulitis is characterized by inflammation of the skin
gouty arthritis caused by a buildup of uric acid
ovarian cysts do not include neuroblastoma
rhabdomyoma is coded as either a benign or malignant neoplasm of the connective tissue
fluorescein angiography is not used to detect retinal detachment
what type of error is in the following billing scenario upcoding
clinical pathology consultation is not reporting of results without interpretative judgement
vaginal delivery after a previous cesarean deliver is coded as 59612
procedures associated with central venous access catheters do not include implantation
fractures/dislocations are coded as fractures
critical care visits are not based on visit
which of the following is not a type of ectopic pregnancy peroneal
when multiple procedures are performed proper anesthesia code is the code for the most complex procedure
which of the following is not a type of salmonella lymphadenitis
co-morbidities are not considered in selecting an E/M code unless their presence significantly increases the complexity of the medical decision
in the ICD-10 book, destruction is not shaving
the extension of the foot downward is plantar flexion
what is the basic unit for an APC visit outpatient visit
an authorization for release of information would not include patient's previous hospitalization
guarantor the person responsible for payment of services
an eponym is a person's name
palliative means relieving by not curing
in vitro means experiments conducted outside of an organism
side effects of radiotherapy do not include incontinence
medical necessity provides linkage between CPT and ICD-10 codes
a CVA is not caused by septicemia
what is a Fowler-Stephens procedure orchiopexy
what is not a type of presenting problem for E/M codes detailed
Which of the following is not an accepted accrediting body for behavioral healthcare organizations? American Psychological Association
During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the lega Alert hospital legal counsel of the practice
Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. Operative report
In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action? Request the physician dictate an addendum to the discharge summary
Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. T Parentheses ( )
What type of standard establishes uniform definitions for clinical terms? Vocabulary standard
What was the goal of the new MS-DRG system? To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely i
Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________. Autoauthentication
The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary? AIDS
In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems. ADT
What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses? 18
What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm? A fine of not more than $250,000, not more than 10 years in jail, or both
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. Performance improvement programs
How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form? By reviewing al the diagnosis codes assigned to explain the reasons the services were provided
Which of the following is a core ethical obligation of health information staff? Protecting patients' privacy and confidential communications
Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers? Outcomes and Assessment Information Set (OAIS)
Who is responsible for writing and signing discharge summaries and discharge instructions? Attending physician
Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? Use of Mary's individually identifiable information related to her asthma treatments
When correcting erroneous information in a health record, which of the following is not appropriate? Use black pen to obliterate the entry
Tissue transplated from one individual to another of the same species but different genotype is called a(n): Allograft or allogeneic graft
Mohs micrographic surgery involves the surgeon acting as: Both surgeon and pathologist
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? New technology
What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases
CPT was developed and is maintained by: AMA
What healthcare organization collects UHDDS data? All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes
What is abstracting? Compiling the pertinent information from the medical record based on predetermined data sets
Per CPT guidelines, a separate procedure is: Considered to be an integral part of another, larger procedure
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: Social history
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals? State licensure agencies
What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs? Recovery audit contractors (RACs)
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________. History record
The dis. sum. must be completed w/in ________ after discharge for most pts but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours 30 days / 24 hours / 48 hours
ICD-10-CM defines the "newborn period" as birth through the ___________ day following birth. 28th
What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient? Six
Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in Appendix G
According to ICD-10-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older: 35
Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? Psychotherapy notes
When coding a selective catheterization in CPT, how are codes assigned? One code for the final vessel entered
Which of the following would not be found in a medical history? Vital signs
Observation E/M codes (99218 through 99220) are used in physician billing when: A patient is referred to a designated observation service.
The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form? Pathology report
Which of the following activities would be in violation of AHIMA's Code of Ethics? Coding an intentionally inappropriate level of service
What is the name of the organization that develops the billing form that hospitals are required to use? National Uniform Billing Committee (NUBC)
Identify the correct ICD-10-CM diagnosis code(s) for a patient with pneumonia and persistent cough. J44.9
The codes in the musculoskeletal section of CPT may be used by: Any physician
What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil? Aspiration pneumonia
Which of the following activities is considered an unethical practice? Backdating progress notes
Which answer below is not correct for assignment of the MS-DRG? Attending and consulting physicians
assignment of the MS-DRG? Diagnoses and procedures (principal and secondary) Presence of major or other complications and co morbidities (MCC or CC) Discharge disposition or status
Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? Consent for operative procedure, history, physical examination
Where would a coder who needed to locate the histology of a tissue sample most likely find this information Pathology report
What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? Identifier standard
Which organization developed the first hospital standardization program? American College of Surgeons
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure? A "with manipulation" code
Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? Data warehouse
What is the basic formula for calculating each MS-DRG hospital payments? Hospital payment = DRG relative weight x hospital base rate
Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1). They will also be sending her records to her physician for continuity of care (2). Under HIPAA, these two functions are: Use (1) and disclosure (2)
In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called: Selective catheterization
Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? Beneficence
Created by: wallace263