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RHIA Chap 3
PRG2017/Classification Systems and Secondary Data Sources
| Question | Answer |
|---|---|
| Which system is a classification of health and health related domains that describe body functions and structures, domains of activities and participation, environmental factors that interact with all of these components? | ICF (international classification on functioning, disability and health) |
| A MD performed an OP surgical procedure on the eye orbit of at pt with Medicare. Upon searching the CPT codes an d consulting with the MD, the coder is unable to find a code for the procedure. The coder should assign... | an unlisted procedure code located in the eye and ocular adnexa section |
| A system preferred terminology for naming disease processes is known as a | medical nomenclature |
| Which of the following is NOT included as a part of the minimum data maintained in the MPI (master patient index) | principal diagnosis |
| The HIM dept receives research from committees in the hospital. One committee wants to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which would be the best source to identify the necessary charts? | disease index |
| One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued? | for the life of the patient |
| A pt is admitted for a L herniorrhaphy, A coder discovers an extremely low potassium level . The coder notices that intravenous potassium was ordered. The MD didn't list any indication of abnormal potassium or any other conditions. The coder should | confer with the MD and ask him/her to list the condition as a final diagnosis if her or she considers the abnormal potassium level to be clinically significant |
| DSM 5 is used most frequently in what type of healthcare setting? | behavioral health centers |
| A coder notes that a patient is taking prescription Pilocarpine (used to treat eye pressure). The final diagnoses on the discharge summary are CHF and diabetes mellitus. The coder should query the MD about adding a diagnosis of... | glaucoma |
| The patient is diagnosed with CHF. A drug of choice is... | digoxin |
| ICD-10-CM utilized a placeholder character. This is used as a 5th character placeholder at certain 6 character codes to allow for future expansion. the placeholder character is | X |
| The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct... | ICD-10-CM codes |
| All children will be entered into which of the following registries at birth, and thus will continue to be monitored by the registry in their geographic area? | Immunization Registry |
| In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when.. | A new patient is seen in the office (** only two components if it is a subsequent visit for a patient**) |
| The registry collects data on recipients of heart valves and pacemakers | implant registry |
| Which classification system was developed to standardized terminology and codes for use in clinical laboratories | LOINC (logical observation identifiers, names, and codes) |
| Which classification system is used to neoplasms according to site, morphology and behavior? | ICD-O (international classification of diseases for Oncology) |
| According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is define as a ... | significant procedure |
| You need to analyze data on the types of care provided to Medicare patients in your geographic are by DRG. Which of the following would be most helpful to you? | MEDPAR |
| An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a | logic based encoder |
| Which classification system was designed with electronic systems in mind and is currently used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trial, disease surveillance and images? | SNOMED CT |
| The UMLS (unified medical language system) is a project sponsored by the | National Library of Medicine |
| You have recently been hired as a Medical Staff Coordinator at your hospital. Which database/registry will you utilized most often? | NPDB (National Practitioner Data Bank) |
| You need to retrieve information on a particular MD in you facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information? | Physician Index |
| You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called? | abstracting |
| Which system is used primarily to report services and supplies for reimbursement purposes? | HCPCS |
| You are looking at statistics for your facility that include average length of stay and discharge data by DRG. What type of data are you reviewing? | Aggregate data |
| In which registry would you expect to fin an Injury Severity Score? | Trauma Registry |
| At the request of one MD, a second MD provides advice regarding the evaluation and management of a specific problem. This is called... | a consultation |
| Which of the following systems facilitates capturing standardized data with the electronic documentation of patient at the point of care | Clinical Care Classification (CCC) |
| The most widely discussed and debated unique patient identifier is... | patients social security number |
| A nomenclature of code and medical terms that provide standard terminology for reporting physicians' services for third party reimbursement is | CPT (current procedural terminology) |
| A cancer program is surveyed for approval by | Commission on Cancer of the American College of Surgeons |
| The nursing staff would most likely use which of the following to facilitated aggregation of data for comparison at local, regional, national, and international levels? | ABC codes |
| The Level II (national) codes of HCPCS coding system are maintained by the | CMS (centers for Medicare and Medicaid services) |
| A patient is admitted with PNA. Cultures are requested and determine the infecting organism. Which of the following, if present, would alert the coder to ask the MD whether or not this should be coded as gram-negative PNA. | pseudomonas |
| The Level I 9CPT) codes of the HCPCS coding system are maintained by the | American Medical Association |
| A MD excises a 3.1 cm malignant lesion of the scalp that requires full thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded. | excision of lesion; full thickness skin graft to scalp |
| A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit. | Modifier 57 |
| A patient develops difficulty during surgery and the MD discontinues the procedure. Identify the modifier that may be reported by the MD to indicate that the procedure was discontinued. | Modifier 53 |
| A barrier to widespread use of automated code assignment is | poor quality of documentation |
| In assigning E/M codes, three key components are used. These are... | history, examination, medical decision making |
| Mrs. Jones had an appendectomy on Nov. 1st. She was taken back to surgery on Nov 2nd for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2nd visit. | Modifier 78 |
| The primary goal of a hospital based cancer registry is to.... | improve patient care |
| A secondary data source that houses aggregate extensive data about patients with a certain diagnosis is.. | disease registry |
Created by:
kodom001