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Medical Coding
Outpatient Medical Coding
| Question | Answer |
|---|---|
| What type of profession, other than coding, might skilled coders enter? | consultants, educators, medical auditors |
| What is the difference between outpatient and inpatient coding? | Inpatient coders use ICD-10-CM and ICD-10-PCS |
| What does outpatient coding focus on? | physician services, assigning HCPCS level II and ICD-10-CM codes. |
| What is a mid-level provider? | PA (physician assistants) and NP (nurse practitioners) |
| What are the different parts of Medicare? | Part A, B, C, D |
| Evaluation and management (E/M) services are often provided and documented in a standard format. One such format is SOAP notes. What does SOAP represent? | Subjective, Objective, Assessment, Plan |
| What are five tips for coding operative (op) reports? | Diagnosis code reporting, Start with the procedures listed, look for key words, highlight unfamiliar words, read the body. |
| What is medical necessity? | Relates to whether a procedure or service is considered appropriate in a given circumstance. |
| What is not a common reason Medicare may deny a procedure or service? | covered service |
| Under the Privacy Rule, the minimum necessary standard does NOT apply to what type of disclosures? | Disclosure to the individual who is the subject of the information. |
| Which is NOT one of the seven key components of an internal compliance plan? | Conduct training but not perform education on practice standards and procedures. |
| According to the example LCD from Novitas Solutions, which of the following conditions is considered a systemic condition that may result in the need for routine foot care? | Chronic venous inusufficiency |
| When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost? | $100 or 25 percent |
| Which statement describes a medically necessary service? | Using the least radical service/procedure that allows for effective treatment of the patient's complaint or condition. |
| What form is provided to a patient to indicate a service may not be covered by Medicare and the patient may be responsible for the charges. | ABN |
| Select the TRUE statement regarding ABNs. | ABNs may not be recognized by non-Medicare payers. |
| When presenting a cost estimate on an ABN for a potentially noncovered service, the cost estimate should be within what range of the actual cost? | $100 or 25 percent (whichever is greater) |
| What document assists provider offices with the development of Compliance Manuals? | OIG Compliance Program Guidance |
| Which act was enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA) and affected privacy and security? | HITECH |
| Who would NOT be considered a covered entity under HIPPA? | Patients |
| Under HIPPA, what would be a policy requirement for "minimum necessary"? | Only individuals whose job requires it may have access to protected health information. |
| What document is referenced to when looking for potential problem areas identified by the government indicating scrutiny of the services? | OIG Work Plan |
| A choledochal cyst is a cyst originating from which structure? | Common bile duct - choledoch means common bile duct |
| What gland is also known as the hypophysis cebri? | pituitary gland |
| Which leukocyte does the body use to protect against allergic reactions and parasites? | Eosinophils |
| Squamous cell carcinoma basal cell carcinoma are both cancers off cell tissue of the skin, lining of the blood vessels, respiratory intestinal, urinary tracts, and other body systems. These carcinomas are found in what type of tissue? | Epithelial tissue |
| What type of joint is the most common in the human body? | Synovial |
| The heart circulates blood through the lungs and is sent back into the left atrium of the heart via which vessel(s) | Left and right pulmonary veins |
| What procedure is performed when the spleen is removed? | Splenectomy |
| What suffix means breathing? | pnea |
| Which medical term refers to the cheek? | Buccal |
| Which structure is an internal organ of the male genital system? | Cowper's glands |
| What term is used for pus draining from the ar? | Otopyorrhea |
| Removal of scar tissue resulting from burns or other injuries. | Escharotomy |
| Neurologic movement disorder causing abnormal postures. | Dystonia |
| Suture of a ruptured spleen. | Splenorrhaphy |
| A surgical procedure creating an opening into the jejunum. | Jejunostomy |
| Create an opening to the gland and suture the cut edges to form a pouch. | Marsupialization |
| Deficiency of potassium in the blood. | Hypokalemia |
| An X-ray procedure allowing the visualization of internal organs in motion. | Fluoroscopy |
| Administered into the subarachnoid space. | Intrathecal injection |
| Protrusion of the eyeballs, as seen in Graves' disease. | Exophthalmos |
| Accumulation of pus in the pleural space; empyema. | Pyothorax |
| Diagnosis: Calcification left basal ganglia - Where are the basal ganglia located? | Cerebral cortex |
| Diagnosis: Vesicoureteral reflux - What is that a reflux of? | Urine backflow from bladder into ureters |
| Documentation: The posterior vaginal fornix and outer cervical os were prepped with a cleansing solution. In this statement, what does "os" stand for? | Ostium (opening) |
| Hysterosalpingogram report: "Right cornual contour abnormality." Where is the cornua found anatomically for this case. | The cornua are where the fallopian tube connect to the uterine fundus. |
| Surgical procedure Myringotomy - What anatomic location is being operated on? | Ear |
| Documentation: Recession of left inferior rectus muscle, 5mm - What anatomic location is being operated on? | Eye |
| Diagnosis: Kyphosis - What anatomic location does this diagnosis most often refer to? | Thoracic spine |
| Documentation: Suprapatellar recess shoed no evidence of loose bodies or joint pathology. What anatomic location does this refer to? | Knee (above the patella) |
| Colles' fracture - What anatomic location does this refer to? | Wrist |
| Which part is considered the foundation of a word? | Root |
| Blepharoplasty is performed on which part of the body? | Eyelid |
| Based on word parts, what is the definition of a salpingo-oophorectomy? | Surgical removal of an ovary and tube. |
| Based on word parts, what structure does paronychia refer to? | Nail |
| The prefix sub- means beneath. Based on word parts, what is the definition of subfascial? | Beneath the fascia |
| Based on word parts, what is the definition of a tracheostomy? | Creation of a hole in the trachea |
| Leukocytosis refers to an increase in | White blood cells |
| Based on word parts, what is the definition of glossectomy? | Surgical removal of the tongue |
| A choledochal cyst is a cyst originating from which structure? | Common bile duct |
| A cystourthoroscopy is examination of what structure? | Gallbladder and urethra |
| Squamous cell carcinoma and basal cell carcinoma are cancers of cell tissue of the skin, lining of the blood vessels, respiratory, intestinal, urinary tracts, and other body systems. These carcinomas are found in what type of tissue? | Epithelial tissue |
| The brochi are found in what body cavity? | Thoracic cavity |
| Which type of membrane is found lining the interior walls of the digestive system? | Mucous membrane |
| Which layer of the epidermis is normally found on the palsm of the hands and the soles of the feet? | Stratum Lucidum |
| A procedure requiring the physician to cut down the superficial fascia is documented as cutting down into the | hypodermis |
| What type of fracture is an incomplete fracture commonly found in children? | Greenstick fracture |
| Which of the following belongs to the appendicular skeleton as opposed to the axial skeleton? | Pelvic Girdle |
| What is an example of a long bon? | Metacarpals |
| What type of joint is most common in the human body? | Synovial |
| What is the root meaning joint? | Arthr/o |
| The heart receives deoxygenated blood in the right atrium via which vessel(s)? | Inferior and Superior Vena Cava |
| The heart circulates blood through the lungs and is sent back into the left atrium of the hart via which vessel(s)? | Left and right pumonary veins |
| What is the term for inflammation of the heart and vessel(s)? | Angiocarditis |
| What is the inner layer of the heart? | Endocardium |
| What causes cyanosis? | Oxygen deficiency |
| How does the lymphatic system work to ensure lymph fluid travels one way to the heart? | With a system of one-way valves |
| What type of cell is housed by the lymphatic system to help the body's defense system? | Phargocytes |
| What procedure is performed when the spleen is removed? | Splenectomy |
| The lymphatic ducts empty their contents into what structure? | Subclavian veins |
| What is the medical term for inflammation of lymphatic vessels due to bacterial infection? | Lymphangitis |
| Subcarinal means beneath the carina. Where is the carnia located? | At the bifurcation of the trachea into two bronchi |
| Which structure is responsible for moistening, warming and filtering inspired air? | Nose |
| What is a thoracotomy? | Incision into the chest wall |
| Where is gas exchanged and moved from the respiratory system into the circulatory system? | Alveoli and capillaries |
| Which suffix means breathing? | -pnea |
| What is the term for the first portion of the small intestines? | Duodendum |
| Where is bile produced? | Liver |
| Which part of the large intestine is between the hepatic flexure and the splenic floor? | Transverse colon |
| Which medical term refers to the cheek? | Buccal |
| Food moves through the digestive tract by what means? | Peristalsis |
| Which anatomical structure in the urinary system differs in position and length between the male and female, but serves the same function with regard to urine, and is often treated the same? | Urethra |
| What is the primary function of the urinary system? | Excretion of metabolic wastes, and fluid and electrolyte balance |
| Which structure is an intestinal organ of the male genital system? | Cowper's glands |
| What is the medical gterm for a congenital defect in which the urethra opens on the dorsum of the penis? | Epispadias |
| Where are the Bartholin's glands found? | Either side of the introitus in the female |
| The brain and the spinal cord are part of which system? | Central Nervous System |
| Which layer is the middle layer of the eyeball? | Choroid |
| What prevents the eyeball from collapsing? | Vitreous humor |
| Which structure of the ear is considered the inner ear? | Labyrinth |
| What term is used for pus draining from the ear? | Otopyorrhea |
| What gland secretes thyroid hormone and calcitonin? | Thyroid gland |
| Which structure is not a true endocrine structure? | Carotid body |
| Which gland is larger in early life than in puberty? | Thymus gland |
| Which gland is also known as the hypophysis cebri? | Pituitary gland |
| Which gland has two separate structures called the medulla and the cortex? | Adrenal glands |
| Anemia and polycythemia are disorders related to which blood cell? | Erythrocytes |
| Which leukocyte protects the body from viral infections? | Lymphocytes |
| Which leukocyte is the body's second line of defense against infections? | Monocytes |
| Which leukocyte does the body use to protect against allergic reactions and parasites? | Eosinophils |
| What is the disease of excessive mononuclear leukocytes in the blood? | Mononucleosis |
| There was no cleft of the uvula or submucosal palate by visual and palpable exam. What is being examined? | Oral cavity |
| The mediastinum contains all of the following except: | Lungs (includes heart, trachea and thymus) |
| The corpus luteum secretes progesterone. What is an effect of this secretion? | Thickens the endometrium for implantation and is necessary to sustain pregnancy. |
| What is NOT a function of the skin? | Acts as a gland by synthesizing vitamin A. |
| Which of the following does NOT circulate fluids throuhgout the body? | Endocrine system |
| What is affected by myasthenia gravis? | Neuromuscular junction |
| Which of the following conditions results from an injury to the head? The symptoms include headache, dizziness and vomiting. | Concussion |
| What is the great toe called? | Hallus |
| Upon leaving the stomach, nutrients move through the small intestine in what order? | Duodenum, jejunum, ileum. |
| What is the function of the Cowper's glands? | Helps lubricate the urethra |
| Upon leaving the last portion of the small intestine, nutrients move through the large intestine in what order? | Cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anus |
| The splenic (left colic) flexure lies in the upper left quadrant between what two portions of the large intestine? | The transverse and descending colon |
| Which of the following does NOT contribute to refraction in the eye? | Macula |
| Which of the following is true about the function of the cochlea? | It helps with balance and sound transmission |
| Splenorrhaphy is described as: | Suture of wound of the spleen |
| Bone marrow harvesting is a procedure to obtain bone marrow from a donor. Bone marrow collected from a close relative is: | Allogenic |
| A deficiency of cells in the blood is defined as: | Cytopenia |
| Sialography is an X-ray of: | Salivary glands |
| The meaning of heteropsia (or anisometropia) is: | Unequal vision in the two eyes |
| The operative overlapping of tissue to repair a defect in the diaphragm is called: | Imbrication |
| The word describing the presence of blood in the pleural cavity is: | Hemothorax |
| What condition results from failure of the testis to descend into the scrotum? | Cryptochidism |
| Adrenomegaly is defined as: | Enlargement of the adrenal gland |
| What is the Rinne's test? | Test measuring hearing using bone conduction and air conduction |
| The dome-shaped muscle under the lungs flattening during inspiration is the: | Diaphragm |
| The root word for mouth is: | Stomat/o |
| What does the 4th character in diabetes mellitus diabetes codes indicate? | Any complication associated with diabetes. |
| According to the ICD-10-CM guidelines, how is bilateral glaucoma of the same type stage reported? | A bilateral code can be used to report the type of glaucoma and the stage of glaucoma |
| According to ICD-10-CM guidelines, when a patient is seen for management of anemia due to malignancy, how is it reported? | The malignancy is reported first, followed by the code for the anemia. |
| According to ICD-10-CM guidelines, what is the maximum length of time for a myocardial infarction to be considered acute? | Four weeks (28 days) |
Created by:
hnorton9