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Certified Professional Coder Coding Test
Typology: Exams
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Coding is - ✔the process of translating this written or dictated fmedical record into a series of numeric or alpha-numeric codes Proper code assignment is determined by - ✔content of the medical record and by the unique rules that governs each code set what are 3 things that Coder must master - ✔1. anatomy
What is a physican degree of education - ✔4 years of college, 4 years of medical school plus 3 to 5 years of residency. What is a mid-level providers and who - ✔1. Mid-level providers are know as physician extenders
✔to read and understand the documentation in the medical record in order to accurately code the services rendered. What are some different types of services documented in medical record - ✔Evaluation and management Operative reports X-Rays Evaluation and Management services are provided in what standard format - ✔SOAP What is SOAP - ✔S- Subjective O-Objective A- Asssessment P-Plan What is the definition of S of SOAP - ✔subjective- The patient's statment about his or her health, including symptoms What is the definition of O of SOAP - ✔objective-The provider assesses and documents the patient's illness using observation, palpation, auscultation and percussion. Test and other services performed may be documented here as well What is the definition of A of SOAP - ✔Assessment-Evaluation and conclusion made by the provider. This is usually where the diagnosis(es) for the services are found What is the definition of P of SOAP - ✔Plan-Course of Action. Here, the provider will list eh next steps for the patient, whether it is ordering additional test, or taking over the counter medication What is a operative report - ✔a document the detail of a fprocedure performed on a patient What will most operative notes have - ✔Header and Body what are some of things that operative header note might include? - ✔1. Date and time of procedure
✔if the patient still request the procedures and services but refuses to sign a properly-presented ABN, the provider should cocument the patient's refusal. The provider and a witness should then sign the form. When is a ABN never required and WHY - ✔1. Emergency and urgent care situation
What was ARRA and HITECH promote - ✔the adoption and meaningful use of health information technology Portions of HITECH strengthen HIPAA rules by - ✔addressing the privacy and security concerns assoicated with the electronic transmission of health information HITECH has how many categories of violation - ✔Four What are the categories depending on - ✔the covered entity's level of culpability for releasing protected information and minimum and maximum penalties. HITECH lowers what for what constitutes a voliation but provides what during which any violation not due to willful neglect may be corrected without a penalty - ✔1. Lowers the Bar
✔Toward the side of the body What does Proximal mean - ✔nearer to the point of attachment or to the given reference point what does Distal mean - ✔farther from the point of attachment or from a given reference point What does Superior (cranial) mean - ✔above; toward the head What does Inferior (caudal) mean - ✔below; toward the lower end of the spine what does Superficial (external) - ✔Closer to the surface of the body What does Deep (internal) - ✔Closer to the center of the body What does Sagittal plane mean - ✔cuts through the midline of the body from the front to back and divides the body into right and left sections What does Frontal (coronal) plane mean - ✔cuts at a right angle to the midline cut , from side to side and divides the body into front (anterior) and Back (posterior) sections What does Transverse (horizontal) plane mean - ✔cuts horizontally through the body and separates the body into upper (superior) and lower (inferior) sections The structure of the human body falls into how many categories - ✔ 4 What are the categories of the human body - ✔1. Cells
What does the acroymn RNA means and what does it do - ✔1. Ribonucleic acid
✔the horny layers, outermost layer what is stratum lucidum composed of - ✔clear layer What is stratum Granulosum composed of - ✔Granular layer of cells What are 2 types of Granules - ✔1. Keratohyaline granules
Define Decubitus - ✔Pressure ulcer/bedsore Define Ecchymosis - ✔Condition in which blood seepss into the skin causing discoloration Define Hypodermic - ✔Pertaining to under the skin Define Intradermal - ✔Pertaining to within the skin Define Jaundice - ✔Yellowness of skin Define Melanin - ✔Pigment giving color to the skin Define Melanoma - ✔Pigmented tumor of the skin Define Pediculosis - ✔Infestation with lice Define Subcutaneous - ✔Pertaining to below the skin Define Tinea - ✔Ringworm; a fungal infection of the skin By which week does a developing fetus has its lifetime supply of hair follicles - ✔22 weeks On average a human body have how many follicles - ✔5 million where is greatest concentration of follicles - ✔head Hair on the scalp grows approximately how much per day and per year - ✔1. .3 to .4 mm/day
What are the seven classifications of bones - ✔1. Long