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Medical |! Coding |! 1 |! - |! Final |! Exam |!
with |! precise |! answers
A |! patient |! record |! is |! the |! business |! record |! for |! a |! patient |! encounter |! that |! documents |! __________. |! - |! Correct |! answer |! ✔health |! care |! services |! provided |! to |! a |! patient Which |! type |! of |! physician |! participates |! in |! an |! approved |! GME |! program? |! - |! Correct |! answer |! ✔resident Residents |! are |! supervised |! by |! a(n) |! __________ |! physician |! during |! patient |! care. |! - |! Correct |! answer |! ✔teaching The |! process |! of |! standardizing |! data |! by |! assigning |! alphanumeric |! values |! to |! text |! or |! other |! information |! is |! called |! __________. |! - |! Correct |! answer |! ✔encoding Computer-assisted |! coding |! uses |! software |! to |! automatically |! generate |! __________ |! by |! "reading" |! transcribed |! clinical |! documentation |! provided |! by |! health |! care |! practitioners |! - |! Correct |! answer |! ✔medical |! codes Which |! is |! an |! example |! of |! a |! medical |! nomenclature? |! - |! Correct |! answer |! ✔SNOMED |! CT
Monthly |! newsletter |! published |! by |! AMA |! as |! an |! official |! coding |! resource. |! - |! Correct |! answer |! ✔CPT |! Assistant Medicare |! regulations |! (Centers |! for |! Medicare |! and |! Medicaid |! Services). |! - |! Correct |! answer |! ✔Conditions |! of |! Participation Quarterly |! newsletter |! published |! by |! AHA |! as |! an |! official |! coding |! resource. |! - |! Correct |! answer |! ✔Coding |! Clinic |! for |! HCPCS |! Level |! II Software |! used |! by |! hospitals |! to |! help |! identify |! CPT/HCPCS |! coding |! errors. |! - |! Correct |! answer |! ✔Outpatient |! Code |! Editor Code |! edits |! pairs" |! that |! cannot |! be |! reported |! on |! the |! same |! claim |! for |! payment |! - |! Correct |! answer |! ✔National |! Correct |! Coding |! Initiative Which |! is |! an |! example |! of |! a |! third-party |! payer? |! - |! Correct |! answer |! ✔BlueCross |! BlueShield Reporting |! multiple |! CPT |! codes |! to |! increase |! reimbursement |! when |! a |! combination |! code |! should |! be |! reported. |! - |! Correct |! answer |! ✔Unbundling Reporting |! codes |! that |! are |! not |! supported |! by |! documentation |! in |! the |! patient |! record |! for |! the |! purpose |! of |! increasing |! reimbursement. |! - |! Correct |! answer |! ✔Upcoding
Chief |! complaint, |! social |! data, |! and |! past |! medical |! history |! are |! considered |! part |! of |! the |! problem-oriented |! record |! __________. |! - |! Correct |! answer |! ✔database Diseases, |! injuries, |! impairments, |! other |! health-related |! problems |! and |! their |! manifestations. |! - |! Correct |! answer |! ✔large |! code |! set Substances, |! equipment, |! supplies, |! or |! other |! items. |! - |! Correct |! answer |! ✔Large |! code |! set Race, |! ethnicity, |! type |! of |! facility, |! and |! type |! of |! unit. |! - |! Correct |! answer |! ✔small |! code |! set Causes |! of |! injury, |! disease, |! impairment, |! or |! other |! health-related |! problems. |! - |! Correct |! answer |! ✔large |! code |! set Actions |! related |! to |! disease |! impairment |! management, |! prevention, |! and |! treatment. |! - |! Correct |! answer |! ✔large |! code |! set A |! coder |! acquires |! a |! working |! knowledge |! of |! coding |! systems, |! coding |! conventions |! and |! guidelines, |! government |! regulations, |! and |! third-party |! payer |! requirements |! to |! ensure |! that |! documented |! diagnoses, |! services, |! and |! procedures |! are |! coded |! accurately |! for |! __________, |! research, |! and |! statistical |! purposes. |! - |! Correct |! answer |! ✔reimbursement Medical |! management |! software |! is |! used |! to |! _____. |! - |! Correct |! answer |! ✔automate |! physician |! office |! workflow
A |! coding |! compliance |! program |! ensures |! that |! the |! assignment |! of |! codes |! to |! diagnoses, |! procedures, |! and |! services |! follows |! established |! coding |! guidelines, |! and |! health |! care |! organizations |! write |! policies |! and |! procedures |! to |! assist |! in |! implementing |! the |! coding |! compliance |! stages |! of |! __________. |! - |! Correct |! answer |! ✔detection, |! correction, |! prevention, |! verification, |! and |! comparison Which |! contains |! a |! computer-generated |! list |! of |! procedures, |! services, |! and |! supplies |! and |! corresponding |! revenue |! codes |! along |! with |! charges |! for |! each? |! - |! Correct |! answer |! ✔chargemaster Which |! is |! used |! to |! classify |! diagnoses |! in |! any |! health |! care |! setting? |! - |! Correct |! answer |! ✔ICD-10-CM Which |! classifies |! health |! and |! health-related |! domains |! that |! describe |! body |! functions |! and |! structures, |! activities, |! and |! participation |! and |! complements |! ICD-10, |! looking |! beyond |! mortality |! and |! disease? |! - |! Correct |! answer |! ✔ICF Observations |! about |! the |! patient's |! physical |! findings |! or |! lab |! results |! would |! be |! found |! in |! the |! __________ |! portion |! of |! a |! problem-oriented |! SOAP |! note. |! - |! Correct |! answer |! ✔objective A |! physician |! lists |! "viral |! pneumonia" |! as |! the |! final |! diagnosis. |! However, |! the |! coder |! notes |! that |! laboratory |! results |! state |! "gram-negative |! bacteria." |! There |! is |! also |! documentation |! of |! chest |! pain, |! fever, |! and |! dyspnea |! due |! to |! pneumonia. |! What |! should |! the |! coder |! do? |! - |! Correct |! answer |! ✔Query |! the |! physician |! regarding |! the |! diagnosis |! of |! pneumonia
|! to |! identify |! __________ |! provider |! documentation. |! - |! Correct |! answer |! ✔conflicting, |! incomplete, |! or |! nonspecific Which |! provides |! normalized |! names |! for |! clinical |! drugs |! and |! links |! its |! names |! to |! many |! of |! the |! drug |! vocabularies |! commonly |! used |! in |! pharmacy |! management |! and |! drug |! interaction |! software? |! - |! Correct |! answer |! ✔RxNorm Which |! is |! performed |! by |! health |! care |! facilities |! and |! providers |! for |! the |! purpose |! of |! administrative |! planning, |! submitting |! statistics |! to |! state |! and |! federal |! government |! agencies, |! and |! reporting |! health |! claims |! data |! to |! third-party |! payers? |! - |! Correct |! answer |! ✔health |! data |! collection The |! UB-04 |! claim |! is |! submitted |! by |! __________ |! to |! health |! plans |! for |! reimbursement |! purposes. |! - |! Correct |! answer |! ✔hospitals The |! table |! of |! contents |! for |! the |! problem-oriented |! record |! is |! called |! the |! __________, |! and |! it |! is |! filed |! at |! the |! beginning |! of |! the |! record |! and |! contains |! a |! numbered |! list |! of |! the |! patient's |! problems, |! which |! helps |! to |! index |! documentation |! throughout |! the |! record. |! - |! Correct |! answer |! ✔problem |! list The |! HIPAA |! large |! code |! set |! collects |! information |! concerning |! _____. |! - |! Correct |! answer |! ✔actions |! taken |! to |! prevent, |! diagnose, |! treat, |! and |! manage |! diseases |! and |! injuries Demographic |! data |! is |! patient |! identification |! information |! that |! is |! collected |! according |! to |! facility |! policy |! and |! includes |! information |! such |! as |! the |! __________. |! - |! Correct |! answer |! ✔patient's |! date |! of |! birth
Automated |! case |! abstracting |! software |! is |! used |! by |! hospitals |! to |! __________. |! - |! Correct |! answer |! ✔collect |! data |! for |! statistical |! analysis To |! learn |! more |! about |! the |! patient's |! condition |! and |! the |! management |! of |! the |! conditions, |! review |! the |! __________ |! plans |! in |! the |! problem-oriented |! record. |! - |! Correct |! answer |! ✔diagnostic/management Diagnostic, |! therapeutic, |! and |! education |! plans |! to |! resolve |! the |! problems |! would |! be |! found |! in |! the |! __________ |! portion |! of |! a |! problem-oriented |! SOAP |! note. |! - |! Correct |! answer |! ✔plan Coders |! are |! prohibited |! from |! performing |! assumption |! coding, |! which |! is |! the |! assignment |! of |! codes |! based |! on |! assuming, |! from |! a |! review |! of |! clinical |! evidence |! in |! the |! patient's |! record, |! that |! the |! patient |! has |! certain |! diagnoses |! or |! received |! certain |! procedures/services |! even |! though |! the |! __________. |! - |! Correct |! answer |! ✔provider |! did |! not |! specifically |! document |! those |! diagnoses |! or |! procedures |! and |! services The |! judgment, |! opinion, |! or |! evaluation |! made |! by |! the |! health |! care |! provider |! would |! be |! found |! in |! the |! __________ |! portion |! of |! a |! problem-oriented |! SOAP |! note. |! - |! Correct |! answer |! ✔assessment When |! coders |! have |! questions |! about |! documented |! diagnoses |! or |! procedures/services, |! they |! use |! a |! physician |! query |! process |! to |! contact |! the |! responsible |! physician |! to |! __________. |! - |! Correct |! answer |! ✔request |! clarification |! about |! documentation |! and |! the |! code(s) |! to |! be |! assigned
A |! third-party |! administrator |! (TPA) |! is |! an |! entity |! that |! __________ |! and |! may |! contract |! with |! a |! health |! care |! clearinghouse |! to |! standardize |! data |! for |! claims |! processing. |! - |! Correct |! answer |! ✔processes |! health |! care |! claims |! and |! performs |! related |! business |! functions |! for |! a |! health |! plan A |! secondary |! purpose |! of |! the |! patient |! record |! is |! to |! __________. |! - |! Correct |! answer |! ✔evaluate |! patient |! quality |! of |! care Concurrent |! coding |! is |! the |! review |! of |! records |! and/or |! use |! of |! encounter |! forms |! and |! chargemasters |! to |! assign |! codes |! __________. |! - |! Correct |! answer |! ✔during |! an |! inpatient |! stay |! or |! outpatient |! encounter Which |! incorporates |! software |! search |! features |! to |! facilitate |! the |! location |! and |! verification |! of |! diagnosis |! and |! procedure |! codes? |! - |! Correct |! answer |! ✔encoders Codes |! that |! do |! not |! require |! additional |! character(s) |! are |! considered |! __________ |! codes. |! - |! Correct |! answer |! ✔valid What |! is |! the |! ICD-10-CM |! code |! for |! central |! pain |! syndrome? |! - |! Correct |! answer |! ✔G89. What |! is |! the |! ICD-10-CM |! code |! for |! acute |! atopic |! conjunctivitis, |! left |! eye |! only? |!
- |! Correct |! answer |! ✔H10.
Combination |! codes |! are |! located |! by |! referring |! to |! subterm |! entries |! in |! the |! ICD- 10-CM |! index |! and |! by |! following |! __________ |! notes |! in |! the |! ICD-10-CM |! tabular |! list. |! - |! Correct |! answer |! ✔includes |! and |! excludes Within |! the |! ICD-10-CM |! tabular |! list, |! which |! contain |! groups |! of |! three- character |! categories? |! - |! Correct |! answer |! ✔sections Which |! Department |! of |! Health |! and |! Human |! Services |! federal |! government |! agencies |! provide |! official |! guidelines |! for |! coding |! and |! reporting |! using |! ICD-10- CM? |! - |! Correct |! answer |! ✔CMS |! and |! NCHS ICD-10-CM |! disease |! and |! injury |! codes |! describe |! causes |! of |! illness |! or |! clinical |! symptoms |! exhibited |! by |! the |! patient, |! and |! codes |! assigned |! must |! be |! supported |! by |! __________. |! - |! Correct |! answer |! ✔documentation |! in |! patient |! records In |! this |! ICD-10-CM |! index |! entry, |! "adrenal |! (capsule) |! (cortex) |! (gland) |! E27.8" |! is |! a |! __________. |! - |! Correct |! answer |! ✔subterm What |! is |! the |! ICD-10-CM |! code |! for |! bilateral |! nuclear |! sclerosis |! cataracts? |! - |! Correct |! answer |! ✔H25. Which |! is |! the |! determination |! that |! a |! service |! or |! procedure |! rendered |! is |! reasonable |! and |! necessary |! for |! the |! diagnosis |! or |! treatment |! of |! an |! illness |! or |! injury? |! - |! Correct |! answer |! ✔medical |! necessity
What |! is |! the |! ICD-10-CM |! code |! for |! HIV |! disease? |! - |! Correct |! answer |! ✔B A |! three-character |! code |! is |! to |! be |! assigned |! only |! if |! it |! cannot |! be |! further |! subdivided, |! and |! a |! code |! is |! __________ |! if |! it |! has |! not |! been |! coded |! to |! the |! full |! number |! of |! characters |! required |! for |! that |! code, |! including |! the |! seventh |! character |! extension, |! if |! applicable. |! - |! Correct |! answer |! ✔invalid When |! conditions |! that |! were |! previously |! treated |! no |! longer |! exist, |! it |! is |! acceptable |! to |! report |! __________ |! codes |! for |! those |! conditions |! that |! affect |! patient |! care, |! management, |! or |! treatment. |! - |! Correct |! answer |! ✔history |! (of) Which |! core |! set |! of |! comprehensive |! assessments |! for |! adult |! home |! care |! patients |! is |! reported |! using |! HAVEN |! data |! entry |! software? |! - |! Correct |! answer |! ✔OASIS What |! is |! the |! ICD-10-CM |! code |! for |! accidental |! poisoning, |! sucrose, |! initial |! encounter? |! - |! Correct |! answer |! ✔T50.3X1A It |! is |! appropriate |! to |! report |! secondary |! codes |! for |! __________ |! conditions |! that |! were |! treated |! or |! medically |! managed |! or |! that |! influenced |! the |! treatment |! of |! the |! patient |! during |! the |! encounter. |! - |! Correct |! answer |! ✔coexisting ICD-10-CM |! provides |! codes |! to |! deal |! with |! encounters |! for |! circumstances |! other |! than |! a |! disease |! or |! an |! injury |! in |! the |! __________ |! chapter. |! - |! Correct |! answer |! ✔Factors |! Influencing |! Health |! Status |! and |! Contact |! with |! Health |! Services
The |! ___ |! assigns |! permanent |! codes |! to |! replace |! the |! temporary |! codes |! in |! Chapter |! 22 |! of |! the |! ICD-10-CM. |! - |! Correct |! answer |! ✔WHO What |! is |! the |! ICD-10-CM |! code |! for |! Barrett's |! esophagus? |! - |! Correct |! answer |! ✔K22. For |! patients |! receiving |! __________ |! only, |! assign |! and |! report |! first |! the |! appropriate |! code |! from |! ICD-10-CM |! subcategory |! Z01.81 |! (encounter |! for |! preprocedural |! examinations), |! to |! describe |! the |! preoperative |! consultations. |! - |! Correct |! answer |! ✔preoperative |! evaluations What |! is |! the |! ICD-10-CM |! code |! for |! congenital |! disease |! of |! the |! heart? |! - |! Correct |! answer |! ✔Q24. For |! patients |! receiving |! therapeutic |! services |! only |! during |! an |! outpatient |! encounter |! (except |! chemotherapy |! or |! radiation |! therapy), |! sequence |! first |! the |! diagnosis, |! condition, |! problem, |! or |! other |! reason |! for |! encounter |! that |! is |! __________. |! - |! Correct |! answer |! ✔chiefly |! responsible |! for |! the |! outpatient |! services |! provided |! during |! the |! encounter Assign |! ICD-10-CM |! code |! Z01.89 |! (Encounter |! for |! other |! specified |! special |! examinations) |! and |! the |! reason |! for |! the |! nonroutine |! test |! when |! __________. |! - |! Correct |! answer |! ✔routine |! testing |! is |! performed |! during |! the |! same |! outpatient |! encounter |! as |! a |! test |! to |! evaluate |! a |! sign, |! symptom, |! or |! diagnosis What |! is |! the |! ICD-10-CM |! code |! for |! primary |! osteoarthritis |! of |! left |! hip? |! - |! Correct |! answer |! ✔M16.
What |! is |! the |! ICD-10-CM |! code |! for |! a |! routine |! well |! child |! exam |! of |! 6-year-old |! patient? |! - |! Correct |! answer |! ✔Z00. A |! patient |! with |! end-stage |! lung |! cancer |! receives |! treatment |! for |! congestive |! heart |! failure |! (CHF) |! and |! medical |! management |! of |! the |! lung |! cancer |! in |! the |! hospital's |! outpatient |! department. |! Report |! codes |! for |! __________. |! - |! Correct |! answer |! ✔congestive |! heart |! failure |! and |! lung |! cancer What |! is |! the |! ICD-10-CM |! code |! for |! postpartum |! hemorrhage? |! - |! Correct |! answer |! ✔O72. Coding |! guidelines |! are |! used |! as |! a |! companion |! to |! the |! official |! version |! of |! ICD- 10-CM, |! which |! contain |! coding |! conventions |! to |! ensure |! __________. |! - |! Correct |! answer |! ✔accurate |! coding For |! accurate |! reporting |! of |! ICD-10-CM |! diagnosis |! codes, |! documentation |! should |! describe |! the |! __________, |! using |! terminology |! that |! includes |! specific |! diagnoses |! as |! well |! as |! symptoms, |! problems, |! or |! reasons |! for |! the |! encounter. |! - |! Correct |! answer |! ✔patient's |! condition The |! first-listed |! diagnosis |! for |! an |! outpatient |! may |! be |! reported |! as |! a |! __________ |! when |! a |! diagnosis |! has |! not |! been |! established |! by |! the |! physician. |! - |! Correct |! answer |! ✔sign |! or |! symptom What |! is |! the |! ICD-10-CM |! code |! for |! bruising |! of |! scalp |! of |! newborn |! during |! birth? |! - |! Correct |! answer |! ✔P12.
The |! Diagnostic |! Coding |! and |! Reporting |! Guidelines |! for |! Outpatient |! Services |! were |! __________. |! - |! Correct |! answer |! ✔developed |! by |! the |! federal |! government |! and |! approved |! for |! use |! by |! hospitals |! and |! providers Appropriate |! codes |! from |! the |! ICD-10-CM |! Tabular |! List |! of |! Diseases |! (A00.0 |! through |! T88.9, |! Z00-Z99) |! must |! be |! used |! to |! identify |! __________. |! - |! Correct |! answer |! ✔reasons |! for |! encounter Which |! code |! is |! assigned |! to |! a |! patient |! encounter |! for |! a |! preoperative |! diagnosis |! of |! pain |! in |! the |! knee |! and |! a |! postoperative |! diagnosis |! of |! tear |! in |! the |! medial |! meniscus |! bucket |! handle, |! right |! knee? |! - |! Correct |! answer |! ✔S83.211A A |! patient |! presents |! for |! outpatient |! surgery |! and |! develops |! a |! postoperative |! (postop) |! complication |! that |! requires |! admission |! for |! observation |! care. |! Which |! is |! reported |! as |! the |! first-listed |! diagnosis? |! - |! Correct |! answer |! ✔reason |! for |! surgery What |! is |! the |! ICD-10-CM |! external |! cause |! of |! morbidity |! code |! for |! contact |! with |! hypodermic |! needle, |! initial |! encounter? |! - |! Correct |! answer |! ✔W46.0XXA Which |! was |! established |! by |! the |! federal |! government |! as |! a |! standard |! data |! set |! for |! ambulatory |! care |! facility |! records |! and |! has |! as |! its |! goal |! the |! improvement |! of |! data |! comparison |! for |! outpatient |! care |! settings? |! - |! Correct |! answer |! ✔UACDS What |! is |! the |! ICD-10-CM |! code |! for |! hoarseness? |! - |! Correct |! answer |! ✔R49.
For |! routine |! prenatal |! outpatient |! visits |! for |! patients |! with |! high-risk |! pregnancies, |! report |! an |! ICD-10-CM |! code |! from |! category |! __________ |! as |! the |! first- listed |! diagnosis. |! A |! code |! from |! ICD-10-CM |! Chapter |! 15 |! may |! also |! be |! reported |! as |! a |! secondary |! diagnosis, |! if |! appropriate. |! - |! Correct |! answer |! ✔O09 |! (Supervision |! of |! high-risk |! pregnancy) What |! is |! the |! ICD-10-CM |! code |! for |! heart |! palpitations? |! - |! Correct |! answer |! ✔R00. Codes |! that |! describe |! symptoms |! and |! signs |! instead |! of |! __________ |! are |! acceptable |! for |! reporting |! purposes |! when |! the |! physician |! has |! not |! documented |! an |! established |! diagnosis |! or |! confirmed |! diagnosis. |! - |! Correct |! answer |! ✔definitive |! diagnoses For |! the |! most |! accurate |! assignment |! of |! ICD-10-CM |! codes, |! coders |! review |! __________ |! to |! locate |! conditions |! and |! diseases. |! - |! Correct |! answer |! ✔patient |! records For |! ambulatory |! surgery, |! assign |! an |! ICD-10-CM |! code |! to |! the |! diagnosis |! for |! which |! the |! surgery |! was |! performed; |! if |! the |! postoperative |! diagnosis |! is |! different |! from |! the |! preoperative |! diagnosis |! when |! the |! diagnosis |! is |! confirmed, |! assign |! a |! code |! to |! the |! __________. |! - |! Correct |! answer |! ✔postoperative |! diagnosis |! instead |! because |! it |! is |! more |! definitive An |! emergency |! department |! patient |! received |! treatment |! for |! an |! injury |! to |! the |! right |! arm, |! which |! upon |! x-ray |! revealed |! a |! closed |! displaced |! oblique |! fracture |! of |! the |! shaft |! of |! the |! right |! humerus. |! While |! receiving |! treatment |! for |! the |! fracture, |! the |! physician |! also |! medically |! managed |! the |! patient's |! chronic |! obstructive |!
asthma. |! Which |! is |! reported |! as |! the |! first-listed |! diagnosis? |! - |! Correct |! answer |! ✔closed |! displaced |! oblique |! fracture What |! is |! the |! ICD-10-CM |! code |! for |! calculus |! of |! kidney |! and |! ureter? |! - |! Correct |! answer |! ✔N20. A |! patient |! is |! referred |! to |! a |! radiologist |! for |! an |! outpatient |! chest |! x-ray |! because |! of |! a |! cough. |! The |! result |! of |! the |! chest |! x-ray |! indicates |! the |! patient |! has |! pneumonia. |! During |! the |! performance |! of |! the |! diagnostic |! test, |! it |! was |! determined |! that |! the |! patient |! has |! hypertension |! and |! diabetes |! mellitus. |! Which |! is |! the |! first-listed |! diagnosis? |! - |! Correct |! answer |! ✔pneumonia A |! screening |! code |! may |! be |! a |! __________ |! code |! if |! the |! reason |! for |! the |! visit |! is |! specifically |! the |! screening |! exam. |! - |! Correct |! answer |! ✔first-listed The |! testing |! of |! a |! person |! to |! rule |! out |! or |! confirm |! a |! suspected |! diagnosis |! because |! the |! patient |! has |! some |! sign |! or |! symptom |! is |! a |! __________. |! - |! Correct |! answer |! ✔diagnostic |! examination The |! subcategories |! for |! encounters |! for |! general |! adult |! medical |! examinations, |! Z00.0-, |! provide |! codes |! for |! with |! and |! without |! abnormal |! findings. |! When |! a |! general |! medical |! examination |! results |! in |! abnormal |! findings, |! the |! code |! for |! __________ |! is |! assigned |! as |! the |! first-listed |! diagnosis. |! A |! secondary |! code |! for |! the |! abnormal |! finding |! should |! also |! be |! assigned. |! - |! Correct |! answer |! ✔general |! adult |! medical |! examination |! with |! abnormal |! finding
