Sally Smith Is Reviewing an Inpatient Record for Coding

Clinical Nomenclature Systems

one.	A patient presents with CKD stage Iii, edema and hypertension. The right ICD-10 CM codes for this chart are:
		a. N18.3, I10, R60.9
		b. N18.ix, I10, R60.nine
		c. N18.three, I12.ix
		d. N18.9, I12.9, R60.nine
Per ICD-10CM guidelines do not lawmaking signs and symptoms. Edema is a symptom of both hypertension and CKD. ICD-10CM guidelines state there is a casual human relationship causeless between CKD and hypertension unless the provider specifically states that the hypertension is non related to the CKD, giving this patient hypertensive chronic kidney illness instead of regular hypertension. Incorrect answer. Delight choose another answer.

two.	A 42-year-old female, who is a new patient, presents with foul-smelling urine, frequency, flank pain and fever for 4 days. Patient denies nausea and headache. Patient is not sexually agile and is a not-smoker. The provider performs the post-obit exam in addition to patient's height, weight and blood force per unit area cheque: Full general: Well-developed, well nourished, in no acute distress Ears: external ears normal, TM bilaterally intact Neck: Supple, no thyromegaly Extremities: No edema Cardiovascular: RRR, no bruits Lungs: Clear to auscultation The patient is prescribed ciprofloxacin and given a diagnosis of acute cystitis without hematuria. The right coding for this come across, using 1997 E/Grand guidelines is:
		a. 99202, N30.00
		b. 99203, N30.00, R30.0
		c. 99202, N39.0
		d. 99203, N39.0, R30.0
1997 East/Yard guidelines country that the provider must reach 12 bullet points for a detailed level of test. Although the patient'south chart has a detailed history and moderate medical determination making, the provider only reached 11 bullet points, making this level a 99202. N39.0 is not the most specific code for this chart. Incorrect reply. Please choose another respond.

3.	A patient presents with a cyst at the base of operations of his tailbone. It is bloated and painful for the patient to sit down. The provider drapes the patient in the usual manner, administers lidocaine and uses a scalpel to excise the 2cm cyst and a subcutaneous extension, rinses it with sterile saline, performs an intermediate repair of the wound with a layered closure. The right CPT lawmaking consignment for this procedure is:
		a. 10080, 12001-59
		b. 10081
		c. 11771
		d. 11770, 12031-59
The provider performs an excision, non an incision, completely removing the cyst. The excision is intermediate because information technology involves subcutaneous extensions and the repair is included with the procedure. Wrong answer. Delight choose another answer.

4.	A 7-year-one-time child presents for a series of vaccines. The patient receives MMR and DTaP and counseling on vaccines. The correct CPT lawmaking consignment for this procedure is:
		a. 90460, 90461
		b. 90471, 90472
		c. 90460, 90461x5
		d. 90460x2, 90461x4
Pediatric vaccines with counseling are coded per component. Each showtime component of a vaccine (Measles and Diphtheria in this case) are coded as 1 unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code. Wrong answer. Delight choose another reply.

5.	ICD-10 codes are used:
		a. as procedure codes
		b. in DRGs
		c. as diagnosis codes
		d. All of the higher up
ICD-10 PCS are used equally procedure codes for inpatient visits. DRGs use similar ICD-10CM weights for facility reimbursement and ICD-10CM are used as diagnosis codes for all healthcare settings. Incorrect reply. Delight cull another answer.

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6.	For urosepsis, a coder must:
		a. Use the code for severe sepsis
		b. Use the lawmaking for sepsis with organ dysfunction
		c. Query the provider
		d. Code first localized sepsis
Co-ordinate to ICD-10CM guidelines, urosepsis is a nonspecific term and has no tabular position. The provider must exist queried for clarification. Wrong answer. Please choose some other reply.

7.	A patient comes into the office with white fuzzy patches on their tongue and is diagnosed with oral hairy leukoplakia. The provider runs a test for HIV and notates that the patient has HIV in the chart, but does not accept a positive lab exam nevertheless. The patient is a smoker. What is the correct sequencing of these ICD-10 codes?
		a. B20, K13.3, F17.200
		b. K13.iii, R75, Z87.891
		c. B20, K13.3, Z87.891
		d. K13.3, Z21, F17.200
Co-ordinate to chapter guidelines, if a patient is seen for an HIV-related condition, (which oral hairy leukoplakia is), then B20 is coded first, and so the complications. Only the provider's statement is needed that the patient has HIV, non a positive lab test. F17.200 is to be assigned when the provider documents "smoker", just gives no further clarification (AHA: 2016, 1Q, 36) Wrong answer. Please cull another answer.

eight.	A 25-year-one-time patient is 27 weeks and six days pregnant. The patient is experiencing dysuria and blood in her urine. She is diagnosed with acute cystitis. What is the right coding of this patient'southward chart?
		a. N30.01, Z33.1
		b. O23.32, N39.0, Z3A.27
		c. O23.12, N30.01, Z3A.27
		d. N30.00, Z33.one
Cystitis is an infection of the float. The provider must specifically state that the infection or condition is not affecting the pregnancy for an incidental lawmaking. The patient is experiencing blood in her urine, which gives us the hematuria portion of the diagnosis. Wrong answer. Please choose another reply.

9.	A patient comes in after her force per unit area cooker has exploded and covered her confront with boiling soup. She was luckily wearing a sweater which protected her arms. She has partial-thickness burns covering her unabridged face. What is the correct CPT code to be assigned as the hospital removes chicken, celery and burnt tissue from her face and places dressings on it?
		a. 16020, 97597-59
		b. 11011
		c. 16025
		d. 97597
16025 covers whole face burns and includes debridement. Wrong respond. Delight choose another answer.

x.	A 2-year-erstwhile child had their humerus fractured by a falling dresser and requires anesthesia to repair the break because they volition not concur still for a reduction. The procedure billed is 24505. What anesthesia service is reported?
		a. 01730 P1
		b. 01742 P1, 99100
		c. 01744 P1
		d. 01756 P1, 99100
Anesthesia for all airtight procedures on humerus and elbow. The 99100 code is merely used for patients under 1 year old or over seventy years old. 01744 is for open procedures, not closed. Wrong answer. Please choose another reply.

Confidentiality and Privacy

11.	The Breach Notification Rule, plant in the ______ Rule of HIPAA, states that when _____ individuals take had their confidential information exposed and the covered entity has outdated contact information for them, that the covered entity must_____ for ______ days.
		a. Security Rule, less than 200 individuals but more than than 5, mail service a notice in the paper for 180 days
		b. Bus Rule, less than 500 individuals only more ten, post a notice on their website for xc days
		c. Security Rule, 500 or more individuals, post a find on their website and create a radio advertising for 60 days
		d. Privacy Rule, 5 or more individuals, post a notice on their website, in the anteroom and send postcards with information at least three times over xc days.
The Bus Rule established HITECH and the AARA of 2009 and finalized the Breach Notification Rule, mandating that covered entities who accept more than ten individuals with outdated contact data involved in a data breach must be notified by posting a notice on their website or creating a local ad in the newspaper. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately. Incorrect answer. Please choose another reply.

12.	Sally calls the coding department to contest the duplicate procedures that her adult sister received while admitted to an inpatient mental wellness facility. Sally has her sis's date of nativity, her proper noun only not her ID number. She says her sister is too depressed to advocate for herself and Sally simply wants the charges reviewed. What exercise you practise?
		a. Tell Sally you'll review her sis's nautical chart while she was hospitalized and process a corrected claim if needed.
		b. Tell Sally you're sorry, but her sis must telephone call when she gets out of the hospital, HIPAA does not allow you to speak to Sally without her sister's written consent.
		c. Tell Sally her sister's patient ID number so she can amend advocate for her sister in other departments
		d. Tell Sally that according to HIPAA she must obtain her sister's written consent in order to discuss any protected wellness information with her and give her the fax number where she can send the written release.
HIPAA Privacy Dominion Section 164.510(b)(3) allows providers to discuss PHI with family members if they make up one's mind it is in the patient's best interest for coordination of treatment or payment, unless the patient has expressed wishes that their information is not shared with family. Wrong answer. Delight choose another respond.

13.	Y'all need a second opinion on coding a nautical chart from your Coding Manager, who does not have admission to the patient'southward records. Yous make up one's mind to e-post a screenshot of the chart to the Coding Manager. What steps must you accept to ensure that the patient's information is protected in your email?
		a. Create a confidentiality notice in your email, asking an unintended recipient to delete the data
		b. Follow all company guidelines to encrypt your electronic mail
		c. Remove patient's name, date of birth, insurance ID#, SSN, address and patient number before emailing
		d. All of the above
HIPAA HITECH requires that covered entities have reasonable action to protect electronically transmitted information. Removing protected wellness information, encrypting email and creating confidentiality notices are a multi-layered security approach that is all-time-practice to forbid breaches of data. Wrong answer. Please choose some other answer.

Reimbursement Methodologies

14.	Facility payments are based on:
		a. Fee schedules
		b. ICD-x PCS codes
		c. IPPS using DRGs
		d. RVUs and conversion factors
The Inpatient Prospective Payment Organisation drives value-based care by paying inpatient stays based on DRGs (Diagnosis-Related Group(s)) which are groups of diagnoses with similar weights in social club to determine "how much" a patient's stay ought to cost. These drivers strength hospitals to piece of work to be well-nigh efficient in their employ of resources to come in under what they will be paid in order to avoid losing money. Wrong answer. Delight cull another answer.

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15.	Conversion factors:
		a. Are based on how difficult a procedure is
		b. Depend on the level of education a provider has
		c. Are based on locality
		d. None of the above
RVUs are based off work for each HCPCS. RVUs are multiplied by Geographic Do Cost Indices (GPCI), which account for dr. work, cost of malpractice and practice expenses. A conversion factor, which is a national number that changes annually, is multiplied by the sum of RVUs that are multiplied past the GPCI to calculate payment for professional fee schedules. Wrong respond. Delight choose another reply.

16.	Pressure ulcers, catheter-associated urinary tract infections, falls and caput trauma, DVTs and pulmonary embolisms are all examples of:
		a. DRGs that should have a POA indicator
		b. Infirmary-acquired conditions that volition not be reimbursed
		c. Role of like weight DRGs
		d. Complications that must be coded to receive full reimbursement
The HAC-POA (Hospital acquired condition, present on access) program was created by the Deficit Reduction Act of 2005--any of these weather which are not present on access and could have reasonably been prevented by following accustomed standards of care will not be reimbursed. Usually, adding the DRG weight would have increased the facility's reimbursement, but this forces hospitals to avoid hospital acquired conditions, rather than profit from them. Wrong answer. Please choose another answer.

17.	Relative Value Units are:
		a. Different for each locality
		b. A weight for process codes
		c. Multiplied with conversion factors
		d. All of the above
RVUs multiplied by conversion factor gives y'all the corporeality payable for a provider's fee schedule. Incorrect answer. Please cull another respond.

xviii.	Medicare pays Skilled Nursing Facilities with a prospective payment organisation. Reimbursement is based on:
		a. Reasonable costs
		b. Per Diem
		c. Based on DRGs
		d. Episode of intendance
The Balanced Upkeep Human activity mandated that SNF-PPS be paid per diem for all costs, which is based on a instance-mix of diagnoses. Incorrect answer. Please cull another answer.

19.	For Medicare'south OPPS, payment status indicator C indicates that the HCPCS is:
		a. More complicated than usual, requiring increased reimbursement
		b. Part of a series of concurrent procedures that volition be performed together
		c. But performed in inpatient settings
		d. Performed by the Master surgeon, requiring increased reimbursement.
Payment condition indicator C indicates that the HCPCS is only performed in an in-patient setting. Wrong answer. Please choose another reply.

Wellness Records and Data Content

20.	CMS requires that the patient's history and concrete be completed and documented in the patient's record
		a. Inside 24 hours of access or not greater than thirty days before admission
		b. Immediately upon admission or not greater than ten days earlier admission
		c. Within 6 hours of admission or not greater than 15 days earlier admission
		d. Within 3 hours of access or not greater than three days before admission
CMS weather of participation require that the patient's history and physical be completed and documented inside the patient's record within 24 hours of access, merely not greater than xxx days prior to admission. Incorrect answer. Delight choose another answer.

21.	These components create a patient's history:
		a. Reason for Visit, History of Nowadays Illness, Review of Symptoms, Prior History
		b. Master Complaint, History of Present Illness, Review of Systems, Past Family and Social History
		c. Chronic weather condition, History of Present Illness, Review of Symptoms, Reason for Visit, Surgical history
		d. Chief Complaint, History of Present Illness, Review of Symptoms, Past Family unit and Social History
CC, HPI, ROS and PFSH are the components of a patient history. ROS is performed to make certain the provider did not miss any relevant complaints and can be pulled from the HPI if needed. Incorrect answer. Please choose some other answer.

22.	Co-ordinate to CMS, the provider'south final hallmark of the patient's wellness record must NOT be past:
		a. Condom postage stamp
		b. Electronic signature verified by biometrics
		c. Electronic signature verified by passcodes
		d. Ink signatures in black ink
Condom stamps were prohibited past CMS in 2015 for provider hallmark Incorrect answer. Please choose another answer.

23.	An open-record review is when:
		a. The patient's record, with PHI removed, is presented at a clinical documentation comeback session for providers
		b. The patient'south record is sent to CMS to be audited
		c. When a qualitative assay of the patient'due south record is done while the patient is in active handling
		d. When the patient is given a copy of their chart to ensure everything was documented accurately to the best of their noesis
An open-record review takes place when a qualitative analysis of the patient'southward tape is done while the patient is in active treatment. The Joint Commission requires these reviews to ensure that documentation standards are met while the patient is still nether care. Incorrect respond. Please choose another reply.

24.	Which of the following is NOT a component of Personal Health Information
		a. URL
		b. Zip Code
		c. License plate number
		d. All of the in a higher place are PHI elements
There are xviii unique identifiers protected by HIPAA. Simply the kickoff 3 digits of a patient'due south nada code is not PHI, equally long equally there are more than than 20,000 people in the group that forms all null codes. East.thou. 123XX+123XY+123XZ accept more than 20,000 people. Otherwise the zip code must be inverse to 00000. Wrong respond. Please choose another answer.

Information Technologies

25.	What is the difference between an EHR and an EMR?
		a. EHRs contain financial information while EMRs merely comprise clinical information.
		b. EHRs are able to communicate with other systems, merely EMRs are non.
		c. EHRs incorporate images, while EMRs only independent electronic "paper" chart formats.
		d. At that place is no departure betwixt EHRs and EMRs. It's just a terminology difference.
EHRs are defined by NAHIT every bit able to communicate and substitution information with multiple systems. EMRs do not have this chapters. Incorrect answer. Please choose another answer.

26.	Which of the following standards are used to create standardized classification within an electronic wellness record plan?
		a. ICD-10 CM
		b. Zip PC
		c. CTNS EHR
		d. SNOMED CT
Systemized Nomenclature of Medicine--Clinical Terminology (SNOMED CT) is the global standard for clinicians and is used to define terms in EHRs effectually the world. Incorrect answer. Please choose another answer.

27.	Implemented in 2012, what standard changed the manner that PHI was submitted electronically?
		a. ASC X12 5010
		b. HL7 4010
		c. SDLC 6040
		d. HIPAA 2020
Under Administrative Simplification, HIPAA standard 5010, using ASC X12, was created and implemented. HIPAA standard 4010 was no longer accepted every bit of June 30, 2012 Incorrect answer. Please cull some other answer.

Compliance

28.	Y'all piece of work at a billing company, coding charts for clients. Your manager sends out claims that have non been coded professionally because your squad is two months behind and out of compliance with your service line agreement in the contract with your client, but says that it is okay because the provider has coded the claims at the fourth dimension of service and the customer does not want to pay for extra coding. Which of the post-obit statements is true?
		a. This is fine because the provider coded the claim to the best of their ability and therefore cannot be held liable.
		b. Billing companies have liability for fraudulent claims that they submit, including undercoding, and so this is not acceptable.
		c. Simply overcoding is fraudulent, so this is acceptable.
		d. The providers mostly under-lawmaking their services, then it'due south really saving the insurance coin and saving u.s. piece of work!
The OIG states that billing companies who submit fraudulent claims (as well every bit the person who submitted them!) are just equally responsible as the provider who rendered the services. Both undercoding and overcoding are examples of fraudulent claims, the claim submitted must accurately represent the services rendered. Incorrect reply. Please choose another answer.

29.	Which of the following are considered fraudulent:
		a. Employ of modifier -59 to study a distinct and separate service that would otherwise be prohibited by NCCI guidelines.
		b. Irresolute the lawmaking on a claim because the provider did non run into documentation standards.
		c. Employ of modifier -25 on a minor evaluation and management service that is coded with a related procedure.
		d. All of the above are acceptable practices.
Procedures include a pocket-size evaluation and management service. If the patient complains of an abscess and a I&D is performed, only the process should be reported. If the patient comes in lament of hypertension and an abscess is discovered, then it would be adequate to study an evaluation and management service. Incorrect answer. Please choose some other reply.

thirty.	Which of the following is an example of a compliant query to a physician:
		a. 06/thirty: Dr. Brown, can you add documentation for the procedure you did on for Mrs. Parks 5/22? We've billed information technology out but I'grand worried that there isn't enough documentation to support it. Nosotros know you did the procedure, but but need a little something actress!
		b. 6/thirty: Dr. Brown, can you lot clarify in the patient'due south chart Mrs. Cramb's diagnosis for 6/27 given the positive rapid strep test that was uploaded?
		c. 6/thirty Dr. Pepper, tin can y'all add acute sinusitis (if that'due south what he had!) to Mr. Meltzer's tape--all we have is nasal congestion, headache and malaise and I see you prescribed him antibiotics. Cheers!
		d. 6/thirty Dr. Pepper, I run into that you gave Mr. Evans a diagnosis of unspecified loss of kidney function, just we would become paid a bit more if information technology were Chronic Kidney Disease, would that be an appropriate diagnosis to code for this patient?
Medico queries must exist non-leading, not based on reimbursement, for the purpose of improving patient care and open up-concluded, or Yeah/No questions. Providers must not add documentation solely for the purpose of being reimbursed and it must be inside a reasonable time frame. Incorrect answer. Delight choose another answer.

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Source: https://www.tests.com/practice/Medical-Coding-Practice-Test

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