Deck 6: Nomenclatures and Classification Systems

Question 1

The classification system ICD, is an outdated code that is infrequently used in modern times.

Answer 1

False

Question 2

The goal of the Unified Medical Language System is to enable computer systems to understand medical meaning.

Answer 2

True

Question 3

The CPT System Medical services and procedures are represented by a four-digit code.

Answer 3

False

Question 4

There are numerous classification systems to address different specialty areas.

Question 5

The ICD-9-CM system is composed of three volumes.

Question 6

Groupers are software tools that incorporate the text and logic of coding systems into an automated form.

Question 7

DRGs have been severely criticized, so Medicare has been withdrawing their application and investigating other options to replace this system.

Question 8

The role of coders in health care will stay essentially the same with the continued development of automated systems.

Question 9

The MDC (major diagnostic category) has 25 mutually exclusive categories with no more than 10 diagnosis-related groups in each category.

Question 10

The DSM-IV was developed for facilities for the mentally retarded or developmentally disabled.

Question 11

Encoders are software programs that use branching logic to arrive at the most accurate DRG.

Question 12

Case Mix Management is an organization that analyzes the patient case mix as it relates to reimbursement and the organization's financial health.

Question 13

As new nomenclatures are implemented, the older versions are converted. It is only needed to know the current ones in usage.

Question 14

Cost of and utilization of services are among the most significant areas to review in case mix analysis.

Question 15

The language of medicine forms the basis for the understanding and management of health information.

Question 16

The complexity of today's health care systems has increased the need for a common understanding of medical language and uniform standards of classifying data.

Question 17

Clinical Vocabulary is a vocabulary that specializes in words or phrases of a clinical or medical nature.

Question 18

Three key components are evaluated for E/M coding; history, examination, and medical decision making.

Question 19

Access to the Unified Medical Language System's three (3) Knowledge Sources is fairly expensive, but most health care organizations find the information invaluable and well worth the cost.

Question 20

Each DRG represents the average resources needed to treat patients found in the DRG.

Question 21

SNOMED is a nomenclature developed and published by the American College of Surgeons.

Question 22

With some modifications required due to the prevalence of chronic diseases, ICD began to be used in American hospitals during the 1950s and 1960s.

Question 23

Health care facilities use CPT for outpatient surgery and ancillary department reporting.

Question 24

Evaluation refers to the assessment of information to reach a specific conclusion such as the process of obtaining a medical history and examination.

Question 25

Which of the following coding schemes are most commonly used in the United States today?

A) ICD-9-CM and CPT
B) SNOP and ABC
C) SNDO and SNOMED
D) All of the above

Question 26

Which of the following is an example of a comprehensive nomenclature that crosses lines of specialization?

A) SNDO
B) SNOP
C) SNOMED

Question 27

The Metathesaurus can be used in which of the following applications?

A) automated indexing research
B) natural language processing
C) information retrieval from databases
D) linking patient records to related information in bibliographic, full-text, or factual databases
E) all of the above

Question 28

Grouping into DRG is based on

A) ICD-9-CM codes.
B) CPT-4 codes.
C) both a and b
D) medical partitioning.

Question 29

When a provider collects information for assessment, such as during a history and physical, which of the following would best describe this process?

A) management
B) evaluation
C) classification
D) planning

Question 30

Diagnosis-related groups are formed using a logical decision tree model. What is the first level of the tree?

A) MDS
B) MDC
C) RUG

Question 31

Coding is best described as which of the following?

A) It is the process by which a numeric code listed in a classification system is assigned to data found in the health record.
B) It is the process by which an alphanumeric code listed in a classification system is assigned to data found in the health record.
C) Both a and b
D) None of the above

Question 32

Health care facilities are reimbursed by DRGs on a ____ basis.

A) fee-for-service
B) flat-rate
C) proportional
D) annual

Question 33

In what year did the United States Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA)?

A) 1980
B) 1982
C) 1989
D) 1990

Question 34

The diagnosis-related group (DRG) model was developed by Yale University.

Question 35

Which of the following is(are) central to creating a standardized medical care process?

A) medical vocabularies
B) clinical terminologies
C) classification systems
D) all of the above

Question 36

If the coder wishes to acquire a code from the ICD-9-CM for a patient who had an operation of the digestive system, which volume would this be found in?

A) Volume 1
B) Volume 2
C) Volume 3
D) Volume 4
E) Volume 5

Question 37

The manner in which clinical data is presented using classification systems, clinical vocabularies, other forms of data, and standards is called

A) data mapping
B) clinical data representation
C) encoding
D) case mix

Question 38

What is the process of linking terminology between two different schemes, a target and a source, for a given purpose called

A) data mapping
B) clinical data representation
C) encoding
D) case mix

Question 39

An example of a model that is a classification system which groups patients who are medically related by diagnosis, treatment, length of stay, age, and sex would be

A) PPS
B) CPT
C) DRG
D) MDC

Question 40

Which of the following are nomenclatures that lend themselves to automated use?

A) SNDO and SNOP
B) SNOD and SNOMED
C) SNOMED and CPT
D) SNOP and CPT

Question 41

The DRGs do not address key areas such as severity of illness, prognosis, treatment difficulty, etc., and this has put more emphasis on the facility to analyze the type and volume of patients in their organization. This analysis as it relates to reimbursement and the organization's financial health is called ____________________ ____________________ ____________________.

Question 42

Deliberate miscoding of diagnoses and procedures can be

A) easily done.
B) permissible in certain circumstances.
C) considered fraud and abuse.

Question 43

How many chapter titles are in the tabular for Volume 1 of the ICD-9-CM coding book?

A) 15
B) 16
C) 17
D) 21

Question 44

The International Classification of Diseases for Oncology, third edition (ICD-O-3), is a classification system that used a(n) ______________ digit code.

A) 4
B) 7
C) 10
D) 11

Question 45

Match the word with the best description.
a recognized system of preferred clinical or medical terminology

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology

Question 46

When using the CPT system, the coder should evaluate the following three components: ____________________, ____________________, and ______________________________.

Question 47

Another name for a classification system is ____________________.

Question 48

The ICD-9-CM has ____________________ volumes.

Question 49

The ICD-9-CM system is composed of three volumes, volume 1 contains

A) the alphabetical listing of diagnoses.
B) a tabular numerical listing of diagnosis codes.
C) both the tabular and alphabetical listings of procedures that are primarily used in a hospital setting.

Question 50

An example of a nomenclature used in ambulatory care settings that also serves a dual purpose as a classification system is ____________________ ____________________ ____________________.

Question 51

Match the word with the best description.
a vocabulary that specializes in words or phrases of a clinical or medical nature

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology

Question 52

To code diagnoses, the coder will use which volume or volumes?

A) Volume 1
B) Volume 2
C) Volume 1 and 2
D) Volume 3

Question 53

What is the term for a chosen set of words, usually arranged in alphabetical order, that are understood and accepted by a community.

A) Vocabulary
B) Clinical vocabulary
C) Clinical terminology
D) Medical language

Question 54

ICD-10 will be implemented in what year?

A) 2013
B) 2014
C) 2015
D) Never

Question 55

Match the word with the best description.
words based on the personal names of people

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology

Question 56

Match the word with the best description.
the words, their pronunciation, and the methods of combining them that has been established by long usage and understood by the medical profession

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology

Question 57

What is the term for software tools that incorporate the text and logic of coding systems in an automated form?

A) Grouper
B) DRG
C) Case mix
D) Encoder

Question 58

What is the level of exams when selecting an E/M code?

A) History, examination, and medical decision making
B) Problem-focused, expanded problem-focused, detailed, or comprehensive
C) History, detailed, comprehensive
D) Problem-focused, expanded problem-focused, and detailed

Question 59

How many chapter titles are in the tabular for Volume 3 of the ICD-9-CM coding book?

A) 15
B) 16
C) 17
D) 21

Question 60

An example of a database that can be used by researchers to retrieve and integrate electronic biomedical information is ____________________.

Question 61

How do vocabularies and classifications systems vary?

Question 62

What is Case mix?

Question 63

List three areas of knowledge or skills which would be seen in a good coder.

Question 64

Match the term with its description.
ensures the establishment of effective internal controls that detect, correct, and prevent coding errors and promote adherence to the applicable local, state, and federal laws and regulations and the program requirements of federal, state, and private health plans

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 65

Match the term with its description.
software programs that use branching logic to arrive at the most accurate DRG

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 66

Match the term with its description.
the efforts to establish a culture that promotes prevention, detection, and resolution of instances of conduct that do not conform to applicable local, state, and federal laws and regulations

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 67

Match the word with the best description.
also referred to as terminology

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology

Question 68

Match the term with its description.
practice of selecting a code and submitting a bill for a higher level of reimbursement than actually rendered in order to receive a higher reimbursement

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 69

Match the term with its description.
false misrepresentation or intentional deception of fact that is a departure from reasonable use and could result in unauthorized payment

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 70

Match the term with its description.
automated programs that seek the highest paying DRG based on the codes assigned and in compliance with prevailing regulations

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 71

Match the term with its description.
software tools that incorporate the text and logic of coding systems in an automated form

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 72

Match the term with its description.
persons who are responsible for the development, maintenance, and management of vocabularies and classification systems

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 73

When using the ICD-9-CM, briefly describe how each of the volumes differ. Also briefly define what E-codes and V-codes are and if they are primary or secondary codes.

Question 74

The Unified Medical Language System project has resulted in a set of three Knowledge Sources. Name and describe one of them.

Question 75

Match the term with its description.
software programs that can read and interpret digital text from online documents and automatically assign appropriate codes

A)nosologists
B)encoders
C)groupers
D)optimizing programs
E)natural language processing encoding systems
F)upcoding
G)coding compliance program
H)health care fraud and abuse
I)compliance

Question 76

Match the word with the best description.
a chosen set of words, usually arranged in alphabetical order, understood and accepted by a community

A)medical language
B)eponyms
C)vocabulary
D)clinical vocabulary
E)nomenclature
F)clinical terminology