Question 1

The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed

Accepted Answer

Brachytherapy involves placing radioactive sources directly into or near the tumor, allowing for high intensity radiation to be delivered to the area. Stereotactic radiation treatment and proton beam treatment both use external radiation sources, while external beam radiation is a more general term that can refer to any type of radiation therapy delivered from outside the body.

Question 2

ICD-10-CM has two categories for myocardial infarction: I21, Acute myocardial infarction I22, Subsequent acute myocardial infarction.According to the guidelines, a code from I21 is to be used from onset of the acute MI until __________ following onset.

Accepted Answer

The answer of ICD-10-CM has two categories for myocardial infarction:...

Question 3

The Unified Medical Language System (UMLS) is a project sponsored by the

Accepted Answer

The Unified Medical Language System (UMLS) is a project sponsored by the National Library of Medicine.

Question 4

A patient is admitted with shortness of breath and hemoptysis. A chest x-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected. The principal diagnosis is the

Accepted Answer

The bronchoscopy revealed a small cell carcinoma of the lung, which is the principal diagnosis. The metastatic brain lesion is a secondary diagnosis, as it resulted from the primary lung carcinoma. The pneumonia and hemoptysis are likely complications or symptoms of the lung cancer.

Question 5

The "cooperating party" responsible for maintaining the ICD-9-CM disease classification is the

Accepted Answer

The National Center for Health Statistics (NCHS) is responsible for maintaining the ICD-9-CM disease classification. The Centers for Medicare and Medicaid Services (CMS) is responsible for implementing the use of ICD-9-CM codes for billing purposes, but they do not maintain the classification itself. The American Hospital Association (AHA) and the American Health Information Management Association (AHIMA) are professional organizations that may provide input and guidance on the use and implementation of ICD-9-CM, but they are not the primary parties responsible for maintaining the classification.

Question 6

Which classification system was developed to standardize terminology and codes for use in clinical laboratories?

Accepted Answer

LOINC was specifically designed to standardize terminology and codes used in clinical laboratories to identify tests and measurements of clinical significance. SNOMED is a comprehensive clinical terminology system used in health information technology, while SNOP is specifically for pathology. Read Codes, also known as Clinical Terms Version 3 (CTV3), are a terminology system used primarily in the United Kingdom.

Question 7

The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct

Accepted Answer

E-codes and ICD-9-CM codes are used to classify external causes of injury, including the specific activity involved in the injury, such as skateboarding. This information is important for tracking injury trends and prevention efforts.

Question 8

An encoder that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n)

Accepted Answer

A logic-based encoder uses logic to prompt the coder to answer questions about the documentation in the medical record in order to assign the most accurate codes. Automated codebook refers to a pre-determined list of codes that can be searched for manually, and a grouper is used to group related codes together for reimbursement purposes. Automatic code assignment refers to a system where codes are assigned automatically without human intervention, which is not currently possible in medical coding due to the nuances and complexities of medical documentation.

Question 9

In general, all three key components (history, physical examination, and medical decision making) for the E/M codes in CPT should be met or exceeded when

Accepted Answer

According to CPT guidelines, when a new patient is seen in the office, all three key components (history, physical examination, and medical decision making) should be met or exceeded for the appropriate level of E/M code to be assigned.

Question 10

The Health Information Department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction within the past 6 months. Which of the following would be the best source to identify the necessary charts?

Accepted Answer

The disease index lists all patients diagnosed with a certain condition, making it the best choice to identify charts for patients with anterolateral myocardial infarction. The operation index would only provide information on patients who underwent a specific surgical procedure, the consultation index would only provide information on patients who received a consultation from a specific department, and the physician's index would only provide information on patients seen by specific physicians.

Question 11

A direction to "code first underlying disease" should be considered

Accepted Answer

"Code first underlying disease" is a mandatory instruction given in the ICD-10-CM coding guidelines for certain codes that require underlying disease to be coded first. This instruction applies to all settings, not just inpatient records, and is mandatory for correct code assignment.

Question 12

The patient is diagnosed with congestive heart failure. A drug of choice is

Accepted Answer

Digoxin is a medication commonly used to treat congestive heart failure. It helps to improve the heart's ability to pump blood by increasing the strength of its contractions. Ibuprofen is not appropriate as it is a pain reliever and not used for heart failure. Oxytocin is not appropriate as it is a hormone used to induce labor or control postpartum bleeding. Haloperidol is not appropriate as it is an antipsychotic medication used to treat mental health conditions such as schizophrenia and bipolar disorder.

Question 13

A patient was admitted with severe abdominal pain, elevated temperature, and nausea. The physical examination indicated possible cholecystitis. Acute and chronic pancreatitits secondary to alcoholism was recorded on the face sheet as the final diagnosis. The principal diagnosis is

Accepted Answer

The final diagnosis of acute pancreatitis is the principal diagnosis because it is the most serious condition and the reason for the patient's admission. The other conditions may be contributing factors, but the acute pancreatitis is the primary reason for hospitalization.

Question 14

DSMIV-TR is used most frequently in what type of healthcare setting?

Accepted Answer

DSMIV-TR is a widely used manual for diagnosing mental disorders and is primarily used in behavioral health centers. It is not typically used in ambulatory surgery centers, home health agencies, or nursing homes.

Question 15

A coder notes that a patient is taking prescription Pilocarpine.; The final diagnoses on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of

Accepted Answer

Since the patient is taking prescription Pilocarpine, which is a medication commonly used for treating glaucoma, it would be important to query the physician about adding a diagnosis of glaucoma to the final diagnoses. Arthritis, bronchitis, and laryngitis are not related to the patient's medication or other diagnoses listed.

Question 16

According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a

Accepted Answer

The UHDDS defines a significant procedure as one that is surgical in nature, carries a procedural or anesthetic risk, or requires special training. Therefore, choice B, significant procedure, is the best answer. While the other options may relate to certain types of procedures, they do not align with the UHDDS definition of a significant procedure.

Question 17

In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to.

Accepted Answer

The coder should confer with the physician to confirm if the low potassium level was clinically significant and if it needs to be listed as a final diagnosis. It is important to clarify any unclear or missing information with the physician to ensure accurate coding and billing.

Question 18

Which classification system is used to classify neoplasms according to site, morphology, and behavior?

Accepted Answer

The International Classification of Diseases for Oncology (ICD-O) is the classification system used to classify neoplasms according to site, morphology, and behavior. SNOMED is a comprehensive healthcare terminology system, DSM is a classification system for mental disorders, and CPT is a coding system for medical procedures.

Question 19

A disadvantage of adopting SNOMED for diagnosis coding is that it

Accepted Answer

SNOMED is a comprehensive clinical terminology that is complex and detailed, making it challenging to use directly for reimbursement purposes, which typically require simpler coding systems like ICD.

Question 20

One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow- up be continued?

Accepted Answer

Follow-up should be continued for the life of the patient as cancer can recur many years after initial treatment. This allows for monitoring of any potential recurrences, surveillance for any late effects of treatment, and assessment of long-term outcomes.

Exam 1: Registered Health Information Administrator