Question 1

TO gather statistics for surgical services provided on an outpatient basis, which of the following codes are needed?

Accepted Answer

CPT codes are needed to gather statistics for surgical services provided on an outpatient basis. ICD-9-CM codes are used for diagnostic purposes, Evaluation and Management codes are used for office visits, and HCPCS Level II codes are used for supplies, equipment, and some services not covered by CPT codes.

Question 2

Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?

Accepted Answer

ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) is used for coding and classifying diagnoses and procedures, enabling hospitals to collect detailed information for various purposes including patient care and reimbursement.

Question 3

The best place to ascertain the size of an excised lesion for accurate CPT coding is the

Accepted Answer

The operative report will contain detailed information about the procedure including the size and location of the excised lesion, which is necessary for accurate CPT coding. The pathology report may provide information about the nature of the lesion, but not necessarily its size. The anesthesia record is not relevant to determining the size of the lesion. The discharge summary may provide a summary of the procedure, but may not include detailed information about the size of the lesion.

Question 4

The abstract completed on the patients in your hospital contains the following items: patient demographics; pre-hospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses this data for its

Accepted Answer

The answer of The abstract completed on the patients in...

Question 5

The information collected for your registry includes patient demographic information, diagnosis codes, functional status, and histocompatibility information. This type of registry is a

Accepted Answer

The type of registry described, which includes patient demographic information, diagnosis codes, functional status, and histocompatibility information, is a transplant registry. This type of registry is used to monitor transplantation outcomes and maintain a record of patients who have undergone organ or tissue transplantation.

Question 6

The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the

Accepted Answer

The accession register contains a list of all patients entered into the cancer registry along with their identifying information, including date of entry. Therefore, it would be the best choice for obtaining the requested information. The disease index, tickler file, and suspense file do not necessarily contain information specific to cancer registry patients.

Question 7

In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to

Accepted Answer

Reliability refers to the consistency and reproducibility of coding results, which is determined by the degree of agreement between different coders or repeated coding by the same coder. In other words, if different coders or the same coder on multiple attempts achieve the same codes, the coding has high reliability.  Validity, completeness, and timeliness are not related to coding consistency.

Question 8

Case definition is important of all types of registries. Age will certainly be an important criterion for accessing a case in a(n) ____________ registry.

Accepted Answer

Age is a critical factor in birth defects registries because these registries focus on conditions present at birth, making age a key criterion for case assessment.

Question 9

In the ICD-9-CM classification system, severe shock due to third-degree burns sustained in an industrial accident would be coded as a(n)

Accepted Answer

Severe shock due to third-degree burns sustained in an industrial accident would be coded as a current injury in ICD-9-CM.

Question 10

The reference date for a cancer registry is

Accepted Answer

The reference date for a cancer registry is the date when data collection began. This is important in order to accurately track the incidence and prevalence of cancer cases over time.

Question 11

CPT provides Level I modifiers to explain all of the following situations EXCEPT

Accepted Answer

Level I modifiers are used to provide additional information about a service or procedure, such as reductions, postoperative services by a different surgeon, or repeated tests. Follow-up care after surgery is typically part of the global surgical package and does not require a Level I modifier.

Question 12

The Health care Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the

Accepted Answer

The Health care Cost and Utilization Project (HCUP) is an initiative of the Agency for Health care Research and Quality (AHRQ) which maintains a set of databases that include data on inpatients whose care is paid for by third-party payers.

Question 13

When coding free skin grafts, which of the following is NOT an essential item of data needed for accurate coding?

Accepted Answer

The answer of When coding free skin grafts, which of...

Question 14

In regards to quality of coding, the degree tow which the codes selected accurately reflect the diagnoses and procedures refers to

Accepted Answer

Validity refers to the degree to which the coding accurately reflects the diagnoses and procedures documented in the patient's record. Reliability refers to the consistency of the coding from one coder to another. Completeness refers to the inclusion of all necessary codes, and timeliness refers to the promptness of coding after the patient's encounter.

Question 15

The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with

Accepted Answer

Failure to code all possible diagnoses and procedures means that the coding is incomplete.

Question 16

In CPT, Category III codes include codes

Accepted Answer

Category III codes are used to describe emerging technologies or services that do not have a Category I code yet. These codes are temporary and are used for data collection and tracking purposes.

Question 17

Which of the following contains a list of coding edits developed by CMS in an effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services?

Accepted Answer

The National Correct Coding Initiative (NCCI) is a list of coding edits developed by CMS in an effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services. The other options listed do not specifically address coding edits or bundling/unbundling issues. The National Coverage Determination (NCD) refers to decisions made by CMS on whether to cover specific medical services or items. CPT Assistant provides clarifications and updates on the use of Current Procedural Terminology (CPT) codes, but does not include coding edits. The Health care Common Procedure Coding System (HCPCS) is a coding system used to identify items and services provided in health care, but does not specifically address coding edits or bundling issues.

Question 18

In relation to birth defects registries, active surveillance systems

Accepted Answer

Active surveillance systems use trained staff to actively identify and collect information on cases, rather than relying on passive reporting from hospitals and clinics. This involves reviewing patient records, indexes, vital records, and hospital logs to ensure complete case ascertainment. This method is considered more effective than passive reporting, as it reduces the likelihood of missing cases. However, it is also more resource intensive and therefore less commonly used in all 50 states.

Question 19

In the ICD-9-CM classification systems, shooting pain in the right eye due to the presence of an intact, correctly positioned permanent contact lens would be coded as a(n)

Accepted Answer

The answer of In the ICD-9-CM classification systems, shooting pain...

Question 20

According to the American Medical Association, medical decision making is measured by all of the following except

Accepted Answer

The specialty of the treating physician is not a factor in measuring medical decision making according to the American Medical Association. Instead, it is measured by the number of diagnoses or management options, amount and complexity of data reviewed, and risk of complications.

Exam 1: Registered Health Information Administrator