Question 1

Parker is a type I diabetic with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the

Accepted Answer

The Uniform Hospital Discharge Data Set (UHDDS) provides guidelines for sequencing diagnoses and procedures, which is essential for coding hospital inpatient stays.

Question 2

A patient is 6 weeks post-mastectomy for carcinoma of the breast. She is admitted for chemotherapy. What is the correct sequencing of the codes?

Accepted Answer

The answer of A patient is 6 weeks post-mastectomy for...

Question 3

Parker is a type I diabetic with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. Parker's principal diagnosis is the

Accepted Answer

The principal diagnosis is the condition that was chiefly responsible for the patient's admission to the hospital. In this case, Parker was admitted for an emergency appendectomy, so the principal diagnosis is acute appendicitis. The other conditions listed (hypertension, type 1 diabetes, wound infection) are co-morbidities that may require additional treatment or management during the patient's hospital stay, but they are not the reason for admission.

Question 4

The enforcement of the HIPAA privacy rule has been delegated to the

Accepted Answer

The enforcement of the HIPAA privacy rule has been delegated to the Office of Civil Rights.

Question 5

Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures.

Accepted Answer

CPT code 12035 is appropriate for the closure of two lacerations on the same body part, regardless of their lengths. Therefore, 12035 is the best code for this scenario. Neither 12045 nor 12002 are appropriate, as 12045 is for complex closure and 12002 requires the use of tissue adhesive or other wound closure supplies while only sutures were used in this case. 12004 is for the closure of a single laceration.

Question 6

Most of the children who are seen at MMBC will have a well child visit and two immunizations. If you factor in the reimbursement for two immunizations with each well child visit, which insurance company benefits MMBC most? Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. Data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below:

Accepted Answer

The answer of Most of the children who are seen...

Question 7

A covered entity:

Accepted Answer

A covered entity, under HIPAA, includes healthcare providers who transmit health information electronically in connection with healthcare transactions.

Question 8

You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The only other information you need is

Accepted Answer

The only other information needed to calculate the fee schedule payment amount for physician services covered under Medicare Part B is a national conversion factor. The national conversion factor is a dollar amount used to determine the payment amount for each RVU.

Question 9

The health information practitioner had two patient records, each with a final diagnosis fracture of the pelvis. Patient A had a single break in the pelvic ring; patient B had severe multiple fractures of the pelvis and a possible pulmonary embolus. Although the principal diagnosis is the same, what method can be used to further recognize the patient who is at a higher risk?

Accepted Answer

The severity of illness system is a method that can be used to further recognize the patient who is at a higher risk. It takes into account the severity of the condition and the complexity of the treatment required, and assigns a score or level of severity. In this case, patient B's severe multiple fractures and possible pulmonary embolus would likely result in a higher severity of illness score than patient A's single break in the pelvic ring. SNDO codes and HCPCS codes are used for coding medical procedures and services, and RUGS is a system used in long-term care for determining reimbursement rates based on patient characteristics and care needs, but they do not provide information on the severity of the patient's condition.

Question 10

The physician has documented the final diagnoses as acute myocardial infarction, COPD, CHF, hypertension, atrial fibrillation and status-post cholecystectomy. The following conditions should he reported

Accepted Answer

The answer of The physician has documented the final diagnoses...

Question 11

In your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. When this occurs, who would be expected to authorize the release of the medical information documented in this episode of care to the patient's insurers?

Accepted Answer

Since minors can seek medical treatment for a sexually transmitted disease without parental consent, they are considered mature enough to make their medical decisions. Therefore, they would also be expected to authorize the release of their medical information to insurers.

Question 12

Nicole is developing an agreement that will be used between the hospital and the health care clearing house. This agreement will require the two parties to protect the privacy of data exchanged. This is called a

Accepted Answer

A business associate agreement is a contract between a covered entity (such as a hospital) and a business associate (such as a health care clearinghouse) that requires the parties to protect the privacy and security of any protected health information that is exchanged. This agreement is required by the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.

Question 13

Which of the following is coded as an adverse effect in ICD-9-CM?

Accepted Answer

Tinnitus due to allergic reaction after administration of ear drops is a coded adverse effect in ICD-9-CM. The other options are complications or sequelae of a procedure or disease, not adverse effects.

Question 14

Sheena is an RHIA who continued her education and has a master's degree in Public Health. She is the Director of Health Information for the large County Health Department. In seeking tit most reliable reference for a job applicant, which of the following would be preferred?

Accepted Answer

The most reliable reference for a job applicant would be a telephone reference from a former supervisor of the applicant. This is because the former supervisor would have firsthand knowledge of the applicant's work performance and abilities. A written reference from the former supervisor would also be acceptable, but a telephone reference allows for more in-depth questioning and clarification. A reference from a personal friend or the Human Resources Department of the applicant's former employer would be less reliable, as they may not have direct knowledge or may have a biased perspective.

Question 15

You have been assigned to code the cases listed below. Which one will you appropriately assign to Category 402, Hypertensive Heart Disease?

Accepted Answer

There is no information available in the given code about the medical conditions of Mallory, Emma, or Trevor. However, Taylor is suspected of having hypertensive heart disease, which is categorized under ICD-10 code Category 402. Therefore, the appropriate choice would be C, Taylor.

Question 16

As HIM Director, you receive a call from the CEO informing you that she has received a complaint from a patient. The patient reports that one of the coders in your department revealed the patient's diagnosis to the patient's neighbor. What action is recommended?

Accepted Answer

It is important to gather all the facts before taking any disciplinary action. The HIM Director should investigate the complaint and talk to both the patient and the coder involved to understand what happened. Then, the HIM Director can determine the appropriate course of action, which may include retraining, coaching, or disciplinary action. Terminating the employee immediately for a first offense may not be the best choice without attempting to understand the situation. Holding a departmental meeting to discuss confidentiality after identifying an issue will help the team understand the importance of patient confidentiality.

Question 17

Valley View Hospital collected the data displayed above concerning their four highest volume MS-DRGs. Which MS-DRG generated the most revenue for the hospital?

Accepted Answer

The answer of Valley View Hospital collected the data displayed...

Question 18

As Chief Privacy Officer, you have been asked why you are conducting a risk assessment. Which reason would you give?

Accepted Answer

Conducting a risk assessment is important for preventing breach of confidentiality. It helps identify potential risks and vulnerabilities in the organization's systems and processes, and allows for proactive measures to be taken to prevent incidents before they occur. The other options, getting rid of problem staff and changing organizational culture, are not directly related to the purpose of a risk assessment for privacy.

Question 19

If the same condition is described as both acute and chronic and separate subentries exist in the ICD-9-CM alphabetic index at the same indentation level

Accepted Answer

In cases where the same condition is described as both acute and chronic and separate subentries exist in the ICD-9-CM alphabetic index at the same indentation level, they should both be coded. The acute condition should be sequenced first.

Question 20

In your new position as Director of Health Information Services, you have noticed that department supervisors arbitrarily allow employees to make up missed time due to absences. You decide that you need a policy to reinforce the attendance policy and cut down on tardiness and absences. Which policy statement would support your overall departmental goals?

Accepted Answer

This policy ensures that any changes in work schedules are planned and approved in advance, aligning with departmental operations and goals, thus reducing arbitrary decisions and promoting accountability.

Exam 1: Registered Health Information Administrator