Deck 9: Coding for the Non-Him Professional

Question 1

All entries in a medical record must be dated and:

A) legible.
B) typewritten.
C) timed.
D) both legible and timed.
E) All of these are correct.

Answer 1

C

Question 2

The requirements for dating and timing do not apply for __________________ that are initiated outside the hospital.

A) orders
B) prescriptions
C) both orders and prescriptions
D) None of these is correct.

Answer 2

C

Question 3

There will be times during or after a patient's hospital stay where a practitioner dictates a report or gives an order and needs to authenticate the document. The use of auto-authentication, in which a practitioner dictates a report or order and wants to authenticate it without _____________________ the document, is not permitted.

A) printing
B) signing
C) reading
D) scanning

Answer 3

C

Question 4

Over the years, records progressed from a completely paper file to a(n) ____________________ containing paper that was scanned into a file combined with electronic images.

A) EMR
B) EHR
C) hybrid medical record
D) paper record

Question 5

The __________ health record is comprised of a problem list, the database or the history and physical exam and initial lab findings, the initial plan of what tests or treatments the patient will receive during their stay, and progress notes that are organized so that every member of the healthcare team can easily follow the course of the patient's treatment.

A) Integrated
B) Source-Oriented
C) Paper
D) Problem-Oriented
E) None of these is correct.

Question 6

The content of the ______________________ is arranged in strict chronological order. The order of the record is determined by the date the information was entered, or the date of the service that gives the sequence of the care that the patient received during their stay.

A) Integrated
B) Source-Oriented
C) Paper
D) Problem-Oriented
E) None of these is correct.

Question 7

The ICD-9-CM book is divided into three volumes; Volume II is a(n):

A) tabular list.
B) alphabetic index.
C) classification for procedures.
D) None of these is correct.

Question 8

The ICD-9-CM book is divided into three volumes; Volume III is a(n):

A) tabular list.
B) alphabetic index.
C) classification for procedures.
D) None of these is correct.

Question 9

ICD-9-CM diagnosis codes vary in length anywhere from __________ digits.

A) two to three
B) three to four
C) three to five
D) four to six

Question 10

The first two digits of the procedure code comprise ______________ of the procedure being performed.

A) the category
B) the resource group
C) the cost center
D) both the category and the cost center

Question 11

The third and fourth digits are _____________________ codes that provide the detailed information on the procedure.

A) subcategory
B) service type
C) subclassification
D) both subcategory and subclassification
E) both subcategory and service type

Question 12

If the coder comes across a situation where the same condition is described in the medical record as being both acute and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, the coder will code both and sequence the acute (subacute) code:

A) first.
B) second.
C) not at all.
D) last.

Question 13

The HCPCS is divided into _____________ principal subsystems.

A) two
B) three
C) four
D) five

Question 14

The _______________ is a uniform coding system comprised of descriptive terms and codes that are primarily used to identify medical services and procedures that are furnished by physicians and other healthcare professionals.

A) ICD-9
B) HIPPS
C) CPT
D) ICD-10

Question 15

Level II of the HCPCS is a standardized coding system that is used primarily to identify ___________________________ not included in the Level I CPT codes.

A) products
B) supplies
C) services
D) All of these are correct.
E) None of these is correct.

Question 16

A(n) ____________________ is a patient that has not received any professional services from the physician, qualified healthcare professional, or another physician or qualified healthcare professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.

A) new patient
B) established patient
C) transfer patient
D) None of these is correct.

Question 17

A(n) _____________________ is one who has received professional services from the physician, qualified healthcare professional, or another physician or qualified healthcare professional of the same specialty and subspecialty who belongs to the same group practice, within the past three years.

A) new patient
B) established patient
C) transfer patient
D) None of these is correct.

Question 18

Which of the following codes is used when a patient is admitted and discharged on the same date of service?

A) Office Visit
B) Hospital Observation and Discharge Planning
C) Hospital Inpatient
D) Office Consultation

Question 19

_____________________ are provided in an organized hospital-based facility for the provision of unscheduled episodic services to patients who are in need of immediate medical attention.

A) Office Visits
B) Emergency Services
C) Hospital Inpatients
D) Office Consultations

Question 20

The medical record must meet the standards defined by the Centers for Medicare and Medicaid Services Conditions of Participation, any other federal regulations, state laws, and accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations.

Question 21

All entries in the medical record must be legible. These entries include written progress notes, nursing notes, physical therapy, occupational therapy, speech therapy, consultations, and other notes that are handwritten in the patient's medical record to support the treatment provided during the visit or stay.

Question 22

To be able to effectively code a medical record for a hospital stay or visit to a facility, the entries must be complete and contain sufficient information to identify the patient; support the diagnosis and condition; justify the care, treatment and services; document the course and results of care, treatment, and services; and promote continuity of care among providers.

Question 23

When the EMR system only puts the date and time that the document was created, but not the date and time when the practitioner viewed it, then the practitioner does not need to authenticate the document or acknowledge that the document was reviewed.

Question 24

Health records are legal business records and must be maintained following federal and state regulations to ensure that the information, if accessed, is accurate and complete.

Question 25

The ICD-9-CM guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-9-CM itself. These guidelines are based on coding sequencing instructions found in the three volumes of the ICD-9-CM, but provide additional instruction.

Question 26

The ICD-10-CM is a morbidity classification published by the United States for classifying diagnoses and reasons for visits in all healthcare settings.

Question 27

The term "encounter" is used for all settings and is a professional, direct personal contact between a patient and a physician or other person who is authorized by state licensure law.

Question 28

The term "Late Effect" is a residual effect or a condition produced, before the acute phase of an illness or injury has terminated.

Question 29

If a patient is admitted to an observation unit in a hospital for a medical condition and either does not improve or the condition worsens and is then admitted to the hospital as an inpatient, the coder will use the principal diagnosis as the condition that led to the actual hospital admission.

Question 30

If a patient receives outpatient surgery and is admitted to the same hospital as an inpatient, the principal diagnosis for the admission will be based on the reason for the inpatient admission.

Question 31

If no complications or other conditions are documented as the reason for the inpatient admission after observation, then the coder does not need to assign the reason for the outpatient surgery as the principal diagnosis.

Question 32

If the reason for inpatient admission after observation is another condition that is unrelated to the surgery, the coder will assign the unrelated condition that caused the admission as the principal diagnosis.

Question 33

The HCPCS system was involuntary in the beginning, however, with the implementation of HIPAA, the use of HCPCS for transactions involving healthcare information became mandatory.

Question 34

Modifiers are two-digit alpha or alphanumeric codes. A modifier is designed to give Medicare and other third-party payers additional information needed to process a claim.

Question 35

The levels of E/M services include examinations, evaluations, and treatments; conferences with or concerning patients; preventive pediatric and adult health supervision; and similar medical services such as the determination of the need and/or location for appropriate care.

Question 36

Hospital observation services are provided to patients who are designated as admitted to an "observation status" in a hospital. It is not necessary that the patient is located in the observation unit or area designated by the hospital. If an observation area is not present in the hospital, then the coder will assign these codes as if the patient was placed in such a unit.