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Each month the staff of the clinic with the lowest overall waiting time is awarded a free dessert in the Gulfside healthcare center cafeteria. take a look at the information listed above. the winner will be selected based on a. demonstrative clinical data b. comparative aggregate data c. objective individual data d. duplicate thematic data b. comparative aggregate data a union campaign is being conducted at your facility. as a department manager, it is appropriate for you to tell employees that a. a strike is inevitable if the union wins b. wages will increase if the union is defeated c. you need the names of those involved in union activities d. you are opposed to the union d. you are opposed to the union as the coding supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. you will need to develop a professional relationship with a. the OIG b. MEDPAR representatives c. QIO physicians d. recovery audit contractors d. recovery audit contractors employing the SOAP style of progress notes, choose the "assessment" statement from the following a. patient states low back pain with sciatica is as severe as it was on admission b. patient moving about very cautiously appears to be in pain c. adjust pain medication; begin physical therapy tomorrow. d. sciatica unimproved with hot pack therapy d. sciatica unimproved with hot pack therapy in preparation for an EHR, you are conducting a total facility inventory of all forms currently used. you must name each for for bar coding and indexing. the unnamed document in front of you includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. the document type you give to this form is. a. prenatal record
b. labor record c. delivery room record d. postpartum record d. postpartum record. based on the MS-DRG report above, what is the case-mix index for this facility? a. 0. b. 2. c. 11. d. 57 b. 2. the special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the a. interdisciplinary patient care plan b. medical history and review of systems c. interval summary d. problem list a. interdisciplinary patient care plan Four patients were discharged from crestview hospital yesterday. a final progress note is an appropriate discharge summary for a. howard, who died within 24 hours after his admission for a second heart attack in 2 weeks. b. jackson, who had no comorbidities or complications during this admission for replacement of a pacemaker battery c. fieldstone, who was admitted just 15 days following a heart attack for the acute onset of chest pain. d. babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. d. babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. 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. MMBC receives the best reimbursement for well child visits from a. lifecare b. getwell c. surehealth d. behealthy b. getwell 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.
the patient record c. generally maintained in a facility's electronic mail system until the next face-to-face patient encounter d. not typically maintained or documented as patient encounters. a. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters the proposed national healthcare information network (NHIN) dimensions are graphically depicted in the diagram above. roman numeral are added to allow for the identification of specific areas. where would information concerning a patient's health insurance be located on this chart? a. I b. II c. III d. V b. II The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. the first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. for this information you will consult the a. policy and procedure manual b. hospital's quality management plan. c. data dictionary d. hospital bylaws, rules, and regulations d. hospital bylaws, rule, and regulations. Parker has type 1 diabetes with hypertension taht 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 decision about sequencing the codes for this case, the coder should rely on definitions found in the a. UHDDS b. coding clinic c. CMS coding guidelines d. federal register a. UHDDS Parker has type 1 diabetes with hypertension taht 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 a. complications of hypertension b. comorbidity of the wound infection c. comorbidity of type 1 diabets d. acute appendicitis d. acute appendicitis Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Bake (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's
aftercare to his daughter. Dr. Reed should document discharge instructions a. in the discharge summary b. on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record. c. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record. d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record. d. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record The physician has documented the final diagnoses as acute myocardial infaraction, COPD, CHF, hypertension, atrial fibrillation, and status-post cholecystectomy. The following conditions should be reported: I10 Essential Hypertension, benign I10 Essential Hypertension, unspecified I11 Hypertension, heart disease, unspecified as to malignant or benign, with heart failure I21.3 Acute Myocardial infarction, unspecified site, initial episode of care I48.91 Atrial Fibrilation I50.9 Congestive Heart Failure, unspecified J44.9 Chronic Obstructive Pulmonary Disease Z90.89 Acquire absence of gallbladder a. I21.3, J44.9, I21.3, I48.91, Z90. b. I11, J44.9, I50.9, I10, I48. c. I11, J44.9, I50.9, I10, I48.91, Z90. d. I11, J44.9, I50.9, I10, I48. B. I11, J44.9, I50.9, I10, I48. Mary is 6 weeks postmastectomy for carcinoma of the breast. she is admitted for chemotherapy. What is the correct sequencing of the codes C50.911 Malignant Neoplasm of the Breast Z85.3 Personal History of malignant neople of breast Z51.11 Encounter for antineoplastic chemotherapy Z08 Follow-up exam after surgery a. Z51.11, C50. b. Z51.11, Z85. c. Z08, Z51. d. Z85. A. Z51.11, C50. Which of the following is coded as an adverse effect in ICD- 9 - CM? a. tinnitus due to allergic reaction after administration of ear drops b. mental retardation due to intracranial abscess c. rejection of transplanted kidney d. nonfunctioning pacemaker due to defective soldering a. tinnitus due to allergice reaction after administration of ear drops which of the following scenarios identifies a pathologic fracture? a. greenstick fracture secondary to fall from bed
c. bryan d. matthew c. bryan Patient is admitted for elective cholecystectomy for treatment of chronic cholecystititis with cholelithiasis. prior to administration of general anesthesia, patient suffers cerebral thrombosis. surgery is subsequently canceled. code and sequence the coding from the following codes. I66.9 cerebral thrombosis without cerebral infarction K80.10 chronic cholecystitis with cholelithiasis Z53.09 Iatrogenic cerebrovascular infarction or hemorrhage OFT40ZZ Cholecystectomy, total a. I97.821, K80.10, OFT4OZZ b. K80.10, I66.9, Z53. C. I97.821, I66.9, Z53. d. I66.9, Z53. b. K80.10, I66.9, Z53. The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. the coder would assign. a. a code for myocardial infarction b. a code for the patient's symptoms c. a code for an impending myocardial infarction d. no code for this condition a. a code for myocardial infarction. staging a. refers to the monitoring of incidence and trends associated with a disease b. is continued medical surveillance of a case c. is a system for documenting the extent or spread of cancer d. designated the degree of differentiation of cells c. is a system for documenting the extent or spread of cancer which of these conditions are always considered "present on admission" (POA)? a. congenital conditions b. E codes c. acute conditions d. possible, probable, or suspected conditions a. congenital conditions 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? a. the patient b. a court-appointed guardian on behalf of the patient c. the custodial parent of the patient d. the patient's doctor on behalf of the patient a. the patient a patient is admitted through the emergency department. three days after admission, the physician documents uncontrolled diabetes mellitus. what is the "present on
admission" (POA) indicator for uncontrolled diabetes mellitus? a. "Y" b. "U" c. "W" d. "N" D. "N" The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. 34203 embolectomy or thrombectomy, with or without catheter; popliteal-tibioperoneal 35226 repair blood vessel, direct; lower extremity 35302 thromboendarterectomy, including patch graft if performed; superficial femoral artery 37799 unlisted procedure, vascular surgery a. 34203 b. 37799 c. 35302 d. 35226 a. 34203 Patient was seen for excision of two interdigital neuromas from the left foot 28080 excision, interdigital(morton) neuroma, single, each 64774 excision of neuroma; cutaneous nerve, surgically identifiable 64776 excision of neuroma; digital nerve, one or both, same digit a. 64774 b. 64776 c. 28080 d. 28080, 28080 d. 28080, 28080 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 12002 simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities(including hands and feet); 2.6-7.5cm 12004 simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6-12.5 cm 12035 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet) 12.6-20.0cm 12045 Layer closure of wounds of neck, hands, feet and/or external genitalia; 12- 6 - 20. cm a. 12045 b. 12035 c. 12002, 12004 d. 12004 b. 12035 Office visit for 43-year old male, new patient, with no complications. patient is applying for life insurance and requests a physical examination. a detailed health and family history was obtained and a basic physical was done. physician completed life insurance physical form at patient's request. blood and urine were collected
use 99211 - office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. usually, the presenting problems are minimal. typically 5 minutes are spent performing or supervising procedure a. 90721 b. 90720, 90471 c. 90700, 90748, 99211 d. 90471, 90721 d. 90471, 90721 a patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist 77236 - therapeutic radiology treatment planning; complex 77290 - therapeutic radiology simulation-aided field setting; complex 77315 - teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77334 - treatment devices, design and construction; complex(irregular blocks, special shields, compensators, wedges, molds or casts) a. 77315 b. 77263 c. 77290 d. 7734 b. 77263 a 4-year-old had a repair of an incarcerated inguinal hernia. this is the first time this child had been treated for this condition 49496 - repair initial inguinal hernia full-term infant, under age 6 months, or preterm infant over 50 weeks' post 49501 - repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or strangulated 49521 - repair recurrent inguinal hernia, any age; incarcerated or strangulated 49553 - repair initial femoral hernia, any age; incarcerated or strangulated a. 49553 b. 49496 c. 49521 d. 49501 d. 49501 a quantitative drug assay was performed for a patient to determine digoxin level 80050 - general health panel 80101 - drug screen, qualtitative; single drug class method (e.g. immunoassay, enzyme assay), each drug class 80162 - digoxin (therapeutic drug assay, quantitative examination) 80166 - doxepin (therapeutic drug assay, quantitative examination) a. 80101 b. 80050
c. 80166 d. 80162 d. 80162 provide the CPT code for anesthesia servcies for the transvenous insertion of a pacemaker 00530 - anesthesia for permanent transvenous pacemaker insertion 00560 - anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 33202 - insertion of epicardial electrodes; open incision 33206 - insertion or replacement of permanent pacemaker with transvenous electrodes; atrial a. 00560 b. 33202, 00530 c. 00530 d. 33206, 00560 c. 00530 the transiptionists have collected data on the number and types of problems with the dictation equipment. the best tool to display the data they collected is a a. flowchart b. pareto chart c. gantt chart d. pert chart b. pareto chart based on the information below, what was the net death rate at Seaside Hospital in January? Admission- 280 discharged to home- 212 discharge transfers- 28 death less than 48 hours- 8 death greater than 48 hours- 6 a. 2.4% b. 2.8% c. 3.8% d.5.8% a. 2.4% the formula used to calculate the percentage of ambulatory care visits made with same day appointments is a. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen with addvance appointments for the same period b. number of patients seen with advance appointments for a period x 100 divided by the number of patients seen with the same day appointments for the same period c. number of patients seen with same day appointments for a period x 100 divided by the number of patients seen in the same period d. number of patients seen with advance apointments for a period x 100 divided by the number of patients seen in the same period
b. 46 days c. 47 days d, 48 days c. 47 days release of information has increased its used of part-time prn clerical support in order to respond to increased requests for release of information. the budget variance report will reflect a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area b. the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support c. both the increases in revenue and increased costs for clerical support in ROI d. neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports a. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. you are heading a research study that includes a patient questionnaire. five of the questions will be answered using the following scale: a. stacked bar graph b. pie chart c. frequency table d. frequency polygon c. frequency table your HMO manager has requested a report on the number of patient visits per year for preschool children. which of the age groupings below will you use for your report. a. 0-1 year, 1-2 years, 2-3 years, 3-4 years, 4-5 years b. less than 12 months, 12-24 months, 25-37 months, 38-50 months, 51-63 months. c. greater than 12 months, 12-24 months, 25-37 months, 38-50 months, less than 51 months d. 0-2 years, 3-4 years, 5 years b. less than 12 months, 12-24 months, 25-37 months, 38-50 months, 51-63 months. Collins Family Hospital had a bed count of 150 for the first 6 months of the year. on june 1, it added 15 beds when it opened a new wing. if you are given the average length of stay for the year, can you calculate the annual bed turnover rate? how? a. yes, using the direct method b. yes, using the indirect method. c. yes, using the joint commision method. d. no, there is insufficient data to complete the calculation d. no, there is insufficient data to complete the calculation in a research study that includes a patient questionnaire, five of the questions will be answering using the following scale:
1 - strongly agree 2 - disagree 3 - no opinion 4 - agree 5 - strongly agree the data collected using this scale are called a. cardinal data b. ordinal data c. nominal data d. continuous data b. ordinal data gail smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. according to her sister, gail has had a recent medical history taken at the public health department. the physician on call is grateful that she can access this patient information using the area's a. EDMS system b. CPOE c. expert system d. RHIO d. RHIO the patients family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered a. the best utilization of the hospital's resources. b. an inappropriate use of hospital resources c. a compassionate use of the hospital's resources d. appropriate provided it is limited to a few days b. an inappropriate use of hospital resources the state is considering the closure of the Arcadia Hospital. in reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? a. daily census b. percentage of occupancy c. inpatient service days d. average length of stay b. percentage of occupancy the census taken at midnight on August 1 showed 99 patients remaining in the hospital. on august 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. one of these patients was admitted in the morning and remained only 8 hours. how many inpatient service days were rendered on August 2? a. 94 b. 95 c. 96 d. 97 d. 97
Donaldson wants to use the mean because it is easy to calculate. franklin recommends variance because it is the most preferred and has better interpretive uses. who made the best suggestion a. smithson b. donaldson c. franklin d. howell d. howell sun city repoted 12 cases of chronic heart disease in a population of 8,000 in 2008. in 2011, sun city reported there were still 12 cases of chronic heart disease, but its population had decreased to 6,000. this represents an increase in the a. prevalence of chronic heart disease in sun city b. incidence of chronic heart disease in sun city c. reliability of reporting chronic heart disease in sun city d. occurence of chronic heart disease in sun city. a. prevalence of chronic heart disease in sun city community hospital administration decided to change the number of adult and children beds from 300 to 375 effective July 1. the total number of inpatient services days for adults and children for the year was 111, 963. what was the percentage of occupancy rate for adults and children for the entire year? a. 0.9% b. 45.4% c. 90.8% d. 91.0% c. 90.8% when checking the census data at south beach women's center, you see that just yesterday, there were four sets of triplets, five sets of twins, and eight single births. yesterday, south beach women's center had a. 17 deliveries b. 25 deliveries c. 30 deliveries d. 39 deliveries a. 17 deliveries in preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be a. the average readmission rate for the facility b. the available options for inactive records c. the statute of limitations in your state d. joint commission and AOA standards regarding minimum retention periods. c. the statute of limitations in your state the credentialing committee discovered the problems with dr. hernandez's hip replacements by a. sampling and reviewing dr. henandez's patient records b. reviewing dr. hernandez's physician profile c. querying the national physician data bank d. interviewing the chief of surgery
b. reviewing dr. hernandez's physician profile you are starting your new job as the sole HIM professional at a small psychiatric practice. the practice uses DSM for billing purposes. you find this "theoretically" reasonable because DSM a. is a widely used and accepted classification system b. codes are also valid ICD- 10 - CM codes c. codes are also valid CPT codees d. is the industry standard for physchiatric billing systems b. codes are also valid ICD- 10 - CM codes as the information security office at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. which of the following would you provided. a. audit controls b. entity authentication c. chain-of-trust partner agreements d. workstation use and location d. workstation use and location the MS-DRG weight in a particular case is 2,0671 and the hospital's payment rate is $3,027. how much would the hospital receive as reimbursement in this case? a. $3,027. b. $5,094. c. $6, 257. d. $960. c. $6,257. a patient's husband slipped and fell in your HIM reception are and now he is suing the facility. you have to prepare detailed written answers to a long list of questions and send them to your hospital attorney. you will spend the afternoon working on a. affidavits b. allocutions c. interrogatories d. depostions c. interrogatories use the information on errors in indexing of scanned material that you have collected and presented in the table below to answer the question if you want to begin with the type of material that has the highest error rate, you will start by working on problems with a. consultation reports b. lab slips c. correspondence d. other a. consultation reports
an 11-year old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. her mother was very seriously injured in the same accident and is unconscious. what should be done a. nothing, until consent can be obtained from the nearest relative b. the mother can be treated under implied consent but not the child c. the hospital should quickly seek a court-appointed guardian for the child. d. both patients can be treated under implied consent. d. both patients can be treated under implied consent. a pharmacist at your facility was caught running a drug ring. the pharmacist filed orders of valuable medications with cheap outdated ones purchased on the internet and then sold the good drugs for profit. patients have been injured and the lawsuits are starting. unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of a. adjudicus res b. res ipsa loquitur c. respondeat superior d. stare decisis c. respondeat superior a patient was treated for meningitis at age 3 (15 years ago). the patient is now 18. the patient's attorney is requesting information on the admission. you tell the clerk the information is a. no longer available because your facility retains information for 10 years after the last patient visit b. available, but the attorney will have to obtain a court order before you will release it. c. available, but the patient's parents will have to sign a consent for your to release it d. available, and the patient may sign consent to release the information in the record d. available, and the patient may sign consent to release the information in the record a patient has written to request a copy of his own record. when the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. you advise the clerk to a. comply with the request immediately b. contact the patient's attending physician before complying c. ignore the request and advise you if it is repeated d. aske the patient to send the required fee prior to the release b. contact the patient's attending physician before complying your HIS department receives and authorization for sara may's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. what action is appropriate according to hipaa privacy rules? a. do not honor because the authorization is invalid. b. contact the patient to get permission to respond c. contact the attending physician for permission to respond d. honor the authorization since the patient obviously approves of the release a. do not honor because the authorization is invalid the hospital's strategic plan calls for having the entire health record contact recorded in discrete form within the next 10 years. which system will the HIM director most likely recommend in the early stages of the project as a transition strategy?
a. electronic document management system b. clinical data repository system c. CPOE system d. speech recognition system a. electronic document management system as the information security office at your facility, you have been asked to provide examples of technical security safeguards as a result of HIPAA legislation. which of the following would you provide? a. audit controls b. evidence of security awareness training c. surge protectors d. workstation use and location a. audit controls after your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. the results of your work surprise you because a. you expected the coders to put more emphasis on time pressure b. you thought limited training was the primary reason for the errors c. the rankings show surprising disagreement on the issue d. the results appear to violate the Pareto Principle d. the results appear to violate the Pareto principle joanie howell presents to dr. franklin requesting rhinoplast. because howell is covered by medicare, dr. franklin must provide howell with a. a notice of exclusion, because rhinoplasty is not a medicare covered service b. an advance beneficiary notice, because rhinoplasty is not a medicare covered service c. a notice of exclusion, because howell's rhinoplasty may not be medically necessary. d. an advance beneficiary notice, because howell's rhinoplasty may not be medically necessary d. an advance beneficiary notice because howell's rhinoplasty may not be medically necessary a 19-year-old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the army. the release of information clerk should a. send the records as requested b. inform the young man that specific reports must be identified in his request c. send a letter informing him that faxed requests are not accepted d. deny the request a. send the records as requested a 16-year-old maled was treated at your facility for a closed head injury. the patient's 18- year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. the patient has requested that copies of his medical records be sent to his attorney. who should sign the authorization to release the records? a. the patient b. either of the patient's parents
