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Flashcards in Domain 1 Deck (100)
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1
Q

During a retrospective review of Rose Hunter’s inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

  • Utilization Review
  • Quantitative Review
  • Legal Review
  • Qualitative Review
A

Qualitative Review

2
Q

Which of the following is least likely to be identified by a deficiency analysis technician?

• Discrepancy between post up diagnosis by the
surgeon and pathology diagnosis by the
pathologist
• Missing discharge summary
• Need for physician authentication of two verbal
orders
• X-ray report charted on the wrong record

A

Discrepancy between post up diagnosis by the surgeon and pathology diagnosis by the pathologist

3
Q

The Conditions of Participation require that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered consultation?

• tissue examination done by the pathologist
• impressions of a cardiologist asked to determine
whether patient is a good surgical risk
• interpretation of a radiologic study
• technical interpretation of electrocardiogram

A

impressions of a cardiologist asked to determine whether patient is a good surgical risk

4
Q

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding

• The presence or absence of such items as
preoperative and postoperative diagnosis,
description of findings, and specimens removed
• whether a postoperative infection occurred and
how it was treated
• the quality of follow-up care
• whether the severity of illness and/or intensity of
service warranted acute level care

A

The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed

5
Q

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

  • integrated progress notes
  • interdisciplinary treatment plans
  • source-oriented records
  • SOAP notes
A

integrated progress notes

6
Q

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

  • Chronic pain management
  • palliative care
  • brain injury management
  • vocational evaluation
A

palliative care

7
Q

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?

• Written signature of the provider of care
• identifiable initials of a nurse writing a nursing note
• a unique identification code entered by the person
making the report
• delegated use of computer key by radiology
secretary

A

delegated use of computer key by radiology secretary

8
Q

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

  • DEEDS
  • UHDDS
  • MDS
  • ORYX
A

DEEDS

9
Q

As a new HIM manager of an acute care facility, you have been asked to update the facility’s policy for a physicians verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

  • Consolidated Manual for Hospitals
  • Federal Register
  • Policy and Procedure Manual
  • Hospital Bylaws, Rules, and Regulations
A

Hospital Bylaws, Rules, and Regulations

10
Q

Reviewing a medical record to ensure that all diagnosis are justified by documentation throughout the chart is an example of

  • Peer review
  • quantitative review
  • qualitative review
  • legal analysis
A

qualitative review

11
Q

Accreditation by Joint Commission is a voluntary activity for a facility and it is

• considered unnecessary by most health care
facilities
• required for state license in all states
• conducted in each facility annually
• required for reimbursement of certain patient
groups

A

required for reimbursement of certain patient groups

12
Q

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record

  • database
  • problem list
  • initial plan
  • progress notes
A

problem list

13
Q

As a supervisor of the cancer registry, you report the registry’s annual caseload to administration. The most efficient way to retrieve this information would be to use

  • patient abstracts
  • patient index
  • accession register
  • follow-up files
A

accession register

14
Q

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record

• Patient admitted with COPD 1/4/2016 and
discharged 1/7/2016
• Baby Boy Hiltz, born 1/5/2016, maintained normal
status, discharged 1/7/2016
• Baby Boy Hiltz’s mother admitted 1/5/2016, C-
section delivery, and discharged 1/7/2016
• Baby Boy Doe admitted 1/3/2016, died 1/4/2016

A

Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016

15
Q

Based on the following Documentation in an acute care record, where would you expect this excerpt to appear?
“ Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKG’s remained unchanged. Patient will be discharged and followed as an outpatient.”

  • discharge summary
  • physical exam
  • admission note
  • clinical laboratory report
A

discharge summary

16
Q

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking our specific voluntary accreditation standards and guidelines is the

• Conditions of participation for Rehabilitation
Facilities
• Medical Staff Bylaws, Rules, and Regulations
• Joint Commission Manual
• CARF manual

A

CARF manual

17
Q

Which of the following is a secondary data source that would be used to quickly gather the health record of all juvenile patients treated for diabetes within the past 6 months.

  • disease index
  • patient register
  • pediatric census sheet
  • procedure index
A

disease index

18
Q

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

  • The OIG
  • MEDPAR representatives
  • QIO physicians
  • Recovery audit contractors
A

Recovery audit contractors

19
Q

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data

  • timeliness
  • accuracy
  • comprehensiveness
  • security
A

comprehensiveness

20
Q

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represent the most serious pattern of delinquencies? Fifteen percent of delinquent records show

  • missing signatures on progress notes
  • missing discharge summaries
  • absence of SOAP format in progress notes
  • missing operative reports
A

missing operative reports

21
Q

A primary focus of screen format design in a health record computer application should be to ensure that

• programmers develop standard screen formats for
all hospitals
• the user is capturing essential data elements
• paper forms are easily converted to computer forms
• data fields can be randomly accessed

A

the user is capturing essential data elements

22
Q

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captures on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

  • reliability
  • accessibility
  • legibility
  • completeness
A

reliability

23
Q

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

• written within 24 hours of the patient’s admission
• accepted by charge nurse only
• cosigned by the attending physician within 4 hours
of giving the order
• recorded by persons authorized by hospital
regulations and procedures

A

recorded by persons authorized by hospital regulations and procedures

24
Q

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

• documented in an incident report and filed in the
patient’s health record
• reported as a potentially compesable event
• reported to the Executive Committee
• documented in both the progress notes and the
discharge summary

A

documented in both the progress notes and the discharge summary

25
Q

Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely ch3eck to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and re-certify the patient as appropriate. The time frame for requiring this summary is at least every

  • week
  • month
  • 60 days
  • 90 days
A

60 days

26
Q

You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be

  • medical staff bylaws
  • quality management plan
  • Joint Commission accreditation manual
  • medical staff rules and regulations
A

medical staff rules and regulations

27
Q

A quarterly review reveals the following data for Spring field Hospital:
Springfield Hospital Quarterly Statistics

Average monthly discharges 1,820
Average monthly operative procedures 458
Number of incomplete records 1,002
Number of delinquent records 590

What is the percentage of incomplete records during this quarter?

  • 55%
  • 54%
  • 33%
  • 32%
A

55%

28
Q

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital

  • 55%
  • 32%
  • 33%
  • 54%
A

32%

29
Q

Still referring to the information in the table related to Springfield Hospital, would the facility be out of compliance with Joint Commission standards?

  • Yes
  • No
A

No

30
Q

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the

  • Information security manager
  • clinical data specialist
  • health information manager
  • risk manager
A

health information manager

31
Q

For inpatients, the first data item collected of a clinical nature is usually

  • principle diagnosis
  • expected payer
  • admitting diagnosis
  • review of symptoms
A

admitting diagnosis

32
Q

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare’s Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is

  • beta blocker at discharge
  • blood culture before first antibiotic received
  • early administration of aspirin
  • discharge on antithrombotic
A

blood culture before first antibiotic received

33
Q

One record documentation requirement shared by BOTH acute care and emergency departments is

  • patient’s condition on discharge
  • time and means of arrival
  • advance directive
  • problem list
A

patient’s condition on discharge

34
Q

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

  • standing orders
  • telephone orders
  • stop orders
  • discharge order
A

discharge order

35
Q

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how “review of systems” differs from “physical exam,” you explain that the review of systems is used to document

• objective symptoms observed by the physician
• past and current activities, such as smoking and
drinking habits
• a chronological description of patient’s present
condition from time of onset to present
• subjective symptoms that the patient may have
forgotten to mention or that may have seemed
unimportant

A

subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant

36
Q

Based on the following documentation in an acute care record, where would you expect this excerpt to appear:

“The patient is alert and in no acute distress, Initial vital signs: T98, P102, and regular, R 20 and BP 120/69…”

  • physical exam
  • past medical history
  • social history
  • chief complaint
A

physical exam

37
Q

Which one of the following is NOT a step in developing a health record retention schedule?

  • conducting an inventory of the facility’s records
  • determining the format and location of storage
  • assigning all records the same retention period
  • destroying records that are no longer needed
A

assigning all records the same retention period

38
Q

Information found in which of the following would not be considered secondary data?

  • disease index
  • implant registry
  • health record
  • National Practitioner Data
A

health record

39
Q

Under the Patient Self-Determination Act of 1990, evidence of advance directives

• are required to be documented in the health
record
• are not required to be documented in the health
record
• require a doctor’s approval
• must be prepared by an attorney

A

are required to be documented in the health record

40
Q

A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be take?

• Return inactive records to each individual patient
• Destroy records of all deceased patients
• Destroy inactive records that exceed the statute of
limitations
• Maintain the records indefinitely in hard copy

A

Destroy inactive records that exceed the statute of limitations

41
Q

What is the chief criterion for determining record inactivity?

•	Medicare's definition of inactivity 
•	amount of space available for storage of newer 
        records 
•	efficiency of microfilming 
•	preference of the medical staff
A

amount of space available for storage of newer records

42
Q

How many years does the CMS require that health records be maintained? Medicare Conditions of Participation for Hospitals requires that patient health records be retained for at least _____ years unless a longer period is required by state or local laws.

  • 3
  • 5
  • 7
  • 10
A

5

43
Q

Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be

  • 5 years
  • 7 years
  • 10 years
  • either 5 or 7 years, as determined by the facility
A

7 years

44
Q

A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January. Which of the following indices would be the best source in locating the needed records?

  • master patient index
  • physician index
  • disease index
  • operation index
A

disease index

45
Q

Which of the following should not be included in the documentation of record destruction?

• statement that records were destroyed in the
normal course of business
• method of destruction
• signature of the individuals supervising and
witnessing the destruction
• dates not covered in the destruction

A

dates not covered in the destruction

46
Q

Which of the following is not a consideration when implementing a disaster plan?

• include disaster training in staff orientation
• establish a plan for conducting drills
• provide staff with tools needed to implement the
plan
• test the disaster plan only once

A

test the disaster plan only once

47
Q

Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital?

  • National Practitioner Data Bank
  • Healthcare Integrity and Protection Data Bank
  • MEDPAR file
  • State Administrative Data Bank
A

National Practitioner Data Bank

48
Q

A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors?

  • statute of limitations
  • volume of research
  • readmission rate
  • departmental staffing
A

departmental staffing

49
Q

The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the HIM manager look for this information?

  • patient register
  • disease index
  • operation index
  • birth defects register
A

operation index

50
Q

What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program?

  • 70%
  • 80%
  • 90%
  • 100%
A

90%

51
Q

Unless state of federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long?

  • age of majority plus statute of limitations
  • 10 years after the most recent encounter
  • 10 years after the age of majority
  • permanently
A

age of majority plus statute of limitations

52
Q

A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data?

  • overwriting data with a series of characters
  • disk reformatting
  • magnetic degaussing
  • overwriting the backup tapes
A

magnetic degaussing

53
Q

Which of the following statements would be found in the laboratory report section of the health record?

  • BUN reported as 20mg
  • Morphine sulfate gr. 1/4 q.4h for pain
  • IV sodium Pentohal 1% started at 9:05 AM
  • TPR recorded q.h. for 12 hours
A

BUN reported as 20mg

54
Q

The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should

• issue a copy of the birth certificate from the
patient’s record
• direct the request to the state’s office of vital
records
• direct the request to the attending physician
• issue a copy of the newborn’s record

A

direct the request to the state’s office of vital records

55
Q

A surgeon request the name of a patient he admitted on January 11, 2013. Which of the following would be used to retrieve this information?

  • master patient index
  • number index
  • admission register
  • operation index
A

admission register

56
Q

Where in the health record would the following statement be located?

“Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma”

  • operative report
  • pathology report
  • anesthesia report
  • radiology report
A

pathology report

57
Q

The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of?

  • concurrency
  • access
  • integrity
  • cost
A

access

58
Q

When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT

  • state laws and licensing standards
  • communities of practice requirements
  • needs of the patients
  • Medicare requirements
A

communities of practice requirements

59
Q

Case finding methods for patients with diabetes include a review of all but which of the following?

  • health plans
  • CPT diagnostic codes
  • billing data
  • medication lists
A

CPT diagnostic codes

60
Q

What type of plan is a Joint Commission - accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft?

  • budget
  • disaster
  • case management
  • patient care
A

disaster

61
Q

What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital?

• storing the records off-site at a cost of $25,000 per
year
• scanning all 250,000 for a cost of $195,000
• purging and storing all death records off-site at a
cost of $20,000 per year
• destroying all records older than 3 years for a cost
of $50,000

A

scanning all 250,000 for a cost of $195,000

62
Q

According to AHIMA’s recommended retention standards, which of the following types of health information does NOT need to be retained permanently?

  • physician index
  • register of births
  • register of surgical procedures
  • register of deaths
A

physician index

63
Q

For a healthcare facility to meet its documented destruction needs, the certificate of destruction should include all but which of the following elements?

  • unique and serialized transaction number
  • location of destruction
  • patient notification
  • acceptance of fiduciary responsibility
A

patient notification

64
Q

The steps in developing a record retention program include all but which of the following?

  • determining the storage format and location
  • notifying the courts of the destruction
  • assigning each record a retention period
  • destroying records that are no longer needed
A

notifying the courts of the destruction

65
Q

A healthcare facility has received a request to participate in a statewide study on cleft lip and palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the

  • newborn records
  • state bureau of vital statistics
  • maternal records
  • birth defects registry
A

birth defects registry

66
Q

An example of primary data source is the

  • physician index
  • health record
  • cancer registry
  • hospital statistical report
A

health record

67
Q

Fetal monitoring strips are part of the ____ record and should be maintained ______

• newborns; 10 years past the age of majority
• mother’s; according to the length of time required
for minor records
• newborn; according to the time period specified in
the state’s statute of limitations
• mothers; 10 years

A

mother’s; according to the length of time required for minor records

68
Q

How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained?

  • 5
  • 7
  • 30
  • permanently
A

30

69
Q

What data cannot be retrieved from the MEDPAR?

  • ICD-10-CM diagnosis codes
  • Charges broken down by specific types of services
  • non-Medicare patient data
  • Data on the provider
A

non-Medicare patient data

70
Q

The HIM practitioner’s duty to retain health information via the archiving and storage of health data includes all but which of the following?
• strategies that consider accessibility, natural
disasters, and innovations in storage technology
• strategies ensuring that inactive records are as
secure as active records
• a retention plan for multiple volumes of records
• a retention plan for financial data

A

a retention plan for financial data

71
Q

The function of a (an)___ is limited to data retrieval

  • electronic health record
  • executive information system
  • database management system
  • clinical data repository
A

clinical data repository

72
Q

The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry?

• enhanced databases will provide information for
improved clinical care
• training will be offered by the hospital
• those physicians not in compliance will be denied
admitting privileges
• multiple users will not have access to the same
information simultaneously

A

enhanced databases will provide information for improved clinical care

73
Q

A 16 year old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would

• be filed in a health record created for the infant
• be filed in the mother’s record
• be retained in a separate file in the administrative
offices
• not be retained in hospital records

A

be filed in the mother’s record

74
Q

Which of the following is NOT major management challenge in the storage and retention of electronic health record systems?

• Following state and federal laws and accreditation
requirements when developing retention and
destruction policies.
• Keeping technology updated in order to retrieve
data
• Ensuring that health information can be retrieved in
a timely manner
• Maintaining the paper-based storage system

A

Maintaining the paper-based storage system

75
Q

Which item is collected and maintained in the organ transplant registry?

  • vaccine manufacturer
  • histocompatibility information
  • cytogenetic results
  • state at the time of diagnosis
A

histocompatibility information

76
Q

Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components?

• International Classification of Primary Care
• International Classification on Functioning,
Disability, and Health
• National Drug Codes
• Clinical Care Classification

A

International Classification on Functioning, Disability, and Health

77
Q

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

  • National Library of Medicine
  • CMS
  • World Health Organization
  • Office of Inspector General
A

National Library of Medicine

78
Q

You have recently been hired as the Medical Staff Coordinator at your hospital. Which database/registry will you utilize most often?

  • Trauma Registry
  • MEDPAR
  • LOINC
  • National Practitioners Data Bank (NPDB)
A

National Practitioners Data Bank (NPDB)

79
Q

You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called?

  • Case finding
  • Staging
  • Abstracting
  • Nomenclature
A

Abstracting

80
Q

In which registry would you expect to find an Injury Severity Score (ISS)?

  • Cancer Registry
  • Birth defects registry
  • Trauma Registry
  • Transplant Registry
A

Trauma Registry

81
Q

A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as

  • a referral
  • a consultation
  • risk factor intervention
  • concurrent care
A

a consultation

82
Q

The most widely discussed and debated unique patient identifier is the

  • patient’s date of birth
  • patient’s first and last name
  • patient’s social security number
  • Unique Physician Identification Number (UPIN)
A

patient’s social security number

83
Q

The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels?

  • READ codes
  • ABC codes
  • SPECIALIST codes
  • LOINC
A

ABC codes

84
Q

The Level II (national) codes of the HCPCS coding system are maintained by the

  • American Medical Association.
  • CPT Editorial Panel.
  • local fiscal intermediary.
  • Centers for Medicare and Medicaid Services.
A

Centers for Medicare and Medicaid Services.

85
Q

A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia?

  • pseudomonas
  • clostridium
  • staphylococcus
  • listeria
A

pseudomonas

86
Q

the Level I (CPT) codes of the HCPCS coding system are maintained by the

  • American Medical Association.
  • American Hospital Association.
  • Local fiscal intermediary.
  • Centers for Medicare and Medicaid Services.
A

American Medical Association.

87
Q

A physicians excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?

• full-thickness skin graft to scalp only
• excision of lesion; full-thickness skin graft to scalp
• excision of lesion; full-thickness skin graft to scalp;
excision of skin from thigh
• code 15004 for surgical preparation of recipient
site; full-thickness skin graft to scalp

A

excision of lesion; full-thickness skin graft to scalp

88
Q

A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.

  • -25
  • -55
  • -57
  • -58
A

-57

89
Q

A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the reported by the physician to indicate that the procedure was discontinued.

  • -52
  • -53
  • -73
  • -74
A

-53

90
Q

A barrier to widespread use of automated code assignment is

  • inadequate technology.
  • poor quality of documentation.
  • resistance by physicians.
  • resistance by HIM professionals.
A

poor quality of documentation.

91
Q

In assigning E/M codes, three key components are used. These are

  • history, examination, counseling.
  • history, examination, time.
  • history, nature of presenting problem, time.
  • history, examination, medical decision making.
A

history, examination, medical decision making.

92
Q

Mrs. Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit.

  • -58
  • -76
  • -78
  • -79
A

-78

93
Q

The primary goal of a hospital-based cancer registry is to

• improve patient care.
• allocate hospital resources appropriately.
• determine the need for professional and public
education programs.
• monitor cancer incidence.

A

improve patient care.

94
Q

After reviewing the following excerpt from CPT, code 27646 would be interpreted as

27645 “Radical resection of tumor, tibia”

27646 “Fibula”

27647 “Talus or calcaneus”

• 27646 radical resection of tumor; tibia and fibula.
• 27646 radical resection of tumor; fibula
• 27646 radical resection of tumor; fibula or tibia.
• 27646 radical resection of tumor; fibula, talus,
calcaneus.

A

27646 radical resection of tumor; fibula

95
Q

A population-based cancer registry that is designed to determine rates in a defined population is a(n)

  • incidence-only population-based registry.
  • cancer control population-based registry.
  • research-oriented population-based registry.
  • patient care population-based registry.
A

incidence-only population-based registry.

96
Q

Given the diagnosis “carcinoma of axillary lymph nodes and lungs, metastatic from breast,” what is the primary cancer site(s)?

  • axillary lymph nodes
  • lungs
  • breast
  • A and B
A

breast

97
Q

According to CPT, in which of the following cases would an established E/M code be used?

  • A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities.
  • John and his family have just moved to town. John his asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician.
  • Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom’s regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.
  • A 78-year-old female with weight loss and progressive agitation over the past 2 months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years.
A

Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom’s regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.

98
Q

In order to use the inpatient CPT consultation codes, the consulting physician must

• order diagnostic tests.
• document his findings in the patient’s medical
record.
• communicate orally his opinion to the attending
physician.
• use the term “referral” in his report.

A

document his findings in the patient’s medical record.

99
Q

The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient’s medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient’s response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits?

• an initial inpatient and a follow-up consult
• an initial inpatient consult for both visits
• an initial inpatient consultant and a subsequent
hospital visit
• an initial inpatient consult and initial hospital care

A

an initial inpatient consultant and a subsequent hospital visit

100
Q

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

  • number of diagnoses or management options.
  • amount and complexity of data reviewed.
  • risk of complications.
  • specialty of the treating physicians.
A

specialty of the treating physicians.