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  1. Data consistency is imperative for the documentation within the health record to be considered reliable. Which of the following scenarios would cause the consistency of the data within the health record to be questionable?
    A. A surgeon's discharge summary lists a diagnosis of carcinoma of the right breast, S/P mastectomy; the pathologist documents specimen as left breast.
    B. A patient is admitted for suspected recurrent pneumonia; the emergency department physician documented that the two-view chest X-ray shows infiltrates.
    C. The patient's chief complaint is right upper quadrant abdominal pain radiating to the back with vomiting; the surgical procedure is a laparoscopic cholecystectomy
    D. The final lab indicates the patient has Enterococcus faecalis in the urine; the physician documents a urinary tract infection possibly due to a gram-positive organism.
    A. A surgeon's discharge summary lists a diagnosis of carcinoma of the right breast, S/P mastectomy; the pathologist documents specimen as left breast.
    (this multiple choice question has been scrambled)
  2. National Coverage Determinations (NCDs) are developed by which organization?A surgeon's discharge summary lists a diagnosis of carcinoma of the right breast, S/P mastectomy; the pathologist documents specimen as left breast.The final lab indicates the patient has Enterococcus faecalis in the urine; the physician documents a urinary tract infection possibly due to a gram-positive organism.A patient is admitted for suspected recurrent pneumonia; the emergency department physician documented that the two-view chest X-ray shows infiltrates.The patient's chief complaint is right upper quadrant abdominal pain radiating to the back with vomiting; the surgical procedure is a laparoscopic cholecystectomy.
    A. MAC
    B. AMA
    C. AHA
    D. CMS
    D. CMS
    (this multiple choice question has been scrambled)
  3. physician needs to document the correct V code for the long-term drug monitoring.The physician needs to document the patient's insurance information on the script.The physician needs to document the reason the patient is on Coumadin therapy.The physician needs to provide the original order as you cannot code from a standing order.
  4. Which of the following does NOT qualify as sensitive health information?
    A. a positive finding of genetic risk for breast cancera
    B. set of prenatal communicable disease testing results
    C. delivery records containing evidence of an adoption
    D. a billing record containing insurance authorizations
    D. a billing record containing insurance authorizations
  5. While coding a paper-based health record, you find that the final progress note contains the addressograph label from another patient. Which of the following is an acceptable practice when addressing erroneous documentation?

    A. Draw a single line through the incorrect label and write the word "error." Correct the information, identify your title, then sign and date the document.
    B. Remove the incorrect progress note. Remember to place it in the shredder to comply with HIPAA privacy requirements.
    C. Cut and paste the sections you want to keep onto a new, correctly labeled progress note. Copy and place the photocopy in the health record.
    D. Use correction fluid to cover the inaccurate label, and be sure to make the correction neatly as it will be part of the patient's legal health record
    A. Draw a single line through the incorrect label and write the word "error." Correct the information, identify your title, then sign and date the document.
  6. You have been employed as a coder at a local acute care hospital. When abstracting the records, you have been instructed to follow definitions established within a standardized healthcare data set, the Uniform Hospital Discharge Data Set (UHDDS). Which of the following data elements is NOT included as part of the UHDDS?

    A. newborn birth weight
    B. medication allergies
    C. type of admission
    D. principal diagnosis
    B. medication allergies
  7. A patient was diagnosed with a principal diagnosis of methicillin susceptible Staphylococcus aureus pneumonia and congestive heart failure due to hypertensive cardiovascular disease as secondary diagnosis. The core measures nurse has sent an e-mail to the HIM director requesting that a coder check the code assignments. When auditing the case, the coder finds the following codes were assigned: 482.42, 402.91, and 428.0. What is wrong with this set of codes?

    A. Hypertensive cardiovascular disease with CHF should be coded to 401.9, 429.9, and 428.0.
    B. The coder should have assigned code V09.0 to capture the methicillin susceptibility.
    C. The case has been coded incorrectly as MRSA pneumonia instead of MSSA pneumonia.
    D. The case lacks a code for the causative organism (041.12) and is considered incomplete.
    C. The case has been coded incorrectly as MRSA pneumonia instead of MSSA pneumonia.
  8. You have been asked to code an ambulatory surgery record from the gastrointestinal lab. The gastroenterologist documented the reason for the examination as screening colonoscopy. The examination was normal and no tissue was removed. In order to assign the correct HCPCS code, you need to know the payer. The best place to look for the payer information is within the
    A. history and physical.
    B. demographic record.
    C. surgical consent.
    D. advance directives.
    B. demographic record.
    (this multiple choice question has been scrambled)
  9. The SOAP note is a format used by some physicians to document a problem-oriented progress note. You have been asked to code an inpatient record in which a patient is being treated for sepsis. As you read through the health record, you encounter a SOAP note. Which portion of the SOAP note contains the following documentation?

    WBC has decreased from 16.2 to 12.3.BP is normalizing and currently 112/72.Temp: 100.8, HR 91, respiration 22.

    Patient more alert.
    A. objective
    B. assessment
    C. subjective
    D. plan
    A. objective
  10. The Privacy Rule stipulates that a patient authorization is required for

    A. disclosure for essential government functions.
    B. disclosure for employee background checks.
    C. disclosure for ensuring public health protection.
    D. disclosure for workman's compensation.
    B. disclosure for employee background checks.
    (this multiple choice question has been scrambled)
  11. A patient has been brought to the emergency department by the police for treatment following a domestic dispute. The patient's ex-wife finds out about the visit, from one of their children, and calls the HIM department because she could possibly use this incident to strengthen her case in an ongoing custody battle. You are in the process of coding the medical record and inform the patient's ex-wife that although you understand her circumstances, you are prohibited from discussing the record. What federal regulation prohibits you from releasing the patient's health information to the ex-wife?

    A. the Health Insurance Portability and Accountability Act
    B. the Patient Self-Determination of Health Information Act
    C. the Protected Family Dispute, Disparities, and Disclosure Act
    D. the Balanced Budget and Reconciliation Act
    A. the Health Insurance Portability and Accountability Act
    (this multiple choice question has been scrambled)
  12. Which of the following is the most useful for electronic exchange of drug product information?

    A. RxNorm
    B. NDC
    C. HCPCS
    D. NDF-RT
    B. NDC
    (this multiple choice question has been scrambled)
  13. In the future, the coding process will be performed using a computer-assisted coding program. The purpose of setting up a computer-assisted coding program is
    A. provide departments within an organization a way to charge their own cases.
    B. to provide an organization the option of employing a lower-paid workforce.
    C. allow a coder to assume the role of an editor or auditor of code assignments.
    D. eliminate a coder's position and have everything coded using the software.
    C. Allow a coder to assume the role of an editor or auditor of code assignments.
    (this multiple choice question has been scrambled)
  14. You have been assigned an ancillary case from January 14, 2010. The patient had a cardiac MRI for morphology and function without contrast material, followed by contrast material and further sequences. The test was performed with flow/velocity quantification and stress. CPT codes 75561 and 75564 were submitted for billing. CPT code 75564 was rejected. Which of the following best explains the reason for the rejection of CPT code 75564?

    A. The assignment of CPT code 75564 represents an unbundling of CPT code 75561.
    B. CPT code 75564 must be assigned in conjunction with the add-on CPT code 75565.
    C. The assignment of CPT code 75564 represents the stress, but not the flow.
    D. CPT code 75564 is a deleted CPT code as of January 1, 2010 and is invalid.
    D. CPT code 75564 is a deleted CPT code as of January 1, 2010 and is invalid.
    (this multiple choice question has been scrambled)
  15. Which of the following organizations is NOT involved in establishing documentation guidelines for health records?

    A. The Centers for Medicare and Medicaid Services
    B. The National Alliance for Health Information Technology
    C. The American Health Information Management Association
    D. The Commission on Accreditation of Rehabilitation Facilities
    B. The National Alliance for Health Information Technology
    (this multiple choice question has been scrambled)
  16. An uncontrolled release of health information beyond the original intent authorized by the patient is a common ethical problem encountered when using

    A. need-to-know releases.
    B. blanket authorizations.
    C. do-no-harm agreements.
    D. nonmaleficence forms.
    B. blanket authorizations.
    (this multiple choice question has been scrambled)
  17. The director of the HIM department has given you an emergency department case to review and verify the disposition. As you page through the record, you find that the physician has documented the assessment: "CPR-unsuccessful." Based on the information you have, the correct disposition should be

    A. long-term rehabilitation.
    B. expired.
    C. hospice.
    D. AMA.
    B. expired.
    (this multiple choice question has been scrambled)
  18. A pathology report may contain which of the following?

    A. gross findings
    B. ejection fraction
    C. carcinoembryonic antigen
    D. coagulation profile
    A. gross findings
    (this multiple choice question has been scrambled)
  19. Level II HCPCS codes is a standardized coding system that is used primarily to identify

    A. alpha codes for supplies and services that other insurers cover that are not included in CPT-4.
    B. products, supplies, and services not included in CPT-4 codes
    C. alpha codes for supplies and services Medicare covers that are not included in CPT-4.
    D. products, supplies, and services that are provided in a physician's office.
    B. products, supplies, and services not included in CPT-4 codes
    (this multiple choice question has been scrambled)
  20. A patient is seen in an outpatient surgery center for a gastric balloon procedure for the treatment of obesity. The gastric balloon is inserted into the stomach to reduce the capacity of the stomach and to affect early satiety.The procedure is denied by Medicare. The reason for the denial based on a National Coverage Determination (NCD) for gastric balloon for the treatment of obesity is most likely due to

    A. bariatric surgery for the treatment of morbid obesity should be the first course of treatment performed.
    B. the long-term safety and efficacy of the device in the treatment of obesity has not been established.
    C. the gastric balloon is a medical device developed as a temporary adjunct to diet and behavior.
    D. the gastric balloon is considered cosmetic in nature and is statutorily not covered.
    B. the long-term safety and efficacy of the device in the treatment of obesity has not been established.
    (this multiple choice question has been scrambled)
  21. A diagnostic descriptor that is listed in italics is a(n)

    A. manifestation code.
    B.inappropriate principal diagnosis.
    C. CC exclusion.
    D. code that must be reported first.
    A. manifestation code.
    (this multiple choice question has been scrambled)
  22. A patient was admitted to the observation unit for dehydration, hypokalemia, and mild renal insufficiency. The patient had a comprehensive metabolic panel (CMP) on admission, at which time she was noted to have low sodium, low chloride, and low potassium levels. IV fluids were administered.

    The next day, a basic metabolic panel (BMP) was run to follow up on the electrolytes and creatinine. The tests came back normal, and the patient was discharged.


    The case is coded and processed through the APC grouping software, at which point a message appears indicating that the CMP (CPT code 80053) and the BMP (CPT code 80048) cannot be billed on the same date of service. You verify that all procedure dates are correct.


    How will you proceed?

    A. Ignore the edit because the labs were performed on two different dates of service.
    B. Look at the APC weights assigned to the CMP and the BMP. Delete the CPT code with the lower APC weight.
    C. Call the lab to see if the account was charged correctly. Explain that the grouping software has indicated a charge problem.
    D. Document the specifics of the message. Notify the vendor that you have noted an erroneous message in the grouping software.
    A. Ignore the edit because the labs were performed on two different dates of service.
    (this multiple choice question has been scrambled)
  23.  A 6-year-old child is seen by the physician in his office with acute dehydration secondary to nausea and vomiting due to probable gastroenteritis. The vomiting is brought under control, and the child is rehydrated in the office. Code this scenario using coding guidelines.

    A. 276.5, 787.02, 787.03
    B. 276.5, 787.01, 558.9
    C. 276.51, 787.02, 787.03, 558.9
    D. 276.51, 787.01
    D. 276.51, 787.01
    (this multiple choice question has been scrambled)
  24. Read the following office visit note.

    CC: Medication refill

    S: This is a new patient to me who has a history of peripheral vascular disease, hyperlipidemia and is here for a med refill. The patient had a stent placement 12 weeks ago for peripheral vascular disease in the left leg, just prior to changing insurance.

    A: Peripheral vascular disease, by history. Hyperlipidemia on Lescol. Sexual erectile dysfunction, on Viagra.


    P: The patient was given Lescol prescription 20 mg per day for 60 days with a 1-year refill and also given a Viagra prescription for 5 days, with a 1-year refill.

    If the physician coded a 99202 for this visit, what documentation is missing from this office visit note to substantiate this code?

    A. medical decision-making data
    B. exam data
    C. history data
    D. coordination of care data
    B. exam data
    (this multiple choice question has been scrambled)
  25. Which of the following issues was NOT specifically involved in the adoption of the Standards of Ethical Coding by the American Health Information Management Association (AHIMA)?

    A. ignoring coding errors made by other members of the coding staff
    B. lacking access to a current set of coding materials when assigning codes
    C. assigning inappropriate diagnosis codes to avoid potential conflicts
    D. being unable to maintain or improve consistent coding productivity levels
    D. being unable to maintain or improve consistent coding productivity levels
    (this multiple choice question has been scrambled)
  26. After 14 hours of labor, a normal male infant was delivered over a midline episiotomy using vacuum extraction. However, while repairing the episiotomy, the physician noted a first-degree high vaginal laceration which was subsequently repaired. Select the correct principal and secondary ICD-9-CM procedure codes for this case.

    A. 72.71, 75.69
    B. 75.69, 73.6
    C. 72.71, 73.6
    D. 72.79, 75.69
    A. 72.71, 75.69
    (this multiple choice question has been scrambled)
  27. Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called

    A. .encoders.
    B. natural language processing systems.
    C. monitoring/audit programs
    D. concept, description, and relationship tables.
    A. .encoders.
    (this multiple choice question has been scrambled)
  28. Which modifier from the answer choices below is NOT a HCPCS Level II modifier?

    A. RC
    B. IV
    C. GH
    D. FA
    B. IV
    (this multiple choice question has been scrambled)
  29. Which of the following statements is NOT true regarding the Internet?

    A. Accessing the Internet by way of an intranet is less secure.
    B. E-commerce sites provide education to patients and physicians.
    C. The WAN is used to connect devices throughout the world.
    D. The LAN can be used for internet access throughout a hospital.
    A. Accessing the Internet by way of an intranet is less secure.
    (this multiple choice question has been scrambled)
  30. As a coder, you will use various types of technology to access and complete electronic health records. Which of the following is NOT considered a communications technology option?

    A. fiber optics
    B. Internet
    C. wireless
    D. imaging
    D. imaging
    (this multiple choice question has been scrambled)
  31. A patient was referred to the hospital outpatient radiology department for MRI of the knee to rule out tear of the medial meniscus. The reason for the visit was an acute sprain of the right knee with persistent knee pain. Which of the following is the correct coding for this encounter? (Note: No definitive diagnosis was made.)

    719.46 pain in joint
    836.0 tear of medial meniscus, knee, current
    844.9 sprain, knee, unspecified site
    V72.5 radiologic exam


    A. V72.5, 836.0
    B. 844.9
    C. V72.5, 844.9
    D. 844.9, V72.5, 719.46
    B. 844.9
    (this multiple choice question has been scrambled)
  32. Two laboratory tests were performed on the same day to rule out infection. Initially, a culture for bacterial quantitative colony count, urine (CPT 87086) was performed and subsequently, a culture for bacterial, blood, aerobic (CPT 87040) was performed. What modifier would be required for billing these laboratory exams together?

    A. 59
    B. 25
    C. 77
    D. 90
    A. 59
    (this multiple choice question has been scrambled)
  33. A 45-year-old non-Medicare patient has general anesthesia for a laparoscopic gastric bypass for morbid obesity. The patient has diabetes mellitus and was assigned a physical status three during a preoperative interview with the anesthesiologist. Immediately prior to the procedure, the anesthesiologist inserted an arterial line for intraoperative monitoring. The total anesthesia time was 2 hours 15 minutes. The anesthesiologist's conversion factor is $25.00.

    00700—Anesthesia for procedures on upper anterior abdominal wall; not otherwise specified (Base unit value of 4)00790—Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; not otherwise specified (Base unit value of 7)
    00797—Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; gastric restrictive procedure for morbid obesity (Base unit value of 10)36556—Insertion of nontunneled centrally inserted central venous catheter; age 5 years or older (Base unit value of 4)36620—Arterial catheterization or cannulation for sampling, monitoring, or transfusion (separate procedure); percutaneous (Base unit value of 3)
    P2—A patient with mild systemic disease (Base unit value of 0)
    P3—A patient with severe systemic disease (Base unit value of 1)
    P4—A patient with severe systemic disease that is a constant threat to life (Base unit value of 2)

    Assuming the above parameters are correct, choose the appropriate anesthesia code(s) from the list provided and calculate the charge(s).

    A. 00797–P3 for $475; 36556 for $100
    B. 00797–P3 for $500; 36620 for $75
    C. 00790–P3 for $350

    D. 00790–P2 for $400
    B. 00797–P3 for $500; 36620 for $75

    The correct answer of 00797–P3 for $500 is calculated as follows: Base unit of 10 + 9 15-minute time units + 1 modifying factor x $25.00 conversion factor: (10 + 9 + 1)$25.00 = $500.00.The correct answer of 36620 for $75 is calculated as follows: Base unit of 3 + 0 time units + 0 modifying factors X $25.00 conversion factor: (3)$25.00 = $75.00.Payment for anesthesia services is based on the sum of an anesthesia code-specific base unit value plus anesthesia time units and modifying units multiplied by the locality-specific anesthesia conversion factor. The code-specific base unit value for anesthesia codes represents the degree of difficulty associated with providing anesthesia for a surgical procedure. The anesthesia time units are based on the total anesthesia time, and they are reported as one unit for each 1 minute of anesthesia time.
    (this multiple choice question has been scrambled)
  34. Which of the following would NOT be considered a type of application software?

    A. Microsoft Windows
    B. EXCEL
    C. E-mail
    D. Adobe Reader 9.0
    A. Microsoft Windows
    (this multiple choice question has been scrambled)
  35. Diagnoses described as "possible," "probable," "likely," and "rule out" are reported if present for what type of records?

    A. high-risk pregnancy
    B. inpatient
    C. mental health
    D. outpatient
    B. inpatient
    (this multiple choice question has been scrambled)
  36. The patient had a total abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes: 58150 and 58700. Assignment of these two codes together would be referred to as

    A. unbundling.
    B. global packaging.
    C. optimization.
    D. maximizing.
    A. unbundling
    (this multiple choice question has been scrambled)
  37. Which of the following is NOT considered to be an accreditation organization?

    A. American Osteopathic Association
    B. Centers for Medicare and Medicaid Services
    C. The Commission on Accreditation of Rehabilitation Facilities
    D. The Joint Commission
    B. Centers for Medicare and Medicaid Services
    (this multiple choice question has been scrambled)
  38. In the ICD-9-CM Alphabetic Index, the primary arrangement of main terms is by

    A. condition.
    B. organism.
    C. topography.
    D. site.
    A. CONDITION
    (this multiple choice question has been scrambled)
  39. Which of the following standardized healthcare data sets has NOT been incorporated into the federal regulations as a required data set for federally funded health programs?

    A. uniform ambulatory care data set
    B. minimum data set for long-term care
    C. uniform hospital discharge data set
    D. outcomes assessment information set
    A. uniform ambulatory care data set
    (this multiple choice question has been scrambled)
  40. Which of the following would NOT be coded under HCPCS Level II J0000-J9999?

    A. inhalation treatment drugs
    B. immunosuppressive drugs
    C. chemotherapy drugs
    D. self-administered drugs
    D. self-administered drugs
    (this multiple choice question has been scrambled)
  41. An example of an acceptable National Correct Coding Initiative (NCCI) modifier is

    A. 52
    B. 21
    C. 56
    D. 71
    A. 52
    (this multiple choice question has been scrambled)
  42. A physician writes the following order:

    Give MS IVP, start with 2.5 mg, dilute w/ 5 mL sterile H2O, give slowly.

    This medication order represents a problematic documentation issue addressed within the

    A. Conditions for Coverage of Suppliers of ESRD services.
    B. Health Level Seven list of functions defining the EHR.
    C. plan portion of the treating physician's SOAP note.
    D. Joint Commission's prohibited abbreviations list.
    D. Joint Commission's prohibited abbreviations list.
    (this multiple choice question has been scrambled)
  43. When coding ancillary cases, you are basically working with a registration record, consents, a requisition or script, and the test results. You have been given a day of ancillary cases to code and have come across the following script:
    What information should you request from the physician's office before coding this case?


    A. The physician needs to provide the original order as you cannot code from a standing order.
    B. The physician needs to document the reason the patient is on Coumadin therapy.
    C. The physician needs to document the patient's insurance information on the script.
    D. The physician needs to document the correct V code for the long-term drug monitoring
    B. The physician needs to document the reason the patient is on Coumadin therapy.
    (this multiple choice question has been scrambled)
  44. The following visit is coded as 99213-25, 26735, 73140-TC. When comparing the coding to this patient's progress note, what findings would the auditor have?

    O - The left third digit is positive for edema, resolving ecchymosis and pain over the proximal phalangeal joint upon palpation. Decreased flexion with lateral deviation and decreased strength due to pain. X-ray done in the office today revealed a chip fracture over the proximal phalangeal joint.A - Chip fracture of the left third digit, proximal phalangeal joint.P - Continue with splint from home, refrain from any basketball. Use OTC drugs to decrease inflammation. Repeat visit in 2 weeks for follow-up.

    A. A higher level of office visit should have been coded.
    B. The documentation does not support the codes assigned.
    C. A local anesthetic should have been coded.
    D. A HCPCS Level II supply code should have been coded.
    B. The documentation does not support the codes assigned.
    (this multiple choice question has been scrambled)
  45. Per ICD-9-CM Official Guidelines for Coding and Reporting, chapter 11 codes have sequencing priority over

    A. V codes only.
    B. all codes except V codes.
    C. no other codes.
    D. codes from all other chapters.
    D. codes from all other chapters.
    (this multiple choice question has been scrambled)
  46. What is the best way to ensure that you are prepared to handle an unexpected event that has the potential of resulting in lost or corrupted information?

    A. Print a paper copy of each record you code.
    B. Make sure you log in and out each day.
    C. Change your password on a regular basis.
    D. Know your department's contingency plan.
    D. Know your department's contingency plan.
    (this multiple choice question has been scrambled)
  47. When utilizing the computerized physician/provider order-entry, which of the following statements would be considered to be false?

    A. The computerized order-entry solves illegible handwriting issues.
    B. The computerized order-entry eliminates medication errors.
    C. The computerized order-entry improves quality of care.
    D. The computerized order-entry reduces the time between placing and filling an order.
    B. The computerized order-entry eliminates medication errors.
    (this multiple choice question has been scrambled)
  48. A patient calls the HIM department indicating that she was in the emergency department a week ago and received a blood transfusion and would like to know her blood type. However, she does not want to pay for a copy of the entire medical record and has asked what documentation she should request for this type of information. The best place to find the patient's blood type would be the

    A. emergency physician's assessment.
    B. laboratory test results.
    C. emergency physician's orders.
    D. nurse's triage record.
    B. laboratory test results.
    (this multiple choice question has been scrambled)
  49. You are coding an inpatient record and encounter a photograph labeled as "decubitus ulcer—right hip." The photograph is dated 3 days after the patient was admitted to the hospital. Which of the following would be the best place to look for documentation indicating whether or not the decubitus ulcer of the right hip was present on admission?

    A. advance directives
    B. history and physical
    C. physician's orders
    D. progress notes
    B. history and physical
    (this multiple choice question has been scrambled)
  50. Which entity is NOT responsible for the development of local coverage decisions (LCDs)?

    A. local state government
    B. fiscal intermediary
    C. Medicare administrative contractors
    D. program safeguard contractors
    A. local state government
    (this multiple choice question has been scrambled)
  51. The CPT-4 procedure codes below have a Medically Unlikely Edit "2" in the OPPS Medically Unlikely edits table.

    86707 - Hepatitis BE antibody (HbsAB)82252 - Heparin neutralization
    88309 - Level VI-Surgical pathology, gross and microscopic examination
    87530 - Herpes Simplex virus, quantification

    What does the "2" represent?

    A. the CLIA (Clinical Laboratory Improvement Amendments) criteria for billing have not been met
    B. the maximum number of the procedure that is allowed to be billed on the OPPS claim
    C. the total number of the procedure in excess of 1 that will not be covered
    D. the procedure when paired with a component procedure is not separately payable
    B. the maximum number of the procedure that is allowed to be billed on the OOPS claim.
    (this multiple choice question has been scrambled)
  52. Which standards organization developed the most comprehensive standardized vocabulary used to date?

    A. SNOMED
    B. ISO
    C. ACR/NEMA
    D. HL7
    A. SNOMED
    (this multiple choice question has been scrambled)
  53. Which of the following is NOT considered protected health information?

    A. de-identified information
    B. names of physicians
    C. electronic mail addresses
    D. telephone numbers
    A. de-identified information
    (this multiple choice question has been scrambled)
  54.  The modifier GZ would be used for which of the following?

    A. The provider expects that the service will be denied.
    B. The provider expects that the service is statutorily non-covered.
    C. The provider expects that the service has a medically unlikely edit.
    D. The provider expects that the service is the patient's liability
    A. The provider expects that the service will be denied.
    (this multiple choice question has been scrambled)
  55. You have been hired to work in the HIM department of a large skilled nursing facility. As with any job, you have been required to learn the essential elements of a long-term care health record. Which of the following is NOT part of the records you are using in a skilled nursing facility?

    A. resident assessment protocols (RAPs)
    B. resident assessment instrument (RAI)
    C. minimum data set (MDS) for long-term care
    D. outcomes and assessment information set (OASIS)
    D. outcomes and assessment information set (OASIS)
    (this multiple choice question has been scrambled)
  56. According to National Coverage Determinations (NCD), gradient pressure dressings are Jobst elasticized heavy duty dressings used to reduce hypertrophic scarring and joint contractures following burn injury. Which type of dressing, if reasonable and necessary, would be covered for an individual in need of an occlusive dressing for burns, donors of homografts, decubiti, and other ulcers?

    A. hydrogel dressing, wound cover
    B. gradient pressure exterior wrap
    C. porcine skin, gradient pressure dressing
    D. hydrocolloid dressing, wound cover
    C. porcine skin, gradient pressure dressing
    (this multiple choice question has been scrambled)
  57. You have been asked by the Core Measures Data Coordinator to assist with the collection of data specific to the heart failure core measures. The coordinator needs your help collecting ejection fraction percentages on heart failure cases. You would most likely find the ejection fraction documented within which of the following reports?

    A. the echocardiogram
    B. the emergency department record
    C. the electrocardiogram
    D. the history and physical
    A. the echocardiogram
    (this multiple choice question has been scrambled)
  58. A patient presents to the emergency department for suture removal. The surgery was performed 2 weeks ago. A problem-focused history and examination are performed, and the sutures are removed. What code would be assigned?

    A. 99281
    B. 99284
    C. 99283
    D. 99282
    A. 99281
    (this multiple choice question has been scrambled)
  59. Making ethical decisions can be a complex and involved process. The ethical decision-making matrix is a tool developed for the purpose of making complex ethical decisions in an informed and consistent manner. Which of the following statements does NOT pertain to making ethical decisions?

    A. All ethical decisions require seeking legal counsel.
    B. All ethical questions have more than one response.
    C. All individuals are faced with making ethical decisions.
    D. The ethical decision-making matrix addresses prevention.
    A. All ethical decisions require seeking legal counsel.
    (this multiple choice question has been scrambled)
  60. Which scenario does NOT constitute a potential privacy issue?

    A. Two patients with the same name are on the same unit, at the same time.
    B. Two HIM coders discuss a case at work to resolve a coding issue.
    C. An employee takes pictures of his workstation.
    D. A nurse discusses a case while calling the lab
    B. Two HIM coders discuss a case at work to resolve a coding issue.
    (this multiple choice question has been scrambled)
  61. Which of the following does NOT have the potential to result in a security breach?

    A. access controls
    B. natural disasters
    C. malfunctions
    D. power surges
    A. access controls
    (this multiple choice question has been scrambled)
  62. Which of the following is responsible for mandating privacy standards when encountering or working with identifiable health information?

    A. HIPAA
    B. HL7
    C. EEOA
    D. OSHA
    A. HIPAA
    (this multiple choice question has been scrambled)
  63. You have been hired to assist with clinical documentation issues. You encounter documentation that requires further clarification from the physician. A physician query is typed up and faxed to the physician's office. The next day you receive a call from a school supply company indicating that they received the fax you thought had been sent to the physician's office. What is the best course of action?

    A. Request that the supply company mail the PHI back to you.
    B. Have the patient come in and sign a blanket authorization.
    C. Verify the fax number and attempt to re-fax the physician query.
    D. Notify the privacy officer immediately of the security breach.
    D. Notify the privacy officer immediately of the security breach.
    (this multiple choice question has been scrambled)
  64. A prosthetic device is one that is considered to replace all or part of an internal body organ or to replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. Which prosthetic device from the selection below would Medicare cover?

    A. devices that are dispensed by the physician prior to surgery
    B. diapers and rubber sheets for treatment of urinary incontinence
    C. devices that require carrier preauthorization prior to surgery
    D. devices for parenteral and enteral nutrition supplies and kits
    D. devices for parenteral and enteral nutrition supplies and kits
    (this multiple choice question has been scrambled)
  65. Which of the following types of documentation would NOT be required for a surgical record?

    A. operative report
    B. consent
    C. pathology report
    D. history and physical
    C. pathology report
    (this multiple choice question has been scrambled)
  66. Which of the following regarding the Accredited Standards Committee (ASC X12N) electronic transaction standards is true?

    A. They can be classified as both a terminology standard and a standard for EHRs.
    B. They identify the current content and structure of the electronic health record.
    C. They were developed by HL7 as part of the open system interconnection (OSI) model.
    D. They were designed to facilitate an exchange of data between payers and providers.
    D. They were designed to facilitate an exchange of data between payers and providers.
    (this multiple choice question has been scrambled)
  67. A patient was brought to the interventional radiology suite to have an aortography with a bilateral lower extremity runoff. A catheter was placed within the left common femoral artery and advanced into the aorta above the celiac trunk where an injection was performed. A stenosis was noted within a branch off the celiac trunk. Subsequently, a catheter was advanced from the aorta into the celiac trunk and finally, into the splenic artery where another injection was performed. A severely stenotic lesion, within the splenic artery, was noted. It should be noted that the patient had normal arterial anatomy except for the presence of an additional left renal artery.

    Therapeutic intervention was not contemplated as the patient expressed that he wanted diagnostic work up. He was adamant that should any abnormalities be noted, he would first discuss the findings with his primary care physician before consenting to any therapeutic interventions. The patient left the interventional radiology suite in satisfactory condition and was provided with the proper documentation to follow up with his PCP.

    Using your CPT code book, and the knowledge that the catheterization of the splenic artery was from the aorta, decipher the correct branch order of the splenic artery catheterization.
    A. first order branch (CPT code 36245)
    B. third order branch (CPT code 36247)
    C. beyond a third order branch (CPT code 36248)
    D. second order branch (CPT code 36246)
    D. second order branch (CPT code 36246)
    (this multiple choice question has been scrambled)
  68. Which of the following best reflects a primary purpose of the health record?

    A. public health
    B. education
    C. regulation
    D. patient care
    D. patient care
    (this multiple choice question has been scrambled)
  69. A patient was scheduled for a Halsted repair. Code the following procedure

    A Halsted repair using a mesh associated with an excision of an infected scrotal sebaceous cyst

    A. Principal procedure: 53.05, secondary procedure code: 61.3
    B. Principal procedure: 53.00, secondary procedure code: 61.3
    C. Principal procedure: 62.2, secondary procedure code: 53.00
    D. Principal procedure: 61.3, secondary procedure code: 53.05
    A. Principal procedure: 53.05, secondary procedure code: 61.3

    In ICD-9-CM, surgical procedures can be located within the index under the eponym used to identify the procedure. "Repair, Halsted" leads the coder to the ICD-9-CM procedure code 53.00, which is the code for an inguinal hernia repair. However, the repair was accomplished using a mesh. The coder must go back to the index under "repair, hernia, inguinal, with prosthesis or graft" to find the correct code 53.05. The secondary procedure is found by referencing "excision, lesion, scrotum," which leads the coder to code 61.3.
  70. A patient was admitted to the hospital after being evaluated in the emergency department with signs and symptoms of severe sepsis. The admitting physician received a copy of the preliminary EKG; however, the physician requested that he be given the final EKG after a cardiologist has evaluated the strips. Due to the possibility of severe sepsis, the admitting physician asked that the patient be evaluated by an infectious disease specialist. A dietary consult was also ordered. Which of the following is considered a consulting physician?

    A. The emergency department physician
    B. the cardiologist evaluating the EKG
    C. the dietician performing a dietary consult
    D. the infectious disease specialist
    D. the infectious disease specialist
    (this multiple choice question has been scrambled)
  71. What type of encoding system uses expert or artificial intelligence software to automatically assign code numbers?

    A. natural language processing
    B. diagnosis-related grouping
    C. outpatient prospective payment
    D. prospective payment
    A. natural language processing
    (this multiple choice question has been scrambled)
  72. 68. What is the correct set of ICD-9-CM procedure codes for the following procedure:

    A tibial lengthening, using a bone graft with the application of a monoplanar external fixation device. The bone graft was obtained from a tissue bank.

    A. 78.37, 78.17, 84.71
    B. 78.37, 78.17
    C. 78.37, 84.71
    D. 78.37, 78.07, 84.71
    A. 78.37, 78.17, 84.71
  73. A patient undergoes a laparoscopic cholecystectomy. While performing the cholecystectomy, the physician lysed some flimsy adhesions surrounding the gallbladder. Once the gallbladder was removed, the physician noticed a 0.7 mm lesion within the gallbladder fossa. A biopsy of the liver lesion was taken and submitted for frozen section, which came back benign. The ports were removed and entry sites closed.

    When looking up the references associated with your code assignments, you learn that an adhesiolysis procedure is coded when the adhesions are considered dense, extensive, block access to the surgical site, and/or significantly increase the amount of time it takes to perform the surgery

    Which code set is correct based on the documentation provided?

    A. principal procedure: 50.14, secondary procedure code(s): 51.23 and 54.59
    B. principal procedure: 51.23, secondary procedure code(s): 54.51
    C. principal procedure: 50.11, secondary procedure code(s): 51.23 and 54.51
    D. principal procedure: 51.23, secondary procedure code(s): 50.14
    D. principal procedure: 51.23, secondary procedure code(s): 50.14
    (this multiple choice question has been scrambled)
  74. The following are characteristics of either a classification system or a controlled terminology. Which of the following characteristic(s) is true only of a controlled terminology and NOT of a classification system?

    A. may be used to capture granular patient information
    B. used to index information about a patient
    C. all of these options
    D. helpful in retrieving information about a patient
    A. may be used to capture granular patient information
    (this multiple choice question has been scrambled)
  75. All of the alpha codes below are included in the HCPCS Level II coding system EXCEPT

    A. G codes-Codes used to report/identify professional healthcare procedures and services for which there are no CPT-4 codes.
    B. S codes-Private insurers to report drugs, services, and supplies for which there are no national codes.
    C. B codes-Medicaid State programs to report biologicals/pharmaceuticals for which there are no CPT-4 codes.
    D. H codes-Medicaid state programs to report mental health and alcohol/drug treatment services for which the state mandates separate codes.
    C. B codes-Medicaid State programs to report biologicals/pharmaceuticals for which there are no CPT-4 codes.
    (this multiple choice question has been scrambled)
  76. As a new coder at the hospital, you have been given a set of emergency department cases to code. The coding supervisor states that you may enter up to three diagnoses within the REASON FOR ENCOUNTER abstracting field. Which of the following statements best represents a patient's reason for encounter?

    A. Patient's caregiver states the patient is not in her "usual frame of mind" and is refusing to eat. She constantly rubs her left hand against the left cheek and forehead.
    B. The final diagnosis is unstable angina secondary to an occlusion of the left anterior descending artery (LAD) which was noted during a previous cardiac catheterization.
    C. Emergency department physician stated the patient was still having "a problem providing a urine sample" despite receiving 1,000 mL of 0.9% NaCl to treat her dehydration.
    D. The patient, a current pipe smoker, comes in with hemoptysis and has a possible left lower lobe mass which was incidentally noted during his last annual chest X-ray.
    A. Patient's caregiver states the patient is not in her "usual frame of mind" and is refusing to eat. She constantly rubs her left hand against the left cheek and forehead.
    (this multiple choice question has been scrambled)
  77. The health plan employer data and information set (HEDIS) is a set of standard performance measures that provides pertinent information necessary to compare the performance of managed care healthcare plans. Which of the following issues has the greatest impact on a physician's profile using HEDIS data elements?

    A. the patient's geographic location
    B. the type of practice setting
    C. accurate code assignments
    D. the age of the insured patient
    C. accurate code assignments
    (this multiple choice question has been scrambled)
  78. The most important purpose of establishing accurate and timely documentation requirements for the patient health record is

    A. to obtain accurate and justified reimbursement.
    B. to assist with performance improvement measures.
    C. to ensure and improve the quality of direct patient care.
    D. to comply with regulatory and accreditation requirements.
    C. to ensure and improve the quality of direct patient care.
    (this multiple choice question has been scrambled)
  79. The obstetric delivery record contains all of the following EXCEPT

    A. prenatal care summary.
    B. type of delivery and viability of the baby.
    C. anesthesia and medications administered.
    D. condition of the placenta and umbilical cord.
    A. prenatal care summary
    (this multiple choice question has been scrambled)
  80. You are an employee at a hospital that employs contract coders to help with the backlog. A contract coder brings you an operative report from another facility with the patient's name, the surgeon, and hospital identification. They hand you the report and ask you how to code the procedure. This is an example of

    A. a security breach.
    B. beneficence.
    C. working as a team.
    D. life-long learning.
    A. a security breach.
    (this multiple choice question has been scrambled)
  81.  Which of the following Internet sites could you use to find the name of the drug when all you have to work with is the NDC number?

    A. National Drug Center
    B. U.S. Department of Drugs
    C. National Drug Directory
    D. American Pharmacy Web
    C. National Drug Directory
    (this multiple choice question has been scrambled)
  82. ORYX was developed to track outcome improvements for diseases such as heart failure, myocardial infarctions, and pneumonia by standardizing care. Which of the following is NOT true regarding the ORYX initiative?

    A. ORYX uses the National Drug Code (NDC) Directory to collect data regarding ineffective drug therapy treatments.
    B. It is an initiative that uses nationally standardized performance measures to improve the safety and quality of care.
    C. ORYX involves core measures that may be tracked using ICD-9-CM diagnosis codes such as 410.41, 428.0, and 486
    D. The initiative was named after a particular African animal that can be thought of as a different kind of zebra.
    A. ORYX uses the National Drug Code (NDC) Directory to collect data regarding ineffective drug therapy treatments.
    (this multiple choice question has been scrambled)
  83. The modifier 91 would be used for which of the following?

    A. modifier for a non-covered service provided by provider
    B. modifier for service units greater than 1 for lab service
    C. modifier for repeat radiology services by same physician
    D. modifier for repeat radiology services by different physician
    B. modifier for service units greater than 1 for lab service
    (this multiple choice question has been scrambled)
  84. A patient is admitted for treatment of dehydration secondary to chemotherapy for primary liver cancer. Which condition should be sequenced as the principal diagnosis?

    A. complication of chemotherapy
    B. liver carcinoma
    C. any of these diagnoses
    D. dehydration
    D. dehydration
    (this multiple choice question has been scrambled)
  85.  Operative Report
    Preoperative Diagnosis: Laceration of nerve and tendon, left little finger

    Postoperative Diagnosis: Ulnar nerve laceration, left little finger No tendon laceration

    Operation performed: Repair of ulnar nerve

    Procedure: The patient was brought to the operative suite and then prepared and draped in the usual sterile manner. An exsanguinating tourniquet was used and inflated to approximately 250 mm of mercury. Tendons were noted to be completely intact. The nerve was then isolated in both proximal and distal ends. Utilizing an operating microscope, six through-and-through, 9-0 sutures were placed in the epineurium. When this was finished, the nerve was checked for congruity. It should be stated that the nerve was trimmed and the fascicles were lined up end-to-end as best as possible. After this, copious irrigation was undertaken, and bleeders were cauterized. The skin was then closed with 5-0 nylon and a sterile dressing was applied. The tourniquet was let down and a clamdigger splint with a rubber band through the nail was placed to ensure range of motion. The patient was discharged to the recovery room. No complications. Blood loss was approximately 15 cc. We used approximately 400 cc of Ringer's lactate.

    Provide the correct CPT code(s).

    A. 64836–F4 and 69990
    B. 64836-F2 and 69990
    C. 64831-LT and 29130-LT
    D. 64834 and 13131
    A. 64836–F4 and 69990
    (this multiple choice question has been scrambled)
  86. The surgeon performed a procedure that is unfamiliar to the coder, and she is having trouble locating an appropriate CPT code. What should be the coder's next action?

    A. Call the insurance company.
    B. Call the surgeon's office.
    C. Assign an "unlisted procedure" code.
    D. Research the description of the procedure.
    D. Research the description of the procedure.
    (this multiple choice question has been scrambled)
  87. A postal worker presented to the emergency department complaining of an unexplained rash. He thinks he may have been exposed to an unknown substance upon processing a bag of mail. Due to the nature of the complaint and the presenting symptom, his case was brought to the attention of the FBI as well as the U.S. Department of Homeland Security. Several individuals worked with this patient's record. Which of the following would NOT be considered an individual user of this patient's health record?

    A. an epidemiologist studying all local cases of rashes to track trends
    B. the coding specialist from the HIM department coding the case
    C. an agent from the FBI following up on the nature of the substance
    D. the emergency department physician involved in caring for the patient
    A. an epidemiologist studying all local cases of rashes to track trends
    (this multiple choice question has been scrambled)
  88. The Privacy Rule permits the use and disclosure of protected health information (PHI) by coding and auditing consultants. However, in order to access the patient's PHI, the consultants are required to

    A. obtain a blanket authorization from each patient authorizing the use of their protected health information.
    B. provide evidence of liability insurance and a minimum of 5 continuing education units pertaining to the use of PHI.
    C. have undergone HIPAA training and have passed a privacy test.
    D. have a written business associate agreement stipulating adherence to privacy laws governing the use of the PHI.
    D. have a written business associate agreement stipulating adherence to privacy laws governing the use of the PHI.
    (this multiple choice question has been scrambled)
  89. A 69-year old Medicare patient is admitted to the hospital for treatment of pneumonia. The patient has a history of a previous prostatectomy for prostate cancer. In addition to the pneumonia, the patient complains of severe groin pain at the site of his previous surgery. Upon the request of the patient's attending physician, the anesthesiologist evaluates the patient and elects to perform a pain injection at the site of the previous surgery. The anesthesiologist's conversion factor is $30.00.

    00800—Anesthesia for procedures on lower anterior abdominal wall; not otherwise specified (Base unit value of 4)
    64420—Injection, anesthetic agent; intercostal nerve, single (Base unit value of 5)
    64425—Injection, anesthetic agent, ilioinguinal, iliohypogastric nerves (Base unit value of 5)
    Assuming the above parameters are correct, choose the appropriate anesthesia code(s) from the list provided and calculate the charge(s).

    A. 00800 for $120
    B. 00800 for $120; 64420 for $150
    C. 64420 for $150
    D. 64425 for $150
    D. 64425 for $150
    (this multiple choice question has been scrambled)
  90. Which of the following terms are NOT considered interchangeable?

    A. data and information
    B. EHR and CPR
    C. data currency and data timeliness
    D. health records and resident records
    A. data and information
    (this multiple choice question has been scrambled)
  91. An organization for which you are working has decided to invest in a new electronic health record (EHR) system. A meeting is held to inform all of the organization's employees that the transition from a paper-based system to an EHR system will be established using the systems development life cycle (SDLC). The SDLC will be carried out in four phases: planning and analysis, design, implementation, and finally, maintenance and evaluation. Which of the following tasks would NOT be performed during the implementation process of the SDLC?

    A. selection of a vendor
    B. prepare procedure manuals
    C. training and trial runs
    D. building data tables
    A. selection of a vendor
    (this multiple choice question has been scrambled)
  92. The CPT codebook is published and maintained by the


    A. Department of Health and Human Services.
    B. Centers for Medicare and Medicaid Services.
    C. American Medical Association.
    D. American Hospital Association.
    C. American Medical Association.
    (this multiple choice question has been scrambled)
  93. Which statement is NOT true?

    A. All newborns, which have been born alive, have their own health record.
    B. Data about the baby is never recorded within the mother's health record.
    C. History contained within the newborn record begins with the birth history.
    D. Newborn records contain documentation of feeding and elimination status.
    B. Data about the baby is never recorded within the mother's health record.
    (this multiple choice question has been scrambled)
  94. Thermal intradiscal procedures (TIPs) involve the insertion of a catheter(s)/probe(s) in the spinal disc under fluoroscopy guidance for the purpose of producing or applying heat and/or disruption within the disc to relieve lower back pain.

    According to nationally non-covered indications, TIPS are not covered because

    A. CMS has determined that the procedure is used for patients who are asymptomatic.
    B. CMS has determined that formal protocol has not been established.
    C. CMS has determined that the techniques used are not FDA approved for OPPS payment.
    D. CMS has determined that the procedure is not reasonable and necessary for the treatment of low back pain.
    D. CMS has determined that the procedure is not reasonable and necessary for the treatment of low back pain.
    (this multiple choice question has been scrambled)
  95. What technological advance has had the best success in protecting the health record?

    A. telecommunications
    B. computer-assisted coding
    C. computerized MPI
    D. electronic health record
    D. electronic health record
    (this multiple choice question has been scrambled)
  96. Data consistency is imperative for the documentation within the health record to be considered reliable. Which of the following scenarios would cause the consistency of the data within the health record to be questionable?

    A. A patient is admitted for suspected recurrent pneumonia; the emergency department physician documented that the two-view chest X-ray shows infiltrates.
    B. A surgeon's discharge summary lists a diagnosis of carcinoma of the right breast, S/P mastectomy; the pathologist documents specimen as left breast.
    C. The final lab indicates the patient has Enterococcus faecalis in the urine; the physician documents a urinary tract infection possibly due to a gram-positive organism.
    D. The patient's chief complaint is right upper quadrant abdominal pain radiating to the back with vomiting; the surgical procedure is a laparoscopic cholecystectomy.
    B. A surgeon's discharge summary lists a diagnosis of carcinoma of the right breast, S/P mastectomy; the pathologist documents specimen as left breast.
    (this multiple choice question has been scrambled)
  97. National Coverage Determinations (NCDs) are developed by which organization?

    A. AHA
    B. CMS
    C. AMA
    D. MAC
    B. CMS
    (this multiple choice question has been scrambled)
  98. 97. Which of the following does NOT qualify as sensitive health information?

    A. a billing record containing insurance authorizations
    B. a positive finding of genetic risk for breast cancer
    C. delivery records containing evidence of an adoption
    D. a set of prenatal communicable disease testing results
    A. a billing record containing insurance authorizations
    (this multiple choice question has been scrambled)
  99. While coding a paper-based health record, you find that the final progress note contains the addressograph label from another patient. Which of the following is an acceptable practice when addressing erroneous documentation?

    A. Use correction fluid to cover the inaccurate label, and be sure to make the correction neatly as it will be part of the patient's legal health record.
    B. Cut and paste the sections you want to keep onto a new, correctly labeled progress note. Copy and place the photocopy in the health record.
    C. Remove the incorrect progress note. Remember to place it in the shredder to comply with HIPAA privacy requirements.
    D. Draw a single line through the incorrect label and write the word "error." Correct the information, identify your title, then sign and date the document.
    D. Draw a single line through the incorrect label and write the word "error." Correct the information, identify your title, then sign and date the document.
    (this multiple choice question has been scrambled)
  100. You have been employed as a coder at a local acute care hospital. When abstracting the records, you have been instructed to follow definitions established within a standardized healthcare data set, the Uniform Hospital Discharge Data Set (UHDDS). Which of the following data elements is NOT included as part of the UHDDS?

    A. principal diagnosis
    B. medication allergies
    C. type of admission
    D. newborn birth weight
    B. medication allergies
    (this multiple choice question has been scrambled)
  101.  A patient was diagnosed with a principal diagnosis of methicillin susceptible Staphylococcus aureus pneumonia and congestive heart failure due to hypertensive cardiovascular disease as secondary diagnosis. The core measures nurse has sent an e-mail to the HIM director requesting that a coder check the code assignments. When auditing the case, the coder finds the following codes were assigned: 482.42, 402.91, and 428.0. What is wrong with this set of codes?


    A. The case has been coded incorrectly as MRSA pneumonia instead of MSSA pneumonia.
    B. The coder should have assigned code V09.0 to capture the methicillin susceptibility.
    C. The case lacks a code for the causative organism (041.12) and is considered incomplete.
    D. Hypertensive cardiovascular disease with CHF should be coded to 401.9, 429.9, and 428.0.
    A. The case has been coded incorrectly as MRSA pneumonia instead of MSSA pneumonia
    (this multiple choice question has been scrambled)

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