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.
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. CMS
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.
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
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.
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
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.
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
D. demographic record.
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
The Privacy Rule stipulates that a patient authorization is required for
A. disclosure for employee background checks.
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?
C. the Health Insurance Portability and Accountability Act
Which of the following is the most useful for electronic exchange of drug product information?
D. NDC
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
B. Allow a coder to assume the role of an editor or auditor of code assignments.
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?
D. CPT code 75564 is a deleted CPT code as of January 1, 2010 and is invalid.
Which of the following organizations is NOT involved in establishing documentation guidelines for health records?
B. The National Alliance for Health Information Technology
An uncontrolled release of health information beyond the original intent authorized by the patient is a common ethical problem encountered when using
D. blanket authorizations.
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
B. expired.
A pathology report may contain which of the following?
B. gross findings
Level II HCPCS codes is a standardized coding system that is used primarily to identify
B. products, supplies, and services not included in CPT-4 codes
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
D. the long-term safety and efficacy of the device in the treatment of obesity has not been established.
A diagnostic descriptor that is listed in italics is a(n)
C. manifestation code.
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?
C. Ignore the edit because the labs were performed on two different dates of service.
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. 276.51, 787.01
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. exam data
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. being unable to maintain or improve consistent coding productivity levels
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.
D. 72.71, 75.69
Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called
D. .encoders.
Which modifier from the answer choices below is NOT a HCPCS Level II modifier?
B. IV
Which of the following statements is NOT true regarding the Internet?
A. Accessing the Internet by way of an intranet is less secure.
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. imaging
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. 844.9
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?
B. 59
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).
D. 00790–P2 for $400
A. 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.
Which of the following would NOT be considered a type of application software?
B. Microsoft Windows
Diagnoses described as "possible," "probable," "likely," and "rule out" are reported if present for what type of records?
A. inpatient
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
Which of the following is NOT considered to be an accreditation organization?
C. Centers for Medicare and Medicaid Services
In the ICD-9-CM Alphabetic Index, the primary arrangement of main terms is by
D. CONDITION
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?
D. uniform ambulatory care data set
Which of the following would NOT be coded under HCPCS Level II J0000-J9999?
D. self-administered drugs
An example of an acceptable National Correct Coding Initiative (NCCI) modifier is
D. 52
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. Joint Commission's prohibited abbreviations list.
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?
D. The physician needs to document the reason the patient is on Coumadin therapy.
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.
D. The documentation does not support the codes assigned.
Per ICD-9-CM Official Guidelines for Coding and Reporting, chapter 11 codes have sequencing priority over
B. codes from all other chapters.
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?
C. Know your department's contingency plan.
When utilizing the computerized physician/provider order-entry, which of the following statements would be considered to be false?
C. The computerized order-entry eliminates medication errors.
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. laboratory test results.
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?
C. history and physical
Which entity is NOT responsible for the development of local coverage decisions (LCDs)?
D. local state government
The CPT-4 procedure codes below have a Medically Unlikely Edit "2" in the OPPS Medically Unlikely edits table.
B. the maximum number of the procedure that is allowed to be billed on the OOPS claim.
Which standards organization developed the most comprehensive standardized vocabulary used to date?
B. SNOMED
Which of the following is NOT considered protected health information?
B. de-identified information
The modifier GZ would be used for which of the following?
B. The provider expects that the service will be denied.
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. outcomes and assessment information set (OASIS)
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?
D. porcine skin, gradient pressure dressing
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
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?
D. 99281
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?
D. All ethical decisions require seeking legal counsel.
Which scenario does NOT constitute a potential privacy issue?
D. Two HIM coders discuss a case at work to resolve a coding issue.
Which of the following does NOT have the potential to result in a security breach?
C. access controls
Which of the following is responsible for mandating privacy standards when encountering or working with identifiable health information?
A. HIPAA
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. Notify the privacy officer immediately of the security breach.
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?
B. devices for parenteral and enteral nutrition supplies and kits
Which of the following types of documentation would NOT be required for a surgical record?
A. pathology report
Which of the following regarding the Accredited Standards Committee (ASC X12N) electronic transaction standards is true?
B. They were designed to facilitate an exchange of data between payers and providers.
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.
D. second order branch (CPT code 36246)
Which of the following best reflects a primary purpose of the health record?
D. patient care
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.
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?
C. the infectious disease specialist
What type of encoding system uses expert or artificial intelligence software to automatically assign code numbers?
C. natural language processing
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
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?
B. principal procedure: 51.23, secondary procedure code(s): 50.14
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?
B. may be used to capture granular patient information
All of the alpha codes below are included in the HCPCS Level II coding system EXCEPT
B. B codes-Medicaid State programs to report biologicals/pharmaceuticals for which there are no CPT-4 codes.
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?
B. 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.
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?
D. accurate code assignments
The most important purpose of establishing accurate and timely documentation requirements for the patient health record is
B. to ensure and improve the quality of direct patient care.
The obstetric delivery record contains all of the following EXCEPT
D. prenatal care summary
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
C. a security breach.
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?
C. National Drug Directory
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?
D. ORYX uses the National Drug Code (NDC) Directory to collect data regarding ineffective drug therapy treatments.
The modifier 91 would be used for which of the following?
B. modifier for service units greater than 1 for lab service
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. dehydration
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).
C. 64836–F4 and 69990
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?
B. Research the description of the procedure.
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
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
B. have a written business associate agreement stipulating adherence to privacy laws governing the use of the PHI.
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).
C. 64425 for $150
Which of the following terms are NOT considered interchangeable?
B. data and information
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?
D. selection of a vendor
The CPT codebook is published and maintained by the
C. American Medical Association.
Which statement is NOT true?
C. Data about the baby is never recorded within the mother's health record.
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
D. CMS has determined that the procedure is not reasonable and necessary for the treatment of low back pain.
What technological advance has had the best success in protecting the health record?
C. electronic health record
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?
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.
National Coverage Determinations (NCDs) are developed by which organization?
C. CMS
97. Which of the following does NOT qualify as sensitive health information?
A. a billing record containing insurance authorizations
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?
C. 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.
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?
C. medication allergies
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?
B. The case has been coded incorrectly as MRSA pneumonia instead of MSSA pneumonia
