Question 1

Match each definition to one of the following items.
-GERD

Accepted Answer

A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease 
A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease D

Question 2

The patient history and physical need to be performed and documented within ___________ hours of admission for an inpatient encounter.

Accepted Answer

24

Question 3

Match each definition to one of the following items.
-UHDDS

Accepted Answer

A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease 
A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease C

Question 4

Which of these is NOT considered a physician?

Accepted Answer

A) Internist 
B) Hospitalist 
C) Resident 
D) Medical student 
A) Internist 
B) Hospitalist 
C) Resident 
D) Medical student

Question 5

Match each definition to one of the following items.
-Health care providers

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 6

Match each definition to one of the following items.
-CMS

Accepted Answer

A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease 
A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease

Question 7

Which report should be written or dictated immediately following a procedure?

Accepted Answer

The answer of Which report should be written or dictated...

Question 8

What is the goal of the physician query process?

Accepted Answer

To improve physician documenta

Question 9

One of the most important aspects of developing an effective query form is the manner in which the form is worded.

Accepted Answer

A) True 
 B)False

Question 10

How long after admission is it required by TJC that the admission history and physical be completed?

Accepted Answer

The answer of How long after admission is it required...

Question 11

Match each definition to one of the following items.
-Plan

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 12

In some cases, a patient is ready to be discharged from the hospital, but at the last minute, the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.

Accepted Answer

A) is feeling better 
B) has no pain 
C) has no additional cough 
D) develops a fever 
A) is feeling better 
B) has no pain 
C) has no additional cough 
D) develops a fever

Question 13

Match each definition to one of the following items.
-Chief complaint

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 14

A query should contain all of the following items EXCEPT ____.

Accepted Answer

A) date of service 
B) amount of increased reimbursement due to query 
C) patient name 
D) area for provider signature 
A) date of service 
B) amount of increased reimbursement due to query 
C) patient name 
D) area for provider signature

Question 15

Match each definition to one of the following items.
-Current Procedural Terminology (CPT) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 16

Which is the area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?

Accepted Answer

A) Nursing notes 
B) Anesthesia forms 
C) Physician orders 
D) Progress notes 
A) Nursing notes 
B) Anesthesia forms 
C) Physician orders 
D) Progress notes

Question 17

What does MRI stand for?

Accepted Answer

Magnetic r

Question 18

Match each definition to one of the following items.
-The Joint Commission

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 19

Chronic conditions include all of the following EXCEPT ____.

Accepted Answer

A) hypertension 
B) congestive heart failure 
C) diverticulitis 
D) emphysema 
E) all of the above are correct 
A) hypertension 
B) congestive heart failure 
C) diverticulitis 
D) emphysema 
E) all of the above are correct

Question 20

Abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.

Accepted Answer

A) True 
 B)False

Exam 2: The Health Record As the Foundation of Coding

Match each definition to one of the following items. -GERD

The patient history and physical need to be performed and documented within ___________ hours of admission for an inpatient encounter.

Match each definition to one of the following items. -UHDDS

Which of these is NOT considered a physician?

Match each definition to one of the following items. -Health care providers

Match each definition to one of the following items. -CMS

Which report should be written or dictated immediately following a procedure?

What is the goal of the physician query process?

One of the most important aspects of developing an effective query form is the manner in which the form is worded.

How long after admission is it required by TJC that the admission history and physical be completed?

Match each definition to one of the following items. -Plan

In some cases, a patient is ready to be discharged from the hospital, but at the last minute, the patient develops a condition that requires him or her to stay an additional night. An example of when a patient might have to stay an additional night is when the patient ____.

Match each definition to one of the following items. -Chief complaint

A query should contain all of the following items EXCEPT ____.

Match each definition to one of the following items. -Current Procedural Terminology (CPT) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

Which is the area of the record where the attending physicians, as well as physician consultants, give their directives to the house staff, nursing, and ancillary services?

What does MRI stand for?

Match each definition to one of the following items. -The Joint Commission

Chronic conditions include all of the following EXCEPT ____.

Abnormal findings (lab, x-ray, pathologic, and other diagnostic results) are always coded and reported when they are found.

The Rationale for and History of Coding

ICD-10-Cm Format and Conventions

Basic Steps of Coding

General Coding Guidelines for Diagnosis

Introduction to Icd-10-PCS

General Coding Guidelines for Other Medical- and Surgical-Related Procedures and Ancillary Procedures

Coding Medical and Surgical Procedures

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Certain Infectious and Parasitic Diseases

Neoplasms

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Endocrine, Nutritional, and Metabolic Diseases

Mental, Behavioral, and Neurodevelopmental Disorders

Diseases of the Nervous System, Diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous System

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

Certain Conditions Originating in the Perinatal Period and Congenital Malformations, Deformations, and Chromosomal Abnormalities

Injuries and Certain Other Consequences of External Cases and External Causes of Morbidity

Burns, Adverse Effects, and Poisonings

Complications of Surgical and Medical Care

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