Question 1

Match the following terms with their abbreviations.
-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 2

Match each item to one of the following definitions.
-Subjective

Accepted Answer

A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment 
A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment B

Question 3

What is the definition of subjective complaint as it applies to a patient coming to a healthcare facility?

Accepted Answer

The problem stated in the patient's own words

Question 4

Match each item to one of the following definitions.
-Objective

Accepted Answer

A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment 
A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment

Question 5

What does EKG stand for?

Accepted Answer

A) Electrocardiogram 
B) Electroencephalogram 
C) Electrokariesogram 
D) Electromagnetic 
A) Electrocardiogram 
B) Electroencephalogram 
C) Electrokariesogram 
D) Electromagnetic

Question 6

What does AHQA stand for?

Accepted Answer

American H

Question 7

Match each item to one of the following definitions.
-Chief complaint

Accepted Answer

A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment 
A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment

Question 8

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 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

Match the following terms with their abbreviations.
-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 11

Match the following terms with their abbreviations.
-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

Question 12

What year did the Uniform Hospital Discharge Data Set (UHDDS) mandate that hospitals must report a common core of data?

Accepted Answer

The answer of What year did the Uniform Hospital Discharge...

Question 13

The AHIMA practice brief says that a physician query should____.

Accepted Answer

A) "lead" the physician 
B) contain precise language 
C) be written on scratch paper 
D) sound presumptive 
A) "lead" the physician 
B) contain precise language 
C) be written on scratch paper 
D) sound presumptive

Question 14

What is the goal of the physician query process?

Accepted Answer

To improve physician documenta

Question 15

Give three reasons why a provider should be queried.

Accepted Answer

A provider should be queried when docume

Question 16

Match the following terms with their abbreviations.
-TPR

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 17

Match each item to one of the following definitions.
-The Joint Commission

Accepted Answer

A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment 
A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment

Question 18

If the condition of a patient is being clinically evaluated,the coder would expect to see ____.

Accepted Answer

A) an admission date 
B) letters 
C) clinical observations 
D) an operative report 
A) an admission date 
B) letters 
C) clinical observations 
D) an operative report

Question 19

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 20

Match each item to one of the following definitions.
-Healthcare providers

Accepted Answer

A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment 
A) Accredits and certifies healthcare 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 examination,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 healthcare facility for treatment

Exam 2: The Health Record As the Foundation of Coding

Match the following terms with their abbreviations. -UHDDS

Match each item to one of the following definitions. -Subjective

What is the definition of subjective complaint as it applies to a patient coming to a healthcare facility?

Match each item to one of the following definitions. -Objective

What does EKG stand for?

What does AHQA stand for?

Match each item to one of the following definitions. -Chief complaint

Which of these is NOT considered a physician?

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

Match the following terms with their abbreviations. -CMS

Match the following terms with their abbreviations. -GERD

What year did the Uniform Hospital Discharge Data Set (UHDDS) mandate that hospitals must report a common core of data?

The AHIMA practice brief says that a physician query should____.

What is the goal of the physician query process?

Give three reasons why a provider should be queried.

Match the following terms with their abbreviations. -TPR

Match each item to one of the following definitions. -The Joint Commission

If the condition of a patient is being clinically evaluated,the coder would expect to see ____.

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

Match each item to one of the following definitions. -Healthcare providers

The Rationale for and History of Coding

ICD-10-Cm Format and Conventions

Basic Steps of Coding

General Coding Guidelines for Diagnosis

General Coding Guidelines for Medical and Surgical Procedures

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

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

Reimbursement Methodologies

Out patient Coding

Filters