Question 1

What does EKG stand for?

Accepted Answer

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

Question 2

What is the goal of the physician query process?

Accepted Answer

To improve physician documentation and coding professionals' understanding of the unique clinical situation

Question 3

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

Accepted Answer

Within 24 hours

Question 4

Principal diagnosis is one of the most important concepts for coders to understand and apply.

Accepted Answer

A) True 
 B)False

Question 5

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 6

MATCHING
Match each item to one of the following definitions.
-Principal diagnosis

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 7

Match the following terms with their abbreviations/acronyms:
-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

Question 8

MATCHING
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 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

It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.

Accepted Answer

A) True 
 B)False

Question 11

Every facility should have the same policies and procedures with regard to the query process.

Accepted Answer

A) True 
 B)False

Question 12

The reason,in the patient's own words,for presenting to the hospital is the _________________.

Accepted Answer

The answer of The reason,in the patient's own words,for presenting...

Question 13

MATCHING
Match each item to one of the following definitions.
-Physician

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 14

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 15

Match the following terms with their abbreviations/acronyms:
-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 16

What does MRI stand for?

Accepted Answer

Magnetic r

Question 17

MATCHING
Match each item to one of the following definitions.
-Plan

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

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

Accepted Answer

The proble

Question 19

What are three of the five purposes of a health record?

Accepted Answer

The following are purposes of a health r

Question 20

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

Exam 2: The Health Record As the Foundation of Coding

What does EKG stand for?

What is the goal of the physician query process?

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

Principal diagnosis is one of the most important concepts for coders to understand and apply.

Which of these is NOT considered a physician?

MATCHING Match each item to one of the following definitions. -Principal diagnosis

Match the following terms with their abbreviations/acronyms: -UHDDS

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

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

It is the responsibility of a coder to extract from the health record the diagnoses and procedures for which a patient is being treated.

Every facility should have the same policies and procedures with regard to the query process.

The reason,in the patient's own words,for presenting to the hospital is the _________________.

MATCHING Match each item to one of the following definitions. -Physician

The AHIMA practice brief says that a physician query should____.

Match the following terms with their abbreviations/acronyms: -TPR

What does MRI stand for?

MATCHING Match each item to one of the following definitions. -Plan

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

What are three of the five purposes of a health record?

Chronic conditions include all of the following EXCEPT ____.

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 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

Filters