Question 1

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

Accepted Answer

A) True 
 B)False

Question 2

A _________________ is usually written by the attending physician on a daily basis to describe how the patient is progressing and the plan of care.

Accepted Answer

The answer of A _________________ is usually written by the...

Question 3

MATCHING
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 4

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

Accepted Answer

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

Question 5

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 6

MATCHING
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 7

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

Accepted Answer

The answer of The patient history and physical need to...

Question 8

Sometimes ____ will be used to help diagnose a patient's condition.

Accepted Answer

A) X-rays 
B) history and physical 
C) documentation 
D) a discharge disposition 
A) X-rays 
B) history and physical 
C) documentation 
D) a discharge disposition

Question 9

What does AHQA stand for?

Accepted Answer

American H

Question 10

MATCHING
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

Question 11

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 12

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

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 13

Which is an 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 14

Match the following terms with their abbreviations/acronyms:
-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 15

Give three reasons why a provider should be queried.

Accepted Answer

A provider should be queried when docume

Question 16

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 17

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

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

Match the following terms with their abbreviations/acronyms:
-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 19

MATCHING
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

Question 20

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

Exam 2: The Health Record As the Foundation of Coding

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

A _________________ is usually written by the attending physician on a daily basis to describe how the patient is progressing and the plan of care.

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

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

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

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

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

Sometimes ____ will be used to help diagnose a patient's condition.

What does AHQA stand for?

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

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

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

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

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

Give three reasons why a provider should be queried.

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

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

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

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

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 ____.

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

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