Bundle
AHIMA CDIP / AHIMA CCS Exam Bundle (Grade A)
10 Items
AHIMA CDIP Practice Exam 1 with complete solutions
Assign code(s) for the following diagnosis: Congestive heart failure due to hypertension. I10 Essential (primary) hypertension I11.9 Hypertensive heart d... [Show More] isease without heart failure I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I50.1 Left ventricular failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure I50.23 Acute on chronic systolic (congestive) heart failure a.I10, I50.9 b.I11.0 c.I50.23, I10 d.I11.0, I50.9 - ANSWER-d Heart conditions are assigned a combination code when a causal relationship is stated (due to hypertension) or implied (hypertensive). Use an additional code to identify the type of heart failure in those patients with heart failure (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 41). Assign the best answer to complete the following sentence. The CPT codes for treatment of fractures: a.Use the terminology "manipulation" rather than "reduction" of fracture b.Include internal fixation in all codes c.Do not include application of cast d.Do not differentiate between open and closed treatment; CPT only specifies the site of the fracture - ANSWER-a Manipulation refers to the attempted reduction or restoration of a dislocated joint or fracture (Smith 2015, 84) In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, the coder would assign: a.Two CPT codes expressing each laceration repair b.One CPT code for the largest laceration c.One CPT code, adding the lengths of the lacerations together d.One CPT code for the most complex closure - ANSWER-c When multiple wounds are repaired with the same closure type (for example, simple), lengths of the wounds in the same classification and from all anatomical sites that are grouped together into the same code descriptor should be added together (Smith 2015, 67). Patient admitted for laparoscopic repair of right diaphragmatic hernia. Assign the ICD-10-PCS procedure code for this surgery. 0BQR4ZZ Repair right diaphragm, percutaneous endoscopic approach 0BQROZZ Repair right diaphragm, open approach 0BQS4ZZ Repair left diaphragm, percutaneous endoscopic approach 0BQSOZZ Repair left diaphragm, open approach a.0BQR4ZZ b.0BQR0ZZ c.0BQS4ZZ d.0BQS0ZZ - ANSWER-a Surgery is the only treatment for diaphragmatic hernias. ICD-10-PCS code 0BQR4ZZ, is used for laparoscopic repair of diaphragmatic hernia (Garvin 2015, 192, 284) When trying to determine if documentation is present to substantiate status asthmaticus, the coder should review the record for what terms and phrases? a.Intractable pneumonia b.Refractory asthma and severe, intractable wheezing c.Airway obstruction relieved by bronchodilators d.Limited but pronounced wheezing - ANSWER-b Status asthmaticus is defined as continual wheezing in spite of therapy (Leon-Chisen 2013, 230). Gastrointestinal bleeding can manifest as: a.Hematemesis, which indicates acute upper gastrointestinal hemorrhage b.Petechia c.Vomiting d.Constipation, which indicates upper or lower gastrointestinal hemorrhage - ANSWER-a Gastrointestinal bleeding manifests itself in several ways. These are hematemesis, melena, occult bleeding, hematochezia (Leon-Chisen 2013, 244). Which types of pacemaker devices have a unique ICD-10-PCS code. a.Dual chamber rate responsive b.Single chamber, single chamber rate responsive, and dual chamber c.Multiple chamber d.Multiple chamber rate responsive - ANSWER-b The three types of pacemakers are single chamber, single chamber rate responsive, and dual chamber. A single chamber uses a single lead; a dual chamber requires two leads, one in the atrium and one in the ventricle. The leads should also be coded (Leon-Chisen 2013, 416-418). Mechanical ventilation codes require consideration of which of the following? a.The time when a tracheal tube is inserted b.The replacement of an endotracheal tube c.The start time of endotracheal tube insertion followed by mechanical ventilation d.Mechanical ventilation during surgery - ANSWER-c Codes for mechanical ventilation indicate whether the patient was on mechanical ventilation for less than 24 hours, 24-96 consecutive hours and greater than 96 consecutive hours. The start time for calculating the duration begins with the start time of endotracheal tube insertion as the best method, followed by mechanical ventilation or the time that a patient who is on mechanical ventilation is admitted. The time ends with discontinuance of mechanical ventilation (Leon-Chisen 2013, 239-240). Abbreviations can be a source of patient safety issues due to misinterpretation and miscommunication. Abbreviations in the health record: a.Are not permitted by Joint Commission standards b.Should have only one meaning c.Enhance patient safety d.Are critical to an electronic health record system - ANSWER-b The Joint Commission has established a cautious quality approach to the use of abbreviations in all its accredited organizations. To comply, every healthcare organization should strive to limit or eliminate the use of abbreviations by developing an organizationspecific abbreviation list so that only those abbreviations approved by the organization are used. When more than one meaning for an approved abbreviation exists, an organization should choose only one meaning or context in which the abbreviation is to be used (Shaw and Carter 2014; Brodnik et al. 2012, 180-181). In ICD-10-PCS, what value is used if there is a character that does not apply to a given code? a.X b.Z c.0 d.- - ANSWER-b All ICD-10-PCS codes must be seven characters, and a character cannot be left blank. If a value does not exist for a given character, the Z is used as the value (Shaw and Carter 2014; Kuehn and Jorwic 2013, 5). Which symbol of punctuation is used in the Tabular List to enclose synonyms, alternative wording, or explanatory phrases? a.Parentheses b.Brackets c.Colon d.Comma - ANSWER-a Punctuation is widely used in coding. Brackets are used in the Alphabetic Index to identify manifestation codes as well as to enclose synonyms, alternative wording or explanatory phrases. (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 8) When the documentation in the medical record is insufficient to assign a more specific code, a _______ code is assigned. a.MCC b.CC c.NOS d.Unspecified - ANSWER-d When documentation in the record is not available to assign a more specific code, an unspecified code is assigned (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 10) A 30-year-old cerebral palsy patient was admitted with acute bronchitis, possible pneumonia. In reviewing the diagnoses below what additionally will impact the patient's ICD-10 code assignment. a.Spasticity b.Quadriplegia c.Both A and B d.None of the above - ANSWER-c ICD-10 Cerebral palsy and other paralytic syndromes (G80-G83) has additional specificity for spasticity as well as state of paralysis if any (AHIMA 2015, 23). A 90-year-old female was determined to have a CVA with hemorrhage. The cause of the hemorrhage was determined to be an embolism. What additionally could impact code assignment for the embolism code? a.Hematemesis b.Hypertension c.Site of the hemorrhage d.Seizure - ANSWER-c ICD-10 includes the site of the of the hemorrhage for increased specificity. If a patient undergoes a biopsy immediately before the definitive surgery for a frozen section, how should this be coded with ICD-10-PCS codes? a.The approach to the definitive surgery b.Suture method c.Exploratory surgery d.Open biopsy and definitive surgery - ANSWER-d The open biopsy is performed prior to the definitive surgery so that the pathologist can perform a frozen section of the tissue to determine malignancy. Approaches, suturing, and closure are not coded separately. Exploratory surgery is not coded when definitive surgery is performed (Leon-Chisen 2013, 92). A patient was admitted with diminished responsiveness and hypotension. The patient has a history of hypertension, CVA, CHF, and asthma. The patient suffered a cardiac arrest immediately following admission. The documentation within the record should: a.List hypotension as first-listed b.Include the reason for the cardiac arrest c.Include the date of the previous CVA d.Type of hypotension - ANSWER-b Instructional notes in ICD-10-CM for cardiac arrest states "code first underlying condition". Causes of nonpressure ulcers of the lower limb include: a.Varicose ulcers b.Chronic venous hypertension c.Diabetic ulcer d.All of the above - ANSWER-d The causes of lower limb ulcers include Atherosclerosis of lower extremity, Chronic venous hypertension, Diabetic ulcer, Postphlebitic syndrome, Postthrombotic syndrome, Varicose ulcer, and Other as specified (AHIMA 2015, 38). An 82-year-old female was walking and inadvertently twisted an ankle causing a minor fall. The patient suffered a fracture of the tibia. The patient was treated and released. It was discussed with the patient to take her hydrocodone as prescribed and continue her medications for osteoporosis, hypertension, and calcium. This fracture: a.is only a minor setback for the patient b.has Core measures to meet for quality c.is coded as pathologic with osteoporosis d.is coded as a traumatic fracture - ANSWER-c Osteoporosis with current pathological fracture: A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 51). A patient presented with pain in the right foot; right big toe. On physical exam, the toe was noted to be red and warm to touch. Laboratory findings show an elevated uric acid. The patient has a previous medication history of colchicine. Which diagnosis below was most likely listed in the diagnostic statement? a.Arthritis of the right toe b.Gout of the right toe c.Cellulitis of the right toe d.Elevated uric acid - ANSWER-b Gout inflammation of the joints. This is a metabolic disorder that in acute cases can cause some joints swell up become very painful. Crystals of uric acid that build up mostly in the joints cause the inflammation (NIH n.d.) This 75-year-old patient has a history of Alzheimer's disease. She is admitted with hypertensive encephalopathy with increased confusion. Her daughter states that she has noticed that she filled her once a day antihypertensive prescription 14 days ago and it still contains the original 30 tablets. This patient most likely could be queried for: a.Overdosing b.Underdosing c.A drug interaction d.Advancing Alzheimer's - ANSWER-b Using a prescribed medication less frequently than prescribed, in small doses, or not using the medication as instructed should be documented as "underdosing" by the provider (AHIMA 2015, 56) A patient was admitted with elevated white blood cells at 15.7 in the presence of cough and shortness of breath. Patient with a history of CHF on Lasix and COPD exhibiting symptoms of exacerbation with pulmonary edema along with crackles in the bases on exam with underlying infectious process, pneumonia. Chest x-ray shows left basilar infiltrate. The patient was started on antibiotic; azithromycin with Rocephin added. Physician lists CHF, pneumonia, COPD. In this example, pneumonia is the: a.Principal diagnosis b.Secondary diagnosis c.Query warranted d.Not enough information for assignment of a principal - ANSWER-a The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care." In this example, pneumonia is the principal based on presenting signs, symptoms, workup, and treatment (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 97) Based on the example above, the other/secondary diagnosis(es) would be: a.CHF, pneumonia b.Pneumonia, COPD c.CHF, COPD d.COPD - ANSWER-c The CHF and COPD meet the definition for "other diagnoses" as additional conditions that affect patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital stay; or increased nursing care and/or monitoring (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 100). Following a cholecystectomy for gallstones, a patient developed intractable nausea and vomiting requiring an observation stay. The principal diagnosis for this observation stay should be: a.Gallstones b.Nausea and Vomiting c.Intractable nausea and vomiting d.Postop nausea and vomiting - ANSWER-a Per Official Coding Guidelines, when a patient is admitted for observation for a medical condition, assign a code for the medical condition as the first-listed diagnosis. When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 103). The CDS performs case review after admission to obtain the: a.Case Mix Index b.Core Measure Score c.working DRG d.final DRG - ANSWER-c The CDS performs case review after admission to obtain the "working DRG." Goal should be facility specific but usually 24-48 hours after admission (Hess 2015, 376). A patient is being seen in the clinic for possible CHF. She has pedal edema and shortness of breath. The physician's office note states rule out, CHF; shortness of breath. The patient's reported diagnosis for this outpatient visit should be: a.CHF b.Rule out CHF c.Shortness of breath d.Shortness of breath and pedal edema - ANSWER-d The shortness of breath and pedal edema would be reported for this outpatient visit. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 104). A 32-year-old female had a liver transplant 2 years ago. She has been experiencing problems with her kidneys with a GFR of 20 and Stage IV CKD. She is noted to have some jaundice. Based on this: a.Query should be performed for complication of liver transplant b.Query should be performed for rejection of liver transplant c.Query should not be performed as there are no liver complications d.No additional documentation needed for reporting - ANSWER-a It is noted that the patient has a previous liver transplant and experiencing jaundice. If a transplant complication such as failure or rejection or other transplant complication is documented, see section I.C. 19.g for information on coding complications of a kidney transplant. If the documentation is unclear as to whether the patient has a complication of the transplant, query the provider (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 52). When a patient is admitted for treatment of a secondary malignancy with an active primary site the principal diagnosis should be: a.The primary malignancy b.The secondary malignancy c.Either condition d.Query should be performed - ANSWER-b When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 23). Assign the following diagnosis code: Permanent atrial fibrillation I47.2 Ventricular tachycardia I47.9 Paroxysmal tachycardia, unspecified I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation a.I47.2 b.I47.0 c.I48.1 d.I48.2 - ANSWER-d In the ICD-10 alphabetic index, permanent atrial fibrillation is under the main term chronic atrial fibrillation. Atrial fibrillation can be permanent and medicines or other treatments can't restore normal heart rhythm (ICD-10-CM Official Guidelines for Coding and Reporting 2016b; NIH 2014). The Glasgow Coma Scale includes evaluation of: a.Eye opening response, verbal response, and motor response b.Visual response, verbal response, and motor response c.Eye opening response, verbal Response, and neurological response d.None of the above - ANSWER-a The Glasgow Coma Scale includes Eye Opening Response •Spontaneous-open with blinking at baseline 4 points •To verbal stimuli, command, speech 3 points •To pain only (not applied to face) 2 points •No response 1 point Verbal Response •Oriented 5 points •Confused conversation, but able to answer questions 4 points •Inappropriate words 3 points •Incomprehensible speech 2 points •No response 1 point Motor Response •Obeys commands for movement 6 points •Purposeful movement to painful stimulus 5 points •Withdraws in response to pain 4 points •Flexion in response to pain (decorticate posturing) 3 points •Extension response in response to pain (decerebrate posturing) 2 points •No response 1 point When a patient has complete immobility due to severe physical disability or frailty it is called: a.paralysis b.quadriplegia c.functional quadriplegia d.debility - ANSWER-c Functional quadriplegia is the lack of ability to use one's limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury, should not be used for cases of neurologic quadriplegia. It should only be assigned if functional quadriplegia is specifically documented in the medical record (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 65). Severe sepsis with acute organ dysfunction requires a code for severe sepsis and: a.Specific organ dysfunction b.Underlying infection c.Sepsis only d.Multiple organ dysfunction - ANSWER-b The coding of severe sepsis requires a minimum of 2 codes: first a code for the underlying systemic infection, followed by a code from subcategory R65.2, Severe sepsis. If the causal organism is not documented, assign code A41.9, Sepsis, unspecified organism, for the infection. Additional code(s) for the associated acute organ dysfunction are also required. Due to the complex nature of severe sepsis, some cases may require querying the provider prior to assignment of the codes (ICD-10-CM Official Guidelines for Coding and Reporting 2016b, 21). This root operation alters the diameter or route of a tubular body part and completely closes an orifice orlumen; for example, tubal ligation of Fallopian tubes. a.Dilation b.Ligation c.Occlusion d.Restriction - ANSWER-c Occlusion is applied to a procedure to close off a tubular body part or orifice via natural orifice or an artificially created orifice. Occlusion includes both intraluminal or extraluminal methods of closing off the body part (Leon-Chisen 2013, 98). The patient underwent laparotomy to determine if repair was needed to a patient's gastric bypass due to a fall later the day of procedure while in the hospital. No damage was identified and the wound was closed. The CDS is not sure what root operation to use. The most appropriate root operation would be: a.Inspection b.Revision c.Exploration d.Repair - ANSWER-a This visual exploration is an inspection and may be performed with or without optical instrumentation. This procedure can be directly or through intervening body layers (Leon-Chisen 2013, 98). A 32-year-old female fractured her ankle when she stumbled over the shopping cart while pushing it in the supermarket. The orthopedic surgeon recommended open fusion of the right ankle with direct internal fixation, which was performed. Complete the coding of this procedure using the chart below OSGF _ _ _ ApproachDeviceQualifier0 Open4 Internal Fixation DeviceZ No Qualifier3 Percutaneous5 External Fixation Device4 Percutaneous endoscopic7 Autologous Tissues SubstituteJ Synthetic SubstituteK Nonautologous Tissues SubstituteZ No device a.OSGF34Z b.OSGF05Z c.OSGF04Z d.OSGF35Z - ANSWER-c The correct code assignment for Fusion of the right ankle open with internal fixation is OSGF04Z (Leon-Chisen 2013, 102). One year ago, the patient had a hysterectomy for adenocarcinoma of the uterus. The patient is scheduled for removal of both fallopian tubes due to extension with recent diagnosis of adenocarcinoma of the left fallopian tube. Based on this, the adenocarcinoma of the uterus should be coded as: a.Adenocarcinoma of the uterus b.Adenocarcinoma of the uterus, recurrent c.History of malignant neoplasm of the uterus d.Not coded - ANSWER-c When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy (ICD-10-CM Official Guidelines for Coding and Reporting, 2016b). The adenocarcinoma of the fallopian tube should be coded as a.Adenocarcinoma of the fallopian tube, primary b.Adenocarcinoma of the fallopian tube, secondary c.History of malignant neoplasm of the fallopian tube d.Not coded - ANSWER-b Any mention of extension, invasion, or metastasis to another site (in this case uterus with extension to fallopian tubes) is coded as a secondary malignant neoplasm to that site. The secondary site may be the principal or first-listed with the Z85 code used as a secondary code (ICD-10-CM Official Guidelines for Coding and Reporting, 2016b). Modifier 59 provides guidance that a service is distinct and separate. Beginning January 2015, 4 new modifiers were created to provide greater reporting specificity in situations where modifier 59 was previously reported and may be utilized in lieu of modifier 59 whenever possible. These modifiers are a.XA, XB, XC, XD b.CC44, CC45, CC46, CC47 c.XE, XS, XP, XU d.44, 45, 45, 47 - ANSWER-c Modifiers, XE, XS, XP, XU, were created to be utilized in lieu of modifier 59 to provide increased specificity (CMS 2014a). E/M services refer to visits and consultations furnished by physicians and the following qualified NPPs: a.Physical therapists; clinical nurse specialists; certified nurse midwives; and physician assistants b.Nurse practitioners; clinical nurse specialists; certified nurse midwives; and physician assistants c.Speech therapists, clinical nurse specialists; certified nurse midwives; and physician assistants d.These services are furnished for physicians only - ANSWER-b E/M services refer to visits and consultations furnished by physicians and the following qualified NPPs: •Nurse practitioners; •Clinical nurse specialists; •Certified nurse midwives; and •Physician assistants. A NPP's Medicare benefit must permit him or her to bill for E/M services, and the services must be furnished within the scope of practice in the State in which the NPP practices in order to receive payment from Medicare (CMS 2015a). Every organization should develop a query policy and procedure that is specific to its organization and that addresses when to ask queries, who asks queries and to whom, the hospital's responsibility in supporting the query process, acceptable ways to respond to queries, and ___________ a.How to optimize revenue b.The physician's responsibility in responding to queries c.Number of queries to ask d.DRGs to target for revenue impact - ANSWER-b Every organization should develop a query policy and procedure that is specific to its organization and that addresses: •When to ask queries, •Who asks queries and to whom, •The hospital's responsibility in supporting the query process, •Acceptable ways to respond to queries, as well as the physician's responsibility in responding to queries Oversight of the CDI program should be comprised of the physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with: a.Executive leadership b.Service line directors c.Patient Financial Services d.Information Technology - ANSWER-a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105). Anywhere Hospital has been experiencing problems interacting with the medical staff. Anywhere should utilize which committee to assist with these problems? a.Compliance committee b.Executive committee c.Medical staff committee d.Oversight committee - ANSWER-a A CDI program should have support for physician advisor or leader for clinical documentation and CDI, and the manager of the CDI program, along with executive leadership (Hess 2015, 105). A new or restructuring CDI program should ask: a.How can the bottom line be increased? b.How many queries must be performed for financial success? c.Why does clinical documentation need to be improved? d.How fast can this be done? - ANSWER-c Understanding why a facility want to improve clinical documentation to support the vision of the program for all involved in the effort (Hess 2015, 205). A new CDI program is experiencing conflicts within the health record between a consulting physician and the physician ultimately responsible for the documentation of the patient. The physician ultimately responsible is the: a.Consulting physician b.Hospitalist c.Attending physician d.Intensivist - ANSWER-c The attending physicians are responsible for the documentation that supports the final diagnostic statement for the patient (42 CFR 412.46). The attending physician should be asked to provide the final documented response when inconsistencies arise within the record (42 CFR 412.46; Hess 2015, 29). Which of the following would generally be found in a query to a physician? a.Health record number and demographic information b.Name and contact number of the individual initiating the query and account number c.Date query initiated and date query must be completed d.Demographic information and name and contact number of individual initiating the query - ANSWER-b It is recommended that the healthcare entity's policy address the query format. A query generally includes the following information: patient name, admission date or date of service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart (for example, history and physical states urosepsis, lab reports WBC of 14,400, emergency department report fever of 102°F) (Shaw and Carter, 2014; Schraffenberger and Kuehn 2011, 45-46). In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a.Note the condition as present on admission b.Query the physician to determine if the condition was present on admission c.Note the condition as unknown on admission d.Note the condition as not present on admission - ANSWER-b As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 42). The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Jill makes an average of eight errors per day, Mary makes an average of four errors per day, and Carl and Deb each make an average of three errors per day. Given this information, what action should the coding supervisor take? a.Counsel Jill because she has the highest error rates b.Encourage Jill and Mary to get additional training c.Provide Carl and Deb with incentive pay for low coding error rates d.Take no action, since not enough information is given to make a judgment - ANSWER-d The error rates are not comparable since there is no data about the number of records coded during the period by each coder (Shaw and Carter 2014; Schraffenberger and Kuehn 2011, 319-320). Which of the following statements is most accurate regarding effective communication? a.Use passive listening b.Monitor others' nonverbal behaviors for cues that they are following or confused c.Make sure all parties are distracted to better communicate your message d.Message content is more important than how it is delivered - ANSWER-b To communicate effectively, managers must pay just as much attention to how their message is received and interpreted as they do to its content. In order to enhance the accuracy and acceptance of communication, the communicator needs to monitor others' nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties would not enhance effective communication (Shaw and Carter 2014; LaTour et al. 2013, 698). Dr. Smith is the physician advisor for a 200-bed hospital in the south. He has a very close relationship with the physicians within this small facility and they all share many of the patients. Dr. Smith should: a.Tell the physicians he has the best relationships with the physicians and can tell them what to document b.Document specifically what is needed in the health record for the patient c.Not tell or ask a treating physician to document something specifically d.Respond to queries on patients they both have seen in the past 3 years - ANSWER-c Within small communities patients may migrate from physician to physician. However, it is imperative that physician executives limit their documentation only to those patients whom they are treating. In particular, physician executives may not tell or ask a treating physician to document something specifically in the patient's record Physician executives can ask open-ended questions based on the criteria. (Hess 2015, 30). Communication within a CDI program is important from the very beginning. The three key concepts that should be considered in communication for the program are who communicates it, what is communicated, and_____: a.When is it communicated? b.How will it be communicated? c.How long will it be communicated? d.All of the above - ANSWER-b It is important to communicate information on the CDI process prior to starting or operationalizing a CDI program. Key concepts to cover are: •WHO communicates it—From whom will communications come? •HOW will it be communicated—What media will the CDI program use? •WHAT is communicated—What information will the CDI staff communicate? (Hess 2015, 109) To ensure a CDI program is successful and sustainable it should have: a.Physician leadership b.Metrics c.A CDI manager d.Resources such as CDI software - ANSWER-a Physician leadership is essential to a successful and sustainable CDI program (Marco and Buchman 2003; Keogh and Martin 2004; Hess 2015, 122). Dr. Bach has noted he has been increasingly negotiating problems between coders, CDS staff, and physicians. Dr. Bach stated he will no longer do this as this is not the role of the physician advisor: a.This is an accurate statement b.This is an inaccurate statement c.The CDI manager should begin to fill this role d.The HIM or coding manager should begin to fill this role - ANSWER-b It is important for the physician to undergo training and fully understand their role. The leader should be available to assist in particularly challenging reviews and when the CDI specialist encounters a problematic physician (Hess 2015, 122). The role of the physician advisor for CDI should require a minimum of: a.No formal training b.10 hours of training c.40 hours of training d.1 year of coding experience - ANSWER-c Physician advisors should participate in a minimum of 40 hours of training regarding CDI (Hess 2015, 124). Pat, the CDI manager at Uno Hospital, has hired 2 new CDS members. She wants to ensure they understand the standards of CDI internally and nationally. She could have them read and sign the: a.Uno HIPAA statement b.AHIMA Standards of Ethical Coding c.AHIMA Ethical Standards for Clinical Documentation Improvement (CDI) Professionals d.Uno Memorandum of Understanding - ANSWER-c As stated by AHIMA, The AHIMA Code of Ethics (available on the AHIMA web site: http://www.ahima.org/about/ethics.asp) is relevant to all AHIMA members and credentialed HIM professionals and students, regardless of their professional functions, the settings in which they work, or the populations they serve. The AHIMA Ethical Standards for Clinical Documentation Improvement Professionals are intended to assist in decision making processes and actions, outline expectations for making ethical decisions in the workplace, and demonstrate the professionals' commitment to integrity. They are relevant to all clinical documentation improvement professionals and those who manage the clinical documentation improvement (CDI) function, regardless of the healthcare setting in which they work, or whether they are AHIMA members or nonmembers. Which of the following is an example of ethical issues related to coding? a.Inaccurate performance data b.Fraud and abuse c.Release of sensitive data d.Mistreatment of a vulnerable population - ANSWER-b Failure to heed the complex rules of coding for reimbursement can lead to problems with compliance and with fraud and abuse for the HIM professional (Harman 2013, 356). Terms synonymous with query are clarification, clinical clarification, documentation alert, and___________: a.Inquiry b.Documentation clarification c.None, query is the only term d.Physician inquiry - ANSWER-b Other terminology that means the same as query are clarification, clinical clarification, documentation alert, and documentation clarification (AHIMA 2014a, 4). The work and activities of the CDI professional should be tracked and monitored with a: a.Report b.Manager c.Quality assurance (QA) audit tool d.Performance improvement tool - ANSWER-c Monitoring a program can be vital for any process. Utilizing a Quality Assurance (QA) audit tool can ensure compliance and program success. (AHIMA 2014a, 6). [Show Less]
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AHIMA CDIP Exam prep Questions and Answers (Graded A)
Cert - ANSWER-Comprehensive error testing rate Cpt - ANSWER-Current procedural terminology. The amas list of 5 digit codes used to report outpatient hos... [Show More] pital and Physicians Medical and surgical services. CPT is used to report outpatient or Physician Office claims only and is updated annually in January. Hac - ANSWER-Hospital-acquired conditions are defined as for discharges occurring on or after October one 2008 ipps hospitals will not receive additional payment for cases when one of the selected conditions is acquired during hospitalization. In such cases payment will not be driven Higher by the secondary diagnosis if it is identified as an h a c. Qio - ANSWER-An organization responsible for determining whether care and services provided were medically necessary and meet Professional Standards regarding eligibility for reimbursement under Medicare and Medicaid programs. Rom - ANSWER-The anticipated likelihood of dying Soi - ANSWER-Severity of illness supportive documentation reflecting objective clinical indicators of a patient illness and the extent of physiologic decompensation or loss of organ system function. Wbc - ANSWER-Normal range for WBC is 5 to 10 mm 3. The critical value for this lab value is less than 2.5 or greater than 30. Hgb - ANSWER-Hemoglobin for males normal range is 14 through 18 for females normal range is 12 through 16. Hct - ANSWER-Hematocrit normal range for males is 42 to 52. Normal range for females is 37 to 47. Platelets - ANSWER-Normal range 150000 to 450000 mm 3 Cardiac markers include - ANSWER-CPK normal value 25 to 200. C K - MB normal value less than 12 if total CK less than 400. Troponin normal value less than 0.4. BNP normal value less than 100. However in patients with chronic renal failure or heart failure Base Line levels will be higher. Blood chemistry normal values - ANSWER-Sodium 1:36 to 1:45. Chloride 98 through 106. Potassium 3.525. Carbon dioxide 23 to 30. Calcium 8.5 to 10.5. BUN 7 to 20. Creatinine 0.5 to 1.5. glucose 8220. Hemoglobin A1c less than six. Ammonia 10 to 40 amylase 25 to 150. Lipase 0 to 1:40. Albumin 3.5 to 5. Abgs - ANSWER-pH normal 7.35 to 7.45. Paco2 35 to 45. Pao2 80 to 100. Hco3 21 to 28. O2 saturation 95 to 100%. Assigning the drg - ANSWER-Identify the principal diagnosis. Identify the secondary diagnosis. Validate that all DX findings nurses notes lab values treatments and medications ordered are explained in documentation. Identify procedures. Assign the ms-drg for all appropriate options. Secondary diagnosis that impact severity of illness and risk of mortality - ANSWER-Acidosis, alkalosis, apnea, autoimmune diseases, awaiting transplant status, BMI, bundle branch block, CHF, CKD stages 2 or 3, COPD, dementia, dependence on oxygen, dependence on ventilator, diabetes linked to manifestation such as neuropathy and nephropathy, dysphagia, hematuria, hemiplegia, history of cardiac arrest, hypocalcemia, hypokalemia, hypomagnesemia, hypotension hypoxia, mitral regurgitation, malnutrition, morbid obesity, obesity, pressure ulcer, residual from CVA, thrombocytopenia, trach status, transplant status Hrrp Hospital readmission Reduction - ANSWER-The hrrp program is administered by CMS as part of its inpatient Quality Reporting program, or IQR and was authorized under the Affordable Care Act of 2010 to link quality (readmission rates) to medicare payment. Under this program Hospital readmission rates are measured retrospectively via a three-year rolling of data. How are Hospital readmissions tracked? - ANSWER-Seven types of admissions including acute and I, heart failure, ammonia, COPD, total hip arthroplasty, total knee arthroplasty, CAbg. What is all-cause readmission? - ANSWER-As previously noted this is not part of the hrrp program and currently hospitals are not assessed penalties based on excess admissions but this information is being tracked and is publicly available on the CMS Hospital compare website. The outcome for this measure is all cause unplanned readmissions within 30 days. Patients are divided into six mutually exclusive specialty cohorts for appropriate readmission risk assessment classification. These include medicine gynecology cardiorespiratory cardiovascular and neurology. The index admission criteria is the same as for the hrrp program and includes patients enrolled in Medicare fee-for-service, age 65 or over, DC from non-federal acute care hospital or VA Hospital alive, not transferred to another acute care facility, and enrolled in part A & B Medicare for the 12 months prior to the date of the index admission. Index ignitions excluded from the measure include admission to PPS exempt cancer hospitals, admission without at least 30 days post DC enrollment in ffs Medicare, DC Ama, admit for primary psych diagnosis, admit for Rehab, admit for medical treatment of cancer. Ekg rhythms - ANSWER-Common EKG rhythms include sinus rhythm, atrial fibrillation, atrial flutter, AV pacing, ventricular tachycardia, ventricular fibrillation, and agonal rhythm Conditions associated with dehydration - ANSWER-Renal failure, CHF, respiratory insufficiency, Burns, dka, hhn see, siadh, intestinal obstruction, gee I lost, post-operative state Conditions associated with hyper natremia - ANSWER-CHF, hhnc Conditions associated with metabolic acidosis - ANSWER-CHF Burns dka intestinal obstruction GI loss post-op state Conditions associated with metabolic alkalosis - ANSWER-CHF GI loss post-op state Conditions associated with respiratory acidosis - ANSWER-Respiratory insufficiency Burns intestinal obstruction post-op state Linked diagnosis - ANSWER-Alcohol needs to be linked with cirrhosis hepatitis. Anemia needs to be linked with the specified type. Chronic renal failure needs to be linked with diabetes or other causes of CRF except hypotension. Complications need to be linked with either post-op and or due to device. CHF needs to be linked with acute chronic and diastolic or systolic, diabetes needs to be linked with all manifestations. Drug and alcohol use needs to be linked with abuse or dependency. Fractures need to be linked with terms such as pathological, stress, non-traumatic. Hypertension needs to be linked with a cardiovascular diagnosis. Infections or slut sepsis needs to be linked with due to device, specific organism, or post-operative. Pneumonia needs to be linked with a specified type organism Gram stain or aspiration. Hcc - ANSWER-Hcc's are hierarchical condition categories and were developed by CMS in 2004 to adjust Medicare capitation payments to the Medicare Advantage Plans part c. Raf - ANSWER-RAF score or risk adjustment factor is a total score of all relative factors related to one patient for a total year submitted from the following sources: principal diagnosis hospital inpatient secondary diagnosis hospital inpatient Hospital outpatient Physician's Clinic Lee trained non-physician such as a psychologist or podiatrist. In addition scores are adjusted for age, living Arrangement, Medicaid disability status and interaction with age and sex, HCC category, interaction between certain disease condition in categories, and interaction between certain disease categories and disability status. Psi - ANSWER-Patient safety indicators are used by a wide range of organizations and initiatives. Safety indicators include psi2: death rate and low mortality diagnosis groups,ps3 pressure ulcer rate, PSI for death rate among surgical in patients with serious treatable conditions, PSI 5 retained surgical items or unretrieved device fragment count, PSI 6 pneumothorax rate, PSI 7 venous catheter related bloodstream infection rate, PSI 8 in hospital fall with hip fracture rate, PSI 9 perioperative Hemorrhage or hematoma rate, PSI 10 post-operative acute kidney injury requiring dialysis, PSI 11 post-operative respiratory failure rate, PSI 12 post-operative pulmonary embolism or deep vein thrombosis rape, PSI 13 post-operative sepsis rate, PSI 14 post-operative wound dehiscence rate, PSI 1500 unrecognized abdominopelvic accidental puncture or laceration rate, PSI 16 transfusion reaction count, PSI 17 birth trauma rate in neonate, PSI 18 obstetric trauma rate vaginal delivery with instrument, PSI 19 obstetric trauma rate vaginal delivery without instrument. Icd 10 PCS root operations - ANSWER-Alteration bypass Change Control creation-destruction Detachment dilation division drainage excision extirpation extraction fragmentation Fusion insertion inspection map occlusion reattachment release removal repair replacement reposition resection restriction revision supplement transfer transplantation Icd 10 coding guidelines - ANSWER- CMS coding guidelines and directives - ANSWER-Published annually and include rules for code sets code assignment sequencing guidelines and chapter specific guidelines. Directives include instructional notes such as code first code additional and excludes notes. In addition the AHA Central coating offices published icd-10-cm and icd-10-pcs coding handbook and coding clinics four times a year. [Show Less]
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AHIMA CDIP Practice Exam 2 Questions with Verified Answers (Graded A)
A physician admits a patient with shortness of breath and chest pain, then treats the patient with Lasix, oxygen, and Theophylline. The physician's final d... [Show More] ocumented diagnosis for the patient is acute exacerbation of COPD. What is missing from this diagnosis that would make it reliable information in the treatment of this patient? a.No additional information is needed. b.The type of COPD c.The reason the patient was treated with Lasix d.The reason for the Theophylline - ANSWER- If the physician does not document the diagnosis, the coding professional cannot assume the patient has a diagnosis based solely on a.An abnormal lab finding b.Abnormal pathology reports c.Both A and B d.None of the above - ANSWER-c The coder cannot assume diagnoses on abnormal findings such as lab reports. Abnormal findings (laboratory, X-ray, pathologic, and other diagnostic results) are not coded and reported unless the physician indicates their clinical significance. If the findings are outside the normal range and the physician has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the physician whether the diagnosis should be added (AHA 1990, 15). These documents would be used for are used by clinicians and providers to identify abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators. a.Nurses' graphic records b.Vital sign flowsheets c.Both A and B d.None of the above - ANSWER-c Clinicians and providers utilize various documents to identify abnormal temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators. These documents are often called nurses' graphic records or vital sign flowsheets (Hess 2015, 43). The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Healthcare Statistics (NCHS) are all a.Cooperating parties b.Governing bodies c.Coding associations d.Work independently to develop coding guidelines - ANSWER-a The American Hospital Association (AHA), the American Health Information Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) are all cooperating parties that developed and approved ICD-10-CM/PCS (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 1). A patient was admitted with HIV and pneumocystic carini. The patient should have a principal diagnosis in ICD-10 of: a.AIDS b.Asymptomatic HIV c.Pneumonia d.Not enough information - ANSWER-a If a patient is admitted for an HIV-related condition, the principal diagnosis should be B20, Human immunodeficiency virus [HIV] disease followed by additional diagnosis codes for all reported HIV-related conditions (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 17). APR-DRGs have levels (subclasses) of severity entitled: a.Excessive, Major, Moderate, Minor b.Extreme, Major, Moderate, Minor c.Extreme, Major, Moderate, Minimal d.Excessive, Major - ANSWER-b The APR-DRG system is distributed into levels (subclasses) similar to MS-DRGs. These levels are entitled Extreme, Major, Moderate, Minor (Hess 2015, 48) During an outpatient procedure for removal of a bladder cyst, the urologist accidentally tore the urethral sphincter requiring an observation stay. This should be assigned as the principal diagnosis: a.The reason for the outpatient surgery b.The reason for admission c.Either the reason for the outpatient surgery or the reason for admission d.None of the above - ANSWER-a When a patient presents for outpatient surgery and develops complications requiring admission to observation, code the reason for the surgery as the first reported diagnosis (reason for the encounter), followed by codes for the complications as secondary diagnoses (ICD-10-CM Official Guidelines for Coding and Reporting 2016a, 103). In 1990, 3M created which DRG system that several states use for Medicaid reimbursement and is also used by facilities to analyze some portion of the data for Medicare Quality Indicators. What is this system called? a.MS-DRGs b.AP-DRGs c.APR-DRGs d.CPT-DRGs - ANSWER-c In 1990, 3M created APR-DRGs, which several states use for Medicaid reimbursement. APR-DRGs are used by facilities to analyze some portion of the data for Medicare Quality Indicators (Hess 2015, 48) A patient was admitted to an acute care facility with a temperature of 102 and atrial fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the physician of pneumonia in the progress notes and discharge summary. The patient was treated with oral antiarrhythmia medications and IV antibiotics. What is the principal diagnosis? a.Pneumonia b.Arrhythmia c.Atrial fibrillation d.Both a and c - ANSWER-a The patient presented with clinical signs of Pneumonia along with treatment. The atrial fibrillation was a chronic condition that can be reported additionally (CMS 2016b). The Cooperating Parties, which develop and approve ICD-10, include: a.American Hospital Association (AHA) and American Health Information Management Association (AHIMA) b.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Disease Control (CDC) c.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) d.American Hospital Association (AHA), American Health Information Management Association (AHIMA), and the World Health Organization (WHO) - ANSWER-c The cooperating parties developed and approved ICD-10-CM/PCS and include (4) organizations American Hospital Association (AHA), American Health Information Management Association (AHIMA), and Centers for Medicare and Medicaid Services (CMS), and National Center for Health Statistics (NCHS) (CMS 2016c). Mildred Smith was admitted to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome." Underneath the diagnosis, her medical information was listed along with a summary of the care already provided. This information is documented on the: a.Transfer record b.Release of information form c.Patient's rights acknowledgment form d.Admitting physical evaluation record - ANSWER-a Transfer records are created whenever a patient is transferred from one facility to another. The transfer record contains a summary of the care provided in the facility from which the patient is being transferred as well as the reason for transfer. Transfer records are important to the continuum of care because they document communication between caregivers in multiple settings (Shaw and Carter 2014; Fahrenholz and Russo 2013, 225). A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and a ruptured appendix was discovered. The chief complaint was: a.Ruptured appendix b.Exploratory laparoscopy c.Abdominal pain d.Cholelithiasis - ANSWER-c The abdominal pain is the chief complaint and is the reason the patient presented/reason for visit (Shaw and Carter 2014; Fahrenholz and Russo 2013, 225). A patient arrived via ambulance to the emergency department following a motor vehicle accident. The patient sustained a fracture of the ankle, 3.0 cm superficial laceration of the left arm, 5.0 cm laceration of the scalp with exposure of the fascia, and a concussion. The patient received the following procedures: x-ray of the ankle that showed a bimalleolar ankle fracture requiring closed manipulative reduction and simple suturing of the arm laceration and layer closure of the scalp. Provide CPT codes for the procedures done in the emergency department for the facility bill. 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm 12032 Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm 27810 Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli); with manipulation 27818 Closed treatment of trimalleolar ankle fracture; with manipulation a.27810, 12032 b.27818, 12004, 12032 c.27810, 12032, 12002 d.27810, 12004 - ANSWER-c The closed reduction of the fracture is coded first following principal procedure guidelines. The laceration repair is also coded. When more than one classification of wound repair is performed, all codes are reported with the code for the most complicated procedure listed first (Kuehn 2013, 26-27, 111-113). The appeal coordinator received a denial that stated: On presentation, patient had hemoglobin of 8.8 with blood in stool noted in physician office...patient sent as direct admission straight to hospital. The physician notes 11/05/14 states GI bleeding will consider transfusion 11/06/14. Note also states melenic stools and states hemoccult positive. Endoscopy report states - Acute Posthemorrhagic Anemia with iron deficiency anemia due to blood loss. "Multiple small angioectasias without bleeding were found in the second part of the duodenum. Red blood was found on the greater curvature of the stomach. Multiple small angioectasias with stigmata of recent bleeding were found in the gastric body. No active bleeding or clear which angioectasia are bleeding source." Multiple recently bleeding angioectasias in the stomach. Hemoglobin and hematocrit low on admission and decreased following admission at 8.8 to 8.2 and 27.8 to 26.8 respectively. Patient transfused packed RBCs on 11/5/14. Based on the above information , the review contractor: a.Denied the DRG inappropriately b.Was correct to deny the DRG, no query needed c.Should not have denied the DRG d.Was correct to deny, query needed - ANSWER-a The assignment of the code is appropriate. If the physician clearly documents the anemia is due to acute blood loss, code D62 Acute posthemorrhagic anemia should be assigned. Anemia due to chronic blood loss is coded to D50.0 Secondary to blood loss (chronic). The physician should always be queried if there is a lack of sufficient documentation. Never assume cause and effect relationship (AHA Fourth Quarter 1993, 34; ICD-10-CM Official Guidelines 2016b). This is a communication tool used to clarify documentation in the health record for accurate code assignment. a.Attestation b.Query c.Health record inquiry d.Additional documentation request - ANSWER-b A query is a communication tool used to clarify documentation in the health record for accurate code assignment. This tool is usually generated by coding and CDI staff (AHIMA 2013b, 1). What coding system is published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. a.CPT b.ICD-10-PCS c.ICD-10 CM d.POA - ANSWER-a Level I of HCPCS is composed of the CPT codes as published by the AMA and represents medical services and procedures performed by physicians and other healthcare providers. The Level I (CPT) codes (other than the Category II and III codes) are five-digit numeric codes (Palkie 2013, 394). A patient has a prostate malignancy that had not been excised, removed, and still under treatment. The patient presents to the hospital with irregular heartbeat, malaise and gross hematuria with large amounts of blood being passed via the urethra with the inability to urinate. Patient was noted to have a hemoglobin of 10.8 due to significant blood loss, the patient was transfused and bladder irrigation was begun. Following significant irrigation, urine ran clear. Based on the above scenario, what is the principal diagnosis? a.Blood loss b.Prostate malignancy c.Gross hematuria d.Query warranted to determine the principal - ANSWER-c The diagnosis of gross hematuria should be selected as principal as the treatment was not directed toward the malignancy and the rule of assignment of the principal diagnosis would apply to this circumstance (AHA Second Quarter 2010). Based on the diagnosis of gross hematuria, signs and symptoms of irregular heartbeat, malaise, and hemoglobin of 10.8 with transfusion, query for anemia due to blood loss may be______: a.Appropriate b.Inappropriate - ANSWER-a The generation of a query should be considered when the health record documentation: •Is conflicting, imprecise, incomplete, illegible, ambiguous, or inconsistent •Describes or is associated with clinical indicators without a definitive relationship to an underlying diagnosis •Includes clinical indicators, diagnostic evaluation, and/or treatment not related to a specific condition or procedure •Provides a diagnosis without underlying clinical validation •Is unclear for present on admission indicator assignment The _________ diagnosis is designated and defined as the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital a.Secondary b.DRG diagnosis c.Most resource intensive d.Principal - ANSWER-d The Principal diagnosis should be assigned as the first-listed diagnosis for the hospital admission as the cause of the hospital stay after study and evaluation by the responsible physician (ICD-10-CM Official Coding Guidelines 2016b, 88). A patient was admitted for ruptured appendix and an emergent appendectomy was performed. Abscess was noted on visual exam. During the admission, the patient had an MI and a stent was placed. What sequencing order should the procedures be placed in and which should be principal? a.The stent placement is more severe and should be first listed b.The appendectomy is considered incidental c.The appendectomy should be first listed d.Either can be assigned as the principal procedure - ANSWER-c When two definitive procedures have been performed, the for sequencing should be based on the procedure most related to the principal diagnosis as the first procedure to be listed (AHA Fourth Quarter 2012, 80). A patient presents with a myocardial infarction (MI) and intervention was carried out. It was noted the patient does have coronary artery disease (CAD). The consulting physician has stated to staff the CAD should be sequenced first. What should be the principal diagnosis? a.CAD b.MI c.Chest pain d.Ill-defined condition - ANSWER-b No, the consultant's advice is not correct. Sequence the AMI as the principal diagnosis since it is the acute condition and the reason for the admission. You should continue to follow correct coding and reporting practices and report the AMI as the principal diagnosis (AHA Third Quarter 2009, 9-10. AHA, First Quarter 2012, 7). At times, patients present to the hospital with hematoma. There is noted midline shift of mass effect. Based on the diagnosis, signs or symptoms, and treatment: a.The CDS could consider mass effect query b.The CDS could consider cerebral blood clot query c.The CDS could consider brain compression query d.The CDS could have no considerations - ANSWER-c The coder should query the provider and if the provider clarifies and documents that the mass effect or midline shift is brain compression, the coder may then assign a code for the brain compression (AHA 2011, 11). If a patient is given Levophed, the patient is most likely being treated for which of the following diagnoses? a.Shock b.Infection c.Hemorrhage d.Infarction - ANSWER-a This is a treatment for shock (septic and cardiogenic). (Society of Critical Care Medicine 2013) A 68-year-old nursing home patient with status post CVA 2 weeks ago presents via the emergency department with a 1-day history of fever, and elevated blood sugars in the 180-210 range. The patient has stated they have significant pain of the right buttock since the previous admission. The patient has a history of diabetes, and is on long-term insulin. On physical exam, it is noted the patient had a fever of 101.3 with purulent drainage with exposure of subcutaneous fat. This type of ulcer can be called a: a.Stage I b.Stage II c.Stage III d.Stage IV - ANSWER-c This is a Stage III ulcer; Full thickness skin loss. The National Pressure Ulcer Advisory Panel (NPUAP) has redefined the definition of a pressure ulcer and the stages of pressure ulcers. (AHA Fourth Quarter 2008, 132) This catheter is inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. a.Peripherally inserted central catheter (PICC) b.Vascular access device (VAD) c.Central venous catheter d.None of the above - ANSWER-c Central venous catheters are inserted into larger, deeper veins such as the subclavian, jugular, or femoral veins. The catheter is then advanced into the superior vena cava leading directly to the heart. Central venous catheters may be inserted by physicians, but are often inserted by other specially trained personnel such as physician assistants, nurse practitioners, or critical care nurses. Central venous catheterization is usually performed in the subclavian vein by a subclavicular approach. Another site is the internal jugular vein. The femoral vein is used infrequently because of concern over deep vein thrombosis (DVT) (AHA First Quarter 1996, 3-4). Within 2 hours following surgery, a 68 year-old female began to develop noisy breathing, fever, tachypnea, chest discomfort, and cough. Chest x-ray was performed which showed increased interstitial markings, lobar consolidation, and atelectasis. The physician documented pneumonia; concern for aspiration. The patient was started on Cefepime. The CDS would most likely query for: a.Postoperative aspiration pneumonia b.Respiratory failure c.Bacterial pneumonia d.No query needed - ANSWER-a Postprocedural aspiration pneumonia was developed to uniquely capture this condition and distinguish it from other respiratory complications Query as appropriate utilizing appropriate query format. (AHIMA 2013b). Patient is admitted with acute congestive heart failure treated with diuretics and education. The patient also had atrial fibrillation which the physician stated as the cause of the heart failure. Which condition should be assigned as principal? a.Coding rules state query should be performed b.The condition documented as causing the admission c.Either diagnosis d.Neither - ANSWER-b If both conditions are present on admission and meet the definition of principal diagnosis, either condition may be sequenced as principal diagnosis. The Official Guidelines for Coding and Reporting, Section II, B., state "When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise." If, however, one of the conditions is clearly documented as causing the admission, then that condition should be designated as the principal diagnosis. See also Coding Clinic, Second Quarter 1990, page 4, for additional examples (AHA First Quarter 2012, 7). If a patient has a chronic conditions with ongoing or long-term therapy but has presented to the hospital for another acute condition. These chronic conditions: a.Should be reported when they present to their office visit b.Cannot be reported c.Can be reported d.Are irrelevant diagnoses - ANSWER-c Based on Official Coding Guidelines for Coding and Reporting: For reporting purposes the definition for 'Other diagnoses" is interpreted as additional conditions that affect patient care in terms of requiring: Clinical evaluation; or Therapeutic treat [Show Less]
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AHIMA CDIP Exam 2023 Questions and Answers (Graded A)
CDI program data includes: - ANSWER-1. All cases that were reviewed 2. Number of cases with queries 3. Nature of the query 4. Physician response to the ... [Show More] query Queries should only be asked: - ANSWER-1. If there is clinical evidence that the documentation is imcomplete or does not meet one of the seven criteria for high-quality clinical documentation. 2. By an individual with solid clinical knowledge. 3. In an open-ended manner (no yes or no questions) 4. In a nonleading manner. 5. To the individual whose documentaion is in question or who is responible for interpreting test results or other data in the patient's record. Query process and procedure should address: - ANSWER-1. When queries will be asked. 2. Who will ask queries and to whom queries will be asked. 3. The hospital's responsibility in supporting the quering process. 4. The physician's responsibility in responding to queries. 5. Acceptable ways to responding to queries. Examples of when a query is required may include: - ANSWER-1. Documentation of reportable conditions or procedures is conflicting, ambigious, or is otherwise incomplete. 2. Abnormal diagnostic test results indicate the possible addition of a secondary diagnosis or higher specificity of an already documented condition. 3. The patient is receiving treatment for a condition that has not been documented. 4. Abnormal operative or procedureal findings are not documented. 5. It is unclear as to whether a condition was ruled out. 6. The pricipal diagnosis is not clearly identified. Septicemia - ANSWER-A systemic disease with the presence and persistence of pathogenic micro-organisms or toxins in the blood. No longer considered synonymous with sepsis. Sepsis - ANSWER-Sepsis is SIRS due to an infection . Infection can originate anywhere in the body and be triggered by a bacterial, viral, parasitic, or fungal infection. Severe Sepsis - ANSWER-SIRS due to infection with organ dysfunction. Sepsis associated with acute dysfunction in one or more organs. Organ dysfunction bay be cardiovascular, renal, respiratory, hepatic, hematological, central nervous system, or metabolic acidosis. SIRS - ANSWER-SIRS is the systemic response to infection or trauma. The systemic response is manifested by a variety of clinical signs and symptoms such as: Fever (>100.4 degrees F), Hypothermia (<96.8 degrees F), WBC >= to 12000 cellsmm3 (leukocytosis), WBC <= to 4000 cells/mm3 or 10% immature cells, heart reat >90 bpm, respirations >20 breaths/minute or PcCO2 <32 mg of mercury, hypotension, altered mental status. Septic Shock - ANSWER-Sepsis with hypotension or a failure of the cardiovascular system. Endotoxic shock and gram negative shock are synomymous with septic shock, septic shock = severe sepsis Bacteremia - ANSWER-Bacteria in the blood without an associated inflammatory response. Denotes laboratory findings of viable bateria in the blood with no systemic manifestations. Progresses to septicemia only when there is a more severe infections process or an impaired immune system. Urosepsis - ANSWER-Infection confined to the urinary system. Refers to pyuria or bacteria in the urine (not in the blood). Query the physician to determine if the bacteria in the urine has progressed to septicemia or sepsis. 7 criteria for high-quality documentation - ANSWER-Legible Complete Timely Reliable Consistent Precise Clear EBM - ANSWER-Evidence Based Medicine-practicing medicine using only the best scientific data available. Four kinds of standards in EBM - ANSWER-Design Performance Terminology Procedural Theory of high-quality of clinical documentation - ANSWER-If the 7 criteria of high-quality clinical documentation are applied ot clinical documentation, then clinical documentation quality will be high and the accuracy of care, quality indicators, reimbursement, healthcare planning, and research will be improved. What year was TEFRA (Tax Equity and Fiscal Responsibility Act) implemented? - ANSWER-1982 DRGs - ANSWER-Developed by Yale in the 70's to describe all types of patient care in an acute care hospital. Implemented for Medicare IPP in 1983. AP-DRGs - ANSWER-Implemented in 1987 by 3m. For NY non-Medicare discharges reimbursement program. APR-DRGs - ANSWER-Developed by 3m in 1990; addressed severity of illness and risk of mortality over all patient populations. When did CMS adopt MS-DRGs to better recognize severity of illness (SOI) in Medicare IPPS? - ANSWER-FY2007 CY2008 Comorbidity - ANSWER-A pre-existing condition which because of it's presence with the principal diagnosis will increase the LOS by at least 1 day in approximately 75% of cases. Complication - ANSWER-A condition arising in a hospital that prolongs the LOS by at lease one day in approximately 75% of cases. What is the 3 tiered structure of MS-DRGs? - ANSWER-1. MCC-Major complication/cormorbidity 2. CC-Complication/comorbidity 3. Non-CC How to calculate CMI - ANSWER-Sum of all of the DRG's relative weights/# of cases per time period MCE - ANSWER-Medicare Code Editor-Addresses 3 basic types of edits that support MS-DRG assignment which are code edits, coverage edits, and clinical edits. MCC/CC conditions consist of: - ANSWER-Significant acute diseases, acute exacerbations of chronic significant diseases, advanced end-stage diseases, chronic diseases with extensive debility, consistnely greater impact on hospital resources. Levels of DRGS in each system: MS-DRGs - ANSWER-Stand alone DRGs (TIA), without a CC, with a CC, with a MCC. Levels of DRGS in each system: AP-DRGs - ANSWER-Stand alone DRGs (TIA), without a CC, with a CC, with a MCC. Levels of DRGS in each system: APR DRGs - ANSWER-No stand alone DRGs, severity 1 (minor), severity 2 (moderate), severity 3 (major), severity 4 (extreme). What is the ultimate of the POA program? - ANSWER-To craft a reimbursement system that considers not only severity and resouce utilization, but also quality indicators. POA Indicators and Definitions - ANSWER-Y = Present at the time of inpatient admission N = Not present at the time of inpatient admission U = documentation is insufficient to determine if conditions is present on admission W = provider is unable to clinically determine whether condition was present on admission or not MS-DRGs MCC/CC List - ANSWER-MCC/CC conditions consist of: Significant acute diseases Acute exacerbations of chronic significant diseases Advanced end stage diseases Chronic diseases with extensive debility Consistenly greater impact of hospital resources Key Facts to CMI - ANSWER-Two Major Factors with IPPS DRGs and CMI: -Medical record documentation -Coding Changes Changes in documentation and/or coding practices will affect the DRG assignment and thus the CMI Changes in the coding process for translating the diagnostic information into standard codes likewise affects DRG assignment. The DRG System - ANSWER-1970's: Yale University developed DRGs to describe all types of patient care in an acute care hospital. 1983: DRGs implemented for the Medicare IPPS. 1987: 3M developed AP-DRGs to address severity of illness and risk of mortality over all patient populations 2007: CMS adopted MS-DRGs to better recognize severity of illness in Medicare payment rates for acute care hospitals. PPS Examples - ANSWER-Acute inpatient PPS (IPPS): DRGs Hospital Outpatient PPS (OPPS): APCs Home Health PPS (HH PPS): OASIS Skilled Nursing Facility PPS (SNF PPS): MDS Inpatient Rehabilitation Facility (IRF PPS): PAI Who makes quality measure available to the public? - ANSWER-AHRQ via their annual report, CMS via Hospital Compare, and Leapfrog via the Individual Hospital website. Who is recognized as the leading source of HIM knowledge? - ANSWER-AHIMA Who serves as the WHO collaborating center for North America? - ANSWER-National Center for Health Statistics (NCHS) What did CMS introduce in 2007? - ANSWER-MS DRGs What resulted from the Medicare Prescription Drug Improvement and Modernization Act of 2003? - ANSWER-IPPS Quality Measures Created in 2006 by the Tax Relief and Health CAre Act this reporting measure has over 100 current measures. - ANSWER-Physician Quality Reporting Initiative (PQRI) Which agency strives to advance the health of individuals and communities? - ANSWER-AHA What association is a part of HCPRO? - ANSWER-The Association of Clinical Documentation Specialists (ACDIS) Which external auditor began the audit revolution and returned over $240 million dollars to the Medicare Trust Fund in the first six months of 2011? - ANSWER-RAC [Show Less]
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AHIMA CDIP Exam 2023 with complete solutions
eMAR - ANSWER-Electronic medication administration record PACS - ANSWER-Picture archive and communication system CPOE - ANSWER-Computerized provider/... [Show More] practitioner/physician order entry CAMP - ANSWER-Coaching, asking, mastering, peer learning ICEHR - ANSWER-Integrated care EHR HCO - ANSWER-Health care organization HIM - ANSWER-Health Information Management Stage 0 EHR implementation - ANSWER-Lowest level of transformation Stage 1 EHR implementation - ANSWER-Electronic capture of health info is in standardized format, track key clinical conditions, communicate info for care coordination process, reports clinical quality measure and public health info, uses info to engage px and their families in their care Stage 2 EHR implementation - ANSWER-Increases amount of patient-centric measures providers require Stage 3 EHR implementation - ANSWER-•Vital signs and flow sheets required as electronic documentation. • Median stage most acute care facilities have reached Stage 4 EHR implementation - ANSWER-Strongest correlation btw higher quality indicators and hospital's EHR scores. Hospital has a CPOE system in place along with 2nd level of clinical decision support capabilities related to EBM protocols Stage 5 EHR implementation - ANSWER-HCO fully implements closed loop eMAR environment in at least one patient care area Stage 6 EHR implementation - ANSWER-Implementing full physician documentation and charting using structured templates for at least one px areas Stage 7 EHR implementation - ANSWER-• SEHR benchmark with a mixture of discreet data, document imaging and medical imaging. • Makes health info available to patients 5 Rights to medication - ANSWER-Right patient, medication, dose, route, time NLP - ANSWER-Natural language processing 4 phases of NPL - ANSWER-• 1940-1960: Machine Translation • 1960-1970: Artificial intelligence • 1970-g1989: Grammatico-logical phase • 1990-2000: Statistical language processing Real-time deficiency tracking - ANSWER-Provides mined information from a narrative content combined with structured EHR data to identify deficiencies in clinical documentation SNOMED-CT - ANSWER-Systemized Nomenclature of Medicine-Clinical Terms CAC - ANSWER-Computer Assisted Coding CLU - ANSWER-Clinical Language Understanding ICD-10-CM/PCS - ANSWER-International Classification of Disease, Tenth Revision, Clinical Modification and Procedure Coding System RVU - ANSWER-Relative value unit CPT - ANSWER-Current Procedural Terminology Six levels of higher level complex thinking - ANSWER-KCAASE: Knowledge, Comprehension, Application, Analysis, Synthesis, Evaluation. MLP - ANSWER-Mid level practitioner CIM - ANSWER-Complimentary and Integrative Medicine IPPS/OPPS - ANSWER-Inpatient prospective payment system/ Outpatient prospective payment system ADT - ANSWER-Admission Discharge Transfer CMS - ANSWER-Centers for Medicare and Medicaid Services NCHS - ANSWER-National Center for Health Statistics HHS - ANSWER-Health and Human Services AHA - ANSWER-American Hospital Association Parties that developed and approved ICD-9-CM - ANSWER-AHA, AHIMA, CMS, NCHS Timeliness - ANSWER-Is the biggest challenge for discharge summary followed by consistency. DRG- 1975 - ANSWER-Diagnosis related group developed by Robert Fetter in 1975 ICD-9 codes into DRG- 1982 - ANSWER-CMS started paying for Medicare using a method that groups ICD-9 codes into DRGs More refined DRG-2008 i.e. MS-DRG (Medicare Severity) - ANSWER-CMS has used this since 2008. Relies to a greater degree on a patients SOI rather than just resource utilization to calculate reimbursement. 3 severity based DRG systems - ANSWER-Medicare severity DRG (MS-DRG), All patient DRGs (AP-DRGs), All Patient Refined DRGs (APR-DRGs) AP-DRG 1987 - ANSWER-3M company created AP-DRG in 1987 as part of NY non-Medicare hospital reimbursement program AP-DRG 1990 - ANSWER-3M company created APR-DRG in 1990. Many states use this for Medicaid reimbursement. Also used for quality indicators MS-DRG and AP-DRG - ANSWER-1. Stand alone DRGs (TIA), 2. Without CC 3. With CC 4. With Major CC APR-DRG - ANSWER-1. No stand alone DRGs 2. Severity 1 (minor) 3. Severity 2 (moderate) 4. Severity 3 (major) 5. Severity 4 (extreme). APR-DRGs are assigned based on SOI and ROM levels (subclasses) APR-DRG - ANSWER-There is a level score between 1 and 4 for SOI and 1 for ROM MDC - ANSWER-Major Diagnostic Category Hospitals focus on inpatient clinical documentation (CD) because of - ANSWER-Large reimbursement, coding quality and medical necessity for inpatient services Reasons for Outpatient CD - ANSWER-Increasing outpx volume, diagnostics, outpx surgery, observation bed admission HCPCS - ANSWER-Healthcare Common Procedure Coding System AAPC - ANSWER-American Academy of Professional Coders Coding - ANSWER-Translating physician clinical documentation into diagnostic and procedural coded data- aggregates diagnostics, treatment and response info of px into uniform data set. Helps with research, planning, billing and patient-care purposes. Progress note - ANSWER-The essence of the health record on which the coder relies Anesthesiologist - ANSWER-A query is necessary if there's a conflict between them and the attending physician. AHD - ANSWER-American Hospital Directory OIG - ANSWER-Office of the Inspector General QIO - ANSWER-Quality Improvement Organization ASCQR - ANSWER-Ambulatory Surgical Center Quality Reporting Recommended Data to review - ANSWER-Discharges by service and by MDC, Discharges by DRG, CMI, Complications and Major Complication Rates, Severity Levels(MS-DRG and APR-DRG), Medicare Quality Indicators FMQAI - ANSWER-Florida Medical Quality Assurance Inc. contracted with CMS to develop the Medication Measures Special Innovation Project NQF - ANSWER-National Quality Forum IQR - ANSWER-Inpatient Quality Reporting PQRS - ANSWER-Physician Quality Reporting System CC/MCC focus - ANSWER-ARF, Acute respiratory failure, congestive heart failure, encephalopathy, excision debridement, HIV, AIDS, TB, sepsis, anemia, MI MEDPAR - ANSWER-Medicare Provider and Analysis Review APC - ANSWER-Ambulatory Payment Classification. It allows for multiple assignments for each encounter and for the analysis of clinical documentation to remain on coding level Capture rate - ANSWER-Key indicator used to monitor a successful CDI program. Ten best CDI Operational Practices - ANSWER-1. CDI is Px centered 2. Create a Vision 3. Initial compulsory physician education 4. Creating policies and procedures that require sign-off 5. Maintaining complete query documentation 6. Feedback loop between denials, management, and CDI 7. Feedback loop between CDI and compliance 8. Feedback loop between HIM and CDI 9. Continuous targeted physician education and relationship building 10. Using rigorous management tools. Organizations responsible for functions that continually integrate with CDI - ANSWER-Compliance, HIM, case manager, finance, medical staff, data analysts, case mix managers, EHR staff Key outcomes of CDI - ANSWER-High-quality care, high-perceived quality, improved px satisfaction and accurate reimbursement CDI best practices feedback loop with - ANSWER-Denials, Management, Compliance, HIM, CDI program staff RAC - ANSWER-Recovery Audit Contractors MAC - ANSWER-Medicare Administrative Contractors Best practices for CDI must benefit the system in at least 2 of the following - ANSWER-Operation, strategy and compliance 4 criteria for describing basics of best of practice CDI program - ANSWER-• Remain constant over time (timeless) • Practice supported by research and actual application by multiple healthcare systems • Affect at least 2 management areas (operation, strategy and compliance) • Provide some measurable value to the organization HIM - ANSWER-CDI staff work directly with HIM staff to obtain data about retrospective physician query 5 Best practices for management of financial measures in the CDI program - ANSWER-1. Track CMI closely and identify real patient mix change 2. Track and report on CC rates overall and by service 3. Know the benchmarks and validate the data regularly 4. Do the right thing for the most accurate data outcome 5. Create a concurrent process with physician leadership. HIPAA - ANSWER-Health Information Portability and Accountability Act CMS and OIG - ANSWER-The two-part theory for high-quality clinical documentation is a cause and effect theory is derived from CMS and OIG Activities clinical documentation impacts - ANSWER-Care, quality indicators, reimbursement, healthcare planning and research EBM standards - ANSWER-Design, Terminology, Performance, Procedural JCAHO - ANSWER-Joint Commission on Accreditation of Healthcare Organization Estimated payment - ANSWER-Volume x Weight x Hospital-Specific Base Rate 4 levels to consider in order to staff the program - ANSWER-Reporting Management Staffing Physician leadership CDIP - ANSWER-Should be an effective physician communicator and excellent at reading clinical documentation and data to uncover low-quality clinical documentation. UHDDS - ANSWER-Uniform Hospital Discharge Data Set Highest level of quality in clinical documentation is gotten from - ANSWER-Health record review process and physician queries HPMP - ANSWER-Hospital Payment Monitoring Program Septicemia - ANSWER-Systemic disease with the presence of persistent pathogenic micro-organisms or toxins in the blood SIRS- Systemic inflammatory response syndrome - ANSWER-Systemic response to infection or trauma Sepsis - ANSWER-SIRS caused by infection Severe sepsis - ANSWER-Sepsis + organ failure/dysfunction Septic Shock - ANSWER-Sepsis + CVS failure or hypotension. Endotoxic shock and gram negative shock are synonymous with septic shock. Septic shock= severe sepsis Bacteremia - ANSWER-Bacteria in blood without any inflammatory response Urosepsis - ANSWER-Infection confined to the urinary system- puris, bacteriuria Problematic CMS diagnosis - ANSWER-• Malnutrition • Respiratory failure • Sepsis • Renal failure • Acute blood loss anemia • Congestive heart failure • Pneumonia CMI - ANSWER-Average DRG relative weight for inpatient cases and an indicator of average reimbursement per patient KPI - ANSWER-Key Performance Indicators Clinical documentation - ANSWER-Is the basis of the coding and billing activity in every organization DTM - ANSWER-Direct Teaching Method Key components of compliant CDI program - ANSWER-1. Documented mandatory physician training 2. Detailed query documentation 3. CDI policies and procedures with annual sign-off from all program staffing Goal of CDI compliance review - ANSWER-Is to monitor compliant query generation and physician responses HIMSS - ANSWER-Healthcare Information and Systems Society DORA - ANSWER-Department of Regulatory Agencies Revenue integrity - ANSWER-Department responsible for providing the CDI team with CMI and DRG payment analytics MDT- multidisciplinary team - ANSWER-HIM department, CDI, care management, utilization review, revenue integrity, quality, compliance and IT [Show Less]
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AHIMA CDIP Domain 1: Clinical Coding Practice Exam Questions with correct Answers
Coding Clinic - ANSWER-Valuable reference tool for coders that is published by AHA each quarter CPT - ANSWER-Current Procedural Terminology MS-DRGs -... [Show More] ANSWER-Medicare Severity-Diagnosis Related Groups CPT Assistant - ANSWER-Monthly publication by the AMA that provides coding advice for CPT coding scenarios Encoder Nosology - ANSWER-Provides coding professionals from the encoder company that are available to help answer tough coding questions History & Physical - ANSWER-Provides the initial chief complaint and initial impressions of the provider when the patient is first admitted. It also has a comprehensive physical review of the patient's body systems and vital signs, and provides the initial treatment plan, medications, and tests that are being ordered to treat the patient. Progress Notes - ANSWER-Provide information about what is going on with the patient on a day-to-day basis; they should include the diagnoses that are being treated as well as any information about any changes in the patient's well-being and tests/procedures being performed. Operative and Pathology Reports - ANSWER-Summarize the invasive procedures performed and any samples that are removed from the patient's body Pathology report - ANSWER-Provides detailed information from the pathologist of the facility as to the status of the tissues or organs removed from the patient's body Encoder - ANSWER-Specialty software used to facilitate the assignment of diagnostic and procedural codes according to the rules of the coding system What is the value of utilizing coding software? - ANSWER-It facilitates accurate coding by providing links to coding resources, groups diagnosis and procedure codes to the correct MS-DRG, and provides edits with additional information for the coder to consider when placing codes into the encoder Principal diagnosis - ANSWER-Diagnosis that, after study, is the reason for the patient's admission to the hospital. Secondary diagnoses - ANSWER-Additional supporting information for the conditions the patient is being cared for MCC - ANSWER-Major Complication or Comorbidity CC - ANSWER-Complication or Comorbidity CMI - ANSWER-Case Mix Index LOS - ANSWER-Length of Stay Complication - ANSWER-A condition arising during the hospital stay that prolongs the LOS by at least one day in approximately 75% of the cases Comorbidity - ANSWER-A pre-existing condition which because of its presence with the principal diagnosis will increase the LOS by at least one day in 75% of the cases Primary procedures - ANSWER-Procedure codes that best represent the procedure that has been performed Secondary procedures - ANSWER-Do not typically impact the MS-DRG; however, they are important for capturing the details of the care the patient has received while in the hospital. Coding conventions for ICD-10-CM - ANSWER-General rules for the use of the classification independent of the guidelines Letter that ICD-10 utilizes as a placeholder for certain codes - ANSWER-X Excludes1 - ANSWER-Indicates that the code excluded should never be used with the code above the Excludes1 note. Excludes2 - ANSWER-Indicates that, when appropriate, it is acceptable to use both the code and the excluded code together. Inclusion terms - ANSWER-List of terms that are included under some codes. They are the conditions for which the code should be used. CMS - ANSWER-Centers for Medicare & Medicaid Services Medicare patients are reimbursed by - ANSWER-MS-DRGs Medicaid has it's rates set by - ANSWER-each individual state PPS - ANSWER-Prospective Payment System Prospective Payment System - ANSWER-Payment method based on a predetermined amount that results from a particular service APR-DRG - ANSWER-All Patient Refined Diagnosis Related Groups All Patient Refined DRGs - ANSWER-Incorporate severity of illness as a part of assigning DRGs to determine the complexity of the patient and the need for an increased utilization of resources as the patient moves to a higher level of severity of illness based on additional diagnoses. APG - ANSWER-Ambulatory Patient Group Ambulatory Patient Group - ANSWER-Provides fixed reimbursement to a facility for outpatient procedures or visits and includes data regarding the reason for the visit and patient data Each individual MS-DRG has these components - ANSWER-title, geometric mean length of stay, arithmetic mean length of stay, relative weight, and ICD code range. Formula used to calculate payment for a specific case - ANSWER-The hospital's payment rate per case X the weight of the MS-DRG to which the case is assigned = Payment SOI - ANSWER-Severity of Illness Severity of Illness - ANSWER-Extent of physiologic decomposition or organ system loss of function ROM - ANSWER-Risk of Mortality Risk of Mortality - ANSWER-The likelihood of dying Levels of SOI and ROM - ANSWER-1=Minor, 2= Moderate, 3=Major, and 4= Extreme OPPS - ANSWER-Hospital Outpatient Prospective Payment System APCs - ANSWER-Ambulatory Payment Classifications HH PPS - ANSWER-Home Health Prospective Payment System OASIS - ANSWER-Outcome and Assessment Information Set SNF PPS - ANSWER-Skilled Nursing Facility Prospective Payment System MDS - ANSWER-Minimum Data Set The Hospital Outpatient Prospective Payment System utilizes - ANSWER-Ambulatory Payment Classifications (APCs) Home Health Prospective Payment System utilizes - ANSWER-A case-mix methodology based on data elements from OASIS Skilled Nursing Facilitates Prospective Payment System utilizes - ANSWER-Minimum Data Set Minimum Data Set - ANSWER-A standardized screening and assessment tool that gives a multidimensional view of the patients functional capability. IRF PPS - ANSWER-Inpatient Rehabilitation Facility Prospective Payment System Inpatient Rehabilitation Facility prospective payment system utilizes - ANSWER-The patient assessment instrument (PAI) to assign patients to case-mix groups according to their clinical status and resource requirements. The final MS-DRG assignment is based on factors such as - ANSWER-Principal and secondary diagnoses, principal and secondary procedures, patient gender, and discharge status Communication between the coders and the CDI specialist should be - ANSWER-Open and supportive Level 1-CPT codes are maintained by - ANSWER-American Medical Association (AMA) Level II National Codes are maintained by - ANSWER-CMS The six sections within category one of Level 1 CPT are - ANSWER-Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology/Laboratory, and Medicine How many categories are under Level 1 CPT? - ANSWER-3 HCPCS - ANSWER- [Show Less]
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AHIMA Quiz with complete solutions
AHIMA engage - ANSWER-It is a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA. It is only open to AHIMA members ... [Show More] AHIMA Structure and Operation - ANSWER-*Components-Volunteer, staff *Leadership- Board of Directors *Engage *National committees *Practice councils *Workgroups *House of delegates *Component state associations *Chief executive officer Certification Board - ANSWER-Created eligibility criteria for certification with examination. Commission on Certification for Health Informatics and Information Management (CCHIIM) fellowship program - ANSWER-A program of earned recognition for AHIMA members who have made significant and sustained contributions to the HIM profession. Healthcare Information and Management Systems Society (HIMSS) - ANSWER-Is a non-profit organization who is "focused on better health through information technology (IT). Association for Healthcare Documentation Integrity (AHID) - ANSWER-*It was formerly knows as the American Association for Medical Transcription. *Is a professional organization dedicated to the capture of health data and documentation. American Academy of Professional Coders (AAPC) - ANSWER-Educates and certifies medical coders. They sponsors certifications in coding, medical compliance and medical auditing. National Cancer Registrars Association (NCRA) - ANSWER-Represents cancer registrar professionals. Their mission is "to serve as the premier education,credentialing, and advocacy resource for cancer data professionals. The organization that accredits HIM education program: - ANSWER-CAHIIM Our college has applied to become accredited by CAHIIM. What is the name of the interim stage of accreditation? - ANSWER-Candidacy What function governs the HIM profession? - ANSWER-House of delegates The primary focus of AHIMA is to - ANSWER-Foster professional development of its member Name a certification that is administered by CCHIIM - ANSWER-Registered Health Information Technicians 6th type of member Emeritus - ANSWER-In recognition of their service to the profession, AHIMA members that are age 65 and over are eligible for recognition as a member Emeritus and shall be eligible for senior member dues status. Global - ANSWER-Any professional in the health information management profession or its related fields whose primary mailing address is outside the United States is eligible for Global membership. Global Members shall be entitled to digital membership privileges including the right to vote on matters before the members. Purposes and Mission - ANSWER-The primary purpose of AHIMA as a member association is to commit to excellence in the management of health information for the benefit of patients and providers. Its mission is to lead the health informatics and information management community to advance professional practice and standards Members - ANSWER-AHIMA shall have one or more types of members, as shall be determined from time to time by the Board of Directors. The members of AHIMA shall be those qualifying individuals who support the mission and purposes of AHIMA and are willing to abide by the AHIMA Code of Ethics Special Meetings of the Members - ANSWER-Special meetings of the members of AHIMA or of any committees or teams of members may be held at any time or place upon call by the Chair of the Board of Directors. Notice shall be provided stating the time and place of the meeting and the purpose or purposes for which the meeting is called Abbreviated Injury Scale (AIS) - ANSWER-A set of numbers used in a trauma registry to indicate the nature and severity of injuries by body system. Abstracting - ANSWER-The process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome (2) The process of extracting elements of data from a source document or database and entering them into an automated system. Accession registry - ANSWER-A list of cases in a cancer registry in the order in which they were entered Accreditation Association for Ambulatory Health Care (AAAHC) - ANSWER-A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single- and multi specialty group practices, ambulatory surgery centers, college/university health services, and community health centers Accreditation Commission for Health Care (ACHC) - ANSWER-A private nonprofit accreditation organization offering accreditation services for home health, hospice, and alternative site healthcare such as infusion nursing, and home/durable medical equipment supplies. Accreditation organization - ANSWER-A professional organization that establishes the standards against which healthcare organizations are measured and conducts periodic assessments of the performance of individual healthcare organizations Active membership - ANSWER-Individuals interested in the AHIMA purpose and willing to abide by the Code of Ethics are eligible for active membership. Active Members in good standing shall be entitled to all membership privileges including the right to vote. Administrative controls - ANSWER-Policies and procedures that address the management of computer resources Administrative simplification - ANSWER-A term referring to HIPAA's attempt to streamline and standardize the healthcare industry's nonuniform and seemingly chaotic business practices, such as billing Admission-discharge transfer (ADT) - ANSWER-The name given to the computer systems in healthcare facilities that register and track patterns Admission utilization review - ANSWER-A review of planned services (intensity of service) and/or a patient's condition (severity of illness) to determine whether care must be delivered in an acute care setting Advance Beneficiary Notice (ABN) - ANSWER-A statement signed by the patient when he or she is notified by the provider, prior to a service or procedure being down, that Medicare may not reimburse the provider for the service, wherein the patient indicates that he will be responsible for any charges Advanced directive - ANSWER-A legal, written document that describes the patient's preferences regarding future healthcare or stipulates the person who is authorized to make medical decisions in the event the patient is incapable of communicating his or her preferences Agency for Healthcare Research and Quality (AHRQ) - ANSWER-The branch of the United States Public Health Service that supports general health research and distributes research findings and treatment guidelines with the goal of improving the quality, appropriateness, and effectiveness of healthcare services Aggregate Data - ANSWER-Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed Aggregate information system - ANSWER-The combining of various data sets in order to compile overview or summary statistics All patient DRGs (AP-DRGs) - ANSWER-A case-mix system developed by 3M and used in a number of state reimbursement systems to classify non-Medicare discharges for reimbursement purposes. Allied Health professional - ANSWER-A credentialed healthcare worker who is not a physician, nurse, psychologist, or pharmacist (for example, a physical therapist, dietician, social worker, or occupational therapist) Alphabetic filing system - ANSWER-A system of health record identification and storage that uses the patient's last name as first component of identification and his or her first name and middle name or initial for further definition Alphanumeric filing system - ANSWER-A system of health record identification and storage that uses a combination of alphabetic letters (usually the first two letters of the patient's last name) and numbers to identify individual records Ambulatory payment classification (APC) - ANSWER-Hospital outpatient prospective payment system (HOPPS). The classification is a resource-based reimbursement system. The payment unit is the ambulatory payment classification group (APC group) Ambulatory payment classification group (APC group) - ANSWER-Basic unit of the ambulatory payment classification (APC) system. Within a group, the diagnoses and procedures are similar in terms of resources used, complexity of illness, and conditions represented. A single payment is made for the outpatient services provided. APC groups are based on single payment is made for the outpatient services provided. APC groups are based on HCPCS/CPT codes. A single visit can result in multiple APC groups. APC groups consist of five types of service: significant procedures, surgical services, medical visits, ancillary services, and partial hospitalization. The APC group was formerly known as the ambulatory visit group (AVG) and ambulatory patient group (APG). Ambulatory Surgery Center (ASC) - ANSWER-Under Medicare, an outpatient surgical facility that has its own national identifier; is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, record keeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation American Accreditation Healthcare Commission/URAC - ANSWER-An organization that focuses on implementing and maintaining accreditation standards for managed care facilities American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) - ANSWER-An organization that sets standards for accrediting ambulatory surgical facilities American Association of Medical Colleges (AAMC) - ANSWER-The organization established in 1876 to standardize the curriculum for medical schools in the United States and to promote the licensure of physicians American Associated of Medical Record Librarians (AAMRL) - ANSWER-The name adopted by the Association of Record Librarians of North America in 1944; precursor of the American Health Information Management Association American College of Healthcare Executives (ACHE) - ANSWER-The national professional organization of healthcare administration that provides certification services for its members and promotes excellence in the field. American Recovery and Reinvestment Act of 2009 (ARRA) - ANSWER-Previously known as the "stimulus bill" or HR 1. The actions related to health information technology are spread throughout the law; however, the bulk of the items are in Title XIII -- Health Information Technology; also called Health Information Technology for Economic and Clinical Health Act or HITECH Ancillary systems - ANSWER-Electronic system that generate clinical information (such as laboratory information systems, radiology information systems, pharmacy information systems, and so on) APC grouper - ANSWER-Software programs that help coders determine the appropriate ambulatory payment classification for an outpatient encounter Component state associations (CSAs) - ANSWER-Component state associations are part of the volunteer structure of AHIMA and are organized in every state, the District of Columbia, and the Commonwealth of Puerto Rico. The purpose of each Component State Association shall be to promote the mission and purpose of AHIMA in its state. House of Delegates - ANSWER-An important component of the volunteer structure of the American Health Information Management Association that conducts the official business of the organization and functions as its legislative body. Information governance - ANSWER-The accountability framework and decision rights to achieve enterprise information management (EIM). IG is the responsibility of executive leadership for developing and driving the IG strategy throughout the organization. IG encompasses both data governance (DG) and information technology governance (ITG). National Cancer Registrars Association (NCRA) - ANSWER-A not-for-profit association representing cancer registry professionals and Certified Tumor Registrars (CTR). The primary focus is education and certification with the goal to ensure all cancer registry professionals have the required knowledge to be superior in their field. New graduate membership - ANSWER-AHIMA membership level for student members who are recent graduates of accredited associate, bachelor's, and master's degree programs as well as AHIMA-approved coding programs. Registered Health Information Administrator (RHIA) - ANSWER-A type of certification granted after completion of an AHIMA-accredited four-year program in health information management and a credentialing examination. Registered Health Information Technician (RHIT) - ANSWER-A type of certification granted after completion of an AHIMA-accredited two-year program in health information management and a credentialing examination. Which group brings together stakeholders to address issues related to the future of the HIM profession and education? - ANSWER-Councel for Excellence in eduction Which is an information oriented HIM function? - ANSWER-Data manipulation Which is the accreditation organization for HIM programs? - ANSWER-CAHIIM Which entity is at the head of the AHIMA volunteer structure and holds responsibility for managing the property, affairs, and operations of AHIMA? - ANSWER-Board of directors The accreditation program of AHIMA is concerned with: - ANSWER-Establishing standards for the content of college programs in health information management which organization should be contacted regarding the certified healthcare documentation specialist exam? - ANSWER-Association for Healthcare documentation integrity Which makes up a virtual network of AHIMA members who co [Show Less]
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AHIMA CCS Exam Prep Questions and Answer 2023
CPT defines a separate procedure as - Procedure considered an integral part of a more major service No combination code available - Use separate codes f... [Show More] or hypertension and acute renal failure Documentation from the nursing staff or other allied health professionals' notes can be used to provide specificity for code assignment for which of the following diagnoses? - Body Mass Index (BMI) POA Indicator - Y - Y-Yes, present at the time of inpatient admission POA Indicator - N - N-No, not present at the time of inpatient admission POA Indicator - U - U-Unknown, documentation is insufficient to determine if condition is present on admission and you cannot speak to the physician to figure it out POA Indicator - W - W-Clinically undetermined, provider is unable to clinically determine whether condition was present on admission or not POA Indicator - E - E-Exempt, unreported/not used, some facilities will leave these blank, others will use the letter "E" Present on Admission Indicator (POA) - A Present On Admission (POA) indicator is required on all diagnosis codes for the inpatient setting except for admission. The indicator should be reported for principal diagnosis codes, secondary diagnosis codes, Z-codes, and External cause injury codes. The use of the outpatient code editor (OCE) is designed to: - Identify incomplete and incorrect claims Medicare's identification of medically necessary services is outlined in: - Local Coverage Determinations (LCDs) Medically unlikely edits are used to identify: - Maximum units of service for a HCPCS code National Correct Coding Initiative (NCCI) Edits are released how often? - Quarterly In 2000, CMS issued the final rule on the outpatient prospective payment system (OPPS). The final rule: - Divided outpatient services into fixed payment groups Diagnostic-related groups (DRGs) and ambulatory patient classifications (APCs) are similar in that they are both: - Prospective payment systems What are APCs? - APCs or "Ambulatory Payment Classifications" are the government's method of paying facilities for outpatient services for the Medicare program. How do APCs work? - The payments are calculated by multiplying the APCs relative weight by the OPPS conversion factor and then there is a minor adjustment for geographic location. APC Status Indicator - C - Inpatient Procedures, not paid under OPPS APC Status Indicator - N - Items and Services Packaged into APC Rates APC Status Indicator - S - Significant Procedure, Not Discounted When Multiple APC Status Indicator - T - Significant Procedure, Multiple Reduction Applies APC Status Indicator - V - Clinic or Emergency Department Visit APC Status Indicator - X - Ancillary Services APC Status Indicator - Y - Non-Implantable Durable Medical Equipment Medicare exerts control of provider reimbursement through adjustment of this component of the resource-based relative value scale (RBRVS) - Conversion factor The process of collecting data elements from a source document is known as: - Abstracting What piece of claims data from hospital A alerts a payer that the patient was transferred to hospital B? - Discharge disposition Admission source code used to identify a patient admitted to the facility from home: - Non-Healthcare Facility Admission source code used to identify a patient admitted to the facility from hospice care: - Transfer from hospice When a patient is transferred from an acute care facility to a skilled nursing home facility, what abstracted data element can impact the DRG assignment? - Discharge disposition A complication or comorbidity - Hypernatremia - A high concentration of sodium in the blood. Hypernatremia most often occurs in people who don't drink enough water. A major complication comorbidity: - Acute diastolic congestive heart failure MCC - major complication or comorbidity increases the use of medical and hospital expenses CC - complication or comorbidity Which condition meets the definition of comorbidity? - Hypertension Myocardial Infarction - CPK elevation with MB enzymes elevated and the EKG ST changes denote MI (myocardial infarction) Coding a Cardiac Catheterization - Include: the approach the side of the heart into which catheter was inserted note if any additional procedures were performed Coding a Wound Closure - Include: the site and length of the closure the repair type: simple, intermediate, or complex CHF - Congestive Heart Failure Query - POA - Yes/No queries are permissible to establish POA status Compliant queries include - Relevant clinical indicators Query must: - Provide a concise presentation of facts and clinical indicators Acute Bronchiolitis - Bronchiolitis is a common lung infection in young children and infants. It causes inflammation and congestion in the small airways (bronchioles) of the lung. Bronchiolitis is almost always caused by a virus. Gram-negative Pneumonia - Clinical indicators include: infiltrate in the lungs shortness of breath fever chest pain Authentication of health record entries - Prove authorship of documents Medical Staff Bylaws - Include requirements for documentation and record completion, as well as penalties for nonadherence Data Quality - Ensuring the accuracy and completeness of an organization's data Information Management - Supports decision making According to Medicare requirements, a history and physical must: - Be completed for each patient no more than 30 days before or 24 hours after admission or registration, but prior to surgery Revenue Code - Revenue codes are 4-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient. A medical claim will not be paid if this is missing from a bill. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. PSI - The Patient Safety Indicators (PSIs) provide information on potentially avoidable safety events that represent opportunities for improvement in the delivery of care. More specifically, they focus on potential in-hospital complications and adverse events following surgeries, procedures, and childbirth. The UHDDS definition of principal diagnosis does not apply to the coding of outpatient encounters because - Short duration of the evaluation does not allow enough time to make an "after study" determination The UHDDS definition of principal diagnosis does not apply in the: - Provider Office (Outpatient Services) UHDDS - Uniform Hospital Discharge Data Set - A defined set of data that give a minimum description of a hospital episode or admission; recommended upon discharge for all hospital stays reimbursed under Medicare and Medicaid. APC Codes (Ambulatory Payment Classifications) - APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. APCs are an outpatient prospective payment system applicable only to hospitals. MS-DRGs - Medicare Severity Diagnosis Related Groups - Defined by a particular set of patient attributes which include principal diagnosis, specific secondary diagnoses, procedures, sex and discharge status. What is difference between a DRG and a MS-DRG? - Medicare Severity-Diagnosis Related Groups (MS-DRG) is a severity-based system. So the patient might have five CCs, but will only be assigned to the DRG based on one CC. In contrast to MS-DRGs, full severity-adjusted systems do not just look at one diagnosis. All Patients Refined Diagnosis Related Groups (APR DRG) - a classification system that classifies patients according to their reason of admission, severity of illness and risk of mortality. All APR DRGs have 4 severity levels. All Patient DRGs (AP-DRGs) - an expansion of the basic DRGs to be more representative of Non-Medicare populations such as pediatric patients. The All Patient Refined DRGs (APR-DRG) incorporate severity of illness subclasses into the AP-DRGs. Prolonged Pregnancy - 42 weeks + Cardiac Lead - use of a guide wire - percutaneous approach CPT - an endoscopy that is undertaken to the level of the midtransverse colon - colonoscopy A patient admitted with pneumococcal pneumonia and severe pneumococcal sepsis - Assign codes for sepsis, pneumonia and severe sepsis Code three codes A code for the systemic infection is sequenced first followed by the code for the localized infection and a code from category R65.2 Patient admitted with insulin dependent diabetes (type of diabetes not specified) - If not specified, the default is E11.- Type 2 diabetes mellitus Patient admitted with unstable angina & congestive heart failure. What is the coding sequence? - Assign both codes (unstable angina & CHF), sequence either first Facilities use X modifiers in place of which modifier - 59 Patient admitted with SOB & CHF - develops respiratory failure - Respiratory Failure is listed as a secondary Dx - does not meet the definition of a primary Dx Congestive Heart Failure & Respiratory Failure The Outpatient Code Editor (OCE) has all of the following types of edits except - valid diagnosis edits The Outpatient Code Editor looks for invalid entries: - Sex & procedure edits Invalid revenue edits Diagnosis & age edits The National Correct Coding Initiative (NCCI) Edits apply tp services billed by - The same provider, for the same beneficiary, on the same date of service Medicare payment to physicians for services rendered is made under the - Resource-based Relative Value Scale Inpatient procedures are coded with - ICD-10_PCS Under the Inpatient Prospective Payment System (IPPS), what can be used to measure the cost of care for inpatients? - Case-mix index The abstracting of this data element has an impact on the DRG reimbursement - Discharge disposition Which of the following is a data element that coders typically are tasked with abstracting? - Date of surgery When a patient goes home with an order for home health to start one week after an inpatient admission, this is categorized as a - discharge Major complications & comorbidities (MCCs) are determined to require the greatest degree of resources with a payment group and also reflect the greatest - SOI - Severity of Illness Major complications & comorbidities (MCCs) - Type 2 Myocardial Infarction Asthma with status asthmaticus - An acute asthmatic attack in which the degree of bronchial obstruction is not relieved by the usual treatment, such as epinephrine and aminophylline Patient discharged with Dx acute pulmonary edema due to congestive heart failure - Code: Congestive Heart Failure Diagnosis listed as "possible" or "rule out" - Outpatient coding does not permit the use of "possible" or "rule out" diagnoses. The most challenging type of provider query is issued for - Establishing clinical validation When creating a compliant query to clarify conflicting information from the surgeon and the attending physician, to whom should the query be directed - attending physician Verbal queries - Must have a written response in the record for coding purposes Most hospitals require a medical record to be completed within - 30 days A completed and signed operative report needs clarification of the size of the skin lesions that were removed. What process is used for that clarification? - Amendment Conditions on the hospital-acquired condition list: - Stage 3 & 4 pressure ulcers are on the HAC list What is the term used for applying the HIPAA privacy rule over state rule(s) which are less strict? - Preemption According to the UHDDS, section 3, the definition of other diagnoses is all conditions that: - Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay Which patient specific UHDDS items also have the potential to an impact on MS-DRG assignment? - Sex and discharge disposition Inpatient setting - "Rule Out" Dx - In this setting, "rule out" Dx are coded as if they exist Open biopsy for a frozen section immediately before definitive surgery - Code both: Open Biopsy & Definitive Surgery Exploratory surgery not coded when definitive surgery is performed The "code if applicable, any causal condition first" note in the ICD-10-CM Tabular list indicates that this code may be assigned when the causal condition is unknown or not applicable. When the causal condition is known, the code for that condition may be reported as which type of diagnosis? - Principal Functions of the Outpatient Code Editor (OCE) - Editing the data on the claim for accuracy Specifying the action the FI should take when specific edits occur Assign APCs to the claim (for hospital outpatient services) Determining payment-related conditions that require direct reference to HCPCS codes and modifiers Units of service - Number of body parts NOT a function of the Outpatient Code Editor (OCE) - Determining payment-related conditions that require direct reference to ICD-10-CM codes Medicare reimburses inpatient stays based on - MS-DRGs Esophageal varices - Often associated with Cirrhosis of the liver Neurogenic claudication - Leg pain, tingling & cramping when present with lumbar stenosis A discrepancy in the record while the patient is still on the floor - who is responsible for obtaining clarity on the information? - Clinical document specialist Morbid obesity - Coder cannot assign without physician documentation of the condition Compliant multiple choice queries can: - provide a new diagnosis with supporting clinical indicators Sepsis/Septic Shock - Fever, chills, tachycardia, tachypnea, lactic acidosis (signs of sepsis) when you add respiratory issues requiring mechanical ventilation & circulatory failure (vasopressers) - points to septic shock Under which of the following circumstances does a facility lose a potential increase in reimbursement when a hospital acquired condition (HAC) is coded with POA indicator "Y" - When the HAC is the only CC/MCC on the account HAC & POA indicators were implemented by Medicare to address - Quality issues Under HIPAA, every organization must have - Privacy & Security Officers According to the UHDDS, the definition of a secondary diagnosis is a condition that: - Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care The UHDDS definition of principal procedure indicates that the principal procedure can be assigned for which of the following? - Ad [Show Less]
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AHIMA CCS Practice Exam with complete solutions
A 12-year-old boy was seen in an ambulatory surgical center for pain in his right arm. The x-ray showed fracture of ulna. Patient underwent closed reductio... [Show More] n of fracture right proximal ulna and an elbow-to-finger cast was applied. What diagnostic and procedure codes should be assigned? S52.101AUnspecified fracture of upper end of right radius, initial encounter for closed fracture S52.101BUnspecified fracture of upper end of right radius, initial encounter for open fracture S52.001AUnspecified fracture of upper end of right ulna, initial encounter for closed fracture S52.001BUnspecified fracture of upper end of right ulna, initial encounter for open fracture 0PSH0ZZReposition right radius, open approach 0PSK0ZZReposition right ulna, open approach 24670Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process(es) ); without manipulation 24675Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process(es) ); with manipulation 25560Closed treatment of radial and ulnar shaft fractures; without manipulation 29075Application, cast; elbow to finger (short arm) a. S52.101A, S52.001A, 0PSK0ZZ b. S52.101B, S52.001B, 0PSH0ZZ c. S52.101B, S52.001B, 25560, 29075 d. S52.001A, 24675 - ANSWER-Correct Answer: D The patient has a fracture of the right proximal ulna and closed reduction is necessary. In the ICD-10-CM Code Book, under Fracture, ulna, proximal, the coder is referred to Fracture, ulna, upper end. The term "manipulation" is used to indicate reduction in CPT. According to CPT guidelines, cast application or strapping (including removal) is only reported as a replacement procedure or when the cast application or strapping is an initial service performed without a restorative treatment or procedure (AMA CPT Professional Edition 2020, 182). (Note: Since this is an ambulatory surgery center case, CPT codes are assigned rather than ICD-10-PCS codes.) A laparoscopic tubal ligation is completed. What is the correct CPT code assignment? 49320Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320 - ANSWER-Correct Answer: B The code that best reports the tubal ligation is 58670 Laparoscopy, surgical; with fulguration of oviducts because there are no clips or excision of lesion completed during the procedure (CPT Assistant Nov. 1999, 29; March 2000, 10). Normal twin delivery at 30 weeks. Both babies were delivered vaginally and were liveborn. What conditions should have codes assigned? O30.003Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimester O30.009Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, unspecified trimester O60.14X0Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecified O60.14X1 Preterm labor third trimester with preterm delivery third trimester, fetus 1 O60.14X2Preterm labor third trimester with preterm delivery third trimester, fetus 2O80Encounter for full-term uncomplicated delivery Z3A.3030 weeks gestation of pregnancy Z37.0Single live birth Z37.2Twins, both liveborn a. O80, Z3A.30, Z37.0 b. O30.003, O60.14X0, Z3A.30, Z37.2 c. O60.14X1, O60.14X2 O30.003, Z3A.30, Z37.2 d. O80, O30.009, Z3A.30, Z37.2 - ANSWER-Correct Answer: C A code for preterm labor and delivery is assigned for each fetus since both babies were born preterm as noted in Coding Clinic. Additionally, a code from category O30, Multiple gestations, must be assigned (Leon-Chisen 2020, 325; AHA Coding Clinic 2016 2nd Quarter, 10-11). A patient with acute respiratory failure, hypertension, and congestive heart failure is admitted for intubation and ventilation. The patient's heart failure is stable on current medications. What are the correct diagnosis codes and sequencing? I10Essential hypertension I11.0Hypertensive heart with heart failure I50.9Heart failure, unspecified J96.00Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.20Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia a. J96.00, I11.0, I50.9 b. I50.9, J96.00, I10 c. J96.20, I10, I50.9 d. I50.9, J96.20, I11.0 - ANSWER-Correct Answer: A The patient was admitted and treated for respiratory failure. The other conditions present are also coded. The classification presumes a causal relationship between hypertension and congestive heart failure unless the physician documents otherwise (Leon-Chisen 2020, 228-231; CMS 2020a, Section I.C.10.b., 53, Section I.C.9.a, 46; AHA Coding Clinic 2017 1st Quarter, 47). A 64-year-old female was discharged with the final diagnosis of acute renal failure and hypertension. What coding guideline applies? a. Use combination code of hypertension and chronic renal failure. b. Use separate codes for hypertension and chronic renal failure. c. Use separate codes for hypertension and acute renal failure. d. Use combination code for hypertension and acute renal failure. - ANSWER-Correct Answer: C There is not a combination code for acute renal failure and hypertension. Acute kidney failure is not the same as chronic kidney disease (CMS 2020a, Section I.C.9. 2-3, 46-47; Leon-Chisen 2020, 262). A patient was discharged from the same-day-surgery unit with the following diagnoses: posterior subcapsular, mature, incipient, senile cataract right eye, diabetes mellitus, hypertension, and was treated for mild acute renal failure. Which codes are correct? E11.36Type 2 diabetes mellitus with diabetic cataract E11.29Type 2 diabetes mellitus with other diabetic kidney complication E11.9Type 2 diabetes mellitus without complications H25.9Unspecified age-related cataract H25.21Age-related cataract, morgagnian type, right eye H25.041Posterior subcapsular polar age-related cataract, right eyeI10Essential hypertension I12.9Hypertensive chronic kidney disease with stage 1 through stage 4, or unspecified chronic kidney disease N17.9Acute kidney failure, unspecified a. H25.21, E11.29, I12.9, N17.9 b. E11.36, H25.041, I10, N17.9 c. H25.9, E11.29, I12.9, N17.9 d. H25.041, E11.9, I12.9 - ANSWER-Correct Answer: B The patient has posterior subcapsular, mature, incipient, senile cataract right eye, diabetes mellitus, hypertension, acute renal failure. The hypertension and diabetes are not related to the renal failure as it is acute and not chronic. Because of this, no combination code is assigned for hypertension, diabetes and chronic renal failure. However, the diabetes and cataract are related conditions which are coded using a combination code. The classification presumes a relationship between diabetes and cataracts (CMS 2020a, Sections I.A.15, 12-13 and I.B.9., 15; AHA Coding Clinic 2016 2nd Quarter, 36-37; AHA Coding Clinic 2019 2nd Quarter, 30). 145 Correct0 Wrong1 Unanswered45 Current Procedural Terminology (CPT) defines a separate procedure as which of the following? a. Procedure considered an integral part of a more major service b. Provision of anesthesia c. Procedure that requires an add-on code d. A surgical procedure performed in conjunction with an E&M visit - ANSWER-Correct Answer: A When a procedure is designated as a separate procedure in the CPT code book and it is performed in conjunction with another service, it is considered an integral part of the major service. The CPT code description includes "separate procedure." The intention is not to provide payment for a procedure that is already integral to any given procedure (Smith 2020, 68-69; AMA CPT Professional Edition 2020, 72-73). Documentation from the nursing or other allied health professionals' notes can be used to provide specificity for code assignment for which of the following diagnoses? a. Body mass index (BMI) b. Malnutrition c. Aspiration pneumonia d. Fatigue - ANSWER-Correct Answer: A The physician must establish the diagnosis—obesity or morbid obesity—and the additional information can be pulled from ancillary documentation to establish the correct code assignment for body mass index (BMI) (CMS 2020a, Section I.B.14, 17-18). A laparoscopic cholecystectomy was performed. What is the correct ICD-10-PCS code? 0FB40ZZExcision of gallbladder, open approach 0FB44ZZExcision of gallbladder, percutaneous endoscopic approach 0FT40ZZResection of gallbladder, open approach 0FT44ZZResection of gallbladder, percutaneous endoscopic approach a. 0FB40ZZ b. 0FT40ZZ c. 0FT44ZZ d. 0FB44ZZ - ANSWER-Correct Answer: C A cholecystectomy includes complete removal of the gallbladder; therefore, the correct root operation is Resection. Since the procedure is specified as a laparoscopic cholecystectomy, the approach is percutaneous endoscopic (Leon-Chisen 2020, 247-248). Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions over the dome and posterior wall (1.9 cm.) was completed. A biopsy was taken of a lesion in the lateral wall. What modifier should be added to the biopsy procedure code? a. -50, Bilateral procedure b. -51, Multiple procedures c. -59, Distinct procedural service d. -99, Multiple modifiers - ANSWER-Correct Answer: C The surgery is done on two distinct areas within the bladder with two distinct approaches. The biopsy is not of the area that was resected and warrants the use of -59 (CPT Assistant Sept. 2001; CPT Professional Edition 2020, Appendix A). A bronchoscopy with multiple biopsies of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure code billed by the facility? a. -59, Distinct procedural service b. -51, Multiple procedures c. -76, Repeat procedure or service by same physician d. No modifiers should be reported - ANSWER-Correct Answer: D The procedure is reported with code 31625, the description of which indicates biopsy of single or multiple sites. When reporting this code, it is not necessary to indicate multiple procedures as the code itself does that (AMA CPT Professional Edition 2020, Appendix A). A patient is admitted with fever and urinary burning. Urosepsis is suspected. The discharge diagnosis is Escherichia coli, urinary tract infection; sepsis ruled out. Which of the following represents the diagnoses to report for this encounter and the appropriate sequencing of the codes for those conditions? a. Fever, urinary burning, urosepsis b. Fever, urinary burning, sepsis c. Escherichia coli sepsis d. Urinary tract infection, Escherichia coli - ANSWER-Correct Answer: D Symptoms are not coded when a related definitive diagnosis is present on discharge. The patient has a discharge diagnosis of urinary tract infection, secondary to E. coli. A secondary code of B96.20 is assigned to identify E. coli as the cause of the infection (CMS 2020a, Section II.A., 108). A patient was admitted to the emergency department for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. In addition to gastroenteritis, the final diagnostic statement included angina and chronic obstructive pulmonary disease. List the diagnoses that would be coded and their correct sequence. a. Abdominal pain, infectious gastroenteritis, chronic obstructive pulmonary disease, angina b. Infectious gastroenteritis, chronic obstructive pulmonary disease, angina c. Gastroenteritis, abdominal pain, angina d. Diarrhea, chronic obstructive pulmonary disease, angina - ANSWER-Correct Answer: B The abdominal pain and diarrhea are not coded as they are symptoms integral to the diagnosis of infectious gastroenteritis. Review Coding Guideline IV.D for additional information on coding of symptoms, signs, and ill-defined conditions (CMS 2020a, Section IV.D., 113). A patient was admitted to the endoscopy unit for a screening colonoscopy. During the colonoscopy, polyps of the colon were found and a polypectomy was performed. What diagnostic codes should be used and how should they be sequenced? Z12.11Encounter for screening for malignant neoplasm of colon D12.6Benign neoplasm of colon, unspecified Z86.010Personal history of colonic polyps a. Z12.11, Z86.010 b. D12.6, Z12.11, Z86.010 c. Z12.11, D12.6 d. D12.6, Z12.11 - ANSWER-Correct Answer: C The circumstances of the encounter are for a screening colonoscopy. Because of this screening, colonoscopy is listed first, followed by a code for the polyps (CMS 2020a, Section I.C.21.c.5, 97-98). The patient is admitted for chest pain and is found to have an acute inferior myocardial infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient underwent a CABG ×2 from aorta to the right anterior descending and right obtuse, using the left greater saphenous vein which was harvested via an open approach. Cardiopulmonary bypass was utilized. The appropriate sequencing and ICD codes for the hospitalization would be: I25.10Atherosclerotic heart disease of native coronary artery without angina pectorisI21.19ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wallI22.1Subsequent ST elevation (STEMI) myocardial infarction of inferior wallI21.3ST elevation (STEMI) myocardial infarction, of unspecified siteI22.9Subsequent ST elevation (STEMI) myocardial infarction of unspecified siteI48.91Unspecified atrial fibrillationR07.9Chest pain, unspecified02100AWBypass coronary artery, one artery from aorta with autologous arterial tissue, open approach021109WBypass coronary artery, two arteries from aorta with autologous venous tissue, open approach06BQ0ZZExcision of left saphenous vein, open approach5A1221ZPerformance of cardiac output, continuous a. R07.9, I21.3, I48.91, I22.9, 02100AW, 5A1221Z b. I21.19, I48.91, I22.9, 02100AW c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z d. I22.1, I48.91, I21.19, 021109W - ANSWER-Correct Answer: C The patient's hospitalization includes a definitive diagnosis of myocardial infarction of the inferior wall as well as the other diagnoses of coronary artery disease and atrial fibrillation. The chest pain is not coded as it is a symptom of the MI. The patient underwent CABG ×2 with cardiopulmonary bypass and harvesting of the left saphenous vein to be used as graft material. All three procedures are reportable and should be coded (Leon-Chisen 2020, 393-396, 430- 434). A patient is admitted with hemoptysis. A bronchoscopy with transbronchial biopsy of the lower lobe was undertaken that revealed squamous cell carcinoma of the right lung. Which conditions should be identified as present on admission? C34.30Malignant neoplasm of lower lobe, unspecified bronchus or lung C34.31Malignant neoplasm of lower lobe, right bronchus or lung P26.9Unspecified pulmonary hemorrhage originating in the perinatal period R04.2Hemoptysis a. C34.31, R04.2 b. R04.2 c. C34.31 d. C34.30, P26.9, R04.2 - ANSWER-Correct Answer: C The diagnosis after study (lung cancer) was present on admission. The symptom (hemoptysis) of the carcinoma should not be assigned and therefore, will not have a POA indicator. Code P26.9 would not be assigned because it is not diagnosed and only applies to the perinatal period (CMS 2020a, Appendix I, 117-121). A condition is considered present on admission when it is: a. The principal diagnosis b. In accordance with medical staff bylaws c. A condition that occurs prior to an inpatient admission d. Present within three days after admission - ANSWER-Correct Answer: C It is important to understand the time frame for assigning a status code specifying that a condition is present on admission. A condition is present on admission when it occurs prior to inpatient admission (CMS 2020a, Appendix I, 117-121). A newborn is diagnosed with meconium aspiration at birth. What is the appropriate POA indicator for the meconium aspiration? a. Y b. N c. U d. W - ANSWER-Correct Answer: A Conditions present at birth are considered POA for newborns (CMS 2020a, Appendix I, 117-121). A woman is admitted to the hospital for an exacerbation of COPD and mentions a lump she has noticed in her right breast. While she in the hospital, a biopsy is done of the breast lump and a diagnosis of ductal carcinoma is made. What is the POA assignment for the carcinoma? a. Y b. N c. U d. W - ANSWER-Correct Answer: A Even though the diagnosis of cancer was made after admission, the patient clearly had the condition when admitted. Therefore, a POA indicator of Y should be assigned (CMS 2020a, Appendix I, 117-121). The use of the outpatient code editor (OCE) is designed to: a. Correct documentation of home health visits b. Facilitate reporting of adverse drug events c. Reduce the use of computer assisted coding d. Identify incomplete or incorrect claims - ANSWER-Correct Answer: D The code editor software reviews many data elements and compares them to what data specifications are required in order to weed out incomplete or incorrect claims (Smith 2020, 314-315). Medicare's identification of medically necessary services is outlined in: a. Program transmittals b. Claims processing manual c. Local coverage determinations d. National Correct Coding Initiative - ANSWER-Correct Answer: C Local coverage determinations (LCDs) are the mechanism by which Medicare identifies medical necessity for services, procedures, and supplies (Casto 2018, 255). Medically unlikely edits are used to identify: a. Pairs of procedure codes that should not be billed together b. Maximum units of service for a HCPCS code c. Diagnoses that don't meet medical necessity d. Procedure and gender discrepancies - ANSWER-Correct Answer: B Medically unlikely edits are in place to identify the maximum number of units of service for a given HCPCS code for one beneficiary on one date of service (Casto 2018, 256). National Correct Coding Initiative (NCCI) Edits are released how often? a. Monthly b. Quarterly c. Semi-annually d. Annually - ANSWER-Correct Answer: B NCCI edits are released on a quarterly basis by Medicare (Casto 2018, 256). In 2000, the Centers for Medicare and Medicaid Services (CMS) issued the final rule on the outpatient prospective payment system (OPPS). The final rule: a. Identified the payment structure for long-term care b. Divided outpatient services into fixed payment groups c. Created less opportunity for health information management professionals d. Facilitated greater use of ICD-9-CM procedure codes - ANSWER-Correct Answer: B This final rule established APCs by dividing outpatient services into fixed-payment groups (Smith 2020, 315). Diagnostic-related groups (DRGs) and ambulatory patient classifications (APCs) are similar in that they are both: a. Determined by HCPCS codes b. Focused on hospital outpatients c. Focused on hospital inpatients d. Prospective payment systems - ANSWER-Correct Answer: D Both are types of prospective payment systems (Casto 2018, 5). Medicare exerts control of provider reimbursement through adjustment of this component of the resource-based relative value scale (RBRVS). a. Conversion factor b. Geographic adjustment c. Relative value unit d. Practice expense - ANSWER-Correct Answer: A The conversion factor is Medicare's method for directly controlling provider reimbursement as it is a constant that is applied across the board for all providers (Casto 2018, 143). The process of collecting data elements from a source document is known as: a. Extracting b. Mining c. Abstracting d. Drilling - ANSWER-Correct Answer: C Abstracting is the process of taking data elements from a source document to enter into an automated system (Sayles 2020, 70). What piece of claims data from Hospital A alerts a payer that the patient was transferred to Hospital B? a. Admission source b. Admit diagnosis c. Discharge disposition d. Discharge diagnosis - ANSWER-Correct Answer: C The discharge disposition that is assigned to a patient's record will indicate to the payer whether the patient was discharged or transferred (Casto 2018, 125). When a patient is transferred from an acute-care facility to a skilled nursing facility, what abstracted data element can impact the DRG assignment? a. Admission source b. Patient's blood type c. Discharge disposition d. Patient's age - ANSWER-Correct Answer: C The patient's discharge disposition can impact the DRG assignment when a transfer takes place from acute care to skilled care (Casto 2018, 125). For a patient with a principal diagnosis of septicemia, reporting which of the following procedures will have the greatest impact on the MS-DRG? a. Excision of left main bronchus, percutaneous endoscopic approach, diagnostic (0BB74ZX) b. Excision of toe nail, external approach (0HBRXZZ) c. Extraction of perineum skin, external approach (0HD9XZZ) d. Respiratory ventilation, greater than 96 consecutive hours (5A1955Z) - ANSWER-Correct Answer: D The ventilator management is the procedure that will impact the MS-DRG to provide appropriate reimbursement. The MS-DRG with the highest weight is 870 (CMS 2019b). Respiratory Ventilation, Greater than 96 Consecutive Hours (5A1955Z). Medicare DRG assigned: 0870, SEPTICEMIA OR SEVERE SEPSIS W MV 96+ HOURS DRG weight = 06.3243. Incorrect answer option explanations provided for clarity: Bronchoscopy with biopsy (0BB74ZX) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect) Debridement of toenail (0HBRXZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect) Nonexcisional debridement of skin ulcer with abrasion (0HD9XZZ) reference: Medicare DRG assigned: 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 + HOURS W/O MCC MDC: 18 DRG weight = 1.0393 (incorrect) Which of the following is considered a complication or comorbidity? a. Hypokalemia b. Dehydration c. Hypernatremia d. Fluid overload - ANSWER-Correct Answer: C Hypernatremia is a complication or comorbidity (Optum 2019). A patient is admitted for a cerebral infarction. Residual effects at discharge include aphasia and dysphagia. The patient developed acute diastolic congestive heart failure while admitted and was treated with Lasix in addition to being given Betapace for his long-standing hypertension.Which condition is considered a major complication comorbidity? [Show Less]
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AHIMA CCS 2023 Exam Questions and Answers
The root operation of resection applies to which of the following? a. Removal of the entire body part and removal of an entire lobe of the liver b. Par... [Show More] tial incidental appendectomy and the closure portion of a procedure c. Blunt, digital, manual, or mechanical lysis of adhesions d. Partial cholecystectomy - ANSWER-A. Removal of the entire body part and removal of an entire lobe of the liver. When coding benign neoplasm of the skin, the section noted above directs the coder to: D23- Other benign neoplasms of skinIncludes: Benign neoplasm of hair follicles Benign neoplasm of sebaceous glands Benign neoplasm of sweat glands Excludes 1: benign lipomatous neoplasms of skin (D17.0-D17.3) melanocytic nevi (D22.-) a. Use category D23 for benign neoplasm of sweat glands b. Use category D23 for melanocytic nevi c. Use category D23 for benign lipomatous neoplasms of skin d. Use category D23 for malignant neoplasm of the skin - ANSWER-A. Use category D23 for benign neoplasm of sweat glands A 64-year-old female was discharged with the final diagnosis of acute renal failure and hypertension. What coding rule applies? a. Use combination code of hypertension and renal failure. b. Use separate codes for hypertension and chronic renal failure. c. Use separate codes for hypertension and acute renal failure. d. Use separate codes for elevated blood pressure and chronic renal failure. - ANSWER-C Use separate codes for hypertension and acute renal failure Coding professionals need to have surgical references in order to discriminate between: a. Correct and incorrect documentation based on Joint Commission requirements b. Reportable and nonreportable procedures c. Chemotherapeutic drugs d. A comorbid condition and a complication that prolongs the length of stay - ANSWER-B. Reportable and non reportable procedures A patient is admitted with an acute inferior myocardial infarction and discharged alive. Which condition would increase the MS-DRG weight? a. Respiratory failure b. Atrial fibrillation c. Hypertension d. History of myocardial infarction - ANSWER-A. Respiratory failure If a patient has undergone an outpatient echocardiogram and the cardiologist concludes in the report that the patient has mitral regurgitation, the coder should: a. Assign a diagnostic code for mitral regurgitation b. Query the physician about the diagnosis c. Code an abnormal finding of the echocardiogram d. No code can be assigned - ANSWER-A. Assign a diagnostic code for mitral regurgitation A patient was treated in the emergency department with lacerations of the neck and underwent a repair of two (2) wounds of the neck (2.0 cm and 1.4 cm) with layered closure. What are the diagnosis (excluding external cause codes) and procedure codes assigned? S11.91XA Laceration without foreign body of unspecified part of neck, initial encounter S11.92XA Laceration with foreign body of unspecified part of neck, initial encounter 0HQ4XZZ Repair neck skin, external approach 12041 Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 12042 Repair, intermediate, wounds of neck, hands, feet, and/or external genitalia; 2.6 cm to 7.5 cm a. S11.91XA, 0HQ4XZZ b. S11.92XA, 0HQ4XZZ c. S11.92XA, 12041, 12041 d. S11.91XA, 12042 - ANSWER-D. S11.91XA, 12042 A patient is admitted to an acute care facility for detoxification from alcohol and barbiturate intoxication with chronic alcoholism and barbiturate abuse. The patient also has cirrhosis of the liver due to alcoholism. What codes should be assigned? a. F10.229, F13.129, K70.30, HZ2ZZZZ b. F10.129, F13.229, K70.30, HZ2ZZZZ c. F10.29, F13.129, K70.10, HZ2ZZXZ d. F10.229, F13.129, K70.9, HZ2ZZZZ - ANSWER-A. F10.229, F13.129, K70.30, HZ2ZZZZ Patient with renal tumors received percutaneous cryotherapy ablation of three tumors on the right kidney in the same operative episode at Memorial Hospital. Assign a CPT code for this procedure. 50250 Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound guidance and monitoring, if performed 50590 Lithotripsy, extracorporeal shock wave 50592 Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy a. 50250 b. 50590 c. 50592 d. 50593 - ANSWER-D. 50593 When coding a documented ventilator-associated pneumonia (VAP), what codes should be assigned first for ICD-10-CM and then supported by CPT? a. The pneumonia is coded first; the CPT will be from code range 94010 to 94799 b. The complication of surgery diagnosis is coded first, then the VAP, with the CPT will be from code range 99500 to 99602 c. The specific code for ventilator-associated pneumonia is coded first and the organism is coded as a secondary code if known; the CPT will be from code range 94002 to 94005 d. An additional code for the type of pneumonia, that is, lobar or pneumonia NOS, is coded; the CPT will be from code range 33946 to 33989 - ANSWER-c. The specific code for ventilator-associated pneumonia is coded first and the organism is coded as a secondary code if known; the CPT will be from code range 94002 to 94005 A nurse inadvertently recorded an incorrect vital sign in a patient electronic health record. The next day, a correction was made in the electronic health record. This resulted in the corrected vital sign being recorded at the time the correction was made due to the software. What would be the result of this correction? a. The vital signs would be listed in the correct sequence. b. When a correction is made in an electronic health record, the incorrect data is deleted. c. The quality of patient care would not be affected. d. There was a distorted trend line of vital signs data. - ANSWER-d. There was a distorted trend line of vital signs data. Poor-quality data collection and reporting can affect: a. Patient care, documentation, revenue generation, outcomes evaluation, and public health reporting b. Use of patient record for legal purposes c. Patient care, communication, research activities, and public health reporting d. All of the above - ANSWER-d. All of the above The billing department has requested that copies of the final coding summary with associated code meanings for Medicare be printed remotely in the admission department. Currently they request the summaries only when there is an unspecified procedure. Each time the coding supervisor goes to the admission department, the coding summaries have been left on a table near the patient entrance. Of the actions presented here, what would be the best action for the coding supervisor to take? a. Comply with the request. b. Refuse to undertake this without further explanation. c. Ignore the request. d. Explain to the billing department supervisor that leaving the coding summary in public view violates the patient's right to privacy. - ANSWER-d. Explain to the billing department supervisor that leaving the coding summary in public view violates the patient's right to privacy. What percentage will the facility be paid for procedure code 10060? 989323 T 10060 0006 $500 989323 T 64605 0220 $1,000 a. 50% b. 75% c. 0% d. 100% - ANSWER-a. 50% To correct an entry in the medical record, the provider should: a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order b. Draw a double line through the error, initial and date, add the reason for the correction c. Draw a single line through the error, and add the correct information in chronological order d. Draw several lines through the error, obliterate the documentation as much as possible, initial and date, add the correct information in chronological order - ANSWER-a. Draw a single line through the error, add a note explaining the error, initial and date, add the correct information in chronological order Most hospitals require a medical record is completed within: a. 5 days b. 10 days c. 7 days d. 30 days - ANSWER-d. 30 days The patient was admitted from the emergency department because of chest pain. Following blood work, it was determined that the patient had elevated CPKs and MB enzymes. The EKG shows nonspecific ST changes. What type of diagnosis might this indicate? a. Unstable angina b. Myocardial infarction c. Congestive heart failure d. Mitral valve stenosis - ANSWER-b. Myocardial infarction Two areas of documentation in the health record that are significant areas of focus of accrediting agencies are: a. Incident reports notation in the medical record and attorney's notes b. Past medical reports and social worker's notes c. Timeliness and legibility of medical documents d. Patient documentation and pastoral counseling - ANSWER-c. Timeliness and legibility of medical documents A patient is discharged with a diagnosis of acute pulmonary edema due to congestive heart failure. What condition(s) should be coded? a. Acute pulmonary edema b. Congestive heart failure c. Acute pulmonary edema and congestive heart failure d. Unable to determine based on the information provided - ANSWER-b. Congestive heart failure Using the following evaluation and management map, which answers represent documentation that should be considered when assigning an E/M code for hospital acuity points assignment? a. The surgical procedure performed b. The anesthesia provided c. Number of tests ordered d. The post visit follow-up date - ANSWER-c. Number of tests ordered Assign the code(s) for diagnostic left and right cardiac catheterization, left and right coronary arteriogram with low osmolar contrast and fluoroscopic guidance. 4A023N6 Measurement of cardiac sampling and pressure, right heart, percutaneous approach 4A023N7 Measurement of cardiac sampling and pressure, left heart, percutaneous approach 4A023N8 Measurement of cardiac sampling and pressure, bilateral, percutaneous approach B2141ZZ Fluoroscopy of right heart using low osmolar contrast B2151ZZ Fluoroscopy of left heart using low osmolar contrast B2161ZZ Fluoroscopy of right and left heart using low osmolar contrast B2111ZZ Fluoroscopy of multiple coronary arteries using low osmolar contrast a. 4A023N6, 4A023N7 b. 4A023N8, B2111ZZ c. 4A023N6 d. 4A023N7 - ANSWER-b. 4A023N8, B2111ZZ The patient is admitted for chest pain and is found to have an acute inferior myocardial infarction with coronary artery disease and atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient underwent a CABG ×2 from aorta to the right anterior descending and right obtuse, autologous venous tissue using the left greater saphenous vein which was harvested via an open approach. Cardiopulmonary bypass was utilized. The appropriate sequencing and ICD codes for the hospitalization would be: a. R07.9, I21.34, I48.91, I22.9, 021109W, 5A1221Z b. I21.19, I48.91, I22.9, I48.91, 021109W c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z d. I22.1, I48.91, I21.19, 021109W - ANSWER-c. I21.19, I25.10, I48.91, 021109W, 06BQ0ZZ, 5A1221Z A 23-year-old female is admitted for shock following treatment of a miscarriage. The pathology report from the previous admission reveals that the patient had no decidua or products of conception in the tissue removed. This encounter would be coded as: a. O03.81, Spontaneous abortion complicated by shock b. O08.9, Complication following abortion and ectopic and molar pregnancies c. R57.9, Shock NOS d. T81.10XA, Postoperative shock - ANSWER-b. O08.9, Complication following abortion and ectopic and molar pregnancies The committee responsible for medical record completion reports to which medical staff committee? a. Compliance Committee b. Medical Executive Committee c. Discharge Planning Committee d. Nursing Executive Committee - ANSWER-b. Medical Executive Committee A patient undergoes a colposcopy with endometrial biopsy. Which of the following is correct? a. The colposcopy and endometrial biopsy are represented by a combination code. b. Two codes would be used with modifier -59 appended. c. Two codes would be used in accordance with CPT code instructions. d. Only one code is used and it does not state that it includes endometrial biopsy specifically. - ANSWER-c. Two codes would be used in accordance with CPT code instructions. When a Medicare patient receives an injection of IM penicillin G benzathine, 100,000 units only, what is the appropriate code assignment? 96372 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular 96374 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug J0558 Injection, penicillin G benzathine, and penicillin G procaine 100,000 unitsJ0561 Injection, penicillin G benzathine, 100,000 units a. 96372 b. J0558 c. 96374 d. 96372, J0561 - ANSWER-d. 96372, J0561 If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and the: a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the margins excised as described in the operative report - ANSWER-d. Diameter of the lesion as well as the margins excised as described in the operative report The use of the outpatient code editor (OCE) is designed to: a. Correct documentation of home health visits b. Facilitate reporting of adverse drug events c. Reduce the use of computer assisted coding d. Identify incomplete or incorrect claims - ANSWER-d. Identify incomplete or incorrect claims A patient is admitted with a high temperature, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient also has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." What is the next step for the coder? a. Code sepsis as the principal with a secondary diagnosis of urinary tract infection due to E. coli. b. Code urinary tract infection with sepsis as a secondary diagnosis. c. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms. d. Ask the physician whether the patient had septic shock so that this may be used as the principal diagnosis. - ANSWER-c. Query the physician to determine if the patient is being treated for sepsis, highlighting the clinical signs and symptoms. A patient is admitted because of congestive heart failure (CHF). During the treatment of the CHF, the patient was also found to have elevated liver function tests. The physician worked up the elevated liver function tests but was not able to determine a diagnosis. The following diagnoses should be assigned: a. Congestive heart failure with liver disease b. Abnormal liver function tests c. Congestive heart failure and abnormal liver function tests d. Congestive heart failure - ANSWER-c. Congestive heart failure and abnormal liver function tests The use of standard protocols to enable different computer systems to communicate is referred to as: a. Digital assistance b. A data set c. Interoperability d. Pay for communication - ANSWER-c. Interoperability Data accuracy is also referred to as: a. Consistency b. Comprehensiveness c. Timeliness d. Validity - ANSWER-d. Validity A routine computer back-up procedure is an example of a security program that ensures data loss does not occur. This type of control is: a. Computer b. Validity c. Responsive d. Preventive - ANSWER-d. Preventive A bronchoscopy with biopsy of the left bronchus was completed and revealed adenocarcinoma. What, if any, modifier should be added to the procedure codes? a. −50, Bilateral procedure b. −51, Multiple procedures c. −LT, Left side d. No modifiers should be reported. - ANSWER-d. No modifiers should be reported. Based on the AHIMA Code of Ethics, which of the following is not considered an ethical activity? a. Coding audits b. Using medical records for educational purposes within the department c. Reviewing the history and physical of a coworker when not part of work assignment d. Completion of code assignment - ANSWER-c. Reviewing the history and physical of a coworker when not part of work assignment A 59-year-old female patient presents with acquired hallux valgus. Hallux valgus repair is performed with resection of the joint with implant in the first left toe proximal phalanx. What codes would be assigned? a. M20.12, 28291-LT b. M20.22, 28291-TA c. M20.31, 28291-TA d. M20.12, 28291-TA - ANSWER-d. M20.12, 28291-TA According to the UHDDS, the definition of a secondary diagnosis is a condition that: a. Is recorded in the patient record b. Receives evaluation and is documented by the physician c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care d. Is considered to be essential by the physicians involved and is reflected in the record - ANSWER-c. Receives clinical evaluation, therapeutic treatment, further evaluation, extends the length of stay, increases nursing monitoring and care A facility located near a national park has a significant number of snake bites, and patients receive treatment with antivenom in urgent-care settings. Sometimes a patient is admitted to the hospital after several days. Can the urgent-care setting provide the hospital with a list of names of patients treated with snake antivenom? a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot be provided. b. A list of names could be provided. c. No information can be obtained under any circumstances. d. A list of patients may be available after consultation with the national park ranger. - ANSWER-a. Only the names of patients who are admitted to the hospital can be requested if the physician needs it for continuity of care, but an entire list of patients cannot be provided. An 84-year-old woman was admitted and discharged with hemiplegia and aphasia. A CT scan of the brain was performed that revealed an acute cerebral infarction and a possible small brain mass. After further testing, the patient was discharged with a final diagnosis of acute cerebral infarction. The condition(s) that should be coded are: a. Acute cerebral infarction b. Hemiplegia and aphasia c. Acute cerebral infarction, hemiplegia, and aphasia d. Possible brain mass, hemiplegia, and aphasia - ANSWER-c. Acute cerebral infarction, hemiplegia, and aphasia A quality improvement study showed that maternity cases are not being coded with the correct diagnostic codes reflecting the need for a cesarean section delivery. What index could be used to evaluate this? a. Birth certificate registry or master patient index b. Transcription registry or correspondence registry c. Quality improvement or operative registry d. Disease index from billing and reimbursement data - ANSWER-d. Disease index from billing and reimbursement data According to the UHDDS, section III, the definition of other diagnoses is all conditions that: a. Coexist at the time of admission, that develop subsequently, or that affect the treatment received or the length of stay b. Receive evaluation and are documented by the physician c. Receive clinical evaluation, therapeutic treatment, further evaluation, extend the length of stay, increase nursing monitoring/care d. Are considered to be essential by the physicians involved and are reflected in the record - ANSWER-a. Coexist at the time of admission, that develop subsequently, or that affect the treatment [Show Less]
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