Brochure Examples of Medical Chart Review and Coding

Clinical Classification Systems

1.	A patient presents with CKD stage 3, edema and hypertension. The correct ICD-x CM codes for this chart are:
		a. N18.3, I10, R60.9
		b. N18.9, I10, R60.9
		c. N18.3, I12.9
		d. N18.nine, I12.9, R60.ix
Per ICD-10CM guidelines do not code signs and symptoms. Edema is a symptom of both hypertension and CKD. ICD-10CM guidelines land there is a coincidental relationship assumed between CKD and hypertension unless the provider specifically states that the hypertension is non related to the CKD, giving this patient hypertensive chronic kidney disease instead of regular hypertension. Incorrect answer. Please choose another answer.

two.	A 42-twelvemonth-old female person, who is a new patient, presents with foul-smelling urine, frequency, flank pain and fever for 4 days. Patient denies nausea and headache. Patient is not sexually active and is a non-smoker. The provider performs the post-obit exam in improver to patient's height, weight and blood force per unit area check: General: Well-developed, well nourished, in no astute distress Ears: external ears normal, TM bilaterally intact Neck: Supple, no thyromegaly Extremities: No edema Cardiovascular: RRR, no bruits Lungs: Clear to auscultation The patient is prescribed ciprofloxacin and given a diagnosis of acute cystitis without hematuria. The correct coding for this meet, using 1997 Due east/1000 guidelines is:
		a. 99202, N30.00
		b. 99203, N30.00, R30.0
		c. 99202, N39.0
		d. 99203, N39.0, R30.0
1997 E/M guidelines state that the provider must attain 12 bullet points for a detailed level of exam. Although the patient's chart has a detailed history and moderate medical decision making, the provider only reached 11 bullet points, making this level a 99202. N39.0 is not the almost specific lawmaking for this nautical chart. Incorrect respond. Please choose another answer.

3.	A patient presents with a cyst at the base of his tailbone. It is swollen and painful for the patient to sit down. The provider drapes the patient in the usual style, administers lidocaine and uses a scalpel to excise the 2cm cyst and a subcutaneous extension, rinses it with sterile saline, performs an intermediate repair of the wound with a layered closure. The correct CPT code consignment for this procedure is:
		a. 10080, 12001-59
		b. 10081
		c. 11771
		d. 11770, 12031-59
The provider performs an excision, not an incision, completely removing the cyst. The excision is intermediate considering it involves subcutaneous extensions and the repair is included with the procedure. Incorrect answer. Please cull another answer.

iv.	A vii-yr-erstwhile kid presents for a series of vaccines. The patient receives MMR and DTaP and counseling on vaccines. The right CPT code assignment for this procedure is:
		a. 90460, 90461
		b. 90471, 90472
		c. 90460, 90461x5
		d. 90460x2, 90461x4
Pediatric vaccines with counseling are coded per component. Each commencement component of a vaccine (Measles and Diphtheria in this case) are coded every bit one unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code. Wrong answer. Delight cull another reply.

v.	ICD-10 codes are used:
		a. as procedure codes
		b. in DRGs
		c. every bit diagnosis codes
		d. All of the to a higher place
ICD-x PCS are used every bit procedure codes for inpatient visits. DRGs utilise similar ICD-10CM weights for facility reimbursement and ICD-10CM are used equally diagnosis codes for all healthcare settings. Incorrect respond. Please cull another answer.

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6.	For urosepsis, a coder must:
		a. Use the code for severe sepsis
		b. Use the code for sepsis with organ dysfunction
		c. Query the provider
		d. Code first localized sepsis
According to ICD-10CM guidelines, urosepsis is a nonspecific term and has no tabular position. The provider must be queried for clarification. Incorrect reply. Please choose another answer.

vii.	A patient comes into the part with white fuzzy patches on their tongue and is diagnosed with oral hairy leukoplakia. The provider runs a test for HIV and notates that the patient has HIV in the nautical chart, but does non have a positive lab exam yet. The patient is a smoker. What is the correct sequencing of these ICD-x codes?
		a. B20, K13.3, F17.200
		b. K13.3, R75, Z87.891
		c. B20, K13.iii, Z87.891
		d. K13.3, Z21, F17.200
According to affiliate guidelines, if a patient is seen for an HIV-related condition, (which oral hairy leukoplakia is), and then B20 is coded kickoff, and so the complications. Only the provider's statement is needed that the patient has HIV, not a positive lab test. F17.200 is to be assigned when the provider documents "smoker", but gives no further description (AHA: 2016, 1Q, 36) Incorrect answer. Please choose another answer.

8.	A 25-yr-old patient is 27 weeks and 6 days pregnant. The patient is experiencing dysuria and blood in her urine. She is diagnosed with astute cystitis. What is the correct coding of this patient's chart?
		a. N30.01, Z33.1
		b. O23.32, N39.0, Z3A.27
		c. O23.12, N30.01, Z3A.27
		d. N30.00, Z33.1
Cystitis is an infection of the float. The provider must specifically state that the infection or condition is not affecting the pregnancy for an incidental code. The patient is experiencing blood in her urine, which gives us the hematuria portion of the diagnosis. Wrong answer. Delight cull some other respond.

9.	A patient comes in after her pressure cooker has exploded and covered her face with boiling soup. She was luckily wearing a sweater which protected her artillery. She has partial-thickness burns roofing her entire confront. What is the right CPT code to be assigned equally the hospital removes chicken, celery and burnt tissue from her face and places dressings on information technology?
		a. 16020, 97597-59
		b. 11011
		c. 16025
		d. 97597
16025 covers whole face up burns and includes debridement. Incorrect answer. Delight choose some other answer.

ten.	A 2-year-old child had their humerus fractured by a falling dresser and requires anesthesia to repair the break because they will not hold still for a reduction. The procedure billed is 24505. What anesthesia service is reported?
		a. 01730 P1
		b. 01742 P1, 99100
		c. 01744 P1
		d. 01756 P1, 99100
Anesthesia for all closed procedures on humerus and elbow. The 99100 code is just used for patients under 1 year old or over 70 years old. 01744 is for open up procedures, not closed. Wrong answer. Please cull another answer.

Confidentiality and Privacy

11.	The Breach Notification Rule, found in the ______ Rule of HIPAA, states that when _____ individuals have had their confidential information exposed and the covered entity has outdated contact information for them, that the covered entity must_____ for ______ days.
		a. Security Rule, less than 200 individuals only more than 5, post a notice in the newspaper for 180 days
		b. Passenger vehicle Rule, less than 500 individuals but more than ten, post a notice on their website for xc days
		c. Security Rule, 500 or more individuals, post a find on their website and create a radio ad for 60 days
		d. Privacy Rule, 5 or more individuals, post a notice on their website, in the lobby and send postcards with information at least 3 times over ninety days.
The Double-decker Rule established HITECH and the AARA of 2009 and finalized the Breach Notification Rule, mandating that covered entities who have more than 10 individuals with outdated contact information involved in a information breach must be notified past posting a notice on their website or creating a local advert in the paper. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately. Incorrect respond. Delight choose some other answer.

12.	Emerge calls the coding department to contest the indistinguishable procedures that her adult sis received while admitted to an inpatient mental health facility. Sally has her sister's engagement of birth, her name but not her ID number. She says her sister is as well depressed to abet for herself and Sally just wants the charges reviewed. What do you do?
		a. Tell Sally y'all'll review her sister's chart while she was hospitalized and process a corrected claim if needed.
		b. Tell Emerge y'all're distressing, but her sis must phone call when she gets out of the hospital, HIPAA does not allow you to speak to Sally without her sis's written consent.
		c. Tell Sally her sis's patient ID number so she tin can better abet for her sister in other departments
		d. Tell Sally that co-ordinate to HIPAA she must obtain her sister's written consent in order to discuss whatever protected health data with her and give her the fax number where she can ship the written release.
HIPAA Privacy Rule Department 164.510(b)(iii) allows providers to discuss PHI with family members if they determine it is in the patient's all-time interest for coordination of treatment or payment, unless the patient has expressed wishes that their information is non shared with family. Incorrect answer. Delight choose some other answer.

thirteen.	You demand a second stance on coding a chart from your Coding Manager, who does not take admission to the patient's records. You lot decide to e-mail a screenshot of the chart to the Coding Manager. What steps must you have to ensure that the patient'south data is protected in your email?
		a. Create a confidentiality discover in your email, asking an unintended recipient to delete the information
		b. Follow all company guidelines to encrypt your email
		c. Remove patient'south name, date of nativity, insurance ID#, SSN, accost and patient number earlier emailing
		d. All of the above
HIPAA HITECH requires that covered entities accept reasonable activity to protect electronically transmitted information. Removing protected health information, encrypting email and creating confidentiality notices are a multi-layered security arroyo that is best-practise to prevent breaches of data. Wrong respond. Please choose another answer.

Reimbursement Methodologies

14.	Facility payments are based on:
		a. Fee schedules
		b. ICD-10 PCS codes
		c. IPPS using DRGs
		d. RVUs and conversion factors
The Inpatient Prospective Payment Arrangement drives value-based care by paying inpatient stays based on DRGs (Diagnosis-Related Grouping(s)) which are groups of diagnoses with similar weights in guild to decide "how much" a patient's stay ought to cost. These drivers forcefulness hospitals to work to be near efficient in their utilise of resources to come up in under what they will be paid in order to avoid losing money. Incorrect answer. Please choose some other answer.

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xv.	Conversion factors:
		a. Are based on how difficult a process is
		b. Depend on the level of didactics a provider has
		c. Are based on locality
		d. None of the above
RVUs are based off work for each HCPCS. RVUs are multiplied by Geographic Practice Toll Indices (GPCI), which account for physician work, price of malpractice and practice expenses. A conversion gene, which is a national number that changes annually, is multiplied past the sum of RVUs that are multiplied by the GPCI to calculate payment for professional person fee schedules. Incorrect respond. Please choose another answer.

xvi.	Pressure ulcers, catheter-associated urinary tract infections, falls and head trauma, DVTs and pulmonary embolisms are all examples of:
		a. DRGs that should take a POA indicator
		b. Hospital-acquired weather that volition non be reimbursed
		c. Part of similar weight DRGs
		d. Complications that must be coded to receive full reimbursement
The HAC-POA (Infirmary caused condition, nowadays on admission) programme was created by the Deficit Reduction Act of 2005--any of these conditions which are non present on admission and could have reasonably been prevented by following accepted standards of intendance volition not be reimbursed. Usually, adding the DRG weight would have increased the facility's reimbursement, but this forces hospitals to avert hospital acquired weather, rather than profit from them. Wrong respond. Delight cull some other answer.

17.	Relative Value Units are:
		a. Unlike for each locality
		b. A weight for procedure codes
		c. Multiplied with conversion factors
		d. All of the above
RVUs multiplied by conversion factor gives you lot the corporeality payable for a provider's fee schedule. Incorrect answer. Please choose another answer.

18.	Medicare pays Skilled Nursing Facilities with a prospective payment system. Reimbursement is based on:
		a. Reasonable costs
		b. Per Diem
		c. Based on DRGs
		d. Episode of intendance
The Balanced Budget Deed mandated that SNF-PPS be paid per diem for all costs, which is based on a example-mix of diagnoses. Incorrect answer. Please choose another answer.

19.	For Medicare'south OPPS, payment status indicator C indicates that the HCPCS is:
		a. More complicated than usual, requiring increased reimbursement
		b. Part of a series of concurrent procedures that volition exist performed together
		c. Simply performed in inpatient settings
		d. Performed past the Chief surgeon, requiring increased reimbursement.
Payment status indicator C indicates that the HCPCS is but performed in an in-patient setting. Wrong respond. Please choose another reply.

Health Records and Data Content

20.	CMS requires that the patient's history and physical exist completed and documented in the patient's record
		a. Within 24 hours of admission or not greater than xxx days before admission
		b. Immediately upon admission or not greater than ten days before access
		c. Inside 6 hours of admission or not greater than xv days before admission
		d. Within 3 hours of admission or not greater than 3 days before admission
CMS atmospheric condition of participation require that the patient's history and physical exist completed and documented within the patient's record within 24 hours of access, but not greater than 30 days prior to admission. Incorrect answer. Please choose some other respond.

21.	These components create a patient's history:
		a. Reason for Visit, History of Present Affliction, Review of Symptoms, Prior History
		b. Chief Complaint, History of Nowadays Illness, Review of Systems, Past Family and Social History
		c. Chronic conditions, History of Nowadays Illness, Review of Symptoms, Reason for Visit, Surgical history
		d. Primary Complaint, History of Present Illness, Review of Symptoms, Past Family unit and Social History
CC, HPI, ROS and PFSH are the components of a patient history. ROS is performed to make sure the provider did non miss any relevant complaints and can exist pulled from the HPI if needed. Incorrect answer. Please choose another reply.

22.	According to CMS, the provider'southward concluding authentication of the patient's wellness record must Not be by:
		a. Rubber stamp
		b. Electronic signature verified by biometrics
		c. Electronic signature verified past passcodes
		d. Ink signatures in blackness ink
Prophylactic stamps were prohibited past CMS in 2015 for provider authentication Incorrect answer. Please cull another answer.

23.	An open-tape review is when:
		a. The patient's record, with PHI removed, is presented at a clinical documentation improvement session for providers
		b. The patient'south record is sent to CMS to exist audited
		c. When a qualitative assay of the patient'south tape is done while the patient is in active handling
		d. When the patient is given a copy of their nautical chart to ensure everything was documented accurately to the best of their knowledge
An open up-record review takes place when a qualitative analysis of the patient's record is washed while the patient is in active treatment. The Joint Commission requires these reviews to ensure that documentation standards are met while the patient is still nether care. Incorrect reply. Delight cull some other answer.

24.	Which of the following is Not a component of Personal Health Information
		a. URL
		b. Zip Code
		c. License plate number
		d. All of the above are PHI elements
There are 18 unique identifiers protected by HIPAA. Simply the start three digits of a patient'southward zip code is not PHI, as long as there are more than 20,000 people in the grouping that forms all zip codes. E.g. 123XX+123XY+123XZ have more than twenty,000 people. Otherwise the zip code must be changed to 00000. Incorrect answer. Please choose another respond.

Information Technologies

25.	What is the difference between an EHR and an EMR?
		a. EHRs contain financial information while EMRs simply comprise clinical information.
		b. EHRs are able to communicate with other systems, but EMRs are not.
		c. EHRs contain images, while EMRs only contained electronic "paper" chart formats.
		d. In that location is no departure between EHRs and EMRs. Information technology's just a terminology difference.
EHRs are defined by NAHIT as able to communicate and commutation data with multiple systems. EMRs exercise non have this capacity. Wrong answer. Delight choose another answer.

26.	Which of the following standards are used to create standardized nomenclature within an electronic health record program?
		a. ICD-10 CM
		b. NADA PC
		c. CTNS EHR
		d. SNOMED CT
Systemized Nomenclature of Medicine--Clinical Terminology (SNOMED CT) is the global standard for clinicians and is used to define terms in EHRs effectually the earth. Incorrect answer. Please cull another reply.

27.	Implemented in 2012, what standard inverse the way that PHI was submitted electronically?
		a. ASC X12 5010
		b. HL7 4010
		c. SDLC 6040
		d. HIPAA 2020
Nether Administrative Simplification, HIPAA standard 5010, using ASC X12, was created and implemented. HIPAA standard 4010 was no longer accepted equally of June 30, 2012 Incorrect respond. Delight cull another answer.

Compliance

28.	Y'all work at a billing company, coding charts for clients. Your manager sends out claims that have not been coded professionally because your team is ii months behind and out of compliance with your service line agreement in the contract with your client, but says that it is okay because the provider has coded the claims at the time of service and the client does not want to pay for extra coding. Which of the following statements is true?
		a. This is fine because the provider coded the claim to the best of their ability and therefore cannot be held liable.
		b. Billing companies accept liability for fraudulent claims that they submit, including undercoding, so this is not acceptable.
		c. Only overcoding is fraudulent, so this is acceptable.
		d. The providers by and large under-code their services, so information technology's really saving the insurance money and saving us work!
The OIG states that billing companies who submit fraudulent claims (every bit well every bit the person who submitted them!) are only as responsible equally the provider who rendered the services. Both undercoding and overcoding are examples of fraudulent claims, the merits submitted must accurately represent the services rendered. Incorrect answer. Please cull another answer.

29.	Which of the following are considered fraudulent:
		a. Use of modifier -59 to study a singled-out and split service that would otherwise be prohibited by NCCI guidelines.
		b. Irresolute the code on a claim because the provider did non meet documentation standards.
		c. Use of modifier -25 on a minor evaluation and direction service that is coded with a related procedure.
		d. All of the higher up are acceptable practices.
Procedures include a minor evaluation and management service. If the patient complains of an abscess and a I&D is performed, only the procedure should exist reported. If the patient comes in complaining of hypertension and an abscess is discovered, and so it would be acceptable to report an evaluation and management service. Incorrect reply. Please choose another answer.

30.	Which of the following is an example of a compliant query to a physician:
		a. 06/30: Dr. Brown, tin can yous add documentation for the procedure you did on for Mrs. Parks 5/22? We've billed information technology out but I'm worried that there isn't enough documentation to support it. We know you did the procedure, but just need a little something extra!
		b. half dozen/30: Dr. Brown, can you clarify in the patient'south nautical chart Mrs. Cramb'southward diagnosis for six/27 given the positive rapid strep exam that was uploaded?
		c. half-dozen/thirty Dr. Pepper, can you add acute sinusitis (if that's what he had!) to Mr. Meltzer'southward record--all nosotros take is nasal congestion, headache and malaise and I come across you prescribed him antibiotics. Thanks!
		d. 6/xxx Dr. Pepper, I see that you gave Mr. Evans a diagnosis of unspecified loss of kidney function, but we would get paid a scrap more than if information technology were Chronic Kidney Disease, would that exist an advisable diagnosis to code for this patient?
Physician queries must be non-leading, not based on reimbursement, for the purpose of improving patient care and open-concluded, or Aye/No questions. Providers must non add documentation solely for the purpose of existence reimbursed and it must be within a reasonable fourth dimension frame. Incorrect respond. Please cull some other answer.

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Source: https://www.tests.com/practice/Medical-Coding-Practice-Test

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