Question 1

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

Accepted Answer

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

Question 2

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

Accepted Answer

A) True 
 B)False

Question 3

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

Accepted Answer

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

Question 4

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

Accepted Answer

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

Question 5

Sometimes ____ is/are used to help diagnose a patient's condition.

Accepted Answer

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

Question 6

Give three reasons why a provider should be queried.

Accepted Answer

A provider should be queried when docume

Question 7

Match each definition to one of the following items.
-Consultations

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 8

What does AHQA stand for?

Accepted Answer

American H

Question 9

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

Accepted Answer

A) True 
 B)False

Question 10

Match each definition to one of the following items.
-Physician

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 11

The AHIMA practice brief says that a physician query should____.

Accepted Answer

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

Question 12

When coding a record, where is one of the best places to begin?

Accepted Answer

The discha

Question 13

Match each definition to one of the following items.
-TPR

Accepted Answer

A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease 
A) Centers for Medicare and Medicaid Services 
B) Temperature, pulse, and respiration 
C) Uniform Hospital Discharge Data Set 
D) Gastroesophageal reflux disease

Question 14

What does EKG stand for?

Accepted Answer

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

Question 15

Match each definition to one of the following items.
-Principal diagnosis

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 16

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

Accepted Answer

The following are purposes of a health r

Question 17

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

Accepted Answer

A) True 
 B)False

Question 18

Match each definition to one of the following items.
-Objective

Accepted Answer

A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment 
A) Accredits and certifies health care organizations 
B) The problem in the patient's own words 
C) The approach the practitioner is taking to solve the patient's problem 
D) The condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care 
E) Codes reported on health insurance claim forms that should be supported by documentation in the medical record
F)Person qualified by education and legally authorized to practice medicine
G)Requested by the attending physician to gain an expert opinion on the treatment of a particular aspect of the patient's condition that is outside the expertise of the attending physician
H)People who treat patients
I)The physician identifies the history, physical exam, and diagnostic tests
J)Where the subjective and objective combine for conclusion
K)Words of the patient; the reason the patient has presented to a health care facility for treatment

Question 19

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

Accepted Answer

The proble

Question 20

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

Accepted Answer

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

Exam 2: The Health Record As the Foundation of Coding

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

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

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

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

Sometimes ____ is/are used to help diagnose a patient's condition.

Give three reasons why a provider should be queried.

Match each definition to one of the following items. -Consultations

What does AHQA stand for?

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

Match each definition to one of the following items. -Physician

The AHIMA practice brief says that a physician query should____.

When coding a record, where is one of the best places to begin?

Match each definition to one of the following items. -TPR

What does EKG stand for?

Match each definition to one of the following items. -Principal diagnosis

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

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

Match each definition to one of the following items. -Objective

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

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

The Rationale for and History of Coding

ICD-10-Cm Format and Conventions

Basic Steps of Coding

General Coding Guidelines for Diagnosis

Introduction to Icd-10-PCS

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

Coding Medical and Surgical Procedures

Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

Certain Infectious and Parasitic Diseases

Neoplasms

Diseases of the Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism

Endocrine, Nutritional, and Metabolic Diseases

Mental, Behavioral, and Neurodevelopmental Disorders

Diseases of the Nervous System, Diseases of the Eye and Adnexa, and Diseases of the Ear and Mastoid Process

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous System

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

Certain Conditions Originating in the Perinatal Period and Congenital Malformations, Deformations, and Chromosomal Abnormalities

Injuries and Certain Other Consequences of External Cases and External Causes of Morbidity

Burns, Adverse Effects, and Poisonings

Complications of Surgical and Medical Care

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