Question 1

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

Accepted Answer

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

Question 2

In some cases a patient is ready to be discharged from the hospital,but at the last minute the patient develops a condition that requires him or her to stay an additional night.An example of when a patient might have to stay an additional night is when the patient ____.

Accepted Answer

A) is feeling better 
B) has no pain 
C) has no additional cough 
D) develops a fever 
A) is feeling better 
B) has no pain 
C) has no additional cough 
D) develops a fever

Question 3

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

Accepted Answer

The answer of How long after admission is it required...

Question 4

Chronic conditions include all of the following EXCEPT ____.

Accepted Answer

A) hypertension 
B) congestive heart failure 
C) diverticulitis 
D) emphysema 
E) all of the above are correct 
A) hypertension 
B) congestive heart failure 
C) diverticulitis 
D) emphysema 
E) all of the above are correct

Question 5

What does MRI stand for?

Accepted Answer

Magnetic r

Question 6

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

Accepted Answer

The following are purposes of a health r

Question 7

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

Accepted Answer

The discha

Question 8

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

Accepted Answer

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

Question 9

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

Accepted Answer

A) True 
 B)False

Question 10

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

Accepted Answer

A) True 
 B)False

Question 11

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

Accepted Answer

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

Question 12

Match each item to one of the following definitions.
-Consultations

Accepted Answer

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

Question 13

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

Accepted Answer

A) Nursing notes 
B) Anesthesia forms 
C) Physician orders 
D) Progress notes 
A) Nursing notes 
B) Anesthesia forms 
C) Physician orders 
D) Progress notes

Question 14

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

Accepted Answer

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

Question 15

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

Accepted Answer

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

Question 16

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

Accepted Answer

A) True 
 B)False

Question 17

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

Accepted Answer

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

Question 18

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

Accepted Answer

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

Question 19

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

Exam 2: The Health Record As the Foundation of Coding

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

In some cases a patient is ready to be discharged from the hospital,but at the last minute the patient develops a condition that requires him or her to stay an additional night.An example of when a patient might have to stay an additional night is when the patient ____.

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

Chronic conditions include all of the following EXCEPT ____.

What does MRI stand for?

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

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

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

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

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

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

Match each item to one of the following definitions. -Consultations

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

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

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

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

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

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

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

The Rationale for and History of Coding

ICD-10-Cm Format and Conventions

Basic Steps of Coding

General Coding Guidelines for Diagnosis

General Coding Guidelines for Medical and Surgical Procedures

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

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

Certain Infectious and Parasitic Diseases

Neoplasms

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

Endocrine, Nutritional, and Metabolic Diseases

Mental, Behavioral, and Neuro developmental Disorders

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

Diseases of the Circulatory System

Diseases of the Respiratory System

Diseases of the Digestive System

Diseases of the Skin and Subcutaneous Tissue

Diseases of the Musculoskeletal System and Connective Tissue

Diseases of the Genitourinary System

Pregnancy, Childbirth, and the Puerperium

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

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

Burns, adverse Effects, and Poisonings

Complications of Surgical and Medical Care

Reimbursement Methodologies

Out patient Coding

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