Question 1

Dr. Zambrano ordered a CEA test for Mr. Logan. Dr. Zambrano may be considering a diagnosis of

Accepted Answer

A)  cancer. 
B)  carpet tunnel syndrome. 
C)  cardiomyopathy. 
D)  congestive heart failure.

Question 2

A record documentation requirement shared by BOTH acute care and emergency departments

Accepted Answer

A)  condition on discharge. 
B)  time and means of arrival. 
C)  known advance directive. 
D)  problem list.

Question 3

The physician documents that the patient has diabetes that was diagnosed prior to admission.

Accepted Answer

A)  Y=Yes 
B)  N=No 
C)  U=Unknown 
D)  W=clinically undetermined 
E)  Unreported/Not Used (Exempt from PO
A)  reporting

Question 4

End-stage kidney disease which resulted from malignant hypertension

Accepted Answer

A)  403.01, 585.6 
B)  585.9, 401.0 
C)  403.00 
D)  401.0, 585.9

Question 5

Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion.

Accepted Answer

A)  19100; 19125 
B)  19100; 19120-LT 
C)  19120-LT 
D)  19100; 19120; 19120

Question 6

You are a new supervisor in the HIM department and find it difficult to deal with performance issues. Laney, an employee in the Release of Information section. has been late several times month. She has already been given a verbal warning. She was late again today. According to progressive discipline process, your next step will be to

Accepted Answer

A)  reinforce the institution's policies. 
B)  reissue the verbal warning. 
C)  suspend the employee. 
D)  issue a written warning.

Question 7

A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. Which is the correct code?

Accepted Answer

A)  414.8 chronic MI 
B)  410.1x acute MI 
C)  412 old MI 
D)  413.0 angina

Question 8

The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed

Accepted Answer

A)  stereotactic radiation treatment. 
B)  proton beam treatment. 
C)  brachytherapy. 
D)  external beam radiation.

Question 9

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

Accepted Answer

A)  strong personnel component that reduces the rapid turnover of nursing personnel. 
B)  coding compliance program that prevents fraudulent coding and billing. 
C)  component that increases the security of medical records. 
D)  substantial program that increases the availability of clinical data.

Question 10

Employers may be able to demonstrate that age is a reasonable requirement for a position. Su an exception to the Age Discrimination in Employment Act (ADEA) is called a

Accepted Answer

A)  job description essential. 
B)  bona fide occupational qualification. 
C)  essential element for employment. 
D)  there is no such exception to ADEA.

Question 11

Richard is admitted for chemotherapy for leukemia. Chemotherapy is administered. Given this information,

Accepted Answer

A)  the leukemia code and a procedure code for the chemotherapy will be assigned. 
B)  an admission for chemotherapy code and a chemotherapy procedure code will be assigned. 
C)  an admission for chemotherapy code, a leukemia code, and a procedure code for the chemotherapy should be assigned and the principal diagnosis will be the admission for chemotherapy V code. 
D)  an admission for chemotherapy code, a leukemia code, and a procedure code for the chemotherapy should be assigned and the principal diagnosis will be the leukemia code.

Question 12

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

Accepted Answer

A)  24 hours. 
B)  3 days. 
C)  15 days. 
D)  60 days.

Question 13

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made.

Accepted Answer

A)  99304 
B)  99325 
C)  99324 
D)  99334

Question 14

The centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS­DRG payment the hospital stay. Therefore hospitals are required to report an ____________ indicator for each diagnosis.

Accepted Answer

A)  sentinel event 
B)  payment status 
C)  hospital acquired 
D)  present on admission

Question 15

Hysteroscopy with D&C and polypectomy

Accepted Answer

A)  58563 
B)  58558 
C)  58120; 58100; 58555 
D)  58558; 58120

Question 16

Margaret Vargas need to have her mitral valve replaced. Her surgeon will discuss which of the following issues with her before the surgery?

Accepted Answer

A)  a mechanical valve will require that she take a "blood thinner" for the rest of her life 
B)  a biological value (usually porcine) will last 10 to 15 years 
C)  a mechanical valve increase the risk of blood clots that can cause stroke 
D)  all of the above

Question 17

Your transcription system is set up to back up your hard drive every 5 minutes. The backup is on the hard drive of another computer. This computer is located in the room next door to the primary computer. What should be done to improve the backup process?

Accepted Answer

A)  Place the backup on an optical disk. 
B)  Back up on a daily basis. 
C)  Back up on a diskette. 
D)  Move backup computer to an office 100 miles away.

Question 18

Patient comes into the outpatient department at.the local hospital for an MRI of the cervical spine with contrast. Patient is status post automobile accident.

Accepted Answer

A)  72156 
B)  72142 
C)  72149 
D)  72126

Question 19

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and ten minutes providing critical care for this patient.

Accepted Answer

A)  99281, 99291, 99292, 94002 
B)  99291, 99292, 94002 
C)  99291, 94002 
D)  99291

Question 20

Urinary retention requiring insertion of Foley catheter

Accepted Answer

A)  788.21, 57.94 
B)  788.20, 57.93 
C)  788.20, 57.94 
D)  788.29, 57.93

Exam 1: Registered Health Information Administrator

Dr. Zambrano ordered a CEA test for Mr. Logan. Dr. Zambrano may be considering a diagnosis of

A record documentation requirement shared by BOTH acute care and emergency departments

The physician documents that the patient has diabetes that was diagnosed prior to admission.

End-stage kidney disease which resulted from malignant hypertension

Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion.

A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. Which is the correct code?

The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

Employers may be able to demonstrate that age is a reasonable requirement for a position. Su an exception to the Age Discrimination in Employment Act (ADEA) is called a

Richard is admitted for chemotherapy for leukemia. Chemotherapy is administered. Given this information,

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made.

The centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MSDRG payment the hospital stay. Therefore hospitals are required to report an ____________ indicator for each diagnosis.

Hysteroscopy with D&C and polypectomy

Margaret Vargas need to have her mitral valve replaced. Her surgeon will discuss which of the following issues with her before the surgery?

Your transcription system is set up to back up your hard drive every 5 minutes. The backup is on the hard drive of another computer. This computer is located in the room next door to the primary computer. What should be done to improve the backup process?

Patient comes into the outpatient department at.the local hospital for an MRI of the cervical spine with contrast. Patient is status post automobile accident.

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and ten minutes providing critical care for this patient.

Urinary retention requiring insertion of Foley catheter

Exam 1: Registered Health Information Administrator

Dr. Zambrano ordered a CEA test for Mr. Logan. Dr. Zambrano may be considering a diagnosis of

A record documentation requirement shared by BOTH acute care and emergency departments

The physician documents that the patient has diabetes that was diagnosed prior to admission.

End-stage kidney disease which resulted from malignant hypertension

Female patient has a percutaneous needle biopsy of the left breast lesion in the lower outer quadrant. Following the biopsy frozen section results, the physician followed this with an excisional removal of the same lesion.

A patient is admitted to your hospital 6 weeks post myocardial infarction with severe chest pains. Which is the correct code?

The use of radioactive sources placed into a tumor-bearing area to generate high intensity radiation is termed

A health care organization's compliance plans should not only focus on regulatory compliance, but also have a

Employers may be able to demonstrate that age is a reasonable requirement for a position. Su an exception to the Age Discrimination in Employment Act (ADEA) is called a

Richard is admitted for chemotherapy for leukemia. Chemotherapy is administered. Given this information,

A pathologist on the Health Record Committee asks about the time requirement for reporting a provisional diagnosis when an autopsy is performed. You respond confidently that this information must be on the health record within

The physician provided services to a new patient who was in a rest home for an ulcerative sore on the hip. A problem-focused history and physical examination were performed and a straightforward medical decision was made.

The centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MS­DRG payment the hospital stay. Therefore hospitals are required to report an ____________ indicator for each diagnosis.

Hysteroscopy with D&C and polypectomy

Margaret Vargas need to have her mitral valve replaced. Her surgeon will discuss which of the following issues with her before the surgery?

Your transcription system is set up to back up your hard drive every 5 minutes. The backup is on the hard drive of another computer. This computer is located in the room next door to the primary computer. What should be done to improve the backup process?

Patient comes into the outpatient department at.the local hospital for an MRI of the cervical spine with contrast. Patient is status post automobile accident.

A doctor provides critical care services in the emergency department for a patient in respiratory failure. He initiates ventilator management and spends an hour and ten minutes providing critical care for this patient.

Urinary retention requiring insertion of Foley catheter

The centers for Medicare and Medicaid Services (CMS) will make an adjustment to the MSDRG payment the hospital stay. Therefore hospitals are required to report an ____________ indicator for each diagnosis.