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1. A coder acquires a working knowledge of coding systems, coding conventions and guidelines, government regulations, and third-party payer requirements to ensure that documented diagnoses, services, and procedures are coded accurately for __________, research, and statistical purposes. a. compliance
b. continuity of care
c. quality assurance
d. reimbursement
ANSWER: d
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:37 PM
2. During internships (or professional practice experiences) at health care facilities, coding students receive __________ training.
a. continuing education
b. on-the-job
c. paid
d. virtual
ANSWER: b
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:41 PM
3. Which is the person to whom the student reports at the health care facility internship site? a. college instructor
b. department manager
c. internship supervisor
d. volunteer coordinator
ANSWER: c
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:42 PM
4. Which is the most likely reason a student would be terminated from the internship site, fails internship course, or suspended and/or expelled from the academic program?
a. arriving late due to weather conditions
b. breaching patient confidentiality
c. contacting the site about an absence
d. dressing in a business casual style
ANSWER: b
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:43 PM
5. Coders also have the opportunity to work at home for employers who partner with an Internet-based organization called a(n) __________, which is a third-party entity that manages and distributes software-based services and solutions to customers using the Internet.
a. application service provider (ASP)
b. knowledge process outsourcing (KPO)
c. third-party logistics (TPL)
d. wide area network (WAN)
ANSWER: a
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:44 PM
6. Which professional is employed by third-party payers to review health-related claims to determine whether the costs are reasonable and medically necessary based on the patient’s diagnosis? a. health information technician
b. insurance specialist
c. liability underwriter
d. medical assistant ANSWER: b
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:47 PM
7. Students who join a professional association for a reduced membership fee often receive most of the same benefits as active members. Which is an example of a benefit of joining a professional association? a. guaranteed receipt of academic scholarship and grants
b. opportunity to network with members of the association
c. placement by the association at an internship facility
d. waiver provided for certification examination fees
ANSWER: b
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 2:47 PM
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:30 PM
45. The primary purpose of the record is to provide for __________.
a. facility medicolegal interests
b. health care reimbursement
c. patient continuity of care
d. quality review studies
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:31 PM
46. A secondary purpose of the patient record is to __________.
a. assist in planning patient care
b. evaluate patient quality of care
c. provide patient continuity of care
d. serve as a communication method
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:31 PM
47. Patient record documentation must be __________.
a. dated and authenticated by the responsible provider
b. evaluated prior to patient discharge from the facility
c. provided to third-party payers for reimbursement
d. stored using an automated electronic record format
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:32 PM
48. A teaching hospital is engaged in an approved graduate medical education __________ program in medicine, osteopathy, dentistry, or podiatry. a. health care
b. medicolegal
c. residency
d. third-party
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:32 PM
49. Residents are supervised by a(n) __________ physician during patient care. a. admitting
b. attending
c. responsible
d. teaching
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:32 PM
50. Which type of physician participates in an approved GME program? a. attending
b. emergency
c. resident
d. teaching
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:33 PM
51. A hospitalist is a physician whose practice emphasizes providing care for hospital __________, and they are often internal medicine specialists who handle a patient’s entire admission process. a. clinic patients
b. ED patients
c. inpatients
d. outpatients
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:33 PM
52. For medical necessity purposes, the patient record must support codes submitted for third-party payer reimbursement, and patient diagnoses must __________.
a. evaluate the quality of patient care received in the health care facility
b. justify diagnostic and/or therapeutic procedures or services provided
c. provide clinical evidence for a higher degree of specificity or severity
d. serve the medicolegal interests of the patient, facility, and providers of care
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:33 PM
53. Which type of record is paper based?
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: c
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:34 PM
54. Which type of record uses computer technology?
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:34 PM
55. Patient records that consist of handwritten progress notes and automated laboratory results are an example of __________ records.
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:35 PM
56. In a source-oriented record, reports are organized according to __________ in labeled sections. a. documentation source
b. health care provider
c. procedures and services
d. reimbursement type ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:35 PM
57. Which is a systematic method of documentation that consists of four components: database, initial plan, problem list, and progress notes?
a. integrated record
b. problem-oriented record
c. sectionalized record
d. source-oriented record
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:36 PM
58. Chief complaint, social data, and past medical history are considered part of the problem-oriented record __________. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:36 PM
59. The table of contents for the problem-oriented record is called the __________, and it is filed at the beginning of the record and contains a numbered list of the patient’s problems, which helps to index documentation throughout the record. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
60. The problem-oriented record __________ contains the strategy for managing patient care and any actions taken to investigate the patient’s condition and to treat and educate the patient. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
61. Which is documented about each problem assigned to the patient, using the SOAP structure of the problem-oriented record?
a. database
b. initial plan
c. problem list
d. progress note
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
62. To learn more about the patient’s condition and the management of the conditions, review the __________ plans in the problem-oriented record.
a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:38 PM
63. To determine how the patient will be informed about conditions for which he or she is being treated, review the __________ plans in the problem-oriented record. a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:38 PM
64. To learn more about specific medications, goals, procedures, therapies, and treatments used to treat the patient, review the __________ plans in the problem-oriented record. a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
65. Observations about the patient’s physical findings or lab results would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
66. The patient’s statement about how he or she feels would be found in the __________ portion of a problem-oriented SOAP note.
a. assessment
b. objective
c. plan
d. subjective
ANSWER: d
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
67. The judgment, opinion, or evaluation made by the health care provider would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:40 PM
68. Diagnostic, therapeutic, and education plans to resolve the problems would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: c
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:40 PM
69. The progress notes section of the POR contains a(n) __________ note to summarize the patient’s care, treatment, response to care, and condition on release from the facility. a. discharge
b. emergency
c. follow-up
d. transfer
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:41 PM
70. The progress notes section of the POR contains a(n) __________ note when the patient is relocated to another facility, and it summarizes the reason for admission, current diagnoses and medical information, and reason for relocation. a. discharge
b. emergency
c. follow-up
d. transfer
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:41 PM
71. Integrated record reports are arranged in strict chronological date order (or in reverse date order), which allows for __________, and many facilities integrate only physician and ancillary services progress notes, which require entries to be identified by appropriate authentication.
a. collection of information by a number of providers at different facilities about a patient
b. linking of information created at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. summarization of patient care, treatment, response to care, condition on discharge
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:42 PM
72. The electronic health record is a(n) __________.
a. collection of information by a number of providers at different facilities about a patient
b. linking of information created at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. summarization of patient care, treatment, response to care, and condition on discharge
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:43 PM
73. The electronic medical record is a(n) __________.
a. created using vendor software, which also assists in provider decision making
b. linking of information generated at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. practice management software solution for acute and long-term care hospitals
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:43 PM
74. Document imaging supplements the EHR or EMR by scanning paper records so that they are __________.
a. converted to an electronic image and saved on storage media
b. linked using a unique patient identifier assigned by the government
c. paper-based solutions for facilities that cannot afford automated records
d. stored on computers at regional health care centers in each state
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:44 PM
75. Which is used during the document imaging process to create images of patient reports? a. index
b. jukebox
c. optical disk
d. scanner
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:44 PM
76. During the optical disk imaging process, each patient report is __________ with a unique identification number assigned by the facility. a. documented
b. indexed
c. scanned
d. tabulated
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:45 PM
77. Which is performed by health care facilities and providers for the purpose of administrative planning, submitting statistics to state and federal government agencies, and reporting health claims data to third-party payers? a. health data collection
b. provider documentation
c. reimbursement processing
d. statistical analysis
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:45 PM
78. Automated case abstracting software is used by hospitals to __________.
a. collect data for statistical analysis
b. generate accounting aging reports
c. register patients for encounters
d. schedule patient appointments
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
79. The UB-04 claim is submitted by __________ to health plans for reimbursement purposes. a. departments of health
b. hospitals
c. physician offices
d. third-party payers
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
80. The CMS-1500 claim is submitted by __________ to third-party payers for processing.
a. departments of health
b. government agencies
c. physician offices
d. third-party payers ANSWER: c
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
81. Medical management software is used to _____.
a. automate physician office workflow
b. collect hospital data for analysis
c. generate patient satisfaction surveys
d. process UB-04 outpatient claims
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
Match each statement of purpose with the reference/resource listed below. a. Conditions of Participation
b. CPT Assistant
c. National Correct Coding Initiative
d. Outpatient Code Editor
e. Coding Clinic for HCPCS Level II
DIFFICULTY: Moderate
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
82. Medicare regulations (Centers for Medicare and Medicaid Services)
ANSWER: a
POINTS: 1
83. Software used by hospitals to help identify CPT/HCPCS coding errors
ANSWER: d
POINTS: 1
84. Monthly newsletter published by AMA as an official coding resource
ANSWER: b
POINTS: 1
85. Quarterly newsletter published by AHA as an official coding resource
ANSWER: e
POINTS: 1
86. Code edits pairs” that cannot be reported on the same claim for payment
ANSWER: c
POINTS: 1
Match each illegal coding practice with the correct term listed below. a. Downcoding
b. Jamming
c. Overcoding
d. Unbundling
e. Upcoding
DIFFICULTY: Difficult
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
87. Reporting multiple CPT codes to increase reimbursement when a combination code should be reported ANSWER: d
POINTS: 1
88. Reporting codes for associated signs and symptoms in addition to an established diagnosis ANSWER: c
POINTS: 1
89. Routinely assigning lower-level CPT codes as a convenience instead of reviewing documentation and the coding manual to determine the proper code to be reported
ANSWER: a
POINTS: 1
90. Routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number
ANSWER: b
POINTS: 1
91. Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement ANSWER: e
POINTS: 1
Match each credential with the corresponding credentialing organization listed below. a. AAMA
b. AAPC
c. AHIMA
d. AMBA
DIFFICULTY: Easy
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:54 AM
92. CCS
ANSWER: c
POINTS: 1
93. CMA
ANSWER: a
POINTS: 1
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:33 PM
52. For medical necessity purposes, the patient record must support codes submitted for third-party payer reimbursement, and patient diagnoses must __________.
a. evaluate the quality of patient care received in the health care facility
b. justify diagnostic and/or therapeutic procedures or services provided
c. provide clinical evidence for a higher degree of specificity or severity
d. serve the medicolegal interests of the patient, facility, and providers of care
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:33 PM
53. Which type of record is paper based?
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: c
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:34 PM
54. Which type of record uses computer technology?
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:34 PM
55. Patient records that consist of handwritten progress notes and automated laboratory results are an example of __________ records.
a. automated
b. hybrid
c. manual
d. systematized
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:35 PM
56. In a source-oriented record, reports are organized according to __________ in labeled sections. a. documentation source
b. health care provider
c. procedures and services
d. reimbursement type ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:35 PM
57. Which is a systematic method of documentation that consists of four components: database, initial plan, problem list, and progress notes?
a. integrated record
b. problem-oriented record
c. sectionalized record
d. source-oriented record
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:36 PM
58. Chief complaint, social data, and past medical history are considered part of the problem-oriented record __________. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:36 PM
59. The table of contents for the problem-oriented record is called the __________, and it is filed at the beginning of the record and contains a numbered list of the patient’s problems, which helps to index documentation throughout the record. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
60. The problem-oriented record __________ contains the strategy for managing patient care and any actions taken to investigate the patient’s condition and to treat and educate the patient. a. database
b. initial plan
c. problem list
d. progress note
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
61. Which is documented about each problem assigned to the patient, using the SOAP structure of the problem-oriented record?
a. database
b. initial plan
c. problem list
d. progress note
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:37 PM
62. To learn more about the patient’s condition and the management of the conditions, review the __________ plans in the problem-oriented record.
a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:38 PM
63. To determine how the patient will be informed about conditions for which he or she is being treated, review the __________ plans in the problem-oriented record. a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:38 PM
64. To learn more about specific medications, goals, procedures, therapies, and treatments used to treat the patient, review the __________ plans in the problem-oriented record. a. diagnostic/management
b. follow-up
c. patient education
d. therapeutic
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
65. Observations about the patient’s physical findings or lab results would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: b
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
66. The patient’s statement about how he or she feels would be found in the __________ portion of a problem-oriented SOAP note.
a. assessment
b. objective
c. plan
d. subjective
ANSWER: d
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:39 PM
67. The judgment, opinion, or evaluation made by the health care provider would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: a
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:40 PM
68. Diagnostic, therapeutic, and education plans to resolve the problems would be found in the __________ portion of a problem-oriented SOAP note. a. assessment
b. objective
c. plan
d. subjective
ANSWER: c
POINTS: 1
DIFFICULTY: Difficult
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:40 PM
69. The progress notes section of the POR contains a(n) __________ note to summarize the patient’s care, treatment, response to care, and condition on release from the facility. a. discharge
b. emergency
c. follow-up
d. transfer
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:41 PM
70. The progress notes section of the POR contains a(n) __________ note when the patient is relocated to another facility, and it summarizes the reason for admission, current diagnoses and medical information, and reason for relocation. a. discharge
b. emergency
c. follow-up
d. transfer
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:41 PM
71. Integrated record reports are arranged in strict chronological date order (or in reverse date order), which allows for __________, and many facilities integrate only physician and ancillary services progress notes, which require entries to be identified by appropriate authentication.
a. collection of information by a number of providers at different facilities about a patient
b. linking of information created at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. summarization of patient care, treatment, response to care, condition on discharge
ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:42 PM
72. The electronic health record is a(n) __________.
a. collection of information by a number of providers at different facilities about a patient
b. linking of information created at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. summarization of patient care, treatment, response to care, and condition on discharge
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:43 PM
73. The electronic medical record is a(n) __________.
a. created using vendor software, which also assists in provider decision making
b. linking of information generated at different locations using a unique patient identifier
c. observation about how the patient responds to treatment based on test results
d. practice management software solution for acute and long-term care hospitals
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:43 PM
74. Document imaging supplements the EHR or EMR by scanning paper records so that they are __________.
a. converted to an electronic image and saved on storage media
b. linked using a unique patient identifier assigned by the government
c. paper-based solutions for facilities that cannot afford automated records
d. stored on computers at regional health care centers in each state
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:44 PM
75. Which is used during the document imaging process to create images of patient reports? a. index
b. jukebox
c. optical disk
d. scanner
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:44 PM
76. During the optical disk imaging process, each patient report is __________ with a unique identification number assigned by the facility. a. documented
b. indexed
c. scanned
d. tabulated
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:45 PM
77. Which is performed by health care facilities and providers for the purpose of administrative planning, submitting statistics to state and federal government agencies, and reporting health claims data to third-party payers? a. health data collection
b. provider documentation
c. reimbursement processing
d. statistical analysis
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:45 PM
78. Automated case abstracting software is used by hospitals to __________.
a. collect data for statistical analysis
b. generate accounting aging reports
c. register patients for encounters
d. schedule patient appointments
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
79. The UB-04 claim is submitted by __________ to health plans for reimbursement purposes. a. departments of health
b. hospitals
c. physician offices
d. third-party payers
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
80. The CMS-1500 claim is submitted by __________ to third-party payers for processing.
a. departments of health
b. government agencies
c. physician offices
d. third-party payers ANSWER: c
POINTS: 1
DIFFICULTY: Easy
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/24/2018 3:46 PM
81. Medical management software is used to _____.
a. automate physician office workflow
b. collect hospital data for analysis
c. generate patient satisfaction surveys
d. process UB-04 outpatient claims
ANSWER: a
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
Match each statement of purpose with the reference/resource listed below. a. Conditions of Participation
b. CPT Assistant
c. National Correct Coding Initiative
d. Outpatient Code Editor
e. Coding Clinic for HCPCS Level II
DIFFICULTY: Moderate
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
82. Medicare regulations (Centers for Medicare and Medicaid Services)
ANSWER: a
POINTS: 1
83. Software used by hospitals to help identify CPT/HCPCS coding errors
ANSWER: d
POINTS: 1
84. Monthly newsletter published by AMA as an official coding resource
ANSWER: b
POINTS: 1
85. Quarterly newsletter published by AHA as an official coding resource
ANSWER: e
POINTS: 1
86. Code edits pairs” that cannot be reported on the same claim for payment
ANSWER: c
POINTS: 1
Match each illegal coding practice with the correct term listed below. a. Downcoding
b. Jamming
c. Overcoding
d. Unbundling
e. Upcoding
DIFFICULTY: Difficult
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:53 AM
87. Reporting multiple CPT codes to increase reimbursement when a combination code should be reported ANSWER: d
POINTS: 1
88. Reporting codes for associated signs and symptoms in addition to an established diagnosis ANSWER: c
POINTS: 1
89. Routinely assigning lower-level CPT codes as a convenience instead of reviewing documentation and the coding manual to determine the proper code to be reported
ANSWER: a
POINTS: 1
90. Routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code number
ANSWER: b
POINTS: 1
91. Reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement ANSWER: e
POINTS: 1
Match each credential with the corresponding credentialing organization listed below. a. AAMA
b. AAPC
c. AHIMA
d. AMBA
DIFFICULTY: Easy
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:54 AM
92. CCS
ANSWER: c
POINTS: 1
93. CMA
ANSWER: a
POINTS: 1
94. CPC
ANSWER: b
POINTS: 1
95. CMRS
ANSWER: d
POINTS: 1
Match each description with the type of code set listed below. a. large code set
b. small code set
DIFFICULTY: Moderate
QUESTION TYPE: Matching
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:55 AM
96. Actions related to disease impairment management, prevention, and treatment
ANSWER: a
POINTS: 1
97. Causes of injury, disease, impairment, or other health-related problems
ANSWER: a
POINTS: 1
98. Diseases, injuries, impairments, other health-related problems and their manifestations
ANSWER: a
POINTS: 1
99. Race, ethnicity, type of facility, and type of unit
ANSWER: b
POINTS: 1
100. Substances, equipment, supplies, or other items
ANSWER: a
POINTS: 1
101. Which provides normalized names for clinical drugs and links its names to many of the drug vocabularies commonly used in pharmacy management and drug interaction software? a. NDC
b. NLM
c. NTF-RT
d. RxNorm
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:56 AM
102. Which classifies health and health-related domains that describe body functions and structures, activities, and participation and complements ICD-10, looking beyond mortality and disease? a. DSM
b. HIPPS
c. ICD-O-3
d. ICF
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:57 AM
103. Which was implemented in 2001 to classify a tumor according to primary site (topography) and morphology (histology, behavior, and aggression of tumor)? a. ICD-9-CM
b. ICD-10-CM
c. ICD-10-PCS
d. ICD-O-3
ANSWER: d
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:57 AM
104. Which is published by the American Psychiatric Association and contains diagnostic assessment criteria used as tools to identify psychiatric disorders? a. CPT
b. DSM
c. HCPCS
d. ICD
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:57 AM
105. Which provides a new standardized framework and a unique coding structure for assessing, documenting, and classifying home health and ambulatory care? a. Alternative Billing Codes
b. ambulatory payment classifications
c. Clinical Care Classification System
d. diagnosis-related groups ANSWER: c
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:58 AM
106. Which is an electronic database and universal standard that is used to identify medical laboratory observations for the purpose of clinical care and management? a. CCC
b. LOINC
c. SNOMED
d. UMLS
ANSWER: b
POINTS: 1
DIFFICULTY: Moderate
QUESTION TYPE: Multiple Choice
HAS VARIABLES: False
DATE CREATED: 7/24/2018 11:44 AM
DATE MODIFIED: 10/25/2018 11:58 AM
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