Deck 2: The Health Record As the Foundation of Coding

Question 1

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

Answer 1

True

Question 2

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

Answer 2

progress note

Question 3

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

Answer 3

chief complaint

Question 4

Match each definition to one of the following items.
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
Physician

Question 5

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

Question 6

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

Question 7

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 ____.

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

Question 8

A query should contain all of the following items EXCEPT ____.

A)date of service
B)amount of increased reimbursement due to query
C)patient name
D)area for provider signature

Question 9

Which of these is NOT considered a physician?

A)Internist
B)Hospitalist
C)Resident
D)Medical student

Question 10

What does EKG stand for?

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

Question 11

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

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

Question 12

Match each definition to one of the following items.
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
Health care providers

Question 13

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

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

Question 14

One of the most important aspects of developing an effective query form is the manner in which the form is worded.

Question 15

Chronic conditions include all of the following EXCEPT ____.

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

Question 16

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

Question 17

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

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

Question 18

The AHIMA practice brief says that a physician query should____.

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

Question 19

Match each definition to one of the following items.
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
Chief complaint

Question 20

The patient history and physical need to be performed and documented within ___________ hours of admission for an inpatient encounter.

Question 21

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

Question 22

Match each definition to one of the following items.
a.Centers for Medicare and Medicaid Services
b.Temperature, pulse, and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
UHDDS

Question 23

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

Question 24

Match each definition to one of the following items.
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
Consultations

Question 25

Match each definition to one of the following items.
a.Centers for Medicare and Medicaid Services
b.Temperature, pulse, and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
GERD

Question 26

Match each definition to one of the following items.
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
Objective

Question 27

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

Question 28

Match each definition to one of the following items.
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
Plan

Question 29

What does MRI stand for?

Question 30

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

Question 31

Match each definition to one of the following items.
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
Subjective

Question 32

Match each definition to one of the following items.
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
The Joint Commission

Question 33

Match each definition to one of the following items.
a.Centers for Medicare and Medicaid Services
b.Temperature, pulse, and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
CMS

Question 34

What is the goal of the physician query process?

Question 35

Match each definition to one of the following items.
a.Centers for Medicare and Medicaid Services
b.Temperature, pulse, and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
TPR

Question 36

Match each definition to one of the following items.
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
Assessment

Question 37

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

Question 38

What does AHQA stand for?

Question 39

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

Question 40

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

Question 41

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

Question 42

Give three reasons why a provider should be queried.