Deck 2: The Health Record As the Foundation of Coding

Question 1

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

Answer 1

D

Question 2

Match each item to one of the following definitions.
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
The Joint Commission

Answer 2

A

Question 3

Match each item to one of the following definitions.
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
Subjective

Answer 3

B

Question 4

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

Question 5

Which of these is NOT considered a physician?

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

Question 6

Match each item to one of the following definitions.
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
Chief complaint

Question 7

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

Question 8

Match each item to one of the following definitions.
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
Healthcare providers

Question 9

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

Question 10

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 11

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

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

Question 12

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 13

Match each item to one of the following definitions.
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
Physician

Question 14

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?

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

Question 15

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

Question 16

What does EKG stand for?

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

Question 17

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 18

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

Question 19

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 20

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 21

Match the following terms with their abbreviations.
a.Centers for Medicare and Medicaid Services
b.Temperature,pulse,and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
TPR

Question 22

What does MRI stand for?

Question 23

Match the following terms with their abbreviations.
a.Centers for Medicare and Medicaid Services
b.Temperature,pulse,and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
GERD

Question 24

Match the following terms with their abbreviations.
a.Centers for Medicare and Medicaid Services
b.Temperature,pulse,and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
CMS

Question 25

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

Question 26

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

Question 27

Give three reasons why a provider should be queried.

Question 28

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

Question 29

What is the goal of the physician query process?

Question 30

What does AHQA stand for?

Question 31

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

Question 32

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

Question 33

Match each item to one of the following definitions.
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
Plan

Question 34

Match the following terms with their abbreviations.
a.Centers for Medicare and Medicaid Services
b.Temperature,pulse,and respiration
c.Uniform Hospital Discharge Data Set
d.Gastroesophageal reflux disease
UHDDS

Question 35

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

Question 36

Match each item to one of the following definitions.
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
Consultations

Question 37

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

Question 38

Match each item to one of the following definitions.
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
Assessment

Question 39

Match each item to one of the following definitions.
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
Objective