Domain 1

Question 1

During a retrospective review of Rose Hunter’s inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

• Utilization Review
• Quantitative Review
• Legal Review
• Qualitative Review

Answer 1

Qualitative Review

Question 2

Which of the following is least likely to be identified by a deficiency analysis technician?

• Discrepancy between post up diagnosis by the
surgeon and pathology diagnosis by the
pathologist
• Missing discharge summary
• Need for physician authentication of two verbal
orders
• X-ray report charted on the wrong record

Answer 2

Discrepancy between post up diagnosis by the surgeon and pathology diagnosis by the pathologist

Question 3

The Conditions of Participation require that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be considered consultation?

• tissue examination done by the pathologist
• impressions of a cardiologist asked to determine
whether patient is a good surgical risk
• interpretation of a radiologic study
• technical interpretation of electrocardiogram

Answer 3

impressions of a cardiologist asked to determine whether patient is a good surgical risk

Question 4

The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding

• The presence or absence of such items as
preoperative and postoperative diagnosis,
description of findings, and specimens removed
• whether a postoperative infection occurred and
how it was treated
• the quality of follow-up care
• whether the severity of illness and/or intensity of
service warranted acute level care

Answer 4

The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed

Question 5

In your facility, the health care providers from every discipline document progress notes sequentially on the same form. Your facility is utilizing

• integrated progress notes
• interdisciplinary treatment plans
• source-oriented records
• SOAP notes

Answer 5

integrated progress notes

Question 6

Which of the following services is LEAST likely to be provided by a facility accredited by CARF?

• Chronic pain management
• palliative care
• brain injury management
• vocational evaluation

Answer 6

palliative care

Question 7

Which method of identification of authorship or authentication of entries would be inappropriate to use in a patient’s health record?

• Written signature of the provider of care
• identifiable initials of a nurse writing a nursing note
• a unique identification code entered by the person
making the report
• delegated use of computer key by radiology
secretary

Answer 7

delegated use of computer key by radiology secretary

Question 8

As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set?

• DEEDS
• UHDDS
• MDS
• ORYX

Answer 8

DEEDS

Question 9

As a new HIM manager of an acute care facility, you have been asked to update the facility’s policy for a physicians verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the

• Consolidated Manual for Hospitals
• Federal Register
• Policy and Procedure Manual
• Hospital Bylaws, Rules, and Regulations

Answer 9

Hospital Bylaws, Rules, and Regulations

Question 10

Reviewing a medical record to ensure that all diagnosis are justified by documentation throughout the chart is an example of

• Peer review
• quantitative review
• qualitative review
• legal analysis

Answer 10

qualitative review

Question 11

Accreditation by Joint Commission is a voluntary activity for a facility and it is

• considered unnecessary by most health care
facilities
• required for state license in all states
• conducted in each facility annually
• required for reimbursement of certain patient
groups

Answer 11

required for reimbursement of certain patient groups

Question 12

Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record

• database
• problem list
• initial plan
• progress notes

Answer 12

problem list

Question 13

As a supervisor of the cancer registry, you report the registry’s annual caseload to administration. The most efficient way to retrieve this information would be to use

• patient abstracts
• patient index
• accession register
• follow-up files

Answer 13

accession register

Question 14

Select the appropriate situation for which a final progress note may legitimately be substituted for a discharge summary in an inpatient medical record

• Patient admitted with COPD 1/4/2016 and
discharged 1/7/2016
• Baby Boy Hiltz, born 1/5/2016, maintained normal
status, discharged 1/7/2016
• Baby Boy Hiltz’s mother admitted 1/5/2016, C-
section delivery, and discharged 1/7/2016
• Baby Boy Doe admitted 1/3/2016, died 1/4/2016

Answer 14

Baby Boy Hiltz, born 1/5/2016, maintained normal status, discharged 1/7/2016

Question 15

Based on the following Documentation in an acute care record, where would you expect this excerpt to appear?
“ Initially the patient was admitted to the medical unit to evaluate the x-ray findings and the rub. He was started on Levaquin 500 mg initially and then 250 mg daily. The patient was hydrated with IV fluids and remained afebrile. Serial cardiac enzymes were done. The rub, chest pain, and shortness of breath resolved. EKG’s remained unchanged. Patient will be discharged and followed as an outpatient.”

• discharge summary
• physical exam
• admission note
• clinical laboratory report

Answer 15

discharge summary

Question 16

The information security officer is revising the policies at your rehabilitation facility for handling all patient clinical information. The best resource for checking our specific voluntary accreditation standards and guidelines is the

• Conditions of participation for Rehabilitation
Facilities
• Medical Staff Bylaws, Rules, and Regulations
• Joint Commission Manual
• CARF manual

Answer 16

CARF manual

Question 17

Which of the following is a secondary data source that would be used to quickly gather the health record of all juvenile patients treated for diabetes within the past 6 months.

• disease index
• patient register
• pediatric census sheet
• procedure index

Answer 17

disease index

Question 18

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting over payments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with

• The OIG
• MEDPAR representatives
• QIO physicians
• Recovery audit contractors

Answer 18

Recovery audit contractors

Question 19

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data

• timeliness
• accuracy
• comprehensiveness
• security

Answer 19

comprehensiveness

Question 20

In preparation for an upcoming site visit by Joint Commission, you discover that the number of delinquent records for the preceding month exceeded 50% of discharged patients. Even more alarming was the pattern you noticed in the type of delinquencies. Which of the following represent the most serious pattern of delinquencies? Fifteen percent of delinquent records show

• missing signatures on progress notes
• missing discharge summaries
• absence of SOAP format in progress notes
• missing operative reports

Answer 20

missing operative reports

Question 21

A primary focus of screen format design in a health record computer application should be to ensure that

• programmers develop standard screen formats for
all hospitals
• the user is capturing essential data elements
• paper forms are easily converted to computer forms
• data fields can be randomly accessed

Answer 21

the user is capturing essential data elements

Question 22

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captures on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data

• reliability
• accessibility
• legibility
• completeness

Answer 22

reliability

Question 23

Medicare rules state that the use of verbal orders should be infrequent and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

• written within 24 hours of the patient’s admission
• accepted by charge nurse only
• cosigned by the attending physician within 4 hours
of giving the order
• recorded by persons authorized by hospital
regulations and procedures

Answer 23

recorded by persons authorized by hospital regulations and procedures

Question 24

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave

• documented in an incident report and filed in the
patient’s health record
• reported as a potentially compesable event
• reported to the Executive Committee
• documented in both the progress notes and the
discharge summary

Answer 24

documented in both the progress notes and the discharge summary

Question 25

Your committee is charged with developing procedures for the Health Information Services staff of a new home health agency. You recommend that the staff routinely ch3eck to verify that a summary on each patient is provided to the attending physician so that he or she can review, update, and re-certify the patient as appropriate. The time frame for requiring this summary is at least every * week * month * 60 days * 90 days

Answer 25

60 days

Question 26

You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be * medical staff bylaws * quality management plan * Joint Commission accreditation manual * medical staff rules and regulations

Answer 26

medical staff rules and regulations

Question 27

A quarterly review reveals the following data for Spring field Hospital: Springfield Hospital Quarterly Statistics Average monthly discharges 1,820 Average monthly operative procedures 458 Number of incomplete records 1,002 Number of delinquent records 590 What is the percentage of incomplete records during this quarter? * 55% * 54% * 33% * 32%

Answer 27

55%

Question 28

Referring to the data in the previous question, determine the delinquent record rate for Springfield Hospital * 55% * 32% * 33% * 54%

Answer 28

32%

Question 29

Still referring to the information in the table related to Springfield Hospital, would the facility be out of compliance with Joint Commission standards? * Yes * No

Answer 29

No

Question 30

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the * Information security manager * clinical data specialist * health information manager * risk manager

Answer 30

health information manager

Question 31

For inpatients, the first data item collected of a clinical nature is usually * principle diagnosis * expected payer * admitting diagnosis * review of symptoms

Answer 31

admitting diagnosis

Question 32

Documentation found in acute care health records should include core measure quality indicators required for compliance with Medicare's Health Care Quality Improvement Program (HCQIP). A typical indicator for patients with pneumonia is * beta blocker at discharge * blood culture before first antibiotic received * early administration of aspirin * discharge on antithrombotic

Answer 32

blood culture before first antibiotic received

Question 33

One record documentation requirement shared by BOTH acute care and emergency departments is * patient's condition on discharge * time and means of arrival * advance directive * problem list

Answer 33

patient's condition on discharge

Question 34

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain * standing orders * telephone orders * stop orders * discharge order

Answer 34

discharge order

Question 35

As the Chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document • objective symptoms observed by the physician • past and current activities, such as smoking and drinking habits • a chronological description of patient's present condition from time of onset to present • subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant

Answer 35

subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant

Question 36

Based on the following documentation in an acute care record, where would you expect this excerpt to appear: "The patient is alert and in no acute distress, Initial vital signs: T98, P102, and regular, R 20 and BP 120/69..." * physical exam * past medical history * social history * chief complaint

Answer 36

physical exam

Question 37

Which one of the following is NOT a step in developing a health record retention schedule? * conducting an inventory of the facility's records * determining the format and location of storage * assigning all records the same retention period * destroying records that are no longer needed

Answer 37

assigning all records the same retention period

Question 38

Information found in which of the following would not be considered secondary data? * disease index * implant registry * health record * National Practitioner Data

Answer 38

health record

Question 39

Under the Patient Self-Determination Act of 1990, evidence of advance directives • are required to be documented in the health record • are not required to be documented in the health record • require a doctor's approval • must be prepared by an attorney

Answer 39

are required to be documented in the health record

Question 40

A 200-bed acute care hospital currently has 15 years of paper health records and filing space is limited. What action should be take? • Return inactive records to each individual patient • Destroy records of all deceased patients • Destroy inactive records that exceed the statute of limitations • Maintain the records indefinitely in hard copy

Answer 40

Destroy inactive records that exceed the statute of limitations

Question 41

What is the chief criterion for determining record inactivity? ``` • Medicare's definition of inactivity • amount of space available for storage of newer records • efficiency of microfilming • preference of the medical staff ```

Answer 41

amount of space available for storage of newer records

Question 42

How many years does the CMS require that health records be maintained? Medicare Conditions of Participation for Hospitals requires that patient health records be retained for at least _____ years unless a longer period is required by state or local laws. * 3 * 5 * 7 * 10

Answer 42

5

Question 43

Your state regulations require health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be * 5 years * 7 years * 10 years * either 5 or 7 years, as determined by the facility

Answer 43

7 years

Question 44

A research request has been received by the HIM Department from the Quality Improvement Committee. The Committee plans to review the records of all patients who were admitted with CHF in the month of January. Which of the following indices would be the best source in locating the needed records? * master patient index * physician index * disease index * operation index

Answer 44

disease index

Question 45

Which of the following should not be included in the documentation of record destruction? • statement that records were destroyed in the normal course of business • method of destruction • signature of the individuals supervising and witnessing the destruction • dates not covered in the destruction

Answer 45

dates not covered in the destruction

Question 46

Which of the following is not a consideration when implementing a disaster plan? • include disaster training in staff orientation • establish a plan for conducting drills • provide staff with tools needed to implement the plan • test the disaster plan only once

Answer 46

test the disaster plan only once

Question 47

Dr. Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital? * National Practitioner Data Bank * Healthcare Integrity and Protection Data Bank * MEDPAR file * State Administrative Data Bank

Answer 47

National Practitioner Data Bank

Question 48

A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors? * statute of limitations * volume of research * readmission rate * departmental staffing

Answer 48

departmental staffing

Question 49

The Chief of the Medical Staff requests a report on the number of coronary artery bypass grafts performed by a particular physician in April of the previous year. Where would the HIM manager look for this information? * patient register * disease index * operation index * birth defects register

Answer 49

operation index

Question 50

What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer program? * 70% * 80% * 90% * 100%

Answer 50

90%

Question 51

Unless state of federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long? * age of majority plus statute of limitations * 10 years after the most recent encounter * 10 years after the age of majority * permanently

Answer 51

age of majority plus statute of limitations

Question 52

A health care facility has made a decision to destroy computerized data. AHIMA recommends which one of the following as the preferred method of destruction for computerized data? * overwriting data with a series of characters * disk reformatting * magnetic degaussing * overwriting the backup tapes

Answer 52

magnetic degaussing

Question 53

Which of the following statements would be found in the laboratory report section of the health record? * BUN reported as 20mg * Morphine sulfate gr. 1/4 q.4h for pain * IV sodium Pentohal 1% started at 9:05 AM * TPR recorded q.h. for 12 hours

Answer 53

BUN reported as 20mg

Question 54

The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should • issue a copy of the birth certificate from the patient's record • direct the request to the state's office of vital records • direct the request to the attending physician • issue a copy of the newborn's record

Answer 54

direct the request to the state's office of vital records

Question 55

A surgeon request the name of a patient he admitted on January 11, 2013. Which of the following would be used to retrieve this information? * master patient index * number index * admission register * operation index

Answer 55

admission register

Question 56

Where in the health record would the following statement be located? "Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma" * operative report * pathology report * anesthesia report * radiology report

Answer 56

pathology report

Question 57

The clinical laboratory department staff can use a database that allows them to see what laboratory tests were conducted and the results of those tests. By contrast, the billing department staff can only see that portion of the database that lists the laboratory tests that generate a charge, but they cannot see the test results. What kind of control is this an example of? * concurrency * access * integrity * cost

Answer 57

access

Question 58

When health care facilities close or medical practices dissolve, procedures for disposition of patient records should take into consideration all of the following EXCEPT * state laws and licensing standards * communities of practice requirements * needs of the patients * Medicare requirements

Answer 58

communities of practice requirements

Question 59

Case finding methods for patients with diabetes include a review of all but which of the following? * health plans * CPT diagnostic codes * billing data * medication lists

Answer 59

CPT diagnostic codes

Question 60

What type of plan is a Joint Commission - accredited facility required to maintain to protect health information from catastrophes such as fire, flooding, bomb threats, and theft? * budget * disaster * case management * patient care

Answer 60

disaster

Question 61

What would be the most cost-effective and prudent course of action for the storage or disposition of 250,000 records at a large teaching and research hospital? • storing the records off-site at a cost of $25,000 per year • scanning all 250,000 for a cost of $195,000 • purging and storing all death records off-site at a cost of $20,000 per year • destroying all records older than 3 years for a cost of $50,000

Answer 61

scanning all 250,000 for a cost of $195,000

Question 62

According to AHIMA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently? * physician index * register of births * register of surgical procedures * register of deaths

Answer 62

physician index

Question 63

For a healthcare facility to meet its documented destruction needs, the certificate of destruction should include all but which of the following elements? * unique and serialized transaction number * location of destruction * patient notification * acceptance of fiduciary responsibility

Answer 63

patient notification

Question 64

The steps in developing a record retention program include all but which of the following? * determining the storage format and location * notifying the courts of the destruction * assigning each record a retention period * destroying records that are no longer needed

Answer 64

notifying the courts of the destruction

Question 65

A healthcare facility has received a request to participate in a statewide study on cleft lip and palate. This study would include data from the past year and subsequent years. Given that each of the data sources cited below contains the necessary information, the initial data would be most easily collected from the * newborn records * state bureau of vital statistics * maternal records * birth defects registry

Answer 65

birth defects registry

Question 66

An example of primary data source is the * physician index * health record * cancer registry * hospital statistical report

Answer 66

health record

Question 67

Fetal monitoring strips are part of the ____ record and should be maintained ______ • newborns; 10 years past the age of majority • mother's; according to the length of time required for minor records • newborn; according to the time period specified in the state's statute of limitations • mothers; 10 years

Answer 67

mother's; according to the length of time required for minor records

Question 68

How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained? * 5 * 7 * 30 * permanently

Answer 68

30

Question 69

What data cannot be retrieved from the MEDPAR? * ICD-10-CM diagnosis codes * Charges broken down by specific types of services * non-Medicare patient data * Data on the provider

Answer 69

non-Medicare patient data

Question 70

The HIM practitioner's duty to retain health information via the archiving and storage of health data includes all but which of the following? • strategies that consider accessibility, natural disasters, and innovations in storage technology • strategies ensuring that inactive records are as secure as active records • a retention plan for multiple volumes of records • a retention plan for financial data

Answer 70

a retention plan for financial data

Question 71

The function of a (an)___ is limited to data retrieval * electronic health record * executive information system * database management system * clinical data repository

Answer 71

clinical data repository

Question 72

The Director of the HIM Department is explaining incentives to physicians for entering their clinical documentation in the electronic health record. Which of the following would be the key advantage in using this type of data entry? • enhanced databases will provide information for improved clinical care • training will be offered by the hospital • those physicians not in compliance will be denied admitting privileges • multiple users will not have access to the same information simultaneously

Answer 72

enhanced databases will provide information for improved clinical care

Question 73

A 16 year old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would • be filed in a health record created for the infant • be filed in the mother's record • be retained in a separate file in the administrative offices • not be retained in hospital records

Answer 73

be filed in the mother's record

Question 74

Which of the following is NOT major management challenge in the storage and retention of electronic health record systems? • Following state and federal laws and accreditation requirements when developing retention and destruction policies. • Keeping technology updated in order to retrieve data • Ensuring that health information can be retrieved in a timely manner • Maintaining the paper-based storage system

Answer 74

Maintaining the paper-based storage system

Question 75

Which item is collected and maintained in the organ transplant registry? * vaccine manufacturer * histocompatibility information * cytogenetic results * state at the time of diagnosis

Answer 75

histocompatibility information

Question 76

Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components? • International Classification of Primary Care • International Classification on Functioning, Disability, and Health • National Drug Codes • Clinical Care Classification

Answer 76

International Classification on Functioning, Disability, and Health

Question 77

The Unified Medical Language System (UMLS) is a project sponsored by the * National Library of Medicine * CMS * World Health Organization * Office of Inspector General

Answer 77

National Library of Medicine

Question 78

You have recently been hired as the Medical Staff Coordinator at your hospital. Which database/registry will you utilize most often? * Trauma Registry * MEDPAR * LOINC * National Practitioners Data Bank (NPDB)

Answer 78

National Practitioners Data Bank (NPDB)

Question 79

You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called? * Case finding * Staging * Abstracting * Nomenclature

Answer 79

Abstracting

Question 80

In which registry would you expect to find an Injury Severity Score (ISS)? * Cancer Registry * Birth defects registry * Trauma Registry * Transplant Registry

Answer 80

Trauma Registry

Question 81

A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician is referred to as * a referral * a consultation * risk factor intervention * concurrent care

Answer 81

a consultation

Question 82

The most widely discussed and debated unique patient identifier is the * patient's date of birth * patient's first and last name * patient's social security number * Unique Physician Identification Number (UPIN)

Answer 82

patient's social security number

Question 83

The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels? * READ codes * ABC codes * SPECIALIST codes * LOINC

Answer 83

ABC codes

Question 84

The Level II (national) codes of the HCPCS coding system are maintained by the * American Medical Association. * CPT Editorial Panel. * local fiscal intermediary. * Centers for Medicare and Medicaid Services.

Answer 84

Centers for Medicare and Medicaid Services.

Question 85

A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia? * pseudomonas * clostridium * staphylococcus * listeria

Answer 85

pseudomonas

Question 86

the Level I (CPT) codes of the HCPCS coding system are maintained by the * American Medical Association. * American Hospital Association. * Local fiscal intermediary. * Centers for Medicare and Medicaid Services.

Answer 86

American Medical Association.

Question 87

A physicians excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded? • full-thickness skin graft to scalp only • excision of lesion; full-thickness skin graft to scalp • excision of lesion; full-thickness skin graft to scalp; excision of skin from thigh • code 15004 for surgical preparation of recipient site; full-thickness skin graft to scalp

Answer 87

excision of lesion; full-thickness skin graft to scalp

Question 88

A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit. * -25 * -55 * -57 * -58

Answer 88

-57

Question 89

A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the reported by the physician to indicate that the procedure was discontinued. * -52 * -53 * -73 * -74

Answer 89

-53

Question 90

A barrier to widespread use of automated code assignment is * inadequate technology. * poor quality of documentation. * resistance by physicians. * resistance by HIM professionals.

Answer 90

poor quality of documentation.

Question 91

In assigning E/M codes, three key components are used. These are * history, examination, counseling. * history, examination, time. * history, nature of presenting problem, time. * history, examination, medical decision making.

Answer 91

history, examination, medical decision making.

Question 92

Mrs. Jones had an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit. * -58 * -76 * -78 * -79

Answer 92

-78

Question 93

The primary goal of a hospital-based cancer registry is to • improve patient care. • allocate hospital resources appropriately. • determine the need for professional and public education programs. • monitor cancer incidence.

Answer 93

improve patient care.

Question 94

After reviewing the following excerpt from CPT, code 27646 would be interpreted as 27645 "Radical resection of tumor, tibia" 27646 "Fibula" 27647 "Talus or calcaneus" • 27646 radical resection of tumor; tibia and fibula. • 27646 radical resection of tumor; fibula • 27646 radical resection of tumor; fibula or tibia. • 27646 radical resection of tumor; fibula, talus, calcaneus.

Answer 94

27646 radical resection of tumor; fibula

Question 95

A population-based cancer registry that is designed to determine rates in a defined population is a(n) * incidence-only population-based registry. * cancer control population-based registry. * research-oriented population-based registry. * patient care population-based registry.

Answer 95

incidence-only population-based registry.

Question 96

Given the diagnosis "carcinoma of axillary lymph nodes and lungs, metastatic from breast," what is the primary cancer site(s)? * axillary lymph nodes * lungs * breast * A and B

Answer 96

breast

Question 97

According to CPT, in which of the following cases would an established E/M code be used? * A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. * John and his family have just moved to town. John his asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician. * Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago. * A 78-year-old female with weight loss and progressive agitation over the past 2 months is seen by her primary care physician for drug therapy. She has not seen her primary care physician in 4 years.

Answer 97

Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.

Question 98

In order to use the inpatient CPT consultation codes, the consulting physician must • order diagnostic tests. • document his findings in the patient's medical record. • communicate orally his opinion to the attending physician. • use the term "referral" in his report.

Answer 98

document his findings in the patient's medical record.

Question 99

The attending physician requests a consultation from a cardiologist. The cardiologist takes a detailed history, performs a detailed examination, and utilizes moderate medical decision making. The cardiologist orders diagnostic tests and prescribes medication. He documents his findings in the patient's medical record and communicates in writing with the attending physician. The following day the consultant visits the patient to evaluate the patient's response to the medication, to review results from the diagnostic tests, and to discuss treatment options. What codes should the consultant report for the two visits? • an initial inpatient and a follow-up consult • an initial inpatient consult for both visits • an initial inpatient consultant and a subsequent hospital visit • an initial inpatient consult and initial hospital care

Answer 99

an initial inpatient consultant and a subsequent hospital visit

Question 100

According to the American Medical Association, medical decision making is measured by all of the following except the * number of diagnoses or management options. * amount and complexity of data reviewed. * risk of complications. * specialty of the treating physicians.

Answer 100

specialty of the treating physicians.