CORRECT ANSWERS
In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.
You must name each form for bar coding and indexing. The unnamed document in front of you
includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. The doument
type you give to this form is ✅✅CORRECT ANSW-postpartum record
Based on the MS-DRG report above, what is the case-mix index for this facility? ✅✅CORRECT
ANSW-2.965807
The special form or view that plays the central role in planning and providing care at nursing,
psychiatric, and rehabilitation facilities is the ✅✅CORRECT ANSW-interdisciplinary patient care
plan
Four patients were discharged from Crestview Hospital yesterday. A final progress note is an
appropriate discharge summary for ✅✅CORRECT ANSW-Babson, who delivered a healthy 8-
pound boy without complications for either mother or child,and was discharged within 36 hours of
admission
Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four
insurance companies. Data on the services they provided and the reimbursement they received from
the four companies are listed in the two tables below.
MMBC receives the best reimbursement for well child visits from ✅✅CORRECT ANSW-Getwell
Each month, the staff of the clinic with the lowest overall waiting time is awarded a free dessert in
the Gulfside Healthcare Center cafeteria. Take a look at the information listed above. The winner will
be selected based on ✅✅CORRECT ANSW-comparative aggregate data
A union campaign is being conducted at your facility. As a department manager, it is appropriate for
you to tell employees that ✅✅CORRECT ANSW-you are opposed to the union
As the Coding Supervisor, your job description includes working with agents who have been charged
with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service
program. You will need to develop a professional relationship with ✅✅CORRECT ANSW-recovery
audit contractors
,Employing the SOAP style of progress notes, choose the "assessment" statement from the following:
✅✅CORRECT ANSW-Sciatica unimproved with hot pack therapy.
Most of the children who are seen at MMBC will have a well child visit and two immunizations. If you
add the reimbursement for two immunizations to the reimbursement for each well child visit, which
insurance company benefits MMBC most ✅✅CORRECT ANSW-Getwell
You are calculating the fee schedule payment amount for physician services covered under Medicare
Part B. You already have the relative value unit figure. The only other information you need is
✅✅CORRECT ANSW-a national conversion factor
Key West Hospital collected the data displayed above concerning its four highest volume MSDRGs.
Which MS-DRG generated the most revenue for the hospital ✅✅CORRECT ANSW-MS-DRG C
In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex
post-surgery. There is no mention of a postoperative complication in the attending physician's
discharge summary. Before querying the doctor, the coder will seek to confirm the infection by
reviewing the ✅✅CORRECT ANSW-lab report
Stan works in an acute care general hospital, Fran works for a skilled nursing facility, Ann is
employed at an assisted living facility, and Dan works for a home care provider. Which people are
employed in facilities that may seek Joint Commission accreditation? ✅✅CORRECT ANSW-Dan,
Stan, and Fran
Sunset Beach Clinic allows patients to communicate by e-mail to ask questions regarding their
treatment and request appointment changes. E-mails and text messages are ✅✅CORRECT ANSW-
considered health care business records and are subject to the same regulations as records created
in face-to-face patient encounters
The proposed National Healthcare Information Network (NHIN) dimensions are graphically depicted
in the diagram above. Roman numerals are added to allow for the identification of specific areas.
Where would information concerning a patient's health insurance be located on this chart?
✅✅CORRECT ANSW-II
The facility's policy for physician's verbal orders in accordance with state law and regulations needs
updating. The first area of investigation is the qualifications of those individuals who have been
, authorized to record verbal orders. For this information you will consult the ✅✅CORRECT ANSW-
hospital bylaws, rules, and regulations
Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker
was admitted through the ED for an emergency appendectomy. Following surgery, the patient
developed an infection at the wound site that was treated with antibiotics. When making decisions
about sequencing the codes for this case, the coder should rely on definitions found in the
✅✅CORRECT ANSW-UHDDS
Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker
was admitted through the ED for an emergency appendectomy. Following surgery, the patient
developed an infection at the wound site that was treated with antibiotics. Parker's principal
diagnosis is the ✅✅CORRECT ANSW-acute appendicitis.
Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and
moderately senile) just could not seem to understand or remember what the doctor said. Mr.
Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed
should document discharge instructions ✅✅CORRECT ANSW-in the discharge summary and on a
patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's
medical record
The physician has documented the final diagnoses as acute myocardial infarction, COPD, CHF,
hypertension, atrial fibrillation, and status-post cholecystectomy. The following conditions should be
reported:
401.1 Essential Hypertension, benign
401.9 Essential Hypertension, unspecified
402.91 Hypertension, heart disease, unspecified as to malignant or benign, with heart failure
410.91 Acute myocardial infarction, unspecified site, initial episode of care
427.31 Atrial fibrillation
428.0 Congestive heart failure, unspecified
496 Chronic obstructive pulmonary disease
V45.79 Acquired absence of gallbladder ✅✅CORRECT ANSW-410.91, 496, 428.0, 401.9, 427.31
Mary is 6 weeks postmastectomy for carcinoma of the breast. She is admitted for chemotherapy.
What is the correct sequencing of the codes?