1.
Data security policies and procedures should be reviewed at least:
a. Semi-annually
b. Annually
c. Every two years
d. Quarterly - ANSWERCorrect Answer: B
All data security policies and procedures should be reviewed and evaluated at least every year to make
sure they are up-to-date and still relevant to the organization (Johns 2011, 995).
2.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.
a. 780.2
b. 780.2, 787.02
c. 780.2, 787.01
d. 780.4, 787.02 - ANSWERCorrect Answer: B
Near-syncope and nausea are both signs and symptoms and therefore not integral to the other. Both
conditions should be coded (Hazelwood and Venable 2012, 71).
,3.
The codes in the musculoskeletal section of CPT may be used by:
a. Orthopedic surgeons only
b. Orthopedic surgeons and emergency department physicians
c. Any physician
d. Orthopedic surgeons and neurosurgeons - ANSWERCorrect Answer: C
Any physician may use the codes in any section of CPT (AHIMA 2012a, 587).
4.
In an EHR, what is the risk of copying and pasting?
a. Reduction in the time required to document
b. The system not recording who entered the data
c. Quicker overall system response time
d. System thinking that the original documenter recorded the note - ANSWERCorrect Answer: B
The system not recording who entered the data (Johns 2011, 433).
5.
,Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a
digital rectal examination and is given three small cards to take home and return with fecal samples to
screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.
a. 82270
b. 82271
c. 82272
d. 82274 - ANSWERCorrect Answer: A
CPT code 82270 describes a test for occult blood using feces source for the purpose of neoplasm
screening with the use of three cards or single triple card for consecutive collection (AMA 2012b, 417).
6.
Identify the punctuation mark that is used to supplement words or explanatory information that may or
may not be present in the statement of a diagnosis or procedure in ICD-9-CM coding. The punctuation
does not affect the code number assigned to the case. The punctuation is considered a nonessential
modifier, and all three volumes of ICD-9-CM use them.
a. Parentheses ( )
b. Square brackets [ ]
c. Slanted brackets [ ]
d. Braces { } - ANSWERCorrect Answer: A
Parentheses enclose supplementary words or explanatory information that may or may not be present
in the statement of a diagnosis or procedure. They do not affect the code number assigned in the case.
Terms in parentheses are considered nonessential modifiers, and all three volumes of ICD-9-CM use
, them. Bronchiectasis (fusiform) (postinfectious) (recurrent) is an example of a diagnosis statement with
nonessential modifiers noted with parentheses (Schraffenberger 2012, 26-28).
7.
Documentation regarding a patient's marital status; dietary, sleep, and exercise patterns; and use of
coffee, tobacco, alcohol, and other drugs may be found in the:
a. Physical examination record
b. History record
c. Operative report
d. Radiological report - ANSWERCorrect Answer: B
A complete medical history documents the patient's current complaints and symptoms and lists his or
her past medical, personal, and family history (Johns 2011, 63).
8.
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable
alignment, what type of code should be assigned for the procedure?
a. A "with manipulation" code
b. A "without manipulation" code
c. An unlisted procedure code
d. An E/M code only - ANSWERCorrect Answer: A
Data security policies and procedures should be reviewed at least:
a. Semi-annually
b. Annually
c. Every two years
d. Quarterly - ANSWERCorrect Answer: B
All data security policies and procedures should be reviewed and evaluated at least every year to make
sure they are up-to-date and still relevant to the organization (Johns 2011, 995).
2.
Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.
a. 780.2
b. 780.2, 787.02
c. 780.2, 787.01
d. 780.4, 787.02 - ANSWERCorrect Answer: B
Near-syncope and nausea are both signs and symptoms and therefore not integral to the other. Both
conditions should be coded (Hazelwood and Venable 2012, 71).
,3.
The codes in the musculoskeletal section of CPT may be used by:
a. Orthopedic surgeons only
b. Orthopedic surgeons and emergency department physicians
c. Any physician
d. Orthopedic surgeons and neurosurgeons - ANSWERCorrect Answer: C
Any physician may use the codes in any section of CPT (AHIMA 2012a, 587).
4.
In an EHR, what is the risk of copying and pasting?
a. Reduction in the time required to document
b. The system not recording who entered the data
c. Quicker overall system response time
d. System thinking that the original documenter recorded the note - ANSWERCorrect Answer: B
The system not recording who entered the data (Johns 2011, 433).
5.
,Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a
digital rectal examination and is given three small cards to take home and return with fecal samples to
screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.
a. 82270
b. 82271
c. 82272
d. 82274 - ANSWERCorrect Answer: A
CPT code 82270 describes a test for occult blood using feces source for the purpose of neoplasm
screening with the use of three cards or single triple card for consecutive collection (AMA 2012b, 417).
6.
Identify the punctuation mark that is used to supplement words or explanatory information that may or
may not be present in the statement of a diagnosis or procedure in ICD-9-CM coding. The punctuation
does not affect the code number assigned to the case. The punctuation is considered a nonessential
modifier, and all three volumes of ICD-9-CM use them.
a. Parentheses ( )
b. Square brackets [ ]
c. Slanted brackets [ ]
d. Braces { } - ANSWERCorrect Answer: A
Parentheses enclose supplementary words or explanatory information that may or may not be present
in the statement of a diagnosis or procedure. They do not affect the code number assigned in the case.
Terms in parentheses are considered nonessential modifiers, and all three volumes of ICD-9-CM use
, them. Bronchiectasis (fusiform) (postinfectious) (recurrent) is an example of a diagnosis statement with
nonessential modifiers noted with parentheses (Schraffenberger 2012, 26-28).
7.
Documentation regarding a patient's marital status; dietary, sleep, and exercise patterns; and use of
coffee, tobacco, alcohol, and other drugs may be found in the:
a. Physical examination record
b. History record
c. Operative report
d. Radiological report - ANSWERCorrect Answer: B
A complete medical history documents the patient's current complaints and symptoms and lists his or
her past medical, personal, and family history (Johns 2011, 63).
8.
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable
alignment, what type of code should be assigned for the procedure?
a. A "with manipulation" code
b. A "without manipulation" code
c. An unlisted procedure code
d. An E/M code only - ANSWERCorrect Answer: A
