321 Code It Exam 1 Updated Actual Questions And Correct Answers

321 CODE IT EXAM 1 UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS
Question:
The Centers for Medicare & Medicaid Services (CMS) is
a(n) __________ in the federal Department of Health and
Human Services (DHHS).
private organization
administrative agency
third-party payer
compliance section
Answer:
dministrative agencya

Question:
The purpose of a clinical documentation improvement
(CDI) program is to help health care facilities comply with
government programs and other initiatives with the goal
of improving health care quality. Thus, a CDI specialist
initiates concurrent and retrospective reviews of inpatient
records to identify __________ provider documentation.
conflicting, incomplete, or nonspecific
illegible physician queries
redacted health insurance claims
abusive and fraudulent
Answer:
conflicting, incomplete, or nonspecific

Question:
A patient record is the business record for a patient
encounter that documents __________.
inaccurate information that cannot be altered
encounter forms data sent to third-party payers
insurance claims submitted to health care plans
health care services provided to a patient
Answer:
health care services provided to a patient

Question:
Which is used to classify procedures in an inpatient
hospital setting?
ICD-10-CM
ICD-10-PCS
CPT
HCPCS Level II
Answer:

,IC-10-PCS

Question:
The electronic health record is a(n) __________.
collection of information by a number of providers at
different facilities about a patient
observation about how the patient responds to treatment
based on test results
linking of information created at different locations using
a unique patient identifier
summarization of patient care, treatment, response to
care, and condition on discharge
Answer:
collection of information by a number of providers at different facilities about a
patient

Question:
Which is documented about each problem assigned to
the patient, using the SOAP structure of the problem-
oriented record?
initial plan
problem list
database
progress note
Answer:
progress note

Question:
Which is another term for a health plan?
health care provider
third-party payer
third-party administrator
health care clearinghouse
Answer:
third party payer

Question:
Chief complaint, social data, and past medical history are
considered part of the problem-oriented record __________.
progress note
initial plan
database
problem list
Answer:
database

Question:

, Diagnostic, therapeutic, and education plans to resolve
the problems would be found in the __________ portion of a
problem-oriented SOAP note.
plan
objective
subjective
assessment
Answer:
plan

Question:
A physician lists "viral pneumonia" as the final diagnosis.
However, the coder notes that laboratory results state
"gram-negative bacteria." There is also documentation of
chest pain, fever, and dyspnea due to pneumonia. What
should the coder do?
assign a code to the final dx of viral pneumonia
code bacterial pneumonia, chest pain, and dyspnea
report symptom codes for chest pain, fever, and dyspnea
query the physician regarding the dx of pneumonia
Answer:
query the physician regarding the dx of pneumonia

Question:
Coding is the assignment of codes to diagnoses, services,
and procedures based on __________.
federal govt. regulations
health information management
third-party payer requirements
patient record documentation
Answer:
patient record documentation

Question:
The electronic medical record is a(n) __________.
practice management software solution for acute and
long-term care hospitals
linking of information generated at different locations
using a unique patient identifier
created using vendor software, which also assists in
provider decision making
observation about how the patient responds to treatment
based on test results
Answer:
created using vender software, which also assists in provider decision making

Question: