Medical Coding 1 - Final Exam
Questions and Answers
Observations about the patient's physical findings or lab results would be found in
the __________ portion of a problem-oriented SOAP note. - Answer-objective
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? -
Answer-Query the physician regarding the diagnosis of pneumonia
Patient record documentation must be __________. - Answer-dated and
authenticated by the responsible provider
For medical necessity purposes, the patient record must support codes submitted for
third-party payer reimbursement, and patient diagnoses must __________. -
Answer-justify diagnostic and/or therapeutic procedures or services provided
Coding is the assignment of codes to diagnoses, services, and procedures based on
__________. - Answer-patient record documentation
In a source-oriented record, reports are organized according to __________ in
labeled sections. - Answer-documentation source
Which is used to classify procedures in an inpatient hospital setting? - Answer-ICD-
10-PCS
The progress notes section of the POR contains a(n) __________ note to
summarize the patient's care, treatment, response to care, and condition on release
from the facility. - Answer-discharge
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. - Answer-conflicting, incomplete, or nonspecific
Which provides normalized names for clinical drugs and links its names to many of
the drug vocabularies commonly used in pharmacy management and drug
interaction software? - Answer-RxNorm
Which is performed by health care facilities and providers for the purpose of
administrative planning, submitting statistics to state and federal government
agencies, and reporting health claims data to third-party payers? - Answer-health
data collection
The UB-04 claim is submitted by __________ to health plans for reimbursement
purposes. - Answer-hospitals
, The table of contents for the problem-oriented record is called the __________, and
it is filed at the beginning of the record and contains a numbered list of the patient's
problems, which helps to index documentation throughout the record. - Answer-
problem list
The HIPAA large code set collects information concerning _____. - Answer-actions
taken to prevent, diagnose, treat, and manage diseases and injuries
Demographic data is patient identification information that is collected according to
facility policy and includes information such as the __________. - Answer-patient's
date of birth
Automated case abstracting software is used by hospitals to __________. - Answer-
collect data for statistical analysis
To learn more about the patient's condition and the management of the conditions,
review the __________ plans in the problem-oriented record. -
Answer-diagnostic/management
Diagnostic, therapeutic, and education plans to resolve the problems would be found
in the __________ portion of a problem-oriented SOAP note. - Answer-plan
Coders are prohibited from performing assumption coding, which is the assignment
of codes based on assuming, from a review of clinical evidence in the patient's
record, that the patient has certain diagnoses or received certain
procedures/services even though the __________. - Answer-provider did not
specifically document those diagnoses or procedures and services
The judgment, opinion, or evaluation made by the health care provider would be
found in the __________ portion of a problem-oriented SOAP note. - Answer-
assessment
When coders have questions about documented diagnoses or procedures/services,
they use a physician query process to contact the responsible physician to
__________. - Answer-request clarification about documentation and the code(s) to
be assigned
The problem-oriented record __________ contains the strategy for managing patient
care and any actions taken to investigate the patient's condition and to treat and
educate the patient. - Answer-initial plan
Patient records that consist of handwritten progress notes and automated laboratory
results are an example of __________ records. - Answer-hybrid
The HIPAA small code set collects information concerning _____. - Answer-race,
ethnicity, type of facility, and type of unit
Which is published by the AMA and used to classify procedures and services in an
outpatient setting? - Answer-CPT
Questions and Answers
Observations about the patient's physical findings or lab results would be found in
the __________ portion of a problem-oriented SOAP note. - Answer-objective
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? -
Answer-Query the physician regarding the diagnosis of pneumonia
Patient record documentation must be __________. - Answer-dated and
authenticated by the responsible provider
For medical necessity purposes, the patient record must support codes submitted for
third-party payer reimbursement, and patient diagnoses must __________. -
Answer-justify diagnostic and/or therapeutic procedures or services provided
Coding is the assignment of codes to diagnoses, services, and procedures based on
__________. - Answer-patient record documentation
In a source-oriented record, reports are organized according to __________ in
labeled sections. - Answer-documentation source
Which is used to classify procedures in an inpatient hospital setting? - Answer-ICD-
10-PCS
The progress notes section of the POR contains a(n) __________ note to
summarize the patient's care, treatment, response to care, and condition on release
from the facility. - Answer-discharge
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. - Answer-conflicting, incomplete, or nonspecific
Which provides normalized names for clinical drugs and links its names to many of
the drug vocabularies commonly used in pharmacy management and drug
interaction software? - Answer-RxNorm
Which is performed by health care facilities and providers for the purpose of
administrative planning, submitting statistics to state and federal government
agencies, and reporting health claims data to third-party payers? - Answer-health
data collection
The UB-04 claim is submitted by __________ to health plans for reimbursement
purposes. - Answer-hospitals
, The table of contents for the problem-oriented record is called the __________, and
it is filed at the beginning of the record and contains a numbered list of the patient's
problems, which helps to index documentation throughout the record. - Answer-
problem list
The HIPAA large code set collects information concerning _____. - Answer-actions
taken to prevent, diagnose, treat, and manage diseases and injuries
Demographic data is patient identification information that is collected according to
facility policy and includes information such as the __________. - Answer-patient's
date of birth
Automated case abstracting software is used by hospitals to __________. - Answer-
collect data for statistical analysis
To learn more about the patient's condition and the management of the conditions,
review the __________ plans in the problem-oriented record. -
Answer-diagnostic/management
Diagnostic, therapeutic, and education plans to resolve the problems would be found
in the __________ portion of a problem-oriented SOAP note. - Answer-plan
Coders are prohibited from performing assumption coding, which is the assignment
of codes based on assuming, from a review of clinical evidence in the patient's
record, that the patient has certain diagnoses or received certain
procedures/services even though the __________. - Answer-provider did not
specifically document those diagnoses or procedures and services
The judgment, opinion, or evaluation made by the health care provider would be
found in the __________ portion of a problem-oriented SOAP note. - Answer-
assessment
When coders have questions about documented diagnoses or procedures/services,
they use a physician query process to contact the responsible physician to
__________. - Answer-request clarification about documentation and the code(s) to
be assigned
The problem-oriented record __________ contains the strategy for managing patient
care and any actions taken to investigate the patient's condition and to treat and
educate the patient. - Answer-initial plan
Patient records that consist of handwritten progress notes and automated laboratory
results are an example of __________ records. - Answer-hybrid
The HIPAA small code set collects information concerning _____. - Answer-race,
ethnicity, type of facility, and type of unit
Which is published by the AMA and used to classify procedures and services in an
outpatient setting? - Answer-CPT
