QUESTIONS AND 100% CORRECT
ANSWERS 2025 NEW UPDATE |A+
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A physician admits a patient with shortness of breath and chest pain, then treats the
patient with Lasix, oxygen, and Theophylline. The physician's final documented diagnosis
for the patient is acute exacerbation of COPD. What is missing from this diagnosis that
would make it reliable information in the treatment of this patient?
a. No additional information is needed.
b. The type of COPD
c. The reason the patient was treated with Lasix
d. The reason for the Theophylline
Answer: d The reason for the Theophylline
If the physician does not document the diagnosis, the coding professional cannot assume
the patient has a diagnosis based solely on:
a. An abnormal lab finding
b. Abnormal pathology reports
c. Both A and B
d. None of the above
Answer: c Both A and B
These documents would be used by clinicians and providers to identify abnormal
temperature, blood pressure, pulse, respiration, oxygen levels, and other indicators.
a. Nurses' graphic records
b. Vital sign flowsheets
c. Both A and B
d. None of the above
Answer: c Both A and B
The American Hospital Association (AHA), the American Health Information
Management Association (AHIMA), Center for Medicare and Medicaid Services (CMS),
and National Center for Healthcare Statistics (NCHS) are all:
a. Cooperating parties
,b. Governing bodies
c. Coding associations
d. Work independently to develop coding guidelines
Answer: a Cooperating parties
A patient was admitted with HIV and pneumocystic carini. The patient should have a
principal diagnosis in ICD-10 of:
a. AIDS
b. Asymptomatic HIV
c. Pneumonia
d. Not enough information
Answer: a AIDS
APR-DRGs have levels (subclasses) of severity entitled:
a. Excessive, Major, Moderate, Minor
b. Extreme, Major, Moderate, Minor
c. Extreme, Major, Moderate, Minimal
d. Excessive, Major
Answer: b Extreme, Major, Moderate, Minor
During an outpatient procedure for removal of a bladder cyst, the urologist accidentally
tore the urethral sphincter requiring an observation stay. This should be assigned as the
principal diagnosis:
a. The reason for the outpatient surgery
b. The reason for admission
c. Either the reason for the outpatient surgery or the reason for admission
d. None of the above
Answer: a The reason for the outpatient surgery
In 1990, 3M created which DRG system that several states use for Medicaid
reimbursement and is also used by facilities to analyze some portion of the data for
Medicare Quality Indicators. What is this system called?
a. MS-DRGs
b. AP-DRGs
c. APR-DRGs
d. CPT-DRGs
Answer: c APR-DRGs
, A patient was admitted to an acute care facility with a temperature of 102 and atrial
fibrillation. The chest x-ray reveals pneumonia with subsequent documentation by the
physician of pneumonia in the progress notes and discharge summary. The patient was
treated with oral antiarrhythmia medications and IV antibiotics. What is the principal
diagnosis?
a. Pneumonia
b. Arrhythmia
c. Atrial fibrillation
d. Both a and c
Answer: a Pneumonia
The Cooperating Parties, which develop and approve ICD-10, include:
a. American Hospital Association (AHA) and American Health Information Management
Association (AHIMA)
b. American Hospital Association (AHA), American Health Information Management
Association (AHIMA), and Centers for Disease Control (CDC)
c. American Hospital Association (AHA), American Health Information Management
Association (AHIMA), and Centers for Medicare and Medicaid Services (CMS), and National
Center for Health Statistics (NCHS)
d. American Hospital Association (AHA), American Health Information Management
Association (AHIMA), and the World Health Organization (WHO)
Answer: c American Hospital Association (AHA), American Health Information
Management Association (AHIMA), and Centers for Medicare and Medicaid Services
(CMS), and National Center for Health Statistics (NCHS)
Mildred Smith was admitted to a nursing facility with the following information: "Patient
is being admitted for Organic Brain Syndrome." Underneath the diagnosis, her medical
information was listed along with a summary of the care already provided. This
information is documented on the:
a. Transfer record
b. Release of information form
c. Patient's rights acknowledgment form
d. Admitting physical evaluation record
Answer: a Transfer record
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal
pain. The attending physician requested an upper GI series and laboratory evaluation of
CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased