AHIMA Practice Test 1 – Problem-Oriented
Medical Record, ICD-10, Audits & Quality
Improvement
What is a key characteristic of the POMR (problem oriented medical record)? -
answer✔✔uses an itemized list of the patient's past and present medical problems in
developing an internal coding audit review program, what are two risk areas that should be
targeted for audit? - answer✔✔chargemaster description and medical mecessity what
are some coding compliance activities? - answer✔✔reviewing all rejected claims;
developing procedures for identifying coding errors; coding diagnoses only when all
applicable information is documented in the health record what are some things that ICD-10
can be used for? Sayles pg 183 - answer✔✔the basis for epidemiological research; in the
evaluation of medical care planning for healthcare delivery systems; to facilitate data
storage and retrieval a skin lesion was removed from a patient's cheek in the
dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior
to billing the pathology report returns with a diagnosis of basal cell carcinoma? what action
should be done by the coding professional for claim submission? cpt pg376 -
answer✔✔code basal cell carcinoma what is the approved method for conducting
1
business in an organization? Sayles pg 408 - answer✔✔procedure prcedres are specific
Page
Medical Record, ICD-10, Audits & Quality
Improvement
What is a key characteristic of the POMR (problem oriented medical record)? -
answer✔✔uses an itemized list of the patient's past and present medical problems in
developing an internal coding audit review program, what are two risk areas that should be
targeted for audit? - answer✔✔chargemaster description and medical mecessity what
are some coding compliance activities? - answer✔✔reviewing all rejected claims;
developing procedures for identifying coding errors; coding diagnoses only when all
applicable information is documented in the health record what are some things that ICD-10
can be used for? Sayles pg 183 - answer✔✔the basis for epidemiological research; in the
evaluation of medical care planning for healthcare delivery systems; to facilitate data
storage and retrieval a skin lesion was removed from a patient's cheek in the
dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior
to billing the pathology report returns with a diagnosis of basal cell carcinoma? what action
should be done by the coding professional for claim submission? cpt pg376 -
answer✔✔code basal cell carcinoma what is the approved method for conducting
1
business in an organization? Sayles pg 408 - answer✔✔procedure prcedres are specific
Page
