Medical Billing and Coding Final Exam With Complete Solution

During Mrs. Smith's visit to Dr. Johnson she provides a description of a concerning health condition.. Mrs. Smith believes that Dr. Johnson will use this information to evaluate and manage her condition and for no other purpose. Mrs. Smith's belief is an expectation of ____. - Answer confidentiality The documentation type that contains various types of analyses or examinations of body substances collected from the patient. - Answer Lab Report Vital statistics for live births that are sent to a healthcare database are an example of _____. - Answer secondary data Which of the following is NOT a benefit of switching from a paper-based record to an electronic-based record? - Answer Coding accuracy A portal through which patients can view and manage their healthcare information online is called a(n)_____ this information is owned and managed by ______. - Answer personal health record; the patient Which of the following is an ancillary report? - Answer Radiology Which of the following is true in regard to the release of protected health information (ROI)? - Answer A covered entity must provide access to PHI in the manner requested by the individual Healthcare Delivery Systems - Answer After suffering a stroke, a patient requires therapy to assist in performing activities of daily living such as getting dressed and cooking. Which department would assist this patient? - Answer Occupational therapy Which federal agency is tasked with governing and regulating healthcare in the United States? - Answer Department of Health and Human Services (DHHS) Dr. Taylor wants to join the medical staff at ABC hospital. Which of the following would the medical administration office check to see if Dr. Taylor meets the qualifications for hospital privileges? - Answer Medical staff bylaws Which of the following is another name for outpatient care? - Answer Ambulatory care Which of the follow departments/specialties uses radioactive substances to diagnose and treat patients? - Answer Nuclear Medicine and Radiation Therapy Mrs.Thomas is discharged from the hospital but she will continue with IV antibiotics for 2 weeks. Which type of care would manage the administration of her antibiotics? - Answer Home Care Mr. Thomas has moved to a new city and is looking for a physician to help manage his diabetes. Which type of specialist would he look for? - Answer Endo Legal And Compliance - Answer Which of the following should NOT be included in a tracking system for disclosures of PHI? - Answer Social security numbers and diagnosis codes for the patient Which of the following is NOT an example of a secure site through which PHI could be sent electronically? - Answer Registries and databases In a medical malpractice lawsuit, the physician would be considered the ________. - Answer defendant The legal health record must be maintained according to all of the following except: - Answer The OIG work plan Which of the following is true about destruction of the health record? - Answer Destruction must be done as part of the organization's usual course of business For which of the following is authorization NOT required for the release of protected health information? - Answer All of the above Mary is a coder at ABC hospital. During her review of the documentation in Miss Miller's electronic health record, she reads reports from previous visits. Mary's actions are a violation of ______. - Answer the standard of minimum necessary Reimbursement Methodologies - Answer Teri is verifying Medicare benefits for a certain procedure. The national coverage determination (NCD) he reviewed does not answer all his questions. Which of the following is the next resource Teri should consult for additional information? - Answer Local coverage determinations (LCDs) Fee-for-service reimbursement provided after health services have been given is called____? - Answer retrospective payment Billing for two or three codes when one comprehensive code is more appropriate? - Answer Unbundling Capitation, global/prospective payment, and prospective payment are examples of this type of reimbursement method. - Answer Episode-of-care Under this reimbursement method, a third-party payer contracts with a healthcare provider to pay a flat fee per individual enrolled in the healthcare plan. - Answer Capitation Dr. Johnson recommends a procedure for Mr. Thomas who is a Medicare patient. The procedure is not reimbursed under Mr. Thomas' Medicare policy. In order to bill Mr. Thomas for the procedure, Dr. Johnson's office must collect a(n)____ from Mr. Thomas. - Answer advance beneficiary notice of noncoverage Which of the following is NOT an element of the healthcare reimbursement process? - Answer clinical documentation review Sue was admitted to ABC hospital as an inpatient. During the admission, Dr. Butler removed her appendix. Dr. Butler would bill for his services with ___ codes submitted on a ____ claim form. - Answer CPT; CMS-1500 A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of cases. - Answer Comorbid condition Of the following, which does NOT directly influence the assignment of MS-DRGs? - Answer Severity of illness Medical Terminology - Answer Which of the following terms describes a woman who loses her first pregnancy at 13 weeks gestation? - Answer Nullipara A term the is comprised of multiple word roots and a suffix is called a(n) ____. - Answer compound word Ichthyosis means: - Answer Fishlike or scaly condition The suffix that means surgical puncture - Answer -centesis The word which means muscle fiber pain. - Answer Fibromyalgia Which of the following means lying horizontally on the back, face up? - Answer Supine The word that means paralysis of all four extremities. - Answer Quadriplegia The word which means loss of hearing due to the natural aging process. - Answer Presbycusis Anatomy And Physiology - Answer Which of the following is NOT one of the 12 cranial nerves? - Answer Radioulnar nerve Which structure contracts to form a slight vacuum in the chest cavity to facilitate inspiration? - Answer Diaphragm The elongated middle portion or shaft of a long bone, often referred to as the body. - Answer Diaphysis These nerves control the skeletal muscles and parts of the body that are under conscious control: - Answer Somatic Which portion of the brain contains structures associated with visual reflexes and hearing? - Answer Mesencephalon The three membranes that surround and protect the brain and spinal cord are collectively called: - Answer Meninges The ________ of the lung is the medial depression where the primary bronchi and pulmonary blood vessels enter each lung. - Answer hilum Involved in both the digestive and endocrine systems, the _________ secretes hormones as well as digestive juices for the breakdown of foods. - Answer pancreas Introduction To Coding - Answer From the following list of clinical indicators, what is the diagnosis that is being evaluated? Impaired gag reflex (in patients that are unconscious or semi-conscious) after a stroke or brain injury Esophageal disorder (obstruction, cancer, stenosis, varices) Dysphagia Positive swallowing study Positive infiltrate on chest x-ray - Answer Aspiration pneumonia Which of the following takes precedence over the ICD-10-CM Coding Guidelines? - Answer Instructions and conventions Which of the following is/was NOT a result of CMS' use of Recovery Audit Contractors (RACs)? - Answer Consolidation of Medicare parts A and B This terminology is only used in an electronic health record. - Answer SNOMED CT This type of computer-assisted coding uses artificial intelligence and linguistics to extract data from the record and convert it into medical codes. - Answer Natural language processing ICD-10-CM Coding Guidelines - Answer Codes for signs and symptoms are reported when the provider has documented a related definitive diagnosis. - Answer false There is no time frame defining when pain becomes chronic pain. The physician's documentation should be used to determine if the pain is considered chronic. - Answer true When a patient has an adverse drug reaction, code both the reaction and the code from T36-T50. - Answer true Inoculation and vaccination Z codes can be reported as the first listed or additional codes. - Answer true When the cause of an injury is suspected to be the result of terrorism, a code from category Y38 should be assigned. - Answer false When a patient with a high-risk pregnancy is being seen for a routine prenatal outpatient visit, the supervision of high-risk pregnancy code should be reported as the first-listed diagnosis. - Answer true The second trimester is defined as 12 weeks 0 days to less than 28 weeks 0 days. - Answer false When the physician documents suspected or possible avian influenza, a code from category J09 should be reported. - Answer false