CPC exam- Practice Questions & Answers 100% Correct

Which of the following elements is not a component of most patient records? Patient Idenfification Clincal History Financial Information Test Results - Answer Financial information Identify where the following information would be found in the acute care record. Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion. Anesthesia report Physican progress report Operative report Recovery Room Record - Answer Operative report Identify where the following information would be found in the acute care record. "cbc: wbc 12.0, rbc 4.65, HGB 14.8, HCT 43.8" Medical Laboratory report Pathology report physical examination physician orders - Answer Medical Laboratory Report Identify where the following information would be found in the acute-care record" "PA and Lateral Chest, The lungs are clear. The heart and mediastinum are normal size and configuration. There are minor degenerative changes of the lower thoracic spine Medical laboratory report Physical examination Physician progress note Radiography report - Answer Radiology Report The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. Chest: Good Bilateral chest sounds." Where would this information be documented History Pathology report Physical examination Operation Report - Answer Physical examination The following is documented in an acute care record: "Microscopic: Sections are of squamous mucosa with no atypic." Where would this information be documented? History Pathology report Physical examination Operation Report - Answer Pathology report The following is documented in an acute care record: Admit to 3c, Diet NPO, Meds: Compazine 10 mg, Where would this information be documented. Admission order History Physical examination Progress notes - Answer Admission order The following is documented in an acute care record: 38 weeks gestation, Apgars 8/9, 6# 8oz, good cry" Where would this information be documented. Admission note Clinical laboratory Newborn record physician order - Answer Newborn record The following is documented in an acute care record: Atrial Fibrillation with rapid ventricular repose, left axis deviation, left bundle branch block." Where would this information be documented. Admission Order Clinical Laboratory Report ECG Report radiology report - Answer ECG Report The following is documented in an acute care record: I was asked to evaluate this level 1 trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." Where would this information be documented. Admission Note Consultation Report discharge summary Nursing Progress Notes - Answer Consultation Report The following is documented in an acute care record: Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." Where would this information be documented. Admission note Nursing Note Physican process note Social Work Note - Answer Social Work Note Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______. UHDDS UACDS MDS ORYX - Answer UHDDS Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for: performance improvement programs billing and claims data processing developing hospital discharge abstracting systems developing individual care plans for residents - Answer performance improvement programs A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a problem-oriented medical record progress note would this be written? Subjective Objective Assessment Plan - Answer Subjective A notation for a diabetic patient in a physician progress note reads: FBS 110mg%, using sugar, no acetone. In which part of a problem-oriented medical record progress note would this be written? Subjective Objective Assessment Plan - Answer Objective A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with diurnal, 500 msg once daily. return in 2 weeks" In which part of a problem-oriented medical record progress note would this be written? Subjective Objective Assessment Plan - Answer Plan A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled" In which part of a problem-oriented medical record progress note would this be written? Subjective Objective Assessment Plan - Answer Assessment Reviewing a health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of _____ review. Quantitative Qualitative Statistical Outcome - Answer Quantitative Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? Data Completeness Data relevancy Data currency Data presicion - Answer Data currency The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? a. Data completeness b. Data consistency c. Data accessibility d. Data comprehensiveness - Answer Data consistency Which of the following is an example of clinical data? Admitting diagnosis data and time of admission Insurance information Health Record Number - Answer Admitting diagnosis Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record? Home Health Behavioral health End-stage renal disease rehabilitative care - Answer Home Health Which of the following materials is not documented in an emergency room record? Patients instructions at discharge Time and means of the patients arrival Patients complete medical history Emergy care administered before arrival at the facility - Answer Patients complete medical history Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? Anesthesia report Laboratory report Operative report Pathology Report - Answer Pathology Report What is the defining characteristic of an integrated health record format? Each section of the record is maintained by the patient care department that provided the care. Integrated health records include both paper forms and computer printouts. Integrated health records are intended to be used in ambulatory settings. Integrated health record components are arranged in strict chronological order. - Answer Integrated health record components are arranged in strict chronological order. Which of the following represents documentation of patient's current and past health status. Physical examination Medical history Physician orders Patient Consent - Answer Medical history Which of the following contains the physician's findings based on an examination of the patient. Physical Examination Discharge Summary Medical History Patient Instructions - Answer Physical Examination What is the function of a consolation report? Provides a chronological summary of the patients medical history and illness. Documents opinions about the patients condition from the perspective of a physician not previously involved in the patient's care. Concisely summarizes the patients treatment and stay in the hospital. Documents the physicians instruction to other parties involved in providing care to a patient. - Answer Documents opinions about the patients condition from the perspective of a physician not previously involved in the patient's care. What is the function of physicians orders? Provide a chronological summary of the patients illness and treatment. Documents the patients current and past health status. Document the physicians instructions to other parties involved in providing care to a patient. Document the providers follow-up care instuctions given to the patient or patients caregiver. - Answer Document the physicians instructions to other parties involved in providing care to a patient. Which type of patient care record includes documentation of a family bereavement period. Hospice record Home Health Record Long term care record Ambulatory care record - Answer Hospice record In a joint effort of the Department of Health and Human Services, Office of Inspector General (OIG), Centers for Medicare and Medicaid (CMS), and Administration on Aging (AOA), which program was released in 1995 to target fraud and abuse amount healthcare providers? Operation Restore Trust program Medicare Integrity Program Tax Equity and Fiscal Responsibility Act Medicare and Medicaid Patient and Program Protection Act - Answer Operation Restore Trust program All of the following should be part of the core areas of coding compliance except: Physician query process Correct use of encoder software Coding diagnoses supported by medical record documentation Tracking length of stay - Answer Tracking length of stay Common forms of fraud and abuse include all of the following except: Upcoding Unbundling or exploding charges Refiling claims after denials Billing for services not furnished to patients - Answer Refiling claims after denials What is the primary use of the case-mix index? Benchmark of emergency room levels Defines how a hospital compares to peers and whether the facility is at risk Audit of APCS and the comparison to same size hospitals A tool for a coding manager to compare coder productivity - Answer Defines how a hospital compares to peers and whether the facility is at risk What resource can managers use to discover current, hot areas of compliance? Policies and procedures Nation coverage determinations Official coding guidelines OIG workplan - Answer OIG workplan This is a program unveiled in 1998 by the OIG that encourages healthcare providers to report fraudulent conduct affecting Medicare, Medicaid, and other federal healthcare programs: World Health Organization Voluntary Disclosure Program Compliance Disclosure Program Fraud and Abuse Program - Answer Voluntary Disclosure Program What is the process used to transform text into an untelligbloe string of characters that can be transmitted vial communications media with a high degree of security and then decrypted when it reaches a secure destination? Distortion Extrication Encryption Encoded - Answer Encryption Using uniform technology is a way to improve: Validity Data Timeliness Audit trails Data Reliability - Answer Data Reliability The ____ mandated the development of standards for electronic medical records. Medicare and Medicaid legislation of 1965 Prospective payment act of 1983 Health insurance portability and accountability act of 1996 (HIPAA) Balanced budget act of 1997 - Answer Health insurance portability and accountability act of 1996 (HIPAA) Messaging standards for electronic data interchange in healthcare have been developed by: HL7 IEE The joint commission CMS - Answer HL7 What is the incentive to improve quality of clinical outcomes using the electronic health record that could result in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts? Pay for performance and quality Patient referrals Payer of last resort Performance evaluations - Answer Pay for performance and quality A threat to data security is: a. Encryption b. Malware c. Audit trail d. Data quality - Answer Malware Data security refers to: Guaranteeing privacy Controlling access Using uniform terminology Transparency - Answer Controlling access A record of all transactions in the computer system that has maintained and reviewed for unauthorized access is called a: Security breach Audit trail Unauthorized access Privacy trail - Answer Audit trail Which of the following is a true statement about data stewardship? HIM professionals are not qualified to address date of stewardship issues. Data stewardship addresses the needs of the healthcare organization but not the patient HIM professionals have worked with many data stewardship issues for years. Data stewardship does not include privacy issues. - Answer HIM professionals have worked with many data stewardship issues for years. Performance counseling usually begins with which of the following Submitting an action plan of steps employee will do to resolve the issue and improve performance. Job termination Informal counseling or verbal warning Put the coder on unpaid leave of absence - Answer Informal counseling or verbal warning A health information technician (HIT) is hired as the chief compliance officer For a large group practice. In evaluating the current program, the HIT learns that they are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following sure the compliance officer also ensure are in place? Compliance program education and training programs for all employees in the organization Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation Adopt procedures to adequately identify individuals who make complaint so that appropriate follow up can be conducted Establish a corporate compliance committee who report directly to the CFO - Answer Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? Current coding personnel Medical staff Newly hired coding personnel Nursing staff - Answer Nursing staff Which of the following issues a compliance program guidance? AHIMA CMS Federal register HHS office of Inspector General (OIG) - Answer HHS office of Inspector General (OIG)