Unit 8 Assignment 1 Chart Review for Medical Coding 1

Clinical Nomenclature Systems

i.	A patient presents with CKD phase III, edema and hypertension. The correct ICD-10 CM codes for this nautical chart are:
		a. N18.3, I10, R60.9
		b. N18.nine, I10, R60.9
		c. N18.three, I12.ix
		d. N18.9, I12.ix, R60.9
Per ICD-10CM guidelines do not code signs and symptoms. Edema is a symptom of both hypertension and CKD. ICD-10CM guidelines state there is a casual human relationship assumed betwixt CKD and hypertension unless the provider specifically states that the hypertension is not related to the CKD, giving this patient hypertensive chronic kidney illness instead of regular hypertension. Incorrect reply. Delight choose another answer.

2.	A 42-year-quondam female, who is a new patient, presents with foul-smelling urine, frequency, flank pain and fever for 4 days. Patient denies nausea and headache. Patient is not sexually active and is a non-smoker. The provider performs the following test in addition to patient's acme, weight and blood pressure check: General: Well-developed, well nourished, in no acute distress Ears: external ears normal, TM bilaterally intact Neck: Supple, no thyromegaly Extremities: No edema Cardiovascular: RRR, no bruits Lungs: Clear to auscultation The patient is prescribed ciprofloxacin and given a diagnosis of acute cystitis without hematuria. The correct coding for this run into, using 1997 E/Chiliad guidelines is:
		a. 99202, N30.00
		b. 99203, N30.00, R30.0
		c. 99202, N39.0
		d. 99203, N39.0, R30.0
1997 E/M guidelines land that the provider must reach 12 bullet points for a detailed level of exam. Although the patient'south chart has a detailed history and moderate medical decision making, the provider only reached eleven bullet points, making this level a 99202. N39.0 is not the well-nigh specific code for this chart. Incorrect reply. Delight choose another reply.

3.	A patient presents with a cyst at the base of operations of his tailbone. It is swollen and painful for the patient to sit down down. The provider drapes the patient in the usual manner, administers lidocaine and uses a scalpel to excise the 2cm cyst and a subcutaneous extension, rinses information technology with sterile saline, performs an intermediate repair of the wound with a layered closure. The right CPT code consignment for this procedure is:
		a. 10080, 12001-59
		b. 10081
		c. 11771
		d. 11770, 12031-59
The provider performs an excision, not an incision, completely removing the cyst. The excision is intermediate because it involves subcutaneous extensions and the repair is included with the process. Wrong answer. Please choose another answer.

4.	A 7-twelvemonth-old kid presents for a series of vaccines. The patient receives MMR and DTaP and counseling on vaccines. The right CPT code consignment for this procedure is:
		a. 90460, 90461
		b. 90471, 90472
		c. 90460, 90461x5
		d. 90460x2, 90461x4
Pediatric vaccines with counseling are coded per component. Each first component of a vaccine (Measles and Diphtheria in this case) are coded as ane unit of 90460. Each additional component to the vaccine (mumps, rubella, tetanus and acellular pertussis) receive another 90461 for an additional component code. Incorrect answer. Please choose some other answer.

5.	ICD-10 codes are used:
		a. equally procedure codes
		b. in DRGs
		c. every bit diagnosis codes
		d. All of the above
ICD-10 PCS are used as process codes for inpatient visits. DRGs utilize similar ICD-10CM weights for facility reimbursement and ICD-10CM are used every bit diagnosis codes for all healthcare settings. Incorrect reply. Please choose another answer.

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6.	For urosepsis, a coder must:
		a. Utilise the code for astringent sepsis
		b. Use the lawmaking for sepsis with organ dysfunction
		c. Query the provider
		d. Code start localized sepsis
Co-ordinate to ICD-10CM guidelines, urosepsis is a nonspecific term and has no tabular position. The provider must be queried for clarification. Incorrect answer. Please choose another reply.

7.	A patient comes into the office with white fuzzy patches on their tongue and is diagnosed with oral hairy leukoplakia. The provider runs a test for HIV and notates that the patient has HIV in the chart, but does non have a positive lab test however. The patient is a smoker. What is the correct sequencing of these ICD-10 codes?
		a. B20, K13.3, F17.200
		b. K13.3, R75, Z87.891
		c. B20, K13.three, Z87.891
		d. K13.3, Z21, F17.200
Co-ordinate to chapter guidelines, if a patient is seen for an HIV-related condition, (which oral hairy leukoplakia is), then B20 is coded first, then the complications. Just the provider'south argument is needed that the patient has HIV, not a positive lab test. F17.200 is to be assigned when the provider documents "smoker", but gives no farther description (AHA: 2016, 1Q, 36) Incorrect answer. Please choose another reply.

8.	A 25-year-former patient is 27 weeks and half dozen days pregnant. The patient is experiencing dysuria and blood in her urine. She is diagnosed with acute cystitis. What is the correct coding of this patient'southward chart?
		a. N30.01, Z33.one
		b. O23.32, N39.0, Z3A.27
		c. O23.12, N30.01, Z3A.27
		d. N30.00, Z33.ane
Cystitis is an infection of the float. The provider must specifically state that the infection or condition is non affecting the pregnancy for an incidental code. The patient is experiencing claret in her urine, which gives us the hematuria portion of the diagnosis. Wrong answer. Please choose another answer.

9.	A patient comes in subsequently her pressure cooker has exploded and covered her face with humid soup. She was luckily wearing a sweater which protected her artillery. She has partial-thickness burns covering her unabridged face. What is the correct CPT code to exist assigned every bit the infirmary removes chicken, celery and burnt tissue from her face and places dressings on it?
		a. 16020, 97597-59
		b. 11011
		c. 16025
		d. 97597
16025 covers whole face burns and includes debridement. Incorrect reply. Delight choose some other respond.

ten.	A 2-year-old child had their humerus fractured by a falling dresser and requires anesthesia to repair the break because they volition not hold still for a reduction. The procedure billed is 24505. What anesthesia service is reported?
		a. 01730 P1
		b. 01742 P1, 99100
		c. 01744 P1
		d. 01756 P1, 99100
Anesthesia for all closed procedures on humerus and elbow. The 99100 code is just used for patients under 1 year sometime or over lxx years quondam. 01744 is for open procedures, not closed. Incorrect respond. Please cull another answer.

Confidentiality and Privacy

11.	The Breach Notification Dominion, institute in the ______ Dominion of HIPAA, states that when _____ individuals have had their confidential information exposed and the covered entity has outdated contact information for them, that the covered entity must_____ for ______ days.
		a. Security Rule, less than 200 individuals just more than five, post a notice in the newspaper for 180 days
		b. Jitney Dominion, less than 500 individuals simply more than than 10, post a notice on their website for 90 days
		c. Security Rule, 500 or more individuals, post a find on their website and create a radio advertisement for lx days
		d. Privacy Rule, 5 or more individuals, postal service a observe on their website, in the lobby and send postcards with data at least 3 times over xc days.
The Charabanc Rule established HITECH and the AARA of 2009 and finalized the Breach Notification Rule, mandating that covered entities who have more than 10 individuals with outdated contact information involved in a data breach must be notified by posting a notice on their website or creating a local ad in the newspaper. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately. Incorrect respond. Delight choose some other respond.

12.	Sally calls the coding department to competition the indistinguishable procedures that her adult sister received while admitted to an inpatient mental health facility. Sally has her sister's date of birth, her name just not her ID number. She says her sis is too depressed to advocate for herself and Sally merely wants the charges reviewed. What do you do?
		a. Tell Emerge you'll review her sister's chart while she was hospitalized and process a corrected claim if needed.
		b. Tell Emerge yous're lamentable, only her sister must call when she gets out of the hospital, HIPAA does non let yous to speak to Sally without her sister's written consent.
		c. Tell Sally her sister's patient ID number so she can improve advocate for her sister in other departments
		d. Tell Emerge that according to HIPAA she must obtain her sister'southward written consent in order to discuss whatsoever protected health information with her and requite her the fax number where she can send the written release.
HIPAA Privacy Dominion Section 164.510(b)(three) allows providers to discuss PHI with family members if they determine it is in the patient'south best interest for coordination of treatment or payment, unless the patient has expressed wishes that their data is not shared with family unit. Incorrect answer. Please choose another answer.

13.	You need a second opinion on coding a nautical chart from your Coding Manager, who does not have access to the patient'due south records. Yous determine to e-mail a screenshot of the chart to the Coding Manager. What steps must you take to ensure that the patient's information is protected in your email?
		a. Create a confidentiality notice in your email, asking an unintended recipient to delete the information
		b. Follow all visitor guidelines to encrypt your e-mail
		c. Remove patient's proper noun, appointment of birth, insurance ID#, SSN, address and patient number earlier emailing
		d. All of the above
HIPAA HITECH requires that covered entities take reasonable action to protect electronically transmitted information. Removing protected health information, encrypting electronic mail and creating confidentiality notices are a multi-layered security approach that is best-practise to forestall breaches of data. Wrong respond. Please choose another answer.

Reimbursement Methodologies

xiv.	Facility payments are based on:
		a. Fee schedules
		b. ICD-10 PCS codes
		c. IPPS using DRGs
		d. RVUs and conversion factors
The Inpatient Prospective Payment System drives value-based intendance by paying inpatient stays based on DRGs (Diagnosis-Related Group(s)) which are groups of diagnoses with like weights in order to determine "how much" a patient'due south stay ought to cost. These drivers force hospitals to work to be nigh efficient in their use of resource to come in under what they will exist paid in order to avert losing money. Incorrect answer. Please choose some other respond.

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15.	Conversion factors:
		a. Are based on how difficult a procedure is
		b. Depend on the level of education a provider has
		c. Are based on locality
		d. None of the above
RVUs are based off work for each HCPCS. RVUs are multiplied by Geographic Practice Cost Indices (GPCI), which account for md work, cost of malpractice and practice expenses. A conversion factor, which is a national number that changes annually, is multiplied by the sum of RVUs that are multiplied by the GPCI to summate payment for professional fee schedules. Incorrect answer. Delight choose some other answer.

sixteen.	Pressure level ulcers, catheter-associated urinary tract infections, falls and head trauma, DVTs and pulmonary embolisms are all examples of:
		a. DRGs that should take a POA indicator
		b. Hospital-acquired weather condition that volition not be reimbursed
		c. Part of similar weight DRGs
		d. Complications that must be coded to receive total reimbursement
The HAC-POA (Hospital acquired condition, present on admission) plan was created by the Arrears Reduction Deed of 2005--whatever of these atmospheric condition which are not nowadays on access and could have reasonably been prevented past following accepted standards of care volition not be reimbursed. Usually, adding the DRG weight would have increased the facility's reimbursement, merely this forces hospitals to avoid hospital acquired conditions, rather than turn a profit from them. Incorrect answer. Please choose another answer.

17.	Relative Value Units are:
		a. Different for each locality
		b. A weight for process codes
		c. Multiplied with conversion factors
		d. All of the above
RVUs multiplied by conversion factor gives yous the amount payable for a provider's fee schedule. Incorrect answer. Please choose some other answer.

18.	Medicare pays Skilled Nursing Facilities with a prospective payment system. Reimbursement is based on:
		a. Reasonable costs
		b. Per Diem
		c. Based on DRGs
		d. Episode of care
The Balanced Upkeep Human action mandated that SNF-PPS be paid per diem for all costs, which is based on a case-mix of diagnoses. Incorrect answer. Please choose another reply.

19.	For Medicare's OPPS, payment status indicator C indicates that the HCPCS is:
		a. More complicated than usual, requiring increased reimbursement
		b. Part of a series of concurrent procedures that will be performed together
		c. But performed in inpatient settings
		d. Performed past the Chief surgeon, requiring increased reimbursement.
Payment condition indicator C indicates that the HCPCS is only performed in an in-patient setting. Incorrect answer. Please choose another answer.

Health Records and Data Content

20.	CMS requires that the patient'southward history and physical be completed and documented in the patient'south record
		a. Inside 24 hours of admission or not greater than 30 days before admission
		b. Immediately upon admission or not greater than 10 days before admission
		c. Within 6 hours of access or not greater than xv days before access
		d. Within 3 hours of admission or not greater than 3 days before admission
CMS conditions of participation require that the patient's history and physical be completed and documented within the patient's record inside 24 hours of access, but non greater than xxx days prior to admission. Incorrect answer. Please cull some other answer.

21.	These components create a patient's history:
		a. Reason for Visit, History of Present Disease, Review of Symptoms, Prior History
		b. Chief Complaint, History of Present Illness, Review of Systems, Past Family and Social History
		c. Chronic conditions, History of Nowadays Illness, Review of Symptoms, Reason for Visit, Surgical history
		d. Chief Complaint, History of Present Illness, Review of Symptoms, Past Family and Social History
CC, HPI, ROS and PFSH are the components of a patient history. ROS is performed to make certain the provider did not miss whatsoever relevant complaints and tin can exist pulled from the HPI if needed. Incorrect respond. Delight cull another answer.

22.	According to CMS, the provider's final authentication of the patient's wellness tape must NOT be past:
		a. Rubber stamp
		b. Electronic signature verified past biometrics
		c. Electronic signature verified by passcodes
		d. Ink signatures in blackness ink
Rubber stamps were prohibited by CMS in 2015 for provider authentication Incorrect respond. Delight choose another answer.

23.	An open-record review is when:
		a. The patient's record, with PHI removed, is presented at a clinical documentation improvement session for providers
		b. The patient's record is sent to CMS to be audited
		c. When a qualitative analysis of the patient's record is done while the patient is in active treatment
		d. When the patient is given a copy of their nautical chart to ensure everything was documented accurately to the best of their noesis
An open-record review takes identify when a qualitative analysis of the patient'southward record is done while the patient is in active treatment. The Joint Commission requires these reviews to ensure that documentation standards are met while the patient is still under intendance. Incorrect answer. Please choose another answer.

24.	Which of the following is NOT a component of Personal Wellness Information
		a. URL
		b. Naught Code
		c. License plate number
		d. All of the above are PHI elements
There are 18 unique identifiers protected past HIPAA. Only the start 3 digits of a patient's zip code is not PHI, as long as in that location are more than 20,000 people in the group that forms all zip codes. E.thou. 123XX+123XY+123XZ take more than xx,000 people. Otherwise the zip lawmaking must be inverse to 00000. Incorrect respond. Please choose some other respond.

Information Technologies

25.	What is the difference between an EHR and an EMR?
		a. EHRs comprise financial information while EMRs only incorporate clinical information.
		b. EHRs are able to communicate with other systems, simply EMRs are not.
		c. EHRs comprise images, while EMRs only contained electronic "paper" nautical chart formats.
		d. There is no difference between EHRs and EMRs. It's only a terminology difference.
EHRs are defined by NAHIT as able to communicate and exchange information with multiple systems. EMRs practise not have this capacity. Incorrect answer. Delight cull another reply.

26.	Which of the post-obit standards are used to create standardized nomenclature within an electronic health record program?
		a. ICD-10 CM
		b. Nil PC
		c. CTNS EHR
		d. SNOMED CT
Systemized Classification of Medicine--Clinical Terminology (SNOMED CT) is the global standard for clinicians and is used to ascertain terms in EHRs around the world. Incorrect answer. Please choose another answer.

27.	Implemented in 2012, what standard changed the manner that PHI was submitted electronically?
		a. ASC X12 5010
		b. HL7 4010
		c. SDLC 6040
		d. HIPAA 2020
Under Authoritative Simplification, HIPAA standard 5010, using ASC X12, was created and implemented. HIPAA standard 4010 was no longer accepted as of June 30, 2012 Incorrect answer. Delight choose another answer.

Compliance

28.	You piece of work at a billing company, coding charts for clients. Your director sends out claims that have non been coded professionally because your squad is 2 months behind and out of compliance with your service line agreement in the contract with your client, but says that it is okay because the provider has coded the claims at the fourth dimension of service and the customer does non desire to pay for actress coding. Which of the following statements is true?
		a. This is fine because the provider coded the claim to the best of their power and therefore cannot be held liable.
		b. Billing companies take liability for fraudulent claims that they submit, including undercoding, so this is not acceptable.
		c. Only overcoding is fraudulent, so this is adequate.
		d. The providers mostly under-code their services, then it'south actually saving the insurance money and saving us work!
The OIG states that billing companies who submit fraudulent claims (likewise equally the person who submitted them!) are only equally responsible equally the provider who rendered the services. Both undercoding and overcoding are examples of fraudulent claims, the merits submitted must accurately stand for the services rendered. Incorrect answer. Please choose another respond.

29.	Which of the following are considered fraudulent:
		a. Utilise of modifier -59 to report a distinct and separate service that would otherwise be prohibited past NCCI guidelines.
		b. Irresolute the code on a merits because the provider did not meet documentation standards.
		c. Use of modifier -25 on a minor evaluation and management service that is coded with a related process.
		d. All of the to a higher place are acceptable practices.
Procedures include a pocket-size evaluation and management service. If the patient complains of an abscess and a I&D is performed, simply the procedure should be reported. If the patient comes in complaining of hypertension and an abscess is discovered, then it would be acceptable to study an evaluation and management service. Incorrect answer. Please choose another respond.

30.	Which of the following is an case of a compliant query to a doctor:
		a. 06/30: Dr. Chocolate-brown, can you add documentation for the procedure you lot did on for Mrs. Parks 5/22? We've billed it out simply I'm worried that in that location isn't enough documentation to support it. We know you lot did the procedure, but just need a little something extra!
		b. 6/30: Dr. Brown, can you clarify in the patient'southward nautical chart Mrs. Cramb'south diagnosis for half-dozen/27 given the positive rapid strep test that was uploaded?
		c. vi/30 Dr. Pepper, can you add acute sinusitis (if that's what he had!) to Mr. Meltzer'due south tape--all nosotros take is nasal congestion, headache and malaise and I run into you prescribed him antibiotics. Thank you!
		d. 6/30 Dr. Pepper, I run across that you gave Mr. Evans a diagnosis of unspecified loss of kidney function, just we would get paid a bit more if it were Chronic Kidney Illness, would that exist an advisable diagnosis to code for this patient?
Dr. queries must be non-leading, not based on reimbursement, for the purpose of improving patient care and open-ended, or Yep/No questions. Providers must not add documentation solely for the purpose of being reimbursed and information technology must be inside a reasonable time frame. Wrong respond. Delight cull another answer.

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