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What is the term that means evaluating the appropriateness of the setting for the healthcare service and the level of service? a. Coordination of service benefits b. Community rating c. Outcomes assessment d. Utilization review
d. Utilization review
Which of the following actions would be best to determine whether present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? a. Identify all records for a period having these indicators for these conditions and determine whether these conditions are the only secondary diagnoses present on the claim that will lead to higher payment. b. Identify all records for a period that have these indicators for these conditions. c. Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement. d. Take a random sample of records for a period of records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.
a. Identify all records for a period having these indicators for these conditions and determine whether these conditions are the only secondary diagnoses present on the claim that will lead to higher payment.
A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. Which of the following could be considered a comorbid condition? a. Acute appendicitis b. Acute lower abdominal pain c. Diabetes d. Wound infection
c. Diabetes
A coding audit shows that an inpatient coding professional is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? a. Counsel the coding professional and stop the practice immediately. b. Report the practice to the OIG. c. Require all coding professionals to implement this practice. d. Put the coding professional on unpaid leave of absence.
a. Counsel the coding professional and stop the practice immediately.
NCCI edits prevent improper payments in which of the following cases? a. Medical necessity has not been justified by a diagnosis. b. The account is potentially upcoded. c. The claim contains any of a variety of errors. d. Incorrect code combinations are on the claim.
d. Incorrect code combinations are on the claim.
Medicare inpatient reimbursement levels are based on: a. CPT codes reported during the encounter b. MS-DRG calculated for the encounter c. Charges accumulated during the episode of care d. Usual and customary charges reported during the encounter
b. MS-DRG calculated for the encounter
A physician query may not be appropriate in which of the following instances? a. Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae b. Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay c. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis d. Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI
c. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis
A 54-year-old patient is seen with a high fever, chest pain, and a cough. Gram stain of the sputum showed staph. The physician documented staphylococcal pneumonia. What code(s) would be assigned for this patient? B95.7 Other staphylococcus as the cause diseases classified elsewhere J15.20 Pneumonia due to staphylococcus, unspecified J18.9 Pneumonia, unspecified organism R05 Cough R07.9 Chest pain, unspecified R50.9 Fever, unspecified a. R50.9, R05, R07.9 b. R50.9, R05, R07.9, J15.20 c. J15.20 d. J18.9, B95.7
c. J15.20
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the margins excised as described in the operative report
d. Diameter of the lesion as well as the margins excised as described in the operative report
The present on admission indicator is a requirement for: a. Inpatient Medicare claims submitted by hospitals b. Inpatient Medicare and Medicaid claims submitted by hospitals c. Medicare claims submitted by all entities d. Inpatient skilled nursing facility Medicare claims
a. Inpatient Medicare claims submitted by hospitals
The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this case? a. Acute cholecystitis, nausea, vomiting, abdominal pain b. Abdominal pain, vomiting, nausea, acute cholecystitis c. Nausea, vomiting, abdominal pain d. Acute cholecystitis
d. Acute cholecystitis
A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious gastroenteritis; chronic obstructive pulmonary disease; angina b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina c. Gastroenteritis; abdominal pain; angina d. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina
b. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina
An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should this case be coded? a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. b. Code urinary tract infection with sepsis as the principal diagnosis. c. Query the physician to ask if the patient has septicemia because of the symptomatology. d. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.
c. Query the physician to ask if the patient has septicemia because of the symptomatology.
The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: a. Unbundling b. Billing for services not provided c. Medically unnecessary services d. Upcoding
d. Upcoding
A 65-year-old patient with a history of lung cancer is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department as well as a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? a. Ataxia b. Fractured arm c. Metastatic carcinoma of the brain d. Carcinoma of the lung
c. Metastatic carcinoma of the brain
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? a. Complex b. Intermediate c. Not specified d. Simple
a. Complex
A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostate carcinoma three years ago and is status post a radical resection of the prostate. CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay? a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy c. Metastatic carcinoma of the brain; history of carcinoma of the prostate d. Carcinoma of the prostate; metastatic carcinoma to the brain
c. Metastatic carcinoma of the brain; history of carcinoma of the prostate
A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: a. Either the pancreatitis or noncalculus cholecystitis sequenced as principal diagnosis b. Pancreatitis; noncalculus cholecystitis; abdominal pain c. Noncalculus cholecystitis; pancreatitis; abdominal pain d. Abdominal pain; pancreatitis; noncalculus cholecystitis
a. Either the pancreatitis or noncalculus cholecystitis sequenced as principal diagnosis
A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus d. Chronic obstructive asthma
c. Asthma with status asthmaticus
The ICD-10-CM utilizes a placeholder character at certain codes to allow for future expansion of the classification system. What letter is used to represent this placeholder character? a. A b. G c. U d. X
d. X
A physician orders a chest x-ray for an office patient who presents with fever, productive cough, and shortness of breath. The physician indicates in the progress notes: "Rule out pneumonia." What should the coding professional report for the visit when the results have not yet been received? a. Pneumonia b. Fever, cough, shortness of breath c. Cough, shortness of breath d. Pneumonia, cough, shortness of breath, fever
b. Fever, cough, shortness of breath
A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis
a. Miscarriage
The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on: a. Case-mix index b. Query rate c. Principal diagnosis d. Record review rate
a. Case-mix index
Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient but another physician performed the surgical procedure. a. -22, Increased procedural services b. -54, Surgical care only c. -32, Mandated service d. -55, Postoperative management only
d. -55, Postoperative management only
Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket. a. 33223, Relocation of skin pocket for implantable defibrillator b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) c. 33212, Insertion of pacemaker pulse generator only; with existing single lead d. 33222, Relocation of skin pocket for pacemaker
d. 33222, Relocation of skin pocket for pacemaker
In the inpatient prospective payment system, the calculation of the DRG begins with the: a. Principal diagnosis b. Primary diagnosis c. Secondary diagnosis d. Surgical procedure
a. Principal diagnosis
Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32408, Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when performed b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)
b. 37609, Ligation or biopsy, temporal artery
In ICD-10-PCS, the root operation defined as taking or letting out fluids and/or gases from a body part is: a. Control b. Drainage c. Excision d. Release
b. Drainage
When reporting an encounter for a patient who is HIV positive but has never had any symptoms, the following code is assigned: a. B20, Human immunodeficiency virus [HIV] disease b. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status c. R75, Inconclusive laboratory evidence of human immunodeficiency virus [HIV] d. Z20.6, Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
b. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status
What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified? a. Case management b. Continuum of care c. Quality improvement d. Utilization review
d. Utilization review
What type of value-based purchasing program is the Hospital-Acquired Conditions Reduction Program? a. Quality consumer assessment b. Pay for reporting c. Quality incentive program d. Paying for value
d. Paying for value
Under outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Mr. Smith had a minor procedure performed in the hospital outpatient department at a charge of $85. In addition, Mr. Smith has paid his deductible for the year. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case? a. $15 b. $17 c. $68 d. $85
a. $15
Which of the following is the condition established after study to be the reason for hospitalization? a. Principal procedure b. Complication c. Comorbidity d. Principal diagnosis
a. Principal procedure
MS-DRGs may be split into a maximum of _____ payment tiers based on severity as determined by the presence of a major complication or comorbidity, a CC, or no CC. a. Two b. Three c. Four d. Five
b. Three
The purpose of the present on admission indicator is to: a. Differentiate between conditions present on admission and conditions that develop during an inpatient admission b. Track principal diagnoses c. Distinguish between principal and primary diagnoses d. Determine principal diagnosis
a. Differentiate between conditions present on admission and conditions that develop during an inpatient admission
The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what immediate action should the coding supervisor take? a. Counsel Tim and Jane because they have the highest error rates. b. Encourage Tim and Jane to get additional training. c. Provide Bob and Susan with incentive pay for a low coding error rate. d. Take no action because not enough information is given to make a judgment.
d. Take no action because not enough information is given to make a judgment.
The National Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for: a. Part A Medicare claims b. Part B Medicare claims c. Medicaid claims d. Medicare and Medicaid claims
b. Part B Medicare claims
A quality data review based on specific problem areas that comes after an initial baseline review has been completed in a hospital is called a: a. Compliance initiative b. Concurrent review c. Focused review d. Internal audit
c. Focused review
Unbundling refers to: a. Use of a comprehensive code to appropriately maximize reimbursement b. Use of multiple procedure codes when a comprehensive code is available c. Combined billing for pre- and postsurgery physician services d. Using the incorrect DRG code
b. Use of multiple procedure codes when a comprehensive code is available
A patient who has been diagnosed with hypertension visits her physician on a monthly basis. The nurse conducted the blood pressure check under the physician's supervision. Code the office visit. a. 99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional. b. 99202, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision. c. 99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. d. 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision.
a. 99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional.
In the healthcare industry, what is the term for the written report that insurers use to notify insureds about the extent of payments made on a claim? a. Certificate of Insurance b. Coordination of Benefits c. Explanation of Benefits d. Summary of Benefits and Coverage
c. Explanation of Benefits
You are the coding supervisor, and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." What should have been coded as the patient's diagnosis? a. Chronic cough b. Observation and evaluation without need for further medical care c. Diagnosis of unknown etiology d. Lung cance
a. Chronic cough
The function of the NCCI editor is to: a. Report poor performing physicians b. Identify procedures and services that cannot be billed together on the same day of service for a patient c. Identify poor performing coding professionals d. Identify problems in the national coding system
b. Identify procedures and services that cannot be billed together on the same day of service for a patient
A select group of reasonably preventable conditions for which hospitals should not receive additional payment when one of the conditions was not present on admission is called a: a. Charge code b. Hospital-acquired condition c. Principal diagnosis d. Value-based purchasing list
b. Hospital-acquired condition
When multiple burns are present, the first sequenced diagnosis is the: a. Burn that is treated surgically b. Burn that is closest to the head c. Highest-degree burn d. Burn that is treated first
c. Highest-degree burn
The results of a recent coding audit show that two of the inpatient coding professionals are missing the correct principal diagnosis selection that affects MS-DRG payment for the hospital. As the coding manager, you are tasked to provide coding education to the coding professionals to correct this problem. What should be included in this training? a. How to use the CPT index b. Definitions of root operations c. How to calculate the case mix d. Definitions of principal diagnosis
d. Definitions of principal diagnosis
A patient known to have AIDS is admitted to the hospital for treatment of Pneumocystis carinii pneumonia. Assign the principal diagnosis for this patient. a. B20, Human immunodeficiency virus [HIV] disease b. J18.9, Pneumonia, unspecified organism c. B59, Pneumocystosis d. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status
a. B20, Human immunodeficiency virus [HIV] disease
A patient is seen as an outpatient to receive chemotherapy for distal esophageal carcinoma. What is the appropriate first-listed diagnosis? a. Z48.3, Aftercare following surgery for neoplasm b. Z51.11, Encounter for antineoplastic chemotherapy c. C15.5, Malignant neoplasm of lower third of esophagus d. C15.3, Malignant neoplasm of upper third of esophagus
b. Z51.11, Encounter for antineoplastic chemotherapy
The discharged, not final billed report (also known as "discharged, no final bill" or "accounts not selected for billing") includes what types of accounts? a. Accounts that have been discharged and have not been billed for a variety of reasons b. Only discharged inpatient accounts awaiting generation of the bill c. Only uncoded patient records d. Accounts that are within the system hold days and not eligible to be billed
a. Accounts that have been discharged and have not been billed for a variety of reasons
NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for: a. Services that cannot reasonably be billed together b. Services that are components of a more comprehensive procedure c. Unnecessary procedures d. Comprehensive procedures
a. Services that cannot reasonably be billed together
What is the benefit to comparing the coding assigned by coding professionals to the coding appearing on the claim? a. May find that more codes are required to support the claim b. May find that the charge description master soft coding is inaccurate c. Serves as a way for HIM to take over the management of patient financial services d. Could find claim generation issues that cannot be found other ways
d. Could find claim generation issues that cannot be found other ways
A clinical documentation improvement (CDI) program facilitates accurate coding and helps coding professionals avoid: a. NCCI edits b. Upcoding c. Coding without a completed face sheet d. Assumption coding
d. Assumption coding
When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? a. Assign the removal by snare technique code. b. Assign the removal by hot biopsy forceps code. c. Assign the ablation code. d. Query the physician as to the method used.
d. Query the physician as to the method used.
The hospital-acquired conditions provision of the Medicare PPS is an example of which type of value-based purchasing system? a. Paying for value b. Penalty-based c. Reward-based d. Penalty for value
a. Paying for value
Which of the following would be classified in ICD-10-CM with an external cause code? a. Echocardiogram b. Fall from curb c. Adenocarcinoma d. Admission for plastic surgery
b. Fall from curb
A patient is scheduled for an outpatient colonoscopy, but due to a sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given general anesthetic prior to the procedure. How should this procedure be coded? a. Assign the code for colonoscopy with modifier 74, Discontinued outpatient procedure after anesthesia administration. b. Assign the code for a colonoscopy with modifier 52, Reduced services. c. Assign no code because no procedure was performed. d. Assign an anesthesia code only
a. Assign the code for colonoscopy with modifier 74, Discontinued outpatient procedure after anesthesia administration.
When documentation in the health record is not clear, the coding professional should: a. Submit the question to the coding clinic. b. Refer to dictation from other encounters for the patient to get clarification. c. Query the physician who originated the progress note or other report in question. d. Query a physician who consistently responds to queries in a timely manner.
c. Query the physician who originated the progress note or other report in question.
Which of the following procedures or services could not be assigned a code with CPT? a. Gastroscopy b. Anesthesia c. Glucose tolerance test d. Crutches
d. Crutches
Which of the following would generally be found in a query to a physician? a. Health record number and demographic information b. Name and contact number of the individual initiating the query and account number c. Date query initiated and date query must be completed d. Demographic information and name and contact number of the individual initiating the queryllowing would generally be found in a query to a physician?
b. Name and contact number of the individual initiating the query and account number
In ICD-10-PCS, what is the root operation for a left heart catheterization with sampling and pressure measurement? a. Insertion b. Introduction c. Measurement d. Monitoring
c. Measurement
When assigning evaluation and management codes for hospital outpatient services, the coding professional should follow: a. The hospital's own internal guidelines b. AHIMA guidelines c. CMS guidelines d. AHA guidelines
a. The hospital's own internal guidelines
The main purpose of National Correct Coding Initiative edits is to prohibit: a. ICD-10-CM procedure code errors b. DRG assignment errors c. Unbundling of procedures d. Incorrect POA assignment
c. Unbundling of procedures
Date of service: 1/3/2022. Last date of treatment: 2/12/2021.The patient is seen in the physician's office for a cough and sore throat. The physician performs a medically appropriate examination, and medical decision-making is straightforward. What is the correct E/M code for this service? a. 99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making b. 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward decision making c. 99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making d. 99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician or other healthcare professional
b. 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward decision making
Which of the following statements best defines utilization management? a. It is the process of determining whether the medical care provided to a patient is necessary. b. It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. c. It is a process that determines whether a planned service or a patient's condition warrants care in an inpatient setting. d. It is an ongoing infection surveillance program
a. It is the process of determining whether the medical care provided to a patient is necessary.
All of the following are steps in medical necessity and utilization review, except: a. Initial clinical review b. Peer clinical review c. Access consideration d. Appeals consideration
c. Access consideration
A patient was admitted to the hospital for treatment of a myocardial infarction (heart attack) and the MS-DRG assigned was 236 Coronary bypass w/o cardiac cath w/o MCC. During the patient's admission, a bypass procedure was performed on day 2; on day 4, the patient was diagnosed with sepsis, which was not present on admission. Sepsis is a major complication. This case was identified as coded incorrectly in a recent audit by the coding manager. What was the error that was made by the coding professional? a. The sepsis was not coded, and so an MCC was missed. b. The coronary bypass procedure was coded incorrectly. c. The claim was coded correctly; no error was made. d. The cardiac catheterization procedure was not coded
a. The sepsis was not coded, and so an MCC was missed.
Which of the following services is most likely to be considered medically necessary? a. Caregivers' convenience or relief b. Cosmetic improvement c. Investigational cancer prevention d. Standard of care for health condition
d. Standard of care for health condition
In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures with the payment status indicator T performed during the same operative session, which of the following would apply? a. Bundling of services b. Discounting of procedures c. Outlier adjustment d. Pass-through payment
b. Discounting of procedures
When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n) _______ indicating that Medicare might not pay and that the patient might be responsible for the entire charge. a. OIG b. ABN c. LOS d. EOB
b. ABN
The period of time between discharge and claim submission, which a facility defines by policy, is called the: a. AR days b. Bill hold c. Cash flow days d. Denial period
b. Bill hold
When an obstetric patient enters the hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the final character in ICD-10-CM selected for the antepartum condition should be: a. For the trimester in which the complication developed b. For the trimester in which the patient delivered c. For the trimester in which the patient was discharged d. For any trimester as long as the same character is used for all complications
a. For the trimester in which the complication developed
In order to determine the hospital's expected MS-DRG payment, the hospital's blended rate is multiplied by the MS-DRG's _______ to determine the dollar amount paid. a. Length of stay b. Case-mix number c. Relative weight d. Major diagnostic category
c. Relative weight
Which of the following is the average relative weight of all cases treated at a given facility or by a given physician? a. Case-mix index b. Sampling c. Hospital-acquired condition d. Present on admission indicator386. Which of the following is the average relative weight of all cases treated at a given facility or by a given physician? a. Case-mix index b. Sampling c. Hospital-acquired condition d. Present on admission indicator
a. Case-mix index
A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed? a. Continued stay utilization review b. Discharge plan c. Retrospective utilization review d. Case management
c. Retrospective utilization review
The evaluation of coding professionals is recommended at least quarterly for the purpose of measurement and assurance of: a. Speed b. Data quality and integrity c. Accuracy d. Effective relationships with physicians and facility personnel
b. Data quality and integrityty and integrity
The quality improvement organizations (QIOs) under contract with CMS conduct audits on high-risk and hospital-specific data from claims data in which of the following? a. Hospital Payment Monitoring Program b. Payment Error Prevention Program c. Program for Evaluation Payment Patterns Electronic Report d. Compliance Program Guidance for Hospitals
Program for Evaluation Payment Pc. Program for Evaluation Payment Patterns Electronic Reportatterns Electronic Report
Community Hospital has launched a clinical documentation improvement (CDI) initiative. Currently, clinical documentation does not always adequately reflect the severity of illness of the patient or support optimal HIM coding accuracy. Given this situation, which of the following would be the best action to validate that the new program is achieving its goals? a. Hire clinical documentation specialists to review records prior to coding. b. Ask coding professionals to query physicians more often. c. Provide physicians the opportunity to add addenda to their reports to clarify documentation issues. d. Conduct a retrospective review of all query opportunities for the year.
d. Conduct a retrospective review of all query opportunities for the year.
In a typical acute-care setting, the Explanation of Benefits (EOB), Medicare Summary Notice (MSN), and Remittance Advice (RA) documents (provided by the payer) are monitored in which revenue cycle area? a. Preclaims submission b. Claims processing c. Claims reconciliation and collections d. Accounts receivable
c. Claims reconciliation and collections
A facility recently submitted two claims for the same service for a patient's recent encounter for chemotherapy. If the third-party payer pays both of these claims, the facility will receive a higher reimbursement than deserved. This is called: a. Appropriate payment b. Overpayment c. Unbundling d. Waste
b. Overpayment
Which of the following would not be a focus area of claims auditing for healthcare services provided in the emergency department? a. Ensuring claims are not submitted more than once b. Ensuring procedures are reported at the appropriate level c. Ensuring documentation supports services reported on the claim d. Ensuring patients are satisfied with their services
d. Ensuring patients are satisfied with their services
The clinical documentation improvement (CDI) program must keep high-quality records of the query process for: a. Revenue cycle analysis b. Compliance issues c. Chart deficiency tracking d. Reducing the workload on HIM
b. Compliance issues
Detailed query documentation can be used to: a. Protect the hospital from lawsuits b. Protect the hospital against claims from physicians about leading queries c. Show the effects of follow-up training d. Protect the auditor from corrective action
d. Protect the auditor from corrective action
If a patient notices an unknown item in the explanation of benefits they receive from an insurance company and they do not recognize the service being paid for, the patient should: a. Contact the insurer and the provider who billed for the services to correct the information. b. Contact the police. c. Contact human resources and let them know there has been a mistake. d. Not do anything.
a. Contact the insurer and the provider who billed for the services to correct the information.
Insurance companies pool premium payments for all the insureds in a group, then use actuarial data to calculate the group's premiums so that which of the following occurs? a. Premium payments are lowered for insurance plan payers. b. The pool is large enough to pay losses of the entire group. c. Accounting for the group's plan is simplified. d. Insurance companies are guaranteed to never have a loss.
b. The pool is large enough to pay losses of the entire group.
When a provider does not accept the amount paid by the healthcare insurance plan and requires the patient to pay the remaining charges of a service, this is called: a. Accept assignment b. Bundled payment c. Balanced billing d. Capitated payment
c. Balanced billing
Which of the following is not a reason to query a provider? a. To clear up ambiguous documentation b. If conflicting information is found between the documentation of two different providers c. If the documentation is incomplete d. To question why a physician would document a condition
d. To question why a physician would document a condition
Dr. Jones is a podiatrist who performs over 100 bunionectomies a year. Western Health Insurance insures several of Dr. Jones' patients. Western Health Insurance reimburses Dr. Jones one amount for the preoperative visit, the surgery, and routine postoperative follow-up visits. Which reimbursement methodology does Western Health Insurance use to reimburse Dr. Jones? a. Global payment method b. Fee schedule c. Case-rate methodology d. Prospective payment methodology
a. Global payment method
Dr. Gilbert sees a 14-year-old male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was canceled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents who have health insurance through the mother's employment at the State Department of Treasury.
Who is the first party in this healthcare reimbursement scenario? a. Patient b. Parents c. Dr. Gilbert d. Insurance company
b. Parents
Dr. Gilbert sees a 14-year-old male with adolescent idiopathic thoracic scoliosis. Surgery for spinal fusion was canceled after the patient was diagnosed with mononucleosis. On today's visit the patient is started on prednisone for severe sore throat and difficulty swallowing. The patient was accompanied by his parents who have health insurance through the mother's employment at the State Department of Treasury.
Who is the second party in this healthcare reimbursement scenario? a. Patient b. Parents c. Dr. Gilbert d. Society
c. Dr. Gilbert
Which key performance indicator (KPI) measures the effectiveness of coding management? a. Case-mix index b. Denial rate c. Clean claim rate d. Discharged, not final billed
a. Case-mix index
How many times is a CDI specialist required to examine a patient's medical record documentation prior to the patient being discharged or transferred? a. Once, on the last day of the admission b. Twice, on the first and last days of the admission c. As many times as the admission length of stay d. As many times as warranted based on the clinical documentation and circumstances of the admission
d. As many times as warranted based on the clinical documentation and circumstances of the admission
Kyle is the CDI supervisor at University Hospital. He is reviewing data for the month of March. There were 215 discharges available for review in March. His CDI team was able to review 174. What is the review rate for March? a. 1.24% b. 44.7% c. 80.9% d. Cannot determine because the number of CDI professionals is not provided
c. 80.9%
Which of the following would be considered a back-end process of the revenue cycle? a. Adjudication b. Prior authorization c. Charge capture d. Diagnosis of coding
a. Adjudication
Which of the following sections in the ICD-10-PCS coding system contains codes for services that are new to ICD-10-PCS or that capture services not routinely captured in ICD-10-PCS that have been presented for public comment at the Coordination and Maintenance Committee Meeting? a. Other Procedures b. New Technology c. New Procedures d. Other Technology
b. New Technology
On a CMS-1500 billing form, linking refers to which of the following? a. Attaching modifiers to CPT codes b. Substituting a HCPCS code for the appropriate CPT code c. Assigning a diagnosis code to a CPT code on a claim d. Pairing professional charges to technical charges on a claim
c. Assigning a diagnosis code to a CPT code on a claim
A code used to describe what a patient was doing at the time of injury or other health condition occurred is called: a. External cause status code b. Place of occurrence code c. External cause code d. Activity code
d. Activity code
What is the function of a clearinghouse? a. It ensures that computer viruses are removed from billing software. b. It manages the process of claims appeals for Medicare. c. It reprices claims for a physician network. d. It transfers electronic claims to individual insurers.
d. It transfers electronic claims to individual insurers.
Gloria is the CDI supervisor at Memorial Hospital. She is reviewing data for the month of October. The CDI team sent 35 requests to physicians for clarification on severity. Twenty-one of these clarifications increased or impacted the MS-DRG assignment. What is the physician clarification impact rate for October? a. 14% b. 56% c. 60% d. 735%
c. 60%
Dr. Smith submitted 130 claims for code 36415 during the past year. The claim history file shows: 36415 $8.25 — 10 claims 36415 $8.75 — 20 claims 36415 $9.25 — 100 claims What is Dr. Smith's fee profile for 36415, using usual and customary (U/C) rules? a. $8.25 b. $8.75 c. $9.10 d. $9.25
c. $9.10
What do insurance companies receive in return for assuming the insured's exposure to risk or loss? a. Bonus b. Stipend c. Formulary d. Premium
d. Premium
Note
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