Rhit, Domain 2

Front 1

Lesion removal CPT code is determined by the body area from

Back 1

Diameter of lesion as well as the margin excised as described in the operative report

Front 2

Complex closure

Back 2

According to CPT a repair of laceration that includes retention sutures would be considered this type of closure

Front 3

Acute cholecystitis diagnosis

Back 3

A patient admitted with nausea vomiting and abdominal pain with physician documentation on the discharge summary of acute cholecystitis, nausea, vomiting and abdominal pain

Front 4

Miscarriage principal diagnosis

Back 4

A patient admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she was afebrile at this time. She was treated with aspiration dilation and curettage curettage. Products of conception are found.

Front 5

Query The Physician and ask if the patient has septicemia because of the symptomology.

Back 5

An 80 year old female is admitted with fever lethargy hypotension tachycardia oliguria and elevated white blood cell count. The patient has more than 100,000 organisms of E coli . The patient has more than 100,000 organisms of E coli per cc of

urine. The attending physician documents urosepsis.

Front 6

Upcoding

Back 6

Results in a higher payment to the provider then the code actually reflects the service or item provided

Front 7

Principal diagnosis Metastatic carcinoma of the brain

Back 7

A 65 year old patient with a history of 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 a fracture in the emergency department and 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.

Front 8

Infectious gastroenteritis; obstructive pulmonary disease; angina

Back 8

A patient was admitted for abdominal pain with diarrhea and diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease

Front 9

Metastatic carcinoma of the brain history of carcinoma prostate

Back 9

A patient is admitted with a history of prostate cancer and mental confusion. The patient completed radiation therapy for prostatic carcinoma 3 years ago and is status post a radical resection of the prostate. A CT scan of the brain during the recurrent admission reveals metastasis.

Front 10

Either pancreatitis or non calculus cholecystitis sequence as primary diagnosis

Back 10

Patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and non calculus cholecystitis. Both diagnoses are equally treated.

Front 11

According to the UHDDS this is a definition of other diagnoses

Back 11

All conditions that coexist at the time of admission or develop subsequently that affect treatment and/or length of stay

Front 12

Asthma with status asthmatics

Back 12

A 7 year old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatment. The shortness of breath and wheezing unabated following treatment.

Front 13

Hypertension

Back 13

A coder might find this diagnosis on a problem list if the medication list contains Procardia

Front 14

Fever, cough, shortness of breath

Back 14

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".

Hint 14

Signs symptoms abnormal test results or other reasons for the outpatient visits are used when physician qualifies a diagnostic statement as possible probable suspected questionable rule out or working diagnosis or other similar terms indicating uncertainty

Front 15

HCPCS

Back 15

Healthcare common procedure coding system

Front 16

Healthcare common procedure coding system

Back 16

Promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services.

Front 17

International classification of diseases for oncology, Third Edition

Back 17

Detailed classification systems for coding the histology, topography, and behavior of neoplasms.

Front 18

SNOMED CT

Back 18

Provides the most comprehensive, controlled vocabulary for coding the content of the patient record.

Front 19

"Type 1 diabetic gangrene" documentation

Back 19

implies a causal relationship between diabetes and peripheral angiopathy with gangrene. Allowed per guidelines.

Hint 19

To sign these codes documentation and the health record must support a causal relationship. Type 1 diabetic gangrene implies a causal relationship between diabetes and peripheral angiopathy with gangrene.

Front 20

Replacement for ICD-9 volumes 1 and 2

Back 20

International classification of diseases, 10th revision, clinical modification

Hint 20

Volumes 1 & 2 are used for reporting all diseases, injuries, and parents, other health problems and causes of.

Front 21

World Health Organization

Back 21

Originally published ICD-10

Hint 21

It evolved from a classification developed by Dr.Jaques Bertillon. This classification system was revised throughout the early 1900's.

Front 22

Z21, asymptomatic HIV infection status

Back 22

a patient who is hiv-positive but never had any symptoms

Hint 22

Do not use this code if the term AIDS is used or if the patient is treated for any hiv-related illness or is described as having any condition resulting from HIV positive status comma use B20 in these cases

Front 23

-55, postoperative management only

Back 23

Modifier indicating another physician performs a surgical procedure

Hint 23

136

Front 24

Relocation of skin pocket for pacemaker

Back 24

Also known as Revision of the pacemaker skin pocket

Hint 24

137

Front 25

X

Back 25

Placeholder character

Hint 25

138

Front 26

37609, Ligation or biopsy, temporal artery

Back 26

63 year old female with a temporal artery biopsy completed in the Outpatient Surgical Center

Front 27

Drainage

Back 27

Root operation Define is taking or letting out fluids and/or gases from a body part

Front 28

Do not query a physician

Back 28

Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis

Front 29

CPT

Back 29

Current procedural terminology

Front 30

Current procedural terminology

Back 30

System for coding the clinical procedures and services provided by The Physicians and other clinical professionals

Front 31

Pressure ulcers , catheter-associated urinary tract infections, Falls and fractures

Back 31

Conditions included on the hospital-acquired conditions provision list

Front 32

Most comprehensive solution to handle documentation issues

Back 32

Present at the next medical staff meeting to inform Physicians on documentation standards and guidelines

Front 33

Validity

Back 33

Degree to which codes accurately reflect the patients diagnoses and procedures

Front 34

Diabetes

Back 34

In the drg system this would be considered a comorbid condition.

Front 35

Principal diagnosis

Back 35

The condition established after study to be the reason for hospitalization

Front 36

MS-DRG

Back 36

Prospective payment system implemented for inpatient services

Front 37

Principal diagnosis

Back 37

Calculation of the DRG begins with the

Front 38

Major diagnostic categories

Back 38

Diagnostic related groups are organized by this

Front 39

NCCI edits

Back 39

Prevent improper payments an incorrect code combinations on the claim

Front 40

MS-DRG for the encounter

Back 40

Medicare inpatient reimbursement levels are based on this

Front 41

Providers documentation

Back 41

Coding and billing documentation must be based on

Front 42

Unbundling

Back 42

Use of a comprehensive code to appropriately maximize reimbursement

Front 43

3

Back 43

Payment tiers based on severity as determined by the presence of MCC for cc's

Front 44

Present on admission indicator

Back 44

To differentiate between conditions present on admission and conditions that developed during inpatient admission

Front 45

Inpatient Medicare claims submitted by hospitals

Back 45

Require present on admission indicator

Front 46

Counsel the coder and stop the practice immediately

Back 46

A coding audit shows an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of a procedure performed.

Front 47

Part b Medicare claims

Back 47

Ncci edits were developed to control and proper coding leading to improper payments for these

Front 48

NCCI

Back 48

National correct coding initiative

Front 49

Function of the ncci editor

Back 49

Identify procedures and services that cannot be built together on the same day of service for patient

Front 50

Services that cannot reasonably be billed together

Back 50

Ncci edit files contain code pairs, called mutually exclusive edits, that prevent payment

Front 51

Data quality and integrity

Back 51

EVALUATION of coders is recommended at least quarterly for the purpose of measurement and Assurance of this

Front 52

Close to is 100% as possible

Back 52

Quality standards for coding accuracy should be this

Front 53

Mental or behavior problems

Back 53

A coder notes that the patient is taking prescribed Haldol. The final diagnosis is the progress notes include diabetes, acute pharyngitis, and malnutrition. What possible dx should they query the physician about?

Front 54

One inpatient visit under MS-DRG

Back 54

A patient presented to the emergency department with chest pains and shortness of breath. They were treated for congestive heart failure and returned home. Two days later they returned and presented to the emergency department and admitted this time for treatment of congestive heart failure. The hospital will Bill Medicare for this.

Front 55

Undercoding

Back 55

Can affect the hospitals Case mix by making it lower than warranted byreducing the actual services or resource intensity

Front 56

Staph infections

Back 56

Not included on hospital-acquired conditions provision list for year 2009

Front 57

Highest degree burn

Back 57

When multiple are present the first sequenced is this

Front 58

Hypertension and chronic kidney disease

Back 58

A coding professional may assume a cause-and-effect relationship between hypertension and this

Front 59

B20, human immunodeficiency virus

Back 59

A patient known to have AIDS is admitted to the hospital for treatment pneumocystis carinii pneumonia, what is the principal diagnosis?

Front 60

Quality and quantity

Back 60

Coding productivity is MEASURED by this

Front 61

Chronic Cough

Back 61

You are the coding supervisor and you are doing an audit of outpatient coding. Robert was seen in the outpatient Department with a chronic cough and the record states "rule out lung cancer." This should have been the diagnosis.

Front 62

APC

Back 62

Ambulatory patient class

Front 63

APC

Back 63

Medicare outpatients are grouped

Front 64

Coding completed by new coders

Back 64

Could be the focus of a quality review program

Front 65

To identify which coder should be disciplined

Back 65

Not a reason for establishing a coding quality program.

Front 66

Find Claim generation issues that cannot be found other ways

Back 66

Benefit to comparing the coding assigned by coders to the coding appearing on the claim

Front 67

MCC

Back 67

Major complication and comorbidity

Front 68

Z51 .11, for antineoplastic chemotherapy

Back 68

Outpatient chemotherapy for distal esophageal carcinoma

Front 69

Query The Physician as to the method used

Back 69

When the physician does not specify the method used to remove the lesion during endoscopy

Front 70

Paying for value

Back 70

Hospital-acquired conditions provision of the Medicare PPS example of value-based purchasing system

Front 71

Hcpcs level II

Back 71

Crutches

Front 72

Fall from curb

Back 72

Would be classified with an external cause code in ICD-10

Front 73

Generator

Back 73

Also known as pacemaker battery in CPT

Front 74

Modified 74 discontinued outpatient procedure after anesthesia Administration

Back 74

When a planned procedure is terminated prior to completion but after the patient is given general anesthetic prior to the procedure.

Hint 74

Kuehn 2013, 220

Front 75

For unclear documentation

Back 75

Query The Physician who originated the progress note or other type of report in question

Front 76

Insignificant information

Back 76

Should not be a query to the physician

Front 77

CMS

Back 77

MS-DRG refers to a DRG system developed by

Front 78

OCE

Back 78

Outpatient code editor, operates in the systems of Medicare administrative contractors or MAC's. It provides a series of flags that can affect APC payments because it identifies coding errors in claims

Front 79

Unbundling of procedures

Back 79

The main purpose of correct coding initiative edits, NCCI. They are updated quarterly

Front 80

Best coding education

Back 80

Not sending staff to external seminars

Front 81

Name, contact number, and account number

Back 81

Generally would be found in a query to the physician

Front 82

Record over record method

Back 82

Accuracy calculation method that divides the number of Records where there was no change in APC or DRG assignment by the total number of cases reviewed

Hint 82

199

Front 83

Hospitals own internal guidelines

Back 83

The coder should follow for Hospital outpatient services when assigning evaluation and management codes

Front 84

Staff work

Back 84

Not a component of the total relative value unit for a given procedure

Front 85

Malignant

Back 85

Correct neoplasm type for adenocarcinoma

Front 86

99212, at least 2 of 3 components, problem-focused exam, straightforward medical decision

Back 86

DOS 1/3/2014- LAST DATE OF TX: 2/12/2013. The patient is seen in the physician's office for a cough and sore throat. The Physician performs a problem-focused history, expanded problem-focused examination, and medical decision-making is straightforward.

Front 87

88305, level IV, surgical pathology, gross and microscopic examination

Back 87

The pathologist performed a gross and microscopic examination of a kidney biopsy

Front 88

Measurement

Back 88

The root operation for left heart catheterization with sampling and pressure measurement

Front 89

Exploratory laparotomy

Back 89

The CPT for a Physician preformed exploratory laparotomy in the abdomen, Peritoneal, and omentum subsection, is a separate procedure and should not be reported when it is part of a larger procedure.

Front 90

N20.0, calculus of kidney and 0T788DZ, dilation ureters intraluminal device

Back 90

Patient with right flank pain was admitted and found to have calculus of the left kidney.

Utereroscpy with placement of ureteral stents was performed.

Hint 90

Flank pain symptoms of the calculus

Front 91

Blood pressure check with the nurse

Back 91

99211, office or other outpatient visit of the evaluation and management established patient that may not require the presence of a physician or other qualified health professional

Hint 91

Not require a history, examination, medical decision-making, or presence of a physician.

Front 92

N30.20, other chronic cystitis without hematuria and 0TBB8ZX, Excision

Back 92

Patient admitted with chronic cystitis. A cystoscopy and biopsy of the bladder work performed

Front 93

The procedure code for a patient who had ventilator management for more than 96 hours in ICD-10 PCS

Back 93

5A1955Z, Extracorporeal assistance and performance physiological systems, performance: completely taking over a physiological function by extracoporeal means, respiratory, greater than 96 consecutive hours, ventilation, No qualifier

Hint 93

Root operation performance

Front 94

CPT 59559, with lysis of intrauterine adhesions

Back 94

Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method)

Hint 94

212

Front 95

N39.3, stress incontinence, (female), (male). 0TSD0ZZ, supplement, synthetic substitute

Back 95

Female patient is admitted for stress incontinence a urethral suspension is performed

Hint 95

Root operation reposition

Front 96

Diagnostic and statistical Manual of mental disorders, 4th revision

Back 96

Provides a means to record information about patients treated for substance abuse and mental disorders

Front 97

Database management system

Back 97

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productivity hours worked per day the health record ID, type of Records coded, and other data and to provide weekly productivity reports and analysis

Front 98

Goal of icd-10-pcs

Back 98

Reduce inconsistency due to overlapping of terms

Front 99

Completeness

Back 99

Degree to which the code assignments captures all the diagnoses and procedures documented in the health record

Front 100

IOCE

Back 100

Integrated outpatient code editor

Front 101

Reviews claims prior to releasing billed data to Medicare program

Back 101

The latest version of the Medicare integrated outpatient code editor should be installed prior

Front 102

Medicare integrated outpatient code editor (IOCE) contains

Back 102

The national coding correct initiative (NCCI) edits for current procedural terminology (CPT) to evaluate relationships between CPT codes on Part B claims

Front 103

Ncci edits

Back 103

Evaluate the relationships between CPT codes on the bill and control improper coding on Part B claims. They also identify component codes that were used instead of the appropriate comprehensive code as well as other types of errors

Front 104

The dehydration is sequenced first followed by the code for malignancy

Back 104

When admission is for management of dehydration due to malignancy and only the dehydration is being treated

Front 105

Calculation of payment for services under the outpatient prospective payment system (OPPS)

Back 105

Based on the categorization of outpatient services into APC groups according TO CPT/ HCPCS codes

Front 106

Root operation extirpation

Back 106

Taking a cutting out solid material from a body part.

Front 107

Diagnoses documented as probable, suspected, questionable, rule out or working diagnosis

Back 107

In the outpatient setting indicate uncertainty and would not be coded as existing. Code to the highest degree of certainty for these.

Front 108

Predefined audit process

Back 108

Accuracy of coding is best determined by

Front 109

Quarterly with appropriate training needs identified

Back 109

Coders should be evaluated at least this much facilitated and reassessed over time. Only through this continuous process of evaluation can data quality and integrity be accurately measured and insured

Front 110

52240,cysturethroscopy with fulguration (including cryosurgery or laser surgery ) and/or resection of; large bladder tumors

Back 110

Carcinoma of multiple overlapping sites of the bladder, CPT for Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9 CM, 6.0 cm) are undertaken

Front 111

In cases of cesarean delivery, the selection of principal diagnosis should be

Back 111

The condition established after the study that was responsible for the patient's admission. (I.e. emergency C-section due to hemorrhage. Patient had placenta previa with delivery of twins. Primary diagnosis would be placenta previa)

Front 112

Subcategory codes

Back 112

When provided be used. That is most specific to the diagnosis

Front 113

Multiple laceration repairs

Back 113

The length of multiple laceration repairs located in the same classification are added together and one code is assigned

Front 114

Query The Physician for

Back 114

Positive lab results but no physician documentation regarding the results or condition

Front 115

Codes should be modified changed or deleted only

Back 115

After or when the physician documents in the health record

Front 116

Highest degree of certainty for the encounter

Back 116

In the outpatient setting do not code to diagnosis documented as probable.

Front 117

CC's and MCCS

Back 117

Play a part in determining the Medicare severity diagnosis-related group or MS-DRG.

Front 118

Complication

Back 118

Is it secondary condition that arises during hospitalization

Front 119

Comorbidity

Back 119

Is a secondary condition that exists at the time of admission

Front 120

MCC

Back 120

Would be an even higher level severity CC for a DRG and would pay more

Front 121

Abstracting

Back 121

Process of extracting elements from data and entering them into an automated system available for later use

Front 122

Hybrid records

Back 122

Affect productivity and workflow

Front 123

Essential for integrity of data collected

Back 123

Well-trained coding staff ensure complete and accurate coding. All coders in the facility should receive continuing education.

Front 124

Precise coding

Back 124

Helps ensure compliance with regulatory requirements and helps facilitate consistency of coding. Coding staff consider Continuing Education and Training as an enhancement to their jobs. Organizations that provide continuing education take additional steps in retaining qualified coding staff.

Front 125

Query program types

Back 125

Concurrent, retrospective, post bill, or combination

Front 126

Concurrent

Back 126

Initiated while patient is still present

Front 127

Retrospective

Back 127

Initiated after discharge and before bill is submitted

Front 128

Post bill

Back 128

Initiated after Bill has been submitted

Front 129

Cooperating parties

Back 129

Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the... and any other official coding rules and guidelines established for use with mandated standard code sets

Front 130

POA

Back 130

Present on admission

Front 131

POA vs. undocumented upon admission

Back 131

Conditions that developed during the admission are hospital-acquired

Front 132

Principal diagnosis

Back 132

The first step in an inpatient record review is to verify the correct assignment. When several diagnosis is meet those requirements any of them could be selected as the principal diagnosis

Front 133

Quantitative analysis or record content review

Back 133

Usually referred to as a concurrent review because the review occurs concurrently with the patients stay in the hospital conduct review on a continuing basis

Front 134

Root operation division

Back 134

Cutting into a body part without drawing fluids and or gases from the body part in order to separate or transact a body part

Front 135

Toxins in the blood

Back 135

Sepsis generally refers to a systemic disease associated with the presence of pathological microorganisms which can include bacteria viruses fungi or other organisms such as this

Front 136

Only the diverticulitis of the colon is coded

Back 136

Because abdominal pain is a symptom

Front 137

HCPCS

Back 137

Health Care procedures supplies products and services

Hint 137

A collection of codes and descriptors used to represent

Front 138

Abdominal pain

Back 138

Is a symptom of gastroenteritis

Front 139

Previous condition

Back 139

One that has resolved before being admitted to the hospital would be considered

Front 140

Excludes 1

Back 140

Indicate that the conditions listed cannot ever be used at the same time as the code above

Front 141

Average relative weight

Back 141

The case mix index is best of all cases treated at a given facility or by a given position which reflects the resource intensity or clinical severity of a specific group in relation to other groups in the classification system. The calculation for this data is 33.0785/30 = 1.1026

Hint 141

Sayles 2013, 499

Front 142

Including margins

Back 142

The total size of the excised area and this is needed for accurate coding. Usually provided in the operative report.

Front 143

Taking margins

Back 143

During surgery, physicians may take some normal looking skin around the growth. Removal of the normal looking skin is known as this.

Front 144

Secondary site code is assigned first

Back 144

A patient may have a history of primary site malignancy but later develop secondary neoplasm or metastatic site at another location. When this occurs the treatment is likely to be directed towards the secondary site. The secondary site code is a signed first then use the category Z85 as an additional diagnosis code

Front 145

Status code T

Back 145

APC payment is subject to payment reduction when multiple procedures are performed during the same visit

Front 146

Geometric mean LOS

Back 146

Defined as the total days of service, excluding any outliers or transfers, divided by the total number of patients.

Front 147

GPCI

Back 147

Geographic practice cost index

Front 148

Geographic practice cost index

Back 148

The number used to multiply each RVU so that it better reflects a geographical areas relative costs

Front 149

PPS, prospective payment system

Back 149

In 1983, CMS implemented this for inpatient care provided to Medicare beneficiaries. The methodology is called Medicare severity diagnosis Related Groups.

Front 150

To determine the appropriate ms-drg

Back 150

A claim for healthcare and counter is first classified into one of twenty five major diagnostic categories or MDC. The principal diagnosis determine the MDC assignment

Hint 150

Sayles 2013, 266-267

Front 151

Inpatient hospitals

Back 151

Were required to submit POA information on diagnosis for inpatient medicare discharges on or after October 1 2007

Hint 151

Sayles 2013, 270

Front 152

72-hour window

Back 152

Medicare patients both outpatient and inpatient need to be reviewed to ensure complete and accurate coding and ms-drg assignment

Front 153

Data quality improvement program goals

Back 153

To establish ongoing monitor for identifying problems or developing opportunities to improve the quality of coded data

Front 154

Data quality improvement program goals #2

Back 154

Proactively identify variations in coding practice among staff members, determine the cause and scope of identify problems, set priorities for resolving identify problems, Implement mechanisms to address and resolve issues identified, and share corrective action for problems.

Front 155

Data quality improvement program goals # 3

Back 155

Implement a program to achieve compliance and also meet the needs of the organization

Front 156

Removal by either snow or hot biopsy forceps

Back 156

It is never appropriate for the coder to assume that the removal was done by either

Front 157

Designate malignancy as the principal diagnosis

Back 157

If the treatment is directed at the malignancy unless a patient is admitted for the purpose of radiotherapy, immunotherapy, or chemotherapy

Front 158

HCPCS LEVEL II

Back 158

For use in reporting Health Services not covered in CPT. Such as injectable drugs, ambulance services, prosthetic devices, has selected providers services.

Front 159

Severity adjustment component

Back 159

In fiscal year 2008 CMS developed the ms-drg system to add a severity adjustment component

Hint 159

Casto and Forrestal 2013, 128

Front 160

E/M codes

Back 160

Hospitals have been able to develop their own criteria for assigning these codes that determine the level of visit

Front 161

APC follow

Back 161

The CPT coding rules set forth by the AMA

Front 162

Three components of the total RVU

Back 162

Physician work, practice expense, malpractice expenses

Front 163

Outcomes and assessment information set

Back 163

OASIS-C, data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement improvement

Front 164

A policy

Back 164

Statement that describes General guidelines that directed Behavior or direct and constrained decision-making in the organization

Hint 164

Sayles 2013, 407

Front 165

Three fraud risk areas

Back 165

Coding and billing, documentation, medical necessity for tests and procedures.