A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 2.docx

A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 2: DOCUMENTATION AND CODING REVIEW MATCHING Directions: Select the word or phrase that best completes each sentence. QUESTIONS ANSWERS Information collected from the patient or other historian. E Procedure that was performed for the definitive treatment of the main condition or complication of the condition. Q Established orders to direct procedures to follow for a particular diagnosis or procedure. C Patient stated subjective information regarding the current present illness. T The process of ensuring medical necessity is met for patients receiving care in the appropriate healthcare setting. A Condition that existed at admission and is thought to increase the length of stay at least one day for approximately 75% of patients. R Personal identifying information documented in the healthcare record. K The physician’s assessment of the patient’s current health status. N A chronological record of the patient’s condition during an episode of care and/or while received treatment from a provider. D Information documented in the healthcare record describing the patient’s condition and course of treatment. S The routine examination of sample fluids and substances such as blood, urine, spinal fluid, sputum, and other substances collected from patients. P Formal process to ensure appropriate level of service is performed in an efficient and cost-effective manner in the appropriate setting based on the patient’s physical needs and quality of life. F Secondary condition that arises during hospitalization and is thought to increase the length of stay by at least 1 day in approximately 75% of patients. G Subjective description of immediate family members illnesses and/or diseases. L The advice of another physician or physicians regarding a patient’s diagnosis or therapeutic options. O Subjective description of other symptoms or illnesses pertaining to individual body systems. B Subjective description of personal health habits and social status. M Condition established, after study, to have been the main reason for the patient’s admission for inpatient treatment. J Patient-provided subjective description of the events or reason why the patient sought out medical treatment. H Subjective description of childhood and adult illnesses and medical conditions. I CHOICES: Utilization management Review of systems Standing orders Progress note Subjective information Medical necessity Complication Chief complaint Past medical history Principal diagnosis Administrative documentation Family medical history Social and personal history Objective documentation Consultation Laboratory report Principal procedure Comorbidity Clinical documentation Present illness MULTIPLE CHOICE Directions: Select the word or phrase that best completes each sentence or best answers the question. QUESTION ANSWER Which of the following is a primary source document for coders? Progress note Operative report Physician order Consultation report B Which document is the main source document for the principal diagnosis, secondary diagnoses, and principal procedure? Discharge summary Face sheet Procedure report Progress note A Which of the following data elements is part of administrative documentation? Date of birth Cytology report Current condition Past procedures A The admission form is also known as the: demographic sheet. face sheet. financial profile. consent form. B Information provided by the patient to the healthcare provider should be documented with: ICD-10-CM codes. physician clinical terms. the patient’s own words. formal nomenclature. C Which of the following is a confirmatory document for coders? HPI Physical examination Discharge summary Physical therapy report D Which of the following is a comorbidity? Ventilator-associated pneumonia Controlled Type II diabetes mellitus Hypertension Fall from the hospital bed C Smoking, drinking, or drug abuse are part of the patient’s ______ history. family medical social past C The _____ is a primary source document from which current signs, symptoms, previous medical history, personal history, and family history is gathered. history of present illness physical examination discharge summary diagnostic report A A physical examination of the ______ typically includes temperature, turgor, vascularity, color, edema, and lesions. throat vital signs sinuses skin D _____ orders may address specifically artificial breathing or cardiopulmonary resuscitation and extend to pain control and nutrition. Restraint DNR Standing Discharge B All information regarding diagnoses in the consultation reports should be correlated with the _______ in the acute care setting. chief complaint therapeutic reports progress notes discharge summary D What should coders do when they see an order for an antibiotic? Assign a code for long-term use of antibiotics. Assign a code for unknown infectious disease. Review the record to identify the type of infection. Query the physician regarding why the antibiotic was ordered. C Which of the following is a complication? Congestive heart failure Metastatic colon cancer Dependence on a ventilator due to quadriplegia Urinary tract infection after a Foley catheter is inserted D Diagnosis documentation on the face sheet may be utilized as the: admit diagnosis. principal diagnosis. discharge diagnosis. primary diagnosis. A A routine order to start physical therapy treatment on day two after a myocardial infarction by sitting up at bedside is an example of _____ orders. passive standing admitting discharge B Which of the following is an example of a consultation? The patient seeks a second surgical opinion because he/she is unsure about the need for a coronary bypass. The attending physician discusses discharge plans with a patient. The primary care physician requests that a cardiologist examine a patient due to complaints of chest pain. The primary care physician sees a patient for follow-up on laboratory tests. C Which form of imaging has little to no risk of complications? Real-time imaging Chest x-ray Nuclear medicine Guided surgical procedure B The statement “fibrous material of the breast tissue” would likely be found in the _____ report. imaging pathology consultation laboratory B The patient’s principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures and disposition of the patient are documented in the _______. face sheet clinical information abstract summary discharge summary D Medication to prevent the patient from movement or doing harm to self or others is an example of a _______ order. discharge standing seclusion restraint D Patient’s reason for seeking care from the physician is found under which component of a SOAP note? S O A P A Which of the following does NOT require the patient to sign a consent form? Immunization Medication prescription Notice of privacy practices Operative procedure B The first “solid” place to find physician information regarding the diagnosis or diagnoses and/or treatment planned for the patient during this episode of care is the _____. face sheet chief complaint physical examination history of present illness C The immunization record is typically found in what setting? Acute inpatient Physician office Emergency department Same-day surgery B A summary of all medical diagnoses and issues, along with surgical history, which are watched or managed long term by the physician, is found in the ______. patient history questionnaire HPI discharge summary problem list D What type of report describes microscopic and macroscopic examination of a specimen or foreign body? Laboratory report Imaging report Operative report Pathology report D Which of the following data elements is typically NOT found in an operative report? Description of specimens removed Procedure definition Physical examination findings Estimated blood loss C The physician’s diagnosis and impression regarding current episode of care is found under which component of a SOAP note? S O A P C Which of the following is NOT a subjective medical history question? What is your date of birth? What prescription medications are you currently taking? What were you doing when the problem was first experienced? What over-the-counter medications are you currently taking? A Which of the following can be coded directly from report results? Liver panel showing elevated liver enzymes Culture showing streptococcus infection MRI showing presence of a tumor Chest x-ray showing pneumonia B Financial data is collected on the: insurance form. patient history questionnaire. HPI. face sheet. D Comorbidities and complications are conditions that are thought to increase the length of stay at least _____ day(s) for 75% of patients. 1 2 5 7 A A physical examination of the ______ typically includes trill, rhythm, friction, and apical impulse. heart lungs abdomen neurological system A A ______ is a secondary condition that arises during hospitalization. comorbidity secondary diagnosis complication chronicity C “If it isn’t _____, it wasn’t done.” medically necessary documented coded diagnosed B The patient’s means of arrival is typically found in _____ documentation. physician office acute inpatient emergency department same-day surgery C An acute care facility may utilize ________ to look at coordination of services provided to the patient. progress notes discharge summary consultation reports laboratory reports A COP refers to: clinic outpatient. conditions of participation. coding by provider. consultation of patient. B Documentation in same-day surgery settings resembles that of the _____. acute inpatient hospital physician office operative report emergency department A