CCS-P Exam Review Questions 2022 COMPLETE SOLUTION

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For continuity of care, ambulatory care providers are more likely than providers of ACS to rely on the documentation found in the - ✔✔Problem list (PCPs, pharmacy consultations and transfer summ... aries are likely to be found on the records of longterm care patients). All of the following organizations make up the Cooperating Parties for the approval of ICD-9-CM coding guidelines EXCEPT: - ✔✔Americal Medical Association Define Status asthmaticus - ✔✔An acute asthmatic attack in which the degree of bronchial obstruction is not relieved by usual treatments such as pinephrine or aminophylline. Only a physician can diagnose status asthmaticus. If te coder suspects the condition based on the symptoms in the record, the coder should query the physician. A data element you would expect to be collected in the MDS but NOT in the UHDDS would be: - ✔✔Level of cognition Heart system transplant - ✔✔Is coded with Category III code because no Category I code is available. The physician has ordered potassium replacement for the patient for a diagnosis of: - ✔✔Hypokalemia (decreased levels of potassium in the blood) When the CPT index and tabular do not contain a code that descrbies an adequately documented procedure that was performed by the physician, what action should the coder take? - ✔✔Assign the nlisted cde from the orresponding anatomical section One essential item to be captured on the physical exam is the: - ✔✔Objective survey of body systems (Performed during the PE. This adds objective data to the subjective data provided by the patient. The exam includes all body systems).Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff? - ✔✔Physician index Accreditation by Joint Commission is a voluntary activity for a facility and it is - ✔✔required for reimbursement of certain patient groups Joint commission standards require that a complete history and physical be documented on the health records of operative patients. Does this report carry a time requirement? - ✔✔Yes, prior to surgery What would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? - ✔✔Disease index (contains abstracting patient code numbers into a computer database, allowing a variety of reports to be generated) The lack of a discharge order may indcate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave: - ✔✔Documented in both the progress notes and the discharge summary. When is an Incident report written? - ✔✔When there is an account of an unusual event that has an adverse effect on a patient, employee, or facility visitor and it should never be filed with the patient's record. The foundation for communicating all patient care goals in long-term care settings is the - ✔✔Interdisciplinary patient care plan COP requires a consultation report when - ✔✔1. Patients that are not a good surgical risk. 2. Those with obscure diagnoses. 3. If a physician has doubts as to the best therapeutic measure to be taken. 4. If there is a question of criminal activity.One distinct advantage of the EHR over paper-based health records is the - ✔✔accessibility of the record by multiple data users. Problem list - ✔✔Is a distinct compenent of the problem-oriented record that serves to help index documentation throughout the record. A POMR contains what? - ✔✔1. H&P 2. Problem list (titles, #'s, dates) 3. Initial plan (diagnostic, therapeutic, pt ed plans) 4. Progress notes All of which is summarized in a discharge summary or transfer note at the end of the stay. R-ADT system contains - ✔✔Info re patients who are transferred to the oncology unit (or other specialty unit). R-ADT - ✔✔Registration-admission, discharge, and transfer system What is the best resource for checking out specific accreditation standards and guideleines for a Rehab facility? - ✔✔CARF manual (Commission on Accreditation of Rehab Facilities) A home health agency does a new patient's certification period every - ✔✔60 days (recertification can cont. every 62 days until the pt is discharged from home health services) What is a procedural method for protecting the data of a CPR? - ✔✔Having confidentiality statement signed by all staff utilizing the computer-based patient record. What is a technical method of protecting computerized data? - ✔✔1. Limiting access of certain screens 2. Auditing capability to track data access 3. Using computer backup systemsWhen is it appropriate to substitute a final progress note for a discharge sumary? - ✔✔When a pt is hospitalized less than 48 hours with problems of a minor nature, normal newborns, and uncomplicated obstetrical deliveries. Regional health information organization - ✔✔Are intended to support health information exchange within a geographic region Medical staff rules and regulations - ✔✔Spells out the documentation requirements for patient records; designates the time frame for completion by he active medical staff; and indicates the penalties for failure to comply with record standards. Antepartum record contains - ✔✔A comprehensive history and PE on each OB patient visit with particular attention to menstrual and reproductive history. Biometrics-based identifier - ✔✔Measures a borrower's unique physical characteristics, such as fingerprints or a retinal scan, and compares it to a stored digital template to identify if the person. When can an original health record be physically removed from the hospital? - ✔✔When the director of health records is acting in response to a subpoena duces tecum and takes the health record to court. Most carbon dioxide is carried in the - ✔✔Red blood cells A pathological diagnosis of transitional cell carcinoma is made. The examined tissue was removed from the - [Show More]

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