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CCS-P Exam Review 2022 – COMPLETE SOLUTION 294 Questions with 100% CORRECT ANSWERS

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CCS-P Exam Review 2022 – COMPLETE SOLUTION 294 Questions with 100% CORRECT ANSWERS For continuity of care, ambulatory care providers are more likely than providers of ACS to rely on the documenta... tion found in the - ✔✔Problem list (PCPs, pharmacy consultations and transfer summaries 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 - ✔✔Bladder All of the following are examples of direct transmission of a disease EXCEPT - ✔✔contaminated foods Cancer derived from epithelial tissue is classified as a - ✔✔Carcinoma Full-blown AIDS sets in as - ✔✔helper T-cell concentration decreasesWhich of the following anatomical parts is involved in both the respiratory and digestive systems - ✔✔Phyranx The most fatal type of lung cancer is - ✔✔small cell cancer Diastole occurs when - ✔✔the ventricles fill Gas exchange in the lungs takes place at the - ✔✔alveoli A key diagnostic finding for typical pneumonia is - ✔✔lung consolidation x-ray John Palmer was in a car accident and sustained severe chest trauma resulting in a tension pneumothorax. Manifestations of this disorder include all of the following EXCEPT - ✔✔clubbing In order to determine which information should be considered confidential, a health information manager should consider and answer yes to all the following questions EXCEPT: - ✔✔Is there a need for all health care providers to access the patient information? The medical record is generally accepted as being the property of the - ✔✔institution With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory? - ✔✔utilization review The hospital has a policy that states, "Original medical records may be removed from the Medical Record Department jurisdiction only by court order." Which situation would be a violation of the policy? - ✔✔The physician has been sued and wants to study the original record at home prior to his deposition. Which of the following established legal liability for hospitals in 1965? - ✔✔Darling v. Charleston Community Memorial HospitalThe process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality is referred to as - ✔✔benchmarking Upon retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing? - ✔✔qualitative review qualitative review - ✔✔Quantitative analysis involves checking for the presence or absence of necessary reports or signatures while qualitative analysis may involve checking documentation consistency, such as comparing a patient's pharmacy drug profile with the medication administration record. To comply with ORYX, a nursing home administrator would need to - ✔✔collect performance measure data that apply to the residents HIM professionals are bound to protect the confidentiality of patient information under the - ✔✔AHIMA's Code of Ethics HEDIS gathers data in the following area: - ✔✔measures of quality (e.g. cholesterol screenings) HEDIS - ✔✔The Health Plan Employer Data and Information Set (HEDIS) is a standardized set of performance measures designed to allow purchasers and consumers to compare the performance of managed care plans. HEDIS defines 3 methods of data collection. The ownership of the information contained in the physical medical/health record is considered to belong to the - ✔✔patientThe effective coordination of utilization review, quality assessment functions, and risk management activities can help eliminate - ✔✔duplicate record review. The premise that charitable institutions could be held blameless for their negligent acts is known as - ✔✔doctrine of charitable immunity A health care organization's compliance plans should not only focus on regulatory compliance, but also have a - ✔✔coding compliance program that prevents fraudulent coding and billing Most health care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay. - ✔✔severity of illness/intensity of service criteria (SI/IS) IS/SI - ✔✔Definition: Evaluation of need before admission and for continued stay use criteria that are performed are referred to as Intensity of service/severity of illness criteria (IS/SI criteria) reviews. Utilization management uses IS/SI to effectively control resource utilization. HEDIS is Health Plan Employer Data and Information Set. Which of the following is a hereditary disease of the cerebral cortex? - ✔✔Lou Gehrig Disease The cause of aplastic anemia is - ✔✔bone marrow failure Which one of the following cells produce antibodies - ✔✔plasma cells Penicillin is effective in the treatment of all of the following diseases EXCEPT - ✔✔Lordosis Which of the following autoimmune diseases affects tissues of the nervous system? - ✔✔myasthenia gravisDr. Zambrano ordered a CEA test for Mr. Logan. Dr. Zambrano may be considering a diagnosis of: - ✔✔Cancer Impetigo can - ✔✔be caused by Streptococcus Each of the following pertains to COPD EXCEPT - ✔✔pneumonia Which of the following is a lethal arrhythmia? - ✔✔ventricular fibrillation Portal hypertension can contribute to all of the following EXCEPT - ✔✔kidney failure The causative organism for Severe Acute Respiratory Syndrome (SARS) is a - ✔✔coronavirus Before leaving the hospital, all newborns are screened for an autosomal recessive genetic disorder of defective enzymatic conversion in protein metabolism. With early detection and a protein-restricted diet, brain damage is prevented. This disease is - ✔✔phenylketonuria A serum potassium level of 2.8 would indicate - ✔✔diabetic ketoacidosis The first stage of alcoholic liver disease is - ✔✔Fatty liver The patient's pathology report revealed the presence of Reed-Sternberg cells. This is indicative of - ✔✔Hodgkin's disease Ulcerations of the small intestine are characteristic of - ✔✔Crohn disease The most common rickettsial disease in the US is - ✔✔Rocky Mountain spotted feverCommon kidney stone treatments that allow small particles to be flushed out of the body through the urinary system include all of the following EXCEPT - ✔✔ureteroscopy and stone basketing Which of the following is an effect of insulin? - ✔✔increases glucose metabolism In general, excessive RBC breakdown could result in - ✔✔high bilirubin levels Most of the digestion of food and absorption of nutrients occurs in the - ✔✔Small intestine Mary Mulholland has diabetes. Her physician has told her about some factors that put her more at risk for infections. Which of the following factors would probably NOT be applicable? - ✔✔Increased blood supply Which of the following is a risk factor involved in the etiology of gall stones - ✔✔being overweight The Correct Coding Initiative (CCI) edits contain a listing of codes under two columns titled, "comprehensive codes" and "component codes". According to the CCI edits when a provider bills Medicare for a procedure that appears in both columns for the same beneficiary on the same date of service - ✔✔code only the comprehensive code The hospital outpatient prospective payment system for Medicare applies to all of the following, EXCEPT, for - ✔✔professional services, such as physician fees If a physician is a non-participating physician who does not accept assignment, he may collect a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount. - ✔✔Physician can balance bill and collect from the patient the difference between the nonPAR Medicare fee schedule amount and the total charge amount. Therefore, the patient's financial liability is $38.00 + 28.50 =$66.50.If a physician is a non-participating physician who does not accept assignment; he may collect a maximum of 15% (the limiting charge) over the nonPAR Medicare fee schedule amount. - ✔✔In this case, the nonPAR Medicare fee schedule amount is $190.00 and 15% over this amount is $28.50; therefore, the total that he can collect is $218.50. Under the outpatient prospective payment system (OPPS), status indicator "___" is a payment indicator that refers to "significant procedures for which the multiple procedure reduction applies". This means that the reported CPT and/or HCPCS Level II code will be paid a discounted APC reimbursement rate when reported with other procedures on the same claim. - ✔✔"S" According to the Federal Register, the definition of a "new" patient when assigning a CPT Evaluation and Management (medical visit) code to a Medicare hospital outpatient under the prospective payment system is a patient that has - ✔✔not already been assigned a medical record number The definition of "new patient" in the CPT Code Book is - ✔✔"one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years". This definition is used by physicians. What is the definition used by hospitals for a "New patient" under the outpatient prospective payment system (APCs). - ✔✔In the April 7, 2000 Federal Register (page 18451) CMS defined "new patient as "one who does not already have a medical record number". The _________________ refers to a statement sent to the patient to clarify which services were provided, amount billed and amount of payments made by the health plan. - ✔✔medicare su [Show More]

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