AHIMA Exam Questions & Answers
(Grade A+)
explain the process a coder must follow when conflicting
documentation exists -
correct answer ✅patients who are admitted to an inpatient status
in the hospital may be assessed by multiple physicians. inevitably,
the documentation of the various physicians will conflict. for
example, the attending physician may document acute renal failure,
but the nephrology consultant documents acute renal failure., but
the nephrology consultant documents acute renal disease. since
failure and disease in this particular case equate to different codes,
the coder will need clarification, and that clrification is best
achieved through the initiation of a query. the query would need to
reveal the conflicting information and ask for the final decision as to
which diagnosis is correct, other clinical indicators should be a part
of thr query in order to demonstrate to the physician why the
information is conflicting. for example, in this acute renal failure
versus disease scenario, the coder may choose to include the
clinical indicators pertaining to a rise in the bun\creatinine as well
as the urine output amounts.
you are a member of hospitals HIM committee. the committee has
created a HIPAAcompliant authorization form which of the
following items does the privacy rule require for the form? -
correct answer ✅identification of the person oe entity authorized
to receive PHI
,AHIMA Exam Questions & Answers
(Grade A+)
provide examples of a leading query -
correct answer ✅leading provider\physician queries are not
acceptable in healthcare. following are examples of inappropriate
leading queries: a query that providesthe physician with options
that only leadto additional reimbursement. a query that does not
contain all the required clinical indicators to paint the full clinical
picture of the patients condition. a query wherein the statements
are directive in nature, such as indicating what the provider should
document, rather than querying the provider for his\her
professional determination of the clinical facts. a query that leads
the provider to one desired outcome. a query that omits
reasonable clinically supported options. a query that omits an
option that no additional documentation or clarification may be
provided.
explain the 4 major attributes of icd 10 pcs codes -
correct answer ✅the structure of icd 9 cm colume 3 for
procedural coding was not capable of involving into more codes
necessary for keeping up with the explosion of technological
advances in healthcare. it became mandatory in the icd 10 realm
for procedural codes to be designed in such a way as to
accomodate growth long term. the results was icd 10 pcs with
elimination of a third volume. icd 10 pcs was developed with 4
major attributes and their meaning in mind: completeness
(meaning one unique code for each different procedure)
,AHIMA Exam Questions & Answers
(Grade A+)
expandibility (meaning- icd 10 pcs allows for the incorporation of
new procedure codes ) multiaxial (meaning-codes consist of
independent characters with the capability of each retaining
meaning across broad ranges of codes) and standardized
terminology (meaning0=-each term must have a specific meaning)
it is important that coders thoroughly understand the definitions
for all the procedures and the various approaches to operations as
this will be key to correct code assignments.
briefly explain how a mentoring plan for new coders might be
implemented -
correct answer ✅with the advent of icd 10 in Oct 2015, new
coding challenges surfaced. many seasoned or experienced coders
retired, and new coder interest was insufficient. many healthcare
entities have been forced to develop training plans for new coders.
these training plans may include a mentorship. an ideal mentorship
program would be strucutred in the following manner: assign a
mentor ( an experienced coding professional) to 2 new coders. the
mentor will then review 100% of all coded accounts by the new
coders prior to billing. the mentor will provide educational
feedback should always reference applicable medical information
and\or coding clinic references. time should be allotted for the new
coders to review the feedback, hold discussions, and review
multiple training resources. a key component of this training plan is
, AHIMA Exam Questions & Answers
(Grade A+)
open communication, especially if mentors and coders work in
remote environments.
elaborate on this adage " if it isnt documented , it hasnt been done"
-
correct answer ✅the statement has been a longstanding adage
well known to health information professionals. healthcare
provider documentation of diagnoses and treatment rendered is
the key to preventing denials, winning appeals, and preventing
accusations of fraudulent activity by governmental agencies. the
center for medicare and medicaid services points out that clear and
concise health information documentation is critical to the quality
of patient care and is required for payment of services rendered.
documentation is necessary to support the medical necessity of
services and to ensure compliance with regulatory requirements.
healthcare organizations must have policies and procedures in
place to maintain the integrity of the health record.
discuss the intent of a physician query -
correct answer ✅a physician query is a tool of communication
between CDI specialist\ coders and physicians to clarify incomplete,
ambiguous, or conflicting documentation in the medical record. the
intention of the communication tool is to facilitate completeness,
accuracy, consistency, and timely documentation for coding, and
(Grade A+)
explain the process a coder must follow when conflicting
documentation exists -
correct answer ✅patients who are admitted to an inpatient status
in the hospital may be assessed by multiple physicians. inevitably,
the documentation of the various physicians will conflict. for
example, the attending physician may document acute renal failure,
but the nephrology consultant documents acute renal failure., but
the nephrology consultant documents acute renal disease. since
failure and disease in this particular case equate to different codes,
the coder will need clarification, and that clrification is best
achieved through the initiation of a query. the query would need to
reveal the conflicting information and ask for the final decision as to
which diagnosis is correct, other clinical indicators should be a part
of thr query in order to demonstrate to the physician why the
information is conflicting. for example, in this acute renal failure
versus disease scenario, the coder may choose to include the
clinical indicators pertaining to a rise in the bun\creatinine as well
as the urine output amounts.
you are a member of hospitals HIM committee. the committee has
created a HIPAAcompliant authorization form which of the
following items does the privacy rule require for the form? -
correct answer ✅identification of the person oe entity authorized
to receive PHI
,AHIMA Exam Questions & Answers
(Grade A+)
provide examples of a leading query -
correct answer ✅leading provider\physician queries are not
acceptable in healthcare. following are examples of inappropriate
leading queries: a query that providesthe physician with options
that only leadto additional reimbursement. a query that does not
contain all the required clinical indicators to paint the full clinical
picture of the patients condition. a query wherein the statements
are directive in nature, such as indicating what the provider should
document, rather than querying the provider for his\her
professional determination of the clinical facts. a query that leads
the provider to one desired outcome. a query that omits
reasonable clinically supported options. a query that omits an
option that no additional documentation or clarification may be
provided.
explain the 4 major attributes of icd 10 pcs codes -
correct answer ✅the structure of icd 9 cm colume 3 for
procedural coding was not capable of involving into more codes
necessary for keeping up with the explosion of technological
advances in healthcare. it became mandatory in the icd 10 realm
for procedural codes to be designed in such a way as to
accomodate growth long term. the results was icd 10 pcs with
elimination of a third volume. icd 10 pcs was developed with 4
major attributes and their meaning in mind: completeness
(meaning one unique code for each different procedure)
,AHIMA Exam Questions & Answers
(Grade A+)
expandibility (meaning- icd 10 pcs allows for the incorporation of
new procedure codes ) multiaxial (meaning-codes consist of
independent characters with the capability of each retaining
meaning across broad ranges of codes) and standardized
terminology (meaning0=-each term must have a specific meaning)
it is important that coders thoroughly understand the definitions
for all the procedures and the various approaches to operations as
this will be key to correct code assignments.
briefly explain how a mentoring plan for new coders might be
implemented -
correct answer ✅with the advent of icd 10 in Oct 2015, new
coding challenges surfaced. many seasoned or experienced coders
retired, and new coder interest was insufficient. many healthcare
entities have been forced to develop training plans for new coders.
these training plans may include a mentorship. an ideal mentorship
program would be strucutred in the following manner: assign a
mentor ( an experienced coding professional) to 2 new coders. the
mentor will then review 100% of all coded accounts by the new
coders prior to billing. the mentor will provide educational
feedback should always reference applicable medical information
and\or coding clinic references. time should be allotted for the new
coders to review the feedback, hold discussions, and review
multiple training resources. a key component of this training plan is
, AHIMA Exam Questions & Answers
(Grade A+)
open communication, especially if mentors and coders work in
remote environments.
elaborate on this adage " if it isnt documented , it hasnt been done"
-
correct answer ✅the statement has been a longstanding adage
well known to health information professionals. healthcare
provider documentation of diagnoses and treatment rendered is
the key to preventing denials, winning appeals, and preventing
accusations of fraudulent activity by governmental agencies. the
center for medicare and medicaid services points out that clear and
concise health information documentation is critical to the quality
of patient care and is required for payment of services rendered.
documentation is necessary to support the medical necessity of
services and to ensure compliance with regulatory requirements.
healthcare organizations must have policies and procedures in
place to maintain the integrity of the health record.
discuss the intent of a physician query -
correct answer ✅a physician query is a tool of communication
between CDI specialist\ coders and physicians to clarify incomplete,
ambiguous, or conflicting documentation in the medical record. the
intention of the communication tool is to facilitate completeness,
accuracy, consistency, and timely documentation for coding, and
