1.
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery
suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow
instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased
prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following
instrument removal, a catheter is inserted and left in place. Which of the following code sets will be
reported for this service?
a. 600.20, 53852
b. 600.20, 52601
c. 600.00, 53852
d. 222.2, 53850 - ANSWERCorrect Answer: A
When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical
resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20
(AHIMA 2012a, 697).
2.
The HIPAA Privacy Rule requirement that covered entities must limit use, access, and disclosure of PHI
to the least amount necessary to accomplish the intended purpose. What concept is this an example of?
a. Minimum necessary
b. Notice of Privacy Practice
c. Consent
,d. Authorization - ANSWERCorrect Answer: A
The Privacy Rule introduced the standard of minimum necessary, a "need to know" filter that is applied
to limit access to a patient's protected health information (PHI) and to limit the amount of PHI used,
disclosed, and requested (Brodnik et al. 2009, 176).
3.
An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs
are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in
the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress
syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be
correct?
a. V30.01, 765.03, 765.24
b. 765.03, 769
c. V30.01, 765.03, 765.24, 769
d. V30.01, 769 - ANSWERCorrect Answer: C
The codes for prematurity 765.03 and code 765.24 for weeks of gestation meet reporting guidelines as
additional diagnoses. A birth code of V30.01 is reported as the principal diagnosis (CMS 2010c, Section I,
C, 15b; AHA 2006, 190). See instructional note under 765.0x to "Use Additional Code" for weeks of
gestation. A code is also needed for the respiratory distress syndrome, 769 (AHIMA 2012a, 676)
4.
Which of the following statements about Category III CPT codes is false?
a. They are temporary codes.
,b. They are updated more frequently than the rest of the CPT codes.
c. They are intended to allow for the coding of new technologies, services, and procedures.
d. They are tracking codes that can be used for performance measurement. - ANSWERCorrect Answer: D
Category II CPT codes are used for performance measurement (AMA 2012b, 535).
5.
Which statement fails to be true for Medicare coverage?
a. Medicare pays for healthcare services provided to Social Security beneficiaries 65 years old and older
b. Medicare pays for healthcare services provided to Social Security beneficiaries for new moms 65 years
and younger and their newborn babies
c. Medicare pays for healthcare services provided to Social Security beneficiaries for people under 65
years old with certain disabilities
d. Medicare pays for healthcare services provided to Social Security beneficiaries for people of all ages
with end-stage renal disease - ANSWERCorrect Answer: B
Medicare does not cover moms and newborn babies unless the mother has a disability. Moms and
newborn babies can be covered under the Medicaid program if they meet specific income guidelines
(Johns 2011, 293, 301).
6.
A health information technician has been asked to design a problem list for an electronic health record
(EHR). Which of the following data elements should be included on the problem list?
a. Problem number, problem description, date problem entered
, b. Problem number, problem name, date of consent for treatment
c. Patient identifying information, problem number, examination results
d. Problem name, date of onset, physical exam - ANSWERCorrect Answer: A
The problem list describes any significant current and past illnesses and conditions as well as the
procedures the patient has undergone (Johns 2011, 94).
7.
Identify the CPT procedure code(s) for an automated CBC with automated differential.
a. 85027
b. 85025
c. 85041
d. 85007, 85025 - ANSWERCorrect Answer: B
Index Blood Cell Count, hemogram, added indices, resulting in code range 85025-85027. The codes for
reporting CBCs (complete blood counts) are very specific and should be carefully reviewed. The
appropriate code for a CBC with automated white blood cell differential is 85025 (AHIMA 2012a, 628).
8.
Who is responsible for ensuring the quality of health record documentation?
a. Board of directors
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient surgery
suite. The urologist inserts an endoscope in the penile urethra and dilates the structure to allow
instrument passage. After endoscope placement, a radiofrequency stylet is inserted, and the diseased
prostate is excised with radiant energy. Bleeding is controlled with electrocoagulation. Following
instrument removal, a catheter is inserted and left in place. Which of the following code sets will be
reported for this service?
a. 600.20, 53852
b. 600.20, 52601
c. 600.00, 53852
d. 222.2, 53850 - ANSWERCorrect Answer: A
When thermotherapy is used code 53852 is reported. Code 52601 is reported for electrosurgical
resection; 53850 is reported for radiofrequency. Adenoma of the prostate is reported with 600.20
(AHIMA 2012a, 697).
2.
The HIPAA Privacy Rule requirement that covered entities must limit use, access, and disclosure of PHI
to the least amount necessary to accomplish the intended purpose. What concept is this an example of?
a. Minimum necessary
b. Notice of Privacy Practice
c. Consent
,d. Authorization - ANSWERCorrect Answer: A
The Privacy Rule introduced the standard of minimum necessary, a "need to know" filter that is applied
to limit access to a patient's protected health information (PHI) and to limit the amount of PHI used,
disclosed, and requested (Brodnik et al. 2009, 176).
3.
An infant is born by cesarean section at 27 weeks' gestation. The baby weights 945 g. The baby's lungs
are immature, and the baby develops respiratory distress syndrome, requiring a 25-day hospital stay in
the NICU. Discharge diagnosis: Extreme immaturity, with 27-week gestation, with respiratory distress
syndrome, delivered by cesarean section. Which of the following diagnosis ICD-9-CM codes would be
correct?
a. V30.01, 765.03, 765.24
b. 765.03, 769
c. V30.01, 765.03, 765.24, 769
d. V30.01, 769 - ANSWERCorrect Answer: C
The codes for prematurity 765.03 and code 765.24 for weeks of gestation meet reporting guidelines as
additional diagnoses. A birth code of V30.01 is reported as the principal diagnosis (CMS 2010c, Section I,
C, 15b; AHA 2006, 190). See instructional note under 765.0x to "Use Additional Code" for weeks of
gestation. A code is also needed for the respiratory distress syndrome, 769 (AHIMA 2012a, 676)
4.
Which of the following statements about Category III CPT codes is false?
a. They are temporary codes.
,b. They are updated more frequently than the rest of the CPT codes.
c. They are intended to allow for the coding of new technologies, services, and procedures.
d. They are tracking codes that can be used for performance measurement. - ANSWERCorrect Answer: D
Category II CPT codes are used for performance measurement (AMA 2012b, 535).
5.
Which statement fails to be true for Medicare coverage?
a. Medicare pays for healthcare services provided to Social Security beneficiaries 65 years old and older
b. Medicare pays for healthcare services provided to Social Security beneficiaries for new moms 65 years
and younger and their newborn babies
c. Medicare pays for healthcare services provided to Social Security beneficiaries for people under 65
years old with certain disabilities
d. Medicare pays for healthcare services provided to Social Security beneficiaries for people of all ages
with end-stage renal disease - ANSWERCorrect Answer: B
Medicare does not cover moms and newborn babies unless the mother has a disability. Moms and
newborn babies can be covered under the Medicaid program if they meet specific income guidelines
(Johns 2011, 293, 301).
6.
A health information technician has been asked to design a problem list for an electronic health record
(EHR). Which of the following data elements should be included on the problem list?
a. Problem number, problem description, date problem entered
, b. Problem number, problem name, date of consent for treatment
c. Patient identifying information, problem number, examination results
d. Problem name, date of onset, physical exam - ANSWERCorrect Answer: A
The problem list describes any significant current and past illnesses and conditions as well as the
procedures the patient has undergone (Johns 2011, 94).
7.
Identify the CPT procedure code(s) for an automated CBC with automated differential.
a. 85027
b. 85025
c. 85041
d. 85007, 85025 - ANSWERCorrect Answer: B
Index Blood Cell Count, hemogram, added indices, resulting in code range 85025-85027. The codes for
reporting CBCs (complete blood counts) are very specific and should be carefully reviewed. The
appropriate code for a CBC with automated white blood cell differential is 85025 (AHIMA 2012a, 628).
8.
Who is responsible for ensuring the quality of health record documentation?
a. Board of directors
