Medical Coding 1 - Final Exam
A patient record is the business record for a patient encounter that documents
__________. *** health care services provided to a patient
Which type of physician participates in an approved GME program? *** resident
Residents are supervised by a(n) __________ physician during patient care. ***
teaching
The process of standardizing data by assigning alphanumeric values to text or other
information is called __________. *** encoding
Computer-assisted coding uses software to automatically generate __________ by
"reading" transcribed clinical documentation provided by health care practitioners ***
medical codes
Which is an example of a medical nomenclature? *** SNOMED CT
Monthly newsletter published by AMA as an official coding resource. *** CPT Assistant
Medicare regulations (Centers for Medicare and Medicaid Services). *** Conditions of
Participation
Quarterly newsletter published by AHA as an official coding resource. *** Coding Clinic
for HCPCS Level II
Software used by hospitals to help identify CPT/HCPCS coding errors. *** Outpatient
Code Editor
Code edits pairs" that cannot be reported on the same claim for payment *** National
Correct Coding Initiative
Which is an example of a third-party payer? *** BlueCross BlueShield
Reporting multiple CPT codes to increase reimbursement when a combination code
should be reported. *** Unbundling
Reporting codes that are not supported by documentation in the patient record for the
purpose of increasing reimbursement. *** Upcoding
Routinely assigning lower-level CPT codes as a convenience instead of reviewing
documentation and the coding manual to determine the proper code to be reported. ***
Downcoding
, Reporting codes for associated signs and symptoms in addition to an established
diagnosis. *** Overcoding
Routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the
coding manual to select the appropriate code number. *** Jamming
Which is published by the American Psychiatric Association and contains diagnostic
assessment criteria used as tools to identify psychiatric disorders? *** DSM
The CMS-1500 claim is submitted by __________ to third-party payers for processing.
*** physician offices
Which professional is employed by third-party payers to review health-related claims to
determine whether the costs are reasonable and medically necessary based on the
patient's diagnosis? *** insurance specialist
Which organizes a medical nomenclature according to similar conditions, diseases,
procedures, and services, and contains codes for each? *** classification system
Chief complaint, social data, and past medical history are considered part of the
problem-oriented record __________. *** database
Diseases, injuries, impairments, other health-related problems and their manifestations.
*** large code set
Substances, equipment, supplies, or other items. *** Large code set
Race, ethnicity, type of facility, and type of unit. *** small code set
Causes of injury, disease, impairment, or other health-related problems. *** large code
set
Actions related to disease impairment management, prevention, and treatment. ***
large code set
A coder acquires a working knowledge of coding systems, coding conventions and
guidelines, government regulations, and third-party payer requirements to ensure that
documented diagnoses, services, and procedures are coded accurately for
__________, research, and statistical purposes. *** reimbursement
Medical management software is used to _____. *** automate physician office workflow
A coding compliance program ensures that the assignment of codes to diagnoses,
procedures, and services follows established coding guidelines, and health care
organizations write policies and procedures to assist in implementing the coding
A patient record is the business record for a patient encounter that documents
__________. *** health care services provided to a patient
Which type of physician participates in an approved GME program? *** resident
Residents are supervised by a(n) __________ physician during patient care. ***
teaching
The process of standardizing data by assigning alphanumeric values to text or other
information is called __________. *** encoding
Computer-assisted coding uses software to automatically generate __________ by
"reading" transcribed clinical documentation provided by health care practitioners ***
medical codes
Which is an example of a medical nomenclature? *** SNOMED CT
Monthly newsletter published by AMA as an official coding resource. *** CPT Assistant
Medicare regulations (Centers for Medicare and Medicaid Services). *** Conditions of
Participation
Quarterly newsletter published by AHA as an official coding resource. *** Coding Clinic
for HCPCS Level II
Software used by hospitals to help identify CPT/HCPCS coding errors. *** Outpatient
Code Editor
Code edits pairs" that cannot be reported on the same claim for payment *** National
Correct Coding Initiative
Which is an example of a third-party payer? *** BlueCross BlueShield
Reporting multiple CPT codes to increase reimbursement when a combination code
should be reported. *** Unbundling
Reporting codes that are not supported by documentation in the patient record for the
purpose of increasing reimbursement. *** Upcoding
Routinely assigning lower-level CPT codes as a convenience instead of reviewing
documentation and the coding manual to determine the proper code to be reported. ***
Downcoding
, Reporting codes for associated signs and symptoms in addition to an established
diagnosis. *** Overcoding
Routinely assigning an unspecified ICD-10-CM disease code instead of reviewing the
coding manual to select the appropriate code number. *** Jamming
Which is published by the American Psychiatric Association and contains diagnostic
assessment criteria used as tools to identify psychiatric disorders? *** DSM
The CMS-1500 claim is submitted by __________ to third-party payers for processing.
*** physician offices
Which professional is employed by third-party payers to review health-related claims to
determine whether the costs are reasonable and medically necessary based on the
patient's diagnosis? *** insurance specialist
Which organizes a medical nomenclature according to similar conditions, diseases,
procedures, and services, and contains codes for each? *** classification system
Chief complaint, social data, and past medical history are considered part of the
problem-oriented record __________. *** database
Diseases, injuries, impairments, other health-related problems and their manifestations.
*** large code set
Substances, equipment, supplies, or other items. *** Large code set
Race, ethnicity, type of facility, and type of unit. *** small code set
Causes of injury, disease, impairment, or other health-related problems. *** large code
set
Actions related to disease impairment management, prevention, and treatment. ***
large code set
A coder acquires a working knowledge of coding systems, coding conventions and
guidelines, government regulations, and third-party payer requirements to ensure that
documented diagnoses, services, and procedures are coded accurately for
__________, research, and statistical purposes. *** reimbursement
Medical management software is used to _____. *** automate physician office workflow
A coding compliance program ensures that the assignment of codes to diagnoses,
procedures, and services follows established coding guidelines, and health care
organizations write policies and procedures to assist in implementing the coding
