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HEALTHCARE CODING AND DATA ACTUAL EXAM 2025 ||70 QUESTIONS ANSWERED

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If a medical record analyst discovers multiple unsigned orders during a routine audit, what should be their course of action to ensure compliance with healthcare regulations? Flag each record for the physician and document the findings Ignore the unsigned orders if they are not critical Delete the unsigned orders to prevent confusion Contact the patients for their consent 2. According to the Uniform Hospital Discharge Data Set (UHDDS), what is the definition of 'Other Diagnosis'? Conditions that develop during hospitalization Conditions that are treated after discharge All conditions that coexist at the time of admission

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HEALTHCARE CODING AND DATA ACTUAL EXAM 2025
||70 QUESTIONS ANSWERED

1. If a medical record analyst discovers multiple unsigned orders
during a routine audit, what should be their course of action to ensure
compliance with healthcare regulations?
Flag each record for the physician and document the findings
Ignore the unsigned orders if they are not

critical Delete the unsigned orders to prevent

confusion Contact the patients for their

consent

2. According to the Uniform Hospital Discharge Data Set (UHDDS),
what is the definition of 'Other Diagnosis'?
Conditions that develop during

hospitalization Conditions that are treated

after discharge

All conditions that coexist at the time of admission

, Conditions that are unrelated to the primary diagnosis

3. What is the primary purpose of the Uniform Hospital Discharge
Data Set (UHDDS)?
To provide a comprehensive list of all medical procedures
To ensure consistent data reporting for multiple users
To classify healthcare providers by

specialty To track patient satisfaction

scores

4. The Center for Medicaid/Medicare Services (CMS) influences
economics in healthcare by:
establishing reimbursement rates for treatments provided to
beneficiaries

, reimbursing healthcare organizations for meals served
accomodating consumers preference for healthcare

plans auditing patient records for compliance with

codes

5. Explain the significance of the Present on Admission (POA) indicator
in the context of healthcare coding and data management.
It helps in determining the length of hospital stays.
It provides a basis for identifying pre-existing conditions for
accurate coding.
It is used solely for financial reimbursement

purposes. It has no impact on patient care or

treatment plans.

6. Explain the purpose of the International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10-CM) in healthcare
coding.
To classify diseases and procedures for billing

purposes To provide a universal language for

healthcare providers

, To ensure accurate patient health records and data management
All of the above

7. What is one of the primary purposes of the National Correct Coding
Initiatives (NCCI) as developed by the Centers for Medicare and
Medicaid Services (CMS)?
To enhance patient health records
To control improper coding practices
To classify medical procedures
To manage healthcare data repositories

8. How is fee-for-service generally described?

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