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1. Which one of the following requirements is outlined in the guidelines established in HIPAA’s Privacy Rule?
A. Hospital administrators must encrypt data within older data files.
B. Managers must secure medical records immediately following patient admission.
C. Patients must receive notice if their information will be used or disclosed to third parties.
D. Physicians must not disclose patient information to consulting physicians.
2. A tethered health record allows patients to
A. amend the diagnoses listed in the health record.
B. use a secure portal to access their own records.
C. restructure insurance copayments.
D. compare their health records to the records of patients with similar diagnoses.
3. A patient sustains a fracture of the femur while playing football in a nearby park. What ICD-10-CM code would be assigned?
4. Which one of the following structures is part of the male secondary genitalia?
5. What is the full code description for 25515?
A. Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex
B. Open treatment of radial shaft fracture, includes internal fixation, when performed
C. Closed treatment of radial shaft fracture; without manipulation
D. Closed treatment of ulnar shaft fracture; without manipulation
6. Another name for XXY syndrome is
A. Turner’s syndrome.
B. Huntington’s chorea.
C. Cooley’s anemia.
D. Klinefelter syndrome.
7. The hammer-shaped bone in the middle ear is called the
8. Codes beginning with the letter K are related to the _______ system.
9. Which of the following statements is true of the olfactory nerve?
A. It’s located in the mitral valve and helps to circulate blood throughout the heart.
B. It’s found in the nose and allows the senses to detect and distinguish odors.
C. It’s susceptible to erosion due to Peyronie’s disease.
D. It conveys the fluid from lymph glands to other areas of the body.
10. A patient has a Foley catheter inserted prior to a planned surgical procedure. How is this coded?
11. What is the CPT code for simple drainage of a finger abscess?
12. Usually, a comprehensive EHR includes
A. secure standalone cluster controllers for hospitals in rural environments.
B. software, hardware, implementation, and future program upgrades.
C. coaxial cable connections between mainframe servers only.
D. customizable XHRLT processes for ambulatory surgery centers.
13. What ICD-10-CM code would be assigned for a patient with acute tubule-interstitial nephritis?
14. An echocardiogram shows that the wall of a patient’s artery has dilated. The dilation has resulted in a saclike swelling. This swelling is called a/an
C. mesenteric venous thrombosis.
D. benign tumor.
15. What is Medicare Part D?
A. The component of Medicare Part A that covers outpatient surgeries
B. Supplemental coverage for war veterans and their dependents
C. Add-on coverage for dental procedures
D. Add-on coverage for prescription drugs provided through insurance companies approved by Medicare
16. The suffix –stasis means
B. stopping and controlling.
17. The outcome of delivery code should be
A. omitted from the maternal record for stillborn delivery.
B. assigned to the newborn record only.
C. assigned to both the maternal and newborn records.
D. assigned to the maternal record when a delivery occurs.
18. A patient who was involved in a motor vehicle accident is taken to the hospital by ambulance and admitted to the hospital in critical care. The physician sees the patient for 74 minutes in critical care. The physician leaves to attend to other patients in the ICU and the NICU of the same hospital. Five hours later, the physician returns to the patient and continues to treat the patient in critical care for an additional 30 minutes. The patient spends a total of 104 minutes in critical care. What codes are assigned?
A. 99292, 99292, 99293
B. 99291, 99291
C. 99291, 99292
D. 99292, 99293
19. The root word OBSTETR/O means
20. Coders can use the Microsoft Office suite to create spreadsheets in
B. Lotus 1-2-3.
21. A patient undergoes an appendectomy and later returns to the operating room for a related procedure the same day. Which modifier should be assigned to the CPT code?
22. The concept of meaningful use pertains to
A. categorization of patient information.
B. medical office protocol and document organization.
C. resource management in the inpatient setting.
D. electronic health record implementation.
23. The study of disease is called
24. Modifier -23 indicates that
A. a procedure was performed bilaterally.
B. the patient received general anesthesia for a procedure that would ordinarily be performed with local or no anesthesia.
C. a physician reviewed and interpreted a radiology procedure.
D. two surgeons performed a procedure.
25. Releasing genetic information is forbidden under the terms of HIPAA because it may
A. indicate susceptibility to a future illness, without the patient actually being diagnosed with the condition.
B. allow immediate family members to have access to a patient’s medical records.
C. not be successfully transmitted to all health care facilities.
D. require physicians to fulfill contractual obligations for treatments provided in ambulatory surgery centers.
26. Provision of security against a hurt, loss, or damage with specific cash payments is called
B. secured loss.
27. Physicians typically refer to anatomical locations using directional terms, which are often
A. used primarily by chiropractors.
B. used to describe surgical incisions.
C. referenced horizontally.
D. paired in opposites.
28. The code for an ESWL would be found in the
A. Digestive System of CPT.
B. Urinary and Male Genital Systems of CPT.
C. Chemotherapy section of HCPCS.
D. Cardiovascular System of CPT.
29. What code would be assigned for a tube pericardiostomy?
30. HCPCS modifier –E2 indicates that the patient had a surgical procedure performed on the
A. upper left eyelid.
B. upper right eyelid.
C. lower left eyelid.
D. lower right eyelid.
31. Providers that receive reimbursement after health care services have been provided are being compensated under the _______ system.
C. retrospective payment
D. prospective payment
32. What happens when HIPAA rules conflict with state law?
A. The interpretation of HIPAA rules is left to the physician’s discretion.
B. The Supreme Court’s decision becomes final in binding arbitration.
C. Conflicting state rules are overridden by federal law.
D. State laws overrule federal law.
33. The method that physicians use to bill for each service or visit individually rather than on a pre-paid basis is called
A. pre-paid care.
B. managed care.
34. The suffix -sis means
35. A new patient is seen in a clinic for complaints of shortness of breath, fever, difficulty swallowing, runny nose, and cough. The physician performs a detailed history, detailed examination, and medical decision making of low complexity. The physician also obtains a chest x-ray and lab workup. Based on the results of the diagnostic tests, the physician renders a diagnosis of upper respiratory tract infection and lymphadenopathy. What ICD-10 and CPT codes are assigned?
A. 99215, M19.011, R13.10
B. 99203, J06.9, R59.0
C. 99213, R06.82, F10.229
D. 99202, D63.1, J45.909
36. A physician is called to the intensive care unit for a patient with second-degree burns sustained on 55% of his body while cooking in the kitchen where he works. The physician sees the patient in the critical care unit for two hours, leaves the unit, and returns later the same day to provide an additional hour of critical care. What ICD-10-CM and CPT codes would be assigned?
A. L91.8, 99291 × 2, 99292 × 4
B. T31.50, 99291, 99292 × 4
C. Z30.09, 99293, 99294 × 2
D. R53.81, 99291, 99293 × 5
37. A physician who cares for a patient throughout an entire pregnancy, from beginning to end, is providing
A. comprehensive prenatal management.
B. routine global obstetric care.
C. puerperal obstetric care.
D. antenatal global supervision.
38. A patient is seen in the emergency room complaining of abdominal pain in the left lower quadrant. It’s determined that the patient is experiencing inflammation of the pancreas, which is also called
A. pancreaticoduodonal arcade.
39. The covering on the brain and spinal cord in the dorsal cavity is called the
40. The regulations in HIPAA apply to three groups of individual and corporate entities, each involved in electronic medical records transfer. These groups are collectively referred to as
A. health care administrators.
B. protected personnel.
C. provisional health care data collectors.
D. covered entities.
41. The retention period is the amount of time that
A. insurance billing documents must be retained in filing cabinets.
B. medications must be kept in the medical office.
C. records must be kept.
D. HIM employee files must be retained upon termination or resignation.
42. A physician has a meeting with a pharmaceutical sales representative. During the course of the conversation, the physician reveals the diagnosis and past family, medical, and social history of a patient currently being treated with one of the medications that the sales representative is selling. In this situation, the doctor could be sued for
A. invasion of privacy.
B. undue harm and fraud.
43. Epithelial tissue that secretes its products directly into the bloodstream is made of
A. endoplasmic reticulum.
B. endocrine gland cells.
C. extracellular matrix.
D. columnar epithelial cells.
44. A physician obtains cells from the bone marrow cavity using a needle and a syringe. How would this procedure be coded?
45. The vitreous humor can be found in the
46. The study of tissue disease using macroscopic or microscopic analysis is called
47. Placing a catheter into the aorta or directly into an artery or vein is called
A. selective catheter placement.
B. brachiocephalic manipulation.
C. third order placement.
D. nonselective catheter placement.
48. A patient is diagnosed with acne. What ICD-10-CM code would be assigned?
49. Members of the uniformed services, their families and survivors, and retired members and their families qualify for
A. OIG Recovery.
50. A 35-year-old male is brought to the emergency department with memory disturbance after being accidentally exposed to lead paint. What ICD-10-CM codes should be assigned?
A. T42.4X1A, R40.0
B. T23.009A, R23.8
C. T56.0X1A, R41.3
D. T57.0X1A, R10.9
51. Health care practitioners who submit fraudulent bills to increase reimbursement may
A. be listed in the Coding Directory of Fraudulent Billing published annually by the Department of Health and Human Services.
B. be reported to the Office of the Attorney General.
C. be blacklisted according to geographic location.
D. face financial penalties or, in some cases, imprisonment.
52. A patient comes to the ambulatory surgery center for a fusion of the cervical spine. Prior to the beginning of the surgery, the patient suffers an allergic reaction to the anesthesia shortly after it’s administered. Because of this reaction, the surgery is not performed. What code would be assigned as the first-listed diagnosis?
A. The anesthesia administration
B. The allergy code
C. The reason that the surgery was scheduled to be performed
D. The observation code
53. The root word ENTER/O means
54. When coding burns, coders should
A. assign separate codes for each burn site.
B. assign the code for chronic burns.
C. classify all burns as acute burns.
D. assign the code for third-degree burns.
55. Which of the following forms is used to bill outpatient charges?
A. CMS-1500 or UCF-1500.
B. AMA-14 or UCF-1250
C. HCFA-1400 or CMS-1540
D. HCFA-1350 or CMS-650
56. A significant, separately identifiable E/M service performed by the same physician in conjunction with another service performed on the same day would be reported using what modifier?
57. Which of the following modifiers would be assigned for a moribund patient?
58. Taking certain steps to protect PHI from being accidentally released to individuals who don’t need to know the information is called the
A. minimum necessary standard.
B. information provision standard.
C. privacy management statute.
D. health information guardianship guideline.
59. Codes for plastic repair of the perineum are found in which code range?
60. A coder overhears a confidential statement made outside of the court, and then, when called to testify, repeats the statement as being truth. This is an example of
C. a direct quote.
61. A nurse sustains an accidental needle pinprick to the right third finger while administering an injection. If an employee has an occupational exposure, what must happen?
A. An in-service meeting should be held for all employees who may potentially be exposed to the same occupational hazard.
B. The employee should contact the proper authorities.
C. Hospital administrators must maintain the nurse’s medical record for the remainder of her employment plus an additional 30 years.
D. The guidelines for OSHA should be included in the employment file.
62. Another name for third-party contractors who have access to medical information is
A. healthcare vendors.
B. insurance administrators.
C. covered entities.
D. business associates.
63. A patient receives two venous pressure clamps for hemodialysis. What HCPCS Level II code is assigned?
B. A4918 × 2
C. A4751 × 2
64. The anatomical location of the calyx is the
65. A patient comes to the clinic complaining of ongoing headaches. The headaches began one week prior and have persisted ever since. A lumbar spinal tap is performed to pinpoint the source of the patient’s headaches. What CPT and ICD-10-CM codes are assigned?
A. 62270, G74.3
B. 62270, G44.1
C. 62141, G46.8
D. 62272, G46.9
66. A coder assigns a HCPCS Level II code to a patient’s medical record. The code description reads as follows: Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape. Based on this description, which HCPCS Level II code was assigned?
67. To conform to the HIPAA Privacy Rule, which of the following safeguards must be maintained in health care facilities?
A. ICD-7 provisional safeguards
B. Immunization and injection safeguards
C. Reasonable administrative, technical, and physical safeguards
D. Hazardous waste protection safeguards
68. A patient receives a blood glucose monitor. What HCPCS Level II code would be assigned?
69. Alternative dispute resolution (ADR) allows
A. lawyer-to-lawyer mediation during trial recess.
B. mediating disputes with a judge in the presence of the bailiff.
C. resolving medical malpractice suits by submitting pretrial depositions.
D. litigants to resolve disputes prior to or after the start of litigation.
70. A 65-year-old patient is admitted to the hospital for 48 hours to receive treatment from her physician. This patient would be covered under
A. Medicare Part B.
B. Medicare Part A.
C. Medicare Part D.
D. Medicare Part C.
71. Another term for disease evolution is
72. In relation to HIPAA regulations regarding the manner in which information can be disclosed, which of the following statements is true?
A. Protected health information must be disclosed only when the patient is unable to testify in a court proceeding.
B. Protected health information may never be disclosed.
C. Protected health information may be disclosed in a judicial or administrative proceeding if the request is made through an order from a court or administrative tribunal.
D. Protected health information may be disclosed only within a deposition.
73. The gatekeeper concept refers to the operation of
A. ambulatory payment surgery centers.
B. prospective payment organizations.
C. retrospective payment organizations.
D. health maintenance organizations.
74. Which of the following procedures would be performed to treat prostate cancer?
A. Transurethral resection of the prostate (TURP)
75. What diagnosis code would be assigned for a patient diagnosed with Type 2 diabetes mellitus with diabetic nephropathy?
76. Another name for Medicare Advantage is
A. Medicare Part A.
B. Medicare Part C.
C. Medicare Part B.
D. Medicare Part D.
77. The codes for pacemakers and implantable defibrillators would be found in what section of CPT?
78. A patient comes to the emergency room complaining of abdominal pain. She was previously diagnosed with type I diabetes. She also complains of watery eyes, congestion, pressure in the sinuses, and difficulty breathing. Her final diagnoses are right lower quadrant abdominal pain, type I diabetes, acute sinusitis, and asthma. What CPT and ICD-10-CM codes are assigned?
A. 99222, R18.91, E16.9, J01.91, J45.919
B. 99221, R17.41, E17.9, J01.90, J45.909
C. 99223, R14.31, E15.9, J01.90, J45.929
D. 99221, R10.31, E10.9, J01.90, J45.909
79. What is considered to be protected health information (PHI)?
A. Any health information that can identify the individual to whom it refers
B. Records pertaining to ancestry
C. Statistical data compiled for research purposes only
D. Census data
80. In what CPT code range is Surgical Pathology found?
81. The federal law that requires a patient’s written consent prior to disclosure of certain medical information by government agencies is called the
A. Health Care Amendment of 1976.
B. Privacy Act of 1974.
C. Health Information Law of 2002.
D. Medical Consent Act of 1965.
82. Data stored in a health care facility must
A. be organized in accordance with state standards for electronic data interchange.
B. adhere to OIG policies and procedures.
C. conform to the physician’s expectations for data storage.
D. comply with HIPAA rules and must be maintained securely.
83. Under HIPAA, health care facilities must
A. maintain a clean, safe working environment.
B. choose a privacy officer in accordance with HIPAA policies and procedures.
C. keep records of patients who refill prescriptions more than once within a three-month timeframe.
D. follow up with patients who repeatedly miss scheduled appointments for mandatory services.
84. What CPT code would be assigned for a colpocentesis?
85. A patient is prescribed a medication that narrows the blood vessels and raises her blood pressure. The medication is most likely a
86. If patients choose to obtain copies of their medical records, under the terms of HIPAA, providers can
A. complete employee paperwork.
B. charge a reasonable fee for providing copies of those records.
C. reschedule office visits to allow time to update medical records.
D. also fulfill requests for prescription data.
87. According to the CMS National Physician Fee Schedule, what is the conversion factor for basic life support mileage?
88. According to HIPAA, a patient’s information may be released for
A. determining premiums based on a patient’s past medical history.
B. paternity testing.
D. transferring electronic medical records to remote locations.
89. A patient comes to the clinic complaining of fever, diarrhea, nausea, and vomiting. The patient is diagnosed with salmonella meningitis. What ICD-10-CM code would be assigned?
90. Which of the following anatomical locations would contain the diaphysis?
91. A patient comes to the clinic complaining of nausea, vomiting, fever, dizziness, and intermittent confusion. The physician conducts a detailed history and examination and reviews the patient’s lab results. The patient is diagnosed with pyelonephritis and is scheduled for an ultrasound to review the state of the kidneys and other organs. What CPT and ICD-10-CM codes are assigned?
A. 76775-TC, N15
B. 71010-26, B12
C. 76775-26, N10