COLUMN 1
You are responsible for calculating and reporting average length of stay (ALOS) for your hospital each month. This month, there were 92 discharges, and the total discharge days equal 875. One of the patients discharged this month had a total of 428 discharge days, so the ALOS is distorted by this unusually long stay. In this situation, you should report an ALOS of
What is 4.91 days
Continuous quality improvement is best described by
What is corrective action targets clinicians more so than processes?
A system of preferred terminology for naming disease processes is known as a
What is medical nomenclature.
Which is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months?
What is disease index
The PQRS is a reporting system established by the federal government for physician practices who participate in Medicare for quality measure reporting. Beginning in 2017, this program transitioned into
What is MIPS.
A qualitative review of a health record reveals that the history and physical for a patient admitted on June 26 was performed on June 30 and transcribed on July 1. Which of the following statements regarding the history and physical is true in this situation? Completion and charting of the H&P indicates
What is noncompliance with Joint Commission standards.
A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section?
What is office and other outpatient services, established patient
Which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?
What is problem list
Which of the organs listed below has endocrine and exocrine functions?
What is pancreas
Use the following case scenario to answer the question.
A patient with Medicare is seen in the physician's office.The total charge for this office visit is $250.00.The patient has previously paid his deductible under Medicare Part B.The PAR Medicare fee schedule amount for this service is $200.00.The non-PAR Medicare fee schedule amount for this service is $190.00.
If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount the physician will receive is
What is $218.50.
Which of the following is a form or view that is typically seen in the health record of a long-term care patient but is rarely seen in records of acute care patients?
What is pharmacy consultation
When a decubitus ulcer has progressed to a stage in which osteomyelitis is present, the ulcer has extended to the
What is bone.
In ICD-10-PCS, routine insertion of indwelling Foley catheter
Rationale:
Insertion, indwelling Foley catheter
1. Section = 0 (The Surgery Section)
2. Body system = T (Urinary System)
3. Root operation = 9 (Extraction)
4. Body part = B (Bladder)
5. Approach = 7 (Via Natural or Artificial Opening approach)
6. Device = 0 (Drainage device)
7. Qualifier = Z (No Qualifier)
What is 0T9B70Z
Which of the following classification systems was designed with electronic systems in mind and is currently being used for problem lists, ICU monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and images?
What is SNOMED CT
An out-of-town patient presents to a walk-in clinic to have a prescription refilled for a nonsteroidal anti-inflammatory drug. The physician performs a problem-focused history and physical examination with a straightforward decision.
What is 99201
Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets
What is CMS standards.
The ________________________ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider.
What is Medicare Summary Notice
The census taken at midnight on January 1 showed 99 patients remaining in the hospital. On January 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on January 2?
What is 97
An example of a primary data source is the
What is health record.
Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to
What is reducing clinical denials for medical necessity.
After a camping trip in the deep woods during the summer, Arthur was diagnosed with Lyme disease. A while later, as a result of the Lyme disease, he developed meningitis. Report this with:
A69.20Lyme disease, unspecified
A69.21Meningitis due to Lyme disease
G00.8Other bacterial meningitis
G00.9Bacterial meningitis
G01 Meningitis in bacterial diseases classified elsewhere
What is A69.21
Explain the designated record set.
What is a set that contains both medical and billing information.
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes.
I66.9 Occlusion and stenosis of unspecified cerebral artery
K80.10Chronic cholecystitis with chronic cholelithiasis without obstruction
Z53.09 Procedure and treatment not carried out because of other contraindication
I97.821 Postprocedural cerebrovascular infarction during other surgery
0FT40ZZ Resection of gallbladder, open approach (cholecystectomy)
What is I66.9, Z53.09