HIM 478 RHIA REVIEW QUESTIONS CHAPTER 9 Flashcards
A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator is.
A. N = not present at the time of inpatient admission.
B. W = provider is unable to clinically determine if condition was present at the time of admission.
C. Y = present at the time of inpatient admission.
D. U = documentation is insufficient to determine if condition was present at the time of admission.
Y = present at the time of inpatient admission.
The nursing initial assessment upon admission documents the presence of a decubitus ulcer. There is no mention of the decubitus ulcer in the physician documentation until several days after admission. The present on admission (POA) indicator is
A. Y = present at the time of inpatient admission.
B. W = provider is unable to clinically determine if condition was present at the time of admission.
C. N = not present at the time of inpatient admission.
D. U = documentation is insufficient to determine if condition was present at the time of admission.
U = documentation is insufficient to determine if condition was present at the time of admission.
This document is published by the Office of Inspector General (OIG) every year. It details the OIG’s focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS’s website.
A. the OIG’s Evaluation and Management Documentation Guidelines
B. the OIG’s Model Compliance Plan
C. the Federal Register
D. the OIG’s Work Plan
the OIG’s Work Plan
When a provider bills separately for procedures that are a part of the major procedure, this is called
A. fraud
B. packaging
C. unbundling
D. discounting
unbundling
When health care providers are found guilty under any of the civil false claims statutes, the Office of Inspector General is responsible for negotiating these settlements and the provider is placed under a
A. Recovery Audit Contract
B. Corporate Integrity Agreement
C. Noncompliance Agreement
D. Fraud Prevention Memorandum of Understanding
Corporate Integrity Agreement
A patient is admitted for chronic diastolic congestive heart failure and pneumonia. The patient is placed on IV Lasix and IV antibiotics on admission. Which coding rule applies?
a. Two or more diagnoses that equally meet the criteria for principal diagnosis; either may be sequenced first.
b. Two or more diagnoses that meet the criteria for principal diagnosis; code the sign or symptom first.
c. Two or more diagnoses that equally meet the criteria for principal diagnosis; always choose the higher-paying DRG.
d. Two or more diagnoses that meet the criteria for principal diagnosis, code the diagnosis as “probable.”
Two or more diagnoses that equally meet the criteria for principal diagnosis; either may be sequenced first.
An elderly patient with a history of lung cancer is admitted from the nursing home with ataxia, syncope, and a fractured arm as the result of a fall. The patient undergoes a closed fracture reduction of the humerus in the ED, and a complete work up for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the brain. Which of the following is the principal diagnosis?
A. Ataxia
B. Fracture humerus
C. Metastatic carcinoma of the brain
D. Carcinoma of the lung
Metastatic carcinoma of the brain
As a result of the disparity in documentation practices, queries can be made in which of the following scenarios?
A. To clarify specificity or severity
B. To clarify a cause-and-effect relationship between two conditions
C. To clarify POA assignment
D. Both A and B
E. All the above
All the above
The following query was found in a patient’s health record. Which of the answers best applies to this query? “Dr. Smith—please document acute COPD in a progress note to substantiate the use of oxygen therapy, and steroid treatment.”
A. This is a leading query
B. This query brings in information not documented within the chart and is inappropriate
C. This is a yes/no query
D. This is an appropriate query
This is a leading query
A patient is admitted through the emergency room for shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
A. Acute bronchitis
B. Acute bronchitis with COPD
C. Asthma with status asthmaticus
D. Chronic obstructive asthma
Asthma with status asthmaticus
