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2.
A 42-year-old female, who is a new patient, presents with foul-smelling urine, frequency, flank pain and fever for 4 days. Patient denies nausea and headache. Patient is not sexually active and is a non-smoker. The provider performs the following exam in addition to patient's height, weight and blood pressure check: General: Well-developed, well nourished, in no acute distress Ears: external ears normal, TM bilaterally intact Neck: Supple, no thyromegaly Extremities: No edema Cardiovascular: RRR, no bruits Lungs: Clear to auscultation The patient is prescribed ciprofloxacin and given a diagnosis of acute cystitis without hematuria. The correct coding for this encounter, using 1997 E/M guidelines is:
a. 99202, N30.00
b. 99203, N30.00, R30.0
c. 99202, N39.0
d. 99203, N39.0, R30.0
1997 E/M guidelines state that the provider must reach 12 bullet points for a detailed level of exam. Although the patient's chart has a detailed history and moderate medical decision making, the provider only reached 11 bullet points, making this level a 99202. N39.0 is not the most specific code for this chart.
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7.
A patient comes into the office with white fuzzy patches on their tongue and is diagnosed with oral hairy leukoplakia. The provider runs a test for HIV and notates that the patient has HIV in the chart, but does not have a positive lab test yet. The patient is a smoker. What is the correct sequencing of these ICD-10 codes?
a. B20, K13.3, F17.200
b. K13.3, R75, Z87.891
c. B20, K13.3, Z87.891
d. K13.3, Z21, F17.200
According to chapter guidelines, if a patient is seen for an HIV-related condition, (which oral hairy leukoplakia is), then B20 is coded first, then the complications. Only the provider's statement is needed that the patient has HIV, not a positive lab test. F17.200 is to be assigned when the provider documents "smoker", but gives no further clarification (AHA: 2016, 1Q, 36)
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11.
The Breach Notification Rule, found in the ______ Rule of HIPAA, states that when _____ individuals have had their confidential data exposed and the covered entity has outdated contact information for them, that the covered entity must_____ for ______ days.
a. Security Rule, less than 200 individuals but more than 5, post a notice in the newspaper for 180 days
b. Omnibus Rule, less than 500 individuals but more than 10, post a notice on their website for 90 days
c. Security Rule, 500 or more individuals, post a notice on their website and create a radio ad for 60 days
d. Privacy Rule, 5 or more individuals, post a notice on their website, in the lobby and send postcards with information at least 3 times over 90 days.
The Omnibus Rule established HITECH and the AARA of 2009 and finalized the Breach Notification Rule, mandating that covered entities who have more than 10 individuals with outdated contact information involved in a data breach must be notified by posting a notice on their website or creating a local ad in the newspaper. For breaches over 500 individuals, major news outlets must be contacted and the Secretary of HHS immediately.
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21.
These components create a patient's history:
a. Reason for Visit, History of Present Illness, Review of Symptoms, Prior History
b. Chief Complaint, History of Present Illness, Review of Systems, Past Family and Social History
c. Chronic conditions, History of Present Illness, Review of Symptoms, Reason for Visit, Surgical history
d. Chief Complaint, History of Present Illness, Review of Symptoms, Past Family and Social History
CC, HPI, ROS and PFSH are the components of a patient history. ROS is performed to make sure the provider did not miss any relevant complaints and can be pulled from the HPI if needed.
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30.
Which of the following is an example of a compliant query to a physician:
a. 06/30: Dr. Brown, can you add documentation for the procedure you did on for Mrs. Parks 5/22? We've billed it out but I'm worried that there isn't enough documentation to support it. We know you did the procedure, but just need a little something extra!
b. 6/30: Dr. Brown, can you clarify in the patient's chart Mrs. Cramb's diagnosis for 6/27 given the positive rapid strep test that was uploaded?
c. 6/30 Dr. Pepper, can you add acute sinusitis (if that's what he had!) to Mr. Meltzer's record--all we have is nasal congestion, headache and malaise and I see you prescribed him antibiotics. Thanks!
d. 6/30 Dr. Pepper, I see that you gave Mr. Evans a diagnosis of unspecified loss of kidney function, but we would get paid a bit more if it were Chronic Kidney Disease, would that be an appropriate diagnosis to code for this patient?
Physician queries must be non-leading, not based on reimbursement, for the purpose of improving patient care and open-ended, or Yes/No questions. Providers must not add documentation solely for the purpose of being reimbursed and it must be within a reasonable time frame.
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