Solution and Answer Guide: Green, 3-2-1 Code It!

2024, 9780357932209; Chapter 1: Overview of Coding

Solution and Answer Guide

GREEN, 3-2-1 C ODE IT! 2024, 9780357932209; CHAPTER 1: OVERVIEW OF CODING

TABLE OF CONTENTS
Exercises...............................................................................................1
Exercise 1.1: Career as a Coder.............................................................................. 1
Exercise 1.2: Professional Associations...................................................................2
Exercise 1.3: Coding Systems and Processes..........................................................3
Exercise 1.4: Other Classification Systems and Databases.....................................4
Exercise 1.5: Documentation as Basis for Coding...................................................6
Exercise 1.6: Health Data Collection.......................................................................8
Review..................................................................................................9
Multiple Choice........................................................................................................ 9

EXERCISES

EXERCISE 1.1: CAREER AS A CODER

1. A coder is required to have a working knowledge of the CPT, HCPCS Level II, ICD-10-
CM, and __________ coding systems.

Answer: ICD-10-PCS

Analysis: A coder is required to have a working knowledge of the CPT, HCPCS Level II,
ICD-10-CM, and ICD-10-PCS coding systems.

2. The complexity and intensity of procedures performed and services provided during
an outpatient or physician office encounter are captured as part of __________ coding.

Answer: professional

Analysis: The complexity and intensity of procedures performed and services

provided during an outpatient or physician office encounter are captured as part of
professional coding.

3. The intensity of services and severity of illness associated with inpatient care are
captured as part of __________ (or facility) coding.

Answer: institutional

Analysis: The intensity of services and severity of illness associated with inpatient
care are captured as part of institutional (or facility) coding.

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4. When a multi-hospital system provides physician office services along with traditional
inpatient, outpatient, and emergency department hospital care, the concept of
__________ coding is adopted to facilitate professional and institutional billing.

Answer: single-path

Analysis: When a multi-hospital system provides physician office services along with
traditional inpatient, outpatient, and emergency department hospital care, the
concept of single-path coding is adopted to facilitate professional and institutional
billing.

5. A profession that is closely related to that of a coder is a health __________ specialist

(or claims examiner) who reviews health-related claims to determine whether the
costs are reasonable and medically necessary based on the patient’s diagnosis
reported for procedures performed and services provided.

Answer: insurance

Analysis: A profession that is closely related to that of a coder is a health insurance

specialist (or claims examiner) who reviews health-related claims to determine
whether the costs are reasonable and medically necessary based on the patient’s
diagnosis reported for procedures performed and services provided.

EXERCISE 1.2: PROFESSIONAL ASSOCIATIONS

1. Students who become members of __________ association(s) usually pay a reduced
membership fee and receive most of the same benefits as active members.
Answer: professional

Analysis: Students who become members of professional association(s) usually pay a

reduced membership fee and receive most of the same benefits as active members.

2. Attending professional association conferences and meetings provides opportunities

to __________ (or interact) with other professionals, which can facilitate being placed
for internship or job placement.

Answer: network
Analysis: Attending professional association conferences and meetings provides
opportunities to network (or interact) with other professionals, which can facilitate
being placed for internship or job placement.

3. A medical assistant usually joins the American Medical Technologists (AMT) or the
__________.

Answer: American Association of Medical Assistants (AAMA)

Analysis: A medical assistant usually joins the American Medical Technologists (AMT)
or the American Association of Medical Assistants (AAMA).

4. An Internet-based discussion forum that covers a variety of professional topics and

issues is called an online discussion board or __________.

Answer: listserv

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 Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding

Analysis: An Internet-based discussion forum that covers a variety of professional

topics and issues is called an online discussion board or listserv.

5. A coder usually joins either the American Health Information Management

Association (AHIMA) or the __________.

Answer: AAPC

Analysis: A coder usually joins either the American Health Information Management
Association (AHIMA) or the AAPC.

EXERCISE 1.3: CODING SYSTEMS AND PROCESSES

1. A medical nomenclature that is organized according to similar conditions, diseases,
procedures, and services, and contains codes for each is called a __________ (or
classification) system.

Answer: coding

Analysis: A medical nomenclature that is organized according to similar conditions,

diseases, procedures, and services, and contains codes for each is called a coding (or
classification) system.

2. All diseases, injuries, and reasons for an encounter, whether patients are treated as
inpatients or outpatients, are coded using the __________ classification system.

Answer: ICD-10-CM

Analysis: All diseases, injuries, and reasons for an encounter, whether patients are
treated as inpatients or outpatients, are coded using the ICD-10-CM classification
system.

3. Inpatient hospital procedures and services are coded using the __________
classification system.

Answer: ICD-10-PCS

Analysis: Inpatient hospital procedures and services are coded using the ICD-10-PCS
classification system.

4. A public or private entity that processes or facilitates the processing of health

information and claims from a nonstandard to a standard format is called a health
care __________.

Answer: clearinghouse

Analysis: A public or private entity that processes or facilitates the processing of

health information and claims from a nonstandard to a standard format is called a
health care clearinghouse.

5. Routinely assigning lower-level CPT codes for convenience instead of reviewing

patient record documentation and the coding manual to determine the proper code
to be reported is called __________.

Answer: downcoding

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 Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding

Analysis: Routinely assigning lower-level CPT codes as a convenience instead of

reviewing patient record documentation and the coding manual to determine the
proper code to be reported is called downcoding.

6. Reporting codes that are not supported by documentation in the patient record for
the purpose of increasing reimbursement is called __________.

Answer: upcoding

Analysis: Reporting codes that are not supported by documentation in the patient
record for the purpose of increasing reimbursement is called upcoding.

7. Reporting codes for signs and symptoms in addition to the established diagnosis
code is called __________.

Answer: overcoding

Analysis: Reporting codes for signs and symptoms in addition to the established
diagnosis code is called overcoding.

8. Reporting multiple codes to increase reimbursement when a single combination code

should be reported is called __________.

Answer: unbundling

Analysis: Reporting multiple codes to increase reimbursement when a single

combination code should be reported is called unbundling.

9. Coders should always avoid assumption coding, and can do so by generating a

physician __________ when documentation needs clarification prior to the assignment of
codes.

Answer: query

Analysis: Coders should always avoid assumption coding, and can do so by generating a
physician query when documentation needs clarification prior to the assignment of
codes.

10. Software that automatically generates medical codes by analyzing clinical

documentation in the electronic health record or electronic medical record is called
__________.

Answer: computer-assisted coding (CAC)

Analysis: Software that automatically generates medical codes by analyzing clinical

documentation in the electronic health record or electronic medical record is called
computer-assisted coding (CAC).

EXERCISE 1.4: OTHER CLASSIFICATION SYSTEMS AND DATABASES

1. The classification of neoplasms used by cancer registries throughout the world to
record incidence of malignancy and survival rates is called the __________.

Answer: International Classification of Diseases for Oncology, Third Edition (ICD-O-3)

Analysis: The classification of neoplasms used by cancer registries throughout the

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world to record incidence of malignancy and survival rates is called the ICD-O-3. (The
capital letter O in the classification system’s abbreviation refers to Oncology.)

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2. Specific sets of patient characteristics (or case-mix groups) on which payment

determinations are made under several prospective payment systems are represented
by the __________.

Answer: Health Insurance Prospective Payment System (HIPPS)

Analysis: Specific sets of patient characteristics (or case-mix groups) on which

payment determinations are made under several prospective payment systems are
represented by the Health Insurance Prospective Payment System (HIPPS).

3. The set of files and software that allows many health and biomedical vocabularies
and standards to enable interoperability among computer systems is called the
__________.

Answer: Unified Medical Language System (UMLS)

Analysis: The set of files and software that allows many health and biomedical
vocabularies and standards to enable interoperability among computer systems is
called the Unified Medical Language System (UMLS).

4. The coding system that is used to classify dental procedures and services is called
the __________.

Answer: Current Dental Terminology (CDT)

Analysis: The coding system that is used to classify dental procedures and services is
called the Current Dental Terminology (CDT).

5. The system that classifies health and health-related domains to describe body
functions and structures, activities, and participation is called the __________.

Answer: International Classification of Functioning, Disability and Health (ICF)

Analysis: The system that classifies health and health-related domains to describe
body functions and structures, activities, and participation is called the International
Classification of Functioning, Disability and Health (ICF).

6. The system that classifies services not included in the CPT manual to describe the
service, supply, or therapy provided and may also be assigned to report nursing
services and alternative medicine procedures is called __________.

Answer: Alternative Billing Codes (ABC codes)

Analysis: The system that classifies services not included in the CPT manual to
describe the service, supply, or therapy provided and may also be assigned to report
nursing services and alternative medicine procedures is called Alternative Billing
Codes (ABC codes).

7. The nomenclature that provides normalized names for clinical drugs and links its
names to many of the drug vocabularies commonly used in pharmacy management
and drug interaction software is called __________.

Answer: RxNorm

Analysis: The nomenclature that provides normalized names for clinical drugs and
links its names to many of the drug vocabularies commonly used in pharmacy

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 Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding

management and drug interaction software is called RxNorm.

8. An electronic database and universal standard that is used to identify medical

laboratory observations and for the purpose of clinical care and management is
called the __________.

Answer: Logical Observation Identifiers Names and Codes (LOINC)

Analysis: An electronic database and universal standard that is used to identify

medical laboratory observations and for the purpose of clinical care and management
is called the Logical Observation Identifiers Names and Codes (LOINC).

9. The American Psychiatric Association published a standard classification of mental

disorders called the __________-5.

Answer: DSM

Analysis: The American Psychiatric Association published a standard classification of

mental disorders called the DSM-5. DSM means Diagnostic and Statistical Manual of
Mental Disorders, and -5 refers to the fifth edition.

10. The system that provides a new standardized framework and a unique coding
structure for assessing, documenting, and classifying home health and ambulatory
care is called the __________ System.

Answer: Clinical Care Classification (CCC)

Analysis: The system that provides a new standardized framework and a unique
coding structure for assessing, documenting, and classifying home health and
ambulatory care is called the Clinical Care Classification (CCC) System.

EXERCISE 1.5: DOCUMENTATION AS BASIS FOR CODING

1. Continuity of patient care is considered a __________ purpose of the patient record.
a. primary
b. secondary

Answer: a
Analysis:
a. Correct. Continuity of patient care is considered a primary purpose of the
patient, and it involves documenting patient care procedures and services so
that others who treat the patient have a source of information upon which to
base additional care and treatment.
b. Incorrect. Secondary purposes of the record include evaluating the quality of
patient care; providing data for use in clinical research, epidemiology studies,
education, public policy making, facilities planning, and health care statistics;
providing information to third-party payers for reimbursement; and serving
the medicolegal interests of the patient, facility, and providers of care.
Continuity of patient care is a primary purpose of the patient, and it involves
documenting patient care procedures and services so that others who treat
the patient have a source of information upon which to base additional care
and treatment.

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 Solution and Answer Guide: Green, 3-2-1 Code It! 2024, 9780357932209; Chapter 1: Overview of Coding

2. Evaluating quality of patient care is considered a __________ purpose of the patient

record.
a. primary
b. secondary

Answer: b

Analysis:
a. Incorrect. The primary purpose of the patient record is to provide for
continuity of care, which involves documenting patient care services so that
others who treat the patient have a source of information on which to base
additional care and treatment. Evaluating the quality of patient care is
considered a secondary purpose of the patient record. Secondary purposes of
the record include evaluating the quality of patient care; providing data for
use in clinical research, epidemiology studies, education, public policy
making, facilities planning, and health care statistics; providing information to
third-party payers for reimbursement; and serving the medicolegal interests
of the patient, facility, and providers of care.
b. Correct. Evaluating the quality of patient care is considered a secondary
purpose of the patient record. Secondary purposes of the record include
evaluating the quality of patient care; providing data for use in clinical
research, epidemiology studies, education, public policy making, facilities
planning, and health care statistics; providing information to third-party
payers for reimbursement; and serving the medicolegal interests of the
patient, facility, and providers of care.

3. Which is an example of patient demographic data?

a. date of birth
b. discharge diagnosis

Answer: a

Analysis:
a. Correct. The date of birth is an example of patient demographic data.
Demographic data are patient identification information that is collected
according to facility policy.
b. Incorrect. The discharge diagnosis is an example of patient clinical data. The
date of birth is an example of patient demographic data. Demographic data
are patient identification information that is collected according to facility
policy.

4. Medical necessity requires providers to document procedures, services, and supplies

that are proper and needed for the
a. convenience of the physician or health care facility.
b. diagnosis or treatment of a patient’s medical condition.

Answer: b

Analysis:
a. Incorrect. Performing procedures, services, and supplies for the convenience
of the physician or health care facility is not permitted. Medical necessity
requires providers to document procedures, services, and supplies that are

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proper and needed for the diagnosis or treatment of a patient’s medical

condition.
b. Correct. Medical necessity requires providers to document procedures,
services, and supplies that are proper and needed for the diagnosis or
treatment of a patient’s medical condition.

5. Which is the business record for a patient encounter because it documents health
care services provided?
a. demographic data collected on admission
b. patient record housed in the facility

Answer: b

Analysis:
a. Incorrect. Demographic data collected on admission is included on the face
sheet of the manual patient record or in the electronic health record; however,
it is not the business record for a patient record because it does not document
health care services provided. The patient record housed in the facility is the
business record for a patient encounter because it documents health care
services provided.
b. Correct. The patient record housed in the facility is the business record for a
patient encounter because it documents health care services provided.

EXERCISE 1.6: HEALTH DATA COLLECTION

1. Appointment scheduling and claims processing are processes associated with
medical __________ software.

Answer: management

Analysis: Appointment scheduling and claims processing are processes associated

with medical management software, which is a combination of practice management
and medical billing software that automates the daily workflow and procedures of a
physician’s office or clinic. The software automates appointment scheduling, claims
processing, patient invoicing, patient management, and generating reports.

2. Hospital coders and abstractors use automated case __________ software to collect
and report inpatient and outpatient data for statistical analysis and reimbursement
purposes.

Answer: abstracting

Analysis: Hospitals (and other health care facility) coders and abstractors use
automated case abstracting software to collect and report inpatient and outpatient
data for statistical analysis and reimbursement purposes. Data is entered into an
abstracting software program, and the facility’s billing department imports it to the
UB-04 claim for submission to third-party payers.

3. Physicians’ offices submit data to third-party payers on the __________ claim.

Answer: CMS-1500

Analysis: Physicians’ offices submit data to third-party payers on the CMS-1500

claim, which is the standard claim submitted by physicians to third-party payers for

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office encounters and professional services (e.g., provided to hospital inpatients).

Physician offices use medical management software to enter claims data for
electronic submission to third-party payers or clearinghouses. Some eligible medical
practices continue to print paper-based CMS-1500 claims, and are mailed or faxed to
clearinghouses or third-party payers for processing.

4. Hospitals submit data to third-party payers on the __________ (or CMS-1450) claim.

Answer: UB-04

Analysis: Hospitals submit data to third-party payers on the UB-04 (or CMS-1450)
claim, which is the standard claim submitted by health care institutions to third-party
payers for inpatient and outpatient services. (UB means “uniform bill.”)

5. Claims are denied if __________ necessity of procedures or services is not established.

Answer: medical

Analysis: Claims are denied if medical necessity of procedures or services is not

established. The patient’s diagnosis must justify diagnostic or therapeutic procedures
or services provided to meet medical necessity. Procedures, services, and supplies
must also meet the standards of good medical practice in the local area, are provided
and needed for the diagnosis or treatment of a medical condition, and are not mainly
for the convenience of the physician or health care facility.

REVIEW

MULTIPLE CHOICE
1. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires two
types of code sets, large code sets and small code sets, to be adopted for the
purpose of __________ data elements.
a. decrypting
b. encoding
c. interpreting
d. translating

Answer: b

Analysis:
a. Incorrect. The Health Insurance Portability and Accountability Act of 1996
(HIPAA) requires two types of code sets, large code sets and small code sets,
to be adopted for the purpose of encoding data elements.
b. Correct. The Health Insurance Portability and Accountability Act of 1996
(HIPAA) requires two types of code sets, large code sets and small code sets,
to be adopted for the purpose of encoding data elements.
c. Incorrect. The Health Insurance Portability and Accountability Act of 1996
(HIPAA) requires two types of code sets, large code sets and small code sets,
to be adopted for the purpose of encoding data elements.

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d. Incorrect. The Health Insurance Portability and Accountability Act of 1996

(HIPAA) requires two types of code sets, large code sets and small code sets,
to be adopted for the purpose of encoding data elements.

2. Which is considered to be a small code set according to HIPAA?

a. Actions taken to prevent, diagnose, treat, and manage diseases and injuries
b. Causes of injury, disease, impairment, or other health-related problems
c. Diseases, injuries, impairments, and other health-related problems
d. Race, ethnicity, type of facility, and type of unit

Answer: d

Analysis:
a. Incorrect. Large code sets encode actions taken to prevent, diagnose, treat,
and manage diseases and injuries. Small code sets encode race, ethnicity,
type of facility, and type of unit.
b. Incorrect. Large code sets encode causes of injury, disease, impairment, or
other health-related problems. Small code sets encode race, ethnicity, type of
facility, and type of unit.
c. Incorrect. Large code sets encode diseases, injuries, impairments, and other
health-related problems. Small code sets encode race, ethnicity, type of
facility, and type of unit.
d. Correct. Small code sets encode race, ethnicity, type of facility, and type of
unit.

3. Which coding system was adopted by HIPAA for use by clearinghouses, health plans,
and providers?
a. CDT
b. CMIT
c. ICD-9
d. SNOMED CT

Answer: a

Analysis:
a. Correct. Current Dental Terminology (CDT) was adopted by HIPAA for use by
clearinghouses, health plans, and providers.
b. Incorrect. The CMS Measure Inventory Tool (CMIT) is a repository of records
that contains information about measures CMS uses to promote healthcare
quality and quality improvement. Current Dental Terminology (CDT) was
adopted by HIPAA for use by clearinghouses, health plans, and providers.
c. Incorrect. The World Health Organization replaced ICD-9 with ICD-10 in 2000.
Current Dental Terminology (CDT) was adopted by HIPAA for use by
clearinghouses, health plans, and providers.
d. Incorrect. SNOMED CT is a clinical terminology that is used with medical
nomenclatures, such as the LOINC® database. Current Dental Terminology
(CDT) was adopted by HIPAA for use by clearinghouses, health plans, and
providers.

4. The purpose of adopting standard code sets was to

a. establish a medical nomenclature to standardize HIPAA data submissions.
b. improve data quality and simplify claims submission for providers.

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c. increase costs associated with processing health insurance claims.

d. regulate health care clearinghouses and third-party administrators.

Answer: b

Analysis:
a. Incorrect. The purpose of adopting standard code sets was to improve data
quality and simplify claims submission for providers.
b. Correct. The purpose of adopting standard code sets was to improve data
quality and simplify claims submission for providers.
c. Incorrect. The purpose of adopting standard code sets was to improve data
quality and simplify claims submission for providers.
d. Incorrect. The purpose of adopting standard code sets was to improve data
quality and simplify claims submission for providers.

5. According to HIPAA, health plans that do not accept standard code sets are required
to modify their systems to accept all valid codes or to contract with a(n)
a. electronic data interchange.
b. health care clearinghouse.
c. insurance company.
d. third-party administrator.

Answer: b

Analysis:
a. Incorrect. According to HIPAA, health plans that do not accept standard code sets
are required to modify their systems to accept all valid codes or to contract with a
health care clearinghouse.
b. Correct. According to HIPAA, health plans that do not accept standard code sets
are required to modify their systems to accept all valid codes or to contract with a
health care clearinghouse.
c. Incorrect. According to HIPAA, health plans that do not accept standard code sets
are required to modify their systems to accept all valid codes or to contract with a
health care clearinghouse.
d. Incorrect. According to HIPAA, health plans that do not accept standard code sets
are required to modify their systems to accept all valid codes or to contract with a
health care clearinghouse.

6. Which type of clinical terminologies and clinical vocabularies are used by health care
providers to document patient care?
a. Classification system
b. Demographic data
c. Medical nomenclature
d. Patient record

Answer: c

Analysis:
a. Incorrect. A classification system organizes a medical nomenclature according
to similar conditions, diseases, procedures, and services, and it contains
codes for each. A medical nomenclature includes clinical terminologies and
clinical vocabularies that are used by health care providers to document
patient care.

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b. Incorrect. Demographic data is patient identification information that is

collected according to facility policy. A medical nomenclature includes clinical
terminologies and clinical vocabularies that are used by health care providers
to document patient care.
c. Correct. A medical nomenclature includes clinical terminologies and clinical
vocabularies that are used by health care providers to document patient care.
d. Incorrect. The patient record includes provider documentation about
diagnostic and therapeutic procedures and services provided to a patient. A
medical nomenclature includes clinical terminologies and clinical vocabularies
that are used by health care providers to document patient care.

7. The requirement that patient diagnoses justify diagnostic and/or therapeutic

procedures or services provided is called
a. continuity of care.
b. facilities planning.
c. medical necessity.
d. policy making.

Answer: c

Analysis:
a. Incorrect. Continuity of care is the process of documenting patient care
services so that others who treat the patient have a source of information on
which to base additional care and treatment. The requirement that patient
diagnoses justify diagnostic and/or therapeutic procedures or services
provided is called medical necessity. Medical necessity requires providers to
document services or supplies that are proper and needed for the diagnosis or
treatment of a medical condition; provided for the diagnosis, direct care, and
treatment of a medical condition; consistent with standards of good medical
practice in the local area; and not mainly for the convenience of the physician
or health care facility.
b. Incorrect. Facilities planning is performed by organizational leadership in
cooperation with facility managers and project managers. The requirement
that patient diagnoses justify diagnostic and/or therapeutic procedures or
services provided is called medical necessity. Medical necessity requires
providers to document services or supplies that are proper and needed for the
diagnosis or treatment of a medical condition; provided for the diagnosis,
direct care, and treatment of a medical condition; consistent with standards of
good medical practice in the local area; and not mainly for the convenience of
the physician or health care facility.
c. Correct. The requirement that patient diagnoses justify diagnostic and/or
therapeutic procedures or services provided is called medical necessity.
Medical necessity requires providers to document services or supplies that are
proper and needed for the diagnosis or treatment of a medical condition;
provided for the diagnosis, direct care, and treatment of a medical condition;
consistent with standards of good medical practice in the local area; and not
mainly for the convenience of the physician or health care facility.
d. Incorrect. Policy making is performed by organizational leadership. The
requirement that patient diagnoses justify diagnostic and/or therapeutic
procedures or services provided is called medical necessity. Medical necessity

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requires providers to document services or supplies that are proper and

needed for the diagnosis or treatment of a medical condition; provided for the
diagnosis, direct care, and treatment of a medical condition; consistent with
standards of good medical practice in the local area; and not mainly for the
convenience of the physician or health care facility.

8. Which is the business record for a patient encounter (inpatient or outpatient) that
documents health care services provided to a patient?
a. Demographic data
b. Financial record
c. Health care statistics
d. Medical record

Answer: d

Analysis:
a. Incorrect. Demographic data is patient identification information that is
collected according to facility policy. A medical record (or patient record) is
the business record for an inpatient or outpatient encounter that documents
health care services provided to a patient, stores patient demographic data
and documentation that supports diagnoses and justifies treatment, and
contains results of treatment provided.
b. Incorrect. A financial record represents monetary transactions of a business or
an individual. A medical record (or patient record) is the business record for
an inpatient or outpatient encounter that documents health care services
provided to a patient, stores patient demographic data and documentation
that supports diagnoses and justifies treatment, and contains results of
treatment provided.
c. Incorrect. Healthcare statistics include data, such as number of births or
deaths, and are also called vital statistics. A medical record (or patient record)
is the business record for an inpatient or outpatient encounter that documents
health care services provided to a patient, stores patient demographic data
and documentation that supports diagnoses and justifies treatment, and
contains results of treatment provided.
d. Correct. A medical record (or patient record) is the business record for an
inpatient or outpatient encounter that documents health care services
provided to a patient, stores patient demographic data and documentation
that supports diagnoses and justifies treatment, and contains results of
treatment provided.

9. The primary purpose of the patient record is __________, which involves documenting
patient care services so that others who treat the patient have a source of
information on which to base additional care and treatment.
a. continuity of care
b. medical necessity
c. medicolegal
d. quality of care

Answer: a

Analysis:

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a. Correct. The primary purpose of the patient record is continuity of care,

which involves documenting patient care services so that others who treat the
patient have a source of information on which to base additional care and
treatment.
b. Incorrect. Medical necessity requires providers to document services or
supplies that are proper and needed for the diagnosis or treatment of a
medical condition. The primary purpose of the patient record is continuity of
care, which involves documenting patient care services so that others who
treat the patient have a source of information on which to base additional
care and treatment.
c. Incorrect. A secondary purpose of the record includes serving the medicolegal
interests of the patient, facility, and providers of care. The primary purpose of the
patient record is continuity of care, which involves documenting patient care
services so that others who treat the patient have a source of information on
which to base additional care and treatment.
d. Incorrect. A secondary purpose of the record includes evaluating the quality of
patient care. The primary purpose of the patient record is continuity of care,
which involves documenting patient care services so that others who treat the
patient have a source of information on which to base additional care and
treatment.

10. Which is a secondary purpose of the medical record that does not relate directly to
patient care?
a. Clinical research
b. Continuity of care
c. Discharge note
d. Hybrid record

Answer: a

Analysis:
a. Correct. Clinical research is a secondary purpose of the medical record that
does not relate directly to patient care.
b. Incorrect. The primary purpose of the record is to provide for continuity of
care. Clinical research is a secondary purpose of the medical record that does
not relate directly to patient care.
c. Incorrect. A discharge note is documented in the progress notes to summarize
the patient’s care, treatment, response to care, and condition on discharge.
Clinical research is a secondary purpose of the medical record that does not
relate directly to patient care.
d. Incorrect. A hybrid record consists of both paper-based and computer-
generated (electronic) documents. Clinical research is a secondary purpose of
the medical record that does not relate directly to patient care.

11. Which type of medical record format stores documentation in labeled sections?
a. Integrated record
b. Problem-oriented record
c. Source-oriented record
d. SOAP notes

Answer: c

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Analysis:
a. Incorrect. The integrated record arranges documents in strict chronological
date order. Source-oriented records (SOR) reports are organized according to
documentation (or data) source in labeled sections.
b. Incorrect. The problem-oriented record (POR) systematic method of
documentation consists of the database, problem list, initial plan, and
progress notes. Source-oriented records (SOR) reports are organized
according to documentation (or data) source in labeled sections.
c. Correct. Source-oriented records (SOR) reports are organized according to
documentation (or data) source in labeled sections.
d. Incorrect. SOAP notes are documented by the physician and include a
subjective, objective, assessment, and plan for each patient encounter.
Source-oriented records (SOR) reports are organized according to
documentation (or data) source in labeled sections.

12. A progress note contains diagnoses of muscle strain and weakness. This statement
would be located in the __________ portion of the POR progress note.
a. Assessment
b. Objective
c. Plan
d. Subjective

Answer: a

Analysis:
a. Correct. A progress note contains diagnoses of muscle strain and weakness. This
statement would be located in the assessment portion of the POR progress note.
An assessment is the judgment, opinion, or evaluation made by the health care
provider.
b. Incorrect. The objective portion of the POR is observations about the patient,
such as physical findings, or lab or x-ray results. A progress note contains
diagnoses of muscle strain and weakness. This statement would be located in
the assessment portion of the POR progress note. An assessment is the
judgment, opinion, or evaluation made by the health care provider.
c. Incorrect. The plan portion of the POR is diagnostic, therapeutic, and
education plans to resolve the problems. A progress note contains diagnoses
of muscle strain and weakness. This statement would be located in the
assessment portion of the POR progress note. An assessment is the judgment,
opinion, or evaluation made by the health care provider.
d. Incorrect. The subjective portion of the POR is the patient’s statement about
how he or she feels, including symptomatic information. A progress note
contains diagnoses of muscle strain and weakness. This statement would be
located in the assessment portion of the POR progress note. An assessment is
the judgment, opinion, or evaluation made by the health care provider.

13. A progress note contains documentation that the patient is to be followed up with in
the physician’s office two weeks after discharge from the hospital. This statement
would be located in the __________ portion of the POR progress note.
a. Assessment
b. Objective
c. Plan

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d. Subjective

Answer: c

Analysis:
a. Incorrect. The assessment portion of the POR includes the judgment, opinion,
or evaluation made by the health care provider. A progress note contains
documentation that the patient is to be followed up with in the physician’s
office two weeks after discharge from the hospital. This statement would be
located in the plan portion of the POR progress note. The plan portion of the
POR contains diagnostic, therapeutic, and education plans to resolve the
patient’s problems.
b. Incorrect. The objective portion of the POR includes observations about the
patient, such as physical findings or lab and x-ray results. A progress note
contains documentation that the patient is to be followed up with in the
physician’s office two weeks after discharge from the hospital. This statement
would be located in the plan portion of the POR progress note. The plan portion of
the POR contains diagnostic, therapeutic, and education plans to resolve the
patient’s problems.
c. Correct. A progress note contains documentation that the patient is to be
followed up with in the physician’s office two weeks after discharge from the
hospital. This statement would be located in the plan portion of the POR
progress note. The plan portion of the POR contains diagnostic, therapeutic,
and education plans to resolve the patient’s problems.
d. Incorrect. The subjective portion of the POR includes the patient’s statement
about how they feel, including symptomatic information. A progress note
contains documentation that the patient is to be followed up with in the
physician’s office two weeks after discharge from the hospital. This statement
would be located in the plan portion of the POR progress note. The plan portion of
the POR contains diagnostic, therapeutic, and education plans to resolve the
patient’s problems.

14. A progress note contains documentation that the EKG showed elevated T-wave changes.
This statement would be located in the __________ portion of the POR progress note.
a. Assessment
b. Objective
c. Plan
d. Subjective

Answer: b

Analysis:
a. Incorrect. The assessment portion of the POR includes the judgment, opinion,
or evaluation made by the health care provider. A progress note contains
documentation that the EKG showed elevated T-wave changes. This
statement would be located in the objective portion of the POR progress note.
The objective portion of the POR includes observations about the patient, such
as physical findings, or lab or x-ray results.
b. Correct. A progress note contains documentation that the EKG showed
elevated T-wave changes. This statement would be located in the objective
portion of the POR progress note. The objective portion of the POR includes

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observations about the patient, such as physical findings, or lab or x-ray

results.
c. Incorrect. The plan portion of the POR includes diagnostic, therapeutic, and
education plans to resolve the patient’s problems. A progress note contains
documentation that the EKG showed elevated T-wave changes. This
statement would be located in the objective portion of the POR progress note.
The objective portion of the POR includes observations about the patient, such
as physical findings, or lab or x-ray results.
d. Incorrect. The subjective portion of the POR includes the patient’s statement
about how they feel, including symptomatic information. A progress note
contains documentation that the EKG showed elevated T-wave changes. This
statement would be located in the objective portion of the POR progress note.
The objective portion of the POR includes observations about the patient, such
as physical findings, or lab or x-ray results.

15. Which is documented in the progress notes section of the POR to summarize the
patient’s care, treatment, response to care, and condition on release from the
facility?
a. Demographic data
b. Discharge note
c. Medical necessity
d. Transfer note

Answer: b

Analysis:
a. Incorrect. Demographic data is patient identification information that is
collected according to facility policy. A discharge note is documented in the
progress notes section of the POR to summarize the patient’s care, treatment,
response to care, and condition on release from the facility.
b. Correct. A discharge note is documented in the progress notes section of the
POR to summarize the patient’s care, treatment, response to care, and
condition on release from the facility.
c. Incorrect. Medical necessity requires providers to document services or
supplies that are proper and needed for the diagnosis or treatment of a
medical condition. A discharge note is documented in the progress notes
section of the POR to summarize the patient’s care, treatment, response to
care, and condition on release from the facility.
d. Incorrect. A transfer note is documented when a patient is being transferred
to another facility, and it summarizes the reason for admission, current
diagnoses, medical information, and reason for transfer. A discharge note is
documented in the progress notes section of the POR to summarize the
patient’s care, treatment, response to care, and condition on release from the
facility.

16. Which is used to capture paper record images onto storage media?
a. EHR
b. EMR
c. Documentation cloning
d. Scanner

Answer: d

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Analysis:
a. Incorrect. The electronic health record (EHR) is an automated patient record
that can be viewed and documented by a number of providers at different
facilities at the same time. A scanner is used to capture paper record images
onto storage media.
b. Incorrect. The electronic medical record (EMR) is an automated patient record
typically used by physician practices. A scanner is used to capture paper
record images onto storage media.
c. Incorrect. Documentation cloning can supplement the EHR or EMR by
converting paper records to an electronic format using laser technology. A
scanner is used to capture paper record images onto storage media.
d. Correct. A scanner is used to capture paper record images onto storage
media.

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17. To provide the maximum benefit to students, internships are typically __________ work
experiences that are arranged by academic program faculty.
a. elective
b. nonpaid
c. optional
d. voluntary

Answer: b

Analysis:
a. Incorrect. To provide the maximum benefit to students, internships are
typically nonpaid work experiences that are arranged by academic program
faculty.
b. Correct. To provide the maximum benefit to students, internships are
typically nonpaid work experiences that are arranged by academic program
faculty.
c. Incorrect. To provide the maximum benefit to students, internships are
typically nonpaid work experiences that are arranged by academic program
faculty.
d. Incorrect. To provide the maximum benefit to students, internships are
typically nonpaid work experiences that are arranged by academic program
faculty.

18. To whom does the student report at the professional practice experience (or
internship) site?
a. Human resources
b. PPE or internship supervisor
c. Program faculty
d. Volunteer department

Answer: b

Analysis:
a. Incorrect. The PPE or internship supervisor is the person to whom the student
reports at the site. The student reports to the supervisor at the professional
practice experience (or internship) site.
b. Correct. The PPE or internship supervisor is the person to whom the student
reports at the site. The student reports to the supervisor at the professional
practice experience (or internship) site.
c. Incorrect. The PPE or internship supervisor is the person to whom the student
reports at the site. The student reports to the supervisor at the professional
practice experience (or internship) site.
d. Incorrect. The PPE or internship supervisor is the person to whom the student
reports at the site. The student reports to the supervisor at the professional
practice experience (or internship) site.

19. Which is a benefit of joining a professional association?

a. Free certification examination fees
b. Opportunities to network with other members
c. Reduced benefits as compared with nonmembers
d. Website-only access to professional journals

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Answer: b

Analysis:
a. Incorrect. The benefits of joining a professional association include eligibility
for scholarships, opportunity to network, free publications, reduced
certification exam fees, and website access.
b. Correct. The benefits of joining a professional association include eligibility
for scholarships, opportunity to network, free publications, reduced
certification exam fees, and website access.
c. Incorrect. The benefits of joining a professional association include eligibility
for scholarships, opportunity to network, free publications, reduced
certification exam fees, and website access.
d. Incorrect. The benefits of joining a professional association include eligibility
for scholarships, opportunity to network, free publications, reduced
certification exam fees, and website access.

20. Which processes health care claims and performs related business functions for a
health plan?
a. Health care clearinghouse
b. Health care provider
c. Third-party administrator
d. Third-party payer

Answer: c

Analysis:
a. Incorrect. The health care clearinghouse is a public or private entity that
processes or facilitates the processing of health information and claims from a
nonstandard to a standard format. The third-party administrator is an entity
that processes health care claims and performs related business functions for
a health plan.
b. Incorrect. The health care provider is a physician or another health care
professional who performs procedures or provides services to patients. The
third-party administrator is an entity that processes health care claims and
performs related business functions for a health plan.
c. Correct. The third-party administrator is an entity that processes health care
claims and performs related business functions for a health plan.
d. Incorrect. The third-party payer is an insurance company that establishes a
contract to reimburse health care facilities and patients for procedures and
services provided. The third-party administrator is an entity that processes
health care claims and performs related business functions for a health plan.

21. Which classifies outpatient hospital and physician office procedures and services?
a. CDT
b. CPT
c. ICD-10-CM
d. ICD-10-PCS

Answer: b

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Analysis:
a. Incorrect. CDT classifies dental procedures and services. CPT classifies
procedures and services, and it is used by physicians and outpatient health care
settings to assign codes for reporting procedures and services on health
insurance claims.
b. Correct. CPT classifies procedures and services, and it is used by physicians
and outpatient health care settings to assign codes for reporting procedures
and services on health insurance claims.
c. Incorrect. ICD-10-CM classifies all diseases, injuries, and reasons for an
encounter. CPT classifies procedures and services, and it is used by physicians
and outpatient health care settings to assign codes for reporting procedures
and services on health insurance claims.
d. Incorrect. ICD-10-PCS classifies inpatient hospital procedures and services.
CPT classifies procedures and services, and it is used by physicians and
outpatient health care settings to assign codes for reporting procedures and
services on health insurance claims.

22. Which is a standard classification of mental disorders used by mental health

professionals in the United States?
a. ABC
b. CCC
c. DSM
d. ICF

Answer: c

Analysis:
a. Incorrect. Alternate Billing Codes (ABC) classify services not included in the
CPT manual to describe the service, supply, or therapy provided. The
Diagnostic and Statistical Management of Mental Disorders (DSM) is a
standard classification of mental disorders used by mental health
professionals in the United States.
b. Incorrect. The Clinical Care Classification (CCC) provides coding structure for
assessing, documenting, and classifying home health and ambulatory care.
The Diagnostic and Statistical Management of Mental Disorders (DSM) is a
standard classification of mental disorders used by mental health
professionals in the United States.
c. Correct. The Diagnostic and Statistical Management of Mental Disorders (DSM)
is a standard classification of mental disorders used by mental health
professionals in the United States.
d. Incorrect. The International Classification of Functioning, Disability and Health
(ICF) classifies health and health-related domains that describe body functions
and structures, activities, and participation. The Diagnostic and Statistical
Management of Mental Disorders (DSM) is a standard classification of mental
disorders used by mental health professionals in the United States.

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23. Which is an electronic database and universal standard used for clinical care and
management?
a. LOINC®
b. SNOMED CT
c. READ
d. UMLS

Answer: a

Analysis:
a. Correct. Logical Observation Identifiers Names and Codes (LOINC®) is an
electronic database and universal standard that is used to identify medical
laboratory observations and for the purpose of clinical care and management.
b. Incorrect. Systematized Nomenclature of Medicine Clinical Terms (SNOMED
CT) is a comprehensive and multilingual clinical terminology of body
structures, clinical findings, diagnoses, medications, outcomes, procedures,
specimens, therapies, and treatments. Logical Observation Identifiers Names
and Codes (LOINC®) is an electronic database and universal standard that is
used to identify medical laboratory observations and for the purpose of clinical
care and management.
c. Incorrect. READ Codes were developed in the early 1980s by Dr. James Read
to record and retrieve primary care data in a computer; that system is now
called the United Kingdom’s National Health Service’s Clinical Terms Version
3. Logical Observation Identifiers Names and Codes (LOINC®) is an electronic
database and universal standard that is used to identify medical laboratory
observations and for the purpose of clinical care and management.
d. Incorrect. The Unified Medical Language System (UMLS) is a set of files and
software that allows many health and biomedical vocabularies and standards
to enable interoperability among computer systems. Logical Observation
Identifiers Names and Codes (LOINC®) is an electronic database and universal
standard that is used to identify medical laboratory observations and for the
purpose of clinical care and management.

24. Hospitals and other health care facilities use automated case abstracting software to
a. collect and report data for statistical analysis and reimbursement purposes.
b. generate claims data for electronic submission to health care providers.
c. justify diagnostic or therapeutic procedures or services provided to patients.
d. submit standard claims to providers for inpatient and outpatient services.

Answer: a

Analysis:
a. Correct. Hospitals and other health care facilities use automated case
abstracting software to collect and report (inpatient and outpatient) data for
statistical analysis and reimbursement purposes.
b. Incorrect. Facility billing departments and physician office medical practice
management software generate claims data for electronic submission to third-
party payers, not health care providers. Hospitals and other health care
facilities use automated case abstracting software to collect and report
(inpatient and outpatient) data for statistical analysis and reimbursement
purposes.

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c. Incorrect. The patient’s diagnosis must justify diagnostic or therapeutic

procedures or services provided as part of medical necessity requirements.
Hospitals and other health care facilities use automated case abstracting
software to collect and report (inpatient and outpatient) data for statistical
analysis and reimbursement purposes.
d. Incorrect. The UB-04 is a standard claim submitted by health care institutions to
payers for inpatient and outpatient services, and it is populated by abstracted
data. Hospitals and other health care facilities use automated case abstracting
software to collect and report (inpatient and outpatient) data for statistical
analysis and reimbursement purposes.

25. Which is the standard claim submitted by physicians’ offices to third-party payers?
a. CMS-1450
b. CMS-1500
c. UB-04
d. UB-92

Answer: b

Analysis:
a. Incorrect. The CMS-1450 (or UB-04) is the standard claim submitted by health
care institutions to payers for inpatient and outpatient services; UB means
uniform bill. The CMS-1500 is the standard claim submitted by physicians’
offices to third-party payers.
b. Correct. The CMS-1500 is the standard claim submitted by physicians’ offices
to third-party payers.
c. Incorrect. The UB-04 (or CMS-1450) is the standard claim submitted by health
care institutions to payers for inpatient and outpatient services; UB means
uniform bill. The CMS-1500 is the standard claim submitted by physicians’
offices to third-party payers.
d. Incorrect. The UB-92 was replaced by the updated UB-04 (or CMS-1450). The
CMS-1500 is the standard claim submitted by physicians’ offices to third-party
payers.

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