1. A 19-year-old male is seen in the ER after complaints of abdominal pain for a two-day duration. There are no previous surgeries; patient is not taking any medications. What key component of a history is missing from this documentation?

A. chief complaint

B. review of systems

C. past history

D. history of present illness

2. The physician's order states that the patient needs a "GC culture and VDRL." Which of the following diagnoses would support medical necessity for these tests?

A. impetigo

B. seizure disorder

C. gastroenteritis

D. vaginitis

3. A patient develops difficulty during surgery and the physician discontinues the procedure. Which of the following is the modifier that should be appended to the CPT code by the physician to indicate that the procedure was discontinued?

A. -52

B. -53

C. -73

D. -74

4. A female patient was incorrectly assigned a CPT code for a PSA test. Which of the following software programs is designed to detect this error?

A. Correct Coding Initiative (CCI)

B. encoder software

C. Outpatient Code Editor (OCE)

D. compliance software

5. An otherwise healthy patient is in need of cataract surgery. This patient would most likely be

A. referred to an ambulatory surgery center.

B. admitted to the hospital.

C. referred to a subacute facility.

D. admitted to a skilled nursing facility.

6. The Correct Coding Initiative is updated at least

A. quarterly.

B. monthly.

C. twice a year.

D. yearly.

7. Which of the following is the correct coding assignment for melena with acute gastritis?

A. 535.01

B. 535.51

C. 535.41

D. 578.1, 535.50

8. A coder reviews the following chargemaster information:

Which of the following errors is depicted in this report?

A. unbundled revenue codes

B. revenue code incorrect for specified CPT code

C. invalid CPT code(s)

D. upcoding

9. Which of the following data is necessary to assign patients to severity of illness?

A. complications and comorbitities

B. physician specialty

C. operative procedure

D. age of patient

10. Which of the following ensures data integrity by allowing only reasonable and predetermined values to be entered into the computer?

A. edit checks

B. physical access controls

C. risk analysis

D. entity authentication

11. The physician orders the following:  "CT of head."  The results of this order would be found in which of the following sections of the health record?

A. radiology

B. ultrasound

C. laboratory

D. pathology

12. A patient with Medicare insurance is seen in the physician's office for bronchitis. The physician's services will be reimbursed based on which of the following reimbursement systems?

A. APC

B. DRG

C. RBRVS

D. RUGs

13. Which of the following data can affect reimbursement under the DRG system?

A. date of surgery

B. DNR status

C. disposition

D. number of consultations

14. In the physicians' office, a subsequent debridement of a burned finger was performed without anesthesia. Choosing from the CPT excerpt listed below, which of the following is the correct CPT coding assignment?

16010            dressings and/or debridement, initial or subsequent;

                       under anesthesia, small

16015             under anesthesia, medium or large, or with major

                        debridement

16020              without anesthesia, office or hospital, small

16025              without anesthesia, medium (e.g. whole face or

                         whole extremity)

A. 16010

B. 16015

C. 16020

D. 16025

15. Which of the following is the correct ICD-9-CM code assignment for Type I, diabetic nephropathy, out of control?

A. 250.63, 357.2

B. 250.61, 357.2

C. 250.43, 583.81

D. 250.41, 583.81

16. When reporting a code for a supply (e.g., crutches, hearing aid battery) to Medicare, which of the following would be used?

A. HCPCS National codes

B. CPT Medicine codes

C. no codes needed; list item on HCFA-1500 form

D. CPT Category III codes

17. Review the following denial report from the insurance carrier:

Which of the following errors is depicted in this report?

A. age discrepancy

B. sex discrepancy

C. uncovered procedures

D. incomplete diagnosis

18. Which of the following is a basic method for protecting data security?

A. light pens

B. screen savers

C. passwords

D. audit trails

19. Which of the following is the correct CPT coding assignment for direct laryngoscopy for excision of polyp?

A. 31540

B. 31530

C. 31535

D. 31512

20. The Operative Report states the following:

Preoperative Diagnosis: Suspicious skin lesion of the left side of cheek

Postoperative Diagnosis: 3.5 cm lesion of cheek

Operation: Excision of lesion, left side of cheek with simple wound closure

Pathology Report indicates: 3.0 cm basal cell carcinoma of the cheek

Note the following excerpt of the HCFA-1500:

Which of the following errors is displayed on the claim?

A. Morphology of lesion is incorrectly reported.

B. Size of lesion is incorrectly reported.

C. Modifier should be appended to the CPT code.

D. Simple wound closure code should be added.