Medical Records Management
Exam Materials
Course Introduction
Medical Records Management focuses on the principles and practices involved in efficiently collecting, organizing, maintaining, and securing patient health information within healthcare settings. The course covers topics such as health record formats, electronic health record (EHR) systems, legal and ethical considerations for confidentiality, compliance with healthcare regulations (including HIPAA), coding and classification systems, and the impact of technology on records management. Emphasis is placed on ensuring data accuracy, availability, and privacy to support quality patient care and organizational operations.
Recommended Textbook
Step by Step Medical Coding 2016 1st Edition by Carol J. Buck
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27 Chapters
1233 Verified Questions
1233 Flashcards
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Page 2
Chapter 1: Reimbursement, Hipaa, and Compliance
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50 Flashcards
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Sample Questions
Q1) RBRVS ________________________________________
Answer: Resource Based Relative Value Scale
Q2) Kickbacks from patients are allowed under certain circumstances according to Medicare guidelines.
A)True
B)False
Answer: False
Q3) This program is also known as Medicare Advantage.
A)Part A
B)Part B
C)Part C
D)Part D
Answer: C
Q4) Fraud is an intentional deception or misrepresentation that an individual knows to be false or does not believe to be true and makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person.
A)True
B)False
Answer: True
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Chapter 2: An Overview of ICD-10-CM
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Sample Questions
Q1) The following are characteristics of the ICD-10-CM index:
A)Main terms are in bold type.
B)Subterms are indented under the main term.
C)Only the first four characters of some codes are given.
D)All of the above.
Answer: D
Q2) The maximum number of characters in an ICD-10-CM code is:
A)4
B)5
C)6
D)7
Answer: D
Q3) Notable improvements in the content and format of the ICD-10-CM include expansion of signs and symptoms codes.
A)True
B)False
Answer: False
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Chapter 3: ICD-10-CM Outpatient Coding and Reporting
Guidelines
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28 Flashcards
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Sample Questions
Q1) Screening for respiratory tuberculosis.
ICD-10-CM Code: ___________________
Answer: Z11.1
Q2) A patient may have an unconfirmed diagnosis for more than three visits if a definitive diagnosis has not been stated by the physician in the medical documentation.
A)True
B)False
Answer: True
Q3) A multigravida 48-year-old patient presents for routine prenatal visit, first trimester. No complications are noted.
ICD-10-CM Code: ___________________
Answer: O09.521
Q4) In the outpatient setting, a diagnosis that is documented as "rule out" should not be reported.
A)True
B)False Answer: True
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Chapter 4: Using ICD-10-CM
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Sample Questions
Q1) Primary hypertension.
ICD-10-CM Code:____________________
Q2) Rubella meningoencephalitis.
ICD-10-CM Code:____________________
Q3) Aphasia and cognitive defects, as a result of nontraumatic intracranial hemorrhage.
ICD-10-CM Codes:____________________, ____________________
Q4) A late effect is the residual effect after the acute phase of an illness or injury has passed.
A)True
B)False
Q5) The correct reporting for acute cholecystitis with cholelithiasis with obstruction:
A)K80.19
B)K80.12
C)K80.10
D)K80.01
Q6) Acute and chronic prostatitis due to Escherichia coli bacterial infection.
ICD-10-CM Codes: _________________, _________________,
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Chapter 5: Introduction to CPT
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Sample Questions
Q1) This act mandated the adoption of national uniform standards for electronic transmission of financial and administrative health information.
A) HPIAA
B) HAPIA
C) HIAPA
D) HIPAA
Q2) The rules that govern coding in various health care settings are:
A)variable
B)static
C)unchanging
D)nationally established
Q3) Which punctuation mark between codes in the index of the CPT manual indicates a range of codes is available?
A)period
B)hyphen
C)comma
D)semicolon
Q4) There are two types of codes, but only ____________________ codes have the full description.
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Chapter 6: Introduction to Level II National Codes HCPSC
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Sample Questions
Q1) intraveneous
A)IT
B)IV
C)IM
D)SC
E)IHN
Q2) What is the HCPCS Level II code for home blood glucose monitor?
Q3) The entries in the index of the National Codes may be listed under more than ____________________(two words) term.
Q4) Subset HCPCS modifier indicating the service was provided by a resident under a teaching physician's direction.
A)GE
B)TH
C)GC
D)TE
Q5) What is the HCPCS Level II code for Injection, gadoterate meglumine, 0.1 ml?
Q6) Reporting of National Codes is _________________ on all Medicare and Medicaid claims submitted to report professional services, procedures and supplies.
Q7) J codes do not include drug _____________.
Page 8
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Chapter 7: Modifiers
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Sample Questions
Q1) Modifier -32 is used to indicate a service is mandated. Which of the following is an example of when a service is "mandated?"
A)Another physician requests a second opinion.
B)An insurance company requires a second opinion prior to surgery.
C)The patient requests a second opinion.
D)All of the above.
Q2) Modifier -59, distinct procedure service, is used to indicate that:
A)services that are usually bundled into one payment were provided as separate services
B)a subsequent surgery was planned or staged
C)a service was repeated
D)a patient is taken back to the operating room for surgical treatment of a complication resulting from a previous surgery
Q3) The modifier that indicates only the professional component of the service was provided is:
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Page 9
Chapter 8: Evaluation and Management EM Services
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Sample Questions
Q1) The code range for Home Services is ____________________.
Q2) According to E/M guidelines, a(n) ____ exam encompasses a complete single-specialty exam or a complete multisystem exam.
A)problem-focused
B)expanded problem-focused
C)detailed
D)comprehensive
Q3) What are the three key components that are present in every patient case, except counseling encounters or time-based codes, and enable the coder to choose the appropriate level of service?
Q4) respiratory
A) BA
B) OS
Q5) What are the four elements of history?
Q6) The four types of patient status are: ________________, ___________________, ________________, and ____________________
Q7) Modifier ____________________ is used to indicate that a separately identifiable E/M service was performed by the same individual on the same day as the preventive medicine service.
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Chapter 9: Anesthesia
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Sample Questions
Q1) Local anesthesia is a type of anesthesia that provides a decreased level of consciousness.
A)True
B)False
Q2) Anesthesia for radical hysterectomy.
CPT Code: ____________________
Q3) Anesthesia code for a tympanostomy of the left ear performed on an 11-month-old female.
CPT Codes: _____________, _____________
Q4) Codes for Qualifying Circumstances are located in both the Anesthesia Guidelines and the ____________________ section of the CPT manual.
Q5) Assign a CPT anesthesia code and applicable modifiers for anesthesia services for a 9-month-old normal child who received anesthesia for hernia repair in the lower abdomen.
CPT Code: ____________________
Q6) Physical status modifier P3 indicates a patient with _________________ systemic disease.
Q7) Daily hospital management of epidural, continuous drug administration.
CPT Code: ____________________
Page 11
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Chapter 10: Surgery Guidelines and General Surgery
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Sample Questions
Q1) What code is used to report routine postoperative care?
A)No code
B)99212
C)99024
D)99211
Q2) The correct code for an unlisted procedure for the breast is:
A)11949
B)99499
C)19499
D)14949
Q3) Unlisted codes are assigned to identify procedures for which there is no more specific code.
A)True
B)False
Q4) This information is placed after some codes in the CPT manual and contains helpful information.
A)parenthetical information
B)Guidelines
C)index locations
D)bracketed information
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Chapter 11: Extension 1: Chapter-Specific Guidelines:
ICD-10-CM Chapters 1-10
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Sample Questions
Q1) I-10 presumes a cause-and-effect relationship between hypertension and acute kidney disease.
A)True
B)False
Q2) Buerger's disease.
ICD-10-CM Code: _____________________
Q3) Diabetes insipidus.
ICD-10-CM Code: ____________________
Q4) Intractable epileptic seizures related to alcohol.
ICD-10-CM Code: ____________________
Q5) Encounter for treatment of pancytopenia due to primary angiosarcoma of the liver.
ICD-10-CM Codes: _____________________, _____________________
Q6) Sickle-cell crisis with acute chest syndrome.
ICD-10-CM Code: _____________________
Q7) Chronic asthmatic bronchitis with COPD.
ICD-10-CM Code: _____________________
Q8) COPD with acute exacerbation.
ICD-10-CM Code: _____________________
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Chapter 13: Musculoskeletal System
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Sample Questions
Q1) Where is the bimalleolar bone located?
A)wrist
B)shoulder
C)knee
D)ankle
Q2) Location: Inpatient Hospital
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.
POSTOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.
PROCEDURE PERFORMED: Placement of halo.
ANESTHESIA: General.
PROCEDURE: Under general anesthesia, the patient's head was prepped. The halo was applied. The pins were secured. The vest was secured. The patient was monitored with sensory-evoked potentials. There were no changes throughout the case. Films were done postop which showed the alignment was acceptable at C6-7.
CPT Code: ____________________
Q3) Open treatment of a hip fracture of proximal neck with prosthetic femoral hip replacement.
CPT Code: ____________________
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Chapter 14: Integumentary System
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Sample Questions
Q1) drainage
A) to remedy, replace, or heal
B) suffix for molding or surgically forming
C) free flow or withdrawal of fluids from a wound or cavity
D) cutting or taking away
E) to unite parts by stitching them together
F) inspection of body organs or cavities by the use of a lighted scope that may be placed through an existing opening or through a small incision
G) scraping of a cavity using a spoon-shaped instrument
H) forcing a fluid into a vessel or cavity
I) suffix for suturing
J) suffix for puncture of a cavity
K) suffix for removal of part or all of an organ of the body
L) removal of a small piece of living tissue for diagnostic examination
M) surgically cutting into
N) binding or tying off, as in constricting blood flow of a vessel or binding fallopian tubes for sterilization
O) suffix for incision into
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15
Chapter 14: Respiratory System
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Sample Questions
Q1) Tracheostomy
A)repair of a damaged trachea
B)incision made over the larynx
C)creation of an opening into the trachea
D)establishment of an airway
Q2) Removal of a lung cyst by major thoracotomy.
CPT Code: ____________________
Q3) Lavage
A)removal by cutting
B)washing out an organ
C)destruction of tissue by burning
D)free flow or withdrawal of fluids
Q4) Excision of tracheal tumor using cervical approach.
CPT Code: ____________________
Q5) A surgical sinus endoscopy includes a sinusotomy (when appropriate) and diagnostic endoscopy.
A)True
B)False
Q6) Flexible bronchoscopy with use of laser therapy to relieve stenosis.
CPT Code: ____________________
Page 16
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Chapter 15: Extension 2: Chapter-Specific Guidelines:
ICD-10-CM Chapters 11-14
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55 Verified Questions
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Sample Questions
Q1) Stress fracture of the right foot, subsequent encounter with delayed healing.
ICD-10-CM Code:____________________
Q2) Recurrent chronic pancreatitis
ICD-10-CM Code:_____________________
Q3) Osteopathy of right lower leg following poliomyelitis.
ICD-10-CM Codes:____________________, ____________________
Q4) Acute gastrectasis (distention of stomach).
ICD-10-CM Code:_____________________
Q5) Dyskinesia of esophagus.
ICD-10-CM Code:_____________________
Q6) Staphylococcus aureus arthritis of the left ankle is an example of when the organism is reported first, followed by a code to report the pyogenic arthritis.
A)True
B)False
Q7) Itching.
ICD-10-CM Code:____________________
Page 17
Q8) Patient with arthropathy of left hip associated with dysentery due to enteritis Yersina enterocolitica.
ICD-10-CM Codes: _____________________, _____________________
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Page 18
Chapter 16: Cardiovascular System
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Sample Questions
Q1) A thromboendarterectomy of the carotid artery by neck incision, with a patch graft.
CPT Code: ____________________
Q2) The implantation of a patient-activated cardiac event recorder.
CPT Code: ____________________
Q3) Insertion of a single lead implantable defibrillator pulse generator.
CPT Code: ____________________
Q4) If the clinic physician performs the catheterization procedure at the hospital, which modifier would you append to the catheterization code?
A)-51
B)-26
C)-TC
D)no modifier needed
Q5) To correctly report coronary bypass grafts, you must know the anatomical site from which the vessel being grafted came.
A)True
B)False
Q6) Duplex scan of aorta, complete study.
CPT Code: ____________________
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Chapter 17: Hemic, Lymphatic, Mediastinum, and Diaphragm
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Sample Questions
Q1) How many categories are located in the Mediastinum subheading?
A)4
B)3
C)6
D)2
Q2) Mediastinotomy
A) Overlapping
B) Grafting tissue from one source to another
C) Inflammation of lymph nodes
D) Cutting into the mediastinum
Q3) The upper jugular group of lymph nodes are located in the groin.
A)True
B)False
Q4) The physician performs a complete axillary lymphadenectomy.
CPT Code: ____________________
Q5) What word describes a lymphadenectomy in which only the lymph nodes are removed?
A)radical
B)partial
C)segmental
D)limited Page 20
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Chapter 18: Digestive System
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Sample Questions
Q1) When a diagnostic colonoscopy is coded, the code includes:
A)anoscopy
B)proctosigmoidoscopy
C)sigmoidoscopy
D)all of the above
Q2) A diagnostic, transoral, flexible esophagoscopy was performed. During the procedure an esophageal polyp was found and removed by hot biopsy forceps.
CPT Code: ____________________
Q3) ____________________ is the term that describes the displacement of an organ or tissue that protrudes through the wall or from the cavity that usually contains it.
Q4) A physician is placing a nasogastric tube using fluoroscopic guidance.
CPT Code: ____________________
Q5) For a fine-needle aspiration of the salivary gland, the correct code would be 42400.
A)True
B)False
Q6) Transection of the esophagus with repair for esophageal varices.
CPT Code: ____________________
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Page 22
Chapter 19: Urinary and Male Genital Systems
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Sample Questions
Q1) A cystourethroscope is passed through the urethra to the bladder to view the urinary collecting system.
A)True
B)False
Q2) To report the cystourethroscopic removal of a self-retaining indwelling ureteral stent, the correct codes would be 52310 or 52315. What modifier would be applied?
A)-25
B)-57
C)-58
D)none of the above
Q3) Code 54699 is the correct code to report an unlisted procedure of the male genital system.
A)True B)False
Q4) Bilateral vasectomy.
CPT Code: ____________________
Q5) A nephrectomy with a total ureterectomy and bladder cuff, through different incisions.
CPT Code: ____________________
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Chapter 20: Reproductive, Intersex Surgery, Female Genital
System, and Maternity Care and Delivery
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Sample Questions
Q1) Treatment of an incomplete abortion that was treated surgically during the second trimester.
CPT Code: ____________________
Q2) Hysterectomy codes are first divided in the CPT manual based on the ____ and then on any secondary procedure(s) that were done.
A)approach
B)severity
C)duration
D)patient age
Q3) Drainage of left ovarian cyst, abdominal approach.
CPT Code: ____________________
Q4) Code the treatment of a septic abortion that was completed surgically.
CPT Code: ____________________
Q5) The code for destruction of a vaginal lesion is 17000.
A)True
B)False
Q6) ____________________ describes cutting into the vagina to gain access to the pelvic cavity.
CPT Code: ____________________ Page 24
Q7) Code the vaginal removal of a 230-gram uterus.
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Chapter 21: Extension 3: Chapter-Specific Guidelines :
ICD-10-CM Chapters 15-21
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Q1) Greenstick closed fracture of the right arm, shaft of the radius, initial encounter.
ICD-10-CM Code: ____________________
Q2) Complete traumatic amputation of left arm, below the elbow, subsequent encounter.
ICD-10-CM Code: ____________________
Q3) Congenital cystic kidney disease.
ICD-10-CM Code: ____________________
Q4) Left lower quadrant abdominal pain.
ICD-10-CM Code: ____________________
Q5) Accidental asphyxiation due to smothering under pillow, initial encounter.
ICD-10-CM Code: ____________________
Q6) The outcome of delivery is indicated on the mother's medical record only. A)True B)False
Q7) Transitory neonatal hypoglycemia.
ICD-10-CM Code: ____________________
Q8) Vitamin K deficiency of newborn.
ICD-10-CM Code: ____________________
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Chapter 22: Endocrine and Nervous Systems
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Sample Questions
Q1) What procedure is often performed with a laminectomy?
A)discectomy
B)corpectomy
C)arthrodesis
D)creation of a shunt
Q2) Posterior hemilaminectomy with herniated discectomy L2 thru L4. (Separate the codes with a comma in your response as follows: XXXXX, XXXXX.)
CPT Codes: ____________________, ____________________
Q3) Craniotomy
A) method of identifying a specific area or point in the brain
B) removal of a portion of the skull
C) a small opening in the skull
D) an incision of the skull
Q4) The physician resects an easily accessible arteriovenous malformation (AVM) in the infratentorial region of the brain.
CPT Code: ____________________
Q5) Incision and drainage of an infected thyroglossal duct cyst.
CPT Code: ____________________
Q6) Name the four glands represented in the Endocrine subsection.
Page 27
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Chapter 23: Eye, Ocular Adnexa, Auditory, and Operating Microscope
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Q1) Removal of a superficial foreign body in the external left eye.
CPT Code: ____________________
Q2) Cataract and lens replacement uses ____ different approaches.
A)3
B)2
C)4
D)1
Q3) The codes in the Eye and Ocular Adnexa subsection are bilateral codes.
A)True
B)False
Q4) Sclera lesion excision, left eye.
CPT Code: ____________________
Q5) Otoplasty of the right ear, with size reduction.
CPT Code: ____________________
Q6) Bilateral repair of blepharoptosis with frontalis muscle technique.
CPT Code: ____________________
Q7) The destruction codes in the Posterior Segment subsection include one or more sessions.
A)True
B)False Page 28
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Chapter 24: Radiology Section
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Q1) Radiologic examination, nasal bones, complete, minimum of three views.
CPT Code: ____________________
Q2) anterior (ventral)
A) toward the midline of the body
B) toward the head or the upper part of the body; also known as cephalad or cephalic C) in front of
D) away from the midline of the body (to the side) E) in back of F) away from the head or the lower part of the body; also known as caudad or caudal
Q3) It is acceptable for the radiologist to communicate his/her opinion via telephone instead of a written report.
A)True
B)False
Q4) Parathyroid imaging.
CPT Code: ____________________
Q5) X-ray shoulder arthrography, supervision and interpretation only.
CPT Code: ____________________
Q6) ____________________ means lying down.
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Chapter 25: Pathology/Laboratory Section
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Q1) A service that is rarely provided, unusual, variable, or new would always require a special report in determining medical appropriateness of the service.
A)True
B)False
Q2) Pathologists have specific codes for clinical pathology consultations.
A)True
B)False
Q3) A three-specimen glucose tolerance test. CPT Code: ____________________
Q4) Immunology codes are used to report conditions of the ____________________ system.
Q5) A blood count, CBC, automated with a differential. CPT Code: ____________________
Q6) In the Pathology/Laboratory section of the CPT, drugs are listed by their ____ names.
A)brand
B)manufacturer's
C)chemical
D)generic
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Chapter 26: The Medicine Section
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Sample Questions
Q1) What word is used to describe the pushing of liquid into the body over a long period of time?
A)instillation
B)introduction
C)infusion
D)intrusion
Q2) Psychiatric diagnostic interview examination includes:
A)history
B)mental status
C)disposition and communication with family or other sources
D)all of the above
Q3) Which of the following would be used to code drugs?
A)B codes
B)C codes
C)J codes
D)K codes
Q4) Postoperative follow-up visit 4 weeks after a surgery that has a 90-day global period.
CPT Code: ____________________
Q5) The administration code for an influenza vaccine is ____________________.
Page 32
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Chapter 27: Inpatient Coding
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Q1) Patient is admitted with epigastric pain due to acute pancreatitis.
Q2) When two or more diagnoses equally meet the definition for principal diagnosis, either one can be selected as the principal diagnosis.
A)True
B)False
Q3) In the inpatient setting, a CPT code would be assigned for a procedure code.
A)True
B)False
Q4) In the inpatient setting, a procedure code from ICD-10-PCS would be assigned to identify a procedure.
A)True
B)False
Q5) The root operation that is defined as restoring, to the extent possible, a body part to its natural anatomic structure is:
A)map
B)replacement
C)restriction
D)repair
Q6) Patient was discharged with a diagnosis of probable myocardial infarction.
Page 33
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