Question 1

Patient presents to the operating room for a secondary Achilles tendon repair. https://kxbjsyuhceggsyvxdkof.supabase.co/storage/v1/object/public/file-images/AHIMA_RHIA/page_226_img_1.jpg

Accepted Answer

B

Explanation: The CPT® code set makes a clear distinction between primary and secondary repairs. A primary repair is performed on an acute injury, whereas a secondary repair is performed for a failed primary repair or a chronic, neglected rupture. The question explicitly states the procedure is a "secondary Achilles tendon repair." CPT code 27654 is defined as "Repair, secondary, Achilles tendon, with or without graft." This code precisely describes the service rendered. The other options represent different types of procedures (primary repair, debridement) or are for unlisted procedures, which are inappropriate when a specific code is available.

Question 2

There was an unexpected hardware failure for our EHR. It is expected to be up and operational in three hours. Until then, which of the following plans would you need to initiate?

Accepted Answer

C

Explanation: A Business Continuity Plan (BCP) is the formal organizational strategy for responding to an unplanned disruption of critical business functions. An unexpected EHR hardware failure is precisely this type of event. The BCP contains predefined procedures, often called downtime procedures, that guide staff on how to continue operations, such as patient care and documentation, using manual or alternative methods until the primary system is restored. Initiating the BCP ensures a coordinated and effective response to maintain patient safety and minimize operational impact during the three-hour outage.

Question 3

Patient comes in through the emergency room with a wound that was caused by an electric saw. Patient is taken to the operating room where two ulna nerves are sutured.

Accepted Answer

C

Explanation: The procedure described is the suture of two ulnar nerves. In the CPT codebook, the section for "Suture of Nerve (Neurorrhaphy)" provides specific codes for this procedure. CPT code 64836, "Suture of one nerve, hand or foot; ulnar motor," is the correct code for the primary procedure on the first nerve. Because a second ulnar nerve was also repaired during the same operative session, the add-on code 64837, "Suture of each additional nerve, hand or foot," must also be reported. This combination accurately reflects the repair of two distinct nerves.

Question 4

A coworker complained of the sudden onset of chest pain and was admitted. A myocardial infarction was ruled out. You would code

Accepted Answer

D

Explanation: According to the ICD-10-CM Official Guidelines for Coding and Reporting, signs and symptoms are appropriate for coding when a related definitive diagnosis has not been established or confirmed by the provider. In this case, the patient presented with chest pain, and the suspected diagnosis of a myocardial infarction (MI) was definitively "ruled out." Since the scenario does not provide an alternative established diagnosis, the coder must report the sign or symptom that prompted the encounter. Therefore, coding only the chest pain is the correct procedure. Coding a condition that has been ruled out is a violation of standard coding principles.

Question 5

Which of the following is an effect of insulin?

Accepted Answer

D

Explanation: Insulin is a primary anabolic hormone that regulates glucose metabolism. When blood glucose levels rise, the pancreas secretes insulin, which binds to receptors on target cells (primarily muscle, fat, and liver cells). This binding facilitates the transport of glucose from the bloodstream into the cells. Once inside, glucose is used for energy production through glycolysis or stored as glycogen (glycogenesis) in the liver and muscles. By promoting both the uptake and utilization of glucose by cells, insulin effectively increases the rate of glucose metabolism, thereby lowering blood glucose concentrations.

Question 6

You are developing a complete data dictionary for your facility. Which of the following resources will
be most helpful in providing standard definitions for data commonly collected in acute care
hospitals?

Accepted Answer

B

Explanation: The Uniform Hospital Discharge Data Set (UHDDS) is the most appropriate resource. It was established by the U.S. Department of Health, Education, and Welfare to create a minimum, common core of data elements for all hospital discharges. It provides standardized definitions for patient-specific data items (e.g., principal diagnosis, principal procedure, other significant procedures) that are routinely collected by acute care hospitals. This standardization is essential for building a reliable and comparable data dictionary, ensuring that data elements are defined and used consistently across the facility and when reporting to external agencies.

Question 7

Referring to Case Study #2, the written answers to questions you have been asked to provide are known as a(n)

Accepted Answer

A

Explanation: An interrogatory is a formal discovery tool used in litigation that consists of a series of written questions served by one party to another. The receiving party is legally required to provide written answers under oath. This method is used to obtain specific factual information about the case from the opposing party before trial. The term encompasses both the written questions asked and the written answers provided in response.

Question 8

Dizziness and blurred vision following ingestion of prescribed Allegra and a glass of wine at dinner would be reported as a(n)

Accepted Answer

A

Explanation: According to the ICD-10-CM Official Guidelines for Coding and Reporting, a poisoning occurs when a substance is used incorrectly. This includes the interaction of a drug taken as prescribed with a nonprescribed substance, such as alcohol. In this scenario, the patient took a prescribed medication (Allegra) with wine (alcohol), and the resulting symptoms are due to this interaction. Therefore, the event is classified as a poisoning, not an adverse effect. An adverse effect would only be applicable if the drug was taken correctly and without any interacting, nonprescribed substances.

Question 9

Male with urinary incontinence. Sling procedure was performed 6 months ago and now the patient has returned for a revision of the sling procedure.

Accepted Answer

B

Explanation: The procedure described is a "revision" of a male sling procedure performed six months prior. In CPT coding, a revision of this nature involves removing the existing device and placing a new one. CPT code 53442, "Removal and replacement of suburethral sling for male urinary incontinence, including placement of new sling," accurately and specifically describes this service. The code for the initial placement (53440) is inappropriate because this is a subsequent, replacement procedure. The other codes describe different types of procedures or devices for treating incontinence or urethral issues.

Question 10

Blindness due to an allergic reaction to ampicillin administered 6 years ago would be reported as a(n)

Accepted Answer

D

Explanation: The current condition, blindness, is a residual effect of a past event. The term "late effect," or sequela, is used to code a condition that remains after the acute phase of an illness or injury has resolved. The initial event was an "allergic reaction" to a correctly administered drug (ampicillin), which is classified as an adverse reaction. Poisoning refers to reactions from improper use of a medication (e.g., overdose, wrong substance). Therefore, the blindness is correctly identified as a late effect of an adverse reaction, as it occurred six years after the initial event.

Question 11

The most common cause of dementia in the United States is

Accepted Answer

B (ASSUMING "SUPPLIES" IS A TYPOGRAPHICAL ERROR FOR "ALZHEIMER'S DISEASE")

Explanation: The most common cause of dementia in the United States is Alzheimer's disease, which accounts for an estimated 60 to 80 percent of all cases. This progressive brain disorder slowly destroys memory and thinking skills. The question as written is invalid due to the nonsensical option "B. supplies." To provide a logical answer, one must assume this is a significant data entry error for "Alzheimer's disease." Under this critical assumption, option B becomes the correct choice, as Alzheimer's is by far the most prevalent cause of dementia.

Question 12

The supervisor of release of information in a Health Information Department is preparing a woe
distribution chart in the hopes of identifying some problem areas. Although the work distribution
chart can provide the supervisor with a great deal of information concerning the work performed by
her staff, it will not indicate

Accepted Answer

B

Explanation: A work distribution chart is an analytical management tool that provides a snapshot of the tasks performed by a department's employees and the time allocated to each task. Its primary purpose is diagnostic: to help a supervisor identify operational issues such as an uneven distribution of work, duplication of effort, or a mismatch between employee skills and assigned tasks. While the chart is invaluable for pinpointing problem areas and inefficiencies, it does not inherently contain or suggest the solutions. The supervisor must interpret the data presented in the chart and then use their managerial expertise and problem-solving skills to develop and implement an appropriate corrective action plan.

Question 13

The prospective payment system to hospitals for Medicare hospital s outpatients is called ___ and became effective on _________

Accepted Answer

C

Explanation: The Centers for Medicare & Medicaid Services (CMS) implemented the hospital Outpatient Prospective Payment System (OPPS) as mandated by the Balanced Budget Act of 1997. This system replaced the previous cost-based reimbursement model. The effective date for the OPPS was August 1, 2000. The payment methodology is based on grouping outpatient services into Ambulatory Payment Classifications (APCs), which bundle services with similar clinical intensity, resource utilization, and costs. Each APC is assigned a relative payment weight that is multiplied by a conversion factor to determine the national payment rate for the services within that group.

Question 14

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used.
You must name each form for bar coding and indexing. The unnamed document in front you includes
a checklist for assessing an obstetric patient's lochia, fundus, and perineum. document type you give
to this form is

Accepted Answer

D

Explanation: The form described is used for assessing a patient's condition after childbirth. The key indicators mentioned—lochia (vaginal discharge post-delivery), fundus (the top of the uterus, which is monitored for contraction back to its normal size), and perineum (checked for healing from tears or an episiotomy)—are all standard clinical assessments performed during the postpartum period. This period begins immediately after delivery and continues for approximately six weeks. Therefore, a form dedicated to tracking these specific physiological changes is correctly classified as a postpartum record.

Question 15

In preparing your facility for initial accreditation by Joint Commission, you are trying to improve the
process of ongoing record review. All health record reviews are presently performed by a team of
Him department personnel. The committee meets quarterly and reports to a Quality Management
Committee. In reviewing Joint Commission standards your first recommended change is to

Accepted Answer

D

Explanation: The Joint Commission (TJC) standards for ongoing record review emphasize an interdisciplinary approach to evaluate the quality and appropriateness of patient care. The current process, limited to HIM personnel, primarily assesses technical compliance (e.g., completeness, timeliness) but lacks the clinical perspective necessary for a comprehensive quality review. Shifting to an interdisciplinary team of care providers—including physicians, nurses, and other relevant clinicians—aligns the review process with TJC's focus on using the health record to assess and improve clinical performance and patient outcomes. This change is fundamental to meeting the intent of TJC's Record of Care and Performance Improvement standards.

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