Health Information & Data Content Flashcards
7 cards from real CPC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Health Information & Data Content flashcards as text
What is a 'superbill' in the context of physician office coding?
Answer: A form listing common diagnoses and services used to capture charges at the point of care
A superbill (also called an encounter form) is a pre-printed form used in physician offices to document services rendered and diagnoses for billing purposes.
Which component of the medical record is the legal basis for a surgical procedure and must be signed by the patient before a non-emergency operation?
Answer: Informed consent form
An informed consent form documents that the patient was advised of the risks, benefits, and alternatives and agreed to the procedure.
In ICD-10-PCS, how many characters does every complete procedure code contain?
Answer: 7
Every ICD-10-PCS code is exactly 7 alphanumeric characters, each representing a specific axis of classification.
A 'chief complaint' in the medical record is best described as:
Answer: The patient's own description of the symptom or condition that brought them to seek care
The chief complaint is the patient's own statement, typically in their own words, describing the reason for the encounter.
Which federal regulation mandates that hospitals retain medical records for a minimum period as a condition of Medicare participation?
Answer: 42 CFR Part 482 (Conditions of Participation)
42 CFR Part 482 sets the Conditions of Participation for hospitals, including a minimum 5-year medical record retention requirement.
What is the purpose of an 'Excludes1' note in ICD-10-CM?
Answer: It indicates two conditions cannot be coded together because they are mutually exclusive
An Excludes1 note means the excluded code should never be used with the code it is associated with because the conditions cannot occur together.
Which health record documentation is typically the first to be completed when a patient is admitted to an inpatient facility?
Answer: History and physical (H&P)
The history and physical must be completed within 24 hours of inpatient admission and serves as the initial clinical record.