CPC Health Information & Data Content 2 — Questions and Answers
Question 1: Which data element in the UB-04 claim form identifies the attending physician?
- Field Locator 76 (Correct answer)
- Field Locator 82
- Field Locator 74
- Field Locator 80
Correct answer: Field Locator 76
Field Locator 76 on the UB-04 identifies the attending physician by NPI and name.
Question 2: A coder notices that the discharge summary is missing from the medical record 24 hours after patient discharge. What is the most appropriate action?
- Query the attending physician for the missing document (Correct answer)
- Code from the history and physical only
- Delay billing indefinitely without notification
- Use the operative report as a substitute for the discharge summary
Correct answer: Query the attending physician for the missing document
The coder should query the attending physician to obtain the missing discharge summary before finalizing the code assignment.
Question 3: Which Act established national standards for electronic health care transactions and code sets?
- HIPAA (Correct answer)
- HITECH
- ACA
- ARRA
Correct answer: HIPAA
HIPAA (Health Insurance Portability and Accountability Act) established the national standards for electronic transactions and code sets.
Question 4: What term describes the process of converting verbal or written descriptions of diseases and procedures into numeric or alphanumeric codes?
- Clinical coding (Correct answer)
- Data abstraction
- Transcription
- Clinical documentation improvement
Correct answer: Clinical coding
Clinical coding is the process of translating diagnoses, procedures, and services into standardized code sets.
Question 5: An 'addendum' added to a medical record must include which of the following?
- Date, time, author signature, and reason for the addendum (Correct answer)
- Only the corrected information and the author's initials
- The original entry crossed out with a single line
- A notation approved by the medical records director only
Correct answer: Date, time, author signature, and reason for the addendum
A proper addendum must include the date, time, author signature, and the reason it was added to maintain record integrity.
Question 6: In ICD-10-CM, what is the purpose of the 'dummy placeholder' character 'X'?
- To allow future code expansion and meet the 7th character requirement (Correct answer)
- To indicate an unknown diagnosis
- To mark an excludes note
- To identify a secondary code
Correct answer: To allow future code expansion and meet the 7th character requirement
The placeholder 'X' is used in certain codes to allow for future expansion and to satisfy the requirement of a 7th character.
Question 7: Which organization maintains the ICD-10-CM code set in the United States?
- CDC's National Center for Health Statistics (NCHS) (Correct answer)
- American Medical Association (AMA)
- American Health Information Management Association (AHIMA)
- Centers for Medicare and Medicaid Services (CMS)
Correct answer: CDC's National Center for Health Statistics (NCHS)
The CDC's National Center for Health Statistics (NCHS) is responsible for maintaining the diagnosis portion of ICD-10-CM in the US.
CPC Health Information & Data Content 2
Which data element in the UB-04 claim form identifies the attending physician?