CPC Health Information & Data Content 2

Question 1

Which data element in the UB-04 claim form identifies the attending physician?

Accepted Answer

Field Locator 76

Answer

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?

Accepted Answer

Query the attending physician for the missing document

Answer

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?

Accepted Answer

HIPAA

Answer

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?

Accepted Answer

Clinical coding

Answer

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?

Accepted Answer

Date, time, author signature, and reason for the addendum

Answer

A proper addendum must include the date, time, author signature, and the reason it was added to maintain record integrity.

(CPC) Certified Professional Coder Practice Test