CPC Health Information & Data Content 3

Question 1

What does the acronym 'EHR' stand for in the context of health information management?

Accepted Answer

Electronic Health Record

Answer

EHR stands for Electronic Health Record, a digital version of a patient's paper chart that is real-time and patient-centered.

Question 2

Which section of the medical record documents a patient's subjective complaints, objective findings, clinical assessment, and treatment plan?

Accepted Answer

SOAP note

Answer

A SOAP note organizes clinical documentation into Subjective, Objective, Assessment, and Plan sections.

Question 3

A 'late effect' or 'sequela' in ICD-10-CM coding refers to:

Accepted Answer

A residual condition that remains after the acute phase of an illness or injury has resolved

Answer

Sequela describes the residual condition or late effect that persists after the acute phase of the original illness or injury is resolved.

Question 4

Which type of health record release requires a signed patient authorization before disclosure?

Accepted Answer

Release to the patient's attorney for litigation

Answer

Releasing records to an attorney for litigation requires a signed patient authorization because it is not a routine treatment, payment, or operations purpose.

Question 5

In CPT coding, what is the significance of a 'semicolon' (;) in a code description?

Accepted Answer

The portion before the semicolon is shared by the parent code and all indented codes below it

Answer

In CPT, the common descriptor before the semicolon applies to the parent code and all indented child codes that follow.

(CPC) Certified Professional Coder Practice Test

(CPC) Certified Professional Coder Practice Test

CPC Health Information & Data Content 3