CLC – Nursing Theory and Conceptual Model Presentation 2025

This is a Collaborative Learning Community (CLC) assignment. Nursing theories are tested and systematic ways to implement nursing practice. Select a nursing theory and its conceptual model. Prepare a 10-15 slide PowerPoint in which you describe the nursing theory and its conceptual model and demonstrate its application in nursing practice. Include the following: Present an overview of the nursing theory. Provide evidence that demonstrates support for the model’s efficacy in nursing practice. Explain how the theory proves the conceptual model. Explain how the nursing theory incorporates the four metaparadigm concepts. Provide three evidence-based examples that demonstrate how the nursing theory supports nursing practice. Provide support and rationale for each. Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style. While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

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NURS 6600: CAPSTONE SYNTHESIS PRACTICUM – Discussion 1 (Very Important for me please – Need only A work on this) 2025

PLEASE READ ALL THE INSTRUCTIONS AND DO IT. IF YOU DONT READ ALL THE INSTRUCTIONS AND DONT FOLLWO IT, PLEASE DONT DO IT. I NEED THE POST ON TIME MENTIONED IN THE POST. ALL DOCUMENTS AND REFERENCES ARE ATTACHED. Discussion: Preparing for Professional Transitions Consider the following scenario: Marcus recalls the beginning of his career, when he started as a nurse at Grand View Hospital. He had heard the organization was soliciting proposals from various companies so they could weigh the pros and cons associated with adopting a new health information technology system. He has been curious about the request for proposal (RFP) process ever since. Now, as he looks forward to new professional opportunities, he would like to ensure that he develops the skills and expertise needed to formulate an RFP. What are your professional aims? How can you apply what you have learned in your coursework to your practicum setting? How will you leverage your experiences in the practicum to facilitate your development as a nurse leader-manager or informaticist? In this Discussion, you reflect on your aspirations and consider the transitions that may be required to achieve them. You identify professional development objectives and evaluate opportunities for achieving them through your experiences in the practicum. Think about the professional role changes you have been undergoing or that you may undertake following completion of this MSN program. Review the information related to professional development and role change in the Learning Resources, and conduct additional research as necessary to address any questions or concerns you may have. Consider the following questions: What types of professional positions interest you? Are they significantly different from the types of positions you have held in the past? If so, how? What challenges are you likely to encounter as you transition into a new role? What resources could help you to manage this change? Consider your inner resources (e.g., drawing on previous experiences, stress management), resources available to you through your relationships with others, and institutional supports. Consider how you could use this Practicum Experience to apply what you have learned and enhance or acquire specialization skills and knowledge, regardless of whether you intend to change roles or stay in your current position for the time being. Review the NURS 6600 Course Outcomes listed in the Syllabus. Determine how your experiences in the practicum could help you to achieve one or more of these outcomes. Review the information in the Introduction to the Practicum (in this week’s Practicum area) and the School of Nursing Practicum Manual as necessary to ensure you have a clear understanding of the practicum requirements. Review the suggestions for developing effective learning objectives provided in the Learning Resources. Think of two or three objectives that could help guide your professional development during your practicum. These objectives, referred to as your practicum professional development objectives, must be: Specific Measurable Attainable Results-focused Time-focused Reflective of the higher-order domains of Bloom’s Taxonomy (i.e., Application level and above) Select one or more practicum professional development objectives to focus on for this Discussion. (You may continue to hone these objectives as you work on this week’s Application Assignment.) Reflect on how you could achieve each objective through your Practicum Experience. Post an explanation of your professional aspirations and how you intend to use the Practicum Experience to promote career change and/or enhance your performance. Describe at least one objective to facilitate your professional growth, and explain the steps you could take to achieve the objective(s) during your Practicum Experience. Support your response with examples from the literature. Read a selection of your colleagues’ responses. Respond to at least two of your colleagues on two different days, using one or more of the following approaches: Suggest strategies for using the Practicum Experience to deepen or broaden their knowledge. Offer suggestions for refining their practicum professional objective(s). Required Readings Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Cipriano, P. F., & Murphy, J. (2011). The future of nursing and health IT: The quality elixir. Nursing Economic$, 29(5), 286–289. Note: Retrieved from the Walden Library databases. “Technology tools will continue to revolutionize how we plan, deliver, document, review, evaluate, and derive the evidence about care” (p. 289). This article examines how nurses can use information technology to transform nursing and redesign the health care system. It focuses on the use of technology to promote quality and notes that technology can also be used to address challenges in education, research, leadership, and policy. McKimm, J., & Swanwick, T. (2009). Setting learning objectives. British Journal of Hospital Medicine, 70(7), 406–409. Note: Retrieved from the Walden Library databases. This article clarifies the terminology associated with learning objectives and explains how learning objectives relate to professional development and the transformation from novice to expert. It also introduces common pitfalls when setting learning objectives and provides suggestions for avoiding them. Murphy, J. (2011). The nursing informatics workforce: Who are they and what do they do? Nursing Economic$, 29(3), 150–153. Note: Retrieved from the Walden Library databases. The author examines the nursing informatics workforce, explaining that professionals in this well-established specialty area can play an integral role in transforming health care. Sørensen, E. E., Delmar, C., & Pedersen, B. D. (2011). Leading nurses in dire straits: Head nurses’ navigation between nursing and leadership roles. Journal of Nursing Management, 19(4), 421–430. Note: Retrieved from the Walden Library databases. “Successful nursing leaders navigate between nursing and leadership roles while nourishing a double identity” (p. 421). In this article, the authors examine how individuals in key professional roles negotiate between and apply nursing and leadership skills. Warm, D., & Thomas, B. (2011). A review of the effectiveness of the clinical informaticist role. Nursing Standard, 25(44), 35–38. Note: Retrieved from the Walden Library databases. The authors investigate the application of specialized knowledge and expertise to facilitate the appropriate use of emerging technologies in clinical settings. They argue for informaticists’ involvement in strategic development and delivery of information management and technology initiatives to promote patient-centered outcomes. Wilkinson, J. E., Nutley, S. M., & Davies, H. T. O. (2011). An exploration of the roles of nurse managers in evidence-based practice implementation. Worldviews on Evidence-Based Nursing, 8(4), 236–246. Note: Retrieved from the Walden Library databases. In this article, the authors examine the role nurse managers should play in leading and facilitating evidence-based practice. Armstrong, P. (2013). Bloom’s taxonomy. Retrieved from http://cft.vanderbilt.edu/teaching-guides/pedagogical/blooms-taxonomy/ Vanderbilt University provides this overview of Bloom’s taxonomy. This site also presents the original and updated versions of the taxonomy along with verb suggestions for each level. Clark, D. (2013). Bloom’s taxonomy of learning domains. Retrieved from http://www.nwlink.com/~donclark/hrd/bloom.html This article addresses three domains of learning: cognitive, affective, and psychomotor. University of Central Florida, Office of Experiential Learning (n.d.). Writing SMART learning objectives, Retrieved from http://explearning.ucf.edu/registered-students/tips-for-success/writing-smart-learning-objectives/195 This blog post focuses on the distinction between learning outcomes and objectives. Consider this information as you develop your practicum professional development objectives this week. The University of North Carolina at Charlotte, Center for Teaching & Learning. (2013). Writing objectives using Bloom’s taxonomy. Retrieved from http://teaching.uncc.edu/articles-books/best-practice-articles/goals-objectives/writing-objectives-using-blooms-taxonomy This resource outlines elements of Bloom’s Taxonomy. Document: Practicum Professional Experience Plan (Word Document) Use this form to develop your Practicum Professional Experience Plan as outlined this week. Document: Practicum Professional Experience Plan (Word Document) Use this form to develop your Practicum Professional Experience Plan as outlined this week. Document: Practicum Journal (Word Document) During your Practicum Experience, you are required to submit your time log and three journal entries. You will use this form to complete your journal reflections. Document: School of Nursing Practicum Manual: Master of Science in Nursing (MSN): Quarter-Based Programs (PDF) This comprehensive manual outlines all of the requirements for the Practicum Experience. Clinical Resources Document: Introduction to Clinical Experiences (PowerPoint) Document: Practicum Manual (PDF) Required Media Laureate Education (Producer). (2012a). Professional behavior in the practicum setting [Interactive media]. Note: Retrieved from the Walden Library databases. In this audio presentation, Dr. Jeanne Morrison discusses topics that demonstrate professional behavior in the practicum setting, such as dressing professionally, punctuality, and communication. Please click here for the Transcript (PDF). Laureate Education (Producer). (2012b). Professional best practices [Interactive media]. Note: Retrieved from the Walden Library databases. In this audio segment, Dr. Jeanne Morrison provides an overview of best practices and tips for students engaged in the Practicum Experience. She discusses what activities are included in practicum hours, the importance of staying in touch with your Preceptor, and strategies for dealing with stress. Please click here for the Transcript (PDF). Laureate Education (Producer). (2012c). Professionalism and the practicum experience [Interactive media]. Note: Retrieved from the Walden Library databases. What is the Practicum Experience all about? What are the roles of the Faculty Member and the Preceptor? In this media presentation, Dr. Jeanne Morrison discusses these and other critical aspects of the Practicum Experience. She also provides an overview of the professional demeanor expected of all students throughout the Practicum Experience. Please click here for the Transcript (PDF).

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Enhancing Quality and Safety 2025

Assessment 1 Instructions: Enhancing Quality and Safety For this assessment, you will develop a 3-5 page paper that examines a safety quality issue pertaining to medication administration in a health care setting. You will analyze the issue and examine potential evidence-based and best-practice solutions from the literature as well as the role of nurses and other stakeholders in addressing the issue. Health care organizations and professionals strive to create safe environments for patients however, due to the complexity of the health care system, maintaining safety can be a challenge. Since nurses comprise the largest group of health care professionals, a great deal of responsibility falls in the hands of practicing nurses. Quality improvement (QI) measures and safety improvement plans are effective interventions to reduce medical errors and sentinel events such as medication errors, falls, infections, and deaths. A 2000 Institute of Medicine (IOM) report indicated that almost one million people are harmed annually in the United States, (Kohn et al., 2000) and 210,000–440,000 die as a result of medical errors (Allen, 2013). The role of the baccalaureate nurse includes identifying and explaining specific patient risk factors, incorporating evidence-based solutions to improving patient safety and coordinating care. A solid foundation of knowledge and understanding of safety organizations such as Quality and Safety Education for Nurses (QSEN), the Institute of Medicine (IOM), and The Joint Commission and its National Patient Safety Goals (NPSGs) program is vital to practicing nurses with regard to providing and promoting safe and effective patient care. You are encouraged to complete the Identifying Safety Risks and Solutions activity. This activity offers an opportunity to review a case study and practice identifying safety risks and possible solutions. We have found that learners who complete course activities and review resources are more successful with first submissions. Completing course activities is also a way to demonstrate course engagement. Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: Competency 1: Analyze the elements of a successful quality improvement initiative. Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs. Competency 2: Analyze factors that lead to patient safety risks. Explain factors leading to a specific patient-safety risk focusing on medication administration. Competency 4: Explain the nurse’s role in coordinating care to enhance quality and reduce costs. Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs. Identify stakeholders with whom nurses would need to coordinate to drive quality and safety enhancements with medication administration. Competency 5: Apply professional, scholarly, evidence-based strategies to communicate in a manner that supports safe and effective patient care. Communicate using writing that is clear, logical, and professional with correct grammar and spelling using current APA style. References Allen, M. (2013). How many die from medical mistakes in U.S. hospitals? Retrieved from https://www.npr.org/sections/health-shots/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals. Kohn, L. T., Corrigan, J., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system . Washington, DC: National Academy Press. Professional Context As a baccalaureate-prepared nurse, you will be responsible for implementing quality improvement (QI) and patient safety measures in health care settings. Effective quality improvement measures result in systemic and organizational changes, ultimately leading to the development of a patient safety culture. Scenario Consider the hospital-acquired conditions that are not reimbursed under Medicare/Medicaid, some of which are specific safety issues such as infections, falls, medication errors, and other concerns that could have been prevented or alleviated with the use of evidence-based guidelines. Choose a specific condition of interest surrounding a medication administration safety risk and incorporate evidence-based strategies to support communication and ensure safe and effective care. For this assessment: Analyze a current issue or experience in clinical practice surrounding a medication administration safety risk and identify a quality improvement (QI) initiative in the health care setting. Instructions The purpose of this assessment is to better understand the role of the baccalaureate-prepared nurse in enhancing quality improvement (QI) measures that address a medication administration safety risk. This will be within the specific context of patient safety risks at a health care setting of your choice. You will do this by exploring the professional guidelines and best practices for improving and maintaining patient safety in health care settings from organizations such as QSEN and the IOM. Looking through the lens of these professional best practices to examine the current policies and procedures currently in place at your chosen organization and the impact on safety measures for patients surrounding medication administration, you will consider the role of the nurse in driving quality and safety improvements. You will identify stakeholders in QI improvement and safety measures as well as consider evidence-based strategies to enhance quality of care and promote medication administration safety in the context of your chosen health care setting. Be sure that your plan addresses the following, which corresponds to the grading criteria in the scoring guide. Please study the scoring guide carefully so that you know what is needed for a distinguished score. Explain factors leading to a specific patient-safety risk focusing on medication administration. Explain evidence-based and best-practice solutions to improve patient safety focusing on medication administration and reducing costs. Explain how nurses can help coordinate care to increase patient safety with medication administration and reduce costs. Identify stakeholders with whom nurses would coordinate to drive safety enhancements with medication administration. Communicate using writing that is clear, logical, and professional, with correct grammar and spelling, using current APA style. Additional Requirements Length of submission: 3-5 pages, plus title and reference pages. Number of references: Cite a minimum of 4 sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old. APA formatting: References and citations are formatted according to current APA style. Portfolio Prompt : Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final Capstone course. Scoring Guide Use the scoring guide to understand how your assessment will be evaluated.

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ASSIGNMENT 2025

Details: Rate yourself using the results from the “Nurse Manager Skills Inventory”: http://www.aone.org/resources/nurse-manager-skills-inventory.pdf Write a reflection of 750-1,000 words in which you identify your strengths and weaknesses related to the four content areas below: Personal and professional accountability Career planning Personal journey disciplines Reflective practice reference behaviors/tenets Discuss how you will use your current leadership skill set to advocate for change in your workplace. Identify one personal goal for your leadership growth and discuss your implementation plan to achieve that goal. While APA format is not required for the body of this assignment, solid academic writing is expected and in-text citations and references should be presented using APA documentation guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are required to submit this assignment to Turnitin. Please refer to the directions in the Student Success Center.

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Medical Coding and Billing Sample Certification Questions 2025

4. Which one of the following statements accurately represents the practice known as unbundling? A. Combination codes are assigned separately in ICD-10-CM. B. Codes that should be grouped into one code are broken into separate codes to maximize physician reimbursement. C. ICD-10-PCS codes are broken into separate codes for congruent assignment. D. Codes listed as separate procedures are assigned individually. 5. Placing a catheter into the aorta or directly into an artery or vein is called A. brachiocephalic manipulation. B. third order placement. C. selective catheter placement. D. nonselective catheter placement. 6. What ICD-10-CM code would be assigned for a patient with acute tubule-interstitial nephritis? A. L50.0 B. Z02.6 C. N10 D. B96.2 7. The suffix -sis means A. inflammation. B. drooping. C. condition. D. process. 8. The concept of meaningful use pertains to A. medical office protocol and document organization. B. electronic health record implementation. C. resource management in the inpatient setting. D. categorization of patient information. 9. In what CPT code range is Surgical Pathology found? A. 88400–80499 B. 88000–80299 C. 88300–88309 D. 88515–88598 10. According to the CMS National Physician Fee Schedule, what is the conversion factor for basic life support mileage? A. $32.4726 B. $34.5741 C. $28.8457 D. $36.0666 11. A patient who was involved in a motor vehicle accident is taken to the hospital by ambulance and admitted to the hospital in critical care. The physician sees the patient for 74 minutes in critical care. The physician leaves to attend to other patients in the ICU and the NICU of the same hospital. Five hours later, the physician returns to the patient and continues to treat the patient in critical care for an additional 30 minutes. The patient spends a total of 104 minutes in critical care. What codes are assigned? A. 99291, 99292 B. 99292, 99293 C. 99291, 99291 D. 99292, 99292, 99293 12. The prefix endo- means A. beneath. B. outside of. C. adjacent to. D. within. 13. What is the CPT code for a three-view x-ray of the mandible? A. 70200 B. 70100 C. 70150 D. 70240 14. Rules of evidence control the A. amount of evidence that may be admitted during a civil trial. B. processes and procedures for question and answer sessions. C. documents that can be considered during jury trial. D. length of criminal court proceedings, but not civil court proceedings. 15. The ampulla, isthmus, interstitium, and fimbria are examples of A. implantation sites of ectopic pregnancy. B. incision sites for pacemaker insertion. C. membranes in the abdomen. D. bones in the ankle. 16. Code J9165 is assigned for intravenous diethylstilbestrol diphosphate. According to the code description, what dosage was administered? A. 20 mg B. 50 mg C. Up to 0.5 mg D. 250 mg 17. Members of the uniformed services, their families and survivors, and retired members and their families qualify for A. TRICARE. B. OIG Recovery. C. Medicare. D. Medicaid. 18. A patient comes to the emergency room complaining of abdominal pain. She was previously diagnosed with type I diabetes. She also complains of watery eyes, congestion, pressure in the sinuses, and difficulty breathing. Her final diagnoses are right lower quadrant abdominal pain, type I diabetes, acute sinusitis, and asthma. What CPT and ICD-10-CM codes are assigned? A. 99222, R18.91, E16.9, J01.91, J45.919 B. 99221, R17.41, E17.9, J01.90, J45.909 C. 99221, R10.31, E10.9, J01.90, J45.909 D. 99223, R14.31, E15.9, J01.90, J45.929 19. Under HIPAA, health care facilities must A. follow up with patients who repeatedly miss scheduled appointments for mandatory services. B. keep records of patients who refill prescriptions more than once within a three-month timeframe. C. maintain a clean, safe working environment. D. choose a privacy officer in accordance with HIPAA policies and procedures. 20. What is the ICD-10-CM code for unspecified acute pericarditis? A. I30.89 B. I30.9 C. I30 D. I30.79 21. What is the full code description for 25515? A. Open treatment of radial shaft fracture, includes internal fixation, when performed B. Closed treatment of ulnar shaft fracture; without manipulation C. Closed treatment of radial shaft fracture; without manipulation D. Open treatment of radial shaft fracture, includes internal fixation, when performed, and open treatment of distal radioulnar joint dislocation (Galeazzi fracture/dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex 22. Which of the following anatomical locations would contain the diaphysis? A. Metatarsal B. Diaphragm C. Septum D. Tibia 23. A patient recently became eligible for health insurance through her employer. Her health insurance is considered to be an 80-20 policy. Under the terms of an 80-20 policy, the insurer pays 80 percent and the insured pays 20 percent of expenses. This 80-20 policy is an example of A. coinsurance. B. prospective payment. C. capitation. D. case management. 24. The Outpatient Prospective Payment System (OPPS) pays A. an established rate for outpatient services in specific hospitals. B. a percentage of the national average for the same surgery performed in a different geographic location. C. 65% of the schedule C rate for all surgeries. D. subsidies to contain health care costs in rural facilities. 25. The study of disease is called A. physiology. B. pathology. C. urology. D. neurology. 26. Superficial injuries such as abrasions or contusions are A. not coded when associated with more severe injuries of the same site. B. queried to determine if the injuries are confined to the same site. C. coded when associated with more severe injuries of the same site. D. coded only when debridement is performed. 27. Another name for XXY syndrome is A. Turner’s syndrome. B. Cooley’s anemia. C. Klinefelter syndrome. D. Huntington’s chorea. 28. The method that physicians use to bill for each service or visit individually rather than on a pre-paid basis is called A. fee-for-service. B. capitation. C. pre-paid care. D. managed care. 29. A physician has a meeting with a pharmaceutical sales representative. During the course of the conversation, the physician reveals the diagnosis and past family, medical, and social history of a patient currently being treated with one of the medications that the sales representative is selling. In this situation, the doctor could be sued for A. invasion of privacy. B. malfeasance. C. undue harm and fraud. D. malice. 30. A patient is prescribed a medication that narrows the blood vessels and raises her blood pressure. The medication is most likely a A. tranquilizer. B. cardiogenic. C. vasoconstrictor. D. cardiotonic 31. Physicians typically refer to anatomical locations using directional terms, which are often A. paired in opposites. B. used primarily by chiropractors. C. used to describe surgical incisions. D. referenced horizontally. 32. The study of tissue disease using macroscopic or microscopic analysis is called A. immunology. B. histopathology. C. cytopathology. D. microbiology. 33. A physician obtains cells from the bone marrow cavity using a needle and a syringe. How would this procedure be coded? A. 36575 B. 37328 C. 38220 D. 35092 34. What is Medicare Part D? A. The component of Medicare Part A that covers outpatient surgeries B. Add-on coverage for prescription drugs provided through insurance companies approved by Medicare C. Supplemental coverage for war veterans and their dependents D. Add-on coverage for dental procedures 35. A female patient is seen for her annual gynecological examination. During the examination, the physician performs a test to detect cervical cancer. This test is called a/an A. immunoassay test. B. Pap smear. C. carcinoembryonic antigen test. D. mycobacterial culture. 36. A physician is called to the intensive care unit for a patient with second-degree burns sustained on 55% of his body while cooking in the kitchen where he works. The physician sees the patient in the critical care unit for two hours, leaves the unit, and returns later the same day to provide an additional hour of critical care. What ICD-10-CM and CPT codes would be assigned? A. L91.8, 99291 × 2, 99292 × 4 B. R53.81, 99291, 99293 × 5 C. Z30.09, 99293, 99294 × 2 D. T31.50, 99291, 99292 × 4 37. A change in the tissues and cells within a specific area on or in the body is called a A. lesion. B. cyst. C. neoplasm. D. tumor. 38. Information about a patient can becan be released for research under the terms of HIPAA, only if A. the patient signs an authorization immediately upon admission. B. the research is critical for technological development. C. the patient has authorized the release and only a limited amount of information is released. D. researchers obtain authorization from the admitting physician. 39. A patient is diagnosed with breast cancer and undergoes a partial mastectomy. What CPT code would be assigned? A. 19305 B. 19307 C. 19304 D. 19301 40. To conform to the HIPAA Privacy Rule, which of the following safeguards must be maintained in health care facilities? A. Immunization and injection safeguards B. Reasonable administrative, technical, and physical safeguards C. ICD-7 provisional safeguards D. Hazardous waste protection safeguards 41. A patient sustains a fracture of the femur while playing football in a nearby park. What ICD-10-CM code would be assigned? A. S72.001A B. S72.009A C. S72.003A D. S49.006A 42. According to the guidelines for medical records outlined in the Health Insurance Portability and Accountability Act (HIPAA), patients A. have the right to have errors reviewed by a hospital administrator. B. have the right to correct errors in identification data only. C. have the right to have errors in their medical records corrected. D. do not have the right to have errors corrected, as the data has been previously verified by the physician. 43. Modifier -23 indicates that A. two surgeons performed a procedure. B. a procedure was performed bilaterally. C. a physician reviewed and interpreted a radiology procedure. D. the patient received general anesthesia for a procedure that would ordinarily be performed with local or no anesthesia. 44. The Health Insurance Portability and Accountability Act (HIPAA) was created for the purpose of A. streamlining claims processing and reducing paperwork through electronic transmission. B. stabilizing administrative costs and productivity. C. decreasing employee turnover and reducing the volume of new hire paperwork. D. modifying legal and ethical issues surrounding medical records retention. 45. A patient is seen in the emergency room complaining of abdominal pain in the left lower quadrant. It’s determined that the patient is experiencing inflammation of the pancreas, which is also called A. pancreaticoduodonal arcade. B. pancreatitis. C. pancreatolysis. D. pancreatonia. 46. A 55-year-old patient was injured while working as a carpenter on a construction site. While framing the roof of a two-story house, he fell and hit his head. He was diagnosed with a concussion to the left side of his head, and underwent a right frontal parietal craniotomy with removal of a subdural hematoma. During the patient’s period of recovery, he was given a medication that resulted in a rash on his abdomen. The physician conducted an expanded problem focused history and exam, with straightforward medical decision making. What CPT code(s) should be assigned? A. 99251 B. 99252 C. 99292, 99291 D. 99253 47. Taking certain steps to protect PHI from being accidentally released to individuals who don’t need to know the information is called the A. minimum necessary standard. B. privacy management statute. C. health information guardianship guideline. D. information provision standard. 48. The main term represents the most basic aspect of a disease or condition. For example, the main term of a diagnosis involving a broken arm is A. broken. B. break. C. fracture. D. arm. 49. Performing a daily check for viruses and malware is one of the A. requirements of the Help Desk. B. routine aspects of software maintenance. C. sensible guidelines for Internet use in health care facilities. D. functions of HIM encoders. 50. A coder overhears a confidential statement made outside of the court, and then, when called to testify, repeats the statement as being truth. This is an example of A. cross-examination. B. hearsay. C. speculation. D. a direct quote. 51. A patient receives two venous pressure clamps for hemodialysis. What HCPCS Level II code is assigned? A. A4751 B. A4751 × 2 C. A4918 × 2 D. A4918 52. The process of removing tissue for histopathology is called A. shaving. B. debridement. C. excision. D. biopsy. 53. A coder would assign modifier -53 to report A. dental procedures. B. repeat procedures. C. anesthesia administration. D. procedures cancelled due to the patient’s condition. 54. Alternative dispute resolution (ADR) allows A. resolving medical malpractice suits by submitting pretrial depositions. B. lawyer-to-lawyer mediation during trial recess. C. mediating disputes with a judge in the presence of the bailiff. D. litigants to resolve disputes prior to or after the start of litigation. 55. Code range 99231–99233 pertains to A. initial hospital care. B. subsequent hospital care. C. consultation services. D. hospital discharge services. 56. A patient comes to the emergency room complaining of abdominal pain, nausea, and intractable vomiting. Unable to pinpoint the source of the patient’s complaints, the physician decides to admit the patient to the hospital. After conducting a complete history and examination, the patient’s final diagnosis is determined to be chronic duodenal ulcer. The patient remains hospitalized for three days. The physician sees the patient on the day of discharge. What ICD-10 and CPT codes are assigned? A. 99234, N17.9 B. 99223, I48.91 C. 99238, K26.7 D. 99291, D63.1 57. The specific guidelines that constitute a valid release of information under the HIPAA Privacy Rule are described as A. OIG specifications. B. E/M levels. C. considerations in relation to risk management. D. core elements. 58. The suffix –centesis means A. abnormal condition. B. calculus or stone. C. a surgical puncture for fluid removal. D. separation, breakdown, destruction. 59. The code for an ESWL would be found in the A. Urinary and Male Genital Systems of CPT. B. Chemotherapy section of HCPCS. C. Digestive System of CPT. D. Cardiovascular System of CPT. 60. A female patient is diagnosed with breast cancer of the lower-inner quadrant of the right breast. The patient undergoes a modified radical mastectomy of the right breast in an attempt to circumvent the spread of the cancer to any secondary anatomical sites. The procedure was performed in three stages. In addition to the radical mastectomy, the physician also performed a right breast biopsy to treat the breast tumor in the lower-inner quadrant. What ICD-10-CM and CPT codes are assigned? A. 19307-58-RT, 19101-59-RT, C50.311 B. 15852-58, Z48.01 C. 11602, 15240, C50.312 D. 19307-RT, 19101-RT, C50.211 61. A patient comes to the ambulatory surgery center for a fusion of the cervical spine. Prior to the beginning of the surgery, the patient suffers an allergic reaction to the anesthesia shortly after it’s administered. Because of this reaction, the surgery is not performed. What code would be assigned as the first-listed diagnosis? A. The observation code B. The reason that the surgery was scheduled to be performed C. The allergy code D. The anesthesia administration 62. Anti-inflammatory drugs applied to the skin to relieve skin disorders are called A. topical corticosteroids. B. antiseptics. C. keratolytics. D. astringents. 63. The _______ nerve sends visual data to the occipital lobe of the brain. A. abducens B. trochlear C. optic D. oculomotor 64. The root word OBSTETR/O means A. pregnancy. B. cesarean. C. midwife. D. birth. 65. The root word ENTER/O means A. tooth. B. stomach. C. intestine. D. secretion. 66. What code would be assigned for gastropathy? A. K29.7 B. K41.31 C. K31.9 D. K41.2 67. A patient comes to the physician’s office complaining of neck irritation. The physician examines her neck and notes that she has a 15 cm neck scar. Upon further examination, the physician notes that the neck scar requires extensive debridement and retention sutures. The physician performs a dermabrasion to treat the neck scar and then closes the complex wound with the sutures. What ICD-10 and CPT codes are assigned? A. 13132, 13133 × 2, L90.5 B. 13132, 13133 × 3, H81.09, L92.9 C. 13133-51, 13131-79, L60.0 D. 13132, L76.82 68. The bulbourethral gland is found in the _______ system. A. neurological B. cardiovascular C. male genital D. female genital 69. A tethered health record allows patients to A. restructure insurance copayments. B. use a secure portal to access their own records. C. compare their health records to the records of patients with similar diagnoses. D. amend the diagnoses listed in the health record. 70. A patient is diagnosed with lymphocytic lymphoma. Another patient is seen several weeks later and is diagnosed with histiocytic lymphoma. Both of these diagnoses are examples of _______ lymphoma. A. basic B. Hodgkin’s C. non-Hodgkin’s D. Burkitt’s 71. A patient receives a blood glucose monitor. What HCPCS Level II code would be assigned? A. E0976 B. E0607 C. E0562 D. E4752 72. A good compliance program in the health care setting includes A. HHS surveillance. B. regular tracking and monitoring of coding activities. C. meetings with compliance officers. D. regular audit consultations with trustees of the AAPC. 73. A patient with numerous symptoms is seen in the laboratory for a general health panel to gauge her overall physical well-being. What CPT code would be assigned for a general health panel? A. 80051 B. 82136 C. 84135 D. 80050 74. Code 71030-TC indicates a/an A. complete chest x-ray, four views, technical component only. B. incomplete chest x-ray, two views, technical and professional component. C. complete chest x-ray, two views, technical component only. D. incomplete chest x-ray, three views, technical and professional component 75. If patients choose to obtain copies of their medical records, under the terms of HIPAA, providers can A. also fulfill requests for prescription data. B. reschedule office visits to allow time to update medical records. C. complete employee paperwork. D. charge a reasonable fee for providing copies of those records. 76. A patient comes to the clinic complaining of fever, diarrhea, nausea, and vomiting. The patient is diagnosed with salmonella meningitis. What ICD-10-CM code would be assigned? A. A23.24 B. A02.21 C. A05.26 D. A07.21 77. A patient comes to the emergency room complaining of right knee pain. He states that he was playing baseball the previous evening and accidentally fell when sliding into first base. The physician obtains an expanded problem focused history and examination, as well as a two-view x-ray of the right knee. The physician reviews the x-ray, as well as the notes in the medical record, and renders a diagnosis of osteoarthritis of the knee. The physician performs a patellofemoral arthroplasty to repair the knee. What ICD-10-CM and CPT codes are assigned? A. 27477, M17.12 B. 27506-RT, N17.11 C. 27477-RT, D17.39 D. 27447-RT, M17.11 78. Provision of security against a hurt, loss, or damage with specific cash payments is called A. copayment. B. protection. C. indemnity. D. secured loss. 79. HCPCS modifier –E2 indicates that the patient had a surgical procedure performed on the A. lower left eyelid. B. upper left eyelid. C. upper right eyelid. D. lower right eyelid. 80. When is code 58120 assigned? A. The code is assigned for permanent pacemaker insertion. B. The code has been deleted and cannot be assigned. C. The code is assigned for a patient undergoing dilatation and curettage. D. The code is assigned as an add-on code. 81. Epithelial tissue that secretes its products directly into the bloodstream is made of A. extracellular matrix. B. endocrine gland cells. C. endoplasmic reticulum. D. columnar epithelial cells. 82. Which of the following modifiers would be assigned for a moribund patient? A. P4 B. P1 C. P5 D. P3 83. The anatomical location of the calyx is the A. spine. B. brain. C. arm. D. kidney. 84. Which one of the following requirements is outlined in the guidelines established in HIPAA’s Privacy Rule? A. Hospital administrators must encrypt data within older data files. B. Physicians must not disclose patient information to consulting physicians. C. Patients must receive notice if their information will be used or disclosed to third parties. D. Managers must secure medical records immediately following patient admission. 85. The I-10 helps coders classify patient A. morbidity and mortality. B. management information. C. evaluation files. D. reimbursement data. 86. During a routine examination, a male patient is diagnosed with an elevated PSA. The physician performs a biopsy of the prostate with a rectal ultrasound to pinpoint the source of the problem. Which CPT and ICD-10-CM codes would be assigned? A. 55725, 76000-26, R93.6 B. 55700, 76872-26, R97.2 C. 55734, 73200-26, R97.2 D. 55720, 74000-26, R97.3 87. Health care practitioners must maintain records of privacy policy practices and procedures for A. 20 years. B. 10 months. C. 2 years. D. 6 years. 88. A patient comes to the emergency department of a rural hospital. He complaints of problems sleeping, foot swelling, and insomnia. After a detailed review of the patient’s history and a detailed examination, the patient is diagnosed with chronic renal insufficiency, nephrotic syndrome, and anemia, based on the values listed in his blood test. The patient undergoes a biopsy of the left and right kidneys under physician guidance. A CT scan is also used for guidance and needle placement. A follow-up CT scan with physician review and interpretation is also performed. What ICD-10 and CPT codes are assigned? A. 50500-73, 51200-LT, C79.2, C61 B. 50200-RT-LT, 50310-RT, 51252-26, E46, N18.9, N04.9 C. 51000, 50310-59-LT, J90, Z90.12, E85.4 D. 50200-50, 50200-59-RT, 77012.26, N18.9, N04.9, D64.9 89. Data stored in a health care facility must A. comply with HIPAA rules and must be maintained securely. B. adhere to OIG policies and procedures. C. be organized in accordance with state standards for electronic data interchange. D. conform to the physician’s expectations for data storage. 90. Health care practitioners who submit fraudulent bills to increase reimbursement may A. be blacklisted according to geographic location. B. be listed in the Coding Directory of Fraudulent Billing published annually by the Department of Health and Human Services. C. be reported to the Office of the Attorney General. D. face financial penalties or, in some cases, imprisonment. 91. Which of the following anesthesia modifiers indicates a normal, healthy patient? A. P3 B. P1 C. P4 D. P2 92. When coding burns, coders should A. classify all burns as acute burns. B. assign separate codes for each burn site. C. assign the code for third-degree burns. D. assign the code for chronic burns. 93. A 65-year-old patient is admitted to the hospital for 48 hours to receive treatment from her physician. This patient would be covered under A. Medicare Part D. B. Medicare Part A. C. Medicare Part B. D. Medicare Part C. 94. A patient comes to the clinic complaining of ongoing headaches. The headaches began one week prior and have persisted ever since. A lumbar spinal tap is performed to pinpoint the source of the patient’s headaches. What CPT and ICD-10-CM codes are assigned? A. 62270, G44.1 B. 62270, G74.3 C. 62141, G46.8 D. 62272, G46.9 95. What code would be assigned for a tube pericardiostomy? A. 33210 B. 33026 C. 33015 D. 33050 96. What is the code description for 65101-LT? A. Removal of ocular implant performed laterally B. Fine needle aspiration of orbital contents on the left third of the orbit C. Biopsy of cornea performed on the lower third of the cornea D. Enucleation of eye, without implant, performed on the left side of the body 97. Another name for diazepam is A. Flexeril. B. Valium. C. Norflex. D. Myolastan. 98. The gatekeeper concept refers to the operation of A. prospective payment organizations. B. retrospective payment organizations. C. ambulatory payment surgery centers. D. health maintenance organizations. 99. The CPT code for thrombolysis is A. 93000. B. 92975. C. 92920. D. 93797. 100. According to HIPAA, a patient’s information may be released for A. paternity testing. B. research. C. determining premiums based on a patient’s past medical history. D. transferring electronic medical records to remote locations. 101. Which of the following statements is true of the Affordable Care Act? A. It includes a provision for military service members who served in Afghanistan. B. It requires health care facilities to maintain health records for at least 10 years. C. It makes it mandatory for patients to carry health insurance. D. It offers parents supplementary coverage for dependents with chronic illness 102. A patient is seen in the physician’s office after the results of an earlier mammogram demonstrated microcalcification in the right breast as well as a breast lesion. The lesion is excised using needle localization. The patient’s final diagnosis is fibrosclerosis of the right breast. What CPT and ICD-10-CM codes are assigned? A. 19120-RT, L10.11 B. 19125-RT, N60.31 C. 19126-LT, M25.1 D. 19123-RT, H16.11 103. A coder would assign a Q code as a temporary code for A. holistic treatments for spinal procedures. B. durable medical equipment only. C. procedures or services only. D. procedures, services, and supplies 104. Which of the following forms is used to bill outpatient charges? A. HCFA-1350 or CMS-650 B. HCFA-1400 or CMS-1540 C. AMA-14 or UCF-1250 D. CMS-1500 or UCF-1500. 105. During a routine examination, a patient indicates that she is taking an antihypertensive medication that causes her kidneys to excrete more urine. These antihypertensive medications are called A. calcium-channel blockers. B. anticoagulants. C. beta blockers. D. diuretics. 106. A patient comes to the emergency room complaining of postnasal drip, frequent nosebleeds, headaches, and difficulty breathing. She is diagnosed with a deviated nasal septum, hypertrophy of the turbinate, and inflammation of the ethmoid sinuses. The physician performs an endoscopic ethmoidectomy of the left nasal sinus, septoplasty, and turbinate excision. What ICD-10-CM and CPT codes are assigned? A. 31255, 30520, 30130, J34.2, J34.3, J32.2 B. 31255-LT, 30520-51, 30130-51, J34.2, J34.3, J32.2 C. 31230, 30520, J34.2, J34.3, J32.2 D. 31230-51, 30520-LT, J34.2 107. A physician is analyzing specific organs in a particular region of the patient’s body. In her notes, she refers to the transverse or cross-sectional plane, which divides the body A. inferiorly. B. vertically. C. horizontally. D. bilaterally. 108. A patient comes to the emergency room after having dinner at a restaurant, where she began to experience chest tightness during the meal. She is seen for a cardiology consultation in the outpatient setting for a diagnosis of chest tightness. Which CPT and ICD-10-CM codes would be assigned? A. 99245, R07.89 B. 99244, R07.59 C. 99242, R17.52 D. 99243, R25.96 109. Providers that receive reimbursement after health care services have been provided are being compensated under the _______ system. A. prospective payment B. retrospective payment C. capitation D. UCR 110. The regulations in HIPAA apply to three groups of individual and corporate entities, each involved in electronic medical records transfer. These groups are collectively referred to as A. health care administrators. B. covered entities. C. provisional health care data collectors. D. protected personnel. 111. The largest salivary glands are called the _______ glands. A. amylase B. parotid C. sublingual D. submandibular 112. Which modifier indicates a staged or related procedure performed during the postoperative period? A. -59 B. -57 C. -58 D. -54 113. The voluntary program that’s financed through a combination of payments from general federal revenues and premiums paid by beneficiaries who elect to participate is called A. CHAMPVA. B. Medicare Part B. C. Medicaid. D. TRICARE. 114. What is the full code description for 33536? A. Repair of postinfarction ventricular septal defect, with or without myocardial resection B. Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts C. Repair of double outlet right ventricle with intraventricular tunnel repair D. Closure of atrioventricular valve (mitral or tricuspid) by suture or patch 115. Categorically needy and medically needy patients may qualify for A. Medicaid. B. CHAMPVA. C. Champus. D. Medicare Advantage 116. ICD-10-CM code S50.351A indicates that the patient has a superficial foreign body of the right elbow. The A indicates that A. code S50.351A should be assigned to page 1 of the medical record, but not subsequent pages. B. this is the patient’s first encounter. C. this is the patient’s second encounter for the same original diagnosis. D. code S50.351A should be sequenced before secondary codes. 117. The foramen ovale is found in which anatomical location? A. Fibula B. Heart C. Pancreas D. Liver 118. A new patient is seen in a clinic for complaints of shortness of breath, fever, difficulty swallowing, runny nose, and cough. The physician performs a detailed history, detailed examination, and medical decision making of low complexity. The physician also obtains a chest x-ray and lab workup. Based on the results of the diagnostic tests, the physician renders a diagnosis of upper respiratory tract infection and lymphadenopathy. What ICD-10 and CPT codes are assigned? A. 99203, J06.9, R59.0 B. 99202, D63.1, J45.909 C. 99213, R06.82, F10.229 D. 99215, M19.011, R13.10 119. A patient has a disorder in which the bone marrow produces an overabundance of white blood cells. What is this disorder called? A. Leukemia B. Hemophilia C. Coagulation D. Septicemia 120. A patient is diagnosed with acne. What ICD-10-CM code would be assigned? A. L74.2 B. L72.3 C. L70.0 D. L73.1 121. A coder assigns a HCPCS Level II code to a patient’s medical record. The code description reads as follows: Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/flushing syringe, administration set tubing, dressings, tape. Based on this description, which HCPCS Level II code was assigned? A. B4072 B. B4125 C. B4034 D. B4278 122. The Health Insurance Portability and Accountability Act (HIPAA) standards were developed to A. ensure that coders could easily access each medical record. B. determine the structure of insurance carrier payments for health care practitioners. C. protect patient confidentiality when health information is transferred electronically. D. define XLTM standards for health records management. 123. Another name for third-party contractors who have access to medical information is A. business associates. B. insurance administrators. C. healthcare vendors. D. covered entities. 124. Bones inside the nose are called A. maxillae. B. turbinates. C. ethmoids. D. septal mucosa. 125. The atrioventricular (tricuspid) valve is located in the A. fibula. B. lung. C. heart. D. brain. 126. Another term for disease evolution is A. exacerbation. B. remission. C. pathogenesis. D. morphology. 127. The vitreous humor can be found in the A. ear. B. tongue. C. nose. D. eye. 128. The codes for pacemakers and implantable defibrillators would be found in what section of CPT? A. 33202–33273 B. 33200–33205 C. 33437–33537 D. 33533–33799 129. The HIPAA Privacy Rule indicates that A. practitioners should disclose only the minimum amount of health information necessary for the purpose of the disclosure. B. physicians may release medical information at their own discretion. C. restrictions on information disclosure exist only for patients with life-threatening illnesses. D. the level of information disclosure permitted is based on the nature of the procedure. 130. The abbreviation INH indicates what route of drug administration? A. Inhaled and intrathecal administration B. Inhaled and intravenous administration C. Intrathecal injection D. Inhalant solution 131. A patient comes to the clinic complaining of nausea, vomiting, fever, dizziness, and intermittent confusion. The physician conducts a detailed history and examination and reviews the patient’s lab results. The patient is diagnosed with pyelonephritis and is scheduled for an ultrasound to review the state of the kidneys and other organs. What CPT and ICD-10-CM codes are assigned? A. 76775-TC, N15 B. 76775-26, N10 C. 73256-TC, M11 D. 71010-26, B12 132. What happens when HIPAA rules conflict with state law? A. Conflicting state rules are overridden by federal law. B. The interpretation of HIPAA rules is left to the physician’s discretion. C. State laws overrule federal law. D. The Supreme Court’s decision becomes final in binding arbitration 133. Which of the following statements is true of the olfactory nerve? A. It’s susceptible to erosion due to Peyronie’s disease. B. It’s located in the mitral valve and helps to circulate blood throughout the heart. C. It conveys the fluid from lymph glands to other areas of the body. D. It’s found in the nose and allows the senses to detect and distinguish odors. 134. The first step in EHR implementation is A. structuring the timeline for EHR implementation. B. analyzing the content of the traditional medical record. C. conducting an assessment of the goals, needs, and financial stability of the health care practice. D. reviewing the list of established patients currently being seen in the practice. 135. The outcome of delivery code should be A. omitted from the maternal record for stillborn delivery. B. assigned to the newborn record only. C. assigned to the maternal record when a delivery occurs. D. assigned to both the maternal and newborn records. 136. A patient is seen in the office for complaints of dizziness and insomnia. The physician records a chronological description of specific elements of the patient’s condition. This chronological description is called the A. history of present illness. B. examination. C. review of systems. D. chief complaint. 137. What is the CPT code description for 64483? A. Injection(s) anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level B. Injection, anesthetic agent, sphenopalatine ganglion C. Injection(s) anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, multiple levels D. Transforaminal epidural injection under ultrasound guidance 138. Releasing genetic information is forbidden under the terms of HIPAA because it may A. allow immediate family members to have access to a patient’s medical records. B. require physicians to fulfill contractual obligations for treatments provided in ambulatory surgery centers. C. indicate susceptibility to a future illness, without the patient actually being diagnosed with the condition. D. not be successfully transmitted to all health care facilities. 139. Prescribing combination drugs that contain multiple medications to cut down on the number of pills patients take on a daily basis A. compounds the drugs’ effectiveness. B. increases the likelihood of compliance. C. decreases the frequency of drug interactions. D. supports good body function. 140. A patient who has paralysis of all four limbs is called A. quadriplegic. B. paraplegic. C. tetraplegic. D. hemiplegic. 141. Which of the following is true about HIPAA national standards? A. The national standards apply to any electronic data interchange. B. The national standards apply only to data exchange within a specified geographical region. C. The national standards do not apply to surgical procedures in the inpatient setting. D. The national standards do not apply to data exchanged within a claim clearinghouse. 142. A patient undergoes an appendectomy and later returns to the operating room for a related procedure the same day. Which modifier should be assigned to the CPT code? A. -51 B. -AA C. -78 D. -76 143. The portion of health insurance that an insured pays before he or she is entitled to receive benefits from an insurance plan is called the A. deductible. B. OPPS reimbursement. C. capitation. D. coinsurance. 144. A patient is seen in follow-up two weeks after undergoing cholecystectomy. During the follow-up examination, the physician notes that the abdominal wound has not yet healed. The patient undergoes a split-thickness autograft due to a nonhealing left lower abdominal wound that’s 10 square centimeters. Which CPT and ICD-10-CM codes would be assigned? A. 15350, L52.64 B. 15250, L34.74 C. 15200, L85.64 D. 15100, L76.82 145. The Female Genital System subsection covers which CPT code range? A. 56203–56303 B. 56607–56809 C. 56300–56499 D. 56405–58999 146. What ICD-10-CM code would be assigned for unilateral primary osteoarthritis of the right hip? A. M16.12 B. M16.30 C. M16.11 D. M16.10 147. Which of the following anatomical locations would contain the superior vena cava? A. Hip B. Nose C. Lungs D. Heart 148. A patient receives an injection of nandrolone decanoate. What HCPCS Level II code would be assigned? A. J2323 B. J3530 C. J2320 D. J2300 149. The suffix –stasis means A. breakdown. B. stopping and controlling. C. kinetic. D. flow. 150. A patient undergoes a sigmoidoscopy. The coder would assign CPT code A. 45852. B. 45330. C. 45397. D. 45919.

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