Case Study: Mr. C. 2025

Case Study: Mr. C. It is necessary for an RN-BSN-prepared nurse to demonstrate an enhanced understanding of the pathophysiological processes of disease, the clinical manifestations and treatment protocols, and how they affect clients across the life span. Evaluate the Health History and Medical Information for Mr. C., presented below. Based on this information, formulate a conclusion based on your evaluation, and complete the Critical Thinking Essay assignment, as instructed below. Health History and Medical Information Health History Mr. C., a 32-year-old single male, is seeking information at the outpatient center regarding possible bariatric surgery for his obesity. He currently works at a catalog telephone center. He reports that he has always been heavy, even as a small child, gaining approximately 100 pounds in the last 2-3 years. Previous medical evaluations have not indicated any metabolic diseases, but he says he has sleep apnea and high blood pressure, which he tries to control by restricting dietary sodium. Mr. C. reports increasing shortness of breath with activity, swollen ankles, and pruritus over the last 6 months. Objective Data: Height: 68 inches; weight 134.5 kg BP: 172/98, HR 88, RR 26 3+ pitting edema bilateral feet and ankles Fasting blood glucose: 146 mg/dL Total cholesterol: 250 mg/dL Triglycerides: 312 mg/dL HDL: 30 mg/dL Serum creatinine 1.8 mg/dL BUN 32 mg/dl Critical Thinking Essay In 750-1,000 words, critically evaluate Mr. C.’s potential diagnosis and intervention(s). Include the following: Describe the clinical manifestations present in Mr. C. Describe the potential health risks for obesity that are of concern for Mr. C. Discuss whether bariatric surgery is an appropriate intervention. Assess each of Mr. C.’s functional health patterns using the information given. Discuss at least five actual or potential problems can you identify from the functional health patterns and provide the rationale for each. (Functional health patterns include health-perception, health-management, nutritional, metabolic, elimination, activity-exercise, sleep-rest, cognitive-perceptual, self-perception/self-concept, role-relationship, sexuality/reproductive, coping-stress tolerance.) Explain the staging of end-stage renal disease (ESRD) and contributing factors to consider. Consider ESRD prevention and health promotion opportunities. Describe what type of patient education should be provided to Mr. C. for prevention of future events, health restoration, and avoidance of deterioration of renal status. Explain the type of resources available for ESRD patients for nonacute care and the type of multidisciplinary approach that would be beneficial for these patients. Consider aspects such as devices, transportation, living conditions, return-to-employment issues. You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice. Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. 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. Refer to the LopesWrite Technical Support articles for assistance. RUBRIC Attempt Start Date: 30-Sep-2019 at 12:00:00 AM Due Date: 06-Oct-2019 at 11:59:59 PM Maximum Points: 120.0 Case Study: Mr. C. No of Criteria: 11 Achievement Levels: 5 CriteriaAchievement LevelsDescriptionPercentageUnsatisfactory0.00 %Less Than Satisfactory75.00 %Satisfactory79.00 %Good89.00 %Excellent100.00 %Content80.0 Clinical Manifestations of Mr. C.10.0Clinical manifestations are omitted.Clinical manifestations are partially presented. There are major omissions and inaccuracies.Clinical manifestations are summarized. An overview of the general symptoms is presented. Some findings are incomplete.Subjective and objective clinical manifestations are described. Overall, the clinical manifestations are accurate and reflect observed and perceived signs and symptoms.Subjective and objective clinical manifestations are detailed. The clinical manifestations are accurate and clearly report the observed and perceived signs and symptoms.Potential Health Risks for Obesity and Bariatric Surgery10.0Potential health risks for obesity and whether bariatric surgery is an appropriate intervention are not discussed.A partial summary on the potential health risks for obesity and whether bariatric surgery is an appropriate intervention is presented. There are major inaccuracies. More information is needed. No evidence or rationale is provided to support discussion.A summary on the potential health risks for obesity and whether bariatric surgery is an appropriate intervention is presented. There are some inaccuracies. More evidence or rationale is needed to support discussion.A discussion on the potential health risks for obesity is presented. A discussion on whether bariatric surgery is an appropriate intervention is presented but needs some evidence or rationale for support.A detailed discussion of the potential health risks for obesity is presented. A through and compelling discussion on whether bariatric surgery is an appropriate intervention is presented. The discussion is well-developed and supported by evidence and additional rationale.Functional Health Patterns15.0Actual or potential problems based on the assessment of functional health patterns of the patient are omitted or are irrelevant for the patient and his condition. The overall criteria for this assignment are not met.At least four actual or potential problems identified from the functional health patterns are presented. The identified problems are not entirely relevant for the patient and his condition. Rationale or evidence is required for support.At least five actual or potential problems identified from the functional health patterns are summarized. The identified problems are generally relevant for the patient and his condition. Some rationale and evidence is required for support.Five or more actual or potential problems identified from the functional health patterns are discussed. The identified problems are relevant for the patient and his condition. Overall, the discussion is supported by rationale and evidence. Some detail is needed for clarity or accuracy.Five or more actual or potential problems identified from the functional health patterns are discussed. The discussion is insightful, and the identified problems are highly relevant for the patient and his condition. The discussion is well-supported by rationale and evidence.Staging and Contributing Factors of End-Stage Renal Disease (ESRD)10.0Staging and contributing factors for ESRD are omitted or inaccurate.Staging of ESRD is partially summarized. The contributing factors for ESRD are vague. There are inaccuracies.The staging of ESRD and the contributing factors for ESRD are generally explained. Some information is required; there are minor inaccuracies.The staging of ESRD and the contributing factors for ESRD are explained. Some information or detail is needed for clarity or detail.The staging of ESRD and the contributing factors for ESRD are explained. The information is accurate and reflects contemporary practice and research.Health Promotion and Prevention for ESRD20.0Patient education for the prevention of future events, health restoration, and avoidance of deterioration of renal status is omitted.Patient education for the prevention of future events, health restoration, and avoidance of deterioration of renal status is partially summarized. There are inaccuracies. Some aspects are not relevant for the patient and his health status.Patient education for the prevention of future events, health restoration, and avoidance of deterioration of renal status is generally described. There are minor inaccuracies. Overall, the proposed items are relevant for the patient and his health status. Some evidence and rationale are needed to support the discussion.Patient education for the prevention of future events, health restoration, and avoidance of deterioration of renal status is described. The proposed items are relevant and appropriate for the patient and his health status. Evidence and rationale generally support the discussion.Patient education for the prevention of future events, health restoration, and avoidance of deterioration of renal status is thoroughly described. The proposed items are clearly presented and highly relevant and supportive of patient and his health status. Strong evidence and rationale generally support the discussion.Resources for ESRD Patients for Nonacute Care and Multidisciplinary Approach15.0Types of resources available for ESRD patients for nonacute care, and the beneficial types of multidisciplinary approaches, are not discussed.An incomplete explanation on the types of resources available for ESRD patients for nonacute care, and the beneficial types of multidisciplinary approaches, is presented. There are major inaccuracies.A general explanation on the types of resources available for ESRD patients for nonacute care, and the beneficial types of multidisciplinary approaches, is presented. There are minor inaccuracies. Some additional information is required.An explanation on the types of resources available for ESRD patients for nonacute care, and the beneficial types of multidisciplinary approaches, is presented. Some detail is required for clarity.A clear and detailed explanation on the types of resources available for ESRD patients for nonacute care, and the beneficial types of multidisciplinary approaches, is presented. The explanation demonstrates insight into both resources and multidisciplinary approaches for nonacute care for ESRD patients. Organization, Effectiveness, and Format20.0 Thesis Development and Purpose5.0Paper lacks any discernible overall purpose or organizing claim.Thesis is insufficiently developed or vague. Purpose is not clear.Thesis is apparent and appropriate to purpose.Thesis is clear and forecasts the development of the paper. Thesis is descriptive and reflective of the arguments and appropriate to the purpose.Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.Argument Logic and Construction5.0Statement of purpose is not justified by the conclusion. The conclusion does not support the claim made. Argument is incoherent and uses noncredible sources.Sufficient justification of claims is lacking. Argument lacks consistent unity. There are obvious flaws in the logic. Some sources have questionable credibility.Argument is orderly but may have a few inconsistencies. The argument presents minimal justification of claims. Argument logically, but not thoroughly, supports the purpose. Sources used are credible. Introduction and conclusion bracket the thesis.Argument shows logical progression. Techniques of argumentation are evident. There is a smooth progression of claims from introduction to conclusion. Most sources are authoritative.Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.Mechanics of Writing (includes spelling, punctuation, grammar, language use)5.0Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, or word choice are present.Some mechanical errors or typos are present, but they are not overly distracting to the reader. Correct sentence structure and audience-appropriate language are used.Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.Writer is clearly in command of standard, written, academic English.Paper Format (use of appropriate style for the major and assignment)2.0Template is not used appropriately, or documentation format is rarely followed correctly.Appropriate template is used, but some elements are missing or mistaken. A lack of control with formatting is apparent.Appropriate template is used. Formatting is correct, although some minor errors may be present.Appropriate template is fully used. There are virtually no errors in formatting style.All format elements are correct.Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)3.0Sources are not documented.Documentation of sources is inconsistent or incorrect, as appropriate to assignment and style, with numerous formatting errors.Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.Sources are documented, as appropriate to assignment and style, and format is mostly correct.Sources are completely and correctly documented, as appropriate to assignment and style, and format is free of error. Total Percentage 100

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Data Analysis and Quality Improvement Initiative Proposal 2025

Prepare an 8–10-page data analysis and quality improvement initiative proposal based on a health issue of professional interest to you. The audience for your analysis and proposal is the nursing staff and the interprofessional team who will implement the initiative. “A basic principle of quality measurement is: If you can’t measure it, you can’t improve it” (Agency for Healthcare Research and Quality, 2013). Health care providers are on an endless quest to improve both care quality and patient safety. This unwavering commitment requires hospitals and care givers to increase their attention and adherence to treatment protocols to improve patient outcomes. Health informatics, along with new and improved technologies and procedures, are at the core of virtually all quality improvement initiatives. The data gathered by providers, along with process improvement models and recognized quality benchmarks, are all part of a collaborative, continuing effort. As such, it is essential that professional nurses are able to correctly interpret, and effectively communicate information revealed on dashboards that display critical care metrics. Show More Toggle Drawer Questions to Consider As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment. Reflect on QI initiatives focused on measuring and improving patient outcomes with which you are familiar. How important is the role of nurses in QI initiatives? What quality improvement initiatives have made the biggest difference? Why? When a QI initiative does not succeed as planned, what steps are taken to improve or revise the effort? Toggle Drawer Resources Required Resources MSN Program Journey Please review this guide for your degree program. It can help you stay on track for your practicum experience, so you may wish to bookmark it for later reference. MSN Program Journey | Transcript . Show More Assessment Instructions Preparation In this assessment, you will propose a quality improvement (QI) initiative proposal based on a health issue of professional interest to you. The QI initiative proposal will be based on an analysis of dashboard metrics from a health care facility. You have one of two options: Option 1 If you have access to dashboard metrics related to a QI initiative proposal of interest to you: Analyze data from the health care facility to identify a health care issue or area of concern. You will need access to reports and data related to care quality and patient safety. If you work in hospital setting, contact the quality management department to obtain the data you need. You will need to identify basic information about the health care setting, size, and specific type of care delivery related to the topic that you identify. You are expected to abide by HIPAA compliance standards. Option 2 If you do not have access to a dashboard or metrics related to a QI initiative proposal: You may use the hospital data set provided in the media piece titled Vila Health: Data Analysis. You will analyze the data to identify a health care issue or area of concern. You will follow the same instructions and provide the same deliverables as your peers who select Option 1. Instructions Analyze dashboard metrics related to the selected issue. Provide the selected data set in the proposal. Assess the stability of processes or outcomes. Delineate any problematic variations or performance failures. Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement. Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team. Outline a QI initiative proposal based on the selected health issue and data analysis. Identify target areas for improvement. Define what processes can be modified to improve outcomes. Propose strategies to improve quality. Define interprofessional roles and responsibilities as they relate to the QI initiative. Provide recommendations for effective communication strategies for the interprofessional team to ensure the success of the QI initiative. Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style. Note : Remember, you can submit all, or a portion of, your draft to Smarthinking for feedback, before you submit the final version of your analysis for this assessment. However, be mindful of the turnaround time for receiving feedback, if you plan on using this free service. The numbered points below correspond to grading criteria in the scoring guide. The bullets below each grading criterion further delineate tasks to fulfill the assessment requirements. Be sure that your Quality Improvement Initiative Evaluation addresses all of the content below. You may also want to read the scoring guide to better understand the performance levels that relate to each grading criterion. Analyze data to identify a health care issue or area of concern. Identify the type of data you are analyzing (from your institution or from the media piece). Discuss why the data matters, what it is telling you, and what is missing. Analyze dashboard metrics and provide the data set in the proposal. Present dashboard metrics related to the selected issue. Delineate any problematic variations or performance failures. Assess the stability of processes or outcomes. Evaluate the quality of the data and what can be learned from it. Identify trends, outcome measures and information needed to calculate specific rates. Analyze what metrics indicate opportunities for quality improvement. Outline a QI initiative proposal based on a selected health issue and supporting data analysis. Identify benchmarks aligned to existing QI initiatives set by local, state, or federal health care policies or laws. Identify existing QI initiatives related to the selected issue, and explain why they are insufficient. Identify target areas for improvement, and define what processes can be modified to improve outcomes. Propose evidence-based strategies to improve quality. Evaluate QI initiatives on the selected health issue with existing quality indicators from other facilities, government agencies, and non-governmental bodies on quality improvement. Analyze challenges that meeting prescribed benchmarks can pose for a heath care organization and the interprofessional team. Integrate interprofessional perspectives to lead quality improvements in patient safety, cost effectiveness, and work-life quality. Define interprofessional roles and responsibilities as they relate to the data and the QI initiative. Explain how you would you make sure that all relevant roles are fully engaged in this effort. Explain what non-nursing concepts would you incorporate into the initiative? Identify how outcomes to measure the effect of the intervention affect the interprofessional team. Briefly reflect on the impact of the proposed initiative on work-life quality of the nursing staff and interprofessional team. Describe how work-life quality is improved or enriched by the initiative. Apply effective communication strategies to promote quality improvement of interprofessional care. Identify the kind of interprofessional communication strategies that will be effective to promote and ensure the success of this performance improvement plan or quality improvement initiative. In addition to writing, identify communication models (like CUS, SBAR) that you would include in your initiative proposal. Communicate evaluation and analysis in a professional and effective manner, writing content clearly and logically with correct use of grammar, punctuation, and spelling. Integrate relevant sources to support arguments, correctly formatting citations and references using current APA style. Submission Requirements Length of submission: 8–10 double-spaced, typed pages, not including title and reference page. Number of references: Cite a minimum of five sources (no older than seven years, unless seminal work) of scholarly, peer-reviewed, or professional evidence that support your evaluation, recommendations, and plans.

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Global Healthcare Comparison Matrix and Narrative Statement 2025

Assignment: Global Healthcare Comparison Matrix and Narrative Statement If you talk about a possible poor health outcome, do you believe that outcome will occur? Do you believe eye contact and personal contact should be avoided? You would have a difficult time practicing as a nurse if you believed these to be true. But they are very real beliefs in some cultures. Differences in cultural beliefs, subcultures, religion, ethnic customs, dietary customs, language, and a host of other factors contribute to the complex environment that surrounds global healthcare issues. Failure to understand and account for these differences can create a gulf between practitioners and the public they serve. In this Assignment, you will examine a global health issue and consider the approach to this issue by the United States and by one other country. To Prepare: Review the World Health Organization’s (WHO) global health agenda and select one global health issue to focus on for this Assignment. Select at least one additional country to compare to the U.S. for this Assignment. Reflect on how the global health issue you selected is approached in the U.S. and in the additional country you selected. Review and download the Global Health Comparison Matrix provided in the Resources. The Assignment: (1- to 2-page Global Health Comparison Matrix; 1-page Plan for Social Change) Part 1: Global Health Comparison Matrix Focusing on the country you selected and the U.S., complete the Global Health Comparison Matrix. Be sure to address the following: Consider the U.S. national/federal health policies that have been adapted for the global health issue you selected from the WHO global health agenda. Compare these policies to the additional country you selected for study. Explain the strengths and weaknesses of each policy. Explain how the social determinants of health may impact the global health issue you selected. Be specific and provide examples. Using the WHO’s Organization’s global health agenda as well as the results of your own research, analyze how each country’s government addresses cost, quality, and access to the global health issue selected. Explain how the health policy you selected might impact the health of the global population. Be specific and provide examples. Explain how the health policy you selected might impact the role of the nurse in each country. Explain how global health issues impact local healthcare organizations and policies in both countries. Be specific and provide examples. Part 2: A Plan for Social Change Reflect on the global health policy comparison and analysis you conducted in Part 1 of the Assignment and the impact that global health issues may have on the world, the U.S., your community, as well as your practice as a nurse leader. In a 1-page response, create a plan for social change that incorporates a global perspective or lens into your local practice and role as a nurse leader. Explain how you would advocate for the incorporation of a global perspective or lens into your local practice and role as a nurse leader. Explain how the incorporation of a global perspective or lens might impact your local practice and role as a nurse leader. Explain how the incorporation of a global perspective or lens into your local practice as a nurse leader represents and contributes to social change. Be specific and provide examples.

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Assignment: Policy/Regulation Fact Sheet 2025

As a professional nurse, you are expected to apply your expertise to patient care. On occasion, you will also be expected to share that expertise. With evolving technology and continuous changes to regulations designed to keep up these changes, there is usually a need to share information and expertise to inform colleagues, leadership, patients, and other stakeholders. In this Assignment, you will study a recent nursing informatics-related healthcare policy, and you will share the relevant details via a fact sheet designed to inform and educate. To Prepare: Review the Resources on healthcare policy and regulatory/legislative topics related to health and nursing informatics. Consider the role of the nurse informaticist in relation to a healthcare organization’s compliance with various policies and regulations, such as the Medicare Access and CHIP Reauthorization Act (MACRA). Research and select one health or nursing informatics policy (within the past 5 years) or regulation for further study. The Assignment: (1 page) Create a 1-page fact sheet that your healthcare organization could hypothetically use to explain the health or nursing informatics policy/regulation you selected. Your fact sheet should address the following: Briefly and generally explain the policy or regulation you selected. Address the impact of the policy or regulation you selected on system implementation. Address the impact of the policy or regulation you selected on clinical care, patient/provider interactions, and workflow. Highlight organizational policies and procedures that are/will be in place at your healthcare organization to address the policy or regulation you selected. Be specific. APA 3 to 5 References less than 5 years

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CPT Medical Coding Assigment 2025

ANSWER ALL THE QUESTIONS -MAKE SURE THEY ARE ALL CORRECT SEND BACK TO ME WITHIN 48 HOURS 1.  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. Managers must secure medical records immediately following patient admission. C. Patients must receive notice if their information will be used or disclosed to third parties. D. Physicians must not disclose patient information to consulting physicians. 2.  A tethered health record allows patients to A. amend the diagnoses listed in the health record. B. use a secure portal to access their own records. C. restructure insurance copayments. D. compare their health records to the records of patients with similar diagnoses. 3.  A patient sustains a fracture of the femur while playing football in a nearby park. What ICD-10-CM code would be assigned? A. S72.003A B. S72.001A C. S49.006A D. S72.009A 4.  Which one of the following structures is part of the male secondary genitalia? A. Gonads B. Urethra C. Testes D. Vulva 5.  What is the full code description for 25515? A. 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 B. Open treatment of radial shaft fracture, includes internal fixation, when performed C. Closed treatment of radial shaft fracture; without manipulation D. Closed treatment of ulnar shaft fracture; without manipulation 6.  Another name for XXY syndrome is A. Turner’s syndrome. B. Huntington’s chorea. C. Cooley’s anemia. D. Klinefelter syndrome. 7.  The hammer-shaped bone in the middle ear is called the A. cochlea. B. stapes. C. malleus. D. incus. 8.  Codes beginning with the letter K are related to the _______ system. A. circulatory B. digestive C. endocrine D. sensory 9.  Which of the following statements is true of the olfactory nerve? A. It’s located in the mitral valve and helps to circulate blood throughout the heart. B. It’s found in the nose and allows the senses to detect and distinguish odors. C. It’s susceptible to erosion due to Peyronie’s disease. D. It conveys the fluid from lymph glands to other areas of the body. 10.  A patient has a Foley catheter inserted prior to a planned surgical procedure. How is this coded? A. 55520 B. 52630 C. 51702 D. 52601 11.  What is the CPT code for simple drainage of a finger abscess? A. 26010 B. 26020 C. 26034 D. 26011 12.  Usually, a comprehensive EHR includes A. secure standalone cluster controllers for hospitals in rural environments. B. software, hardware, implementation, and future program upgrades. C. coaxial cable connections between mainframe servers only. D. customizable XHRLT processes for ambulatory surgery centers. 13.  What ICD-10-CM code would be assigned for a patient with acute tubule-interstitial nephritis? A. Z02.6 B. B96.2 C. L50.0 D. N10 14.  An echocardiogram shows that the wall of a patient’s artery has dilated. The dilation has resulted in a saclike swelling. This swelling is called a/an A. aneurysm. B. cyst. C. mesenteric venous thrombosis. D. benign tumor. 15.  What is Medicare Part D? A. The component of Medicare Part A that covers outpatient surgeries B. Supplemental coverage for war veterans and their dependents C. Add-on coverage for dental procedures D. Add-on coverage for prescription drugs provided through insurance companies approved by Medicare 16.  The suffix –stasis means A. flow. B. stopping and controlling. C. breakdown. D. kinetic. 17.  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 both the maternal and newborn records. D. assigned to the maternal record when a delivery occurs. 18.  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. 99292, 99292, 99293 B. 99291, 99291 C. 99291, 99292 D. 99292, 99293 19.  The root word OBSTETR/O means A. cesarean. B. pregnancy. C. birth. D. midwife. 20.  Coders can use the Microsoft Office suite to create spreadsheets in A. Excel. B. Lotus 1-2-3. C. PowerPoint. D. Word. 21.  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. -76 D. -78 22.  The concept of meaningful use pertains to A. categorization of patient information. B. medical office protocol and document organization. C. resource management in the inpatient setting. D. electronic health record implementation. 23.  The study of disease is called A. pathology. B. urology. C. physiology. D. neurology. 24.  Modifier -23 indicates that A. a procedure was performed bilaterally. B. the patient received general anesthesia for a procedure that would ordinarily be performed with local or no anesthesia. C. a physician reviewed and interpreted a radiology procedure. D. two surgeons performed a procedure. 25.  Releasing genetic information is forbidden under the terms of HIPAA because it may A. indicate susceptibility to a future illness, without the patient actually being diagnosed with the condition. B. allow immediate family members to have access to a patient’s medical records. C. not be successfully transmitted to all health care facilities. D. require physicians to fulfill contractual obligations for treatments provided in ambulatory surgery centers. 26.  Provision of security against a hurt, loss, or damage with specific cash payments is called A. protection. B. secured loss. C. copayment. D. indemnity. 27.  Physicians typically refer to anatomical locations using directional terms, which are often A. used primarily by chiropractors. B. used to describe surgical incisions. C. referenced horizontally. D. paired in opposites. 28.  The code for an ESWL would be found in the A. Digestive System of CPT. B. Urinary and Male Genital Systems of CPT. C. Chemotherapy section of HCPCS. D. Cardiovascular System of CPT. 29.  What code would be assigned for a tube pericardiostomy? A. 33015 B. 33050 C. 33026 D. 33210 30.  HCPCS modifier –E2 indicates that the patient had a surgical procedure performed on the A. upper left eyelid. B. upper right eyelid. C. lower left eyelid. D. lower right eyelid. 31.  Providers that receive reimbursement after health care services have been provided are being compensated under the _______ system. A. UCR B. capitation C. retrospective payment D. prospective payment 32.  What happens when HIPAA rules conflict with state law? A. The interpretation of HIPAA rules is left to the physician’s discretion. B. The Supreme Court’s decision becomes final in binding arbitration. C. Conflicting state rules are overridden by federal law. D. State laws overrule federal law. 33.  The method that physicians use to bill for each service or visit individually rather than on a pre-paid basis is called A. pre-paid care. B. managed care. C. fee-for-service. D. capitation. 34.  The suffix -sis means A. process. B. drooping. C. inflammation. D. condition. 35.  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. 99215, M19.011, R13.10 B. 99203, J06.9, R59.0 C. 99213, R06.82, F10.229 D. 99202, D63.1, J45.909 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. T31.50, 99291, 99292 × 4 C. Z30.09, 99293, 99294 × 2 D. R53.81, 99291, 99293 × 5 37.  A physician who cares for a patient throughout an entire pregnancy, from beginning to end, is providing A. comprehensive prenatal management. B. routine global obstetric care. C. puerperal obstetric care. D. antenatal global supervision. 38.  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. pancreatonia. C. pancreatolysis. D. pancreatitis. 39.  The covering on the brain and spinal cord in the dorsal cavity is called the A. sheath. B. peritoneum. C. ganglia. D. meninges. 40.  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. protected personnel. C. provisional health care data collectors. D. covered entities. 41.  The retention period is the amount of time that A. insurance billing documents must be retained in filing cabinets. B. medications must be kept in the medical office. C. records must be kept. D. HIM employee files must be retained upon termination or resignation. 42.  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. undue harm and fraud. C. malice. D. malfeasance. 43.  Epithelial tissue that secretes its products directly into the bloodstream is made of A. endoplasmic reticulum. B. endocrine gland cells. C. extracellular matrix. D. columnar epithelial cells. 44.  A physician obtains cells from the bone marrow cavity using a needle and a syringe. How would this procedure be coded? A. 38220 B. 36575 C. 35092 D. 37328 45.  The vitreous humor can be found in the A. eye. B. nose. C. tongue. D. ear. 46.  The study of tissue disease using macroscopic or microscopic analysis is called A. microbiology. B. histopathology. C. immunology. D. cytopathology. 47.  Placing a catheter into the aorta or directly into an artery or vein is called A. selective catheter placement. B. brachiocephalic manipulation. C. third order placement. D. nonselective catheter placement. 48.  A patient is diagnosed with acne. What ICD-10-CM code would be assigned? A. L74.2 B. L70.0 C. L72.3 D. L73.1 49.  Members of the uniformed services, their families and survivors, and retired members and their families qualify for A. OIG Recovery. B. Medicaid. C. Medicare. D. TRICARE. 50.  A 35-year-old male is brought to the emergency department with memory disturbance after being accidentally exposed to lead paint. What ICD-10-CM codes should be assigned? A. T42.4X1A, R40.0 B. T23.009A, R23.8 C. T56.0X1A, R41.3 D. T57.0X1A, R10.9 51.  Health care practitioners who submit fraudulent bills to increase reimbursement may A. be listed in the Coding Directory of Fraudulent Billing published annually by the Department of Health and Human Services. B. be reported to the Office of the Attorney General. C. be blacklisted according to geographic location. D. face financial penalties or, in some cases, imprisonment. 52.  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 anesthesia administration B. The allergy code C. The reason that the surgery was scheduled to be performed D. The observation code 53.  The root word ENTER/O means A. secretion. B. intestine. C. stomach. D. tooth. 54.  When coding burns, coders should A. assign separate codes for each burn site. B. assign the code for chronic burns. C. classify all burns as acute burns. D. assign the code for third-degree burns. 55.  Which of the following forms is used to bill outpatient charges? A. CMS-1500 or UCF-1500. B. AMA-14 or UCF-1250 C. HCFA-1400 or CMS-1540 D. HCFA-1350 or CMS-650 56.  A significant, separately identifiable E/M service performed by the same physician in conjunction with another service performed on the same day would be reported using what modifier? A. -TC B. -47 C. -90 D. -25 57.  Which of the following modifiers would be assigned for a moribund patient? A. P5 B. P1 C. P4 D. P3 58.  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. information provision standard. C. privacy management statute. D. health information guardianship guideline. 59.  Codes for plastic repair of the perineum are found in which code range? A. 57000–57426 B. 57000–57010 C. 57150–57180 D. 56800–56810 60.  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. speculation. B. hearsay. C. a direct quote. D. cross-examination. 61.  A nurse sustains an accidental needle pinprick to the right third finger while administering an injection. If an employee has an occupational exposure, what must happen? A. An in-service meeting should be held for all employees who may potentially be exposed to the same occupational hazard. B. The employee should contact the proper authorities. C. Hospital administrators must maintain the nurse’s medical record for the remainder of her employment plus an additional 30 years. D. The guidelines for OSHA should be included in the employment file. 62.  Another name for third-party contractors who have access to medical information is A. healthcare vendors. B. insurance administrators. C. covered entities. D. business associates. 63.  A patient receives two venous pressure clamps for hemodialysis. What HCPCS Level II code is assigned? A. A4751 B. A4918 × 2 C. A4751 × 2 D. A4918 64.  The anatomical location of the calyx is the A. arm. B. kidney. C. spine. D. brain. 65.  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, G74.3 B. 62270, G44.1 C. 62141, G46.8 D. 62272, G46.9 66.  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. B4278 B. B4125 C. B4072 D. B4034 67.  To conform to the HIPAA Privacy Rule, which of the following safeguards must be maintained in health care facilities? A. ICD-7 provisional safeguards B. Immunization and injection safeguards C. Reasonable administrative, technical, and physical safeguards D. Hazardous waste protection safeguards 68.  A patient receives a blood glucose monitor. What HCPCS Level II code would be assigned? A. E0976 B. E0562 C. E4752 D. E0607 69.  Alternative dispute resolution (ADR) allows A. lawyer-to-lawyer mediation during trial recess. B. mediating disputes with a judge in the presence of the bailiff. C. resolving medical malpractice suits by submitting pretrial depositions. D. litigants to resolve disputes prior to or after the start of litigation. 70.  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 B. B. Medicare Part A. C. Medicare Part D. D. Medicare Part C. 71.  Another term for disease evolution is A. remission. B. pathogenesis. C. morphology. D. exacerbation. 72.  In relation to HIPAA regulations regarding the manner in which information can be disclosed, which of the following statements is true? A. Protected health information must be disclosed only when the patient is unable to testify in a court proceeding. B. Protected health information may never be disclosed. C. Protected health information may be disclosed in a judicial or administrative proceeding if the request is made through an order from a court or administrative tribunal. D. Protected health information may be disclosed only within a deposition. 73.  The gatekeeper concept refers to the operation of A. ambulatory payment surgery centers. B. prospective payment organizations. C. retrospective payment organizations. D. health maintenance organizations. 74.  Which of the following procedures would be performed to treat prostate cancer? A. Transurethral resection of the prostate (TURP) B. Meniscectomy C. Vasoconstriction D. Arthroscopy 75.  What diagnosis code would be assigned for a patient diagnosed with Type 2 diabetes mellitus with diabetic nephropathy? A. E11.21 B. E11.01 C. E11.22 D. E11.9 76.  Another name for Medicare Advantage is A. Medicare Part A. B. Medicare Part C. C. Medicare Part B. D. Medicare Part D. 77.  The codes for pacemakers and implantable defibrillators would be found in what section of CPT? A. 33200–33205 B. 33437–33537 C. 33202–33273 D. 33533–33799 78.  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. 99223, R14.31, E15.9, J01.90, J45.929 D. 99221, R10.31, E10.9, J01.90, J45.909 79.  What is considered to be protected health information (PHI)? A. Any health information that can identify the individual to whom it refers B. Records pertaining to ancestry C. Statistical data compiled for research purposes only D. Census data 80.  In what CPT code range is Surgical Pathology found? A. 88515–88598 B. 88300–88309 C. 88400–80499 D. 88000–80299 81.  The federal law that requires a patient’s written consent prior to disclosure of certain medical information by government agencies is called the A. Health Care Amendment of 1976. B. Privacy Act of 1974. C. Health Information Law of 2002. D. Medical Consent Act of 1965. 82.  Data stored in a health care facility must A. be organized in accordance with state standards for electronic data interchange. B. adhere to OIG policies and procedures. C. conform to the physician’s expectations for data storage. D. comply with HIPAA rules and must be maintained securely. 83.  Under HIPAA, health care facilities must A. maintain a clean, safe working environment. B. choose a privacy officer in accordance with HIPAA policies and procedures. C. keep records of patients who refill prescriptions more than once within a three-month timeframe. D. follow up with patients who repeatedly miss scheduled appointments for mandatory services. 84.  What CPT code would be assigned for a colpocentesis? A. 57135 B. 57859 C. 57600 D. 57020 85.  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. vasoconstrictor. C. cardiotonic. D. cardiogenic. 86.  If patients choose to obtain copies of their medical records, under the terms of HIPAA, providers can A. complete employee paperwork. B. charge a reasonable fee for providing copies of those records. C. reschedule office visits to allow time to update medical records. D. also fulfill requests for prescription data. 87.  According to the CMS National Physician Fee Schedule, what is the conversion factor for basic life support mileage? A. $34.5741 B. $32.4726 C. $28.8457 D. $36.0666 88.  According to HIPAA, a patient’s information may be released for A. determining premiums based on a patient’s past medical history. B. paternity testing. C. research. D. transferring electronic medical records to remote locations. 89.  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. A07.21 B. A02.21 C. A05.26 D. A23.24 90.  Which of the following anatomical locations would contain the diaphysis? A. Metatarsal B. Tibia C. Septum D. Diaphragm 91.  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. 71010-26, B12 C. 76775-26, N10 D. 73256-TC, M11 92.  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. 15852-58, Z48.01 B. 19307-58-RT, 19101-59-RT, C50.311 C. 19307-RT, 19101-RT, C50.211 D. 11602, 15240, C50.312 93.  The concept of confidentiality can be substantiated based on the right of A. easement. B. constitutionality. C. totality. D. privacy. 94.  The abbreviation INH indicates what route of drug administration? A. Inhaled and intrathecal administration B. Intrathecal injection C. Inhalant solution D. Inhaled and intravenous administration 95.  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. 19123-RT, H16.11 B. 19126-LT, M25.1 C. 19125-RT, N60.31 D. 19120-RT, L10.11 96.  What is the code description for 65101-LT? A. Removal of ocular implant performed laterally B. Biopsy of cornea performed on the lower third of the cornea C. Enucleation of eye, without implant, performed on the left side of the body D. Fine needle aspiration of orbital contents on the left third of the orbit 97.  The foramen ovale is found in which anatomical location? A. Fibula B. Heart C. Liver D. Pancreas 98.  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. diuretics. D. beta blockers. 99.  Code range 99231–99233 pertains to A. initial hospital care. B. hospital discharge services. C. consultation services. D. subsequent hospital care. 100.  A 7-year-old patient is seen in follow-up after an earlier diagnosis of excessive daytime sleepiness. The physician obtains a sleep study and then reviews and interprets the results. What CPT and ICD-10-CM codes are assigned? A. 95810-26, R40.0 B. 95811-TC, J14.0 C. 95815-TC, G45.0 D. 95812-26, H40.0 101.  If a physician provides preoperative management only to a patient prior to surgery, which modifier would be added to the surgery code? A. -56 B. -44 C. -32 D. -91 102.  The HIPAA Privacy Rule indicates that A. restrictions on information disclosure exist only for patients with life-threatening illnesses. B. the level of information disclosure permitted is based on the nature of the procedure. C. practitioners should disclose only the minimum amount of health information necessary for the purpose of the disclosure. D. physicians may release medical information at their own discretion. 103.  The atrioventricular (tricuspid) valve is located in the A. fibula. B. lung. C. heart. D. brain. 104.  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. horizontally. B. vertically. C. inferiorly. D. bilaterally. 105.  A health care practitioner who knowingly submits false statements to obtain federal health care reimbursement is guilty of A. Medicare fraud. B. DHS claim misrepresentation. C. Health Insurance Privacy and Portability misuse. D. Medicaid omission. 106.  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. do not have the right to have errors corrected, as the data has been previously verified by the physician. C. have the right to have errors in their medical records corrected. D. have the right to correct errors in identification data only. 107.  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. 108.  A coder would assign modifier -53 to report A. procedures cancelled due to the patient’s condition. B. anesthesia administration. C. dental procedures. D. repeat procedures. 109.  A patient is diagnosed with breast cancer and undergoes a partial mastectomy. What CPT code would be assigned? A. 19305 B. 19301 C. 19304 D. 19307 110.  Which of the following anesthesia modifiers indicates a normal, healthy patient? A. P1 B. P4 C. P3 D. P2 111.  A coder searching for codes pertaining to tissue expanders would find them in what section of CPT? A. 16200–16799 B. 12000–12300 C. 11960–11971 D. 15000–15999 112.  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. 99223, I48.91 B. 99238, K26.7 C. 99234, N17.9 D. 99291, D63.1 113.  What is the code for excision of Meckel’s diverticulum? A. 44820 B. 44700 C. 44800 D. 44850 114.  The Health Insurance Portability and Accountability Act (HIPAA) was created for the purpose of A. modifying legal and ethical issues surrounding medical records retention. B. stabilizing administrative costs and productivity. C. decreasing employee turnover and reducing the volume of new hire paperwork. D. streamlining claims processing and reducing paperwork through electronic transmission. 115.  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. 116.  The I-10 helps coders classify patient A. management information. B. morbidity and mortality. C. evaluation files. D. reimbursement data. 117.  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. capitation. C. prospective payment. D. case management. 118.  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. 119.  Bones inside the nose are called A. septal mucosa. B. maxillae. C. turbinates. D. ethmoids. 120.  A group of doctors who belong to the same network and provide discounted services to enrollees is called a/an A. Managed Care Organization (MCO). B. Individual Practice Association (IPA). C. Health Maintenance Organization (HMO). D. Preferred Provider Organization (PPO). 121.  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. Pap smear. B. carcinoembryonic antigen test. C. mycobacterial culture. D. immunoassay test. 122.  Businesses that provide support services, like administration, to individual physicians are called A. integrated provider organizations. B. medical foundations. C. management services organizations. D. physician-hospital organizations 123.  What is the full code description for 33536? A. Repair of double outlet right ventricle with intraventricular tunnel repair B. Repair of postinfarction ventricular septal defect, with or without myocardial resection C. Closure of atrioventricular valve (mitral or tricuspid) by suture or patch D. Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts 124.  The CPT code for thrombolysis is A. 93000. B. 92920. C. 93797. D. 92975. 125.  Which of the following statements is true of the Affordable Care Act? A. It offers parents supplementary coverage for dependents with chronic illness. B. It makes it mandatory for patients to carry health insurance. C. It includes a provision for military service members who served in Afghanistan. D. It requires health care facilities to maintain health records for at least 10 years. 126.  A qualifying circumstance indicates a A. situation that makes anesthesia administration more difficult. B. condition that reduces the average recovery time for a particular type of surgery. C. situation that may extend a patient’s length of stay in the hospital setting. D. condition that impacts the outcome of surgery. 127.  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. capitation. B. OPPS reimbursement. C. coinsurance. D. deductible. 128.  A good compliance program in the health care setting includes A. regular audit consultations with trustees of the AAPC. B. HHS surveillance. C. meetings with compliance officers. D. regular tracking and monitoring of coding activities. 129.  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. 99253 B. 99252 C. 99292, 99291 D. 99251 130.  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. 55720, 74000-26, R97.3 B. 55700, 76872-26, R97.2 C. 55734, 73200-26, R97.2 D. 55725, 76000-26, R93.6 131.  When is code 58120 assigned? A. The code is assigned for a patient undergoing dilatation and curettage. B. The code has been deleted and cannot be assigned. C. The code is assigned for permanent pacemaker insertion. D. The code is assigned as an add-on code. 132.  A patient is seen for 167 minutes of critical care. What CPT codes would be assigned? A. 99291, 99292 × 4 B. 99291, 99292 × 2 C. 99291, 99292 × 3 D. 99291, 99292 × 5 133.  The prefix endo- means A. outside of. B. within. C. beneath. D. adjacent to. 134.  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. 99243, R25.96 B. 99242, R17.52 C. 99244, R07.59 D. 99245, R07.89 135.  The prefix sub- means A. above. B. horizontal. C. under. D. lateral. 136.  What CPT code range is used to code for a limited lymphadenectomy? A. 38700–38780 B. 38562–38564 C. 39501–39599 D. 37501–37650 137.  The process of removing tissue for histopathology is called A. excision. B. shaving. C. debridement. D. biopsy. 138.  Which of the following anatomical locations would contain the superior vena cava? A. Heart B. Nose C. Hip D. Lungs 139.  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. chief complaint. B. review of systems. C. examination. D. history of present illness. 140.  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 × 3, H81.09, L92.9 B. 13133-51, 13131-79, L60.0 C. 13132, 13133 × 2, L90.5 D. 13132, L76.82 141.  The first step in EHR implementation is A. analyzing the content of the traditional medical record. B. conducting an assessment of the goals, needs, and financial stability of the health care practice. C. structuring the timeline for EHR implementation. D. reviewing the list of established patients currently being seen in the practice. 142.  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. 15200, L85.64 B. 15250, L34.74 C. 15350, L52.64 D. 15100, L76.82 143.  A patient is diagnosed with severe sepsis and septic shock after experiencing a severe drop in blood pressure. What ICD-10-CM code would be assigned? A. T79.4 B. T81.12 C. R65.21 D. R65.10 144.  A patient has a disorder in which the bone marrow produces an overabundance of white blood cells. What is this disorder called? A. Septicemia B. Coagulation C. Leukemia D. Hemophilia 145.  Which modifier indicates a staged or related procedure performed during the postoperative period? A. -59 B. -54 C. -57 D. -58 146.  The Female Genital System subsection covers which CPT code range? A. 56203–56303 B. 56405–58999 C. 56607–56809 D. 56300–56499 147.  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. 82136 B. 84135 C. 80051 D. 80050 148.  A patient undergoes a sigmoidoscopy. The coder would assign CPT code A. 45919. B. 45852. C. 45330. D. 45397. 149.  Code 71030-TC indicates a/an A. complete chest x-ray, four views, technical component only. B. incomplete chest x-ray, three views, technical and professional component. C. complete chest x-ray, two views, technical component only. D. incomplete chest x-ray, two views, technical and professional component. 150.  Health care practitioners must maintain records of privacy policy practices and procedures for A. 2 years. B. 20 years. C. 6 years. D. 10 months.

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