1. The patient presented in the ED at 10 p.m., was seen and treated, and

1. The patient presented in the ED at 10 p.m., was seen and treated, and left the ED at 3 p.m. the following afternoon. What is the patient’s status? a. Inpatient b. Outpatient c. ED d. Emergent care 2. The patient presented in the ED at 5 a.m. complaining of chest pain. Tests were done in the ED. The physician wrote an order to move the patient to observation status at 10 a.m. and the patient was transferred to telemetry. At 2 p.m. additional testing confirmed an acute myocardial infarction and the physician wrote an order to admit. The patient remained in telemetry, where he was treated until he expired at 11 p.m. that night. What is the patient’s status at discharge? a. Outpatient, because he wasn’t moved from telemetry. b. Inpatient, because the order triggered inpatient status. c. Outpatient, because he was admitted and discharged (expired) on the same day. d. Inpatient, because he was moved to a nursing unit. 3. The Medicare patient was seen in the ED for chest pain on Monday. On Wednesday, the patient returned to the ED and was admitted for treatment of a myocardial infarction. How should the Monday ED encounter and the Wednesday inpatient admission be handled? a. The Monday ED visit and the Wednesday inpatient visit should be billed separately because the diagnosis is not the same. b. The Monday and Wednesday ED visits should be changed to inpatient status and combined with the Wednesday inpatient admission. c. The Monday ED visit and the Wednesday ED visit should be combined and billed separately from the Wednesday inpatient admission. d. The Monday ED visit charges and the Wednesday ED visit charges should be combined with the Wednesday inpatient admission. 4. There are several physicians on staff who continue to write “urosepsis” in the patient charts. The term “urosepsis” has no meaning in the ICD-10-CM code set. Coders repeatedly have to query the physicians to ask for a definitive diagnosis. What is the most efficient way to solve the problem? a. The HIM director should speak to the physicians and tell them to write “urinary tract infection” instead of “urosepsis.” b. Patient financial services should meet with the physicians to educate them. c. CDI staff should be alert to this documentation issue so they query the term while the patient is still in house, and the physicians should be counseled by the chief medical officer or CDI liaison regarding the correct documentation. d. The physicians should be placed on suspension until they learn to document correctly. 5. Which key performance indicator reflects that CDI is working to ensure complete documentation of patient care? a. Reconciliation data comparing concurrent CDI queries with the final code list for the case. b. Percentage of changes in DRG. c. Increase in CMI d. All of the above 6. The ED is creating a paper form for staff to request charge corrections. The form must contain all of the data required to reverse the incorrect charge and post the corrected charge. What essential data is missing from this form? Charge Error Correction Request Form Charge Error: Service Date Posting Date Description G/L account HCPCS/CPT Code Quantity Price Correction Service Date Description G/L account HCPCS/CPT Code Quantity Price Requestor name, date, and signature: _________________________________________ Approval name, date, and signature: __________________________________________ a. Patient medical record number b. Billing date c. Patient account number d. Posting date of the correction 7. Your hospital has an outpatient dialysis unit. Every month, the same three blood tests are ordered for every patient, in addition to other patient-specific tests. What is an efficient way to facilitate this recurring situation by leveraging your system capabilities? a. Include an exploding charge in the chargemaster to order all three tests with one entry. b. Train patient registration to enter all three charges. c. Have the physician’s staff enter the order. d. Program the lab system to post a single result for the three orders. 8. In order to capture a medication administration, the nurse calls up the patient account on the system, then scans the barcode on the medication as well as the patient’s wristband. The system matches the medication order and the patient identity. This is an example of what type of control? a. Corrective b. Detective c. Preventive d. Internal 9. The ED accounts require a level charge and the hospital wants all service-specific goods, such as splints, casts, and IVs to be charged separately in order to track costs. The hospital does not want to invest in a new ED system to capture charges concurrently. Currently, a comprehensive charge ticket is created for every encounter and ED staff post the charges. Sometimes, these paper tickets get lost, misposted, or posted late. What internal control should be put in place to ensure that all appropriate charges are captured on a timely basis? a. The HIM department should post these charges. b. A single staff person should be responsible for the posting. c. The hospital should invest in an automated charging module. d. The medical record should be reviewed against the posted charges daily in order to ensure that nothing was missed. 10. The PFS department is reporting to the revenue cycle committee that there has been a recent increase in the number of bills that are not dropping because they are missing a radiology charge. The order is in the system, but the charge has not posted because the order was not closed when the service was performed. Radiology says that there is a new technician on staff and they will re-train the person. What control should be in place to facilitate timely billing? a. The radiology department should reconcile radiology orders versus charges daily. b. The radiology department should reconcile the patient record versus the orders daily. c. The HIM coders should reconcile the patient record versus the orders daily. d. All of the above

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