Discussion of Medical Coding

Discussion of Medical Coding

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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.