CCA Prep Exam 1 (100 Questions)

100 Questions  I  By Melodey23
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CCA Prep Exam 1 - 100 Questions - Entered 03/12/2012 Domain 1: Health Records and Data Content Domain 2: Health Information Requirements and Standards Domain 3: Clinical Classification Systems Domain 4: Reimbursement Methodologies Domain 5: Information and Communication Technologies Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues

  
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  • 1. 
    An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?
    • A. 

      DEEDS

    • B. 

      EMEDS

    • C. 

      UACDS

    • D. 

      UHDDS


  • 2. 
    Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of __________.
    • A. 

      Transaction standards

    • B. 

      Content and structure standards

    • C. 

      Vocabulary standards

    • D. 

      Security standards


  • 3. 
    A family practitioner requests the opinion of a physician specialist in endocrinology who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in which type of report?
    • A. 

      Consultation

    • B. 

      Medical history

    • C. 

      Physical examination

    • D. 

      Progress notes


  • 4. 
    Which of the following is not a function of the discharge summary?
    • A. 

      Providing information about the patient's insurance coverage

    • B. 

      Ensuring the continuity of future care

    • C. 

      Providing information to support the activities of the medical staff review committee

    • D. 

      Providing concise information that can be used to answer information requests


  • 5. 
    Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the:
    • A. 

      Discharge summary

    • B. 

      Autopsy report

    • C. 

      Incident report

    • D. 

      Consent to treatment


  • 6. 
    A 65-year-old white male was aditted to the hospital on 1/15 complaining of abdominal pain. The Attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and ruptured appendix was discovered. The chief complaint was:
    • A. 

      Ruptured appendix

    • B. 

      Exploratory laparoscopy

    • C. 

      Abdominal pain

    • D. 

      Cholelithiasis


  • 7. 
    All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data:
    • A. 

      Clinical

    • B. 

      Identification

    • C. 

      Secondary

    • D. 

      Financial


  • 8. 
    What type of data is exemplified by the insured party's member identification number?
    • A. 

      Demographic data

    • B. 

      Clinical data

    • C. 

      Certification data

    • D. 

      Financial Data


  • 9. 
    Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format?
    • A. 

      The problem list is an index

    • B. 

      The initial plan

    • C. 

      The SOAP form of progress notes

    • D. 

      The database


  • 10. 
    While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on __________.
    • A. 

      Reason for admission

    • B. 

      Reason for encounter

    • C. 

      Discharge diagnosis

    • D. 

      Activities of daily living


  • 11. 
    Mildred Smith was admitted from an acute hospital to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome".  Underneath the diagnosis was listed her medical information along with her rehabilitation potential. On which form is this information documented.
    • A. 

      Transfer or referral

    • B. 

      Release of information

    • C. 

      Patients rights acknowledgement

    • D. 

      Admitting physical evaluation


  • 12. 
    The coder notes that the physician has prescribed Synthroid for the patient. The coder might find which of the following on the patient's problem list?
    • A. 

      Acromegaly

    • B. 

      Hypothyroidism

    • C. 

      Dwarfism

    • D. 

      Cushing's disease


  • 13. 
    A male patient is seen by the physician and diagnosed with pneumonia. The doctor took cultures to try to determine which organism was causing the pneumonia. Which of the following organisms would alert the coder to code it as a gram-negative pneumonia?
    • A. 

      Staphylococcus

    • B. 

      Clostridium

    • C. 

      Klebsiella

    • D. 

      Streptococcus


  • 14. 
    What is the best source of documentation to determine the size of a removed malignant lesion?
    • A. 

      Pathology report

    • B. 

      Postacute care unit record

    • C. 

      Operative report

    • D. 

      Physical examination


  • 15. 
    The coder might find which of the following on a patient's problem list if the medication list contains the drug Protonix?
    • A. 

      High blood pressure

    • B. 

      Esophagitis

    • C. 

      Congestive heart failure

    • D. 

      AIDS


  • 16. 
    The patient is seen in the physician office with a chief complaint of shortness of breath. In the patient's progress notes, the physician documents the diagnosis of asthma and recommends the patient present to the emergency department of XYZ Hospital immediately. The physician further documents that the patient has severe wheezing and no obvious relief with bronchodilators. Which action will the coder take?
    • A. 

      Code asthma

    • B. 

      Code asthma with status asthmaticus

    • C. 

      Code asthma with acute exacerbation

    • D. 

      Query the physician for more detail about asthma


  • 17. 
    The coder notes that the physician has ordered potassium replacement for the patient. The coder might expect to see a diagnosis of:
    • A. 

      Hypokalemia

    • B. 

      Hyponatremia

    • C. 

      Hyperkalemia

    • D. 

      Hypernatremia


  • 18. 
    The __________ may contain information about diseases among relatives in which heredity may play a role.
    • A. 

      Physical examination

    • B. 

      History

    • C. 

      Laboratory report

    • D. 

      Administrative data


  • 19. 
    The physician orders a chest x-ray for a patient who presents at the office with fever, productive cough, a shortness of breath. The physician indicates in the progress notes: "Ruled out pneumonia" What diagnosis (es) should be coded for the visit when the results have not yet been received?
    • A. 

      Pneumonia

    • B. 

      Fever, cough, shortness of breath

    • C. 

      Cough, shortness of breath

    • D. 

      Pneumonia, cough, shortness of breath


  • 20. 
    Which term describes the linking of every procedure or service received by a patient to a diagnosis that justifies the need to performing the service?
    • A. 

      Medical necessity

    • B. 

      Managed care

    • C. 

      Medical decision making

    • D. 

      Levels of services


  • 21. 
    To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health  record no later than 24 hours after amission.  Which of the following would by the best way to ensure the completeness of health records?
    • A. 

      Retrospectively review each patient's medical record to make sure history and physical are present

    • B. 

      Review each patient's medical report concurrently to make sure history andphysical are present and meet the accreditation standards

    • C. 

      Establish a process to review medical records immediately on discharge

    • D. 

      Do a review of records for all patients discharged in the previous 60 days


  • 22. 
    Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceed the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. To improve compliance, which of the following would be a next step to overcoming noncompliance?
    • A. 

      Discuss the problem with the hospital CEO

    • B. 

      Call the Joint Commission

    • C. 

      Contact other hospitals to see what methods they use to ensure compliance

    • D. 

      Drop the issue because non-compliance is always a problem


  • 23. 
    How do accrediation organizations such as the Join Commission use the health record?
    • A. 

      To serve as a source for case study information

    • B. 

      To determine whether the documentation supports the provider's claim for reimbursement

    • C. 

      To provide healthcare services

    • D. 

      To determine whether standards of care are being met


  • 24. 
    Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must be facility meet in order to become certified for these programs?
    • A. 

      Joint Commission Accreditation Standards

    • B. 

      Accreditation Association for Ambulatory Healthcare Standards

    • C. 

      Conditions of Participation

    • D. 

      Outcomes and Assessment Information Set


  • 25. 
    Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state in which they are located.
    • A. 

      Accreditation

    • B. 

      Certification

    • C. 

      Licensure

    • D. 

      Permission


  • 26. 
    This document includes a microscopic description of tissue excised during surgery:
    • A. 

      Recovery room record

    • B. 

      Pathology report

    • C. 

      Operative report

    • D. 

      Discharge summary


  • 27. 
    A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____________ .
    • A. 

      Suspended record

    • B. 

      Delinquent record

    • C. 

      Pending record

    • D. 

      Illegal record


  • 28. 
    Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation?
    • A. 

      The record is not in compliance as the physical exam must be completed within 24 hours of admission.

    • B. 

      The record is not in compliance as the physical exam must be completed within 48 hours of admission.

    • C. 

      The record is in compliance as the physical examination must be completed within 48 hours.

    • D. 

      The record is in compliance because the physical examination was completed within 72 hours of admission.


  • 29. 
    According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?
    • A. 

      Admission record

    • B. 

      Physician's order

    • C. 

      Report of history and physical examination

    • D. 

      Discharge summary


  • 30. 
    Which of the following programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards?
    • A. 

      Internal DRG audits

    • B. 

      Peer review

    • C. 

      Managed care

    • D. 

      Quality improvement


  • 31. 
    The HIM director is having difficulty with the on-cal physicians in the emergency services department completing their health records. Currently, three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situations?
    • A. 

      Routinely send out a fourth notice

    • B. 

      Post the hospital policy in the emergency department

    • C. 

      Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices

    • D. 

      Call the Joint Commission


  • 32. 
    HIM coding professionals and the orgs that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated?
    • A. 

      Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete

    • B. 

      Follow-up on and monitor identified problems

    • C. 

      Evaluate and trend diagnoses and procedures code selections

    • D. 

      Report data quality review results to organizational leadership, compliance staff, and the medical staff


  • 33. 
    What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed?
    • A. 

      Operative report

    • B. 

      Tissue report

    • C. 

      Pathology report

    • D. 

      Anesthesia record


  • 34. 
    Where would information on treatment given on a particular encounter be found in the health record?
    • A. 

      Problem list

    • B. 

      Physician's orders

    • C. 

      Progress Notes

    • D. 

      Physical examination


  • 35. 
    Identify the code for a patient with a closed transcervical fracture of the epiphysis.
    • A. 

      820.09

    • B. 

      820.02

    • C. 

      820.03

    • D. 

      820.01


  • 36. 
    Identify the ICD-9-CM dx code(s) for neonatal tooth eruption
    • A. 

      525.0

    • B. 

      520.6, 525.0

    • C. 

      520.9

    • D. 

      520.6


  • 37. 
    Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers and interrupted sutures.
    • A. 

      21012

    • B. 

      21012; 12052

    • C. 

      21014

    • D. 

      21014; 12052


  • 38. 
    Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a braest biopsy.
    • A. 

      10022

    • B. 

      1022; 19295-LT

    • C. 

      10022; 19295-LT; 76942

    • D. 

      10022; 76942


  • 39. 
    Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease.
    • A. 

      335.20

    • B. 

      334.8

    • C. 

      335.29

    • D. 

      335.2


  • 40. 
    Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads.
    • A. 

      37.83, 37.73

    • B. 

      37.83, 37.71

    • C. 

      37.81, 37.73, 37.71

    • D. 

      37.83, 37.72


  • 41. 
    Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker.
    • A. 

      37.87

    • B. 

      37.85

    • C. 

      37.87, 37.89

    • D. 

      37.85, 37.89


  • 42. 
    Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block.
    • A. 

      426.3, 426.4

    • B. 

      426.53

    • C. 

      426.4, 426.53

    • D. 

      426.52


  • 43. 
    Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for reprogramming of a cardiac pacemaker.
    • A. 

      V53.31

    • B. 

      37.85

    • C. 

      V53.02

    • D. 

      V53.31, 37.85


  • 44. 
    This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with brady-arrhythmias. Prolonged includes insertions of a permament cardiac pacemaker.
    • A. 

      Atrial fibrillation (427.31)

    • B. 

      Atrial flutter (427.32)

    • C. 

      Paroxysmal supraventricular tachycardia (427.0)

    • D. 

      Sick sinus syndrome (SSS)(427.81)


  • 45. 
    Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary-coronary artery bypass.
    • A. 

      36.15, 36.16

    • B. 

      36.15

    • C. 

      36.16

    • D. 

      36.12, 36.16


  • 46. 
    Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the tachnique using two catheters inserted percutaneously through the femoral artery.
    • A. 

      Combined right and left (88.54)

    • B. 

      Stones (88.55)

    • C. 

      Judkins (88.56)

    • D. 

      Other and unspecified (88.57)


  • 47. 
    Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.
    • A. 

      V58.83, V58.61

    • B. 

      V58.83, V58.63

    • C. 

      V58.61, 790.92

    • D. 

      V58.61


  • 48. 
    Identify the CPD code(s) for the following patient: A 2-yr-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance.
    • A. 

      43752

    • B. 

      43761

    • C. 

      43761; 76000

    • D. 

      49450


  • 49. 
    Identify the CPT code(s) for the following patient:  A 2-yr-old male presented to the hospital to have his gastrostomy tube changed under flouroscopic guidance.
    • A. 

      43752

    • B. 

      43760

    • C. 

      43761; 76000

    • D. 

      49450


  • 50. 
    Identify the ICD-9-CM dx code for blighted ovum
    • A. 

      236.1

    • B. 

      661.00

    • C. 

      631

    • D. 

      634.90


  • 51. 
    Identify the ICD-9-CM dx code(s) for the following:  threatened abortion with hemorrhage at 15 weeks; home undelivered.
    • A. 

      640.01, 640.91

    • B. 

      640.03

    • C. 

      640.83

    • D. 

      640.80


  • 52. 
    Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment Cesarean delivery with single live-born female.
    • A. 

      661.01, V27.0, 74.1

    • B. 

      661.21, 74.1

    • C. 

      661.01, 74.0

    • D. 

      661.21, V27, 74.1


  • 53. 
    Identify the ICD-9-CM code for diaper rash, elderly patient.
    • A. 

      690.10

    • B. 

      691.0

    • C. 

      782.1

    • D. 

      705.1


  • 54. 
    Identify the ICD-9-CM code(s) for infected ingrown nail.
    • A. 

      703.0

    • B. 

      703.8, 681.11

    • C. 

      681.11

    • D. 

      681.9


  • 55. 
    Identify the ICD-9-CM code for acute lymphadenitis.
    • A. 

      785.6

    • B. 

      683

    • C. 

      289.1

    • D. 

      289.3


  • 56. 
    Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip.
    • A. 

      715.95

    • B. 

      715.15

    • C. 

      721.90

    • D. 

      715.16


  • 57. 
    Identify the ICD-9-CM diagnosis code for chondromalacia of the patella.
    • A. 

      717.7

    • B. 

      733.92

    • C. 

      748.3

    • D. 

      716.86


  • 58. 
    Identify the ICD-9-CM diagnostic code for Paget's disease of the bone (no bone tumor noted)
    • A. 

      170.9

    • B. 

      213.9

    • C. 

      238.0

    • D. 

      731.0


  • 59. 
    Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to staphylococcus.
    • A. 

      730.06

    • B. 

      730.07

    • C. 

      730.07, 041.1

    • D. 

      730.07, 041.10


  • 60. 
    Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to chemotherapy.
    • A. 

      284.9

    • B. 

      284.89

    • C. 

      285.9

    • D. 

      285.22


  • 61. 
    Identify the ICD-9-CM diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, ex-preemie".
    • A. 

      V20.1, 765.10

    • B. 

      V20.2

    • C. 

      V20.2, 765.10

    • D. 

      V20.2, 765.19


  • 62. 
    Identify the ICD-9-CM diagnostic code for diastolic dysfunction
    • A. 

      428.1

    • B. 

      428.30

    • C. 

      428.9

    • D. 

      429.9


  • 63. 
    Identify the ICD-9-CM diagnostic code(s) for the following: A 73-year-old female was treated for hemorrhage of the inferior mesenteric artery. She was admitted to the hospital for a transcatheter embolization of the bleeders with polyvinyl alcohol (PVA) microspheres and coils and abdominal angiography.
    • A. 

      39.73, 88.47

    • B. 

      39.71, 88.47

    • C. 

      39.79, 88.49

    • D. 

      39.79, 88.47


  • 64. 
    Identify the ICD-9-CM diagnostic code for allogeneic donor lymphocyte stem cell infusion.
    • A. 

      41.02

    • B. 

      41.03

    • C. 

      41.05

    • D. 

      41.08


  • 65. 
    Identify the ICD-9-CM diagnostic code for atypical ductal hyperplasia
    • A. 

      610.1

    • B. 

      610.4

    • C. 

      610.8

    • D. 

      610.9


  • 66. 
    Which of the following is the correct ICD-9-CM procedure code for a Mayo operation known as a bunionectomy?
    • A. 

      77.54

    • B. 

      77.69

    • C. 

      77.59

    • D. 

      77.51


  • 67. 
    Which of the following is the correct ICD-9-CM code(s) for thoracoscopic lobectomy of left lung?
    • A. 

      32.30

    • B. 

      32.41

    • C. 

      32.49

    • D. 

      34.02, 32.41


  • 68. 
    Which of the following is the correct ICD-9-CM code(s) for laparoscopic cholecystectomy?
    • A. 

      51.21

    • B. 

      51.22, 54.21

    • C. 

      51.23, 54.21

    • D. 

      51.23


  • 69. 
    Which of the following is the correct ICD-9-CM procedure code(s) for cystoscopy with biopsy?
    • A. 

      57.34

    • B. 

      57.32, 57.33

    • C. 

      57.33

    • D. 

      57.39


  • 70. 
    Identify the ICD-9-CM procedure code(s) for insertion of tissue expander in breast, post mastectomy.
    • A. 

      85.94

    • B. 

      85.89

    • C. 

      86.89, 85.46

    • D. 

      85.95


  • 71. 
    Which of the following software applications would be used to aid in the coding function in a physician's office?
    • A. 

      Grouper

    • B. 

      Encoder

    • C. 

      Pricer

    • D. 

      Diagnosis calculator


  • 72. 
    Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system?
    • A. 

      Diagnosis-related groups

    • B. 

      Resource-based relative value scale system

    • C. 

      Long-term care drugs

    • D. 

      Resource utilization drugs


  • 73. 
    The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150, Total abdominal hysterectomy, with/without removal of tubes and ovaries 58700, Salpingectomy, complete or partial, unilateral/bilateral (separate procedure) What error has the coder made by using these codes?
    • A. 

      Maximizing

    • B. 

      Upcoding

    • C. 

      Unbundling

    • D. 

      Optimizing


  • 74. 
    What is the best reference tool to determine how CPT codes should be assigned?
    • A. 

      Local coverage determination from Medicare

    • B. 

      American Medical Association's CPT Assistant newsletter

    • C. 

      American Hospital Association's Coding Clinic

    • D. 

      CMS Web site


  • 75. 
    An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of:
    • A. 

      Optimizing

    • B. 

      Unbundling

    • C. 

      Sequencing

    • D. 

      Classifying


  • 76. 
    In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporate the greater number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of the panel?
    • A. 

      Report the remaining tests using individual test codes accordinto to CPT.

    • B. 

      Do not report the remaining individual test codes.

    • C. 

      Report only those test codes that are part of the panel.

    • D. 

      Do not report a test code more than once regardless if the test was performed twice.


  • 77. 
    There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further defines removal of foreign body (45379) and bipsy, single or multiple (45380) and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule?
    • A. 

      Unbundling

    • B. 

      Optimizing

    • C. 

      Sequencing

    • D. 

      Maximizing


  • 78. 
    What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims?
    • A. 

      Outpatient Perspective Payment System (OPPS)

    • B. 

      National Correct Coding Inditiative (NCCI)

    • C. 

      Ambulatory Payment Classifications (APCs)

    • D. 

      Comprehensive Outpatient Rehab Facilities (CORFs)


  • 79. 
    What is the best reference tool to receive ICD-9-CM coding advice?
    • A. 

      AMA's CPT Assistant

    • B. 

      AHA's Coding Clinic for HCPCS

    • C. 

      AHA's Coding Clinic for ICD-9-CM

    • D. 

      National Correct Coding Initiative (NCCI)


  • 80. 
    CMS developed Medically Unlikely Edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007 and are applied to which code set?
    • A. 

      Diagnosis-related groups

    • B. 

      HCPCS/CPT codes

    • C. 

      ICD-90CM diagnosis and procedure codes

    • D. 

      Resource utilization groups


  • 81. 
    A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM departments. Which of the following electronic systems would fullfill this purpose?
    • A. 

      Chart deficiency system

    • B. 

      Chart tracking system

    • C. 

      Chart abstracting system

    • D. 

      Chart encoder


  • 82. 
    What does audit trail check for?
    • A. 

      Unauthorized access to a system

    • B. 

      Loss of data

    • C. 

      Presence of a virus

    • D. 

      Successful completion of a backup


  • 83. 
    An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?
    • A. 

      Role-based

    • B. 

      User-based

    • C. 

      Context-based

    • D. 

      Situation-based


  • 84. 
    Which of the following statements about a firewall is false?
    • A. 

      It is a system or combination of systems that supports an access control policy between two networks.

    • B. 

      The most common place to find a firewall is between the healthcare organization's internal network and the Internet.

    • C. 

      Firewalls are effective for preventing all types of attacks on a healthcare system.

    • D. 

      A firewall can limit internal users from accessing various portions of the Internet.


  • 85. 
    The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is ___________.
    • A. 

      Optical character recognition

    • B. 

      Bar coding

    • C. 

      Neural networks

    • D. 

      Electronic data interchange


  • 86. 
    A software interface is a ___________.
    • A. 

      Device to enter data

    • B. 

      Protocol for describing data

    • C. 

      Program to exchange data

    • D. 

      Standard vocabulary


  • 87. 
    A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previouosly treated. According to HIPAA regulations, was this action correct?
    • A. 

      Yes; HIPAA only requires the current records to be produced for the patient.

    • B. 

      Yes; this is hospital policy for which HIPAA has no control

    • C. 

      No; the records from the previous hohspital are considered part of the designated record set and should be given to the patient.

    • D. 

      No; the records from the previous hospital are not included in the designated record set but should be released anyway.


  • 88. 
    A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient requests the hospital provide the medical records in paper format. How should the hospital respond?
    • A. 

      Provide the medical records in paper format

    • B. 

      Burn another CD since this is hospital policy

    • C. 

      Provide the patient with both paper and CD copies of the medical record

    • D. 

      Review the CD copies with the patient on a hospital computer


  • 89. 
    Which of the following definitions best describes the concept for confidentiality?
    • A. 

      The right individuals to control access to their personal health information

    • B. 

      The protection of healthcare information from damage, loss, and unauthorized alteration

    • C. 

      The expectation that personal information shared by an individual with healthcare provider during the course of care will be used only for its intended purpose

    • D. 

      The expectation that only individuals with the appropriate authority will be allowed to access healthcare information


  • 90. 
    The release of information function requires the HIM professional to have knowledge of _______________.
    • A. 

      Clinical coding principals

    • B. 

      Database development

    • C. 

      Federal and state confidentiality laws

    • D. 

      Human resource management


  • 91. 
    The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?
    • A. 

      HIPAA does not allow a patient's name to be announced in a waiting room.

    • B. 

      There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.

    • C. 

      HIPAA allows only the use of the patient's first name.

    • D. 

      HIPAA requires that patients be given numbers and only the number be announced.


  • 92. 
    A health information technician receives a subpoena duces tecum for the records of a discharged patient. To respond to the subpoena, which of the following should the technician do?
    • A. 

      Review the subpoena to determine what document must be produced

    • B. 

      Review the subpoena and notify the hospital administrator

    • C. 

      Consult with the hospital legal counsel

    • D. 

      Review the subpoena and alrt the hospital risk-management department


  • 93. 
    The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of:
    • A. 

      Confidentiality

    • B. 

      Privacy

    • C. 

      Integrity

    • D. 

      Security


  • 94. 
    What types of covered entity health records are subject to HIPAA privacy regulations?
    • A. 

      Only health records in paper format

    • B. 

      Only health records in electronic format

    • C. 

      Health records in paper or electronic format

    • D. 

      Health records in any format


  • 95. 
    Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician?
    • A. 

      Closed communication

    • B. 

      Open communication

    • C. 

      Private communication

    • D. 

      Privileged communication


  • 96. 
    Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the option listed here, what is best course of action?
    • A. 

      Allow Dr. Smith to see the records becausse he was the daughter's guardian at the time of the tonsillectomy.

    • B. 

      Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff.

    • C. 

      Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record.

    • D. 

      Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.


  • 97. 
    Which of the following four sources of law is also known as judge-made or case law?
    • A. 

      Constitutional law

    • B. 

      Statutory law

    • C. 

      Common law

    • D. 

      Administrative law


  • 98. 
    The sequence of the correct steps when evaluating an ethical problem is:
    • A. 

      Consider the values and obligations of others; consider the choice that are both justified and not justified; determine the facts; identify prevention options.

    • B. 

      Consider the choices that are both justified and not justified; consider the values and obligations of others; identify prevention options; determine the facts.

    • C. 

      Determine the facts; consider the choices that are both justified and not justified; consider the values and obligations of others; identify prevention options.

    • D. 

      Determine the facts; consider the values and obligations of others; consider the choices that are both justified and not justified; identify prevention options.


  • 99. 
    What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?
    • A. 

      Ignore the state law and follow the HIPAA standard

    • B. 

      Follow the state law and ignore the HIPAA standard

    • C. 

      Comply with both the state law and the HIPAA standard

    • D. 

      Ignore both the state law and the HIPAA standard and follow relevant accreditation standards


  • 100. 
    Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given:
    • A. 

      No information due to the highly sensitive nature of his illness

    • B. 

      Admission date and location in the facility

    • C. 

      General condition and acknowledgement of admission

    • D. 

      Location in the facility and diagnosis


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