CCA prep exam 200 questions

200 Preguntes  I  By Melodey23
200 Practice questions

  
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1.  Which of the following statements is not true abount a business associate agreement?
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2.  Diagnosis-related groups are organized into __________.
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3.  Which stage of the litigation process focuses on how strong a case the opposing party has?
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4.  Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of ________________ review.
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5.  Which of the following is a secondary purpose of the health record?
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6.  What are four-digit ICD-9-CM diagnosis codes referred to as?
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7.  Which of the following is not a characteristic of high-quality healthcare data?
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8.  A nurse is responsible for which of the following types of acute care documentation?
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9.  Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
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10.  Which of the following technologies would allow a hospital to get as much medical record information online as quickly as possible?
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11.  Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
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12.  Which of the following statements represents an example of nonmaleficence?
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13.  CPT Category III code can be used by what groups of providers
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14.  Which of the following is a standard terminology used to code medical procedures and services?
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15.  Identify the appropriate CPT code(s) for a routine EKG with 15 leads, with the physician providing only the interpretation and report
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16.  The goal of coding compliance programs is to prevent _________.
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17.  The following is documented in an acute care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear?
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18.  At which level of classification system are the most specific ICD-9-CM codes found?
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19.  When a provider accepts assignment, this means the __________.
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20.  Law enacted by a legislative body is a(n) _________.
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21.  A health information technician is hired as the chief compliance officer for a large group practice. In evaluating the current program the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audiots in place to monitor compliance. Which of the following should the compliance officer also ensure are in place?
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22.  The __________ notifies physicians that Medicare payments to the facility is partly based on the patient's principal and secondary diagnoses, as well as the major procedures performed, and that falsification of records can lead to fines, imprisonment, or civil penalty under federal laws.
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23.  A patient was discharged with the following diagnoses: "Cerebral occlusion, hemiparesis, aspasia, and hypertension." Which of the following code assignments would be appropriate for this case? 342.90   Hemiparesis affecting unspecified side 342.91   Hemiparesis affecting dominant side 342.92   Hemiparesis affecting nondominant side 434.90   Cerebral artery occlusion unspecified, without mention of cerebral infarction 434.91   Cerebral artery occlusion unspecified with cerebral infarction 401                   Hypertension 401.0                Malignant hypertension 401.1                Benign hypertension 401.9                Unspecified hypertension 428.0     Congestive heart failure 784.3     Aphasia
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24.  What is the defining characteristic of an integrated health record format?
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25.  Attorneys for healthcare organizations use the health record to _________.
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26.  The HIM department is planning to scan noneelectronic medical record documentation. The project include the scanning of health record documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalizations?
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27.  A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?
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28.  Which of the following contains the physician's findings based on an examination of the patient?
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29.  Which of the following isues compliance program guidance?
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30.  The legal health record is a(n) _____________.
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31.  The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) and/or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting?
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32.  CPT codes describing endovascular repair of the descending thoracic aorta include all of the following procedures except one. Which procedure is not included in the repair code?
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33.  The attending physician is responsible for which of the following types of acute care documentations?
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34.  What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?
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35.  The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the ________.
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36.  Exceptions to the consent requirement include:
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37.  Identify where the following information would be found in the acute care record:  "CBC; WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93".
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38.  Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note?
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39.  The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the __________.
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40.  Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April.
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41.  The Uniform Health Care Decisions Act ranks the next-of-kin in the following order for medical decision-making purposes:
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42.  Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
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43.  Reference codes 49491 through 49525 for inguinal hernia repair. Patient is 47 years old. What is the correct code for an initial inguinal herniorrhaphy for incarcerated hernia?
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44.  A health information technician is processing payments for hospital outpatient services to be reimbursed by Medicare for a patient who had two physician visits, underwent radiology examinations, clinical laboratory tests, and who received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?
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45.  Identify where the following information would be found in the acute care record. Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.
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46.  Employees in the Hospital Busines Office may have legitimate access to patient health information without patient authorization based on what HIPAA standard/principle?
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47.  Which of the following is required in order to prescribe medications?
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48.  What is the term used in reference to the systematic review of sample health records to determine whether health record documentation standards are being met?
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49.  A female patient is admitted for stress incontinence. A urethral suspension is performed.
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50.  Which of the following is a condition that arises during hospitalization?
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51.  Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record?
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52.  A patient seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out chest pain versus GERD". The correct ICD-9-CM code is:
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53.  The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?
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54.  Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment?
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55.  Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
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56.  Dr. Smith sees his patient, Bob Jones, in the nursing home where he has resided for 11 months. Bob is stable and happy, and Dr. Smith performs an annual physical examination and completes the minimum data set instrument. He performs and documents a detailed interval history, comprehensive examination, and performs medical decision making of low complexity. Assign the appropriate CPT code.
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57.  Dr. Williams is on the medical staff of Sutter Hospital and he has asked to see the health record of his wife who was recently hospitalized. Dr. Jones was the patient's physician. Of the options listed here, which is the best course of action?
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58.  Which of the following federal laws passed in 1996 resulted in new privacy regulations for healthcare organizations?
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59.  Which of the following is an example of clinical data?
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60.  The patient was admitted with nausea, vomitting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nauea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this case?
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61.  Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ________.
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62.  According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
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63.  Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called _________.
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64.  A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?
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65.  Accreditation standards and the Medicare Conditions of Participation require that the patient's __________ be documented by the attending physician in the patient's health record no more than 30 days after discharge.
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66.  A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient?
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67.  Patient returns during a 90-day postoperative period from a ventral hernia repair; now complaining of eye pain. What modifier would a physician setting use with the Evaluation and Management code?
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68.  The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:
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69.  A special Web page that offers secure access to data is called a(n):
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70.  A skin lesion is removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission?
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71.  The sum of a hospital's relative DRG rates for a year was 15,192 and the hospital had 10,471 discharges for the year. Given this information what would be the hospital's case-mix index for that year?
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72.  In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
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73.  Identify where the following information would be found in the acute care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine".
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74.  A 61-year-old male patient is being assessed for possible colon cancer and treated in the special procdure unit of the hospital. He undergoes a colonoscopy into the ascending colon with biopsy of a suspicious area in the transverse colon using the cold biopsy forceps. In addition, a colonic ultrasound of the area is performed, the transmural bipsy of an area of the mesentery adjacent to the transverse colon. Assign the appropriate CPT codes.
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75.  What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?
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76.  Messaging standards for electronic data interchange in healthcare have been developed by ___________.
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77.  In a problem-oriented medical record, problems are organized ________.
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78.  Which of the following would a health record technician use to perform the billing function for a physician's office?
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79.  The ______ mandated the development of standards for electronic medical records.
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80.  A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
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81.  A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a POMR progress note would this notation be written?
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82.  Which of the following represents documentation of the patient's current and past health status?
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83.  Which of the following actions would be best to determine if present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement?
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84.  A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.
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85.  An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-9-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.)
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86.  A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.
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87.  A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebullizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?
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88.  A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written?
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89.  A coding audit shows that an impatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case?
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90.  A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis?
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91.  Which of the following dictates how the medical staff operates?
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92.  Patient with flank pain was admitted and found to have a calculus of the kidney. Ureteroscopy with placement of ureteral stents was performed.
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93.  Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient retruns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment?
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94.  Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedures?
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95.  A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?
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96.  From the information provided, how many APCs would this patient have? (See handout if table is not aligned) Billing        Status          CPT/HCPCS     APC Number     Indicator 998323       V                  99285-25          0612 998324       T                  25500                0044 998325       X                  72050                0261 998326       S                  72128                0283 998327       S                  70450                0283  
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97.  Sleeping patterns, head and chest measurements, feeding and elimination status, weight, and Apgar scores are recorded in which of the following records?
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