CCA prep exam 200 questions

200 Preguntes  I  By Melodey23
200 Practice questions

  
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1.  According to the UHDDS, which of the following is the definition of "other diagnoses"?
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2.  Patient admitted with major depression, recurrent, severe.
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3.  In designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions is the E1384 standard promulgated by the:
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4.  Which of the following is not true of notices of privacy practices?
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5.  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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6.  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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7.  The following is documented in an acute care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear?
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8.  Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?
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9.  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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10.  The physician performs an exploratory laparotomy with bilateral salpingo-oophorectomy. What is the correct CPT code assignment for this procedure?
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11.  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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12.  The protection measures and tools for safeguarding information and information systems is a definition of:
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13.  Which of the following contains the physician's findings based on an examination of the patient?
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14.  An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis". How should the coder proceed to code this case?
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15.  Attorneys for healthcare organizations use the health record to _________.
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16.  The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed:
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17.  Which of the following would a health record technician use to perform the billing function for a physician's office?
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18.  Which of the following best describes data completeness?
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19.  Prospective payment systems were developed by the federal government to:
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20.  Privacy can be defined as the ________.
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21.  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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22.  The goal of coding compliance programs is to prevent _________.
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23.  To be in compliance with HIPAA regulations, a hospital would make its membership in a RHIO known to its patients through which of the following?
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24.  What is the defining characteristic of an integrated health record format?
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25.  While the focus of inpatient data collection in the UHDDS is on principal diagnosis, the focus of outpatient data collection in the UACDS is on ___________.
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26.  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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27.  The following is documented in an acute care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear?
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28.  Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called _________.
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29.  Which of the following statements is false?
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30.  The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds. "In which of the following would this documentation appear?
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31.  Which of the following ICD-9-CM codes are always alphanumeric
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32.  Which of the following is required in order to prescribe medications?
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33.  A nurse is responsible for which of the following types of acute care documentation?
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34.  Patient was admitted through the emergency department following a fall from a ladder while painting an interior room in his house. He had contusions of the scalp and face and an open fracture of the acetabulum. The fracture site was debrided and the fracture was reduced by open procedure with an external fixation device applied, which is the correct code assignment?
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35.  Which of the following spells out the powers of the three branches of the federal government?
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36.  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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37.  Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket:
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38.  Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity _________.
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39.  What is the function of a consultation report?
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40.  Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM?
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41.  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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42.  Which of the following must be reported to the medical examiner?
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43.  Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures?
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44.  A 35-year-old male was admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy was performed. Identify the code for the ICD-9-CM diagnosis and procedure.
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45.  Which of the following provides a system for coding the clinical procedures and services provided by physicians and other clinical professionals?
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46.  Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect?
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47.  Identify the diagnosis code(s) for benign melanoma of skin of shoulder.
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48.  Given the following information, which of the following statements is correct? Given the following information, which of the following statements is correct? (see handout if table is not aligned) MS-DRG    MDC  Type      MS-DRG Title                                 Weight      Discharges      Geometric       Arithmetic                                                                                                                                                               Mean             Mean 191              04      MED     Chronic obstructive                       0.9757          10                          4.1                  5.0                                               pulmonary disease w CC 192              04      MED     Chronic obstructive                       0.7254           20                         3.3                  4.0                                               pulmonary disease                                               w/o CC/MCC 193              04      MED     Simple pneumonia &                    1.4327         10                          5.4                  6.7                                               pleurisy w MCC 194              04      MED     Simple pneumonia &                    1.0056         20                          4.4                  5.3                                                pleurisy w CC 195              04      MED     Simple pneumonia &                    0.7316         10                          3.5                  4.1
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49.  Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for _________.
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50.  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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51.  Which of the following is not a characteristic of high-quality healthcare data?
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52.  Adoption of the Minimum Standards marked the beginning of this modern __________ process for healthcare organizations.
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53.  To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________ days.
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54.  Which of the following dictates how the medical staff operates?
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55.  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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56.  A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
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57.  Which of the following materials is not documented in an emergency care record?
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58.  Which stage of the litigation process focuses on how strong a case the opposing party has?
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59.  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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60.  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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61.  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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62.  What are four-digit ICD-9-CM diagnosis codes referred to as?
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63.  Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
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64.  A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case.
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65.  A 65-year-old woman is admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?
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66.  In a managed fee-for service agreement, which of the following would be used as a cost-control process for inpatient surgical services?
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67.  The legal health record is a(n) _____________.
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68.  Messaging standards for electronic data interchange in healthcare have been developed by ___________.
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69.  The following is documented in an acute care record: "Admit to 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear?
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70.  What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation?
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71.  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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72.  Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2?
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73.  The following is documented in an acute care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?
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74.  Which of the following statements represents an example of nonmaleficence?
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75.  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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76.  A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
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77.  Community Hospital is launching a clinical documentation improvement initiative because currently clinical documentation does not always adequately reflect the severity of illiness of the patient and does not support optimal HIM coding quality and accuracy. Given the situation, which of the following would be the best action to provide improved documentation for patient care and coding?
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78.  Which of the following isues compliance program guidance?
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79.  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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80.  What are the five-digit ICD-9-CM diagnosis code referred to as?
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81.  Which of the following elements is not a component of most patient records?
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82.  The folowing is documented in an acute care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear?
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83.  Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals?
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84.  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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85.  A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease (COPD). Which of the following would be the correct coding and sequencing for this case?
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86.  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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87.  When coding benign neoplasm of the skin, the section noted here directs the coder to: 216   Benign Neoplasm of Skin                   Includes:                            Blue Nevus                             Dermatofibroma                            Hydrocystoma                            Pigmented Nevus                            Syringoadenoma                            Syringoma                   Excludes:                             Skin of genital organs (221.0-222.9) 216.0   Skin of lip                    Excludes:                              Vermilion border of lip (210.0) 216.1   Eyelid, including canthus                    Excludes:                               Cartilage of eyelid (215.0)
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88.  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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89.  A special Web page that offers secure access to data is called a(n):
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90.  Identify the correct diagnosis code for lipoma of the face.
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91.  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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92.  A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent an intradiscal electrothermal annuloplasy (IDET) in the radiology suite. What ICD-9-CM code should be used?
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93.  Which of the following statements does not apply to ICD-9-CM?
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94.  Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure
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95.  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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96.  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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97.  Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
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98.  Patient admitted with senile cataract, diabetes mellitus, and extracapsular cataract extraction with simultaneous insertion of intraocular lens.
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99.  In which setting may treatment records travel with the patient between treatment centers?
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100.  Data definition refers to _________.
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101.  A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis versus noncalculus cholecystitis. Both diagnose are equally treated. The correct coding and sequencing for this case would be:
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102.  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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103.  The attending physician is responsible for which of the following types of acute care documentations?
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104.  A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia, which is the correct code assignment?
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105.  What is it called when accrediting bodies such as the Joint Commission or American Osteopathic Association (AOA) Healthcare Facilities Accreditation Program can survey facilities for compliance with the Medicare Conditions of Participation of Hospitals instead of the government?
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106.  Which of the following tasks may not be performed in an electronic health record system?
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107.  Which organization originally published ICD-9-CM?
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108.  Which of the following is a direct command that requires an individual or a representative of an organization to appear in court or to present an object to the court?
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109.  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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110.  The ______ mandated the development of standards for electronic medical records.
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111.  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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112.  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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113.  Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries?
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114.  In processing a bill under the Medicare outpatient prospective payment system (OPPS), where a patient had three surgical procedures performed during the same operative session, which of the following would apply?
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115.  A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.
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116.  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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117.  The ability to electronically send data from one electronic system to a different elctronic system and still retain its meaning is called _____________.  
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118.  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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119.  Which of the following statements is not true abount a business associate agreement?
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120.  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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121.  Electronic system used by nurses and physicians to document assessments and findings are called:
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122.  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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123.  Which of the following federal laws passed in 1996 resulted in new privacy regulations for healthcare organizations?
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124.  At which level of classification system are the most specific ICD-9-CM codes found?
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125.  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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126.  In a problem-oriented medical record, problems are organized ________.
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127.  In the relational database here the patient table and the visit table are related by _________.                Patient Table Patient#   Last Name     First Name       DOB 021234     Smith              Donna               03/21/1944 022366     Jones             William              04/09/1960 034457     Collins            Mary                   08/21/1977                Visit Table Visit#            Date of Visit      Practitioner#     Patient# 0045678    11/12/2008         456                     021234 0045679    11/12/2008         997                     021234 0045680    11/12/2008         456                     034457  
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128.  According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
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129.  Which of the following is not one of the purpose of ICD-9-CM?
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130.  Given NCCI edits, if the replacement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for:
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131.  What is the functions of physician's orders?
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132.  CPT Category III code can be used by what groups of providers
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133.  Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an insertion of self-contained inflatable penile prosthesis for impotence.
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134.  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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135.  Which of the following provides a set of codes used for collecting data abount substance abuse and mental health disorders?
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136.  Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
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137.  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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138.  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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139.  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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140.  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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141.  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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142.  Use of the health record to monitor bioterrorism activity is considered a ______________
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143.  The diagnosis of a patient was recorded as an abscess in the procedure report, but was listed as carcinoma on the discharge summary. This is an example of a problem with:
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144.  The inpatient data set that has been incorporated into federal law and is required for Medicare reporting is the __________.
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145.  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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146.  These codes are used to assign a diagnosis to a patient who is seeking health services, but is not necessarily sick.
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147.  The key data element for linking data about an individual who is seen in a variety of care settings is the _________.
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148.  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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149.  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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150.  A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Using the codes listed here, what are the appropriate ICD-9-CM codes and sequencing for both hospitalizations? 410.00     Myocardial infarction of anterolateral wall, episode unspecified 410.01     Myocardial infarction of anterolateral wall, initial episode 410.40     Myocardial infarction of inferior wall, episode unspecified 410.41     Myocardial infarction of inferior wall, initial episode 410.42     Myocardial infarction of inferior wall, subsequent episode 427           Cardiac dysrhythmias 427.3                Atrial fibrillation and flutter 427.31              Atrial fibrillation 786.50     Chest pain, unspecified 36.13        Aortocoronary bypass of three coronary arteries
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151.  Which type of patient care record includes documentation of a family bereavement period?
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152.  A female patient is admitted for stress incontinence. A urethral suspension is performed.
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153.  Which of the following is a condition that arises during hospitalization?
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154.  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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155.  A patient is admitted to an acute care hospital for acute intoxication and alcohol withdrawal syndrome due to chronic alcoholism.
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156.  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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157.  Fee schedules are updated by third-party payers _____________.
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158.  In processing a Medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following?
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159.  Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
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160.  A patient is admitted with acute exacerbation of COPD, chronic renal failure, and hypertension.
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161.  What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions?
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162.  Patient arrived via ambulance to the emergency department following a motor vehicle accident. Patient sustained a fracture of the ankle; 3.0 cm superficial laceration of the left arm; 5.0 laceration of the scalp with exposure of the fascia; and a concussion. Patient received the following procedures: X-ray of the ankle which showed a bimalleolar ankle fracture which required closed manipulative reduction and simple suturing of the laceration. Provide CPT codes for the procedures done in the emergency department for the facility bill.
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163.  In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation wouild a coder look for to substantiate the diagnosis of aspiration pneumonia (PNA)
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164.  Which of the following is a secondary purpose of the health record?
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165.  Law enacted by a legislative body is a(n) _________.
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