CCA Exam Preparation Practice Test!

A coder who needs to locate the histology of a tissue sample would most likely find this information in a pathology report. Pathology reports are comprehensive documents that provide detailed information about the examination and analysis of tissues, including the histological findings. These reports are generated by pathologists who specialize in diagnosing diseases through the examination of tissue samples. Therefore, it is logical to assume that the histology of a tissue sample would be documented and accessible in a pathology report.

A hospital should comply with both the state law and the HIPAA standard because the state law requires more stringent privacy protection than the federal HIPAA privacy standard. By following both, the hospital ensures that it meets the requirements of both the state law and the federal standard, thereby protecting patient privacy to the highest extent possible. Ignoring either the state law or the HIPAA standard would result in non-compliance and potential legal and ethical implications.

Backdating progress notes is considered an unethical practice because it involves falsifying documentation by recording information at a later date than when it actually occurred. This can lead to inaccurate medical records, potential legal issues, and compromised patient care. It is important to maintain the integrity and accuracy of medical records to ensure patient safety and provide quality healthcare.

The core ethical obligation of health information staff is to protect patients' privacy and confidential communications. This includes ensuring that patients' personal health information is kept secure and confidential, and that it is only accessed by authorized individuals for legitimate purposes. This obligation is crucial in maintaining trust between healthcare providers and patients, and in upholding the principles of patient autonomy and confidentiality.

When a patient with pneumonia inhales food, liquid, or oil, the most likely diagnosis would be aspiration pneumonia. Aspiration pneumonia occurs when foreign material, such as food or liquids, is inhaled into the lungs, leading to an infection. This can happen when a person has difficulty swallowing or when they accidentally inhale while eating or drinking. The symptoms of aspiration pneumonia can include coughing, shortness of breath, chest pain, and fever. It is important to diagnose and treat aspiration pneumonia promptly to prevent complications and further lung damage.

The correct answer is history record. A patient's marital status, dietary habits, sleep patterns, exercise routines, and substance use are typically documented in their history record. This record includes information about the patient's past medical history, family history, social history, and lifestyle factors that may be relevant to their current health condition. The history record provides valuable information for healthcare providers to assess the patient's overall health and make appropriate treatment decisions.

Coding an intentionally inappropriate level of service would be in violation of AHIMA's Code of Ethics because it goes against the principle of accuracy and integrity in coding. AHIMA's Code of Ethics requires healthcare professionals to accurately and ethically code services provided to patients. Intentionally coding an inappropriate level of service would be considered fraudulent and unethical behavior.

The operative report includes the names of the surgeon and assistants, the date of the procedure, the duration of the procedure, and a description of the procedure itself, including any specimens that were removed. This report provides a detailed account of the surgical procedure and is used for documentation and communication purposes. Anesthesia report focuses on the administration of anesthesia during the procedure, pathology report provides information about the examination of tissues for diagnosis, and laboratory report includes test results.

The attending physician is responsible for writing and signing discharge summaries and discharge instructions. As the primary physician overseeing the patient's care, they have the most comprehensive understanding of the patient's condition and treatment plan. They are in the best position to provide accurate and detailed information regarding the patient's discharge, including any follow-up care instructions and medication prescriptions. The attending physician's signature ensures the validity and accountability of the discharge documentation.

The supervisor should determine what information was printed and why in order to understand the employee's actions. This will help identify any potential misuse or unauthorized access to patient records. Reprimanding or firing the employee without first investigating the situation may not be appropriate or fair. Revoking the employee's access privileges may be necessary if it is found that the printing was unauthorized or violated any policies or regulations.

Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the social history. The social history includes information about the patient's lifestyle, habits, and social support system, which can provide valuable insights into their overall well-being and potential risk factors. The history of drug, alcohol, and tobacco use is relevant to understanding the patient's past behaviors and any potential impact on their current health status. This information can help healthcare professionals assess the patient's risk for certain conditions and tailor their treatment accordingly.

Psychotherapy notes cannot be disclosed to patients under the HIPAA Rule. While patients have the right to access their personal health information, including interpretation of x-rays, billing records, and progress notes, psychotherapy notes are an exception. These notes are considered separate from the rest of the patient's medical records and are not required to be shared with the patient. This is to protect the privacy and confidentiality of the psychotherapy process and ensure that patients feel comfortable expressing themselves during therapy sessions.

The given information describes the physical condition of the patient, including their appearance, mobility issues, vital signs, and specific observations such as shaking arms and leg edema. This information is typically recorded during a physical examination, where a healthcare provider assesses the patient's overall health and identifies any abnormalities or concerns. The physical examination report would include these details, making it the correct answer.

The codes in the musculoskeletal section of CPT may be used by any physician. This means that all physicians, regardless of their specialty, can utilize these codes when billing for services related to the musculoskeletal system. It is not limited to orthopedic surgeons or any specific group of physicians.

This clinical statement would be documented on a pathology report. Pathology reports provide detailed information about the microscopic examination of tissue samples, including the identification of cells and any abnormalities or diseases present. In this case, the statement describes the appearance of the gallbladder lining, which is a microscopic finding that would be reported in a pathology report.

Staphylococcus aureus would be classified to an ICD-9-CM category for bacterial diseases because it is a bacterium that can cause various infections in humans. The ICD-9-CM classification system is used to categorize and code different diseases and medical conditions, including bacterial infections. Staphylococcus aureus is a common bacterium that can cause skin infections, pneumonia, and other types of infections, and therefore it would fall under the category of bacterial diseases in the ICD-9-CM system.

The correct answer is AIDS. The coder notes that the physician has prescribed Retrovir, which is a medication commonly used to treat HIV/AIDS. Therefore, it can be inferred that the patient has been diagnosed with AIDS, and this information might be documented on the patient's discharge summary.

The best course of action in this case would be to request the physician to dictate an addendum to the discharge summary. This is because the discharge summary was dictated on 1/26/2009, but the patient was actually discharged two days later. By requesting an addendum, the physician can provide an updated summary that accurately reflects the date of discharge. This ensures that the health record is complete and accurately represents the patient's information.

Parentheses ( ) are used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The use of parentheses does not affect the code number assigned to the case. They are considered a nonessential modifier and are used in all three volumes of ICD-9-CM.

The correct answer is AMA, which stands for the American Medical Association. The AMA played a significant role in the development and maintenance of the Current Procedural Terminology (CPT) system. CPT is a standardized medical coding system used for reporting medical procedures and services. The AMA ensures that CPT is regularly updated to reflect changes in medical practices, technology, and healthcare regulations. AMA's involvement in the development and maintenance of CPT makes it the correct answer to this question.

The given information refers to the gross description of a tissue sample, which is typically included in a medical laboratory report. This report provides detailed information about the specimen received, including its size, color, and any abnormalities observed. It is used to document the findings of laboratory tests and procedures performed on the sample. The other options, such as discharge summary, medical history, and physical examination, do not typically include this specific information about a tissue sample.

ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This classification is used to identify and categorize health care services and procedures related to newborns. The newborn period is critical for monitoring the health and development of infants during their initial days and weeks of life.

Using a black pen to obliterate the entry is not appropriate when correcting erroneous information in a health record. This method of correction is not recommended because it makes it difficult to trace the original information and can raise concerns about the integrity of the record. It is better to clearly identify the error by printing "error" above the entry, enter the correction in chronological sequence, and add the reason for the change.

Medicare or other third-party payers determine whether a patient has medical necessity for the tests, procedures, or treatment billed on a claim form by reviewing all the diagnosis codes assigned to explain the reasons the services were provided. These diagnosis codes provide information about the patient's condition and help determine if the services were necessary and appropriate for the patient's health. By reviewing the diagnosis codes, payers can ensure that the services were medically necessary and meet the criteria for coverage.

The basic formula for calculating each MS-DRG hospital payment is by multiplying the DRG relative weight with the hospital base rate. This formula allows for determining the payment amount based on the severity and complexity of the patient's condition (DRG relative weight) and the predetermined rate set by the hospital (hospital base rate).

Under HIPAA (Health Insurance Portability and Accountability Act), individuals or entities that willfully and knowingly violate the Privacy Rule with the intent to sell, transfer, or use Protected Health Information (PHI) for commercial advantage, personal gain, or malicious harm face severe penalties. This includes hefty fines and significant prison time, reflecting the serious nature of such violations and the need to protect patient privacy.

The patient developed a fever after undergoing a laparoscopic appendectomy, indicating a possible post-operative infection. Since the infection occurred after the surgery, it should not be tagged as present on admission (POA), as it was not present at the time of admission. Therefore, the correct answer is "Postoperative infection."

Autoauthentication refers to the process of automatically approving and signing dictated reports by Dr. Jones unless she makes corrections within 72 hours. This means that the reports are considered valid and authenticated without the need for manual intervention or additional signatures. It streamlines the approval process and ensures efficiency in the documentation of Dr. Jones' reports.

A data warehouse is a centralized repository that allows organizations to access data from multiple databases and combine the results into a single interface for querying and reporting. It is designed to support analytical processing and provide a consolidated view of data across different sources. By consolidating data into a data warehouse, organizations can easily retrieve and analyze information from various databases, enabling better decision-making and reporting capabilities.

Based on the information provided, the coder notes that the patient is taking prescribed Haldol, which is an antipsychotic medication commonly used to treat schizophrenia. Therefore, the coder might suspect that the patient has schizophrenia and should query the physician for confirmation or further information.

Edit checks should be in place to minimize this security breach. Edit checks are a security measure that ensures the accuracy and validity of data entered into a system. In this case, the coding analyst consistently enters the wrong code for patient gender, so implementing edit checks can help catch and prevent these errors. Edit checks can validate the entered code against a predefined set of acceptable values for patient gender, alerting the analyst if an incorrect code is entered. This can help minimize the security breach caused by consistently entering the wrong code for patient gender.

The correct answer is "No; it is a violation of the HIPAA Privacy Rule." This is because dentists are considered healthcare providers and are therefore covered entities under HIPAA. As a covered entity, they are required to provide patients with a Notice of Privacy Practices, which explains how their health information may be used and disclosed. Therefore, the dentist's failure to provide Janet Kim with a Notice of Privacy Practices is a violation of the HIPAA Privacy Rule.

Prior to performing a surgical procedure, it is essential to have the patient's consent for the operation, as well as a thorough understanding of their medical history and physical condition. The consent for operative procedure ensures that the patient understands the risks and benefits of the surgery and gives their permission for it to be performed. The history and physical examination provide crucial information about the patient's overall health, any pre-existing conditions, and any potential risks or complications that may arise during the surgery. Therefore, including the consent for operative procedure, history, and physical examination in the patient's medical record is necessary before performing a surgical procedure.

The correct answer is 40. "Late pregnancy" is a category code used to indicate that a woman is over 40 weeks pregnant. This category is used to track and monitor the progress of a pregnancy that has gone beyond the expected due date.

Under the HIPAA privacy standard, psychotherapy notes must be specifically identified in an authorization. This is because psychotherapy notes are treated differently from other types of protected health information (PHI). While other types of PHI can be disclosed for treatment, payment, and healthcare operations without explicit authorization, psychotherapy notes require the patient's specific consent for disclosure. This is to ensure the privacy and confidentiality of sensitive mental health information.

Including ancillary clinical and medical staff in the process would be the best way to ensure that everyone understands the importance of the CDI program. By involving these staff members, they will have a firsthand understanding of the program's goals and objectives. This will help them see the relevance of improving clinical documentation in supporting quality of care, data quality, and coding accuracy. Additionally, involving a diverse group of staff members will promote collaboration and a shared understanding of the program's importance throughout the hospital.

Recovery audit contractors (RACs) is the correct answer because RACs are responsible for identifying and recovering improper payments in the Medicare Fee-for-Service programs. They conduct audits and reviews of Medicare claims to detect any errors or fraudulent activities. RACs play a crucial role in ensuring the integrity of the Medicare system by detecting and correcting improper payments, thereby preventing wastage of funds and protecting the program's financial sustainability.

The correct answer suggests that the HIM director should inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This is the most appropriate response because it addresses the concern raised about adding the time of notation to all entries. Instead of focusing on the specific issue of time notation, the HIM director provides a broader guideline that ensures all entries are authenticated and dated, which is a requirement by Medicare. This response helps to maintain the integrity and accuracy of the medical record documentation.

Category II codes cover topics such as patient management, therapeutic, preventative, or other interventions, and patient safety. However, they do not address new technology. This means that Category II codes do not provide specific codes for documenting or tracking the use of new technologies in healthcare.

The correct answer is Appendix G. The CPT codebook provides a list of codes for procedures that include conscious sedation when administered by the same surgeon who performs the procedure. This information can be found in Appendix G of the codebook.

If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, a "with manipulation" code should be assigned for the procedure. This is because the surgeon attempted to manipulate or realign the fracture, even though they were unsuccessful in achieving the desired alignment. The "with manipulation" code acknowledges the attempted procedure, regardless of the outcome.

Computer-assisted coding is a type of coding that is a natural outgrowth of the electronic health record. This technology helps automate the coding process by analyzing clinical documentation and suggesting appropriate codes based on predefined rules and algorithms. It improves coding accuracy, efficiency, and productivity by reducing the manual effort required for coding. With computer-assisted coding, healthcare providers can streamline their coding workflows and ensure accurate and consistent coding practices.

Mohs micrographic surgery is a specialized technique used for the treatment of skin cancer. During this procedure, the surgeon acts as both a surgeon and a pathologist. They remove thin layers of cancerous tissue and examine them under a microscope to ensure complete removal of the tumor. This allows for precise removal of cancer cells while preserving healthy tissue. The surgeon's ability to perform the surgery and interpret the microscopic findings makes them both a surgeon and a pathologist in this context.

The correct answer is National Uniform Billing Committee (NUBC). This organization is responsible for developing the billing form that hospitals are required to use. They work to standardize the billing process and ensure that all hospitals use a uniform form for submitting claims. The NUBC plays a crucial role in streamlining the billing system and ensuring accurate and efficient billing practices in the healthcare industry.

Information access controls should be implemented to prevent this security breach. These controls include measures such as user authentication, role-based access control, and access restrictions based on the principle of least privilege. By implementing information access controls, the employee will only be able to access the clinical information system for legitimate work-related purposes, preventing them from snooping on personal information of neighbors and friends.

Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting and analyzing data, these programs can identify areas of improvement and implement strategies to enhance patient outcomes, safety, and overall healthcare delivery. The data collected can be used to measure performance, compare it to established benchmarks, and implement evidence-based practices to improve the quality of care provided to patients.

Sandy soils tend to have low organic matter content and poor nutrient retention, making nitrogen particularly susceptible to leaching. As a result, nitrogen deficiency is common in sandy soils, and careful management practices, such as regular soil testing and appropriate fertilization, are required to ensure adequate nitrogen availability for optimal crop production.

Beneficence is the ethical principle being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it. Beneficence refers to the duty to do good and act in the best interest of others. By safeguarding patient information and only providing access to authorized individuals, the HIT professional is promoting the well-being and protecting the rights of the patients. This principle ensures that patient privacy and confidentiality are respected, maintaining trust and promoting ethical practices in healthcare.

Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and gathering specific data points or elements from the record, such as diagnoses, procedures, medications, and patient demographics. The purpose of abstracting is to organize and summarize the essential information in a standardized manner, which can then be used for various purposes like research, reporting, billing, and quality improvement.

The correct ICD-9-CM diagnosis code for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms is V72.5. This code is used to indicate a routine general medical examination, which includes diagnostic laboratory and radiology services. It does not require any specific signs or symptoms to be present. The other codes listed are not appropriate for this scenario.