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CCA Prep Exam 100 Questions

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CCA Practice Exam 2 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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Questions and Answers
  • 1. 
    Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
    • A. 

      Physical examination record

    • B. 

      History record

    • C. 

      Operative report

    • D. 

      Radiological report

  • 2. 
    • A. 

      Postoperative infection

    • B. 

      Appendicitis

    • C. 

      COPD

    • D. 

      Hypertension

  • 3. 
    Which of the following would not be found in a medical history?
    • A. 

      Chief complaint

    • B. 

      Vital signs

    • C. 

      Present illness

    • D. 

      Review of systems

  • 4. 
    • A. 

      Consent for operative procedure, anesthesia report, surgical report

    • B. 

      Consent for operative procedure, history, physical examination

    • C. 

      History, physical examination, anesthesia report

    • D. 

      Problem list, history, physical examination

  • 5. 
    Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
    • A. 

      Operative report

    • B. 

      Anesthesia report

    • C. 

      Pathology report

    • D. 

      Laboratory report

  • 6. 
    Identify the acute-care record report where the following information would be found:  The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs.
    • A. 

      Discharge summary

    • B. 

      Medical history

    • C. 

      Medical laboratory report

    • D. 

      Physical examination

  • 7. 
    • A. 

      Discharge summary

    • B. 

      Medical history

    • C. 

      Medical laboratory report

    • D. 

      Physical examination

  • 8. 
    • A. 

      Operative report

    • B. 

      Pathology report

    • C. 

      Discharge summary

    • D. 

      Nursing note

  • 9. 
    Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
    • A. 

      Performance improvement programs

    • B. 

      Billing and claims data processing

    • C. 

      Developing hospital discharge abstracting systems

    • D. 

      Developing individual care plans for residents

  • 10. 
    • A. 

      Compiling the pertinent information from the medical record based on predetermined data sets

    • B. 

      Assigning the appropriate code or nomenclature term for categorization

    • C. 

      Assembling a chronological set of data for an express purpose

    • D. 

      Conducting qualitative and quantitative analysis of documentation against standards and policy

  • 11. 
    What type of standard establishes uniform definitions for clinical terms?
    • A. 

      Identifier standard

    • B. 

      Vocabulary standard

    • C. 

      Transaction and messaging standard

    • D. 

      Structure and content standard

  • 12. 
    According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older:
    • A. 

      30

    • B. 

      35

    • C. 

      38

    • D. 

      40

  • 13. 
    ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
    • A. 

      28th

    • B. 

      14th

    • C. 

      60th

    • D. 

      30th

  • 14. 
    "Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
    • A. 

      41

    • B. 

      39

    • C. 

      40

    • D. 

      42

  • 15. 
    Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
    • A. 

      Herpes simplex

    • B. 

      Staphylococcus aureus

    • C. 

      Influenza, types A and B

    • D. 

      Candida albicans

  • 16. 
    The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary?
    • A. 

      Otitis media

    • B. 

      AIDS

    • C. 

      Toxic shock syndrome

    • D. 

      Bacteremia

  • 17. 
    What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
    • A. 

      Lobar pneumonia

    • B. 

      Pneumocystitis carinii pneumonia

    • C. 

      Interstitial pneumonia

    • D. 

      Aspiration pneumonia

  • 18. 
    Where would a coder who needed to locate the histology of a tissue sample most likely find this information
    • A. 

      Pathology report

    • B. 

      Progress notes

    • C. 

      Nurse's notes

    • D. 

      Operative report

  • 19. 
    The coder notes 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?
    • A. 

      Insomnia

    • B. 

      Hypertension

    • C. 

      Schizophrenia

    • D. 

      Rheumatoid arthritis

  • 20. 
    Which organization developed the first hospital standardization program?
    • A. 

      Joint Commission

    • B. 

      American Osteopathic Association

    • C. 

      American College of Surgeons

    • D. 

      American Association of Medical Colleges

  • 21. 
    • A. 

      Suggest that only hospital clock time be noted in clinical documentation

    • B. 

      Suggest that only electronic documentation have time notated

    • C. 

      Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated

    • D. 

      Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time

  • 22. 
    When correcting erroneous information in a health record, which of the following is not appropriate?
    • A. 

      Print "error" above the entry

    • B. 

      Enter the correction in chronological sequence

    • C. 

      Add the reason for the change

    • D. 

      Use black pen to obliterate the entry

  • 23. 
    Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program?
    • A. 

      Request that the CEO write a memorandum to all hospital staff

    • B. 

      Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation

    • C. 

      Include ancillary clinical and medical staff in the process

    • D. 

      Request a letter from the Joint Commission

  • 24. 
    In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action?
    • A. 

      Request that the physician dictate another discharge summary

    • B. 

      Have the record analyst note the date discrepancy

    • C. 

      Request the physician dictate an addendum to the discharge summary

    • D. 

      File the record as complete since the discharge summary includes all the pertinent patient information

  • 25. 
    • A. 

      Immediately stop the practice of changing transcribed reports

    • B. 

      Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form

    • C. 

      Conduct a verification audit

    • D. 

      Alert hospital legal counsel of the practice

  • 26. 
    During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices?
    • A. 

      Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately

    • B. 

      Determine how many nurses are involved in this practice

    • C. 

      Institute an in-service training session on documentation practices

    • D. 

      Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system

  • 27. 
    Who is responsible for writing and signing discharge summaries and discharge instructions?
    • A. 

      Attending physician

    • B. 

      Head nurse

    • C. 

      Primary physician

    • D. 

      Admitting nurse

  • 28. 
    Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________.
    • A. 

      Autoauthentication

    • B. 

      Electronic signature

    • C. 

      Automatic record completion

    • D. 

      Chart tracking

  • 29. 
    The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours.
    • A. 

      30 days / 48 hours / 24 hours

    • B. 

      14 days / 24 hours / 48 hours

    • C. 

      14 days / 48 hours / 24 hours

    • D. 

      30 days / 24 hours / 48 hours

  • 30. 
    Which of the following is not an accepted accrediting body for behavioral healthcare organizations?
    • A. 

      American Psychological Association

    • B. 

      Joint Commission

    • C. 

      Commission on Accreditation of Rehabilitation Facilities

    • D. 

      National Committee for Quality Assurance

  • 31. 
    What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers?
    • A. 

      Vocabulary standard

    • B. 

      Identifier standard

    • C. 

      Structure and content standard

    • D. 

      Security standard

  • 32. 
    What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
    • A. 

      Accreditation organizations

    • B. 

      Certification organizations

    • C. 

      State licensure agencies

    • D. 

      Conditions of participation agencies

  • 33. 
    Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers?
    • A. 

      Patient Assessment Instrument

    • B. 

      Minimum Data Set for Long-Term Care

    • C. 

      Resident Assessment Protocol

    • D. 

      Outcomes and Assessment Information Set

  • 34. 
    Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago.
    • A. 

      709.2

    • B. 

      906.1

    • C. 

      709.2, 906.1

    • D. 

      906.1, 709.2

  • 35. 
    Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago.
    • A. 

      787.20, 438.12

    • B. 

      784.59, 438.12

    • C. 

      438.12

    • D. 

      787.20, 438.89

  • 36. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis.
    • A. 

      558.9

    • B. 

      787.01, 558.9

    • C. 

      787.02, 787.03, 558.9

    • D. 

      787.01, 558.41

  • 37. 
    Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result.
    • A. 

      796.4

    • B. 

      790.6

    • C. 

      792.9

    • D. 

      790.93

  • 38. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.
    • A. 

      780.2

    • B. 

      780.2, 787.02

    • C. 

      780.2, 787.01

    • D. 

      780.4, 787.02

  • 39. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with abnormal glucose tolerance test.
    • A. 

      790.29

    • B. 

      790.21

    • C. 

      790.21, 790.29

    • D. 

      790.22

  • 40. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough.
    • A. 

      786.2, 490

    • B. 

      486, 786.2

    • C. 

      486

    • D. 

      481

  • 41. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy, ruled out.
    • A. 

      780.39

    • B. 

      345.9

    • C. 

      780.39, 345.9

    • D. 

      345.90

  • 42. 
    Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence.
    • A. 

      625.6

    • B. 

      788.30

    • C. 

      788.32

    • D. 

      788.39

  • 43. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea.
    • A. 

      789.03

    • B. 

      789.03, 787.02, 787.03, 787.91

    • C. 

      789.03, 787.91

    • D. 

      789.03, 787.01, 787.91

  • 44. 
    • A. 

      Parentheses ( )

    • B. 

      Square brackets [ ]

    • C. 

      Slanted brackets  [  ]

    • D. 

      Braces { }

  • 45. 
    From the health record of a patient newly diagnosed with a malignancy: Preoperative Diagnosis:  Suspicious lesions, main bronchus Postoperative Diagnosis:  Carcinoma, in situ, main bronchus Indications:  Previous bronchoscopy showed two suspicious lesions in the main bronchus. Laser photoresection is planned for destruction of these lesions, because bronchial washings obtained previously showed carcinoma in situ. Procedure:  Following general anesthesia in the hospital same-day surgery area, with a high-frequency jet ventilator, a rigid bronchoscope is inserted and advanced through the larynx to the main bronchus. The areas were treated with laser photoresection. Identify the ICD-9-CM diagnosis code and CPT procedure code(s) for this service?
    • A. 

      162.2, 31641, 31623-59

    • B. 

      231.2, 31641, 31623-59

    • C. 

      231.2, 31641

    • D. 

      162.2, 31641

  • 46. 
    A 22-year-old patient presents for a closure of a patent ductus arteriosus. The patient's thorax is opened posteriorly and the vagus nerve is isolated away. The PDA is divided and sutured individually in the aorta and pulmonary artery. How is this procedure coded?
    • A. 

      33813

    • B. 

      33820

    • C. 

      33822

    • D. 

      33824

  • 47. 
    Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode.
    • A. 

      410.11

    • B. 

      410.01

    • C. 

      410.02

    • D. 

      410.12

  • 48. 
    Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome.
    • A. 

      042, 112.4, V01.79

    • B. 

      112.4, 042

    • C. 

      042, 112.4, V08

    • D. 

      042, 112.4

  • 49. 
    Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli.
    • A. 

      599.0

    • B. 

      599.0, 041.4

    • C. 

      041.4

    • D. 

      041.4, 599.0

  • 50. 
    • A. 

      204.00, 787.01, V58.11

    • B. 

      V58.11, 204.00, 787.01

    • C. 

      V58.11, 204.00

    • D. 

      204.22, 787.01

  • 51. 
    Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung.
    • A. 

      153.9, 162.9

    • B. 

      197.0, 153.9

    • C. 

      153.9, 197.0

    • D. 

      153.9, 239.1

  • 52. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia.
    • A. 

      038.11, 995.91

    • B. 

      995.91, 038.11

    • C. 

      038.11

    • D. 

      038.11, 995.92

  • 53. 
    Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition.
    • A. 

      250.02

    • B. 

      250.01, 263.1

    • C. 

      250.02, 263.1

    • D. 

      250.01, 263.0

  • 54. 
    Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.
    • A. 

      288.00

    • B. 

      288.00, 780.60

    • C. 

      288.01

    • D. 

      288.00, 780.61

  • 55. 
    Identify the correct ICD-9-CM diagnosis code(s) for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms.
    • A. 

      V72.81

    • B. 

      V72.5

    • C. 

      V72.5, 793.99

    • D. 

      V70.9, 793.1

  • 56. 
    • A. 

      82270

    • B. 

      82271

    • C. 

      82272

    • D. 

      82274

  • 57. 
    Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
    • A. 

      Patient management

    • B. 

      New technology

    • C. 

      Therapeutic, preventative, or other interventions

    • D. 

      Patient safety

  • 58. 
    Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in:
    • A. 

      Appendix E

    • B. 

      Appendix F

    • C. 

      Appendix G

    • D. 

      Appendix H

  • 59. 
    Per CPT guidelines, a separate procedure is:
    • A. 

      Coded when it is performed as part of another, larger procedure

    • B. 

      Considered to be an integral part of another, larger procedure

    • C. 

      Never code under any circumstance

    • D. 

      Both a and b

  • 60. 
    CPT was developed and is maintained by:
    • A. 

      CMS

    • B. 

      AMA

    • C. 

      Cooperating Parties

    • D. 

      WHO

  • 61. 
    The codes in the musculoskeletal section of CPT may be used by:
    • A. 

      Orthopedic surgeons only

    • B. 

      Orthopedic surgeons and emergency department physicians

    • C. 

      Any physician

    • D. 

      Orthopedic surgeons and neurosurgeons

  • 62. 
    Observation E/M codes (99218 through 99220) are used in physician billing when:
    • A. 

      A patient is admitted and discharged on the same date.

    • B. 

      A patient is admitted for routine nursing care following surgery.

    • C. 

      A patient does not meet admission criteria.

    • D. 

      A patient is referred to a designated observation service.

  • 63. 
    Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the:
    • A. 

      Past medical history

    • B. 

      Social history

    • C. 

      Systems review

    • D. 

      History of present illness

  • 64. 
    Tissue transplated from one individual to another of the same species but different genotype is called a(n):
    • A. 

      Autograft

    • B. 

      Xenograft

    • C. 

      Allograft or allogeneic graft

    • D. 

      Heterograft

  • 65. 
    Mohs micrographic surgery involves the surgeon acting as:
    • A. 

      Both plastic surgeon and general surgeon

    • B. 

      Both surgeon and pathologist

    • C. 

      Both plastic surgeon and dermatologist

    • D. 

      Both dermatologist and pathologist

  • 66. 
    If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure?
    • A. 

      A "with manipulation" code

    • B. 

      A "without manipulation" code

    • C. 

      An unlisted procedure code

    • D. 

      An E/M code only

  • 67. 
    Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa.
    • A. 

      10060

    • B. 

      10140

    • C. 

      23030

    • D. 

      23031

  • 68. 
    In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called:
    • A. 

      Selective catheterization

    • B. 

      Nonselective catheterization

    • C. 

      Manipulative catheterization

    • D. 

      Radical catheterization

  • 69. 
    • A. 

      One code for each vessel entered

    • B. 

      One cod for the point of entry vessel

    • C. 

      One code for the final vessel entered

    • D. 

      One code for the vessel of entry and one for the final vessel, with interventing vessels not coded

  • 70. 
    How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form?
    • A. 

      By requesting the medical record for each service provided

    • B. 

      By reviewing al the diagnosis codes assigned to explain the reasons the services were provided

    • C. 

      By reviewing all physician orders

    • D. 

      By reviewing the discharge summary and history and physical for the patient over the last year

  • 71. 
    What is the name of the organization that develops the billing form that hospitals are required to use?
    • A. 

      American cademy of Billing Forms (AABF)

    • B. 

      National Uniform Billing Committee (NUBC)

    • C. 

      National Uniform Claims Committee (NUCC)

    • D. 

      American Billing and Claims Academy (ABCA)

  • 72. 
    • A. 

      All outpatient settings including physician clinics and ambulatory surgical centers

    • B. 

      All outpatient settings including cancer centers, independent testing facilities, and nursing homes

    • C. 

      All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes

    • D. 

      All inpatient settings and outpatient settings with a focus on ambulatory surgical centers

  • 73. 
    What was the goal of the new MS-DRG system?
    • A. 

      To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients

    • B. 

      To improve Medicare's capability to recognize poor quality of care and pay hospitals on an incentive grid that allow hospitals to be paid by performance.

    • C. 

      To improve Medicare's capability to recognize groups of data by patient populations which will further allow Medicare to adjust the hospitals wage indexes based on the data. This adjustment will be a system to pay hospitals fairly across all geographic locations

    • D. 

      To improve Medicare's capability to recognize practice patterns among hospitals that are inappropriately optimizing payments by keeping patients in the hospital longer than the median length of stay.

  • 74. 
    • A. 

      Hospital payment = DRG relative weight x hospital base rate

    • B. 

      Hospital payment = DRG relative weight x hospital base rate -1

    • C. 

      Hospital payment = DRG relative weight / hospital base rate +1

    • D. 

      Hospital payment = DRG relative weight / hospital base rate

  • 75. 
    • A. 

      Additional payments may be made to locum tenens, increased emergency room services, stays over the average length of stay, and for cost outlier cases.

    • B. 

      Additional payment may be made to critical access hospitals, higher than normal volumes, unexpected hospital emergencies, and for cost outlier cases.

    • C. 

      Additional payments may be made to increased emergency room services, critical access hospitals, for increased labor costs, and for cost outlier cases.

    • D. 

      Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases.

  • 76. 
    What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs?
    • A. 

      Medicare administrative contractors (MACs)

    • B. 

      Recovery audit contractors (RACs)

    • C. 

      Comprehensive error rate testing (CERT)

    • D. 

      Fiscal intermediaries (FIs)

  • 77. 
    What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient?
    • A. 

      Three

    • B. 

      Nine

    • C. 

      Five

    • D. 

      Six

  • 78. 
    Which answer below is not correct for assignment of the MS-DRG?
    • A. 

      Diagnoses and procedures (principal and secondary)

    • B. 

      Attending and consulting physicians

    • C. 

      Presence of major or other complications and co morbidities (MCC or CC)

    • D. 

      Discharge disposition or status

  • 79. 
    What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses?
    • A. 

      22

    • B. 

      18

    • C. 

      16

    • D. 

      9

  • 80. 
    A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended?
    • A. 

      User name and password

    • B. 

      Automatic session terminations

    • C. 

      Cable locks

    • D. 

      Encryption

  • 81. 
     A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in plce to minimize this security breach?
    • A. 

      Access controls

    • B. 

      Audit trails

    • C. 

      Edit checks

    • D. 

      Password controls

  • 82. 
    • A. 

      Make admission date a required field

    • B. 

      Provide an input mask for entering data in the field

    • C. 

      Make admission date a numeric field

    • D. 

      Provide sufficient space for input of data

  • 83. 
    In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems.
    • A. 

      MIS

    • B. 

      CDS

    • C. 

      ADT

    • D. 

      ABC

  • 84. 
    Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface?
    • A. 

      Client-server computer

    • B. 

      Data warehouse

    • C. 

      Local area network

    • D. 

      Internet

  • 85. 
    The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record.
    • A. 

      Automated codebook

    • B. 

      Computer-assisted coding

    • C. 

      Logic based encoder

    • D. 

      Decision support database

  • 86. 
    • A. 

      Yes, after he has completed alegitimate release of information authorization.

    • B. 

      Decline to release the information and contact the hospital's attorney.

    • C. 

      Contact the Office of Child Protection for permission to release the record.

    • D. 

      Refer the matter to the hospital administrator and follow the administration's instructions after he meets with the father.

  • 87. 
    A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest?
    • A. 

      Avoid displaying the number on any document, screen, or data collection field

    • B. 

      Allow the information in both electronic and paper forms since a variety of people need this data

    • C. 

      Require employees to sign coinfidentiality agreements if they have access to social security numbers

    • D. 

      Contact legl counsel for advice

  • 88. 
    Which of the following activities is considered an unethical practice?
    • A. 

      Backdating progress notes

    • B. 

      Performing quantitative analysis

    • C. 

      Verifying that an insurance company is one that is authorized to receive patient information

    • D. 

      Determining what information is required to fulfill an authorized request for information

  • 89. 
    Which of the following ethical principles is being followed when an HIT professional ensures thtat patient information is only released to those who have a legl right to access it?
    • A. 

      Autonomy

    • B. 

      Beneficence

    • C. 

      Justice

    • D. 

      Nonmaleficence

  • 90. 
    Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients?
    • A. 

      Interpretation of x-rays by the radiologist

    • B. 

      Billing records

    • C. 

      Progress notes written by the attending physician

    • D. 

      Psychotherapy notes

  • 91. 
    Which of the following is a core ethical obligation of health information staff?
    • A. 

      Coding diseases and operations

    • B. 

      Protecting patients' privacy and confidential communications

    • C. 

      Transcribing medical reports

    • D. 

      Performing quantitative analysis on record content

  • 92. 
    Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization?
    • A. 

      History and physical reports

    • B. 

      Operative reports

    • C. 

      Consultation reports

    • D. 

      Psychotherapy notes

  • 93. 
    • A. 

      A fine of not more than $10,000 only

    • B. 

      A fine of not more than $10,000, not more than 1 year in jail, or both

    • C. 

      A fine of not more than $5,000 only

    • D. 

      A fine of not more than $250,000, not more than 10 years in jail, or both

  • 94. 
    Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?
    • A. 

      No a dentist is a healthcare clearinghouse, which is covered entity under HIPAA.

    • B. 

      Yes; a dentist is not a covered entity per the HIPAA Privacy Rule.

    • C. 

      No; it is a violation of the HIPAA Privacy Rule.

    • D. 

      Yes; the Notice of Privacy Practices is not required until June 2012.

  • 95. 
    Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1).  They will also be sending her records to her physician for continuity of care (2).  Under HIPAA, these two functions are:
    • A. 

      Use (1) and disclosure (2)

    • B. 

      Request (1) and disclosure (2)

    • C. 

      Disclosure (1) and use (2)

    • D. 

      Disclosures (1 and 2)

  • 96. 
    • A. 

      Use of Mary's information about her myocardial infarction, deidentified

    • B. 

      Use of Mary's information about her asthma, in a limited data set

    • C. 

      Use of Mary's individually identifiable information related to her asthma treatments

    • D. 

      Use of medical information about Jim, Mary's deceased husband

  • 97. 
    • A. 

      Coding an intentionally inappropriate level of service

    • B. 

      Following established coding policies and procedures

    • C. 

      Protecting the confidentiality of patients' written and electronic records

    • D. 

      Taking remedial action when there is direct knowledge of a colleague's incompetence or impairment

  • 98. 
    • A. 

      Audit controls

    • B. 

      Information access controls

    • C. 

      Facility access controls

    • D. 

      Workstation security

  • 99. 
    On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this caes, what should the supervisor do?
    • A. 

      Reprimand the employee

    • B. 

      Fire the employee

    • C. 

      Determine what information was printed and why

    • D. 

      Revoke the employee's access priviliges

  • 100. 
    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