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CCA Prep Exam 100 Questions

100 Questions  I  By Melodey23
CCA prep exam 100 questions
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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Question Excerpt

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1.  What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
A.
B.
C.
D.
2.  What is the name of the organization that develops the billing form that hospitals are required to use?
A.
B.
C.
D.
3.  Identify the punctuation mark that is 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 punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifer, and all three volumes of ICD-9-CM use them.
A.
B.
C.
D.
4.  The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?
A.
B.
C.
D.
5.  Mohs micrographic surgery involves the surgeon acting as:
A.
B.
C.
D.
6.   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.
B.
C.
D.
7.  Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.
A.
B.
C.
D.
8.  Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition.
A.
B.
C.
D.
9.  A child was examined and treated for child abuse in the emergency department at the hospital. s a result, the child ha been taken into protective custody by the Office of Child Protection because of suspected child abuse by parents. The father requests copies of the designated record set for the visit. He has a copy of the child's birth certificate listing him as the fther and he possesses a picture ID. Do you release a copy of the emergency department record?
A.
B.
C.
D.
10.  Which of the following activities would be in violation of AHIMA's Code of Ethics?
A.
B.
C.
D.
11.  A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
A.
B.
C.
D.
12.  Which of the following is not an accepted accrediting body for behavioral healthcare organizations?
A.
B.
C.
D.
13.  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.
B.
C.
D.
14.  Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications.
A.
B.
C.
D.
15.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia.
A.
B.
C.
D.
16.  What was the goal of the new MS-DRG system?
A.
B.
C.
D.
17.  Identify the acute care record report where the following information would be found:  Gross Description:  Received fresh designated left lacrimal gland is a single, unoriented, irregular tan-pink portion of soft tissue measuring 0.8 x 0.6 x 0.1 cm, which is submitted entirely, intact, in one cassette.
A.
B.
C.
D.
18.  What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm?
A.
B.
C.
D.
19.  Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)?
A.
B.
C.
D.
20.  Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode.
A.
B.
C.
D.
21.  What type of standard establishes uniform definitions for clinical terms?
A.
B.
C.
D.
22.  The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form?
A.
B.
C.
D.
23.  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.
B.
C.
D.
24.  Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers?
A.
B.
C.
D.
25.  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.
B.
C.
D.
26.  What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient?
A.
B.
C.
D.
27.  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.
B.
C.
D.
28.  Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli.
A.
B.
C.
D.
29.  What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers?
A.
B.
C.
D.
30.  What is the basic formula for calculating each MS-DRG hospital payments?
A.
B.
C.
D.
31.  When correcting erroneous information in a health record, which of the following is not appropriate?
A.
B.
C.
D.
32.  Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result.
A.
B.
C.
D.
33.  The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record.
A.
B.
C.
D.
34.  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.
B.
C.
D.
35.  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.
B.
C.
D.
36.  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.
B.
C.
D.
37.  Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the:
A.
B.
C.
D.
38.  Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization?
A.
B.
C.
D.
39.  Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
A.
B.
C.
D.
40.  "Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
A.
B.
C.
D.
41.  Which of the following would not be found in a medical history?
A.
B.
C.
D.
42.  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.
B.
C.
D.
43.  Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome.
A.
B.
C.
D.
44.  Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients?
A.
B.
C.
D.
45.  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.
B.
C.
D.
46.  Where would a coder who needed to locate the histology of a tissue sample most likely find this information
A.
B.
C.
D.
47.  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.
B.
C.
D.
48.  Tissue transplated from one individual to another of the same species but different genotype is called a(n):
A.
B.
C.
D.
49.  Observation E/M codes (99218 through 99220) are used in physician billing when:
A.
B.
C.
D.
50.  During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?
A.
B.
C.
D.
51.  Which answer below is not correct for assignment of the MS-DRG?
A.
B.
C.
D.
52.  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.
B.
C.
D.
53.  Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
A.
B.
C.
D.
54.  Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?
A.
B.
C.
D.
55.  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.
B.
C.
D.
56.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.
A.
B.
C.
D.
57.  Which of the following is a core ethical obligation of health information staff?
A.
B.
C.
D.
58.  Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
A.
B.
C.
D.
59.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough.
A.
B.
C.
D.
60.  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.
B.
C.
D.
61.  ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
A.
B.
C.
D.
62.  What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs?
A.
B.
C.
D.
63.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea.
A.
B.
C.
D.
64.  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.
B.
C.
D.
65.  The codes in the musculoskeletal section of CPT may be used by:
A.
B.
C.
D.
66.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with abnormal glucose tolerance test.
A.
B.
C.
D.
67.  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.
B.
C.
D.
68.  Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes?
A.
B.
C.
D.
69.  Which organization developed the first hospital standardization program?
A.
B.
C.
D.
70.  Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence.
A.
B.
C.
D.
71.  An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach?
A.
B.
C.
D.
72.  Which of the following activities is considered an unethical practice?
A.
B.
C.
D.
73.  What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard? 
A.
B.
C.
D.
74.  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.
B.
C.
D.
75.  Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa.
A.
B.
C.
D.
76.  What is abstracting?
A.
B.
C.
D.
77.  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.
B.
C.
D.
78.  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.
B.
C.
D.
79.  Who is responsible for writing and signing discharge summaries and discharge instructions?
A.
B.
C.
D.
80.  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.
B.
C.
D.
81.  Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.
A.
B.
C.
D.
82.  CPT was developed and is maintained by:
A.
B.
C.
D.
83.  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.
B.
C.
D.
84.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy, ruled out.
A.
B.
C.
D.
85.  What healthcare organization collects UHDDS data?
A.
B.
C.
D.
86.  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.
B.
C.
D.
87.  Per CPT guidelines, a separate procedure is:
A.
B.
C.
D.
88.  What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
A.
B.
C.
D.
89.  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.
B.
C.
D.
90.  In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems.
A.
B.
C.
D.
91.  What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment?
A.
B.
C.
D.
92.  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.
B.
C.
D.
93.  Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung.
A.
B.
C.
D.
94.  When coding a selective catheterization in CPT, how are codes assigned?
A.
B.
C.
D.
95.  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.
B.
C.
D.
96.  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.
B.
C.
D.
97.  Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis.
A.
B.
C.
D.
98.  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.
B.
C.
D.
99.  Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?
A.
B.
C.
D.
100.  Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
A.
B.
C.
D.
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