CCA Prep Exam 1 (100 Questions)

The history may contain information about diseases among relatives in which heredity may play a role. This is because the history includes details about a person's past medical conditions, family medical history, and any genetic conditions that may be present in the family. By gathering information about the diseases that run in the family, healthcare professionals can better understand the potential hereditary factors that may contribute to a person's current health condition.

The formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed is called the operative report. This report contains detailed information about the procedure, including the patient's preoperative condition, the surgical technique used, any complications encountered, and the surgeon's findings. It serves as a permanent record of the surgery and is important for future reference and medical documentation.

When a state law requires more stringent privacy protection than the federal HIPAA privacy standard, a hospital should comply with both the state law and the HIPAA standard. This means that the hospital must adhere to the requirements of the state law in order to meet the higher privacy standards set by the state, while still following the baseline privacy protections mandated by HIPAA at the federal level. By complying with both, the hospital ensures that it is meeting the minimum requirements set by HIPAA while also meeting the more stringent requirements set by the state law.

All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered clinical data. Clinical data refers to information that is directly related to the patient's medical condition, including symptoms, medical history, test results, treatment plans, and progress notes. This type of data is crucial for healthcare professionals to make informed decisions about the patient's care and monitor their progress. It is also important for research, quality improvement, and billing purposes.

Electronic data interchange (EDI) is the technology commonly utilized for automated claims processing. EDI allows for the electronic exchange of data between different computer systems, making it efficient and accurate for sending bills directly to third-party payers. It eliminates the need for manual data entry and reduces errors and processing time. EDI enables seamless communication and data transfer between healthcare providers and insurance companies, streamlining the claims processing workflow.

The release of information function in healthcare requires HIM professionals to have knowledge of federal and state confidentiality laws. This is because these laws govern the privacy and security of patient information and dictate how it can be shared and disclosed. HIM professionals need to understand these laws to ensure that they are compliant and protect patient confidentiality when releasing information to authorized individuals or entities. This knowledge is crucial in maintaining patient privacy and upholding legal and ethical standards in healthcare.

The coder notes that the physician has prescribed Synthroid for the patient. Synthroid is a medication commonly used to treat hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormones. Therefore, the coder might find "Hypothyroidism" on the patient's problem list as the reason for prescribing Synthroid.

The best first step in trying to rectify the current situation would be to consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices. This step allows for open communication and collaboration with the physician who has authority over the on-call doctors. By seeking their input and suggestions, the HIM director can gain valuable insights into the reasons behind the non-compliance and work towards finding effective solutions. This approach promotes teamwork and a proactive approach to resolving the issue.

An encoder is a software application that would be used to aid in the coding function in a physician's office. Coding involves assigning specific codes to medical procedures and diagnoses for billing and record-keeping purposes. An encoder helps in accurately assigning the appropriate codes by providing a database of codes and guidelines, allowing the user to search for specific terms or conditions and find the corresponding codes. It helps streamline the coding process and ensures accuracy in medical documentation and billing.

The best course of action is to inform Dr. Smith that he cannot access his daughter's health record without her signed authorization. This is because the daughter is now an adult at the age of 25, and her medical records are protected by patient confidentiality laws. Even though Dr. Smith was her guardian at the time of the tonsillectomy, he no longer has automatic access to her records without her explicit permission. It is important to respect the patient's privacy and follow legal and ethical guidelines regarding the release of medical records.

Assigning codes to an incomplete record goes against the responsibility of HIM coding professionals and the organizations that employ them to maintain data quality. It is important to ensure that codes are reviewed after the records are complete to accurately capture the diagnoses and procedures. By assigning codes to incomplete records, there is a risk of coding errors and inaccuracies, which can adversely affect data quality. Therefore, this behavior should not be tolerated.

A chart tracking system would fulfill the purpose of recording the location of health records removed from the filing system and documenting the date of their return to the HIM department. This system would allow the hospital HIM department to keep track of the movement of health records, ensuring their proper management and retrieval. It would provide a digital record of when and where each record is taken, allowing for efficient tracking and monitoring of the records' whereabouts.

Unbundling refers to the practice of reporting and billing individual component codes separately, instead of grouping them together as a panel. In this case, if the electrolyte panel is reported and billed by reporting and billing each component code individually, it would be considered as unbundling.

The physician has indicated in the progress notes that pneumonia has been ruled out. Therefore, it would not be appropriate to code for pneumonia as a diagnosis for the visit. However, the patient is presenting with symptoms of fever, productive cough, and shortness of breath. These symptoms should be coded as the diagnosis for the visit, as the results of the chest x-ray have not yet been received.

Medical necessity refers to the requirement that every procedure or service received by a patient must be linked to a diagnosis that justifies the need for performing the service. This ensures that medical treatments and services are provided based on the patient's medical condition and are deemed necessary for their health and well-being. It helps prevent unnecessary or inappropriate medical interventions and ensures that healthcare resources are used efficiently and effectively.

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a delinquent record. This means that the record has not been properly completed or updated within the required timeframe, and may be considered incomplete or non-compliant with the regulations.

A pathology report is the most likely document to include a microscopic description of tissue excised during surgery. Pathologists analyze tissue samples under a microscope to identify any abnormalities or diseases. The report provides detailed information about the tissue, including its cellular composition, presence of any tumors or lesions, and any other relevant findings. This information is crucial for diagnosing and treating patients, as well as monitoring their progress post-surgery. The recovery room record, operative report, and discharge summary may contain important information about the patient's condition and the surgical procedure, but they are unlikely to provide a microscopic description of the excised tissue.

The correct answer is "Abdominal pain" because the patient's chief complaint upon admission to the hospital was abdominal pain. The other options (ruptured appendix, exploratory laparoscopy, cholelithiasis) are findings or procedures that were discovered or performed as a result of the patient's abdominal pain.

Vocabulary standards are used to standardize medical terminology to avoid differences in naming various medical conditions and procedures. This helps to ensure that healthcare professionals and systems use consistent and standardized terms, preventing confusion and miscommunication. By using vocabulary standards, healthcare information can be easily shared and understood across different healthcare settings and systems.

The physician specialist would record findings, impressions, and recommendations in a consultation report. This type of report is typically used when a healthcare provider seeks the opinion or advice of another specialist in order to assist in the diagnosis or treatment of a patient. In this case, the family practitioner is seeking the opinion of the endocrinologist, who will review the patient's health record and examine the patient before documenting their findings and recommendations in a consultation report.

The correct answer is "Unbundling". Unbundling refers to the practice of reporting multiple codes for separate components of a procedure that should be reported as a single code. In this case, reporting the basic form of a colonoscopy (45378) along with a separate code for removal of a foreign body (45379) or biopsy (45380) would be considered unbundling, as these services are already included in the basic colonoscopy code.

The Centers of Medicare and Medicaid Services developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. NCCI is a set of coding edits that identify pairs of codes that should not be reported together in certain circumstances. These edits help ensure that medical services are coded accurately and that payments are made appropriately based on the services provided.

The HIM director should advise the committee that there is no HIPAA violation for announcing a patient's name in a waiting room. However, the committee may want to consider implementing practices that could reduce this practice in order to prioritize patient privacy and confidentiality.

The discharge summary serves multiple functions, such as ensuring the continuity of future care, providing concise information for information requests, and supporting the activities of the medical staff review committee. However, it does not typically include information about the patient's insurance coverage. This information is usually handled separately by the billing or insurance department.

A discharge summary is a document that contains important information about a patient's hospital stay, including their medical history, diagnosis, treatment plan, and any follow-up care needed. It is typically sent to the patient's attending physician, referring physician, and any consulting physicians to ensure continuity of care. This allows the receiving healthcare providers to have a comprehensive understanding of the patient's condition and treatment, enabling them to provide appropriate and effective care in the future.

Many facilities that have not adopted the whole problem-oriented format still use the SOAP form of progress notes. SOAP stands for Subjective, Objective, Assessment, and Plan, which is a structured format for documenting patient information. This format allows healthcare providers to organize and communicate patient data effectively, making it a commonly used part of the problem-oriented medical record even in facilities that have not fully adopted the entire format.

Transfer or referral - document between care givers in multiple healthcare setting

Accreditation organizations like the Joint Commission use health records to determine whether standards of care are being met. By reviewing the documentation in the health records, these organizations can assess if healthcare providers are following the established standards and guidelines for patient care. This helps ensure that patients are receiving the quality of care they deserve and that healthcare facilities are meeting the necessary requirements for accreditation.

According to Joint Commission standards, the physical exam must be completed within 24 hours of admission. In this situation, the physical exam was completed on June 23, which is more than 24 hours after Bob Smith was admitted on June 21. Therefore, the record is not in compliance with the standards.

According to the Joint Commission Accreditation Standards, the report of history and physical examination must be placed in the patient's record before a surgical procedure may be performed. This document provides crucial information about the patient's medical history, current condition, and any potential risks or complications that may arise during the surgery. It helps the surgical team make informed decisions and ensures that the patient receives appropriate and safe care.

If a group of tests in the laboratory section of CPT overlaps two or more panels, the coder would report the panel that incorporates the greater number of tests to fulfill the code definition. However, the remaining test codes that are not part of the panel should still be reported using individual test codes according to CPT guidelines. Therefore, the correct answer is to report the remaining tests using individual test codes according to CPT.

Audit trails are used to track and record all activities and events within a system. They provide a detailed log of user actions, such as login attempts, file access, and system changes. By checking for unauthorized access to a system, the audit trail helps to identify any potential security breaches or unauthorized activities. It helps in ensuring the integrity and security of the system by monitoring and detecting any unauthorized access attempts.

HIPAA privacy regulations apply to health records in any format. This means that whether the health records are in paper or electronic format, they are subject to the regulations. This ensures that the privacy and security of individuals' health information is protected, regardless of the medium in which it is stored or transmitted.

The coder notes that the physician has ordered potassium replacement for the patient. Hypokalemia is a condition characterized by low levels of potassium in the blood. The physician's order for potassium replacement suggests that the patient may have hypokalemia and requires additional potassium to correct the deficiency.

The hospital should respond by providing the medical records in paper format. This is because the patient requested the records in this format after finding that she cannot read the CD on her computer.

The correct answer is "Reason for encounter". Inpatient data collection primarily focuses on the principal diagnosis, which refers to the main reason for a patient's hospitalization. On the other hand, outpatient data collection emphasizes the reason for encounter, which refers to the primary purpose of a patient's visit to a healthcare facility. This can include routine check-ups, consultations, or treatment for specific symptoms or conditions. Therefore, the focus of outpatient data collection is on the reason for the encounter rather than the reason for admission or discharge diagnosis.

According to HIPAA regulations, the records from the previous hospital are considered part of the designated record set and should be given to the patient. This means that the HIM clerk's action of removing those records from another hospital without providing them to the patient was incorrect. HIPAA requires the release of all relevant medical records to the patient upon request, including records from previous healthcare providers.

The best reference tool to receive ICD-9-CM coding advice is AHA's Coding Clinic for ICD-9-CM. This resource specifically focuses on providing guidance and advice for ICD-9-CM coding. AMA's CPT Assistant primarily provides guidance for Current Procedural Terminology (CPT) coding, AHA's Coding Clinic for HCPCS focuses on Healthcare Common Procedure Coding System (HCPCS) coding, and the National Correct Coding Initiative (NCCI) provides guidance on correct coding practices in general. Therefore, AHA's Coding Clinic for ICD-9-CM is the most appropriate tool for ICD-9-CM coding advice.

Judkins (88.56) is the correct answer because it refers to a technique in coronary arteriography where two catheters are inserted percutaneously through the femoral artery. This technique allows for the visualization and detection of obstructions within both the right and left coronary arteries. The other options listed, such as Combined right and left (88.54), Stones (88.55), and Other and unspecified (88.57), do not specifically describe the technique of using two catheters inserted through the femoral artery.

Healthcare organizations must obtain licensure from government entities such as the state in which they are located before they can provide services. Licensure ensures that the organization meets specific standards and regulations set by the government to protect the health and safety of patients. It also ensures that the organization has the necessary qualifications and resources to provide quality healthcare services. Accreditation and certification are similar processes but are usually voluntary and focus on meeting specific industry standards, while licensure is a legal requirement for operating as a healthcare organization. Permission is a general term that does not specifically indicate the legal authorization required for healthcare services.

Privacy refers to the right of an individual to keep their personal information confidential and prevent it from being disclosed to others. It involves maintaining control over personal data and ensuring that it is protected from unauthorized access or use. Privacy is essential in maintaining trust and autonomy, allowing individuals to have control over their own personal information and make decisions about how it is shared or used. It is a fundamental right that is protected by laws and regulations in many jurisdictions.

A software interface refers to a program that facilitates the exchange of data between different software systems. It acts as a bridge, enabling communication and data transfer between various applications or components. This allows different software programs to interact and share information seamlessly, enhancing interoperability and functionality.

The correct answer is 661.01, V27.0, 74.1. This answer includes the appropriate ICD-9-CM diagnostic code (661.01) for term pregnancy with failure of cervical dilation, the procedure code (74.1) for lower uterine segment Cesarean delivery, and the V-code (V27.0) for the single live-born female.

Reviewing each patient's medical report concurrently to make sure history and physical examinations are present and meet the accreditation standards would be the best way to ensure the completeness of health records. This approach ensures that the documentation is reviewed in a timely manner, within 24 hours of admission, and allows for any necessary corrections or additions to be made promptly. It also ensures that the documentation meets the accreditation standards set by the Joint Commission, ensuring compliance with their requirements.

The correct answer is 631. A blighted ovum is a type of early pregnancy loss where a fertilized egg implants in the uterus but does not develop into an embryo. In medical coding, the ICD-9-CM dx code 631 is used to identify blighted ovum.

The correct answer is 703.0. This code represents an infected ingrown nail according to the ICD-9-CM coding system.

The correct ICD-9-CM code for laparoscopic cholecystectomy is 51.23. This code specifically represents the laparoscopic removal of the gallbladder. The other options either include additional procedures or do not accurately represent the laparoscopic approach.

To overcome noncompliance with medical record completion at Community Hospital, contacting other hospitals to see what methods they use to ensure compliance would be a next step. This approach can provide valuable insights and best practices from hospitals that have successfully addressed similar challenges. By learning from their experiences, Community Hospital can identify effective strategies and implement them to improve compliance. This proactive approach demonstrates a commitment to finding solutions and continuous improvement in addressing the problem.

The appropriate ICD-9-CM diagnosis code for right and left bundle branch block is 426.53. This code specifically represents bilateral bundle branch block, indicating that both the right and left bundle branches are affected. This code is the most accurate and specific choice among the given options.

The correct answer is 691.0. Diaper rash is a common condition in infants, but it can also occur in elderly patients who wear adult diapers or have incontinence issues. The ICD-9-CM code 691.0 specifically refers to diaper rash in adults.