CCA Prep Exam 1 (100 Questions)

100 Questions | Total Attempts: 2393

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CCA Prep Exam 1 - 100 Questions - Entered 03/12/2012 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


Questions and Answers
  • 1. 
    An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?
    • A. 

      DEEDS

    • B. 

      EMEDS

    • C. 

      UACDS

    • D. 

      UHDDS

  • 2. 
    Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of __________.
    • A. 

      Transaction standards

    • B. 

      Content and structure standards

    • C. 

      Vocabulary standards

    • D. 

      Security standards

  • 3. 
    A family practitioner requests the opinion of a physician specialist in endocrinology who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in which type of report?
    • A. 

      Consultation

    • B. 

      Medical history

    • C. 

      Physical examination

    • D. 

      Progress notes

  • 4. 
    Which of the following is not a function of the discharge summary?
    • A. 

      Providing information about the patient's insurance coverage

    • B. 

      Ensuring the continuity of future care

    • C. 

      Providing information to support the activities of the medical staff review committee

    • D. 

      Providing concise information that can be used to answer information requests

  • 5. 
    Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the:
    • A. 

      Discharge summary

    • B. 

      Autopsy report

    • C. 

      Incident report

    • D. 

      Consent to treatment

  • 6. 
    A 65-year-old white male was aditted to the hospital on 1/15 complaining of abdominal pain. The Attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy and ruptured appendix was discovered. The chief complaint was:
    • A. 

      Ruptured appendix

    • B. 

      Exploratory laparoscopy

    • C. 

      Abdominal pain

    • D. 

      Cholelithiasis

  • 7. 
    All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data:
    • A. 

      Clinical

    • B. 

      Identification

    • C. 

      Secondary

    • D. 

      Financial

  • 8. 
    What type of data is exemplified by the insured party's member identification number?
    • A. 

      Demographic data

    • B. 

      Clinical data

    • C. 

      Certification data

    • D. 

      Financial Data

  • 9. 
    Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format?
    • A. 

      The problem list is an index

    • B. 

      The initial plan

    • C. 

      The SOAP form of progress notes

    • D. 

      The database

  • 10. 
    While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on __________.
    • A. 

      Reason for admission

    • B. 

      Reason for encounter

    • C. 

      Discharge diagnosis

    • D. 

      Activities of daily living

  • 11. 
    Mildred Smith was admitted from an acute hospital to a nursing facility with the following information: "Patient is being admitted for Organic Brain Syndrome".  Underneath the diagnosis was listed her medical information along with her rehabilitation potential. On which form is this information documented.
    • A. 

      Transfer or referral

    • B. 

      Release of information

    • C. 

      Patients rights acknowledgement

    • D. 

      Admitting physical evaluation

  • 12. 
    The coder notes that the physician has prescribed Synthroid for the patient. The coder might find which of the following on the patient's problem list?
    • A. 

      Acromegaly

    • B. 

      Hypothyroidism

    • C. 

      Dwarfism

    • D. 

      Cushing's disease

  • 13. 
    A male patient is seen by the physician and diagnosed with pneumonia. The doctor took cultures to try to determine which organism was causing the pneumonia. Which of the following organisms would alert the coder to code it as a gram-negative pneumonia?
    • A. 

      Staphylococcus

    • B. 

      Clostridium

    • C. 

      Klebsiella

    • D. 

      Streptococcus

  • 14. 
    What is the best source of documentation to determine the size of a removed malignant lesion?
    • A. 

      Pathology report

    • B. 

      Postacute care unit record

    • C. 

      Operative report

    • D. 

      Physical examination

  • 15. 
    The coder might find which of the following on a patient's problem list if the medication list contains the drug Protonix?
    • A. 

      High blood pressure

    • B. 

      Esophagitis

    • C. 

      Congestive heart failure

    • D. 

      AIDS

  • 16. 
    The patient is seen in the physician office with a chief complaint of shortness of breath. In the patient's progress notes, the physician documents the diagnosis of asthma and recommends the patient present to the emergency department of XYZ Hospital immediately. The physician further documents that the patient has severe wheezing and no obvious relief with bronchodilators. Which action will the coder take?
    • A. 

      Code asthma

    • B. 

      Code asthma with status asthmaticus

    • C. 

      Code asthma with acute exacerbation

    • D. 

      Query the physician for more detail about asthma

  • 17. 
    The coder notes that the physician has ordered potassium replacement for the patient. The coder might expect to see a diagnosis of:
    • A. 

      Hypokalemia

    • B. 

      Hyponatremia

    • C. 

      Hyperkalemia

    • D. 

      Hypernatremia

  • 18. 
    The __________ may contain information about diseases among relatives in which heredity may play a role.
    • A. 

      Physical examination

    • B. 

      History

    • C. 

      Laboratory report

    • D. 

      Administrative data

  • 19. 
    The physician orders a chest x-ray for a patient who presents at the office with fever, productive cough, a shortness of breath. The physician indicates in the progress notes: "Ruled out pneumonia" What diagnosis (es) should be coded for the visit when the results have not yet been received?
    • A. 

      Pneumonia

    • B. 

      Fever, cough, shortness of breath

    • C. 

      Cough, shortness of breath

    • D. 

      Pneumonia, cough, shortness of breath

  • 20. 
    Which term describes the linking of every procedure or service received by a patient to a diagnosis that justifies the need to performing the service?
    • A. 

      Medical necessity

    • B. 

      Managed care

    • C. 

      Medical decision making

    • D. 

      Levels of services

  • 21. 
    To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health  record no later than 24 hours after amission.  Which of the following would by the best way to ensure the completeness of health records?
    • A. 

      Retrospectively review each patient's medical record to make sure history and physical are present

    • B. 

      Review each patient's medical report concurrently to make sure history andphysical are present and meet the accreditation standards

    • C. 

      Establish a process to review medical records immediately on discharge

    • D. 

      Do a review of records for all patients discharged in the previous 60 days

  • 22. 
    Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceed the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. To improve compliance, which of the following would be a next step to overcoming noncompliance?
    • A. 

      Discuss the problem with the hospital CEO

    • B. 

      Call the Joint Commission

    • C. 

      Contact other hospitals to see what methods they use to ensure compliance

    • D. 

      Drop the issue because non-compliance is always a problem

  • 23. 
    How do accrediation organizations such as the Join Commission use the health record?
    • A. 

      To serve as a source for case study information

    • B. 

      To determine whether the documentation supports the provider's claim for reimbursement

    • C. 

      To provide healthcare services

    • D. 

      To determine whether standards of care are being met

  • 24. 
    Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must be facility meet in order to become certified for these programs?
    • A. 

      Joint Commission Accreditation Standards

    • B. 

      Accreditation Association for Ambulatory Healthcare Standards

    • C. 

      Conditions of Participation

    • D. 

      Outcomes and Assessment Information Set

  • 25. 
    Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state in which they are located.
    • A. 

      Accreditation

    • B. 

      Certification

    • C. 

      Licensure

    • D. 

      Permission

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