CCA Prep Exam 1 (100 Questions)

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1/100 Questions

The __________ may contain information about diseases among relatives in which heredity may play a role.
- Physical examination
- History
- Laboratory report
- Administrative data

About This Quiz

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

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2.

What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed?
- Operative report
- Tissue report
- Pathology report
- Anesthesia record
Correct Answer

A. Operative report

Explanation

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.

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3.

What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?
- Ignore the state law and follow the HIPAA standard
- Follow the state law and ignore the HIPAA standard
- Comply with both the state law and the HIPAA standard
- Ignore both the state law and the HIPAA standard and follow relevant accreditation standards
Correct Answer

A. Comply with both the state law and the HIPAA standard

Explanation

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.

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1
4.

All documentation entered in the medical record relating to the patient's diagnosis and treatment are considered this type of data:
- Clinical
- Identification
- Secondary
- Financial
Correct Answer

A. Clinical

Explanation

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.

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5.

The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is ___________.
- Optical character recognition
- Bar coding
- Neural networks
- Electronic data interchange
Correct Answer

A. Electronic data interchange

Explanation

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.

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1
6.

The release of information function requires the HIM professional to have knowledge of _______________.
- Clinical coding principals
- Database development
- Federal and state confidentiality laws
- Human resource management
Correct Answer

A. Federal and state confidentiality laws

Explanation

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.

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7.

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?
- Acromegaly
- Hypothyroidism
- Dwarfism
- Cushing's disease
Correct Answer

A. Hypothyroidism

Explanation

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.

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8.

The HIM director is having difficulty with the on-cal physicians in the emergency services department completing their health records. Currently, three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situations?
- Routinely send out a fourth notice
- Post the hospital policy in the emergency department
- Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
- Call the Joint Commission
Correct Answer

A. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices

Explanation

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.

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9.

HIM coding professionals and the orgs that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated?
- Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete
- Follow-up on and monitor identified problems
- Evaluate and trend diagnoses and procedures code selections
- Report data quality review results to organizational leadership, compliance staff, and the medical staff
Correct Answer

A. Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete

Explanation

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.

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10.

Which of the following software applications would be used to aid in the coding function in a physician's office?
- Grouper
- Encoder
- Pricer
- Diagnosis calculator
Correct Answer

A. Encoder

Explanation

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.

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11.

Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the option listed here, what is best course of action?
- Allow Dr. Smith to see the records becausse he was the daughter's guardian at the time of the tonsillectomy.
- Call the hospital administrator for authorization to release the record to Dr. Smith since he is on the medical staff.
- Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record.
- Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.
Correct Answer

A. Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record.

Explanation

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.

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12.

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM departments. Which of the following electronic systems would fullfill this purpose?
- Chart deficiency system
- Chart tracking system
- Chart abstracting system
- Chart encoder
Correct Answer

A. Chart tracking system

Explanation

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.

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13.

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?
- Pneumonia
- Fever, cough, shortness of breath
- Cough, shortness of breath
- Pneumonia, cough, shortness of breath
Correct Answer

A. Fever, cough, shortness of breath

Explanation

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.

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14.

An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of:
- Optimizing
- Unbundling
- Sequencing
- Classifying
Correct Answer

A. Unbundling

Explanation

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.

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1
15.

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?
- Medical necessity
- Managed care
- Medical decision making
- Levels of services
Correct Answer

A. Medical necessity

Explanation

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.

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16.

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____________ .
- Suspended record
- Delinquent record
- Pending record
- Illegal record
Correct Answer

A. Delinquent record

Explanation

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.

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17.

This document includes a microscopic description of tissue excised during surgery:
- Recovery room record
- Pathology report
- Operative report
- Discharge summary
Correct Answer

A. Pathology report

Explanation

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.

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18.

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:
- Ruptured appendix
- Exploratory laparoscopy
- Abdominal pain
- Cholelithiasis
Correct Answer

A. Abdominal pain

Explanation

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.

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19.

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 __________.
- Transaction standards
- Content and structure standards
- Vocabulary standards
- Security standards
Correct Answer

A. Vocabulary standards

Explanation

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.

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1
20.

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?
- Consultation
- Medical history
- Physical examination
- Progress notes
Correct Answer

A. Consultation

Explanation

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.

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21.

Which of the following is not a function of the discharge summary?
- Providing information about the patient's insurance coverage
- Ensuring the continuity of future care
- Providing information to support the activities of the medical staff review committee
- Providing concise information that can be used to answer information requests
Correct Answer

A. Providing information about the patient's insurance coverage

Explanation

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.

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1
22.

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:
- Discharge summary
- Autopsy report
- Incident report
- Consent to treatment
Correct Answer

A. Discharge summary

Explanation

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.

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23.

Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format?
- The problem list is an index
- The initial plan
- The SOAP form of progress notes
- The database
Correct Answer

A. The SOAP form of progress notes

Explanation

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.

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24.

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.
- Transfer or referral
- Release of information
- Patients rights acknowledgement
- Admitting physical evaluation
Correct Answer

A. Transfer or referral

Explanation

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

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25.

How do accrediation organizations such as the Join Commission use the health record?
- To serve as a source for case study information
- To determine whether the documentation supports the provider's claim for reimbursement
- To provide healthcare services
- To determine whether standards of care are being met
Correct Answer

A. To determine whether standards of care are being met

Explanation

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.

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2
26.

There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further defines removal of foreign body (45379) and bipsy, single or multiple (45380) and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule?
- Unbundling
- Optimizing
- Sequencing
- Maximizing
Correct Answer

A. Unbundling

Explanation

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.

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27.

What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims?
- Outpatient Perspective Payment System (OPPS)
- National Correct Coding Inditiative (NCCI)
- Ambulatory Payment Classifications (APCs)
- Comprehensive Outpatient Rehab Facilities (CORFs)
Correct Answer

A. National Correct Coding Inditiative (NCCI)

Explanation

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.

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28.

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?
- HIPAA does not allow a patient's name to be announced in a waiting room.
- There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.
- HIPAA allows only the use of the patient's first name.
- HIPAA requires that patients be given numbers and only the number be announced.
Correct Answer

A. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.

Explanation

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.

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29.

Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation?
- The record is not in compliance as the physical exam must be completed within 24 hours of admission.
- The record is not in compliance as the physical exam must be completed within 48 hours of admission.
- The record is in compliance as the physical examination must be completed within 48 hours.
- The record is in compliance because the physical examination was completed within 72 hours of admission.
Correct Answer

A. The record is not in compliance as the physical exam must be completed within 24 hours of admission.

Explanation

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.

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30.

According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?
- Admission record
- Physician's order
- Report of history and physical examination
- Discharge summary
Correct Answer

A. Report of history and physical examination

Explanation

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.

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31.

The coder notes that the physician has ordered potassium replacement for the patient. The coder might expect to see a diagnosis of:
- Hypokalemia
- Hyponatremia
- Hyperkalemia
- Hypernatremia
Correct Answer

A. Hypokalemia

Explanation

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.

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2
32.

In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporate the greater number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of the panel?
- Report the remaining tests using individual test codes accordinto to CPT.
- Do not report the remaining individual test codes.
- Report only those test codes that are part of the panel.
- Do not report a test code more than once regardless if the test was performed twice.
Correct Answer

A. Report the remaining tests using individual test codes accordinto to CPT.

Explanation

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.

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1
33.

What does audit trail check for?
- Unauthorized access to a system
- Loss of data
- Presence of a virus
- Successful completion of a backup
Correct Answer

A. Unauthorized access to a system

Explanation

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.

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34.

What types of covered entity health records are subject to HIPAA privacy regulations?
- Only health records in paper format
- Only health records in electronic format
- Health records in paper or electronic format
- Health records in any format
Correct Answer

A. Health records in any format

Explanation

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.

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35.

A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient requests the hospital provide the medical records in paper format. How should the hospital respond?
- Provide the medical records in paper format
- Burn another CD since this is hospital policy
- Provide the patient with both paper and CD copies of the medical record
- Review the CD copies with the patient on a hospital computer
Correct Answer

A. Provide the medical records in paper format

Explanation

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.

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36.

While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on __________.
- Reason for admission
- Reason for encounter
- Discharge diagnosis
- Activities of daily living
Correct Answer

A. Reason for encounter

Explanation

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.

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37.

A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previouosly treated. According to HIPAA regulations, was this action correct?
- Yes; HIPAA only requires the current records to be produced for the patient.
- Yes; this is hospital policy for which HIPAA has no control
- No; the records from the previous hohspital are considered part of the designated record set and should be given to the patient.
- No; the records from the previous hospital are not included in the designated record set but should be released anyway.
Correct Answer

A. No; the records from the previous hohspital are considered part of the designated record set and should be given to the patient.

Explanation

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.

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38.

Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the tachnique using two catheters inserted percutaneously through the femoral artery.
- Combined right and left (88.54)
- Stones (88.55)
- Judkins (88.56)
- Other and unspecified (88.57)
Correct Answer

A. Judkins (88.56)

Explanation

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.

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39.

What is the best reference tool to receive ICD-9-CM coding advice?
- AMA's CPT Assistant
- AHA's Coding Clinic for HCPCS
- AHA's Coding Clinic for ICD-9-CM
- National Correct Coding Initiative (NCCI)
Correct Answer

A. AHA's Coding Clinic for ICD-9-CM

Explanation

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.

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1
40.

Before healthcare organizations can provide services, they usually must obtain ________ by government entities such as the state in which they are located.
- Accreditation
- Certification
- Licensure
- Permission
Correct Answer

A. Licensure

Explanation

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.

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41.

The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of:
- Confidentiality
- Privacy
- Integrity
- Security
Correct Answer

A. Privacy

Explanation

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.

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42.

Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment Cesarean delivery with single live-born female.
- 661.01, V27.0, 74.1
- 661.21, 74.1
- 661.01, 74.0
- 661.21, V27, 74.1
Correct Answer

A. 661.01, V27.0, 74.1

Explanation

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.

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43.

A software interface is a ___________.
- Device to enter data
- Protocol for describing data
- Program to exchange data
- Standard vocabulary
Correct Answer

A. Program to exchange data

Explanation

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.

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44.

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?
- Retrospectively review each patient's medical record to make sure history and physical are present
- Review each patient's medical report concurrently to make sure history andphysical are present and meet the accreditation standards
- Establish a process to review medical records immediately on discharge
- Do a review of records for all patients discharged in the previous 60 days
Correct Answer

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

Explanation

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.

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45.

Identify the ICD-9-CM dx code for blighted ovum
- 236.1
- 661.00
- 631
- 634.90
Correct Answer

A. 631

Explanation

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.

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46.

Identify the ICD-9-CM code(s) for infected ingrown nail.
- 703.0
- 703.8, 681.11
- 681.11
- 681.9
Correct Answer

A. 703.0

Explanation

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

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47.

Which of the following is the correct ICD-9-CM code(s) for laparoscopic cholecystectomy?
- 51.21
- 51.22, 54.21
- 51.23, 54.21
- 51.23
Correct Answer

A. 51.23

Explanation

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.

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48.

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?
- Discuss the problem with the hospital CEO
- Call the Joint Commission
- Contact other hospitals to see what methods they use to ensure compliance
- Drop the issue because non-compliance is always a problem
Correct Answer

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

Explanation

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.

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49.

Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block.
- 426.3, 426.4
- 426.53
- 426.4, 426.53
- 426.52
Correct Answer

A. 426.53

Explanation

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.

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CCA Prep Exam 1 (100 Questions)

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

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What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed?

What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?

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

The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is ___________.

The release of information function requires the HIM professional to have knowledge of _______________.

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?

HIM coding professionals and the orgs that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated?

Which of the following software applications would be used to aid in the coding function in a physician's office?

Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the option listed here, what is best course of action?

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM departments. Which of the following electronic systems would fullfill this purpose?

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?

An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of:

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 health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____________ .

This document includes a microscopic description of tissue excised during surgery:

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 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?

Which of the following is not a function of the discharge summary?

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:

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

How do accrediation organizations such as the Join Commission use the health record?

What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims?

Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation?

According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?

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

In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporate the greater number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of the panel?

What does audit trail check for?

What types of covered entity health records are subject to HIPAA privacy regulations?

A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient requests the hospital provide the medical records in paper format. How should the hospital respond?

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

A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previouosly treated. According to HIPAA regulations, was this action correct?

Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the tachnique using two catheters inserted percutaneously through the femoral artery.

What is the best reference tool to receive ICD-9-CM coding advice?

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

The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of:

Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment Cesarean delivery with single live-born female.

A software interface is a ___________.

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?

Identify the ICD-9-CM dx code for blighted ovum

Identify the ICD-9-CM code(s) for infected ingrown nail.

Which of the following is the correct ICD-9-CM code(s) for laparoscopic cholecystectomy?

Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block.