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
Transaction standards
Content and structure standards
Vocabulary standards
Security standards
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Consultation
Medical history
Physical examination
Progress notes
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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
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Discharge summary
Autopsy report
Incident report
Consent to treatment
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Ruptured appendix
Exploratory laparoscopy
Abdominal pain
Cholelithiasis
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Clinical
Identification
Secondary
Financial
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Demographic data
Clinical data
Certification data
Financial Data
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The problem list is an index
The initial plan
The SOAP form of progress notes
The database
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Reason for admission
Reason for encounter
Discharge diagnosis
Activities of daily living
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Transfer or referral
Release of information
Patients rights acknowledgement
Admitting physical evaluation
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Acromegaly
Hypothyroidism
Dwarfism
Cushing's disease
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Staphylococcus
Clostridium
Klebsiella
Streptococcus
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Pathology report
Postacute care unit record
Operative report
Physical examination
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High blood pressure
Esophagitis
Congestive heart failure
AIDS
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Code asthma
Code asthma with status asthmaticus
Code asthma with acute exacerbation
Query the physician for more detail about asthma
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Hypokalemia
Hyponatremia
Hyperkalemia
Hypernatremia
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Physical examination
History
Laboratory report
Administrative data
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Pneumonia
Fever, cough, shortness of breath
Cough, shortness of breath
Pneumonia, cough, shortness of breath
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Medical necessity
Managed care
Medical decision making
Levels of services
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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
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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
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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
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Joint Commission Accreditation Standards
Accreditation Association for Ambulatory Healthcare Standards
Conditions of Participation
Outcomes and Assessment Information Set
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Accreditation
Certification
Licensure
Permission
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Recovery room record
Pathology report
Operative report
Discharge summary
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Suspended record
Delinquent record
Pending record
Illegal record
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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.
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Admission record
Physician's order
Report of history and physical examination
Discharge summary
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Internal DRG audits
Peer review
Managed care
Quality improvement
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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
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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
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Operative report
Tissue report
Pathology report
Anesthesia record
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Problem list
Physician's orders
Progress Notes
Physical examination
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820.09
820.02
820.03
820.01
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525.0
520.6, 525.0
520.9
520.6
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21012
21012; 12052
21014
21014; 12052
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10022
1022; 19295-LT
10022; 19295-LT; 76942
10022; 76942
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335.20
334.8
335.29
335.2
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37.83, 37.73
37.83, 37.71
37.81, 37.73, 37.71
37.83, 37.72
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37.87
37.85
37.87, 37.89
37.85, 37.89
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426.3, 426.4
426.53
426.4, 426.53
426.52
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V53.31
37.85
V53.02
V53.31, 37.85
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Atrial fibrillation (427.31)
Atrial flutter (427.32)
Paroxysmal supraventricular tachycardia (427.0)
Sick sinus syndrome (SSS)(427.81)
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36.15, 36.16
36.15
36.16
36.12, 36.16
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Combined right and left (88.54)
Stones (88.55)
Judkins (88.56)
Other and unspecified (88.57)
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V58.83, V58.61
V58.83, V58.63
V58.61, 790.92
V58.61
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43752
43761
43761; 76000
49450
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43752
43760
43761; 76000
49450
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