CCA Prep Exam 1 (100 Questions)

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Quizzes Created: 4 | Total Attempts: 35,708

Questions: 100 | Attempts: 3,435 | Updated: Mar 20, 2023

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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
Correct Answer
C. UACDS

Explanation
The clinic should consult the UACDS dataset to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system.

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1
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
Correct Answer
C. 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
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
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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1
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
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
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
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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1
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
Correct Answer
C. 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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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
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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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
Correct Answer
D. Financial Data

Explanation
The insured party's member identification number is an example of financial data because it is used to track and identify individuals for billing and payment purposes. This data is typically associated with financial transactions and is used to manage and process insurance claims, premiums, and reimbursements.

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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
Correct Answer
C. 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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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
Correct Answer
B. 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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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
Correct Answer
A. Transfer or referral

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

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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
Correct Answer
B. 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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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
Correct Answer
C. Klebsiella

Explanation
Klebsiella is the correct answer because it is a gram-negative organism. Gram-negative pneumonia is caused by bacteria that stain pink when subjected to the Gram stain test. Klebsiella is a type of gram-negative bacteria that can cause pneumonia in certain cases. Staphylococcus, Clostridium, and Streptococcus are all gram-positive organisms, so they would not be coded as gram-negative pneumonia.

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1
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
Correct Answer
C. Operative report

Explanation
The operative report is the best source of documentation to determine the size of a removed malignant lesion. This report provides detailed information about the surgical procedure, including the size and location of the lesion. It includes information about the incision made, the extent of the excision, and any other relevant details. The pathology report may provide information about the nature of the lesion, but it may not necessarily include specific details about its size. The postacute care unit record and physical examination are unlikely to provide accurate information about the size of the removed lesion.

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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
Correct Answer
B. Esophagitis

Explanation
If the medication list contains the drug Protonix, it suggests that the patient is being treated for acid reflux or gastroesophageal reflux disease (GERD). Esophagitis is inflammation of the esophagus caused by the reflux of stomach acid. Therefore, it is likely to be found on the patient's problem list if they are taking Protonix. High blood pressure, congestive heart failure, and AIDS are unrelated to the use of Protonix and would not be expected to be found on the problem list in this context.

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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
Correct Answer
D. Query the physician for more detail about asthma

Explanation
The correct answer is to query the physician for more detail about asthma. This is because the physician's documentation is not clear enough to determine the specific type or severity of asthma. By querying the physician for more information, the coder can ensure accurate coding and billing for the patient's condition.

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2
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
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
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
Correct Answer
B. History

Explanation
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.

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1
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
Correct Answer
B. 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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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
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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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
Correct Answer
B. 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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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
Correct Answer
C. 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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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
Correct Answer
D. 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
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
Correct Answer
C. Conditions of Participation

Explanation
In order for Valley High, a skilled nursing facility, to become certified for federal government reimbursement programs such as Medicare, it must meet the Conditions of Participation. These are a set of standards and requirements that healthcare providers must adhere to in order to participate in these programs. By meeting these conditions, Valley High can ensure that it is providing quality care and meeting the necessary criteria to be eligible for reimbursement from the government.

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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
Correct Answer
C. 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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26.

This document includes a microscopic description of tissue excised during surgery:
- A.
  
  Recovery room record
- B.
  
  Pathology report
- C.
  
  Operative report
- D.
  
  Discharge summary
Correct Answer
B. 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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27.

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____________ .
- A.
  
  Suspended record
- B.
  
  Delinquent record
- C.
  
  Pending record
- D.
  
  Illegal record
Correct Answer
B. 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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1
28.

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?
- A.
  
  The record is not in compliance as the physical exam must be completed within 24 hours of admission.
- B.
  
  The record is not in compliance as the physical exam must be completed within 48 hours of admission.
- C.
  
  The record is in compliance as the physical examination must be completed within 48 hours.
- D.
  
  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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29.

According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?
- A.
  
  Admission record
- B.
  
  Physician's order
- C.
  
  Report of history and physical examination
- D.
  
  Discharge summary
Correct Answer
C. 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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30.

Which of the following programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards?
- A.
  
  Internal DRG audits
- B.
  
  Peer review
- C.
  
  Managed care
- D.
  
  Quality improvement
Correct Answer
D. Quality improvement

Explanation
Quality improvement programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards. These programs aim to enhance patient care and outcomes by continuously monitoring and evaluating the quality of healthcare services provided. They involve systematic data collection, analysis, and implementation of interventions to improve the delivery of care. Quality improvement programs help healthcare organizations identify areas for improvement, reduce medical errors, and ensure compliance with regulatory standards.

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31.

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?
- A.
  
  Routinely send out a fourth notice
- B.
  
  Post the hospital policy in the emergency department
- C.
  
  Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
- D.
  
  Call the Joint Commission
Correct Answer
C. 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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32.

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?
- A.
  
  Assign codes to an incomplete record with organizational policies in place to ensure codes are reviewed after the records are complete
- B.
  
  Follow-up on and monitor identified problems
- C.
  
  Evaluate and trend diagnoses and procedures code selections
- D.
  
  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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33.

What is the name of the formal document prepared by the surgeon at the conclusion of surgery to describe the surgical procedure performed?
- A.
  
  Operative report
- B.
  
  Tissue report
- C.
  
  Pathology report
- D.
  
  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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34.

Where would information on treatment given on a particular encounter be found in the health record?
- A.
  
  Problem list
- B.
  
  Physician's orders
- C.
  
  Progress Notes
- D.
  
  Physical examination
Correct Answer
C. Progress Notes

Explanation
FYI - These are cronological statements about the patient response to treatments during his/her stay.

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1
35.

Identify the code for a patient with a closed transcervical fracture of the epiphysis.
- A.
  
  820.09
- B.
  
  820.02
- C.
  
  820.03
- D.
  
  820.01
Correct Answer
D. 820.01

Explanation
The code 820.01 represents a patient with a closed transcervical fracture of the epiphysis. This code specifically indicates a fracture in the neck of the femur (thigh bone) that is closed, meaning the bone has not broken through the skin. The term "transcervical" refers to the location of the fracture, which is in the neck of the femur. Therefore, 820.01 is the correct code for this specific type of fracture.

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36.

Identify the ICD-9-CM dx code(s) for neonatal tooth eruption
- A.
  
  525.0
- B.
  
  520.6, 525.0
- C.
  
  520.9
- D.
  
  520.6
Correct Answer
D. 520.6

Explanation
Neonatal tooth eruption refers to the eruption of a tooth in a newborn baby. The ICD-9-CM code for this condition is 520.6. This code specifically represents "supernumerary teeth," which are additional teeth that can erupt in neonates. The other options, 525.0 and 520.9, do not specifically pertain to neonatal tooth eruption. Therefore, the correct answer is 520.6.

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37.

Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers and interrupted sutures.
- A.
  
  21012
- B.
  
  21012; 12052
- C.
  
  21014
- D.
  
  21014; 12052
Correct Answer
A. 21012

Explanation
The correct answer is 21012. This code is used for the excision of a benign or malignant tumor, subcutaneous tissue, or fascia, without extensive undermining or dissecting. In this case, the 3.0-cm tumor on the forehead was excised, with an incision made through the skin and subcutaneous tissue, and the wound closed in layers with interrupted sutures.

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1
38.

Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a braest biopsy.
- A.
  
  10022
- B.
  
  1022; 19295-LT
- C.
  
  10022; 19295-LT; 76942
- D.
  
  10022; 76942
Correct Answer
C. 10022; 19295-LT; 76942

Explanation
The correct answer is 10022; 19295-LT; 76942. The CPT code 10022 represents fine needle aspiration biopsy without imaging guidance. The code 19295-LT represents the placement of a localization clip during a breast biopsy under ultrasound guidance. The code 76942 represents the use of ultrasound guidance during the procedure. Therefore, all three codes accurately describe the procedures performed on the Medicare patient in this scenario.

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39.

Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease.
- A.
  
  335.20
- B.
  
  334.8
- C.
  
  335.29
- D.
  
  335.2
Correct Answer
A. 335.20

Explanation
The correct answer is 335.20 because it is the specific ICD-9-CM diagnosis code for Lou Gehrig's disease, also known as amyotrophic lateral sclerosis (ALS). The other options are not the correct codes for this condition.

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40.

Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads.
- A.
  
  37.83, 37.73
- B.
  
  37.83, 37.71
- C.
  
  37.81, 37.73, 37.71
- D.
  
  37.83, 37.72
Correct Answer
D. 37.83, 37.72

Explanation
The correct answer is 37.83, 37.72. The insertion of a dual chamber cardiac pacemaker and both atrial and ventricular leads is coded using two procedure codes. The first code, 37.83, represents the insertion of a dual chamber cardiac pacemaker. The second code, 37.72, represents the insertion of both atrial and ventricular leads. Therefore, the correct answer includes both of these codes.

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41.

Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker.
- A.
  
  37.87
- B.
  
  37.85
- C.
  
  37.87, 37.89
- D.
  
  37.85, 37.89
Correct Answer
A. 37.87

Explanation
The correct ICD-9-CM procedure code for replacement of an old dual pacemaker with a new dual pacemaker is 37.87.

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42.

Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block.
- A.
  
  426.3, 426.4
- B.
  
  426.53
- C.
  
  426.4, 426.53
- D.
  
  426.52
Correct Answer
B. 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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1
43.

Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for reprogramming of a cardiac pacemaker.
- A.
  
  V53.31
- B.
  
  37.85
- C.
  
  V53.02
- D.
  
  V53.31, 37.85
Correct Answer
A. V53.31

Explanation
The appropriate diagnostic code for reprogramming a cardiac pacemaker is V53.31. This code is used to indicate a procedure for adjustment and management of the pacemaker. It specifically refers to the reprogramming of the device to optimize its functioning. The other codes listed (37.85 and V53.02) are not relevant to this specific procedure.

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44.

This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with brady-arrhythmias. Prolonged includes insertions of a permament cardiac pacemaker.
- A.
  
  Atrial fibrillation (427.31)
- B.
  
  Atrial flutter (427.32)
- C.
  
  Paroxysmal supraventricular tachycardia (427.0)
- D.
  
  Sick sinus syndrome (SSS)(427.81)
Correct Answer
D. Sick sinus syndrome (SSS)(427.81)

Explanation
Sick sinus syndrome (SSS) is the correct answer because it matches the description provided in the question. The condition is characterized by various symptoms such as sinus arrest, sinoatrial exit block, persistent sinus bradycardia, and recurrent supraventricular tachycardias associated with brady-arrhythmias. SSS is often caused by drug therapy and may require the insertion of a permanent cardiac pacemaker for prolonged treatment. Atrial fibrillation, atrial flutter, and paroxysmal supraventricular tachycardia are not mentioned in the description and do not match the given characteristics of the condition.

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45.

Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary-coronary artery bypass.
- A.
  
  36.15, 36.16
- B.
  
  36.15
- C.
  
  36.16
- D.
  
  36.12, 36.16
Correct Answer
C. 36.16

Explanation
The appropriate ICD-9-CM procedure code for a double internal mammary-coronary artery bypass is 36.16. This code specifically represents a bilateral procedure, indicating that both internal mammary arteries were used for the bypass. The other options either do not specify the use of both internal mammary arteries (36.15) or include additional procedures that are not necessary for a double bypass (36.12, 36.16).

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46.

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.
- A.
  
  Combined right and left (88.54)
- B.
  
  Stones (88.55)
- C.
  
  Judkins (88.56)
- D.
  
  Other and unspecified (88.57)
Correct Answer
C. 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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47.

Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.
- A.
  
  V58.83, V58.61
- B.
  
  V58.83, V58.63
- C.
  
  V58.61, 790.92
- D.
  
  V58.61
Correct Answer
A. V58.83, V58.61

Explanation
The correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's coumadin levels would be V58.83 and V58.61. V58.83 represents the need for long-term monitoring of the patient's anticoagulant treatment, while V58.61 indicates the need for other specified prophylactic measures, such as monitoring of PT levels. These codes accurately capture the reason for the patient's visit and the specific monitoring required.

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48.

Identify the CPD code(s) for the following patient: A 2-yr-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance.
- A.
  
  43752
- B.
  
  43761
- C.
  
  43761; 76000
- D.
  
  49450
Correct Answer
C. 43761; 76000

Explanation
The correct answer is 43761; 76000. CPD codes are used to classify medical procedures for billing and reimbursement purposes. In this case, the patient is a 2-year-old male who came to the emergency room to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance. The CPD code 43761 represents the repositioning of a nasogastric tube using fluoroscopic guidance, while the CPD code 76000 represents the fluoroscopic guidance itself. Therefore, both codes are applicable in this scenario.

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49.

Identify the CPT code(s) for the following patient: A 2-yr-old male presented to the hospital to have his gastrostomy tube changed under flouroscopic guidance.
- A.
  
  43752
- B.
  
  43760
- C.
  
  43761; 76000
- D.
  
  49450
Correct Answer
D. 49450

Explanation
The correct answer is 49450. This code represents the insertion of a gastrostomy tube without a laparotomy. In this case, the patient is only having the tube changed, not inserted, so the correct code would be for the change of the tube. The other codes listed are not applicable to this scenario.

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1
50.

Identify the ICD-9-CM dx code for blighted ovum
- A.
  
  236.1
- B.
  
  661.00
- C.
  
  631
- D.
  
  634.90
Correct Answer
C. 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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CCA Prep Exam 1 (100 Questions)

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?

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:

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

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

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

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

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 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?

What is the best source of documentation to determine the size of a removed malignant lesion?

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

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

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

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?

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?

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?

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

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?

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

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

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

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?

Which of the following programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards?

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?

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

Where would information on treatment given on a particular encounter be found in the health record?

Identify the code for a patient with a closed transcervical fracture of the epiphysis.

Identify the ICD-9-CM dx code(s) for neonatal tooth eruption

Identify CPT code(s) for the following patient. A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed in layers and interrupted sutures.

Identify CPT code(s) for the following Medicare patient. A 67-year-old female undergoes a fine needle aspiration of the left breast with ultrasound guidance to place a localization clip during a braest biopsy.

Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease.

Identify the ICD-9-CM procedure code(s) for insertion of dual chamber cardiac pacemaker and atrial and ventricular leads.

Identify the correct ICD-9-CM procedure code(s) for replacement of an old dual pacemaker with a new dual pacemaker.

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

Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for reprogramming of a cardiac pacemaker.

Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary-coronary artery bypass.

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.

Identify the correct diagnosis ICD-9-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.

Identify the CPD code(s) for the following patient: A 2-yr-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance.

Identify the CPT code(s) for the following patient: A 2-yr-old male presented to the hospital to have his gastrostomy tube changed under flouroscopic guidance.

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