CCA Prep Exam 200 Questions

200 Preguntes | Total Attempts: 488

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The Certified coding associate course is an entry level credential certifying data quality skills for coding professionals in all healthcare settings and is offered by the American health information management association. Take it up and see if you are completely ready for the exam. Good luck and keep on revising!


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Questions and Answers
  • 1. 
    Which of the following elements is not a component of most patient records?
    • A. 

      Patient identification

    • B. 

      Clinical history

    • C. 

      Financial Information

    • D. 

      Test results

  • 2. 
    Which of the following is not a characteristic of high-quality healthcare data?
    • A. 

      Data relevancy

    • B. 

      Data currency

    • C. 

      Data consistency

    • D. 

      Data Accountability

  • 3. 
    Identify where the following information would be found in the acute care record. Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion.
    • A. 

      Anesthesia report

    • B. 

      Physician progress notes

    • C. 

      Operative report

    • D. 

      Recovery room record

  • 4. 
    Identify where the following information would be found in the acute care record:  "CBC; WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93".
    • A. 

      Medical laboratory report

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Physician orders

  • 5. 
    Identify where the following information would be found in the acute care record: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine".
    • A. 

      Medical laboratory report

    • B. 

      Physical examination

    • C. 

      Physician progress note

    • D. 

      Radiography report

  • 6. 
    The following is documented in an acute care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds. "In which of the following would this documentation appear?
    • A. 

      History

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Operation report

  • 7. 
    The folowing is documented in an acute care record: "Microscopic: Sections are of squamous mucosa with no atypia." In which of the following would this documentation appear?
    • A. 

      History

    • B. 

      Pathology report

    • C. 

      Physical examination

    • D. 

      Operation report

  • 8. 
    The following is documented in an acute care record: "Admit to 3C. Diet: NPO Meds: Compazine 10mg IV Q 6 PRN." In which of the following would this documentation appear?
    • A. 

      Admission order

    • B. 

      History

    • C. 

      Physical examination

    • D. 

      Progress notes

  • 9. 
    The following is documented in an acute care record: "38 weeks gestation, Apgars 8/9, 6# 9.8 oz, good cry." In which of the following would this documentation appear?
    • A. 

      Admission note

    • B. 

      Clinical laboratory

    • C. 

      Newborn record

    • D. 

      Physician order

  • 10. 
    The following is documented in an acute care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." In which of the following would this documentation appear?
    • A. 

      Admission order

    • B. 

      Clinical laboratory report

    • C. 

      ECG report

    • D. 

      Radiology report

  • 11. 
    The following is documented in an acute care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear?
    • A. 

      Admission note

    • B. 

      Consultation report

    • C. 

      Discharge summary

    • D. 

      Nursing progress notes

  • 12. 
    The following is documented in an acute care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear?
    • A. 

      Admission note

    • B. 

      Nursing note

    • C. 

      Physician progress note

    • D. 

      Social work note

  • 13. 
    A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?
    • A. 

      Insomnia

    • B. 

      Hypertension

    • C. 

      Mental or behavior problems

    • D. 

      Rheumatoid arthritis

  • 14. 
    In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation wouild a coder look for to substantiate the diagnosis of aspiration pneumonia (PNA)
    • A. 

      Diffuse parenchymal lung disease on x-ray

    • B. 

      Patient has history of inhaled food, liquid, or oil

    • C. 

      Positive culture for Pneumocystis carinii

    • D. 

      Positive culture for Streptococcus pneumoniae

  • 15. 
    In conducting a qualitative review the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
    • A. 

      Note the condition as present on admission

    • B. 

      Quary the physician to determine if the condition was present on admission

    • C. 

      Note the condition as unknown on admission

    • D. 

      Note the condition as not present on admission

  • 16. 
    Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ________.
    • A. 

      UHDDS

    • B. 

      UACDS

    • C. 

      MDS

    • D. 

      ORYX

  • 17. 
    Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for _________.
    • A. 

      Performance improvement programs

    • B. 

      Billing and claims data processing

    • C. 

      Developing hospital discharge abstracting systems

    • D. 

      Developing individual care plans for residents

  • 18. 
    While the focus of inpatient data collection in the UHDDS is on principal diagnosis, the focus of outpatient data collection in the UACDS is on ___________.
    • A. 

      Reason for admission

    • B. 

      Reason for encounter

    • C. 

      Discharge diagnosis

    • D. 

      Activities of daily living

  • 19. 
    In long-term care, the resident's care plan is based on data collected in the _____________.
    • A. 

      UHDDS

    • B. 

      OASIS

    • C. 

      MDS Version 3.0

    • D. 

      HEDIS

  • 20. 
    A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. Says she is following her diabetic diet." In which part of a POMR progress note would this notation be written?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan

  • 21. 
    A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%, urine sugar, no acetone." In which part of a POMR progress note would this notation be written?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan

  • 22. 
    A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Continue with Diuril, 500 mgs once daily. Return visit in 2 weeks." In which part of a POMR progress note would this notation be written?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan

  • 23. 
    A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a POMR progress note would this notation be written?
    • A. 

      Subjective

    • B. 

      Objective

    • C. 

      Assessment

    • D. 

      Plan

  • 24. 
    Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record?
    • A. 

      CPT

    • B. 

      HCPCS

    • C. 

      ICD-9-CM

    • D. 

      SNOMED CT

  • 25. 
    Which of the following provides a set of codes used for collecting data abount substance abuse and mental health disorders?
    • A. 

      CPT

    • B. 

      DMS-IV-TR

    • C. 

      HCPCS

    • D. 

      SNOMED CT