CCA Exam Preparation Practice Test!

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CCA Exam Preparation Practice Test! - Quiz

Get ready for the CCA Exam with our comprehensive Practice Test! Designed to assess your knowledge and prepare you for success, this quiz covers key topics and concepts that you'll encounter in the CCA Exam. From coding guidelines and documentation requirements to reimbursement methodologies and coding ethics, this practice test will challenge your understanding of the Certified Coding Associate certification. Test your skills, identify areas for improvement, and boost your confidence before the actual exam. Whether you're a seasoned coder or just starting your CCA journey, this practice test is a valuable tool to enhance your exam preparation. So, let's Read moreget started and ace the CCA Exam!


Questions and Answers
  • 1. 

    Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tobacco, alcohol, and other drugs may be found in the _____________.

    • A.

      Physical examination record

    • B.

      History record

    • C.

      Operative report

    • D.

      Radiological report

    Correct Answer
    B. History record
    Explanation
    The correct answer is history record. A patient's marital status, dietary habits, sleep patterns, exercise routines, and substance use are typically documented in their history record. This record includes information about the patient's past medical history, family history, social history, and lifestyle factors that may be relevant to their current health condition. The history record provides valuable information for healthcare providers to assess the patient's overall health and make appropriate treatment decisions.

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  • 2. 

    A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?

    • A.

      Postoperative infection

    • B.

      Appendicitis

    • C.

      COPD

    • D.

      Hypertension

    Correct Answer
    A. Postoperative infection
    Explanation
    The patient developed a fever after undergoing a laparoscopic appendectomy, indicating a possible post-operative infection. Since the infection occurred after the surgery, it should not be tagged as present on admission (POA), as it was not present at the time of admission. Therefore, the correct answer is "Postoperative infection."

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  • 3. 

    Which of the following would not be found in a medical history?

    • A.

      Chief complaint

    • B.

      Vital signs

    • C.

      Present illness

    • D.

      Review of systems

    Correct Answer
    B. Vital signs
    Explanation
    Vital signs would not be found in a medical history. A medical history typically includes information about the patient's past and current medical conditions, medications, allergies, surgeries, and family medical history. It also includes details about the patient's chief complaint, present illness, and review of systems. Vital signs, on the other hand, are measurements of the body's basic functions, such as heart rate, blood pressure, temperature, and respiratory rate. While vital signs are important for assessing a patient's current health status, they are typically recorded separately and not included in the medical history.

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  • 4. 

    Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?

    • A.

      Consent for operative procedure, anesthesia report, surgical report

    • B.

      Consent for operative procedure, history, physical examination

    • C.

      History, physical examination, anesthesia report

    • D.

      Problem list, history, physical examination

    Correct Answer
    B. Consent for operative procedure, history, physical examination
    Explanation
    Prior to performing a surgical procedure, it is essential to have the patient's consent for the operation, as well as a thorough understanding of their medical history and physical condition. The consent for operative procedure ensures that the patient understands the risks and benefits of the surgery and gives their permission for it to be performed. The history and physical examination provide crucial information about the patient's overall health, any pre-existing conditions, and any potential risks or complications that may arise during the surgery. Therefore, including the consent for operative procedure, history, and physical examination in the patient's medical record is necessary before performing a surgical procedure.

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  • 5. 

    Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.

    • A.

      Operative report

    • B.

      Anesthesia report

    • C.

      Pathology report

    • D.

      Laboratory report

    Correct Answer
    A. Operative report
    Explanation
    The operative report includes the names of the surgeon and assistants, the date of the procedure, the duration of the procedure, and a description of the procedure itself, including any specimens that were removed. This report provides a detailed account of the surgical procedure and is used for documentation and communication purposes. Anesthesia report focuses on the administration of anesthesia during the procedure, pathology report provides information about the examination of tissues for diagnosis, and laboratory report includes test results.

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  • 6. 

    Identify the acute-care record report where the following information would be found:  The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs.

    • A.

      Discharge summary

    • B.

      Medical history

    • C.

      Medical laboratory report

    • D.

      Physical examination

    Correct Answer
    D. Physical examination
    Explanation
    The given information describes the physical condition of the patient, including their appearance, mobility issues, vital signs, and specific observations such as shaking arms and leg edema. This information is typically recorded during a physical examination, where a healthcare provider assesses the patient's overall health and identifies any abnormalities or concerns. The physical examination report would include these details, making it the correct answer.

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  • 7. 

    Identify the acute care record report where the following information would be found:  Gross Description:  Received fresh designated left lacrimal gland is a single, unoriented, irregular tan-pink portion of soft tissue measuring 0.8 x 0.6 x 0.1 cm, which is submitted entirely, intact, in one cassette.

    • A.

      Discharge summary

    • B.

      Medical history

    • C.

      Medical laboratory report

    • D.

      Physical examination

    Correct Answer
    C. Medical laboratory report
    Explanation
    The given information refers to the gross description of a tissue sample, which is typically included in a medical laboratory report. This report provides detailed information about the specimen received, including its size, color, and any abnormalities observed. It is used to document the findings of laboratory tests and procedures performed on the sample. The other options, such as discharge summary, medical history, and physical examination, do not typically include this specific information about a tissue sample.

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  • 8. 

    The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form?

    • A.

      Operative report

    • B.

      Pathology report

    • C.

      Discharge summary

    • D.

      Nursing note

    Correct Answer
    B. Pathology report
    Explanation
    This clinical statement would be documented on a pathology report. Pathology reports provide detailed information about the microscopic examination of tissue samples, including the identification of cells and any abnormalities or diseases present. In this case, the statement describes the appearance of the gallbladder lining, which is a microscopic finding that would be reported in a pathology report.

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  • 9. 

    Both HEDIS and the Joint Commission's ORYX program 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

    Correct Answer
    A. Performance improvement programs
    Explanation
    Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting and analyzing data, these programs can identify areas of improvement and implement strategies to enhance patient outcomes, safety, and overall healthcare delivery. The data collected can be used to measure performance, compare it to established benchmarks, and implement evidence-based practices to improve the quality of care provided to patients.

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  • 10. 

    What is abstracting?

    • A.

      Compiling the pertinent information from the medical record based on predetermined data sets

    • B.

      Assigning the appropriate code or nomenclature term for categorization

    • C.

      Assembling a chronological set of data for an express purpose

    • D.

      Conducting qualitative and quantitative analysis of documentation against standards and policy

    Correct Answer
    A. Compiling the pertinent information from the medical record based on predetermined data sets
    Explanation
    Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and gathering specific data points or elements from the record, such as diagnoses, procedures, medications, and patient demographics. The purpose of abstracting is to organize and summarize the essential information in a standardized manner, which can then be used for various purposes like research, reporting, billing, and quality improvement.

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  • 11. 

    What type of standard establishes uniform definitions for clinical terms?

    • A.

      Identifier standard

    • B.

      Vocabulary standard

    • C.

      Transaction and messaging standard

    • D.

      Structure and content standard

    Correct Answer
    B. Vocabulary standard
    Explanation
    A vocabulary standard establishes uniform definitions for clinical terms. This standard ensures that healthcare professionals and systems use consistent terminology when documenting and communicating patient information. It helps to improve interoperability and understanding among different healthcare organizations and systems. By following a vocabulary standard, healthcare professionals can effectively communicate and share information, leading to better patient care and outcomes.

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  • 12. 

    According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older:

    • A.

      30

    • B.

      35

    • C.

      38

    • D.

      40

    Correct Answer
    B. 35
    Explanation
    According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of 35 or older. This means that a woman who is 35 years old or above and is pregnant for the first time would be considered an elderly primigravida according to this classification system.

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  • 13. 

    ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.

    • A.

      28th

    • B.

      14th

    • C.

      60th

    • D.

      30th

    Correct Answer
    A. 28th
    Explanation
    ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This means that the newborn period includes the first 28 days of a baby's life.

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  • 14. 

    "Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.

    • A.

      41

    • B.

      39

    • C.

      40

    • D.

      42

    Correct Answer
    C. 40
    Explanation
    The correct answer is 40. "Late pregnancy" is a category code used to indicate that a woman is over 40 weeks pregnant. This category is used to track and monitor the progress of a pregnancy that has gone beyond the expected due date.

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  • 15. 

    Which of the following would be classified to an ICD-9-CM category for bacterial diseases?

    • A.

      Herpes simplex

    • B.

      Staphylococcus aureus

    • C.

      Influenza, types A and B

    • D.

      Candida albicans

    Correct Answer
    B. Staphylococcus aureus
    Explanation
    Staphylococcus aureus would be classified to an ICD-9-CM category for bacterial diseases because it is a bacterium that can cause various infections in humans. The ICD-9-CM classification system is used to categorize and code different diseases and medical conditions, including bacterial infections. Staphylococcus aureus is a common bacterium that can cause skin infections, pneumonia, and other types of infections, and therefore it would fall under the category of bacterial diseases in the ICD-9-CM system.

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  • 16. 

    The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary?

    • A.

      Otitis media

    • B.

      AIDS

    • C.

      Toxic shock syndrome

    • D.

      Bacteremia

    Correct Answer
    B. AIDS
    Explanation
    The correct answer is AIDS. The coder notes that the physician has prescribed Retrovir, which is a medication commonly used to treat HIV/AIDS. Therefore, it can be inferred that the patient has been diagnosed with AIDS, and this information might be documented on the patient's discharge summary.

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  • 17. 

    What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?

    • A.

      Lobar pneumonia

    • B.

      Pneumocystitis carinii pneumonia

    • C.

      Interstitial pneumonia

    • D.

      Aspiration pneumonia

    Correct Answer
    D. Aspiration pneumonia
    Explanation
    When a patient with pneumonia inhales food, liquid, or oil, the most likely diagnosis would be aspiration pneumonia. Aspiration pneumonia occurs when foreign material, such as food or liquids, is inhaled into the lungs, leading to an infection. This can happen when a person has difficulty swallowing or when they accidentally inhale while eating or drinking. The symptoms of aspiration pneumonia can include coughing, shortness of breath, chest pain, and fever. It is important to diagnose and treat aspiration pneumonia promptly to prevent complications and further lung damage.

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  • 18. 

    Where would a coder who needed to locate the histology of a tissue sample most likely find this information

    • A.

      Pathology report

    • B.

      Progress notes

    • C.

      Nurse's notes

    • D.

      Operative report

    Correct Answer
    A. Pathology report
    Explanation
    A coder who needs to locate the histology of a tissue sample would most likely find this information in a pathology report. Pathology reports are comprehensive documents that provide detailed information about the examination and analysis of tissues, including the histological findings. These reports are generated by pathologists who specialize in diagnosing diseases through the examination of tissue samples. Therefore, it is logical to assume that the histology of a tissue sample would be documented and accessible in a pathology report.

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  • 19. 

    The coder notes 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.

      Schizophrenia

    • D.

      Rheumatoid arthritis

    Correct Answer
    C. Schizophrenia
    Explanation
    Based on the information provided, the coder notes that the patient is taking prescribed Haldol, which is an antipsychotic medication commonly used to treat schizophrenia. Therefore, the coder might suspect that the patient has schizophrenia and should query the physician for confirmation or further information.

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  • 20. 

    Which organization developed the first hospital standardization program?

    • A.

      Joint Commission

    • B.

      American Osteopathic Association

    • C.

      American College of Surgeons

    • D.

      American Association of Medical Colleges

    Correct Answer
    C. American College of Surgeons
    Explanation
    The American College of Surgeons developed the first hospital standardization program. This organization is known for its efforts in improving the quality of surgical care and setting standards for hospitals to follow. Through their program, they aim to ensure that hospitals provide safe and effective surgical services to patients.

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  • 21. 

    The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?

    • A.

      Suggest that only hospital clock time be noted in clinical documentation

    • B.

      Suggest that only electronic documentation have time notated

    • C.

      Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated

    • D.

      Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time

    Correct Answer
    C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
    Explanation
    The correct answer suggests that the HIM director should inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This is the most appropriate response because it addresses the concern raised about adding the time of notation to all entries. Instead of focusing on the specific issue of time notation, the HIM director provides a broader guideline that ensures all entries are authenticated and dated, which is a requirement by Medicare. This response helps to maintain the integrity and accuracy of the medical record documentation.

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  • 22. 

    When correcting erroneous information in a health record, which of the following is not appropriate?

    • A.

      Print "error" above the entry

    • B.

      Enter the correction in chronological sequence

    • C.

      Add the reason for the change

    • D.

      Use black pen to obliterate the entry

    Correct Answer
    D. Use black pen to obliterate the entry
    Explanation
    Using a black pen to obliterate the entry is not appropriate when correcting erroneous information in a health record. This method of correction is not recommended because it makes it difficult to trace the original information and can raise concerns about the integrity of the record. It is better to clearly identify the error by printing "error" above the entry, enter the correction in chronological sequence, and add the reason for the change.

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  • 23. 

    Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program?

    • A.

      Request that the CEO write a memorandum to all hospital staff

    • B.

      Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation

    • C.

      Include ancillary clinical and medical staff in the process

    • D.

      Request a letter from the Joint Commission

    Correct Answer
    C. Include ancillary clinical and medical staff in the process
    Explanation
    Including ancillary clinical and medical staff in the process would be the best way to ensure that everyone understands the importance of the CDI program. By involving these staff members, they will have a firsthand understanding of the program's goals and objectives. This will help them see the relevance of improving clinical documentation in supporting quality of care, data quality, and coding accuracy. Additionally, involving a diverse group of staff members will promote collaboration and a shared understanding of the program's importance throughout the hospital.

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  • 24. 

    In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action?

    • A.

      Request that the physician dictate another discharge summary

    • B.

      Have the record analyst note the date discrepancy

    • C.

      Request the physician dictate an addendum to the discharge summary

    • D.

      File the record as complete since the discharge summary includes all the pertinent patient information

    Correct Answer
    C. Request the physician dictate an addendum to the discharge summary
    Explanation
    The best course of action in this case would be to request the physician to dictate an addendum to the discharge summary. This is because the discharge summary was dictated on 1/26/2009, but the patient was actually discharged two days later. By requesting an addendum, the physician can provide an updated summary that accurately reflects the date of discharge. This ensures that the health record is complete and accurately represents the patient's information.

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  • 25. 

    During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following?

    • A.

      Immediately stop the practice of changing transcribed reports

    • B.

      Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form

    • C.

      Conduct a verification audit

    • D.

      Alert hospital legal counsel of the practice

    Correct Answer
    D. Alert hospital legal counsel of the practice
    Explanation
    The HIM director should recommend alerting hospital legal counsel of the practice because the concern is that changes made to transcribed reports long after initial transcription may jeopardize the legal principle that documentation must occur near the time of the event. By involving legal counsel, the hospital can ensure that they are following proper legal guidelines and avoid any potential legal issues that may arise from this practice.

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  • 26. 

    During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste function of the hospital's new EHR system for documenting nursing notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices?

    • A.

      Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately

    • B.

      Determine how many nurses are involved in this practice

    • C.

      Institute an in-service training session on documentation practices

    • D.

      Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system

    Correct Answer
    D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
    Explanation
    The HIM director should develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. This will provide clear guidelines for nurses on acceptable documentation practices and ensure consistency in the use of the copy and paste function. Informing the nurses and stopping the practice immediately may not be enough, as they may not fully understand the implications of their actions. Determining the number of nurses involved is important, but it does not address the root cause of the issue. Instituting an in-service training session may be helpful, but it is not as comprehensive as developing policies and procedures.

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  • 27. 

    Who is responsible for writing and signing discharge summaries and discharge instructions?

    • A.

      Attending physician

    • B.

      Head nurse

    • C.

      Primary physician

    • D.

      Admitting nurse

    Correct Answer
    A. Attending physician
    Explanation
    The attending physician is responsible for writing and signing discharge summaries and discharge instructions. As the primary physician overseeing the patient's care, they have the most comprehensive understanding of the patient's condition and treatment plan. They are in the best position to provide accurate and detailed information regarding the patient's discharge, including any follow-up care instructions and medication prescriptions. The attending physician's signature ensures the validity and accountability of the discharge documentation.

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  • 28. 

    Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________.

    • A.

      Autoauthentication

    • B.

      Electronic signature

    • C.

      Automatic record completion

    • D.

      Chart tracking

    Correct Answer
    A. Autoauthentication
    Explanation
    Autoauthentication refers to the process of automatically approving and signing dictated reports by Dr. Jones unless she makes corrections within 72 hours. This means that the reports are considered valid and authenticated without the need for manual intervention or additional signatures. It streamlines the approval process and ensures efficiency in the documentation of Dr. Jones' reports.

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  • 29. 

    The discharge summary must be completed within ________ after discharge for most patients but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours.

    • A.

      30 days / 48 hours / 24 hours

    • B.

      14 days / 24 hours / 48 hours

    • C.

      14 days / 48 hours / 24 hours

    • D.

      30 days / 24 hours / 48 hours

    Correct Answer
    D. 30 days / 24 hours / 48 hours
    Explanation
    The discharge summary must be completed within 30 days after discharge for most patients but within 24 hours for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than 48 hours.

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  • 30. 

    Which of the following is not an accepted accrediting body for behavioral healthcare organizations?

    • A.

      American Psychological Association

    • B.

      Joint Commission

    • C.

      Commission on Accreditation of Rehabilitation Facilities

    • D.

      National Committee for Quality Assurance

    Correct Answer
    A. American Psychological Association
    Explanation
    The American Psychological Association (APA) is not an accepted accrediting body for behavioral healthcare organizations. The APA is a professional organization that represents psychologists and promotes psychology as a science and profession. However, it does not accredit healthcare organizations. The other three options, Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and National Committee for Quality Assurance, are all recognized accrediting bodies for behavioral healthcare organizations.

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  • 31. 

    What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers?

    • A.

      Vocabulary standard

    • B.

      Identifier standard

    • C.

      Structure and content standard

    • D.

      Security standard

    Correct Answer
    B. Identifier standard
    Explanation
    An identifier standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers. This standard ensures that each entity within the healthcare system has a distinct identifier that can be used for identification and tracking purposes. It helps in maintaining accurate and reliable records, facilitating communication and coordination among different stakeholders, and ensuring patient safety and privacy.

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  • 32. 

    What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?

    • A.

      Accreditation organizations

    • B.

      Certification organizations

    • C.

      State licensure agencies

    • D.

      Conditions of participation agencies

    Correct Answer
    C. State licensure agencies
    Explanation
    State licensure agencies work under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals. These agencies are responsible for ensuring that hospitals meet the necessary standards and regulations to participate in these government healthcare programs. They conduct surveys to assess the quality of care provided by hospitals and determine their eligibility for Medicare and Medicaid reimbursement. These agencies play a crucial role in monitoring and enforcing compliance with federal regulations in the healthcare industry.

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  • 33. 

    Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers?

    • A.

      Patient Assessment Instrument

    • B.

      Minimum Data Set for Long-Term Care

    • C.

      Resident Assessment Protocol

    • D.

      Outcomes and Assessment Information Set

    Correct Answer
    D. Outcomes and Assessment Information Set
    Explanation
    The Outcomes and Assessment Information Set (OASIS) must be used by Medicare-certified home care providers. OASIS is a specialized patient assessment tool that is used to collect data on home health patients and is required by the Centers for Medicare & Medicaid Services (CMS). It includes a set of standardized questions and measures that assess the patient's health status, functional abilities, and outcomes of care. This information is used for quality measurement, payment, and regulatory purposes. The other options listed are not specific to home care providers or Medicare certification.

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  • 34. 

    Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago.

    • A.

      709.2

    • B.

      906.1

    • C.

      709.2, 906.1

    • D.

      906.1, 709.2

    Correct Answer
    C. 709.2, 906.1
    Explanation
    Late affect would never be the first diagnosis

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  • 35. 

    Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago.

    • A.

      787.20, 438.12

    • B.

      784.59, 438.12

    • C.

      438.12

    • D.

      787.20, 438.89

    Correct Answer
    C. 438.12
    Explanation
    The correct answer is 438.12. This is the correct sequence and ICD-9-CM diagnosis code for a patient with dysphasia secondary to an old cerebrovascular accident sustained one year ago.

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  • 36. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis.

    • A.

      558.9

    • B.

      787.01, 558.9

    • C.

      787.02, 787.03, 558.9

    • D.

      787.01, 558.41

    Correct Answer
    A. 558.9
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with nausea, vomiting, and gastroenteritis is 558.9. This code represents noninfectious gastroenteritis and colitis, unspecified, which includes symptoms such as nausea and vomiting. The other options include additional codes for specific types of gastroenteritis or colitis, which may not be applicable in this case.

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  • 37. 

    Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result.

    • A.

      796.4

    • B.

      790.6

    • C.

      792.9

    • D.

      790.93

    Correct Answer
    D. 790.93
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result is 790.93. This code is used to indicate an abnormal PSA level, which can be a sign of prostate cancer or other prostate conditions. The other options (796.4, 790.6, and 792.9) do not specifically address an elevated PSA test result.

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  • 38. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea.

    • A.

      780.2

    • B.

      780.2, 787.02

    • C.

      780.2, 787.01

    • D.

      780.4, 787.02

    Correct Answer
    B. 780.2, 787.02
    Explanation
    The correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea are 780.2 and 787.02. The code 780.2 represents syncope and collapse, while the code 787.02 represents nausea. These two codes together accurately describe the patient's symptoms of near-syncope event and nausea.

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  • 39. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with abnormal glucose tolerance test.

    • A.

      790.29

    • B.

      790.21

    • C.

      790.21, 790.29

    • D.

      790.22

    Correct Answer
    D. 790.22
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with abnormal glucose tolerance test is 790.22. This code specifically represents impaired glucose tolerance, which is a condition where blood glucose levels are higher than normal but not high enough to be classified as diabetes. The other options (790.29 and 790.21) do not accurately represent the specific diagnosis of abnormal glucose tolerance test.

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  • 40. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough.

    • A.

      786.2, 490

    • B.

      486, 786.2

    • C.

      486

    • D.

      481

    Correct Answer
    C. 486
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with pneumonia and persistent cough is 486. This code specifically refers to pneumonia, which is the primary condition, and includes the symptom of persistent cough. The other options either do not include the code for pneumonia (481) or do not include the code for persistent cough (786.2).

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  • 41. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy, ruled out.

    • A.

      780.39

    • B.

      345.9

    • C.

      780.39, 345.9

    • D.

      345.90

    Correct Answer
    A. 780.39
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with seizures; epilepsy, ruled out is 780.39. This code is used for patients who have experienced seizures but do not have a confirmed diagnosis of epilepsy. It indicates that epilepsy has been considered as a possible diagnosis but has been ruled out. The code 345.9 is incorrect as it is used for epilepsy without further specification. The combination of codes 780.39 and 345.9 is also incorrect as it suggests that both conditions are present, which is not the case. The code 345.90 is incorrect as it is used for unspecified epilepsy, which is not applicable in this scenario.

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  • 42. 

    Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence.

    • A.

      625.6

    • B.

      788.30

    • C.

      788.32

    • D.

      788.39

    Correct Answer
    C. 788.32
    Explanation
    The correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence is 788.32. This code is specifically used for stress incontinence, which is the involuntary leakage of urine during physical activity or exertion. It is important to accurately code the diagnosis in order to ensure proper documentation and billing for the patient's condition.

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  • 43. 

    Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea.

    • A.

      789.03

    • B.

      789.03, 787.02, 787.03, 787.91

    • C.

      789.03, 787.91

    • D.

      789.03, 787.01, 787.91

    Correct Answer
    D. 789.03, 787.01, 787.91
    Explanation
    The correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea are 789.03, 787.01, and 787.91. The code 789.03 represents the abdominal pain, 787.01 represents the nausea and vomiting, and 787.91 represents the diarrhea.

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  • 44. 

    Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifer, and all three volumes of ICD-9-CM use them.

    • A.

      Parentheses ( )

    • B.

      Square brackets [ ]

    • C.

      Slanted brackets  [  ]

    • D.

      Braces { }

    Correct Answer
    A. Parentheses ( )
    Explanation
    Parentheses ( ) are used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The use of parentheses does not affect the code number assigned to the case. They are considered a nonessential modifier and are used in all three volumes of ICD-9-CM.

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  • 45. 

    From the health record of a patient newly diagnosed with a malignancy: Preoperative Diagnosis:  Suspicious lesions, main bronchus Postoperative Diagnosis:  Carcinoma, in situ, main bronchus Indications:  Previous bronchoscopy showed two suspicious lesions in the main bronchus. Laser photoresection is planned for destruction of these lesions, because bronchial washings obtained previously showed carcinoma in situ. Procedure:  Following general anesthesia in the hospital same-day surgery area, with a high-frequency jet ventilator, a rigid bronchoscope is inserted and advanced through the larynx to the main bronchus. The areas were treated with laser photoresection. Identify the ICD-9-CM diagnosis code and CPT procedure code(s) for this service?

    • A.

      162.2, 31641, 31623-59

    • B.

      231.2, 31641, 31623-59

    • C.

      231.2, 31641

    • D.

      162.2, 31641

    Correct Answer
    C. 231.2, 31641
    Explanation
    The correct answer is 231.2, 31641. The preoperative diagnosis indicates that there were suspicious lesions in the main bronchus, and the postoperative diagnosis confirms that there was carcinoma in situ in the main bronchus. The procedure performed was laser photoresection to destroy these lesions. Therefore, the ICD-9-CM diagnosis code 231.2, which represents carcinoma in situ of bronchus and lung, is appropriate. The CPT procedure code 31641, which represents bronchoscopy with destruction of tumor(s), laser, is also appropriate.

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  • 46. 

    A 22-year-old patient presents for a closure of a patent ductus arteriosus. The patient's thorax is opened posteriorly and the vagus nerve is isolated away. The PDA is divided and sutured individually in the aorta and pulmonary artery. How is this procedure coded?

    • A.

      33813

    • B.

      33820

    • C.

      33822

    • D.

      33824

    Correct Answer
    D. 33824
    Explanation
    The correct answer is 33824 because this code specifically describes the closure of a patent ductus arteriosus (PDA) through a thoracotomy approach. The procedure involves dividing and suturing the PDA individually in both the aorta and pulmonary artery. The other codes listed do not accurately describe this specific procedure.

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  • 47. 

    Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode.

    • A.

      410.11

    • B.

      410.01

    • C.

      410.02

    • D.

      410.12

    Correct Answer
    B. 410.01
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode is 410.01. This code specifically identifies a myocardial infarction occurring in the anterolateral wall of the heart and indicates that it is the patient's first episode of this condition.

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  • 48. 

    Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome.

    • A.

      042, 112.4, V01.79

    • B.

      112.4, 042

    • C.

      042, 112.4, V08

    • D.

      042, 112.4

    Correct Answer
    D. 042, 112.4
    Explanation
    The correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome are 042 and 112.4. The code 042 represents the diagnosis of AIDS, while the code 112.4 represents the diagnosis of disseminated candidiasis. These two codes should be sequenced in that order to accurately reflect the patient's condition.

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  • 49. 

    Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli.

    • A.

      599.0

    • B.

      599.0, 041.4

    • C.

      041.4

    • D.

      041.4, 599.0

    Correct Answer
    B. 599.0, 041.4
    Explanation
    The correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli are 599.0 and 041.4. The code 599.0 represents urinary tract infection, while the code 041.4 represents infection due to Escherichia coli. Both codes should be listed in the order of their significance, with the code for the infection due to E. coli (041.4) listed first.

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  • 50. 

    Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications.

    • A.

      204.00, 787.01, V58.11

    • B.

      V58.11, 204.00, 787.01

    • C.

      V58.11, 204.00

    • D.

      204.22, 787.01

    Correct Answer
    B. V58.11, 204.00, 787.01
    Explanation
    The correct sequence of ICD-9-CM diagnosis codes for a patient admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia with severe nausea and vomiting treated with medications is V58.11, 204.00, 787.01. The code V58.11 represents the encounter for antineoplastic chemotherapy, while 204.00 represents acute lymphocytic leukemia, and 787.01 represents nausea with vomiting. This sequence accurately reflects the reason for admission, the primary diagnosis, and the symptom that required treatment.

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Quiz Review Timeline +

Our quizzes are rigorously reviewed, monitored and continuously updated by our expert board to maintain accuracy, relevance, and timeliness.

  • Current Version
  • Jul 21, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Mar 13, 2012
    Quiz Created by
    Melodey23

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