CCA Exam Preparation Practice Test!
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Where would a coder who needed to locate the histology of a tissue sample most likely find this information
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Pathology report
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Progress notes
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Nurse's notes
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Operative report
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Get ready for the CCA Exam with our comprehensive CCA exam questions 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 CCA exam practice test will challenge your understanding of See morethe Certified Coding Associate certification.
Test your skills with a variety of CCA exam questions, identify areas for improvement, and boost your confidence before the actual exam. This CCA exam practice test is a valuable tool to enhance your exam preparation. So, let's get started and ace the CCA Exam with these targeted CCA exam questions!
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- 2.
What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?
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Ignore the state law and follow the HIPAA standard
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Follow the state law and ignore the HIPAA standard
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Comply with both the state law and the HIPAA standard
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Ignore both the state law and the HIPAA standard and follow relevant accreditation standards
Correct Answer
A. Comply with both the state law and the HIPAA standardExplanation
A hospital should comply with both the state law and the HIPAA standard because the state law requires more stringent privacy protection than the federal HIPAA privacy standard. By following both, the hospital ensures that it meets the requirements of both the state law and the federal standard, thereby protecting patient privacy to the highest extent possible. Ignoring either the state law or the HIPAA standard would result in non-compliance and potential legal and ethical implications.Rate this question:
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- 3.
Which of the following activities is considered an unethical practice?
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Backdating progress notes
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Performing quantitative analysis
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Verifying that an insurance company is one that is authorized to receive patient information
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Determining what information is required to fulfill an authorized request for information
Correct Answer
A. Backdating progress notesExplanation
Backdating progress notes is considered an unethical practice because it involves falsifying documentation by recording information at a later date than when it actually occurred. This can lead to inaccurate medical records, potential legal issues, and compromised patient care. It is important to maintain the integrity and accuracy of medical records to ensure patient safety and provide quality healthcare.Rate this question:
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- 4.
Which of the following is a core ethical obligation of health information staff?
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Coding diseases and operations
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Protecting patients' privacy and confidential communications
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Transcribing medical reports
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Performing quantitative analysis on record content
Correct Answer
A. Protecting patients' privacy and confidential communicationsExplanation
The core ethical obligation of health information staff is to protect patients' privacy and confidential communications. This includes ensuring that patients' personal health information is kept secure and confidential, and that it is only accessed by authorized individuals for legitimate purposes. This obligation is crucial in maintaining trust between healthcare providers and patients, and in upholding the principles of patient autonomy and confidentiality.Rate this question:
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- 5.
What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
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Lobar pneumonia
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Pneumocystitis carinii pneumonia
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Interstitial pneumonia
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Aspiration pneumonia
Correct Answer
A. Aspiration pneumoniaExplanation
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.Rate this question:
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- 6.
Which of the following activities would be in violation of AHIMA's Code of Ethics?
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Coding an intentionally inappropriate level of service
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Following established coding policies and procedures
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Protecting the confidentiality of patients' written and electronic records
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Taking remedial action when there is direct knowledge of a colleague's incompetence or impairment
Correct Answer
A. Coding an intentionally inappropriate level of serviceExplanation
Coding an intentionally inappropriate level of service would be in violation of AHIMA's Code of Ethics because it goes against the principle of accuracy and integrity in coding. AHIMA's Code of Ethics requires healthcare professionals to accurately and ethically code services provided to patients. Intentionally coding an inappropriate level of service would be considered fraudulent and unethical behavior.Rate this question:
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- 7.
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 _____________.
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Physical examination record
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History record
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Operative report
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Radiological report
Correct Answer
A. History recordExplanation
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.Rate this question:
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- 8.
Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
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Operative report
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Anesthesia report
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Pathology report
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Laboratory report
Correct Answer
A. Operative reportExplanation
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.Rate this question:
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- 9.
Who is responsible for writing and signing discharge summaries and discharge instructions?
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Attending physician
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Head nurse
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Primary physician
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Admitting nurse
Correct Answer
A. Attending physicianExplanation
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.Rate this question:
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- 10.
On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this caes, what should the supervisor do?
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Reprimand the employee
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Fire the employee
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Determine what information was printed and why
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Revoke the employee's access priviliges
Correct Answer
A. Determine what information was printed and whyExplanation
The supervisor should determine what information was printed and why in order to understand the employee's actions. This will help identify any potential misuse or unauthorized access to patient records. Reprimanding or firing the employee without first investigating the situation may not be appropriate or fair. Revoking the employee's access privileges may be necessary if it is found that the printing was unauthorized or violated any policies or regulations.Rate this question:
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- 11.
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the:
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Past medical history
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Social history
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Systems review
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History of present illness
Correct Answer
A. Social historyExplanation
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the social history. The social history includes information about the patient's lifestyle, habits, and social support system, which can provide valuable insights into their overall well-being and potential risk factors. The history of drug, alcohol, and tobacco use is relevant to understanding the patient's past behaviors and any potential impact on their current health status. This information can help healthcare professionals assess the patient's risk for certain conditions and tailor their treatment accordingly.Rate this question:
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- 12.
Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients?
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Interpretation of x-rays by the radiologist
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Billing records
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Progress notes written by the attending physician
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Psychotherapy notes
Correct Answer
A. Psychotherapy notesExplanation
Psychotherapy notes cannot be disclosed to patients under the HIPAA Rule. While patients have the right to access their personal health information, including interpretation of x-rays, billing records, and progress notes, psychotherapy notes are an exception. These notes are considered separate from the rest of the patient's medical records and are not required to be shared with the patient. This is to protect the privacy and confidentiality of the psychotherapy process and ensure that patients feel comfortable expressing themselves during therapy sessions.Rate this question:
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- 13.
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.
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Discharge summary
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Medical history
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Medical laboratory report
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Physical examination
Correct Answer
A. Physical examinationExplanation
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.Rate this question:
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- 14.
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?
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Operative report
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Pathology report
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Discharge summary
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Nursing note
Correct Answer
A. Pathology reportExplanation
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.Rate this question:
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- 15.
Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
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Herpes simplex
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Staphylococcus aureus
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Influenza, types A and B
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Candida albicans
Correct Answer
A. Staphylococcus aureusExplanation
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.Rate this question:
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- 16.
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?
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Request that the physician dictate another discharge summary
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Have the record analyst note the date discrepancy
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Request the physician dictate an addendum to the discharge summary
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File the record as complete since the discharge summary includes all the pertinent patient information
Correct Answer
A. Request the physician dictate an addendum to the discharge summaryExplanation
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.Rate this question:
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- 17.
The codes in the musculoskeletal section of CPT may be used by:
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Orthopedic surgeons only
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Orthopedic surgeons and emergency department physicians
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Any physician
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Orthopedic surgeons and neurosurgeons
Correct Answer
A. Any physicianExplanation
The codes in the musculoskeletal section of CPT may be used by any physician. This means that all physicians, regardless of their specialty, can utilize these codes when billing for services related to the musculoskeletal system. It is not limited to orthopedic surgeons or any specific group of physicians.Rate this question:
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- 18.
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?
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Otitis media
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AIDS
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Toxic shock syndrome
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Bacteremia
Correct Answer
A. AIDSExplanation
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.Rate this question:
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- 19.
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.
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Parentheses ( )
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Square brackets [ ]
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Slanted brackets [ ]
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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.Rate this question:
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- 20.
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.
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Discharge summary
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Medical history
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Medical laboratory report
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Physical examination
Correct Answer
A. Medical laboratory reportExplanation
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.Rate this question:
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- 21.
CPT was developed and is maintained by:
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CMS
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AMA
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Cooperating Parties
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WHO
Correct Answer
A. AMAExplanation
The correct answer is AMA, which stands for the American Medical Association. The AMA played a significant role in the development and maintenance of the Current Procedural Terminology (CPT) system. CPT is a standardized medical coding system used for reporting medical procedures and services. The AMA ensures that CPT is regularly updated to reflect changes in medical practices, technology, and healthcare regulations. AMA's involvement in the development and maintenance of CPT makes it the correct answer to this question.Rate this question:
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- 22.
How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form?
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By requesting the medical record for each service provided
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By reviewing al the diagnosis codes assigned to explain the reasons the services were provided
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By reviewing all physician orders
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By reviewing the discharge summary and history and physical for the patient over the last year
Correct Answer
A. By reviewing al the diagnosis codes assigned to explain the reasons the services were providedExplanation
Medicare or other third-party payers determine whether a patient has medical necessity for the tests, procedures, or treatment billed on a claim form by reviewing all the diagnosis codes assigned to explain the reasons the services were provided. These diagnosis codes provide information about the patient's condition and help determine if the services were necessary and appropriate for the patient's health. By reviewing the diagnosis codes, payers can ensure that the services were medically necessary and meet the criteria for coverage.Rate this question:
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- 23.
ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
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28th
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14th
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60th
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30th
Correct Answer
A. 28thExplanation
ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This classification is used to identify and categorize health care services and procedures related to newborns. The newborn period is critical for monitoring the health and development of infants during their initial days and weeks of life.Rate this question:
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- 24.
What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use pHI for commercial advantage, personal gain, or malicious harm?
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A fine of not more than $10,000 only
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A fine of not more than $10,000, not more than 1 year in jail, or both
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A fine of not more than $5,000 only
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A fine of not more than $250,000, not more than 10 years in jail, or both
Correct Answer
A. A fine of not more than $250,000, not more than 10 years in jail, or bothExplanation
Under HIPAA (Health Insurance Portability and Accountability Act), individuals or entities that willfully and knowingly violate the Privacy Rule with the intent to sell, transfer, or use Protected Health Information (PHI) for commercial advantage, personal gain, or malicious harm face severe penalties. This includes hefty fines and significant prison time, reflecting the serious nature of such violations and the need to protect patient privacy.Rate this question:
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- 25.
When correcting erroneous information in a health record, which of the following is not appropriate?
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Print "error" above the entry
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Enter the correction in chronological sequence
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Add the reason for the change
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Use black pen to obliterate the entry
Correct Answer
A. Use black pen to obliterate the entryExplanation
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.Rate this question:
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- 26.
What is the basic formula for calculating each MS-DRG hospital payments?
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Hospital payment = DRG relative weight x hospital base rate
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Hospital payment = DRG relative weight x hospital base rate -1
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Hospital payment = DRG relative weight / hospital base rate +1
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Hospital payment = DRG relative weight / hospital base rate
Correct Answer
A. Hospital payment = DRG relative weight x hospital base rateExplanation
The basic formula for calculating each MS-DRG hospital payment is by multiplying the DRG relative weight with the hospital base rate. This formula allows for determining the payment amount based on the severity and complexity of the patient's condition (DRG relative weight) and the predetermined rate set by the hospital (hospital base rate).Rate this question:
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- 27.
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 _____________.
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Autoauthentication
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Electronic signature
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Automatic record completion
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Chart tracking
Correct Answer
A. AutoauthenticationExplanation
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.Rate this question:
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- 28.
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?
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Postoperative infection
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Appendicitis
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COPD
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Hypertension
Correct Answer
A. Postoperative infectionExplanation
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."Rate this question:
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- 29.
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?
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Insomnia
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Hypertension
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Schizophrenia
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Rheumatoid arthritis
Correct Answer
A. SchizophreniaExplanation
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.Rate this question:
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- 30.
A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in plce to minimize this security breach?
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Access controls
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Audit trails
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Edit checks
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Password controls
Correct Answer
A. Edit checksExplanation
Edit checks should be in place to minimize this security breach. Edit checks are a security measure that ensures the accuracy and validity of data entered into a system. In this case, the coding analyst consistently enters the wrong code for patient gender, so implementing edit checks can help catch and prevent these errors. Edit checks can validate the entered code against a predefined set of acceptable values for patient gender, alerting the analyst if an incorrect code is entered. This can help minimize the security breach caused by consistently entering the wrong code for patient gender.Rate this question:
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- 31.
Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface?
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Client-server computer
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Data warehouse
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Local area network
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Internet
Correct Answer
A. Data warehouseExplanation
A data warehouse is a centralized repository that allows organizations to access data from multiple databases and combine the results into a single interface for querying and reporting. It is designed to support analytical processing and provide a consolidated view of data across different sources. By consolidating data into a data warehouse, organizations can easily retrieve and analyze information from various databases, enabling better decision-making and reporting capabilities.Rate this question:
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- 32.
Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?
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No a dentist is a healthcare clearinghouse, which is covered entity under HIPAA.
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Yes; a dentist is not a covered entity per the HIPAA Privacy Rule.
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No; it is a violation of the HIPAA Privacy Rule.
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Yes; the Notice of Privacy Practices is not required until June 2012.
Correct Answer
A. No; it is a violation of the HIPAA Privacy Rule.Explanation
The correct answer is "No; it is a violation of the HIPAA Privacy Rule." This is because dentists are considered healthcare providers and are therefore covered entities under HIPAA. As a covered entity, they are required to provide patients with a Notice of Privacy Practices, which explains how their health information may be used and disclosed. Therefore, the dentist's failure to provide Janet Kim with a Notice of Privacy Practices is a violation of the HIPAA Privacy Rule.Rate this question:
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- 33.
Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?
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Consent for operative procedure, anesthesia report, surgical report
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Consent for operative procedure, history, physical examination
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History, physical examination, anesthesia report
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Problem list, history, physical examination
Correct Answer
A. Consent for operative procedure, history, physical examinationExplanation
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.Rate this question:
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- 34.
"Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
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41
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39
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40
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42
Correct Answer
A. 40Explanation
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.Rate this question:
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- 35.
What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs?
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Medicare administrative contractors (MACs)
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Recovery audit contractors (RACs)
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Comprehensive error rate testing (CERT)
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Fiscal intermediaries (FIs)
Correct Answer
A. Recovery audit contractors (RACs)Explanation
Recovery audit contractors (RACs) is the correct answer because RACs are responsible for identifying and recovering improper payments in the Medicare Fee-for-Service programs. They conduct audits and reviews of Medicare claims to detect any errors or fraudulent activities. RACs play a crucial role in ensuring the integrity of the Medicare system by detecting and correcting improper payments, thereby preventing wastage of funds and protecting the program's financial sustainability.Rate this question:
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- 36.
Under the HIPAA privacy standard, which of the following types of protected health information (pHI) must be specifically identified in an authorization?
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History and physical reports
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Operative reports
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Consultation reports
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Psychotherapy notes
Correct Answer
A. Psychotherapy notesExplanation
Under the HIPAA privacy standard, psychotherapy notes must be specifically identified in an authorization. This is because psychotherapy notes are treated differently from other types of protected health information (PHI). While other types of PHI can be disclosed for treatment, payment, and healthcare operations without explicit authorization, psychotherapy notes require the patient's specific consent for disclosure. This is to ensure the privacy and confidentiality of sensitive mental health information.Rate this question:
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- 37.
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?
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Suggest that only hospital clock time be noted in clinical documentation
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Suggest that only electronic documentation have time notated
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Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
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Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time
Correct Answer
A. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and datedExplanation
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.Rate this question:
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- 38.
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?
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Request that the CEO write a memorandum to all hospital staff
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Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation
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Include ancillary clinical and medical staff in the process
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Request a letter from the Joint Commission
Correct Answer
A. Include ancillary clinical and medical staff in the processExplanation
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.Rate this question:
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- 39.
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
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Patient management
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New technology
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Therapeutic, preventative, or other interventions
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Patient safety
Correct Answer
A. New technologyExplanation
Category II codes cover topics such as patient management, therapeutic, preventative, or other interventions, and patient safety. However, they do not address new technology. This means that Category II codes do not provide specific codes for documenting or tracking the use of new technologies in healthcare.Rate this question:
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- 40.
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure?
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A "with manipulation" code
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A "without manipulation" code
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An unlisted procedure code
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An E/M code only
Correct Answer
A. A "with manipulation" codeExplanation
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, a "with manipulation" code should be assigned for the procedure. This is because the surgeon attempted to manipulate or realign the fracture, even though they were unsuccessful in achieving the desired alignment. The "with manipulation" code acknowledges the attempted procedure, regardless of the outcome.Rate this question:
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- 41.
The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record.
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Automated codebook
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Computer-assisted coding
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Logic based encoder
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Decision support database
Correct Answer
A. Computer-assisted codingExplanation
Computer-assisted coding is a type of coding that is a natural outgrowth of the electronic health record. This technology helps automate the coding process by analyzing clinical documentation and suggesting appropriate codes based on predefined rules and algorithms. It improves coding accuracy, efficiency, and productivity by reducing the manual effort required for coding. With computer-assisted coding, healthcare providers can streamline their coding workflows and ensure accurate and consistent coding practices.Rate this question:
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- 42.
Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in:
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Appendix E
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Appendix F
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Appendix G
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Appendix H
Correct Answer
A. Appendix GExplanation
The correct answer is Appendix G. The CPT codebook provides a list of codes for procedures that include conscious sedation when administered by the same surgeon who performs the procedure. This information can be found in Appendix G of the codebook.Rate this question:
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- 43.
Mohs micrographic surgery involves the surgeon acting as:
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Both plastic surgeon and general surgeon
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Both surgeon and pathologist
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Both plastic surgeon and dermatologist
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Both dermatologist and pathologist
Correct Answer
A. Both surgeon and pathologistExplanation
Mohs micrographic surgery is a specialized technique used for the treatment of skin cancer. During this procedure, the surgeon acts as both a surgeon and a pathologist. They remove thin layers of cancerous tissue and examine them under a microscope to ensure complete removal of the tumor. This allows for precise removal of cancer cells while preserving healthy tissue. The surgeon's ability to perform the surgery and interpret the microscopic findings makes them both a surgeon and a pathologist in this context.Rate this question:
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- 44.
What is the name of the organization that develops the billing form that hospitals are required to use?
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American cademy of Billing Forms (AABF)
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National Uniform Billing Committee (NUBC)
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National Uniform Claims Committee (NUCC)
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American Billing and Claims Academy (ABCA)
Correct Answer
A. National Uniform Billing Committee (NUBC)Explanation
The correct answer is National Uniform Billing Committee (NUBC). This organization is responsible for developing the billing form that hospitals are required to use. They work to standardize the billing process and ensure that all hospitals use a uniform form for submitting claims. The NUBC plays a crucial role in streamlining the billing system and ensuring accurate and efficient billing practices in the healthcare industry.Rate this question:
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- 45.
An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach?
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Audit controls
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Information access controls
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Facility access controls
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Workstation security
Correct Answer
A. Information access controlsExplanation
Information access controls should be implemented to prevent this security breach. These controls include measures such as user authentication, role-based access control, and access restrictions based on the principle of least privilege. By implementing information access controls, the employee will only be able to access the clinical information system for legitimate work-related purposes, preventing them from snooping on personal information of neighbors and friends.Rate this question:
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- 46.
Which of the following soil nutrients is most likely to be deficient in sandy soils and thus requires careful management for optimal crop production?
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Nitrogen
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Phosphorus
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Potassium
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Calcium
Correct Answer
A. NitrogenExplanation
Sandy soils tend to have low organic matter content and poor nutrient retention, making nitrogen particularly susceptible to leaching. As a result, nitrogen deficiency is common in sandy soils, and careful management practices, such as regular soil testing and appropriate fertilization, are required to ensure adequate nitrogen availability for optimal crop production.Rate this question:
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- 47.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
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Performance improvement programs
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Billing and claims data processing
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Developing hospital discharge abstracting systems
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Developing individual care plans for residents
Correct Answer
A. Performance improvement programsExplanation
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.Rate this question:
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- 48.
What is abstracting?
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Compiling the pertinent information from the medical record based on predetermined data sets
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Assigning the appropriate code or nomenclature term for categorization
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Assembling a chronological set of data for an express purpose
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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 setsExplanation
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.Rate this question:
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- 49.
Which of the following ethical principles is being followed when an HIT professional ensures thtat patient information is only released to those who have a legl right to access it?
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Autonomy
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Beneficence
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Justice
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Nonmaleficence
Correct Answer
A. BeneficenceExplanation
Beneficence is the ethical principle being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it. Beneficence refers to the duty to do good and act in the best interest of others. By safeguarding patient information and only providing access to authorized individuals, the HIT professional is promoting the well-being and protecting the rights of the patients. This principle ensures that patient privacy and confidentiality are respected, maintaining trust and promoting ethical practices in healthcare.Rate this question:
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Nov 25, 2024Quiz Edited by
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Mar 13, 2012Quiz Created by
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