CCA Exam Preparation Practice Test!

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

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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About This Quiz
CCA Exam Preparation Practice Test! - Quiz

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,... see morethis CCA exam practice test will challenge your understanding of the 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? 

Explanation

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.

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3. Which of the following activities is considered an unethical practice?

Explanation

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.

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4. Which of the following is a core ethical obligation of health information staff?

Explanation

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.

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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?

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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6. 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 _____________.

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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7. Which of the following activities would be in violation of AHIMA's Code of Ethics?

Explanation

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.

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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.

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

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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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?

Explanation

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.

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11. Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the:

Explanation

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.

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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?

Explanation

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.

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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.

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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14. The codes in the musculoskeletal section of CPT may be used by:

Explanation

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.

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15. 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?

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

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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17. 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?

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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18. 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?

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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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.

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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20. CPT was developed and is maintained by:

Explanation

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.

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21. 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.

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

Explanation

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.

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

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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24. 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?

Explanation

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.

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25. What is the basic formula for calculating each MS-DRG hospital payments?

Explanation

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).

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26. 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?

Explanation

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.

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27. 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?

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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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 _____________.

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. 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?

Explanation

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.

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30. 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?

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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31.  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?

Explanation

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.

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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?

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.

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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?

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

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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35. Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization?

Explanation

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.

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36. 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?

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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37. What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs?

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.

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38. 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?

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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39. Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?

Explanation

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.

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40. 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:

Explanation

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.

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41. 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?

Explanation

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.

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42. The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record.

Explanation

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.

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43. Mohs micrographic surgery involves the surgeon acting as:

Explanation

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.

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44. What is the name of the organization that develops the billing form that hospitals are required to use?

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.

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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?

Explanation

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.

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46. Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.

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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47. Which of the following soil nutrients is most likely to be deficient in sandy soils and thus requires careful management for optimal crop production?

Explanation

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.

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48. 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?

Explanation

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.

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49. What is abstracting?

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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50. Tissue transplated from one individual to another of the same species but different genotype is called a(n):

Explanation

An allograft or allogeneic graft refers to tissue that is transplanted from one individual to another within the same species but with different genotypes. This means that the donor and recipient have different genetic makeup. Autograft refers to tissue transplanted from one part of the individual's own body to another, xenograft refers to tissue transplanted between different species, and heterograft refers to tissue transplanted between individuals of different species but same genotype.

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51. Identify the correct ICD-9-CM diagnosis code(s) for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms.

Explanation

The correct ICD-9-CM diagnosis code for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms is V72.5. This code is used to indicate a routine general medical examination, which includes diagnostic laboratory and radiology services. It does not require any specific signs or symptoms to be present. The other codes listed are not appropriate for this scenario.

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52. What healthcare organization collects UHDDS data?

Explanation

The correct answer is all non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes. This means that healthcare organizations such as hospitals, psychiatric hospitals, nursing homes, and rehabilitation facilities are responsible for collecting UHDDS data. Outpatient settings like physician clinics and ambulatory surgical centers do not collect UHDDS data.

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53. Which answer below is not correct for assignment of the MS-DRG?

Explanation

The assignment of the MS-DRG is based on several factors, including diagnoses and procedures, presence of major or other complications and co-morbidities (MCC or CC), and discharge disposition or status. However, the attending and consulting physicians do not play a role in the assignment of the MS-DRG. The MS-DRG is determined based on the patient's condition and the services provided, rather than the specific physicians involved in the care.

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54. A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended?

Explanation

Automatic session terminations would be the best strategy to minimize data breaches when the home computer is unattended. This means that if the computer is left idle for a certain period of time, the session will automatically log out, requiring the user to enter their credentials again to access the system. This helps to prevent unauthorized access to sensitive information in case the computer is left unattended or accessed by someone else. By terminating the session, it reduces the risk of data breaches and ensures the security of the hospital's data.

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55. In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems.

Explanation

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ADT systems. ADT stands for Admission, Discharge, and Transfer, which are the key processes involved in managing patient information and movement within a healthcare facility. These systems help streamline administrative tasks, improve patient safety, and enhance overall efficiency in hospitals.

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56. Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1).  They will also be sending her records to her physician for continuity of care (2).  Under HIPAA, these two functions are:

Explanation

The personnel at Mercy Hospital need to review Katie Grace's medical records for utilization review purposes, which falls under the category of "use" according to HIPAA. Additionally, they will be sending her records to her physician for continuity of care, which is considered a "disclosure" under HIPAA. Therefore, the correct answer is "Use (1) and disclosure (2)."

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

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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58. 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:

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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59. Which organization developed the first hospital standardization program?

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

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

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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62. Observation E/M codes (99218 through 99220) are used in physician billing when:

Explanation

Observation E/M codes (99218 through 99220) are used in physician billing when a patient is referred to a designated observation service. This means that the patient is not admitted for routine nursing care following surgery, does not meet admission criteria, or is not admitted and discharged on the same date. Instead, they are specifically referred to a designated observation service for further evaluation and monitoring.

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63. 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?

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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64. Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition.

Explanation

The correct answer is 250.02, 263.1. This is because uncontrolled type II diabetes mellitus is represented by the ICD-9-CM code 250.02, and mild malnutrition is represented by the code 263.1. Therefore, both codes need to be included to accurately identify the diagnosis.

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65. Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes?

Explanation

Per the HIPAA Privacy Rule, the use of Mary's individually identifiable information related to her asthma treatments requires authorization for research purposes. This means that Mary's personal information, such as her name, address, and medical history, cannot be used for research without her explicit consent. The other options mentioned, such as using deidentified information about Mary's myocardial infarction or using information about Jim, Mary's deceased husband, do not require authorization for research purposes as they do not involve the use of individually identifiable information.

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

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

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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68. What was the goal of the new MS-DRG system?

Explanation

The goal of the new MS-DRG system is to improve Medicare's capability to recognize the severity of illness in its inpatient hospital payments. This means that the system aims to accurately assess the level of illness or medical condition of patients in order to determine appropriate payment amounts to hospitals. The new system is designed to increase payments to hospitals for services provided to sicker patients, who require more intensive and costly treatments, while decreasing payments for treating less severely ill patients. This is intended to ensure that hospitals are adequately compensated for the level of care they provide, based on the severity of the patients' conditions.

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69. In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called:

Explanation

Selective catheterization refers to the technique of manipulating the tip of the catheter from the insertion point in the aorta to another specific artery. This technique allows for targeted access to specific arteries for diagnostic or therapeutic purposes. It is different from nonselective catheterization, which involves the catheter tip being manipulated within a larger vessel without targeting a specific artery. Manipulative catheterization and radical catheterization are not commonly used terms in the context of arterial catheterizations.

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70. What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient?

Explanation

The maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient is six. This means that a hospital can list up to six different procedures or treatments that were performed during the inpatient stay on the claim form.

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71. Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.

Explanation

The appropriate CPT code to report this occult blood sampling is 82270. This code is used for the examination of fecal occult blood utilizing immunoassay, with or without microscopy. Since Mr. Smith is given three small cards to take home and return with fecal samples, it indicates that the physician is performing an immunoassay test on the samples to screen for colorectal cancer.

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72. Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)?

Explanation

An input mask for entering data in the field would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR). An input mask provides a predefined format for data entry, guiding the user to enter the date in a specific format. This helps to prevent errors and inconsistencies in the notation of the admission date.

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

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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74. Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa.

Explanation

CPT code 23031 is the correct procedure code for incision and drainage of an infected shoulder bursa. This code specifically refers to the drainage of a deep abscess or hematoma in the shoulder region. The other options, 10060, 10140, and 23030, are not specific to the shoulder bursa or do not accurately describe the procedure being performed.

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

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

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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77. 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.

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.

Submit
78. 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.

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.

Submit
79. When coding a selective catheterization in CPT, how are codes assigned?

Explanation

When coding a selective catheterization in CPT, the codes are assigned based on the final vessel entered. This means that only one code is used to represent the final vessel that was accessed during the procedure. The other vessels that were entered or any intervening vessels are not separately coded.

Submit
80. A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest?

Explanation

In this situation, the Health Information Management (HIM) director should suggest avoiding the display of the social security number on any document, screen, or data collection field. This approach reduces the risk of identity fraud while still addressing the concerns regarding patient identification. The HIM director can emphasize that alternative methods for patient identification can be implemented, such as using unique patient identifiers or medical record numbers. Additionally, providing training for staff on best practices for handling sensitive information and ensuring compliance with privacy regulations can further mitigate risks while maintaining the necessary identification processes.

Submit
81. 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.

Explanation

The correct ICD-9-CM diagnosis code for a scar on the right hand secondary to a laceration sustained two years ago is 906.1 (Late effect of open wound of hand without mention of complication). This code is used to report the long-term effects of an injury, such as a scar. The code 709.2 (Scar conditions and fibrosis of skin) is not used in this case because it is a less specific code and does not capture the fact that the scar is a late effect of a previous injury.

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

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).

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

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.

Submit
84. Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung.

Explanation

The correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung are 153.9 and 197.0. Code 153.9 represents malignant neoplasm of the colon, while code 197.0 represents secondary malignant neoplasm of the lung. These codes accurately describe the diagnosis of metastatic carcinoma of the colon to the lung.

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

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.

Submit
86. A child was examined and treated for child abuse in the emergency department at the hospital. s a result, the child ha been taken into protective custody by the Office of Child Protection because of suspected child abuse by parents. The father requests copies of the designated record set for the visit. He has a copy of the child's birth certificate listing him as the fther and he possesses a picture ID. Do you release a copy of the emergency department record?

Explanation

The correct answer is to decline to release the information and contact the hospital's attorney. Even though the father has a copy of the child's birth certificate and a picture ID, it is important to prioritize the safety and well-being of the child. Since the child has been taken into protective custody due to suspected child abuse, it is necessary to involve the hospital's attorney to ensure that releasing the information does not jeopardize the child's safety or violate any legal obligations.

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

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.

Submit
88. 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?

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.

Submit
89. Per CPT guidelines, a separate procedure is:

Explanation

According to CPT guidelines, a separate procedure is Coded when it is performed as part of another, larger procedure and Considered to be an integral part of another, larger procedure. Therefore, the correct answer is Both a and b.

Explanation:

Coded when it is performed as part of another, larger procedure: If a separate procedure is performed alongside a major procedure, it can be coded separately.

Considered to be an integral part of another, larger procedure: This means that if the separate procedure is not clearly identifiable as being distinct from the larger procedure, it is considered an integral part and should not be coded separately.

Thus, both statements (a and b) are correct, making option Both a and b the right choice.

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

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.

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

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.

Submit
92. What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principal and secondary diagnoses?

Explanation

The UB-04 paper claim form allows for a maximum of 17 diagnosis codes in locator 67. This includes one principal diagnosis, which is the main condition responsible for the patient's hospital admission, plus up to 16 secondary diagnoses. Secondary diagnoses are conditions that coexist at the time of admission or develop subsequently and impact the treatment provided and/or the length of stay. While the UB-04 form has a cap of 17 diagnosis codes, electronic claims (837I) can accommodate more. It is essential to code to the highest level of specificity, as accurate and complete diagnosis coding is vital for proper reimbursement and data collection.

Submit
93. What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment?

Explanation

Hospitals can receive additional "add-on" payments from Medicare in several specific circumstances beyond the basic Diagnosis-Related Group (DRG) payment. These include payments to Disproportionate Share Hospitals (DSH) that serve a high number of low-income patients, which help offset their financial burdens. Additional payments may also be provided for Indirect Medical Education (IME) costs associated with training medical professionals, as teaching hospitals typically incur higher expenses. Furthermore, Medicare offers extra compensation for the use of new technologies that are not fully covered by standard payments and for cost outlier cases, where the expenses for treatment significantly exceed the average costs associated with a specific DRG.

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

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.

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

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.

Submit
96. Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia.

Explanation

The correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia are 038.11 and 995.91. The code 038.11 represents septicemia due to staphylococcus aureus, while 995.91 represents sepsis. Both codes are necessary to accurately capture the diagnosis of the patient.

Submit
97. 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?

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.

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

Explanation

The correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to an old cerebrovascular accident sustained one year ago is:

438.12, 784.59



438.12 is the ICD-9-CM code for "Late effects of cerebrovascular disease; dysphasia." This code captures the primary diagnosis, which is the lasting effect (dysphasia) of the old cerebrovascular accident (CVA).

784.59 is the ICD-9-CM code for "Other speech disturbance." This code provides additional detail about the specific type of dysphasia the patient is experiencing.

Submit
99. Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.

Explanation

The correct ICD-9-CM diagnosis code for neutropenic fever is 288.00. Neutropenic fever is a condition characterized by a low white blood cell count, specifically a low neutrophil count, which makes the individual more susceptible to infections. The code 288.00 represents the diagnosis of neutropenic fever. The code 780.61, on the other hand, represents the diagnosis of fever, which is a symptom often associated with neutropenic fever but does not specifically indicate the condition itself. Therefore, the correct answer is 288.00, 780.61.

Submit
100. 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?

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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On review of the audit trail for an EHR system, the HIM director...
Documentation in the history of use of drugs, alcohol, and/or tobacco...
Although the HIPAA Rule allows patient access to personal health...
Identify the acute-care record report where the...
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The clinical statement, "microscopic sections of the gallbladder...
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Identify the punctuation mark that is used to supplement words or...
CPT was developed and is maintained by:
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A patient with known COPD and hypertension under treatment was...
Dr. Jones has signed a statement that all of her dictated reports...
Which of the following provides organizations with the ability to...
The coder notes the patient is taking prescribed Haldol. The...
 A coding analyst consistently enters the wrong code for patient...
Today, Janet Kim visited her new dentist for an appointment. She was...
Which of the following documentation must be included in a...
"Late pregnancy" (category code 645) is used to demonstrate...
Under the HIPAA privacy standard, which of the following types of...
Community Hospital implemented a clinical document improvement...
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The hospital is revising its policy on medical record documentation....
Category II codes cover all but one of the following topics. Which is...
Referencing the CPT codebook, a list of codes describing procedures...
If an orthopedic surgeon attempted to reduce a fracture but was...
The ___________ is a type of coding thta is a natural outgrowth of the...
Mohs micrographic surgery involves the surgeon acting as:
What is the name of the organization that develops the billing form...
An employee in the physical therapy department arrives early...
Both HEDIS and the Joint Commission's ORYX program are designed to...
Which of the following soil nutrients is most likely to be deficient...
Which of the following ethical principles is being followed when an...
What is abstracting?
Tissue transplated from one individual to another of the same species...
Identify the correct ICD-9-CM diagnosis code(s) for a patient who...
What healthcare organization collects UHDDS data?
Which answer below is not correct for assignment of the MS-DRG?
A hospital is planning on allowing coding professionals to work at...
In hospitals, automated systems for registering patients and tracking...
Mercy Hospital personnel need to review the medical records for...
Which of the following would not be found in a medical history?
According to ICD-9-CM, an elderly primigravida is defined as a...
Which organization developed the first hospital standardization...
Identify the correct ICD-9-CM diagnosis code for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing...
Observation E/M codes (99218 through 99220) are used in physician...
During a review of documentation practices, the HIM...
Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II...
Per the HIPAA Privacy Rule, which of the following requires...
What type of standard establishes methods for creating unique...
Identify the correct ICD-9-CM diagnosis code for a male patient with...
What was the goal of the new MS-DRG system?
In coding arterial catheterizations, when the tip of the catheter is...
What is the maximum number of procedure codes that can appear on a...
Mr. Smith is seen in his primary care physician's office for his...
Which of the following would be the best technique to ensure that...
Identify the correct ICD-9-CM diagnosis code for a patient with an...
Identify the correct CPT procedure code for incision and drainage of...
What type of organization works under contract with the CMS to conduct...
Which of the following is not an accepted accrediting body for...
Identify the correct ICD-9-CM diagnosis codes and sequence for a...
The discharge summary must be completed within ________ after...
When coding a selective catheterization in CPT, how are codes...
A hospital currently includes the patient's social...
Identify the correct sequence and ICD-9-CM diagnosis code(s) for...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
A child was examined and treated for child abuse in the emergency...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
A 22-year-old patient presents for a closure of a patent ductus...
Per CPT guidelines, a separate procedure is:
Which of the following specialized patient assessment tools must be...
Identify the correct ICD-9-CM diagnosis code(s) and sequence for a...
What is the maximum number of diagnosis codes that can appear on the...
What are possible "add-on" payments that a hospital...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
From the health record of a patient newly diagnosed with a malignancy:...
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a...
Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.
During an audit of health records, the HIM director finds...
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