CCA Prep Exam 100 Questions

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1/100 Questions

Where would a coder who needed to locate the histology of a tissue sample most likely find this information
- Pathology report
- Progress notes
- Nurse's notes
- Operative report

About This Quiz

CCA Practice Exam 2
Domain 1: Health Records and Data Content
Domain 2: Health Information Requirements and Standards
Domain 3: Clinical Classification Systems
Domain 4: Reimbursement Methodologies
Domain 5: Information and Communication Technologies
Domain 6: Privacy, Confidentiality, Legal, and Ethical Issues

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2.

Who is responsible for writing and signing discharge summaries and discharge instructions?
- Attending physician
- Head nurse
- Primary physician
- Admitting nurse
Correct Answer

A. Attending physician

Explanation

The attending physician is responsible for writing and signing discharge summaries and discharge instructions. As the primary healthcare provider overseeing the patient's care, the attending physician has the knowledge and authority to provide detailed instructions for the patient's post-discharge care. They are responsible for summarizing the patient's medical history, treatment plan, and any necessary follow-up care. The attending physician's signature on these documents ensures their accuracy and provides legal documentation of the patient's care.

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3.

Which of the following is a core ethical obligation of health information staff?
- Coding diseases and operations
- Protecting patients' privacy and confidential communications
- Transcribing medical reports
- Performing quantitative analysis on record content
Correct Answer

A. Protecting patients' privacy and confidential communications

Explanation

Protecting patients' privacy and confidential communications is a core ethical obligation of health information staff because they have access to sensitive patient information. It is their responsibility to ensure that this information is kept confidential and not disclosed to unauthorized individuals. This obligation is in line with the principles of medical ethics, which prioritize patient autonomy, privacy, and confidentiality. By safeguarding patient privacy, health information staff contribute to maintaining trust between patients and healthcare providers and upholding the ethical standards of the healthcare profession.

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4.

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?
- Reprimand the employee
- Fire the employee
- Determine what information was printed and why
- Revoke the employee's access priviliges
Correct Answer

A. Determine what information was printed and why

Explanation

The supervisor should determine what information was printed and why because this will help understand the employee's actions and intentions. It is important to gather all the facts before taking any disciplinary action. By investigating the specific records that were printed and the reasons behind it, the supervisor can assess if there was a legitimate need for accessing and printing those records or if there is a potential breach of privacy or misuse of patient information. This will allow the supervisor to make an informed decision on how to address the situation appropriately.

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5.

What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?
- Ignore the state law and follow the HIPAA standard
- Follow the state law and ignore the HIPAA standard
- Comply with both the state law and the HIPAA standard
- 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 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 and federal regulations, providing the highest level of privacy protection for patients. Ignoring either the state law or the HIPAA standard could result in legal and ethical consequences for the hospital.

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6.

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?
- Access controls
- Audit trails
- Edit checks
- Password controls
Correct Answer

A. Edit checks

Explanation

Edit checks should be in place to minimize this security breach. Edit checks are a type of security measure that validate and verify data entered into a system. In this case, by implementing edit checks in the electronic billing system, the coding analyst's incorrect entries for patient gender can be flagged and prevented from being accepted. This helps ensure that accurate and valid codes are entered, reducing the risk of security breaches caused by incorrect data.

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7.

Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients?
- Interpretation of x-rays by the radiologist
- Billing records
- Progress notes written by the attending physician
- Psychotherapy notes
Correct Answer

A. Psychotherapy notes

Explanation

Psychotherapy notes cannot be disclosed to patients according to the HIPAA Rule. While patients have the right to access their personal health information, psychotherapy notes are an exception. These notes are considered separate from other medical records and are intended for the therapist's personal use. They contain sensitive information related to the patient's mental health treatment and are protected to ensure patient privacy and maintain the effectiveness of the therapy. Therefore, patients do not have the right to access or receive copies of their psychotherapy notes.

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8.

Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?
- No a dentist is a healthcare clearinghouse, which is covered entity under HIPAA.
- Yes; a dentist is not a covered entity per the HIPAA Privacy Rule.
- No; it is a violation of the HIPAA Privacy Rule.
- 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 covered entities under HIPAA, which means they are required to provide patients with a Notice of Privacy Practices. Failing to do so would be a violation of the HIPAA Privacy Rule.

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9.

Which of the following activities would be in violation of AHIMA's Code of Ethics?
- Coding an intentionally inappropriate level of service
- Following established coding policies and procedures
- Protecting the confidentiality of patients' written and electronic records
- Taking remedial action when there is direct knowledge of a colleague's incompetence or impairment
Correct Answer

A. Coding an intentionally inappropriate level of service

Explanation

Coding an intentionally inappropriate level of service would be in violation of AHIMA's Code of Ethics. This action goes against the principle of accuracy and integrity in coding, as it involves intentionally misrepresenting the level of service provided. AHIMA's Code of Ethics emphasizes the importance of maintaining the highest standards of professional conduct, which includes being honest and truthful in all coding practices.

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10.

Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
- Physical examination record
- History record
- Operative report
- Radiological report
Correct Answer

A. History record

Explanation

The correct answer is history record. The history record contains important information about the patient's personal and social history, including their marital status, dietary habits, sleep patterns, exercise routines, and substance use. This information is crucial for healthcare providers to understand the patient's lifestyle and make appropriate treatment decisions. The physical examination record focuses on the current physical findings, while the operative and radiological reports are specific to surgical procedures and imaging results, respectively.

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11.

Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed.
- Operative report
- Anesthesia report
- Pathology report
- Laboratory report
Correct Answer

A. Operative report

Explanation

The operative report includes all the necessary details such as the names of the surgeon and assistants, the date of the procedure, the duration of the procedure, a description of the procedure, and any specimens that were removed. This report provides a comprehensive account of the surgical procedure and is important for documentation, communication, and follow-up care. The anesthesia report focuses on the administration of anesthesia during the procedure, the pathology report focuses on the examination of tissues and specimens, and the laboratory report focuses on the results of various laboratory tests.

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12.

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.
- Discharge summary
- Medical history
- Medical laboratory report
- Physical examination
Correct Answer

A. Physical examination

Explanation

The given information describes the physical condition and characteristics of the patient, such as their appearance, mobility, vital signs, and physical symptoms. This information is typically documented in a physical examination report, which provides an assessment of the patient's overall health and any abnormalities or findings observed during the examination.

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13.

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.
- Discharge summary
- Medical history
- Medical laboratory report
- Physical examination
Correct Answer

A. Medical laboratory report

Explanation

The given information describes the gross description of a tissue sample, including its size, color, and orientation. This type of information is typically found in a medical laboratory report, where pathologists and technicians document their observations and findings from analyzing tissue samples. The other options, such as discharge summary, medical history, and physical examination, do not typically include detailed descriptions of tissue samples.

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14.

What type of standard establishes uniform definitions for clinical terms?
- Identifier standard
- Vocabulary standard
- Transaction and messaging standard
- Structure and content standard
Correct Answer

A. Vocabulary standard

Explanation

A vocabulary standard establishes uniform definitions for clinical terms. This standard ensures that healthcare professionals and systems use consistent and standardized terminology when documenting and communicating clinical information. It helps to improve interoperability and accuracy in healthcare data exchange, enabling effective communication and understanding between different healthcare organizations and systems.

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15.

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?
- Suggest that only hospital clock time be noted in clinical documentation
- Suggest that only electronic documentation have time notated
- Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
- 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 dated

Explanation

The HIM director should suggest informing the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This suggestion aligns with the current policy of the hospital, which requires legible, complete, dated, and signed entries in the medical record. Adding the time notation may be difficult and prone to error due to the lack of coordination between personal watches and hospital clocks. Therefore, it is best to adhere to the Medicare regulations and focus on ensuring that all documentation is properly authenticated and dated.

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16.

When correcting erroneous information in a health record, which of the following is not appropriate?
- Print "error" above the entry
- Enter the correction in chronological sequence
- Add the reason for the change
- Use black pen to obliterate the entry
Correct Answer

A. Use black pen to obliterate the entry

Explanation

Using a black pen to obliterate the entry is not appropriate when correcting erroneous information in a health record. This method can make it difficult to read or retrieve the original information, which is important for maintaining an accurate and complete medical history. Instead, it is recommended to print "error" above the entry, enter the correction in chronological sequence, and add the reason for the change to ensure transparency and clarity in the health record.

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17.

Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the:
- Past medical history
- Social history
- Systems review
- History of present illness
Correct Answer

A. Social history

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 personal and social life, including habits, lifestyle, and substance use. This information is important in understanding the patient's overall health and can provide insights into potential risk factors or underlying issues that may impact their medical care.

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18.

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?
- By requesting the medical record for each service provided
- By reviewing al the diagnosis codes assigned to explain the reasons the services were provided
- By reviewing all physician orders
- 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 provided
19.

What is the basic formula for calculating each MS-DRG hospital payments?
- Hospital payment = DRG relative weight x hospital base rate
- Hospital payment = DRG relative weight x hospital base rate -1
- Hospital payment = DRG relative weight / hospital base rate +1
- Hospital payment = DRG relative weight / hospital base rate
Correct Answer

A. Hospital payment = DRG relative weight x hospital base rate

Explanation

The basic formula for calculating each MS-DRG hospital payments is by multiplying the DRG relative weight by the hospital base rate. This formula allows for the determination of the payment amount based on the specific DRG classification and the hospital's base rate.

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20.

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?
- Client-server computer
- Data warehouse
- Local area network
- Internet
Correct Answer

A. Data warehouse

Explanation

A data warehouse provides organizations with the ability to access data from multiple databases and combine the results into a single question-and-reporting interface. It is a centralized repository that stores large amounts of data from various sources. By consolidating data from different databases, organizations can analyze and report on the data more easily and efficiently. This helps in making informed decisions and gaining insights from the combined data.

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21.

Which of the following activities is considered an unethical practice?
- Backdating progress notes
- Performing quantitative analysis
- Verifying that an insurance company is one that is authorized to receive patient information
- Determining what information is required to fulfill an authorized request for information
Correct Answer

A. Backdating progress notes

Explanation

Backdating progress notes is considered an unethical practice because it involves falsifying the date on which the progress note was actually made. This can lead to inaccurate documentation and potential legal issues, as it misrepresents the timing and sequence of events in a patient's medical record. It is important for progress notes to accurately reflect the date and time of the encounter to ensure proper continuity of care and to maintain ethical standards in healthcare.

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22.

ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth.
- 28th
- 14th
- 60th
- 30th
Correct Answer

A. 28th

Explanation

ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This means that the classification system considers the first 28 days of a person's life as the newborn period. This is an important distinction for medical coding and billing purposes, as certain procedures and treatments may be specific to the newborn period.

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23.

"Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________.
- 41
- 39
- 40
- 42
Correct Answer

A. 40

Explanation

The category code "Late pregnancy" (645) is used to indicate that a woman is over 40 weeks pregnant. This is the correct answer because a full-term pregnancy is considered to be 40 weeks, so anything beyond that is considered late pregnancy.

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24.

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?
- Audit controls
- Information access controls
- Facility access controls
- Workstation security
Correct Answer

A. Information access controls

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 data encryption. By implementing these controls, the employee's unauthorized access to the clinical information system can be prevented, ensuring that only authorized individuals have access to sensitive information.

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25.

Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure?
- Consent for operative procedure, anesthesia report, surgical report
- Consent for operative procedure, history, physical examination
- History, physical examination, anesthesia report
- Problem list, history, physical examination
Correct Answer

A. Consent for operative procedure, history, physical examination

Explanation

Prior to performing a surgical procedure, it is essential to include the consent for the operative procedure in the patient's medical record. This ensures that the patient has given informed consent for the surgery. Additionally, the history and physical examination must also be included in the medical record as they provide important information about the patient's medical condition and help in assessing their suitability for the surgery. The anesthesia report may also be necessary to document the type and dosage of anesthesia administered during the procedure.

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26.

Which organization developed the first hospital standardization program?
- Joint Commission
- American Osteopathic Association
- American College of Surgeons
- American Association of Medical Colleges
Correct Answer

A. American College of Surgeons

Explanation

The American College of Surgeons developed the first hospital standardization program. This organization has been at the forefront of promoting high-quality surgical care and setting standards for surgical practice. They have played a significant role in improving patient safety and ensuring that hospitals meet certain criteria and guidelines for providing optimal surgical care. Their program has helped to standardize practices, enhance surgical outcomes, and ensure that hospitals adhere to the highest standards of patient care.

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27.

Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
- Patient management
- New technology
- Therapeutic, preventative, or other interventions
- Patient safety
Correct Answer

A. New technology

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 specifically focus on coding and reporting new technologies or procedures. Instead, they primarily focus on the measurement of performance and quality improvement activities.

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28.

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?
- Operative report
- Pathology report
- Discharge summary
- Nursing note
Correct Answer

A. Pathology report

Explanation

The given clinical statement describes the microscopic findings of the gallbladder, indicating the type and appearance of its cells. This information is typically documented in a pathology report, which provides a detailed analysis of tissue samples obtained during a biopsy or surgical procedure. The pathology report helps in diagnosing and monitoring various diseases and conditions, making it the most appropriate medical record form for documenting this specific clinical statement.

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29.

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?
- Otitis media
- AIDS
- Toxic shock syndrome
- Bacteremia
Correct Answer

A. AIDS

Explanation

The coder might find the diagnosis of AIDS on the patient's discharge summary because Retrovir is a medication commonly prescribed for the treatment of HIV infection, which is the underlying cause of AIDS. The prescription of Retrovir indicates that the patient has been diagnosed with AIDS.

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30.

What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil?
- Lobar pneumonia
- Pneumocystitis carinii pneumonia
- Interstitial pneumonia
- Aspiration pneumonia
Correct Answer

A. Aspiration pneumonia

Explanation

When a patient with pneumonia inhales food, liquid, or oil, it can lead to aspiration pneumonia. Aspiration pneumonia occurs when foreign substances, such as food or liquid, are inhaled into the lungs, causing infection and inflammation. This can happen when the normal swallowing reflex is impaired, allowing substances to enter the airway instead of the digestive tract. Aspiration pneumonia is a specific type of pneumonia that is caused by the inhalation of these substances, and it is the expected diagnosis in this case.

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31.

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?
- Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately
- Determine how many nurses are involved in this practice
- Institute an in-service training session on documentation practices
- Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
Correct Answer

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

Explanation

The HIM director should develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. This will provide clear guidelines for the nurses on acceptable documentation practices and ensure consistency in their documentation. Informing the nurses that "copy and paste" is not acceptable may not be enough, as they may not fully understand the reasons behind this rule. Determining how many nurses are involved in this practice is important, but it does not address the root cause or provide a solution. Instituting an in-service training session on documentation practices may be helpful, but it may not be sufficient to address the specific issue of copying and pasting.

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32.

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.
- Parentheses ( )
- Square brackets [ ]
- Slanted brackets [ ]
- Braces { }
Correct Answer

A. Parentheses ( )

Explanation

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

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33.

Tissue transplated from one individual to another of the same species but different genotype is called a(n):
- Autograft
- Xenograft
- Allograft or allogeneic graft
- Heterograft
Correct Answer

A. Allograft or allogeneic graft

Explanation

An allograft or allogeneic graft refers to tissue transplantation from one individual to another of the same species but with a different genotype. This means that the donor and recipient share the same species but have different genetic makeups. Autograft refers to tissue transplantation from one part of an individual's body to another part, Xenograft refers to tissue transplantation between different species, and heterograft refers to tissue transplantation between different species or individuals with different genetic makeups.

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34.

Under the HIPAA privacy standard, which of the following types of protected health information (pHI) must be specifically identified in an authorization?
- History and physical reports
- Operative reports
- Consultation reports
- Psychotherapy notes
Correct Answer

A. Psychotherapy notes

Explanation

Under the HIPAA privacy standard, psychotherapy notes must be specifically identified in an authorization. Psychotherapy notes are a specific type of protected health information that contains the mental health records of a patient, including the therapist's observations and analysis. Unlike other types of health information, such as history and physical reports, operative reports, and consultation reports, psychotherapy notes require explicit authorization due to their sensitive nature and potential impact on an individual's mental health and well-being.

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35.

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?
- Avoid displaying the number on any document, screen, or data collection field
- Allow the information in both electronic and paper forms since a variety of people need this data
- Require employees to sign coinfidentiality agreements if they have access to social security numbers
- Contact legl counsel for advice
Correct Answer

A. Avoid displaying the number on any document, screen, or data collection field

Explanation

The HIM director should suggest avoiding displaying the social security number on any document, screen, or data collection field. This is because the risk manager has identified it as a potential identity fraud risk. Although others in the hospital may argue that they need the information for identification and other purposes, the potential risk of identity fraud outweighs the convenience of having the social security number easily accessible. By removing the number from display, the hospital can minimize the risk of identity theft and protect the privacy and security of their patients.

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36.

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 _____________.
- Autoauthentication
- Electronic signature
- Automatic record completion
- Chart tracking
Correct Answer

A. Autoauthentication

Explanation

Autoauthentication refers to the process in which a statement or report is automatically considered approved and signed if no corrections are made within a specified time frame. In this case, Dr. Jones has signed a statement indicating that her dictated reports will be automatically considered approved and signed unless she makes corrections within 72 hours. This process eliminates the need for manual review and approval, streamlining the workflow and ensuring efficiency in the documentation process.

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37.

Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition.
- 250.02
- 250.01, 263.1
- 250.02, 263.1
- 250.01, 263.0
Correct Answer

A. 250.02, 263.1

Explanation

The correct answer is 250.02, 263.1. This is because 250.02 is the ICD-9-CM diagnosis code for uncontrolled type II diabetes mellitus, and 263.1 is the code for mild malnutrition. So, if a patient has both uncontrolled type II diabetes mellitus and mild malnutrition, these are the correct codes to use for their diagnosis.

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38.

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?
- User name and password
- Automatic session terminations
- Cable locks
- Encryption
Correct Answer

A. Automatic session terminations

Explanation

Automatic session terminations would be the best strategy to ensure that data breaches are minimized when the home computer is unattended. This means that if the computer is left unattended for a certain period of time, the session will automatically be terminated, requiring the user to log in again. This helps to prevent unauthorized access to the computer and the data it contains, reducing the risk of data breaches.

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39.

The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record.
- Automated codebook
- Computer-assisted coding
- Logic based encoder
- Decision support database
Correct Answer

A. Computer-assisted coding

Explanation

Computer-assisted coding is a type of coding that is a natural outgrowth of the electronic health record. This coding method utilizes technology to assist in the coding process, making it more efficient and accurate. It involves the use of software that analyzes clinical documentation and suggests appropriate codes based on predefined rules and algorithms. This helps coders save time and reduces the risk of errors in coding. Overall, computer-assisted coding improves coding productivity and accuracy by leveraging technology to streamline the coding process.

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40.

Which of the following would not be found in a medical history?
- Chief complaint
- Vital signs
- Present illness
- Review of systems
Correct Answer

A. Vital signs

Explanation

Vital signs would not be found in a medical history. A medical history typically includes information about the patient's chief complaint, which is the main reason for seeking medical attention, as well as details about their present illness and a review of systems, which involves asking questions about various body systems to assess overall health. Vital signs, such as blood pressure, heart rate, and temperature, are typically measured during a physical examination rather than being documented in the medical history.

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41.

What is abstracting?
- Compiling the pertinent information from the medical record based on predetermined data sets
- Assigning the appropriate code or nomenclature term for categorization
- Assembling a chronological set of data for an express purpose
- Conducting qualitative and quantitative analysis of documentation against standards and policy
Correct Answer

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

Explanation

Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and organizing the necessary data to create a comprehensive summary. It does not involve assigning codes or conducting analysis, but rather focuses on gathering and assembling the pertinent information for a specific purpose.

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42.

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?
- Insomnia
- Hypertension
- Schizophrenia
- Rheumatoid arthritis
Correct Answer

A. Schizophrenia

Explanation

Based on the information provided, the coder notes that the patient is taking prescribed Haldol, which is an antipsychotic medication commonly used to treat schizophrenia. Therefore, the coder might suspect that the patient has schizophrenia and should query the physician to confirm this diagnosis.

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43.

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?
- Request that the physician dictate another discharge summary
- Have the record analyst note the date discrepancy
- Request the physician dictate an addendum to the discharge summary
- 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 summary

Explanation

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

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1
44.

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems.
- MIS
- CDS
- ADT
- ABC
Correct Answer

A. ADT

Explanation

Automated systems in hospitals that register patients and track their encounters are commonly referred to as ADT systems. ADT stands for Admission, Discharge, and Transfer, which accurately describes the functions of these systems. These systems help in efficiently managing patient admissions, discharges, and transfers, ensuring accurate and up-to-date patient information is available to healthcare providers. They also aid in streamlining administrative tasks and improving patient care coordination.

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45.

The codes in the musculoskeletal section of CPT may be used by:
- Orthopedic surgeons only
- Orthopedic surgeons and emergency department physicians
- Any physician
- Orthopedic surgeons and neurosurgeons
Correct Answer

A. Any physician

Explanation

The codes in the musculoskeletal section of CPT may be used by any physician. This means that not only orthopedic surgeons, but also other physicians from different specialties can utilize these codes. The musculoskeletal section of CPT includes codes for procedures related to bones, joints, muscles, and other components of the musculoskeletal system. Therefore, any physician who performs procedures in this area can use these codes to accurately report and bill for their services.

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46.

When coding a selective catheterization in CPT, how are codes assigned?
- One code for each vessel entered
- One cod for the point of entry vessel
- One code for the final vessel entered
- One code for the vessel of entry and one for the final vessel, with interventing vessels not coded
Correct Answer

A. One code for the final vessel entered

Explanation

Codes for selective catheterization in CPT 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 individually coded.

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47.

What was the goal of the new MS-DRG system?
- To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients
- To improve Medicare's capability to recognize poor quality of care and pay hospitals on an incentive grid that allow hospitals to be paid by performance.
- To improve Medicare's capability to recognize groups of data by patient populations which will further allow Medicare to adjust the hospitals wage indexes based on the data. This adjustment will be a system to pay hospitals fairly across all geographic locations
- To improve Medicare's capability to recognize practice patterns among hospitals that are inappropriately optimizing payments by keeping patients in the hospital longer than the median length of stay.
Correct Answer

A. To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients

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. The system is designed to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients. This will help ensure that hospitals are appropriately compensated based on the level of care required for each patient.

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48.

Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________.
- Performance improvement programs
- Billing and claims data processing
- Developing hospital discharge abstracting systems
- Developing individual care plans for residents
Correct Answer

A. Performance improvement programs

Explanation

Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting data on various performance measures, these programs can identify areas for improvement and help organizations implement initiatives to enhance patient care and outcomes.

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49.

Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
- Herpes simplex
- Staphylococcus aureus
- Influenza, types A and B
- Candida albicans
Correct Answer

A. Staphylococcus aureus

Explanation

Staphylococcus aureus would be classified to an ICD-9-CM category for bacterial diseases because it is a bacterium that can cause various infections in humans. The ICD-9-CM coding system is used to classify and code diseases and medical conditions, including bacterial diseases. Staphylococcus aureus is a common bacterium that can cause skin infections, pneumonia, bloodstream infections, and other types of infections. Therefore, it would be appropriate to classify it under the category for bacterial diseases in the ICD-9-CM coding system.

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Current Version
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Quiz Edited by
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Jan 23, 2018

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CCA Prep Exam 100 Questions

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

Quiz Preview

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

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

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?

What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard?

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?

Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients?

Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable?

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

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

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

What type of standard establishes uniform definitions for clinical terms?

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

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

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?

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

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?

Which of the following activities is considered an unethical practice?

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

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

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?

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

Which organization developed the first hospital standardization program?

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

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?

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?

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

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

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

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 _____________.

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

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

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

What is abstracting?

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?

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?

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

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

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

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

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

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