CCA Prep Exam 100 Questions

A coder who needs to locate the histology of a tissue sample would most likely find this information in the pathology report. Pathology reports contain detailed information about the examination of tissue samples, including the histology or microscopic study of the cells and tissues. This report is prepared by a pathologist who analyzes the sample and provides a diagnosis or description of the tissue's characteristics. Therefore, the pathology report is the most appropriate source for finding information about the histology of a tissue sample.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 healthcare facilities meet the necessary standards and regulations to participate in these government healthcare programs. They assess the quality of care provided by hospitals and determine if they are eligible for reimbursement from Medicare and Medicaid.

The correct answer is AMA, which stands for the American Medical Association. The AMA is responsible for developing and maintaining the Current Procedural Terminology (CPT) code set. CPT codes are used to report medical, surgical, and diagnostic procedures and services provided by healthcare professionals. The AMA regularly updates and revises the CPT codes to ensure accuracy and reflect changes in medical practices.

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 ensure that the billing form is standardized and uniform across all healthcare facilities, allowing for accurate and efficient processing of claims.