CCA Prep Exam 100 Questions

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CCA Quizzes & Trivia

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


Questions and Answers
  • 1. 

    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 _____________.

    • A.

      Physical examination record

    • B.

      History record

    • C.

      Operative report

    • D.

      Radiological report

    Correct Answer
    B. History record
    Explanation
    The correct answer is history record. 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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  • 2. 

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

    • A.

      Postoperative infection

    • B.

      Appendicitis

    • C.

      COPD

    • D.

      Hypertension

    Correct Answer
    A. Postoperative infection
    Explanation
    The diagnosis of postoperative infection should not be tagged as POA because it developed after the patient underwent the laparoscopic appendectomy. POA stands for "Present on Admission," which means the condition was present at the time of admission. In this case, the postoperative infection occurred after the patient was admitted to the hospital and underwent surgery, so it cannot be considered present on admission.

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  • 3. 

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

    • A.

      Chief complaint

    • B.

      Vital signs

    • C.

      Present illness

    • D.

      Review of systems

    Correct Answer
    B. Vital signs
    Explanation
    Vital signs would not be found in a medical history. A medical history typically includes information about the patient's 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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  • 4. 

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

    • A.

      Consent for operative procedure, anesthesia report, surgical report

    • B.

      Consent for operative procedure, history, physical examination

    • C.

      History, physical examination, anesthesia report

    • D.

      Problem list, history, physical examination

    Correct Answer
    B. Consent for operative procedure, history, physical examination
    Explanation
    Prior to performing a surgical procedure, it is essential to 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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  • 5. 

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

    • A.

      Operative report

    • B.

      Anesthesia report

    • C.

      Pathology report

    • D.

      Laboratory report

    Correct Answer
    A. Operative report
    Explanation
    The operative report includes 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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  • 6. 

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

    • A.

      Discharge summary

    • B.

      Medical history

    • C.

      Medical laboratory report

    • D.

      Physical examination

    Correct Answer
    D. Physical examination
    Explanation
    The given information describes the physical condition 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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  • 7. 

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

    • A.

      Discharge summary

    • B.

      Medical history

    • C.

      Medical laboratory report

    • D.

      Physical examination

    Correct Answer
    C. Medical laboratory report
    Explanation
    The given information 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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  • 8. 

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

    • A.

      Operative report

    • B.

      Pathology report

    • C.

      Discharge summary

    • D.

      Nursing note

    Correct Answer
    B. Pathology report
    Explanation
    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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  • 9. 

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

    • A.

      Performance improvement programs

    • B.

      Billing and claims data processing

    • C.

      Developing hospital discharge abstracting systems

    • D.

      Developing individual care plans for residents

    Correct Answer
    A. Performance improvement programs
    Explanation
    Both HEDIS and the Joint Commission's ORYX program are designed to collect data for performance improvement programs. These programs aim to assess and enhance the quality of healthcare services provided by healthcare organizations. By collecting 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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  • 10. 

    What is abstracting?

    • A.

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

    • B.

      Assigning the appropriate code or nomenclature term for categorization

    • C.

      Assembling a chronological set of data for an express purpose

    • D.

      Conducting qualitative and quantitative analysis of documentation against standards and policy

    Correct Answer
    A. Compiling the pertinent information from the medical record based on predetermined data sets
    Explanation
    Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and 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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  • 11. 

    What type of standard establishes uniform definitions for clinical terms?

    • A.

      Identifier standard

    • B.

      Vocabulary standard

    • C.

      Transaction and messaging standard

    • D.

      Structure and content standard

    Correct Answer
    B. Vocabulary standard
    Explanation
    A vocabulary standard establishes uniform definitions for clinical terms. This standard ensures that healthcare professionals and systems use consistent 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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  • 12. 

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

    • A.

      30

    • B.

      35

    • C.

      38

    • D.

      40

    Correct Answer
    B. 35
    Explanation
    According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of 35 or older. This term is used to describe pregnancies in women who are considered to be of advanced maternal age.

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  • 13. 

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

    • A.

      28th

    • B.

      14th

    • C.

      60th

    • D.

      30th

    Correct Answer
    A. 28th
    Explanation
    ICD-9-CM defines the "newborn period" as birth through the 28th day following birth. This means that the 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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  • 14. 

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

    • A.

      41

    • B.

      39

    • C.

      40

    • D.

      42

    Correct Answer
    C. 40
    Explanation
    The 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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  • 15. 

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

    • A.

      Herpes simplex

    • B.

      Staphylococcus aureus

    • C.

      Influenza, types A and B

    • D.

      Candida albicans

    Correct Answer
    B. Staphylococcus aureus
    Explanation
    Staphylococcus aureus would be classified to an ICD-9-CM category for bacterial diseases because it is a bacterium that can cause various infections in humans. The ICD-9-CM 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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  • 16. 

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

    • A.

      Otitis media

    • B.

      AIDS

    • C.

      Toxic shock syndrome

    • D.

      Bacteremia

    Correct Answer
    B. AIDS
    Explanation
    The 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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  • 17. 

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

    • A.

      Lobar pneumonia

    • B.

      Pneumocystitis carinii pneumonia

    • C.

      Interstitial pneumonia

    • D.

      Aspiration pneumonia

    Correct Answer
    D. Aspiration pneumonia
    Explanation
    When a patient with pneumonia inhales food, liquid, or oil, 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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  • 18. 

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

    • A.

      Pathology report

    • B.

      Progress notes

    • C.

      Nurse's notes

    • D.

      Operative report

    Correct Answer
    A. Pathology report
    Explanation
    A coder who needs to locate the histology of a tissue sample would most likely find this information in 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.

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  • 19. 

    The coder notes the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has and should query the physician?

    • A.

      Insomnia

    • B.

      Hypertension

    • C.

      Schizophrenia

    • D.

      Rheumatoid arthritis

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

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  • 20. 

    Which organization developed the first hospital standardization program?

    • A.

      Joint Commission

    • B.

      American Osteopathic Association

    • C.

      American College of Surgeons

    • D.

      American Association of Medical Colleges

    Correct Answer
    C. American College of Surgeons
    Explanation
    The American College of Surgeons developed the first hospital standardization program. This organization 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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  • 21. 

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

    • A.

      Suggest that only hospital clock time be noted in clinical documentation

    • B.

      Suggest that only electronic documentation have time notated

    • C.

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

    • D.

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

    Correct Answer
    C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
    Explanation
    The 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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  • 22. 

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

    • A.

      Print "error" above the entry

    • B.

      Enter the correction in chronological sequence

    • C.

      Add the reason for the change

    • D.

      Use black pen to obliterate the entry

    Correct Answer
    D. Use black pen to obliterate the entry
    Explanation
    Using a black pen to obliterate the entry is not appropriate when correcting erroneous information in a health record. This method 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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  • 23. 

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

    • A.

      Request that the CEO write a memorandum to all hospital staff

    • B.

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

    • C.

      Include ancillary clinical and medical staff in the process

    • D.

      Request a letter from the Joint Commission

    Correct Answer
    C. Include ancillary clinical and medical staff in the process
    Explanation
    Including ancillary clinical and medical staff in the process would be the best way to ensure that everyone understands the importance of the CDI program. By involving these staff members, they will have a better understanding of how their documentation impacts the quality of care, data quality, and coding accuracy. This will help to create a sense of ownership and responsibility among all staff members, leading to improved clinical documentation throughout the hospital.

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  • 24. 

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

    • A.

      Request that the physician dictate another discharge summary

    • B.

      Have the record analyst note the date discrepancy

    • C.

      Request the physician dictate an addendum to the discharge summary

    • D.

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

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

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  • 25. 

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

    • A.

      Immediately stop the practice of changing transcribed reports

    • B.

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

    • C.

      Conduct a verification audit

    • D.

      Alert hospital legal counsel of the practice

    Correct Answer
    D. Alert hospital legal counsel of the practice
    Explanation
    The HIM director should recommend alerting hospital legal counsel of the practice because changes made to transcribed reports after a week jeopardize the legal principle that documentation must occur near the time of the event. By involving legal counsel, they can provide guidance on how to address this issue and ensure compliance with legal requirements.

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  • 26. 

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

    • A.

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

    • B.

      Determine how many nurses are involved in this practice

    • C.

      Institute an in-service training session on documentation practices

    • D.

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

    Correct Answer
    D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
    Explanation
    The HIM director should develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system. This will provide clear guidelines for 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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  • 27. 

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

    • A.

      Attending physician

    • B.

      Head nurse

    • C.

      Primary physician

    • D.

      Admitting nurse

    Correct Answer
    A. Attending physician
    Explanation
    The attending physician is responsible for writing and signing discharge summaries and discharge instructions. As the primary 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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  • 28. 

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

    • A.

      Autoauthentication

    • B.

      Electronic signature

    • C.

      Automatic record completion

    • D.

      Chart tracking

    Correct Answer
    A. Autoauthentication
    Explanation
    Autoauthentication refers to the process 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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  • 29. 

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

    • A.

      30 days / 48 hours / 24 hours

    • B.

      14 days / 24 hours / 48 hours

    • C.

      14 days / 48 hours / 24 hours

    • D.

      30 days / 24 hours / 48 hours

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

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  • 30. 

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

    • A.

      American Psychological Association

    • B.

      Joint Commission

    • C.

      Commission on Accreditation of Rehabilitation Facilities

    • D.

      National Committee for Quality Assurance

    Correct Answer
    A. American Psychological Association
    Explanation
    The American Psychological Association (APA) is not an accepted accrediting body for behavioral healthcare organizations. The APA is a professional organization that represents psychologists in the United States, but it does not accredit healthcare organizations. Accrediting bodies for behavioral healthcare organizations typically include organizations such as the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance. These organizations set standards and evaluate healthcare organizations to ensure they meet quality and safety standards.

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  • 31. 

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

    • A.

      Vocabulary standard

    • B.

      Identifier standard

    • C.

      Structure and content standard

    • D.

      Security standard

    Correct Answer
    B. Identifier standard
    Explanation
    The correct answer is "Identifier standard." 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, which helps in accurately identifying and tracking individuals and organizations involved in healthcare processes.

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  • 32. 

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

    • A.

      Accreditation organizations

    • B.

      Certification organizations

    • C.

      State licensure agencies

    • D.

      Conditions of participation agencies

    Correct Answer
    C. State licensure agencies
    Explanation
    State licensure agencies work under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals. These agencies are responsible for ensuring that 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.

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  • 33. 

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

    • A.

      Patient Assessment Instrument

    • B.

      Minimum Data Set for Long-Term Care

    • C.

      Resident Assessment Protocol

    • D.

      Outcomes and Assessment Information Set

    Correct Answer
    D. Outcomes and Assessment Information Set
    Explanation
    The Outcomes and Assessment Information Set (OASIS) must be used by Medicare-certified home care providers. OASIS is a standardized assessment tool that collects data on the patient's health status, functional abilities, and service needs. It helps to ensure that patients receive appropriate and quality care by providing a comprehensive assessment of their condition. OASIS is used to determine the patient's eligibility for Medicare home health services and to develop a personalized care plan. It also facilitates communication and coordination among healthcare providers involved in the patient's care.

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  • 34. 

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

    • A.

      709.2

    • B.

      906.1

    • C.

      709.2, 906.1

    • D.

      906.1, 709.2

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

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  • 35. 

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

    • A.

      787.20, 438.12

    • B.

      784.59, 438.12

    • C.

      438.12

    • D.

      787.20, 438.89

    Correct Answer
    C. 438.12
    Explanation
    The correct sequence and ICD-9-CM diagnosis code for a patient with dysphasia secondary to an old cerebrovascular accident sustained one year ago is 438.12. This code represents late effects of cerebrovascular disease, specifically dysphasia. The other options either do not include the correct code for dysphasia or include additional codes that are not necessary for this specific scenario.

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  • 36. 

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

    • A.

      558.9

    • B.

      787.01, 558.9

    • C.

      787.02, 787.03, 558.9

    • D.

      787.01, 558.41

    Correct Answer
    A. 558.9
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with nausea, vomiting, and gastroenteritis is 558.9. This code represents noninfectious gastroenteritis and colitis, unspecified. It is the most appropriate code for the given symptoms and condition.

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  • 37. 

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

    • A.

      796.4

    • B.

      790.6

    • C.

      792.9

    • D.

      790.93

    Correct Answer
    D. 790.93
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result is 790.93. This code is used to indicate an elevated level of PSA, which is a protein produced by the prostate gland. An elevated PSA test result can be an indication of prostate cancer or other prostate-related conditions.

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  • 38. 

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

    • A.

      780.2

    • B.

      780.2, 787.02

    • C.

      780.2, 787.01

    • D.

      780.4, 787.02

    Correct Answer
    B. 780.2, 787.02
    Explanation
    The correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea are 780.2 and 787.02. The code 780.2 represents the diagnosis of syncope and pre-syncope, which includes near-syncope. The code 787.02 represents the diagnosis of nausea. Therefore, both codes are necessary to accurately describe the patient's symptoms of near-syncope and nausea.

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  • 39. 

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

    • A.

      790.29

    • B.

      790.21

    • C.

      790.21, 790.29

    • D.

      790.22

    Correct Answer
    D. 790.22
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with abnormal glucose tolerance test is 790.22. This code is used to indicate impaired glucose tolerance, which means the patient's blood sugar levels are higher than normal but not high enough to be diagnosed as diabetes. The other options (790.29 and 790.21, 790.29) do not specifically indicate abnormal glucose tolerance and 790.21 is used for fasting hyperglycemia.

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  • 40. 

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

    • A.

      786.2, 490

    • B.

      486, 786.2

    • C.

      486

    • D.

      481

    Correct Answer
    C. 486
    Explanation
    The correct answer is 486 because it is the ICD-9-CM diagnosis code for pneumonia. The other options do not include the correct code for pneumonia.

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  • 41. 

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

    • A.

      780.39

    • B.

      345.9

    • C.

      780.39, 345.9

    • D.

      345.90

    Correct Answer
    A. 780.39
    Explanation
    The correct ICD-9-CM diagnosis code for a patient with seizures; epilepsy, ruled out is 780.39. This code is used to indicate that the patient has experienced seizures, but a diagnosis of epilepsy has been ruled out. It is important to accurately document and code the patient's condition to ensure proper treatment and reimbursement. The other options, 345.9 and 345.90, are not appropriate for this scenario as they specifically refer to epilepsy without ruling it out. The option 780.39, 345.9 is not necessary as 780.39 alone is sufficient to indicate the ruling out of epilepsy.

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  • 42. 

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

    • A.

      625.6

    • B.

      788.30

    • C.

      788.32

    • D.

      788.39

    Correct Answer
    C. 788.32
    Explanation
    The correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence is 788.32. This code specifically represents stress incontinence, which is the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, or exercising. This code is appropriate for a male patient experiencing stress urinary incontinence.

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  • 43. 

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

    • A.

      789.03

    • B.

      789.03, 787.02, 787.03, 787.91

    • C.

      789.03, 787.91

    • D.

      789.03, 787.01, 787.91

    Correct Answer
    D. 789.03, 787.01, 787.91
  • 44. 

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

    • A.

      Parentheses ( )

    • B.

      Square brackets [ ]

    • C.

      Slanted brackets  [  ]

    • D.

      Braces { }

    Correct Answer
    A. Parentheses ( )
    Explanation
    Parentheses ( ) are used 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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  • 45. 

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

    • A.

      162.2, 31641, 31623-59

    • B.

      231.2, 31641, 31623-59

    • C.

      231.2, 31641

    • D.

      162.2, 31641

    Correct Answer
    C. 231.2, 31641
    Explanation
    The correct answer is 231.2, 31641. The patient's postoperative diagnosis is carcinoma in situ, main bronchus, which corresponds to the ICD-9-CM code 231.2. The procedure performed is laser photoresection of the suspicious lesions in the main bronchus, which is represented by the CPT code 31641.

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  • 46. 

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

    • A.

      33813

    • B.

      33820

    • C.

      33822

    • D.

      33824

    Correct Answer
    D. 33824
    Explanation
    The correct answer is 33824 because this code is used for the closure of a patent ductus arteriosus (PDA) through a thoracotomy approach. In this procedure, the thorax is opened posteriorly, and the vagus nerve is isolated away. The PDA is then divided and sutured individually in the aorta and pulmonary artery. This code accurately represents the specific steps involved in the procedure described.

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  • 47. 

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

    • A.

      410.11

    • B.

      410.01

    • C.

      410.02

    • D.

      410.12

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

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  • 48. 

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

    • A.

      042, 112.4, V01.79

    • B.

      112.4, 042

    • C.

      042, 112.4, V08

    • D.

      042, 112.4

    Correct Answer
    D. 042, 112.4
    Explanation
    The correct answer is 042, 112.4. Disseminated candidiasis is a fungal infection caused by Candida species that has spread throughout the body. AIDS-like syndrome refers to a condition that mimics the symptoms of AIDS but is not caused by HIV infection. In this case, the patient has disseminated candidiasis as a result of an AIDS-like syndrome. The ICD-9-CM diagnosis code for disseminated candidiasis is 112.4, and the code for the AIDS-like syndrome is 042. Therefore, the correct diagnosis code(s) and sequence for this patient would be 042, 112.4.

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  • 49. 

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

    • A.

      599.0

    • B.

      599.0, 041.4

    • C.

      041.4

    • D.

      041.4, 599.0

    Correct Answer
    B. 599.0, 041.4
    Explanation
    The correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli are 599.0 and 041.4. This is because 599.0 represents the diagnosis code for urinary tract infection, while 041.4 represents the diagnosis code for infection due to E. coli. The proper sequencing would be to list the code for the urinary tract infection (599.0) first, followed by the code for the infection due to E. coli (041.4).

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  • 50. 

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

    • A.

      204.00, 787.01, V58.11

    • B.

      V58.11, 204.00, 787.01

    • C.

      V58.11, 204.00

    • D.

      204.22, 787.01

    Correct Answer
    B. V58.11, 204.00, 787.01
    Explanation
    The correct answer is V58.11, 204.00, 787.01. The first code, V58.11, represents the encounter for chemotherapy administration. The second code, 204.00, represents acute lymphocytic leukemia. The third code, 787.01, represents nausea with vomiting. This sequence accurately reflects the reason for the patient's admission, the primary diagnosis of acute lymphocytic leukemia, and the treatment provided for the symptom of severe nausea with vomiting.

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

  • Current Version
  • Mar 22, 2023
    Quiz Edited by
    ProProfs Editorial Team
  • Jan 23, 2018
    Quiz Created by
    Letosha

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