CCA Prep Exam 2 (100 Questions)

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1/100 Questions

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

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.

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 falsely documenting that certain actions or events occurred at an earlier date than they actually did. This can be done to cover up mistakes, inaccuracies, or delays in documentation, which can compromise patient care and medical records integrity. It also violates professional standards, ethical guidelines, and legal requirements for accurate and timely documentation in healthcare settings.

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3.

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, the coder would expect to see a diagnosis of aspiration pneumonia. Aspiration pneumonia occurs when foreign material, such as food or liquid, is inhaled into the lungs, leading to infection and inflammation. This can happen when a person has difficulty swallowing or coughs while eating or drinking, causing the material to enter the airway instead of the digestive system. Aspiration pneumonia typically presents with symptoms such as cough, chest pain, fever, and difficulty breathing.

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4.

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
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 a pathology report. A pathology report is a document that contains detailed information about the examination of tissues and cells under a microscope. It provides information about the type of tissue, any abnormalities or diseases present, and the histological characteristics of the sample. Therefore, the pathology report is the most appropriate source for the coder to find the histology of a tissue sample.

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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.
- Operative report
- Anesthesia report
- Pathology report
- Laboratory report
Correct Answer

A. Operative report

Explanation

The operative report includes 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 detailed information about the surgical procedure that was performed, including the names of the individuals involved, the timeline of the procedure, and any relevant details about the procedure and specimens.

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6.

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. This is because the attending physician is the primary physician who has been directly involved in the patient's care throughout their hospital stay. They have the knowledge and expertise to accurately summarize the patient's medical condition, treatment, and future care instructions. The attending physician's signature on these documents ensures their accountability and provides a clear communication to the patient and the healthcare team involved in the patient's follow-up care.

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7.

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

The core ethical obligation of health information staff is to protect patients' privacy and confidential communications. This means ensuring that patients' personal information and medical records are kept secure and confidential, and that any communication regarding their health is handled with utmost privacy. This obligation is crucial in maintaining trust and respect between healthcare providers and patients, and is essential for maintaining the confidentiality and privacy rights of individuals.

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8.

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 activity goes against the principle of integrity and accuracy in coding. AHIMA's Code of Ethics requires professionals to accurately represent the services provided by healthcare providers and to code in a manner that reflects the true level of service. Intentionally coding an inappropriate level of service would be considered unethical and could potentially lead to fraudulent billing practices.

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9.

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. This is important because it will help in understanding the employee's actions and whether they were justified or not. It could be possible that the employee had a legitimate reason for printing more records, such as conducting research or fulfilling a specific request. By investigating further, the supervisor can gather all the necessary information to make an informed decision on how to address the situation appropriately.

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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 because it is a comprehensive document that includes information about a patient's personal and medical history. It typically contains details about the patient's marital status, dietary habits, sleep patterns, exercise routines, and substance use. This information is important for healthcare providers to understand the patient's lifestyle and make appropriate treatment decisions. The physical examination record focuses more 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.

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 lifestyle, habits, and social support system. It provides important context for understanding the patient's overall health and can help identify potential risk factors or influences on their well-being. In this case, documenting the use of drugs, alcohol, and tobacco is relevant to understanding the patient's social behaviors and potential impact on their health.

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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 vital signs of the patient, including their appearance, mobility issues, blood pressure, pulse, weight, shaking of arms, jugular venous distension, heart irregularity, clear lungs, and edema in both legs. This information is typically documented in the physical examination section of an acute-care record report.

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13.

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, including interpretation of x-rays, billing records, and progress notes, psychotherapy notes are an exception. These notes are typically kept separate from the rest of the patient's medical records and are considered highly confidential. Disclosing psychotherapy notes to patients could potentially harm their treatment or compromise the privacy of other individuals mentioned in the notes.

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14.

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 specimen, specifically the left lacrimal gland. This type of information is typically found in a medical laboratory report, where the description and analysis of specimens collected during a patient's care are documented.

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15.

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 reflects the correct date of discharge. This ensures that the health record is accurate and complete.

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16.

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

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17.

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 all physicians, regardless of their specialty, are allowed to use these codes when billing for services related to musculoskeletal conditions. This allows for flexibility and ensures that all physicians have access to the appropriate codes for their patients' needs.

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18.

What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use pHI for commercial advantage, personal gain, or malicious harm?
- A fine of not more than $10,000 only
- A fine of not more than $10,000, not more than 1 year in jail, or both
- A fine of not more than $5,000 only
- A fine of not more than $250,000, not more than 10 years in jail, or both
Correct Answer

A. A fine of not more than $250,000, not more than 10 years in jail, or both

Explanation

The penalties that can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm include a fine of not more than $250,000, not more than 10 years in jail, or both. This means that the violator can face significant financial penalties, imprisonment, or both, depending on the severity of the violation.

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19.

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.

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20.

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 type of bacteria. ICD-9-CM is a coding system used to classify and categorize diseases, and bacterial diseases are a specific category within this system. Staphylococcus aureus is a common bacterium that can cause various infections in humans, such as skin infections, pneumonia, and bloodstream infections. Therefore, it would be appropriately classified under the bacterial diseases category in the ICD-9-CM coding system.

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21.

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 would find AIDS on the patient's discharge summary because Retrovir is a medication used to treat HIV infection, which is the underlying cause of AIDS.

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22.

CPT was developed and is maintained by:
- CMS
- AMA
- Cooperating Parties
- WHO
Correct Answer

A. AMA

Explanation

The correct answer is AMA, which stands for the American Medical Association. The AMA is a professional organization that represents physicians and medical students in the United States. They are involved in various activities related to healthcare, including the development and maintenance of the Current Procedural Terminology (CPT) code set. The CPT codes are used for reporting medical procedures and services, and the AMA ensures that they are regularly updated and reflect current medical practices.

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23.

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 does not involve any subtraction or addition.

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24.

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

This statement would be documented on a pathology report because it describes the microscopic findings of the gallbladder. Pathology reports provide detailed information about the examination of tissues and cells, including their appearance and any abnormalities observed. In this case, the report would describe the appearance of the gallbladder lining as tall columnar cells of uniform size and shape. This information is important for diagnosing and monitoring conditions related to the gallbladder.

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25.

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 for confirmation or further information.

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26.

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 an appropriate method for correcting erroneous information in a health record. This is because obliterating the entry makes it difficult to read and can create confusion. Instead, the correct approach would be to print "error" above the entry to indicate that it is incorrect, enter the correction in chronological sequence, and add the reason for the change.

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27.

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 is a centralized repository that allows organizations to access data from multiple databases and combine the results into a single interface for querying and reporting. It is designed to support decision-making processes by providing a consolidated and consistent view of data from various sources. Unlike client-server computers, local area networks, or the internet, a data warehouse specifically focuses on data integration and analysis, making it the correct answer for this question.

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28.

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

A. Postoperative infection

Explanation

The 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 to the hospital. Since the infection developed after the surgery, it is considered a complication of the procedure rather than a condition present on admission.

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29.

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 provide codes for documenting or tracking new technologies or procedures. Instead, they focus on capturing data related to patient care, outcomes, and quality improvement.

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30.

Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in:
- Appendix E
- Appendix F
- Appendix G
- Appendix H
Correct Answer

A. Appendix G

Explanation

The correct answer is Appendix G. The CPT codebook provides a list of codes for procedures that include conscious sedation, when administered by the same surgeon who performs the procedure, in Appendix G. This appendix specifically addresses the codes related to conscious sedation, making it the appropriate reference for finding these codes.

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31.

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. This is because psychotherapy notes are considered to be particularly sensitive and confidential information. Unlike other types of protected health information (PHI), such as history and physical reports, operative reports, and consultation reports, psychotherapy notes contain detailed information about a patient's mental health treatment, including conversations with the therapist, personal observations, and interpretations. Therefore, obtaining explicit authorization is necessary to ensure the privacy and confidentiality of these sensitive notes.

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32.

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 have the patient's consent for the operation, as well as a thorough understanding of their medical history and physical examination. The consent for the operative procedure ensures that the patient has given their informed consent for the surgery. The history and physical examination provide crucial information about the patient's overall health status, any pre-existing conditions, and potential risks or complications that may arise during the surgery. Including these documents in the patient's medical record ensures that the healthcare team has all the necessary information to proceed with the surgical procedure safely and effectively.

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33.

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?
- Request that the CEO write a memorandum to all hospital staff
- Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation
- Include ancillary clinical and medical staff in the process
- Request a letter from the Joint Commission
Correct Answer

A. 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 direct role in the program and will be able to see the impact of their documentation on the quality of care, data quality, and coding accuracy. This will help them understand the importance of accurate and thorough clinical documentation and will encourage their active participation and support for the program.

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34.

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 that is transplanted from one individual to another within the same species but with different genotypes. This means that the donor and recipient have different genetic compositions. This type of graft is commonly used in organ transplantation, where organs such as kidneys or hearts are transplanted from a genetically different donor to a recipient in need. The term "allograft" is used to distinguish it from autografts (tissue transplanted from the same individual) and xenografts (tissue transplanted from a different species).

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35.

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

Explanation

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 reviewing all the diagnosis codes assigned to explain the reasons the services were provided. These codes provide information about the patient's condition and justify the need for the specific services rendered. By reviewing these codes, payers can assess whether the services were medically necessary and should be reimbursed.

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36.

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 terminology when documenting and exchanging clinical information. It helps to avoid confusion and promotes accurate communication and understanding between different healthcare entities.

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37.

"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 point at which a pregnancy is considered overdue, as a normal pregnancy typically lasts around 40 weeks. Therefore, the correct answer is 40.

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38.

The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM direct suggest?
- 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 correct answer suggests that the HIM should inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated. This means that regardless of whether the time is noted or not, the entries in the medical record must be authenticated and dated. This response addresses the concerns raised by the committee members about the difficulty of noting the time and the potential lack of coordination between personal watches and hospital clocks.

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39.

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 where Dr. Jones' dictated reports are automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This means that the reports are authenticated automatically without the need for manual approval or signature.

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40.

Mohs micrographic surgery involves the surgeon acting as:
- Both plastic surgeon and general surgeon
- Both surgeon and pathologist
- Both plastic surgeon and dermatologist
- Both dermatologist and pathologist
Correct Answer

A. Both surgeon and pathologist

Explanation

Mohs micrographic surgery is a specialized surgical technique used to treat skin cancer. During the procedure, the surgeon acts as both a surgeon and a pathologist. They remove thin layers of cancerous tissue and immediately examine them under a microscope to check for any remaining cancer cells. This process is repeated until all cancer cells are removed, ensuring the highest possible cure rate and minimal damage to healthy tissue. The surgeon's dual role as both a surgeon and a pathologist allows for real-time evaluation and precise removal of cancerous cells.

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41.

If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure?
- A "with manipulation" code
- A "without manipulation" code
- An unlisted procedure code
- An E/M code only
Correct Answer

A. A "with manipulation" code

Explanation

If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, a "with manipulation" code should be assigned for the procedure. This indicates that the surgeon attempted to manipulate the fracture in order to achieve proper alignment, even though it was not successful.

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42.

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 minimize data breaches 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 log out or terminate, requiring the user to enter their credentials again to access the data. This helps to prevent unauthorized access to sensitive information in case the computer is left unattended or someone tries to gain access to it while the user is away.

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43.

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

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ADT systems. ADT stands for Admission, Discharge, and Transfer, which accurately describes the main functions of these systems. These systems are responsible for efficiently managing patient admissions, discharges, and transfers, as well as maintaining accurate and up-to-date records of patient encounters.

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1
44.

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 enable organizations to identify areas for improvement, implement changes, and monitor the impact of those changes on patient outcomes and satisfaction. The collected data can also be used for benchmarking purposes, allowing organizations to compare their performance with national standards and best practices.

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45.

What is the name of the organization that develops the billing form that hospitals are required to use?
- American cademy of Billing Forms (AABF)
- National Uniform Billing Committee (NUBC)
- National Uniform Claims Committee (NUCC)
- American Billing and Claims Academy (ABCA)
Correct Answer

A. National Uniform Billing Committee (NUBC)

Explanation

The correct answer is National Uniform Billing Committee (NUBC). This organization is responsible for developing the billing form that hospitals are required to use. They ensure that the billing form is standardized and uniform across different healthcare facilities, making it easier for insurance companies to process claims and for patients to understand their medical bills.

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46.

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 are a security measure that should be in place to minimize the security breach caused by consistently entering the wrong code for patient gender in the electronic billing system. Edit checks can help identify and prevent errors by validating the entered data against predefined rules or criteria. By implementing edit checks, the system can prompt the coding analyst to review and correct any incorrect or inconsistent gender codes, reducing the likelihood of security breaches and ensuring accurate data entry.

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47.

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 under the HIPAA Privacy Rule, healthcare providers, including dentists, are required to provide patients with a Notice of Privacy Practices. This notice informs patients about their rights regarding the privacy of their health information and how their information may be used and disclosed. Failing to provide this notice is a violation of the HIPAA Privacy Rule.

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1
48.

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 program aimed to establish consistent and high-quality medical practices in hospitals. It played a crucial role in improving patient care and safety by setting standards for surgical procedures, training, and hospital management. The program has since been adopted by various healthcare organizations worldwide to ensure excellence in surgical care.

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1
49.

What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs?
- Medicare administrative contractors (MACs)
- Recovery audit contractors (RACs)
- Comprehensive error rate testing (CERT)
- Fiscal intermediaries (FIs)
Correct Answer

A. Recovery audit contractors (RACs)

Explanation

Recovery audit contractors (RACs) is the correct answer because RACs are responsible for detecting and correcting improper payments in the Medicare Fee-for-Service (FFS) programs. They conduct audits and reviews of Medicare claims to identify overpayments and underpayments, and they help ensure that Medicare payments are made accurately and appropriately. RACs play a crucial role in preventing fraud, waste, and abuse in the Medicare program by identifying and recovering improper payments.

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Quiz Edited by
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Dec 21, 2011

Quiz Created by
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CCA Prep Exam 2 (100 Questions)

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

Quiz Preview

Which of the following activities is considered an unethical practice?

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

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

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

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?

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

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?

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 _____________.

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

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

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?

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

What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use pHI for commercial advantage, personal gain, or malicious harm?

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

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

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?

CPT was developed and is maintained by:

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

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 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?

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

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?

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

Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in:

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

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

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

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 type of standard establishes uniform definitions for clinical terms?

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

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 _____________.

Mohs micrographic surgery involves the surgeon acting as:

If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure?

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

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

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

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?

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

Which organization developed the first hospital standardization program?

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