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
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
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Lobar pneumonia
Pneumocystitis carinii pneumonia
Interstitial pneumonia
Aspiration pneumonia
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Pathology report
Progress notes
Nurse's notes
Operative report
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Operative report
Anesthesia report
Pathology report
Laboratory report
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Attending physician
Head nurse
Primary physician
Admitting nurse
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Coding diseases and operations
Protecting patients' privacy and confidential communications
Transcribing medical reports
Performing quantitative analysis on record content
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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
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Reprimand the employee
Fire the employee
Determine what information was printed and why
Revoke the employee's access priviliges
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Physical examination record
History record
Operative report
Radiological report
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Past medical history
Social history
Systems review
History of present illness
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Discharge summary
Medical history
Medical laboratory report
Physical examination
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Interpretation of x-rays by the radiologist
Billing records
Progress notes written by the attending physician
Psychotherapy notes
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Discharge summary
Medical history
Medical laboratory report
Physical examination
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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
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Parentheses ( )
Square brackets [ ]
Slanted brackets [ ]
Braces { }
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Orthopedic surgeons only
Orthopedic surgeons and emergency department physicians
Any physician
Orthopedic surgeons and neurosurgeons
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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
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28th
14th
60th
30th
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Herpes simplex
Staphylococcus aureus
Influenza, types A and B
Candida albicans
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Otitis media
AIDS
Toxic shock syndrome
Bacteremia
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CMS
AMA
Cooperating Parties
WHO
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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
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Operative report
Pathology report
Discharge summary
Nursing note
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Insomnia
Hypertension
Schizophrenia
Rheumatoid arthritis
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Print "error" above the entry
Enter the correction in chronological sequence
Add the reason for the change
Use black pen to obliterate the entry
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Client-server computer
Data warehouse
Local area network
Internet
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Postoperative infection
Appendicitis
COPD
Hypertension
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Patient management
New technology
Therapeutic, preventative, or other interventions
Patient safety
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Appendix E
Appendix F
Appendix G
Appendix H
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History and physical reports
Operative reports
Consultation reports
Psychotherapy notes
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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
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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
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Autograft
Xenograft
Allograft or allogeneic graft
Heterograft
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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
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Identifier standard
Vocabulary standard
Transaction and messaging standard
Structure and content standard
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41
39
40
42
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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
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Autoauthentication
Electronic signature
Automatic record completion
Chart tracking
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Both plastic surgeon and general surgeon
Both surgeon and pathologist
Both plastic surgeon and dermatologist
Both dermatologist and pathologist
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A "with manipulation" code
A "without manipulation" code
An unlisted procedure code
An E/M code only
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User name and password
Automatic session terminations
Cable locks
Encryption
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MIS
CDS
ADT
ABC
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Performance improvement programs
Billing and claims data processing
Developing hospital discharge abstracting systems
Developing individual care plans for residents
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American cademy of Billing Forms (AABF)
National Uniform Billing Committee (NUBC)
National Uniform Claims Committee (NUCC)
American Billing and Claims Academy (ABCA)
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Access controls
Audit trails
Edit checks
Password controls
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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.
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Joint Commission
American Osteopathic Association
American College of Surgeons
American Association of Medical Colleges
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Medicare administrative contractors (MACs)
Recovery audit contractors (RACs)
Comprehensive error rate testing (CERT)
Fiscal intermediaries (FIs)
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