CCA Prep Exam 2 (100 Questions)

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

Explanation

A hospital should comply with both the state law and the HIPAA standard because the state law requires more stringent privacy protection than the federal HIPAA privacy standard. By complying with both, the hospital ensures that it meets the requirements of both the state law and the federal standard, thereby protecting patient privacy to the maximum extent required by law. Ignoring either the state law or the HIPAA standard could result in legal and ethical consequences for the hospital.

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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

2. Which of the following activities is considered an unethical practice?

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?

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

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.

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?

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?

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?

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?

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 _____________.

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:

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.

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?

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.

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?

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.

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:

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?

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.

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?

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?

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:

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?

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?

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?

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?

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?

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?

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?

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:

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?

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?

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?

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):

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?

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?

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 _______________.

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?

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 _____________.

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:

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?

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?

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.

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

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?

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?

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?

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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48. Which organization developed the first hospital standardization program?

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

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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50. Which of the following ethical principles is being followed when an HIT professional ensures thtat patient information is only released to those who have a legl right to access it?

Explanation

Beneficence is the ethical principle being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it. Beneficence refers to the obligation to do good and promote the well-being of others. By restricting access to patient information to only those who are legally authorized, the HIT professional is acting in the best interest of the patients and protecting their privacy and confidentiality. This ensures that the patients' rights are respected and their information is not misused or disclosed to unauthorized individuals.

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51. What is abstracting?

Explanation

Abstracting refers to the process of compiling the relevant information from a medical record based on predetermined data sets. This involves extracting and gathering the necessary data points and organizing them in a systematic manner. The purpose of abstracting is to ensure that all essential information is captured and categorized appropriately for analysis and reporting purposes. It is an important step in medical record management and helps in maintaining accurate and standardized documentation.

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52. What healthcare organization collects UHDDS data?

Explanation

The correct answer is All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes. This is because the UHDDS (Uniform Hospital Discharge Data Set) is a standardized set of data elements that are collected by healthcare organizations in non-outpatient settings. These settings include acute care hospitals, short-term care facilities, long-term care facilities, psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes. Outpatient settings such as physician clinics and ambulatory surgical centers do not collect UHDDS data.

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53. Which answer below is not correct for assignment of the MS-DRG?

Explanation

The attending and consulting physicians are not factors that are considered in the assignment of the MS-DRG. The MS-DRG (Medicare Severity-Diagnosis Related Group) is a system used by Medicare to classify hospital cases into groups based on similar clinical characteristics and costs. It takes into account factors such as diagnoses and procedures (principal and secondary), presence of major or other complications and co-morbidities (MCC or CC), and discharge disposition or status. The attending and consulting physicians may play a role in the patient's care, but they are not directly used in determining the MS-DRG assignment.

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

Explanation

Computer-assisted coding is a type of coding that is a natural outgrowth of the electronic health record. It refers to the use of technology to assist in the coding process, making it more efficient and accurate. This technology analyzes clinical documentation and suggests appropriate codes based on the content. It helps coders save time and reduces the risk of errors.

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55. Observation E/M codes (99218 through 99220) are used in physician billing when:

Explanation

Observation E/M codes (99218 through 99220) are used in physician billing when a patient is referred to a designated observation service. This means that the patient is not admitted to the hospital as an inpatient, but rather placed in an observation unit for further evaluation and monitoring. These codes are used to bill for the physician's evaluation and management services during the patient's stay in the observation unit.

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56. An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach?

Explanation

Information access controls should be implemented to prevent this security breach. These controls include measures such as user authentication, role-based access control, and data encryption. By implementing information access controls, the employee's unauthorized access to the clinical information system can be restricted, ensuring that only authorized individuals can access the system and its data. This helps to protect the privacy and confidentiality of the information stored in the system.

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

Explanation

Vital signs are not typically found in a medical history. A medical history usually includes information about the patient's chief complaint, present illness, and review of systems. Vital signs, such as blood pressure, heart rate, and temperature, are typically recorded during a physical examination or at the time of the patient's visit. They provide objective measurements of the patient's current health status and are not typically included in the medical history documentation.

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58. 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:

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 means that if a woman gives birth to her first child at the age of 35 or above, she would be considered an elderly primigravida according to the ICD-9-CM classification system.

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59. Identify the correct ICD-9-CM diagnosis code(s) for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms.

Explanation

The correct ICD-9-CM diagnosis code for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms is V72.5. This code is specifically used for examinations and investigations that are performed without any signs or symptoms present. It indicates that the patient is seeking a routine diagnostic examination without any specific concerns.

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60. 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?

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 how to appropriately use the copy and paste function. By implementing these policies, the HIM director can ensure that the nurses understand the acceptable documentation practices and prevent any potential issues or errors that may arise from improper use of the function.

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

Explanation

The correct answer is 250.02, 263.1. The ICD-9-CM diagnosis code 250.02 represents uncontrolled type II diabetes mellitus. The code 263.1 represents mild malnutrition. Therefore, the correct answer includes both codes to accurately describe the patient's condition.

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62. In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called:

Explanation

Selective catheterization refers to the technique of manipulating the tip of the catheter from the initial insertion point in the aorta to another specific artery. This technique allows for targeted access to a particular artery for diagnostic or therapeutic purposes. Nonselective catheterization, on the other hand, refers to the placement of the catheter without specific targeting of a particular artery. Manipulative catheterization and radical catheterization are not recognized terms in the context of arterial catheterizations.

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

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 in the healthcare system can be identified accurately and consistently, allowing for effective communication, record-keeping, and coordination of care.

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

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 put pressure on the bladder, such as coughing, sneezing, or lifting heavy objects.

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

Explanation

The correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode is 410.01. This code specifically denotes an acute myocardial infarction of the anterolateral wall.

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

Explanation

The correct ICD-9-CM diagnosis code for urinary tract infection due to E. coli is 599.0. Additionally, code 041.4 should be sequenced after 599.0 to indicate the specific organism causing the infection.

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

Explanation

Codes for selective catheterization in CPT are assigned based on the final vessel entered. This means that only one code is used to represent the final vessel that was accessed during the procedure. The other vessels that may have been entered or accessed during the catheterization are not individually coded. The focus is on the final vessel that was reached, as this is the most significant aspect of the procedure.

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68. Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)?

Explanation

Providing an input mask for entering data in the field would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR). An input mask is a predefined format that guides the user in entering data correctly. By providing an input mask for the admission date field, the system can enforce a specific format (e.g., MM/DD/YYYY) and validate the input to ensure that it follows the correct notation consistently. This helps to minimize errors and inconsistencies in recording the admission date.

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69. Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1).  They will also be sending her records to her physician for continuity of care (2).  Under HIPAA, these two functions are:

Explanation

The correct answer is "Use (1) and disclosure (2)". In this scenario, the Mercy Hospital personnel need to review Katie Grace's medical records for utilization review purposes, which falls under the category of "use" of the records. They will also be sending her records to her physician for continuity of care, which falls under the category of "disclosure" of the records. Therefore, both functions, use and disclosure, are applicable in this situation.

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

Explanation

The goal of the new MS-DRG system is to improve Medicare's ability to recognize the severity of illness in its inpatient hospital payments. This means that the system aims to accurately assess the level of illness or medical complexity of patients in order to appropriately adjust payment rates for hospitals. The new system is designed to increase payments for hospitals that provide services to sicker patients, who require more intensive and costly care, while decreasing payments for treating less severely ill patients. This ensures that hospitals are fairly compensated based on the level of care they provide.

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71. Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes?

Explanation

The correct answer is "Use of Mary's individually identifiable information related to her asthma treatments." According to the HIPAA Privacy Rule, individually identifiable health information can only be used or disclosed for research purposes with the individual's authorization. In this case, Mary's information about her asthma treatments is considered individually identifiable, so it would require her authorization for research purposes. The other options either involve deidentified information or limited data sets, which have different requirements under the HIPAA Privacy Rule.

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

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 for abnormal PSA levels, indicating a potential issue with the prostate. The other options are not specific to PSA test results or prostate-related conditions.

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73. Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa.

Explanation

CPT code 23031 is the correct code for incision and drainage of an infected shoulder bursa. This code specifically refers to the procedure of making an incision and draining the infected fluid from the bursa in the shoulder. Codes 10060 and 10140 are for incision and drainage procedures, but they do not specifically mention the shoulder bursa. Code 23030 is for drainage of the subcutaneous tissue, which is not the same as draining an infected bursa.

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74. A child was examined and treated for child abuse in the emergency department at the hospital. s a result, the child ha been taken into protective custody by the Office of Child Protection because of suspected child abuse by parents. The father requests copies of the designated record set for the visit. He has a copy of the child's birth certificate listing him as the fther and he possesses a picture ID. Do you release a copy of the emergency department record?

Explanation

In this scenario, the child has been taken into protective custody due to suspected child abuse. Therefore, it is crucial to prioritize the safety and well-being of the child. Releasing the emergency department record to the father without proper authorization could potentially compromise the child's safety or interfere with the ongoing investigation. Contacting the hospital's attorney is the appropriate course of action to ensure legal compliance and protect the best interests of the child.

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

Explanation

The American Psychological Association (APA) is not an accepted accrediting body for behavioral healthcare organizations. While the APA is a professional organization that sets ethical standards and guidelines for psychologists, it does not specifically accredit healthcare organizations. The Joint Commission, Commission on Accreditation of Rehabilitation Facilities (CARF), and National Committee for Quality Assurance (NCQA) are all recognized accrediting bodies in the healthcare industry.

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76. What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient?

Explanation

The maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient is six. This means that a hospital can list up to six different procedure codes for the services provided to an inpatient on the claim form.

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77. 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.

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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78. Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.

Explanation

The appropriate CPT code to report this occult blood sampling is 82270. This code is used for the screening of colorectal cancer using fecal occult blood tests.

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79. Per CPT guidelines, a separate procedure is:

Explanation

A separate procedure is considered to be an integral part of another, larger procedure. This means that it is not coded separately but is instead included in the code for the larger procedure.

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80. A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest?

Explanation

The HIM director should suggest avoiding displaying the social security number on any document, screen, or data collection field. This is because the risk manager has identified it as a potential identity fraud risk, and removing the information would help mitigate this risk. The argument made by physicians and others in the hospital that they need the information for identification and other purposes is not a strong enough reason to continue displaying it, considering the potential risk involved.

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

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-funded healthcare programs. They conduct surveys and inspections to assess the quality of care provided by hospitals and determine their eligibility for reimbursement from Medicare and Medicaid.

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

Explanation

The correct ICD-9-CM diagnosis code for a patient with seizures and epilepsy ruled out is 780.39. This code is used to indicate other convulsions and related conditions, excluding epilepsy. It is important to accurately document and code the patient's condition to ensure proper diagnosis and treatment.

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

Explanation

The correct ICD-9-CM diagnosis code for a patient with pneumonia and persistent cough is 486. This code specifically represents pneumonia, which is the primary diagnosis, and includes the symptom of persistent cough. The other options either do not include the symptom of persistent cough or do not specifically represent pneumonia as the primary diagnosis.

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84. What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment?

Explanation

The correct answer states that additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases. This means that hospitals that serve a high number of low-income patients, hospitals that provide education and training to medical students, hospitals that use new and advanced technologies, and hospitals with unusually high costs for certain cases may receive additional payments in addition to the basic Medicare DRG payment.

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85. 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.

Explanation

Late affect would never be the first diagnosis

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86. What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses?

Explanation

The maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses is 18. This means that a hospital can list up to 18 different diagnoses for a patient on this form.

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

Explanation

The Outcomes and Assessment Information Set (OASIS) must be used by Medicare-certified home care providers. OASIS is a specialized patient assessment tool that is used to collect data on patients receiving home health services. It is designed to measure patient outcomes and facilitate quality improvement initiatives. OASIS is used to assess the patient's physical, psychological, and social functioning, as well as their health status and service needs. It is a crucial tool for Medicare-certified home care providers to ensure accurate and comprehensive assessment of their patients.

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88. 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.

Explanation

The correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia are V58.11, 204.00, 787.01. The code V58.11 indicates the encounter for antineoplastic chemotherapy, while 204.00 represents acute lymphocytic leukemia, and 787.01 represents nausea with vomiting. This sequence follows the guidelines of coding the primary diagnosis first, followed by any secondary diagnoses or symptoms.

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

Explanation

The correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea are 789.03, 787.01, 787.91. This is because 789.03 represents the abdominal pain, 787.01 represents the nausea and vomiting, and 787.91 represents the diarrhea.

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

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 represent the patient's symptoms.

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

Explanation

The correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome are 042 and 112.4. This is because code 042 represents the HIV infection, which is the underlying cause of the AIDS-like syndrome, and code 112.4 represents the disseminated candidiasis. These two codes should be sequenced in that order to accurately represent the relationship between the two conditions. The other options either do not include the correct codes or do not have the correct sequencing.

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92. 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?

Explanation

The HIM director should recommend developing a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. This will help establish a clear guideline for how long a transcribed document can be changed after initial transcription, ensuring that documentation occurs near the time of the event as required by the legal principle. This policy will help prevent any potential legal issues and maintain the integrity of the health records.

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93. 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?

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 vagus nerve is isolated and the PDA is divided and sutured individually in the aorta and pulmonary artery. The other options (33813, 33820, 33822) do not specifically describe the closure of a PDA through a thoracotomy approach.

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94. Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung.

Explanation

The correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung are 153.9 and 197.0. Code 153.9 represents malignant neoplasm of the colon, while code 197.0 represents secondary malignant neoplasm of the lung. These codes accurately describe the diagnosis of metastatic carcinoma of the colon to the lung.

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

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 given the symptoms described in the question.

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96. 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.

Explanation

The correct answer is 438.12. This code represents the diagnosis of dysphasia secondary to an old cerebrovascular accident sustained one year ago. The code 438.12 specifically identifies the late effects of cerebrovascular disease, which includes dysphasia. The other options do not accurately capture the specific diagnosis and the relationship to the cerebrovascular accident.

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97. Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia.

Explanation

The correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia are 038.11 and 995.91. The code 038.11 represents septicemia due to Staphylococcus aureus, which is the underlying infection causing sepsis. The code 995.91 represents sepsis, which is the systemic response to the infection. Both codes are necessary to accurately describe the patient's condition.

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

Explanation

The correct ICD-9-CM diagnosis code for a patient with abnormal glucose tolerance test is 790.22. This code is used for the diagnosis of impaired glucose tolerance, which indicates an abnormal response to a glucose tolerance test. The other options (790.29, 790.21, and 790.21, 790.29) do not specifically indicate abnormal glucose tolerance and are therefore not the correct codes for this diagnosis.

Submit
99. Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.

Explanation

Neutropenic fever is a condition characterized by a low count of neutrophils (a type of white blood cell) in the blood, leading to a weakened immune system and an increased risk of infection. The correct ICD-9-CM diagnosis code for neutropenic fever is 288.00, which represents the neutropenia itself. Additionally, 780.61 is also a correct code as it represents the fever symptom associated with neutropenia.

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100. 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?

Explanation

The correct answer is 231.2, 31641. The preoperative diagnosis of "Suspicious lesions, main bronchus" is coded as 231.2, which represents carcinoma in situ of the bronchus. The procedure code 31641 is used for laser photoresection of the bronchus.

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What should a hospital do when a state law requires more...
Which of the following activities is considered an unethical practice?
What diagnosis would the coder expect to see when a patient with...
Where would a coder who needed to locate the histology of a tissue...
Which of the following reports include names of the...
Who is responsible for writing and signing discharge summaries...
Which of the following is a core ethical obligation of health...
Which of the following activities would be in violation of AHIMA's...
On review of the audit trail for an EHR system, the HIM director...
Documentation regarding a patient's marital status, dietary,...
Documentation in the history of use of drugs, alcohol, and/or tobacco...
Identify the acute-care record report where the...
Although the HIPAA Rule allows patient access to personal health...
Identify the acute care record report where the following information...
In a routine health record quantitative analysis review it...
Identify the punctuation mark that is used to supplement words or...
The codes in the musculoskeletal section of CPT may be used by:
What penalties can be enforced against a person or entity that...
ICD-9-CM defines the "newborn period" as birth through the...
Which of the following would be classified to an ICD-9-CM category for...
The coder notes that the physician has presribed Retrovir for the...
CPT was developed and is maintained by:
What is the basic formula for calculating each MS-DRG hospital...
The clinical statement, "microscopic sections of the gallbladder...
The coder notes the patient is taking prescribed Haldol. The...
When correcting erroneous information in a health record, which...
Which of the following provides organizations with the ability to...
A patient with known COPD and hypertension under treatment was...
Category II codes cover all but one of the following topics. Which is...
Referencing the CPT codebook, a list of codes describing procedures...
Under the HIPAA privacy standard, which of the following types of...
Which of the following documentation must be included in a...
Community Hospital implemented a clinical document improvement...
Tissue transplated from one individual to another of the same species...
How does Medicare or other third-party payers determine whether the...
What type of standard establishes uniform definitions for clinical...
"Late pregnancy" (category code 645) is used to demonstrate...
The hospital is revising its policy on medical record documentation....
Dr. Jones has signed a statement that all of her dictated reports...
Mohs micrographic surgery involves the surgeon acting as:
If an orthopedic surgeon attempted to reduce a fracture but was...
A hospital is planning on allowing coding professionals to work at...
In hospitals, automated systems for registering patients and tracking...
Both HEDIS and the Joint Commission's ORYX program are designed to...
What is the name of the organization that develops the billing form...
 A coding analyst consistently enters the wrong code for patient...
Today, Janet Kim visited her new dentist for an appointment. She was...
Which organization developed the first hospital standardization...
What is the name of the national program to detect and correct...
Which of the following ethical principles is being followed when an...
What is abstracting?
What healthcare organization collects UHDDS data?
Which answer below is not correct for assignment of the MS-DRG?
The ___________ is a type of coding thta is a natural outgrowth of the...
Observation E/M codes (99218 through 99220) are used in physician...
An employee in the physical therapy department arrives early...
Which of the following would not be found in a medical history?
According to ICD-9-CM, an elderly primigravida is defined as a...
Identify the correct ICD-9-CM diagnosis code(s) for a patient who...
During a review of documentation practices, the HIM...
Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II...
In coding arterial catheterizations, when the tip of the catheter is...
What type of standard establishes methods for creating unique...
Identify the correct ICD-9-CM diagnosis code for a male patient with...
Identify the correct ICD-9-CM diagnosis code for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing...
When coding a selective catheterization in CPT, how are codes...
Which of the following would be the best technique to ensure that...
Mercy Hospital personnel need to review the medical records for...
What was the goal of the new MS-DRG system?
Per the HIPAA Privacy Rule, which of the following requires...
Identify the correct ICD-9-CM diagnosis code for a patient with an...
Identify the correct CPT procedure code for incision and drainage of...
A child was examined and treated for child abuse in the emergency...
Which of the following is not an accepted accrediting body for...
What is the maximum number of procedure codes that can appear on a...
The discharge summary must be completed within ________ after...
Mr. Smith is seen in his primary care physician's office for his...
Per CPT guidelines, a separate procedure is:
A hospital currently includes the patient's social...
What type of organization works under contract with the CMS to conduct...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
What are possible "add-on" payments that a hospital...
Identify the correct sequence and ICD-9-CM diagnosis code(s) for...
What is the maximum number of diagnosis codes that can appear on the...
Which of the following specialized patient assessment tools must be...
Identify the correct ICD-9-CM diagnosis codes and sequence for a...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) and sequence for a...
During an audit of health records, the HIM director finds...
A 22-year-old patient presents for a closure of a patent ductus...
Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for a patient with...
Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever.
From the health record of a patient newly diagnosed with a malignancy:...
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