CCA Prep Exam 2 (100 Questions)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.