AHIMA CCA- Exam
2023-2024
1.
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal
pain. The attending physician
... [Show More] requested an upper GI series and laboratory evaluation of
CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an
increased white blood cell count. The patient was taken to surgery for an exploratory
laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
a. Ruptured appendix
b. Exploratory laparoscopy
c. Abdominal pain
d. Cholelithiasis - Answer-c. Abdominal pain
The nature and duration of the symptoms that caused the patient to seek medical
attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331).
2.
84. An individual stole and used another person's insurance information to obtain
medical care. This action would be considered:
a. Violation of bioethics
b. Fraud and abuse
c. Medical identity theft
d. Abuse - Answer-c. Medical identity theft
Correct Answer: 84. c. Medical identity theft occurs when someone uses a person's
name and sometimes other parts of their identity without the victim's knowledge or
consent to obtain medical services or goods (Johns 2011, 773).
3.
Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to
Staphylococcus.
a. 730.06
b. 730.07
c. 730.07, 041.1
d. 730.07, 041.10 - Answer-d. 730.07, 041.10
Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the
Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger
2012, 305-306).
4.
A system that provides alerts and reminders to clinicians is a(n):
a. Clinical decision support system
b. Electronic data interchange
c. Point of care charting system
d. Knowledge database - Answer-Correct Answer: A Clinical decision support includes
providing documentation of clinical findings and procedures, active reminders about
medication administration, suggestions for prescribing less expensive but equally
effective drugs, protocols for certain health maintenance procedures, alerts that a
duplicate lab test is being ordered, and countless other decision-making aids for all
stakeholders in the care process (Johns 2011, 138).
5.
What does an audit trail check for?
a. Unauthorized access to a system
b. Loss of data
c. Presence of a virus
d. Successful completion of a backup - Answer-Correct Answer: A
Audit trails can provide tracking information such as who accessed which records and
for what purpose (Johns 2011, 403).
6.
This is a condition with an imprecise diagnosis with various characteristics. The
condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit
block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy,
such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or
antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias
associated with bradyarrhythmias. Prolonged ambulatory monitoring may be indicated
to establish a diagnosis of this condition. Treatment includes insertion of a permanent
cardiac pacemaker.
a. Atrial fibrillation (427.31)
b. Atrial flutter (427.32)
c. Paroxysmal supraventricular tachycardia (427.0)
d. Sick sinus syndrome (SSS) (427.81) - Answer-d. Sick sinus syndrome (SSS)
(427.81)
Correct Answer: D SSS is the imprecise diagnosis with various characteristics treated
with the insertion of a permanent cardiac pacemaker. The other three conditions are
treated with cardioversion and different pharmacological therapy (Schraffenberger 2012,
194-195).
7.
Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip.
a. 715.95
b. 715.15
c. 721.90
d. 715.16 - Answer-b. 715.15
Correct Answer: B Index Osteoarthrosis, localized, primary. For category 715, refer to
the table for the fifth digit of 5 for pelvic region and thigh (Schraffenberger 2012, 303-
304).
8.
A health record with deficiencies that is not complete within the timeframe specified in
the medical staff rules and regulations is called a(n):
a. Suspended record
b. Delinquent record
c. Pending record
d. Illegal record - Answer-Correct Answer: B
An incomplete record not rectified within a specific number of days as indicated in the
medical staff rules and regulations is considered to be delinquent (Johns 2011, 412).
9.
A hospital HIM department wants to purchase an electronic system that records the
location of health records removed from the filing system and documents the date of
their return to the HIM department. Which of the following electronic systems would
fulfill this purpose?
a. Chart deficiency system
b. Chart tracking system
c. Chart abstracting system
d. Chart encoder - Answer-Correct Answer: B
With an automated tracking system, it is easy to track how many records are charged
out of the system, their location, and whether they have been returned on the due dates
indicated (Johns 2011, 402).
10.
Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease.
a. 335.20
b. 334.8
c. 335.29
d. 335.2 - Answer-Correct Answer: A
Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is
another name for Lou Gehrig's disease. Many diseases carry the name of a person or
an eponym. The main terms for eponyms are located in the Alphabetic Index under the
eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).
11.
In the laboratory section of CPT, if a group of tests overlaps two or more panels, report
the panel that incorporates the greatest number of tests to fulfill the code definition.
What would a coder do with the remaining test codes that are not part of a panel?
a. Report the remaining tests using individual test codes, according to CPT.
b. Do not report the remaining individual test codes.
c. Report only those test codes that are part of a panel.
d. Do not report a test code more than once regardless whether the test was performed
twice. - Answer-Correct Answer: A
Reporting additional test codes that overlap codes in a panel allows the coder to assign
all appropriate codes for services provided. It is inappropriate to assign additional panel
codes when all codes in the panel are not performed. Reporting individual lab codes is
appropriate when all codes in a panel have not been provided (AMA 2012b, 402).
12.
An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon
dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of
the component codes are reported and billed individually on a claim form, this would be
a form of:
a. Optimizing
b. Unbundling
c. Sequencing
d. Classifying - Answer-Correct Answer: B
Unbundling occurs when a panel code exists and the individual tests are reported
rather than the panel code (AMA 2012b, 402).
13.
Coronary arteriography serves as a diagnostic tool in detecting obstruction within the
coronary arteries. Identify the technique using two catheters inserted percutaneously
through the femoral artery.
a. Combined right and left (88.54)
b. Stones (88.55)
c. Judkins (88.56)
d. Other and unspecified (88.57) - Answer-Correct Answer: C
The Judkins technique provides x-ray imaging of the coronary arteries by introducing
one catheter into the femoral artery with maneuvering up into the left coronary artery
orifice, followed by a second catheter guided up into the right coronary artery, and
subsequent injection of a contrast material (Schraffenberger 2012, 206).
Ensuring the continuity of future care by providing information to the patient's attending
physician, referring physician, and any consulting physicians is a function of the:
a. Discharge summary
b. Autopsy report
c. Incident report
d. Consent to treatment - Answer-Correct Answer: A
The discharge summary is a concise account of the patient's illness, course of
treatment, response to treatment, and condition at the time the patient is discharged
(Johns 2011, 78).
15.
This document includes a microscopic description of tissue excised during surgery:
a. Recovery room record
b. Pathology report
c. Operative report
d. Discharge summary - Answer-Correct Answer: B
The pathology report describes specimens examined by the pathologist (Johns 2011,
77).
16.
CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of
services greater than the norm would indicate. These MUEs were implemented on
January 1, 2007, and are applied to which code set?
a. Diagnosis-related groups
b. HCPCS/CPT codes
c. ICD-9-CM diagnosis and procedure codes
d. Resource utilization groups - Answer-Correct Answer: B
CMS developed MUEs to prevent providers from billing units in excess and receiving
inappropriate payments. This new editing was the result of the outpatient prospective
payment system which pays providers passed on the HCPCS/CPT code and units.
Payment is directly related to units for specified HCPCS/CPT codes assigned to an
ambulatory payment classification (CMS 2012b).
17.
Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to
chemotherapy.
a. 284.9
b. 284.89
c. 285.9
d. 285.22 - Answer-Correct Answer: B
Index Anemia, aplastic, due to, antineoplastic chemotherapy. A coder should always
assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic
(Schraffenberger 2012, 133-135 ).
18.
When the physician does not specify the method used to remove a lesion during an
endoscopy, what is the appropriate procedure?
a. Assign the removal by snare technique code.
b. Assign the removal by hot biopsy forceps code.
c. Assign the ablation code.
d. Query the physician as to the method used. - Answer-Correct Answer: D
It is not appropriate for the coder to assume the removal was done by either snare or
hot biopsy forceps. The ablation code is only assigned when a lesion is completely
destroyed and no specimen is retrieved. The coding professional must query the
physician to assign the appropriate code (AHIMA 2012a, 607).
19.
What is the best reference tool to determine how CPT codes should be assigned?
a. Local coverage determination from Medicare
b. American Medical Association's CPT Assistant newsletter
c. American Hospital Association's Coding Clinic
d. CMS website - Answer-Correct Answer: B
CPT Assistant provides additional CPT coding guidance on how to assign a CPT code
by providing intent on the use of the code and explanation of parenthetical instructions.
The American Medical Association publishes the guidance monthly (AMA 2012b).
20.
Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch
block.
a. 426.3, 426.4
b. 426.53
c. 426.4, 426.53
d. 426.52 - Answer-Correct Answer: B
Index Block, left, with right bundle branch block. Right and left bundle branch block is
inclusive of one code. It is inappropriate to assign a code for right (426.4) and left
(426.3) bundle branch block when a combination code includes both the right and left
(Schraffenberger 2012, 201-207).
21.
A software interface is a:
a. Device to enter data
b. Protocol for describing data
c. Program to exchange data
d. Standard vocabulary - Answer-Correct Answer: C
A software interface is a computer program that allows different applications to
communicate and exchange data (Johns 2011, 137).
22.
What did the Centers of Medicare and Medicaid Services develop to promote national
correct coding methodologies and to control improper coding leading to inappropriate
payment in Part B claims?
a. Outpatient Perspective Payment System (OPPS)
b. National Correct Coding Initiative (NCCI)
c. Ambulatory Payment Classifications (APCs)
d. Comprehensive Outpatient Rehab Facilities (CORFs) - Answer-Correct Answer: B
CMS developed the NCCI to control improper coding practices leading to inappropriate
payments in Part B claims (CMS 2012a).
23.
Identify the appropriate diagnostic and/or procedure ICD-9-CM code(s) for
reprogramming of a cardiac pacemaker.
a. V53.31
b. 37.85
c. V53.02
d. V53.31, 37.85 - Answer-Correct Answer: A
Index Fitting (of) pacemaker (cardiac). No procedure code exists in ICD-9-CM to
describe reprogramming (Schraffenberger 2012, 204-205).
24.
Which of the following hospitals are excluded from the Medicare acute-care prospective
payment system?
a. Children's
b. Small community
c. Tertiary
d. Trauma - Answer-Correct Answer: A
Children's hospitals are excluded from PPS because the PPS diagnosis-related groups
do not accurately account for the resource costs for the types of patients treated (Johns
2011, 321).
25.
Which of the following programs has been in place in hospitals for years and has been
required by the Medicare and Medicaid programs and accreditation standards?
a. Internal DRG audits
b. Peer review
c. Managed care
d. Quality improvement - Answer-Correct Answer: D
Quality improvement (QI) programs have been in place in hospitals for years and have
been required by the Medicare/Medicaid programs and accreditation standards. QI
programs have covered medical staff as well as nursing and other departments or
processes (LaTour and Eichenwald Maki 2010, 33).
26.
Identify the code for a patient with a closed transcervical fracture of the epiphysis.
a. 820.09
b. 820.02
c. 820.03
d. 820.01 - Answer-Correct Answer: D
Index Fracture, femur, epiphysis, capital. Fifth digits are required for further
classification of a specific condition. Many publishers include special symbols and/or
color highlighting to identify codes that require a fourth or fifth digit (Schraffenberger
2012, 7).
27.
What is the best source of documentation to determine the size of a removed malignant
lesion?
a. Pathology report
b. Post-acute care unit record
c. Operative report
d. Physical examination - Answer-Correct Answer: C
The total size of a removed lesion, including margins, is needed for accurate coding.
This information is best provided in the operative report. The pathology report typically
provides the specimen size rather than the size of the excised lesion. Because the
specimen tends to shrink, this is not an accurate measurement (Kuehn 2012, 110-111).
28.
Which of the following definitions best describes the concept of confidentiality?
a. The right of individuals to control access to their personal health information
b. The protection of healthcare information from damage, loss, and unauthorized
alteration
c. The expectation that personal information shared by an individual with a healthcare
provider during the course of care will be used only for its intended purpose
d. The expectation that only individuals with the appropriate authority will be allowed to
access healthcare information - Answer-Correct Answer: C
Confidentiality refers to the expectation that the personal information shared by an
individual with a healthcare provider during the course of care will be used only for its
intended purpose (Johns 2011, 49).
29.
Identify the ICD-9-CM diagnosis code for Paget's disease of the bone (no bone tumor
noted).
a. 170.9
b. 213.9
c. 238.0
d. 731.0 - Answer-Correct Answer: D
Index Paget's disease, bone. The main terms for eponyms are located in the Alphabetic
Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012,
13).
30.
Which of the following fails to meet the CMS classification of a hospital-acquired
condition?
a. Foreign object retained after surgery
b. Air embolism
c. Gram-negative pneumonia
d. Blood incompatibility - Answer-Correct Answer: C
Gram-negative pneumonia (Johns 2011, 326).
31.
Which of the following is (are) the correct ICD-9-CM procedure code(s) for cystoscopy
with biopsy?
a. 57.34
b. 57.32, 57.33
c. 57.33
d. 57.39 - Answer-Correct Answer: C
Index Cystoscopy (transurethral), with biopsy (Schraffenberger 2012, 251).
32.
Identify the ICD-9-CM diagnosis code for chondromalacia of the patella.
a. 717.7
b. 733.92
c. 748.3
d. 716.86 - Answer-Correct Answer: A
Index Chondromalacia, patella (Schraffenberger 2012, 303-304).
33.
Identify the ICD-9-CM diagnosis code for blighted ovum.
a. 236.1
b. 661.00
c. 631.8
d. 634.90 - Answer-Correct Answer: C
Index Ovum, blighted (Schraffenberger 2012, 282-283).
34.
Each year the OIG develops a work plan that details areas of compliance it will be
investigating for that year. What is the expectation of the hospital in relation to the OIG
work plan?
a. Hospitals are required to follow the same work plan and deploy audits based on that
work plan.
b. Hospitals should plan their compliance and auditing projects around the OIG work
plan to ensure they are in compliance with the target areas in the plan.
c. Hospitals must not develop their audits based on the OIG work plan; rather, they
must develop their own and look for high-risk areas that need improvement.
d. Hospitals must use the plan developed by their state hospital association that is
specific to state laws and compliance activities. - Answer-Correct Answer: B
Hospitals are encouraged but not required to follow the same work plan as the OIG.
Hospitals should review the plan carefully and plan their compliance program around
the target areas (Johns 2011, 275).
35.
The _____ may contain information about diseases among relatives in which heredity
may play a role.
a. Physical examination
b. History
c. Laboratory report
d. Administrative data - Answer-Correct Answer: B
A complete medical history documents the patient's current complaints and symptoms
and lists the patient's past medical, social, and family history (Johns 2011, 63).
36.
There are several codes to describe a colonoscopy. CPT code 45378 describes the
most basic colonoscopy without additional services. Additional codes in the
colonoscopy section of CPT further define removal of foreign body (45379); biopsy,
single or multiple (45380); and others. Reporting the basic form of a colonoscopy
(45378) with a foreign body (45379) or biopsy code (45380) would violate which rule?
a. Unbundling
b. Optimizing
c. Sequencing
d. Maximizing - Answer-Correct Answer: A
The coder should assign the most comprehensive code to describe the entire
procedure performed. When a code describes the entire service provided, the coder
should not code each component separately. Assigning additional codes inherent to the
main code would be a form of unbundling (Hazelwood and Venable 2012, 336).
37.
Corporate compliance programs were released by the OIG for hospitals to develop and
implement their own compliance programs. All of the following except _____ are basic
elements of a corporate compliance program.
a. Designation of a Chief Compliance Officer
b. Implementation of regular and effective education and training programs for all
employees
c. Medical staff appointee for documentation compliance
d. The use of audits or other evaluation techniques to monitor compliance - AnswerCorrect Answer: C
Seven elements are required as part of the basic elements of a corporate compliance
program and a medical staff appointee is not one of them (Johns 2011, 274).
38.
The electronic claim format (837I) replaces which paper billing form?
a. CMS-1500
b. CMS-1450 (UB-04)
c. UB-92
d. CMS-1400 - Answer-Correct Answer: B
The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing
form (Johns 2011, 343).
39.
According to the Joint Commission Accreditation Standards, which document must be
placed in the patient's record before a surgical procedure may be performed?
a. Admission record
b. Physician's order
c. Report of history and physical examination
d. Discharge summary - Answer-Correct Answer: C
According to the Joint Commission, except in emergency situations, every surgical
patient's chart must include a report of a complete history and physical conducted no
more than seven days before the surgery is to be performed (Odom-Wesley et al. 2009,
150).
40.
The right of an individual to keep information about himself or herself from being
disclosed to anyone is a definition of:
a. Confidentiality
b. Privacy
c. Integrity
d. Security - Answer-Correct Answer: B
Privacy is the right of an individual to be left alone. It includes freedom from observation
or intrusion into one's private affairs and the right to maintain control over certain
personal and health information (Johns 2011, 755).
41.
Standardizing medical terminology to avoid differences in naming various medical
conditions and procedures (such as the synonyms bunionectomy, McBride procedure,
and repair of hallus valgus) is one purpose of:
a. Transaction standards
b. Content and structure standards
c. Vocabulary standards
d. Security standards - Answer-Correct Answer: C
Vocabulary standards establish common definitions for medical terms to encourage
consistent descriptions of an individual's condition in the health record (Johns 2011,
227).
42.
An outpatient clinic is reviewing the functionality of a computer system it is considering
purchasing. Which of the following datasets should the clinic consult to ensure all the
federally required data elements for Medicare and Medicaid outpatient clinical
encounters are collected by the system?
a. DEEDS
b. EMEDS
c. UACDS
d. UHDDS - Answer-Correct Answer: C
Uniform Ambulatory Care Data Set (Odom-Wesley et al. 2009, 310).
43.
Identify the ICD-9-CM diagnostic code for diastolic dysfunction.
a. 428.1
b. 428.30
c. 428.9
d. 429.9 - Answer-Correct Answer: D
Index Dysfunction, diastolic (Schraffenberger 2012, 182-183).
44.
Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammarycoronary artery bypass.
a. 36.15, 36.16
b. 36.15
c. 36.16
d. 36.12, 36.16 - Answer-Correct Answer: C
Index Bypass, internal mammary-coronary artery (single), double vessel (36.16).
Internal mammary-coronary artery bypass is accomplished by loosening the internal
mammary artery from its normal position and using the internal mammary artery to bring
blood from the subclavian artery to the occluded coronary artery. Codes are selected
based on whether one or both internal mammary arteries are used, regardless of the
number of coronary arteries involved (Schraffenberger 2012, 203-204).
45.
Identify the CPT code(s) for the following patient: A 2-year-old male presented to the
emergency room in the middle of the night to have his nasogastric feeding tube
repositioned through the duodenum under fluoroscopic guidance.
a. 43752
b. 43761
c. 43761, 76000
d. 49450 - Answer-Correct Answer: C
Code 43761 is assigned to report repositioning of a nasogastric or orogastric feeding
tube through the duodenum. An instructional note guides the coder to report code
76000 when image guidance is performed (AMA 2012b, 235).
Which of the following is the correct ICD-9-CM procedure code for a Mayo operation
known as a bunionectomy?
a. 77.54
b. 77.69
c. 77.59
d. 77.51 - Answer-Correct Answer: C Index Bunionectomy or Mayo operation,
bunionectomy. The main terms for eponyms are located in the Alphabetic Index under
the eponym or the disease, syndrome, operation, or disorder (Schraffenberger 2012,
13).
47.
Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of
outpatient data collection is on:
a. Reason for admission
b. Reason for encounter
c. Discharge diagnosis
d. Activities of daily living - Answer-Correct Answer: B
The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to
ambulatory care, such as the reason for the encounter with the healthcare provider
(LaTour and Eichenwald Maki 2010, 166).
48.
How do accreditation organizations such as the Joint Commission use the health
record?
a. To serve as a source for case study information
b. To determine whether the documentation supports the provider's claim for
reimbursement
c. To provide healthcare services
d. To determine whether standards of care are being met - Answer-Correct Answer: D
Surveyors review the documentation of patient care services to determine whether the
standards for care are being met (Johns 2011, 40).
49.
Mildred Smith was admitted from an acute-care hospital to a nursing facility with the
following information: "Patient is being admitted for organic brain syndrome."
Underneath the diagnosis, her medical information along with her rehabilitation potential
were also listed. On which form is this information documented?
a. Transfer or referral
b. Release of information
c. Patient rights acknowledgement
d. Admitting physical evaluation - Answer-Correct Answer: A
The transfer or referral form provides document communication between caregivers in
multiple healthcare settings. It is important that a patient's treatment plan be consistent
as the patient moves through the healthcare delivery system (Odom-Wesley et al. 2009,
131).
50.
Which of the following statements is true?
a. The higher the relative weight, the higher the payment rates.
b. The lower the relative weight, the higher the payment rates.
c. The lower the relative weight, the sicker the patient.
d. The higher the relative weight, the lesser reimbursement due the facility. - AnswerCorrect Answer: A
Higher relative weights link to higher payment rates (Casto and Layman 2011, 13).
51.
A coder needs to locate electronic health records for a patient across a health
information exchange (HIE). What tool(s) should the coder use?
a. Certification
b. Identity-matching algorithm and record locator service
c. Interoperability and certification
d. Meaningful use - Answer-Correct Answer: B
An HIE organization requires an identity-matching algorithm and record locator service
(RLS). An identity-matching algorithm must be used by the HIE to identify any patient
for whom data are to be exchanged. This algorithm uses sophisticated probability
equations to identify patients. The RLS, then, is a process that seeks information about
where a patient may have a health record available to the HIE organization (Johns
2011, 151).
52.
All documentation entered in the medical record relating to the patient's diagnosis and
treatment is considered this type of data:
a. Clinical
b. Identification
c. Secondary
d. Financial - Answer-Correct Answer: A
Clinical information is data related to the patient's diagnosis or treatment in a
healthcare facility (Odom-Wesley et al. 2009, 55).
53.
What type of data is exemplified by the insured party's member identification number?
a. Demographic data
b. Clinical data
c. Certification data
d. Financial data - Answer-Correct Answer: D
Financial data include details about the patient's occupation, employer, and insurance
coverage (Odom-Wesley et al. 2009, 42).
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