CCA Exam Preparation
CCA practice exam 2 domain 1: health records and data content domain 2: health information
requirements and standards domain 3:
... [Show More] clinical classification systems domain 4: reimbursement
methodologies domain 5: information and communication technologies domain 6: privacy,
confidentiality, legal, and ethical issues
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? - Answer-Develop
a facility policy that defines the acceptable period of time allowed for a transcribed
document to remain in a draft form.
What is the basic formula for calculating each MS-DRG hospital payments? - AnswerHospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics? -
Answer-Coding an intentionally inappropriate level of service
What is abstracting? - Answer-Compiling the pertinent information from the medical
record based on predetermined data sets
ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth. - Answer-28th
What healthcare organization collects UHDDS data? - Answer-All non-outpatient
settings including acute care, short term care, long term care, an psychiatric hospitals,
home health agencies, rehabilitation facilities, and nursing home.
A coding analyst consistently enters the wrong code for patient gender in the electronic
billing system. What security measures should be in place to minimize this security
breach? - Answer-Edit checks
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: - Answer-Use and
disclosure
Who is responsible for writing and signing discharge summaries and discharge
instructions? - Answer-Attending physician
Although the HIPAA Rule allows patient access to personal health information about
themselves, which of the following cannot be disclosed to patients? - AnswerPsychotherapy notes
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 modifier, and all three volumes of
ICD-9-CM use them. - Answer-Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are
required to use? - Answer-National Uniform Billing Committee (NUBC)
Which of the following ethical principles is being followed when an HIT professional
ensures that patient information is only released to those who have a legal right to
access it? - Answer-Beneficence
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? - Answer-Avoid
displaying the number on any document, screen, or data collection field.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to
be used for ______________. - Answer-Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial
diseases? - Answer-Staphylococcus aureous
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? - Answer-Postoperative infection
CPT was developed and is maintained by: - Answer-AMA
Which organization developed the first hospital standardization program? - AnswerAmerican College of Surgeon
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 cases, what should the supervisor do? -
Answer-Determine what information was printed and why
What are possible "add-on" payments that a hospital could receive in addition to the
basic Medicare DRG payment? - Answer-Additional payments may be made to
disproportionate share hospitals, for indirect medical education, for new technologies,
and for cost outlier cases.
The ___________ is a type of coding that is a natural outgrowth of the electronic heath
record. - Answer-Computer-assisted coding
Today, Janet Kim visited her new dentist for an appointment. She was not presented
with a Notice of Privacy Practices. Is this acceptable? - Answer-No, it is a violation of
the HIPAA Privacy rule
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)? - Answer-Provide an input mask for entering data in the field
What should a hospital do when a state law requires more stringent privacy protection
than the federal HIPAA privacy standard? - Answer-Comply with both the state law and
the HIPAA Standard
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? - Answer-Information access controls
According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth
to her first child at the age of ______ or older: - Answer-35
Which of the following reports include names of the surgeon and assistants, date,
duration, and description of the procedure and any specimens removed. - AnswerOperative report
Which answer below is not correct for assignment of the MS-DRG? - Answer-Attending
and consulting physicians
Which of the following documentation must be included in a patient's medical record
prior to performing a surgical procedure? - Answer-Consent for operative procedure,
history, physical examination.
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? -
Answer-25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part
of the: - Answer-Social history
Which of the following is a core ethical obligation of health information staff? - AnswerProtecting patients privacy and confidential communications
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
_____________. - Answer-History record
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? - Answer-Data warehouse
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? - AnswerInclude ancillary clinical and medical staff in the process
Which of the following activities is considered an unethical practice? - AnswerBackdating progress notes
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? - Answer-Request the
physician dictate an addendum to the discharge summary
Mohs micrographic surgery involves the surgeon acting as: - Answer-Both surgeon and
pathologist
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? - Answer-Automatic session
terminations
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 _____________. - Answer-Autoauthentication
What type of standard establishes methods for creating unique designations for
individual patients, healthcare professionals, healthcare provider organizations, and
healthcare vendors and suppliers? - Answer-Identifier standard
When coding a selective catheterization in CPT, how are codes assigned? - AnswerOne code for the final vessel entered
What is the maximum number of procedure codes that can appear on a UB-04 paper
claim form for a hospital inpatient? - Answer-six
In hospitals, automated systems for registering patients and tracking their encounters
are commonly known as _________ systems. - Answer-ADT
Category II codes cover all but one of the following topics. Which is not addressed by
Category II codes? - Answer-New technology
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: - Answer-Appendix G
Per the HIPAA Privacy Rule, which of the following requires authorization for research
purposes? - Answer-Use of Mary's individually identifiable information related to her
asthma treatments
When correcting erroneous information in a health record, which of the following is not
appropriate? - Answer-Use black pen to obliterate the entry
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? - Answer-A fine of not more
than $250.000, not more than 10 years in jail, or both
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? - Answer-Operative report
Which of the following specialized patient assessment tools must be used to Medicarecertified home care providers? - Answer-Outcomes and Assessment Protocol
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? -
Answer-By reviewing all the diagnosis codes assigned to explain the reasons the
services were provided
Under the HIPAA privacy standard, which of the following types of protected health
information (PHI) must be specifically identified in an authorization? - AnswerPsychotherapy notes
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. - Answer-Medical laboratory report
Observation E/M codes (99218 through 99220) are used in physician billing when: -
Answer-A patient is referred to a designated observation service.
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: - AnswerSelective catherization
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. - Answer-30 days/24 hours/48 hours
Which of the following would not be found in a medical history? - Answer-Vital signs
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? - Answer-Develop policies and procedures related
to cutting, copying, and pasting documentation en the EHR system.
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? - Answer-Decline to release the information and contact
the hospital's attorney
What type of standard establishes uniform definitions for clinical terms? - AnswerIdentifier standard
Which of the following is not an accepted accrediting body for behavioral healthcare
organizations? - Answer-American Psychological Association
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? - Answer-inform the committee that according to the Medicare
Conditions of Participation all documentation must be authenticated and dated
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? -
Answer-Schizophrenia
What is the name of the national program to detect and correct improper payments in
the Medicare Fee-for-Service (FFS) programs - Answer-Recovery audit contractors
(RACs)
Where would a coder who needed to locate the histology of a tissue sample most likely
find this information - Answer-Pathology report
What type of organization works under contract with the CMS to conduct Medicare and
Medicaid certification surveys for hospitals? - Answer-State licensure agencies
What diagnosis would the coder expect to see when a patient with pneumonia (PNA)
has inhaled food, liquid, or oil?...
Continues... [Show Less]