Mock CCA (2024/2025) | 100 Questions and Answers Your organization is sending confidential patient information across the Internet using technology that
... [Show More] will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called a. firewall c. a call-back process b. validity processing d. data encryption As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the a. doctor's admitting progress note b. nurse's admit note c. review of systems d. discharge summary Employing the SOAP style of progress notes, choose the "assessment" statement from the following: a. Patient states low back pain with sciatica is as severe as it was on admission b. Patient moving about very cautiously and appears to be in pain c. Adjust pain medication; begin physical therapy tomorrow d. Sciatica unimproved with hot pack therapy You have been hired to work with a computer-assisted coding initiative. The technology that you will be working with is a. electronic data interchange b. intraoperability c. message standards d. natural language processing A final progress note is appropriate as a discharge summary for a hospitalization in which the patient a. dies within 24 hours of admission b. has no comorbidities or complications during this episode of care c. was admitted within 30 days with the same diagnosis d. was an obstetric admission with a normal delivery and no complications In reviewing a medical record for coding purposes, the coder notes that the discharge summary has not yet been transcribed. In its absence, the best place to look for the patient’s response to treatment and documentation of any complications that may have developed during this episode of care is in the a. doctor's progress note section b. operative report c. history and physical d. doctor's orders You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the a. prenatal record b. labor record c. delivery room record d. postpartum record A patient is admitted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? a. "Y" b. "U" c. "W" d. "N" (the DM wasn't considered uncontrolled until 3 days after admission) The special form that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities is the a. interdisciplinary patient care plan b. medical history and review of systems c. interval summary d. problem list What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? a. res ipsa loquitur b. qui tam c. quid pro quo d. respondeat superior Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with a. a copy of the facility coding guidelines, along with written information on improved documentation b. the UHDDS and information on where each data element is collected and/or verified in your facility c. regular in-service presentations on documentation, including its importance and tips for improvement d. feedback on specific instances when improved documentation would improve coding Which of the following diagnoses or procedures would prevent the normal delivery code, 650, from being assigned? a. occiput presentation b. single liveborn c. episiotomy d. low forceps Which of the following are considered late effects regardless of time? a. congenital defect b. nonunion c. nonhealing fracture d. poisoning Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes: 574.10 Calculus of gallbladder with other cholecystitis without mention of obstruction 434.00 Cerebral thrombosis without cerebral infarction V64.1 Surgical or other procedure not carried out because of contraindication b. 574.10, 434.00, V64.1 Some ICD-9-CM codes are exempt from POA reporting because they a. represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury b. are always present on admission c. are both A and B d. represent V codes and E codes Which of these conditions are always considered "present on admission" (POA)? a. congenital conditions b. E codes c. acute conditions d. possible, probable, or suspected conditions When coding multiple wound repairs in CPT, a. only the most complex repair is reported b. only the least complex repair is reported c. up to nine individual repair codes may be reported d. all wound repairs are coded with the most complex reported first Which of the following is vital for determining why the reimbursement from an insurance company is less than that which was expected? a. a CPT codebook b. the remittance advice c. talking to the patient d. knowledge of the individual insurance company's policies Four people were seen in your Emergency Department yesterday. Which one will be coded as a poisoning? Robert: diagnosed with digitalis intoxication Gary: had an allergic reaction to a dye administered for a pyelogram David: developed syncope after taking Contac pills with a double scotch Brian: had an idiosyncratic reaction between two properly administered prescription drugs a. Robert b. Gary c. David d. Brian Present on Admission (POA) indicators apply to a. inpatient reporting of diagnosis codes b. outpatient reporting of procedure codes c. inpatient reporting of diagnosis and procedure codes d. outpatient reporting of diagnosis and procedure codes Using the ICD-10-CM code structure, which of the following would be used for "right upper quadrant abdominal tenderness"? a. 108.11 b. R10811.11 c. R10.811 d. 1.0811 Which of the following scenarios identifies a pathologic fracture? a. greenstick fracture secondary to fall from a bed b. compression fracture of the skull after being hit with a baseball bat c. vertebral fracture with cord compression following a car accident d. compression fracture of the vertebrae as a result of bone metastasis All of the following signs/symptoms suggest gram-negative pneumonia EXCEPT a. fever b. patchy infiltrate c. purulent sputum d. decreased leukocyte count During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the V code for sterilization, V25.2 is a. not used b. used and sequenced as the principal diagnosis c. used and sequenced as a secondary diagnosis d. the only code used Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data a. Accuracy b. Validity c. integrity d. quality Which of the following statements is true? a. A surgical procedure may include one or more surgical operations. b. The terms surgical operation and surgical procedure are synonymous. c. A surgical operation may include one or more surgical procedures. d. The term surgical procedure is an incorrect term and should not be used. Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called a. data translators b. passwords c. data manipulation engines d. firewalls The Joint Commission requires that all medical records be completed within ____________following patient discharge. a. 30 days b. 14 days c. 7 days d. 90 days You are conducting and educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to a. implement your QI process b. make recommendations for improvement to the other department or organization c. improve your department's processes d. compare your department with another Which of the following procedures can be identified as "destruction" of lesions? a. removal of skin tags b. shaving of skin lesion c. laser removal of condylomata d. paring of hyperkeratotic lesion A ________ is a collection of information or data that is organized in such a way that its contents can be queried and relationships created. a. database b. field c. record d. table Staging a. refers to the monitoring of incidence and trends associated with a disease b. is continued medical surveillance of a case c. is a system for documenting the extent or spread of cancer d. designates the degree of differentiation of cells Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? a. primary diagnosis b. principal diagnosis c. significant diagnosis d. admitting diagnosis Which of the following would NOT require HCPCS/CPT codes? a. hospital ambulatory surgery visit b. hospital outpatient visit c. clinic visit d. hospital inpatient procedure Patient was seen in the emergency department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. 12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/ or extremities (including hands and feet); 2.6 cm to 7.5 cm 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/ or extremities (including hands and feet); 7.6 cm to 12.5 cm 12035 Layer closure of wounds of scalp, axillae, trunk, and / or extremities (excluding hands and feet); 12.6 cm to 20 cm. 12045 Layer closure of wounds of neck, hands, feet, and / or genitalia; 12.6 cm to 20 cm Patient was seen for excision of two interdigital neuroma from the left foot 28080 Excision, interdigital (Morton) neuroma, single, each 64774 Excision of neuroma; cutaneous nerve, surgically identifiable 64776 Excision of neuroma; digital nerve, one or both, same digit 28080 x 2 Excision, interdigital (Morton) neuroma, single, each Patient was seen today for regular hemodialysis. No problems reported; patient tolerated procedure well. 90935 Hemodialysis procedure with single physician evaluation 90937 Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription 90945 Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation 99354 Basic life and/or disability examination that includes completion of a medical history following a life insurance pro forma Office visit for 43-year old male, new patient, with no complaints. Patients is applying for life insurance and requests a physical examination. A detailed health and family history was obtained, and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected. 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, new patient; infant (age under 1 year) 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient; 40 -64 years. 99450 Basic life and/or disability examination that includes completion of a medical history following a life insurance pro forma A quantitative drug assay was performed for a patient to determine digoxin level. 80050 General health panel 80101 Drug screen, qualitative; single drug class method (e.g. Immunoassay, enzyme assay), each drug class 80162 Digoxin (therapeutic drug assay, quantitative examination) 80166 Doxepin (therapeutic drug assay, quantitative examination) Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker. 00530 Anesthesia for permanent transvenous pacemaker insertion 00560 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 33202 Insertion of epicardial electrode(s); by open incision [Show Less]