CCA Exam Preparation With Complete Solutions Latest Update, Exams of Nursing

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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? - correct answers 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? - correct answers Hospital payment = DRG relative weight x hospital base rate Which of the following activities would be in violation of AHIMA's Code of Ethics? - correct answers Coding an intentionally inappropriate level of service What is abstracting? - correct answers 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. - correct answers 28th What healthcare organization collects UHDDS data? - correct answers 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? - correct answers 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: - correct answers Use and disclosure Who is responsible for writing and signing discharge summaries and discharge instructions? - correct answers Attending physician Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? - correct answers Psychotherapy 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. - correct answers Parentheses ( ) What is the name of the organization that develops the billing form that hospitals are required to use? - correct answers 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? - correct answers 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? - correct answers 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 ______________. - correct answers Performance improvement programs Which of the following would be classified to an ICD-9-CM category for bacterial diseases? - correct answers 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? - correct answers Postoperative infection CPT was developed and is maintained by: - correct answers AMA Which organization developed the first hospital standardization program? - correct answers American 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? - correct answers 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? - correct answers 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. - correct answers 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? - correct answers 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)? - correct answers 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? - correct answers 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? - correct answers 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: - correct answers 35 Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. - correct answers Operative report Which answer below is not correct for assignment of the MS-DRG? - correct answers Attending and consulting physicians

Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? - correct answers 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? - correct answers 25 Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: - correct answers Social history Which of the following is a core ethical obligation of health information staff? - correct answers Protecting 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 _____________. - correct answers 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? - correct answers 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? - correct answers Include ancillary clinical and medical staff in the process Which of the following activities is considered an unethical practice? - correct answers Backdating 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? - correct answers Request the physician dictate an addendum to the discharge summary Mohs micrographic surgery involves the surgeon acting as: - correct answers 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? - correct answers 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 _____________. - correct answers Autoauthentication What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? - correct answers Identifier standard When coding a selective catheterization in CPT, how are codes assigned? - correct answers One 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? - correct answers six In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems. - correct answers ADT

Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? - correct answers 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: - correct answers Appendix G Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? - correct answers 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? - correct answers 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?

• correct answers 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? - correct answers Operative report Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers? - correct answers 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? - correct answers 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? - correct answers Psychotherapy 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. - correct answers Medical laboratory report

Observation E/M codes (99218 through 99220) are used in physician billing when: - correct answers 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: - correct answers Selective 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. - correct answers 30 days/24 hours/48 hours Which of the following would not be found in a medical history? - correct answers 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? - correct answers 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? - correct answers Decline to release the information and contact the hospital's attorney What type of standard establishes uniform definitions for clinical terms? - correct answers Identifier standard Which of the following is not an accepted accrediting body for behavioral healthcare organizations? - correct answers 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? - correct answers 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? - correct answers Schizophrenia What is the name of the national program to detect and correct improper payments in the Medicare Fee-for- Service (FFS) programs - correct answers Recovery audit contractors (RACs) Where would a coder who needed to locate the histology of a tissue sample most likely find this information - correct answers Pathology report What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification

surveys for hospitals? - correct answers State licensure agencies What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil? - correct answers Aspiration pneumonia 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? - correct answers A "with manipulation"code What was the goal of the new MS-DRG system? - correct answers To improve Medicare's capability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients. 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? - correct answers AIDS Tissue transplated from one individual to another of the same species but different genotype is called a(n): - correct answers Allograft or allogeneic graft

Per CPT guidelines, a separate procedure is: - correct answers Considered to be an integral part of another, larger procedure A Revenue code is: - correct answers A four digits number used for medicare billing. The diagnostic statement indicates the patient has metastatic carcinoma to the bone. This side is consider to be: - correct answers Secondary What is the purpose of quantitative analysis performed by him professionals. - correct answers Review the record for completeness. A patient is admitted with HIV and a related condition, the principal diagnosis is: - correct answers HIV The principal diagnosis is defined as: - correct answers The condition after study that caused the admission of the patient to the hospital for care. What are two partitions that each major diagnostic category is divided into based on the patient's treatment?

• correct answers Medical & Surgical.

The purpose of a fee schedule is to: - correct answers Provide a list of services and procedures and charges related to each. The Medicare inpatient prospective payment system reimburses facilities for the treatments of medicare beneficiaries who are. - correct answers admitted to inpatient status in an acute care facility. Medicare - Severity Diagnosis-Related Groups (MS-DRG) are defined as: - correct answers A reimbursement system that categorizes patients w/related diagnosis and treatment and length to stay. The acronym APC represents? - correct answers Ambulatory Payment Classifications The primary purpose of the chargemaster - correct answers Accurately charge for routine services and supplies. How many APC, may be assigned to a medicare beneficiary who is treated during an outpatient encounter at a hospital? - correct answers 0 an unlimited of APC per encounter

There are many important tools available for coders to aid in the correct reporting of codes. One of these is the LCD. LCD stand for: - correct answers Local coverage determinations. A medicare beneficiary who is treated during an outpatient encounter at a hospital may have a combination of payments paid to the facility including ambulatory payment classification (APC) system and. - correct answers payment based on various fee schedules such as.. An example of unethical coding practice is - correct answers Selecting codes that will by pass a particular edit According to UHDDS guidelines the condition established after study to be chiefly responsible for admission of the patient to the hospital is the: - correct answers Principal Diagnosis. The Uniform Hospital Discharge Data Set (UHDDS) was developed to: - correct answers Improve the consistency and comparability of healthcare data. A patient with bradycardia has a heartbeat that is - correct answers Slow

When reporting privacy violations an employee should first: - correct answers Speak with the immediate supervisor. Which of the following grants accreditation to acute care hospitals when they are found to be in compliance with published standards? - correct answers The Join Commission. According to the Join Commission standards for documentation, what is the surgeon's time-frame for dictating an operative report? - correct answers immediately following surgery. Which of the following is an unacceptable documentation practice in a patient's health record? - correct answers Backdating progress notes after a patient discharge Elements of coding quality include reliability, completeness, timeless and - correct answers consistency Which of the following is a review able sentinel event according to the joint commission? - correct answers An operation on the wrong side of the patient body.

The portion of the health record that is disclosed upon request to parties outside the organization is known as the: - correct answers Personal health record Federal regulations which govern the form and content of acute care health records are known as the - correct answers HIPPA policies Which of the following computer peripherals is an input device? - correct answers Scanner The master program that resides in RAM ( random access memory) while the computer is on and manage the basic of the computer is knows the computer's .. - correct answers Operating System What is the major purpose of a database - correct answers Store and retrieve data Which of the following is a storage device utilized in information system? - correct answers Hard disk drive Which of the following is an input device for hardware used in information system? - correct answers Keyboard

The concept of "minimum necessary" included in the Health Insurance Portability and Accountability Act (HIPAA) mean that healthcare provider must - correct answers limit, use, access, and disclosure to the minimum necessary to accomplish the intended purpose. Up coding is defined as - correct answers increasing the number of codes assigned Which of the following services would not be packaged into the ambulatory payment classification (APC) payment for a patient who had outpatient day surgery at the hospital - correct answers most pharmaceutical drug Which of the following is not considered sensitive health information that requires special attention concerning the confidentiality of the health information - correct answers Pregnancy testing According to the AHIMA standards of ethical coding, which of the following activities is the responsibility of an ethical coder? - correct answers Changes codes on a claim form at the request In which setting may treatment records travel with the patient between treatment centers? - correct answers Correctional facility care

A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case. - correct answers Metastatic carcinoma of the brain In long-term care, the resident's care plan is based on data collected in the _____________. - correct answers MDS Version 3.0 Data definition refers to _________. - correct answers meaning of data Dr. Smith sees his patient, Bob Jones, in the nursing home where he has resided for 11 months. Bob is stable and happy, and Dr. Smith performs an annual physical examination and completes the minimum data set instrument. He performs and documents a detailed interval history, comprehensive examination, and performs medical decision making of low complexity. Assign the appropriate CPT code. - correct answers 99318

Which of the following is the planned replacement for ICD-9-CM Volumes 1 and 2? - correct answers International Classification of Diseases, Tenth Revision, Clinical Modification A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? - correct answers Complication of spontaneous abortion with sepsis A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case - correct answers Hematuria; adverse reaction to Coumadin The following is documented in an acute care record: "I was asked to evaluate this Level I trauma patient with an open left humeral epicondylar fracture. Recommendations: Proceed with urgent surgery for debridement, irrigation, and treatment of open fracture." In which of the following would this documentation appear? - correct answers Admission note Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? -

correct answers Centers of Medicare and Medicaid Services (CMS) Which of the following statements represents an example of nonmaleficence? - correct answers HITs must ensure that patient-identifiable information is not released to unauthorized parties. The ______ mandated the development of standards for electronic medical records. - correct answers Health Insurance Portability and Accountability Act (HIPAA) of 1996 Which of the following provides the most comprehensive controlled vocabulary for coding the content of a patient record? - correct answers SNOMED CT To be in compliance with HIPAA regulations, a hospital would make its membership in a RHIO known to its patients through which of the following? - correct answers Notice of Privacy Practices A 65-year-old woman is admitted to the hospital. She was diagnosed with septicemia secondary to staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment?

1. 038.8, 562.11, 789.00

2. 038.11, 562.11

3. 038.8, 562.11, 041.11

4. 038.9, 562.11 - correct answers 2. 038.11, 562.11 According to the UHDDS, which of the following is the definition of "other diagnoses"? - correct answers 3. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and/or monitoring. Which of the following contains the physician's findings based on an examination of the patient? - correct answers Physical exam Identify the correct diagnosis code(s) for adenoma of adrenal cortex with Conn's syndrome.
5. 227.0, 255.12
6. 227.0
7. 255.12
8. 225.12, 227.8 - correct answers 1. 227.0,255.12 The Uniform Health Care Decisions Act ranks the next-of- kin in the following order for medical decision-making purposes - correct answers Spouse; adult child; parent; adult sibling