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CCA Practice Test | (2026) Certified Coding Associate Questions PDF, Exams of Medical Records

University of Cincinnati (UC)Medical Records

INSTANT PDF DOWNLOAD – CCA Exam Preparation Domains 1–6 Practice Test with verified questions and answers covering ICD-10-CM/PCS coding, CPT coding, reimbursement methodologies, health records, compliance, healthcare data management, anatomy and physiology, and AHIMA Certified Coding Associate (CCA) certification preparation. CCA practice test, CCA exam questions, Certified Coding Associate exam, CCA domains 1 6, AHIMA CCA practice exam, ICD-10-CM coding questions, ICD-10-PCS coding practice, CPT coding exam prep, medical coding certification, health information management, coding compliance questions, reimbursement methodologies, diagnosis coding practice, procedure coding questions, AHIMA certification review, inpatient coding exam, outpatient coding exam, coding associate study guide, medical records coding, healthcare data management, coding exam PDF, coding certification questions, CCA review questions, coding practice answers,

Typology: Exams

2025/2026

Available from 06/03/2026

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CCA Exam Preparation Questions and Answers
2026 - 2027 (100% Verified )
1. 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 tran- scription. 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
>>> Develop a facility policy that defines the acceptable period of time allowed for a
transcribed document to remain in a draft form.
2. What is the basic formula for calculating each MS-DRG hospital pay- ments
>>> Hospital payment = DRG relative weight x hospital base rate
3. Which of the following activities would be in violation of AHIMA's Code of Ethics
>>> Coding an intentionally inappropriate level of service
4. What is abstracting >>> Compiling the pertinent information from the medical
record based on predetermined data sets
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Download CCA Practice Test | (2026) Certified Coding Associate Questions PDF and more Exams Medical Records in PDF only on Docsity!

CCA Exam Preparation Questions and Answers

2026 - 2027 (100% Verified )

  1. During an audit of health records, the HIM director finds that transcribedreports are being changed by the author up to a week after initial tran- scription. 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 shouldrecommend which of the following >>> Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in a draftform.
  2. What is the basic formula for calculating each MS-DRG hospital pay-ments >>> Hospital payment = DRG relative weight x hospital base rate
  3. Which of the following activities would be in violation of AHIMA's Code ofEthics >>> Coding an intentionally inappropriate level of service
  4. What is abstracting >>> Compiling the pertinent information from the medical record based on predetermined data sets
  1. ICD-9-CM defines the "newborn period" as birth through the day following birth.: 28 th
  2. What healthcare organization collects UHDDS data >>> All non-outpatient set- tings including acute care, short term care, long term care, an psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing home.
  3. 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 >>> Edit checks
  4. 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 twofunctions are>>> Use and disclosure
  5. Who is responsible for writing and signing discharge summaries and discharge instructions >>> Attending physician

nonessential modifier, and all three volumes of ICD-9-CM use them.: Paren-theses ( )

  1. What is the name of the organization that develops the billing form that hospitals are required to use >>> National Uniform Billing Committee (NUBC)
  2. Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those whohave a legal right to access it >>> Beneficence 14. 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 whosay that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest >>> Avoid displayingthe number on any document, screen, or data collection field.
  3. Both HEDIS and the Joint Commission's ORYX program are designedto collect data to be used for .: Performance improvement programs
  1. Which of the following would be classified to an ICD-9-CM category forbacterial diseases >>> Staphylococcus aureous
  2. 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 patientwas 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 >>> Postoperative infection
  3. CPT was developed and is maintained by>>> AMA
  4. Which organization developed the first hospital standardization pro-gram >>> American College of Surgeon
  5. 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 >>> Determine what information was printed and why

made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases.

  1. The is a type of coding that is a natural outgrowth of the electronic heath record.: Computer-assisted coding
  2. Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable >>> No, it is a violation of the HIPAA Privacy rule
  3. Which of the following would be the best technique to ensure that regis- tration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR) >>> Provide an input mask for entering data in the field
  4. What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard >>> Comply withboth the state law and the HIPAA Standard
  5. An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential in- formation about neighbors and friends. What security mechanisms should be implemented to prevent this security breach >>> Information access controls
  6. According to ICD-9-C.M, an elderly primigravida is defined as a womanwho gives birth to her first child at the age of or older>>> 35
  7. Which of the following reports include names of the surgeon and assis-tants, date, duration, and description of the procedure and any specimens removed.:

Operative report

  1. Which answer below is not correct for assignment of the MS-DRG >>> At- tending and consulting physicians
  2. Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure >>> Consent for opera-tive procedure, history, physical examination.
  3. What is the maximum number of diagnosis codes that can appear on the UB- paper claim form locator 67 for a hospital inpatient principle andsecondary diagnoses >>> 25
  4. Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the>>> Social history
  5. Which of the following is a core ethical obligation of health informationstaff >>> Protecting patients privacy and confidential communications

associated with this practice. Which of the following would bebest to ensure that data breaches are minimized when the home computer is unattended >>> Automatic session terminations

  1. 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 .: Autoauthentication
  2. What type of standard establishes methods for creating unique designa-tions for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers >>> Identifier standard
  3. When coding a selective catheterization in CPT, how are codes as-signed >>> One code for the final vessel entered
  4. What is the maximum number of procedure codes that can appear on aUB- paper claim form for a hospital inpatient >>> six
  1. In hospitals, automated systems for registering patients and trackingtheir encounters are commonly known as systems.: ADT
  2. Category II codes cover all but one of the following topics. Which is not addressed by Category II codes >>> New technology
  3. 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>>> Appendix G
  4. Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes >>> Use of Mary's individually identifiable information relat- ed to her asthma treatments
  5. When correcting erroneous information in a health record, which of the following is not appropriate >>> Use black pen to obliterate the entry
  6. 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 >>> Afine of not more than $250.000, not more than 10 years in jail, or both
  7. The clinical statement, "microscopic sections of the gallbladder revealsa surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form >>> Operative report
  8. Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers >>> Outcomes and AssessmentProtocol
  9. How does Medicare or other third-party payers determine whether the patient
  1. Observation E/M codes (99218 through 99220) are used in physician billing when>>> A patient is referred to a designated observation service.
  2. In coding arterial catheterizations, when the tip of the catheter is manip- ulated from the insertion into the aorta and then out into another artery, this is called>>> Selective catherization
  3. The discharge summary must be completed within after dis- charge 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.: 30 days/24 hours/ hours
  4. Which of the following would not be found in a medical history >>> Vital signs
  5. 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 arecopying and pasting the objective data from the lab system and intake-out-put records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following shouldthe HIM director do to ensure the nurses are following acceptable documen-tation practices >>> Develop policies and procedures related to cutting, copying, and pasting documentation en the EHR system.
  6. 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 protectivecustody by the Office

of Child Protection because of suspected child abuseby 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 >>> Decline to release the information and contact the hospital'sattorney

62. What type of standard establishes uniform definitions for clinical terms?- : Identifier standard

  1. Which of the following is not an accepted accrediting body for behavioral healthcare organizations >>> American Psychological Association 64. 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

in obtaining acceptable alignment, what type of code should beassigned for the procedure >>> A "with manipulation"code

  1. What was the goal of the new MS-DRG system >>> 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 providedto sicker patients and decrease payments for treating less severely ill patients.
  2. 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 >>> AIDS
  3. Tissue transplated from one individual to another of the same species but different genotype is called a(n)>>> Allograft or allogeneic graft
  4. Per CPT guidelines, a separate procedure is>>> Considered to be an integralpart of another, larger procedure
  1. A Revenue code is>>> A four digits number used for medicare billing.
  2. The diagnostic statement indicates the patient has metastatic carcinomato the bone. This side is consider to be>>> Secondary
  3. What is the purpose of quantitative analysis performed by him profes-sionals.: Review the record for completeness.
  4. A patient is admitted with HIV and a related condition, the principal diagnosis is>>> HIV
  5. The principal diagnosis is defined as>>> The condition after study that causedthe admission of the patient to the hospital for care.
  6. What are two partitions that each major diagnostic category is dividedinto based on the patient's treatment >>> Medical & Surgical.
  7. The purpose of a fee schedule is to>>> Provide a list of services and proce-dures and charges related to each.
  8. The Medicare inpatient prospective payment system reimburses facilitiesfor the treatments of medicare beneficiaries who are.: admitted to inpatient status in an acute care facility.
  9. Medicare - Severity Diagnosis-Related Groups (MS-DRG) are defined as>>> A reimbursement system that categorizes patients w/related diagnosis andtreatment and length to stay.
  10. The acronym APC represents >>> Ambulatory Payment Classifications
  11. The primary purpose of the chargemaster: Accurately charge for routineservices
  1. According to UHDDS guidelines the condition established after studyto be chiefly responsible for admission of the patient to the hospital is the>>> Principal Diagnosis. 91. The Uniform Hospital Discharge Data Set (UHDDS) was developed to>>> - Improve the consistency and comparability of healthcare data.
  2. A patient with bradycardia has a heartbeat that is: Slow
  3. When reporting privacy violations an employee should first>>> Speak withthe immediate supervisor.
  4. Which of the following grants accreditation to acute care hospitals whenthey are found to be in compliance with published standards >>> The Join Commission.
  5. According to the Join Commission standards for documentation, what is the surgeon's time-frame for dictating an operative report >>> immediatelyfollowing surgery.
  6. Which of the following is an unacceptable documentation practice in apatient's health record >>> Backdating progress notes after a patient discharge
  7. Elements of coding quality include reliability, completeness, timelessand: consistency
  8. Which of the following is a review able sentinel event according to thejoint commission >>> An operation on the wrong side of the patient body.
  9. The portion of the health record that is disclosed upon request to partiesoutside the organization is known as the>>> Personal health record
  1. Federal regulations which govern the form and content of acute carehealth records are known as the: HIPPA policies
  2. Which of the following computer peripherals is an input device >>> Scan-ner
  3. The master program that resides in RAM ( random access memory) while the computer is on and manage the basic of the computer is knowsthe computer's ..: Operating System
  4. What is the major purpose of a database: Store and retrieve data
  5. Which of the following is a storage device utilized in information sys-tem >>> Hard disk drive
  6. Which of the following is an input device for hardware used in informa-tion system >>> Keyboard