Certified Coding Associate (CCA) Exam Preparation 2018- With Rationale With Complete Solut, Exams of Nursing

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Certified Coding Associate (CCA) Exam

Preparation 2018- With Rationale With

Complete Solutions Latest Update

c. Edit checks Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Rinehart-Thompson 2016a, 265). - correct answers A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What data quality or data integrity measures should be in place to ensure that only allowable code numbers are entered? a. Access controls b. Audit trail c. Edit checks d. Password controls b. Delinquent record 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 (Sayles 2016, 65). - correct answers 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 b. Provide an input mask for entering data in the field When several people enter data in an EHR, you can define how users must enter data in specific fields to help maintain consistency. For example, an input mask for a form means that users can only enter the date in a specified format (MacDonald 2010, chapter 4; Carter and Palmer 2016, 506). - correct answers 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)? a. Make admission date a required field b. Provide an input mask for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data a. UHDDS

In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (Oachs and Watters 2016, 223). - correct answers Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is _____. a. UHDDS b. UACDS c. MDS d. ORYX a. Meaning of data Data definition means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent (Sayles 2016, 52). - correct answers Data definition refers to: a. Meaning of data b. Completeness of data

c. Consistency of data d. Detail of data a. Provide the medical records in paper format The covered entity must provide access to the personal health information in the form or format requested when it is readily producible in such form or format. When it is not readily producible in the form or format requested, it must be produced in a readable hard-copy form or such other form or format agreed upon by the covered entity and the individual (Gordon and Gordon 2016b, 615-616).

• correct answers A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the medical records in paper format. How should the hospital respond? a. Provide the medical records in paper format b. Burn another CD because this is hospital policy c. Provide the patient with both paper and CD copies of the medical record d. Review the CD copies with the patient on a hospital computer b. Objective

Objective information may be measured or observed by the healthcare provider (Amatayakul 2016, 294). - correct answers A notation for a diabetic patient in a physician progress note reads: "FBS 110mg%, urine sugar, no acetone." Which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan d. Query the physician as to the method used. 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 2016, 454). - correct answers 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.

d. E-discovery Although e-Discovery is the same pretrial process as discovery, the electronic health record has promoted this concept (Rinehart-Thompson 2016b, 215). - correct answers The Federal Rules of Civil Procedure (FRCP) incorporated the pre-trial process through the creation of: a. Bench warrants b. Court orders c. Depositions d. E-discovery d. Standards Standards are fixed rules that must be followed, which is different from a guideline that provides general direction (Sayles 2016, 66; Brickner 2016, 82). - correct answers Statements that define the performance expectations and structures or processes that must be in place are _____. a. Rules b. Policies c. Guidelines d. Standards b. Information access controls

An EHR can be viewed by multiple users and from multiple locations at any time, and organizations must have in place appropriate security access control measures to ensure the safety of the data (Sayles 2016, 53; Amatayakul 2016, 285 Kellogg 2016b, 482-483). - correct answers 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? a. Audit controls b. Information access controls c. Facility access controls d. Workstation security c. Major diagnostic categories Diagnosis-related groupings (DRGs) are classified by one of 25 major diagnostic categories (MDCs) (Hazelwood and Venable 2016, 224). - correct answers Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values

b. Is information from which personal characteristics have been stripped Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped (Rinehart-Thompson 2016b, 222). - correct answers Deidentified information _____. a. Does identify an individual b. Is information from which personal characteristics have been stripped c. Can be later constituted or combined to re-identify an individual d. Pertains to a person that is identified within the information b. History A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Brickner 2016, 90). - correct answers 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 b. Electronic signature authentication Electronic signature authentication systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval (Sayles 2016, 89). - correct answers This system will require the author to sign onto the system using a user ID and password to complete the entries made. a. Digital dictation b. Electronic signature authentication c. Single sign on technology d. Clinical data repository b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. It is suggested that covered entities use PHI with certain specified direct identifiers removed as a guideline for disclosing only minimum necessary information while providing the amount needed to accomplish the intended purpose (Gordon and Gordon 2016b, 615-616). - correct answers The Medical Record Committee is reviewing the

privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced. b. Beneficence Beneficence means promoting good (Gordon and Gordon, 2016b, 604, 618). - correct answers 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? a. Autonomy b. Beneficence c. Justice

d. Nonmaleficence a. American Psychological Association The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance are all acceptable accrediting bodies for behavioral healthcare settings (Fahrenholz and Russo 2013, 624). - correct answers Which of the following is not an accepted accrediting body for behavioral healthcare organizations? a. American Psychological Association b. Joint Commission c. Commission on Accreditation of Rehabilitation Facilities d. National Committee for Quality Assurance b. Data warehouse A data warehouse is a special type of database that consolidates and stores data from various databases (Oachs and Watters 2016, 998). - correct answers 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? a. Client-server computer b. Data warehouse

c. Local area network d. Internet c. Report of history and physical examination 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 (Fahrenholz and Russo 2013, 238). - correct answers 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 a. Postoperative infection Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2017a, Appendix I). - correct answers 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 postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Postoperative infection b. Appendicitis c. COPD d. Hypertension d. Improved collection of data about nursing care CMS designed ICD-10-PCS with goals to improve coding accuracy, reduce training effort, and improve communication with physicians. It is not used to collect data about nursing care (Giannangelo 2016,124). - correct answers Which of the following purpose and use goals does not apply to ICD-10-PCS? a. Improved accuracy and efficiency of coding b. Reduced training effort c. Improved communication with physicians d. Improved collection of data about nursing care a. 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. For fiscal year 2008, Medicare adopted a severity- adjusted diagnosis-related groups system called Medicare Severity-DRGs (MS-DRGs). This was the most drastic revision to the DRG system in 24 years. The goal of the new MS-DRG system was to significantly improve Medicare's ability to recognize severity of illness in its inpatient hospital payments. The new system is projected to increase payments to hospitals for services provided to the sicker patients and decrease payments for treating less severely ill patients (Schraffenberger 2017, 700). - correct answers What was the goal of the MS-DRG system? a. 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. b. To improve Medicare's capability to recognize poor quality of care and pay hospitals on an incentive grid that allows hospitals to be paid by performance. c. To improve Medicare's capability to recognize groups of data by patient populations, which will further allow Medicare to adjust the hospitals' wage indexes based on the data. This adjustment will be a system to pay hospitals fairly across all geographic locations.

d. To improve Medicare's capability to recognize practice patterns among hospitals that are inappropriately optimizing payments by keeping patients in the hospital longer than the median length of stay. b. Social history Documentation of history of use of drugs, alcohol, and tobacco is considered part of the social history. The review of systems is a part of the history of present illness. See E/M Services Guidelines, instructions for selecting a level of E/M service, in the CPT manual (AMA 2016, 6-10). - correct answers Documentation in the history of use of drugs, alcohol, and tobacco is considered as part of the _____. a. Past medical history b. Social history c. Systems review d. History of present illness b. L Index Rash, diaper, L22 (Schraffenberger 2017, 394). - correct answers Identify the ICD-10-CM code for diaper rash in elderly patient. a. L21.

b. L c. R d. L74. b. Critical access hospitals Critical access hospitals are paid on a cost-based payment system and are not part of the prospective payment system (Kellogg 2016a, 32). - correct answers Which of the following is not reimbursed according to the Medicare outpatient prospective payment system? a. CMHC partial hospitalization services b. Critical access hospitals c. Hospital outpatient departments d. Vaccines provided by CORFs b. CMS-1450 (UB-04) The electronic claim form (screen 837I) replaced the UB- 04 (CMS 1450) paper billing form (Smith 2016, 13-14). - correct answers The electronic claim format (837I) replaces which paper billing form? a. CMS- b. CMS-1450 (UB-04) c. UB-

d. CMS- d. Seventh The seventh character provides information about encounter of care, such as initial encounter, subsequent encounter, or sequelae (Giannangelo 2016, 123). - correct answers Which character in an ICD-10-CM diagnosis code provides information regarding encounter of care? a. Fourth b. Fifth c. Sixth d. Seventh a. Value-based insurance design (VBID) VBID calculates both the benefit and the costs of clinical services (Casto and Forrestal 2015, 78). - correct answers The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost? a. Value-based insurance design (VBID) b. Cost-based reimbursement (CBR)

c. Pay for performance design (PPD) d. Prospective payment system (PPS) a. Selective catheterization If the tip of the catheter is manipulated, it is a selective catheterization. In the case of a nonselective catheterization, the tip of the catheter remains in either the aorta or the artery that was originally entered (AHIMA 2016, 451). - correct answers 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 __________. a. Selective catheterization b. Nonselective catheterization c. Manipulative catheterization d. Radical catheterization d. The identity of the patient's nearest relative and emergency contact number The identity of the patient's nearest relative and an emergency contact number are not relative to securing payment from the insurer. The encounter should include the date of the encounter and the identity of the observer (Smith 2016, 9-10). - correct answers The documentation

of each patient encounter should include the following to secure payment from the insurer except _____. a. The reason for the encounter and the patient's relevant history, physical examination, and prior diagnostic test results b. A patient assessment, clinical impression, or diagnosis c. A plan of care d. The identity of the patient's nearest relative and emergency contact number c. Federal and state confidentiality laws Because federal regulations such as HIPAA and state laws govern the release of health record information, HIM department personnel must know what information needs to be included on the authorization for it to be considered valid (Gordon and Gordon 2016, 615-616). - correct answers The release of information function requires the HIM professional to have knowledge of __________. a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management a. A41.

Index: Sepsis, Staphylococcus, aureus A41.01. Sepsis is the systemic infection. Because the organism is indicated in the sepsis code, B95.61 is redundant and should not be coded (Schraffenberger 2017, 110, 113-116). - correct answers Identify the correct ICD-10-CM diagnosis code(s) for a patient with sepsis due to Staphylococcus aureus. a. A41. b. A41. c. A41.9, B95. d. A41. a. Role-based Role-based access control (RBAC) is a control system in which access decisions are based on the roles of individual users as part of an organization (Brodnik et al. 2012, 304). - correct answers An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system? a. Role-based b. User-based c. Context-based d. Situation-based

b. Monies paid to the healthcare provider cannot exceed charges. The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Hazelwood and Venable 2016, 223-225). - correct answers A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. The patient receives any monies paid by the insurance companies over and above the charges. b. Monies paid to the healthcare provider cannot exceed charges. c. The decision on which company is primary is based on remittance advice. d. The patient should not have a Medicare supplement. b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. Documentation policies are used to define the acceptable practices that should be followed by all applicable staff to ensure consistency, continuity, and clarity in documentation (Brickner 2016, 82-87). - correct answers 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? a. Immediately stop the practice of changing transcribed reports. b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form. c. Conduct a verification audit. d. Alert hospital legal counsel of the practice. a. Unauthorized access to a system Audit trails can provide tracking information such as who accessed which records and for what purpose (Sandefer 2016, 366). - correct answers 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

b. Malware Computer viruses and other malware constitute a threat to data security (Rinehart-Thompson, 2016, 256-258). - correct answers A threat to data security is _____. a. Encryption b. Malware c. Audit trail d. Data quality c. Cost outlier To qualify for a cost outlier, a hospital's charges for a case (adjusted to cost) must exceed the payment rate for the MS-DRG by a specific threshold amount determined by CMS for each fiscal year (Hazelwood and Venable 2016, 225). - correct answers What is the term used when a Medicare hospital inpatient admission results in exceptionally high costs when compared to other cases in the same DRG? a. Rate increase b. Charge outlier c. Cost outlier d. Day outlier

a. Children's 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 (Gordon and Gordon 2016a, 440). - correct answers 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 d. To determine whether standards of care are being met Surveyors review the documentation of patient care services to determine whether the standards for care are being met (Brickner 2016, 82-87). - correct answers 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

d. S79.012D Index Fracture, traumatic, femur, capital epiphyseal. Seventh character is required for further classification of an episode of care and the healing status (Schraffenberger 2017, 565-566). - correct answers Identify the ICD-10-CM code for a patient with a subsequent encounter for routine healing of a closed traumatic capital epiphyseal fracture of the left femur. a. S79.012A b. S79.019D c. M84.452D d. S79.012D d. K00.6 Index either Neonatal, tooth K00.6, or Eruption, teeth/tooth (Schraffenberger 2017, 364-366). - correct answers Identify the ICD-10-CM code(s) for neonatal tooth eruption. a. K01.1 b. K00.6, K08.0 c. K01.0 d. K00.6