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EXAM 2 AHIMA CCA 2025/ 2026
QUESTIONS & ANSWERS| GRADE A| 100%
CORRECT (VERIFIED SOLUTIONS)
Data safety policies and tactics ought to be reviewed at least: a. Semi-yearly b. Annually c. Every two years d. Quarterly - ANSCorrect Answer: B All information safety regulations and techniques have to be reviewed and evaluated as a minimum every year to ensure they may be up-to-date and nonetheless applicable to the employer (Johns 2011, 995).
Identify the right ICD- 9 - CM diagnosis code(s) for a patient with close to-syncope event and nausea. A. 780. b. 780.2, 787. c. 780.2, 787. d. 780.4, 787.02 - ANSCorrect Answer: B Near-syncope and nausea are both symptoms and signs and therefore now not indispensable to the other. Both conditions should be coded (Hazelwood and Venable 2012, 71).
The codes within the musculoskeletal segment of CPT can be utilized by: a. Orthopedic surgeons handiest b. Orthopedic surgeons and emergency branch physicians c. Any physician
d. Orthopedic surgeons and neurosurgeons - ANSCorrect Answer: C Any doctor may additionally use the codes in any section of CPT (AHIMA 2012a, 587). Four. In an EHR, what's the threat of copying and pasting? A. Reduction within the time required to document b. The system not recording who entered the information c. Quicker ordinary machine response time d. System wondering that the original documenter recorded the be aware - ANSCorrect Answer: B The system not recording who entered the records (Johns 2011, 433). Five. Mr. Smith is seen in his number one care doctor's office for his annual bodily examination. He has a digital rectal examination and is given 3 small playing cards to take domestic and go back with fecal samples to display screen for colorectal most cancers. Assign an appropriate CPT code to file this occult blood sampling. A. 82270 b. 82271 c. 82272 d. 82274 - ANSCorrect Answer: A CPT code 82270 describes a take a look at for occult blood the use of feces supply for the cause of neoplasm screening with the usage of three playing cards or unmarried triple card for consecutive series (AMA 2012b, 417).
Identify the punctuation mark this is used to complement phrases or explanatory facts that could or won't be gift in the assertion of a analysis or system in ICD- 9 - CM coding. The punctuation does now not have an effect on the code number assigned to the case. The punctuation is taken into consideration a nonessential modifier, and all three volumes of ICD- 9 - CM use them. A. Parentheses ( )
Nine. What is the most wide variety of diagnosis codes that can appear at the UB- 04 paper claim shape locator 67 for a clinic inpatient most important and secondary diagnoses? A. 35 b. 25 c. 18 d. 9 - ANSCorrect Answer: B As of January 1, 2011, CMS lets in a complete of 25 ICD- 9 - CM diagnosis codes (one primary and 24 additional diagnoses) for 837 Institutional claims filing (Schraffenberger 2012, sixty six).
What type of general establishes methods for growing particular designations for individual patients, healthcare professionals, healthcare issuer groups, and healthcare providers and providers? A. Vocabulary standard b. Identifier wellknown c. Structure and content standard d. Security fashionable - ANSCorrect Answer: B Identifier requirements set up methods for assigning a completely unique identifier to person patients, healthcare professionals, healthcare company groups, and healthcare carriers and suppliers (Odom-Wesley et al. 2009, 311). Eleven. Identify the correct ICD- 9 - CM prognosis code for a affected person with anterolateral wall myocardial infarction, preliminary episode. A. 410.Eleven b. 410. c. 410. d. 410.12 - ANSCorrect Answer: B
Index Infarction, myocardium, anterolateral (wall) with 5th digit for initial episode (Schraffenberger 2012, 26-28).
A patient has medical insurance guidelines: Medicare and a Medicare complement. Which of the following statements is true? A. The patient receives any monies paid through the coverage corporations over and above the costs. B. Monies paid to the healthcare company can't exceed fees. C. The selection on which employer is primary is primarily based on remittance advice. D. The affected person must now not have a Medicare complement. - ANSCorrect Answer: B The monies accrued from 1/3-birthday celebration payers can't be greater than the quantity of the company's costs (Johns 2011, 343). Thirteen. Identify the ICD-nine-CM diagnosis code(s) for uncontrolled kind II diabetes mellitus; mild malnutrition. A. 250. b. 250.01, 263. c. 250.02, 263. d. 250.01, 263.Zero - ANSCorrect Answer: C Diabetes (with out difficulty) with 5th digit of two = kind II, uncontrolled. 263.1 Malnutrition, slight, not stated as related to diabetes (Schraffenberger 2012, 122-124).
Identify an appropriate sequence and ICD-nine-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago. A. 709. b. 906. c. 709.2, 906.
c. Nurse's notes d. Operative record - ANSCorrect Answer: A Histology refers to the tissue type of a lesion. The histology of tissue is determined by a pathologist and documented in the pathology report (Johns 2011, seventy seven).
A affected person with known COPD and high blood pressure under remedy became admitted to the health facility with signs of a lower belly pain. He undergoes a laparoscopic appendectomy and develops a fever. The affected person changed into eventually discharged from the clinic with a most important diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and high blood pressure. Which of the subsequent diagnoses ought to not be tagged as POA? A. Postoperative contamination b. Appendicitis c. COPD d. Hypertension - ANS**Correct Answer: A Present on admission is described as present at the time the order for inpatient admission occurs (CMS 2011c, 97).
A health facility desires to recognise how tons Medicare paid on a claim that allows you to invoice the secondary coverage. What have to the hospital consult with? A. Explanation of blessings b. Medicare Summary Notice c. Remittance recommendation d. Coordination of benefits - ANSCorrect Answer: C Remittance advice (RA) is sent to the company to provide an explanation for bills made by means of 1/3-celebration payers (Johns 2011, 346).
Which of the following would be the quality method to ensure that registration clerks constantly use the precise notation for assigning admission date in an digital fitness report (EHR)?
A. Make admission date a required area b. Provide an enter mask for entering statistics inside the field c. Make admission date a numeric discipline d. Provide sufficient area for enter of records - ANSCorrect Answer: B When several humans input facts in an EHR, you could define how customers have to input information in specific fields to assist keep consistency. For instance, an input masks for a shape method that customers can best enter the date in a particular layout (MacDonald 2007, bankruptcy four).
Which of the following threatens the "want-to-know" precept? A. Backdating development notes b. Blanket authorization c. HIPAA regulations d. Surgical consent - ANSCorrect Answer: B A blanket authorization is a common ethical problem while misused. Patients regularly signal a blanket authorization, which authorizes the discharge of data from that point ahead, with out know-how the results. The problem is the patient isn't privy to what data is being accessed (Johns 2011, 778-779).
A charge schedule is: a. Developed by means of third-birthday celebration payers and includes a listing of healthcare services, techniques, and fees related to each b. Developed by way of carriers and includes a list of healthcare services provided to a patient c. Developed with the aid of 1/3-celebration payers and includes a list of healthcare offerings provided to a affected person d. Developed through vendors and lists fee codes - ANSCorrect Answer: A
A. Patient control b. New generation c. Therapeutic, preventative, or other interventions d. Patient protection - ANSCorrect Answer: B New technology is addressed by the Category III codes (AHIMA 2012a, 584).
The health facility is revising its coverage on clinical document documentation. Currently, all entries in the scientific report should be legible, complete, dated, and signed. The committee chairperson desires to upload that, in addition, all entries should have the time referred to. However, another clinician suggests that adding the time of notation is difficult and seldom can be correct for the reason that non-public watches and medical institution clocks may not be coordinated. Another committee member consents and says best electronic documentation wishes a time stamp. Given this discussion, which of the subsequent might the HIM director advise? A. Suggest that only health center clock time be stated in scientific documentation b. Suggest that most effective electronic documentation have time referred to c. Inform the committee that consistent with the Medicare Conditions of Participation, all documentation should be authenticated and dated d. Inform the committee that consistent with the Medi - ANSCorrect Answer: C All entries must be legible and complete, and should be authenticated and dated promptly by the character (recognized with the aid of name and field) who's answerable for ordering, providing, or comparing the provider furnished (forty two CFR 482.24).
How are amendments dealt with in an EHR? A. Automatically appended to the authentic word; no additional signature is required. B. Amendments must be entered by means of the same individual because the unique note. C. Amendments can not be entered after 24 hours of the occasion's prevalence. D. The modification ought to have a separate signature, date, and time. - ANSCorrect Answer: D
The addendum ought to have a separate signature, date, and time from the original entry (Johns 2011, 437).
What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the cause to promote, transfer, or use PHI for business benefit, personal benefit, or malicious harm? A. A nice of not more than $10,000 handiest b. A quality of not extra than $10,000, now not extra than 1 year in jail, or each c. A pleasant of not greater than $five,000 only d. A pleasant of not greater than $250,000, no longer more than 10 years in prison, or both - ANSCorrect Answer: D When a person or entity willfully and knowingly violates the HIPAA Privacy Rule, a high-quality of not extra than $250,000, now not greater than 10 years in prison, or each can be imposed (LaTour and Eichenwald Maki 2010, 292).
Which of the subsequent reports includes names of the physician and assistants, date, duration and outline of the system, and any specimens removed? A. Operative record b. Anesthesia report c. Pathology report d. Laboratory document - ANSCorrect Answer: A An operative file describes the surgical approaches carried out on the patient (Johns 2011, 73).
A provision of the regulation that hooked up the aid-based relative fee scale (RBRVS) stipulates that refinements to relative fee units (RVUs) need to hold: a. Moderate price increases b. Market basket will increase
c. 041. d. 041.Forty nine, 599.Zero - ANSCorrect Answer: B Connecting words or connecting phrases are subterms that suggest a relationship among the main term and an related circumstance or etiology within the Alphabetic Index. The connecting term "due to" connects the organism E. Coli to the urinary tract infection. The instructional observe "Use extra code" is determined within the Tabular List of ICD- 9 - CM. This notation indicates that use of an extra code might also provide a extra entire picture of the prognosis or method. The additional code must constantly be assigned if the fitness file gives supportive documentation. Infection, urinary (tract) Tabular List—use additional code to perceive organism. Infection, Escherichia coli (Schraffenberger 2012, 22-23, seventy nine).
What is it referred to as when a Medicare health center inpatient admission consequences in highly high fees while in comparison to other instances within the identical DRG? A. Rate increase b. Charge outlier c. Cost outlier d. Day outlier - ANSCorrect Answer: C To qualify for a value outlier, a medical institution's charges for a case (adjusted to value) have to exceed the payment charge for the MS-DRG via a selected threshold quantity determined with the aid of CMS for each financial year (Johns 2011, 374).
Health coverage for spouses, kids, or both is known as: a. Dependent (family) insurance b. Individual (single) coverage c. Group insurance d. Inclusive coverage - ANSCorrect Answer: A Health coverage for spouses, children, or each is known as dependent (own family) insurance (Casto and Layman 2011, 5).
In a habitual fitness file quantitative analysis assessment, it changed into determined that a medical doctor dictated a discharge summary on 1/26/20XX. The patient, but, became discharged days later. In this case, what will be the first-rate direction of movement? A. Request that the doctor dictate every other discharge precis. B. Have the record analyst observe the date discrepancy. C. Request the medical doctor dictate an addendum to the release summary. D. File the file as complete because the release precis consists of all the pertinent patient records. - ANSCorrect Answer: C An addendum may be protected within the medical record to replace or complement documentation that has been recorded (AHIMA 2008b, eighty three-88).
Observation E/M codes (99218-99220) are utilized in doctor billing while: a. A patient is admitted and discharged at the identical date. B. A affected person is admitted for habitual nursing care following surgical operation. C. A patient does not meet admission standards. D. A affected person is referred to a delegated observation fame. - ANSCorrect Answer: D See instructional notes preceding code 99217. In order to file those codes, the admission order must designate statement repute. Whether the patient meets admission standards or is admitted following surgery does no longer affect the remark code choice. If the affected person is admitted and discharged on the same date, codes 99234 - 99236 are appropriate (AMA 2012b, thirteen).
When coding a selective catheterization in CPT, how are codes assigned? A. One code for each vessel entered b. One code for the point of entry vessel c. One code for the final vessel entered
d. Increase compensation as shape of optimization - ANSCorrect Answer: C Improve documentation to assist services billed (Johns 2011, 348).
Identify the appropriate ICD-nine-CM prognosis code(s) for a patient with seizures; epilepsy dominated out. A. 780. b. 345.Nine c. 780.39, 345. d. 345.90 - ANSCorrect Answer: A Code symptoms and symptoms while a condition is ruled out, which means that the situation has been proven not to exist. The code for seizures (780.39) is assigned when a greater unique diagnosis can't be made even after all of the records bearing at the case were investigated (Hazelwood and Venable 2012, 68-seventy three).
The Privacy Rule applies to: a. All covered entities involved with transmitting or acting any electronic transactions distinct within the act b. Healthcare carriers only c. Only healthcare carriers that get hold of Medicare reimbursement d. Only entities funded through the federal government - ANSCorrect Answer: A The Privacy Rule is relevant to all protected entities worried, either at once or not directly, with transmitting or appearing any digital transactions exact inside the act (Johns 2011, 823). Forty four. Which solution FAILS to provide a demand for venture of the MS-DRG? A. Diagnoses and approaches (primary and secondary) b. Attending and consulting physicians
c. Presence of foremost or other complications and comorbidities (MCC or CC) d. Discharge disposition or status - ANS**Correct Answer: B Attending and consulting physicians have no bearing on the venture of the MS-DRG and payment to the medical institution (Schraffenberger 2012, 471-473).
Who is liable for writing and signing discharge summaries and discharge commands? A. Attending doctor b. Head nurse c. Primary physician d. Admitting nurse - ANSCorrect Answer: A The physician mainly accountable for the affected person's medical institution care writes and signs the release precis (Odom-Wesley et al. 2009, 200).
Under the HIPAA privacy fashionable, which of the following sorts of blanketed fitness statistics (PHI) have to be specially identified in an authorization? A. History and bodily reviews b. Operative reports c. Consultation reviews d. Psychotherapy notes - ANSCorrect Answer: D The difference of psychotherapy notes is vital due to HIPAA requirements that those notes may not be released unless especially specified in an authorization (Odom-Wesley et al. 2009, 440). Forty seven. In hospitals, automated systems for registering patients and monitoring their encounters are generally known as systems. A. MIS b. CDS
A. To improve Medicare's capability to recognize severity of infection in its inpatient hospital bills. The new device is projected to boom bills to hospitals for offerings provided to sicker patients and decrease payments for treating less critically unwell patients. B. To improve Medicare's capability to recognize terrible first-rate of care and pay hospitals on an incentive grid that allows hospitals to be paid with the aid of overall performance. C. To improve Medicare's functionality to apprehend corporations of records by means of patient populations, with a view to similarly allow Medicare to modify the hospitals salary indexes based totally on the facts. This adjustment may be a device to pay hospitals fairly throughout all geographic locations. D. To improve Medicare's functionality to understand practice styles among hospitals that are inappropriately optimizing payments by keeping patients inside the medical institution longer than the media - ANS**Correct Answer: A For economic year 2008, Medicare followed a severity-adjusted analysis-associated corporations system called Medicare Severity-DRGs (MS-DRGs). This changed into the most drastic revision to the DRG gadget in 24 years. The purpose of the new MS-DRG device became to noticeably enhance Medicare's capacity to apprehend severity of illness in its inpatient medical institution bills. The new device is projected to boom payments to hospitals for services furnished to the sicker sufferers and decrease bills for treating less critically unwell patients (Schraffenberger 2012, 471-473).
A sanatorium is making plans on allowing coding professionals to work at home. The health center is within the system of identifying techniques to minimize the security dangers associated with this exercise. Which of the subsequent could be first-class to make sure that statistics breaches are minimized while the home laptop is unattended? A. User call and password b. Automatic session terminations c. Cable locks d. Encryption - ANSCorrect Answer: B Automatic consultation termination will assist to control get right of entry to to the computer while unattended by robotically ending the consultation whilst not in use, preventing unauthorized get admission to (HHS 2006a). Fifty two. What healthcare businesses collect UHDDS data?
A. All outpatient settings along with medical doctor clinics and ambulatory surgical facilities b. All outpatient settings together with most cancers centers, impartial checking out facilities, and nursing homes c. All non-outpatient settings inclusive of acute-care, brief-term care, lengthy-term care, and psychiatric hospitals; home fitness agencies; rehabilitation centers; and nursing homes d. All inpatient settings and outpatient settings with a focal point on ambulatory surgical facilities
- ANSCorrect Answer: C The Uniform Hospital Discharge Data Set become promulgated with the aid of the US Department of Health, Education, and Welfare in 1974 at the least, commonplace center of facts on man or woman acute-care, quick-time period hospital discharges in Medicare and Medicaid applications. It sought to improve the uniformity and comparison of medical institution discharge facts. In 1985, the facts became expanded to encompass all nonoutpatient settings (Schraffenberger 2012, 63-65).
What ought to a clinic do when a nation regulation calls for extra stringent privateness safety than the federal HIPAA privateness fashionable? A. Ignore the state regulation and follow the HIPAA preferred b. Follow the nation law and ignore the HIPAA widespread c. Comply with each the kingdom law and the HIPAA popular d. Ignore each the country regulation and the HIPAA wellknown and observe applicable accreditation requirements - ANSCorrect Answer: C When a country regulation is extra stringent than a federal regulation, hospitals need to observe both (Odom-Wesley et al. 2009, 68).
What need to be accomplished while the HIM branch's errors or accuracy fee is deemed unacceptable? A. A corrective action ought to be taken. B. The problem need to be treated as an isolated incident. C. The system for determining the charge might also need to be adjusted.
