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AHIMA CCA EXAM QUESTIONS
WITH VERIFIED ANSWERS
- A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: A. Ruptured appendix B. Exploratory laparoscopy C. Abdominal pain D. Cholelithiasis Correct Answer-C. Abdominal pain The nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331).
- An individual stole and used another person's insurance information to obtain medical care. This action would be considered: A. Violation of bioethics B. Fraud and abuse C. Medical identity theft D. Abuse Correct Answer: C. medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity without the victim's knowledge or consent to obtain medical services or goods (Johns 2011, 773).
- Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus.
A. 730.
B. 730.
C. 730.07, 041.
D. 730.07, 041.
Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger 2012, 305-306).
- A system that provides alerts and reminders to clinicians is a(n): A. Clinical decision support system B. Electronic data interchange C. Point of care charting system D. Knowledge database Correct Answer: A Clinical decision support includes providing documentation of clinical findings and procedures, active reminders about medication administration, suggestions for prescribing less expensive but equally effective drugs, protocols for certain health maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-making aids for all stakeholders in the care process (Johns 2011, 138).
- 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 Correct Answer: A
- 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 - Correct Answer: B 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 (Johns 2011, 412).
- A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? A. Chart deficiency system B. Chart tracking system C. Chart abstracting system D. Chart encoder Correct Answer: B With an automated tracking system, it is easy to track how many records are charged out of the system, their location, and whether they have been returned on the due dates indicated (Johns 2011, 402).
- Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease. A. 335. B. 334. C. 335. D. 335.
Correct Answer: A Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is another name for Lou Gehrig's disease. Many diseases carry the name of a person or an eponym. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).
- In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel? A. Report the remaining tests using individual test codes, according to CPT. B. Do not report the remaining individual test codes. C. Report only those test codes that are part of a panel. D. Do not report a test code more than once regardless whether the test was performed twice. Correct Answer: A Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (AMA 2012b, 402).
- An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of: A. Optimizing B. Unbundling C. Sequencing D. Classifying Correct Answer: B Unbundling occurs when a panel code exists and the individual tests are reported rather than the panel code (AMA 2012b, 402).
D. Discharge summary Correct Answer: B The pathology report describes specimens examined by the pathologist (Johns 2011, 77).
- CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set? A. Diagnosis-related groups B. HCPCS/CPT codes C. ICD-9-CM diagnosis and procedure codes D. Resource utilization groups - Correct Answer- Correct Answer: B CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate payments. This new editing was the result of the outpatient prospective payment system which pays providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2012b).
- Identify the ICD-9-CM diagnostic code for other specified aplastic anemia secondary to chemotherapy. A. 284. B. 284. C. 285. D. 285. Correct Answer: B Index Anemia, aplastic, due to, antineoplastic chemotherapy. A coder should always assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic (Schraffenberger 2012, 133-135 ).
- 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. Correct Answer: D 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 2012a, 607).
- What is the best reference tool to determine how CPT codes should be assigned? A. Local coverage determination from Medicare B. American Medical Association's CPT Assistant newsletter C. American Hospital Association's Coding Clinic D. CMS website Correct Answer: B CPT Assistant provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly (AMA 2012b).
- Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block. A. 426.3, 426. B. 426. C. 426.4, 426. D. 426.
C. V53.
D. V53.31, 37.
Correct Answer: A Index Fitting (of) pacemaker (cardiac). No procedure code exists in ICD-9-CM to describe reprogramming (Schraffenberger 2012, 204-205).
- 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 Correct Answer: A 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 (Johns 2011, 321).
- Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards? A. Internal DRG audits B. Peer review C. Managed care D. Quality improvement Correct Answer: D Quality improvement (QI) programs have been in place in hospitals for years and have been required by the Medicare/Medicaid programs and accreditation standards. QI programs have covered medical staff as well as nursing and other departments or processes (LaTour and Eichenwald Maki 2010, 33)
- Identify the code for a patient with a closed transcervical fracture of the epiphysis.
A. 820.
B. 820.
C. 820.
D. 820.
Correct Answer: D Index Fracture, femur, epiphysis, capital. Fifth digits are required for further classification of a specific condition. Many publishers include special symbols and/or color highlighting to identify codes that require a fourth or fifth digit (Schraffenberger 2012, 7).
- What is the best source of documentation to determine the size of a removed malignant lesion? A. Pathology report B. Post-acute care unit record C. Operative report D. Physical examination Correct Answer: C The total size of a removed lesion, including margins, is needed for accurate coding. This information is best provided in the operative report. The pathology report typically provides the specimen size rather than the size of the excised lesion. Because the specimen tends to shrink, this is not an accurate measurement (Kuehn 2012, 110- 111).
- Which of the following definitions best describes the concept of confidentiality? A. The right of individuals to control access to their personal health information B. The protection of healthcare information from damage, loss, and unauthorized alteration C. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
B. 57.32, 57.
C. 57.
D. 57.
Correct Answer: C Index Cystoscopy (transurethral), with biopsy (Schraffenberger 2012, 251).
- Identify the ICD-9-CM diagnosis code for chondromalacia of the patella. A. 717. B. 733. C. 748. D. 716.86 - Correct Answer- Correct Answer: A Index Chondromalacia, patella (Schraffenberger 2012, 303-304).
- Identify the ICD-9-CM diagnosis code for blighted ovum. A. 236. B. 661. C. 631. D. 634.90 – Correct Answer: C Index Ovum, blighted (Schraffenberger 2012, 282-283).
- Each year the OIG develops a work plan that details areas of compliance it will be investigating for that year. What is the expectation of the hospital in relation to the OIG work plan? A. Hospitals are required to follow the same work plan and deploy audits based on that work plan.
B. Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan. C. Hospitals must not develop their audits based on the OIG work plan; rather, they must develop their own and look for high-risk areas that need improvement. D. Hospitals must use the plan developed by their state hospital association that is specific to state laws and compliance activities. Correct Answer: B Hospitals are encouraged but not required to follow the same work plan as the OIG. Hospitals should review the plan carefully and plan their compliance program around the target areas (Johns 2011, 275).
- 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 Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Johns 2011, 63).
- There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further define removal of foreign body (45379); biopsy, single or multiple (45380); and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule? A. Unbundling B. Optimizing C. Sequencing D. Maximizing
A. Admission record B. Physician's order C. Report of history and physical examination D. Discharge summary Correct Answer: C 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 (Odom-Wesley et al. 2009, 150).
- The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of: A. Confidentiality B. Privacy C. Integrity D. Security Correct Answer: B Privacy is the right of an individual to be left alone. It includes freedom from observation or intrusion into one's private affairs and the right to maintain control over certain personal and health information (Johns 2011, 755).
- Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of: A. Transaction standards B. Content and structure standards C. Vocabulary standards D. Security standards Correct Answer: C
Vocabulary standards establish common definitions for medical terms to encourage consistent descriptions of an individual's condition in the health record (Johns 2011, 227).
- An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system? A. DEEDS B. EMEDS C. UACDS D. UHDDS Correct Answer: C Uniform Ambulatory Care Data Set (Odom-Wesley et al. 2009, 310).
- Identify the ICD-9-CM diagnostic code for diastolic dysfunction. A. 428. B. 428. C. 428. D. 429. Correct Answer: D Index Dysfunction, diastolic (Schraffenberger 2012, 182-183).
- Identify the appropriate ICD-9-CM procedure code(s) for a double internal mammary- coronary artery bypass. A. 36.15, 36. B. 36. C. 36. D. 36.12, 36. Correct Answer: C
A. Reason for admission B. Reason for encounter C. Discharge diagnosis D. Activities of daily living Correct Answer: B The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider (LaTour and Eichenwald Maki 2010, 166).
- 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 Correct Answer: D Surveyors review the documentation of patient care services to determine whether the standards for care are being met (Johns 2011, 40).
- Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: "Patient is being admitted for organic brain syndrome." Underneath the diagnosis, her medical information along with her rehabilitation potential were also listed. On which form is this information documented? A. Transfer or referral B. Release of information C. Patient rights acknowledgement D. Admitting physical evaluation Correct Answer: A
The transfer or referral form provides document communication between caregivers in multiple healthcare settings. It is important that a patient's treatment plan be consistent as the patient moves through the healthcare delivery system (Odom-Wesley et al. 2009, 131).
- Which of the following statements is true? A. The higher the relative weight, the higher the payment rates. B. The lower the relative weight, the higher the payment rates. C. The lower the relative weight, the sicker the patient. D. The higher the relative weight, the lesser reimbursement due the facility. Correct Answer: A Higher relative weights link to higher payment rates (Casto and Layman 2011, 13).
- A coder needs to locate electronic health records for a patient across a health information exchange (HIE). What tool(s) should the coder use? A. Certification B. Identity-matching algorithm and record locator service C. Interoperability and certification D. Meaningful use Correct Answer: B An HIE organization requires an identity-matching algorithm and record locator service (RLS). An identity-matching algorithm must be used by the HIE to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients. The RLS, then, is a process that seeks information about where a patient may have a health record available to the HIE organization (Johns 2011, 151).
- All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered this type of data: A. Clinical B. Identification
