CCA EXAM PREP 2022
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? A. Yes, after he has completed alegitimate release of information authorization. B. Decline to release the information and contact the hospital's attorney. C. Contact the Office of Child Protection for permission to release the record. D. Refer the matter to the hospital administrator and follow the administration's instructions after he meets with the father
. Decline to release the information and contact the hospital's attorney.
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 _____________. A.Autoauthentication B.Electronic signature C.Automatic record completion D.Chart tracking
A. Autoauthentication
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? A. 22 B. 18 C. 16 D. 9
B. 18
According to ICD-9-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older: A. 30 B. 35 C. 38 D. 40
B. 35
Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode. A. 410.11 B. 410.01 C. 410.02 D. 410.12
B. 410.01
Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea. A. 780.2 B. 780.2, 787.02 C. 780.2, 787.01 D. 780.4, 787.02
B. 780.2, 787.02
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? A. Otitis media B. AIDS C. Toxic shock syndrome D. Bacteremia
B. AIDS
) CPT was developed and is maintained by: A. CMS B. AMA C. Cooperating Parties D. WHO
B. AMA
Which answer below is not correct for assignment of the MS-DRG? A. Diagnoses and procedures (principal and secondary) B. Attending and consulting physicians C. Presence of major or other complications and co morbidities (MCC or CC) D. Discharge disposition or status
B. Attending and consulting physicians
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? A. User name and password B. Automatic session terminations C. Cable locks D. Encryption
B. Automatic session terminations
Which of the following ethical principles is being followed when an HIT professional ensures thtat patient information is only released to those who have a legl right to access it? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence
B. Beneficence
Mohs micrographic surgery involves the surgeon acting as: A. Both plastic surgeon and general surgeon B. Both surgeon and pathologist C. Both plastic surgeon and dermatologist D. Both dermatologist and pathologist
B. Both surgeon and pathologist
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? A. By requesting the medical record for each service provided B. By reviewing al the diagnosis codes assigned to explain the reasons the services were provided C. By reviewing all physician orders D. By reviewing the discharge summary and history and physical for the patient over the last year
B. By reviewing al the diagnosis codes assigned to explain the reasons the services were provided
The ___________ is a type of coding thta is a natural outgrowth of the electronic heath record. A. Automated codebook B. Computer-assisted coding C. Logic based encoder D. Decision support database
B. Computer-assisted coding
Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? A. Consent for operative procedure, anesthesia report, surgical report B. Consent for operative procedure, history, physical examination C. History, physical examination, anesthesia report D. Problem list, history, physical examination
B. Consent for operative procedure, history, physical examination
Per CPT guidelines, a separate procedure is: A. Coded when it is performed as part of another, larger procedure B. Considered to be an integral part of another, larger procedure C. Never code under any circumstance D. Both a and b
B. Considered to be an integral part of another, larger procedure
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
B. Data warehouse
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, Tabaco, alcohol, and other drugs may be found in the _____________. A. Physical examination record B. History record C. Operative report D. Radiological report
B. History record
What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? A. Vocabulary standard B. Identifier standard C. Structure and content standard D. Security standard
B. Identifier 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? A. Audit controls B. Information access controls C. Facility access controls D. Workstation security
B. Information access controls
What is the name of the organization that develops the billing form that hospitals are required to use? A. American cademy of Billing Forms (AABF) B. National Uniform Billing Committee (NUBC) C. National Uniform Claims Committee (NUCC) D. American Billing and Claims Academy (ABCA)
B. National Uniform Billing Committee (NUBC)
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? A. Patient management B. New technology C. Therapeutic, preventative, or other interventions D. Patient safety
B. New technology
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? A. Operative report B. Pathology report C. Discharge summary D. Nursing note
B. Pathology report
Which of the following is a core ethical obligation of health information staff? A. Coding diseases and operations. B. Protecting patients' privacy and confidential communications C. Transcribing medical reports D. Performing quantitative analysis on record content
B. Protecting patients' privacy and confidential communications
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
B. Provide an input mask for entering data in the field
What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs? A. Medicare administrative contractors (MACs) B. Recovery audit contractors (RACs) C. Comprehensive error rate testing (CERT) D. Fiscal intermediaries (FIs)
B. Recovery audit contractors (RACs)
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: A. Past medical history B. Social history C. Systems review D. History of present illness
B. Social history
Which of the following would be classified to an ICD-9-CM category for bacterial diseases? A. Herpes simplex B. Staphylococcus aureus C. Influenza, types A and B D. Candida albicans
B. Staphylococcus aureus
Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications. A. 204.00, 787.01, V58.11 B. V58.11, 204.00, 787.01 C. V58.11, 204.00 D. 204.22, 787.01
B. V58.11, 204.00, 787.01
Identify the correct ICD-9-CM diagnosis code(s) for a patient who presents to the hospital outpatient department for a routine chest x-ray without signs and symptoms. A. V72.81 B. V72.5 C. V72.5, 793.99 D. V70.9, 793.1
B. V72.5
Which of the following would not be found in a medical history? A. Chief complaint B. Vital signs C. Present illness D. Review of systems
B. Vital signs
What type of standard establishes uniform definitions for clinical terms? A. Identifier standard B. Vocabulary standard C. Transaction and messaging standard D. Structure and content standard
B. Vocabulary standard
identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli. A.599.0 B.599.0, 041.4 C.041.4 D.041.4, 599.0
B.599.0, 041.4
) What healthcare organization collects UHDDS data? A. All outpatient settings including physician clinics and ambulatory surgical centers B. All outpatient settings including cancer centers, independent testing facilities, and nursing homes C. All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes D. All inpatient settings and outpatient settings with a focus on ambulatory surgical centers
C. All non-outpatient settings including acute care, short term care, long term care, and psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes
Tissue transplanted from one individual to another of the same species but different genotype is called a(n) A. Autograft B. Xenograft C. Allograft or allogeneic graft D. Heterograft
C. Allograft or allogeneic graft
Which organization developed the first hospital standardization program? A. Joint Commission B. American Osteopathic Association C. American College of Surgeons D. American Association of Medical Colleges
C. American College of Surgeons
The codes in the musculoskeletal section of CPT may be used by: A. Orthopedic surgeons only B. Orthopedic surgeons and emergency department physicians C. Any physician D. Orthopedic surgeons and neurosurgeons
C. Any physician
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: A. Appendix E B. Appendix F C. Appendix G D. Appendix H
C. Appendix G
What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard? A. Ignore the state law and follow the HIPAA standard B. Follow the state law and ignore the HIPAA standard C. Comply with both the state law and the HIPAA standard D. Ignore both the state law and the HIPAA standard and follow relevant accreditation standards
C. Comply with both the state law and the HIPAA standard
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 case, what should the supervisor do? A.Reprimand the employee B.Fire the employee C.Determine what information was printed and why D.Revoke the employee's access priviliges
C. Determine what information was printed and why
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? A. Access controls B. Audit trails C. Edit checks D. Password controls
C. Edit checks
Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? A. Interpretation of x-rays by the radiologist B. Billing records C. Progress notes written by the attending physician D. Psychotherapy notes
D. Psychotherapy notes
Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? A. History and physical reports B. Operative reports C. Consultation reports D. Psychotherapy notes
D. Psychotherapy notes
When correcting erroneous information in a health record, which of the following is not appropriate? A. Print "error" above the entry B. Enter the correction in chronological sequence C. Add the reason for the change D. Use black pen to obliterate the entry
D. Use black pen to obliterate the entry
What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient? A. three B. nine C. five D. six
D. six
Identify the correct ICD-9-CM diagnosis code(s) for a patient with sepsis due to staphylococcus aureus septicemia. A. 038.11, 995.91 B. 995.91, 038.11 C. 038.11 D. 038.11, 995.92
A. 038.11, 995.91
ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth. A. 28th B. 14th C. 60th D. 30th
A. 28th
Identify the correct ICD-9-CM diagnosis code(s) for a patient with nausea, vomiting, and gastroenteritis. A. 558.9 B. 787.01, 558.9 C. 787.02, 787.03, 558.9 D. 787.01, 558.41
A. 558.9
Identify the correct ICD-9-CM diagnosis code(s) for a patient with seizures; epilepsy, ruled out A. 780.39 B. 345.9 C. 780.39, 345.9 D. 345.90
A. 780.39
Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling. A. 82270 B. 82271 C. 82272 D. 82274
A. 82270
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? A. A "with manipulation" code B. A "without manipulation" code C. An unlisted procedure code D. An E/M code only
A. A "with manipulation" code
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
A. American Psychological Association
Who is responsible for writing and signing discharge summaries and discharge instructions? A. Attending physician B. Head nurse C. Primary physician D. Admitting nurse
A. Attending physician
Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa. A. 10060 B. 10140 C. 23030 D. 23031
D. 23031
Identify the correct ICD-9-CM diagnosis code(s) for neutropenic fever. A. 288.00 B. 288.00, 780.60 C. 288.01 D. 288.00, 780.61
D. 288.00, 780.61
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. A. 30 days / 48 hours / 24 hours B. 14 days / 24 hours / 48 hours C. 14 days / 48 hours / 24 hours D. 30 days / 24 hours / 48 hours
D. 30 days / 24 hours / 48 hours
A 22-year-old patient presents for a closure of a patent ductus arteriosus. The patient's thorax is opened posteriorly and the vagus nerve is isolated away. The PDA is divided and sutured individually in the aorta and pulmonary artery. How is this procedure coded? A. 33813 B. 33820 C. 33822 D. 33824
D. 33824
Identify the correct ICD-9-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea. A. 789.03 B. 789.03, 787.02, 787.03, 787.91 C. 789.03, 787.91 D. 789.03, 787.01, 787.91
D. 789.03, 787.01, 787.91
Identify the correct ICD-9-CM diagnosis code(s) for a patient with abnormal glucose tolerance test. A. 790.29 B. 790.21 C. 790.21, 790.29 D. 790.22
D. 790.22
Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result. A. 796.4 B. 790.6 C. 792.9 D. 790.93
D. 790.93
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? A. A fine of not more than $10,000 only B. A fine of not more than $10,000, not more than 1 year in jail, or both C. A fine of not more than $5,000 only D. A fine of not more than $250,000, not more than 10 years in jail, or both
D. A fine of not more than $250,000, not more than 10 years in jail, or both
Observation E/M codes (99218 through 99220) are used in physician billing when: A. A patient is admitted and discharged on the same date. B. A patient is admitted for routine nursing care following surgery. C. A patient does not meet admission criteria. D. A patient is referred to a designated observation service.
D. A patient is referred to a designated observation service.
What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? A. Additional payments may be made to locum tenens, increased emergency room services, stays over the average length of stay, and for cost outlier cases. B. Additional payment may be made to critical access hospitals, higher than normal volumes, unexpected hospital emergencies, and for cost outlier cases. C. Additional payments may be made to increased emergency room services, critical access hospitals, for increased labor costs, and for cost outlier cases. D. Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases.
D. Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases.
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
D. Alert hospital legal counsel of the practice
What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil? A. Lobar pneumonia B. Pneumocystis' carinii pneumonia C. Interstitial pneumonia D. Aspiration pneumonia
D. Aspiration pneumonia
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? A. Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately B. Determine how many nurses are involved in this practice C. Institute an in-service training session on documentation practices D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
D. Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers? A. Patient Assessment Instrument B. Minimum Data Set for Long-Term Care C. Resident Assessment Protocol D. Outcomes and Assessment Information Set
D. Outcomes and Assessment Information Set
Identify the acute-care record report where the following information would be found: The patient is well-developed, obese male who does not appear to be in any distress, but has considerable problem with mobility. He has difficulty rising up from a chair and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in April). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Show edema of both legs. A. Discharge summary B. Medical history C. Medical laboratory report D. Physical examination
D. Physical examination
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? A. Avoid displaying the number on any document, screen, or data collection field B. Allow the information in both electronic and paper forms since a variety of people need this data C. Require employees to sign confidentiality agreements if they have access to social security numbers D. Contact legal counsel for advice
A. Avoid displaying the number on any document, screen, or data collection field
Which of the following activities is considered an unethical practice? A. Backdating progress notes B. Performing quantitative analysis C. Verifying that an insurance company is one that is authorized to receive patient information D. Determining what information is required to fulfill an authorized request for information
A. Backdating progress notes
Which of the following activities would be in violation of AHIMA's Code of Ethics? A. Coding an intentionally inappropriate level of service B. Following established coding policies and procedures C. Protecting the confidentiality of patients' written and electronic records D. Taking remedial action when there is direct knowledge of a colleague's incompetence or impairment
A. Coding an intentionally inappropriate level of service
What is abstracting? A. Compiling the pertinent information from the medical record based on predetermined data sets B. Assigning the appropriate code or nomenclature term for categorization C. Assembling a chronological set of data for an express purpose D. Conducting qualitative and quantitative analysis of documentation against standards and policy
A. Compiling the pertinent information from the medical record based on predetermined data sets
What is the basic formula for calculating each MS-DRG hospital payments? A. Hospital payment = DRG relative weight x hospital base rate B. Hospital payment = DRG relative weight x hospital base rate -1 C. Hospital payment = DRG relative weight / hospital base rate +1 D. Hospital payment = DRG relative weight / hospital base rate
A. Hospital payment = DRG relative weight x hospital base rate
Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. A. Operative report B. Anesthesia report C. Pathology report D. Laboratory report
A. Operative report
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 modifer, and all three volumes of ICD-9-CM use them. A. Parentheses ( ) B. Square brackets [ ] C. Slanted brackets [ ] D. Braces { }
A. Parentheses ()
Where would a coder who needed to locate the histology of a tissue sample most likely find this information A. Pathology report B. Progress notes C. Nurse's notes D. Operative report
A. Pathology report
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. A. Performance improvement programs B. Billing and claims data processing C. Developing hospital discharge abstracting systems D. Developing individual care plans for residents
A. Performance improvement programs
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? A. Postoperative infection B. Appendicitis C. COPD D. Hypertension
A. Postoperative infection
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
A. Selective catheterization
What was the goal of the new 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 allow 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.
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
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: A. Use (1) and disclosure (2) B. Request (1) and disclosure (2) C. Disclosure (1) and use (2) D. Disclosures (1 and 2)
A. Use (1) and disclosure (2)
Identify the correct ICD-9-CM diagnosis codes for metastatic carcinoma of the colon to the lung. A. 153.9, 162.9 B. 197.0, 153.9 C. 153.9, 197.0 D. 153.9, 239.1
C. 153.9, 197.0
From the health record of a patient newly diagnosed with a malignancy: Preoperative Diagnosis: Suspicious lesions, main bronchus Postoperative Diagnosis: Carcinoma, in situ, main bronchus Indications: Previous bronchoscopy showed two suspicious lesions in the main bronchus. Laser photoreception is planned for destruction of these lesions, because bronchial washings obtained previously showed carcinoma in situ. Procedure: Following general anesthesia in the hospital same-day surgery area, with a high-frequency jet ventilator, a rigid bronchoscope is inserted and advanced through the larynx to the main bronchus. The areas were treated with laser photoreception. Identify the ICD-9-CM diagnosis code and CPT procedure code(s) for this service? A. 162.2, 31641, 31623-59 B. 231.2, 31641, 31623-59 C. 231.2, 31641 D. 162.2, 31641
C. 231.2, 31641
"Late pregnancy" (category code 645) is used to demonstrate that a woman is over _______________. A. 41 B. 39 C. 40 D. 42
C. 40
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with dysphasia secondary to old cerebrovascular accident sustained one year ago. A. 787.20, 438.12 B. 784.59, 438.12 C. 438.12 D. 787.20, 438.89
C. 438.12
Identify the correct ICD-9-CM diagnosis code(s) for a patient with pneumonia and persistent cough. A. 786.2, 490 B. 486, 786.2 C. 486 D. 481
C. 486
Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago. A. 709.2 B. 906.1 C. 709.2, 906.1 D. 906.1, 709.2
C. 709.2, 906.1
Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence. A. 625.6 B. 788.30 C. 788.32 D. 788.39
C. 788.32
In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems. A. MIS B. CDS C. ADT D. ABC
C. ADT
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? A. Suggest that only hospital clock time be noted in clinical documentation B. Suggest that only electronic documentation have time notated C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated D. Inform the committee that according to the Medicare Conditions of Participation only medication orders must include date and time
C. Inform the committee that according to the Medicare Conditions of Participation all documentation must be authenticated and dated
Identify the acute care record report where the following information would be found: Gross Description: Received fresh designated left lacrimal gland is a single, un-oriented, 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 A. Discharge summary B. Medical history C. Medical laboratory report D. Physical examination
C. Medical laboratory report
Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable? A. No a dentist is a healthcare clearinghouse, which is covered entity under HIPAA. B. Yes; a dentist is not a covered entity per the HIPAA Privacy Rule. C. No; it is a violation of the HIPAA Privacy Rule. D. Yes; the Notice of Privacy Practices is not required until June 2012.
C. No; it is a violation of the HIPAA Privacy Rule.
When coding a selective catheterization in CPT, how are codes assigned? A. One code for each vessel entered B. One cod for the point of entry vessel C. One code for the final vessel entered D. One code for the vessel of entry and one for the final vessel, with intervening vessels not coded
C. One code for the final vessel entered
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? A. Request that the physician dictate another discharge summary B. Have the record analyst note the date discrepancy C. Request the physician dictate an addendum to the discharge summary D. File the record as complete since the discharge summary includes all the pertinent patient information
C. Request the physician dictate an addendum to the discharge summary
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? A. Insomnia B. Hypertension C. Schizophrenia D. Rheumatoid arthritis
C. Schizophrenia
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals? A. Accreditation organizations B. Certification organizations C. State licensure agencies D. Conditions of participation agencies
C. State licensure agencies
Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? A. Use of Mary's information about her myocardial infarction, deidentified B. Use of Mary's information about her asthma, in a limited data set C. Use of Mary's individually identifiable information related to her asthma treatments D. Use of medical information about Jim, Mary's deceased husband
C. Use of Mary's individually identifiable information related to her asthma treatments
Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition. A. 250.02 B. 250.01, 263.1 C. 250.02, 263.1 D. 250.01, 263.0
C.250.02, 263.1
Identify the correct ICD-9-CM diagnosis code(s) and sequence for a patient with disseminated candidiasis secondary to AIDS-like syndrome. A. 042, 112.4, V01.79 B. 112.4, 042 C. 042, 112.4, V08 D. 042, 112.4
D. 042, 112.4
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? A. Request that the CEO write a memorandum to all hospital staff B. Give the chairperson of the CDI committee authority to fire employees who don't improve their clinical documentation C. Include ancillary clinical and medical staff in the process D. Request a letter from the Joint Commission
Include ancillary clinical and medical staff in the process