HIT 252

AHIIMA CCA exam passing score is:

300/400 points or 75%

Domain 3 (CCA Exam):

* Retrieval of Medical Records * Assemble medical records according to the healthcare setting *Analyze medical records quantitatively for completeness * Analyze medical records qualitatively for deficiencies.

CCA 6 Domains and % of CCA Exam:

1. Clinical Classification Systems (30-34%) - LARGEST portion of the exam. 2. Reimbursement Methodologies (21-25%) 3. Health Records and Data Content (13-17%) 4. Compliance (12-16%) 5. Information Technologies (6-10%) 6. Confidentiality & Privacy (6-10%)

CCA exam Tasks for Domain 6

1. Ensure patient confidentiality 2. Educate healthcare staff on privacy and confidentiality issues 3. Recognize and report privacy issues/violations 4. Maintain a secure work environment 5. Utilize pass codes 6. Access only minimal necessary documents/information 7. Release patient-specific data to authorized individuals 8. Protect electronic documents through encryption 9. Transfer electronic documents through secure sites 10. Retain confidential records appropriately 11. Destroy confidential records appropriately

ICD-10-CM Alphabetical Index includes what 4 parts?

1. Index to Diseases & Injuries 2. Neoplasm Table 3. Table of Drugs & Chemicals 4. External Causes Index

Domain 5: Information Technologies, include the following tasks:

1. Navigate throughout the EHR 2. Utilize encoding and grouping software 3. Utilize practice management and HIM systems 4. Utilize CAC software that automatically assigns codes based on electronic text 5. Validate the codes assigned by CAC software

Benefits of Computer-Assisted Coding Software (CACS:)

1. Remote Coding 2. Saves Time 3. Traceability 4. Eliminates Unnecessary Paperwork 5. Reduces Denials 6. Security of Information 7. Higher Revenue 8. Improves Compliance 9. Improves Coding Accuracy & Consistency 10. Increases Transparency 11. Increases Productivity

Coding Scenario: Reason for Visit: Foreign body-left index finger Additional procedures: Radiology exam, left index finger. What is/are the correct CPT codes?

10120-F1: incision and removal of foreign body; subcutaneous tissue; simple; left hand, second digit 73140-F1: Radiologic examination; upper extremity; without contrast material; left hand, second digit.

Domain 4: Compliance Makes up how much of the CCA Exam?

12-16%

Coding Scenario: Exam: Ct Abdomen /Pelvis Without IV Contrast Without Oral. What is the CPT code for the Outpatient Surgery?

74716

You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet the standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at

24 hours after admission or prior to surgery.

Coding Scenario: PROCEDURES: 1. EGD 2. Endoscopic ultrasound. What is/are the correct CPT codes?

43237

Domain 5: Information Technologies counts for what percentage of the CCA exam?

6-10%

master patient index:

A hospital's main patient database. Identifies patients across separate clinical, financial and administrative systems and is needed for information exchange to consolidate the patient list from the various RPMS databases. The MPI contains records for all the patients from all of the IHS facilities.

According to the following table, the most serious record delinquency problem occurred in which of the following months? (See Image) A. April B. May C. June D. cannot determine from these data

A. April A recommendation for improvement from Joint Commission is indicated if the number of delinquent records is greater than 50% or if the percentage of records with delinquent records due to missing H&Ps exceeds 2% of the average monthly discharges. In the month of April, both of these delinquency problems are reflected. The percentage of incomplete records is not relevant.

Which of the following is a standard terminology used to code medical procedures and services? Why? A. CPT B. HCPCS C. ICD-10-CM D. SMOMED CT

A. CPT Rationale: CPT is a comprehensive listing of terms and coding reporting diagnostic and therapeutic procedures and medical services.

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? Why? A. complex B. intermediate C. not specified D. simple

A. Complex Rationale: complex includes the repair of wounds recurring more than layered closure, namely, scar revision, debridement, extensive undermining, stents, or retention sutures

Health care claims transactions use one of three electronic formats, including which one of those listed below?

ANSI ASC X12N 837 format

Pulling out information from a medical record is known as:

Abstraction or Abstracting

The Cancer Committee at your hospital requests a list of all patients entered into your cancer registry in the last year. This information would be obtained by checking the:

Accession Register

You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use:

Accession Register

ICD-10-CM is divided into what 2 areas?

Alphabetical Index Tabular List

CPT is maintained by and updated when?

American Medical Association, every January 1st.

Which type of the following makes data easier but may harm data quality? A. Use of templates B. Copy and paste C. Drop-down boxes D. Structured data

B. Copy and paste

A covered entity must adopt reasonable and appropriate policies and procedures to comply with the provisions of the Security Rule. A covered entity must maintain, until _____ years after the later of the date of their creation or last effective date, written security policies and procedures and written records of required actions, activities or assessments. A.5 B. 10 C. 6 D. 7

C. 6

Which of the following tasks MAY NOT be performed in an electronic health record system? A. Document Imaging B. Analysis C. Assembly D. Indexing

C. Assembly

A health care facility has made a decision to destroy computerized data. AHIMA recommends identify which of the following is the method that AHIMA recommends as the preferred method of destruction for computerized data? A. overwriting the backup tapes B. overwriting data with a series of characters C. magnetic degaussing disk reformatting

C. magnetic degaussing

A system requires the health record to be electronic for the system to have the clinical data to analyze and assign codes.

CAC

Improving the specificity of clinical reports through the use of a physician query is a documentation goal that may be shared by the coding staff and this specialist:

CDIP (Certified Documentation Improvement Practitioner)

HCPCS is maintained by and updated when?

CMS (The Centers for Medicare and Medicaid). every January 1st.

Which of the following systems facilitates capturing standardized data with the electronic documentation of patient at the point of care?

Clinical Care Classification (CCC)

The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the

Commission on Accreditation of Rehabilitation Facilities (CARF Manual)

Which of the following should NOT be included in the documentation of record destruction? A. statement that records were destroyed in the normal course of business B. method of destruction C. signature of the individuals supervising and witnessing the destruction D. dates not covered in destruction

D. dates not covered in destruction

The patient returning during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician use with the evaluation and management code? Why? A. 79 B. 25 C, 21 D. 24

D. 24 Rationale: 24 is used for unrelated evaluation and management (E&M) service by the same physician during a post-operative period.

Determine which of the following is an appropriate use of the emergency access procedure. A. The coder who usually codes the emergency room charts is out sick and the charts are left on a desk in the ER admitting area. B. Data is collected for administrative purposes. C. An audit is being conducted by the OIG. D. A patient is crashing. The attending physician is not in the hospital, so a physician who is available helps the patient.

D. A patient is crashing. The attending physician is not in the hospital, so a physician who is available helps the patient.

Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data:

Precision

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to disclose proof of immunization to a school without: A. written authorization by the child. B. y communication with the parent. C. documentation of any kind. D. written authorization of the parent.

D. written authorization of the parent.

Domain 6. Confidentiality & Privacy (6-10% of exam)

HIT 120 and HIT 141 courses

The protection measures and tools for safeguarding information and information systems is a definition of:

Data security

Good encoding software should include ___________ to ensure data quality.

Edit Checks

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classification are called:

Encoders

Joint Commission does not approve of auto authentication of entries in a health record. Assess and determine the primary objection to this practice:

Evidence cannot be provided that the physician actually reviewed and approved each report.

As the chair of a Forms Review Committee, you need to track the field name of a particular data field and the security levels applicable to that field. Determine the best source for this information:

Facility's Data Dictionary

Domain 3:

Health Records and Data Content (13%-17% of exam)

Determine which one of the following would be an essential item captured on the physical exam.

General appearance as assessed by the physician

Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS website or on a CD-ROM.

HAVEN (Home Assessment Validation and Entry)

The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job Description Summative Report" identified that most clinical documentation improvement specialists report directly to the:

HIM Department

Determine which of the following is an example of a primary data source for health care statistics is the:

Hospital Census

Which of the following is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?

ICD-10-CM

Health Informatics, Inc. is a vendor with a large collection of clinical information systems and hospital information systems that are designed to share data without human or technical intervention. This is a(an)

Interfaced system (Computer systems that transmit data back and forth, part of a network)

An encoder that is built using expert system techniques such as rule-based is a (n):

Logic-based encoder

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the

MDS

MPI means:

Master Patient Index

The Quality Payment Program was implemented as part of ________.

Medicare Access and Chip Reauthorization Act (MACRA)

You need to analyze data on the types of care provided to Medicare patients in your geographic area by DRG. Which of the following would be most helpful?

Medicare Provider Analysis and Review (MEDPAR)

The Unified Medical Language System (UMLS) is a project sponsored by the

National Library of Medicine

Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the:

Office of Civil Rights

Microscopic Diagnosis: Liver (needle biopsy), metastatic adenocarcinoma would be located in what report?

Pathology Report

You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information?

Physician Index

How long should the MPI be retained?

Permanently

The old practices of flagging records for deficiencies and requiring retrospective documentation add little or no value to patient care. You try to convince the entire health care team to consistently enter data into the patient's record at the time and location of service instead of waiting for retrospective analysis to alert them to complete the record. You are proposing:

Point-of-Care documentation

A special webpage that offers secure access to data is called a(n):

Portal

Assuring the information on the forms complete. Checking for errors and inconsistencies in documentation is known as:

Qualitative Analysis

Assuring that the medical record meets all documentation requirements is known as:

Quantitative Analysis

AHIMA exam questions are classified based on one of the following Cognitive Levels.

Recall - ability to remember terms, facts, procedures, guidelines Application - apply guidelines Analysis - given a specific scenario and you will need to analyze it and answer the questions.

Which of the following stores data in predefined tables consisting of rows and columns?

Relational database

Electronic Document Management System (EDMS) is:

Software system for organizing and storing different kinds of documents. Stores both digital and paper documents.

What is an encoder?

Software used to assign diagnosis and procedure codes.

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate:

The overall quality of documentation in the record.

Alisa has trouble remembering her password. She taped the password to the bottom of her keyboard. As the chief privacy officer, your appropriate response is:

This is inappropriate and must be removed.

You are developing a complete data dictionary for your facility. Determine which of the following resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

Uniform Hospital Discharge Data Set

The key data element for linking data about an individual who is seen in a variety of care settings is the:

Unique patient identifier Rationale: This is a unique number assigned by a healthcare provider to a patient that distinguishes the patient's medical record from all others.

EHR is:

a digital version of a patients paper chart.

You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing?

aggregate data

Identify the correct root operation term used in ICD-10-PCS for the following: Creation of arteriovenous graft brachial artery left arm for hemodialysis

alteration

The Cancer Committee at Wharton General Hospital wants to compare long-term survival rates for pancreatic cancer by evaluating medical versus surgical treatment of the cancer. The best source of these data is the

cancer registry abstracts.

CBC definition:

complete blood count

What is CAC?

computer-assisted coding

It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed?

dates of admission, discharge, and encounters

The computer-to-computer transfer of data between providers and third-party payers in a data format agreed upon by both parties is called

electronic data interchange (EDI).

ICD-10-CM & ICD-10-PCS are updated when?

every October 1st

In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the

general appearance as assessed by the physician.

A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n)

grouper

Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data:

integrity

________ is used to enter the results of a CBC into the computer system.

laboratory system.

Several recent studies suggest that this issue/condition is now the third leading cause of death in the United States, is responsible for at least 10% of all deaths in the United States, and is an underrecognized and therefore underreported cause of death in the United States. This issue/condition is

medical errors

A surgical procedure that is performed to realign and stabilize a fractured femur with a rod and screws is referred to as a(n):

open reduction with internal fixation.

In preparation for an EHR, you are working with a team conducting a total facility inventory of all forms currently used. You must name each form for barcoding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is

pathology report.

Determine which of the four distinct components of the problem-oriented record serves to help index documentation throughout the record?

problem list

operation index:

shows a company's performance on a key performance indicator, a metric, compared with the median or average performance of that metric in the Peer Universe over a period of time.

The minimum length of time for retaining original medical records is primarily governed by:

state law

When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document:

subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant

In which brain lobe is the processing of smell and hearing stimuli performed?

temporal lobe

As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman that:

the H&P copy is acceptable as long as she documents any interval changes the H&P copy is acceptable as long as she documents any interval changes

When developing a data collection system, the most effective approach first considers

the end user's needs.

Pathology definition:

the science of the causes and effects of diseases, especially the branch of medicine that deals with the laboratory examination of samples of body tissue for diagnostic or forensic purposes.

What are groupers?

they take codes and group them together to yield some type of prospective payment system numbers such as a DRG or an APC.

When a provider bills separately for procedures that are a part of the major procedure, this is called

unbundling

disease index:

used to provide cross-reference for locating health records of all patient types for the purposes of epidemiological and biomedical studies; health services research; and statistical research on occurrence rates, ages, sex, complications, and associated conditions; as well as continuous quality improvement/total quality management activities.

Under which of the following conditions can an original paper-based patient health record be physically removed from the hospital?

when the director of health records is acting in response to a subpoena duces tecum and takes the health record to court