CCA exam 3

a pharyngeal culture is taken from a 13-year-old male patient presenting to the ER with fever, painful cervical lymph nodes, purulent tonsillitis exudate and difficulty swallowing. A blood agar culture plate shows complete hemolysis around streptococcus pyogenes bacterial colonies. The patient is given a prescription for erythromycin. The diagnosis in this case is

A group A beta hemolytic streptococcal throat infection

Which of the following statements Best summarizes the current status of cervical cancer

A new three shot vaccination series protects against the types of HPV that causes most cervical cancer cases

Which of the following is a liver function test

AST (SGOT)

Established 42-year-old patient comes into his office to obtain vaccines required for his trip to Sri Lanka. The nurse injects intramuscularly The following vaccines, hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As a coding specialist, what would you report on the CMS 1500 form?

Administration of two or more single vaccines, vaccine products for hepatitis A and B, cholera and yellow fever.

Cadaver donor

Allogeneic

Sepsis is coded first

Also severe sepsis is coded first

A severe allergic reaction can be life-threatening, due to a swollen throat, difficulty breathing, rash, and dizziness that must be treated with injectable epinephrine is termed

Anaphylaxis

Which of the following is not a technical security control employed by electronica health record system

Automatic log off

02 is carried in the blood

Bound to hemoglobin

Joel Palmer was in a car accident and sustained severe chest trauma resulting in tension pneumothorax. Manifestations of this disorder include all the following except: shock, dyspnea, Severe chest pain, or clubbing

Clubbing

The correct coding initiative edits contain a listing of codes under two columns titled comprehensive codes and component codes. According to the CCI edits, when a provider bills Medicare for a procedure that appears in both columns on the same beneficiary on the same date of service

Code only the comprehensive code

The first code on a babies chart is always to code from being born or Z Code

Delivery code is first

A retrospective review as a part of quality improvement activities is conducted after the patient has been

Discharged

Which of the following pieces of equipment records electrical activity of the brain

EEG

Which of the following tubes convey sperm from the seminal vesicle to the urethra

Ejaculatory duct

Which step of the chain of infection is disrupted by eliminating the standing water in all tires, bird baths, and empty buckets when combating the Zika virus epidemic

Eliminating the reservoir

Identify the correct route operation for the following: uterine dilation and curettage

Extraction

What common vitamin should be taken by pregnant women to substantially reduce the occurrence of defect's, such as spinal bifida, any developing fetus

Folic acid

Mappings between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called

GEMS (General Equivalency Mappings)

A patient is being cared for in his or her home by a qualified agency participating in Medicare. The data entry software used to conduct all patient assessments is known as

HAVEN

The term hard coding refers to

HCPCS/CPT codes that appear in the hospital's chargemaster and will be included automatically on the patient's bill

An example of a primary data source for healthcare statistics is the

Health record

In 2014 AHIMA foundations clinical documentation improvement job description supportive report identified that most clinical documentation improvement specialist report directly to the

Him department

What perspective payment system reimburses the provider accordingly to determine rates for a 60 day episode of care

Home health resource groups

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the a. Hospital Bylaws, Rules, and Regulations. b. Policy and Procedure Manual. c. Federal Register. d. Consolidated Manual for Hospitals.

Hospital Bylaws, Rules, and Regulations

Which of the following is an example of a secondary data source

Hospital census

Needle sticks, patient or employee falls, medication errors, or any event not consistent with routine patient care activities will require risk reporting documentation in the form of a

Incident report

Some services are performed by another physician practitioner. These services are an integral component of a physicians treatment. A physician must have personally performed an initial visit and must remain actively involved in the continuing care. Medicare requires direct supervision for these services to be billed. This is called

Incident to billing

A popular base cancer registry that is designated to determine rates and trends in a defined population is a

Incidents only population-based registry

As part of the joint commission is national patient safety goals initiative, acute care hospitals are required to use a preoperative verification process to confirm the patient's true identity and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for

Making the surgical site

One of the patients at your physician group practice has asked for an electric copy of her medical record. Your electric computer system will not allow you to accommodate this request. Chances are, you are not in compliance with

Meaningful use requirements

________ requires present on admission indicator to be assigned to the ________ diagnosis for all claims for _____ Admissions

Medicare, principal and secondary, inpatient

This is a 10 digit, intelligence free, numeric identifier design to replace previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued for our HIPPA covered entities. It is mandatory on the CMS-1500 and UB- 04 claim forms

National provider identifier

Currently the enforcement of HIPPA privacy and security rules is responsibility of

Office for civil rights

APCs are groups of service that the 0PPS will reimburse. Which of the following services are not included in APCs

Organ transplantation

An example of objective entry in the health record supplied by a healthcare practitioner is the

Physical assessment

In a global payment mythology which is sometimes applied to radiological and similar types of procedures that involve professional and technical components, all the following are part of the technical components except

Physicians services

The childhood viral disease that unvaccinated pregnant women should be prevented from contracting because it may be passed to the fetus, thus causing congenital anomalies such as mental retardation, blindness and deafness is

Rubella

An African-American couple is undergoing genetic counseling to determine the likelihood of producing children with a recessively genetic blood condition. The genetic test revealed that the father carries the trait to produce abnormal hemoglobin, HbS, which causes crystallization and RBCs and deforms their shape when O2 is low. This condition causes painful cries in multiple infarct's and is termed

Sickle cell anemia

A key data item you would expect to find recorded on an ER record would probably not see in acute care record is the: Instructions to follow up care, time and means of arrival, lab and diagnostic test results, or physical findings

Time in means of arrival

The patient was brought into the ER with a deep laceration to the ulnar vein. The repair of this is reported from the ________ body system character of the ICD 10 PCS code

Upper veins

The physicians H&P at admission includes that the patient was diagnosed with type two diabetes mellitus in 2015. The The present on admission indicator is.

Yes

Under APCs payment status indicator S means

a. significant procedure, multiple procedure reduction does not apply.

Under the Patient Self-Determination Act of 1990, evidence of advance directives

are required to be documented in the health record

the inner ear with fluid disruption in the semicircular Canal that causes vertigo is

both labyrinthitis and Ménière's disease

A treatment for sensorineural hearing loss is

cochlear implants

The accounting method attributes a dollar figure to every input required to provide a service

cost accounting

Which of the following should not be included in the documentation of record destruction

dates not covered in destruction

A 68-year-old female patient has no visible bleeding but remains anemic. Her physician is concerned about possible gastrointestinal bleeding. Which of the following tests might be ordered

guaiac smear test

The foundation for communicating all patient care goals in long-term care settings is the

interdisciplinary plan of care

To enter the results of a CBC into the computer system, you would use

laboratory system

Which of the following services is least likely to be provided by facility accredited by CARF

palliative care

Most of the digestion of food and absorption of nutrients occur in the

small intestine

Which type of joint such as the sutures of the skull has no movement

synarthrosis

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

temporal

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

unbundling