AHIMA CCA COMPREHENSIVE EXAM 2026/2027
QUESTIONS AND SOLUTIONS RATED A+
✔✔35.
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).
✔✔36.
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 - ✔✔Correct Answer: A
The coder should assign the most comprehensive code to describe the entire
procedure performed. When a code describes the entire service provided, the coder
should not code each component separately. Assigning additional codes inherent to the
main code would be a form of unbundling (Hazelwood and Venable 2012, 336).
✔✔37.
Corporate compliance programs were released by the OIG for hospitals to develop and
implement their own compliance programs. All of the following except _____ are basic
elements of a corporate compliance program.
a. Designation of a Chief Compliance Officer
, b. Implementation of regular and effective education and training programs for all
employees
c. Medical staff appointee for documentation compliance
d. The use of audits or other evaluation techniques to monitor compliance - ✔✔Correct
Answer: C
Seven elements are required as part of the basic elements of a corporate compliance
program and a medical staff appointee is not one of them (Johns 2011, 274).
✔✔38.
The electronic claim format (837I) replaces which paper billing form?
a. CMS-1500
b. CMS-1450 (UB-04)
c. UB-92
d. CMS-1400 - ✔✔Correct Answer: B
The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing
form (Johns 2011, 343).
✔✔39.
According to the Joint Commission Accreditation Standards, which document must be
placed in the patient's record before a surgical procedure may be performed?
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).
✔✔40.
The right of an individual to keep information about himself or herself from being
disclosed to anyone is a definition of:
QUESTIONS AND SOLUTIONS RATED A+
✔✔35.
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).
✔✔36.
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 - ✔✔Correct Answer: A
The coder should assign the most comprehensive code to describe the entire
procedure performed. When a code describes the entire service provided, the coder
should not code each component separately. Assigning additional codes inherent to the
main code would be a form of unbundling (Hazelwood and Venable 2012, 336).
✔✔37.
Corporate compliance programs were released by the OIG for hospitals to develop and
implement their own compliance programs. All of the following except _____ are basic
elements of a corporate compliance program.
a. Designation of a Chief Compliance Officer
, b. Implementation of regular and effective education and training programs for all
employees
c. Medical staff appointee for documentation compliance
d. The use of audits or other evaluation techniques to monitor compliance - ✔✔Correct
Answer: C
Seven elements are required as part of the basic elements of a corporate compliance
program and a medical staff appointee is not one of them (Johns 2011, 274).
✔✔38.
The electronic claim format (837I) replaces which paper billing form?
a. CMS-1500
b. CMS-1450 (UB-04)
c. UB-92
d. CMS-1400 - ✔✔Correct Answer: B
The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing
form (Johns 2011, 343).
✔✔39.
According to the Joint Commission Accreditation Standards, which document must be
placed in the patient's record before a surgical procedure may be performed?
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).
✔✔40.
The right of an individual to keep information about himself or herself from being
disclosed to anyone is a definition of:
