CCA Mock Examination Questions & Answers complete solution Your organization is sending confidential patient information across the internet using technology that will transform the original data into unintelligible code that can be re -created by authorized users. This technique is called? -✔✔ Data Encryption As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the H&P or in the _______. -✔✔ Review of systems (ROS) Sciatica unimproved with hot pack therapy is an example of what in the SOAP style of progress notes? -✔✔ A-Assessment You have been hired to work with computer -assisted coding initiative. The technology that you will be working with is what? -✔✔ Natural language processing A final progress note is appropriate as a discharge summary for a hospitalization in which the patient ________. -✔✔ Was an obstetric admission with a normal delivery and no complications. In reviewing a medica l record for coding purposes, the coder notes that the discharge summary has not yet been transcribed. In its absence, the best place to look for the patient's response to treatment and documentation of any complications that may have developed during this episode of care is in the _______. -✔✔ Doctors' progress note section You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on what type of record? -✔✔ Postpartum record A patient is adm itted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled DM. What is the "Present on Admission" (POA)? -✔✔ N-No, the DM wasn't considered uncontrolled until 3 days after admission How do you figure out the Case -mix index for a facility? (CMI) -✔✔ multiply relative weight by # of patients with this MS -DRG (in the row) and then add up all the numbers and divide by the total number of patients. The special form that plays the central ro le in planning providing care at nursing, psychiatric, and rehabilitation facilities is the ________. -✔✔ Interdisciplinary patient care plan What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, the request f or sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? -✔✔ Quid pro quo Your facility would like to improve physician documentation in order to allow improved coding. As a coding supervisor, you have found it very effective to provide the physicians with what? -
✔✔ Feedback on specific instances when improved documentation would improve coding. Using the chart on page 279: One week's productivity information is shown in the table. What percentage of the coder s is meeting the productivity standards? -✔✔ 100% Which diagnosis or procedure would prevent the normal delivery code (O80) from being assisgned? -✔✔ Low forceps What is considered to be a late effect (sequelae) regardless of time? -✔✔ nonunion Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding. -✔✔ K80.10, 434.00, Z53.09
✔✔ Feedback on specific instances when improved documentation would improve coding. Using the chart on page 279: One week's productivity information is shown in the table. What percentage of the coder s is meeting the productivity standards? -✔✔ 100% Which diagnosis or procedure would prevent the normal delivery code (O80) from being assisgned? -✔✔ Low forceps What is considered to be a late effect (sequelae) regardless of time? -✔✔ nonunion Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding. -✔✔ K80.10, 434.00, Z53.09
