CCA Exam Preparation UPDATED Actual
Exam Questions and CORRECT Answers
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? - CORRECT ANSWER- ✔✔Develop a
facility policy that defines the acceptable period of time allowed for a transcribed document
to remain in a draft form.
What is the basic formula for calculating each MS-DRG hospital payments? - CORRECT
ANSWER- ✔✔Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics? -
CORRECT ANSWER- ✔✔Coding an intentionally inappropriate level of service
What is abstracting? - CORRECT ANSWER- ✔✔Compiling the pertinent information from
the medical record based on predetermined data sets
ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth. - CORRECT ANSWER- ✔✔28th
What healthcare organization collects UHDDS data? - CORRECT ANSWER- ✔✔All non-
outpatient settings including acute care, short term care, long term care, an psychiatric
hospitals, home health agencies, rehabilitation facilities, and nursing home.
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? -
CORRECT ANSWER- ✔✔Edit checks
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: - CORRECT ANSWER- ✔✔Use and
disclosure
,Who is responsible for writing and signing discharge summaries and discharge instructions? -
CORRECT ANSWER- ✔✔Attending physician
Although the HIPAA Rule allows patient access to personal health information about
themselves, which of the following cannot be disclosed to patients? - CORRECT ANSWER-
✔✔Psychotherapy notes
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 modifier, and all three volumes of ICD-9-CM use
them. - CORRECT ANSWER- ✔✔Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are required
to use? - CORRECT ANSWER- ✔✔National Uniform Billing Committee (NUBC)
Which of the following ethical principles is being followed when an HIT professional ensures
that patient information is only released to those who have a legal right to access it? -
CORRECT ANSWER- ✔✔Beneficence
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? - CORRECT ANSWER- ✔✔Avoid displaying the
number on any document, screen, or data collection field.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be
used for ______________. - CORRECT ANSWER- ✔✔Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases? -
CORRECT ANSWER- ✔✔Staphylococcus aureous
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? -
CORRECT ANSWER- ✔✔Postoperative infection
CPT was developed and is maintained by: - CORRECT ANSWER- ✔✔AMA
Which organization developed the first hospital standardization program? - CORRECT
ANSWER- ✔✔American College of Surgeon
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 cases, what should the supervisor do? - CORRECT
ANSWER- ✔✔Determine what information was printed and why
What are possible "add-on" payments that a hospital could receive in addition to the basic
Medicare DRG payment? - CORRECT ANSWER- ✔✔Additional payments may be made to
disproportionate share hospitals, for indirect medical education, for new technologies, and for
cost outlier cases.
The ___________ is a type of coding that is a natural outgrowth of the electronic heath
record. - CORRECT ANSWER- ✔✔Computer-assisted coding
Today, Janet Kim visited her new dentist for an appointment. She was not presented with a
Notice of Privacy Practices. Is this acceptable? - CORRECT ANSWER- ✔✔No, it is a
violation of the HIPAA Privacy rule
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)? - CORRECT ANSWER- ✔✔Provide an input mask for entering data in the
field
What should a hospital do when a state law requires more stringent privacy protection than
the federal HIPAA privacy standard? - CORRECT ANSWER- ✔✔Comply with both the state
law and the HIPAA 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? -
CORRECT ANSWER- ✔✔Information access controls
According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth to
her first child at the age of ______ or older: - CORRECT ANSWER- ✔✔35
Which of the following reports include names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed. - CORRECT ANSWER-
✔✔Operative report
Which answer below is not correct for assignment of the MS-DRG? - CORRECT ANSWER-
✔✔Attending and consulting physicians
Which of the following documentation must be included in a patient's medical record prior to
performing a surgical procedure? - CORRECT ANSWER- ✔✔Consent for operative
procedure, history, physical examination.
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? - CORRECT
ANSWER- ✔✔25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of
the: - CORRECT ANSWER- ✔✔Social history
Which of the following is a core ethical obligation of health information staff? - CORRECT
ANSWER- ✔✔Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use
of coffee, tabacco, alcohol, and other drugs may be found in the _____________. -
CORRECT ANSWER- ✔✔History record
Exam Questions and CORRECT Answers
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? - CORRECT ANSWER- ✔✔Develop a
facility policy that defines the acceptable period of time allowed for a transcribed document
to remain in a draft form.
What is the basic formula for calculating each MS-DRG hospital payments? - CORRECT
ANSWER- ✔✔Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics? -
CORRECT ANSWER- ✔✔Coding an intentionally inappropriate level of service
What is abstracting? - CORRECT ANSWER- ✔✔Compiling the pertinent information from
the medical record based on predetermined data sets
ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth. - CORRECT ANSWER- ✔✔28th
What healthcare organization collects UHDDS data? - CORRECT ANSWER- ✔✔All non-
outpatient settings including acute care, short term care, long term care, an psychiatric
hospitals, home health agencies, rehabilitation facilities, and nursing home.
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? -
CORRECT ANSWER- ✔✔Edit checks
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: - CORRECT ANSWER- ✔✔Use and
disclosure
,Who is responsible for writing and signing discharge summaries and discharge instructions? -
CORRECT ANSWER- ✔✔Attending physician
Although the HIPAA Rule allows patient access to personal health information about
themselves, which of the following cannot be disclosed to patients? - CORRECT ANSWER-
✔✔Psychotherapy notes
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 modifier, and all three volumes of ICD-9-CM use
them. - CORRECT ANSWER- ✔✔Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are required
to use? - CORRECT ANSWER- ✔✔National Uniform Billing Committee (NUBC)
Which of the following ethical principles is being followed when an HIT professional ensures
that patient information is only released to those who have a legal right to access it? -
CORRECT ANSWER- ✔✔Beneficence
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? - CORRECT ANSWER- ✔✔Avoid displaying the
number on any document, screen, or data collection field.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be
used for ______________. - CORRECT ANSWER- ✔✔Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases? -
CORRECT ANSWER- ✔✔Staphylococcus aureous
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? -
CORRECT ANSWER- ✔✔Postoperative infection
CPT was developed and is maintained by: - CORRECT ANSWER- ✔✔AMA
Which organization developed the first hospital standardization program? - CORRECT
ANSWER- ✔✔American College of Surgeon
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 cases, what should the supervisor do? - CORRECT
ANSWER- ✔✔Determine what information was printed and why
What are possible "add-on" payments that a hospital could receive in addition to the basic
Medicare DRG payment? - CORRECT ANSWER- ✔✔Additional payments may be made to
disproportionate share hospitals, for indirect medical education, for new technologies, and for
cost outlier cases.
The ___________ is a type of coding that is a natural outgrowth of the electronic heath
record. - CORRECT ANSWER- ✔✔Computer-assisted coding
Today, Janet Kim visited her new dentist for an appointment. She was not presented with a
Notice of Privacy Practices. Is this acceptable? - CORRECT ANSWER- ✔✔No, it is a
violation of the HIPAA Privacy rule
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)? - CORRECT ANSWER- ✔✔Provide an input mask for entering data in the
field
What should a hospital do when a state law requires more stringent privacy protection than
the federal HIPAA privacy standard? - CORRECT ANSWER- ✔✔Comply with both the state
law and the HIPAA 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? -
CORRECT ANSWER- ✔✔Information access controls
According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth to
her first child at the age of ______ or older: - CORRECT ANSWER- ✔✔35
Which of the following reports include names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed. - CORRECT ANSWER-
✔✔Operative report
Which answer below is not correct for assignment of the MS-DRG? - CORRECT ANSWER-
✔✔Attending and consulting physicians
Which of the following documentation must be included in a patient's medical record prior to
performing a surgical procedure? - CORRECT ANSWER- ✔✔Consent for operative
procedure, history, physical examination.
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? - CORRECT
ANSWER- ✔✔25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of
the: - CORRECT ANSWER- ✔✔Social history
Which of the following is a core ethical obligation of health information staff? - CORRECT
ANSWER- ✔✔Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use
of coffee, tabacco, alcohol, and other drugs may be found in the _____________. -
CORRECT ANSWER- ✔✔History record
