CCS-P Ahima CCS-P Exam Questions
and Answers
According to AMA medical decision making is measured by - Answer -1. number of dx
or management options
3. risk of complications
CPT Assistant - Answer -provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - Answer -poor quality
of documentation
When should coders assign codes from lab reports alone - Answer -Never. If findings
are out of normal range and the physician has ordered additional testing or treatment;
consult with the physician as to whether the Dx should be added or if an abnormal
finding should be listed.
4 cooperating parties of ICD-9 and responsibilities of each - Answer -NCHS (national
center for health statistics): maintaines dx classifications in Vol 1&2
CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health
information management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER code
- Answer -When the patient meets the definition of critical care and receives outpatient
care on the same day
limiting charge - Answer -this is the amount a NON PAR Medicare provider can collect
from a patient in excess of 15% over the NON PAR Medicare approved amount.
When does CMS send the payment directly to the patient - Answer -when a NON PAR
provider does not accept assignment
,hard coding - Answer -refers to CPT/HCPCS codes that appear in the hospitals
chargemaster and will be included automatically on the patient's bill.
CAC- computer assisted coding - Answer -AHIMA defines as the use of computer
software that automatically generates a set of medical codes for review , validation, and
use based upon the documentation provided by the various providers of healthcare.
modifier: A1-principle physical of record - Answer -required for patients covered by
Medicare when reporting Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - Answer -Organized by problem
number
Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of care
Discharge Note/ Transfer Note: summarizes episode of care and current status of
patient
Cost Sharing Provision of Health Ins. - Answer -formulary for drugs
co-pay
benefit limitations
Common Complication of Labor and Delivery - Answer -forceps or vacuum extractor
delivery without mention of indication
renal sphincter tear, not associated with 3rd degree peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to children under 18 - Answer -defers to state law on matters that
concern minors
disease index - Answer -list diagnostic codes in order
physician index - Answer -lists cases in order by physician name or number
master patient index - Answer -cross reference patient name and medical record
number
operation index - Answer -list medical records by operative procedures
,Point of Care Service - Answer -when clinical documentation is entered in computer at
the same time and location of service
Federal Register - Answer -published by CMS. Contains both proposed and final notes
for Conditions of Participation for hospitals
NEC - Answer -Books fault> Doctor has detail documented, book does not contain
matching detail
NOS - Answer -Doctors fault> Doctor lacks specific documentation although ICD has
detailed options
V codes - Answer -supplemental classification
Problem based include: need for vaccine
Fact based include: history of, outcome of delivery
Service based: dialysis, chemo, therapy
When is an interval H&P permitted - Answer -when a patient is readmitted for the same
or related problem with-in 30 days
Required data for Acute Care and ER records - Answer -physical findings
lab and diagnostic test results
follow-up instructions
subpeona duces tecum - Answer -ONLY reason that warrants the original patient chart
to leave the premisses of the hospital
OBRA - Answer -Omnibus Budget Reconciliation Act of 1987
MDS - Answer -Minimum Data Set- used to collect assessment data elements on Nsg
home episodes
facility data dictionary - Answer -includes security levels for each form field and
definitions for all entities
Consultation Report - Answer -used for obscure diagnoses. patients that physicians are
not sure of the best therapeutic action and / or question of criminal activity o patient.
Medical Staff By Laws, Rules, and Regulations - Answer -H&P Exam completed
documentation is due within 24 hours after admission prior to surgery.
integrated health record - Answer -arranged in strict chronological order
SOMR-Source Oriented Health Record - Answer -organized by subject matter, then
chronologically within each subject; labs together, progress notes together etc.
, methicillin-resistant staphyllococus - Answer -SUPERBUG, a major source of hospital-
acquired infections
Prion Disease - Answer -family of rare progressive neuro-degenerative disorders.
Including:
Creutzfeldt-Jakob disease (human)
Varient Creutzfeld-Jakob disease (human)
Gertsmann-Straussler-Scheinker Syndrome (human)
Fatal Familial Insomnia
Kuru, aka TSE's transmissible spongiform encephalopathies
Synthroid - Answer -Rx prescribed to replace small levels of thyroid hormone
criteria for assigning CPT preventative medicine codes - Answer -age
Fetal Death - Answer -state law determines weight and weeks of gestation, normal
parameters are 500 + grams or 22 + weeks of gestation
missed abortion - Answer -fetal death prior to completion of 22 weeks gestation
Unlisted codes in CPT - Answer -only use when there is actually no code for the
procedure
DO NOT USE when the coder does not understand the procedure or document
additional information MUST be submitted with the claim including; description of
procedure, time/ effort necessary to preform procedure, type of equipment required,
medical reason for procedure
Superbill - Answer -Aka; charge ticket
Data Quality Analysis - Answer -accuracy
accessibility
comprehensives
consistency
currency
definition
granularity
integrity
precision
relevancy
timeliness
NON PAR Medicare reimbursement - Answer -95% of the PAR Medicare allowed.
Providers can bill up to 115% of the NON PAR allowed amount.
and Answers
According to AMA medical decision making is measured by - Answer -1. number of dx
or management options
3. risk of complications
CPT Assistant - Answer -provides official guidance in CPT coding
published by the AMA
A barrier to wide spread use of automated code assignments is - Answer -poor quality
of documentation
When should coders assign codes from lab reports alone - Answer -Never. If findings
are out of normal range and the physician has ordered additional testing or treatment;
consult with the physician as to whether the Dx should be added or if an abnormal
finding should be listed.
4 cooperating parties of ICD-9 and responsibilities of each - Answer -NCHS (national
center for health statistics): maintaines dx classifications in Vol 1&2
CMS: maintains procedural classification in Vol 3
AHIMA & AHA: give advice & assistance on coding guidelines in conjunction with health
information management practitioners, physicians, & other users of ICD-9
When can code 99291 (E/M critical care) be used in place of a medical visit or ER code
- Answer -When the patient meets the definition of critical care and receives outpatient
care on the same day
limiting charge - Answer -this is the amount a NON PAR Medicare provider can collect
from a patient in excess of 15% over the NON PAR Medicare approved amount.
When does CMS send the payment directly to the patient - Answer -when a NON PAR
provider does not accept assignment
,hard coding - Answer -refers to CPT/HCPCS codes that appear in the hospitals
chargemaster and will be included automatically on the patient's bill.
CAC- computer assisted coding - Answer -AHIMA defines as the use of computer
software that automatically generates a set of medical codes for review , validation, and
use based upon the documentation provided by the various providers of healthcare.
modifier: A1-principle physical of record - Answer -required for patients covered by
Medicare when reporting Initial Hospital Service codes
POMR- PROBLEM ORIENTED MEDICAL RECORD - Answer -Organized by problem
number
Database: history and physical
Problem List: titles, numbers, dates of problems..."Table of Contents" of the record
Initial Plan: describes diagnostic, therapeutic, and patient education plans
Progress Note: documents the progress of a patient throughout the episode of care
Discharge Note/ Transfer Note: summarizes episode of care and current status of
patient
Cost Sharing Provision of Health Ins. - Answer -formulary for drugs
co-pay
benefit limitations
Common Complication of Labor and Delivery - Answer -forceps or vacuum extractor
delivery without mention of indication
renal sphincter tear, not associated with 3rd degree peritoneal laceration
trauma to perineum and vulva during delivery
HIPAA law in regards to children under 18 - Answer -defers to state law on matters that
concern minors
disease index - Answer -list diagnostic codes in order
physician index - Answer -lists cases in order by physician name or number
master patient index - Answer -cross reference patient name and medical record
number
operation index - Answer -list medical records by operative procedures
,Point of Care Service - Answer -when clinical documentation is entered in computer at
the same time and location of service
Federal Register - Answer -published by CMS. Contains both proposed and final notes
for Conditions of Participation for hospitals
NEC - Answer -Books fault> Doctor has detail documented, book does not contain
matching detail
NOS - Answer -Doctors fault> Doctor lacks specific documentation although ICD has
detailed options
V codes - Answer -supplemental classification
Problem based include: need for vaccine
Fact based include: history of, outcome of delivery
Service based: dialysis, chemo, therapy
When is an interval H&P permitted - Answer -when a patient is readmitted for the same
or related problem with-in 30 days
Required data for Acute Care and ER records - Answer -physical findings
lab and diagnostic test results
follow-up instructions
subpeona duces tecum - Answer -ONLY reason that warrants the original patient chart
to leave the premisses of the hospital
OBRA - Answer -Omnibus Budget Reconciliation Act of 1987
MDS - Answer -Minimum Data Set- used to collect assessment data elements on Nsg
home episodes
facility data dictionary - Answer -includes security levels for each form field and
definitions for all entities
Consultation Report - Answer -used for obscure diagnoses. patients that physicians are
not sure of the best therapeutic action and / or question of criminal activity o patient.
Medical Staff By Laws, Rules, and Regulations - Answer -H&P Exam completed
documentation is due within 24 hours after admission prior to surgery.
integrated health record - Answer -arranged in strict chronological order
SOMR-Source Oriented Health Record - Answer -organized by subject matter, then
chronologically within each subject; labs together, progress notes together etc.
, methicillin-resistant staphyllococus - Answer -SUPERBUG, a major source of hospital-
acquired infections
Prion Disease - Answer -family of rare progressive neuro-degenerative disorders.
Including:
Creutzfeldt-Jakob disease (human)
Varient Creutzfeld-Jakob disease (human)
Gertsmann-Straussler-Scheinker Syndrome (human)
Fatal Familial Insomnia
Kuru, aka TSE's transmissible spongiform encephalopathies
Synthroid - Answer -Rx prescribed to replace small levels of thyroid hormone
criteria for assigning CPT preventative medicine codes - Answer -age
Fetal Death - Answer -state law determines weight and weeks of gestation, normal
parameters are 500 + grams or 22 + weeks of gestation
missed abortion - Answer -fetal death prior to completion of 22 weeks gestation
Unlisted codes in CPT - Answer -only use when there is actually no code for the
procedure
DO NOT USE when the coder does not understand the procedure or document
additional information MUST be submitted with the claim including; description of
procedure, time/ effort necessary to preform procedure, type of equipment required,
medical reason for procedure
Superbill - Answer -Aka; charge ticket
Data Quality Analysis - Answer -accuracy
accessibility
comprehensives
consistency
currency
definition
granularity
integrity
precision
relevancy
timeliness
NON PAR Medicare reimbursement - Answer -95% of the PAR Medicare allowed.
Providers can bill up to 115% of the NON PAR allowed amount.
