CCA Mock Exam 2,
interpretation of documentation in the record
The health information management professional (HIM) is responsible for attesting
What type of testimony is inappropriate for
to the fact of whether or not the record was generated during the usual course of
a health information manager serving as
business; the accessibility of the record; the authenticity of the record, whether or
custodian of the record when he or she is
not the record was altered; and was the security of the record upheld. The HIM
called to be a witness in court?
professional is not a clinician and is not responsible for providing care to the patient.
The HIM professional is not authorized or clinically trained to interpret
documentation written by physicians and other clinicians.
UB-04
The standard claim form used by hospitals UB-04 is a claim form used by hospitals. This is the correct answer.
to request reimbursement for inpatient and Incorrect answers:
outpatient procedures performed or CMS-1491 is a claim form used for ambulance services.
services provided is called the CMS-1500 is a claim form used for physician services, as well as outpatient
services.
CMS-1600 is the claim form that does not exist currently.
6
A covered entity must adopt reasonable
and appropriate policies and procedures to HIPAA Policies and Procedures and Documentation Requirements
comply with the provisions of the Security A covered entity must adopt reasonable and appropriate policies and procedures to
Rule. A covered entity must maintain, until comply with the provisions of the Security Rule. A covered entity must maintain, until
_____ years after the later of the date of six years after the later of the date of their creation or last effective date, written
their creation or last effective date, written security policies and procedures and written records of required actions, activities or
security policies and procedures and assessments.
written records of required actions, Updates. A covered entity must periodically review and update its documentation in
activities or assessments. response to environmental or organizational changes that affect the security of
electronic protected health information (e-PHI).
1/19
, 54520
Patient has been diagnosed with prostate
cancer. Patient arrived in the operating
Assign code 54520 for the therapeutic orchiectomy procedure.
room where a therapeutic orchiectomy is
To determine the correct code, you must identify that the orchiectomy was simple as
performed
opposed to radical. Exploration was not performed during this procedure.
O80, Z37.0, Z3A.38
Vaginal, full-term live-born delivery = O80
[Outcome of delivery] single live-born infant = Z37.0
After 38-week gestation = Z3A.38
A woman has a vaginal delivery of a full-
Confirm this with Official Guidelines Section I.C. Chapter-Specific Coding
term live-born infant after 38 weeks
Guidelines, 15.n.1) Encounter for full term uncomplicated delivery, as well as 3)
gestation.
Outcome of delivery for O80.
There is a notation at the very beginning of the Tabular List, Chapter 15. Pregnancy,
Childbirth, and the Puerperium (O00-O9A), that states, "Use additional code from
category Z3A, /weeks of gestation, to identify the specific week of the pregnancy, if
known."
MDS
The Minimum Data Set (MDS) is a basic component of the long-term care Resident
The federally mandated resident
Assessment Instrument Minimum Data Set (RAI). The wrong answers: 1) DEEDS
assessment instrument used in long-term
stands for Data Elements for Emergency Department Systems and is a uniform
care facilities consists of three basic
method of collecting data in emergency departments. 2) OASIS stands for Outcome
components, including the new care area
and Assessment Information Set and is an assessment method used in home
assessment, utilization guidelines, and the
health. 3) UHDDS stands for Uniform Hospital Discharge Data Set it seeks to
improve the standardization and comparability of hospital discharge data and is
used primarily in acute care facilities.
Patient comes into his physician's office 25246, 73115
complaining of wrist pain. Physician gives
the patient an injection and sends the Assign code 25246 for the injection for wrist arthrography. Also assign code 73115
patient to the hospital for an arthrography. for the radiological supervision and interpretation.
Code the complete procedure
APR-DRGs
Based on CMS's DRG system, other
systems have been developed for payment APR-DRGs stand for All-Patient Refined Diagnosis-Related Groups. This is the
purposes. The one that classifies the non- correct answer.
Medicare population, such as HIV patients, Incorrect answers:
neonates, and pediatric patients, is known AP-DRGs stand for All-Patient Diagnosis-Related Groups.
as IR-DRGs stand for International-Refined Diagnosis-Related Groups.
R-DRGs stand Refined Diagnosis-Related Groups.
HCPCS/CPT code
HCPCS stands for Healthcare Common Procedure Coding System and refers to a
code set that includes CPT codes. This is the correct answer.
Which type of code or key provides a
Incorrect answers:
uniform system for identifying procedures,
Charge/service code is the assigned identification number to products and
services, or supplies?
procedures provided in this facility, as listed in their chargemaster.
General ledger key is an accounting term.
Revenue code identifies the source, within the hospital, of the charge, that is, which
department within the hospital provided the service.
92928-RC
The patient's physician performed a
balloon angioplasty (PTCA) with insertion
Assign code 92928 for balloon angioplasty (PTCA) with insertion of drug-eluting
of drug-eluting stent in the right coronary
stent in right coronary artery. Add modifier -RC to code 92928 to indicate procedure
artery.
was performed on the right coronary artery.
2/19
, collection of overpayments.
The RAC program is mandated to find and correct improper Medicare payments
The Recovery Audit Contractor (RAC) paid to health care providers participating in the Medicare reimbursement program.
program was developed to identify and Wrong answers: 1) Medicare claims-Filing a claim for reimbursement purposes for
reduce improper payments for services rendered for a Medicare beneficiary. 2) Medicaid claims- Filing a claim for
reimbursement purposes for services rendered for a Medicaid beneficiary
magnetic degaussing
Computerized data can be erased by neutralizing the magnetic field. This
destruction method is called magnetic degaussing.
Incorrect answers:
A health care facility has made a decision
to destroy computerized data. AHIMA Disk reformatting is the process of preparing or revising a device such as a USB
recommendations identify which of the flash drive to store new or different data.
following methods as the preferred method
Overwriting the backup tapes is a recycling process by overwriting backup tapes
of destruction for computerized data?
with new backup data. This is usually done on a schedule, for example, daily or
weekly. This deletion process is not secure.
Overwriting data with a series of characters is a process to remove data by
overwriting the data with algorithms. This deletion method is never secure.
improve patient care
The National Cancer Data Base is a joint program of hospital registries of the
Commission on Cancer and the American Cancer Society. Its purpose is to ensure
The primary goal of a hospital-based quality cancer care by providing data to evaluate patient management within
cancer registry is to hospitals and other treatment centers, make comparisons of cancer care and
outcomes between institutions, and set standard to help improve quality of cancer
care
Based on the following documentation in operative record
an acute care record, determine where
would you expect this excerpt to appear? Operative record documents the details of a procedure or surgery. This entry is a
typical example of a surgical procedure. Wrong answers: 1)Physical exam routine
examination performed by the healthcare provider to assess the patient's overall
With the patient in the supine position, the health status. 2) Nursing progress notes are notes made by a nurse providing an
right side of the neck was appropriately accurate assessments and changes in patient conditions. 3) Physician progress
prepped with betadine solution and notes are the part of a medical record where the provider documents a patient's
draped. I was able to pass the central line clinical status and changes during the course of hospitalization or treatment
which was taped to skin and used for
administration of drugs during
resuscitation.
a patient claim may have multiple MS-DRGs
The determination of an Medicare Severity-Diagnosis Related Group (MS-DRG) is
All of the following statements are true of
calculated by the entire stay by the patient. Therefore, there can only be one
MS-DRGs, EXCEPT Medicare Severity-Diagnosis Related Group (MS-DRG) group for one patient's stay
in the hospital.
The screen should read left to right.
You have been asked to establish
guidelines on screen design that will be There are best practices for screen design such as screens should have the same
used in all of your information system look and feel, the fields should be in a logical order, and the screen should be read
projects. Identify a standard that should be from left to right and top to bottom. Red and green should not be used because of
included. color-blind users. There is no problem with using hyperlinks where appropriate.
3/19
interpretation of documentation in the record
The health information management professional (HIM) is responsible for attesting
What type of testimony is inappropriate for
to the fact of whether or not the record was generated during the usual course of
a health information manager serving as
business; the accessibility of the record; the authenticity of the record, whether or
custodian of the record when he or she is
not the record was altered; and was the security of the record upheld. The HIM
called to be a witness in court?
professional is not a clinician and is not responsible for providing care to the patient.
The HIM professional is not authorized or clinically trained to interpret
documentation written by physicians and other clinicians.
UB-04
The standard claim form used by hospitals UB-04 is a claim form used by hospitals. This is the correct answer.
to request reimbursement for inpatient and Incorrect answers:
outpatient procedures performed or CMS-1491 is a claim form used for ambulance services.
services provided is called the CMS-1500 is a claim form used for physician services, as well as outpatient
services.
CMS-1600 is the claim form that does not exist currently.
6
A covered entity must adopt reasonable
and appropriate policies and procedures to HIPAA Policies and Procedures and Documentation Requirements
comply with the provisions of the Security A covered entity must adopt reasonable and appropriate policies and procedures to
Rule. A covered entity must maintain, until comply with the provisions of the Security Rule. A covered entity must maintain, until
_____ years after the later of the date of six years after the later of the date of their creation or last effective date, written
their creation or last effective date, written security policies and procedures and written records of required actions, activities or
security policies and procedures and assessments.
written records of required actions, Updates. A covered entity must periodically review and update its documentation in
activities or assessments. response to environmental or organizational changes that affect the security of
electronic protected health information (e-PHI).
1/19
, 54520
Patient has been diagnosed with prostate
cancer. Patient arrived in the operating
Assign code 54520 for the therapeutic orchiectomy procedure.
room where a therapeutic orchiectomy is
To determine the correct code, you must identify that the orchiectomy was simple as
performed
opposed to radical. Exploration was not performed during this procedure.
O80, Z37.0, Z3A.38
Vaginal, full-term live-born delivery = O80
[Outcome of delivery] single live-born infant = Z37.0
After 38-week gestation = Z3A.38
A woman has a vaginal delivery of a full-
Confirm this with Official Guidelines Section I.C. Chapter-Specific Coding
term live-born infant after 38 weeks
Guidelines, 15.n.1) Encounter for full term uncomplicated delivery, as well as 3)
gestation.
Outcome of delivery for O80.
There is a notation at the very beginning of the Tabular List, Chapter 15. Pregnancy,
Childbirth, and the Puerperium (O00-O9A), that states, "Use additional code from
category Z3A, /weeks of gestation, to identify the specific week of the pregnancy, if
known."
MDS
The Minimum Data Set (MDS) is a basic component of the long-term care Resident
The federally mandated resident
Assessment Instrument Minimum Data Set (RAI). The wrong answers: 1) DEEDS
assessment instrument used in long-term
stands for Data Elements for Emergency Department Systems and is a uniform
care facilities consists of three basic
method of collecting data in emergency departments. 2) OASIS stands for Outcome
components, including the new care area
and Assessment Information Set and is an assessment method used in home
assessment, utilization guidelines, and the
health. 3) UHDDS stands for Uniform Hospital Discharge Data Set it seeks to
improve the standardization and comparability of hospital discharge data and is
used primarily in acute care facilities.
Patient comes into his physician's office 25246, 73115
complaining of wrist pain. Physician gives
the patient an injection and sends the Assign code 25246 for the injection for wrist arthrography. Also assign code 73115
patient to the hospital for an arthrography. for the radiological supervision and interpretation.
Code the complete procedure
APR-DRGs
Based on CMS's DRG system, other
systems have been developed for payment APR-DRGs stand for All-Patient Refined Diagnosis-Related Groups. This is the
purposes. The one that classifies the non- correct answer.
Medicare population, such as HIV patients, Incorrect answers:
neonates, and pediatric patients, is known AP-DRGs stand for All-Patient Diagnosis-Related Groups.
as IR-DRGs stand for International-Refined Diagnosis-Related Groups.
R-DRGs stand Refined Diagnosis-Related Groups.
HCPCS/CPT code
HCPCS stands for Healthcare Common Procedure Coding System and refers to a
code set that includes CPT codes. This is the correct answer.
Which type of code or key provides a
Incorrect answers:
uniform system for identifying procedures,
Charge/service code is the assigned identification number to products and
services, or supplies?
procedures provided in this facility, as listed in their chargemaster.
General ledger key is an accounting term.
Revenue code identifies the source, within the hospital, of the charge, that is, which
department within the hospital provided the service.
92928-RC
The patient's physician performed a
balloon angioplasty (PTCA) with insertion
Assign code 92928 for balloon angioplasty (PTCA) with insertion of drug-eluting
of drug-eluting stent in the right coronary
stent in right coronary artery. Add modifier -RC to code 92928 to indicate procedure
artery.
was performed on the right coronary artery.
2/19
, collection of overpayments.
The RAC program is mandated to find and correct improper Medicare payments
The Recovery Audit Contractor (RAC) paid to health care providers participating in the Medicare reimbursement program.
program was developed to identify and Wrong answers: 1) Medicare claims-Filing a claim for reimbursement purposes for
reduce improper payments for services rendered for a Medicare beneficiary. 2) Medicaid claims- Filing a claim for
reimbursement purposes for services rendered for a Medicaid beneficiary
magnetic degaussing
Computerized data can be erased by neutralizing the magnetic field. This
destruction method is called magnetic degaussing.
Incorrect answers:
A health care facility has made a decision
to destroy computerized data. AHIMA Disk reformatting is the process of preparing or revising a device such as a USB
recommendations identify which of the flash drive to store new or different data.
following methods as the preferred method
Overwriting the backup tapes is a recycling process by overwriting backup tapes
of destruction for computerized data?
with new backup data. This is usually done on a schedule, for example, daily or
weekly. This deletion process is not secure.
Overwriting data with a series of characters is a process to remove data by
overwriting the data with algorithms. This deletion method is never secure.
improve patient care
The National Cancer Data Base is a joint program of hospital registries of the
Commission on Cancer and the American Cancer Society. Its purpose is to ensure
The primary goal of a hospital-based quality cancer care by providing data to evaluate patient management within
cancer registry is to hospitals and other treatment centers, make comparisons of cancer care and
outcomes between institutions, and set standard to help improve quality of cancer
care
Based on the following documentation in operative record
an acute care record, determine where
would you expect this excerpt to appear? Operative record documents the details of a procedure or surgery. This entry is a
typical example of a surgical procedure. Wrong answers: 1)Physical exam routine
examination performed by the healthcare provider to assess the patient's overall
With the patient in the supine position, the health status. 2) Nursing progress notes are notes made by a nurse providing an
right side of the neck was appropriately accurate assessments and changes in patient conditions. 3) Physician progress
prepped with betadine solution and notes are the part of a medical record where the provider documents a patient's
draped. I was able to pass the central line clinical status and changes during the course of hospitalization or treatment
which was taped to skin and used for
administration of drugs during
resuscitation.
a patient claim may have multiple MS-DRGs
The determination of an Medicare Severity-Diagnosis Related Group (MS-DRG) is
All of the following statements are true of
calculated by the entire stay by the patient. Therefore, there can only be one
MS-DRGs, EXCEPT Medicare Severity-Diagnosis Related Group (MS-DRG) group for one patient's stay
in the hospital.
The screen should read left to right.
You have been asked to establish
guidelines on screen design that will be There are best practices for screen design such as screens should have the same
used in all of your information system look and feel, the fields should be in a logical order, and the screen should be read
projects. Identify a standard that should be from left to right and top to bottom. Red and green should not be used because of
included. color-blind users. There is no problem with using hyperlinks where appropriate.
3/19
