CERTIFIED CODING ASSOCIATE (CCA)
EXAM PREPARATION 2018- WITH
RATIONALE
c. uEdit uchecks
Edit uchecks uhelp uensure udata uintegrity uby uallowing uonly ureasonable uand
upredetermined uvalues uto ube uentered uinto uthe ucomputer u(Rinehart-Thompson
u2016a, u265). u- ucorrect uanswers u-A ucoding uanalyst uconsistently uenters uthe uwrong
ucode ufor upatient ugender uin uthe uelectronic ubilling usystem. uWhat udata uquality uor
udata uintegrity umeasures ushould ube uin uplace uto uensure uthat uonly uallowable ucode
unumbers uare uentered?
a. uAccess ucontrols
b. uAudit utrail
c. uEdit uchecks
d. uPassword ucontrols
b. uDelinquent urecord
,An uincomplete urecord unot urectified uwithin ua uspecific unumber uof udays uas
uindicated uin uthe umedical ustaff urules uand uregulations uis uconsidered uto ube
udelinquent u(Sayles u2016, u65). u- ucorrect uanswers u-A uhealth urecord uwith
udeficiencies uthat uis unot ucomplete uwithin uthe utimeframe uspecified uin uthe umedical
ustaff urules uand uregulations uis ucalled ua(n):
a. uSuspended urecord
b. uDelinquent urecord
c. uPending urecord
d. uIllegal urecord
b. uProvide uan uinput umask ufor uentering udata uin uthe ufield
When useveral upeople uenter udata uin uan uEHR, uyou ucan udefine uhow uusers umust
uenter udata uin uspecific ufields uto uhelp umaintain uconsistency. uFor uexample, uan
uinput umask ufor ua uform umeans uthat uusers ucan uonly uenter uthe udate uin ua
uspecified uformat u(MacDonald u2010, uchapter u4; uCarter uand uPalmer u2016, u506). u-
ucorrect uanswers u-Which uof uthe ufollowing uwould ube uthe ubest utechnique uto
uensure uthat uregistration uclerks uconsistently uuse uthe ucorrect unotation ufor
uassigning uadmission udate uin uan uelectronic uhealth urecord u(EHR)?
a. uMake uadmission udate ua urequired ufield
b. uProvide uan uinput umask ufor uentering udata uin uthe ufield
c. uMake uadmission udate ua unumeric ufield
d. uProvide usufficient uspace ufor uinput uof udata
a. uUHDDS
In u1974, uthe ufederal ugovernment uadopted uthe uUHDDS uas uthe ustandard ufor
ucollecting udata ufor uthe uMedicare uand uMedicaid uprograms. uWhen uthe uProspective
uPayment uAct uwas uenacted uin u1983, uUHDDS udefinitions uwere uincorporated uinto
uthe urules uand uregulations ufor uimplementing udiagnosis-related ugroups u(DRGs). uA
ukey ucomponent uwas uthe uincorporation uof uthe udefinitions uof uprincipal udiagnosis,
uprincipal uprocedure, uand uother usignificant uprocedures, uinto uthe uDRG ualgorithms
u(Oachs uand uWatters u2016, u223). u- ucorrect uanswers u-Mary uSmith, uRHIA, uhas
ubeen ucharged uwith uthe uresponsibility uof udesigning ua udata ucollection uform uto ube
uused uon uadmission uof ua upatient uto uthe uacute-care uhospital uin uwhich ushe uworks.
uThe ufirst uresource uthat ushe ushould uuse uis u_____.
a. uUHDDS
b. uUACDS
c. uMDS
d. uORYX
a. uMeaning uof udata
,Data udefinition umeans uthat uthe udata uand uinformation udocumented uin uthe uhealth
urecord uare udefined; uusers uof uthe udata umust uunderstand uwhat uthe udata umean
uand urepresent u(Sayles u2016, u52). u- ucorrect uanswers u-Data udefinition urefers uto:
a. uMeaning uof udata
b. uCompleteness uof udata
c. uConsistency uof udata
d. uDetail uof udata
a. uProvide uthe umedical urecords uin upaper uformat
The ucovered uentity umust uprovide uaccess uto uthe upersonal uhealth uinformation uin
uthe uform uor uformat urequested uwhen uit uis ureadily uproducible uin usuch uform uor
uformat. uWhen uit uis unot ureadily uproducible uin uthe uform uor uformat urequested, uit
umust ube uproduced uin ua ureadable uhard-copy uform uor usuch uother uform uor uformat
uagreed uupon uby uthe ucovered uentity uand uthe uindividual u(Gordon uand uGordon
u2016b, u615-616). u- ucorrect uanswers u-A upatient urequests ucopies uof uher upersonal
uhealth uinformation uon uCD. uWhen uthe upatient ugoes uhome, ushe ufinds uthat ushe
ucannot uread uthe uCD uon uher ucomputer. uThe upatient uthen urequests uthe uhospital
uto uprovide uthe umedical urecords uin upaper uformat. uHow ushould uthe uhospital
urespond?
a. uProvide uthe umedical urecords uin upaper uformat
b. uBurn uanother uCD ubecause uthis uis uhospital upolicy
c. uProvide uthe upatient uwith uboth upaper uand uCD ucopies uof uthe umedical urecord
d. uReview uthe uCD ucopies uwith uthe upatient uon ua uhospital ucomputer
b. uObjective
Objective uinformation umay ube umeasured uor uobserved uby uthe uhealthcare uprovider
u(Amatayakul u2016, u294). u- ucorrect uanswers u-A unotation ufor ua udiabetic upatient uin
ua uphysician uprogress unote ureads: u"FBS u110mg%, uurine usugar, uno uacetone."
uWhich upart uof ua uPOMR uprogress unote uwould uthis unotation ube uwritten?
a. uSubjective
b. uObjective
c. uAssessment
d. uPlan
d. uQuery uthe uphysician uas uto uthe umethod uused.
It uis unot uappropriate ufor uthe ucoder uto uassume uthe uremoval uwas udone uby ueither
usnare uor uhot ubiopsy uforceps. uThe uablation ucode uis uonly uassigned uwhen ua
ulesion uis ucompletely udestroyed uand uno uspecimen uis uretrieved. uThe ucoding
uprofessional umust uquery uthe uphysician uto uassign uthe uappropriate ucode u(AHIMA
u2016, u454). u- ucorrect uanswers u-When uthe uphysician udoes unot uspecify uthe
umethod uused uto uremove ua ulesion uduring uan uendoscopy, uwhat uis uthe
uappropriate uprocedure?
a. uAssign uthe uremoval uby usnare utechnique ucode.
, b. uAssign uthe uremoval uby uhot ubiopsy uforceps ucode.
c. uAssign uthe uablation ucode.
d. uQuery uthe uphysician uas uto uthe umethod uused.
d. uE-discovery
Although ue-Discovery uis uthe usame upretrial uprocess uas udiscovery, uthe uelectronic
uhealth urecord uhas upromoted uthis uconcept u(Rinehart-Thompson u2016b, u215). u-
ucorrect uanswers u-The uFederal uRules uof uCivil uProcedure u(FRCP) uincorporated
uthe upre-trial uprocess uthrough uthe ucreation uof:
a. uBench uwarrants
b. uCourt uorders
c. uDepositions
d. uE-discovery
d. uStandards
Standards uare ufixed urules uthat umust ube ufollowed, uwhich uis udifferent ufrom ua
uguideline uthat uprovides ugeneral udirection u(Sayles u2016, u66; uBrickner u2016, u82).
u- ucorrect uanswers u-Statements uthat udefine uthe uperformance uexpectations uand
ustructures uor uprocesses uthat umust ube uin uplace uare u_____.
a. uRules
b. uPolicies
c. uGuidelines
d. uStandards
b. uInformation uaccess ucontrols
An uEHR ucan ube uviewed uby umultiple uusers uand ufrom umultiple ulocations uat uany
utime, uand uorganizations umust uhave uin uplace uappropriate usecurity uaccess ucontrol
umeasures uto uensure uthe usafety uof uthe udata u(Sayles u2016, u53; uAmatayakul
u2016, u285 uKellogg u2016b, u482-483). u- ucorrect uanswers u-An uemployee uin uthe
uphysical utherapy udepartment uarrives uearly uevery umorning uto usnoop uthrough uthe
uclinical uinformation usystem ufor upotential uinformation uabout uneighbors uand ufriends.
uWhat usecurity umechanisms ushould ube uimplemented uto uprevent uthis usecurity
ubreach?
a. uAudit ucontrols
b. uInformation uaccess ucontrols
c. uFacility uaccess ucontrols
d. uWorkstation usecurity
c. uMajor udiagnostic ucategories
Diagnosis-related ugroupings u(DRGs) uare uclassified uby uone uof u25 umajor
udiagnostic ucategories u(MDCs) u(Hazelwood uand uVenable u2016, u224). u- ucorrect
uanswers u-Diagnosis-related ugroups uare uorganized uinto:
EXAM PREPARATION 2018- WITH
RATIONALE
c. uEdit uchecks
Edit uchecks uhelp uensure udata uintegrity uby uallowing uonly ureasonable uand
upredetermined uvalues uto ube uentered uinto uthe ucomputer u(Rinehart-Thompson
u2016a, u265). u- ucorrect uanswers u-A ucoding uanalyst uconsistently uenters uthe uwrong
ucode ufor upatient ugender uin uthe uelectronic ubilling usystem. uWhat udata uquality uor
udata uintegrity umeasures ushould ube uin uplace uto uensure uthat uonly uallowable ucode
unumbers uare uentered?
a. uAccess ucontrols
b. uAudit utrail
c. uEdit uchecks
d. uPassword ucontrols
b. uDelinquent urecord
,An uincomplete urecord unot urectified uwithin ua uspecific unumber uof udays uas
uindicated uin uthe umedical ustaff urules uand uregulations uis uconsidered uto ube
udelinquent u(Sayles u2016, u65). u- ucorrect uanswers u-A uhealth urecord uwith
udeficiencies uthat uis unot ucomplete uwithin uthe utimeframe uspecified uin uthe umedical
ustaff urules uand uregulations uis ucalled ua(n):
a. uSuspended urecord
b. uDelinquent urecord
c. uPending urecord
d. uIllegal urecord
b. uProvide uan uinput umask ufor uentering udata uin uthe ufield
When useveral upeople uenter udata uin uan uEHR, uyou ucan udefine uhow uusers umust
uenter udata uin uspecific ufields uto uhelp umaintain uconsistency. uFor uexample, uan
uinput umask ufor ua uform umeans uthat uusers ucan uonly uenter uthe udate uin ua
uspecified uformat u(MacDonald u2010, uchapter u4; uCarter uand uPalmer u2016, u506). u-
ucorrect uanswers u-Which uof uthe ufollowing uwould ube uthe ubest utechnique uto
uensure uthat uregistration uclerks uconsistently uuse uthe ucorrect unotation ufor
uassigning uadmission udate uin uan uelectronic uhealth urecord u(EHR)?
a. uMake uadmission udate ua urequired ufield
b. uProvide uan uinput umask ufor uentering udata uin uthe ufield
c. uMake uadmission udate ua unumeric ufield
d. uProvide usufficient uspace ufor uinput uof udata
a. uUHDDS
In u1974, uthe ufederal ugovernment uadopted uthe uUHDDS uas uthe ustandard ufor
ucollecting udata ufor uthe uMedicare uand uMedicaid uprograms. uWhen uthe uProspective
uPayment uAct uwas uenacted uin u1983, uUHDDS udefinitions uwere uincorporated uinto
uthe urules uand uregulations ufor uimplementing udiagnosis-related ugroups u(DRGs). uA
ukey ucomponent uwas uthe uincorporation uof uthe udefinitions uof uprincipal udiagnosis,
uprincipal uprocedure, uand uother usignificant uprocedures, uinto uthe uDRG ualgorithms
u(Oachs uand uWatters u2016, u223). u- ucorrect uanswers u-Mary uSmith, uRHIA, uhas
ubeen ucharged uwith uthe uresponsibility uof udesigning ua udata ucollection uform uto ube
uused uon uadmission uof ua upatient uto uthe uacute-care uhospital uin uwhich ushe uworks.
uThe ufirst uresource uthat ushe ushould uuse uis u_____.
a. uUHDDS
b. uUACDS
c. uMDS
d. uORYX
a. uMeaning uof udata
,Data udefinition umeans uthat uthe udata uand uinformation udocumented uin uthe uhealth
urecord uare udefined; uusers uof uthe udata umust uunderstand uwhat uthe udata umean
uand urepresent u(Sayles u2016, u52). u- ucorrect uanswers u-Data udefinition urefers uto:
a. uMeaning uof udata
b. uCompleteness uof udata
c. uConsistency uof udata
d. uDetail uof udata
a. uProvide uthe umedical urecords uin upaper uformat
The ucovered uentity umust uprovide uaccess uto uthe upersonal uhealth uinformation uin
uthe uform uor uformat urequested uwhen uit uis ureadily uproducible uin usuch uform uor
uformat. uWhen uit uis unot ureadily uproducible uin uthe uform uor uformat urequested, uit
umust ube uproduced uin ua ureadable uhard-copy uform uor usuch uother uform uor uformat
uagreed uupon uby uthe ucovered uentity uand uthe uindividual u(Gordon uand uGordon
u2016b, u615-616). u- ucorrect uanswers u-A upatient urequests ucopies uof uher upersonal
uhealth uinformation uon uCD. uWhen uthe upatient ugoes uhome, ushe ufinds uthat ushe
ucannot uread uthe uCD uon uher ucomputer. uThe upatient uthen urequests uthe uhospital
uto uprovide uthe umedical urecords uin upaper uformat. uHow ushould uthe uhospital
urespond?
a. uProvide uthe umedical urecords uin upaper uformat
b. uBurn uanother uCD ubecause uthis uis uhospital upolicy
c. uProvide uthe upatient uwith uboth upaper uand uCD ucopies uof uthe umedical urecord
d. uReview uthe uCD ucopies uwith uthe upatient uon ua uhospital ucomputer
b. uObjective
Objective uinformation umay ube umeasured uor uobserved uby uthe uhealthcare uprovider
u(Amatayakul u2016, u294). u- ucorrect uanswers u-A unotation ufor ua udiabetic upatient uin
ua uphysician uprogress unote ureads: u"FBS u110mg%, uurine usugar, uno uacetone."
uWhich upart uof ua uPOMR uprogress unote uwould uthis unotation ube uwritten?
a. uSubjective
b. uObjective
c. uAssessment
d. uPlan
d. uQuery uthe uphysician uas uto uthe umethod uused.
It uis unot uappropriate ufor uthe ucoder uto uassume uthe uremoval uwas udone uby ueither
usnare uor uhot ubiopsy uforceps. uThe uablation ucode uis uonly uassigned uwhen ua
ulesion uis ucompletely udestroyed uand uno uspecimen uis uretrieved. uThe ucoding
uprofessional umust uquery uthe uphysician uto uassign uthe uappropriate ucode u(AHIMA
u2016, u454). u- ucorrect uanswers u-When uthe uphysician udoes unot uspecify uthe
umethod uused uto uremove ua ulesion uduring uan uendoscopy, uwhat uis uthe
uappropriate uprocedure?
a. uAssign uthe uremoval uby usnare utechnique ucode.
, b. uAssign uthe uremoval uby uhot ubiopsy uforceps ucode.
c. uAssign uthe uablation ucode.
d. uQuery uthe uphysician uas uto uthe umethod uused.
d. uE-discovery
Although ue-Discovery uis uthe usame upretrial uprocess uas udiscovery, uthe uelectronic
uhealth urecord uhas upromoted uthis uconcept u(Rinehart-Thompson u2016b, u215). u-
ucorrect uanswers u-The uFederal uRules uof uCivil uProcedure u(FRCP) uincorporated
uthe upre-trial uprocess uthrough uthe ucreation uof:
a. uBench uwarrants
b. uCourt uorders
c. uDepositions
d. uE-discovery
d. uStandards
Standards uare ufixed urules uthat umust ube ufollowed, uwhich uis udifferent ufrom ua
uguideline uthat uprovides ugeneral udirection u(Sayles u2016, u66; uBrickner u2016, u82).
u- ucorrect uanswers u-Statements uthat udefine uthe uperformance uexpectations uand
ustructures uor uprocesses uthat umust ube uin uplace uare u_____.
a. uRules
b. uPolicies
c. uGuidelines
d. uStandards
b. uInformation uaccess ucontrols
An uEHR ucan ube uviewed uby umultiple uusers uand ufrom umultiple ulocations uat uany
utime, uand uorganizations umust uhave uin uplace uappropriate usecurity uaccess ucontrol
umeasures uto uensure uthe usafety uof uthe udata u(Sayles u2016, u53; uAmatayakul
u2016, u285 uKellogg u2016b, u482-483). u- ucorrect uanswers u-An uemployee uin uthe
uphysical utherapy udepartment uarrives uearly uevery umorning uto usnoop uthrough uthe
uclinical uinformation usystem ufor upotential uinformation uabout uneighbors uand ufriends.
uWhat usecurity umechanisms ushould ube uimplemented uto uprevent uthis usecurity
ubreach?
a. uAudit ucontrols
b. uInformation uaccess ucontrols
c. uFacility uaccess ucontrols
d. uWorkstation usecurity
c. uMajor udiagnostic ucategories
Diagnosis-related ugroupings u(DRGs) uare uclassified uby uone uof u25 umajor
udiagnostic ucategories u(MDCs) u(Hazelwood uand uVenable u2016, u224). u- ucorrect
uanswers u-Diagnosis-related ugroups uare uorganized uinto:
