CCA EXAM 2 QUESTIONS AND 100%
CORRECT ANSWERS!!
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
a. firewall
c. a call-back process
b. validity processing
d. data encryption
d. 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 history and physical or in the
a. doctor's admitting progress note
b. nurse's admit note
c. review of systems
d. discharge summary
a. doctor's admitting progress note
Employing the SOAP style of progress notes, choose the "assessment" statement from the
following:
a. Patient states low back pain with sciatica is as severe as it was on admission
b. Patient moving about very cautiously and appears to be in pain
c. Adjust pain medication; begin physical therapy tomorrow
d. Sciatica unimproved with hot pack therapy
d. Sciatica unimproved with hot pack therapy
You have been hired to work with a computer-assisted coding initiative. The technology
that you will be working with is
a. electronic data interchange
,b. intraoperability
c. message standards
d. natural language processing
d. natural language processing
A final progress note is appropriate as a discharge summary for a hospitalization in which
the patient
a. dies within 24 hours of admission
b. has no comorbidities or complications during this episode of care
c. was admitted within 30 days with the same diagnosis
d. was an obstetric admission with a normal delivery and no complications
d. was an obstetric admission with a normal delivery and no complications
In reviewing a medical 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
patients's response to treatment and documentation of any complications that may have
developed during this episode of care is in the
a. doctor's progress note section
b. operative report
c. history and physical
d. doctor's orders
a. doctor's progress note section
You would expect to find documentation regarding the assessment of an obstetric patient's
lochia, fundus, and perineum on the
a. prenatal record
b. labor record
c. delivery room record
d. postpartum record
d. postpartum record
,A patient is admitted through the emergency department with diabetes mellitus. Three
days after admission, the physician documents uncontrolled diabetes mellitus. What is the
"present on admission" (POA) indicator for uncontrolled diabetes mellitus?
a. "Y"
b. "U"
c. "W"
d. "N"
d. "N"
(the DM wasn't considered uncontrolled until 3 days after admission)
CMI Table
b. 2.965807
The special form that plays the central role in planning and providing care at nursing,
psychiatric, and rehabilitation facilities is the
a. interdisciplinary patient care plan
b. medical history and review of systems
c. interval summary
d. problem list
a. interdisciplinary patient care plan
What legal term is used in describing sexual harassment in reference to unwelcome sexual
advances, request for sexual favors, and verbal or physical conduct of a sexual nature made
in return for job benefits?
a. res ipsa loquitur
b. qui tam
c. quid pro quo
d. respondeat superior
c. quid pro quo
, Your facility would like to improve physician documentation in order to allow improved
coding. As coding supervisor, you have found it very effective to provide the physicians
with
a. a copy of the facility coding guidelines, along with written information on improved
documentation
b. the UHDDS and information on where each data element is collected and/or verified in
your facility
c. regular in-service presentations on documentation, including its importance and tips for
improvement
d. feedback on specific instances when improved documentation would improve coding
d. feedback on specific instances when improved documentation would improve coding
Table
a. 100%
Which of the following diagnoses or procedures would prevent the normal delivery code,
650, from being assigned?
a. occiput presentation
b. single liveborn
c. episiotomy
d. low forceps
d. low forceps
Which of the following are considered late effects regardless of time?
a. congenital defect
b. nonunion
c. nonhealing fracture
d. poisoning
b. nonunion
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with
cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral
CORRECT ANSWERS!!
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
a. firewall
c. a call-back process
b. validity processing
d. data encryption
d. 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 history and physical or in the
a. doctor's admitting progress note
b. nurse's admit note
c. review of systems
d. discharge summary
a. doctor's admitting progress note
Employing the SOAP style of progress notes, choose the "assessment" statement from the
following:
a. Patient states low back pain with sciatica is as severe as it was on admission
b. Patient moving about very cautiously and appears to be in pain
c. Adjust pain medication; begin physical therapy tomorrow
d. Sciatica unimproved with hot pack therapy
d. Sciatica unimproved with hot pack therapy
You have been hired to work with a computer-assisted coding initiative. The technology
that you will be working with is
a. electronic data interchange
,b. intraoperability
c. message standards
d. natural language processing
d. natural language processing
A final progress note is appropriate as a discharge summary for a hospitalization in which
the patient
a. dies within 24 hours of admission
b. has no comorbidities or complications during this episode of care
c. was admitted within 30 days with the same diagnosis
d. was an obstetric admission with a normal delivery and no complications
d. was an obstetric admission with a normal delivery and no complications
In reviewing a medical 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
patients's response to treatment and documentation of any complications that may have
developed during this episode of care is in the
a. doctor's progress note section
b. operative report
c. history and physical
d. doctor's orders
a. doctor's progress note section
You would expect to find documentation regarding the assessment of an obstetric patient's
lochia, fundus, and perineum on the
a. prenatal record
b. labor record
c. delivery room record
d. postpartum record
d. postpartum record
,A patient is admitted through the emergency department with diabetes mellitus. Three
days after admission, the physician documents uncontrolled diabetes mellitus. What is the
"present on admission" (POA) indicator for uncontrolled diabetes mellitus?
a. "Y"
b. "U"
c. "W"
d. "N"
d. "N"
(the DM wasn't considered uncontrolled until 3 days after admission)
CMI Table
b. 2.965807
The special form that plays the central role in planning and providing care at nursing,
psychiatric, and rehabilitation facilities is the
a. interdisciplinary patient care plan
b. medical history and review of systems
c. interval summary
d. problem list
a. interdisciplinary patient care plan
What legal term is used in describing sexual harassment in reference to unwelcome sexual
advances, request for sexual favors, and verbal or physical conduct of a sexual nature made
in return for job benefits?
a. res ipsa loquitur
b. qui tam
c. quid pro quo
d. respondeat superior
c. quid pro quo
, Your facility would like to improve physician documentation in order to allow improved
coding. As coding supervisor, you have found it very effective to provide the physicians
with
a. a copy of the facility coding guidelines, along with written information on improved
documentation
b. the UHDDS and information on where each data element is collected and/or verified in
your facility
c. regular in-service presentations on documentation, including its importance and tips for
improvement
d. feedback on specific instances when improved documentation would improve coding
d. feedback on specific instances when improved documentation would improve coding
Table
a. 100%
Which of the following diagnoses or procedures would prevent the normal delivery code,
650, from being assigned?
a. occiput presentation
b. single liveborn
c. episiotomy
d. low forceps
d. low forceps
Which of the following are considered late effects regardless of time?
a. congenital defect
b. nonunion
c. nonhealing fracture
d. poisoning
b. nonunion
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with
cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral
