CCA Exam Preparation 2025 – Complete Study
Guide with Practice Questions and Coding Concepts
1. During an audit of health records, the HIM director Develop a facility policy
�nds that transcribed reports are being changed by that de�nes the accept-
the author up to a week after initial transcription. The able period of time al-
director is concerned that changes occurring this long lowed for a transcribed
after transcription jeopardize the legal principle that document to remain in a
documentation must occur near the time of the event. draft form.
To remedy this situation, the HIM director should rec-
ommend which of the following?
2. What is the basic formula for calculating each MS-DRG Hospital payment = DRG
hospital payments? relative weight x hospital
base rate
3. Which of the following activities would be in violation Coding an intentionally in-
of AHIMA's Code of Ethics? appropriate level of ser-
vice
4. What is abstracting? Compiling the pertinent
information from the
medical record based on
predetermined data sets
5. ICD-9-CM de�nes the "newborn period" as birth 28th
through the ___________ day following birth.
6. What healthcare organization collects UHDDS data? All non-outpatient settings
including acute care, short
term care, long term care,
an psychiatric hospitals,
home health agencies, re-
habilitation facilities, and
nursing home.
,7. A coding analyst consistently enters the wrong code Edit checks
for patient gender in the electronic billing system.
What security measures should be in place to mini-
mize this security breach?
8. Mercy Hospital personnel need to review the medical Use and disclosure
records for Katie Grace for utilization review purposes
(1). They will also be sending her records to her physi-
cian for continuity of care (2). Under HIPAA, these two
functions are:
9. Who is responsible for writing and signing discharge Attending physician
summaries and discharge instructions?
10. Although the HIPAA Rule allows patient access to per- Psychotherapy notes
sonal health information about themselves, which of
the following cannot be disclosed to patients?
11. Identify the punctuation mark that is used to sup- Parentheses ( )
plement 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 a ect the code number assigned to the case.
The punctuation is considered a nonessential modi�-
er, and all three volumes of ICD-9-CM use them.
12. What is the name of the organization that develops National Uniform Billing
the billing form that hospitals are required to use? Committee (NUBC)
13. Which of the following ethical principles is being fol- Bene�cence
lowed when an HIT professional ensures that patient
information is only released to those who have a legal
right to access it?
,14. A hospital currently includes the patient's social secu- Avoid displaying the num-
rity number on the face sheet of the paper medical ber on any document,
record and in the electronic version of the record. screen, or data collection
The hospital risk manager has identi�ed this as a po- �eld.
tential 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 identi�cation and
other purposes. Given this situation, what should the
HIM director suggest?
15. Both HEDIS and the Joint Commission's ORYX pro- Performance improve-
gram are designed to collect data to be used for ment programs
______________.
16. Which of the following would be classi�ed to an Staphylococcus aureous
ICD-9-CM category for bacterial diseases?
17. A patient with known COPD and hypertension under Postoperative infection
treatment was admitted to the hospital with symp-
toms of a lower abdominal pain. He undergoes a la-
paroscopic appendectomy and develops a fever. The
patient was subsequently discharged from the hos-
pital with a principal diagnosis of acute appendicitis
and secondary diagnoses of post-operative infection,
COPD, and hypertension. Which of the following diag-
noses should not be tagged as POA?
18. CPT was developed and is maintained by: AMA
19. Which organization developed the �rst hospital stan- American College of Sur-
dardization program? geon
, 20. On review of the audit trail for an EHR system, the HIM Determine what informa-
director discovers that a departmental employee who tion was printed and why
has authorized access to patient records is printing
far more records than the average user. In this cases,
what should the supervisor do?
21. What are possible "add-on" payments that a hospital Additional payments may
could receive in addition to the basic Medicare DRG be made to dispropor-
payment? tionate share hospitals, for
indirect medical educa-
tion, for new technologies,
and for cost outlier cases.
22. The ___________ is a type of coding that is a natural Computer-assisted cod-
outgrowth of the electronic heath record. ing
23. Today, Janet Kim visited her new dentist for an ap- No, it is a violation of the
pointment. She was not presented with a Notice of HIPAA Privacy rule
Privacy Practices. Is this acceptable?
24. Which of the following would be the best technique Provide an input mask for
to ensure that registration clerks consistently use the entering data in the �eld
correct notation for assigning admission date in an
electronic health record (EHR)?
25. What should a hospital do when a state law requires Comply with both the state
more stringent privacy protection than the federal law and the HIPAA Stan-
HIPAA privacy standard? dard
26. An employee in the physical therapy department Information access con-
arrives early every morning to snoop through the trols
clinical information system for potential information
about neighbors and friends. What security mecha-
Guide with Practice Questions and Coding Concepts
1. During an audit of health records, the HIM director Develop a facility policy
�nds that transcribed reports are being changed by that de�nes the accept-
the author up to a week after initial transcription. The able period of time al-
director is concerned that changes occurring this long lowed for a transcribed
after transcription jeopardize the legal principle that document to remain in a
documentation must occur near the time of the event. draft form.
To remedy this situation, the HIM director should rec-
ommend which of the following?
2. What is the basic formula for calculating each MS-DRG Hospital payment = DRG
hospital payments? relative weight x hospital
base rate
3. Which of the following activities would be in violation Coding an intentionally in-
of AHIMA's Code of Ethics? appropriate level of ser-
vice
4. What is abstracting? Compiling the pertinent
information from the
medical record based on
predetermined data sets
5. ICD-9-CM de�nes the "newborn period" as birth 28th
through the ___________ day following birth.
6. What healthcare organization collects UHDDS data? All non-outpatient settings
including acute care, short
term care, long term care,
an psychiatric hospitals,
home health agencies, re-
habilitation facilities, and
nursing home.
,7. A coding analyst consistently enters the wrong code Edit checks
for patient gender in the electronic billing system.
What security measures should be in place to mini-
mize this security breach?
8. Mercy Hospital personnel need to review the medical Use and disclosure
records for Katie Grace for utilization review purposes
(1). They will also be sending her records to her physi-
cian for continuity of care (2). Under HIPAA, these two
functions are:
9. Who is responsible for writing and signing discharge Attending physician
summaries and discharge instructions?
10. Although the HIPAA Rule allows patient access to per- Psychotherapy notes
sonal health information about themselves, which of
the following cannot be disclosed to patients?
11. Identify the punctuation mark that is used to sup- Parentheses ( )
plement 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 a ect the code number assigned to the case.
The punctuation is considered a nonessential modi�-
er, and all three volumes of ICD-9-CM use them.
12. What is the name of the organization that develops National Uniform Billing
the billing form that hospitals are required to use? Committee (NUBC)
13. Which of the following ethical principles is being fol- Bene�cence
lowed when an HIT professional ensures that patient
information is only released to those who have a legal
right to access it?
,14. A hospital currently includes the patient's social secu- Avoid displaying the num-
rity number on the face sheet of the paper medical ber on any document,
record and in the electronic version of the record. screen, or data collection
The hospital risk manager has identi�ed this as a po- �eld.
tential 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 identi�cation and
other purposes. Given this situation, what should the
HIM director suggest?
15. Both HEDIS and the Joint Commission's ORYX pro- Performance improve-
gram are designed to collect data to be used for ment programs
______________.
16. Which of the following would be classi�ed to an Staphylococcus aureous
ICD-9-CM category for bacterial diseases?
17. A patient with known COPD and hypertension under Postoperative infection
treatment was admitted to the hospital with symp-
toms of a lower abdominal pain. He undergoes a la-
paroscopic appendectomy and develops a fever. The
patient was subsequently discharged from the hos-
pital with a principal diagnosis of acute appendicitis
and secondary diagnoses of post-operative infection,
COPD, and hypertension. Which of the following diag-
noses should not be tagged as POA?
18. CPT was developed and is maintained by: AMA
19. Which organization developed the �rst hospital stan- American College of Sur-
dardization program? geon
, 20. On review of the audit trail for an EHR system, the HIM Determine what informa-
director discovers that a departmental employee who tion was printed and why
has authorized access to patient records is printing
far more records than the average user. In this cases,
what should the supervisor do?
21. What are possible "add-on" payments that a hospital Additional payments may
could receive in addition to the basic Medicare DRG be made to dispropor-
payment? tionate share hospitals, for
indirect medical educa-
tion, for new technologies,
and for cost outlier cases.
22. The ___________ is a type of coding that is a natural Computer-assisted cod-
outgrowth of the electronic heath record. ing
23. Today, Janet Kim visited her new dentist for an ap- No, it is a violation of the
pointment. She was not presented with a Notice of HIPAA Privacy rule
Privacy Practices. Is this acceptable?
24. Which of the following would be the best technique Provide an input mask for
to ensure that registration clerks consistently use the entering data in the �eld
correct notation for assigning admission date in an
electronic health record (EHR)?
25. What should a hospital do when a state law requires Comply with both the state
more stringent privacy protection than the federal law and the HIPAA Stan-
HIPAA privacy standard? dard
26. An employee in the physical therapy department Information access con-
arrives early every morning to snoop through the trols
clinical information system for potential information
about neighbors and friends. What security mecha-
