CCA EXAM 3 QUESTIONS AND 100%
VERIFIED CORRECT ANSWERS!!!
During an audit of health records, the HIM director finds that transcribed reports are
being changed by the author up to a week after initial transcription. The director is
concerned that changes occurring this long after transcription jeopardize the legal
principle that documentation must occur near the time of the event. To remedy this
situation, the HIM director should recommend which of the following?
Develop a facility policy that defines the acceptable period of time allowed for a transcribed
document to remain in a draft form.
What is the basic formula for calculating each MS-DRG hospital payments?
Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics?
Coding an intentionally inappropriate level of service
What is abstracting?
Compiling the pertinent information from the medical record based on predetermined data sets
ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth.
28th
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, rehabilitation facilities, and nursing home.
A coding analyst consistently enters the wrong code for patient gender in the electronic
billing system. What security measures should be in place to minimize this security breach?
Edit checks
,Mercy Hospital personnel need to review the medical records for Katie Grace for
utilization review purposes (1). They will also be sending her records to her physician for
continuity of care (2). Under HIPAA, these two functions are:
Use and disclosure
Who is responsible for writing and signing discharge summaries and discharge
instructions?
Attending physician
Although the HIPAA Rule allows patient access to personal health information about
themselves, which of the following cannot be disclosed to patients?
Psychotherapy notes
Identify the punctuation mark that is used to supplement 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 affect the code number assigned to the case.
The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM
use them.
Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are
required to use?
National Uniform Billing Committee (NUBC)
Which of the following ethical principles is being followed when an HIT professional
ensures that patient information is only released to those who have a legal right to access
it?
Beneficence
A hospital currently includes the patient's social security number on the face sheet of the
paper medical record and in the electronic version of the record. The hospital risk manager
has identified this as a potential 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 identification and other purposes. Given this
situation, what should the HIM director suggest?
Avoid displaying the number on any document, screen, or data collection field.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be
used for ______________.
Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
Staphylococcus aureous
A patient with known COPD and hypertension under treatment was admitted to the
hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic
appendectomy and develops a fever. The patient was subsequently discharged from the
hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-
operative infection, COPD, and hypertension. Which of the following diagnoses should not
be tagged as POA?
Postoperative infection
CPT was developed and is maintained by:
AMA
Which organization developed the first hospital standardization program?
American College of Surgeon
On review of the audit trail for an EHR system, the HIM director discovers that a
departmental employee who has authorized access to patient records is printing far more
records than the average user. In this cases, what should the supervisor do?
Determine what information was printed and why
What are possible "add-on" payments that a hospital could receive in addition to the basic
Medicare DRG payment?
VERIFIED CORRECT ANSWERS!!!
During an audit of health records, the HIM director finds that transcribed reports are
being changed by the author up to a week after initial transcription. The director is
concerned that changes occurring this long after transcription jeopardize the legal
principle that documentation must occur near the time of the event. To remedy this
situation, the HIM director should recommend which of the following?
Develop a facility policy that defines the acceptable period of time allowed for a transcribed
document to remain in a draft form.
What is the basic formula for calculating each MS-DRG hospital payments?
Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics?
Coding an intentionally inappropriate level of service
What is abstracting?
Compiling the pertinent information from the medical record based on predetermined data sets
ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth.
28th
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, rehabilitation facilities, and nursing home.
A coding analyst consistently enters the wrong code for patient gender in the electronic
billing system. What security measures should be in place to minimize this security breach?
Edit checks
,Mercy Hospital personnel need to review the medical records for Katie Grace for
utilization review purposes (1). They will also be sending her records to her physician for
continuity of care (2). Under HIPAA, these two functions are:
Use and disclosure
Who is responsible for writing and signing discharge summaries and discharge
instructions?
Attending physician
Although the HIPAA Rule allows patient access to personal health information about
themselves, which of the following cannot be disclosed to patients?
Psychotherapy notes
Identify the punctuation mark that is used to supplement 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 affect the code number assigned to the case.
The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM
use them.
Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are
required to use?
National Uniform Billing Committee (NUBC)
Which of the following ethical principles is being followed when an HIT professional
ensures that patient information is only released to those who have a legal right to access
it?
Beneficence
A hospital currently includes the patient's social security number on the face sheet of the
paper medical record and in the electronic version of the record. The hospital risk manager
has identified this as a potential 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 identification and other purposes. Given this
situation, what should the HIM director suggest?
Avoid displaying the number on any document, screen, or data collection field.
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be
used for ______________.
Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases?
Staphylococcus aureous
A patient with known COPD and hypertension under treatment was admitted to the
hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic
appendectomy and develops a fever. The patient was subsequently discharged from the
hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-
operative infection, COPD, and hypertension. Which of the following diagnoses should not
be tagged as POA?
Postoperative infection
CPT was developed and is maintained by:
AMA
Which organization developed the first hospital standardization program?
American College of Surgeon
On review of the audit trail for an EHR system, the HIM director discovers that a
departmental employee who has authorized access to patient records is printing far more
records than the average user. In this cases, what should the supervisor do?
Determine what information was printed and why
What are possible "add-on" payments that a hospital could receive in addition to the basic
Medicare DRG payment?
