AHIMA CCA FINAL EXAM ACTUAL QUESTIONS AND
SOLUTIONS RATED A+
✔✔n processing a bill under the Medicare outpatient prospective payment system
(OPPS) in which a patient had three surgical procedures performed during the same
operative session, which of the following would apply?
a. Bundling of services
b. Outlier adjustment
c. Pass-through payment
d. Discounting of procedures - ✔✔Correct Answer: D
Discounting applies to multiple surgical procedures furnished during the same
operative session. The full rate will be paid to the surgical procedure with the highest
rate and the additional procedures will be discounted 50% of their APC rate (Johns
2011, 330).
✔✔Mary Smith, RHIA, has been charged with the responsibility of designing a data
collection form to be used on admission of a patient to the acute-care hospital in which
she works. The first resource that she should use is:
a. UHDDS
b. UACDS
c. MDS
d. ORYX - ✔✔Correct Answer: A
In 1974, the federal government adopted the UHDDS as the standard for collecting data
for the Medicare and Medicaid programs. When the Prospective Payment Act was
enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for
implementing diagnosis-related groups (DRGs). A key component was the incorporation
of the definitions of principal diagnosis, principal procedure, and other significant
procedures, into the DRG algorithms (LaTour and Eichenwald Maki 2010, 165).
✔✔Computer software programs that assist in the assignment of codes used with
diagnostic and procedural classifications are called:
a. Natural-language processing systems
b. Monitoring/audit programs
,c. Encoders
d. Concept, description, and relationship tables - ✔✔Correct Answer: C
The type of tool used to aid in the coding process is called an encoder (Johns 2011,
269).
✔✔The following is documented in an acute-care record: "Microscopic: Sections are of
squamous mucosa with no atypia." In which of the following would this documentation
appear?
a. History
b. Pathology report
c. Physical examination
d. Operation report - ✔✔The following is documented in an acute-care record:
"Microscopic: Sections are of squamous mucosa with no atypia." In which of the
following would this documentation appear?
a. History
b. Pathology report
c. Physical examination
d. Operation report
✔✔With regard to training in PHI policies and procedures, the following statement is
true:
a. Every member of the covered entity's workforce must be trained.
b. Only individuals employed by the covered entity must be trained.
c. Training only needs to occur when there are material changes to the policies and
procedures.
d. Documentation of training is not required. - ✔✔Correct Answer: A
Every member of the covered entity's workforce must be trained in PHI policies and
procedures according to the Privacy Rule (Johns 2011, 857).
✔✔Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
,a. 231.0
b. 161.0
c. 239.1
d. 212.1 - ✔✔Correct Answer: A
Index Carcinoma, in situ, see also Neoplasm, by site, in situ (Schraffenberger 2012, 94-
95.)
✔✔Data definition refers to:
a. Meaning of data
b. Completeness of data
c. Consistency of data
d. Detail of data - ✔✔Correct Answer: A
Data definition means that the data and information documented in the health record
are defined; users of the data must understand what the data mean and represent
(Johns 2011, 48).
✔✔A 65-year-old woman was admitted to the hospital. She was diagnosed with
septicemia secondary to Staphylococcus aureus and abdominal pain secondary to
diverticulitis of the colon. What is the correct code assignment?
a. 038.8, 562.11, 789.00
b. 038.11, 562.11
c. 038.8, 562.11, 041.11
d. 038.9, 562.11 - ✔✔Correct Answer: B
Septicemia generally refers to a systemic disease associated with the presence of
pathological microorganisms or toxins in the blood, which can include bacteria, viruses,
fungi, or other organisms. Code 038.11 is assigned for septicemia with Staphylococcus
aureus. Because abdominal pain is a symptom of diverticulosis, only the diverticulitis of
the colon (562.11) is coded (Schraffenberger 2012, 80).
✔✔If a patient has an excision of a malignant lesion of the skin, the CPT code is
determined by the body area from which the excision occurs and which of the following?
, a. Length of the lesion as described in the pathology report
b. Dimension of the specimen submitted as described in the pathology report
c. Width times the length of the lesion as described in the operative report
d. Diameter of the lesion as well as the most narrow margins required to adequately
excise the lesion described in the operative report - ✔✔Correct Answer: D
The code selection is determined by measuring the greatest clinical diameter of the
apparent lesion plus that margin required for complete excision (lesion diameter plus
the most narrow margins required equals the excised diameter) (AMA 2012b, 64).
✔✔The key data element for linking data about an individual who is seen in a variety of
care settings is the:
a. Facility medical record number
b. Facility identification number
c. Unique patient identifier
d. Patient birth date - ✔✔Correct Answer: C
A unique patient identifier is a unique number assigned by a healthcare provider to a
patient that distinguishes the patient's medical records from all others (Johns 2011,
1178).
✔✔The Uniform Health Care Decisions Act ranks the next-of-kin in the following order
for medical decision-making purposes:
a. Adult sibling; adult child; spouse; parent
b. Parent; spouse; adult child; adult sibling
c. Spouse; parent; adult sibling; adult child
d. Spouse; adult child; parent; adult sibling - ✔✔Correct Answer: D
The UHCDA suggests that decision-making priority for an individual's next-of-kin be as
follows: Spouse, adult child, parent, adult sibling, or if no one is available who is so
related to the individual, authority may be granted to "an adult who exhibited special
care and concern for the individual" (Brodnik et al. 2009, 113).
✔✔A skin lesion is removed from a patient's cheek in the dermatologist's office. The
dermatologist documents "skin lesion" in the health record. Prior to billing the pathology
SOLUTIONS RATED A+
✔✔n processing a bill under the Medicare outpatient prospective payment system
(OPPS) in which a patient had three surgical procedures performed during the same
operative session, which of the following would apply?
a. Bundling of services
b. Outlier adjustment
c. Pass-through payment
d. Discounting of procedures - ✔✔Correct Answer: D
Discounting applies to multiple surgical procedures furnished during the same
operative session. The full rate will be paid to the surgical procedure with the highest
rate and the additional procedures will be discounted 50% of their APC rate (Johns
2011, 330).
✔✔Mary Smith, RHIA, has been charged with the responsibility of designing a data
collection form to be used on admission of a patient to the acute-care hospital in which
she works. The first resource that she should use is:
a. UHDDS
b. UACDS
c. MDS
d. ORYX - ✔✔Correct Answer: A
In 1974, the federal government adopted the UHDDS as the standard for collecting data
for the Medicare and Medicaid programs. When the Prospective Payment Act was
enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for
implementing diagnosis-related groups (DRGs). A key component was the incorporation
of the definitions of principal diagnosis, principal procedure, and other significant
procedures, into the DRG algorithms (LaTour and Eichenwald Maki 2010, 165).
✔✔Computer software programs that assist in the assignment of codes used with
diagnostic and procedural classifications are called:
a. Natural-language processing systems
b. Monitoring/audit programs
,c. Encoders
d. Concept, description, and relationship tables - ✔✔Correct Answer: C
The type of tool used to aid in the coding process is called an encoder (Johns 2011,
269).
✔✔The following is documented in an acute-care record: "Microscopic: Sections are of
squamous mucosa with no atypia." In which of the following would this documentation
appear?
a. History
b. Pathology report
c. Physical examination
d. Operation report - ✔✔The following is documented in an acute-care record:
"Microscopic: Sections are of squamous mucosa with no atypia." In which of the
following would this documentation appear?
a. History
b. Pathology report
c. Physical examination
d. Operation report
✔✔With regard to training in PHI policies and procedures, the following statement is
true:
a. Every member of the covered entity's workforce must be trained.
b. Only individuals employed by the covered entity must be trained.
c. Training only needs to occur when there are material changes to the policies and
procedures.
d. Documentation of training is not required. - ✔✔Correct Answer: A
Every member of the covered entity's workforce must be trained in PHI policies and
procedures according to the Privacy Rule (Johns 2011, 857).
✔✔Identify the diagnosis code(s) for carcinoma in situ of vocal cord.
,a. 231.0
b. 161.0
c. 239.1
d. 212.1 - ✔✔Correct Answer: A
Index Carcinoma, in situ, see also Neoplasm, by site, in situ (Schraffenberger 2012, 94-
95.)
✔✔Data definition refers to:
a. Meaning of data
b. Completeness of data
c. Consistency of data
d. Detail of data - ✔✔Correct Answer: A
Data definition means that the data and information documented in the health record
are defined; users of the data must understand what the data mean and represent
(Johns 2011, 48).
✔✔A 65-year-old woman was admitted to the hospital. She was diagnosed with
septicemia secondary to Staphylococcus aureus and abdominal pain secondary to
diverticulitis of the colon. What is the correct code assignment?
a. 038.8, 562.11, 789.00
b. 038.11, 562.11
c. 038.8, 562.11, 041.11
d. 038.9, 562.11 - ✔✔Correct Answer: B
Septicemia generally refers to a systemic disease associated with the presence of
pathological microorganisms or toxins in the blood, which can include bacteria, viruses,
fungi, or other organisms. Code 038.11 is assigned for septicemia with Staphylococcus
aureus. Because abdominal pain is a symptom of diverticulosis, only the diverticulitis of
the colon (562.11) is coded (Schraffenberger 2012, 80).
✔✔If a patient has an excision of a malignant lesion of the skin, the CPT code is
determined by the body area from which the excision occurs and which of the following?
, a. Length of the lesion as described in the pathology report
b. Dimension of the specimen submitted as described in the pathology report
c. Width times the length of the lesion as described in the operative report
d. Diameter of the lesion as well as the most narrow margins required to adequately
excise the lesion described in the operative report - ✔✔Correct Answer: D
The code selection is determined by measuring the greatest clinical diameter of the
apparent lesion plus that margin required for complete excision (lesion diameter plus
the most narrow margins required equals the excised diameter) (AMA 2012b, 64).
✔✔The key data element for linking data about an individual who is seen in a variety of
care settings is the:
a. Facility medical record number
b. Facility identification number
c. Unique patient identifier
d. Patient birth date - ✔✔Correct Answer: C
A unique patient identifier is a unique number assigned by a healthcare provider to a
patient that distinguishes the patient's medical records from all others (Johns 2011,
1178).
✔✔The Uniform Health Care Decisions Act ranks the next-of-kin in the following order
for medical decision-making purposes:
a. Adult sibling; adult child; spouse; parent
b. Parent; spouse; adult child; adult sibling
c. Spouse; parent; adult sibling; adult child
d. Spouse; adult child; parent; adult sibling - ✔✔Correct Answer: D
The UHCDA suggests that decision-making priority for an individual's next-of-kin be as
follows: Spouse, adult child, parent, adult sibling, or if no one is available who is so
related to the individual, authority may be granted to "an adult who exhibited special
care and concern for the individual" (Brodnik et al. 2009, 113).
✔✔A skin lesion is removed from a patient's cheek in the dermatologist's office. The
dermatologist documents "skin lesion" in the health record. Prior to billing the pathology
