CCA MAIN EXAMINATION 2026 SET QUESTIONS AND
SOLUTIONS RATED A+
✔✔Is a stage I pressure ulcer considered an H-AC? - ✔✔No, stage I and II are not
considered H-AC, but stage III and IV are H-AC
✔✔The electronic format (8371) replaces which paper billing form? - ✔✔CMS-1450
(UB-04) not to be confused with UB-40, an unemployment form in England that the
band was named for. LOL! :-)
✔✔If an outpt clinic is reviewing functionality of a computer system, which datasets
should they consult to ensure all fed req for CMS are collected by the new system? -
✔✔Uniform Ambulatory Care Data Set (UACDS)
✔✔Standardizing med term is one purpose of: - ✔✔Vocabulary standards
✔✔Family practitioner requests opinion of a specialist who reviews pt's health record
and examines pt; specialist records findings, impressions, and recommendations in
what type report? - ✔✔Consultation report
✔✔What is not a function of the discharge summary if some of the functions are
ensuring care continuity, providing info to support activities of medical staff review
committee, and providing concise info that can be used to answer info request? -
✔✔Providing info abt the pt's ins coverage
✔✔Documentation of monitoring to ensure pt sufficiently recovers from anesthesia is a
function of - ✔✔the recovery room report
✔✔All documentation entered in medical record relating to pt's dx and tx is considered
what type of data? - ✔✔Clinical information
✔✔What type of data is exemplified by insured party's member ID number? -
✔✔financial data
✔✔Which part of prob-oriented med records is used by many facilities that have not
adopted the whole prob-oriented format? - ✔✔SOAP form of progress notes
(Subjective, Objective, Assessment, Plan)
✔✔What is the focus of outpt data collection? - ✔✔Reason for encounter
✔✔What is the focus of inpatient data collection? - ✔✔Principal diagnosis
, ✔✔"Pt is admitted for organic brain syndrome" and underneath this dx is her med info
along with rehab potential. Which form is this info listed? - ✔✔Transfer or referral form
✔✔TJC req which doc to be in pt's record before surgical procedure may be performed?
- ✔✔report of history and physical exam and no more than 7 days before the surgery,
unless in the case of emergency
✔✔Pt admitted to hosp on June 21 and phys exam was completed on June 23.
According to Med Cond of Part the record: - ✔✔is not in compliance since the phys
exam must be completed within 24 hours of admission
✔✔When a health record has deficiencies that are not complete within the specified
timeframe of the med staff rules/regulations, it is called: - ✔✔delinquent record
✔✔What form may contain info abt disease among relatives that could be inherited? -
✔✔History form
✔✔HIM director wants to ensure TJC compliance and make sure that history, phys
exam are documented in pt's record within 24 hours after admission. What would be the
best way to ensure completeness of health records? - ✔✔review pt's med records
concurrently for compliance of accreditation standards
✔✔Med record completion is an issue even after suspension of privileges and
deactivating parking garage keycards of physicians in poor standing. What would be a
good next step to overcome noncompliance? - ✔✔Contact other hospitals to see what
methods they use to ensure compliance
✔✔How do accreditation organizations like TJC use health records? - ✔✔to determine
whether standards of care are being met
✔✔If a skilled nursing facility wants to become certified to take part in Medicare, what
standards must they meet to become certified? - ✔✔Medicare Condition of Participation
✔✔What is the best source of documentation to determine the size of a removed
malignant lesion? - ✔✔Operative report
✔✔What document includes microscopic description of excised tissue from surgery? -
✔✔Pathology report
✔✔If physician does not specify method used to remove lesion during endoscopy, what
is protocol? - ✔✔query physician as to what method was used
SOLUTIONS RATED A+
✔✔Is a stage I pressure ulcer considered an H-AC? - ✔✔No, stage I and II are not
considered H-AC, but stage III and IV are H-AC
✔✔The electronic format (8371) replaces which paper billing form? - ✔✔CMS-1450
(UB-04) not to be confused with UB-40, an unemployment form in England that the
band was named for. LOL! :-)
✔✔If an outpt clinic is reviewing functionality of a computer system, which datasets
should they consult to ensure all fed req for CMS are collected by the new system? -
✔✔Uniform Ambulatory Care Data Set (UACDS)
✔✔Standardizing med term is one purpose of: - ✔✔Vocabulary standards
✔✔Family practitioner requests opinion of a specialist who reviews pt's health record
and examines pt; specialist records findings, impressions, and recommendations in
what type report? - ✔✔Consultation report
✔✔What is not a function of the discharge summary if some of the functions are
ensuring care continuity, providing info to support activities of medical staff review
committee, and providing concise info that can be used to answer info request? -
✔✔Providing info abt the pt's ins coverage
✔✔Documentation of monitoring to ensure pt sufficiently recovers from anesthesia is a
function of - ✔✔the recovery room report
✔✔All documentation entered in medical record relating to pt's dx and tx is considered
what type of data? - ✔✔Clinical information
✔✔What type of data is exemplified by insured party's member ID number? -
✔✔financial data
✔✔Which part of prob-oriented med records is used by many facilities that have not
adopted the whole prob-oriented format? - ✔✔SOAP form of progress notes
(Subjective, Objective, Assessment, Plan)
✔✔What is the focus of outpt data collection? - ✔✔Reason for encounter
✔✔What is the focus of inpatient data collection? - ✔✔Principal diagnosis
, ✔✔"Pt is admitted for organic brain syndrome" and underneath this dx is her med info
along with rehab potential. Which form is this info listed? - ✔✔Transfer or referral form
✔✔TJC req which doc to be in pt's record before surgical procedure may be performed?
- ✔✔report of history and physical exam and no more than 7 days before the surgery,
unless in the case of emergency
✔✔Pt admitted to hosp on June 21 and phys exam was completed on June 23.
According to Med Cond of Part the record: - ✔✔is not in compliance since the phys
exam must be completed within 24 hours of admission
✔✔When a health record has deficiencies that are not complete within the specified
timeframe of the med staff rules/regulations, it is called: - ✔✔delinquent record
✔✔What form may contain info abt disease among relatives that could be inherited? -
✔✔History form
✔✔HIM director wants to ensure TJC compliance and make sure that history, phys
exam are documented in pt's record within 24 hours after admission. What would be the
best way to ensure completeness of health records? - ✔✔review pt's med records
concurrently for compliance of accreditation standards
✔✔Med record completion is an issue even after suspension of privileges and
deactivating parking garage keycards of physicians in poor standing. What would be a
good next step to overcome noncompliance? - ✔✔Contact other hospitals to see what
methods they use to ensure compliance
✔✔How do accreditation organizations like TJC use health records? - ✔✔to determine
whether standards of care are being met
✔✔If a skilled nursing facility wants to become certified to take part in Medicare, what
standards must they meet to become certified? - ✔✔Medicare Condition of Participation
✔✔What is the best source of documentation to determine the size of a removed
malignant lesion? - ✔✔Operative report
✔✔What document includes microscopic description of excised tissue from surgery? -
✔✔Pathology report
✔✔If physician does not specify method used to remove lesion during endoscopy, what
is protocol? - ✔✔query physician as to what method was used
