CCA Exam Preparation| 229 QUESTIONS| WITH COMPLETE SOLUTIONS

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? Correct Answer: 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? Correct Answer: Hospital payment = DRG relative weight x hospital base rate Which of the following activities would be in violation of AHIMA's Code of Ethics? Correct Answer: Coding an intentionally inappropriate level of service What is abstracting? Correct Answer: 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. Correct Answer: 28th What healthcare organization collects UHDDS data? Correct Answer: 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? Correct Answer: 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: Correct Answer: Use and disclosure Who is responsible for writing and signing discharge summaries and discharge instructions? Correct Answer: Attending physician Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? Correct Answer: 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 volu