AHIMA CCA: Exam Questions and 100% CORRECT Answers,2024

1. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Ruptured appendix b. Exploratory laparoscopy c. Abdominal pain d. Cholelithiasis - ANSWERc. Abdominal pain The nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331). 2. 84. An individual stole and used another person's insurance information to obtain medical care. This action would be considered: a. Violation of bioethics b. Fraud and abuse c. Medical identity theft d. Abuse - ANSWERc. Medical identity theft Correct Answer: 84. c. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity without the victim's knowledge or consent to obtain medical services or goods (Johns 2011, 773). 3. Identify the ICD-9-CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus. a. 730.06 b. 730.07 c. 730.07, 041.1 d. 730.07, 041.10 - ANSWERd. 730.07, 041.10 Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger 2012, 305-306). 4. A system that provides alerts and reminders to clinicians is a(n): a. Clinical decision support system b. Electronic data interchange c. Point of care charting system d. Knowledge database - ANSWERCorrect Answer: A Clinical decision support includes providing documentation of clinical findings and procedures, active reminders about medication administration, suggestions for prescribing less expensive but equally effective drugs, protocols for certain health maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-making aids for all stakeholders in the care process (Johns 2011, 138). 5. What does an audit trail check for? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup - ANSWERCorrect Answer: A Audit trails can provide tracking information such as who accessed which records and for what purpose (Johns 2011, 403). 6. This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with bradyarrhythmias. Prolonged ambulatory monitoring may be indicated to establish a diagnosis of this condition. Treatment includes insertion of a permanent cardiac pacemaker. a. Atrial fibrillation (427.31) b. Atrial flutter (427.32) c. Paroxysmal supraventricular tachycardia (427.0) d. Sick sinus syndrome (SSS) (427.81) - ANSWERd. Sick sinus syndrome (SSS) (427.81) Correct Answer: D SSS is the imprecise diagnosis with various characteristics treated with the insertion of a permanent cardiac pacemaker. The other three conditions are treated with cardioversion and different pharmacological therapy (Schraffenberger 2012, 194-195). 7. Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip. a. 715.95 b. 715.15 c. 721.90 d. 715.16 - ANSWERb. 715.15 Correct Answer: B Index Osteoarthrosis, localized, primary. For category 715, refer to the table for the fifth digit of 5 for pelvic region and thigh (Schraffenberger 2012, 303- 304). 8. A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record - ANSWERCorrect Answer: B An incomplete record not rectified within a specific number of days as indicated in the medical staff rules and regulations is considered to be delinquent (Johns 2011, 412). 9. A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? a. Chart deficiency system b. Chart tracking system c. Chart abstracting system d. Chart encoder - ANSWERCorrect Answer: B With an automated tracking system, it is easy to track how many records are charged out of the system, their location, and whether they have been returned on the due dates indicated (Johns 2011, 402). 10. Identify the appropriate ICD-9-CM diagnosis code for Lou Gehrig's disease. a. 335.20 b. 334.8 c. 335.29 d. 335.2 - ANSWERCorrect Answer: A Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is another name for Lou Gehrig's disease. Many diseases carry the name of a person or an eponym. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13). 11. In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel? a. Report the remaining tests using individual test codes, according to CPT. b. Do not report the remaining individual test codes. c. Report only those test codes that are part of a panel. d. Do not report a test code more than once regardless whether the test was performed twice. - ANSWERCorrect Answer: A Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (AMA 2012b, 402). 12. An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of: a. Optimizing b. Unbundling c. Sequencing d. Classifying - ANSWERCorrect Answer: B Unbundling occurs when a panel code exists and the individual tests are reported rather than the panel code (AMA 2012b, 402). 13. Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery. a. Combined right and left (88.54) b. Stones (88.55) c. Judkins (88.56) d. Other and unspecified (88.57) - ANSWERCorrect Answer: C The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material (Schraffenberger 2012, 206). Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the: a. Discharge summary b. Autopsy report c. Incident report d. Consent to treatment - ANSWERCorrect Answer: A The discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged (Johns 2011, 78). 15. This document includes a microscopic description of tissue excised during surgery: