CCA Mock Examination

Your organization is sending confidential patient information across the internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called? - correct answer Data Encryption As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the H&P or in the _______. - correct answer Review of systems (ROS) Sciatica unimproved with hot pack therapy is an example of what in the SOAP style of progress notes? - correct answer A-Assessment You have been hired to work with computer-assisted coding initiative. The technology that you will be working with is what? - correct answer Natural language processing A final progress note is appropriate as a discharge summary for a hospitalization in which the patient ________. - correct answer Was an obstetric admission with a normal delivery and no complications. In reviewing a medical record for coding purposes, the coder notes that the discharge summary has not yet been transcribed. In its absence, the best place to look for the patient's response to treatment and documentation of any complications that may have developed during this episode of care is in the _______. - correct answer Doctors' progress note section You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on what type of record? - correct answer Postpartum record A patient is admitted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled DM. What is the "Present on Admission" (POA)? - correct answer N-No, the DM wasn't considered uncontrolled until 3 days after admission How do you figure out the Case-mix index for a facility? (CMI) - correct answer multiply relative weight by # of patients with this MS-DRG (in the row) and then add up all the numbers and divide by the total number of patients. The special form that plays the central role in planning providing care at nursing, psychiatric, and rehabilitation facilities is the ________. - correct answer Interdisciplinary patient care plan What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, the request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? - correct answer Quid pro quo Your facility would like to improve physician documentation in order to allow improved coding. As a coding supervisor, you have found it very effective to provide the physicians with what? - correct answer Feedback on specific instances when improved documentation would improve coding. Using the chart on page 279: One week's productivity information is shown in the table. What percentage of the coders is meeting the productivity standards? - correct answer 100% Which diagnosis or procedure would prevent the normal delivery code (O80) from being assisgned? - correct answer Low forceps What is considered to be a late effect (sequelae) regardless of time? - correct answer nonunion Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding. - correct answer K80.10, 434.00, Z53.09 The calculus of gallbladder is sequence first Some ICD-9-CM codes are exempt from POA reporting because they _________. - correct answer Represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease AND some are always present on admission. Conditions that are always POA are what? - correct answer Congenital conditions When coding multiple wound repairs in CPT... - correct answer all wound repairs are coded, with the most complex reported first. What is vital for determining why the reimbursement from an insurance company is less than what was expected? - correct answer The remittance advice A patient developed syncope after taking Contac pills with a double scotch, what is this coded as? - correct answer A poisoning What do POA indicators apply to? - correct answer inpatient reporting of diagnosis codes What ICD-10-CM code is used for "right upper quadrant abdominal tenderness" - correct answer R10.811 What type of fracture would "compression fracture of the vertebrae as a result of bone metastasis" be? - correct answer pathological fracture Name signs/symptoms that suggest gram-negative pneumonia. - correct answer fever, patchy infiltrate, purulent sputum During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the code for sterilization (Z30.2) is ___________. - correct answer Used and sequenced as the secondary diagnosis Ensuring that data have only been modified or accessed only by individuals who are authorized to do so is a function of data - correct answer Integrity True or false: A surgical operation may include one or more surgical procedures. - correct answer True Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called what? - correct answer Firewalls The Joint Commission requires that all medical records be completed within _________ following patient discharge. - correct answer 30 Days You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to ___________. - correct answer improve your department's processes Laser removal of condylomata is coded to what in CPT coding? - correct answer Destruction of lesions A ______ is a collection of information or data that is organized in such a way that its contents can be queried and relationships created. - correct answer Database Staging is defined as... - correct answer a system for documenting the extent or spread of cancer. Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? - correct answer Principle diagnosis Would a hospital inpatient procedure require HCPCS/CPT codes? - correct answer No. Patient was seen in the ED with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. What CPT code is used? - correct answer 12035, the two lacerations are added together. Patient was seen for excision of two interdigital neuromas from the left foot. What is the CPT code? - correct answer 28080, 28080