AHIMA CCA: Exam 1
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 - Answer-Correct 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).
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 - Answer-Correct Answer: A
Audit trails can provide tracking information such as who accessed which records and for what purpose
(Johns 2011, 403).
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 - Answer-Correct 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).
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 - Answer-Correct 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).
CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services
greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are
applied to which code set?
a. Diagnosis-related groups
b. HCPCS/CPT codes
c. ICD-9-CM diagnosis and procedure codes
d. Resource utilization groups - Answer-Correct Answer: B
CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate
payments. This new editing was the result of the outpatient prospective payment system which pays
providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified
HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2012b).
What is the best reference tool to determine how CPT codes should be assigned?
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 - Answer-Correct 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).
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 - Answer-Correct Answer: A
Audit trails can provide tracking information such as who accessed which records and for what purpose
(Johns 2011, 403).
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 - Answer-Correct 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).
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 - Answer-Correct 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).
CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services
greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are
applied to which code set?
a. Diagnosis-related groups
b. HCPCS/CPT codes
c. ICD-9-CM diagnosis and procedure codes
d. Resource utilization groups - Answer-Correct Answer: B
CMS developed MUEs to prevent providers from billing units in excess and receiving inappropriate
payments. This new editing was the result of the outpatient prospective payment system which pays
providers passed on the HCPCS/CPT code and units. Payment is directly related to units for specified
HCPCS/CPT codes assigned to an ambulatory payment classification (CMS 2012b).
What is the best reference tool to determine how CPT codes should be assigned?
