CCA PRACTICE EXAM 2 (DOMAIN 1-6) TEST QUESTIONS WITH ACCURATE 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?
Develop a facility policy that defines the acceptable period of time allowed for a
transcribed document to remain in a draft form.
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an electronic health
record (EHR)?
Provide an input mask for entering data in the field
What should a hospital do when a state law requires more stringent privacy protection than
the federal HIPAA privacy standard?
Comply with both the state law and the HIPAA Standard
An employee in the physical therapy department arrives early every morning to snoop
through the clinical information system for potential information about neighbors and
friends. What security mechanisms should be implemented to prevent this security
breach?
Information access controls
According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth to
her first child at the age of ______ or older:
,35
Which of the following reports include names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed.
Operative report
Which answer below is not correct for assignment of the MS-DRG?
Attending and consulting physicians
Which of the following documentation must be included in a patient's medical record prior
to performing a surgical procedure?
Consent for operative procedure, history, physical examination.
What is the maximum number of diagnosis codes that can appear on the UB-04 paper
claim form locator 67 for a hospital inpatient principle and secondary diagnoses?
25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of
the:
Social history
,Which of the following is a core ethical obligation of health information staff?
Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns,
use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
History record
Which of the following provides organizations with the ability to access data from multiple
databases and to combine the results into a single questions-and-reporting interface?
Data warehouse
Community Hospital implemented a clinical document improvement (CDI) program six
months ago. The goal of the program was to improve clinical documentation to support
quality of care, data quality, and HIM coding accuracy. Which of the following would be
best to ensure that everyone understands the importance of this program?
Include ancillary clinical and medical staff in the process
Which of the following activities is considered an unethical practice?
Backdating progress notes
In a routine health record quantitative analysis review it was fund that a physician dictated
a discharge summary on 1/26/2009. The patient, however, was discharged two days later.
In this case, what would be the best course of action?
, Request the physician dictate an addendum to the discharge summary
Mohs micrographic surgery involves the surgeon acting as:
Both surgeon and pathologist
A hospital is planning on allowing coding professionals to work at home. The hospital is in
the process of identifying strategies to minimize the security risks associated with this
practice. Which of the following would be best to ensure that data breaches are minimized
when the home computer is unattended?
Automatic session terminations
Dr. Jones has signed a statement that all of her dictated reports should be automatically
considered approved and signed unless she makes correction within 72 hours of dictating.
This is called _____________.
Autoauthentication
What type of standard establishes methods for creating unique designations for individual
patients, healthcare professionals, healthcare provider organizations, and healthcare
vendors and suppliers?
Identifier standard
When coding a selective catheterization in CPT, how are codes assigned?
One code for the final vessel entered
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?
Develop a facility policy that defines the acceptable period of time allowed for a
transcribed document to remain in a draft form.
Which of the following would be the best technique to ensure that registration clerks
consistently use the correct notation for assigning admission date in an electronic health
record (EHR)?
Provide an input mask for entering data in the field
What should a hospital do when a state law requires more stringent privacy protection than
the federal HIPAA privacy standard?
Comply with both the state law and the HIPAA Standard
An employee in the physical therapy department arrives early every morning to snoop
through the clinical information system for potential information about neighbors and
friends. What security mechanisms should be implemented to prevent this security
breach?
Information access controls
According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth to
her first child at the age of ______ or older:
,35
Which of the following reports include names of the surgeon and assistants, date, duration,
and description of the procedure and any specimens removed.
Operative report
Which answer below is not correct for assignment of the MS-DRG?
Attending and consulting physicians
Which of the following documentation must be included in a patient's medical record prior
to performing a surgical procedure?
Consent for operative procedure, history, physical examination.
What is the maximum number of diagnosis codes that can appear on the UB-04 paper
claim form locator 67 for a hospital inpatient principle and secondary diagnoses?
25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of
the:
Social history
,Which of the following is a core ethical obligation of health information staff?
Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns,
use of coffee, tabacco, alcohol, and other drugs may be found in the _____________.
History record
Which of the following provides organizations with the ability to access data from multiple
databases and to combine the results into a single questions-and-reporting interface?
Data warehouse
Community Hospital implemented a clinical document improvement (CDI) program six
months ago. The goal of the program was to improve clinical documentation to support
quality of care, data quality, and HIM coding accuracy. Which of the following would be
best to ensure that everyone understands the importance of this program?
Include ancillary clinical and medical staff in the process
Which of the following activities is considered an unethical practice?
Backdating progress notes
In a routine health record quantitative analysis review it was fund that a physician dictated
a discharge summary on 1/26/2009. The patient, however, was discharged two days later.
In this case, what would be the best course of action?
, Request the physician dictate an addendum to the discharge summary
Mohs micrographic surgery involves the surgeon acting as:
Both surgeon and pathologist
A hospital is planning on allowing coding professionals to work at home. The hospital is in
the process of identifying strategies to minimize the security risks associated with this
practice. Which of the following would be best to ensure that data breaches are minimized
when the home computer is unattended?
Automatic session terminations
Dr. Jones has signed a statement that all of her dictated reports should be automatically
considered approved and signed unless she makes correction within 72 hours of dictating.
This is called _____________.
Autoauthentication
What type of standard establishes methods for creating unique designations for individual
patients, healthcare professionals, healthcare provider organizations, and healthcare
vendors and suppliers?
Identifier standard
When coding a selective catheterization in CPT, how are codes assigned?
One code for the final vessel entered
