Medical Technology
IIBA-CCA
Certified Coding Associate Examination Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A | Instant
Download Pdf.
Question: 1
Which of the following is NOT an acceptable method for destroying
confidential medical records?
A.Placing them in a medical waste container
B.Shredding, pulverizing, incinerating, and pulping
C.Digital sanitation
D.Transferring them to a disposal vendor
Answer: A
Explanation:
The proper disposal of confidential medical records involves the complete
destruction of personally identifiable data. For paper records, this includes
,shredding, pulverization, incineration pulping, or transferring records to a
destruction or disposal vendor. For electronic records, this includes the
physical destruction of the computer hard drive or other practices that
overwrite protected health information (PHI), such as digital sanitation or
degaussing. When disposing of confidential medical records, a log should be
kept containing minimal demographic information, along with the date,
method of destruction, and any witnesses present at the time of disposal.
When using a destruction or disposal vendor, a certificate of destruction
should be issued.
Question: 2
A patient is seen first by the medical assistant, who documents a body mass
index (BMI) of 36, a history of nicotine dependence, and a blood pressure
reading of 140/85. The physician later documents a diagnosis of hypertension.
What code(s) should be reported for this encounter?
A.110
B.110, Z87.891
C.110, E66.9, Z68.36, Z87.891
D.110, Z68.36, Z87.891
Answer: A
Explanation:
Because medical decision making is the driving force for determining the level
of service, ancillary staff may contribute to the documentation of a medical
record. However, ICD-IO-CM guidelines state that "the assignment of a
diagnosis code is based only on the provider's diagnostic statement." There
are some exceptions, including BMI, depth or stage of an ulcer, Glasgow Coma
Scale, National Institutes of Health Stroke Scale, social determinants of health
(SDOH), laterality, blood alcohol level, and an underimmunzation status. To
report these secondary diagnoses, the provider would need to document the
associated condition. In this scenario, to report the patient's BMI, the provider
would have had to indicate that the patient was overweight or obese.
Question: 3
,Which of the following actions is a violation of the AHIMA Standards of Ethical
Coding?
A.A query was sent to a physician to confirm a diagnosis of suspected
Escherichia coli urinary tract infection.
B.A patient was seen for birth control and pelvic pain. Birth control is not
covered under the patient's insurance; therefore, only pelvic pain is reported
on the claim.
C.An online search engine was used to locate a diagnosis code for thickened
endometrium.
D.Unsolicited advice was provided to educate physicians on correct
documentation.
Answer: B
Explanation:
According to the AHIMA Standards of Ethical Coding, diagnosis and procedure
codes must be reported in a way that most accurately represents the care
rendered. In this scenario, by excluding birth control from the claim, a coding
professional is intentionally omitting information in order to receive
reimbursement from the insurance carrier. Although sending a query to a
physician to confirm a suspected condition, using a search engine to locate a
diagnosis code, and providing unsolicited advice to a physician are not
advantageous actions, they are not considered violations of the AHIMA
Standards of Ethical Coding.
Question: 4
Which diagnosis requires that additional data be abstracted from the health
record?
A.Chronic kidney disease
B.Postprocedural hypothyroidism
C.Acute schizophrenia
D.Tinea corporis
, Answer: A
Explanation:
When abstracting data from a health record, obtaining an accurate and
specific diagnosis is essential, because it affects reimbursement rates and
resource utilization. In this scenario, postprocedural hypothyroidism (E89.0),
acute schizophrenia (F20.9), and tineas corporis (B35.4) are the most specific
descriptors for their category of diseases. On the other hand, chronic kidney
disease (CKD) is an illness that presents itself in six stages. By reporting CKD
unspecified, as opposed to its specific stage, a facility cuts their
reimbursement rate by almost 50%.
Question: 5
A primary care physician may request records from a patient's endocrinologist
without obtaining a patient's authorization under which of the following
laws?
A.Online Privacy Protection Act
B.HIPAA Privacy Rule
C.Privacy Act of 1974
D.Gramm-Leach-Bliley Act
Answer: B
Explanation:
The HIPAA Privacy Rule is a federal law established in 1996 to protect a
patient's health information from being disclosed without their consent.
However, the HIPAA Privacy Rule does allow a covered entity, including health
plans, clearinghouses, and healthcare providers, to release health
information for purposes of obtaining and releasing eligibility, authorizations,
payment, and continuing care. In this scenario, the HIPAA Privacy Rule allows
one physician to request records from another physician without obtaining an
authorization from the patient because it involves continuity of care.
IIBA-CCA
Certified Coding Associate Examination Exam
Questions And Correct Answers (Verified
Answers) Plus Rationales 2026 Q&A | Instant
Download Pdf.
Question: 1
Which of the following is NOT an acceptable method for destroying
confidential medical records?
A.Placing them in a medical waste container
B.Shredding, pulverizing, incinerating, and pulping
C.Digital sanitation
D.Transferring them to a disposal vendor
Answer: A
Explanation:
The proper disposal of confidential medical records involves the complete
destruction of personally identifiable data. For paper records, this includes
,shredding, pulverization, incineration pulping, or transferring records to a
destruction or disposal vendor. For electronic records, this includes the
physical destruction of the computer hard drive or other practices that
overwrite protected health information (PHI), such as digital sanitation or
degaussing. When disposing of confidential medical records, a log should be
kept containing minimal demographic information, along with the date,
method of destruction, and any witnesses present at the time of disposal.
When using a destruction or disposal vendor, a certificate of destruction
should be issued.
Question: 2
A patient is seen first by the medical assistant, who documents a body mass
index (BMI) of 36, a history of nicotine dependence, and a blood pressure
reading of 140/85. The physician later documents a diagnosis of hypertension.
What code(s) should be reported for this encounter?
A.110
B.110, Z87.891
C.110, E66.9, Z68.36, Z87.891
D.110, Z68.36, Z87.891
Answer: A
Explanation:
Because medical decision making is the driving force for determining the level
of service, ancillary staff may contribute to the documentation of a medical
record. However, ICD-IO-CM guidelines state that "the assignment of a
diagnosis code is based only on the provider's diagnostic statement." There
are some exceptions, including BMI, depth or stage of an ulcer, Glasgow Coma
Scale, National Institutes of Health Stroke Scale, social determinants of health
(SDOH), laterality, blood alcohol level, and an underimmunzation status. To
report these secondary diagnoses, the provider would need to document the
associated condition. In this scenario, to report the patient's BMI, the provider
would have had to indicate that the patient was overweight or obese.
Question: 3
,Which of the following actions is a violation of the AHIMA Standards of Ethical
Coding?
A.A query was sent to a physician to confirm a diagnosis of suspected
Escherichia coli urinary tract infection.
B.A patient was seen for birth control and pelvic pain. Birth control is not
covered under the patient's insurance; therefore, only pelvic pain is reported
on the claim.
C.An online search engine was used to locate a diagnosis code for thickened
endometrium.
D.Unsolicited advice was provided to educate physicians on correct
documentation.
Answer: B
Explanation:
According to the AHIMA Standards of Ethical Coding, diagnosis and procedure
codes must be reported in a way that most accurately represents the care
rendered. In this scenario, by excluding birth control from the claim, a coding
professional is intentionally omitting information in order to receive
reimbursement from the insurance carrier. Although sending a query to a
physician to confirm a suspected condition, using a search engine to locate a
diagnosis code, and providing unsolicited advice to a physician are not
advantageous actions, they are not considered violations of the AHIMA
Standards of Ethical Coding.
Question: 4
Which diagnosis requires that additional data be abstracted from the health
record?
A.Chronic kidney disease
B.Postprocedural hypothyroidism
C.Acute schizophrenia
D.Tinea corporis
, Answer: A
Explanation:
When abstracting data from a health record, obtaining an accurate and
specific diagnosis is essential, because it affects reimbursement rates and
resource utilization. In this scenario, postprocedural hypothyroidism (E89.0),
acute schizophrenia (F20.9), and tineas corporis (B35.4) are the most specific
descriptors for their category of diseases. On the other hand, chronic kidney
disease (CKD) is an illness that presents itself in six stages. By reporting CKD
unspecified, as opposed to its specific stage, a facility cuts their
reimbursement rate by almost 50%.
Question: 5
A primary care physician may request records from a patient's endocrinologist
without obtaining a patient's authorization under which of the following
laws?
A.Online Privacy Protection Act
B.HIPAA Privacy Rule
C.Privacy Act of 1974
D.Gramm-Leach-Bliley Act
Answer: B
Explanation:
The HIPAA Privacy Rule is a federal law established in 1996 to protect a
patient's health information from being disclosed without their consent.
However, the HIPAA Privacy Rule does allow a covered entity, including health
plans, clearinghouses, and healthcare providers, to release health
information for purposes of obtaining and releasing eligibility, authorizations,
payment, and continuing care. In this scenario, the HIPAA Privacy Rule allows
one physician to request records from another physician without obtaining an
authorization from the patient because it involves continuity of care.
