CCA Exam Preparation Study Guide Graded A 2023

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. What is the basic formula for calculating each MS-DRG hospital payments? - Hospital payment = DRG relative weight x hospital base rate Which of the following activities would be in violation of AHIMA's Code of Ethics? - Coding an intentionally inappropriate level of service What is abstracting? - Compiling the pertinent information from the medical record based on predetermined data sets ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth. - 28th What healthcare organization collects UHDDS data? - All non-outpatient settings including acute care, short term care, long term care, an psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing home. A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in place to minimize this security breach? - Edit checks Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1). They will also be sending her records to her physician for continuity of care (2). Under HIPAA, these two functions are: - Use and disclosure Who is responsible for writing and signing discharge summaries and discharge instructions? - Attending physician Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? - Psychotherapy notes Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM use them. - Parentheses ( ) What is the name of the organization that develops the billing form that hospitals are required to use? - National Uniform Billing Committee (NUBC) Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? - Beneficence A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? - Avoid displaying the number on any document, screen, or data collection field. Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. - Performance improvement programs Which of the following would be classified to an ICD-9-CM category for bacterial diseases? - Staphylococcus aureous A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? - Postoperative infection CPT was developed and is maintained by: - AMA Which organization developed the first hospital standardization program? - American College of Surgeon On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this cases, what should the supervisor do? - Determine what information was printed and why What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? - Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases. The ___________ is a type of coding that is a natural outgrowth of the electronic heath record. - Computer-assisted coding Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable? - No, it is a violation of the HIPAA Privacy rule 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