Mock CCA Exam

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 a. firewall c. a call-back process b. validity processing d. data encryption - correct answer d. 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 history and physical or in the a. doctor's admitting progress note b. nurse's admit note c. review of systems d. discharge summary - correct answer a. doctor's admitting progress note Employing the SOAP style of progress notes, choose the "assessment" statement from the following: a. Patient states low back pain with sciatica is as severe as it was on admission b. Patient moving about very cautiously and appears to be in pain c. Adjust pain medication; begin physical therapy tomorrow d. Sciatica unimproved with hot pack therapy - correct answer d. Sciatica unimproved with hot pack therapy You have been hired to work with a computer-assisted coding initiative. The technology that you will be working with is a. electronic data interchange b. intraoperability c. message standards d. natural language processing - correct answer d. natural language processing A final progress note is appropriate as a discharge summary for a hospitalization in which the patient a. dies within 24 hours of admission b. has no comorbidities or complications during this episode of care c. was admitted within 30 days with the same diagnosis d. was an obstetric admission with a normal delivery and no complications - correct answer d. 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 patients's response to treatment and documentation of any complications that may have developed during this episode of care is in the a. doctor's progress note section b. operative report c. history and physical d. doctor's orders - correct answer a. doctor's progress note section You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the a. prenatal record b. labor record c. delivery room record d. postpartum record - correct answer d. postpartum record A patient is admitted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? a. "Y" b. "U" c. "W" d. "N" - correct answer d. "N" (the DM wasn't considered uncontrolled until 3 days after admission) CMI Table - correct answer b. 2.965807 The special form that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities is the a. interdisciplinary patient care plan b. medical history and review of systems c. interval summary d. problem list - correct answer a. interdisciplinary patient care plan What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? a. res ipsa loquitur b. qui tam c. quid pro quo d. respondeat superior - correct answer c. quid pro quo Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with a. a copy of the facility coding guidelines, along with written information on improved documentation b. the UHDDS and information on where each data element is collected and/or verified in your facility c. regular in-service presentations on documentation, including its importance and tips for improvement d. feedback on specific instances when improved documentation would improve coding - correct answer d. feedback on specific instances when improved documentation would improve coding Table - correct answer a. 100% Which of the following diagnoses or procedures would prevent the normal delivery code, 650, from being assigned? a. occiput presentation b. single liveborn c. episiotomy d. low forceps - correct answer d. low forceps Which of the following are considered late effects regardless of time? a. congenital defect b. nonunion c. nonhealing fracture d. poisoning - correct answer b. 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 from the following codes: - correct answer 574.10 Calculus of gallbladder with other cholecystitis without mention of obstruction 434.00 Cerebral thrombosis without cerebral infarction V64.1 Surgical or other procedure not carried out because of contraindication b. 574.10, 434.00, V64.1 Some ICD-9-CM codes are exempt from POA reporting because they a. represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury b. are always present on admission c. are both A and B d. represent V codes and E codes - correct answer c. are both A and B Which of these conditions are always considered "present on admission" (POA)? a. congenital conditions b. E codes c. acute conditions d. possible, probable, or suspected conditions - correct answer a. congenital conditions When coding multiple wound repairs in CPT, a. only the most complex repair is reported b. only the least complex repair is reported c. up to nine individual repair codes may be reported d. all wound repairs are coded with the most complex reported first - correct answer d. all wound repairs are coded with the most complex reported first Which of the following is vital for determining why the reimbursement from an insurance company is less than that which was expected? a. a CPT codebook b. the remittance advice c. talking to the patient d. knowledge of the individual insurance company's policies - correct answer b. the remittance advice Four people were seen in your Emergency Department yesterday. Which one will be coded as a poisoning? Robert: diagnosed with digitalis intoxication Gary: had an allergic reaction to a dye administered for a pyelogram David: developed syncope after taking Contac pills with a double scotch Brian: had an idiosyncratic reaction between two properly administered prescription drugs a. Robert b. Gary c. David d. Brian - correct answer c. David: developed syncope after taking Contac pills with a double scotch Present on Admission (POA) indicators apply to a. inpatient reporting of diagnosis codes b. outpatient reporting of procedure codes c. inpatient reporting of diagnosis and procedure codes d. outpatient reporting of diagnosis and procedure codes - correct answer a. inpatient reporting of diagnosis codes Using the ICD-10-CM code structure, which of the following would be used for "right upper quadrant abdominal tenderness"? a. 108.11 b. R10811.11 c. R10.811 d. 1.0811 - correct answer c. R10.811 Which of the following scenarios identifies a pathologic fracture? a. greenstick fracture secondary to fall from a bed b. compression fracture of the skull after being hit with a baseball bat c. vertebral fracture with cord compression following a car accident d. compression fracture of the vertebrae as a result of bone metastasis - correct answer d. compression fracture of the vertebrae as a result of bone metastasis All of the following signs/symptoms suggest gram-negative pneumonia EXCEPT a. fever b. patchy infiltrate c. purulent sputum d. decreased leukocyte count - correct answer d. decreased leukocyte count During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the V code for sterilization, V25.2 is a. not used b. used and sequenced as the principal diagnosis c. used and sequenced as a secondary diagnosis d. the only code used - correct answer c. used and sequenced as a secondary diagnosis Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data a. Accuracy b. Validity c. integrity d. quality - correct answer c. integrity Which of the following statements is true? a. A surgical procedure may include one or more surgical operations. b. The terms surgical operation and surgical procedure are synonymous. c. A surgical operation may include one or more surgical procedures. d. The term surgical procedure