CCA Exam Preparation CORRECT
QUESTIONS & ANSWERS(RATED A)
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? -
ANSWER 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? - ANSWER Hospital payment
= DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics? - ANSWER Coding an
intentionally inappropriate level of service
What is abstracting? - ANSWER 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. -
ANSWER 28th
What healthcare organization collects UHDDS data? - ANSWER 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? - ANSWER 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: - ANSWER Use and disclosure
, Who is responsible for writing and signing discharge summaries and discharge instructions? - ANSWER
Attending physician
Although the HIPAA Rule allows patient access to personal health information about themselves, which
of the following cannot be disclosed to patients? - ANSWER 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. - ANSWER Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are required to use? -
ANSWER 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? - ANSWER 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? - ANSWER
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
______________. - ANSWER Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases? - ANSWER
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? - ANSWER Postoperative infection
CPT was developed and is maintained by: - ANSWER AMA
Which answer below is not correct for assignment of the MS-DRG? - ANSWER Attending and consulting
physicians
Which of the following documentation must be included in a patient's medical record prior to
performing a surgical procedure? - ANSWER 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? - ANSWER 25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: -
ANSWER Social history
Which of the following is a core ethical obligation of health information staff? - ANSWER 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 _____________. - ANSWER 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? - ANSWER 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? - ANSWER Include ancillary clinical and medical staff in the process
, Which of the following activities is considered an unethical practice? - ANSWER 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? - ANSWER Request the physician dictate an addendum to the discharge
summary
Mohs micrographic surgery involves the surgeon acting as: - ANSWER 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? -
ANSWER 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
_____________. - ANSWER Autoauthentication
What type of standard establishes methods for creating unique designations for individual patients,
healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? -
ANSWER Identifier standard
When coding a selective catheterization in CPT, how are codes assigned? - ANSWER One code for the
final vessel entered
What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a
hospital inpatient? - ANSWER six
In hospitals, automated systems for registering patients and tracking their encounters are commonly
known as _________ systems. - ANSWER ADT
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? -
ANSWER New technology
QUESTIONS & ANSWERS(RATED A)
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? -
ANSWER 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? - ANSWER Hospital payment
= DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics? - ANSWER Coding an
intentionally inappropriate level of service
What is abstracting? - ANSWER 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. -
ANSWER 28th
What healthcare organization collects UHDDS data? - ANSWER 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? - ANSWER 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: - ANSWER Use and disclosure
, Who is responsible for writing and signing discharge summaries and discharge instructions? - ANSWER
Attending physician
Although the HIPAA Rule allows patient access to personal health information about themselves, which
of the following cannot be disclosed to patients? - ANSWER 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. - ANSWER Parentheses ( )
What is the name of the organization that develops the billing form that hospitals are required to use? -
ANSWER 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? - ANSWER 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? - ANSWER
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
______________. - ANSWER Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial diseases? - ANSWER
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? - ANSWER Postoperative infection
CPT was developed and is maintained by: - ANSWER AMA
Which answer below is not correct for assignment of the MS-DRG? - ANSWER Attending and consulting
physicians
Which of the following documentation must be included in a patient's medical record prior to
performing a surgical procedure? - ANSWER 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? - ANSWER 25
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: -
ANSWER Social history
Which of the following is a core ethical obligation of health information staff? - ANSWER 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 _____________. - ANSWER 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? - ANSWER 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? - ANSWER Include ancillary clinical and medical staff in the process
, Which of the following activities is considered an unethical practice? - ANSWER 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? - ANSWER Request the physician dictate an addendum to the discharge
summary
Mohs micrographic surgery involves the surgeon acting as: - ANSWER 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? -
ANSWER 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
_____________. - ANSWER Autoauthentication
What type of standard establishes methods for creating unique designations for individual patients,
healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? -
ANSWER Identifier standard
When coding a selective catheterization in CPT, how are codes assigned? - ANSWER One code for the
final vessel entered
What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a
hospital inpatient? - ANSWER six
In hospitals, automated systems for registering patients and tracking their encounters are commonly
known as _________ systems. - ANSWER ADT
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? -
ANSWER New technology
