(CCA) EXAM
"Late pregnancy" (category code 645) is used to demonstrate that a woman is over
- answers-40
A child was examined and treated for child abuse in the emergency department at the
hospital. s a result, the child ha been taken into protective custody by the Office of Child
Protection because of suspected child abuse by parents. The father requests copies of
the designated record set for the visit. He has a copy of the child's birth certificate listing
him as the fther and he possesses a picture ID. Do you release a copy of the
emergency department record?
- answers-Decline to release the information and contact the hospital's attorney.
A health information technician is processing payments for hospital outpatient services
to be reimbursed by Medicare for a patient who had two physician visits, underwent
radiology examinations, clinical laboratory tests, and who received take-home surgical
dressings. Which of the following services is reimbursed under the outpatient
prospective payment system?
- answers-Radiology examinations
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?
A. User name and password
B. Automatic session terminations
C. Cable locks
D. Encryption
- answers-B. Automatic session terminations
A notation for a diabetic patient in a physician progress note reads: "FBS 110 mg%,
urine sugar, no acetone." Which part of a POMR progress note would this notation be
written?
- answers-Objective
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets
hungry. No insulin reactions. Says she is following her diabetic diet." Which part of a
, POMR progress note would this notation be written?
- answers-Subjective
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?
A. Postoperative infection
B. Appendicitis
C. COPD
D. Hypertension
- answers-A. Postoperative infection
Both HEDIS and the Joint Commission's ORYX program are designed to collect data to
be used for __________.
- answers-Performance improvement programs
Category II codes cover all but one of the following topics. Which is not addressed by
Category II codes?
A. Patient management
B. New technology
C. Therapeutic, preventative, or other interventions
D. Patient safety
- answers-B. New technology
CPT was developed and is maintained by:
- answers-AMA
documentation in the history of use of drugs, alcohol and or tacacco is considered part
of the
- answers-social history
Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part
of the:
- answers-Social history
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 _____________.
- answers-Autoauthentication
During a review of documentation practices, the HIM director finds that nurses are
routinely using the copy and paste function of the hospital's new EHR system for
documenting nursing notes. In some cases, nurses are copying and pasting the