AHIMA CCA: EXAM {QUESTIONS AND ANSWERS}
"Use additional Code" - answer-Use additional code notes are found in the tabular list. Example:
Infections in Chapter 1 may be required to identify the bacterail organism causing the infection.
UTI due to e Coli - Report: 599.0 and 041.4
*Candidates will need to click on each tab to review the reports. Candidates will be instructed
on exactly how many codes are required. The key will be displayed as to which codes are
required, meaning Diagnosis or Procedure and how many. In this sample question, the case
requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they
will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1
point. *If candidate does not enter an answer in one of the required boxes they will not be
allowed to move to the next medical record case.
________
DISCHARGE SUMMARY
DATE OF ADMISSION: 2/3
DATE OF DISCHARGE: 2/5
DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant
Patient started labor spontaneously three days before her due date. She was brought to the
hospital by automobile. Labor progressed for a while but then contractions became fewer and -
answer-Case Studies
PDX 663.31 Delivery complicated by nuchal cord without compression
DX2 V27.0 Single liveborn
,DX3 648.61 Other cardiovascular diseases in the mother classifiable elsewhere, but
complicating pregnancy, childbirth, or the puerperium
DX4 424.0 Mitral valve disorders
PP1 73.6 Episiotomy
------
Notes on Inpatient 5
663.31 As per the delivery note, this is a delivery with a nuchal cord wrapped around the baby's
neck (Brown 2012, 289).
V27.0 Outcome of delivery code (Brown 2012, 270).
648.61, 424.0 These must be coded because they affected the monitoring of the patient and
were documented in the medical record. The "use additional code" note at category 648 directs
the coder to add another code to identify the condition (Brown 2012, 276-277).
73.6 Episiotomy—the repair of an episiotomy is included in the code (Brown 2012, 282).
-------
Points of Interest on Patient 5
In terms of documentation, this case is typical of many delivery charts. Often times,
practitioners document the complication of delivery in only one area, such as the delivery note
or the operative report. In this case, the baby has a nuchal cord, but it is only mentioned once in
the delivery record.
This is also an illustration of the three types of codes, at a minimum, that must be on every
delivery chart: a diagnostic code from the delivery or pregnancy category, an outcome of birth
code (V code), and a procedure code.
(Garvin 2013, 124--126, 270.)
1.
,A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain.
The attending physician requested an upper GI series and laboratory evaluation of CBC and UA.
The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell
count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured
appendix was discovered. The chief complaint was:
a. Ruptured appendix
b. Exploratory laparoscopy
c. Abdominal pain
d. Cholelithiasis - answer-c. Abdominal pain
The nature and duration of the symptoms that caused the patient to seek medical attention as
stated in the patient's own words (Odom-Wesley et al. 2009, 331).
1.
Data security policies and procedures should be reviewed at least:
a. Semi-annually
b. Annually
c. Every two years
d. Quarterly - answer-Correct Answer: B
, All data security policies and procedures should be reviewed and evaluated at least every year
to make sure they are up-to-date and still relevant to the organization (Johns 2011, 995).
1.
Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the
month of April.
a. 90965
b. 90964
c. 90966
d. 90970 - answer-Correct Answer: C
Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease (ESRD) related
services for home dialysis per full month for patients 20 years of age and older (Smith 2012,
227).
1.
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient
surgery suite. The urologist inserts an endoscope in the penile urethra and dilates the structure
to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted,
and the diseased prostate is excised with radiant energy. Bleeding is controlled with
electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which
of the following code sets will be reported for this service?
a. 600.20, 53852
"Use additional Code" - answer-Use additional code notes are found in the tabular list. Example:
Infections in Chapter 1 may be required to identify the bacterail organism causing the infection.
UTI due to e Coli - Report: 599.0 and 041.4
*Candidates will need to click on each tab to review the reports. Candidates will be instructed
on exactly how many codes are required. The key will be displayed as to which codes are
required, meaning Diagnosis or Procedure and how many. In this sample question, the case
requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they
will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1
point. *If candidate does not enter an answer in one of the required boxes they will not be
allowed to move to the next medical record case.
________
DISCHARGE SUMMARY
DATE OF ADMISSION: 2/3
DATE OF DISCHARGE: 2/5
DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant
Patient started labor spontaneously three days before her due date. She was brought to the
hospital by automobile. Labor progressed for a while but then contractions became fewer and -
answer-Case Studies
PDX 663.31 Delivery complicated by nuchal cord without compression
DX2 V27.0 Single liveborn
,DX3 648.61 Other cardiovascular diseases in the mother classifiable elsewhere, but
complicating pregnancy, childbirth, or the puerperium
DX4 424.0 Mitral valve disorders
PP1 73.6 Episiotomy
------
Notes on Inpatient 5
663.31 As per the delivery note, this is a delivery with a nuchal cord wrapped around the baby's
neck (Brown 2012, 289).
V27.0 Outcome of delivery code (Brown 2012, 270).
648.61, 424.0 These must be coded because they affected the monitoring of the patient and
were documented in the medical record. The "use additional code" note at category 648 directs
the coder to add another code to identify the condition (Brown 2012, 276-277).
73.6 Episiotomy—the repair of an episiotomy is included in the code (Brown 2012, 282).
-------
Points of Interest on Patient 5
In terms of documentation, this case is typical of many delivery charts. Often times,
practitioners document the complication of delivery in only one area, such as the delivery note
or the operative report. In this case, the baby has a nuchal cord, but it is only mentioned once in
the delivery record.
This is also an illustration of the three types of codes, at a minimum, that must be on every
delivery chart: a diagnostic code from the delivery or pregnancy category, an outcome of birth
code (V code), and a procedure code.
(Garvin 2013, 124--126, 270.)
1.
,A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain.
The attending physician requested an upper GI series and laboratory evaluation of CBC and UA.
The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell
count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured
appendix was discovered. The chief complaint was:
a. Ruptured appendix
b. Exploratory laparoscopy
c. Abdominal pain
d. Cholelithiasis - answer-c. Abdominal pain
The nature and duration of the symptoms that caused the patient to seek medical attention as
stated in the patient's own words (Odom-Wesley et al. 2009, 331).
1.
Data security policies and procedures should be reviewed at least:
a. Semi-annually
b. Annually
c. Every two years
d. Quarterly - answer-Correct Answer: B
, All data security policies and procedures should be reviewed and evaluated at least every year
to make sure they are up-to-date and still relevant to the organization (Johns 2011, 995).
1.
Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the
month of April.
a. 90965
b. 90964
c. 90966
d. 90970 - answer-Correct Answer: C
Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease (ESRD) related
services for home dialysis per full month for patients 20 years of age and older (Smith 2012,
227).
1.
The patient, a 47-year-old male with adenoma of the prostate, is being treated in the outpatient
surgery suite. The urologist inserts an endoscope in the penile urethra and dilates the structure
to allow instrument passage. After endoscope placement, a radiofrequency stylet is inserted,
and the diseased prostate is excised with radiant energy. Bleeding is controlled with
electrocoagulation. Following instrument removal, a catheter is inserted and left in place. Which
of the following code sets will be reported for this service?
a. 600.20, 53852
