CCA Exam Preparation Questions And Answers
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 l...
CCA
Exam
Preparation
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?
-
ANS
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?
-
ANS
Hospital
payment
=
DRG
relative
weight
x
hospital
base
rate
Which
of
the
following
activities
would
be
in
violation
of
AHIMA's
Code
of
Ethics?
-
ANS
Coding
an
intentionally
inappropriate
level
of
service
What
is
abstracting?
-
ANS
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.
-
ANS
28th
What
healthcare
organization
collects
UHDDS
data?
-
ANS
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?
-
ANS
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:
-
ANS
Use
and
disclosure
Who
is
responsible
for
writing
and
signing
discharge
summaries
and
discharge
instructions?
-
ANS
Attending
physician
Although
the
HIPAA
Rule
allows
patient
access
to
personal
health
information
about
themselves,
which
of
the
following
cannot
be
disclosed
to
patients?
-
ANS
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.
-
ANS
Parentheses
(
)
What
is
the
name
of
the
organization
that
develops
the
billing
form
that
hospitals
are
required
to
use?
-
ANS
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?
-
ANS
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?
-
ANS
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
______________.
-
ANS
Performance
improvement
programs
Which
of
the
following
would
be
classified
to
an
ICD-9-CM
category
for
bacterial
diseases?
-
ANS
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?
-
ANS
Postoperative
infection
CPT
was
developed
and
is
maintained
by:
-
ANS
AMA
Which
organization
developed
the
first
hospital
standardization
program?
-
ANS
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?
-
ANS
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?
-
ANS
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.
-
ANS
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?
-
ANS
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)?
-
ANS
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?
-
ANS
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?
-
ANS
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:
-
ANS
35
Which
of
the
following
reports
include
names
of
the
surgeon
and
assistants,
date,
duration,
and
description
of
the
procedure
and
any
specimens
removed.
-
ANS
Operative
report
Which
answer
below
is
not
correct
for
assignment
of
the
MS-DRG?
-
ANS
Attending
and
consulting
physicians
Which
of
the
following
documentation
must
be
included
in
a
patient's
medical
record
prior
to
performing
a
surgical
procedure?
-
ANS
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?
-
ANS
25
Documentation
in
the
history
of
use
of
drugs,
alcohol,
and/or
tobacco
is
considered
part
of
the:
-
ANS
Social
history
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