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CCA Exam PreparationDuring an audit of fitness records, the HIM director finds that transcribed reviews are being
changed by means of the writer as much as a week after preliminary transcription. The director
is concerned that adjustments happening this long after transcription jeopardize the prison
principle that documentation should occur close to the time of the event. To remedy this
example, the HIM director need to recommend which of the subsequent? - ANSDevelop a
facility policy that defines the applicable period of time allowed for a transcribed file to stay in a
draft shape.
What is the simple system for calculating every MS-DRG clinic bills? - ANSHospital payment =
DRG relative weight x medical institution base rate
Which of the subsequent sports might be in violation of AHIMA's Code of Ethics? - ANSCoding
an deliberately inappropriate level of provider
What is abstracting? - ANSCompiling the pertinent facts from the scientific record primarily
based on predetermined information units
ICD-nine-CM defines the "new child duration" as birth through the ___________ day following
beginning. - ANS28th
What healthcare corporation collects UHDDS records? - ANSAll non-outpatient settings which
includes acute care, short term care, long time care, an psychiatric hospitals, home fitness
organizations, rehabilitation centers, and nursing home.
A coding analyst continually enters the incorrect code for affected person gender within the
electronic billing device. What security features have to be in area to limit this security breach? -
ANSEdit assessments
Mercy Hospital employees need to study the medical facts for Katie Grace for usage review
functions (1). They may also be sending her records to her physician for continuity of care (2).
Under HIPAA, those two capabilities are: - ANSUse and disclosure
Who is liable for writing and signing discharge summaries and discharge instructions? -
ANSAttending doctor
Although the HIPAA Rule allows affected person get admission to to non-public fitness records
approximately themselves, which of the following cannot be disclosed to patients? -
ANSPsychotherapy notes
,Identify the punctuation mark that is used to supplement phrases or explanatory statistics which
can or might not be present within the assertion of analysis or manner in ICD-nine-CM coding.
The punctuation does not have an effect on the code variety assigned to the case. The
punctuation is considered a nonessential modifier, and all 3 volumes of ICD-nine-CM use them.
- ANSParentheses ( )
What is the call of the agency that develops the billing form that hospitals are required to apply?
- ANSNational Uniform Billing Committee (NUBC)
Which of the subsequent moral ideas is being followed when an HIT expert guarantees that
patient records is most effective released to the ones who have a legal proper to get admission
to it? - ANSBeneficence
A hospital presently includes the affected person's social security quantity at the face sheet of
the paper scientific record and within the digital model of the report. The clinic chance manager
has recognized this as a ability identity fraud threat and wants the statistics removed. The
chance manager is not getting cooperation from the physicians and others inside the medical
institution who say that they want the information for identification and other purposes. Given
this case, what need to the HIM director propose? - ANSAvoid showing the wide variety on any
document, display, or facts collection area.
Both HEDIS and the Joint Commission's ORYX application are designed to accumulate
information for use for ______________. - ANSPerformance development programs
Which of the subsequent might be labeled to an ICD-nine-CM category for bacterial illnesses? -
ANSStaphylococcus aureous
A affected person with regarded COPD and high blood pressure below remedy become
admitted to the health facility with symptoms of a decrease abdominal ache. He undergoes a
laparoscopic appendectomy and develops a fever. The patient became subsequently
discharged from the medical institution with a foremost prognosis of acute appendicitis and
secondary diagnoses of publish-operative infection, COPD, and hypertension. Which of the
subsequent diagnoses need to not be tagged as POA? - ANSPostoperative infection
CPT changed into developed and is maintained through: - ANSAMA
Which company developed the primary sanatorium standardization program? - ANSAmerican
College of Surgeon
On evaluation of the audit trail for an EHR device, the HIM director discovers that a
departmental worker who has authorized access to patient data is printing a long way extra
records than the common person. In this instances, what have to the manager do? -
ANSDetermine what information was revealed and why
, What are viable "add-on" bills that a health facility ought to obtain similarly to the fundamental
Medicare DRG price? - ANSAdditional bills can be made to disproportionate percentage
hospitals, for indirect scientific schooling, for new technology, and for value outlier instances.
The ___________ is a form of coding that could be a herbal outgrowth of the digital heath
document. - ANSComputer-assisted coding
Today, Janet Kim visited her new dentist for an appointment. She became now not presented
with a Notice of Privacy Practices. Is this desirable? - ANSNo, it is a contravention of the HIPAA
Privacy rule
Which of the subsequent would be the great approach to make sure that registration clerks
continuously use the best notation for assigning admission date in an digital health file (EHR)? -
ANSProvide an enter masks for getting into records within the subject
What have to a health center do when a nation regulation requires greater stringent privateness
safety than the federal HIPAA privateness wellknown? - ANSComply with both the kingdom law
and the HIPAA Standard
An employee inside the bodily remedy department arrives early every morning to snoop thru the
medical facts gadget for capacity data about pals and pals. What protection mechanisms ought
to be applied to prevent this protection breach? - ANSInformation get right of entry to controls
According to ICD-nine-C.M, an elderly primigravida is described as a female who offers delivery
to her first child on the age of ______ or older: - ANS35
Which of the subsequent reviews encompass names of the general practitioner and assistants,
date, length, and description of the process and any specimens removed. - ANSOperative
document
Which answer underneath is not correct for mission of the MS-DRG? - ANSAttending and
consulting physicians
Which of the following documentation need to be covered in a affected person's medical
document prior to acting a surgical operation? - ANSConsent for operative manner, history,
physical exam.
What is the maximum wide variety of prognosis codes that may seem at the UB-04 paper
declare shape locator sixty seven for a sanatorium inpatient principle and secondary
diagnoses? - ANS25
Documentation in the history of use of drugs, alcohol, and/or tobacco is taken into consideration
a part of the: - ANSSocial records
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