Mock CCA Exam Elaboration| Everything you need!!
Your organization is sending confidential patient information across the Internet using
technology that will transform the original data into unintelligible code that can be re-
created by authorized users. This technique is called
a. firewall
c. a call-back process
b. validity processing
d. data encryption Answer - d. data encryption
As part of a concurrent record review, you need to locate the initial plan of action based
on the attending physician's initial assessment of the patient. You can expect to find this
documentation either within the body of the history and physical or in the
a. doctor's admitting progress note
b. nurse's admit note
c. review of systems
d. discharge summary Answer - a. doctor's admitting progress note
Employing the SOAP style of progress notes, choose the "assessment" statement from
the following:
a. Patient states low back pain with sciatica is as severe as it was on admission
b. Patient moving about very cautiously and appears to be in pain
c. Adjust pain medication; begin physical therapy tomorrow
d. Sciatica unimproved with hot pack therapy Answer - d. Sciatica unimproved with hot
pack therapy
You have been hired to work with a computer-assisted coding initiative. The technology
that you will be working with is
a. electronic data interchange
b. intraoperability
c. message standards
d. natural language processing Answer - d. natural language processing
A final progress note is appropriate as a discharge summary for a hospitalization in
which the patient
a. dies within 24 hours of admission
b. has no comorbidities or complications during this episode of care
c. was admitted within 30 days with the same diagnosis
d. was an obstetric admission with a normal delivery and no complications Answer - d.
was an obstetric admission with a normal delivery and no complications
In reviewing a medical record for coding purposes, the coder notes that the discharge
summary has not yet been transcribed. In its absence, the best place to look for the
patients's response to treatment and documentation of any complications that may have
developed during this episode of care is in the
,a. doctor's progress note section
b. operative report
c. history and physical
d. doctor's orders Answer - a. doctor's progress note section
You would expect to find documentation regarding the assessment of an obstetric
patient's lochia, fundus, and perineum on the
a. prenatal record
b. labor record
c. delivery room record
d. postpartum record Answer - d. postpartum record
A patient is admitted through the emergency department with diabetes mellitus. Three
days after admission, the physician documents uncontrolled diabetes mellitus. What is
the "present on admission" (POA) indicator for uncontrolled diabetes mellitus?
a. "Y"
b. "U"
c. "W"
d. "N" Answer - d. "N"
(the DM wasn't considered uncontrolled until 3 days after admission)
CMI Table Answer - b. 2.965807
The special form that plays the central role in planning and providing care at nursing,
psychiatric, and rehabilitation facilities is the
a. interdisciplinary patient care plan
b. medical history and review of systems
c. interval summary
d. problem list Answer - a. interdisciplinary patient care plan
What legal term is used in describing sexual harassment in reference to unwelcome
sexual advances, request for sexual favors, and verbal or physical conduct of a sexual
nature made in return for job benefits?
a. res ipsa loquitur
b. qui tam
c. quid pro quo
d. respondeat superior Answer - c. quid pro quo
Your facility would like to improve physician documentation in order to allow improved
coding. As coding supervisor, you have found it very effective to provide the physicians
with
a. a copy of the facility coding guidelines, along with written information on improved
documentation
b. the UHDDS and information on where each data element is collected and/or verified
in your facility
, c. regular in-service presentations on documentation, including its importance and tips
for improvement
d. feedback on specific instances when improved documentation would improve coding
Answer - d. feedback on specific instances when improved documentation would
improve coding
Table Answer - a. 100%
Which of the following diagnoses or procedures would prevent the normal delivery code,
650, from being assigned?
a. occiput presentation
b. single liveborn
c. episiotomy
d. low forceps Answer - d. low forceps
Which of the following are considered late effects regardless of time?
a. congenital defect
b. nonunion
c. nonhealing fracture
d. poisoning Answer - b. nonunion
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis
with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral
thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the
following codes: Answer - 574.10 Calculus of gallbladder with other cholecystitis
without mention of obstruction
434.00 Cerebral thrombosis without cerebral infarction
V64.1 Surgical or other procedure not carried out because of contraindication
b. 574.10, 434.00, V64.1
Some ICD-9-CM codes are exempt from POA reporting because they
a. represent circumstances regarding the health care encounter or factors influencing
health status that do not represent a current disease or injury
b. are always present on admission
c. are both A and B
d. represent V codes and E codes Answer - c. are both A and B
Which of these conditions are always considered "present on admission" (POA)?
a. congenital conditions
b. E codes
c. acute conditions
d. possible, probable, or suspected conditions Answer - a. congenital conditions
When coding multiple wound repairs in CPT,
a. only the most complex repair is reported
Your organization is sending confidential patient information across the Internet using
technology that will transform the original data into unintelligible code that can be re-
created by authorized users. This technique is called
a. firewall
c. a call-back process
b. validity processing
d. data encryption Answer - d. data encryption
As part of a concurrent record review, you need to locate the initial plan of action based
on the attending physician's initial assessment of the patient. You can expect to find this
documentation either within the body of the history and physical or in the
a. doctor's admitting progress note
b. nurse's admit note
c. review of systems
d. discharge summary Answer - a. doctor's admitting progress note
Employing the SOAP style of progress notes, choose the "assessment" statement from
the following:
a. Patient states low back pain with sciatica is as severe as it was on admission
b. Patient moving about very cautiously and appears to be in pain
c. Adjust pain medication; begin physical therapy tomorrow
d. Sciatica unimproved with hot pack therapy Answer - d. Sciatica unimproved with hot
pack therapy
You have been hired to work with a computer-assisted coding initiative. The technology
that you will be working with is
a. electronic data interchange
b. intraoperability
c. message standards
d. natural language processing Answer - d. natural language processing
A final progress note is appropriate as a discharge summary for a hospitalization in
which the patient
a. dies within 24 hours of admission
b. has no comorbidities or complications during this episode of care
c. was admitted within 30 days with the same diagnosis
d. was an obstetric admission with a normal delivery and no complications Answer - d.
was an obstetric admission with a normal delivery and no complications
In reviewing a medical record for coding purposes, the coder notes that the discharge
summary has not yet been transcribed. In its absence, the best place to look for the
patients's response to treatment and documentation of any complications that may have
developed during this episode of care is in the
,a. doctor's progress note section
b. operative report
c. history and physical
d. doctor's orders Answer - a. doctor's progress note section
You would expect to find documentation regarding the assessment of an obstetric
patient's lochia, fundus, and perineum on the
a. prenatal record
b. labor record
c. delivery room record
d. postpartum record Answer - d. postpartum record
A patient is admitted through the emergency department with diabetes mellitus. Three
days after admission, the physician documents uncontrolled diabetes mellitus. What is
the "present on admission" (POA) indicator for uncontrolled diabetes mellitus?
a. "Y"
b. "U"
c. "W"
d. "N" Answer - d. "N"
(the DM wasn't considered uncontrolled until 3 days after admission)
CMI Table Answer - b. 2.965807
The special form that plays the central role in planning and providing care at nursing,
psychiatric, and rehabilitation facilities is the
a. interdisciplinary patient care plan
b. medical history and review of systems
c. interval summary
d. problem list Answer - a. interdisciplinary patient care plan
What legal term is used in describing sexual harassment in reference to unwelcome
sexual advances, request for sexual favors, and verbal or physical conduct of a sexual
nature made in return for job benefits?
a. res ipsa loquitur
b. qui tam
c. quid pro quo
d. respondeat superior Answer - c. quid pro quo
Your facility would like to improve physician documentation in order to allow improved
coding. As coding supervisor, you have found it very effective to provide the physicians
with
a. a copy of the facility coding guidelines, along with written information on improved
documentation
b. the UHDDS and information on where each data element is collected and/or verified
in your facility
, c. regular in-service presentations on documentation, including its importance and tips
for improvement
d. feedback on specific instances when improved documentation would improve coding
Answer - d. feedback on specific instances when improved documentation would
improve coding
Table Answer - a. 100%
Which of the following diagnoses or procedures would prevent the normal delivery code,
650, from being assigned?
a. occiput presentation
b. single liveborn
c. episiotomy
d. low forceps Answer - d. low forceps
Which of the following are considered late effects regardless of time?
a. congenital defect
b. nonunion
c. nonhealing fracture
d. poisoning Answer - b. nonunion
Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis
with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral
thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the
following codes: Answer - 574.10 Calculus of gallbladder with other cholecystitis
without mention of obstruction
434.00 Cerebral thrombosis without cerebral infarction
V64.1 Surgical or other procedure not carried out because of contraindication
b. 574.10, 434.00, V64.1
Some ICD-9-CM codes are exempt from POA reporting because they
a. represent circumstances regarding the health care encounter or factors influencing
health status that do not represent a current disease or injury
b. are always present on admission
c. are both A and B
d. represent V codes and E codes Answer - c. are both A and B
Which of these conditions are always considered "present on admission" (POA)?
a. congenital conditions
b. E codes
c. acute conditions
d. possible, probable, or suspected conditions Answer - a. congenital conditions
When coding multiple wound repairs in CPT,
a. only the most complex repair is reported
