CCA Exam Preparation Updated Questions and
Answers ;All domain modules with complete solutions
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?
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?
Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics?
Coding an intentionally inappropriate level of service
What is abstracting?
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.
28th
What healthcare organization collects UHDDS data?
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?
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:
Use and disclosure
Who is responsible for writing and signing discharge summaries and discharge
instructions?
Attending physician
Although the HIPAA Rule allows patient access to personal health information
about themselves, which of the following cannot be disclosed to patients?
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.
Parentheses ( )
,What is the name of the organization that develops the billing form that hospitals
are required to use?
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?
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?
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 ______________.
Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial
diseases?
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?
Postoperative infection
CPT was developed and is maintained by:
AMA
Which organization developed the first hospital standardization program?
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?
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?
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.
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?
, 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)?
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?
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?
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:
35
Which of the following reports include names of the surgeon and assistants, date,
duration, and description of the procedure and any specimens removed.
Operative report
Which answer below is not correct for assignment of the MS-DRG?
Attending and consulting physicians
Which of the following documentation must be included in a patient's medical
record prior to performing a surgical procedure?
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?
25
Documentation in the history of use of drugs, alcohol, and/or tobacco is
considered part of the:
Social history
Which of the following is a core ethical obligation of health information staff?
Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise
patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the
_____________.
History record
Which of the following provides organizations with the ability to access data from
multiple databases and to combine the results into a single questions-and-
reporting interface?
Data warehouse
Community Hospital implemented a clinical document improvement (CDI)
program six months ago. The goal of the program was to improve clinical
documentation to support quality of care, data quality, and HIM coding accuracy.
Which of the following would be best to ensure that everyone understands the
importance of this program?
Answers ;All domain modules with complete solutions
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?
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?
Hospital payment = DRG relative weight x hospital base rate
Which of the following activities would be in violation of AHIMA's Code of Ethics?
Coding an intentionally inappropriate level of service
What is abstracting?
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.
28th
What healthcare organization collects UHDDS data?
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?
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:
Use and disclosure
Who is responsible for writing and signing discharge summaries and discharge
instructions?
Attending physician
Although the HIPAA Rule allows patient access to personal health information
about themselves, which of the following cannot be disclosed to patients?
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.
Parentheses ( )
,What is the name of the organization that develops the billing form that hospitals
are required to use?
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?
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?
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 ______________.
Performance improvement programs
Which of the following would be classified to an ICD-9-CM category for bacterial
diseases?
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?
Postoperative infection
CPT was developed and is maintained by:
AMA
Which organization developed the first hospital standardization program?
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?
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?
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.
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?
, 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)?
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?
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?
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:
35
Which of the following reports include names of the surgeon and assistants, date,
duration, and description of the procedure and any specimens removed.
Operative report
Which answer below is not correct for assignment of the MS-DRG?
Attending and consulting physicians
Which of the following documentation must be included in a patient's medical
record prior to performing a surgical procedure?
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?
25
Documentation in the history of use of drugs, alcohol, and/or tobacco is
considered part of the:
Social history
Which of the following is a core ethical obligation of health information staff?
Protecting patients privacy and confidential communications
Documentation regarding a patient's marital status, dietary, sleep, and exercise
patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the
_____________.
History record
Which of the following provides organizations with the ability to access data from
multiple databases and to combine the results into a single questions-and-
reporting interface?
Data warehouse
Community Hospital implemented a clinical document improvement (CDI)
program six months ago. The goal of the program was to improve clinical
documentation to support quality of care, data quality, and HIM coding accuracy.
Which of the following would be best to ensure that everyone understands the
importance of this program?
