AHIMA/ CCA EXAM- LATEST VERSION
UPDATED 2024/2025
A skin lesion is removed from a patient's cheek in the dermatologist's office. Physician
documents "skin lesion" in the health record. Before billing the pathology report returns
with a diagnosis of basal cell carcinoma. What actions should the coder take for this
claim submission? - CORRECT ANSWER Code: Basal Cell Carcinoma: In the
OUTPATIENT setting, when diagnostic tests have been interpreted by the physician
and the final report is available at the time of coding, code any CONFIRMED or
DEFINITIVE diagnosis(es) that are documented in the record. Do NOT code related
signs and symptoms as additional diagnoses. ******NOTE this differs from the coding
practice in the hospital inpatient setting regarding abnormal findings on test results.
*********
Epidural given during labor. Subsequently determined the patient would require a C-
section for cephalopelvic disproportion [baby's head too large for mother's pelvis]
because of obstructed labor [failure of the fetus to descend through the birth canal].
What it the correct ICD-9-CM diagnostic and the CPT anesthesia codes? - CORRECT
ANSWERNEED TO LOOK UP THIS ANSWER
Physician correctly prescribes Coumadin [anticoagulant-blood thinner]. Patient takes the
Coumadin as prescribed but develops hematuria [blood in the urine] as a result of taking
the medication. What the correct way to code this case? - CORRECT
ANSWERHematuria; adverse reaction to Coumadin. An adverse effect can occur when
everything is done correctly. Adverse effects can occur in situations where medications
are administered properly and prescribed correctly in both therapeutic and diagnostic
procedures. The first listed diagnosis is the MANIFESTATION or the nature of the
adverse drug effect - in this case HEMATURIA. Locate the drug in the SUBSTANCE
colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select
the E Code for the drug from the Therapeutic Use column of the Table of Drugs and
Chemicals. Use of the E Code is MANDATORY when coding adverse effects.
What is the procedure for locating a DRUG? - CORRECT ANSWERLocate the drug in
the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to
Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table
of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse
effects.
Briefly describe MS-DRG - CORRECT ANSWERMS-DRG (Medical-Severity-Diagnosis-
Related Group). It is system to classsify hospital cases in groups. DRG's are used to
determine how much Medicare pays the hospital for each "product" [i.e.
,"appendectomy"] since patients within each group are clinically similar and are expected
to use the same level of hospital resources. Each DRG was a payment weight assigned
to it based on the average resources used to treat Medicare patients in that DRG.
Payment weights are affected by geographic location (cost of living), number of low
income patietns in that location, whether the facility is a teaching facility, and if the case
is an outlier case (a particularly costly case). Claim information is gathered: ICD
diagnoses, procedures, age, sex, discharge status, and the presence of complication or
comorbidities. Examples: Normal Newborn, Psychoses, Major Joint Replacement,
Chest Pain, Cesarean Section, Simple pneumonia, Heart Failure. DRG's were
developed to monitor quality of care and resource use, cost efficiency, and use the
indicators to improve quality. Only ONE DRG can be assigned and reimbursed for a
single admission. The payment provided for the DRG is intended to cover the costs of
all hospital services performed during the patient's stay. Under the PPS, hospitals are
paid a set fee for treating patients in a single DRG category, regardless of the acutal
cost of care for the individual.
Patient admitted to the hospital for shortness of breath and congestive heart failure.
Patient subsequently develops respiratory failure. Patient undergoes intubation with
ventilator management. What is the correct sequencing and coding of this case? -
CORRECT ANSWERCongestive Heart Failure, Respiratory Failure, Ventilator
Management, Intubation: Acute Respiratory Failure [518.81] may be assigned as a
principal or secondary diagnosis depending upon the circumstances of the inpatient
admission. {chapter specific coding guidelines provide specific sequencing direction-
obstetrics, poisoning, HIV, newborn}. Respiratory failure may be listed as a secondary
diagnosis. If respiratory failure occurs AFTER admission, it may be listed as a
secondary diagnosis.
Patient admitted to the hospital with abdominal pain. Principal diagnosis is cholecystitis.
Patient has a history of hypertension and diabetes. In the DRG [Diagnosis Related
Group] prospective payment system, which of following determines the MDC [Major
Diagnostic Category] assignment for this patient? a-abdominal pain, b-cholecystitis, c-
hypertension, or d-diabetes - CORRECT ANSWERCholecystitis - The principal
diagnosis determines the MDC.
Patient is admitted to the hospital with symptoms of a stroke and secondary diagnoses
of COPD and hypertension. Patient was subsequently discharged with a principal
diagnosis of cerebral vascular accident and secondary diagnosis of catheter-associated
urinary tract infection, COPD, and hypertension. Which of the following diagnoses
should NOT be tagged as POA? A) catheter-associated UTI, B) CVA, C) COPD, or D-
Hypertension - CORRECT ANSWERA) Catheter-Associated UTI: POA-Present on
Admission is defined as present at the time the order for inpatient admission occurs. [All
claims involving inpatient admissions to general acute care hospitals or other facilities
that are subject to law or regulation mandating collection of present on admission
information.] Conditions that develop during an outpatient encounter, including the ER
Department, observation, or outpatient surgery, are considered POA. Any condition that
occurs after admission is NOT considered a POA condition.
,Patient returns during a 90-day postoperative period from a ventral hernia repair, now
complaining of eye pain. What modifier would a physician setting use with the E&M
[Evaluation and Management] code? - CORRECT ANSWER-24: Unrelated evaluation
and management service by the same physician during a postoperative period. NOTE: -
79: Unrelated procedure or service by the same physician during the postoperative
period... would NOT be used as the question made mention of E&M, not service or
procedure.
Identify the 2-digit modifier that may be reported to indicate a physician performed the
postoperative management of a patient, but another physician performed the surgical
procedure. - CORRECT ANSWER-55: postoperative management only {Modifiers are
appended to code the provide more information to alert the payer that payment change
is required.
An encoder that takes a coder through a series of questions and choices is called: -
CORRECT ANSWERA logic-based encoder: prompts the user through a variety of
questions and choices based on the clinical terminology entered. The coder selects the
most accurate code for a service or condition and any possible complications or co-
morbidities.
A HIT-Health Information Technician is processing payments for hospital outpatient
services to be reimbursed by Medicare for a patient who had 2 physician visits,
underwent radiology examinations, clinical laboratory test, and who received take-home
surgical dressings. Which of the following services is reimbursed under the outpatient
prospective payment system? A) Clinical Laboratory Tests, B) Physician Office Visits,
C) Radiology Examinations, or D) Take-Home Surgical Dressings - CORRECT
ANSWERRadiology Examinations: Radiology procedures are identified under the
prospective payment system with a status indicator X. Status indicator X identifies
ancillary services that are separately paid. ******JOHNS BOOK*****RE-READ this
Which of the following types of hospitals are excluded from the Medicare inpatient
prospective payment system? A) Children's, B) Rural, C) State Supported, or D) Tertiary
(major hospital) - CORRECT ANSWERChildren's: psychiatric ad rehabilitation hospitals,
long-term care hospitals, children's hospitals, cancer hospitals, and critical access
hospitals are pain on the basis of reasonable cost, subject to payment limits per
discharge under separate PPS ********JOHNS BOOK*********RE-READ this
How are Diagnosis-related groups organized? - CORRECT ANSWERDRG's are
organized into MDC's - DRG's are classified by one of 25 major diagnostic categories.
In processing a Medicare payment for outpatient radiology examinations, a hospital
outpatient services department would receive payment under which of the following? A)
DRGs, B) HHRGS, C) OASIS, or D) OPPS - CORRECT ANSWEROPPS - Radiology
procedures performed as outpatients are paid under the Medicare prospective payment
system and are identified with a status indicator X for ancillary services.
, Which of the following is NOT reimbursed according to the Medicare outpatient
prospective payment system? A) CMHC (community mental health center) partial
hospitalization services, B) Critical access hospitals, C) Hospital outpatient
departments, or D) Vaccines provided by CORFs (comprehensive outpatient
rehabilitation facility) - CORRECT ANSWERCritical Access Hospitals are paid on a
cost-based payment system and are not part of the prospective payment system.
*********JOHNS********RE-READ
How often are fee schedules updated by third-party payers? - CORRECT
ANSWERThird-Party Payers who reimburse providers on a fee-for-service basis
generally update fee schedules on an annual basis.
What billing form is used by a health record technician to perform the billing functions
for a physician's office? - CORRECT ANSWERPhysicians submit claims via the
electronic format via the CMS-1500 billing form.
What does it mean when a provide accepts assignment? - CORRECT ANSWERTo
accept assignment means the provider or supplier accepts, as payment in full, the
allowed charge from the fee schedule.
A coding audit shows that an inpatient coder is using multiple codes that describe the
individual components of a procedure rather than using a single code that describes all
the steps of the procedure performed. What should be done in this case? - CORRECT
ANSWERCounsel the coder and stop the practice immediately and review the elements
of the hospital compliance program with the coder.
Why were prospective payment systems developed by the federal government? -
CORRECT ANSWERProspective payment systems were developed to manage the
costs of Medicare and Medicaid. Since 1983, PPS have been used to manage the costs
of the Medicare and Medicaid systems.
What is the goal of a coding compliance program? - CORRECT ANSWERThe goal of a
coding compliance program is to prevent accusations of fraud and abuse.
If a patient's total outpatient bill is $500.00 and the patient's healthcare insurance plan
pays 80% of the allowable charges, what is the amount the patient is responsible for? -
CORRECT ANSWER$100.00 to the patient
In a managed fee-for-service arrangement, which of the following would be used as a
cost-control process for inpatient surgical services? A) prospectively pre-certify the
necessity of inpatient services, B) Determine what services can be bundled, C) pay only
80% of the inpatient bill, or D) require the patient to pay 20% of the inpatient bill -
CORRECT ANSWERA) Pre-certify - managed FFS reimbursement is similar to
traditional FFS reimbursement except that managed FFS care plans control costs
primarily by managing their members' use of healthcare services.
UPDATED 2024/2025
A skin lesion is removed from a patient's cheek in the dermatologist's office. Physician
documents "skin lesion" in the health record. Before billing the pathology report returns
with a diagnosis of basal cell carcinoma. What actions should the coder take for this
claim submission? - CORRECT ANSWER Code: Basal Cell Carcinoma: In the
OUTPATIENT setting, when diagnostic tests have been interpreted by the physician
and the final report is available at the time of coding, code any CONFIRMED or
DEFINITIVE diagnosis(es) that are documented in the record. Do NOT code related
signs and symptoms as additional diagnoses. ******NOTE this differs from the coding
practice in the hospital inpatient setting regarding abnormal findings on test results.
*********
Epidural given during labor. Subsequently determined the patient would require a C-
section for cephalopelvic disproportion [baby's head too large for mother's pelvis]
because of obstructed labor [failure of the fetus to descend through the birth canal].
What it the correct ICD-9-CM diagnostic and the CPT anesthesia codes? - CORRECT
ANSWERNEED TO LOOK UP THIS ANSWER
Physician correctly prescribes Coumadin [anticoagulant-blood thinner]. Patient takes the
Coumadin as prescribed but develops hematuria [blood in the urine] as a result of taking
the medication. What the correct way to code this case? - CORRECT
ANSWERHematuria; adverse reaction to Coumadin. An adverse effect can occur when
everything is done correctly. Adverse effects can occur in situations where medications
are administered properly and prescribed correctly in both therapeutic and diagnostic
procedures. The first listed diagnosis is the MANIFESTATION or the nature of the
adverse drug effect - in this case HEMATURIA. Locate the drug in the SUBSTANCE
colum of the Table of Drugs and Chemicals in the Alphabetic Index to Diseases. Select
the E Code for the drug from the Therapeutic Use column of the Table of Drugs and
Chemicals. Use of the E Code is MANDATORY when coding adverse effects.
What is the procedure for locating a DRUG? - CORRECT ANSWERLocate the drug in
the SUBSTANCE colum of the Table of Drugs and Chemicals in the Alphabetic Index to
Diseases. Select the E Code for the drug from the Therapeutic Use column of the Table
of Drugs and Chemicals. Use of the E Code is MANDATORY when coding adverse
effects.
Briefly describe MS-DRG - CORRECT ANSWERMS-DRG (Medical-Severity-Diagnosis-
Related Group). It is system to classsify hospital cases in groups. DRG's are used to
determine how much Medicare pays the hospital for each "product" [i.e.
,"appendectomy"] since patients within each group are clinically similar and are expected
to use the same level of hospital resources. Each DRG was a payment weight assigned
to it based on the average resources used to treat Medicare patients in that DRG.
Payment weights are affected by geographic location (cost of living), number of low
income patietns in that location, whether the facility is a teaching facility, and if the case
is an outlier case (a particularly costly case). Claim information is gathered: ICD
diagnoses, procedures, age, sex, discharge status, and the presence of complication or
comorbidities. Examples: Normal Newborn, Psychoses, Major Joint Replacement,
Chest Pain, Cesarean Section, Simple pneumonia, Heart Failure. DRG's were
developed to monitor quality of care and resource use, cost efficiency, and use the
indicators to improve quality. Only ONE DRG can be assigned and reimbursed for a
single admission. The payment provided for the DRG is intended to cover the costs of
all hospital services performed during the patient's stay. Under the PPS, hospitals are
paid a set fee for treating patients in a single DRG category, regardless of the acutal
cost of care for the individual.
Patient admitted to the hospital for shortness of breath and congestive heart failure.
Patient subsequently develops respiratory failure. Patient undergoes intubation with
ventilator management. What is the correct sequencing and coding of this case? -
CORRECT ANSWERCongestive Heart Failure, Respiratory Failure, Ventilator
Management, Intubation: Acute Respiratory Failure [518.81] may be assigned as a
principal or secondary diagnosis depending upon the circumstances of the inpatient
admission. {chapter specific coding guidelines provide specific sequencing direction-
obstetrics, poisoning, HIV, newborn}. Respiratory failure may be listed as a secondary
diagnosis. If respiratory failure occurs AFTER admission, it may be listed as a
secondary diagnosis.
Patient admitted to the hospital with abdominal pain. Principal diagnosis is cholecystitis.
Patient has a history of hypertension and diabetes. In the DRG [Diagnosis Related
Group] prospective payment system, which of following determines the MDC [Major
Diagnostic Category] assignment for this patient? a-abdominal pain, b-cholecystitis, c-
hypertension, or d-diabetes - CORRECT ANSWERCholecystitis - The principal
diagnosis determines the MDC.
Patient is admitted to the hospital with symptoms of a stroke and secondary diagnoses
of COPD and hypertension. Patient was subsequently discharged with a principal
diagnosis of cerebral vascular accident and secondary diagnosis of catheter-associated
urinary tract infection, COPD, and hypertension. Which of the following diagnoses
should NOT be tagged as POA? A) catheter-associated UTI, B) CVA, C) COPD, or D-
Hypertension - CORRECT ANSWERA) Catheter-Associated UTI: POA-Present on
Admission is defined as present at the time the order for inpatient admission occurs. [All
claims involving inpatient admissions to general acute care hospitals or other facilities
that are subject to law or regulation mandating collection of present on admission
information.] Conditions that develop during an outpatient encounter, including the ER
Department, observation, or outpatient surgery, are considered POA. Any condition that
occurs after admission is NOT considered a POA condition.
,Patient returns during a 90-day postoperative period from a ventral hernia repair, now
complaining of eye pain. What modifier would a physician setting use with the E&M
[Evaluation and Management] code? - CORRECT ANSWER-24: Unrelated evaluation
and management service by the same physician during a postoperative period. NOTE: -
79: Unrelated procedure or service by the same physician during the postoperative
period... would NOT be used as the question made mention of E&M, not service or
procedure.
Identify the 2-digit modifier that may be reported to indicate a physician performed the
postoperative management of a patient, but another physician performed the surgical
procedure. - CORRECT ANSWER-55: postoperative management only {Modifiers are
appended to code the provide more information to alert the payer that payment change
is required.
An encoder that takes a coder through a series of questions and choices is called: -
CORRECT ANSWERA logic-based encoder: prompts the user through a variety of
questions and choices based on the clinical terminology entered. The coder selects the
most accurate code for a service or condition and any possible complications or co-
morbidities.
A HIT-Health Information Technician is processing payments for hospital outpatient
services to be reimbursed by Medicare for a patient who had 2 physician visits,
underwent radiology examinations, clinical laboratory test, and who received take-home
surgical dressings. Which of the following services is reimbursed under the outpatient
prospective payment system? A) Clinical Laboratory Tests, B) Physician Office Visits,
C) Radiology Examinations, or D) Take-Home Surgical Dressings - CORRECT
ANSWERRadiology Examinations: Radiology procedures are identified under the
prospective payment system with a status indicator X. Status indicator X identifies
ancillary services that are separately paid. ******JOHNS BOOK*****RE-READ this
Which of the following types of hospitals are excluded from the Medicare inpatient
prospective payment system? A) Children's, B) Rural, C) State Supported, or D) Tertiary
(major hospital) - CORRECT ANSWERChildren's: psychiatric ad rehabilitation hospitals,
long-term care hospitals, children's hospitals, cancer hospitals, and critical access
hospitals are pain on the basis of reasonable cost, subject to payment limits per
discharge under separate PPS ********JOHNS BOOK*********RE-READ this
How are Diagnosis-related groups organized? - CORRECT ANSWERDRG's are
organized into MDC's - DRG's are classified by one of 25 major diagnostic categories.
In processing a Medicare payment for outpatient radiology examinations, a hospital
outpatient services department would receive payment under which of the following? A)
DRGs, B) HHRGS, C) OASIS, or D) OPPS - CORRECT ANSWEROPPS - Radiology
procedures performed as outpatients are paid under the Medicare prospective payment
system and are identified with a status indicator X for ancillary services.
, Which of the following is NOT reimbursed according to the Medicare outpatient
prospective payment system? A) CMHC (community mental health center) partial
hospitalization services, B) Critical access hospitals, C) Hospital outpatient
departments, or D) Vaccines provided by CORFs (comprehensive outpatient
rehabilitation facility) - CORRECT ANSWERCritical Access Hospitals are paid on a
cost-based payment system and are not part of the prospective payment system.
*********JOHNS********RE-READ
How often are fee schedules updated by third-party payers? - CORRECT
ANSWERThird-Party Payers who reimburse providers on a fee-for-service basis
generally update fee schedules on an annual basis.
What billing form is used by a health record technician to perform the billing functions
for a physician's office? - CORRECT ANSWERPhysicians submit claims via the
electronic format via the CMS-1500 billing form.
What does it mean when a provide accepts assignment? - CORRECT ANSWERTo
accept assignment means the provider or supplier accepts, as payment in full, the
allowed charge from the fee schedule.
A coding audit shows that an inpatient coder is using multiple codes that describe the
individual components of a procedure rather than using a single code that describes all
the steps of the procedure performed. What should be done in this case? - CORRECT
ANSWERCounsel the coder and stop the practice immediately and review the elements
of the hospital compliance program with the coder.
Why were prospective payment systems developed by the federal government? -
CORRECT ANSWERProspective payment systems were developed to manage the
costs of Medicare and Medicaid. Since 1983, PPS have been used to manage the costs
of the Medicare and Medicaid systems.
What is the goal of a coding compliance program? - CORRECT ANSWERThe goal of a
coding compliance program is to prevent accusations of fraud and abuse.
If a patient's total outpatient bill is $500.00 and the patient's healthcare insurance plan
pays 80% of the allowable charges, what is the amount the patient is responsible for? -
CORRECT ANSWER$100.00 to the patient
In a managed fee-for-service arrangement, which of the following would be used as a
cost-control process for inpatient surgical services? A) prospectively pre-certify the
necessity of inpatient services, B) Determine what services can be bundled, C) pay only
80% of the inpatient bill, or D) require the patient to pay 20% of the inpatient bill -
CORRECT ANSWERA) Pre-certify - managed FFS reimbursement is similar to
traditional FFS reimbursement except that managed FFS care plans control costs
primarily by managing their members' use of healthcare services.
