CCA EXAM PREPARATION EXAM WITH
QUESTIONS AND 100% CORRECT
ANSWERS 2025 UPDATE GRADED A+.
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.
Explanation: A policy defining the acceptable time frame for making changes to
transcribed reports can ensure that documentation is completed in a timely manner and
maintain the legal validity of the records.
1. What is the basic formula for calculating each MS-DRG hospital payment?
ANS: Hospital payment = DRG relative weight x hospital base rate
Explanation: The MS-DRG payment system uses the DRG relative weight assigned to
each diagnosis-related group (DRG) and multiplies it by the hospital's base rate to
calculate the payment.
2. Which of the following activities would be in violation of AHIMA's Code of Ethics?
ANS: Coding an intentionally inappropriate level of service
Explanation: Coding for a service level that is not reflective of the actual care provided
is unethical and a violation of AHIMA’s Code of Ethics.
3. What is abstracting?
ANS: Compiling the pertinent information from the medical record based on
predetermined data sets
, Explanation: Abstracting is the process of reviewing and summarizing the relevant
information from medical records, often to collect data for reporting or research.
4. ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth.
ANS: 28th
Explanation: The "newborn period" is defined as the time from birth through the 28th
day of life.
5. What healthcare organization collects UHDDS data?
ANS: All non-outpatient settings including acute care, short term care, long term care,
psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes.
Explanation: The Uniform Hospital Discharge Data Set (UHDDS) collects data from all
non-outpatient healthcare settings.
6. 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
Explanation: Implementing edit checks can help identify and correct errors such as
incorrect gender coding during data entry.
7. 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
Explanation: Under HIPAA, use refers to sharing information within the organization,
and disclosure refers to sharing information with external parties.
, 8. Who is responsible for writing and signing discharge summaries and discharge
instructions?
ANS: Attending physician
Explanation: The attending physician is responsible for writing and signing discharge
summaries and discharge instructions.
9. 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
Explanation: Psychotherapy notes are protected by HIPAA and cannot be disclosed to patients
without specific conditions.
10. 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 ( )
Explanation: Parentheses are used in ICD-9-CM to provide additional information or
clarification that is not essential to the code.
11. What is the name of the organization that develops the billing form that hospitals are
required to use?
ANS: National Uniform Billing Committee (NUBC)
Explanation: The NUBC develops the billing form required by hospitals for billing purposes,
such as the UB-04 form.
QUESTIONS AND 100% CORRECT
ANSWERS 2025 UPDATE GRADED A+.
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.
Explanation: A policy defining the acceptable time frame for making changes to
transcribed reports can ensure that documentation is completed in a timely manner and
maintain the legal validity of the records.
1. What is the basic formula for calculating each MS-DRG hospital payment?
ANS: Hospital payment = DRG relative weight x hospital base rate
Explanation: The MS-DRG payment system uses the DRG relative weight assigned to
each diagnosis-related group (DRG) and multiplies it by the hospital's base rate to
calculate the payment.
2. Which of the following activities would be in violation of AHIMA's Code of Ethics?
ANS: Coding an intentionally inappropriate level of service
Explanation: Coding for a service level that is not reflective of the actual care provided
is unethical and a violation of AHIMA’s Code of Ethics.
3. What is abstracting?
ANS: Compiling the pertinent information from the medical record based on
predetermined data sets
, Explanation: Abstracting is the process of reviewing and summarizing the relevant
information from medical records, often to collect data for reporting or research.
4. ICD-9-CM defines the "newborn period" as birth through the ___________ day following
birth.
ANS: 28th
Explanation: The "newborn period" is defined as the time from birth through the 28th
day of life.
5. What healthcare organization collects UHDDS data?
ANS: All non-outpatient settings including acute care, short term care, long term care,
psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing homes.
Explanation: The Uniform Hospital Discharge Data Set (UHDDS) collects data from all
non-outpatient healthcare settings.
6. 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
Explanation: Implementing edit checks can help identify and correct errors such as
incorrect gender coding during data entry.
7. 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
Explanation: Under HIPAA, use refers to sharing information within the organization,
and disclosure refers to sharing information with external parties.
, 8. Who is responsible for writing and signing discharge summaries and discharge
instructions?
ANS: Attending physician
Explanation: The attending physician is responsible for writing and signing discharge
summaries and discharge instructions.
9. 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
Explanation: Psychotherapy notes are protected by HIPAA and cannot be disclosed to patients
without specific conditions.
10. 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 ( )
Explanation: Parentheses are used in ICD-9-CM to provide additional information or
clarification that is not essential to the code.
11. What is the name of the organization that develops the billing form that hospitals are
required to use?
ANS: National Uniform Billing Committee (NUBC)
Explanation: The NUBC develops the billing form required by hospitals for billing purposes,
such as the UB-04 form.
