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CCA EXAM 1
Terms in this set (101)
Identify the ICD-10-CM code for a patient with a subsequent encounter for routine healing of a closed traumatic capital epiphyseal fracture of the left femur
Identify the ICD-10-CM code(s) for neonatal tooth eruption
Identify CPT code(s) for the following patient. A 35-year old female undergoes an excision of a 3.0 cm tumor in her forehead. an incision is made through the skin and subcutaneous tissue. The tumor is dissected free of surrounding structures. The wound is closed with interrupted sutures.
Identify CPT code(s) for the following Medicare patient. A 67-year old female undergoes an excision of a breast lesion identified by pre-operative placement of radiological marker
Identify the information classified in the fourth digit for the code G30.0
Alzheimer's disease with early onset.
Identify the ICD-10-PCS code(s) for insertion of dual chamber cardiac pacemaker battery via an incision in the subcutaneous tissue of the chest wall, and percutaneous transvenous insertion of right atrial and right ventricular leads.
0JH606Z, 02H63JZ, 02HK3JZ
Identify the correct ICD-10-PCS code(s) for replacement of an old dual pacemaker battery with a new dual pacemaker battery in the subcutaneous tissue f the chest wall via incisional approach.
Identify the appropriate ICD-10-CM code(s) for Mobitz type I and II heart block
Identify the appropriate ICD-10-CM and ICD-10-PCS code(s) for cardiac pacemaker pulse generator check
This condition has an imprecise diagnosis with various characteristics. the condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. It is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with Brady arrhythmias . Prolonged ambulatory monitoring may be indicated to establish a diagnosis of this condition. Treatment includes insertion of a permanent cardiac pacemaker
Sick sinus syndrome (SSS) (I49.5)
Identify the appropriate ICD-10-PCS code(s) for a coronary artery bypass of two sites, one using the left internal mammary artery to the left proximal anterior descending artery, and one using the right internal mammary artery to the distal left anterior descending artery, both done via thoracotomy.
Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery
Identify the correct ICD-10-CM code(s) for a patient who arrives at the hospital for outpatient laboratory services ordered by the physician to monitor the patient's Coumadin levels. A prothrombin time (PT) is performed to check the patient's long-term use of his anticoagulant treatment.
Identify the CPT code(s) for the following patient: A 2-year-old-boy presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance
Identify the CPT code(s) for the following patient: A 2-year-old boy presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance
Identify the term ICD-10-CM uses for the following definition: "the expulsion of some, but not all, of the products of conception from the uterus."
Identify the ICD-10-CM code(s) for the following: threatened abortion with hemorrhage at 15 weeks; home undelivered
Identify the ICD-10-CM and ICD-10-PCS code(s) for the following: 40 week gestation, term pregnancy with poor cervical dilation; lower uterine segment cesarean delivery, open approach with single liveborn female.
O62.0, Z3A.40, Z37.0, 10D00Z1
Identify the ICD-10-CM code for diaper rash in elderly patient
Identify the ICD-10-CM code(s) for infected ingrown toenail with paronychia of the first toe of the right foot.
Identify the ICD-10-CM code(s) for primary localized osteoarthritis of bilateral hips.
Identify the ICD-10-CM code for chrondromalacia of the left patella
Identify the ICD-10-CM code(s) for acute osteomyelitis of the right index finger due to Staphylococcus aureus
Identify the ICD-10-CM code(s) for acute osteomyelitis of tarsus bones of the right ankle due to Staphylococcus.
Identify the ICD-10-CM code(s) for other specified aplastic anemia secondary to adverse effect of chemotherapy, initial encounter
Identify the ICD-10-CM code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well-child examination. The physician documents, "well child, born premature."
Identify the ICD-10-CM code for ventricular diastolic dysfunction
Identify the chapter in which certain signs and symptoms of breast disease, such as mastodynia, induration of breast, and nipple discharge, are included
Chapter 14 Diseases of the genitourinary system
which of the following is the correct ICD-10-PCS code for a Mayo operation known as a bunionectomy? An incision was made in the right foot and a portion of the first metatarsal head was removed.
Which of the following is not considered an endoscopy?
Which of the following is (are) the correct ICD-10-PCS code(s) for laparoscopic cholecystectomy? The entire gallbladder was removed.
Which of the following is (are) the correct ICD-10-PCS code(s) for cystoscopy with diagnostic biopsy of the bladder?
Which of the following software applications would be used to aid in the coding function in a physician's office?
Which payment system was introduced in 1992 and replaced Medicare's customary, prevailing, and reasonable (CPR) payment system?
Resource-based relative value scale system
The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes:
58150 Total abdominal hysterectomy, with/without removal of tubes and ovaries
58700 Salpingectomy, complete or partial, unilateral/bilateral (separate procedure)
What error has the coder made by using these codes?
What is the best reference tool to determine how CPT codes should be assigned?
American Medical Association's CPT Assistant news
An electrolyte panel (80051) in the laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this would be a form of:
In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel?
report the remaining tests using individual test codes, according to CPT.
The Office of Inspector General (OIG) has identified risk areas for physician practices. One type of risk is "clustering," Identify its definition
Coding or charging one or two middle levels of service codes exclusively
What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment for Part B claims?
National Correct Coding Initiative (NCCI)
What is the best reference tool for ICD-10-CM/PCS coding advice?
AHA's Coding Clinic for ICD-10-CM/PCS
CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of services greater than the norm would indicate. These MUEs were implemented on January 1, 2007 and are applied to which code set?
Several key principles require appropriate physician documentation to secure payment from the insurer. which answer (listed here) fails to impact payment based on physician responsibility?
Documenting the charges and services on the itemized bill.
The documentation of each patient encounter should include the following to secure payment from the insurer except:
The identity of the patient's nearest relative and emergency contact number.
Two patients were hospitalized with bacterial pneumonia. One patient was hospitalized for three days, and the other patient was hospitalized for 30 days. Both cases result in the same DRG with different lengths of stay. Which answer most closely describes how the hospital will be reimbursed?
the hospital will receive the same reimbursement for the same DRG regardless of the length of stay.
Which of the following statements are true?
The higher the relative weight, the higher the payment rates.
Which classification system is in place to reimburse home health agencies?
What reimbursement system uses the Medicare fee schedule?
MS diagnostic-related groups are organized into:
Major diagnostic categories
Which of the following hospitals are excluded from the Medicare acuter-care prospective payment system?
CMS identified conditions that are not present on admission and could be "reasonably preventable." Hospitals are not allowed to receive additional payment for these conditions when the condition is present on admission. What are these conditions called?
Which of the following fails to meet the CMS classification of a hospital-acquired condition?
Which of the following fails to meet the CMS classification of a hospital acquired condition?
Stage I pressure ulcers
The electronic claim format (8371) replaces which paper billing form?
This is a statement sent by third-party payers to the patient to explain services provided, amounts billed, and payments made by the health plan.
Explanation of benefits (EOB)
An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. which of the following datasets should the clinic consult to ensure all the federally required data elements for Medicare and Medicaid outpatient clinical encounters are collected by the system?
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus vagus) is one purpose of:
A family practitioner requests the opinion of a physician specialist endocrinology who reviews the patient's health record and examines the patient. The physician specialist records findings, impressions, and recommendations in which type of report?
Which of the following is not a function of the discharge summary?
Providing information about the patient's insurance coverage.
documentation of monitoring to ensure the patient sufficiently recovers from anesthesia, including a post-anesthesia note, vital signs, and intravenous fluids, is a function of the :
Recovery room report
A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:
All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered as this type of data:
What type of data is exemplified by the insured party's member identification number?
Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented formula?
SOAP form of progress notes
Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on :
Reason for encounter
Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: "patient is being admitted for organic brain syndrome." Underneath the diagnosis, her medical information along with her rehabilitation potential was also listed. On which form is this information documented?
Transfer or referral
According to the Joint Commission Accreditation Standards, which documentation must be placed in the patient's record before a surgical procedure may be performed?
Report of history and physical examination
Bob Smith was admitted to Mercy Hospital on June 21. The physical examination was completed on June 23. According to Medicare Conditions of Participation, which statement applies top this situation?
The record is not in compliance because the physical examination must be completed within 24 hours of admission
A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n):
The _______________ may contain information about diseases among relatives in which heredity may play a role.
To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of health records?
Review each patient's medical record concurrently to make sure history and physicals are present and meet the accreditation standards
Medical record completion compliance is a problem at Community Hospital. the number of incomplete charts often exceeds the standard set by the Joint commission, risking a type I violation. Previous HIM committee chairperson tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. to improve compliance, which of the following would be the next step to overcome noncompliance?
contact other hospitals to see what methods they use to ensure compliance
How do accreditation organizations such as the Joint Commission use the health record?
To determine whether standards of care are being met
Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must the facility meet in order to become certified for these programs?
Conditions of Participation
What is the best source of documentation to determine the size of a removed malignant lesion?
This document includes a microscopic description of tissue excised during surgery:
When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure?
Query the physician as to the method used. and
The Medicare Modernization Act of 2003 (MMA) launched a Medicare payment and recovery demonstration project that would later develop into recovery audit contractors (RACs) serving as a means to ensure correct payments under Medicare. During the demonstration program, the contractors were able to identify _____________ of dollars in improper payments.
Corporate compliance programs were released by the OIG for hospitals to develop and implement their own compliance programs. All of the following except__________ are basic elements of a corporate compliance program.
Medical staff appointee for documentation compliance
Which of the following programs has been in place in hospitals for years and has been required by the Medicare and Medicaid programs and accreditation standards?
Each year the OIG develops a work plan that details area of compliance it will be investigating for that year. what is the expectation of the hospital in relation to the OIG work plan?
Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan.
HIM coding professionals and the organizations that employ them have the responsibility to not tolerate behavior that adversely affects data quality. which of the following is an example of behavior that should not be tolerated?
Omit codes that reflect negatively on quality and patient safety measurement.
The OIG believes that compliance programs have benefits in addition to submitting accurate claims. this includes al of the following except:
Increased potential for criminal and unethical conduct
An individual stole and used another person's insurance information to obtain medical care. This action would be considered:
Medical identity theft
A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose?
Chart tracking system
What does an audit trail check for?
Unauthorized access to a system
An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?
What software will prompt the user through a variety of questions and choices based on the clinical terminology entered to assist the coder in selecting the most appropriate code?
The technology commonly used for automated claims processing (sending bills directly to third-party payers) is :
Electronic data interchange
What refers to the capacity of health record systems to provide electronic communication linkages and allow exchange of health record data among information systems?
a system that provides alerts and reminders to clinicians is a(n):
Clinical decision support system
In what form of health information exchange are data centrally located but physically separated?
A hospital receives a valid request from a patient for copies of his or her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPPA regulations, was this action correct?
No; the records from the previous hospital are considered part of the designated record set and should be given to the patient.
A patient request copies of her personal health information on CD. when the patient goes home, she finds that she cannot read the CD on her computer. the patient then requests the hospital to provide the medical records in paper format. How should the hospital respond?
Provide the medical records in paper format.
Which of the following definitions best describes the concept of confidentiality?>
the expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose
the release of information function requires the HIM professional to have knowledge of:
Federal and State confidentiality laws
The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting rom is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?
There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice
The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of :
The HIM manager is concerned about whether the data transmitted across the hospital network is altered during the transmission. the concept that concerns the HIM manager is
The CIA of security includes confidentiality, data integrity, and data ____________
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