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CCA EXAM 2
Terms in this set (100)
Identify the correct ICD-10-CM diagnosis code(s) and sequencing for the following: patient with a scar on the right hand secondary to a laceration sustained two years ago
Identify the correct ICD-10-CM diagnosis code(s) and sequencing for the following: patient with dysphasia secondary to a previous cerebral infarction
Identify the correct ICD-10-CM diagnosis code(s) for the following: patient with nausea, vomiting, and gastroenteritis
Identify the correct ICD-10-CM diagnosis code for a patient with an elevated prostate-specific antigen(PSA) test result
Identify the correct ICD-10-CM diagnosis code(s) for a patient with near-syncope event and nau
Identify the correct ICD-10-CM diagnosis code(s) for a patient with an elevated glucose tolerance test.
Identify the correct ICD-10-CM diagnosis code(s) for a patient with pneumonia and persistent cough.
Identify the correct ICD-10-CM diagnosis code(s) for a patient with seizures; epilepsy ruled out.
Identify the correct ICD-10-CM diagnosis code(s) for a male patient with stress urinary incontinence.
Identify the correct ICD-10-CM diagnosis code(s) for a patient with right lower quadrant abdominal pain with nausea, vomiting, and diarrhea.
R10.31, R11.2, R19.7
Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of a diagnosis in ICD-10-CM coding. The punctuation does not affect the code number assigned to the case and is considered a ninessential modifier.
Identify the correct ICD-10-CM diagnosis code (s) for a patient with ST elevated anterolateral wall myocardial infarction
Identify the correct ICD-10-CM diagnosis code(s) and sequencing for a patient with disseminated candidiasis secondary to AIDS-related complex.
Identify the correct ICD-10-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli.
Identify the correct ICD-10-CM diagnosis codes and sequencing for a patient who was admitted for outpatient chemotherapy for treatment of acute lymphocytic leukemia. during the procedure, the patient developed severe nausea with vomiting and was treated with medications.
Z51.11, C91.00, R11.2
Identify the correct ICD-10-CM diagnosis code(s) for metastatic carcinoma of the colon to the left lung.
Identify the correct ICD-10-CM diagnosis code(s) for a patient with sepsis due to Staphylococcus aureus.
Identify the correct ICD-10-CM diagnosis code(s) for poorly controlled Type 2 diabetes mellitus; mild malnutrition.
Identify the ICD-10-CM diagnosis code(s) for neutropenic feverA
Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling.
Category II codes cover all but one of the following topics. Which is not addressed by Category II codes?
Per CPT guidelines, a separate procedure is:
Considered to be an integral part of another, larger service
CPT was developed and is maintained by:
The codes in musculoskeletal section of CPT may be used by:
Observation E/M codes (99218-99220) are used in physician billing when:
A patient is referred to a designated observation status
Documentation in the history of use of drugs, alcohol, and tobacco is considered as part of the :
Tissue transplanted from one individual to another of the same species, but different genotype is called a(n):
Allograft or allogeneic graft
Mohs micrographic surgery involves the surgeon acting as:
Both surgeon an pathologist
If an orthopedic surgeon attempted to reduce a fracture but was unsuccessful in obtaining acceptable alignment, what type of code should be assigned for the procedure?
A " with manipulation" code
Identify the correct CPT procedure code for incision and drainage of infected shoulder bursa.
In coding arterial catheterizations, when the tip of the catheter is manipulated from the insertion into the aorta and then out into another artery, this is called:
When coding a selective catheterization in CPT, how are codes assigned?
One code for the final vessel control
How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form?
By reviewing all the diagnosis codes assigned to explain the reasons the services were provided.
What is the name of the organization that develops the billing form that hospitals are required to use?
National Uniform Billing Committee (NUBC)
What healthcare organizations collect UHDDS data?
All non outpatient settings including acute care, short-term care, long-term care, and psychiatric hospitals; home health agencies; rehabilitation facilities; and nursing homes
What was the goal of the MS-DRG system?
To improve Medicare's capability to recognize severity of illness in its inopatient hospital payments. The new system is projected to increase payments to hospitals for services provided to sicker patients and decrease payments for treating less severely ill patients
What is the basic formula for calculating each MS-DRG hospital payment?
Hospital payment= DRG relative weight x hospital base rate
What are the 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, new technologies, and cost outlier cases.
What is the number of the national program to detect and correct improper payments in the Medicare Fee-for-
Service (FFS) program?
Recovery audit contractor (RACs)
What is the maximum number of procedure codes that can appear on a UB-04 institutional claim form via electronic transmission?
Which answer is not required for assignment of the MS-DRG?
Attending and consulting physician
What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inoatient principal and secondary diagnoses?
Which of the following situations would be identified by the NCCI edits?
Billing for two services that are prohibited from being billed on the same day
A hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should the hospital refer to?
A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true?
Monies paid to the healthcare provider cannot exceed charges.
The purpose of a physician query is to:
Improve documentation for patient care and proper reimbursement
What is the term used when a Medicare hospital in patient admission results in exceptionally high costs when compared to other cases in the same DRG?
What is a chargemaster?
A financial management form that contains information about the organization's charges for the healthcare services it provides to patients
A fee schedule is:
Developed by third-party payers and includes a list of healthcare services, procedures, and charges associated with each
The provider or supplier is prohibited from holding the patient responsible for charges in excess of the Medicare fee schedule. This is called:
If a provider believes a service may be denied by Medicare because it could be considered unnecessary, the provider must notify the patient before the treatment begins by using a(n):
Advance beneficiary notice (ABN)
Assignment of benefits is a contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services and the beneficiary for _____________________ and to accept the Medicare payment as payment in full.
Coinsurance or deductible
A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain:
Reimbursement for healthcare services is dependent on patients having a(n):
Health insurance for spouses, children, or both is known as :
Dependent (family) coverage
Documentation regarding a patient's marital status: dietary, sleep, and exercise patterns; and use of coffee, tobacco, alcohol, and other drugs may be found in the:
A patient with known COPD an 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 postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA?
Which of the following would not be found in a medical history?
Which of the following report includes names of the surgeon and assistants, date, duration, and description of the procedure, and any specimens removed?
Identify the acute-care record report where the following information would be found: The patient is a well-developed, obese male who does not appear to be in any distress but has considerable problem with mobility. he has difficulty rising up from a chair, and he uses a cane to ambulate. VITAL SIGNS: His blood pressure today is 158/86, pulse is 80 per minute, weight is 204 pounds (which is 13 pounds below what he weighed in the previous month). He has no pallor. He has rather pronounced shaking of his arms, which he claims is not new. NECK: Showed no jugular venous distension. HEART: Very irregular. LUNGS: Clear. EXTREMITIES: Edema of both legs.
Identify the acute-care record report where the following information would be found: Gross Description: Received fresh designate left lacrimal gland is a single, unoriented, irregular, tan-pink portion of soft tissue measuring 0.8 x 0.6 x0.1 cm, which is submitted entirely intact in one cassette
Which organization develop the first hospital standardization program?
American College of Surgeons
The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. however, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not be coordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?
Inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated
When correcting erroneous information in a health record, which of the following is not appropriate?
Use black pen to obliterate the entry
Community Hospital implemented a clinical document improvement (CDI) program six months ago. the goal of the program was to improve a clinical documentation to support quality of care, data quality, and HIM coding accuracy. which of the following would be the beast to ensure that everyone understands the importance of this program?
Include ancillary clinical and medical staff in the process
In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20xx. the patient, however, was discharged two days later. in this case, what would be the best course of action?
Request the physician dictate an addendum to the discharge summary.
During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up ti a week after initial transcription. The director is concerned that change occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. too 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 draft form.
During a review of documentation practices, the HIM director finds that nurses are routinely using the copy-and-paste function of the hospital's new EHR system for documenting nurses notes. In some cases, nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented b y another practitioner. Which of the following should the HIM director do to ensure the nurses are following acceptable documentation practices?
Develop policies and procedures related to cutting, copying, and pasting documentation in the EHR system
Who is responsible for writing and signing discharge summaries and discharge instructions?
Where would a coder who needed to locate the histology of a tissue sample most likely find this information?
An HIM professional's ethical obligations:
Apply regardless of employment site
Which of the following is the concept of the right of an individual to be left alone?
What should be done when the HIM department's error or accuracy rate is deemed unacceptable?
A corrective action should be taken
Statements that define the performance expectations and structures or processes that must be in place are:
In an EHR, what is the risk of copying and pasting?
The system not recording who entered the data
How are amendments handled in an EHR?
The amendment must have a separate signature, date, and time.
The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI:
For as long as it is maintained
Preempt less- strict state statutes where they exist
The Privacy Rule applies to:
All covered entities involved with transmitting or performing any electronic transactions specified in the act
Which of the following is the area responsible for limiting disclosure of private matters including the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual?
Which of the following is not an accepted accrediting body for behavioral healthcare organizations?
American Psychological Association
Which of the following is an example of a unique identifier for an individual health record to ensure that the information in the record is not misplaced, lost, or confused with information for another person each time a patient visits a facility?
Health record number
What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals?
State licensure agencies
Which of the following threatens the "need-to-know" principle?
A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended?
Automatic session terminations
A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What data quality or data integrity measures should be in place to ensure that only allowable code numbers are entered?
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
In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ______________systems.
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?
The _________________ is a type of coding that is a natural outgrowth of the EHR.
A(n) _________________ is computer software that assists in determining coding accuracy and reliability.
The ______________________ uses expert or artificial intelligence software to automatically assign code numbers.
NLP encoding system
Data security policies and procedures should be reviewed at least:
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?
Which of the following is a threat to data security?
Under the GIPAA privacy standard, which of the following types of protected health information(PHI) must be specifically identified in an authorization?
What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm?
A fine of not more than $250,000, not more than 10 years in jail, or both
An HIT using her password can access and change data in the hospital's master patient index. A billing clerk, using his password, cannot perform the same function. limiting the class of information and functions that can be performed by these two employees is managed by:
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?
Facility access controls
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
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