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CCA Study Aid Report

Exam 1 - Answers

According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? Report of history and physical examination
The pt. seen in physician office w/chief complaint of SOB. In pt. chart progress notes, Dr. documents diagnosis of asthma & recommends pt. present to ER immediately. Dr. documents pt. has severe wheezing & no obvious relief w/bronchodilators. Code: Query the physician for more detail about the asthma
Which of the following programs have been in place in hospitals for years and have been required by the Medicare and Medicaid programs and accreditation standards? Quality Improvement
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
Identify the CPT code(s) for the following patient: “A 2-year-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance.” CPT Codes: 43761; 76000
Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block. CPT Code: 426.53
CMS developed Medically Unlikely Edits (MUEs) t 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? HCPCS / CPT Codes
Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of ______. Vocabulary standards
The release of information function requires the HIM professional to have knowledge of ______. Federal and state confidentiality laws
Identify the correct diagnosis ICD-9-CM code(s) for pt. who arrives at hospital for outpatient lab services ordered by physician to monitor the pt’s Coumadin levels. A Prothrombin time (PT) is performed to check pt’s long-term use of anticoagulant. ICD-9-CM: V58.83; V58.61
Identify the ICD-9-CM diagnostic code(s) for the following: “Threatened abortion with hemorrhage at 15 weeks; home undelivered.” ICD-9 Code: 640.03
Male admitted to hospital complaint: abdominal pain. The Attending Dr. requested upper GI & lab eval of CBC & UA. X-ray revealed possible Cholelithiasis & the UA showed increased WBC. Surgery for exploratory laparoscopy & ruptured appendix discovered. CC: Abdominal pain
Identify ICD-9-CM procedure code: 73-year-old female treated for hemorrhage of inferior mesenteric artery. Admitted to hospital for a trans-catheter embolization of the bleeders with polyvinyl alcohol (PVA) microspheres & coils & abdominal angiography. ICD-9-CM Procedure Codes: 39.79, 88.47
What type of data is exemplified by the insured party's member identification number? Financial data
Identify ICD-9 procedure code for allogeneic donor lymphocyte stem cell infusion. ICD-9 Procedure Code: 41.05
Firewalls are effective for preventing all types of attacks on a healthcare system. False statement. Firewalls cannot protect a system from all types of attacks. Many viruses can hide within documents that will not be stopped by a firewall.
A hospital receives a valid request from a pt. for copies of her medical records. The HIM clerk who is preparing the records removes records not generated at his facility. According to HIPAA 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.
Identify ICD-9 diagnosis code for atypical ductal hyperplasia. ICD-9 Code: 610.8
A 35-year-old female undergoes an excision of a 3.0-cm tumor of her forehead. An incision is made through the skin and subcutaneous tissue. Tumor is dissected free of surrounding structures. Wound is closed in layers & interrupted sutures. CPT Code: 21012
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.
Identify the ICD-9-CM diagnostic code for diastolic dysfunction: ICD-9-CM Code: 429.9
Identify the ICD-9-CM diagnosis code for chondromalacia of the patella: ICD-9-CM Code: 717.7
Identify the appropriate ICD-9-CM procedure code(s)for a double internal mammary-coronary artery bypass: ICD-9 Procedure Code: 36.16 Codes are selected based on whether one or both internal mammary arteries are used, regardless of the number of coronary arteries involved.
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 Participating organizations must follow the Medicare Conditions of Participation to receive federal funds fro the Medicare program for services rendered.
Pt. present with sinus arrest,sinoatrial exit block, or persistent sinus bradycardia. This syndrome often the result of drug therapy (digitalis, calcium channel blockers, beta-blockers, or antiarrhythmics). Sick Sinus Syndrome (SSS) ICD-9 Code:427.81 Another presentation includes recurrent supraventricular tachycardias associated w/brady-arrhythmias. Treatment includes insertion of permanent cardiac pacemaker.
Identify ICD-9-CM procedure code for allogeneic donor lymphocyte stem cell infusion. ICD-9 Procedure Code: 41.05
Identify the appropriate ICD-9-CM diagnosis code(s) for right and left bundle branch block: ICD-9-CM Code: 426.53 It is inappropriate to assign a code for right (426.4) & left (426.3) bundle branch block when a combination code includes both the right & left.
A software interface is a: Program to exchange date A software interface is a computer program that allows different applications to communicate & exchange data.
This document includes a microscopic description of tissue excised during surgery: Pathology report. The pathology report describes specimens examined by the pathologist.
To comply with Joint Commission standards, the HIM director wants to ensure that H&P exams are documented in the pt's health record no later than 24 hrs. after admission. Which would be best way to ensure the completeness of health records? Review each pt's medical record concurrently to make sure history & physicals are present & meet the accreditation stands.
Identify the ICD-9-CM code for diaper rash, elderly patient: ICD-9 Code: 691.0 Index Rash, diaper. ICD-9 classifies dermatitis to Cat. 690-694. Atopic dermatitis & related conditions to 691. Fourth-digit subcat: diaper or napkin rash & other related conditions.
Several codes describe colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Addl. codes define removal of foreign body (45379) & biopsy, single or multiple (45380). Reporting separately would violate which rule? Unbundling The coder should assign the most comprehensive code to describe the entire procedure performed. When a code describes the entire service provided the coder should not code each component separately. To do so would be a form of unbundling.
A family practitioner requests opinion of physician specialist in endocrinology who reviews the health record & examines the pt. The physician specialist would record findings, impressions, & recommendations, & recommendations in which type of report? Consultation. The report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's exam of the pt. & review of his health record.
A health information technician receives a subpoena duces tecum for the records of a discharged pt. To respond to the subpoena, what should the technician do? Review the subpoena to determine what documents must be produced.
The sequence of the correct steps when evaluating an ethical problem is? Determine the facts; consider the values and obligations of others; consider the choices that are both justified & not justified; identify prevention options.
What is the correct ICD-9-CM procedure code(s) for cystoscopy with biopsy? ICD-9 Procedure Code: 57.33
An outpatient clinic reviewing functionality of a computer system purchase. Which dataset should the clinic consult to ensure all the federally required data elements for Medicare & Medicaid outpatient clinical encounters are collected by the system. UACDS (Uniform Ambulatory Care Data Set)
DEEDS stands for: Data Elements for Emergency Departments System
UHDDS stands for: Uniform Hospital Discharge Data Set
UACDS stands for: Uniform Ambulatory Care Data Set
EMEDS stands for: Expeditionary Medical Support
Identify the ICD-9-CM diagnostic code for primary localized osteoarthrosis of the hip: ICD-9 Code: 715.15
Bob Smith was admitted to Mercy Hospital on June 21st. The physical was completed on June 23rd. According to Joint commission standards, which statement applies to this situation? The record is not in compliance as the physical exam must be completed within 24 hours of admission.
Identify the ICD-9 diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, ex-preemie." ICD-9 Codes: V20.2, 765.10
Which of the following software applications would be used to aid in the coding function in a physician's office? Encoder. An encoder is a computer program designed to assist coders in assigning appropriate clinical codes. An encoder helps ensure accurate reporting of diagnoses and procedures.
Identify the ICD-9 diagnostic code(s) for acute osteomyelitis of ankle due to staphylococcus. ICD-9 Codes: 730.07, 041.10 Index Osteomyelitis, acute or subacute. Refer to the table in the index for the fifth digit "5", ankle and foot. Infection, staphylococcal NEC.
Identify the CPT code for the following pt: A 2-year-old male presented to the hospital to have his gastrostomy tube changed under fluoroscopic guidance: CPT Code: 49450 Code 49450 includes replacement of gastrostomy or cecostomy tube, percutaneous, under fluoroscopic guidance incl. contrast injections, image documentation & report. It would not be appropriate to add code 76000 for fluoroscopic guidance.
Pt. had total abdominal hysterectomy w/bilateral salpingo-oophorectomy. The coder assigned the following codes: 58150, Total abdominal hysterectomy & Ovaries, 5870, Salpingectomy, complete or partial.What error was made? Unbundling Unbundling is the practice of coding services separately that should be coded together as a package because all parts are included within one code and therefore, one price.Unbundling on purpose = fraud.
What source of law is also known as judge-made or case law? Common law English common law is the primary source of many legal rules & principles & was based initially on tradition & custom. Common law regularly referred to as unwritten law originating from court decisions where no statute exists.
Identify the correct ICD-9 procedure code for replacement of an old dual pacemaker with a new dual pacemaker. ICD-9 procedure code: 37.87
Identify the ICD-9-CM diagnostic code(s) and procedure code(s) for the following: Term pregnancy with failure of cervical dilation; lower segment Cesarean delivery w/single live-born female: ICD-9 Code: 661.01; V27.0, Diagnostic Code: 74.1
Created by: Laura Duncan