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AHIMA Sample Exam 1

2010 Sample CCA Exam

For Co-Management, it is: Co-management refers to Office visits & standard aftercare following surgery (e.g., cataract surgery). Two doctors cannot be pd. for the same dates for post-op care.
What is VPN and what is it used for? Virtual Private Network: Access medical records remotely via the Internet.
What is SNOMED and what is it used for? Systematized Nomenclature of Medicine. It is a systematically organized computer process-able collection of medical terminology. Covers diseases, findings, procedures, micro-organisms & pharmaceuticals.
In the medical chart, any lose notes or documentation is: Considered part of the medical record, even if it is not clasped or affixed in some manner in the chart.
The "idiopathic" in Idiopathic Thrombocytopenic refractory to medical therapy means: The cause of this condition is unknown. The term "idiopathic" means: unknown
What is a Cross-Coder most likely to be used for? ICD-9 procedural codes to CPT codes. Several cross-coders exist for inpatient coders & CPT to ICD-9 Volume 3 codes. A lot less V. 3 codes than CPT codes (less specific).
Define Cystorrhaphy: Surgical repair of a defect or wound in the urinary bladder.
The reduction of intrathoracic space by removing sections of the chest wall is: Thoracotomy, an incision or cutting
Define Conjunctivoplasty: Plastic surgery on the thin, transparent tissue that covers the outer surface of the eyes. Used to treat medial ectropion of the lower eyelid.
The obturator nerve is found: It is in the medial thigh region, just above the knee.
Which organ has both exocrine and endocrine parts? The Pancreas has both components. The "endocrine" portion secretes internally without ducts, but into the blood directly. The "exocrine" portion secretes outwardly to a free surface through ducts.
Parenteral means: Other than through the gastrointestinal tract. Parenteral is an infection that is either intravenous, subcutaneous, intramuscular, or intramedullary.
What are three (3) functions of the kidneys: To filter blood, to regulate blood pressure, and to eliminate waste. The kidneys also make new red blood cells & maintain healthy bones.
The "adductor magnus" is found: In the Inner Thigh.The adductor muscle draws a part toward the median line.
A strangulated hernia is: An irreducible hernia that is trapped and cannot return to the abdomen. It is possible that blood flow can be cut off, gangrene can result & is considered a life-threatening injury.
Define "keratoplasty": Any surgical modification of the cornea.
List three (3) valid somatic nerves: Vagus Axillary Pudendal Found in CPT in the 64xx range
the difference, respectively, between autogenic and autologous is: None, they are synonymous. the terms mean the same thing.
An "ectopic pregnancy" is: An impregnated ovum anywhere outside the uterus cavity.
List three (3) valid "long-term" (current) use of drug codes: V58.65: steroids V58.66: aspirin V58.67: insulin
What is a "hospitalist": Specialists who work "rounds" in the hospital. They specialize in seeing patient's admitted to the hospital for treatment.
What are "admitting privileges" for a physician: The right granted to a doctor to admit patients to a particular hospital.
Which is not a part of the medical record: A fee ticket, which is a billing document and not part of the medical record. History of medications - surgical history - exam documentation are examples of medical record documentation.
What does a compliance plan "with teeth" mean: The plan must outline disciplinary guidelines and standards. The plan is not valid unless it specifically documents the firing of noncompliant physicians.
Credentialing is: The process of establishing the qualifications of licensed professions, assessing background & legitimacy. Objective evaluation of current licensure, training, competence, including granting privileges & allied health staff memberships.
What is not a component of the periodic coding documentation audit process: The RVU is a billing/payment concept and would not apply to documentation/coding audits.
The Red Flag Rule applies to: Protecting organizations & individuals from data breaches & identity theft. Also refers to coding or reporting anything that might trigger an audit.
What is the NPI and what did it replace The UPIN has been discontinued as of June 2007 & replaced with the National Provider Identifier(NPI).
Under ______, cases with similar characteristics are grouped together and reimbursed at the same rate: The Prospective Payment System - this is the concept of case-mix and DRG grouping.
What is an example of an orthotic device: A splint, brace, shoe insert, or cast are all examples. Wheelchairs, an artificial hand or a breast implant are examples of prosthetic devices.
The prescription was foe Effexor and Abilify. The Psychiatrist had the initials, DO after his name: This is a Doctor of Osteopathy and is perfectly acceptable (the Osteopath must complete the necessary psychiatric training).
Surgical Op Reports are also known as: "Op Reports"
Under OPPS (Outpatient Prospective Payment System), E&M codes: Are grouped into three (3) APC (Ambulatory Payment Classification) Levels. Level 1 & 2 CPT are low-level APC; 3 is mid-level APC, and 4 & 5 are high-level APC.
Medicare Part-A health insurance companies are called: Fiscal Intermediaries
Which Central Venous Access Device code would be correct for the insertion of a PICC line, for a child less than five (5) years of age, non-tunneled w/o a pump or port: Use CPT code 36568. The PICC line is used because it provides central venous access over an extended period of time, eliminates physician participation in the procedure & reduces risk to patient.
The patient, a recent traveler from Hong Kong, presented with coughs, chills and high fever. The ER doctor wrote "SARS associated coronavirus: in the patient's chart. Code: 079.82 - SARS associated coronavirus. There is no reference to pneumonia. If the patient has SARS, it could be argued that coding exposure (V01.82) would be redundant.
Code for a partial excision of the segment 3 lobe of the liver from a living relative. This includes the preparation and maintenance of the graft. 47141 Donor hepatectomy (segments II, III and IV. This is an allograft, (a genetically non-identical person). Includes preparation & maintenance.
Code for an transanal approach for the excision of a partial thickness rectal tumor: CPT code 45171
Code for the destruction of hemorrhoids by cryosurgery: CPT: Use unlisted procedure code 46999.
Which code involves manipulation of the TMJ, therapeutic, requiring an anesthesia service: CPT code 21073
What is a pneumothorax? What are the two types, and how is it confirmed: Air within the pleural space. This air can cause partial or complete lung collapse. Open or closed. Diagnosis is confirmed by chest radiography.
What code would be reported for mild dysplasia of the cervix and what Bethesda System code would this relate to? ICD-9 622.11; CIN I. Caused by HPV & normally detected w/Pap smear. This disorder is abnormal growth of the epithelial tissue on the surface of the cervix. CIN I = Mild
Code for malignant hypertensive nephropathy with uremia. ICD-9 code: 403.01 Uremia is a condition resulting fro advanced stages of kidney failure in which urea & other nitrogen-containing wastes are found in the blood.
Code for a urethrolysis by retropubic approach: CPT code: 53899 - an unlisted code is the correct answer.
Code for the insertion of an implant outside the muscular cone, after evisceration of the ocular contents: CPT code: 67550
Code for head and neck carcinoma with metastases of the tonsils: ICD-9 code: 196.0
What is NOT part of the surgical package for all procedures: General Anesthesia
List three (3) valid auditory surgical procedure? ear piercing removal of a bean from a child's ear removal of ear wax
Is an external, middle and inner ear transplant an example of a valid auditory surgical procedure? NO
Code for a colonoscopy of the entire colon, from the rectum to the secum; plus the terminal ileum with biopsy: CPT code: 45380
The physician made three incisions int the necrotic dermis to lessen the constriction of the third degree circumferential burns of the patient's arm. Code for this: CPT codes: 16035; 16036x2
Code for Excision of dorsal ganglion cyst, left wrist: CPT code: 25111 - selected because the operative report does not indicate this as a recurrent cyst.
Code for Placement of P.A.S. Port, left arm: CPT code: 36571 - selected because the patient is over five years of age; it is a non-tunneled procedure with a PORT.
Code for a fracture of the right fibula due to osteogenesis imperfecta: ICD-9 codes: 733.16; 756.51. This is not a traumatic fracture but a pathologic fracture due to the osteogenesis imperfecta which is coded as the secondary term in this instance.
Dr. Avery performed a bilateral breast reconstruction, immediate, with subsequent tissue expansion (using a tissue expander). Code this procedure as: CPT code: 19357-50 Breast reconstruction is a unilateral procedure, therefore use the bilateral procedure modifier.
A patient presents to the clinic seeking AIDS testing since a former partner has been diagnosed with AIDS and the patient has been exposed. What diagnosis code should be reported: ICD-9 code: V01.7 - contact with or exposure to other viral disease.
Code for diverticular disease of the sigmoid colon and appendix with resolving diverticulitis of the sigmoid colon: ICD-9 codes: 543.9 - appendix; 564.9 - colon with diverticulitis.
Hospital Discharge Codes 99238 and 99239 apply to: Include only those E&M services performed by the discharging physician.
Code for Diabetic Osteomyelitis of shoulder (Type II), controlled: ICD-9: 250,80; 731.8 Look up diabetes in the Index to find osteomyelitis. 250.8 [731.8]
Autosomal deletion syndromes are associated with: Deletions of certain portions of a chromosome may result in very serious defects, such as mental retardation and multiple congenital anomalies.
The surgeon deftly entered through the middle fossa and removed a tumor from the temporal bone from the patient's left ear. 69970-LT
Locations, valid for Critical Care include: Coronary Care Units Intensive Care Units Respiratory Care Units
What code should be reported to Medicare when performing a consultation in 2010? Use the New Patient Codes.
When adding multiple repair sites: Add only same type, same anatomical site grouping (per CPT codes)
Code for the laparoscopic revision and removal of a prosthetic vaginal graft: CPT Code: 57426
Which Modifier would you consider the opposite of Modifier -22, Increased Procedural Service? Modifier -52, Reduced Service
A 55-year-old female underwent a total urethrectomy with cystostomy. Code: CPT Code: 53210
Level II HCPCS modifiers to identify fingers are: FA-F9
Created by: Laura Duncan