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AHIMA Sample Exam 1
2010 Sample CCA Exam
| Question | Answer |
|---|---|
| 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
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