CCA PRACTICE
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| a significant procedure may not | be coded in addition to the principal diagnosis
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| a diagnosis cannot be coded if | there is no documentation in the report
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| when codes are listed in brackets in the alphabetical index it indicates that | both codes must be listed in the specified order
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| review of systems would be located in which medical report | history and physical
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| CMS means | Center for Medicare and Medicaid Services
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| DMEPOS is | Durable Medical Equipment Prosthetics Orthotics and Supplies
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| abuse is | downcoding
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| an EOB |
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| presence of possible lung cancer as evidenced by presence of masses | radiology
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| family history is a standard element in what type of medical report | history and physical exam
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| IPA is |
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| JCAHO is | Joint Commission on Accreditation of Hospital Organizations
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| manipulation |
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| medigap | insurance coverage to cover the costs of deductibles
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| UHDDS | Uniform Hospital Discharge Data Set
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| OPPS |
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| SOAP | Subjective, Objective, Assessment, Plan
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| staff model HMO is | a group of physicians who are employees of an organization that provide health care
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| PID | caused by gonorrhea and chlamydial infection
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| synapse | the space between two neurons
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| sympathetic nerves | are autonomic
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| appendicular skeleton | includes the arms
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| accommodation is | ophthalmic adjustment
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| TURP | is Transurethral Resection of Prostate
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| which of the following is not a part of the heart | carotid
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| pleural effusion is | often characterized by empyema
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| grading of neoplasm is | useful in determining prognosis for patient
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| tomography is | series of pictures
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| arthrocentesis is | a surgical puncture of a joint remove fluid
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| postural problems do not include | spondylosis
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| part of the small intestine do not include | cecum
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| planes of the body do not include | caudal
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| which of the following is not an endocrine gland | spleen
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| cellulitis is characterized by | inflammation of the skin
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| gouty arthritis | caused by a buildup of uric acid
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| ovarian cysts do not include | neuroblastoma
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| rhabdomyoma is coded as | either a benign or malignant neoplasm of the connective tissue
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| fluorescein angiography is not used to detect | retinal detachment
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| what type of error is in the following billing scenario | upcoding
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| clinical pathology consultation is not | reporting of results without interpretative judgement
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| vaginal delivery after a previous cesarean deliver is coded as | 59612
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| procedures associated with central venous access catheters do not include | implantation
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| fractures/dislocations are coded as | fractures
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| critical care visits are not based on | visit
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| which of the following is not a type of ectopic pregnancy | peroneal
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| when multiple procedures are performed | proper anesthesia code is the code for the most complex procedure
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| which of the following is not a type of salmonella | lymphadenitis
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| co-morbidities are not considered in selecting an E/M code | unless their presence significantly increases the complexity of the medical decision
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| in the ICD-10 book, destruction is not | shaving
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| the extension of the foot downward is | plantar flexion
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| what is the basic unit for an APC visit | outpatient visit
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| an authorization for release of information would not include | patient's previous hospitalization
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| guarantor | the person responsible for payment of services
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| an eponym is | a person's name
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| palliative means | relieving by not curing
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| in vitro means | experiments conducted outside of an organism
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| side effects of radiotherapy do not include | incontinence
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| medical necessity | provides linkage between CPT and ICD-10 codes
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| a CVA is not caused by | septicemia
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| what is a Fowler-Stephens procedure | orchiopexy
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| what is not a type of presenting problem for E/M codes | detailed
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| Which of the following is not an accepted accrediting body for behavioral healthcare organizations? | American Psychological Association
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| During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the lega | Alert hospital legal counsel of the practice
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| Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. | Operative report
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| In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. 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
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| Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. T | Parentheses ( )
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| What type of standard establishes uniform definitions for clinical terms? | Vocabulary standard
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| What was the goal of the new MS-DRG system? | To improve Medicare's capability to recognize severity of illness in its inpatient 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 i
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| Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________. | Autoauthentication
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| The coder notes that the physician has presribed Retrovir for the patient. The coder might find which of the following on the patient's discharge summary? | AIDS
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| In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems. | ADT
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| What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses? | 18
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| 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
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| Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. | Performance improvement programs
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| 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 al the diagnosis codes assigned to explain the reasons the services were provided
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| Which of the following is a core ethical obligation of health information staff? | Protecting patients' privacy and confidential communications
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| Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers? | Outcomes and Assessment Information Set (OAIS)
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| Who is responsible for writing and signing discharge summaries and discharge instructions? | Attending physician
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| Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? | Use of Mary's individually identifiable information related to her asthma treatments
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| When correcting erroneous information in a health record, which of the following is not appropriate? | Use black pen to obliterate the entry
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| Tissue transplated from one individual to another of the same species but different genotype is called a(n): | Allograft or allogeneic graft
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| Mohs micrographic surgery involves the surgeon acting as: | Both surgeon and pathologist
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| Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? | New technology
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| What are 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, for new technologies, and for cost outlier cases
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| CPT was developed and is maintained by: | AMA
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| What healthcare organization collects 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
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| What is abstracting? | Compiling the pertinent information from the medical record based on predetermined data sets
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| Per CPT guidelines, a separate procedure is: | Considered to be an integral part of another, larger procedure
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| Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: | Social history
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| What type of organization works under contract with the CMS to conduct Medicare and Medicaid certification surveys for hospitals? | State licensure agencies
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| What is the name of the national program to detect and correct improper payments in the Medicare Fee-for-Service (FFS) programs? | Recovery audit contractors (RACs)
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| Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________. | History record
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| The dis. sum. must be completed w/in ________ after discharge for most pts but within __________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than __________ hours | 30 days / 24 hours / 48 hours
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| ICD-10-CM defines the "newborn period" as birth through the ___________ day following birth. | 28th
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| What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient? | Six
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| Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in | Appendix G
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| According to ICD-10-CM, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older: | 35
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| Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? | Psychotherapy notes
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| When coding a selective catheterization in CPT, how are codes assigned? | One code for the final vessel entered
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| Which of the following would not be found in a medical history? | Vital signs
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| Observation E/M codes (99218 through 99220) are used in physician billing when: | A patient is referred to a designated observation service.
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| The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form? | Pathology report
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| Which of the following activities would be in violation of AHIMA's Code of Ethics? | Coding an intentionally inappropriate level of service
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| What is the name of the organization that develops the billing form that hospitals are required to use? | National Uniform Billing Committee (NUBC)
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| Identify the correct ICD-10-CM diagnosis code(s) for a patient with pneumonia and persistent cough. | J44.9
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| The codes in the musculoskeletal section of CPT may be used by: | Any physician
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| What diagnosis would the coder expect to see when a patient with pneumonia (PNA) has inhaled food, liquid, or oil? | Aspiration pneumonia
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| Which of the following activities is considered an unethical practice? | Backdating progress notes
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| Which answer below is not correct for assignment of the MS-DRG? | Attending and consulting physicians
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| assignment of the MS-DRG? | Diagnoses and procedures (principal and secondary)
Presence of major or other complications and co morbidities (MCC or CC)
Discharge disposition or status
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| Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? | Consent for operative procedure, history, physical examination
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| Where would a coder who needed to locate the histology of a tissue sample most likely find this information | Pathology report
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| What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? | Identifier standard
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| Which organization developed the first hospital standardization program? | American College of Surgeons
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| 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
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| 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? | Data warehouse
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| What is the basic formula for calculating each MS-DRG hospital payments? | Hospital payment = DRG relative weight x hospital base rate
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| Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1). They will also be sending her records to her physician for continuity of care (2). Under HIPAA, these two functions are: | Use (1) and disclosure (2)
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| 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: | Selective catheterization
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| 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? | Beneficence
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