CCA Exam Prep from AHIMA

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is:

UHDDS

UACDS

MDS

ORYX

a

When the CCI editor flags that a comprehensive code and a component code are billed together for the same beneficiary on the same date of service, Medicare will pay for:

The component code but not the comprehensive code

The comprehensive but not the component code

The comprehensive and the component codes

Neither the comprehensive nor the component codes

b

When clean claims are submitted, they can be adjudicated in many ways through computer software automatically. Which statement is not one of the outcomes that can occur as part of auto-adjudication?

Auto-pay

Auto-suspend

Auto-calculate

Auto-deny

c

Which of the following is not a way that ICD-10-CM improves coding accuracy?

Reduces sequencing problems by combining conditions into one code

Provides laterality options

Captures more details for injuries, diabetes, and postoperative complications

Increases cross-referencing

d

Which of the following organizations is responsible for updating the procedure classification of ICD-10-PCS?

Centers for Disease Control (CDC)

Centers for Medicare and Medicaid Services (CMS)

National Center for Health Statistics (NCHS)

World Health Organization (WHO)

b

This program was initiated by the Balanced Budget Act of 1997 and allows states to expand existing insurance programs to cover children up to age 19.

Children's State Medicare Program (CSMP)

State Children's Health Insurance Program (SCHIP)

Children's State Healthcare Alliance (CSHA)

Children's Aid to Healthcare (CAH)

b

Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?

Notice of Privacy Practices

Authorization

Consent for treatment

Minimum necessary

a

The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for:

Part A Medicare claims

Part B Medicare claims

Medicaid claims

Medicare and Medicaid claims

b

The National Correct Coding Initiative was developed to control improper coding leading to inappropriate payment for:

Part A Medicare claims

Part B Medicare claims

Medicaid claims

Medicare and Medicaid claims

b

Which of the following software applications would be used to aid in the coding function in a physician's office?

Grouper

Encoder

Pricer

Diagnosis calculator

b

What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principal and secondary diagnoses?

35

25

18

9

b

CMS identified conditions that are not present on admission and could be "reasonably preventable." Hospitals are not allowed to receive additional payment for these conditions when the condition is present on admission. What are these conditions called?

Conditions of Participation

Present on admission

Hospital-acquired conditions

Hospital-acquired infection

c

Which of the following materials is not documented in an emergency care record?

Patient's instructions at discharge

Time and means of the patient's arrival

Patient's complete medical history

Emergency care administered before arrival at the facility

c

Using uniform terminology is a way to improve:

Validity

Data timeliness

Audit trails

Data reliability

d

When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure?

Assign the removal by snare technique code.

Assign the removal by hot biopsy forceps code.

Assign the ablation code.

Query the physician as to the method used.

d

Which of the following is not reimbursed according to the Medicare outpatient prospective payment system?

CMHC partial hospitalization services

Critical access hospitals

Hospital outpatient departments

Vaccines provided by CORFs

b

The technology commonly used for automated claims processing (sending bills directly to third-party payers) is:

Optical character recognition

Bar coding

Neural networks

Electronic data interchange

d

Timely and correct reimbursement is dependent on:

Adjudication

Clean claims

Remittance advice

Actual charge

b

27. Which answer is not required for assignment of the MS-DRG?

Diagnoses and procedures (principal and secondary)

Attending and consulting physicians

Presence of major or other complications and comorbidities (MCC or CC)

Discharge disposition or status

b

In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures performed during the same operative session, which of the following would apply?

Bundling of services

Outlier adjustment

Pass-through payment

Discounting of procedures

d

In the laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coder do with the remaining test codes that are not part of a panel?

Report the remaining tests using individual test codes, according to CPT.

Do not report the remaining individual test codes.

Report only those test codes that are part of a panel.

Do not report a test code more than once regardless whether the test was performed twice.

a

Which document directs an individual to bring originals or copies of records to court?

Summons

Subpoena

Subpoena duces tecum

Deposition

c

. Which of the following is not a function of the discharge summary?

Providing information about the patient's insurance coverage

Ensuring the continuity of future care

Providing information to support the activities of the medical staff review committee

Providing concise information that can be used to answer information requests

a

The HIM department is planning to scan medical record documentation. The project includes the scanning of documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization?

Ad hoc

Concurrent

Retrospective

Post discharge

b

The practice of assigning a diagnosis or procedure code specifically for the purpose of obtaining a higher level of payment is called:

Billing

Unbundling

Upcoding

Unnecessary service

c

. Exceptions to the consent requirement include:

Medical emergencies

Provider discretion

Implied consent

Informed consent

a

One objective of the Balanced Budget Act (BBA) of 1997 was to:

Improve program integrity for Medicare by educating beneficiaries to report errors noticed on their explanation of benefits (EOBs) to the Department of Health and Human Services (HHS)

Improve the quality of care to its beneficiaries by increasing availability to healthcare

Streamline healthcare costs into one type of payment system for Medicare and Medicaid

Educate hospital providers how to manage quality care with less reimbursement

a

Before healthcare organizations can provide services, they usually must obtain _____ by government entities such as the state in which they are located.

Accreditation

Certification

Licensure

Permission

c

The protection measures and tools for safeguarding information and information systems is a definition of:

Confidentiality

Data security

Informational privacy

Informational access control

b

Both HEDIS and the Joint Commission's ORYX programs are designed to collect data to be used for:

Performance-improvement programs

Billing and claims data processing

Developing hospital discharge abstracting systems

Developing individual care plans for residents

a

When a provider accepts assignment, this means the:

Patient authorizes payment to be made directly to the provider

Provider agrees to accept as payment in full the allowed charge from the fee schedule

Balance billing is allowed on patient accounts, but at a limited rate

Participating provider receives a fee-for-service reimbursement

b

Which of the following threatens the "need-to-know" principle?

Backdating progress notes

Blanket authorization

HIPAA regulations

Surgical consent

b

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?

Autonomy

Beneficence

Justice

Nonmaleficence

b

46. A patient is scheduled for a colonoscopy, but due to sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given a general anesthetic prior to the procedure. How should this procedure be coded by the hospital?

Assign the code for a colonoscopy with modifier -74.

Assign the code for a colonoscopy with modifier -52.

Assign an anesthesia code only.

Do not assign a code because no procedure was performed.

a

Identify where the following information would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93."

Medical laboratory report

Pathology report

Physical examination

Physician orders

a

The ________ mandated the development of standards for electronic medical records.

Medicare and Medicaid legislation of 1965

Prospective Payment Act of 1983

Health Insurance Portability and Accountability Act (HIPAA) of 1996

Balanced Budget Act of 1997

c

The ________ may contain information about diseases among relatives in which heredity may play a role.

Physical examination

History

Laboratory report

Administrative data

b

Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication?

Unit secretary working on the unit where the patient is located

Nurse working on the unit where the patient is located

Health information director

Admissions registrars

b

Medicare's newest claims processing payment contract entities are referred to as:

Recovery audit contractors (RACs)

Medicare administrative contractors (MACs)

Fiscal intermediaries (FIs)

Office of Inspector General contractors (OIGCs)

b

Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceeds the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage keycard of any physician in poor standing. To improve compliance, which of the following would be the next step to overcome noncompliance?

Discuss the problem with the hospital CEO.

Call the Joint Commission.

Contact other hospitals to see what methods they use to ensure compliance.

Drop the issue because noncompliance is always a problem.

c

. Several key principles require appropriate physician documentation to secure payment from the insurer. Which answer (listed here) fails to impact payment based on physician responsibility?

The health record should be complete and legible.

The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred.

Documenting the charges and services on the itemized bill.

The patient's progress and response to treatment and any revision in the treatment plan and diagnoses should be documented.

c

5. When coding benign neoplasm of the breast, the section noted here directs the coder to:

D24 Benign neoplasm of breast

Includes:

Benign neoplasm of connective tissue of breast

Benign neoplasm of soft parts of breast

Fibroadenoma of breast

Excludes 2:

Adenofibrosis of breast (N60.2)

Benign cyst of breast (N60.-)

Benign mammary dysplasia (N60.-)

Benign neoplasm of skin of breast (D22.5, D23.5)

Fibrocystic disease of breast (N60.-)

Use category D24 for fibroadenoma of breast

Use category D24 for malignant melanoma of the breast

Use category D24 for malignant neoplasm of the breast

Use category D24 for benign neoplasm of skin of breast

a

Which is a feature of managed care?

Control and reduce the costs of care

Monitor the activity of physician supervision

Provide incentive for prospective payment

Allow the patient to choose several primary physicians

a

A system that provides alerts and reminders to clinicians is a(n):

Clinical decision support system

Electronic data interchange

Point of care charting system

Knowledge database

a

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?

Audit controls

Information access controls

Facility access controls

Workstation security

b

. A hospital receives a valid request from a patient for copies of his or her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?

Yes; HIPAA only requires that current records be produced for the patient.

Yes; this is hospital policy over which HIPAA has no control.

No; the records from the previous hospital are considered part of the designated record set and should be given to the patient.

No; the records from the previous hospital are not included in the designated record set but should be released anyway.

c

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)

Advance notice of coverage (ANC)

Notice of payment (NOP)

Consent for payment (CFP)

a

The patient had a total abdominal hysterectomy with bilateral salpingo-oophorectomy. The coder assigned the following codes:

58150 Total abdominal hysterectomy, with/without removal of tubes and ovaries

58700 Salpingectomy, complete or partial, unilateral/bilateral (separate procedure)

What error has the coder made by using these codes?

Maximizing

Upcoding

Unbundling

Optimizing

c

. Notices of privacy practices must be available at the site where the individual is treated and:

Must be posted next to the entrance

Must be posted in a prominent place where it is reasonable to expect that patients will read them

May be posted anywhere at the site

Do not have to be posted at the site

b

What is the function of physician's orders?

Provide a chronological summary of the patient's illness and treatment

Document the patient's current and past health status

Document the physician's instructions to other parties involved in providing care to a patient

Document the provider's follow-up care instructions given to the patient or patient's caregiver

c

Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure?

Anesthesia report

Laboratory report

Operative report

Pathology report

d

Tissue transplanted from one individual to another of the same species, but different genotype is called a(n):

Autograft

Xenograft

Allograft or allogeneic graft

Heterograft

c

In what form of health information exchange are data centrally located but physically separated?

Consolidated

Consolidated federated

Centralized

Federated

b

Fee schedules are updated by third-party payers:

Annually

Monthly

Semiannually

Weekly

a

A Medicare Advantage Plan (like an HMO or PPO) is a health coverage option under what part of Medicare?

Part A

Part B

Part C

Part E

c

What process determines how a claim will be reimbursed based on the insurance benefit?

Transaction

Processing

Adjudication

Allowance

c

What part of Medicare covers physician services, outpatient care and home healthcare?

Part A

Part B

Part C

Part D

b

The MS-DRG system creates a hospital's case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of ________ within that MS-DRG.

Admissions

Discharges

CCs

MCCs

b

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called:

Natural-language processing systems

Monitoring/audit programs

Encoders

Concept, description, and relationship tables

c

Common forms of fraud and abuse include all of the following except:

Upcoding

Unbundling or "exploding" charges

Refiling claims after denials

Billing for services not furnished to patients

c

Where would information on treatment given on a particular encounter be found in the health record?

Problem list

Physician's orders

Progress notes

Physical examination

c

To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________ days.

10

20

30

60

c

What is the name of the organization that develops the billing form that hospitals are required to use?

American Academy of Billing Forms (AABF)

National Uniform Billing Committee (NUBC)

National Uniform Claims Committee (NUCC)

American Billing and Claims Academy (ABCA)

b

Each year the OIG develops a work plan that details areas of compliance it will be investigating for that year. What is the expectation of the hospital in relation to the OIG work plan?

Hospitals are required to follow the same work plan and deploy audits based on that work plan.

Hospitals should plan their compliance and auditing projects around the OIG work plan to ensure they are in compliance with the target areas in the plan.

Hospitals must not develop their audits based on the OIG work plan; rather, they must develop their own and look for high-risk areas that need improvement.

Hospitals must use the plan developed by their state hospital association that is specific to state laws and compliance activities.

b

Calling out patient names in a physician's office is:

An incidental disclosure

Not subject to the "minimum necessary" requirement

A disclosure for payment purposes

A HIPAA violation

a

The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." Where would this documentation be found?

Admission order

Clinical laboratory report

ECG report

Radiology report

c

Which of the following situations would be identified by the NCCI edits?

Determining the MS-DRG

Billing for two services that are prohibited from being billed on the same day

Whether data submitted electronically were successfully submitted

Receiving the remittance advice

b

An advantage of computer-assisted coding (CAC) is:

Increased coding productivity

Complexity, quality and format of health record documentation

Technological limitations

User resistance to change

a

A patient is admitted for chest pain with cardiac dysrhythmia to Hospital A. The patient is found to have an acute ST elevation (STEMI) inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. Coumadin therapy and monitoring for the atrial fibrillation continued at Hospital B. Using the codes listed here, what are the appropriate ICD-10-CM codes and sequencing for both hospitalizations?

I21.09 Myocardial infarction of anterior wall, initial

I21.19 Myocardial infarction of inferior wall, initial

I22.0 Myocardial infarction of anterolateral wall, subsequent

I22.1 Myocardial infarction of inferior wall, subsequent

I48.0 Paroxysmal atrial fibrillation

I48.2 Chronic atrial fibrillation

I48.91 Unspecified atrial fibrillation

R07.9 Chest pain, unspecified

021209W Aortocoronary bypass, Three Sites from Aorta with Autologous Venous Tissue, Open Approach

Hospital A: I48.91, R07.9, I21.19; Hospital B: I22.1, I48.91, 021209W

Hospital A: I21.09, I48.0; Hospital B: I22.0, I48.2, 021209W

Hospital A: I21.19, I48.91; Hospital B: I21.19, I48.91, 021209W

Hospital A: I21.19, I48.91; Hospital B: I22.1, I48.91, 021209W

c

A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the medical records in paper format. How should the hospital respond?

Provide the medical records in paper format

Burn another CD because this is hospital policy

Provide the patient with both paper and CD copies of the medical record

Review the CD copies with the patient on a hospital computer

a

The ________ is a type of coding that is a natural outgrowth of the EHR.

Automated codebook

Computer-assisted coding

Logic-based encoder

Decision support database

b

Data definition refers to:

Meaning of data

Completeness of data

Consistency of data

Detail of data

a

The CIA of security includes confidentiality, data integrity, and data ________.

Accessibility

Authentication

Accuracy

Availability

d

Written or spoken permission to proceed with care is classified as:

An advanced directive

Formal consent

Expressed consent

Implied consent

c

Who is responsible for ensuring the quality of health record documentation?

Board of directors

Administrator

Provider

Health information management professional

c

The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record?

Data completeness

Data consistency

Data accessibility

Data comprehensiveness

b

HIT professionals must have knowledge of:

Security issues with regard to the management of healthcare reform

Laws affecting the physician malpractice insurance

AMA's professional ethical principles of practice regarding physician assistants

Laws affecting the use of disclosure of health information

d

Documentation in the history of use of drugs, alcohol, and tobacco is considered as part of the:

Past medical history

Social history

Systems review

History of present illness

b

Which character in an ICD-10-CM diagnosis code provides information regarding encounter of care?

Fourth

Fifth

Sixth

Seventh

d

This document includes a microscopic description of tissue excised during surgery:

Recovery room record

Pathology report

Operative report

Discharge summary

b

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

Deductible only

Coinsurance only

Balance of charges

a

To help clarify terms that currently have overlapping meaning, ICD-10-PCS has defined root operations. What is an example of the root operation of Excision?

Partial nephrectomy

Total nephrectomy

Total lobectomy

Total mastectomy

a

Patient data collection requirements vary according to healthcare setting. One would expect which of the following data elements would be collected in the MDS, but would not be collected in the UHDDS?

Personal identification

Cognitive patterns

Procedures and dates

Principal diagnosis

b

Which part of the problem-oriented medical record is used by many facilities that have not adopted the whole problem-oriented format?

Problem list as an index

Initial plan

SOAP form of progress notes

Database

c

Which of the following contains the physician's findings based on an examination of the patient?

Physical examination

Discharge summary

Medical history

Patient instructions

a

Which of the following is not an accepted accrediting body for behavioral healthcare organizations?

American Psychological Association

Joint Commission

Commission on Accreditation of Rehabilitation Facilities

National Committee for Quality Assurance

a

Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. This is called:

Autoauthentication

Electronic signature

Automatic record completion

Chart tracking

a

What reimbursement system uses the Medicare fee schedule?

APCs

MS-DRGs

RBRVS

RUG-III

c

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." Which part of a POMR progress note would this notation be written?

Subjective

Objective

Assessment

Plan

c

This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services:

General Counsel

Health Information Director

Privacy Officer

Compliance Officer

d

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 $10,000 only

A fine of not more than $10,000, not more than one year in jail, or both

A fine of not more than $5,000 only

A fine of not more than $250,000, not more than 10 years in jail, or both

d

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as ________ systems.

MIS

CDS

ADT

ABC

c

Which statement FAILS to be true for Medicare coverage?

Medicare pays for healthcare services provided to Social Security beneficiaries 65 years old and older

Medicare pays for healthcare services provided to Social Security beneficiaries for new moms 65 years and younger and their newborn babies

Medicare pays for healthcare services provided to Social Security beneficiaries for people under 65 years old with certain disabilities

Medicare pays for healthcare services provided to Social Security beneficiaries for people of all ages with end-stage renal disease

b

. A 7-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected?

Acute bronchitis

Acute bronchitis with chronic obstructive pulmonary disease

Asthma with status asthmaticus

Chronic obstructive asthma

c

The right of an individual to keep information about himself or herself from being disclosed to anyone is a definition of:

Confidentiality

Privacy

Integrity

Security

b

The OIG believes that compliance programs have benefits in addition to submitting accurate claims. This includes all of the following except:

Demonstration of the organization's commitment to responsible conduct toward employees and the community

Provision of a more accurate view of behavior relating to fraud and abuse

Increased potential for criminal and unethical conduct

Improvements in the quality of patient care

c

Which of the following fails to meet the CMS classification of a hospital-acquired condition?

Foreign object retained after surgery

Air embolism

Gram-negative pneumonia

Blood incompatibility

c

Data security refers to:

Guaranteeing privacy

Controlling access

Using uniform terminology

Transparency

b

MS diagnostic-related groups are organized into:

Case-mix classifications

Geographic practice cost indices

Major diagnostic categories

Resource-based relative values

c

An encoder that takes a coder through a series of questions and choices is called a(n):

Automated codebook

Automated code assignment

Logic-based encoder

Decision support database

c