AHIMA CCA: Exam 2 with Answers (100% Correct) 2022

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AHIMA CCA: Exam 2 with Answers (100% Correct) 2022 1. Data security policies and procedures should be reviewed at least: a. Semi-annually b. Annually c. Every two years d. Quarterly - ✔✔Cor ... rect Answer: B All data security policies and procedures should be reviewed and evaluated at least every year to make sure they are up-to-date and still relevant to the organization (Johns 2011, 995). 2. Identify the correct ICD-9-CM diagnosis code(s) for a patient with near-syncope event and nausea. a. 780.2 b. 780.2, 787.02 c. 780.2, 787.01 d. 780.4, 787.02 - ✔✔Correct Answer: BNear-syncope and nausea are both signs and symptoms and therefore not integral to the other. Both conditions should be coded (Hazelwood and Venable 2012, 71). 3. The codes in the musculoskeletal section of CPT may be used by: a. Orthopedic surgeons only b. Orthopedic surgeons and emergency department physicians c. Any physician d. Orthopedic surgeons and neurosurgeons - ✔✔Correct Answer: C Any physician may use the codes in any section of CPT (AHIMA 2012a, 587). 4. In an EHR, what is the risk of copying and pasting? a. Reduction in the time required to document b. The system not recording who entered the data c. Quicker overall system response time d. System thinking that the original documenter recorded the note - ✔✔Correct Answer: B The system not recording who entered the data (Johns 2011, 433).5. Mr. Smith is seen in his primary care physician's office for his annual physical examination. He has a digital rectal examination and is given three small cards to take home and return with fecal samples to screen for colorectal cancer. Assign the appropriate CPT code to report this occult blood sampling. a. 82270 b. 82271 c. 82272 d. 82274 - ✔✔Correct Answer: A CPT code 82270 describes a test for occult blood using feces source for the purpose of neoplasm screening with the use of three cards or single triple card for consecutive collection (AMA 2012b, 417). 6. Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of a diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM use them. a. Parentheses ( ) b. Square brackets [ ] c. Slanted brackets [ ] d. Braces { } - ✔✔Correct Answer: AParentheses enclose supplementary words or explanatory information that may or may not be present in the statement of a diagnosis or procedure. They do not affect the code number assigned in the case. Terms in parentheses are considered nonessential modifiers, and all three volumes of ICD-9-CM use them. Bronchiectasis (fusiform) (postinfectious) (recurrent) is an example of a diagnosis statement with nonessential modifiers noted with parentheses (Schraffenberger 2012, 26-28). 7. Documentation regarding a patient's marital status; dietary, sleep, and exercise patterns; and use of coffee, tobacco, alcohol, and other drugs may be found in the: a. Physical examination record b. History record c. Operative report d. Radiological report - ✔✔Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists his or her past medical, personal, and family history (Johns 2011, 63). 8. 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. A "with manipulation" code b. A "without manipulation" code c. An unlisted procedure coded. An E/M code only - ✔✔Correct Answer: A The "with manipulation" code is used because the fracture was manipulated, even if the manipulation did not result in clinical anatomic alignment. See Musculoskeletal Guidelines, Definitions (AHIMA 2012a, 597). 9. 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? a. 35 b. 25 c. 18 d. 9 - ✔✔Correct Answer: B As of January 1, 2011, CMS allows a total of 25 ICD-9-CM diagnosis codes (one principal and 24 additional diagnoses) for 837 Institutional claims filing (Schraffenberger 2012, 66). 10. What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? a. Vocabulary standard b. Identifier standard c. Structure and content standardd. Security standard - ✔✔Correct Answer: B Identifier standards establish methods for assigning a unique identifier to individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers (Odom-Wesley et al. 2009, 311). 11. Identify the correct ICD-9-CM diagnosis code for a patient with anterolateral wall myocardial infarction, initial episode. a. 410.11 b. 410.01 c. 410.02 d. 410.12 - ✔✔Correct Answer: B Index Infarction, myocardium, anterolateral (wall) with fifth digit for initial episode (Schraffenberger 2012, 26-28). 12. A patient has two health insurance policies: Medicare and a Medicare supplement. Which of the following statements is true? a. The patient receives any monies paid by the insurance companies over and above the charges. b. Monies paid to the healthcare provider cannot exceed charges.c. The decision on which company is primary is based on remittance advice. d. The patient should not have a Medicare supplement. - ✔✔Correct Answer: B The monies collected from third-party payers cannot be greater than the amount of the provider's charges (Johns 2011, 343). 13. Identify the ICD-9-CM diagnosis code(s) for uncontrolled type II diabetes mellitus; mild malnutrition. a. 250.02 b. 250.01, 263.1 c. 250.02, 263.1 d. 250.01, 263.0 - ✔✔Correct Answer: C Diabetes (without complication) with fifth digit of 2 = type II, uncontrolled. 263.1 Malnutrition, mild, not stated as related to diabetes (Schraffenberger 2012, 122-124). 14. Identify the correct sequence and ICD-9-CM diagnosis code(s) for a patient with a scar on the right hand secondary to a laceration sustained two years ago. a. 709.2 b. 906.1 c. 709.2, 906.1d. 906.1, 709.2 - ✔✔Correct Answer: C The residual condition or nature of the late effect is sequenced first, followed by the cause of the late effect (Hazelwood and Venable 2012, 60-61). 15. Which of the following is the concept responsible for limiting disclosure of private matters including the responsibility to use, disclose, or release such information only with the knowledge and consent of the individual? a. Privacy b. Bioethics c. Security d. Confidentiality - ✔✔Correct Answer: D Confidentiality is the responsibility for limiting disclosure (Johns 2011, 755). 16. Tissue transplanted from one individual to another of the same species but different genotype is called a(n): a. Autograft b. Xenograft c. Allograft or allogeneic graftd. Heterograft - ✔✔Correct Answer: C Tissue transplanted from one individual to another of the same species but different genotype is called an allograft or allogeneic graft (AHIMA 2012a, 592-593). 17. Where would a coder who needed to locate the histology of a tissue sample most likely find this information? a. Pathology report b. Progress notes c. Nurse's notes d. Operative report - ✔✔Correct Answer: A Histology refers to the tissue type of a lesion. The histology of tissue is determined by a pathologist and documented in the pathology report (Johns 2011, 77). 18. A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Postoperative infection b. Appendicitisc. COPD d. Hypertension - ✔✔**Correct Answer: A Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2011c, 97). 19. A hospital needs to know how much Medicare paid on a claim so they can bill the secondary insurance. What should the hospital refer to? a. Explanation of benefits b. Medicare Summary Notice c. Remittance advice d. Coordination of benefits - ✔✔Correct Answer: C Remittance advice (RA) is sent to the provider to explain payments made by third-party payers (Johns 2011, 346). 20. Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)? a. Make admission date a required field b. Provide an input mask for entering data in the fieldc. Make admission date a numeric field d. Provide sufficient space for input of data - ✔✔Correct Answer: B When several people enter data in an EHR, you can define how users must enter data in specific fields to help maintain consistency. For example, an input mask for a form means that users can only enter the date in a specified format (MacDonald 2007, chapter 4). 21. Which of the following threatens the "need-to-know" principle? a. Backdating progress notes b. Blanket authorization c. HIPAA regulations d. Surgical consent - ✔✔Correct Answer: B A blanket authorization is a common ethical problem when misused. Patients often sign a blanket authorization, which authorizes the release of information from that point forward, without understanding the implications. The problem is the patient is not aware of what information is being accessed (Johns 2011, 778-779). 22. A fee schedule is: a. Developed by third-party payers and includes a list of healthcare services, procedures, and charges associated with eachb. Developed by providers and includes a list of healthcare services provided to a patient c. Developed by third-party payers and includes a list of healthcare services provided to a patient d. Developed by providers and lists charge codes - ✔✔Correct Answer: A A fee schedule is a list of healthcare services and procedures and charges associated with each (Johns 2011, 350). 23. Identify the correct ICD-9-CM diagnosis code for a male patient with stress urinary incontinence. a. 625.6 b. 788.30 c. 788.32 d. 788.39 - ✔✔Correct Answer: C Index Incontinence, stress, male, NEC 788.32. Category 788.3x indicates incontinence of urine with the fifth digit specific to different types such as urge, stress, mixed, and others (Hazelwood and Venable 2012, 73). 24. Identify the correct ICD-9-CM diagnosis codes and sequence for a patient who was admitted to the outpatient chemotherapy floor for acute lymphocytic leukemia. During the procedure, the patient developed severe nausea with vomiting and was treated with medications. a. 204.00, 787.01, V58.11b. V58.11, 204.00, 787.01 c. V58.11, 204.00 d. 204.22, 787.01 - ✔✔Correct Answer: B When a patient is admitted for the purpose of radiotherapy, chemotherapy, or immunotherapy and develops a complication, such as uncontrolled nausea and vomiting or dehydration, the principal diagnosis is the admission for radiotherapy (V58.0), the admission for the antineoplastic chemotherapy (V58.11), or the admission for the antineoplastic immunotherapy (V58.12). Additional codes would include the cancer and the complication(s) (Hazelwood and Venable 2012, 103). 25. Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? a. Patient management b. New technology c. Therapeutic, preventative, or other interventions d. Patient safety - ✔✔Correct Answer: B New technology is addressed by the Category III codes (AHIMA 2012a, 584). 26. The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that, in addition, all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and hospital clocks may not becoordinated. Another committee member agrees and says only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest? a. Suggest that only hospital clock time be noted in clinical documentation b. Suggest that only electronic documentation have time noted c. Inform the committee that according to the Medicare Conditions of Participation, all documentation must be authenticated and dated d. Inform the committee that according to the Medicare Conditions of Participation, only medication orders must include date and time - ✔✔Correct Answer: C All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished (42 CFR 482.24). 27. How are amendments handled in an EHR? a. Automatically appended to the original note; no additional signature is required. b. Amendments must be entered by the same person as the original note. c. Amendments cannot be entered after 24 hours of the event's occurrence. d. The amendment must have a separate signature, date, and time. - ✔✔Correct Answer: D The addendum must have a separate signature, date, and time from the original entry (Johns 2011, 437).28. 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. A fine of not more than $10,000 only b. A fine of not more than $10,000, not more than 1 year in jail, or both c. A fine of not more than $5,000 only d. A fine of not more than $250,000, not more than 10 years in jail, or both - ✔✔Correct Answer: D When a person or entity willfully and knowingly violates the HIPAA Privacy Rule, a fine of not more than $250,000, not more than 10 years in jail, or both may be imposed (LaTour and Eichenwald Maki 2010, 292). 29. Which of the following reports includes names of the surgeon and assistants, date, duration and description of the procedure, and any specimens removed? a. Operative report b. Anesthesia report c. Pathology report d. Laboratory report - ✔✔Correct Answer: A An operative report describes the surgical procedures performed on the patient (Johns 2011, 73).30. A provision of the law that established the resource-based relative value scale (RBRVS) stipulates that refinements to relative value units (RVUs) must maintain: a. Moderate rate increases b. Market basket increases c. Budget neutrality d. Sustainable growth rate - ✔✔Correct Answer: C Budget neutrality must be maintained annually when the RVUs are adjusted (Casto and Layman 2011, 156). 31. CPT was developed and is maintained by: a. CMS b. AMA c. Cooperating parties d. WHO - ✔✔Correct Answer: B The AMA developed and maintains CPT. CMS developed and maintains HCPCS Level II codes (AHIMA 2012a, 586).32. Identify the correct ICD-9-CM diagnosis code for a patient with an elevated prostate specific antigen (PSA) test result. a. 796.4 b. 790.6 c. 792.9 d. 790.93 - ✔✔Correct Answer: D Review Tabular List: Findings, abnormal, without diagnosis, prostate specific antigen (PSA), 790.93, or Elevation, prostate specific antigen (PSA), 790.93 (Hazelwood and Venable 2012, 69). 33. Identify the correct ICD-9-CM diagnosis code(s) and proper sequencing for urinary tract infection due to E. coli. a. 599.0 b. 599.0, 041.49 c. 041.49 d. 041.49, 599.0 - ✔✔Correct Answer: B Connecting words or connecting terms are subterms that indicate a relationship between the main term and an associated condition or etiology in the Alphabetic Index. The connecting term "due to" connects the organism E. coli to the urinary tract infection. The instructional note "Use additional code" is found in the Tabular List of ICD-9-CM. This notation indicates that use of an additional code mayprovide a more complete picture of the diagnosis or procedure. The additional code should always be assigned if the health record provides supportive documentation. Infection, urinary (tract) Tabular List— use additional code to identify organism. Infection, Escherichia coli (Schraffenberger 2012, 22-23, 79). 34. What is it called when a Medicare hospital inpatient admission results in exceptionally high costs when compared to other cases in the same DRG? a. Rate increase b. Charge outlier c. Cost outlier d. Day outlier - ✔✔Correct Answer: C To qualify for a cost outlier, a hospital's charges for a case (adjusted to cost) must exceed the payment rate for the MS-DRG by a specific threshold amount determined by CMS for each fiscal year (Johns 2011, 374). 35. Health insurance for spouses, children, or both is known as: a. Dependent (family) coverage [Show More]

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