CCA Exam Questions with accurate answers, 100% Accurate, rated A+

CCA Exam Questions with accurate answers, 100% Accurate, rated A+ An encounter that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) - ✔✔- ...

CCA Exam Questions with accurate answers, 100% Accurate, rated A+ An encounter that prompts the coder to answer a series of questions and choices based on the documentation in the medical record is called a(n) - ✔✔-logic-based encoder The best resource for checking out specific voluntary accreditation standards and guidelines for a rehabilitation facility is the - ✔✔-CARF Manual You have been asked to give an example of a clinical information system. Which one of the following would you cite? A. Financial information system B. Admission-discharge-transfer system C. Billing system D. Laboratory information system - ✔✔-D. Laboratory information system You have been appointed as chair of the Health Record Committee at a new hospital. Your committee has been asked to recommend time-limited documentation standards for inclusion in the medical staff bylaws, rules, and regulations. The committee documentation standards must meet he standards of both the Joint Commission and the Medicare Conditions of Participation. The standards for the history and physical exam documentation are discussed first. You advise them that the time period for completion of this report should be set at - ✔✔-24 hours after admission or prior to surgery Health care claims transactions use one of three electronic formats, including which one of those listed below? A. ANSI ASC X12N 837 format B. National Claim Format C. Medicare Summary Notice format D. CMS-1500 flat-file format - ✔✔-A. ANSI ASC X12N 837 format You need to retrieve information on a particular physician in your facility. Specifically, you need to know how many cases he saw during the month of May. What would be your best source of information? - ✔✔-physician index A clinical documentation specialist performs many roles. These include reviewing the data and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) - ✔✔-analyst Which data bank would hospitals, health care providers, and other health care facilities report medical malpractice payments and adverse actions related to fraud and abuse by a licensed health care provider? - ✔✔-HIPDB-Healthcare Integrity and Protections Data Bank In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment date elements are collected on each SNF resident as defined in the - ✔✔-MDS-Minimum Data Set Which one of the following is NOT a technical security control employed by electronic health record systems? A. user-based access controls B. automatic log off C. audit trails D. data encryption protocols - ✔✔-B. Automatic log off Which of the following systems facilitates capturing standardized data with the electronic documentation of patient at the point of care? A. Continuity of Care Document (CCD) B. Clinical Documentation Architecture (CDA) C. Continuity of Care Record (CCR) D. Clinical Care Classification (CCC) - ✔✔-D. Clinical Care Classification (CCC) It is recommended that all but which of the following information should be permanently retained in some format, even when the remainder of the health record is destroyed? A. Nursing notes B. Discharge summaries. C. Physician names D. Dates of admission, discharge ,and encounters - ✔✔-D. Dates of admission, discharge, and encounters Which of the following indices might be protected from unauthorized access through the use of unique identifier codes assigned to members of the medical staff? A. Master Patient Index B. Disease Index C. Procedure Index D. Physician Index - ✔✔-D. Physician Index In the computerization of forms, good screen-view design, along with the options of alerts and alarms, makes it easier to ensure that all essential data items have been captured. One essential item to be captured on the physical exam is the - ✔✔-General appearance as assessed by the physician The purpose of the Correct Coding Initiative is to - ✔✔-Detect and prevent payment for improperly coded services In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to - ✔✔-Reliability When you and your team have identified a problem and must determine the cause or causes of that situation, completing a(n) _______________ can help. - ✔✔-Fishbone Diagram When managers work to keep staff members feeling appreciated and valued for their contributions to the job and the organization, this is known as - ✔✔-Staff satisfaction Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the - ✔✔-National Practitioner Data Bank The Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that include data on inpatients whose care is paid for by third-party payers. HCUP is an initiative of the - ✔✔-Agency for Healthcare research and Quality You have recently been hired as the medical staff coordinator at your local hospital. Which database/registry will you utilize most often? - ✔✔-National Practitioner Data Bank (NPDB) The 2014 AHIMA Foundation's "Clinical Documentation Improvement Job Description Summative Report" identified that most clinical documentation improvement specialists report directly to the - ✔✔- HIM Department An organization that reviews the facility's provision of health care services, respond to Medicare beneficiary complaints that have been filed, and take action by implementing quality of care improvements is known as a(n) - ✔✔-Quality Improvement Organization (QIO) Sally wants to motivate her staff members to earn and submit their required continuing education credits by the deadline, so she is offering a $25 gift card to the first one to complete their requirements. Sally is using _____________ motivation techniques. - ✔✔-extrinsic extrinsic motivators are those that offer a reward or an acknowledgement from an outside source CMS published a final rule indicating a compliance date to implement ICD-10-CM and ICD-10-PCS. The use of these two code sets was effective on - ✔✔-October 1, 2015 Resources that produce little-to-no value to the organization, such as non-utilized talent, inventory miscalculations, and staff members waiting for information so they can do their jobs, is known as ____________, which must be reduced, if not eliminated, in a lean managed organization. - ✔✔-waste As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult the - ✔✔-hospital bylaws, rules, and regulations Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of - ✔✔-qualitative review This law prohibits a physician from referring Medicare patients to clinical laboratory services where the doctor or a member of their family has a financial interest. - ✔✔-the Stark I Law All of these are quality improvement strategies EXCEPT A. Providing patient education B. Error-based penalties C. Performance-based bonuses D. Computer-based reminder alerts - ✔✔-B. Error-based penalties Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient's health are examples of - ✔✔-outcome measures You need to analyze data on the types of care provided to Medicare patients in your geographic area by DRG. Which of the following would be most helpful? A. National Practitioner Data Bank B. Vital Statistics C. MEDPAR D. RxNorm - ✔✔-C. MEDPAR (Medicare Provider Analysis and Review) Under which condition can an original paper-based patient health record be physically removed from the hospital? - ✔✔-When the director of health records is acting in response to a subpoena duces tecum and takes the health record to court You are the office manager at a large group practice. One of the physicians at your practice has asked you to research and supply her with information about the legislation signed into law in 2015 which required the removal of social security numbers from all Medicare cards. You provide this inquisitive physician with a fact sheet concerning this legislation - ✔✔-Medicare Access and CHIP Reauthorization Act (MACRA) In compiling statistics to report the specific cause of death for all open-heart surgery cases, the quality coordinator assists in documenting - ✔✔-patient care outcomes In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the - ✔✔-Federal Register The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate - ✔✔-The overall quality of documentation in the record Setting up a drop down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data - ✔✔-precision As a working HIM professional, you are investigating the workforce development projections of electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of this governmental agency. - ✔✔-ONC (Office of the National Coordinator) A final progress note is appropriate as a discharge summary for a hospitalization in which the patient - ✔✔-was an obstetric admission with a normal delivery and no complications