CCA Exam Review #10, Questions with accurate answers, 100% Accurate, Graded A+

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CCA Exam Review #10, Questions with accurate answers, 100% Accurate, Graded A+ A pt is seen in the ED for chest pain. After evaluation of the pt it is suspected the pt pt may have GERD The fina ... l dx was "chest pain vs GERD." The correct code is: K21.9 R10.11 R07.9 Z03.89 - ✔✔-R07.9 Which of the following represents documentation of the pt's current and past health status? pt consent physician orders physical exam medical history - ✔✔-medical history Common forms of fraud and abuse include all of the following except billing for services not furnished to pts refiling claims after denials unbundling or "exploding" charges upcoding - ✔✔-refiling claims after denials One form of ____ CAC may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation. Structured reports natural-language processing data exchange standards encoded vocabulary - ✔✔-natural-language processing Which is the defining characteristic of an integrated health record format? Integrated health records include both paper forms and computer printouts each section of the record is maintained by the pt care dept. that provided the care integrated health records are intended to be used in ambulatory settings integrated health record components are arranged in strict chronological order - ✔✔-integrated health record components are arranged in strict chronological order Messaging standards for EDI in healthcare have been developed by CMS The Joint Commission HL7 IEE - ✔✔-HL7 The ____ permits penalties to be awarded to those who intentionally submit fraudulent claims to the US govt. HIPAA Anti-kickback statue Balanced Budget Act of 1997 False Claims Act - ✔✔-False Claims Act "Code, if applicable, on causal condition first," note indicates that this code may be assigned as a first listed or principal dx when: the code appears in italicized font the causal condition is a symptom code the code for the condition is unrelated to the causal condition the causal condition is unknown or not applicable - ✔✔-the causal condition is unknown or not applicable The HIM dept. is planning to scan medical record documentation. The project includes the scanning of documentation such as H&Ps, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professional monitor the completeness of health records during a pt's hospitalization. post discharge retrospective concurrent Ad hoc - ✔✔-concurrent A notation for a diabetic pt in a progress note reads: "FBS 110 mg%, urine sugar, no acetone." Which part of a POMR progress note would this notation be written? Plan subjective assessment objective - ✔✔-objective An 80-yr-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The pt has more than 100,000 organisms of E. coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case? Code sepsis as the principal dx w/ UTI due to E. coli as secondary dx query the physician to determine if the pt has sepsis due to the symptomatology query the physician to determine if the pt has septic shock so that this may be used as the principal dx code UTI w/ sepsis as the principal dx - ✔✔-query the physician to determine if the pt has sepsis due to the symptomatology Dr. Jones entered a progress note in a pt's health record 24 hours after he visited the pt. Which quality element is missing from the progress note? data relevancy data precision data ompleteness data currency - ✔✔-data currency The Federal Rules of Civil Procedures (FRCP) incorporated the pre-trial process through the creation of e-discovery court orders depositions bench warrants - ✔✔-e-discovery Code: Right cerebral contusion with 15-minute loss of consciousness, initial encounter for care S06.371A S06.310A S06.311A T14.8 - ✔✔-S06.311A 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 _____ health information director privacy officer general counsel compliance officer - ✔✔-compliance officer A 7-yr-old pt was admitted to the ED for treatment of SOB. The pt is given epinephrine and nebulizer treatments. The SOB and wheezing are unabated following treatment. What dx should be suspected? Acute bronchitis chronic obstructive asthma asthma w/ status asthmaticus acute bronchitis w/ COPD - ✔✔-asthma w/ status asthmaticus Which character in CM dx code provides information regarding encounter of care? 4th 6th 7th 5th - ✔✔-7th The regulations for health care record content and documentation, guidelines and regulations for which facilities are allowed to take part in or join the Medicare and Medicaid programs is Joint Commission Rules Medical Staff Bylaws Conditions of Participation American College of Surgeon's Regulations - ✔✔-Conditions of Participation The ____ mandated the development of standards for EHRs. HIPAA of 1996 Balanced Budget Act of 1997 Medicare and Medicaid legislation of 1965 Prospective Payment Act of 1983 - ✔✔-HIPAA of 1996 Where would you find the following documentation: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." nursing note progress note social work note admission note - ✔✔-social work note Where would you find the following information: "PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuratio [Show More]

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