CCA Mock Exam

CCA Mock Exam A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. - ✔✔45385, 99156, 99157 A c ...

CCA Mock Exam A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. - ✔✔45385, 99156, 99157 A code of 45385 should be used for the colonoscopy procedure with the removal of polpys. No additional codes needed for the colonscopy since it included the colonoscopy and removal of polyps. The moderate sedation also needs to be coded. A code of 99156 should be used to code the moderate sedation services provided by a physician for the intial 15 minutes of intraservice time. An additional code of 99157 should be coded for the additional 15 minutes of intraservice time for the moderate sedation since the patient was sedated for a total of 30 minutes. No additional codes needed. The diagnosis is as follows: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast." Given this which are the primary cancer site(s)? - ✔✔breast Patient has a year history of mitral valve regurgitation and now presents for a mitral valve replacement with bypass. (Code for physician using CPT procedure codes only.) 33425 Valvuloplasty, mitral valve, with cardiopulmonary bypass 33430 Replacement, mitral valve, with cardiopulmonary bypass 33460 Valvectomy, tricuspid valve, with cardiopulmonary bypass 35231 Repair blood vessel with vein graft; neck - ✔✔33430 You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to - ✔✔improve your department's processes Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with - ✔✔feedback on specific instances when improved documentation would improve coding Which of the following procedures can be identified as "destruction" of lesions? - ✔✔laser removal of condylomata The practice of using a code that results in a higher payment to the provider than the code that more accurately reflects the service provided is known as - ✔✔upcoding A ________ is a collection of information or data that is organized in such a way that its contents can be queried and relationships created. - ✔✔database The use of radioactive sources placed into a tumor-bearing area to generate high-intensity radiation is termed - ✔✔brachytherapy Which of the following procedures would NOT be coded to "resection" when using ICD-10- PCS? - ✔✔partial resection of upper left lobe During her hospitalization for her third delivery, Janet had a sterilization procedure performed. When the record is coded, the code for sterilization, Z30.2, is - ✔✔used and sequenced as a secondary diagnosis Some ICD-10-CM codes are exempt from POA reporting because they - ✔✔are always present on admission and represent circumstances regarding the health care encounter or factors influencing health status that do not represent a current disease or injury CMS delegates its daily operations of the Medicare and Medicaid programs to - ✔✔Medicare administrative contractor (MAC) Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? - ✔✔principal diagnosis As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the - ✔✔doctor's admitting progress note The _______________ are the organizations that contract with Medicare to perform reviews of medical records with the corresponding Medicare claims to detect and correct improper payments. - ✔✔recovery audit contractors (RACs) Which of the following could influence a facility's case mix? - ✔✔all answers apply (accuracy of coding, changes in DRG weights, changes in the services offered by a facility) The Joint Commission requires that all medical records be completed within ___________ following patient discharge. - ✔✔30 days If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level - ✔✔they should both be coded, acute sequenced first What legal term is used in describing sexual harassment in reference to unwelcome sexual advances, request for sexual favors, and verbal or physical conduct of a sexual nature made in return for job benefits? - ✔✔quid pro quo Staging - ✔✔is a system for documenting the extent or spread of cancer Which of these conditions are always considered "present on admission" (POA)? - ✔✔congenital conditions Robert Thompson was seen in the outpatient department with a chronic cough and the record states "rule out lung cancer." What should be coded as the patient's diagnosis? - ✔✔chronic cough Case-mix index - ✔✔relative weight x number of patients for each row sum of all rows total relative weight sums / total number of patients When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only - ✔✔the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) - ✔✔advance beneficiary notice 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 When coding multiple wound repairs in CPT - ✔✔all wound repairs are grouped and coded with the most complex reported first You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the - ✔✔postpartum record Which of the following statements is true? - ✔✔A surgical operation may include one or more surgical procedures. A patient has a total abdominal hysterectomy with bilateral salpingectomy. The coder selected the following codes: 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s) with or without removal of ovary(s) 58700 Salpingectomy, complete or partial unilateral or bilateral (separate procedure) This type of coding is referred to as - ✔✔unbundling Which of the following contains a list of coding edits developed by CMS in an effort to promote correct coding nationwide and to prevent the inappropriate unbundling of related services? - ✔✔National Correct Coding Initiative (NCCI) Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data - ✔✔integrity Which of the following diagnoses or procedures would prevent the normal delivery code O80 Normal Delivery, from being assigned? - ✔✔low forceps Present on Admission (POA) indicators apply to - ✔✔inpatient reporting of diagnosis codes You have been hired to work with a computer-assisted coding initiative. The technology that you will be working with is - ✔✔natural language processing Which of the following is classified as a poisoning in ICD-10-CM? - ✔✔syncope due to Contac pills and a three-martini lunch Which of the following are considered sequela regardless of time? - ✔✔nonunion Which of the following would NOT require HCPCS/CPT codes? - ✔✔hospital inpatient procedure Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called - ✔✔firewalls Which of the following is vital for determining why the reimbursement from an insurance company is less than that was expected? - ✔✔the remittance advice The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis. This is called - ✔✔hard coding Which of the following is NOT related to diagnosing hypothyroidism? - ✔✔a decrease in serum cholesterol and prolactin The _______ has the duty to adjust the MS-DRGs if necessary at the beginning of every fiscal year beginning _____________. - ✔✔CMS, October 1 The APC payment system is based on what coding system(s)? - ✔✔CPT/HCPCS codes Which of the following scenarios identifies a pathologic fracture? - ✔✔compression fracture of the vertebrae as a result of bone metastasis All of the following signs/symptoms suggest gram-negative pneumonia EXCEPT - ✔✔decreased leukocyte count A patient is admitted through the emergency department with diabetes mellitus. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? - ✔✔"N" The special form that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities is the - ✔✔interdisciplinary patient care plan Employing the SOAP style of progress notes, choose the "assessment" statement from the following: - ✔✔sciatica unimproved with hot pack therapy S—subjective, records what the patient states is the problem O—objective, records what the practitioner identifies through the history, physical examination, and diagnostic tests A—assessment, combines the subjective and objective into a conclusion P—plan, what approach is going to be taken to resolve the problem The purpose of the Correct Coding Initiative is to - ✔✔detect and prevent payment for improperly coded services Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called - ✔✔data encryption In reviewing a medical record for coding purposes, the coder notes that the discharge summary has not yet been transcribed. In its absence, the best place to look for the patient's response to treatment and documentation of any complications that may have developed during this episode of care is in the - ✔✔doctors' progress note section