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A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator for the atrial fibrillation is
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In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a(n)
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CCA EXAM PREP
| Question | Answer |
|---|---|
| A patient undergoes outpatient surgery. During the recovery period, the patient develops atrial fibrillation and is subsequently admitted to the hospital as an inpatient. The present on admission (POA) indicator for the atrial fibrillation is | Y = present at the time of inpatient admission. |
| In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a(n) | chargemaster |
| Identify the correct root operation, used in ICD-10-PCS, for the following: Cystoscopy | inspection |
| Procedure-to-Procedure (PTP) Edits review claims for codes that report | procedures that cannot or should not be provided to the same patient on the same day. |
| It is September 15th, and you have just received the upcoming year’s ICD-10-PCS code set updates. The next step is to | put in a change ticket for the hospital’s chargemaster to be updated. |
| 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. |
| A physician has come to the HIM department because he wants a new smartphone to be able to access patient records. This way he can enter orders when he is outside of the hospital. You need to direct the IT department to | encrypt the phone so access is protected. |
| The APC payment system is based on what coding system(s)? | CPT/HCPCS codes |
| The Joint Commission requires that all medical records be completed within ___________ following patient discharge. | 30 days |
| You have been hired to work with a computer-assisted coding (CAC) initiative. The technology that you will be working with is | natural language processing |
| External audits may be conducted by several organizations in the federal government as well as the private sector, including | any of these |
| When writing a query to a physician regarding ambiguous details in the documentation, one must be careful to never let the question | imply an answer that will lead to a higher reimbursement rate. |
| If the National Coverage Determination indicates that Medicare will not pay for a specific procedure, you may have to have the patient sign | an Advance Beneficiary Notice (ABN) |
| All health care facilities are obligated by federal legislation to provide a safe and protected workplace for all staff and volunteers. This legislation is known as | OSHA. |
| Employing the SOAP style of progress notes, choose the "assessment" statement from the following: | sciatica unimproved with hot pack therapy. |
| A patient 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 |
| 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. |
| Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called | firewalls. |
| NCCI edits were developed by the Centers for Medicare and Medicare Services (CMS) to | both reinforce accurate coding and identify noncompliant coding 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. |
| NCCI stands for | National Correct Coding Initiative. |
| While CAC systems are convenient, the codes they determine must be validated to ensure accuracy. One method to do this would be | a prospective audit. |
| The outpatient method for reimbursement from CMS for Medicare is | Ambulatory Patient Classification (APC). |
| All of these are acceptable destruction methods when health records are no longer required, EXCEPT | deleting files from the server. |
| One excellent source to guide you to perform ethical coding is | AHIMA |
| 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) |
| f a claim is returned as denied or rejected due to an error, the best thing to do is | correct the claim and resubmit in accordance with the third-party payer. |
| 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 most efficient way to determine the accurate DRG (Diagnosis Related Group) is to utilize software known as | a grouper. |
| Linking diagnosis codes to the CPT codes reported on a claim provides evidence of | medical necessity |
| The purpose of the Correct Coding Initiative is to | detect and prevent payment for improperly coded services. |
| Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data | integrity. |
| DNR and DNI documents are all part of what are known as | advance directives. |
| Medically Unlikely Edits (MUE) are a claims review looking for | incorrect units of service of any procedure, service, or treatment. |
| 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 |
| 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. |
| Which diagnosis should be listed first when sequencing inpatient codes using the UHDDS? | principal diagnosis |
| Diagnosis codes update every year on | October 1. |
| 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) |
| An ethical physician’s query cannot include. | a recommendation for an answer. |
| An HIM professional was tasked with analyzing a group of medical records qualitatively for deficiencies. This would include | reviewing medical records for missing or ambiguous details. |
| A staff member, Louis, in Admissions, occasionally brings his nephew to work after school and permits him to access social media on his computer. He posts selfies and sometimes shares what he sees and hears in the office. As the HIM manager, you must | require Louis to go through HIPAA training again and explain to him the illegality of posting any protected information on social media |
| A claim may be returned by the third-party payer unpaid because it was denied or rejected. If eligibility and coverage was checked prior to the patient being seen, the denial may be due to any of these reasons EXCEPT | the claim submitted is clean. |
| When patient records are no longer required and deemed unnecessary, they must be destroyed, regardless of the format (paper, EHR, etc.). The guidance states that the destruction must be | documented as to method and date. |
| Patient health care records can be released for research purposes or education, without patient permission, if they have been de-identified. This means all details have been removed that may | lead to one specific person. |
| The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis. This is called | hard coding |
| A document that acknowledges patient responsibility for payment if Medicare denies the claim is a(n) | advance beneficiary notice. |
| The required method for the submission of health care claims to third-party payers must be electronic unless the facility has acquired a | waiver from the payer to submit paper claims. |
| The following data is required to be included in a patient health record, EXCEPT | copies of all claims submitted |
| The _______ has the duty to adjust the MS-DRGs if necessary at the beginning of every fiscal year beginning _____________. | CMS, October 1 |
| 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. |
| 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 | doctors' progress note section. |
| CMS delegates its daily operations of the Medicare and Medicaid programs to | Medicare administrative contractor (MAC) |
| The Master Patient Index, __________, which can be used to access data for analysis. | collates patient information from separate systems |
| Patient self-reported documentation may also be used to assign codes for social determinants of health, with the requirement that | the physician includes these details in the encounter documentation. |
| CAC software is used to analyze health care documents and produce appropriate medical codes. This may be used by some health care facilities when there are an insufficient number of certified medical coding candidates. CAC stands for | Computer-Assisted Coding. |
| The patient was seen by the physician on September 30, 2023. By the time the documentation reached the medical coder, it was October 2, 2023. The code set required to report the appropriate diagnosis is | the 2023 ICD-10-CM code set. |
| The patient was admitted through the Emergency Department and she is anxious about notifying her spouse and her sister. Her spouse is out of town on business and her sister lives in another state. The patient is worried about how they can get updates when | the hospital can assign special pass codes. |
| Which of the following are considered sequela regardless of time? | nonunion |
| The primary purpose for keeping a patient health record is | continuity of care. |
| Querying a physician is required by the coder when it is found that the documentation, written by a physician, is any of these EXCEPT: | misspelled in places that do not interfere with the medical information included |
| CDSS is an add-on function included in most electronic health records (EHR). This enables physicians to review evidence-based medical articles and other current industry knowledge. CDSS stands for | Clinical Decision Support System. |
| One expert medical coder in your department is responsible for reviewing the codes determined by the other coders before the claims are submitted to third-party payers. This is known as conducting a(n) | internal audit. |
| HIPAA requires covered entities to retain patient health records for at least _____, from either the date of creation, or the last “effective date,” whichever date is later. | six years |
| Which of the following is classified as a poisoning in ICD-10-CM? | syncope due to Contac pills and a three-martini lunch |
| Based on the following documentation in an acute care record, where would you expect this excerpt to appear? With the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to | operative record |
| In most situations the person who authorizes release of medical information is the | patient. |
| Identify the vocabulary standard that is used in the EHR. | SNOMED |
| Every reasonable effort is made to limit access to PHI to those in the workforce that need access based on their roles in the health care organization. This is the definition of _____, as per HIPAA. | the minimum necessary rule. |
| Two health care staff members are in a booth at a restaurant having lunch. They discuss a patient’s situation, encountered earlier that day, and mention the patient’s name. This is an example of | a HIPAA Privacy Rule breach |
| Mrs. Walters took her stepdaughter Sienna, who is 17 years of age, to Dr. Perine for an annual physical examination. While in the examination room, Dr. Perine informs Sienna her lab results indicate she has a STD, and needs to receive tretment. Sienna req | No, because Sienna has not authorized Dr. Pernine to release this information. |
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