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Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery.
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For pressure ulcers that were present on admission but healed at the time of discharge, the code for the ulcer would be assigned according to which of the following?
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AHIMA 1
CCA EXAM PREP
| Question | Answer |
|---|---|
| Coronary arteriography serves as a diagnostic tool in detecting obstruction within the coronary arteries. Identify the technique using two catheters inserted percutaneously through the femoral artery. | Judkins |
| For pressure ulcers that were present on admission but healed at the time of discharge, the code for the ulcer would be assigned according to which of the following? | The site and stage at the time of admission |
| Identify the chapter of ICD-10-CM in which certain signs and symptoms of breast disease, such as mastodynia, induration of breast, and nipple discharge, are included. | Chapter 14: Diseases of the Genitourinary System |
| Devices used as part of the procedure and removed as the procedure concludes are treated in which manner? | They are not assigned in the ICD-10-PCS sixth character. |
| If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, the coding professional should do which of the following? | Assign two separate codes—one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay. |
| What is the best reference tool to determine how CPT codes should be assigned? | American Medical Association's CPT Assistant newsletter |
| Which of the following software applications would be used to aid in the coding function in a physician’s office? | Encoder |
| In fiscal year 2008, Medicare revamped the inpatient payment system to incorporate three severity levels. The grouping is known as which of the following? | MS-DRGs |
| What is the healthcare program for active duty members of the military and other qualified family members? | Tricare |
| An electrolyte panel (80051) in the Laboratory section of CPT consists of tests for carbon dioxide (82374), chloride (82435), potassium (84132), and sodium (84295). If each of the component codes are reported and billed individually on a claim form, this | Unbundling |
| In the Laboratory section of CPT, if a group of tests overlaps two or more panels, report the panel that incorporates the greatest number of tests to fulfill the code definition. What would a coding professional do with the remaining test codes that are n | Report the remaining tests using individual test codes. |
| The Office of Inspector General’s (OIG) Compliance Program for Hospitals recommends that hospitals appoint a chief compliance officer and do which of the following? | Establish a compliance committee. |
| The front end of the revenue cycle management process includes which of the following? | Insurance verification |
| What is the best reference tool for ICD-10-CM and ICD-10-PCS coding advice? | AHA's Coding Clinic for ICD-10-CM/PCS |
| CMS developed medically unlikely edits (MUEs) to prevent providers from billing units of service greater than the norm would indicate. These MUEs were implemented on January 1, 2007, and are applied to which code set(s)? | HCPCS/CPT codes |
| To secure payment from the insurer, the physician is responsible for ensuring that documentation in the health record meets specific standards. Which of the following is a documentation standard that must be met by the physician? | The rationale for ordering diagnostic and other ancillary services should be documented or easily inferred. |
| Which of the following needs to be included in the documentation of each patient encounter to secure payment from the insurer? | The date of the encounter and the identity of the observer |
| Two Medicare patients were hospitalized with bacterial pneumonia. One patient was hospitalized for three days, and the other patient was hospitalized for 30 days. Both cases result in the same MS-DRG with different lengths of stay. Which of the following | The hospital will receive the same reimbursement regardless of the length of stay. |
| Which payment system is in place to reimburse home health agencies? | HHRGs |
| On October 1, 2012, the Affordable Care Act established which of the following, requiring CMS to reduce payments to IPPS hospitals with excess admissions? | Hospital Readmissions Reduction Program |
| The CMS-HHC model indicates the cost of treating the individual relative to the average beneficiary through a measure identified as which of the following? | Risk score |
| Which of the following types of hospitals are excluded from the Medicare Acute-Care Inpatient Prospective Payment System? | Children's hospitals |
| CMS identified conditions that are “reasonably preventable.” Hospitals are not allowed to receive additional payment for treatment of these conditions when they are not present on admission. What are these conditions called? | Hospital-acquired conditions |
| Which of the following fails to meet the CMS classification of a hospital-acquired condition? | Gram-negative pneumonia |
| The focus on the delivery, measurement, and provision of quality patient care led to several initiatives that link reimbursement to quality care. These initiatives are referred to as which of the following? | Value-base purchasing |
| What is the maximum number of ambulatory payment classifications (APCs) that may be reported per outpatient encounter? | No maximum number |
| Each HCPCS code is assigned a qualifier that establishes how a service, procedure, or item is paid under the Outpatient Prospective Payment System (OPPS). What is the name of this qualifier? | Payment Status Indicator (SI) |
| How should an addendum to the health record be dated? | The day the addendum was created |
| The seven characteristics of high-quality documentation include clarity, completeness, consistency, legibility, preciseness, reliability, and which of the following? | Timeliness |
| The physician has signed a statement that all her dictated reports should be automatically considered approved and signed unless she makes corrections within 72 hours of dictating. What is this process called? | Auto-authentication |
| When creating documentation requirements for hospital bylaws, which of the following should be evaluated? | The documentation needs based on accrediting bodies |
| Which of the following is a function of the discharge summary? | Providing concise information that can be used to answer information requests |
| Under HIPAA, at the time of admission to the facility or prior to treatment by the provider, patients must be informed about the use of individually identifiable health information by signing which of the following? | Notice of privacy practices |
| A 65-year-old white male was admitted to the hospital on January 15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed | Abdominal pain |
| All documentation entered in the medical record relating to the patient’s diagnosis and treatment is considered what type of data? | Clinical |
| What type of data is exemplified by the insured party’s member identification number? | Financial data |
| Which of the following is the type of master patient index (MPI) matching algorithm that assigns weights to specific data elements and uses the weights to compare one record to another? | Rules-based |
| Two patients were assigned the same health record number. This is an example of which of the following? | Overlay |
| Mildred Smith was admitted from an acute-care hospital to a nursing facility with the following information: “Patient is being admitted for organic brain syndrome.” Underneath the diagnosis, her medical information along with her rehabilitation potential | Transfer or referral form |
| According to the Joint Commission Accreditation Standards, which document must be placed in the patient’s record before a surgical procedure may be performed? | Report of history and physical examination |
| Bob Smith was admitted to Mercy Hospital on June 21. The physical examination was completed on June 23. According to Medicare Conditions of Participation, which statement applies to this situation? | The record is not in compliance because the physical examination must be completed within 24 hours of admission. |
| What is a health record with deficiencies that is not completed within the time frame specified in the medical staff rules and regulations? | Delinquent record |
| The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review? | Retrospective |
| To comply with Joint Commission standards, the HIM director wants to ensure that history and physical examinations are documented in the patient’s health record no later than 24 hours after admission. Which of the following would be the best way to ensure | Review each patient's health record concurrently to make sure history and physicals are present to meet accreditation standards. |
| Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceeds the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons tried multiple methods to impr | Contact other hospitals to see what methods they use to ensure compliance. |
| Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis? | Quantitative |
| How do accreditation organizations such as the Joint Commission use the health record? | To determine whether standards of care are being met |
| Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare. What standards must the facility meet in order to become certified for these programs? | Conditions of Participation |
| An effective compliance program should include some basic elements to comply with state and federal laws. These include policies, procedures, and standards of conduct; the identification of a compliance officer and committee; education of staff; establish | Penalties for noncompliance of standards |
| Identify which of the federal fraud and abuse laws prohibits a physician’s referral of designated health services for Medicare and Medicaid patients if the physician has a financial relationship with the entity. | Stark Law |
| Corporate compliance programs were released by the Office of the Inspector General (OIG) for hospitals to develop and implement their own compliance programs. Which of the following is a basic element of a corporate compliance program? | Implementation of regular and effective education and training programs for all employees |
| Which of the following programs is required by the Medicare and Medicaid programs and accreditation standards? | Quality improvement |
| HIM coding professionals and the organizations that employ them have the responsibility to not tolerate behavior that adversely affects data quality. Which of the following is an example of behavior that should not be tolerated? | Omit codes that reflect negatively on quality and patient safety measurement. |
| Which of the following are two types of physician queries? | Open-ended and multiple-choice |
| Maintenance of the charge description master requires expertise in coding, clinical procedures, health record or clinical documentation, and which of the following? | Billing regulations |
| Charge description master (CDM) software is primarily designed to continuously apply edits to point out compliance issues, check validity of CPT and revenue codes, and which of the following? | Identify item pricing |
| Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of which of the following? | Vocabulary standards |
| The inpatient clinical documentation integrity process can be divided into three main functions: query for documentation clarification, physician education, and which of the following? | Record review |
| Which of the following is exemplified by performing one’s job functions with integrity, according to the laws, regulations, and guidelines set forth by Medicare and other third-party payers? | Ethics |
| Which of the following describes the capability for two or more information systems to communicate and exchange information electronically? | Interoperability |
| What software will prompt the user through a variety of questions and choices based on the clinical terminology entered to assist the coding professional in selecting the most appropriate code? | Logic-based encoder |
| What is the technology commonly used for automated claims processing (sending bills directly to third-party payers)? | Electronic data interchange |
| Which type of data entered into electronic systems is free text and has no specific requirements or rules for data entry? | Unstructured data |
| Although used mainly for coding of the health record for reimbursement, what is another purpose for computer-assisted coding (CAC)? | Clinical documentation integrity |
| Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used? | Front-end |
| A standard vocabulary is used to achieve what type of interoperability? | Semantic |
| A valid authorization for disclosure of information requires which of the following? | An expiration date or event |
| Methods of authentication include smart cards, biometrics, and which of the following? | Passwords |
| The right of an individual to keep his or her personal information from being disclosed to anyone is a definition of which of the following? | Privacy |
| The Final Rule that defines practices which constitute information blocking and authorizes the Secretary of Health and Human Services (HHS) to identify reasonable and necessary activities that do not constitute information blocking (referred to as “except | Section 4004 of the 21st Century Cures Act |
| Which of the following statements is true of the HIPAA Notice of Privacy Practices? | It must be provided to every individual at the first time of contact or service with the covered entity |
| The Office of the Inspector General (OIG) believes that compliance programs have benefits in addition to submitting accurate claims. These include which of the following? | Identification and prevention of criminal and unethical conduct |
| The factors to be considered with destruction of records include applicable federal and state statutes and regulations, accreditation standards, pending or ongoing litigation, cost, and which of the following? | Storage capabilities |
| What does an audit trail check for? | Unauthorized access to a system |
| An individual designated as an inpatient coding professional may have access to an electronic health record to code the record. Under what access security mechanism is the coding professional allowed access to the system? | Role-based |
| In what form of health information exchange are data centrally located but physically separated? | Consolidated federated |
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