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An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents “urosepsis.” How should the co
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Which of the following make data entry easier but may harm data quality?
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AHIMA 2
CCA EXAM PREP
| Question | Answer |
|---|---|
| An 80-year-old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents “urosepsis.” How should the co | Query the physician to determine if the patient has sepsis due to the symptomatology. |
| Which of the following make data entry easier but may harm data quality? | Copy and paste |
| Which of the following is reimbursed according to the Medicare Outpatient Prospective Payment System? | Community Mental Health Center (CMHC) partial hospitalization services |
| Documentation by aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record? | Home health |
| Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? | Pathology report |
| What statement is reflective of meeting medical necessity requirements? | A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease. |
| Which decision support system could deliver a reminder to a physician that it is time for the patient’s flu shot? | Clinical |
| Which of the following means that a provider is “accepting assignment” of benefits? | Provider agrees to accept as payment in full the allowed charge from the fee schedule. |
| A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this ca | Infectious gastroenteritis; chronic obstructive pulmonary disease; angina |
| In a managed care fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? | Prospectively pre-certify the necessity of inpatient services |
| Notes appearing under a three-character category apply to which of the following? | To all codes within that category |
| Identify where the following information would be found in the acute-care record: “PA and Lateral Chest: The lungs are clear. The heart and mediastinum are normal in size and configuration. There are minor degenerative changes of the lower thoracic spine. | Radiography report |
| Online transaction processing is conducted in which of the following? | Clinical data repository |
| Which of the following is used by computer-assisted coding software to translate digital text from online documents stored in the information system into codes to match the documentation? | Natural-language processing |
| Which organization developed messaging standards for electronic data interchange in healthcare? | Health Level 7 (HL7) |
| Which of the following is considered the most innocent of improper payments because there is no intent to falsely receive a payment from the payer? | Error |
| Which of the following requires the author to sign into the system using a user ID and password to complete the entries made? | Electronic signature authentication |
| What system assigns each service a value representing the true resources involved in producing it, including the time and intensity of work, the expenses of practice, and the risk of malpractice? | RVUs |
| A notation for a hypertensive patient in a physician ambulatory care progress note reads: “Blood pressure adequately controlled.” In which part of a problem oriented medical record (POMR) progress note would this notation be written? | Assessment |
| The communication and network technologies connections, used by providers to submit orders for medications and lab tests, are known as which of the following? | Computerized order entry systems (CPOEs) |
| A notation for a diabetic patient in a physician progress note reads: “FBS 110 mg%, urine sugar, no acetone.” In which part of a problem oriented medical record (POMR) progress note would this notation be written? | Objective |
| A coding audit shows that an outpatient coding professional is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following shou | Counsel the coding professional and stop the practice immediately. |
| Which of the following should be done if the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin? | Assign code E11, Type 2 diabetes mellitus. |
| How does Medicare define fraud? | Intentional deception or misrepresentation that results in an unauthorized benefit to an individual |
| Which of the following is the government-sponsored program that provides expanded coverage of many healthcare services including HMO plans, PPO plans, special needs plans, and Medical Savings accounts? | Medicare Advantage |
| A patient’s clinical data documents which of the following? | Test results |
| Which of the following is an advance directive created by an individual, while still competent, that designates another person (proxy) to make his or her healthcare decisions consistent with the individual’s wishes on his or her behalf? | Durable power of attorney for healthcare decisions (DPOA-HCD) |
| Given the following information, which of the statements is correct? MCD Type MS-DRG Title Weight Discharges Geometric Mean Arithmetic Mean 191 04 MED Chronic obstructive pulmonary disease w CC 0.9757 10 4.1 5.0 192 04 MED Chronic obstructive pulm | In each MS-DRG the arithmetic mean is lower than the geometric mean. |
| The Information Governance Principles for Healthcare (IGPHC) includes the statement that, “An organization shall maintain its information for an appropriate time, taking into account its legal, regulatory, fiscal, operational, risk, and historical require | Principle of retention |
| Identify where the following information would be found in the acute-care record: “Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fash | Operative report |
| What is the quality control function for the EHR that shows the format in which the data will be displayed? | Input mask |
| The privacy officer reports breaches to the Office of Civil Rights in the Department of Health and Human Services. Which of the following breach notification statements is correct? | The privacy officer must notify the Secretary of Health and Human Services. |
| What is the process used to transform text into an unintelligible string of characters that can be transmitted via communications media with a high degree of security and then decrypted when it reaches a secure destination? | Encryption |
| Which of the following is true of the notices of privacy practices? | It must be posted in a prominent place. |
| What system reimburses hospitals a predetermined amount for each Medicare inpatient admission? | MS-DRG |
| Data definition refers to which of the following? | Meaning of data |
| The NCCI editing system used in processing OPPS claims is part of which of the following? | Outpatient code editor (OCE) |
| Which of the following does Medicare require to identify a wound closed with tissue adhesives? | Level II HCPCS code |
| Which of the following is the cornerstone of accurate coding? | Physician documentation |
| Which of the following has the potential to influence the calculation of MS-DRGs? | Present on admission (POA) indicators |
| 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. |
| Even though state laws may be more stringent, for how long does CMS require acute healthcare records to be maintained by the acute healthcare organization? | At least seven years |
| Medicare beneficiaries who have low incomes and limited financial resources may also receive assistance from which federal matching program? | Medicaid |
| If a procedure is performed on a body part that does not have a specific value in ICD-10-PCS, which two resources can be used to identify the correct body part character to assign? | ICD-10-PCS Alphabetic Index; ICD-10-PCS Body Part Key |
| The patient’s address is the same in the master patient index, electronic health record, laboratory information system, and other information systems. This means that the data values are consistent and therefore indicative of which of the following? | Data integrity |
| Which of the following are the two types of queries used in clinical documentation integrity? | Paper and electronic |
| A physician correctly prescribes warfarin. The patient takes the warfarin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? | Hematuria; adverse reaction to warfarin |
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DeNisha27
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