CCA EXAM PREP
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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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 | show 🗑
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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) | show 🗑
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| show | inspection
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| show | procedures that cannot or should not be provided to the same patient on the same day.
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| It is September 15th, and you have just received the upcoming year’s ICD-10-PCS code set updates. The next step is to | show 🗑
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| show | improve your department's processes.
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| 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 | show 🗑
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| The APC payment system is based on what coding system(s)? | show 🗑
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| The Joint Commission requires that all medical records be completed within ___________ following patient discharge. | show 🗑
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| You have been hired to work with a computer-assisted coding (CAC) initiative. The technology that you will be working with is | show 🗑
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| show | any of these
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| show | imply an answer that will lead to a higher reimbursement rate.
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| show | an Advance Beneficiary Notice (ABN)
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| show | OSHA.
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| Employing the SOAP style of progress notes, choose the "assessment" statement from the following: | show 🗑
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| 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? | show 🗑
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| show | was an obstetric admission with a normal delivery and no complications.
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| Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called | show 🗑
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| NCCI edits were developed by the Centers for Medicare and Medicare Services (CMS) to | show 🗑
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| 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 | show 🗑
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| show | National Correct Coding Initiative.
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| While CAC systems are convenient, the codes they determine must be validated to ensure accuracy. One method to do this would be | show 🗑
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| show | Ambulatory Patient Classification (APC).
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| All of these are acceptable destruction methods when health records are no longer required, EXCEPT | show 🗑
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| One excellent source to guide you to perform ethical coding is | show 🗑
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| show | National Correct Coding Initiative (NCCI)
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| f a claim is returned as denied or rejected due to an error, the best thing to do is | show 🗑
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| show | the remittance advice
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| show | a grouper.
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| show | medical necessity
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| show | detect and prevent payment for improperly coded services.
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| show | integrity.
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| DNR and DNI documents are all part of what are known as | show 🗑
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| Medically Unlikely Edits (MUE) are a claims review looking for | show 🗑
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| show | upcoding
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| show | data encryption.
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| show | principal diagnosis
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| Diagnosis codes update every year on | show 🗑
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| 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. | show 🗑
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| show | a recommendation for an answer.
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| show | reviewing medical records for missing or ambiguous details.
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| 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 | show 🗑
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| show | the claim submitted is clean.
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| 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 | show 🗑
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| 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 | show 🗑
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| show | hard coding
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| show | advance beneficiary notice.
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| The required method for the submission of health care claims to third-party payers must be electronic unless the facility has acquired a | show 🗑
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| The following data is required to be included in a patient health record, EXCEPT | show 🗑
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| The _______ has the duty to adjust the MS-DRGs if necessary at the beginning of every fiscal year beginning _____________. | show 🗑
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| 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 | show 🗑
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| 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 | show 🗑
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| show | Medicare administrative contractor (MAC)
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| The Master Patient Index, __________, which can be used to access data for analysis. | show 🗑
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| show | the physician includes these details in the encounter documentation.
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| show | Computer-Assisted Coding.
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| 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 | show 🗑
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| show | the hospital can assign special pass codes.
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| Which of the following are considered sequela regardless of time? | show 🗑
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| The primary purpose for keeping a patient health record is | show 🗑
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| show | misspelled in places that do not interfere with the medical information included
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| 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 | show 🗑
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| 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) | show 🗑
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| 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. | show 🗑
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| show | syncope due to Contac pills and a three-martini lunch
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| 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 | show 🗑
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| show | patient.
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| Identify the vocabulary standard that is used in the EHR. | show 🗑
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| 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. | show 🗑
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| show | a HIPAA Privacy Rule breach
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| 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 | show 🗑
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