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AHIMA CCA- Exam
A 65-year-old white male was admitted to the hospital on 1/15 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 an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was: a. Ruptured appendix b. Exploratory laparoscopy c. Abdominal pain d. Cholelithiasis - Answer-c. Abdominal pain The nature and duration of the symptoms that caused the patient to seek medical attention as stated in the patient's own words (Odom-Wesley et al. 2009, 331).
An individual stole and used another person's insurance information to obtain medical care. This action would be considered: a. Violation of bioethics b. Fraud and abuse c. Medical identity theft d. Abuse - Answer-c. Medical identity theft Correct Answer: 84. c. Medical identity theft occurs when someone uses a person's name and sometimes other parts of their identity without the victim's knowledge or consent to obtain medical services or goods (Johns 2011, 773).
Identify the ICD- 9 - CM diagnostic code(s) for acute osteomyelitis of ankle due to Staphylococcus. a. 730. b. 730.
c. 730.07, 041. d. 730.07, 041.10 - Answer-d. 730.07, 041. Correct Answer: D Index Osteomyelitis, acute or subacute. Refer to the table in the Index for the fifth digit 5, ankle and foot. Infection, staphylococcal NEC (Schraffenberger 2012, 305-306).
A system that provides alerts and reminders to clinicians is a(n): a. Clinical decision support system b. Electronic data interchange c. Point of care charting system d. Knowledge database - Answer-Correct Answer: A Clinical decision support includes providing documentation of clinical findings and procedures, active reminders about medication administration, suggestions for prescribing less expensive but equally effective drugs, protocols for certain health maintenance procedures, alerts that a duplicate lab test is being ordered, and countless other decision-making aids for all stakeholders in the care process (Johns 2011, 138).
What does an audit trail check for? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup - Answer-Correct Answer: A Audit trails can provide tracking information such as who accessed which records and for what purpose (Johns 2011, 403).
This is a condition with an imprecise diagnosis with various characteristics. The condition may be diagnosed when a patient presents with sinus arrest, sinoatrial exit block, or persistent sinus bradycardia. This syndrome is often the result of drug therapy, such as digitalis, calcium channel blockers, beta-blockers, sympatholytic agents, or antiarrhythmics. Another presentation includes recurrent supraventricular tachycardias associated with bradyarrhythmias. Prolonged ambulatory monitoring may be indicated
A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? a. Chart deficiency system b. Chart tracking system c. Chart abstracting system d. Chart encoder - Answer-Correct Answer: B With an automated tracking system, it is easy to track how many records are charged out of the system, their location, and whether they have been returned on the due dates indicated (Johns 2011, 402).
Identify the appropriate ICD- 9 - CM diagnosis code for Lou Gehrig's disease. a. 335. b. 334. c. 335. d. 335.2 - Answer-Correct Answer: A Index Disease, Lou Gehrig's or Lou Gehrig's disease. Amyotrophic lateral sclerosis is another name for Lou Gehrig's disease. Many diseases carry the name of a person or an eponym. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).
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 coder do with the remaining test codes that are not part of a panel? a. Report the remaining tests using individual test codes, according to CPT. b. Do not report the remaining individual test codes. c. Report only those test codes that are part of a panel.
d. Do not report a test code more than once regardless whether the test was performed twice. - Answer-Correct Answer: A Reporting additional test codes that overlap codes in a panel allows the coder to assign all appropriate codes for services provided. It is inappropriate to assign additional panel codes when all codes in the panel are not performed. Reporting individual lab codes is appropriate when all codes in a panel have not been provided (AMA 2012b, 402).
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 would be a form of: a. Optimizing b. Unbundling c. Sequencing d. Classifying - Answer-Correct Answer: B Unbundling occurs when a panel code exists and the individual tests are reported rather than the panel code (AMA 2012b, 402).
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. a. Combined right and left (88.54) b. Stones (88.55) c. Judkins (88.56) d. Other and unspecified (88.57) - Answer-Correct Answer: C The Judkins technique provides x-ray imaging of the coronary arteries by introducing one catheter into the femoral artery with maneuvering up into the left coronary artery orifice, followed by a second catheter guided up into the right coronary artery, and subsequent injection of a contrast material (Schraffenberger 2012, 206). Ensuring the continuity of future care by providing information to the patient's attending physician, referring physician, and any consulting physicians is a function of the:
Identify the ICD- 9 - CM diagnostic code for other specified aplastic anemia secondary to chemotherapy. a. 284. b. 284. c. 285. d. 285.22 - Answer-Correct Answer: B Index Anemia, aplastic, due to, antineoplastic chemotherapy. A coder should always assign the most specific type of anemia. Anemia due to chemotherapy is often aplastic (Schraffenberger 2012, 133-135 ).
When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? a. Assign the removal by snare technique code. b. Assign the removal by hot biopsy forceps code. c. Assign the ablation code. d. Query the physician as to the method used. - Answer-Correct Answer: D It is not appropriate for the coder to assume the removal was done by either snare or hot biopsy forceps. The ablation code is only assigned when a lesion is completely destroyed and no specimen is retrieved. The coding professional must query the physician to assign the appropriate code (AHIMA 2012a, 607).
What is the best reference tool to determine how CPT codes should be assigned? a. Local coverage determination from Medicare b. American Medical Association's CPT Assistant newsletter c. American Hospital Association's Coding Clinic d. CMS website - Answer-Correct Answer: B CPT Assistant provides additional CPT coding guidance on how to assign a CPT code by providing intent on the use of the code and explanation of parenthetical instructions. The American Medical Association publishes the guidance monthly (AMA 2012b).
Identify the appropriate ICD- 9 - CM diagnosis code(s) for right and left bundle branch block. a. 426.3, 426. b. 426. c. 426.4, 426. d. 426.52 - Answer-Correct Answer: B Index Block, left, with right bundle branch block. Right and left bundle branch block is inclusive of one code. It is inappropriate to assign a code for right (426.4) and left (426.3) bundle branch block when a combination code includes both the right and left (Schraffenberger 2012, 201-207).
A software interface is a: a. Device to enter data b. Protocol for describing data c. Program to exchange data d. Standard vocabulary - Answer-Correct Answer: C A software interface is a computer program that allows different applications to communicate and exchange data (Johns 2011, 137).
What did the Centers of Medicare and Medicaid Services develop to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims? a. Outpatient Perspective Payment System (OPPS) b. National Correct Coding Initiative (NCCI) c. Ambulatory Payment Classifications (APCs) d. Comprehensive Outpatient Rehab Facilities (CORFs) - Answer-Correct Answer: B
Quality improvement (QI) programs have been in place in hospitals for years and have been required by the Medicare/Medicaid programs and accreditation standards. QI programs have covered medical staff as well as nursing and other departments or processes (LaTour and Eichenwald Maki 2010, 33).
Identify the code for a patient with a closed transcervical fracture of the epiphysis. a. 820. b. 820. c. 820. d. 820.01 - Answer-Correct Answer: D Index Fracture, femur, epiphysis, capital. Fifth digits are required for further classification of a specific condition. Many publishers include special symbols and/or color highlighting to identify codes that require a fourth or fifth digit (Schraffenberger 2012, 7).
What is the best source of documentation to determine the size of a removed malignant lesion? a. Pathology report b. Post-acute care unit record c. Operative report d. Physical examination - Answer-Correct Answer: C The total size of a removed lesion, including margins, is needed for accurate coding. This information is best provided in the operative report. The pathology report typically provides the specimen size rather than the size of the excised lesion. Because the specimen tends to shrink, this is not an accurate measurement (Kuehn 2012, 110-111).
Which of the following definitions best describes the concept of confidentiality? a. The right of individuals to control access to their personal health information b. The protection of healthcare information from damage, loss, and unauthorized alteration
c. The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information - Answer-Correct Answer: C Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose (Johns 2011, 49).
Identify the ICD- 9 - CM diagnosis code for Paget's disease of the bone (no bone tumor noted). a. 170. b. 213. c. 238. d. 731.0 - Answer-Correct Answer: D Index Paget's disease, bone. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, or disorder (Schraffenberger 2012, 13).
Which of the following fails to meet the CMS classification of a hospital-acquired condition? a. Foreign object retained after surgery b. Air embolism c. Gram-negative pneumonia d. Blood incompatibility - Answer-Correct Answer: C Gram-negative pneumonia (Johns 2011, 326).
Which of the following is (are) the correct ICD- 9 - CM procedure code(s) for cystoscopy with biopsy? a. 57.
c. Hospitals must not develop their audits based on the OIG work plan; rather, they must develop their own and look for high-risk areas that need improvement. d. Hospitals must use the plan developed by their state hospital association that is specific to state laws and compliance activities. - Answer-Correct Answer: B Hospitals are encouraged but not required to follow the same work plan as the OIG. Hospitals should review the plan carefully and plan their compliance program around the target areas (Johns 2011, 275).
The _____ may contain information about diseases among relatives in which heredity may play a role. a. Physical examination b. History c. Laboratory report d. Administrative data - Answer-Correct Answer: B A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Johns 2011, 63).
There are several codes to describe a colonoscopy. CPT code 45378 describes the most basic colonoscopy without additional services. Additional codes in the colonoscopy section of CPT further define removal of foreign body (45379); biopsy, single or multiple (45380); and others. Reporting the basic form of a colonoscopy (45378) with a foreign body (45379) or biopsy code (45380) would violate which rule? a. Unbundling b. Optimizing c. Sequencing d. Maximizing - Answer-Correct Answer: A The coder should assign the most comprehensive code to describe the entire procedure performed. When a code describes the entire service provided, the coder should not code each component separately. Assigning additional codes inherent to the main code would be a form of unbundling (Hazelwood and Venable 2012, 336).
Corporate compliance programs were released by the OIG for hospitals to develop and implement their own compliance programs. All of the following except _____ are basic elements of a corporate compliance program. a. Designation of a Chief Compliance Officer b. Implementation of regular and effective education and training programs for all employees c. Medical staff appointee for documentation compliance d. The use of audits or other evaluation techniques to monitor compliance - Answer- Correct Answer: C Seven elements are required as part of the basic elements of a corporate compliance program and a medical staff appointee is not one of them (Johns 2011, 274).
The electronic claim format (837I) replaces which paper billing form? a. CMS- 1500 b. CMS-1450 (UB-04) c. UB- 92 d. CMS- 1400 - Answer-Correct Answer: B The electronic claim form (screen 837I) replaced the UB-04 (CMS 1450) paper billing form (Johns 2011, 343).
According to the Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary - Answer-Correct Answer: C According to the Joint Commission, except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no
c. UACDS d. UHDDS - Answer-Correct Answer: C Uniform Ambulatory Care Data Set (Odom-Wesley et al. 2009, 310).
Identify the ICD- 9 - CM diagnostic code for diastolic dysfunction. a. 428. b. 428. c. 428. d. 429.9 - Answer-Correct Answer: D Index Dysfunction, diastolic (Schraffenberger 2012, 182-183).
Identify the appropriate ICD- 9 - CM procedure code(s) for a double internal mammary- coronary artery bypass. a. 36.15, 36. b. 36. c. 36. d. 36.12, 36.16 - Answer-Correct Answer: C Index Bypass, internal mammary-coronary artery (single), double vessel (36.16). Internal mammary-coronary artery bypass is accomplished by loosening the internal mammary artery from its normal position and using the internal mammary artery to bring blood from the subclavian artery to the occluded coronary artery. Codes are selected based on whether one or both internal mammary arteries are used, regardless of the number of coronary arteries involved (Schraffenberger 2012, 203-204).
Identify the CPT code(s) for the following patient: A 2-year-old male presented to the emergency room in the middle of the night to have his nasogastric feeding tube repositioned through the duodenum under fluoroscopic guidance. a. 43752 b. 43761
c. 43761, 76000 d. 49450 - Answer-Correct Answer: C Code 43761 is assigned to report repositioning of a nasogastric or orogastric feeding tube through the duodenum. An instructional note guides the coder to report code 76000 when image guidance is performed (AMA 2012b, 235). Which of the following is the correct ICD- 9 - CM procedure code for a Mayo operation known as a bunionectomy? a. 77. b. 77. c. 77. d. 77.51 - Answer-Correct Answer: C Index Bunionectomy or Mayo operation, bunionectomy. The main terms for eponyms are located in the Alphabetic Index under the eponym or the disease, syndrome, operation, or disorder (Schraffenberger 2012, 13).
Whereas the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: a. Reason for admission b. Reason for encounter c. Discharge diagnosis d. Activities of daily living - Answer-Correct Answer: B The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care, such as the reason for the encounter with the healthcare provider (LaTour and Eichenwald Maki 2010, 166).
How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information
a. Certification b. Identity-matching algorithm and record locator service c. Interoperability and certification d. Meaningful use - Answer-Correct Answer: B An HIE organization requires an identity-matching algorithm and record locator service (RLS). An identity-matching algorithm must be used by the HIE to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients. The RLS, then, is a process that seeks information about where a patient may have a health record available to the HIE organization (Johns 2011, 151).
All documentation entered in the medical record relating to the patient's diagnosis and treatment is considered this type of data: a. Clinical b. Identification c. Secondary d. Financial - Answer-Correct Answer: A Clinical information is data related to the patient's diagnosis or treatment in a healthcare facility (Odom-Wesley et al. 2009, 55).
What type of data is exemplified by the insured party's member identification number? a. Demographic data b. Clinical data c. Certification data d. Financial data - Answer-Correct Answer: D Financial data include details about the patient's occupation, employer, and insurance coverage (Odom-Wesley et al. 2009, 42).
What is the best reference tool for ICD- 9 - CM coding advice? a. AMA's CPT Assistant b. AHA's Coding Clinic for HCPCS c. AHA's Coding Clinic for ICD- 9 - CM d. National Correct Coding Initiative (NCCI) - Answer-Correct Answer: C AHA's Coding Clinic for ICD- 9 - CM is a quarterly publication of the Central Office on ICD- 9 - CM, which allows coders to submit a request for coding advice through the coding publication.
Identify the ICD- 9 - CM diagnostic code(s) for the following: A 6-month-old child is scheduled for a clinic visit for a routine well child exam. The physician documents, "well child, expreemie." a. V20.1, 765. b. V20. c. V20.2, 765. d. V20.2, 765.19 - Answer-Correct Answer: C Index Exam, well baby. Premature, infant NEC. Refer to table in Tabular for fifth digit of "0" to note unspecified birth weight (Schraffenberger 2012, 324-328, ).
Identify the ICD- 9 - CM diagnostic code(s) and procedure code(s) for the following: term pregnancy with failure of cervical dilation; lower uterine segment cesarean delivery with single liveborn female. a. 661.01, V27.0, 74. b. 661.21, 74. c. 661.01, 74. d. 661.21, V27, 74.1 - Answer-Correct Answer: A Index Delivery, cesarean, poor dilation, cervix (661.0). Refer to the ICD- 9 - CM Tabular (660-669) for the correct fifth digit of "1," delivered, with or without mention of
