Certified Coding Associate (CCA) Exam Preparation 2022- with rationale

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c. Edit checks Edit checks help ensure data integrity by allowing only reasonable and predetermined values to be entered into the computer (Rinehart-Thompson 2016a, 265). - ✔✔A coding analyst co ... nsistently enters the wrong code for patient gender in the electronic billing system. What data quality or data integrity measures should be in place to ensure that only allowable code numbers are entered? a. Access controls b. Audit trail c. Edit checks d. Password controls b. Delinquent record An incomplete record not rectified within a specific number of days as indicated in the medical staff rules and regulations is considered to be delinquent (Sayles 2016, 65). - ✔✔A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record b. Provide an input mask for entering data in the field When several people enter data in an EHR, you can define how users must enter data in specific fields to help maintain consistency. For example, an input mask for a form means that users can only enter the date in a specified format (MacDonald 2010, chapter 4; Carter and Palmer 2016, 506). - ✔✔Which of thefollowing would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)? a. Make admission date a required field b. Provide an input mask for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data a. UHDDS In 1974, the federal government adopted the UHDDS as the standard for collecting data for the Medicare and Medicaid programs. When the Prospective Payment Act was enacted in 1983, UHDDS definitions were incorporated into the rules and regulations for implementing diagnosis-related groups (DRGs). A key component was the incorporation of the definitions of principal diagnosis, principal procedure, and other significant procedures, into the DRG algorithms (Oachs and Watters 2016, 223). - ✔✔Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute-care hospital in which she works. The first resource that she should use is _____. a. UHDDS b. UACDS c. MDS d. ORYX a. Meaning of data Data definition means that the data and information documented in the health record are defined; users of the data must understand what the data mean and represent (Sayles 2016, 52). - ✔✔Data definition refers to: a. Meaning of data b. Completeness of data c. Consistency of data d. Detail of dataa. Provide the medical records in paper format The covered entity must provide access to the personal health information in the form or format requested when it is readily producible in such form or format. When it is not readily producible in the form or format requested, it must be produced in a readable hard-copy form or such other form or format agreed upon by the covered entity and the individual (Gordon and Gordon 2016b, 615-616). - ✔✔A patient requests copies of her personal health information on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the medical records in paper format. How should the hospital respond? a. Provide the medical records in paper format b. Burn another CD because this is hospital policy c. Provide the patient with both paper and CD copies of the medical record d. Review the CD copies with the patient on a hospital computer b. Objective Objective information may be measured or observed by the healthcare provider (Amatayakul 2016, 294). - ✔✔A notation for a diabetic patient in a physician progress note reads: "FBS 110mg%, urine sugar, no acetone." Which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan d. Query the physician as to the method used. 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 2016, 454). - ✔✔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. d. E-discovery Although e-Discovery is the same pretrial process as discovery, the electronic health record has promoted this concept (Rinehart-Thompson 2016b, 215). - ✔✔The Federal Rules of Civil Procedure (FRCP) incorporated the pre-trial process through the creation of: a. Bench warrants b. Court orders c. Depositions d. E-discovery d. Standards Standards are fixed rules that must be followed, which is different from a guideline that provides general direction (Sayles 2016, 66; Brickner 2016, 82). - ✔✔Statements that define the performance expectations and structures or processes that must be in place are _____. a. Rules b. Policies c. Guidelines d. Standards b. Information access controls An EHR can be viewed by multiple users and from multiple locations at any time, and organizations must have in place appropriate security access control measures to ensure the safety of the data (Sayles 2016, 53; Amatayakul 2016, 285 Kellogg 2016b, 482-483). - ✔✔An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach? a. Audit controlsb. Information access controls c. Facility access controls d. Workstation security c. Major diagnostic categories Diagnosis-related groupings (DRGs) are classified by one of 25 major diagnostic categories (MDCs) (Hazelwood and Venable 2016, 224). - ✔✔Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values b. Is information from which personal characteristics have been stripped Deidentified information is information that does not identify an individual; essentially it is information from which personal characteristics have been stripped (Rinehart-Thompson 2016b, 222). - ✔✔Deidentified information _____. a. Does identify an individual b. Is information from which personal characteristics have been stripped c. Can be later constituted or combined to re-identify an individual d. Pertains to a person that is identified within the information b. History A complete medical history documents the patient's current complaints and symptoms and lists the patient's past medical, social, and family history (Brickner 2016, 90). - ✔✔The ________ may contain information about diseases among relatives in which heredity may play a role. a. Physical examination b. Historyc. Laboratory report d. Administrative data b. Electronic signature authentication Electronic signature authentication systems require the author to sign onto the system using a user ID and password, review the document to be signed, and indicate approval (Sayles 2016, 89). - ✔✔This system will require the author to sign onto the system using a user ID and password to complete the entries made. a. Digital dictation b. Electronic signature authentication c. Single sign on technology d. Clinical data repository b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. It is suggested that covered entities use PHI with certain specified direct identifiers removed as a guideline for disclosing only minimum necessary information while providing the amount needed to accomplish the intended purpose (Gordon and Gordon 2016b, 615-616). - ✔✔The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no HIPAA violation for announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced. b. BeneficenceBeneficence means promoting good (Gordon and Gordon, 2016b, 604, 618). - ✔✔Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence a. American Psychological Association The Joint Commission, Commission on Accreditation of Rehabilitation Facilities, and the National Committee for Quality Assurance are all acceptable accrediting bodies for behavioral healthcare settings (Fahrenholz and Russo 2013, 624). - ✔✔Which of the following is not an accepted accrediting body for behavioral healthcare organizations? a. American Psychological Association b. Joint Commission c. Commission on Accreditation of Rehabilitation Facilities d. National Committee for Quality Assurance b. Data warehouse A data warehouse is a special type of database that consolidates and stores data from various databases (Oachs and Watters 2016, 998). - ✔✔Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? a. Client-server computer b. Data warehouse c. Local area network d. Internet c. Report of history and physical examinationAccording 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 more than seven days before the surgery is to be performed (Fahrenholz and Russo 2013, 238). - ✔✔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 a. Postoperative infection Present on admission is defined as present at the time the order for inpatient admission occurs (CMS 2017a, Appendix I). - ✔✔A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of postoperative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? [Show More]

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