CCA Exam Preparation Practice Test 2023-2024, Exams of Nursing

Download CCA Exam Preparation Practice Test 2023-2024 and more Exams Nursing in PDF only on Docsity! CCA Exam Preparation Domains 1, 2, 3, 4, 5, & 6 Practice Test 2023-2024 Verified Success 1. A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage and products of conception are found. Which of the following should be the principal diagnosis? a. Miscarriage b. Complications of spontaneous abortion with sepsis c. Sepsis d. Spontaneous abortion with sepsis a. Miscarriage 2. If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? a. Length of the lesion as described in the pathology report b. Dimension of the specimen submitted as described in the pathology report c. Width times the length of the lesion as described in the operative report d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report d. Diameter of the lesion as well as the most narrow margins required to adequately excise the lesion described in the operative report 3. A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case? a. Congestive heart failure, respiratory failure, ventilator management b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management a. Congestive heart failure, respiratory failure, ventilator management 4. Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-10-PCS d. SNOMED CT a. CPT 5. What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? a. 58555, 58559 b. 58559 c. 58559, 58740 d. 58555, 58559, 58740 b. 58559 6. What is the correct CPT code assignment for destruction of internal hemorrhoids with use of infrared coagulation? a. 46255 b. 46930 c. 46260 d. 46945 b. 46930 7.00Identify the diagnosis code(s) for melanoma of skin of right shoulder. a. D03.61, C43.61 b. C43.61 c. C43.60 d. D03.61 b. C43.61 8. A female patient is admitted for stress incontinence. A urethral suspension to reposition the urethra via open approach is performed. Assign the correct ICD-10-CM diagnosis and/or procedure codes. a. N39.3, 0TJB8ZZ b. N23, 0TSD0ZZ c. N39.3, 0TSD0ZZ d. R32, 0TSD4ZZ c. N39.3, 0TSD0ZZ a. J44.1, J44.9, I12.9, N18.9 b. J44.1, N18.9, I10 c. J44.9, N18.9, I10 d. J44.1, I12.9, N18.9 d. J44.1, I12.9, N18.9 18. What does the fourth character of an ICD-10-CM diagnosis code capture? a. Anatomic site b. Severity c. Etiology d. Supplemental information c. Etiology 19. Identify the diagnosis code(s) for carcinoma in situ of vocal cord. a. D02.0 b. C32.0 c. D49.1 d. D14.1 a. D02.0 20. To help clarify terms that currently have overlapping meaning, ICD-10-PCS has defined root operations. What is an example of the root operation of Excision? a. Partial nephrectomy b. Total nephrectomy c. Total lobectomy d. Total mastectomy a. Partial nephrectomy 21. The assignment of a diagnosis code is based on . a. The coder's assessment of the health record. b. The provider's statement that the patient has a particular condition. c. Clinical criteria used by the provider to establish the diagnosis. d. Its inclusion in the discharge summary b. The provider's statement that the patient has a particular condition. 22. Which of the following is a condition that arises during hospitalization? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis b. Complication 23. A patient is admitted to an acute-care hospital for alcohol abuse and uncomplicated alcohol withdrawal syndrome due to chronic alcoholism. His blood alcohol level on admission was 10mg/100mL. a. F10.230, F10.10, Y90.0 b. F10.230 c. F10.10, Y90.0 d. F10.230, Y90.0 d. F10.230, Y90.0 24. Assign the correct CPT code for the following procedure: Reposition of the pacemaker electrode. a. 33226 b. 33243 c. 33217 d. 33215 d. 33215 25. A 35-year-old male was admitted with heartburn that has not improved with over-the-counter medications. An esophagoscopy and closed esophageal biopsy at the upper esophagus was performed. The physician documented esophageal reflux with esophagitis as the final diagnosis based on pathological examination. Identify the correct diagnosis and procedure codes. a. K23, 0DJ07ZZ b. K20.9, 0DB58ZX c. K21.0, 0DB18ZX d. K21.9, 0DB18ZX c. K21.0, 0DB18ZX 26. Which volume of ICD-10-CM contains the Tabular and Alphabetic Index of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. None of the above d. None of the above 27. Patient has been diagnosed with acute depression, sleep-related teeth grinding and psychogenic dysmenorrhea. The appropriate code assignment is: a. F32.8, F45.8 b. F32.9, F45.8 c. F32.9, F45.8, G47.63 d. F32.9, G47.53 c. F32.9, F45.8, G47.63 18. A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin d. Hematuria; adverse reaction to Coumadin 29. 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 coder proceed to code this case? a. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. b. Code urinary tract infection with sepsis as the principal diagnosis. c. Query the physician to determine if the patient has sepsis due to the symptomatology. d. Query the physician to determine if the patient has septic shock so that this may be used as the principal diagnosis. c. Query the physician to determine if the patient has sepsis due to the symptomatology. 30. A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? a. Catheter-associated urinary tract infection a. F33.2 b. F33.40 c. F32.9 d. F31.81 a. F33.2 40. An exception to the Excludes 1 definition is the circumstance when the two conditions . a. Are unrelated to each other. b. Are related to each other. c. Will not be assigned as the principal diagnosis. d. Are injuries with external cause codes. a. Are unrelated to each other. 41. A patient is seen in the emergency department for chest pain. After evaluation of the patient it is suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "chest pain versus GERD." The correct ICD-10-CM code is: a. Z03.89 Encounter for observation for other suspected diseases and conditions ruled out b. R10.11 Right upper quadrant abdominal pain c. K21.9 Gastro-esophageal reflux disease d. R07.9 Chest pain, unspecified d. R07.9 Chest pain, unspecified 42. Patient was admitted through the emergency department following a fall from a ladder while painting an interior bathroom in his farmhouse. He had contusions of the scalp and face and a displaced open fracture of the anterior wall of the right acetabulum. The fracture site was excisionally debrided and the fracture was reduced by open procedure with an internal fixation device inserted. Which is the correct code assignment? a. S32.411A, W11XXA, Y92.012, 0QS404Z, 0QB40ZZ b. S32.411B, S00.03XA, S00.83XA, W11.XXXA, Y92.012, Y93.E9, Y99.8, 0QS404Z, 0QB40ZZ c. S32.414A, W11.XXA, Y93.E9, Y99.8, 0QS304Z, 0QB50ZZ d. S32.411B, W11.XXA, Y92.012, Y93.E9, 0QS404Z, 0QB50ZZ b. S32.411B, S00.03XA, S00.83XA, W11.XXXA, Y92.012, Y93.E9, Y99.8, 0QS404Z, 0QB40ZZ 43. According to the UHDDS, which of the following is the definition of "other diagnoses"? a. Is recorded in the patient record b. Is documented by the attending physician c. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring d. Is documented by at least two physicians and the nursing staff c. Receives clinical evaluation or therapeutic treatment or diagnostic procedures or extends the length of stay or increases nursing care and monitoring 44. To which of the following do notes appearing under a three-character code apply? a. Only to category codes that are exactly three-characters long b. To all codes within that category c. Only to one specific code d. To all codes within that chapter b. To all codes within that category 45. Patient had carcinoma of the anterior bladder wall fulgurated three years ago. The patient returns yearly for a cystoscopy to recheck for bladder tumor. Patient is currently admitted for a routine check. A small recurring malignancy is found and fulgurated during the cystoscopy procedure. Which is the correct code assignment? a. C67.3, Z85.51, 0T5B8ZZ, 0TJB8ZZ b. C79.11, 0T5B8ZZ c. C67.3, 0T5B8ZZ d. C79.11, C67.3, 0T5B8ZZ c. C67.3, 0T5B8ZZ 46. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, . a. Code E10, Type 1 diabetes mellitus, should be assigned. b. Code E11, Type 2 diabetes mellitus, should be assigned. c. Query the endocrinologist or attending physician. d. Check the physician orders or medical order record for additional information. b. Code E11, Type 2 diabetes mellitus, should be assigned. 47. Which of the following organizations is responsible for updating the procedure classification of ICD-10-PCS? a. Centers for Disease Control (CDC) b. Centers for Medicare and Medicaid Services (CMS) c. National Center for Health Statistics (NCHS) d. World Health Organization (WHO) b. Centers for Medicare and Medicaid Services (CMS) 48. Which of the following is not a way that ICD-10-CM improves coding accuracy? a. Reduces sequencing problems by combining conditions into one code b. Provides laterality options c. Captures more details for injuries, diabetes, and postoperative complications d. Increases cross-referencing d. Increases cross-referencing 49. A 45-year-old female is admitted for blood loss anemia due to dysfunctional uterine bleeding. a. D50.0, N93.8 b. D62, N93.8 c. N93.8, D50.0 d. D50.0, D25.9 a. D50.0, N93.8 50. Identify the appropriate ICD-10-CM diagnosis code for right cerebral contusion with 15- minute loss of consciousness, initial encounter for care. a. T14.8 b. S06.371A c. S06.311A d. S06.310A c. S06.311A 51. Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient, but another physician performed the surgical procedure. a. −22 b. −54 c. −32 d. −55 d. −55 52. Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for an extensive destruction of penile lesion by laser. I22.0 Myocardial infarction of anterolateral wall, subsequent I22.1 Myocardial infarction of inferior wall, subsequent I48.0 Paroxysmal atrial fibrillation I48.2 Chronic atrial fibrillation I48.91 Unspecified atrial fibrillation R07.9 Chest pain, unspecified 021209W Aortocoronary bypass, Three Sites from Aorta with Autologous Venous Tissue, Open Approach a. Hospital A: I48.91, R07.9, I21.19; Hospital B: I22.1, I48.91, 021209W b. Hospital A: I21.09, I48.0; Hospital B: I22.0, I48.2, 021209W c. Hospital A: I21.19, I48.91; Hospital B: I21.19, I48.91, 021209W d. Hospital A: I21.19, I48.91; Hospital B: I22.1, I48.91, 021209W Certified Coding Associate (CCA) Exa c. Hospital A: I21.19, I48.91; Hospital B: I21.19, I48.91, 021209W 60. The patient presented to the physical therapy department and received 30 minutes of water aerobics therapeutic exercise with the therapist for treatment of arthritis. What is the appropriate treatment code(s) or modifier for a Medicare patient on a physical therapy plan of care in an outpatient setting? a. 97113 b. 97113-50 c. 97113, 97113 d. 97110 c. 97113, 97113 61. An epidural was given during labor. Subsequently, it was determined that the patient would require a C-section for cephalopelvic disproportion because of obstructed labor. Assign the correct ICD-10-CM diagnostic and CPT anesthesia codes. (Modifiers are not used in this example.) a. O65.4, 64479 b. O65.4, O33.0, 01961 c. O65.4, 01967, 01968 d. O65.4, O33.9, 01996 c. O65.4, 01967, 01968 62. Which of the following purpose and use goals does not apply to ICD-10-PCS? a. Improved accuracy and efficiency of coding b. Reduced training effort c. Improved communication with physicians d. Improved collection of data about nursing care d. Improved collection of data about nursing care 63. Patient returns during a 90-day postoperative period from a ventral hernia repair, now complaining of eye pain. What modifier would a physician setting use with the Evaluation and Management code? a. −79, Unrelated procedure or service by the same physician during the postoperative period b. −25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service c. −21, Prolonged evaluation and management services d. −24, Unrelated evaluation and management service by the same physician during a postoperative period d. −24, Unrelated evaluation and management service by the same physician during a postoperative period 64. A 65-year-old patient, with a history of lung cancer, is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department and undergoes a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? a. Ataxia b. Fractured arm c. Metastatic carcinoma of the brain d. Carcinoma of the lung c. Metastatic carcinoma of the brain 65. The next generation of consumer-directed healthcare will be driven by a design where copayments are set based on the value of the clinical services rather than the traditional practices that focus only on costs of clinical services. What new design will focus on both the benefit and cost? a. Value-based insurance design (VBID) b. Cost-based reimbursement (CBR) c. Pay for performance design (PPD) d. Prospective payment system (PPS) a. Value-based insurance design (VBID) 66. The MS-DRG system creates a hospital's case-mix index (types or categories of patients treated by the hospital) based on the relative weights of the MS-DRG. The case mix can be figured by multiplying the relative weight of each MS-DRG by the number of within that MS-DRG. a. Admissions b. Discharges c. CCs d. MCCs b. Discharges 67. In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures performed during the same operative session, which of the following would apply? a. Bundling of services b. Outlier adjustment c. Pass-through payment d. Discounting of procedures d. Discounting of procedures 68. Sometimes hospital departments must work together to solve claims issue errors to prevent them from happening over and over again. What departments would need to work together if an audit found that the claim did not contain the procedure code or charge for a pacemaker insertion? a. Health Information and Business Office b. Health Information and Materials Management c. Health Information, Business Office, and Cardiac Department d. Health Information and Radiology c. Health Information, Business Office, and Cardiac Department 69. The goal of coding compliance programs is to reduce: a. Liability in regards to fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments a. Liability in regards to fraud and abuse 70. Medicare's newest claims processing payment contract entities are referred to as . a. Annually b. Monthly c. Semiannually d. Weekly a. Annually 80. The government sponsored program that provides expanded coverage of many health care services including HMO plans, PPO plans, special needs and Medical Savings accounts is: a. Medicare Advantage b. Medicare Part A c. Medicare Part B d. Medigap a. Medicare Advantage 81. Medical necessity for inpatient services does not always include: a. LCDs b. Related monetary benefits to payers c. Uniform written procedures for appeals d. Concurrent review a. LCDs 82. If another status T procedure were performed, how much would the facility receive for the second status T procedure? Billing Number Status Indicator CPT/HCPCS APC 998323 V 99285-25 0612 998324 T 25500 0044 998325 X 72050 0261 998326 S 72128 0283 998327 S 70450 0283 a. 0 percent b. 50 percent c. 75 percent d. 100 percent b. 50 percent 83. Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for: a. The placement of the catheter b. The placement of the catheter and the infusion procedure c. The infusion procedure d. Neither the placement of the catheter nor the infusion procedure c. The infusion procedure 84. Which of the following would a health record technician use to perform the billing function for a physician's office? a. CMS-1500 b. UB-04 c. UB-92 d. CMS 1450 a. CMS-1500 85. Which of the following is not an essential data element for a healthcare insurance claim? a. Revenue code b. Procedure code c. Provider name d. Procedure name d. Procedure name 86. Denials of outpatient claims are often generated from all of the following edits except: a. NCCI (National Correct Coding Initiative) b. OCE (outpatient code editor) c. OCE (outpatient claims editor) d. National and local policies c. OCE (outpatient claims editor) 87. A coding audit shows that an inpatient coder 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 should be done in this case? a. Require all coders to implement this practice b. Report the practice to the OIG c. Counsel the coder and stop the practice immediately d. Put the coder on unpaid leave of absence c. Counsel the coder and stop the practice immediately 88. Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system? a. Children's b. Rural c. State supported d. Tertiary a. Children's 89. Which of the following best describes the type of coding utilized when a CPT/HCPCS code is assigned directly through the charge description master for claim submission and bypasses the record review and code assignment by the facility coding staff? a. Hard coding b. Soft coding c. Encoder coding d. Natural-language processing coding a. Hard coding 90 Solutions to address the problem of dirty claims include all of the following except: a. Submitting paper claims b. Submitting claims electronically c. Using electronic health record system that eliminates manual or duplicate entry of data d. Auditing claims' accuracy and compliance with edits prior to submitting a. Submitting paper claims 91. Diagnosis-related groups are organized into: a. Case-mix classifications b. Geographic practice cost indices c. Major diagnostic categories d. Resource-based relative values c. Major diagnostic categories 92. The Medicare program pays for health care services Social Security benefits for those age 65 and older, permanently disabled people and those with: a. End stage renal disease b. Military experience c. Medicaid 998326 S 72128 0283 998327 S 70450 0283 a. 1 b. 4 c. 5 d. 3 c. 5 101. What statement is not reflective of meeting medical necessity requirements? a. A service or supply provided for the diagnosis, treatment, cure, or relief of a health condition, illness, injury, or disease. b. A service or supply provided that is not experimental, investigational, or cosmetic in purpose. c. A service provided that is necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease, or its symptoms. d. A service provided solely for the convenience of the insured, the insured's family, or the provider. d. A service provided solely for the convenience of the insured, the insured's family, or the provider. 102. In a managed fee-for-service arrangement, which of the following would be used as a cost- control process for inpatient surgical services? a. Prospectively precertify the necessity of inpatient services b. Determine what services can be bundled c. Pay only 80 percent of the inpatient bill d. Require the patient to pay 20 percent of the inpatient bill a. Prospectively precertify the necessity of inpatient services 103. If a patient's total outpatient bill is $500, and the patient's healthcare insurance plan pays 80 percent of the allowable charges, what is the amount owed by the patient? a. $10 b. $40 c. $100 d. $400 c. $100 104. What system reimburses hospitals a predetermined amount for each Medicare inpatient admission? a. APR-DRG b. DRG c. APC d. RUG b. DRG We have an expert-written solution to this problem! 105. Timely and correct reimbursement is dependent on: a. Adjudication b. Clean claims c. Remittance advice d. Actual charge b. Clean claims 106. When a provider accepts assignment, this means the: a. Patient authorizes payment to be made directly to the provider b. Provider agrees to accept as payment in full the allowed charge from the fee schedule c. Balance billing is allowed on patient accounts, but at a limited rate d. Participating provider receives a fee-for-service reimbursement b. Provider agrees to accept as payment in full the allowed charge from the fee schedule 107. Effective October 16, 2003, under the Administrative Simplification Compliance section of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all healthcare providers must electronically submit claims to Medicare. Which is the electronic format for hospital technical fees? a. 837I b. 837P c. UB-04 d. 1500 a. 837I 108. Given the following information, which of the following statements is correct? Weight Discharges Geometric Mean Arithmetic Mean 0.9757 10 4.1 5.0 0.7254 20 3.3 4.0 1.4327 10 5.4 6.7 1.0056 20 4.4 5.3 0.7316 10 3.5 4.1 a. In each MS-DRG the geometric mean is lower than the arithmetic mean. b. In each MS-DRG the arithmetic mean is lower than the geometric mean. c. The higher the number of patients in each MS-DRG, the greater the geometric mean for that MS-DRG. d. The geometric means are lower in MS-DRGs that are associated with a CC or MCC. a. In each MS-DRG the geometric mean is lower than the arithmetic mean. 109. Promoting correct coding and control of inappropriate payments is the basis of NCCI claims processing edits that help identify claims not meeting medical necessity. The NCCI automated prepayment edits used by payers is based on all of the following except: a. Coding conventions defined in the CPT book b. National and local policies and coding edits c. Analysis of standard medical and surgical practice d. Clinical documentation in the discharge summary d. Clinical documentation in the discharge summary 110. The NCCI editing system used in processing OPPS claims is referred to as: a. Outpatient code editor (OCE) b. Outpatient national editor (ONE) c. Outpatient perspective payment editor (OPPE) d. Outpatient claims editor (OCE) a. Outpatient code editor (OCE) 111. In the acute care facility, the patient identity management tool that ensures that the right patient connects to the right information relies on: a. Master Patient Index (MPI) b. Case Mix Index (CMI) c. The Organization's clinical staff d. Cancer Registry a. Master Patient Index (MPI) 112. What is the function of a consultation report? a. Provides a chronological summary of the patient's medical history and illness b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care d. Emergency care administered before arrival at the facility c. Patient's complete medical history 122. A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." Which part of a POMR progress note would this notation be written? a. Subjective b. Objective c. Assessment d. Plan c. Assessment 123. Which of the following provides macroscopic and microscopic information about tissue removed during an operative procedure? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report d. Pathology report 124. 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 b. Objective 125. 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 fashion. a. Anesthesia report b. Physician progress notes c. Operative report d. Recovery room record c. Operative report 126. What is the function of physician's orders? a. Provide a chronological summary of the patient's illness and treatment b. Document the patient's current and past health status c. Document the physician's instructions to other parties involved in providing care to a patient d. Document the provider's follow-up care instructions given to the patient or patient's caregiver c. Document the physician's instructions to other parties involved in providing care to a patient We have an expert-written solution to this problem! 127. The following is documented in an acute-care record: "Atrial fibrillation with rapid ventricular response, left axis deviation, left bundle branch block." Where would this documentation be found? a. Admission order b. Clinical laboratory report c. ECG report d. Radiology report c. ECG report 128. Which of the following contains the physician's findings based on an examination of the patient? a. Physical examination b. Discharge summary c. Medical history d. Patient instructions a. Physical examination 129. The following is documented in an acute-care record: "Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN." Where would this documentation be found? a. Admission order b. History c. Physical examination d. Progress notes a. Admission order 130. The admitting data of Mrs. Smith's health record indicated that her birth date was March 21, 1948. On the discharge summary, Mrs. Smith's birth date was recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? a. Data completeness b. Data consistency c. Data accessibility d. Data comprehensiveness a. Data completeness 131. What is the defining characteristic of an integrated health record format? a. Each section of the record is maintained by the patient care department that provided the care. b. Integrated health records are intended to be used in ambulatory settings. c. Integrated health records include both paper forms and computer printouts. d. Integrated health record components are arranged in strict chronological order. d. Integrated health record components are arranged in strict chronological order. 132. Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? a. Data completeness b. Data relevancy c. Data currency d. Data precision c. Data currency 133. Documentation of aides who assist a patient with activities of daily living, bathing, laundry, and cleaning would be found in which type of specialty record? a. Home health b. Behavioral health c. End-stage renal disease d. Rehabilitative care a. Home health 134. 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." a. Medical laboratory report b. Physical examination c. Physician progress note d. Radiography report d. Radiography report a. Pay for performance and quality 144. Notices of privacy practices must be available at the site where the individual is treated and: a. Must be posted next to the entrance b. Must be posted in a prominent place where it is reasonable to expect that patients will read them c. May be posted anywhere at the site d. Do not have to be posted at the site b. Must be posted in a prominent place where it is reasonable to expect that patients will read them 145. Which of the following laws created the Healthcare Integrity and Protection Data Bank? a. Health Information Portability and Accountability Act b. American Recovery and Reinvestment Act c. Consolidate Omnibus Budget Reconciliation Act d. Healthcare Quality Improvement Act a. Health Information Portability and Accountability Act 146. A record of all transactions in the computer system that is maintained and reviewed for unauthorized access is called a(n) . a. Security breach b. Audit trail c. Unauthorized access d. Privacy trail b. Audit trail 147. A health information technician (HIT) is hired as the chief compliance officer for a large group practice. In evaluating the current program, the HIT learns that there are written standards of conduct and policies and procedures that address specific areas of potential fraud as well as audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? a. Compliance program education and training programs for all employees in the organization b. Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation c. Adopt procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted d. Establish a corporate compliance committee who report directly to the CFO b. Establishment of a hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation 128. A threat to data security is . a. Encryption b. Malware c. Audit trail d. Data quality b. Malware 149. Messaging standards for electronic data interchange in healthcare have been developed by: a. HL7 b. IEE c. The Joint Commission d. CMS a. HL7 150. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff d. Nursing staff 151. The HIM department is planning to scan medical record documentation. The project includes the scanning of documentation such as history and physicals, physician orders, operative reports, and nursing notes. Which of the following methods of scanning would be best to help HIM professionals monitor the completeness of health records during a patient's hospitalization? a. Ad hoc b. Concurrent c. Retrospective d. Post discharge b. Concurrent 152. Which of the following issues compliance program guidance? a. AHIMA b. CMS c. Federal Register d. HHS Office of Inspector General (OIG) d. HHS Office of Inspector General (OIG) 153. This person designs, implements, and maintains a program that ensures conformity to all types of regulatory and voluntary accreditation requirements governing the provision of healthcare products or services . a. General Counsel b. Health Information Director c. Privacy Officer d. Compliance Officer d. Compliance Officer 154. An accounting of disclosures must include disclosures . a. For use in law enforcement requests b. To any patient family member who makes a request c. To any individual who requested the information d. Made for public health reporting purposes d. Made for public health reporting purposes 155. In 2009, the HHS and DOJ created the to prevent waste, fraud and abuse, reduce health care costs and improve the quality of care provided to Medicare patient: a. Office of Inspector General (OIG) b. Recovery Audit Contractor (RAC) c. Quality Improvement Organization and Enforcement (QIO) d. Health Care Fraud Prevention Team (HEAT) d. Health Care Fraud Prevention Team (HEAT) 156. All of the following should be part of the core areas of a coding compliance plan except: a. Physician query process b. Correct use of encoder software c. Coding diagnoses supported by medical record documentation d. Tracking length of stay d. Tracking length of stay a. Submitting an action plan of steps the employee will do to resolve the issue and improve performance b. Job termination c. Informal counseling or verbal warning d. Put the coder on unpaid leave of absence c. Informal counseling or verbal warning 167. Data security refers to . a. Guaranteeing privacy b. Controlling access c. Using uniform terminology d. Transparency b. Controlling access 168. Using uniform terminology is a way to improve: a. Validity b. Data timeliness c. Audit trails d. Data reliability d. Data reliability 169. An encoder that is built using expert system techniques such as rule-based systems is a(n): a. Encoder interface b. Logic-based encoder c. Automated code book encoder d. Grouper b. Logic-based encoder 170. The was issued by the Office of the National Coordinator (ONC) for health information technology to be a resource to the nation as a vision and reference: a. Health Information Technology for Economic and Clinical Health (HITECH) b. American Recovery and Reinvestment Act (ARRA) c. Meaningful Use (MU) Program d. Federal Health Information Technology Strategic Plan 2015-2020 d. Federal Health Information Technology Strategic Plan 2015-2020 171. Which of the following make data entry easier but may harm data quality? a. Use of templates b. Copy and paste c. Drop-down boxes d. Structured data b. Copy and paste 182. One form of computer-assisted coding may use, which means that digital text from online documents stored in the information system is read directly by the software, which then suggests codes to match the documentation. a. Encoded vocabulary b. Natural-language processing c. Data exchange standards d. Structured reports b. Natural-language processing 173. Which of the following is not an element of data quality? a. Accessibility b. Data backup c. Precision d. Relevancy b. Data backup 174. One form of uses software to aid the physician in selecting the correct code with processes such as drop-down boxes or the use of touch-screen terminals. a. Integrated workflow processes b. Computer-assisted coding c. Electronic document management system d. Speech recognition system b. Computer-assisted coding 175. A transition technology used by many hospitals to increase access to medical record content is . a. EHR (electronic health record) b. EDMS (electronic document management system) c. ESA (electronic signature authentication) d. PACS (picture archiving and communication system) b. EDMS (electronic document management system) 176. 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. Electronic signature authentication 177. Electronic systems used by nurses and physicians to document assessments and findings are called: a. Computerized provider order entry b. Electronic document management systems c. Electronic medication administration records d. Electronic patient care charting d. Electronic patient care charting 178. Coders will assign codes that have been selected into a computer program called a(n) to assign the patient's case to the correct group based on ICD-10-CM/PCS and/or CPT/HCPCS codes. a. Encoder b. Computer-assisted coding c. Natural-language processor d. Grouper d. Grouper 179. Data definition refers to: a. Meaning of data b. Completeness of data c. Consistency of data d. Detail of data a. Meaning of data 180. A special webpage that offers secure access to data is called a(n) . a. Access control d. Spouse; adult child; parent; adult sibling d. Spouse; adult child; parent; adult sibling 190. Which of the following statements is false? a. A notice of privacy practices must be written in plain language. b. Consent for use and disclosure of information must be obtained from every patient. c. An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operations. d. A notice of privacy practices must give an example of a use or disclosure for healthcare operations. b. Consent for use and disclosure of information must be obtained from every patient. 191. Which document directs an individual to bring originals or copies of records to court? a. Summons b. Subpoena c. Subpoena duces tecum d. Deposition c. Subpoena duces tecum 192. Written or spoken permission to proceed with care is classified as . a. An advanced directive b. Formal consent c. Expressed consent d. Implied consent c. Expressed consent 193. 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. Is information from which personal characteristics have been stripped 194. The number that has been proposed for use as a unique patient identification number but is controversial because of confidentiality and privacy concerns is the . a. Social security number b. Unique physician identification number c. Health record number d. National provider identifier a. Social security number 195. 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. E-discovery 196. What is the legal term used to define the protection of health information in a patient- provider relationship? a. Access b. Confidentiality c. Privacy d. Security b. Confidentiality 197. A well-informed patient will know that the HIPAA Privacy Rule requires that individuals be able to . a. Request restrictions on certain uses and disclosures of PHI b. Remove their record from the facility c. Deny provider changes to their PHI d. Delete portions of the record they think are incorrect a. Request restrictions on certain uses and disclosures of PHI 198. The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? a. Minimum Necessary b. Notice of Privacy Practices c. Authorization d. Consent a. Minimum Necessary We have an expert-written solution to this problem! 199. The term minimum necessary means that healthcare providers and other covered entities must limit use, access, and disclosure to the minimum necessary to . a. Satisfy one's curiosity b. Accomplish the intended purpose c. Treat an individual d. Perform research b. Accomplish the intended purpose 200. Exceptions to the consent requirement include . a. Medical emergencies b. Provider discretion c. Implied consent d. Informed consent a. Medical emergencies