CCA Mock Exam

CCA Mock Exam 1. Patient undergoes a posterior L1-L5 spinal fusion for scoliosis with placement of a Harrington rod. Code using CPT. a. 22612, 22800, 22841 b. 22800, 22840 c. 22800, 22842 d. 22800, 22846 2. D&C for missed abortion, first trimester. (Code CPT for procedures.) a. 59850 b. 59840 c. 59820 d. 59855 3. You would expect to find documentation regarding the assessment of an obstetric patient's lochia, fundus, and perineum on the a. prenatal record. b. delivery room record. c. labor record. d. postpartum record. 4. Procedure-to-Procedure (PTP) Edits review claims for codes that report a. durable medical equipment without medical necessity. b. diagnosis codes that have been deleted. c. procedures that cannot or should not be provided to the same patient on the same day. d. post-operative therapies. 5. It is September 15th, and you have just received the upcoming year’s ICD-10-PCS code set updates. The next step is to ________. a. notify the physicians so they are aware b. put in a change ticket for the hospital’s chargemaster to be updated c. wait until the codes come into effect on October 1st d. immediately work to memorize new codes 6. Hysteroscopy with D&C and polypectomy. (Code CPT for procedures.) a. 58563 b. 58120, 58100, 58555 c. 58558, 58120 d. 58558 7. Patient came to the hospital ambulatory surgical center for repair of incisional inguinal hernia. This is the second time the patient has developed this problem. The hernia was repaired with Gore-Tex graft. Choose the appropriate ICD-10-CM and CPT codes. a. K40.91, 49565, 49568 b. K40.40, K43.9, 49560, 49568 c. K43.9, K40.90, 49520, 49568 d. K40.40, 49565

8. You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to a. improve your department's processes. b. compare your department with another. c. implement your QI process. d. make recommendations for improvement to the other department or organization. 9. 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 a. explain that this would be a HIPAA violation. b. encrypt the phone so access is protected. c. send the physician to computer classes. d. limit the physician's access to the hospital's network. 10.The APC payment system is based on what coding system(s)? a. CPT and ICD-10-CM diagnosis and procedure codes b. AMA's CPT codes c. ICD-10-CM diagnosis and procedure codes d. CPT/HCPCS codes 11.The Joint Commission requires that all medical records be completed within ___________ following patient discharge. a. 90 days b. 30 days c. 14 days d. 7 days 12.Patient has breast carcinoma and is now undergoing complete axillary lymphadenectomy. (Code for physician using CPT procedure codes only.) a. 38562 b. 38740 c. 38745 d. 38525 13.You have been hired to work with a computer-assisted coding (CAC) initiative. The technology that you will be working with is a. intraoperability. b. message standards. c. electronic data interchange. d. natural language processing. 14.External audits may be conducted by several organizations in the federal government as well as the private sector, including ________. a. Humana Fraud Department b. any of these c. OIG d. RAC

22.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? a. observation and evaluation without need for further medical care b. chronic cough c. diagnosis of unknown etiology d. lung cancer 23.Single lung transplant without cardiopulmonary bypass. (Code for physician using CPT procedure codes only.) a. 32850 b. 32652 c. 32852 d. 32851 24.A final progress note is appropriate as a discharge summary for a hospitalization in which the patient a. dies within 24 hours of admission. b. was an obstetric admission with a normal delivery and no complications. c. has no comorbidities or complications during this episode of care. d. was admitted within 30 days with the same diagnosis. 25.Security devices that form barriers between routers of a public network and a private network to protect access by unauthorized users are called a. data manipulation engines. b. passwords. c. data translators. d. firewalls. 26.NCCI edits were developed by the Centers for Medicare and Medicare Services (CMS) to a. identify noncompliant coding processes. b. update the code sets each year. c. both reinforce accurate coding and identify noncompliant coding processes. d. reinforce accurate coding on claims. 27.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 a. regular in-service presentations on documentation, including its importance and tips for improvement. b. a copy of the facility coding guidelines, along with written information on improved documentation. c. feedback on specific instances when improved documentation would improve coding. d. the UHDDS and information on where each data element is collected and/or verified in your facility.

28.Cesarean delivery with antepartum and postpartum care. (Code CPT for procedures.) a. 59514 b. 59510 c. 59610 d. 59400 29.NCCI stands for a. Neutral Collective Coding Initiatives. b. Native Coding and Collective Initiatives. c. National Correct Coding Initiative. d. New Coding and Correlative Infections. 30.While CAC systems are convenient, the codes they determine must be validated to ensure accuracy. One method to do this would be a. a prospective audit. b. a current audit. c. a retrospective audit. d. a noncompliance audit. 31.The outpatient method for reimbursement from CMS for Medicare is a. Usual, Customary, Reasonable (UCR). b. Ambulatory Patient Classification (APC). c. Diagnosis-related Groups (DRGs). d. Resource-Based Relative Value Scale (RBRVS). 32.All of these are acceptable destruction methods when health records are no longer required, EXCEPT a. magnetic degaussing for computerized data. b. shredding or cutting of DVDs. c. deleting files from the server. d. burning, shredding, or pulverizing of paper records. 33.Excision 2 cm subcutaneous soft tissue lipoma of the back. (Code for diagnoses using ICD-10-CM. Code for procedure using CPT.) a. D23.9, 21556 b. D17.30, 21925 c. D23.5, 11600 d. D17.1, 21930 34.A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist. a. 77307 b. 77334 c. 77315 d. 77263

41.The patient was brought in by ambulance to the Emergency Department. An EKG and bloodwork were completed, and the patient was discharged, with a recommendation to see his cardiologist. The next day, the cardiologist admitted this patient to the surgery ward to prepare for a valve replacement procedure. The EKG performed in the ED the day before should a. be reported as an inpatient procedure. b. be reported by the cardiologist. c. not be reported at all. d. be reported as an outpatient procedure. 42.The special form that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities is the a. interdisciplinary patient care plan. b. problem list. c. medical history and review of systems. d. interval summary. 43.As part of a concurrent record review, you need to locate the initial plan of action based on the attending physician's initial assessment of the patient. You can expect to find this documentation either within the body of the history and physical or in the a. review of systems. b. doctor's admitting progress note. c. discharge summary. d. nurse's admit note. 44.Patient was seen for excision of two interdigital neuroma from the left foot. a. 64774 b. 28080 c. 64776 d. 28080, 28080 45.Patient was seen today for regular hemodialysis. No problems reported; patient tolerated procedure well. a. 90937 b. 90935 c. 99354 d. 90945 46.Office visit for 43-year-old male, new patient, with no complaints. Patient is applying for life insurance and requests a physical examination. A detailed health and family history was obtained, and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected. a. 99386 b. 99381 c. 99450 d. 99396

47.If a claim is returned as denied or rejected due to an error, the best thing to do is a. write the loss off as unrecoverable. b. resubmit the same claim form, with no changes, to hope for a different outcome. c. correct the claim and resubmit in accordance with the third-party payer. d. send a bill to the patient. 48.Which of the following is vital for determining why the reimbursement from an insurance company is less than that was expected? a. knowledge of the individual insurance company's policies b. talking to the patient c. a CPT codebook d. the remittance advice 49.The most efficient way to determine the accurate DRG (Diagnosis Related Group) is to utilize software known as a. ADA. b. a grouper. c. CAC. d. CPOE. 50.Linking diagnosis codes to the CPT codes reported on a claim provides evidence of a. medical necessity. b. third-party payer coverage. c. complete evaluation and management exam. d. adherence to coding guidelines. 51.The purpose of the Correct Coding Initiative is to a. detect and prevent payment for improperly coded services. b. teach coders how to unbundle codes. c. restrict Medicare reimbursement to hospitals for ancillary services. d. increase fines and penalties for bundling services into comprehensive CPT codes. 52.Ensuring that data have been modified or accessed only by individuals who are authorized to do so is a function of data a. validity. b. accuracy. c. integrity. d. quality. 53.DNR and DNI documents are all part of what are known as a. health insurance consent forms. b. advance directives. c. admission forms. d. release of information forms. 54.Patient was seen in the emergency department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. a. 12002, 12004 b. 12004 c. 12045 d. 12035

62.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. a. medical outcomes studies b. recovery audit contractors (RACs) c. adjusted clinical groups (ACGs) systems d. Atlas Systems 63.Female with 6 months of stress incontinence. Laparoscopic urethral suspension was completed. Choose the appropriate ICD-10-CM and CPT codes. a. R32, 51845 b. N39.41, 51840 c. N39.3, 51990 d. N39.42, 51992 64.An ethical physician’s query cannot include ________. a. a recommendation for an answer b. the patient’s name c. the diagnosis or procedure in question d. suggested “answer by” date 65.An HIM professional was tasked with analyzing a group of medical records qualitatively for deficiencies. This would include a. identifying the number of medical records which are incomplete. b. calculating the percentage of medical records without physician signatures. c. reviewing medical records for missing or ambiguous details. d. quantifying the completion rate by pediatric oncologists. 66.Provide the CPT code for a patient that had a complicated removal of a wrist prosthesis. a. 25250 b. 25251 c. 25259 d. 25246 67.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 a. require Louis to go through HIPAA training again. b. require Louis to go through HIPAA training again and explain to him the illegality of posting any protected information on social media. c. explain to Louis the risk of permitting his nephew to post on social media from the facility. d. tell Louis not to let his nephew continue to do this again. That is sufficient.

68.A claim may be returned by the third-party payer unpaid because it was denied or rejected. If eligibility and coverage was checked prior to the patient being seen, the denial may be due to any of these reasons EXCEPT a. a typo in the policy number. b. an incorrect or incomplete diagnosis code. c. an inaccurate NPI or absence of the NPI. d. the claim submitted is clean. 69.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 a. witnessed by the patient whose record is being destroyed. b. done only with patient's express permission. c. documented as to method and date. d. recoverable only by authorized individuals and agencies. 70.Lumbar laminectomy (one segment) for decompression of spinal cord. (Code CPT for procedures.) a. 62263 b. 63030 c. 63005 d. 63170 71.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 a. identify the attending physician. b. describe any procedures, services, or treatments that had been performed. c. lead to one specific person. d. confirm a diagnosis or diagnoses. 72.Total transcervical thymectomy. (Code CPT for procedures.) a. 60200 b. 60240 c. 60540 d. 60520 73.The chargemaster relieves the coders from coding repetitive services that require little, if any, formal documentation analysis. This is called a. grouping. b. hard coding. c. soft coding. d. mapping.

78.The following data is required to be included in a patient health record, EXCEPT a. diagnoses. b. vital signs. c. copies of all claims submitted. d. immunization dates. 79.The _______ has the duty to adjust the MS-DRGs if necessary at the beginning of every fiscal year beginning _____________. a. IG, October 1 b. AHA, January 1 c. CMS, January 1 d. CMS, October 1 80.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 a. they should both be coded, chronic sequenced first. b. they should both be coded, acute sequenced first. c. only the chronic condition should be coded. d. only the acute condition should be coded. 81.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 developed during this episode of care is in the a. doctors' progress note section. b. operative report. c. history and physical. d. doctors' orders. 82.CMS delegates its daily operations of the Medicare and Medicaid programs to a. the PRO in each state. b. the office of Inspector General. c. the National Center for Vital and Health Statistics. d. Medicare administrative contractor (MAC). 83.The Master Patient Index, __________, which can be used to access data for analysis. a. catalogs patients by principal diagnosis code b. collates patient information from separate systems c. lists all physicians within one facility on one specific date d. is the same as Case Mix Index 84.Patient self-reported documentation may also be used to assign codes for social determinants of health, with the requirement that a. the patient has the report notarized. b. the physician includes these details in the encounter documentation. c. lab reports confirm that patient's story. d. a nurse or other clinician witness the patient's story.

85.CAC software is used to analyze health care documents and produce appropriate medical codes. This may be used by some health care facilities when there are an insufficient number of certified medical coding candidates. CAC stands for a. Computed Axial Classification. b. Cost Analysis Coding. c. Certified Alcohol Counselor. d. Computer-Assisted Coding. 86.Patient presents to the GI lab for a colonoscopy. During the colonoscopy, polyps were discovered in the ascending colon and in the transverse colon. Polyps in the ascending colon were removed via hot biopsy forceps, and the polyps in the transverse colon were removed by snare technique. a. D12.2, 44392, 44394-59 b. D12.2, D12.3, 45355 c. D12.2, D12.3, 45384, 45385-59 d. D12.3, 45355, 45383-59 87.The patient was seen by the physician on September 30. By the time the documentation reached the medical coder, it was October 2. The code set required to report the appropriate diagnosis is a. the coder may choose which code set to use. b. the 2023 ICD-10-CM code set. c. the 2022 ICD-10-CM code set. d. the third-party payer will choose which code set to use. 88.Provide the CPT code(s) for anesthesia services for the transvenous insertion of a pacemaker. a. 33206, 00560 b. 33202, 00530 c. 00530 d. 00560 89.The patient was admitted through the Emergency Department and she is anxious about notifying her spouse and her sister. Her spouse is out of town on business and her sister lives in another state. The patient is worried about how they can get updates when she is in surgery, when they cannot prove how they are related to her to clear HIPAA limitations. You tell her not to worry, because a. the hospital can use facial recognition. b. the hospital can assign special pass codes. c. they will need to wait until she is out of surgery. d. the hospital can use voice recognition.

95.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. external audit b. legal audit c. circular audit d. internal audit 96.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. a. six years b. three years c. two years d. individual facility’s policy 97.The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. a. 34203 b. 35302 c. 35226 d. 37799 98.Which of the following is classified as a poisoning in ICD-10-CM? a. reaction to dye administered for pyelogram b. idiosyncratic reaction between various drugs c. digitalis intoxication d. syncope due to Contac pills and a three-martini lunch 99.In most situations the person who authorizes release of medical information is the a. health care provider. b. patient. c. CEO. d. CFO. 100. Based on the following documentation in an acute care record, where would you expect this excerpt to appear? a. physical examination b. physician progress notes c. nursing progress notes d. operative report