AHIMA CCA COMPILATION BUNDLE

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur nea...

A 32-year-old patient has a colonoscopy with removal of three polyps by snare. Moderate sedation was used and provided by the physician. The intraservice time was 30 minutes. Correct Answer: 45385, 99156, 99157 A code of 45385 should be used for the colonoscopy procedure with the removal of polp...

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 ...

1. 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...

Name the 4 Cooperating Parties for ICD-9-CM Correct Answer: 1) AHIMA, 2) AHA-American Hospital Association, 3) CMS-Centers for Medicare and Medicaid, and 4) NCHS-National Center for Health Statistics What is a POA Indicator? Correct Answer: The POA-Present on Admission Indicator is used to diff...

Audit trails Correct Answer: can provide tracking information such as who accessed which records and for what purpose AMA Correct Answer: CPT was developed and is maintained by: The discharge summary Correct Answer: is a concise account of the patient's illness, course of treatment, respon...

1. Identify the CPT code for a 42-year-old diagnosed with ESRD who requires home dialysis for the month of April. a. 90965 b. 90964 c. 90966 d. 90970 Correct Answer: Correct Answer: C Dialysis, end-stage renal disease. Code 90966 is for end-stage renal disease (ESRD) related servic...

1. Identify the diagnosis code[s] for carcinoma in situ of vocal cord. a. 231.0 b. 161.0 c. 239.1 d. 212.1 Correct Answer: a. 231.0 Index Carcinoma, in situ, see also Neoplasm, by site, in situ. 2. Identify the diagnosis code[s] for melanoma of skin of shoulder. 1. 172.8, 172.6 b. 1...

A patient presents with a pyloric mass. A laparotomy, excision of the mass, and extensive lysis of adhesions of the small intestine are performed. What are the correct ICD-10-PCS codes for this visit? 1) 0DB70ZZ, 0DNF0ZZ 2) 0DJ60ZZ, 0DN80ZZ 3) 0DT60ZZ, 0DN80ZZ 4) 0DB70ZZ, 0DN80ZZ Correct An...

1. 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 patien...

1. Data security policies and procedures should be reviewed at least: a. Semi-annually b. Annually c. Every two years d. Quarterly Correct Answer: Correct Answer: B All data security policies and procedures should be reviewed and evaluated at least every year to make sure they are ...

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 Correct Answer: b. confidentiality confidentiality is a legal ethical concept that establishes the healthcare provider's respo...

1. Given the following information, which of the following statements is correct? 191, MCD: 04, Type: MED MS-DRG, Title: Chronic obstructive pulmonary disease w/ CC, Weight: 0.9757, Discharges: 10, Geometric Mean: 4.1, Arithmetic Mean: 5.0, 192, MCD: 04, Type: COPD w/o CC/MCC, Weight: 0.7254, ...

1. In a joint effort of the Department of Health and Human Services [DHHS], Office of Inspector General [OIG], Centers for Medicare and Medicaid Services [CMS], and Administration on Aging [AOA], which program was released in 1995 to target fraud and abuse among healthcare providers? a. operation...