Certified Coding Associate (CCA) Exam

Preparation 2022- with rationale

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 consistently 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 the

following 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 data

a. 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 controls