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Professional Review Guide for the CCA Examination 2009 Edition

Patricia J. Schnering, RHIA, CCS Toni Cade, MBA, RHIA, CCS, FAHIMA Lisa Delhomme, MHA, RHIA Irene L. E. Mueller, EdD, RHIA

PRG Publishing, Inc. Professional Review Guides, Inc.

TABLE OF CONTENTS

INTRODUCTION ...................................................................................................................................ix Patricia J. Schnering, RHIA, CCS I. EXAMINATION STUDY STRATEGIES AND RESOURCES .............................................................1 Patricia J. Schnering, RHIA, CCS II. CODING REVIEW ............................................................................................................................13 Toni Cade, MBA, RHIA, CCS, FAHIMA III. HEALTH DATA CONTENT, REQUIREMENTS, AND STANDARDS.............................................49 Patricia Schnering, RHIA, CCS IV. MEDICAL SCIENCE .......................................................................................................................77 Irene L. E. Mueller, EdD, RHIA V. CLASSIFICATION SYSTEMS AND SECONDARY DATA SOURCES...........................................99 Lisa Delhomme, MHA, RHIA VI. ICD-9-CM CODING .......................................................................................................................133 Toni Cade, MBA, RHIA, CCS, FAHIMA VII. CPT CODING ...............................................................................................................................189 Toni Cade, MBA, RHIA, CCS, FAHIMA Lisa Delhomme, MHA, RHIA VIII. MEDICAL BILLING AND REIMBURSEMENT SYSTEMS .........................................................241 Toni Cade, MBA, RHIA, CCS, FAHIMA IX. CCA QUIZ .....................................................................................................................................273 Toni Cade, MBA, RHIA, CCS, FAHIMA Lisa Delhomme, MHA, RHIA X. CCA MOCK EXAMINATION..........................................................................................................283 Lisa Delhomme, MHA, RHIA APPENDICES APPENDIX A--Pharmacology .................................................................................................................319 APPENDIX B--Laboratory Testing......................................................................................................... 329 APPENDIX C--Official ICD-9-CM Guidelines For Coding And Reporting (Effective October 1, 2008) ........................................................................................................................ 333 Evaluation form.................................................................................................................................453

vii

Introduction

Patricia J. Schnering, RHIA, CCS

Introduction · xi

INTRODUCTION TO THE PROFESSIONAL REVIEW GUIDE FOR THE CCA EXAMINATION

The Certified Coding Associate (CCA) Certification is for entry-level coders. In the Certified Coding Associate (CCA) candidate handbook from AHIMA, it is suggested that the candidates have at least 6 months' experience applying ICD-9-CM and CPT-4 coding conventions and guidelines, or have completed either an AHIMA-approved coding certificate program or other formal coding training. This examination review guide represents a renewed effort to provide materials for HIM students and professionals. In reviewing the results of past examinations, we found that it would be beneficial for examination candidates to have additional practice in answering multiple-choice questions. We have selected questions to cover the broad topic of categories necessary for sitting for the CCA Certification Examination. Researching the questions and cases as you study should increase your knowledge such that, when you encounter similar questions, you can arrive at the correct answer. We believe that this review material will jog your memory and build on information you have already gained through your education and professional experiences. This book provides you with a mix of coding questions to both increase your coding skills and provide you with testing that mimics the exam format. The questions in this examination review guide are based on the broad competencies listed in the AHIMA Candidate Handbook for the CCA Examination. Review the latest candidate handbook when preparing for the exam. The beginning of this book offers suggestions for studying and test-taking strategies and a coding review section. The following chapters contain multiple-choice questions covering the competencies for the exam. Then there is a mock examination containing 100 multiple-choice questions. The back of the book contains appendices with information on pharmacology and laboratory testing. We chose to format the book by creating a Health Data Content and Structure section that includes: · · · · Health Records and Data Content Health Information Requirements and Standards Information and Communications Technologies Privacy, Confidentiality, Legal, and Ethical Issues

We included a separate section on biomedical sciences since it is imperative that candidates have a broad understanding of medical terminologies, anatomy and physiology, and disease processes. The Clinical Classification Domain follows the Medical Sciences and includes chapters on: · · · Classification Systems and Secondary Data Sources ICD-9-CM Coding CPT Coding

Then, Reimbursement Methodologies Domain has a chapter before you begin the Mock Exam for the CCA. Appendix A Pharmacology has the most common prescription drugs with examples of diagnoses. Appendix B Laboratory Testing has a listing of common lab tests with the use and possible diagnoses for abnormal levels.

xii · Introduction Table 1 displays the major content areas of this book by sections. Table 1 Professional Review Guide for the CCA Examination Content Areas Content area Number of questions Health Records and Data Content and Structure 89 Data Records and Content Health Information Requirements and Standards Information and Communications Technologies Privacy, Confidentiality, Legal, and Ethical Issues Biomedical Sciences 115 Anatomy and Physiology Medical Terminology Pathophysiology, Disease Process, Pharmacology Clinical Classification 553 Classification Systems and Secondary Data Sources 110 ICD-9-CM Coding 210 CPT Coding 233 Reimbursement Methodologies 113 CCA Quiz 20 Mock Exam 100 TOTAL QUESTIONS 990

Introduction · xiii

ABOUT THE DOMAINS

We suggest that you start by examining the competencies for the Certified Coding Associate provided on the following pages. The Domains and Task Statement Competencies were created to reflect the entry-level competencies for professional practice. A detailed copy of the entry-level competencies is provided in the AHIMA Candidate Handbook for the CCA Examination. It is the responsibility of the American Health Information Management Association's (AHIMA) Council on Certification (COC) to assess what job tasks are frequently executed by newly certified practitioners. Additionally, the COC determines the job tasks that are critical to entry-level practice--in other words, which job tasks, if done incorrectly, could create a negative impact. The process of identifying those critical job functions was accomplished by conducting a job analysis. The objective was to determine how entry-level practice is evolving and to develop the test specifications and a certification examination to correspond with changes that are occurring in the field. The data that were collected as a result of this research provided the essential elements that were necessary to establish the test specifications for the certifying exam. The COC is responsible for developing and administering the certification examination and determining the eligibility of applicants to write the exam. The entry-level task statements for the Certified Coding Associate from the AHIMA Certification Competency Statements were grouped into six domains: Health Records and Data Content Health Information Requirements and Standards Clinical Classification Systems Reimbursement Methodologies Information and Communications Technologies Privacy, Confidentiality, Legal, and Ethical Issues These six domains are divided further into task statements. Weights for each domain are assigned; however, weights were not assigned to the task statements. Each weight correlates to the degree of emphasis, or importance, given to each domain statement as it relates to the health information practice. Table 2 displays the weights that were assigned to each of the domains. The CCA examination has 100 questions (90 questions scored and 10 that are not scored for the exam). The 90 scored questions are the basis for scoring your examination. The 10 unscored questions on the CCA examination are to be used in obtaining statistical information to help in the construction of questions for future examinations. These 10 questions will not be identified in the exam, nor will they count toward the examination pass/fail score. Review the current CCA Candidate Handbook for the CCA Examination from AHIMA. The pass rate for January 1, 2008, through June 30, 2008, was 64%. Table 2 CCA Examination Content with Percentage Questions by Domain Number of Questions Domain 1 Health Records and Data Content 18 Domain 2 Health Information Requirements and Standards 13 Domain 3 Clinical Classification Systems 32 Domain 4 Reimbursement Methodologies 9 Domain 5 Information Technology and Health Care Delivery 5 Domain 6 Privacy, Confidentiality, Legal, and Ethical Issues 13 TOTAL 90 Source: 2008 AHIMA Candidate Handbook for the CCA Examination Domain Percentage of Exam 20% 14% 36% 10% 6% 14% 100%

xiv · Introduction Although we have no way of knowing exactly what questions will be on the examination, the authors have tried to cover the competencies and content areas as comprehensively as possible. Researching the questions as you study should expand your knowledge such that, should you encounter similar questions, you can arrive at the correct answer. We believe this review material will serve to help you build on information you have already gained through your experience and education. We have prepared crosswalks of the Competencies for CCA Mock Exam to the CCA Mock Exam provided in this book. See Table 3 and Table 4. Table 3 Crosswalk of Competencies to questions in the CCA Mock Examination Questions 2, 3, 4, 5, 6, 7, 8, 10, 12, 14, 15,16,17, 20, 22, 23, 24, 28, 30, 31, 34, 36, 74, 76, 89 Domain 2 2, 3, 5, 6, 9, 10, 12, 13, 14, 15, 16,17, 18, 20, 22, 23, 24, 28, 30, 31, 35, 76 Domain 3 4, 14, 15, 16, 17, 19, 21, 22, 24, 25, 26, 28, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 73, 74, 75, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100 Domain 4 9, 18, 20, 22, 71, 72 Domain 5 1,4, 8, 23, 29, 33 Domain 6 1, 11, 27, 29 Refer to the 2008AHIMA Candidate Handbook for the Certified Coding Associate (CCA). Table 4 Crosswalk of CCA Mock Exam Questions by Competency CCA Question 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 X X X X X X X X X X X X X 2 X X X Competency Domains 3 4 5 X 6 X Domains Domain 1

X X x X X X X X X X X X X X X X X

X X X X X X X X

X X X

Introduction · xv Table 4 Crosswalk of CCA Mock Exam Questions by Competency (continued) CCA Question 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 1 X 2 X Competency Domains 3 4 X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 5 6

X X X

xvi · Introduction Table 4 Crosswalk of CCA Mock Exam Questions by Competency (continued) CCA Question 1 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 2 Competency Domains 3 4 X X X X X X X X X X X X X X X X X X X X X X X 5 6

X X X

X

Introduction · xvii

ABOUT THE COGNITIVE LEVELS OF TESTING FOR THE CCA EXAMINATION

The examination questions test your knowledge on three cognitive levels: recall (RE), application (AP), and analysis (AN). The recall level tests your memory of basic facts, such as being able to identify terms, methods, and procedures. The application level tests your ability to interpret data and information, to be able to apply concepts and principles, recognize relationships among data, and calculate mathematical problems. The analysis level measures your ability to solve specific problems by evaluating, comparing, and selecting appropriate solutions for action; and to evaluate information and perform multiple calculations to assemble various elements into a total picture. The following table shows the number of questions by domain and cognitive level. Cognitive Levels for Questions in Part I of the CCA Examination Cognitive Levels Number of Questions Percentage of Questions Recall 32 32 Application 58 58 Analysis 10 10 Total 100 100 Source: 2008 AHIMA Candidate Handbook for the CCA Examinations The general format of the exam is primarily designed to engage your problemsolving and critical thinking skills. These types of questions require you to translate and apply what you have learned as well as interpret information. There are sample questions provided on the AHIMA Web site (http://www.AHIMA.org) so that you can experience the testing situation.

xviii · Introduction

ADDITIONAL INSIGHTS ABOUT THE CCA EXAMINATION

1. Computerized Testing: You will be able to review questions on the computer screen to check your answers before you close the exam file on the computer. 2. On-Screen Information: Any additional information needed to complete the questions will be available on the screen in the testing software. 3. Health Information Systems: These questions tend to be interspersed throughout the other topic categories. From the reality of the workplace, you know that computers are involved in almost every aspect of HIM/Medical Record functions, e.g., coding, billing, and reimbursement, auditing, abstracting, quality studies, etc. Therefore, it stands to reason that questions related to information systems could show up in virtually any category in the CCA Examination questions. 4. Biomedical Sciences: These questions tend to be interspersed throughout the other topic categories. Medical terminology, pathophysiology, and anatomy and physiology are part of the general knowledge base for health information management, coding, and reimbursement. 5. National Exam: Keep in mind that this is a national examination. Concentrate on federal legislation, statutes, and legal issues that would be appropriate nationally in all 50 states. 6. Be prepared to shift gears quickly throughout the exam. Questions on the examinations are scrambled and change topics from question to question. Therefore, you may have a health care data question, followed by a coding question, followed by a reimbursement question, etc. 7. You will need to bring your ICD-9-CM coding book Volumes 1­3 with October 1, 2008, updates and the AMA CPT-4 coding books to the test. It is necessary that the entry-level coding practitioner be adept at using code books. Although some questions are in a narrative form and any necessary codes and/or code narratives will be supplied in the answer options on the computer screen for you to choose from, you will need to use your code books to answer other questions or verify the answer you choose. Practicing coding using your coding books will help increase your speed in finding the codes. Remember, the test is timed. The faster you code, the more time you have to choose your answers. It may be the difference in being able to successfully complete the examination in the time allotted. 8. Review the latest candidate handbook. The AHIMA Candidate Handbook for the CCA Examination contains information on the exam, how to apply for the examination, what to bring, and other pertinent information you need. 9. Make sure that you have the necessary items for admission for testing. You will need to bring your Authorization to Test (ATT), two forms of identification (one with your photograph), and the ICD-9-CM and CPT code books.

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