CCS Clinical Documentation & Record Analysis 3

Question 1

Which federal regulation establishes the legal requirement for maintaining the confidentiality and security of patient health information in the United States?

Accepted Answer

HIPAA

Answer

EMTALA

Answer

STARK Law

Answer

False Claims Act

Question 2

When a patient's record indicates a condition was 'ruled out' during the inpatient stay, how should this be coded for inpatient purposes?

Accepted Answer

Code the signs and symptoms that prompted the workup

Answer

Code the condition that was ruled out as if confirmed

Answer

Code both the condition and the signs and symptoms

Answer

Leave the condition uncoded since it was excluded

Question 3

What is the primary purpose of the electronic health record (EHR) audit trail in the context of medical coding compliance?

Accepted Answer

To record who accessed or modified patient records and when

Answer

To track the number of codes assigned per encounter

Answer

To automatically assign ICD-10 codes based on documentation

Answer

To calculate reimbursement amounts for each encounter

Question 4

Which of the following statements about late entries in the medical record is correct?

Accepted Answer

Late entries must be clearly marked as addenda with the date and time of the late entry

Answer

Late entries are never acceptable in a legal medical record

Answer

Late entries should be backdated to the time the care was provided

Answer

Late entries require co-signature by the medical director

Question 5

Under HIPAA, which type of health information is subject to privacy protections?

Accepted Answer

Individually identifiable health information (Protected Health Information)

Answer

Aggregate de-identified statistical health data

Answer

Publicly available health information from news reports

Answer

Anonymous survey data about health behaviors

Question 6

A coder is reviewing a record where the physician documented 'dehydration due to nausea and vomiting secondary to chemotherapy.' Which condition should be sequenced as the principal diagnosis for an inpatient admission?

Accepted Answer

Dehydration

Answer

Nausea and vomiting

Answer

The underlying malignancy being treated with chemotherapy

Answer

Adverse effect of chemotherapy

Question 7

Which of the following best describes 'upcoding' in the context of medical record documentation and coding compliance?

Accepted Answer

Assigning codes that result in higher reimbursement than the documented services support

Answer

Assigning codes to the highest level of specificity available

Answer

Updating codes annually to reflect ICD-10-CM guideline changes

Answer

Using combination codes instead of multiple codes to describe a condition