Certified Coding Associate Exam Certified Coding Associate Professional 4

Question 1

According to UHDDS guidelines, what is the definition of 'other diagnoses' for inpatient reporting?

Accepted Answer

Conditions that coexist at admission or develop subsequently and affect patient care

Answer

Per UHDDS, other diagnoses are conditions that coexist at the time of admission, develop subsequently, or affect patient care in terms of treatment, length of stay, or nursing care.

Question 2

A patient is seen in the ED and diagnosed with chest pain, rule out MI. The workup is negative. What is the correct coding approach for this outpatient visit?

Accepted Answer

Code the chest pain as the reason for the visit

Answer

For outpatient encounters, uncertain diagnoses (rule-out, possible, probable) are not coded; instead, code the sign or symptom, such as chest pain.

Question 3

Which of the following is an example of a CPT Category II code?

Accepted Answer

4011F

Answer

CPT Category II codes (beginning with a number and ending in 'F') are optional tracking codes used for performance measurement.

Question 4

When coding an obstetric case, the trimester is based on which measurement?

Accepted Answer

The weeks of gestation at the time of the encounter

Answer

ICD-10-CM defines trimesters by weeks of gestation: first (less than 14 weeks), second (14–27 weeks), and third (27 weeks to delivery).

Question 5

What does HIPAA's minimum necessary standard require of healthcare providers?

Accepted Answer

That only the minimum amount of PHI needed to accomplish a task is used or disclosed

Answer

The HIPAA minimum necessary standard requires covered entities to limit PHI use and disclosure to the least amount needed to accomplish the intended purpose.

Certified Coding Associate Exam Practice Test

Certified Coding Associate Exam Practice Test

Certified Coding Associate Exam Certified Coding Associate Professional 4