Experience the Quality With Free CCA Exam Questions That Helps Candidates Pass

The history and physical (HandP) supports medical necessity by describing the patient’s presenting problem, history, and initial clinical findings justifying admission. Progress notes (C) track ongoing care. Discharge instructions (B) address follow-up, while advance directives (D) specify patient wishes but do not justify admission. Coders must confirm the HandP is complete, signed, and timely to validate coding and reimbursement.

COPD with acute exacerbation is coded as J44.1. Option A (J44.9) is unspecified COPD. Option B (J44.0) is COPD with acute lower respiratory infection. Option D (J43.9) is emphysema unspecified, not appropriate without documentation. The coder must note exacerbation vs. infection, as both can be coded together if documented (e.g., COPD with pneumonia). CCA candidates must carefully distinguish clinical terms and follow coding guidelines.

The discharge summary provides a concise overview of the hospital stay, including principal diagnosis, significant procedures, treatment course, condition at discharge, and follow-up instructions. It ensures continuity of care with future providers. Option A describes nursing notes, Option B belongs to operative reports, and Option D is not the discharge summary’s function. Coders rely heavily on discharge summaries to identify principal diagnosis, secondary conditions, and procedure context.

Hospice providers are reimbursed under the Hospice PPS, which uses per diem rates based on level of care (routine home care, continuous home care, inpatient respite care, general inpatient care). OPPS (A) is for outpatient hospitals, MS-DRGs (C) for inpatient hospitals, and RBRVS (D) for physicians. Coders should know the hospice PPS since diagnosis coding supports eligibility and claims integrity.

The legal health record includes documents that support treatment decisions and billing—progress notes, labs, operative reports, discharge summaries. Internal documents like quality assurance committee minutes (C) are not part of the official legal health record. Coders must know what constitutes the LHR to comply with audits, disclosures, and legal proceedings.