AHIMA

the privacy rule generally requires documentation related to its requirements to be retained?

5 years

a breach occurs when unsecured protected health information id sccessed or released. the secretary of HHS and local media must be notified if this threshold of patient records breached has been met or exceeded

500

is this false statement>

a firewall can limit internal users from accessing various portions of the internet?

give an example of an identifier under the privacy rule

blood pressure reading

the HIPAAmethods titled expert determination and safe harbor are ways in which of the following can be achieved legally

deidentification

which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers?

national practioner data bank

a hospital health information department receives a subpoena duces tecum for records of a former patient. when the health reord professional goes to retrieve the patients medical records, it is discovered that the records being subpeoned have been purged in accordance with the state retention laws. in this situation, how should the HIM department respond to the subpeona?

submit a certification of destruvtion in response to the subpeona

mrs davis is preparing to undergo hernia repair surgery at Deaconess Hospital.

the surgeon should obtain Mrs Davis;s informed consent

explain the meaning and purpose of workflow analysis

workflow analysis is the process of reviewing all steps in a workflow to identify inefficiencies and then recommend improvement opportunities. the analysis process involves meeting with "owners" of the workflow to gain an understanding of their current process, any known problems/issues, and their desired outcome. continous process improvement should be sought by healthcare entities, especially in light of technological advancements and constant change. workflow analysis can take into account these changes and make recommendations on how to improve workflows to be more efficient and less costly. a large portion of workflow analysis includes interviewing key individuals involved in the workflow. this includes those who are involved at the beginning of the workflow process and extends to those at the end of the workflow. documentation of each workflow step is key to identifying inefficiencies and identifying opportunities for improvement. once the analysis is completed, the results are typically presented to ;ower level management to ensure that the results are accurate and realistic. after adjustments are made, the final recommendations are made to administration for their consideration.

explain the meaning and purpose of workflows

workflow is the logical progression of steps for the purpose of accomplishing tasks, through the process of passing along data or information to a participant for further action, in compliance with pre established procedural rules. healthcare organizations use workflows to coordinate tasks between individuals or departments and ultimately accomplish procedural efficiency, procedural compliance, cost savings, and transparency (through visible audit traillls). there are basically 3 different types of workflows:sequential workflow (more complex, returning to a previous step if needed), and rules driven workflow (the rules determine the progress of the workflow) workflow software offer many benefits , such as improved productivity, transparency, faster turnaround times, improved accountability, cost savings, and reduction in error rates.

employees, volunteers, trainees, and other persons performing functions on behalf of covered entities and business associates, whether paid or not, are considered to be:

workforce

briefly describe the purpose of the AHIMA advocacy centerify

AHIMA has an advocacy center and public policy center online for members to access for multiple purposes. the advocacy agenda is available for reading. the agenda advances HIMpractices primarily for the purpose of improving the effectiveness of the electronic health record (EHR) throughout the healthcare realm. the agenda has identified several priorities related to AHIMAs overall vision. these priorities are EHR adoption, health information exchange (HIE, privavcy and security of health information, clinical documentation improvement (CDI), HIM workforce, and HIM recognition. the advocacy site has resources available for members to research elected officials and legislative issues through the advocacy assistant.

discuss the meaning and purpose of IGPHC

AHIMAs information governance principles for healthcare (IGPHC) is an organization wide framework for healthcare entities to follow when governing information management strategies. the framework or model can be used for program development for benchmarking. it is based on the following 8 principles accountability- an individual at the healthcare administrative level is given the responsibility of overseer of the information governance plan. transparency- information governance practices should be available for review at any time with an audit trail available to verify activities. integrity-healthcare information will meet authenticity and reliability expectations. protection-healthcare information will be protected against breaches, corruption, and loss. compliance- information governance will meet regulatory requirements. availability- information will be retrieved in a timely and efficient manner. retention- information will be retained\mainatined according to legal time frame requirements. disposition- information will be appropriately disposed of, after legal time frames have passed.

briefly explain the meaning and purpose of DNFB

DNFB is the abbreviation for "discharged, not final billed" it is a familiar term used in medical coding practices, and refers to those accounts wherein the patient has been discharged from the hospital, but the accounts that fall within a 4-5 day billing hold period after discharge and are still in need of code assignments. DNFB is important because it is a vital part of the revenue cycle, affecting the bottom line. it significantly impacts account receivable (A\R) days. the DNFB is calculated by dividing the gross revenue for the month by the days in the month, which provides the average daily gross revenue. for example, 120 million\30 days = 4 million daily. the dollar amount of accounts discharged but not billed is then divided by the average daily gross revenue monthly amount. for example, 28 million\4 million =7 days. a range pertaining to an acceptable number of days 6.2 to 7 days=excellent; 7,1 to 8.2 days caution; >8.3 needs immediate attention\action

briefly describe the layout of the icd10 table

a coder must utilize the icd 10 pcs table to obtain complete and valid procedural codes. the table is constructed with a top and bottom portion. the top portion of the table reflects the first three characters of the code(already determined from the icd 19 pcs index) the bottom portion of the table reflects all valid combinations of code characters 4 through 7 . the 4th through 7th characters must be selected from the same row of data as it expands across the 4 columns pertaining to the body part, procedural approach, device, and qualifier. it is important to understand the characters 4 through 7 cannot be selected at any place on the table; rather, the selections must remain within the same row. the options for code selections per table are innumerable.

explain the purpose of chargemaster

a hospital has a database that contains all charges fir services rendered. this database is known as the chargemaster or charge description master (CDM). the CDMis the core of a hospitals revenue cycle. each hospital department is responsible for entering the type of service or supply provided to a patient. each procedure, supply, or service has its own unique item number. for each charge cpt\hcpcs code and revenue code as well as other financial elements are assigned. the functions of the CDMare to not only assign charges, but also to produce itemized statements , produce a valid claim, monitor costs, and generate financial reporting.

describe the elements of a charge master

a hospitals chargemaster is composed of certain key elements. the typical data elements are the following: charge description: each charge has a title that describes the charge whethe it is a supply, a medication, a procedure cpt\hcpcs code and modifiers: a cpt or hcpcs code may be assigned to a specific procedure or supply, and applicable modifiers may be built in the charge as well. of note, not all charges will have a corresponding cpt\hcpcs code or modifier revenue code: this is a 3 digit number that represents the location of the patient when the service was rendered or the type of service received charge dollar amount: this is the cost associated with the service or supply provided charge coded: this is the unique number assigned to each item listed in the chargemaster. it is also known as the cdm number. charge status: this represents whether or not the charge has been allocated to the patients account and its payment or denial status

an HIM professional violates privacy protection under HIPAAPrivacy rule when he or she releases ----- without specific authorization from the patients or patient representatives

a list of newborns to the local newspaper for publication in the birth announcements section

discuss the intent of a physician query

a physician query is a tool of communication between CDI specialist\ coders and physicians to clarify incomplete, ambiguous, or conflicting documentation in the medical record. the intention of the communication tool is to facilitate completeness, accuracy, consistency, and timely documentation for coding, and reporting practices. queries are an essential tool and provide additional clariffication that allows coding and reporting to the highest level of specifity. it is best for the physicians query to be maintained as a permanent part of the medical record since it is considered to be supporting documentation for assigned codes.

explain the potential risks associated with not having a health information retention schedule

a records retntion policy is an absolute necessity in the health information field. legal compliance with federal and state regulations pertaining to information retention establishes the framework of what information to retain and how to do so. there are risks of not having a health information retention policy, including difficulties in locating information secondary to the lack of an index, noncompliance issues related to the inability to provide information to regulatory bodies, inconsistent destruction of information in a compliant manner, and\or litigation risks. due to these potential risks, it is important to understand how retention procedures should be done systematically and in a controlled fashion. an effective retention schedule will consider all types of records created and utilized for the healthcare entity, and ensure that retention of current information and destruction of outdated information are conducted compliantly.

anywhere general hospital allows all of the icu nurses to log on with a standard id and password. this is not allowed by which standard of the security rule

access control standard

explain the process of adjudication

adjunication in the revenue cycle management worldis a process in which submitted claims are evaluated by the payer for validity and determination of whether payment will be rendered or not. it is during the adjudication process that a claim will be accepted, denied, or rejected. accepted means that the payer has decided the claim is valid. but the payer may not reimburse the claim in full. they are required to process the claim according to the subscribers plan. a denied claim, or course, means the payer has found reason to refuse payment for services rendered. a rejected claim identified during the adjudication process means that the payer has identified a claim error. a rejected claim may be reasubmitted by the provider for reconsideration.

training of staff on security practices at a healthcare organization is an example of this type of access safeguard, which is people focus in nature

administrative

dr smith a member of the medical staff asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. the daughter is now 25 dr jones was the patients physician. of the options listed what is the best course of action?

allow dr smith to see the records because he was the daughters guardian at the time of the tonsilectomy

st joseph hospital has a psychiatric service on the sixth floor. a 31 year old male came to the him department and requested to see a copy of his health record. he told the clerk he was a patient of dr schmidt a psychiatrist, and had been on the sixth floor of st josephs for the last two months. thesee records are not psychotherapy notes. the best course of action for you to take as the HIM director is

allow the patient to access his records

define semantic content of an EHR

an electronic health record (EHR)is a record of a patients healthcare journey composed of electronic documents from various electronic systems. prior to the EHR era, health information was maintained in paper records. upon a patients discharge, the paper records were retrieved from the hospital floors and assembled in a certain prescribed order in the HIM department. in todays EHRenvironment, assembly of the information means that it should be available in a logical and meaningful manner for the healthcare employees use. uniformity and standardization of data collection points (or fields) should be the norm. in an EHRenvironment,semantic content, or the inherent meaning of each data element, must retain its meaning throughout its lifetime as this promotes data integrity.

explain the difference between an EMR and an EHR

an electronic medical record (EMR) and an electronic health record (EHR) are easily confused terms among healthcare providers, but there are differences between the 2 terms. an EHR is more comprehensive in that it contains a cumulative record of health-related information from multiple clinicians from more than 1 healthcare organization,whereas an EMR is a collection of health-related information by a single organization.

briefly explain how all information should be brought together to generate an electronic record

an electronic record is "assembled" through different means of capture: scanned paper documents or document imaging processes are necessary for paper documents or document imaging processes are necessary for paper documents to become a part of the EHR. primarilly, this process involves 3 steps: document preparation (removing staples, repairing tears, and organizing papers by document type) document scanning (actual physical scanning and conversion to an electronic image), and document quality control and indexing (HIMpersonnel check each individual image for quality and index the image based on document type) automatic feeds on certain reports become part of an EHR,such as admission\discharges \ transfers (ADT) transaction report, transcribed reports, and radiology reports. manual entry of data by clinicians into predefined templates of the EHR is a means of data capture. once these steps are completed, each account is processed through coding and deficiency management and finally physician authentication.

briefly explain the process of becoming accredited by joint commision

before the initial joint commision survey is conducted, the healthcare organization should complete the following steps, at a minimum: ensure the state licensure requirements have been met. ensure the CMS855A application has been verified. ensure that patient census requirements are met in order to proovide an ample supply of records to the joint commision surveyors. request a free trial edition of the joint commision stndards. request an accrediation guide. apply for accrediation survey and pay the nonrefundable fee. before the survey has ended, the joint commision surveyors will schedule an exit conference to review a preliminary summary of findings. the preliminary report may be further reviewed by the joint commisions central office. once the review is finalized, a final summary will be posted on the joint commisions extranet site. post survey requests for additional information may be submitted by the joint commision with time limits set for either 45 or 60 days. these are known as evidence of standards compliance (ESC)requests. once these are submitted by the healthcare organizations, the accreditation decision will be rendered.

explain the benefits of collecting accurate healthcare data

benefits of capturing accurate healthcare data include: 1) improving patients quality of care 2) identifying disparities in the delivery of healthcare 3) enhancing healthcare research 4) identifying disease trends that aid providers in resource management and cost effectiveness 5) identifying opportunities to prevent fraudulent claims submission. accurate data assists healthcare management with fiscal planning,budgeting,development of initiatives to reduce patients lengths of stay in the hospital as well as unnecessary readmissions, and development of methods to prevent deaths. associations such as health information and management systems society (HIMSS) aim to opimize health through clinical informatics or data analysis. following suit, healthcare organizations have discovered the power of data when it comes to improving quality of care; therefore, data accuracy is imperative to survival in the current healthcare realm.

identify steps involved in building a successful team

building a team to a level of success will hinge on how well the leader enables each team member to reach his\her best potential and goals. through team approaches, healthcare entities can experience increased production, customer satisfaction, cost savings, and goal achievements. leaders should build teams by establishing goals and objectives, by defining responsibilities for each team member, and by recognizing each member;s unique contribution to the team. the following steps should be considered when developing teams: lay out the problem or issue for collaboration. determine the key stakeholders who need to be included on the team. establish goals and objectives. provide direction and then necessary resources to complete tasks. assess the teams results, provide further direction if needed, and ultimately reward success when goals and objectives are accomplished.

identify the main challenges of HIM consolidations

centrslization or consolidation of HIM services between healthcare entities or through healthcare mergers is quite commonplace in todays healthcare landscape. these consolidations are occuring primarily secondary to shifting reimbursement methodologies, which are affecting healthcare costs. in other words, the cost of healthcare services is out of control, and hospitals and physician offices\clinics are forced to fins ways to save money, and in many cases, the best solution is to merge with other healthcare entities. when healthcare mergers occur, multiple challenges arise primarily due to disparate systems. examples of challenges include reduction arise primarily due to disparate systems. examples of challenges include reduction in staff force, logistics of healthcare locations (eg long distances, making it difficult to transport documents), staffing schedule adjustments, learning curve related to new systems and/or workflow processes, new or unexpected costs, and physician reaction to changes in HIM services.

explain the meaning of change management

change is the only constant in a work environment. change is inevitable. in fact, change is guaranteed in life. people handle change differently-some embrace it, while others resist it. change management is a necessary component of personnel management. change management can be defined as a structured approach of ensuring that changes are implemented successfully and smoothly, and are sustainable (meaning the benefits of change last) it is important to note that change is not isolated to one person, but rather it affects many people, whether the effect is only intradepartmental related or related to the organization as a whole. objectives of change management may include active support from administration or senior levels; involvement of key individuals to oversee the implementation of the changes; determining the impact of the changes on staff; effective open communication to all involved; and, effective staff training prior to, during, and after implementation to ensure all involved are thoroughly prepared for the changes.

the kids foundation , a foundation related to childrens hospital , is mailing fundraising information to the families of all patients who have been treated at Children,s in the past three years. based on the facts given.

childrens hospital must have notified the patient or patients guardians of this disclosure in the notice of privacy practices.

explain the meaning of clinical indicators

compliant coding is dependent on the accuracy and completeness of documentation. healthcare documentation is not sufficient to support code assignments, and in those cases, physician queries are necessary. queries must contain certain elements, and the clinical indicators are one of the elements, and clinical indicators are one of the elements. clinical indicators refer to clinical clues, such as elevated temperature,abnormal vital signs, or elevated white blood blood count levels, which could indicate or support certain diagnoses. for example, if a provider fails to document the diagnosis of sepsis, but there are clinical indicatorsthat point to its diagnosis, a query might be warranted. the coder or clinical documentation improvement (CDI) specialist might include the following clinical indicators in the query: temperature 103, wbc 18500, blood pressure 70\40.these three clinical clues might indicate the diagnosis of sepsis, and the physician would consider these indicators to make a decision.

the workforce security standard has all of the following addressable implementation standards except:

concept supervision

which legal doctrine was established by the darling v charleston community hospital case of 1965?

corporate negligence

explain Icovered entityIin relation to HIPAA

covered entity is common term used when discussing the HIPAAPrivacy Rule. Under the privacy rule, a covered entity will refer to a health plan, a healthcare clearing house, or a healthcare provider. it is important to understand that all employees of a healthcare provider are considered part of the covered entity. all employees would include those who work in a clinical capacity and\or non-clinical capacity

an outpatient laboratory routinely mails the results of health screening exams to its patients. the lab has received numerous complaints from patients who have received another patients health information. even though multiole complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. how should the privacy officer for this healthcar entity respond to the situation?

determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPPA privacy rules.

although an addressable implementation specification, this reduces or prevents access and viewing of ePHI

encryption

explain enterprise content and records management (ECRM)

enterprise content and records management (ECRM) can be defined as the management of electronic information created and stored in analog or digital format, with the records management component referring to the creation, receipt maintenance, use and disposition of the health information. to manage health information\health record content at an enterprise level, various technologies, tools, and methods will be used to create,store,maintain, and deliver the health information. the life cycle begins with the creation of information with the source of creation being an email, paper, or other knowledge source. the newly created health information is reviewed and edited until a final version is published via electronic health record systems, corporate portals, cd roms, or pdf collections. the final version will move through a stage of active use until it becomes inactive and is retained until approved for a final disposition. ecrm tools and technologies aid healthcare entities with record management processes. these tools may include bar coding, optical character recognition, classification tools, and computer output tools to laser disks.

A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach?

facility access controls

discuss ways to generate clean claims, thus reducing the number of denials

for a healthcare entity to have a 100% clean claim rate would be nothing short of a miracle. the reality is there are many challenges with submitting clean claims; however, there are staregies to follow that can reduce the number of "dirty" claims and thus reduce the number of denials. one key strategy would be for a healthcare provider to scrub claims before submitting them to a clearinghouse and\or the insurance payer. through the process of scrubbing claims, errors are identified and routed to the appropriate personnel within the healthcare entity, who can correct the errors before dropping the claim. in order for this process to be effective, it is beneficial for the healthcare provider to be familiar with all payer edits. careful analysis of the reason why claims are rejected by edits in beneficial to understand as well. this ties into another strategy of staying abreast of healthcare revenue trends as well as being vigilant in the ever changing world of governmental regulations.

if an intended procedure is discontinued, determine how the icd 10 pcs coding is assigned

for example, an operative procedure is dicontinued for various reasons. when this occurs, the coder must determine to what extent the procedure was conducted. once this is determined, the coder should code the procedure to the appropriate root operation. for example, a laparoscopic choleycystectomy is planned, and the laparoscope is inserted into the abdominal cavitiy , but the patient becomes hypotensive and the surgery is stopped. in this case, the coder would code the laparoscopic approach only. in other instances, a root operation may not even be performed. in that case, a code should be assigned for inspections of the appropriate body part. understanding this general guideline will aid the coder in selecting the correct root operation that represents character #3 of the procedural code.

Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given

general condition and acknowledge of admission

explain when it would be appropriate to destroy health information

health information may be destroyed when in compliance with federal and state regulations. destruction would be applicable to inactive records only, and the following information should never be destroyed: basic information such as admission and discharge date , responsible physician names, diagnoses and operations,discharge summaries,operative reports, and pathology reports. health information of minors should not be destroyed until after the period of their minority has passed plus any time pertaining to statue of limitations has passed. disease, operative, and physician indices should be kept for a period of 5 to 10 years depending on state regulations. birth and death certificates should be maintained permanently.

the federal law that directed the secretary of health and human services to develop healthcare standards governing electronic data interchange and data security is the:

health insurance portability and accountability act

describe the key elements of policies and procedures

healthcare organizations should follow policy and procedure guideline and templates and\or specified formats. the following are key elements to include in policy and procedures: title (representing the subject or topic) reference number for tracking purposes statement of purpose regulatory citations and\or external references scope that defines resources effective date as well as revision dates administrative approval signatures policy statement that identifies measurabke objectives responsible parties, and monitoring of compliance detailed procedural steps

identify the types of external audits that may be requested of a hospital

hospitals experience audits from external agencies on a regular basis. the external auditors may be representatives of various federal agencies ( office of inspector general, department of justice, medicare administrative contractors). they may represent commercial insurers (BCBS) the types of audits requested may pertain to charges, coding, medical necessity, fraud etc. complete and detailed documentation is key to proving to the external auditor that a submitted claim is valid and meets regulatory compliance.

describe the icd 10 pcs format

icd 10 pcs is formatted in 3 sections: tables, index, and list of codes, the index is an alphabetic listing of procedures\operations. codes are organized in the index according to the general type of procedure. of note, the index only provides the first 3-4 characters of a procedural code. the remaining characters are located in the tables , and thus the tables must be referenced to assign a valid 7 digit code. the tables are designed in rows that provide options for characters 4-7 in the development of valid code combinations. the list of codes is a comprehensive list of all procedural codes along with their descriptions. the process of assigning an icd 10 pcs code begins with their coder accessing the index to locate the appropriate table, and then referncing that table to locate the remaining characters for code completion.

you are a member of hospitals HIM committee. the committee has created a HIPAAcompliant authorization form which of the following items does the privacy rule require for the form?

identification of the person oe entity authorized to receive PHI

when a patient collapses on arrival at the entrance to an emergency department, what type of treatment authorization is in effect?

implied consent

medical information loses PHIstatus and is no longer protected by the HIPAAprivacy rule when it:

is deidentified

the security rule leaves the methods for conducting the security risk analysis to the discretion of the healthcare entity. the first consideration for a healthcare facility should be:

its own characteristics and environment

does this have the legal right to refuse treatment

juanita who is 98 years old and of sound mind linda who is 35, incomponent, and created a living will prior to her becoming incomponent stating that she did not wish to be kept alive by artifical means.

briefly discuss how employees comprhension p&ps can be assessed

just because policies and procedures are made available to employees, this does not mean they understand the content and managements expectations. it is essential for management to implement measures to assess each employees comprehension of p&ps applicable to their job responsibilities. one way to accomplish this is to require employees to take an assessment based on each p&p. the assessments should be scored to identify areas in which lack of comprehension is evident followed by further education or training. access to p&ps, reading of p&ps, and assessment pertaining to p&ps should all be tracked or monitored. this audit trail of access and assessments can prove to an internal or external auditor that p&ps have been applied as required by regulatory bodies.

provide examples of a leading query

leading provider\physician queries are not acceptable in healthcare. following are examples of inappropriate leading queries: a query that providesthe physician with options that only leadto additional reimbursement. a query that does not contain all the required clinical indicators to paint the full clinical picture of the patients condition. a query wherein the statements are directive in nature, such as indicating what the provider should document, rather than querying the provider for his\her professional determination of the clinical facts. a query that leads the provider to one desired outcome. a query that omits reasonable clinically supported options. a query that omits an option that no additional documentation or clarification may be provided.

discuss the purpose of a healthcare compliance audit

multiple types of healthcar compliance audits are being conducted in the present age. to understand the purpose of a compliance audit, it is important to understand the different types of audits. hospitals should be prepared in the following areas (at a minimum)where audits are likely to occur:HIPAA, meaningful use, provider based status , outlier payments, medicares two midnight rule, inpatient claims for mechanical ventilation, ambulatory surgery centers payment system, anesthesia services, outpatient rehab services, immunosuppresive drug claims, hospice and home health services. the list of potential audits by external agencies is extensive. the office of inspector general publishes a work plan for each fiscal year, and this plan is an excellent indicator of where hospitals, skilled nursing facilities, pharmacies, clinics, etc. should focus their attention for internal auditing. the purpose behind each of these external auditors essentially is to identify fraud, waste, and abuse. they are looking for opportunities to improve healthcare efficiency, and in many cases this includes holding accoutable those who violate federal healthcare laws.

the breach notification rule requires covered entities to establish a process for investigating whether a breach has occured and the following

notify affected individuals when a breach occurs

Mary Smith has gone to her doctor to discuss her current medical condition, what is the legal term that best describes the type of communication that has occurred between Mary and her physician?

open communication

describe tools for tracking denials

part of the revenue cycle management process is to track insurance payer denials and trend the reasons for the denial so that future denials can be prevented. healthcare entities should use certain tools for the purpose of tracking denials. a claim denial spreadsheet can be used to track the reaons for denials, follow up status, identify areas responsible for denials, and show impact on income. dashboards are useful to display department specific data compared against benchmarks. trending of data can be incorporated into the dashboards as well. denial tracking by payer is another useful tool. one can identify and quantify such data for trending purposes.

explain the process a coder must follow when conflicting documentation exists

patients who are admitted to an inpatient status in the hospital may be assessed by multiple physicians. inevitably, the documentation of the various physicians will conflict. for example, the attending physician may document acute renal failure, but the nephrology consultant documents acute renal failure., but the nephrology consultant documents acute renal disease. since failure and disease in this particular case equate to different codes, the coder will need clarification, and that clrification is best achieved through the initiation of a query. the query would need to reveal the conflicting information and ask for the final decision as to which diagnosis is correct, other clinical indicators should be a part of thr query in order to demonstrate to the physician why the information is conflicting. for example, in this acute renal failure versus disease scenario, the coder may choose to include the clinical indicators pertaining to a rise in the bun\creatinine as well as the urine output amounts.

placing locks on computer room doors is considered what type of security control

physical access control

explain the importance of having physician query policies

physician queries are an integral part of clinical documentation improvement (CDI) programs in healthcare institutions today. in order to standardize methods for physician query process, query policies are recommended. effective policies should establish query guidelines pertaining to the 4 "Ws" -who (eg which physician is responsible for providing clarity), what (eg, which diagnosis or procedure is unclear), when(egwhen is a query needed) and why (is documentation unclear or conflicting) policies should also address any compliance related issues (avoidance of leading a physician to the selection of a desired diagnosis). query policies should explain appropriate means of following up on unanswered queries. ( time frames, acceptable number of queries to issue)

the legal term used to describe when a patient has the right to maintain control over certain personal information is referref to as:

privacy

for which of the following situations would an audit trail be useful?

reconstructing electronic events

define revenue cycle management

revenue cycle management in healthcare is a 3 part process. it involves management of the healthcare institution claims processing, payment processing, and revenue generation. the revenue cycle begins at the point of determining patient eligibility,collecting the patients copay and\or deductible, correct coding of claims, correct charging of services, tracking claims between the provider and the payer, collecting payments, and claims denial management. two other factors impact revenue for a healthcare entity: provider \physician productivity and patient volume(admissions\discharges\transfers)

sally mitchell was treated for kidney stones at graham hospital last year. she now wants to review her medical record in person. she has requested to review it by herself in a closed room

sallys request does not have to be granted because the hospital is responsible for the integrity of the medical records

addressable security rule implementation specifications

should be implemented unless a healthcare entity determines that the specification is not reasonable and appropriate and documents their reasoning

an individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. under what access security mechanism is the coder allowed access to the system?

situation based

the concept of legal hold reguires

special, tracked handling of patient records involved in litigation to ensure no changes can be made

a hospital employee destroyed a health record so that its contents--which wouuuuuuld be damaging to the employee--could not be used as a trial. in legal terms, the employees actions constitutes:

spoliation

this federal agency is charged with responsibility for the oversight and enforcement of the HIPAA privacy regulations?

the HHSoffice of civil rights

describe CMSs expectations regarding retention of health information

the centers for medicare services (CMS), through the medicare learning network (MLN), issues news flashes regarding pertinent healthcare information. MLN matters #SE1022 addresses medical retention. this MLN matters points out the state laws generally outline the retention reguirements for health information, but federal laws (such as HIPAA) provide guidance as well. cms requires Medicare providers to retain records for 10 years. CMSrequires that financial records, specifically the cost report, be retained for 5 years. not only are these requirements provided the MLN matters #SE1022, but more detailed information can be referenced in the code of federal regulations (CFR)

discuss the purpose of following outpatient coding guidelines

the current procedural code set is a widely accepted nomenclature for the reporting of physician procedures and services. it is endorsed by the us department of health and human services. it is endorsed by the us department of health and human services as the nationally acceptedd coding standard. each section of the cpt code book includes specific guidelines. these coding guidelines are a set of rules for coders to follow in order to appropriately interpert and report procedures and services provided in physicians offices and\or outpatient settings. as with all coding guidelines, they promote consistency among coders and healthcare providers in the assignment of codes.

provide a brief over view of the cpt book

the current procedural terminology book was originally in 1966. it is used to assign codes for procedures and\or services provided by a physician in his\her office, or provided in an outpatient setting such as a surgery center. the cpt book is published by the american medical association (AMA) and updated annually by a cpt editoral panel and advisory committee compromised of healthcare professionals. the cpt procedural codes are used alongside icd 10 diagnostic codes on claims, and both sets of codes are analyzed by payers for reimbursement purposes. the cpt book is composed of an introduction section, 6 main sections ( eval and management, anesthesia, surgery, radiology, path\lab and medicine), 13 appendices (modifiers, summary of add on codes, clinical examples) category II and III codes ( supplemental and\or temporary codes) and an alphabetical index.

the legal health record for disclosure consists of:

the data,documents, reports, and information that compromise the formal business records of any healthcare entity that are to be utilized during legal proceedings.

explain how the E\M section of the CPT code book is divided into categories

the evaluation and management (E\M) section of the cpt book is divided into general categories of office visits, hospital visits, and consultations. these categories are further subdivided into subcategories. for example, the office visit category has subcategories pertaining to new patients and established patients. hospital visits have subcategories pertaining to initial and subsequent visits. formatting similarities between the different categories are as follows: unique codes are listed first, followed by the place and\or type of service, followed by the content of the service noted, followed by the nature of the problem, and concluded with a time element associated with the service\procedure

identify tips for the establishment of coding productivity standards

the formula to calculate a coders production is simple:subtract the hours of non coding tasks (also known as downtime) from the total hours of coding tasks. of note, non coding tasks should include education\training, system technical problems, data analysis projects, etc. then divide the number of accounts coded by the hours spent coding. this will provide the number of accounts coded per hour. this formula can be built into database functions, available for the coder and manager to acknowledge. this formula may be easy, but there are other factors to consider when determining the coders overall skill level. for example, quality of work or coding accuracy must be monitored, striving to reach or surpass the national standard of 95% accuracy.

linda wallace is being admitted to the hospital. she is presented with a notice of privacy . in the notice , it is explained that her PHI will be used and disclosed for treatment, payment , and operations (TPO) purposes. linda states that she does not want her PHI used for those purposes. of the options listed here, what is the best course of action?

the hospital is not required to honor her wishes in this situation, as the notice of privacy practices is informational only

what is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident

the incident report likely becomes discoverable because it is mentioned in a discoverable document.

discuss the structure of the icd 10 tabular list

the key to understanding the icd 10 tabular list is to be aware of how it is categorized and subcategorized. the first principle to understand is that the list is divided into 21 chapters. a coder must process through each available category in order to assign the code with the highest level of specificity, which will only be 3 characters for some codes, while it may be up to 7 characters for others. for those codes with a 7th character that explains whether it is an intial or subsequent encounter or the sequale of a previous disease\condition, it may be necessary to use the placeholder character of "X" to fill in for empty spaces

define the legal health record

the legal health record is a compliation of individually identifiable data as well as the documentation of services rendered to a patient by the healthcare provider. each healthcare entity must define in their policies and bylaws the content of the legal record. the content of the legal record may be composed of both paper and electronic documents. the content of the legal record must comply with the standards set forth by external agencies, such as the joint commission, the centers for medicare and medicaid services (CMS), the health insurance portability and accountability act (HIPAA), and federal and state regulations. the legal health record serves patient care, administrative, business, and financial purposes. additionally, it is considered a legal document that is submissible as evidence in court proceedings.

briefly describe the life cycle of a health record

the life cycle of a health record is composed of 4 parts: creation,utilization,maintenance, and destruction. a record cannot exist without the creation of information; hence, the first phase in the life cycle, creation of the health information happens for the purpose of using the information. the information collected helps to guide the healthcare practioners in the best treatment possible for the patient through this communication tool when an active date of service is over, the record must still be maintained per federal and state retention standards. the maintenance time varies depending on state regulations., but after no further treatment activity, the record is destroyed. destruction policies and procedures must indicate the appropriate methods of destruction for each type of medium that contains the health information. electronic data would likely be archived instead of destroyed.

identify best practices for database maintenance

the primary purpose of database maintenance is to keep the database running smoothly. in a database, constant change occurs, meaning that information is being added, revised, moved or deleted. it is likely that multiple people will be involved with the many changes. because of the constant manipulation of data by multiple individuals, it is inevitable that databases will begin to malfunction. database maintenance is necessary to identify signs of corruptions, problems, malfunctioning indices, and duplicate data. one additional component of data maintenance is to search for security issues and data that have been incorrectly entered. a sign that a database may be malfunctioning is sluggish movement and\or inability to access records.

sometimes federal and state health information privacylaws and regulations are in conflict. when this is the case one law must take precedence. for health information privacy this determined as follows:

the state law always takes precedence

elaborate on this adage " if it isnt documented , it hasnt been done"

the statement has been a longstanding adage well known to health information professionals. healthcare provider documentation of diagnoses and treatment rendered is the key to preventing denials, winning appeals, and preventing accusations of fraudulent activity by governmental agencies. the center for medicare and medicaid services points out that clear and concise health information documentation is critical to the quality of patient care and is required for payment of services rendered. documentation is necessary to support the medical necessity of services and to ensure compliance with regulatory requirements. healthcare organizations must have policies and procedures in place to maintain the integrity of the health record.

explain the 4 major attributes of icd 10 pcs codes

the structure of icd 9 cm colume 3 for procedural coding was not capable of involving into more codes necessary for keeping up with the explosion of technological advances in healthcare. it became mandatory in the icd 10 realm for procedural codes to be designed in such a way as to accomodate growth long term. the results was icd 10 pcs with elimination of a third volume. icd 10 pcs was developed with 4 major attributes and their meaning in mind: completeness (meaning one unique code for each different procedure) expandibility (meaning- icd 10 pcs allows for the incorporation of new procedure codes ) multiaxial (meaning-codes consist of independent characters with the capability of each retaining meaning across broad ranges of codes) and standardized terminology (meaning0=-each term must have a specific meaning) it is important that coders thoroughly understand the definitions for all the procedures and the various approaches to operations as this will be key to correct code assignments.

discuss the options available for query formatting

there are several ways to generate a query : compliant query forms allow for open-ended questions, multiple choice query formats, and\or limited yes\no query formats. an example of open-ended query might appear in this format. based on your clinical judgement, please providea diagnosis that represents the following clinical indicators: temperature 102, cellulitis around ankle with open wound, white blood cell count 15,000. an example of a multiple choice query might appear in this format: per the discharge summary, the patient has congestive heart failure (CHF)can the chf be further specified as 1) acute systolic CHF. 2 ) acute on chronic systolic CHF 3) acute diastolic CHF 4) acute on chronic diastolic CHF 5) undetermined. an example of a yes\no query might appear in this format was the sepsis documented in the discharge summary present on admission? yes, no, clinically unable to determine.

john is the privacy officer at General Hospital and conducts audit trail checks as part of his job duties. what does an audit trail check for?

unauthorized access to a system

describe the code structure of an icd 10 cm code

unlike icd 9 cm code assignments that only contained 3 to 5 characters, icd 10 cm codes contain anywhere from 3 to 7 characters. the first character of the icd 10 cm code will always be one of the following alphabetic letters: A-T and V-Z note, the letter "U" is not used because it has been reserved bt the WHO for other purposes. the second character of the icd 10cm code will always be a numeric, and the remaining characters can be either alpha or numeric. the decimal is still used after the third character in the icd 10 cm code as it was in the icd 9 cm code. secondary to the expansion of the code structure up to 7 characters, there are now more than 68,000 codes, compared to 13,000 of icd 9 codes. the expansion of the code structure allows for greater specifity and clinical detail.

explain unstructured data

unstructured data are described as information that requires manipulation in order for it to be usable unstructured data may present itself in the form of handwritten paper notes, dictation, information contained within emails, scanned reports, diagnostic images. unstructures data are problematic for healthcare organizations because their source of origin lies in multiple disparate systems, and the majority of the data are not standardized and hard to access. technological advances, however, are paving the way for EHRsystems that are highly effective in capturing unstructured data and converting them into usable formats.

discuss ways to effectively manage a virtual meeting

virtual meetings are a commonplace occurrence in healthcare organizations. effective management of a virtual meeting requires practice and development of key skills. these skills may include any of the following: before the meeting, create and distribute an agenda, review the agenda with another individual who can cover the meeting in case you are unexpectedly absent, and practice with the virtual technology. navigation of the vrtual software should be an easy process, so practicing ahead of time will build confidence. when the meeting begins, ask who is in attendance with each IbeepI that is heard, and then consider introducing each member and their role in the meeting so everyone will be clear as to their part(if the meeting attendance is large, introductions may be eliminated) begin the meeting on time in respect of everyones time, and do not restart with every late comer. keep the meeting moving along by staying focused and eliminating distractions. allow time for attendees input and discussion, and recap the important takeaways of the meeting has concluded, distibute bried minutes/notes, and if the meeting was recorded, distribute an emailed link to the webinar online.

anywhere Hospitals coding staff will be working remotely. the entity wants to ensure that they are compling with the HIPAA security rule. what type of network uses a private tunnel through the internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely.

virtual private network (VPN)

explain the medicare appeals process for claim denials

when a healthcare provider disagrees with medicares payment decision (part a) , an appeal may be pursued. the appeal process can be lengthy as there are 5 levels of appeal. level 1 involves a redetermination process by the company who processes claims for medicare. level 2 involves reconsideration by a qualified independent contractor. level 3 would be pursued if the claim needs to be presented to an administrative law judge. if not successful at that level , the claim can be reviewed by the medicare appels council. a final attempt for appeal can be a judicial review in a federal district court, each level has certain requirements to follow, snf time frames can be rather long.

identify important steps to follow when designing electronic HIM workflow processes

when designing an electronic HIM workflow, it is importsnt to first understand basic workflow logic. one step in a workflow process can perform multiple actions if designed to do so. workflow processes should be designed so that they flow logically from the previousstep. if a step in the flow contains only actions and no conditions , then the workflow will perform the designated actions. if a step includes conditions, then the step can only be satsfied when the conditions are met. a workflow must be hyperlinked or attached to a preexisting database, list or library, and if they are no preexisting resources, then a new resource must be created. to complete a newly designed workflow, the final step is to test the process before publishing, and if an error exists (such as a break in a hyperlink), then error symbols will appear next to each step for the parameter that is invalid. measures will then need to be taken to correct the errors.

a professional basketball player from the local team was admitted to your facility for a procedure. during this patients hospital stay, access logs may need to be checked daily in order to determine:

whether the care to the patient meets quality standards

describe the process of ensuring healthcare data is meaningful and useful

with healthcare initiatives focused on quality, outcomes, and payment methodologies, it is a common practice for healthcare institutions to process their data so that it is meaningful; in other words; its purpose ultimately is to promote informed decision making . for data to be meaningful, they must first be captured,queried, and finally analyzed. data capture should ensure that all the right information is collected and stored in a appropriate format. data queries are conducted on the collected information, but it is necessary for the data analyst to be familiar with all the systems where the data pulls from. data analysis should include quality checks, accurate interpretation through application of statstical formulas and\or algorithms, and presentation for informed decision making.

briefly explain how a mentoring plan for new coders might be implemented

with the advent of icd 10 in Oct 2015, new coding challenges surfaced. many seasoned or experienced coders retired, and new coder interest was insufficient. many healthcare entities have been forced to develop training plans for new coders. these training plans may include a mentorship. an ideal mentorship program would be strucutred in the following manner: assign a mentor ( an experienced coding professional) to 2 new coders. the mentor will then review 100% of all coded accounts by the new coders prior to billing. the mentor will provide educational feedback should always reference applicable medical information and\or coding clinic references. time should be allotted for the new coders to review the feedback, hold discussions, and review multiple training resources. a key component of this training plan is open communication, especially if mentors and coders work in remote environments.

with the recent implementation of icd-10 coding practices, identify methods to determine productivity standards for implementation

with the recent implementation of icd-10 as of october 1,2015 and regular updates as of october 1,2016, there are several methods to consider for implementation pertaining to productivity standards. these methods include the following: monitor the average coding time per record and trend the results. initially, the average coding time per record and trend the results. initially, the average coding time would have increased in comparison to icd9 average coding times; however, over time, the average coding times in icd 19 should begin to decrease. 2. monitor coding productivity by the case mix index (CMI) coding productivity, for those coders working in cases with a high CMI, would be longer than those with a low CMI. 3. assess the average coding time for the top 25 drgs for the designated entity. once these results are monitored and trended over a select period of time, productivity standards can be developed because these measures help to identify codes and\or DRGs for which it takes a longer period of time to complete.