RHIT Exam Questions, RHIT Exam Terminology
Run Chart
A chart that displays the history and pattern of variation of a process over time; The measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time
Pandemic
A massive outbreak of a contagious disease over a large geographical area
Critical Incident Method
A method of performance measurement based on the managers' records of both positive and negative examples of employees's work.
Case Finding
A method used to identify the patients who have been seen and/or treated in the facility for the particular disease or condition of interest to the registry.
Clinical Laboratory Report
A report of the tests done on clinical specimens in order to get information about the health of a patient
"Discharged, not final billed" report (also known as "discharged, no final bill" or "accounts not selected for billing")
A report that includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete
Access Controls Standards
A requirement that ensures individuals are given authorization to access only the data they need to perform their respective jobs
Retrospective Utilization Review
A review conducted after the patient has been discharged that examines the medical necessity of the services provided to the patient while in the hospital.
Concurrent Analysis/Review
A review of the health record while the patient is still hospitalized or under treatment
Data Resource Manager
A role that ensures that the organization's information systems meet the needs of people who provide and manage patient services
The Minimum Data Set for Long Term Care (MDS)
A wide ranging functional assessment for patients in long-term care.
A dermatologist documents skin lesion, probable basal cell carcinoma. What actions should the coding professional take to code this encounter?
Code for skin lesion (in an outpatient setting, code the conditions to the highest degree of certainty)
Which of the following is an individual user of the health record?
Coding and billing staff
Which of the following could be a focus of a coding quality review program?
Coding completed by new coders
What could potentially be a focus of a coding quality review program?
Coding completed by new coders; any new coder should have their coded records reviewed for accuracy and quality prior to releasing the claim.
The national patient safety goals score organizations on areas that:
Commonly lead to patient injury
All states have a health department with a division that is required to track and record_____-
Communicable disease;
A ______________is a condition that existed at admission and is thought to increase the patient stay at least one day for approximately 75 percent of the patients
Comorbid Condition
What is a medical condition that coexists with the primary cause of hospitalization and affects the patient's treatment and length of stay?
Comorbidity
Data found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. This data collection is called:
Comparative
_________uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care.
Comparative data collection
Comparative Benchmarking
Comparing a process in the business to a similar, but not exactly correspondent, process in another business
Internal Benchmarking
Comparing the performance of different departments within an organization.
The clinical documentation improvement (CDI) program must keep high-quality records of the query process for:
Compliance Issues
CC/MCC Means
Complication or Comorbidity/ Major complication or Comorbidity
Discharge summery
Concisely summarizes the patient's stay in a hospital
What would be the best action to validate that a new clinical documentation improvement (CDI) initiative is ensuring clinical documentation is adequately reflecting the severity of illnesses in patient's or supporting optimal HIM coding accuracy?
Conduct a retrospective review of all query opportunities for the year.
A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?
Congestive heart failure, respiratory failure, ventilator management, intubation
What piece of data is only rarely on administrative forms for patients in hospice care?
Consent to special procedures
Discrete Data
Consists of meaningful whole numbers with a possibly unknown but extant upper limit.
The statement, "the unique patient identifier must be numeric," is an example of which of the following business rule categories?
Constraint
A coworker discovers that an employee is using the RHIT credential fraudulently and notifies their supervisor. What is the responsibility of the coworker and the supervisor in this situation?
Contact AHIMA and report the abuse
For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it:
Contains data on all payer types.
Physical Examination
Contains the provider's findings based on an examination of the patient
A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is:
Continuity of Care Record (CCR)
Which type of data is a measure of blood pressure?
Continuous Data
Which of the following procedures or services could not be assigned a code with cpt?
Crutches
Division
Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part
The HIM director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. What is the best tool to use for this purpose?
Database Management System
The ________ is the best option to collect, store, manipulate, and retrieve data for this situation.
Database Management System
The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose?
Database management system
Data-Based DSS
Decision support system that focuses on providing access to the various data sources within the organization through one system
What is it called when accrediting bodies, such as the Joint Commission, rather than the government can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals?
Deemed status
The legal health record is a(n)
Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information
A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. IV fluids were administered to the patient. What should be sequenced as the principal diagnosis?
Dehydration
When the Medicare Recovery Audit Contractor (RAC) has determined that incorrect payment has been made to an organization, which document is sent to the provider notifying them of this determination?
Demand Letter
When the Medicare Recovery Audit Contractor has determined that incorrect payment has been made to an organization, which document is sent to the provider notifying them of this determination?
Demand letter
_________is an attribute that is derived through a mathematical calculation of inference from other attributes or systems variables
Derivation
Reports of diagnostic & therapeutic procedures
Describes the procedures performed; gives the names of providers; includes findings of x-ray, mammograms, lab tests, etc.
Your administrator has asked you to generate a report that gives the number of hypertension patients last year. This is an example of ________.
Descriptive analytics
Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle?
Errors that produced changes in MS-DRG assignment
Covered entities must do which of the following to comply with HIPAA security provisions?
Establish a contingency plan
After implementing a new EHR, the HIM department is noticing that documents are occasionally found in the wrong health record or are mislabeled. Which of the following would be the best approach to manage these errors in the EHR?
Establish an error-management team to receive notice of these instances and correct them
The primary goal of the Hospital Standardization Program, established in 1918 by the American College of Surgeons, was to:
Establish minimum quality standards for hospitals
How do patient care managers use the data documented in the health record?
Evaluate the performance of employees
How do Patient care managers use the data documented in the health record?
Evaluate the performance of employees; Evaluate patterns/trends in patient care
Large population-based studies are used to identify the care processes or interventions that achieve the best healthcare outcomes in different types of medical practice. This research concept is called?
Evidence-based medicine
Prevarication Bias
Exists when survey respondents embellish their answers, either by exaggerating their characteristics or providing obfuscating detail.
Sensitivity
Extent to which a test identifies all true positives and false negatives (all true cases)
The advent of the EHR has increased the amount of documentation largely due to:
Ease of entry
A study focuses on determining the proportion of patients with dental problems whose care plans adhere to the American Dental Association's guidelines. Which dimension of performance is addressed by this study?
Efficacy
A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure?
Extirpation
Predictive Analytics
Extracts information from data and uses it to predict future trends and identify behavioral patterns
As a privacy officer, you are required to manager the notification process for the data breach. All of the following would need to be notified of the breach within 60 days:
Individual patient(s), local media, and the Department of Health & Human Services; The attending physicians do NOT need to be notified.
Protected Health Information (PHI)
Individually identifiable health information that is transmitted by electronic media, maintained in an electronic medium, or maintained in any other form/medium.
Users of secondary health information - External
Individuals and Institutions that use secondary health data including: State data banks, federal agencies, etc.
A local nonprofit community hospital is looking to do a fundraiser to add to their surgical center. HIPAA rules restrict activities related to fundraising for healthcare organizations. Which of the following must the hospital do to comply with the HIPAA requirements for fundraising?
Individuals must be informed in the notice of privacy practices that their information may be used for fundraising purposes
Users of secondary health information - Internal
Individuals within the organization that use secondary health data; medical staff, administrative staff, fiscal management, etc.
The type of statistics that makes a best guess about a larger group of data by drawing conclusions from a smaller group of data is called:
Inferential Statistics
The term used to describe controlling information is______
Information Governance
The present on admission indicator is a requirement for____
Inpatient Medicare claims submitted by hospitals
UHDDS (Uniform Hospital Discharge Data Set) =
Inpatient/Acute Care Data Set
What is true regarding organizations and HIPAA security?
Institutions are allowed flexibility in the way they implement HIPAA standards
The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes 7 employees from the analysis, transcription, ROI, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team?
Insufficient knowledge of team members
Which of the following is not an individual user of the health record?
Insurance companies that cover healthcare expenses
The HIM director conducted an analysis of the coding department that revealed that 10 of the coders are credentialed and have at least 10 years of experience. However, the top five coders are leaving their employment within the next three months. This is an example of which type of analysis
Internal Analysis
The ability to electronically send data from one EHR to another while maintaining the original meaning is called____
Interoperability
A physician mistakenly leaves the records in a restaurant, where they are read by a newspaper reporter who publishes an article that identifies the patients. The physician can be sued for:
Invasion of privacy
An HIM director reviews the departmental scanning productivity reports for the past three months and sees that productivity is below that of the national average. Which of the following actions should the director take?
Investigate whether there are factors contributing to the low productivity that are not reflected in the national benchmarks.
Password Management
Involves keeping a record of end users' identifications and passwords then matching the passwords to each end user's privileges
What is a characteristic of breach notification?
It applies when one person's PHI is breached.
What are the disadvantages to the case-control study design?
It can be easily influenced by recall bias, it can be difficult to select an appropriate control group for each study, and validating the information acquired during a case-control study may be difficult.
Which of the following statements best defines utilization management?
It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care.
Spoliation can be defined as which of the following?
It is destroying, changing, or hiding evidence intentionally
What is a true statement about the legal health record?
It may contain metadata.
In order for the burden of proof to shift tot he defendant in a malpractice suit, _____
It must be clear that the injury would not have occurred without negligence that the defendant was totally in control of the process that caused the injury, and that the plaintiff made no contribution to the injury.
What is true about the Notice of Privacy Practices?
It must include a description of the right to request restrictions on certain uses and disclosures; it must explain the patient's right to inspect and copy PHI, it must include a description of the patient's right to amend PHI.
Why is the MEDPAR File limited in terms of being used for research purposes?
It only contains Medicare patients
What are the advantages of the case-control study design?
It requires fewer subjects relative to other study designs, it is relatively inexpensive, allows the use of already existing records, and poses only a slight risk to subjects.
The deception or misrepresentation by a healthcare provider that may result in a false or fictitious claim for inappropriate payment by Medicare or other insurers for items or services either not rendered or rendered to a lesser extent than described in the claim is:
Healthcare Fraud
Examples of institutional users include:
Healthcare delivery organizations, third-party payers, medical review, research, educational, accreditation organizations, government licensing agencies, and policy-making bodies.
This type of chart plots all data points as a cell for two given variables of interest and, depending on frequency of observations in each cell, provides color to visualize high or low frequency.
Heat map
What is the most constant threat to health information integrity?
Humans
What coding system is used most often by AIDS registries?
ICD-10-CM (International Classification of Diseases, 10th Edition, Clinical Modification)
In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited?
ICD-10-CM and ICD-10-PCS coding
The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence?
Identification of the record as the one subpoenaed
A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?
Identify data content requirements for all areas of the organization
Case finding is a method used to:
Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry
The function of the NCCI (National Correct Coding Initiative) editor is to:
Identify procedures and services that cannot be billed together on the same day of service for a patient
Which of the following is a function of the outpatient code editor?
Identify unbundling of codes
A law the FTC (Federal Trade Commission) enforced on August 1, 2009, requires certain businesses and organizations — including many doctors' offices, hospitals, and other health care providers — to develop a written program to spot the warning signs of identity theft.
Red Flags Rule
What is the primary purpose of structured data entry?
Reduce documentation variability in terminology, allowing for standardization
To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?
Review each patient's health record concurrently to make sure that history and physicals are present.
In health insurance, what is the name for an amendment that increases or decrease benefits?
Rider
The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following?
Risk identification and analysis, loss prevention and reduction, and claims management
What tool is used to display performance data over time?
Run Chart
The _____of de-identification requires the removal of 18 specific identifiers from the protected health information
Safe Harbor Method
Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are:
Safe harbors
OPPS Payment Status Indicators: T status -
Significant procedure subject to multiple procedure discounting
A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report?
Medication administration record and clinical laboratory reports
An audit log is an example of a:
Metadata; data about data and include information that track actions such as when and by whom a document was accessed or changed
In a management sense, controlling means:
Monitoring performance
Which of the following would be found in a query to a physician?
Name and contact number of the individual initiating the query and the account number
The Uniform Hospital Discharge Data Set (UHDDS) is maintained by the_____
National Committee on Vital Health Statistics
The _______ assembles and disseminates information about incompetent or malpracticing health care service providers.
National Practitioner Data Bank
Under the Data Use and Reciprocal Support Agreement (DURSA) Organizations will use an agreed upon set of _____
National standards, services, and policies set in coordination with the Office of the National Coordinator for Health Information Technology
A _____ depicts the path of information through a system.
System Flowchart
A ________ is usually a specialized application system and the authoritative source for data about an entity.
System of Record (SOR)
Barcode medication administration record (BC-MAR)
System that uses barcoding technology for positive patient identification and drug information
Disclosures for which an accounting is not required and which are therefore exempt include:
TPO disclosures, pursuant to an authorization, and to meet national security or intelligence requirements
Strategic Plans typically include several____
Tactical Plans
Bench Research
Takes place in a laboratory; may be less time consuming, require fewer participants, or be less expensive, but this is not always the case; conducted under controlled conditions; much less likely to be influenced by unpredictable or unexpected behavior factors
Extirpation
Taking/cutting out solid material from a body part.
Serial Work Division
Tasks or steps in a process are handled separately in sequence by individual workers, as with a factory assembly line, to complete a process
The _______ made significant changes to the Medicare reimbursement structure.
Tax Equity and Fiscal Responsibility Act (TEFRA)
______ are not included in the bed count for percentage of occupancy
Temporary beds
Integrity
Term that refers to guarding against improper information modification or destruction
______summarize or synthesize the research in primary and secondary sources. Ex. Research papers
Tertiary Sources
University medical center would like to give access to the EHR to referring physicians for their patients' information for continuing care. What should the HIM manager recommend?
That access be granted that is view-only
Credential
The recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners and are usually conferred by a national professional organization dedicated to a specific area of healthcare practice
Data Stewardship
The responsibilities and accountabilities associated with managing, collecting, viewing, storing, sharing, disclosing, or making use of PHI.
Prescriptive Analytics
The set of analytical techniques that yield a best course of action; Identify the best alternatives to minimize or maximize some objective
Nominal Data
The set of numbers assigned to different categories; In nominal data sets the exact values are arbitrary.
Range
The simplest measure of spread; it is the difference between the smallest and largest values in a frequency distribution (Max - Min = Range)
Which scenario best illustrates ascertainment bias?
The subjects of a new research study have received a disproportionate amount of health treatment in the past.
What is a positive aspect of using employee self-appraisal as a source of data for performance appraisal?
The supervisor is kept informed of the employee's accomplishments
Which of the following is a positive aspect of using employee self-appraisal as a source of data for performance appraisal?
The supervisor is kept informed of the employee's accomplishments
Ascertainment Bias
The tendency of researchers to more often select research subjects who receive greater amount of medical treatment
The Halo Effect
The tendency to allow perception to become dominated by a single characteristic of the research subject; the most difficult bias to eradicate
Descriptive Analytics
The use of data to understand past and current business performance and make informed decisions
How do accreditation organizations (Joint Commission) use the health record?
To determine whether standards of care are being met.
What is the goal of a clinical documentation improvement (CDI) compliance review?
To monitor compliant query generation and physician responses
What is an example of an external security threat?
Tornadoes
Comorbidity Rate Calculations
Total # of comorbidity/ Total Discharges (including deaths) x 100
Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients?
Tracer Methodology
Which of the following is one of the five best practices for management of financial measures in the CDI program?
Track and report on CC capture rates across the organization and by service
TPO stands for_____
Treatment Payment and Health Care Operations
True or False: there is not a requirement that the covered entity scan documents so the documents be provided in the electronic/requested format.
True: If a covered entity does not maintain the entire designated
True or False: HIPAA allows the covered entity to impose a reasonable cost-based fee when the individual requests a copy of PHI or agrees to accept summary or explanation information.
True: The fee may include the cost of copying, including the cost of supplies, labor, and postage.
True or False: if a minor is married or has been previously married they may authorize the disclosure or use of their information
True; Emancipated minors may authorize the access and disclosure of their PHI
How many times each year are healthcare facilities required to practice emergency preparedness plans?
Twice
In a bimodal distribution of data, you would have:
Two modes, one mean, and one median.
The main purpose of National Correct Coding Initiative edits is to prohibit_____
Unbundling of procedures
In Medicare, the most common forms of fraud and abuse include all except which of the following?
Unbundling/exploding charges, misrepresenting the diagnosis to justify payment, billing for services not furnished
An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?
Uniform Ambulatory Care Data Set - UACDS
A health record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?
Uniform Hospital Discharge Data Set (UHDDS)
UHDDS
Uniform health discharge data set. Needed for Medicare reporting. Data collected for inpatients
Which of the following is true about a primary key in a database table?
Uniquely identifies each row in a table
In which numbering system does a patient retain the same number for each of his or her encounters?
Unit Numbering System
Healthcare fraud is all of the following except:
Unnecessary Costs to a program
The breach notification requirement applies to____
Unsecured PHI only
The breach notification requirement applies to_____
Unsecured PHI only
Which of the following would be the best course of action to take to ensure continuous availability of electronic data?
Use redundant servers.
single sign-on (SSO)
Using one authentication credential to access multiple accounts or applications.
What is the term that means evaluating the appropriateness of the setting for the healthcare service and the level of service?
Utilization review
The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas?
Operative and other invasive procedures, medication management, and blood and blood product use
A laboratory test is intended to measure the incidence of cancer cells in a particular sample, but instead, it determines the number of healthy cells. Which characteristic of this laboratory test is deficient?
Validity
Which of the following elements of coding quality represents the degree to which codes accurately reflect the patient's diagnoses and procedure
Validity
Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following?
Validity of hospital diagnosis and procedure coding data completeness
What piece(s) of data must be collected during each visit to a health practitioner?
Patient's Name
Which of the following materials is not documented in an emergency care record?
Patient's complete medical history
The Uniform Ambulatory Care Data Set (UACDS) data characteristics include:
Patient-specific items for outpatient care.
The hospital-acquired conditions provision of the Medicare PPS is an example of which type of value-based purchasing system?
Paying for value
The Medicare Integrity Program was established under the HIPAA legislation to battle fraud and abuse and is charged with which of the responsibilities?
Payment determinations and audit cost reports.
Before the actual job analysis process begins, an HIM manager must complete the following:
Perform a needs assessment
What is a principle of contemporary performance improvement?
Performance improvement relies on the collection and analysis of data to increase knowledge.
Which of the following is a principle of contemporary performance improvement?
Performance improvement relies on the collection and analysis of data to increase knowledge.
Clinical Research
Performed with patients who have already manifested the condition being studied
Every Joint Commission participating healthcare organization is subject to a_____
Periodic Accreditation Survey
Master Patient Index (MPI)
Permanent record of all patients treated at a healthcare facility
Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered?
Pharmacy information system
A term that refers to the physical protection of information resources from physical damage, loss from natural or other disasters, and theft.
Physical Safeguards
Which of the following are security safeguards that protect equipment, media, and facilities?
Physical Security Safegaurds
This individual assists in educating medical staff members on documentation needed for accurate coding and billing.
Physician Champion
Types of secondary health data
Physician index, patient registration, financial data, master patient index, cancer registries, implants registries, disease registries, etc.
The consultation report is based on the consulting______
Physician's examination of the patient and a review of his or her health record.
The quality improvement organizations (QIOs) under contract with CMS conduct audits on highrisk and hospital-specific data from claims data in this report:
Program for Evaluation Payment Patterns Electronic Report
What are some data items that you would find on the clinical forms for a long-term care patient?
Progress notes, medical history, and a registration record
Which policy ensures that the minimum penalty appropriate to the level of employee offense is applied?
Progressive Penalties
All of the following are measures used to track and assess clinical documentation improvement (CDI) programs except:
Record agreement rate
Ordinal Data
Indicates the position or rank of the data within a value set.
NCCI edits prevent improper payments in which of the following cases?
Incorrect code combinations are on the claim.
Which events must occur in order to maintain patient identity data integrity?
The data must be accurately queried
A hospital has average daily patient revenues of $32,000 and patient accounts receivable of $84,000. What is the hospital's ratio for days of revenue in patient accounts receivable?
$84,000 ÷ $32,000 = 2.6
Weighted average length of stay calculations
(Dept. 1 patients x avg. LOS) + (Dept. 2 patients x avg. LOS) / (Dept. 1 patients + Dept. 2 patients)
Inpatient occupancy rate:
(Service days x 100) / (number of beds x service days) = percentage rate %
Expert Determination Method (Model)
1. choose the expert for de-identification analysis; 2. determine the statistical/scientific method to be used to determine risk; 3. expert applies the method; 4. analyze and assess the risk(s) to the data
Medical History
A record usually provided by the patient that includes the chief complaint, symptoms, history of illness, family history, and a basic review of systems
A health care facility has current assets of $500,000 and current liabilities of $200,000. What is the current ratio of the health care facility?
2.5
For the month of July, the case mix value of a particluar diagnosis-related group was 1.4, and 40 cases were recorded. What was the total value of service for july?
1.4 x 40 = 56; Case Mix Index (CMI) x Cases Recorded = Total Value of Service
How much of the APC payment would a facility receive for a status T procedure?
100%
A 300-bed facility had 12,500 discharge days, 200 deaths, and 1,800 other discharges during the month of August. What was the average length of stay for August at this facility? Round your answer to the nearest hundredth.
6.25
During the month of March, a healthcare facility sees 140 total cases and provides services with a total value of 179. What is the case mix index for this period? (Round answer to the nearest tenth).
179 ÷ 140 = 1.3 Case Mix Index (CMI) = total value of service ÷ total # of cases
How many identifiers are must be removed for a data to be considered de-identified under the Safe Harbor Method?
18
Which of the following would be an indicator of process problems in a health information department?
18% error rate on abstracting data
The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day?
22.5 hours per day
In May, 270 women were admitted to the obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculating the C-section rate?
263; the number of times an event could have occurred
How many days are in the month of July? (use the knuckle test)
31
Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median?
31.5
Angela has been asked by her supervisor to provide the names of two peers and one person in another department with whom she regularly interacts for her annual performance appraisal. These individuals will contribute to Angela's evaluation. This is an example of what type of performance appraisal method?
360 performance appraisal
The acute-care hospital discharges an average of 55 patients per day. The HIM department is open during normal business hours only. The volume productivity standard is six records per hour when coding 4.5 hours per day. Assuming that standards are met, how many FTE coders does the facility need to have on staff in order to ensure that there is no backlog?
385 charts per week / 5 days / 27 standard charts per day = 2.85
Per the HITECH breach notification requirements, what is the threshold for the immediate notification of each individual?
500 individuals affected
HIPAA requires that data security policies and procedures be maintained for a minimum of____
6 years from date of creation or the date when last in effect, whichever is later
Real-Time Analysis
Analysis that is performed on a continuous basis; with results gained in time to alter the run-time system
National Committee on Vital and Health Statistics (NCVHS)
A component of the department of Health and Human Services that is primarily responsible for standardizing health information; It encourages public and private entities to collaborate on a uniform and efficient health information system
Present on Admission (POA)
A condition present at the time of inpatient admission
Uniform Ambulatory Care Data Set (UACDS)
A data set developed by the National Committee on Vital and Health Statistics consisting of a minimum set of patient/client-specific data elements to be collected in ambulatory care settings
Data warehouse; Clinical data warehouse; Clinical Repository
A database that makes it possible to access data from multiple databases and combine the results into a single query and reporting interface
Database Model
A description of the structure to be used to organize data in a healthcare-related database such as an electronic health record.
Premium
A fixed payment made regularly to maintain insurance coverage
Self reported health status
A general measure often placed on a five point scale (poor, fair, good, very good, excellent)
Weighted average length of stay
A good measure for assessing the average length of stay per patient
Policy
A governing principle that describes how a department or an organization is supposed to handle a specific situation or execute a specific process.
Epidemic
A large outbreak of a contagious disease over a geographical region
What type of chart depicts the actual physical movements required for a process?
A layout flowchart (aka movement diagrams)
Data Set
A list of recommended data elements with uniform definitions that are relevant for a particular use
Double-Distribution Method
A nonlinear allocation of costs is assumed, and it is acknowledged that some indirect departments must be allocated to smaller departments before their costs are fully allocated.
Which of the following statements are true with regard to the HIPAA Privacy Rule?
A notice of privacy practices must have a statement that other uses and disclosures will be made only with the individual's written authorization and that the individual may revoke such authorization; A notice of privacy practices must be written in plain language; A notice of privacy practices must give an example of a use or disclosure for healthcare operations.
Overlay
A patient is assigned another patients medical record number.
Which of the following statements about the directory of patients maintained by a covered entity is true?
A patient must be given the opportunity to determine if they want to be placed in the directory or not, but it does not need to be in writing.
Which of the following situations is considered a breach of PHI?
A patient's attorney is sent records not authorized by that patient
Template
A pattern used in computer-based patient records to capture data in a structured manner
Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days. Community Hospital will receive from Medicare:
A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment
Coding accuracy is best determined by:
A predefined audit process
The Commission on Accreditation of Rehabilitation Facilities (CARF)
A private, not for profit organization committed to developing and maintaining practical, customer-focused standards to help organization measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.
Needs Analysis
A procedure performed by collecting and analyzing data to determine what is required, lacking, or desired by an employee, group, or organization.
Needs Assessment
A process for determining how to close a learning or performance gap as it relates to jobs performed in a particular department
Predictive Modeling
A process used in predictive analysis to identify patterns that can be used to determine the odds of a particular outcome based on the observed data.
American Health Information Management Association (AHIMA)
A professional developmental organization that offers training, certification, and research opportunities to those who are interested.
Vital Signs Record
A record comprised of BP readings, temperature, respiration, pulse, etc.
Primary data source
A record developed by healthcare professionals in the process of providing patient care; Patient's health record
Encounter Record
A record that a typical component of ambulatory care record keeping; it will include the diagnosis and treatment protocol.
Audit Trail
A record that traces a user's electronic footsteps by recording activity and transactions, including unsuccessful attempts to view unauthorized screens, within the EHR system.
Registration Record
A record that typically includes the basic diagnosis as well as the allergies and sensitivities of the patient
Access Control
A security measure that defines who can access a computer, device, or network, when they can access it, and what actions they can take while accessing it.
Hospital Acquired Condition (HAC)
A select group of reasonably preventable conditions for which hospitals should not receive additional payment when one of the conditions was not present on admission (POA)
Medication Administration Record (MAR)
A sheet used for documentation listing medications prescribed and times to be given
single sign-off
A single action of signing out terminates access to multiple software systems
Dashboard
A snapshot report that graphically displays inpatient and outpatient coding volume data, employee turnover rates, and the number of claim denials due to coding errors.
OCE (Outpatient Code Editor)
A software program linked to the Correct Code Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided.
Database life cycle (DBLC)
A system consisting of several phases that represent the useful life of a database; including initial study, design, implementation, testing, etc.
Inpatient Prospective Payment System (IPPS)
A system in which Medicare reimburses hospitals for inpatient hospital services according to a predetermined rate for each discharge.
Copayment
A system in which the subscriber pays a certain amount out of his/her pocket for every encounter with the healthcare system; the remaining payment is provided by the insurance company.
Data type
A technical category of data, such as text, numbers, currency, date, etc. that a field in a database can contain
Central Tendency Error
A tendency to group subjects in the middle of the evaluation range. EX. Evaluating peers and not putting one peer over another.
Recency Effect
A tendency to place undue influence on the most recent events
Confidentiality
A term that refers to the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purposes.
What is an example of an institutional user of the health record?
A third-party payer
Data Use and Reciprocal Support Agreement (DURSA)
A trust agreement used when exchanging information with other organizations.
Parallel Work Division
A type of concurrent work design in which one employee does several tasks and takes the job from beginning to end
The Medical Staff Executive Committee has requested a report that identifies all medical staff members who have been suspended in the last six months due to delinquent health records. This is an example of what type of report?
Ad Hoc or Demand
______ outlines the requirements for the content of the notice of privacy practices?
AHIMA
Information that has been taken from the health records of injured patients and entered into the trauma registry database has been:
Abstracted
Information that has been taken from the health records of injured patients and entered into the trauma registry database has been_____
Abstracted
To use a data element for aggregation and reporting, that data element must be:
Abstracted or indexed
To use a data element for aggregation and reporting, that data element must be____
Abstracted or indexed
What are the components of AHIMA's principles of information governance?
Accountability and Integrity
The Patient Account department is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills?
Accounts not selected for billing report
The goal of coding compliance programs is to prevent____
Accusations of fraud and abuse
Behavioral Decision Theory
Acknowledges that decisions makers will never have total knowledge of the situation and suggests that an emphasis should be placed on satisfying rather than optimal choices.
The Medicare Provider Analysis Review (MEDPAR) file is made up____
Acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims.
Performance/Competitive Benchmarking
Administrators compare the performance of their organization with the performance of leaders within another organization
What is not considered an identifier under the Privacy Rule?
Age; must identify the person or provide a reasonable basis; must relate to ones past, present, or future physical or mental health condition; must be held by a covered entity or business associate
What is true regarding the development of health record destruction policies?
All applicable laws must be considered
Endemic
An outbreak prevalent in or restricted to a particular region or population
A comprehensive retrospective review should be conducted at least once a year of what aspect of the clinical documentation improvement program?
All query opportunities
Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to the physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is:
Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment
Prescriptive Analytics
Allows users to prescribe a number of different possible actions; predicts what will happen, but also provides recommendations that will take advantage of the predictions
In which site of care are patient records least likely to contain nursing notes?
Ambulatory Care
UACDS (Uniform Ambulatory Care Data Set) =
Ambulatory Care/Outpatient Care Data Set
Which of the following laws created the HITECH act?
American Recovery and Reinvestment Act
Which of the following laws created the HITECH act?
American Recovery and Reinvestment Act (ARRA)
Context-based access control
An access control system which limits users to accessing information not only in accordance with their identity and role, but to the location and time in which they are accessing the information
Advanced Beneficiary Notice (ABN)
An agreement a patient must sign if denial of payment for treatment for Medicare is possible.
Internal Analysis
An analysis that involves review the inner working of the healthcare organization to determine strengths and weaknesses of the business practice and process
Derivation (Derivation Business Rule)
An attribute that is derived through a mathematical calculation of inference from other attributes or systems variables (calculations for avg. length of stay)
Concurrent Utilization Review
An evaluation of the medical necessity, quality, and cost-effectiveness of a hospital admission and ongoing patient care at or during the time that services are rendered
Leniency Bias (conversely known as the Strictness Bias)
An evaluators individual tendency to be too permissive or harsh in his or her judgements
Calling out patient names in a physician's office is____
An incidental disclosure
A fishbone diagram (also known as a cause-and-effect diagram)
An investigational technique that facilitates the identification of the various factors that contribute to a problem (Manpower, Material, Methods, and Machinery)
What security controls are built into a computer software program?
Application Safeguards
What security controls are built into a computer software program?
Application safeguards
Normative Decision Theory
Assumes that the decision maker will be able to maximize revenue because he/she will be able to survey available options and make the proper choice.
A Clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid:
Assumption coding
In acute care, the health history is usually the responsibility of the
Attending Physician
A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n)____
Audit trail
Which of the following is the best definition of system of record (SOR)?
Authoritative source for data about an entity
Using data mining, an RAC makes a claim determination at the system-level without a human review of the health record. This type of review is called:
Automated review
Clinical documentation policies and procedures should_____
Be created by and specifically for each organization
Why is it essential for members of the compliance team to be involved in the entire EHR implementation Process?
Because of compliance concerns such as cutting and pasting documentation in the EHR
What is one advantage of bench research over clinical research?
Bench research is less likely to be influenced by unpredictable behavior factors
A standard of performance or best practice for a particular process or outcome is called a(n)_____
Benchmark
The hospital-acquired infection rate for our hospital is .2%, whereas the rate at another hospital is .3%. This is an example of a ____
Benchmark
In trying to update scanning productivity standards the employee calls around to other area hospitals to ask what their scanning standards are. This is an example of what source of performance data?
Benchmarking source data
What is an example of how an internal user utilizes secondary data?
Benchmarking with other facilities
Which of the following is an example of how an internal user utilizes secondary data?
Benchmarking with other facilities
Which of the following ethical principles is being followed when a health information management professional ensures that patient information is only released to those who have a legal right to access it?
Beneficence
The HIPAA Privacy Rule requires the covered entity to have _____ in place with each business associate.
Business Associate Agreements
How would someone respond to a subpoena ad testificandum?
By reviewing the subpoena and appearing at the time and place supplied to give a testimony.
The Master Patient Index is used____
By the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information
Which of the following is an individual user of the health record?
Clinical professionals who provide direct patient care, Billers in the healthcare facility's business office, Patient care managers; those who depend on the health record in order to complete their job
Every healthcare facility should have a ________ to establish standards for design, approve new and revised forms, and have oversight of computer screens and other data capture tools.
Clinical Forms Committee/ Forms Design Committee
_____should be reviewed to determine if a partial thromboplastin time (PTT) test was performed.
Clinical Laboratory Report
National Patient Safety Goals (NPSGs)
Goals issued by the Joint Commission to improve patient safety in healthcare organizations nationwide
Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:
Can deny access to psychotherapy notes; information compiled in reasonable anticipation of a civil, criminal, or administrative action or proceeding; or PHI subject to the Clinical Laboratory Improvements Act (CLIA)
After the types of cases to be included in a registry have been determined, what is the next step in data acquisition?
Case Finding
The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on:
Case Mix Index
Total Value of Service calculation:
Case Mix Index (CMI) x Cases Recorded = Total Value of Service
Which of the following is an investigational technique that facilitates the identification of the various factors that contribute to a problem?
Cause-and-effect diagram
Continuing coding education and completing education units is required for:
Certified Coders in order to maintain certification
In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit?
Chargemaster Description
Examples of structured data include:
Check boxes, drop-down boxes, and radio buttons
Which of the following is part of qualitative analysis review?
Checking that only approved abbreviations are used
What position is most likely to be filled by several people in a large hospital?
Chief Operating Officer
In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?
Claims reconciliation and collections
An inpatient, acute-care coder must follow official ICD-9-CM coding guidelines established by the:
Cooperating Parties
Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the _____ and any other official coding rules and guidelines established for use with mandated standard code sets
Cooperating Parties
A(n) ________ is imposed on providers by the OIG when fraud and abuse is discovered through an audit or self-disclosure.
Corporate Integrity Agreement
Which plan should be devised to respond to issues arising from the clinical documentation improvement (CDI) compliance and operational audit process?
Corrective Action Plan
What should be done when the HIM department's error rate is too high or its accuracy rate is too low based on policy?
Corrective action should be taken to meet the department standards
Standard of care for health condition would be much more likely to be considered medically necessary. Services that are ___,___, and ___ are much less likely to be considered medically necessary.
Cosmetic, elective, and investigational
Mortality Rate
Could be any set of death rates, including the infant death rate, net death rate, or gross death rate
What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice?
Credential
As an HIM manager, Chelsea documents both positive and negative examples of her employee's work throughout the year. She refers back to these examples during annual evaluations. What type of performance appraisal method is this?
Critical Incident Method
After an outpatient review, individual audit results by coder should become part of the:
Individual employee's performance evaluation
After an outpatient review, individual audit results by coder should become part of the____
Individual employee's performance evaluation
The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of____
Data quality and integrity
Which of the following is the best example of a data governance business case?
Data silos and fragmented data inhibit data integration
Activities of daily living (ADL) are components of:
Oasis-C
The evaluation of data collected based on business needs and strategy is part of ________.
Data stewardship
Metadata
Data that describes other data; include information that tracks actions such as when and by whom a document was accessed or changed.
Healthcare fraud is all of the following:
Damage to another party that reasonably relied on misrepresentation, false representation of fact, failure to disclose a material fact, etc.
Performance monitoring is data driven and the HIM department needs access to data in order to make important decisions. One way to provide real-time data and important information that can be monitored at a glance is to use which of the following?
Dashboards
An audit of an EHR discovers that the numbers of a patient's DOB are transposed in reports. This situation reflects a problem in___
Data Consistency (the data is reliable and the same across the entire patient encounter.)
Managing an organization's data and those who enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following?
Data Dictionary
Which of the following data sets would be most helpful in developing a hospital trauma data registry?
Data Elements for Emergency Department Systems (DEEDS)
An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with ________
Data Granularity
A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as:
Data Precision
When data has been lost in an EHR, which action is taken to remedy this problem?
Data Recovery
Which HIM role works with patients to help them understand health data?
Data Translator
The Data quality model applies the following quality characteristics:
Data accuracy, accessibility, comprehensiveness, consistency, definition, currency, granulation, precision, relevancy, and timeliness
6 Components of HIM - Data Management
Data collection and storage, QA, processing and flow, and compilation and analysis.
Performance monitoring is____
Data driven
Common Data Elements
Data fields, data type, format, field size, data values, data sources, etc.
Secondary health information
Data is abstracted from the health record and used for many other purposes
The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. The process creates a:
Data map
The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of:
Data quality and integrity
Structured Data
Data that is able to be read and interpreted by a computer.
6 Components of HIM - Information Products
Data which has been analyzed and presented as actionable information.
In risk management, the administrators are more likely to use_____
Occurrence screening
What is the first step an organization should take when developing a data dictionary?
Design a plan
One way for a hospital to demonstrate compliance with OIG guidelines is to:
Develop, implement, and monitor written policies and procedures
One way for a hospital to demonstrate compliance with OIG guidelines is to_____
Develop, implement, and monitor written policies and procedures; ensuring compliance
A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a comorbid condition?
Diabetes
When two pathologist offer conflicting diagnoses of the same specimens, this is an example of_____
Diagnosis Bias; this can be resolved by preventing the pathologist from knowing the provenance of the specimens.
If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following?
Diameter of the lesion as well as the margins excised as described in the operative report
The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?
Digitally scan all paper records post-discharge, and integrate and index these into the existing electronic document management system
In designing an input screen for an EHR, which of the following would be best to capture structured data?
Drop-down menus
Nonresponse bias
Occurs when it is probable that survey respondents will have significantly different characteristics than survey nonrespondents
______applies to multiple surgical procedures that have a payment status T indicator and are performed during the same operative session.
Discounting
In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures with the payment status indicator -T performed during the same operative session, what would apply?
Discounting of Procedures
What are the components of the data analytics process?
Dissemination, Data extraction, data preparation
Consultation
Document opinions about a patient's condition furnished by providers other than the attending physician
Patient instructions
Document the instructions for follow-up care that the provider gives to the patient or patient's caregiver
Physician's Orders
Document the physician's instructions to other parties involved in providing the patient's care including orders for medications and diagnostic/therapeutic procedures
Registration record
Documents demographic information about the patient
Medical History
Documents the patients current and past health status
Survival Bias
Occurs when the results of a study are influenced by the fact that the members of a population who are still alive are more likely to share certain characteristics
What refers to a large outbreak of a contagious disease over a limited geographical area?
Epidemic
Diagnosis Bias
Occurs when there is a disagreement among professionals about the meaning of specimens collected during a research study
Electronic systems used by nurses and physicians to document assessments and findings are called:
Electronic point-of-care charting
Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?
Emergency care
What data item is least likely to appear on the clinical forms of a patient in long-term care?
Encounter Record
What are some focus areas of claims auditing for healthcare services provided in the emergency department?
Ensuring claims are not submitted more than once, procedures are reported at the appropriate level, ensuring documentation supports services reported on the claim, etc.
(Data) Consistency
Ensuring the patient data is reliable and the same across the entire encounter
What are the three components of a PERT (Program Evaluation Review) Network?
Goals-the basic intention of the network; Events-specific activities or groups that will contribute to the achievement of the goal; Activities-the tasks that must be performed in order to move from one event to the other.
True or False: Coding education is best accomplished by sending staff to external seminars.
False - Continuing education can be accomplished without sending staff to costly external seminars/workshops
True or False: If a minor is under the age of 18 and is a parent of a child, the minor may not authorize the access and disclosure of their own information or the information of their child.
False; Minor parents may authorize the access and disclosure of their PHI as well as their child's PHI.
The ROI function requires the HIM professional to have knowledge of:
Federal and State Confidentiality Laws
What filing system would be most appropriate for a facility with a high risk of fire?
Filing cabinet
The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following tools would best aid the team in identifying the root cause of the problem?
Fishbone Diagram (cause and effect diagram)
Standards
Fixed rules that must be followed
Conditions of Participation/Conditions of Coverage
Government reimbursement program standards that apply to facilities that choose to participate in federal programs such as Medicare or Medicaid
The _____ of data is the degree to which it has appropriate specificity.
Granularity
A _____is a basic summation of the steps involved in a particular work process.
Flow Process Chart
The facility's Medicare case-index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?
Focused Audit
A quality data review based on specific problem areas that comes after an initial baseline review has been completed in a hospital is called a___
Focused Review
A quality data review based on specific problem areas that comes after an initial baseline review has been completed in a hospital is called a____
Focused Review
When an obstetric patient enters the hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the final character in ICD-10-CM selected for the antepartum condition should be:
For the trimester in which the complication developed
A _________ organizes the schedule of a complex process
Gantt Chart
Which of the following provide the objective and scope for the HIPAA Security Rule as a whole?
General Rules
Which of the following issues compliance program guidance?
HHS Office of Inspector General
A patient has a right to a notice of privacy practices as defined in the______
HIPAA Privacy Rule
Which statement represents an example of nonmaleficence?
HITs must ensure that patient-identifiable information is not released to unauthorized parties.
Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. What department will be tasked to resolve this issue?
Health Information Management
Resolving failed edits is one of the many duties of the ______
Health Information Management (HIM) department
What types of covered entity health records are subject to the HIPAA privacy regulations?
Health records in any format
A report that lists the ICD-10-CM codes associated with each physician in a healthcare facility can be used to assess the quality of the physician's services before he or she is:
Recommended for staff reappointment
A patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed?
Retrospective Utilization Review
NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for:
Services that cannot reasonably be billed together
In what situation would the burden of proof shift to the defendant in a malpractice suit?
If a patient discovers that a surgical tool has been inadvertently sewn up into their body.
In what example does the gender of the patient constitute information rather than a data element?
In a study comparing the incidence of myocardial infarctions in black males as compared to white females.
The Accounts Not Selected for Billing Report is used to track accounts that are:
In bill hold or in error and awaiting billing
Coincidence
In healthcare, this is the simultaneous occurrence of two distinct conditions
On the problem list in a problem-oriented health record, problems are organized_____
In numeric order
What is a risk of copy and pasting in the EHR?
Inaccurate information can easily be copied, propagation of false information; copying the note in the wrong patients record; etc.
Which of the following would be an example of a reviewable sentinel event?
Incident of infant abduction
Which of the following should be taken into consideration when designing a health record form?
Including original and revised dates
NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for_____
Services that cannot reasonably be billed together
Suppose that you want to display the number of deaths due to breast cancer for the years 2005 through 2015. What is the best graphic technique to use?
Line Graph
Which of the following is the best definition of a forward map in data mapping?
Linking an older version of a code set to a newer version
A tornado touched down in the community and multiple patients were brought to the hospital. The HIM director has asked all department personnel to report to the emergency staging area to help with record management. The HIM director is performing which function of management?
Leading
Legal Health Record
Legal documentation that supports clinical treatment decisions, revenue reimbursement, legal testimony for patient's disease process, injury/treatment, etc.
Before healthcare organizations can provide services, they usually must obtain __ by government entities such as the state or county in which they are located.
Licensure
What would be considered a keyed entry device?
Light Pen; a special instrument that is applied directly to the display screen to enter information
Data Dictionary
Lists all data elements and characteristics within a specific system.
A patient has liver metastasis due to adenocarcinoma of the rectum, which was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is:
Liver metastasis
What is an example of physical safeguards?
Locking computer rooms
An RAI/MDS and care plan are found in records of patients in what setting?
Long term care
An RAI (Resident Assessment Instrument)/MDS (Minimum Data Set) and care plan are found in records of patients in what setting?
Long-term care
Which of the following systems is the key to identifying a patient's multiple hospitalizations?
MPI
In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of he following levels of detail?
MS-DRG triples, pairs, and singles.
If a patient wants to amend his or her health record, the covered entity may require the individual to:
Make an amendment request in writing and provide a rationale for the amendment.
Which of the following describe criteria with specific objectives and measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care?
Meaningful Use
In ICD-10-PCS, what is the root operation for a left heart catheterization with sampling and pressure measurement?
Measurement
Local coverage determinations describe when and under what circumstances which of the following is met:
Medical Necessity
______occurs when a patient uses another person's name and insurance information to receive healthcare benefits. Most often this is done so a person can receive healthcare with an insurance benefit and pay less or nothing for the care received
Medical identity theft
Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?
Medicare Conditions of Participation or Conditions of Coverage
______should be reviewed to determine if heparin was given after the PTT test was performed.
Medication Administration Record (MAR)
A provider's office calls to retrieve emergency room records for a patient's follow-up appointment. The HIM professional refused to release the emergency room records without a written authorization from the patient. Was this action in compliance?
No; the records are needed for continued care of the patient, so no authorization is required
What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services (HHS)?
OIG (Office of Inspector General) Workplans
What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services?
OIG workplans
The following data fields comprise a database table: patient last name, patient first name, street address, city, state, zip code, patient date of birth. Given this information, which of the following is a true statement about maintaining the data integrity of the database table?
None; A primary key must uniquely identify a record. None of the options provided will uniquely identify a record. Multiple individuals may have the same name and birth dates
An HIM technician is paid an hourly rate and is eligible for overtime pay, consistent with the Fair Labor Standards Act. Her position would be classified as which of the following?
Nonexempt
Questionnaires about alcohol consumption are mailed to local residents with a self addressed stamped envelop. The results of the survey indicate that the area has a below-average rate of alcoholism. What is the most likely reason for these results?
Nonresponse Bias
In what type of distribution does data follow a symmetrical curve and the mean, median, and mode are equal?
Normal Distribution
Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linens for off-site laundering. Ready-Clean is:
Not a business associate because it does not use or disclose individually identifiable health information
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is___
Not protected by the Privacy Rule because it is part of a personnel record
Nursing Notes
Notes that outline the patient's condition and treatment protocol in specific terms; typically includes an admission note and a summary of all nursing interventions, including a description of the patient's response.
Progress Notes
Notes used in the patient chart to track the progress and condition of the patient.
The Admissions director maintains that a Notice of Privacy Practices must be provided to the patient on each admission. How should the HIM director respond?
Notice of privacy practices is required on the first provision of service.
What is true about the Notices of Privacy Practices
Notices must be available at the site where the individual is treated; posted in a prominent place where patients can reasonably be expected to read it; and If the facility has a website with information on the covered entity's services or benefits, the notice of privacy practices must be prominently posted to it
The _________ established minimum staffing requirements for long-term care facilities.
Nursing Home Reform Act
Which MDS (Minimum Data Set) applies to home health care and the primary source of information on long-term patient outcomes?
OASIS (The Outcome and Assessment Information Set)
What is most likely to be used in performing an outpatient coding review?
OCE (outpatient code editor)
In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, what would be the correct coding?
One CPT code, adding the lengths of the lacerations together.
Current ratio
One of the most common liquidity ratios used in finance, is simply a comparison of current assets with current liabilities.
If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient_____
Only if a properly executed Advanced Beneficiary Notice (ABN) was obtained before the service was provided
What form of planning has the briefest time horizon?
Operational Planning
Tactical plans typically include several____
Operational Plans
Health and Human Services Data Council
Organizes the data collection efforts in both medical and non-medical areas.
OASIS-C data are used to assess the ________ of home health services.
Outcome
Medicare-Certified home healthcare uses a standardized patient assessment instrument called___
Outcomes and Assessment Information Set (OASIS-C)
OASIS-C
Outcomes and Assessment Information Set; The primary basis for assessing patient outcomes.
Under HIPAA, which of the following is not named as a covered entity?
Outsourced transcription company; they would be business associates of a covered entity
Two patient's records were filed together by mistake. This is an example of___
Overlay
Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request?
PHI sent to a physician who has not treated Sally
One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following?
Parallel Work Division
A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be:
Placenta Previa
__________provide context-sensitive templates that ensure that the appropriate data are collected and guide users in adhering to professional practice standards. Templates may include nursing admission assessments, nursing progress notes, vital signs charting, intake and output records, etc.
Point-of-care charting systems
A statement or guideline that directs decision making or behavior is called a:
Policy
Which of the following is the approved method for implementing an organization's formal position?
Policy and Procedure
Which of the following is the approved method for implementing an organization's formal position?
Policy and procedure
6 Components of HIM - Data Source
Population-based and institution-based data sources.
A risk manager is called in to evaluate a situation in which a visitor to the hospital slipped on spilled water, fell, and fractured his femur. This situation was referred to the risk manager because it involves a:
Potentially compensable event
A managed care organization is using a system that examines the past healthcare behaviors of their patients to determine their future costs for their healthcare. This is an example of ________.
Predictive Modeling
This type of analytics allows users to prescribe a number of different possible actions:
Prescriptive analytics
Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report?
Present an authorization form that at least one of them has signed.
Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered____
Present on Admission (POA)
Statistics that indicate one of every three men will develop benign prostate hypertrophy are referring to _____
Prevalence
What is the term for the percentage of people who have a disease at a particular time?
Prevalence Rate
When subjects are apt to exaggerate the severity of their ailments, this is an illustration of___
Prevarication Bias; this is especially common in situations where research subjects have some incentive to manifest a particular medical condition (like when they are receiving disability compensation)
The utilization manager's (UM) role is essential to:
Prevent denials for inappropriate levels of service
_______are created as close to the original event/phenomenon as possible. Ex. A photograph or video of the event.
Primary sources
In the inpatient prospective payment system, the calculation of the DRG begins with the:
Principal Diagnosis
The first step in an inpatient record review is to verify correct assignment of the:
Principal diagnosis
The first step in an inpatient record review is to verify correct assignment of the _______
Principle Diagnoses
The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:
Privacy
What is the principle goal of internal auditing programs for billing and coding?
Protect providers from sanctions or fines.
Detailed query documentation can be used to:
Protect the hospital against claims from physicians about leading queries
A hospital HIM department wants to move five years of health records to a remote storage location. The records will be stored in boxes and will be filed on open shelves at the remote location. Which of the following should be done so that record location can be easily identified in the remote storage area?
Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier
A patient requests a copy of his health records. When the request is received, the him clerk finds that the records are stored off-site. What is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations?
Provide copies within 60 days (HIPAA requires records to be produced within 30 days with a one-time extension of an additional 30 days if necessary; if this extension is needed the patient must be notified in writing)
A patient requests copies of her medical records in an electronic format. The hospital does not maintain all of the designated records in an electronic format. How should the hospital respond?
Provide the records in paper format only
Clinical observation
Provides a chronological summary of the patient's illness and treatment as documented by physicians, nurses, and allied health professionals
4 major purposes for secondary data collection
Quality, performance, and patient safety; research; population health; administrative
_______data can be numerically counted. They deal with measurements
Quantitative
George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of:
Quantitative Analysis
One of the questions on the patient satisfaction survey that is sent to the patient after discharge asks for the number of times the nurses checked the patient's vital signs in a day. This is an example of which type of data?
Quantitative Data
Healthcare data are divided into two broad categories of quantitative and qualitative data. ______data are numeric while ______ data describe observations.
Quantitative; Qualitative
HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into?
Reasonable diligence
MS-DRG that has the highest weight_____
Receives the highest payment
A family member of a patient states that because the doctor documented their name as caregiver on the patient's health record, that HIPAA regulations apply and that they may receive copies of the patient's health record. In this case, how should an HIM department proceed?
Refuse the request; This does not make them legally authorized as a personal representative for the patient under the Privacy Rule.
After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?
Registration
The _____ of data is the extent to which it applies to the process or function for which it was collected.
Relevancy
Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket.
Relocation of skin pocket for pacemaker
Demand Reports (also known as Ad Hoc Reports)
Reports produced as needed; whenever a manager demands or asks for it; usually they are produced through report generators or database query languages and are customized by the manager
Simultaneous-Equations Method
Requires the use of complex software programs and may require up to twelve different cost distributions
The Medicare Provider Analysis Review (MEDPAR) file is frequently used for___
Research on topics such as charges for particular types of care and MSDRGs
6 Components of HIM
Resources, indicators, data sources, data management, information products, dissemination and use
The benefits of a coding compliance plan include the following:
Retention of high standard of coding
Which of the following is true about health information retention?
Retention periods differ among healthcare facilities
HIPAA does not permit ______to be charged to patients when requesting a copy of PHI.
Retrieval fees
An HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning, such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?
Scanning all documents at the time of patient discharge
The Hospital health record's department director would like to achieve efficiencies through scanning, such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?
Scanning all documents at the time of patient discharge
As part of the data collection phase, the assistant director of the HIM department researches the AHIMA Body of Knowledge to locate different job descriptions already on file. The Body of Knowledge is what source of data?
Secondary Sources
A ________ includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called "________" because they signal the need for immediate investigation and response.
Sentinel Event; Sentinel
Data Silos
Separate repositories of data that do not communicate with each other
If steps in a revenue cycle process are handled separately in sequence by individual workers, the method of organizing work is called which of the following?
Serial work division
In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited?
Speech Recognition
______ Should be used for accounting-type functions.
Spreadsheets
Position descriptions, policies and procedures, training checklists, and performance standards are all examples of:
Staffing Tools
Which of the following is on the list of hospital-acquired conditions provision of the inpatient prospective payment system?
Stage III or IV pressure ulcers
Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system?
Stage III or IV pressure ulcers
The state must notify the ______ whenever a patient is diagnosed with a disease from _____
State public health department; the health departments communicable disease list
Delinquent Record Rate
Statistic calculated by dividing total number of delinquent records by the number of discharges in the period.
Quality assessment is the form of management that makes the most use of____
Statistical analysis
Variance Analysis
Statistical method that identifies the degree of difference between planned and actual performance.
In which cost allocation method does the indirect department that provides the most service to other departments and receives the least service from other indirect departments have its cost allocated first?
Step-Down Method
What kind of planning addresses long-term needs and sets comprehensive plans of action?
Strategic
A ______has the longest time horizon, extending over multiple years in many cases.
Strategic Plan
What do the letters in SWOT analysis represent?
Strength-what the company does well; Weakness-needs for improvement; Opportunities-establish future opportunities; Threats-evaluates threats to those opportunities.
What type of standards provide clear descriptors of data elements to be included in computer-based patient record systems?
Structure and content
_______establish and provide clear and uniform definitions of the data elements to be included in EHR systems. They specify the type of data to be collected in each data field and the attributes and values of each data field, all of which are captured in data dictionaries
Structure and content standards
Performance Improvement (PI) Principles
Structure of a system determines its performance; all systems demonstrate variation; improvements rely on the collection and analysis of data that increase knowledge; PI requires the commitment and support of top administration; PI works best when leaders and employees know and share the organization's mission, vision, and values
A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a problem oriented health record progress note would this be written?
Subjective
Secondary purposes of the health record include:
Support for public health and research
In general examinations, dermatologists tend to overemphasize the significance of moles and ignore more subtle but equally worrisome phenomena. What type of error does this scenario exemplify?
The Halo Effect
What piece of legislation established the National Practitioner Data Bank?
The Health Care Quality Improvement Act
Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
The Joint Commission
Certificates, such as those for births and fetal-deaths, are reported by hospitals to the individual state registrars and maintained permanently. State vital statistics registrars then compile the data and report them to_____
The National Center for Health Statistics (NCHS)
What government body is primarily responsible for standardizing health information?
The National Committee on Vital and Health Statistics
What federal data set was established to enable comparison of outpatient care?
The Uniform Ambulatory Core Data Set (UACDS)
Which MDS (Minimum Data Set) applies to acute care provision?
The Uniform Hospital Discharge Data Set (UHDDS); this data set is used by both federal and state agencies to standardize information for inpatients.
Data Warehousing
The acquisition of all the business data and information from potentially multiple, cross-platform sources warehoused into one consistent format used to analyze data for decision making purposes.
Data Standard; Data Content Standard
The agreed upon specifications for the values acceptable for specific data fields
Procedure
The approved methods for implementing formal positions
What would be considered a derivation business rule?
The average length of stay is the sum of inpatient days for a period divided by the number of discharges for a period
What factor is medical necessity based on?
The beneficial effects of a service for the patient's physical needs and quality of life
Data Timeliness (or Data Currency)
The concept of data quality that involves whether the data is up-to-date and available within a useful time frame.
Why should the copy and paste function not be used in the electronic health record?
The content may contain outdated information
Step-down method
The cost allocation method used by Medicare in its requirements for cost reporting.
For HIPAA implementation specifications that are addressable, which of the following statements is true?
The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment.
Three events must occur in order to maintain patient identity data integrity:
The data must be accurately collected, entered, and queried
Accreditation
The end result of an intensive external review process that indicates a facility has voluntarily met the standards of the independent accrediting body
Specificity
The extent to which a performance measure identifies all true negatives and false positives
Data validity
The extent to which data has been verified to be accurate
An example of ordinal data is___
The five-point self assessment scale, on which patients describe their current health status.
Data Structure
The form in which data is stored; Such as in a file, a database, a data repository, etc.
When assigning evaluation and management codes for hospital outpatient services, the coder should follow:
The hospital's own internal guidelines
When a staff documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected?
The incident report likely becomes discoverable because it is mentioned in a discoverable document
Data Translator
The liaison between the patient and his or her health data. Assists the patient in understanding their rights, such as the right to control access to their protected health information
Prevalence
The likelyhood that a given member of a population would have a certain condition within a certain time. (The rate of the number of existing cases of a condition during a particular interval divided by the total population during that interval.)
What is an example of Discrete Data?
The number of patients admitted by a healthcare facility during a particular interval.
Unit Numbering System
The patient retains the same number for each of his or her encounters
Consent, authorizations and acknowledgement
The patient's agreement to undergo treatment, services, release confidential information, or recognition that information has been received
Specificity
The percentage of all true noncases that are identified; the success of the test at identifying those members of the population that do not have the condition.
Data storage
The physical location and maintenance of data
Attending Physician
The physician responsible for the care and treatment of a patient
Unbundling
The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure
Clinical Documentation Improvement (CDI)
The process an organization undertakes that will improve clinical specificity and documentation that will allow coders to assign more concise disease classification codes
Release of Information (ROI)
The process of disclosing patient-identifiable information from the health record to another authorized party
Data mapping
The process of identifying relationships between two distinct data models/systems
Data security
The process of keeping data, both in transit and at rest, safe from unauthorized access, alteration, or destruction
6 Components of HIM - Dissemination and use
The process of making data available to decision-makers and facilitating the use of that information.
Morbidity Rate
The rate of complications for patients, though it should be noted that thus rate also includes the prevalence and incidence of disease as well as the comorbidity.
The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice pf calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise to the committee?
There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice.
What are some advantages of a prospective study?
These studies are able to determine relative risk exactly, they are notably devoid of recall bias, and they are usually able to identify whether the symptom preceded the disease.
What are some disadvantages of a prospective Study?
These studies are very expensive, takes a long time to produce results, not good at obtaining information about a rare disease, and it may easily be influenced by unpredictable changes in the environment or the behavior patterns of participants
Physician Reappointment Summaries
These summaries outline the number of cases by diagnosis and procedure type, LOS, and infection and mortality statistics.
What is not a characteristic of the common healthcare data sets such as UHDDS and UACDS?
They provide a complete and exhaustive list of data elements that must be collected.
What are some characteristic of the common healthcare data sets such as UHDDS and UACDS?
They provide a framework for data collection in which the facility can add data items, they define the minimum data elements to be collected, the federal government recommends, but does not mandate, implementation of most of the data sets
Continuous Data
This form of data has the potential to carry on infinitely in a meaningful sense; weight and cost are two classic examples of continuous data because there is no upper limit to either.
Chief Information Officer (CIO)
This person is responsible for managing the organization's information resources; this includes financial, clinical, and administrative information operations.
Chief Executive Officer (CEO)
This position is appointed by the board of directors and is the principle authority for the institution.
Chief Financial Officer (CFO); or Director of Finance
This position is responsible for managing the fiscal activities of the institution
Chief Operating Officer (COO)
This position is responsible for managing the performance of individual departments and ensuring employees always act in consonance with the organizational goals.
Sporadic
This term means occurring or appearing in irregular intervals.
Who would be considered as an individual user of the health record?
Those who depend on the health record to complete their job; coders, billing, physicians, etc.
One element of Helen's SWOT analysis mentions the hospital across town recently sent all their coders home to work remotely. Currently all coding done at Helen's hospital is done in-house. In a SWOT analysis, remote coding done by the other hospital would be a(n):
Threat
External Threats
Threats that originate outside an organization; natural disasters like floods.
Internal threats
Threats that originate within an organization; pipe burst, system failure, etc.
When a meaningful ________ is developed, an organization is more likely to achieve its goals and be profitable.
Vision statement
Cancer registries are maintained by hospitals:
Voluntarily or by state law
Dr. Smith wants to use a lot of free text in his EHR. What should be your response?
We recommend that you use little, if any, free text in the EHR.
In data matching which of the following best describes an overlap?
When one entity has different unique identifiers in different databases
Reasonable Diligence
When the healthcare provider has taken actions to comply with the legislative requirements
Interviewer Bias
When the interviewer modifies his/her style of questioning based on the answers given early in the interview; this can be resolved by standardizing the question sequence.
What assists managers with the tasks of monitoring productivity and forecasting budgets
Workload Statistics
In trying to update scanning productivity standards, a supervisor asked the current scanners to track their tasks on an activity log. Each scanner logs in the time it takes to scan a specific amount of records. This is an example of what source of performance data?
Work Sampling
What is occuring when the supervisor gets a snapshot of the current process and then uses that data, along with benchmarking data, to establish standards for a position within their department?
Work imaging
Business Associate Agreement
Written agreement requiring entities to follow HIPAA PHI privacy rules
Consultation report
a narrative report of an opinion about a patient's condition by a practitioner other than the attending physician
Pareto Chart
a bar graph whose bars are drawn in decreasing order of frequency or relative frequency
6 Components of HIM - Indicators
a complete set of indicators and relevant targets, including inputs, outputs, outcomes, determinants of health, and health status indicators
Comorbidity Rate
a condition that the patient has upon being admitted, and that increases the patient's stay by at least a day 3/4 of the time.
The continuity of care record (CCR) standard
a core data set of relevant administrative, demographic, and clinical information elements about a patient's health status and healthcare treatment. It was created to help communicate that information from one provider to another for referral, transfer, or discharge of the patient
National Center for Health Statistics (NCHS)
a division of the Centers for Disease Control and Prevention (CDC); it is an aggregator and disseminator of vital and health statistics
bimodal distribution
a frequency distribution having two different values that are heavily populated with cases
Delinquent Record
a health record with deficiencies that are not complete within the time-frame specified.
Vocabulary standards
a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field
In both the Serial and Serial-Unit Numbering Systems, a patient will receive____
a new number for each encounter
Invasion of Privacy
a person's right to solitude and to be free from unwarranted public exposure
SWOT analysis (situational analysis)
a search for the Strengths, Weaknesses, Opportunities, and Threats affecting the organization
contingency plan
a set of procedures, documented by the organization to be followed when responding to emergencies.
To correct errors or make changes in a paper health record_____should be drawn in ink through the incorrect entry.
a single line
Res Ipsa Loquitur
a situation speaks for itself
subpoena ad testificandum
a subpoena that primarily seeks an individual's testimony
The Patient Self-Determination Act of 1990 mandated____
a wider dissemination of information to patients about their health options and rights
Calculating a hospital's ratio for days of revenue in patient account receivable:
accounts receivable ÷ avg. daily revenue
The goal of coding compliance programs is to prevent____
accusations of fraud and abuse
The CMI value is calculated by____
adding the medicare severity-diagnosis related group (MS-DRG) weight for each discharge; then dividing the total by the total number of discharges.
Calling out patient names in a physician's office is____
allowed; according to the Privacy Rule, this is considered an incidental disclosure.
Whn an insurer denies a claim, an _____may be possible.
appeal
The________of an activity is the extent to which it applies to the clinical needs of the patient.
appropriateness
RACs conduct three types of audits:
automated reviews, semi-automated reviews, and complex reviews.
Risk management is focused on_____
avoiding liability
A ______obtains information from a series of varying black vertical stripes on the document. Bar codes are considered to be extremely accurate, though they may be time-consuming to create.
bar code reader
medical identity theft includes_____
both financial fraud and identity theft, it involves either (a) the inappropriate or unauthorized misrepresentation of one's identity (for example, the use of one's name and Social Security number) to obtain medical services or goods, or (b) the falsifying of claims for medical services in an attempt to obtain money; Ex: Using another person's name to obtain durable medical equipment
The Health Care Financing Administration Common Procedure Coding System (HCPCS) is used ____
by the billing departments on documentation for inpatient, ambulatory, and surgical treatment.
The health record typically begins in patient registration with the _____
capture of patient demographic information
Data content standards allow organizations to____
collect data once and use it many times in many ways; assist in data storage/mining; sharing data with external organizations for benchmarking or other purposes.
A ___________ is a condition that existed at admission and is thought to increase the patient stay at least one day for approximately 75 percent of the patients.
comorbid condition
According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure?
complex
A ________of a wound goes beyond layer closure and requires scar revision, debridement, extensive undermining, stents, or retention sutures
complex repair
OASIS C Items are components of the ______
comprehensive assessment that is the foundation for the plan of care.
The _________ of the study is the extent to which multiple health care providers are able to coordinate and maintain consistent therapy for patients over a long duration.
continuity
-otomy
cutting into; division
Controlling is the function in which performance is ______according to policies and procedures. In HIM, controlling includes_____
monitored; monitoring the performance of employees for quality, accuracy, and timeliness of completion of duties
PHI sent to a physician that has not treated the patient would need____
to be accounted for and included in an accounting of PHI disclosure
To move to a mature value-based purchasing program, Centers for Medicare and Medicaid Services (CMS) desires to Pay For Value. This means____
to promote efficiency in resource use while providing high-quality care.
The problem oriented record is better suited_____
to serve the patient and the end user of the patient information
The accounts not selected for billing report is a _____
daily report used to track the many reasons that accounts may not be ready for billing
The three elements of a security program are ensuring____, _____, and ____.
data availability, protection, and integrity
Which of the following is a technique for graphically depicting the structure of a computer database?
data model
Focused selections of coded accounts are necessary for______
deeper understanding of patterns of error or change in high risk areas or other areas of concern
Safe Harbor method
deidentification method that requires covered entity or business associate to remove 18 data elements from protected health information
Notice of Privacy Practices (NPP)
description of a covered entity's principles and procedures related to the protection of patients' health information
The Systematized Nomenclature of Diseases & Operations (SNOMED) makes it possible for_
distant health care facilities to compare the treatment protocols and patient responses for common conditions
Utilization management focuses on_____
effectively using resources
Predictive Analytics
extracts information from data and uses it to predict future trends and identify behavioral patterns
To be reliable, statistical data must_____
have some consistency
Medicare does have a provision that a patient may be billed for a test that is not medically necessary if _____
he or she receives an advance beneficiary notice (ABN) before the test is performed.
Having real-time data in an easily accessible format like a dashboard allows leaders to keep track of____
high-impact, high-risk, or high-value processes and make adjustments on a daily basis if needed.
The ratio for days of revenue in patient accounts receivable indicates_____
how long it takes the hospital to collect payment or the time over which the hospital is willing to extend credit.
Data timeliness is determined by___
how the data is being used and its context
Determining the Case Mix Index (CMI) enables the health care facility to_____
identify how well resources are being used in the treatment of particular ailments.
The National Patient Safety Goals (NPSGs) include:
identifying patients correctly, improving staff communication, using medicines safely, preventing infection, checking patient medicines, preventing patients from falling, preventing bed sores, and identifying patient safety risks.
The access control standards require _____
implementation of technical procedures to control or limit access to health information.
The purpose of quality assessment is to____
improve care and services by analyzing past performance
The Health Insurance Portability & Accountability Act was created to generally_____
improve the quality, access, and affordability of health insurance
Various hospital departments depend on the coding expertise of the HIM professionals to avoid_____
incorrect coding and potential compliance issues
Each problem on the problem-oriented health record is_____
indexed with a unique number
The Privacy Rule defines PHI as ____
individually identifiable health information that is transmitted by electronic media, maintained in an electronic medium, or maintained in any other form or medium.
The ICD-10-CM coding instrument is generally recommended for the principle diagnosis upon admittance to _____
inpatient treatment; used to make the determination that will inform the patient's treatment from admission
Single sign-on (SSO)
is less frustrating for the end user and can provide better security when getting onto software systems.
Utilization management (UM) staff work with the physician to ensure that the requested services _____
meet medical necessity requirements and are provided in the most appropriate setting
The Nursing Home Reform Act of 1987, established_____
minimum staffing requirements for long-term care facilities
The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form requested by the individuals, if____
it is readily producible in the requested format.
The key characteristic of the problem-oriented health record is an____
itemized list of the patient's past/present social, psychological, and health problems.
A ______ uses a graphical user interface, similar to a Windows Desktop.
keyed entry device
It is important to ensure that the legal health record is _______
legally sound and defensible as a valid document in legal situations
In utilization management, administrators are more likely to use_____
management techniques
An example of data mapping is____
mapping two different coding systems to show equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose.
In a _______employees use a pencil to darken circles on a form, which is then fed into a machine and entered into memory. They functions much like a standardized multiple-choice test
mark-sense reader system
Per CPT Coding Guidelines, when a planned procedure is terminated prior to completion, the intended procedure is coded with a _____
modifier
Institutional users of the health record are organizations that____
need access to health records in order to accomplish their mission.
The fact that a family member is listed in the health record as the caregiver does _____
not make her legally authorized as a personal representative under the Privacy Rule
The average Length of stay calculation:
number of days stayed (discharge days) divided by number of admissions (number of discharges, including deaths)
Data Redundancy
occurs when unnecessary duplicate information exists in a database
Which one of the following indexes contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period?
operation
An_______transmits the image of a paper document into computer memory.
optical scanner
One example of effective form design principles is that each form should include:
original and revised dates for the tracking and purging of obsolete forms
The health record is assigned to new patients during the____
patient registration process
The UHDDS data characteristics include____
patient specific items on every inpatient
The UHDDS data characteristics include _____
patient-specific items on every inpatient.
Secondary data enables users to identify_____
patterns/trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the____
primary coding system for mental conditions
Excision
process of cutting out, surgical removal
The HIM department works with patient registration to ensure the_______
quality of data collected and to correct duplicates and other issues with the MPI.
The last component of the revenue cycle is _______
reconciliation and collections
Accurate clinical documentation can positively affect_____
reimbursement, severity of illness and mortality risk assessment, and reporting of quality and pay-for-performance measures.
A subjective (S) entry in the SOAP format___
relates significant information in the patient's words or from the patient's point of view
A ______ uses a piece of sensory equipment to read the information into its memory system. EX. Mark-sense readers, optical scanners, and bar code readers
scanned entry device
HIPAA allows a covered entity to adopt_____
security measures that are appropriate for its organization as long as they meet the minimum HIPAA security standards.
_________means that as data is entered and processed by one server, that data is also entered and processed simultaneously by a second server. Should the primary server crash, the system should be designed to "fail over" to the second server.
server redundancy
Specificity calculation
true negative/ (true negative + false positive)
Calculating the sensitivity of a test:
true positives ÷ total number of positives (true positives + false negatives = total number of positives)
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) established_____
standards for the transfer and discharge of Medicaid and Medicare recipients.
Original health records may be required by _______ to be produced in person and the custodian of records is required to ______ those records through testimony.
subpoena; authenticate
In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS) to____
support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records
Nonmaleficence would require the HIM professional to ensure____
that the information is not released to someone who does not have authorization to access it and who might harm the patient if access were permitted (EX. a newspaper seeking information about a famous person)
The penalty for over payment of unbundled laboratory charges is____
the amount overpaid and 3 times the amount of that over payment; ex. (175 x $75 = $13,125 then; $13,125 x 3 = $39,375)
Once a Business Associate Agreement has been terminated, it is recommended that____
the covered entity obtain a certification from the business associate that it has either returned, destroyed, or no longer has the PHI from the covered entity.
The Business Associate Agreement must always include provisions regarding:
the destruction or return of PHI upon termination of a business associate's services
Medical necessity is based on_____
the effects of a service for the patient's physical needs and quality of life
Morbidity
the extent to which a population suffers from an illness, injury, or disability
Validity
the extent to which a test measures or predicts what it is supposed to predict
In the provision of health services, efficacy is______
the extent to which an activity achieves its intended outcome.
Reliability
the extent to which it can be depended upon to give a consistent reading in different circumstances
A key component of every accreditation survey is a review of____
the facility's health records.
The Medicare Conditions of Participation are administered by____
the federal government Centers for Medicare and Medicaid Services (CMS)
Diagnoses documented as probable, suspected, rule out, working diagnosis, or questionable in the outpatient setting indicate _____.
uncertainty and would not be coded as if existing
Leading is defined as
the function in which people are directed and motivated to achieve the goals of the healthcare organization.
Health records, x-rays, laboratory reports, consultation reports, and other physical documents related to the delivery of patient care is owned by____
the healthcare organization.
6 Components of HIM - Resources
the legislative, regulatory, and planning frameworks required for system functionality. Includes personnel, financing, logistics support, information and communications technology, and mechanisms for coordinating both within and between the six components.
Deductible
the minimum amount that the beneficiary of an insurance policy must incur before the insurance provider will pay for the remaining treatment
Because minors are legally incompetent and unable to make decisions regarding the use and disclosure of their own health information, this authority belongs to_____
the minor's parent(s) or legal guardian(s); unless an exception applies.
A bed count, also called an inpatient bed count, is ____Temporary beds are not included in the bed count for percentage of occupancy
the number of available hospital inpatient beds, both occupied and vacant, on any given day.
Occupancy rate, occupancy percentage, or percentage of occupancy
the number of inpatient service days ÷ (number of beds x number of days in the month) x 100
Incidence Rate
the number of new cases of a particular condition during an interval. (calculation: the number of new cases during the interval/ the population during the interval
To begin an inpatient record review, the coding supervisor checks the inpatient health record to ensure that the diagnosis billed as principle meets_____
the official Uniform Hospital Discharge Data Set (UHDDS) definition for principle diagnosis.
Patient care managers are responsible for ______
the overall evaluation of services rendered for their particular area of responsibility.
A complete medical history documents_____
the patient's current complaints and symptoms and lists his or her past health, personal, and family history.
Data Recovery
the process of recouping lost data or reconciling conflicting data after the system fails.
Diversion
the removal of a medication from its usual stream of preparation, dispensing, and administration by personnel involved in those steps in order to use or sell the medication in non-healthcare settings.
In the context of healthcare, privacy can be defined as_____
the right of individuals to control access to their personal health information
Surveyors review the documentation of patient care services to determine whether____
the standards of care are being met.
To correct errors or make changes in a paper health record____ should be printed at the top of the entry along with____
the word Error; a legal signature or initials, date, time, and discipline of the person making the change.
Personal Representative
those who are legally authorized to make healthcare decisions on an individual's behalf; or to act on behalf of a deceased individual or that individual's estate.
The first steps for an HIM professional in determining the components of a legal health record are_____
to advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record
The legal health record is important ______
to an organization's business and legal processes; is the record produced upon request (including legal requests)
Quantitative analysis is used by health information management technicians as a method to detect
whether elements of the patient's health record are missing
The HIPAA Privacy Rule requires that records be produced _____ to a patient or personal representative.
within 30 days; 30 additional days can be added under certain circumstances
There is a one time extension for the release of information that allows for an additional 30 days, provided____
written notification to the patient for the additional time.