RHIT Mock Exam Cengage

A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? "U" "W" "Y" "N"

"N" The indicator for this case is N since the diagnosis of diabetes was not present at the time of inpatient admission

Annual costs for the only Release of Information Clerk at Jacksonville Beach Healthcare Center (salary and benefits) are $36,429. The monthly cost for the copier used solely for ROI is $89 (supplies and repairs). It costs the department $0.95 on average for ROI mailings (envelopes and postage). There were 687 requests filled for ROI last month. The cost per request for release of information last month was $4.42. $5.50. $4.63. $4.55.

$5.50. Calculations:• $36,429 annual labor costs / 12 = $3,035.75 cost per month• $3,035.75 + $89 copier cost = $3,124.75 monthly costs/687• ROI last month = 4.548 or $4.55 unit cost (not counting mailing)• $4.55 + 0.95 average mailing cost = $5.50 per ROI

he MS-DRG weight in a particular case is 2.0671 and the hospital's payment rate is $3,027. How much would the hospital receive as reimbursement in this case? $5,094.10 $6,257.11 $3,027.00 $960.00

$6,257.11 A Medicare Severity-Diagnosis Related Group (MS-DRG) is a system of classifying a Medicare patient's hospital stay into various groups in order to facilitate payment of services. Formula: DRG relative weight x hospital base rate Calculation: 2.0671 x 3,027 = 6,257.11

Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker. 00560 00530 33206, 00560 33202, 00530

00530 Code 00530 for the anesthesia for the permanent transvenous pacemaker insertion.

An HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is $2,655. $265. 0.9%. 11%.

11%. A budget variance is the difference between the budgeted amount and the amount actually spent. To determine the percent variance, subtract the budgeted amount from the actual amount and then divide the difference by the budgeted amount. Calculation: 25,000 - 22,345 = 2,655 2,655 / 25,000 = 0.1062 x 100 = 10.62%, rounds to 11%

Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. 12035 12002, 12004 12004 12045

12035 The sizes of the layered wound repairs of the same body area are added together in order to select the correct CPT code.

The coder works 7.5 hours per day. If a time standard is determined from sample observations to be 2.50 minutes per record for coding emergency room records, what is the daily standard for the number of records coded when a 15% fatigue factor is allowed? 180 records per day 153 records per day 200 records per day 192 records per day

153 records per day Calculation:7.5 hours x 60 minutes per hour = 450 minutes per day450 x 15% = 67.5450 − 67.5 = 382.5382.5/2.5 = 153

Based on the MS-DRG report above, what is the case-mix index for this facility?

2.9658 The case-mix index is calculated by multiplying the volume of patients in each category by the DRG weight (e.g., 1.234 DRG weight x 12 patients) and then dividing the total Medicare Severity-Diagnosis Related Group (MS-DRG) relative weights by the total number of discharges for a group. Calculation: 1.234 x 12 = 14.808 3.122 x 10 = 31.22 2.165 x 19 = 41.135 5.118 x 16 = 81.888 14.808 + 31.22 + 41.135 + 81.788 = 169.051 12 + 10 + 19 + 16 = 57 169.051 / 57 = 2.9658

Patient was seen for excision of two interdigital neuromas from the left foot. 64776 64774 28080 28080, 28080

28080, 28080 Look up in CPT codebook index under foot, neuroma.

A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist. 77290 77263 77334 77315

77263 Code 77263 for complex therapeutic radiology treatment planning. No indication of simulation-aided field, teletherapy, or treatment devices.

A quantitative drug assay was performed for a patient to determine digoxin level. 80101 80166 80050 80162

80162 A quantitative drug assay was performed for a patient to determine digoxin level would be coded to 80162.

The file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. There are a total of 4,500 records in the main file. What is the area's accuracy rate? 88.9% 10.0% 8.9% 1.1%

88.9% To calculate the accuracy, the formula for a rate can be applied. A rate is a fraction that is formulated to express the relationship between the numerator or denominator. The basic rule of thumb for calculating rates is to divide the number of times something actually happened in relation to the number of times it could have happened. 400 / 450 = 0.888888 x 100 = 88.9%

You supervise five clerical employees who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for 200 square feet of space for your clerical staff. 350 square feet of space for your clerical staff. 250 square feet of space for your clerical staff. 300 square feet of space for your clerical staff.

300 square feet of space for your clerical staff. Generally, allow 60 sq ft per employee. However, as time progresses, less area is being allotted for personal space.

The correspondence section of your department receives an average of 50 requests per day for release of information. It takes an average of 30 minutes to fulfill each request. Using 6.5 productive hours per day as your standard, calculate the staffing needs for the correspondence section. 2.5 FTE 3.5 FTE 4 FTE 3 FTE

4 FTE Calculation: 50 x 30 = 1,5001,500/60 = 2525/6.5 = 3.8Round up to 4.

Which of the following statements is true? The term surgical procedure is an incorrect term and should not be used. The terms surgical operation and surgical procedure are synonymous. A surgical operation may include one or more surgical procedures. A surgical procedure may include one or more surgical operations.

A surgical operation may include one or more surgical procedures. A surgical operation is one or more surgical procedures performed at one time for one patient using a common approach or for a common purpose.

CDI programs have been traditionally measured by financial data from DRG shifts and the shift in the organization's case-mix index. As CDI has grown, additional measures of success have been utilized. Which of the following items is not a measure of success for a CDI program? Patient safety indicators and hospital-acquired infections Claims denials Bed occupancy rate Reduction of coding queries

Bed occupancy rate Trending denial rates and query rates over time is another method of demonstrating the effectiveness of a Clinical Doumentation Improvement (CDI) program. Many CDI programs report a reduction in claims denials and physician queries due to the proactive collaboration of CDI and physicians for accurate and complete documentation. Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality (AHRQ) to reflect quality of care by measuring potentially avoidable in-hospital complications and adverse events. CDI programs need to be on the lookout for certain PSIs that are used to measure a facility's quality scores and help ensure hospital-acquired conditions and their related present on admission (POA) indicators are reported correctly.

An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done? Both patients can be treated under implied consent. The mother can be treated under implied consent but not the child. Nothing, until consent can be obtained from the nearest relative. The hospital should quickly seek a court-appointed guardian for the child.

Both patients can be treated under implied consent. Even though the mother is not able to give expressed consent for treatment, permission is implied when the provider is acting in the patient's best interest to prevent death or preserve a limb.

Four people were seen in your emergency department yesterday. Which one will be coded as a poisoning? Josh Bryan Matthew Ben

Bryan The condition should be coded as a poisoning when there is an interaction of an over-the-counter drug and alcohol (Bryan). Josh, Ben, and Matthew have adverse effects of a correctly administered prescription drug.

Which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but NOT on the job description of chief privacy officer? Monitor the facility's business associate agreements. Oversee the patient's right to inspect, amend, and restrict access to protected health information. Conduct audit trails to monitor inappropriate access to system information. Cooperate with the Office of Civil Rights in compliance investigations.

Conduct audit trails to monitor inappropriate access to system information. While a privacy officer would likely be involved with facility training in privacy and security standards, a security officer is more likely to be responsible for the technical aspects of monitoring the security of protected health information.

Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. Jackson, who had no comorbidities or complications during this admission for replacement of a pacemaker battery. Howard, who died within 24 hours after his admission for a second heart attack in 2 weeks. Fieldstone, who was admitted for 5 days following a heart attack for the acute onset of chest pain.

Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. Joint Commission standards allow a final progress note to substitute for a discharge summary in the following three cases: uncomplicated OB patient, normal newborn, and a minor stay of less than 48 hours. The Babson admission is the only one that qualifies.

Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA Privacy Rules? Contact the attending physician for permission to respond. Contact the patient to get permission to respond. Do not honor because the authorization is invalid. Honor the authorization since the patient obviously approves of the release.

Do not honor because the authorization is invalid. Once an expiration date has passed on an authorization, it becomes invalid.

Your hospital takes advantage of the 8/80 exemption for health care facilities. Assuming that no employee worked more than 8 hours in a day, which of the employees listed in the table below will be paid overtime this pay period? Employees 101, 102, and 105 Employees 101, 104, and 105 Employees 101 and 105 Employees 101, 103, 104, and 105

Employees 101 and 105 The 8/80 exception allows employers to pay one and one-half times the employee's regular rate for all hours worked in excess of 8 in a workday and 80 in a 14-day period. Although employees 103 and 104 worked more hours than scheduled, they still did not work overtime using the 8/80 rules.

Fred is recovering nicely, so he asks Dr. Jones if he can go home for the weekend. Dr. Jones approves a two-night leave of absence (LOA). Fred stays one more week before final discharge. How will this affect the hospital's statistics for the period when Fred was hospitalized? Fred's LOA will not negatively impact his total discharge days. Fred's LOA will positively impact the percentage of bed occupancy for the period. Fred's LOA will increase the daily inpatient census counts. Fred's LOA will decrease his total discharge days.

Fred's LOA will not negatively impact his total discharge days. Leave of absence days are not counted during the concurrent tallies of census or inpatient service days on the dates of the leave; however, the total discharge days will be computed retrospectively from formal admission to formal discharge, disregarding the days when Fred was on leave.

Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. Data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below. MMBC receives the best reimbursement for well-child visits from SureHealth. Lifecare. Getwell. BeHealthy.

Getwell Calculations: Reimbursement from payor for one well-child visit equals total reimbursement divided by number of visits to the clinic.

An Electronic Document Management Systems (EDMS) allows you to digitize paper patient records so that they can be viewed within the EHR or in a separate viewing platform. Documents are scanned in to the EDMS and indexing is completed through recognitions systems. Which of the following recognition systems utilizes artificial intelligence to allow the system to "learn" the form type through the handwriting or information on the form? OMR OCR ICR IWR

IWR Intelligent Character Recognition (ICR) is an advanced form of OCR in which the system "learns through artificial intelligence or artificial neural networks. Optical Mark Recognition (OMR) is the oldest form of optical recognition and requires pre-printed forms to contain locations for marking specific, limited information that is then read by a scanning system, and the content is incorporated into the EDMS. Optical Character Recognition (OCR) is the scanning of printed or type written text in structured locations on forms into machine-editable text. Intellegent Word Recognition (IWR) allows for the recognition of unconstrained handwritten words.

ORYX is a program that was developed by Joint Commission to link patient outcomes to accreditation. NIH to track communicable diseases. AMA to allow for rapid CPT updates. CMS to track Medicare costs.

Joint Commission to link patient outcomes to accreditation. ORYX is the Joint Commissions performance measurement and improvement tool. ORYX for hospitals is known as the National Hospital Quality Measures, and requires hospitals to collect and transmit data on key patient care, treatment, and service issues.

Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes. I97.821, K80.10, 0FT40ZZ K80.10, I66.9, Z53.09 I97.821, I66.9, Z53.09 I66.9, Z53.09

K80.10, I66.9, Z53.09 The INCLUDES notation beneath I66 informs you that cerebral thrombosis is reported with a code from this code category.

Dr. Reed tried to explain wound care to Mr. Baker prior to discharge, but Baker (who is 104 and moderately senile) just could not seem to understand or remember what the doctor said. Mr. Baker's daughter was with him, so Dr. Reed explained Mr. Baker's aftercare to his daughter. Dr. Reed should document discharge instructions on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Mr. Baker's medical record. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker and filed in Baker's medical record. in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record. in the discharge summary.

in the discharge summary and on a patient instructions form signed by Dr. Reed and Mr. Baker's daughter and filed in Mr. Baker's medical record. Due to Mr. Baker's confusion, the doctor's instructions for his aftercare should be shared with his daughter and her signature should be captured on the instruction sheet sent home with them. Discharge instructions are a critical part of the discharge summary as well.

The special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the interdisciplinary patient care plan. medical history and review of systems. interval summary. problem list.

interdisciplinary patient care plan. The interdisciplinary patient care plan is the foundation around which patient care is organized. It contains input from the unique perspective of each discipline involved. It includes an assessment, statement of goals, identification of specific activities, or strategies to achieve those goals and periodic assessment of goal attainment. The care plan is initiated when a patient begins care or is admitted, and it is updated periodically. It is reviewed and revised as often as the organization, regulatory agencies, and accrediting bodies require when goals change, or when the patient circumstances have changed. The interdisciplinary care plan is required for most patient care sites. Exceptions are a physician's office or clinic and an acute care hospital where the physician plan and other practitioner's plans are documented separately.

A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have been asked to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on affidavits. allocutions. interrogatories. depositions.

interrogatories Interrogatories are a list of questions used in the discovery stage of a trial to obtain information from other parties in a lawsuit. A deposition is sworn verbal testimony that is obtained during the discovery phase of a trial. An allocution, or elocutus, is a formal statement made to the court by the defendant who has been found guilty prior to being sentenced. An affidavit is a written statement confirmed by oath or affirmation for use as evidence in court.

Use the information provided in the table above to calculate the delinquent rate. The delinquent rate cannot be determined. is 71%. is 50%. is 36%.

is 36%. To calculate the delinquency rate, the formula for a rate can be applied. A rate is a fraction that is formulated to express the relationship between the numerator and denominator. The basic rule of thumb for calculating rates is to divide the number of times something actually happened in relation to the number of times it could have happened. (304 / 845) = 0.35976 x 100 = 36%

Johnston City was set upon by a swarm of killer bees. All 5,000 residents are at risk of a bee attack. If 25 residents were attacked by the bees, the incidence of bee attacks is 25 in 1,000. is 5 in 5,000. is 5 in 1,000. cannot be determined at this time.

is 5 in 1,000. Incidence refers to the number of newly reported cases. An incident rate is the number of newly reported cases of a disease in a specified time period divided by the population at that time. The quotient is then multiplied by a constant such as 1000 or 100,000. Calculation: 25 / 5000 = 0.005 0.005 x 1000 = 5 per 1,000

Referring to the data collected on scanning errors above, if you want to work on the type of material with the highest volume, you will work on problems with correspondence. lab slips. other. consultation reports.

lab slips. The highest volume (number) of errors is in lab slips.

Which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned? single live-born low forceps occiput presentation episiotomy

low forceps See the ICD-10-CM Official Guidelines for 2018, Section 1.c.15.n Encounter for full-term uncomplicated delivery Code O80 should be assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is always a principal diagnosis. It is not to be used if any other code from Chapter 15 is needed to describe a current complication of the antenatal, delivery, or perinatal period. Additional codes from other chapters may be used with code O80 if they are not related to or are in any way complicating the pregnancy.

The Systems Development Life Cycle (SDLC) consists of four primary phases. Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of which phase? Design Planning and Analysis Maintenance and Evaluation Implementation

Maintenance and Evaluation Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of the Design phase. The Systems Development Life Cycle (SDLC) consists of four primary phases: Planning and Analysis: In this phase the organization first defines the goals and scope of the project. The focus on this phase is on defining the organization's business problem and the resources that may be needed to develop the project, along with an in-depth assessment of user needs and functional requirements. Design: During this phase the system goals, project objectives and scope, determination and prioritization of system requirements, screening for vendors, development of an RFI or RFP, evaluation of vendors, and contract negotiations are completed. Implementation: Implementation and training occur in this phase. Maintenance and Evaluation: This phase focuses on responding to identified problems and concerns and the ongoing maintenance of the system.

You are the office manager at a large group practice. One of the physicians at your practice has asked you to research and supply her with information about Medicare's newest payment incentives and how to comply with the quality reporting requirements. You will bring this inquisitive physician facts from CMS regarding Stage 2 of meaningful use requirements diagnosis related groups (DRGs) Physician Quality Reporting System (PQRS) Merit-based Incentive Payment System (MIPS)

Merit-based Incentive Payment System (MIPS) The Merit-Based Incentive Payment System (MIPS) is one of two tracks under the Quality Payment Program, which moves Medicare Part B providers to a performance-based payment system. MIPS streamlines three historical Medicare programs—the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) Program, and the Medicare Electronic Health Record (EHR) Incentive Program ( Meaningful Use)—into a single payment program. All Medicare Part B providers who meet the definition of a MIPS Eligible Clinician should plan to participate in MIPS in 2017, or they will be subject to a negative 4% payment adjustment on Medicare Part B reimbursements in 2019.

Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of stay for the year, can you calculate the annual bed turnover rate? How? Yes, using the direct method. Yes, using the indirect method. Yes, using the basic rate method. No, there is insufficient data to complete the calculation.

No, there is insufficient data to complete the calculation. When a hospital's bed count changes during a period under consideration, the indirect formula for bed turnover rate must be used; however, this formula requires bed occupancy data for the period which is not provided.

Incomplete abortion complicated by excessive hemorrhage; dilation and curettage performed. Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS. O03.6, 0UDB7ZZ O03.1, D62, 0UDB7ZZ O03.1, 10D17ZZ​ O03.4, 10D17ZZ

O03.1, 10D17ZZ​ O03 is reported for a spontaneous abortion. A spontaneous abortion may be complete or incomplete. The coding manual needs to be referenced for the assigning codes according to the types of complications.

Vaginal delivery with episiotomy of full-term live-born infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally. Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS. O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ O80, Z37.0, 0UL74ZZ O80, Z37.0, 10E0XZZ, 0UL74ZZ Z37.0, 0W8NXZZ, 0UL74ZZ

O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ Whenever there is a delivery, there must also be an Outcome of Delivery code. Each of these procedures is reported separately: the delivery, the episiotomy, and the occlusion of the fallopian tubes.

You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time? D P A S

P The PDSA cycle is a process for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). It is a four-step cycle that allows you to implement change, solve problems, and continuously improve processes. Its cyclical nature allows it to be utilized in a continuous manner for ongoing improvement. The planning step usually takes the most amount of time.

You are calculating the fee schedule payment amount for physician services covered under Medicare Part B. You already have the relative value unit figure. The system you are likely referencing is IPPS. MS-DRG. RUGS. RBRVS.

RBRVS. The resource-based relative value scale (RBRVS) is a scale of national uniform relative values for all physicians' services in outpatient settings. IPPS: Inpatient Prospective Payment System MS-DRG: Medicare Severity-Diagnosis Related Group (utilized in acute care settings) RUGS: Resource Utilization Groups (utilized in skilled nursing facilities)

Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gail has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's EDMS system. CPOE. RHIO. expert system.

RHIO. A Regional Health Information Organization (RHIS) is a group of organizations within a specific area that share health information electronically, according to accepted health information technology standards. A RHIO typically oversees the health information exchange among various provider settings, payers, and government agencies. The RHIO is one model toward achieving the proposed National Health Information Network (NHIN).

The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training. This will not do because it violates Joint Commission standards and CQI philosophy. This level of involvement is enough to meet Joint Commission standards. The Joint Commission only expects involvement from clinical staff. If you can talk him into training his staff, you can let him skip the training.

This will not do because it violates Joint Commission standards and CQI philosophy. Acceptance of the CQI philosophy must funnel down from the top to truly permeate the organization's culture. Executive leadership must communicate a clear vision and mission statement that every employee can understand and share.

Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the CMS Coding Guidelines. Federal Register. Coding Clinic. UHDDS.

UHDDS. The Uniform Hospital Discharge Data Set (UHDDS) is a required data set for acute care facilities. This data set gives specific definitions of principal diagnosis and secondary diagnoses that must be followed when sequencing codes. The purpose of the UHDDS is to improve uniformity and comparability of data.

The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign a code for the patient's symptoms. a code for an impending myocardial infarction. a code for a myocardial infarction. no code for this condition

a code for a myocardial infarction. When a diagnosis is preceded by the phrase "rule out" in the inpatient setting, code the condition as a present diagnosis for that visit.

The ER staff has collected the data on the number of visits and corresponding wait times in the ER. The data are displayed on the chart shown above. Based on this information, what kind of correlation do you see between the number of visits (Variable X) and the wait times (Variable Y)? a causative correlation between Variable X and Variable Y a conjunctive correlation between Variable X and Variable Y a negative correlation between Variable X and Variable Y a positive correlation between Variable X and Variable Y

a positive correlation between Variable X and Variable Y Scatter diagrams display the strength of relationship between two variables. A strong relationship is seen as the data come closer to forming a straight line. When both variables increase and decrease at the same time, and the line progresses from the lower left toward the upper right corner, a positive relationship is demonstrated.

As the information security officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. Which of the following would you provide? proof of organizational firewalls acceptable policies regarding workstation use and location chain-of-trust partner agreements audit controls

acceptable policies regarding workstation use and location The Security Rule defines physical safeguards as "physical measures, policies, and procedures to protect a covered entity's electronic information systems and related buildings and equipment from natural and environmental hazards and unauthorized intrusions. Physical safeguards include measures that affect facility access control or workstation use such as automatic log offs and the use of privacy screens.

You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use patient abstracts. accession register. follow-up files. patient index.

accession register. When a case is first entered into the cancer registry, an accession number is assigned. The unique number is assigned to the patient (not the tumor). The accession number provides a unique identifier for the patient consisting of the year in which the patient was first seen at the reporting facility and the consecutive order in which the patient was abstracted. The first four numbers specify the year, and the last five numbers are the numeric order the patient was entered into the registry database. There is only one accession number per patient, per facility, and per lifetime. A patient's accession number is never reassigned.

The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered an underutilization of the hospital's resources appropriate provided it is limited to a few days. the best utilization of the hospital's resources. an inappropriate use of hospital resources.

an inappropriate use of hospital resources. The necessity for inpatient hospitalizations and continued stays are strictly regulated by intensity of service and severity of illness criteria which indicate services that can be provided only at an acute level of care. To keep a patient hospitalized for reasons not tied to these criteria would indicate an overutilization of hospital resources and likely, a denial of reimbursement.

A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) analyst. reviewer. ambassador. educator.

analyst. The CDS professional may act as a reviewer and educator, but the duties described are most representative of his or her role as an analyst. Ambassador is a distractor. A CDI analyst conduct ongoing analyses of clinical documentation while providing extensive collaboration with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.

A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be decision matrix. force field analysis. check sheet. flowchart.

check sheet. A checksheet is a data collection tool permitting the recording and compiling of observations or occurrences. It consists of a simple listing of categories, issues, or observations on the left side of the chart and a place on the right for individuals to record checkmarks next to the item when it is observed or counted.

ou are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM-5 for billing purposes. You find this "theoretically" reasonable because DSM-5 codes are also valid CPT codes. is the industry standard for psychiatric billing systems. is a widely used system for coding injury in ambulatory care systems. codes are also valid ICD-10-CM codes.

codes are also valid ICD-10-CM codes. DSM-5 standardizes the clinician's diagnostic process for patients with mental disorder. The codes incorporated into the classification are ICD-10-CM.

Which of the following scenarios identifies a pathologic fracture? vertebral fracture with cord compression following a car accident greenstick fracture secondary to fall from a bed compression fracture of the vertebrae as a result of bone metastasis compression fracture of the skull after being hit with a baseball bat

compression fracture of the vertebrae as a result of bone metastasis A pathologic fracture is one caused by a diseased condition. In this case, the bone cancer is the underlying cause of the fracture.

Which of these conditions are always considered "present on admission" (POA)? acute conditions possible, probable, or suspected conditions congenital conditions E codes

congenital conditions As required by the Deficit Reduction Act of 2005 (DRA), the HAC-POA Indicator Reporting provision requires a quality adjustment in Medicare Severity-Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions (HACs). IPPS hospitals must submit present on admission (POA) information on principal and all secondary diagnoses for inpatient discharges. IPPS hospitals do not receive the higher payment for cases when one of the selected conditions is acquired during hospitalization (i.e., the condition was not POA). The case is paid as though the secondary diagnosis is not present. Hospitals must identify the conditions that are present on admission to receive appropriate reimbursement. A congenital condition is present at birth and would therefore be present on any subsequent admission.

Sunset Beach Clinic allows patients to communicate by email to ask questions regarding their treatment and request appointment changes. Emails and text messages are generally maintained in a facility's electronic mail system until the next face-to-face patient encounter. not typically maintained or documented as patient encounters. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. considered proof of patient contact and should be summarized in a progress note in the patient record.

considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. Best practice for handling a patient's email and/or text questions is to treat the information as protected health information and to apply the same security safeguards as other PHI.

Referring to the data collected on scanning errors above, if you want to begin with the type of material that has the highest error rate, you will start by working on problems with other. correspondence. consultation reports. lab slips.

consultation reports. To calculate the error rate, the formula for a rate can be applied. A rate is a fraction that is formulated to express the relationship between the numerator and denominator. The basic rule of thumb for calculating rates is to divide the number of times something actually happened in relation to the number of times it could have happened. 431 / 2,879 = 0.14970 x 100 = 14.97% 458 / 15,242 = 0.03004855 = 3% 114 / 1,426 = 0.079943 x 100 = 8% 313 / 6,271 = 0.0499122 = 5% The highest percentage of error is in consultation reports.

A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to ask the patient to send the required fee prior to the release. contact the patient's attending physician before complying. ignore the request and to advise you if it is repeated. comply with the request immediately.

contact the patient's attending physician before complying. When releasing information to a patient in a behavioral health setting, it is typical to contact the physician to make sure that releasing the information would not hinder the patient's course of treatment. Under the HIPAA privacy rule, if the physician has determined that access requested is reasonably likely to endanger the life or physical safety of the individual or another person, the organization can or may refuse the request. If release of the information is not in the best interest of the patient, then the physician may prepare a summary of the visit to provide to the patient. The patient may appeal the decision to refuse access.

A supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job analysis. detail. description. process.

description. A job description outlines the work to be performed by a specific employee or group of employees with the same responsibilities. This generally consists of three parts: (1) a summary of the position's requirements and purpose, (2) its functions, and (3) the qualifications needed to perform the job.

The purpose of CMS's National Correct Coding Initiative is to restrict Medicare reimbursement to hospitals for ancillary services. teach coders how to unbundle codes. detect and prevent payment for improperly coded services. increase fines and penalties for bundling services into comprehensive CPT codes.

detect and prevent payment for improperly coded services. CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims.

An effective means of protecting the security of electronic health information would be to require all facility employees to change their passwords at least once a month. install a system that would require fingerprint scanning and recognition for data access. write detailed procedures for the entry of data into the computerized information system. develop clear policies on data security that are supported by the top management of the facility.

develop clear policies on data security that are supported by the top management of the facility. Data security management includes developing, implementing, and enforcing data security policies and procedures.

In preparation for conversion to an electronic health record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data edits. feasibility. dictionary. reasonableness.

dictionary. A data dictionary describes all the primitive level data structures and data elements within a system.

You are the Director of Coding and Billing at a large group practice. The practice manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt Promoting Interoperability (formerly Meaningful Use) technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that in 2015, sanctions for noncompliance began to appear in the form of downward adjustments to Medicare reimbursement. a mandatory action plan for implementing a meaningful use EHR. withdrawal of permission to treat Medicare and Medicaid patients. monetary fines up to $100,000.

downward adjustments to Medicare reimbursement. EHR incentive program penalties will apply specifically to Medicare eligible professionals (EPs) who do not demonstrate and attest to Promoting Interoperability (formerly Meaningful Use). However, Medicaid EPs who see patients under the Medicare Physician Fee Schedule (PFS) are also subject to a payment reduction.

Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with the UHDDS and information on where each data element is collected and/or verified in your facility. feedback on specific instances when improved documentation would improve coding. a copy of the facility coding guidelines, along with written information on improved documentation. regular in-service presentations on the importance of accurate clinical documentation and tips for improvement.

feedback on specific instances when improved documentation would improve coding. Providing feedback to physicians in concurrent and, as appropriate, retrospective reviews is the purpose of Clinical Documentation Improvement (CDI).

In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to quality review committees within the hospital. In this case, the PHI is being used as part of the facility's treatment. payment. documentation improvement plan. health care operations.

health care operations. The HIPAA Privacy Rule allows covered entities to use and disclose protected health information for the purpose of treatment, payments, or health care operations.

The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information, you will consult the hospital bylaws, rules, and regulations. data dictionary. hospital's Quality Management Plan. policy and procedure manual.

hospital bylaws, rules, and regulations. Accreditation standards require a hospital's staff bylaws, rules, and regulations to address who is authorized to accept verbal orders.

You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to make recommendations for improvement. compare your department with another. improve your department's processes. implement your QI process.

improve your department's processes. Benchmarking involves comparing your department to other departments or organizations known to be excellent in one or more areas. The success of benchmarking involves finding out how the other department functions and then incorporating their ideas into your department.

Which of the following is considered a late effect regardless of time? nonhealing fracture nonunion poisoning congenital defect

nonunion See the ICD-10-CM Official Guidelines 2018, Section 1. a. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth, or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section? confirmatory consultations, new or established patient office and other outpatient services, new patient office and other outpatient services, established patient office or other outpatient consultations, new or established patient

office and other outpatient services, established patient Consultation codes can no longer be coded when the physician has taken an active part in the continued care of the patient. Under a referral, the care of the patient is passed by the referring physician to the provider to whom he or she is referred. In contrast, consultants provide an opinion and then return the patient to the requesting doctor's care.

In a research study that includes a patient questionnaire, five of the questions will be answered using the following scale: ordinal data. continuous data. nominal data. cardinal data.

ordinal data. Ordinal data ranks from lowest to highest according to a criterion. Ordinal data can include responses to questionnaires or interviews. The number assigned to each rank does not necessarily indicate an equal difference between each category.

Which of the following is the unique identifier in the database illustrated in the table above? record number patient's last name date of service date of birth

record number The record number is a unique identifier assigned to each patient. The Department of Health and Human Services explains that a unique patient identifier "is required to manage the various clinical and administrative functions relating to the delivery of care."

As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee-for-Service program. You will need to develop a professional relationship with MEDPAR representatives. recovery audit contractors. the OIG. QIO physicians.

recovery audit contractors. The recovery audit contractor program is a government program with a goal of identifying improper payments on claims of health care services already provided to Medicare beneficiaries. All providers, including home health and hospice providers, may be subject to claims review by a RAC. The medical reviews consist of the Medicare contractors collecting information and performing a review to determine whether Medicare's coverage, coding, and medical necessity requirements are met.

A clerk's work performance has diminished dramatically during the past 2 weeks. The supervisor initiates a discussion with the clerk, during which the clerk reveals that he recently accepted that he has an alcohol addiction. The clerk states an intention to quit drinking completely. The supervisor should refer the clerk to the facility's employee assistance program. suspend the clerk if alcohol has diminished the clerk's job performance. terminate the clerk if it can be proved that alcohol was used on the job. give the clerk a leave of absence until these problems can be resolved.

refer the clerk to the facility's employee assistance program. An employee assistance program is an employee benefit program that assists employees with personal problems and/or work-related problems that may impact their job performance, health, mental, and emotional well-being.

Which means of data modeling is illustrated in the table shown above? object-oriented model entity-relationship model relational data model data management model

relational data model This is a relational data model. The relational database model consists of a database with a set of formally described tables, related to each other by a shared reference. Object-oriented data models are databases that represent data in the form of objects and classes. In object-oriented terminology, an object is a real-world entity, and a class is a collection of objects. Entity data model refers to a set of concepts that describe data structure, regardless of its stored form. This model uses three key concepts to describe data structure: entity type, association type, and property. An entity-relationship model describes interrelated things of interest in a specific domain of knowledge. A basic ER model is composed of entity types (which classify the things of interest) and specifies relationships that can exist between entities (instances of those entity types).

A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of adjudicus res. stare decisis. res ipsa loquitur. respondeat superior.

respondeat superior. Respondeat superior means "let the master answer" for the actions of the servant—the doctrine of the "agency." Under the doctrine of respondeat superior, the courts hold employers responsible for the acts of their employees or agents that are acting within the scope of employment. For example, a hospital can be held responsible for the actions of a physical therapist while they are performing the aspects of their position.

Everyone in the health information department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not salaried exempt employees. hourly employees. salaried nonexempt employees. temporary employees.

salaried exempt employees. Salaried exempt employees are paid a set salary per pay period.

A common goal of the Office of the National Coordinator for Health Information Technology, HIEs, and a national infrastructure for information is sharing information among providers. translating images into a digital format. transferring health information within a hospital system. promoting telemedicine.

sharing information among providers. The ONC's mission involves many aspects of health information technology (HIT), including policy coordination, strategic planning for the adoption of health IT and health information exchanges (HIE), establishing governance for the Nationwide Health Information Network, and, above all, promoting a national health IT infrastructure.

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to allow school officials to authorize immunization disclosures on behalf of a child attending their school. require written authorization from a custodial parent before disclosing proof of the child's immunization to the school. allow the minor to authorize the disclosure of the proof of immunization to the school. simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school.

simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school. The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.

Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be space considerations. professional standards. provider preferences. statutory requirements.

statutory requirements. The length of retention depends on laws, regulation, and the use of health records for care and for other purposes such as research and education.

As a new HIM manager, you recognize that employee development is a necessary investment for the long-term survival and growth of the organization. Your goal is to design and implement a staff development program for your employees, so one of your first steps is to establish HIPAA training programs hospital-wide. establish a budget for all hospital employee training. implement training programs that emphasize teamwork. survey the HIM employees to assess their need for new skills or knowledge.

survey the HIM employees to assess their need for new skills or knowledge. The first step in developing a training program is to perform a needs analysis to determine the deficiencies in knowledge and skills between the desired level and the current level of each employee.

The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. the IRB focuses on patient care only, and the Ethics Committee addresses both patient care and business practices. the Ethics Committee reviews ethics complaints, and the IRB focuses on developing policies and procedures. the IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary.

the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. The Institutional Review Board (IRB) is a committee established to protect the rights and welfare of human subjects involved in research activities. The ethics committee is a committee of the organization tasked with reviewing ethics violations and determining the course of action required to remedy the violations.

As a coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with the Recovery Audit Contractor. the Office of the Surgeon General. the FDA. the Office for Civil Rights.

the Recovery Audit Contractor. The Recovery Audit Contractor (RAC) program is a government program with a goal of identifying improper payments on claims of health care services already provided to Medicare beneficiaries. The medical reviews consist of the Medicare contractors collecting information and performing a review to determine whether Medicare's coverage, coding, and medical necessity requirements are met.

Generally, CMS requires the submission of a claim (CMS 1450) for inpatient services provided to a Medicare beneficiary for inpatient services. An exception to this requirement would be when the beneficiary refuses to authorize the submission of a bill to Medicare. attempts are made to charge a beneficiary for a service that is covered by Medicare. an ABN was given to the beneficiary for services unlikely to be covered by Medicare. the physician furnishes a covered service to the beneficiary.

the beneficiary refuses to authorize the submission of a bill to Medicare. When a beneficiary refuses to authorize the submission of a bill to Medicare, the Medicare provider is not required to submit a claim to Medicare.

Release of information has increased its use of part-time PRN clerical support in order to respond to increased requests for release of information in a timely manner. For the line item projecting costs for ROI, this quarter's budget variance report will reflect the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support. both the increases in revenue and increased costs for clerical support in ROI. neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area.

the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. Budget variance reflects the difference between projected or budgeted costs and actual costs. In this case, the budget variance report will compare the costs projected for ROI and the actual cost based on volume.

A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? either of the patient's parents the patient's wife the patient's parent or legal guardian the patient

the patient The patient must authorize the release of his records since he is an emancipated minor by marriage.

After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because you thought limited training was the primary reason for the errors. the results appear to violate the Pareto principle. the rankings show surprising disagreement on the issue. you expected the coders to put more emphasis on time pressure.

the results appear to violate the Pareto principle. The Pareto principle states that 20% of the problem are responsible for 80% of the actual problem. This allows for a concentration of vital resources to address a large number of the actual problems.

In preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be the statute of limitations in your state. the average readmission rate for the facility. the available options for inactive records. best practice standards.

the statute of limitations in your state. Although readmission rates, best practice guidelines, and record archival options may affect the retention period for a facility, the minimum retention period will be mandated by the length of time a patient may bring a lawsuit against the facility.

If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level they should both be coded, acute sequenced first. they should both be coded, chronic sequenced first. only the chronic condition should be coded. only the acute condition should be coded.

they should both be coded, acute sequenced first. If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level, they should both be coded, acute sequenced first.

Which of the following is coded as an adverse effect in ICD-10-CM? mental retardation due to intracranial abscess tinnitus due to allergic reaction after administration of eardrops nonfunctioning pacemaker due to defective soldering rejection of transplanted kidney

tinnitus due to allergic reaction after administration of eardrops An allergic reaction is an adverse effect to medication properly administered.

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations. prohibited use of any abbreviations. use of abbreviations used in the final diagnoses. flagrant use of specialty-specific abbreviations.

use of prohibited or "dangerous" abbreviations. The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form (e.g., "U" for unit, which can be mistaken for "0" (zero) or "4"). Spelling out "unit" is preferred.

A number of key elements for your facility's electronic patient record are still input by clerical staff from handwritten data entry sheets. You are concerned about the transfer of data. If the vital signs stored in the database are not what were originally recorded, the impact on patient care could be severe. You are concerned about the stability of the data. timeliness of the data. granularity of the data. validity of the data.

validity of the data. Validity refers to the credibility of the data.There is concern of the validity because of the transfer of data.

A piece of objective data collected upon initial assessment of the patient is the review of systems. chief complaint. vital signs. history of present illness.

vital signs. Objective data are observable and measurable data (signs) obtained through observation, physical examination, and laboratory and diagnostic testing. The vital signs are objective data that is collected during the initial assessment.

A run or line chart would be most useful for collecting data on medication errors and their causes. waiting time in the Pediatrics Clinic over a 6-month period. a possible relationship between 2 variables. patient satisfaction with the food.

waiting time in the Pediatrics Clinic over a 6-month period. Run charts are best used to track data points over time, such as wait time in a Pediatrics Clinic over several months.

A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that wages will increase if the union is defeated. you need the names of those involved in union activities. you are opposed to the union. a strike is inevitable if the union wins.

you are opposed to the union. Management has both the right and obligation to tell employees that the organization does not believe that union representation is in their best interest and to encourage them to vote no on the ballot. They also should answer employee's questions honestly and assure the commitment of the organization to provide high quality care in a desirable working environment and culture for employees. They should also explain that if they choose to recognize the union, any improvements in wages, benefits, and working conditions will be subject to negotiation and are not guaranteed. Management is not permitted to interrogate individual employees about their union activities. They cannot threaten, coerce, or intimidate employees because of their union support. They may not make specific promises contingent on the outcome of the election or offer unilateral improvements in wages, benefits, or working conditions during the election campaign.Management has both the right and obligation to tell employees that the organization does not believe that union representation is in their best interest and to encourage them to vote no on the ballot. They also should answer employee's questions honestly and assure the commitment of the organization to provide high quality care in a desirable working environment and culture for employees. They should also explain that if they choose to recognize the union, any improvements in wages, benefits, and working conditions will be subject to negotiation and are not guaranteed. Management is not permitted to interrogate individual employees about their union activities. They cannot threaten, coerce, or intimidate employees because of their union support. They may not make specific promises contingent on the outcome of the election or offer unilateral improvements in wages, benefits, or working conditions during the election campaign.

A patient who was admitted to the hospital on January 14 and discharged on March 2 in a nonleap year has a length of stay of 46 days. 47 days. 48 days. 45 days.

47 days. The length of stay is the total number of patient days for an inpatient episode. Calculation: 31 (Days in January) - 14 (Day of admission) + 28 (Days in February) + 2 (Days in March) = 47 days

A 4-year-old child had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition. 49496 49501 49521 49553

49501 Code 49501 for the initial inguinal hernia repair for a 4-year-old child.

Community Hospital Administration decided to change the number of adult and children beds from 300 to 375 effective on the first day in July. The total number of inpatient service days for adults and children for the year was 111,963. What was the percentage of occupancy rate for adults and children for the entire year? 90.8% 0.9% 91.0% 45.4%

90.8% The percentage of occupancy is the occupancy rate that measures the percentage of beds that are occupied by inpatients in relation to the total number of beds within the facility for a specific period of time. Bed Count Days Formula: Number of beds x Number of days in the period Since the bed count changes, you must calculate the total bed count days for each period and then add them together.

An established patient was seen by the physician in the office for DTaP vaccine and Hib. 90700, 90748, 99211 90700 90471, 90748 90748, 90471

90471, 90748 If the immunization is the only service that the patient receives, then two codes are used to report the service. The immunization administration code is first and then the code for the vaccine/toxoid.

The census taken at midnight on January 1 showed 99 patients remaining in the hospital. On January 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on January 2? 96 97 94 95

97 An inpatient service day is a unit of measure denoting the services received by one inpatient in one 24-hour period or any portion of that 24-hour period. The 24-hour period is the time between the census-taking hours on two successive days. One unit of one service day is not usually divided or reported as a fraction of a day. The day of admission is counted as an inpatient service day but the day of discharge is not. Therefore, no patient admitted to an inpatient unit can have a zero-service day stay.

Office visit for 43-year-old male, new patient, with no complaints. Patient is applying for life insurance and requests a physical examination. A detailed health and family history was obtained and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected. 99386 99381 99396 99450

99450 The codes in this subsection are used to report evaluations for life or disability insurance baseline information.

Your HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report? 0-1 year1-2 years2-3 years3-4 years4-5 years 0-2 years3-4 years5 years >12 months12-24 months25-37 months38-50 months<51 months <12 months12-24 months25-37 months38-50 months51-63 months

<12 months12-24 months25-37 months38-50 months51-63 months A grouped frequency distribution shows the values that a variable can take and the number of observations associated with each value. The data are sorted and separated into groups called classes. There are typically 5 to 20 classes are used, but in any case, make sure that you use enough classes to give a good description of the data. The classes must be mutually exclusive (non-overlapping). This means that there is no way that any of the data could fall into two different classes at once. The classes must be continuous—this means that there can be no gaps in the classes. The classes must be exhaustive, meaning that there must be a class for every data value in the data set. Lastly, the classes must be of equal width, otherwise the distribution would give a distorted view of the data. This frequency distribution is mutually exclusive, continuous, exhaustive, and equal. <12 months 12-24 months 25-37 months 38-50 months 51-63 months