RHIT Practice Test Questions 2022

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The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type; date; field length: 15; required field: yes; default value: none; input mask: none. For this data element, data integrity would be better assured if: An input mask was defined. The data type was numeric. The field was not required. The field length was longer.

An input mask was defined.

Which of the following is not a step in strategic planning? Analyzing budget variance reports Developing or revising the values statement Developing specific action steps for the upcoming year Officially documenting the board's approval

Analyzing budget variance reports

In January, the Pomona Valley Hospital had 350 beds and 45 bassinets; 1261 adults and children and 272 newborns had been discharged during the same month. Calculate the bed turnover rate for adults and children.

4.38

The annual volume statistics for New Town Hospital are noted here. How many shelving units will be required to store this year's inpatient discharge records? 41 41.67 42 74

From the information provided, how many APC's would this patient have? 1 4 5 Unable to determine

If an employee produces 1,080 hours of work in the course of a year, how many employees will be required for the coding area if the coding time on average for one record is 30 minutes and there are 10,000 records that must be coded each year? 5 10 36 278

Sabrina was just promoted to coding supervisor. So, her five fellow coders become her subordinates. What is her span of control?

5 coders

In the month of April, 4 adults, 3 children, and 0 newborns died at Corona Regional Hospital. A total of 142 admissions and 183 discharges for adults and children were reported for the same period. Live births for April were 121 with 2 fetal deaths recorded (1 early, 0 intermediate, and 1 late). Autopsies were performed on 2 adults and 3 children, and 1 late fetal death case. One of the adult bodies was released to the medical examiner. What is the gross adult autopsy rate for April?

50%

Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9 cm, 6.0 cm) are undertaken. Which of the following CPT code(s) would be most appropriate? 52234, 52240 52235 52240 52000, 52234, 52240

52240

Use Table 2 to answer the question. Calculate the net autopsy rate for October 2020.

56%

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? 49320, 58662 58670 58671 49320

58670

Community Hospital discharged nine patients on April 1. The length of stay for each of the patients was as follows: for patient A, 1 day; for patient B, 5 days; for patient C, 3 days; for patient D, 3 days; for patient E, 8 days; for patient F, 8 days; for patient G, 8 days; for patient H, 9 days; patient I, 9 days. What was the average length of stay for these nine patients? 5 days 6 days 8 days 9 days

6 days

Given the following file numbers, which are arranged correctly in terminal digit filing order? 43-42-0052-43-0064-55-0170-41-00 43-42-0064-55-0070-41-0052-43-01 70-41-0043-42-0064-55-0052-43-01 52-43-0143-42-0064-55-0070-41-00

70-41-0043-42-0064-55-0052-43-01

An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard? 45.6 pages 68.4 pages 76 pages 190 pages

76 pages

In designing documents for an electronic document management system, all documents should be how large? 8 1/2 by 11 inches 11 by 14 inches No larger than 4 by 6 inches Can be any length but no wider than 8 1/2 inches

8 1/2 by 11 inches

A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used?

Use Table 3 to answer the question. Calculate the bed turnover rate for October 2020.

9.89 days

Community Hospital HIM department conducted a random sample of 540 health records to determine the rate of filing accuracy. Thirteen misfiles were identified. Which of the following percentages represents the filing accuracy at Community Hospital? 2.4% 24.0% 41.5% 97.6%

97.6%

Use Table 4 to answer the question. Calculate the inpatient bed occupancy rate for October 2020.

97.89%

Community Hospital HIM department conducted a random sample of 600 health records to determine the rate of filing accuracy. Nine misfiles were identified. Which of the following percentages represents the filing accuracy at Community Hospital? 15 percent 34 percent 66.7 percent 98.5 percent

98.5 percent

A returning patient comes to the office with conjunctivitis. The physician provides a straightforward diagnosis, and the medical decision-making is simple. Which of the following codes should be assigned for an office visit for this case?

99211 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of the following three key components: problem-focused history, examination, and straightforward medical decision

Karen Luis is a remote coder for San Antonio Community Hospital. She works from home with a VPN and high-speed internet access. When she is not working, she stores all of her work equipment and files in a secured cabinet. Last week, Karen's house was broken into. They stole some audio and visual equipment and broke into her locked cabinet, but they didn't take any equipment. All the patient record files in the cabinet looked undisturbed. Which of the following must Karen report to the Health Information Department?

A burglary and an information breach because the file cabinet had unauthorized access

Which of the following statements best describes Medicare? A state program that finances healthcare services for the elderly. A federal program that finances healthcare services for the elderly. A state program that finances healthcare services for low-income families. A federal program that finances healthcare services for low-income families.

A federal program that finances healthcare services for the elderly.

Which of the following statements best describes an integrated delivery system? A system of healthcare delivery that ensures that patients obtain appropriate, cost-effective services A group of healthcare organizations that collectively provides a full range of coordinated health-related services A healthcare system that contracts directly with physicians in an independent practice or with one or more multispecialty group practices A healthcare system made up of two or more hospitals that are owned by the same organization

A group of healthcare organizations that collectively provides a full range of coordinated health-related services

Which of the following types of healthcare encounters occur using mobile technologies?

A healthcare facility in a rural town has a specialist, who lives in a metropolitan area, video conference to assist in an operative procedure.

Which of the following cases most represents information system interoperability?

A physician's office requests a patient record from another physician's office that uses the same EHR system, so the file is transferred.

In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _____systems. MIS CDS ADT ABC

ADT

Community Hospital is planning implementation of various elements of the EHR in the next six months. Physicians have requested to ability to access the EHR from their offices and from home and to be able to print out the information, if needed. The Medical Record Committee is assessing whether or not to provide this functionality given concerns over patient confidentiality. Given this discussion, what advice should the HIM director provide? HIPAA regulations do not allow this type of access. This access would be covered under the release of PHI for treatment purposes and poses no security or confidentiality threats. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. Access can be permitted because the physicians are on the medical staff of the hospital and are covered by HIPAA as employees.

Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security.

An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? Access controls Audit controls Contingency controls Security incident controls

Access controls

Which of the following can be defined as a voluntary system of institutional review in which a quasi-independent body periodically evaluates the quality of the services provided by healthcare organizations against written criteria? Accreditation Standardization Licensure Professionalization

Accreditation

The barcode on the patient's wristband and on the medication package helps ensure, which of the following during medication administration?

Accurate drug, correct patient

Jose visits the Fullerton Medical Clinic IPA with his Aetna HMO benefits. The office charges $125 per office visit, and his co-pay is $25 for the office visit. How much will the Fullerton Medical Clinic IPA charge Aetna HMO if they have a capitation agreement?

If a patient's total outpatient bill is $500.00, and the patient's healthcare insurance plan pays 80 percent of the allowable charges, what is the amount for which the patient is responsible? $10 $40 $100 $400.00

$100

The HIM department has recently performed an audit of misfiled medical records. The audit showed that for the 10,000 records filed there was a 7 percent error rate. Given that the national average cost of each misfile results in a $200 labor cost, what is the labor cost for the department for handling these misfiled records? $1,400 $14,000 $140,000 $285,714

$140,000

Quin visited Dr. Blackwell's office for syncope. It was a straightforward returning patient visit, so it was assigned the 99212 code, for which Dr. Blackwell charged $160. Quin has two insurance coverages: Medicare and Blue Shield. The Medicare fee schedule allowable for 99212 is $100. How much should Secure Horizons pay once Medicare processes and pays this claim?

$20

The nurse-aid pharmacy was found in violation of the HIPAA privacy law because it dumped thousands of patient medication labels in unsecured trash receptacles. What fiscal penalties may it face per violation?

$50K

A HIM department is calculating the cost of its employee turnover in the transcription area. The area has a total of ten employees with four employees leaving within the past 12 months. The average annual salary of the employees in this area is 40,000 with a benefits package of 30 percent. The anticipated vacancy in calendar days is 50 days. If the cost of employee turnover is 25 percent of the employee salary and benefits, and $200 per day that the job remains vacant, what is the estimated turnover cost for the transcription area this calendar year? $3,000 $10,000 $23,000 $92,000

$92,000

The coding supervisor is ordering office supplies for second quarter of the fiscal year. The budgeted amount for supplies for the year is $5,000 and to date $3,500 has been expended. If the allocated amount is $1,350 per quarter, what is the variance to date for this line item? +$1,200 +$1,500 -$1,500 +$2,250

+$2,250

The budget printer maintenance was set at $1,500 for the year. At the end of the fiscal year, the actual amount spent was $1,245. What is the budget variance?

+255

In preparing a report about health insurance coverage, a health record technician finds that 84.8 percent of the population was covered in 2002, compared to 84.4 percent of the population covered in 2003. What is the percentage of change in coverage between 2002 and 2003? 0.1 percent 0.4 percent 1.0 percent 4.0 percent

0.4 percent

0.82%

Use Table 1 to answer the question. Calculate the gross hospital death rate for October 2020.

0.95%

A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent an intradiscal electrothermal annuloplasy (IDET) in the radiology suite. What ICD-10 code should be used for the procedure? 0SQ23ZZ Repair Lumbar Vertebral Disc, Percutaneous Approach 0S520ZZ Destruction of Lumbar Vertebral Disc, Open Approach 0S523ZZ Destruction of Lumbar Vertebral Disc, Percutaneous Approach 0QQ03ZZ Repair Lumbar Vertebra, Percutaneous Approach

0S523ZZ Destruction of Lumbar Vertebral Disc, Percutaneous Approach

The HIM director is part of the revenue cycle management team. The discharged-not-final-billed days are increasing as a result of an increase in discharges with the number of coding staff remaining the same at five. In an effort to increase productivity, the HIM director is researching staffing alternatives. With the implementation of an electronic document storage system, telecommuting has been suggested as an alternative. Studies have reported that coding productivity can increase as much as 20 percent with telecommuting. Given that discharges have increased from 100 per day to 144, how many more FTEs would need to be hired if the department went to telecommuting? 0.5 FTE 0.75 FTE 1 FTE 2 FTEs

1 FTE

The sum of a hospital's relative DRG rates for a year was 15,192 and the hospital had 10,471 discharges for the year. Given this information what would be the hospital's case-mix index for that year? 0.689 0.689 X 100 1.45 X 100 1.45

1.45

Using the table below, determine the case mix index (CMI). <Insert 409 T20>

1.54

A HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient records at the time of discharge, providing a 24-hour turn-around time. The hospital has an average daily discharge of 120 patients and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time? 100 hours 146 hours 1,000 hours 3,740 hours

100 hours

Community Hospital had a total of 3,000 inpatient service days for the month of September. What was the average daily census for the hospital during September? 10 patients 96.77 patients 97 patients 100 patients

100 patients

From the information provided in this table, what percentage will the facility be paid for procedure 25500? 0 percent 50 percent 75 percent 100 percent

100 percent

Axel was involved in a motorcycle accident. There were two lacerations on his left arm that needed to be repaired. The largest laceration, 3.0 cm, was complex, the second laceration, 1.2 cm, was also complex. Code a laceration in CPT along with the coding guideline. Use the following CPT codes to code this case. <Insert table 9 T01>

13121-LT

Given the information here, which of the following MS-DRGs would have the highest payment? 191 192 193 194

193

A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst not include in the database? Patient date of birth Name of next of kin Date and time of admission Admitting diagnosis

Admitting diagnosis

Alice Thompson has terminal cancer and has decided to stop her cancer treatment. Which of the following legal documents is used to communicate her wishes about end-of-life care?

Advance directive

Susan has been having some trouble breathing. When she went to the provider, she was diagnosed with seasonal allergies. However, Susan requests an echocardiogram test to check her heart. The provider informs her that it will not be covered by her Medicare coverage. Which form does Susan need to sign to acknowledge that she will have to pay for the service?

Advanced beneficiary notice

In the past three months, San Bernardino County has had more cases of measles than any other county in the United States. The Center for Disease Control (CDC) is investigating data from all hospitals in San Bernardino county. This is an example of what type of study?

Aggregate

Which of the following are not features of a certified EHR system?

All certified EHR systems work on PCs

Alison is coding a gastroenterology consult for a hospital patient. Which place of service code should she use?

21 - Inpatient hospital

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? 10 hours per day 11.11 hours per day 12.5 hours per day 22.5 hours per day

22.5 hours per day

Community Hospital wants to compare its hospital acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. 200,000 of these individuals were admitted with a principal diagnosis of UTI; another 300,000 were admitted with a principal diagnosis of infectious diseases, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital? All individuals in the MEDPAR database All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease All individuals in the MEDPAR database except those admitted with a diagnosis of hypertension

All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease

Code the following case using the excerpt from the CPT manual. Posterior arthrodesis for eight vertebral segments, two physicians operating.For the following codes, when two surgeons work together as primary surgeons performing a distinct part(s) of an arthrodesis for spinal deformity, both surgeons should report their distinct operative work by appending modifier 62 to the procedure code. In this situation, modifier 62 may be appended to procedure code(s) 22800-22819 as long as both surgeons continue to work together as primary surgeons.22800 - Arthrodesis. posterior, for spinal deformity, with or without cast up to six vertebral segmentsCPT Assistant Apr 12: 16. Jul 13 322802 - 7 to 12 vertebral segmentsPT Assistant Mar 9610, Apr 12:16, Jul 13:322804 - 13 or more vertebral segmentsCPT Assistant Apr 12: 16. Jul 13322808 - Arthrodesis, anterior, for spinal deformity, with or without cast; two to three vertebral segmentsCPT Assistant Feb 02:4. Apr 12:16, Jul 13322810 - Four to seven vertebral segmentsCPT Assistant Mar 9610, Sep 97 8, Feb 02:4, Apr 1216, Jul 13322812 - Eight or more vertebral segmentsCPT Assistant Feb 02:4. Apr 1216, Jul 13 322818 - Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including body and posterior elements): single or two segmentsCPT Assistant Nov 97 14

22802-62

If an employee produces 1,080 hours of work in the course of a year, how many employees will be required for the file area if the retrieval time is 5 minutes per record, the file time is 10 minutes, and on average 100,000 records are retrieved and filed each year? 4 8 24 462

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What as the total number of inpatient service days for May 2? 240 242 280 320

242

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? 33 263 270 263 + 33

263

Betsy Carter was admitted to Corona General Hospital on August 7, 20XX, and was discharged on September 3, 20XX. What is her length of stay?

27 days

Use Table 5 to answer the question. Calculate the average daily census for October 2020.

270 days

An HIM department needs to increase its storage capacity by 648 linear inches. How many shelving units will it need to purchase, if each unit has 6 shelves that measure 36 inches long with a depth of 12 inches? 1.5 3 9 1

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? 30 32 31.5 35

31.5

Once a healthcare facility earns The Joint Commission accreditation, it lasts for:

39 months.

The HIM department has recently started scanning health records at the time of discharge. The department wants to develop productivity standards for each of the tasks associated with scanning. This table represents the collection of data for a six-week period from employees who prepare records for scanning. From this data, which of the following would be the best beginning benchmark to evaluate further performance? 235 images per hour 390 images per hour 395 images per hour 92,724 images per employee

390 images per hour

The documentation states "Patient in recovery room. Awake and alert and is able to walk and drink some water. The wound is clean. The patient's caregiver is present to take the patient home." Which healthcare facility is this documentation most likely from? Medical office visit Cardiology consultation Ambulatory surgery center Inpatient discharge

Ambulatory surgery center

Which organization developed the first hospital standardization program? Joint Commission American Osteopathic Association American College of Surgeons American Association of Medical Colleges

American College of Surgeons

Which of the following represents information?

Lab results value 19 for units above the range

Henry, the Director of Health Information, comes to work every day by 8:00 a.m. sharp. As a result, the entire department starts work at 8:00 a.m. If we are to apply the Power and Influence theory, which type of leader influence does Henry have?

Lead by example

Mark has noticed that his coding department has been experiencing low morale. Some seasoned coders left the department to work for a larger regional hospital, and there have been some complaints about workloads. As the coding supervisor, Mark is implementing an incentive program to keep the coders motivated. Which function of leadership is employed?

Leading

Suppose that you want to display the number of deaths due to breast cancer for the years 1998 through 2008. What graphic technique would you choose? Table Histogram Line graph Bar chart

Line graph

Which of the following is an example of an advance directive? Living will Authorization to release information Treatment consent Patient's rights acknowledgement

Living will

Activities of daily living (ADL) are components of _____. UACDS and MDS UHDDS and EMDS MDS and OASIS ORYX and RAPs

MDS and OASIS

A HIM director would likely use what type of system to receive weekly reports about health record deficiences? CDSS DSS KMS MIS

MIS

Community Hospital is implementing a hybrid record. Some documentation will be paper-based and digitally scanned post-discharge. Other parts of the record will be totally electronic.The Medical Record Committee is discussing how interim reports in the health record should be handled. Some on the committee feel that all interim reports should be discarded and only the final reports retained in the scanned record. Others take the opposite position. What should the HIM director recommend? Maintain only the final results to provide the greatest measure of security. Maintain only the final results is the best option. Maintain all interim reports to provide the greatest measure of security. Maintain only final reports to result in a high volume of duplicate reports.

Maintain all interim reports to provide the greatest measure of security.

Sabrina was a project manager for the team that implemented a blinking alert on the EHR screen when a patient allergy was present to alert practitioners at the beginning of the healthcare encounter. Today, she is reviewing the surveys submitted from the various users of the alert. What stage in the systems development life cycle (SDLC) is the project in?

Maintenance and evaluation

Catastrophic coverage is categorized as part of which of the following? Major medical insurance Managed care insurance Special risk insurance Coinsurance

Major medical insurance

Which of the following would be the best technique to ensure that nurses do not omit any essential information on the nursing intake assessment in an electronic health record? Provide an input mask for essential data fields Make all essential data fields required Put validation edits on all essential fields Provide sufficient space for all essential fields

Make all essential data fields required

Which of the following is considered the authoritative key in locating a health record? Disease index Master patient index Patient directory Patient registry

Master patient index

Simone is coding the operative report. Should she code surgical suturing as an additional code for the same procedure.

Maybe. Simone should research how the suturing was performed before assigning a separate code.

Which of the following records would not be commonly found in the EHR primary patient record?

Medical equipment maintenance certificate

When CDI professionals support providers in documenting the completed clinical picture of their patients, the diagnostic statements meet which of the following standards?

Medical necessity

Which of the following dictates how the medical staff operates? Medical staff classification Medical staff bylaws Medical staff credentialing Medical staff committees

Medical staff bylaws

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? BC/BS Commercial Medicare TRICARE

Medicare

Recover audit contractors (RACs) are sponsored by __________ to audit submitted health insurance claims to ensure coding compliance and appropriate reimbursements.

Medicare

__________ ensure that all of the prescribed medications, including the ones patients take at home and the new ones recommended at the hospital, are included in one form reviewed by the healthcare provider.

Medication reconciliation forms

A health data analyst has been asked to compile a report of the percentage of patients who had a baseline PTT performed prior to receiving heparin. What clinical reports in the health record would the health data analysts need to consult in order to prepare the report? Physician progress notes and medication record Medication record and clinical laboratory reports Nursing and Physician progress notes Physician orders and laboratory reports

Medication record and clinical laboratory reports

In designing a paper-based storage system, which of the following should be used if conservation of floor space is the major concern? Carousel system Five drawer filing cabinets Mobile filing units Open-shelf filing units

Mobile filing units

Which of the following terms refers to the incidence of disease? Classification Morbidity Mortality Vocabulary

Morbidity

The dashboard of the EHR provides a quick reference for healthcare providers during the encounter. Which of the following data elements may be commonly found on the dashboard?

Most recent lab results

Which of the following would NOT be considered clinical data? Progress notes Physician orders Admission diagnosis Name of the insurance company

Name of the insurance company

The organization that coordinates the collection of performance data for managed care plans is the _____. Joint Commission Centers for Medicare and Medicaid Services National Committee on Vital and Health Statistics National Committee for Quality Assurance

National Committee for Quality Assurance

The Healthcare Effectiveness Data and Information Set (HEDIS) is developed and maintained by the:

National Committee for Quality Assurance (NCQA).

Two home care facilities are in the city: Valley View and Paradise Falls. Valley View keeps all of their paper medical records in a locked file cabinet adjacent to the kitchen. All the residents and care workers walk by it on the way in and out of the kitchen. Paradise Falls maintains a dedicated room for their paper medical records. To access the room, a six-digit code is required, and the file cabinet has a pad lock. Which healthcare facility is in violation of the HIPAA Security Rule and why?

Neither. HIPAA Security Rule states the covered entity to adopt security protection measures are reasonable and appropriate for the size of their organization.

Which of the following is an example of a technical safeguard?

Network username and password

At the long-term acute care hospital, the staff take de-identifiable pictures of the patients from day to day to monitor their health condition. Can this practice be considered a violation of patient privacy, and if so, why?

No, as long as the healthcare facility receives permission from the patient or the patient's caregiver to take the pictures

A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations was this action correct? Yes, HIPAA only requires that current records be produced for the patient. Yes, this is hospital policy for which HIPAA has no control. No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. No, the records from the previous hospital are not included in the designated record set but should be released anyway.

No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.

Henry visited the Total Wellness walk-in clinic to complete his Department of Transportation (DOT) physical exam. The blood test results showed Henry tested positive for HIV. Because this physical exam was ordered by Henry's potential employer, should the clinic report the new HIV diagnosis to the employer?

No. Although the employer requested the physical exam, the information collected belongs to the patient.

Parkside Community Hospital in Arizona is merging with Riverside Community Hospital in California. Parkside Community Hospital has met the Medicare conditions of participation and is accredited by the Joint Commission. Can both Parkside Community Hospital and Riverside Community Hospital now care for Medicare patients after the merger?

No. Riverside Community Hospital cannot care for Medicare patients until it meets the Medicare conditions of participation themselves.

Sally Henderson is requesting her lab results from her doctor's office, but the physician has yet to review and sign off. Is she able to get her report yet, and why?

No. The physician authorization and signature are required prior to patient access to the results.

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 table? Patient last name should be used as the primary key for the table Patient date of birth should be used as the primary key for the table None of the data fields are adequate to use as a primary key for the table Patient last and first name should be used as the primary key for the table

None of the data fields are adequate to use as a primary key for the table

Christopher Sturgis has Medicare Part A coverage. He visits the physician for a scheduled appointment and has some medications prescribed for his blood pressure. Which of the following services are covered under his health insurance plan?

None of these are correct.

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. Notice of Privacy Practices is required every time the patient is provided service. Notice of Privacy Practices is only required for inpatient admissions. Notice of Privacy Practices is required on the first inpatient admission but for every outpatient encounter.

Notice of Privacy Practices is required on the first provision of service.

In the planning phase of EHR implementation, the project manager wants the HIM department to identify the internal customers. Which of the following are considered internal customers?

Nurses and medical assistants

A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? O80: Encounter for full-term uncomplicated delivery Z3A.49- Greater than 42 weeks gestation of pregnancy O48.1: Prolonged pregnancy O66.5- Attempted application of vacuum extractor and forceps

O48.1: Prolonged pregnancy

Which of the following federal agencies administers Meaningful Use standards?

ONC

Data collected to evaluate facility performance in designated core measure areas in order to achieve accreditation is _____. HEDIS ORYX DEEDS OASIS

ORYX

The initiative sponsored by the Joint Commission to establish a continuous, data-driven accreditation process that uses performance measures and data focused on core measures is known as:

ORYX.

Of the following code sets, which is used in the background of the EHR to define narrative-free text for the purpose of database query and analysis?

Michelle just started working as a medical biller for Central Valley Hospital. After reviewing some claims, it seems that the hospital coder is assigning the highest MS-DRG for every inpatient. Michelle brings up this issue with the Department of Health Information manager, but the issue was brushed aside. Where can Michelle file a complaint of misconduct?

Office of the Inspector General

A tornado hit Jackson, Missouri, which caused a tree to shatter the window of the Department of Health Information. The tree fell in the middle of the night, so the broken window exposed the department for several hours prior to securing the space. To which officer in the healthcare facility would the incident need to be reported?

Office of the Inspector General (OIG)

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? Two CPT codes, one for each laceration One CPT code for the largest laceration One CPT code, adding the lengths of the lacerations together One CPT code for the most complex closure

One CPT code, adding the lengths of the lacerations together

What is a key difference in operational and strategic planning?

Operational planning is managed by the board of directors.

Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? Operative report Anesthesia report Pathology report Laboratory report

Operative report

A local cardiologist practice is for sale. The practice boasts a long and dedicated patient list as well as physicians who are credentialed with Medicare and many other managed-care organizations. A nearby general practice is thinking of purchasing the cardiology practice to offer more services to its current practice. In which category of SWOT does this case belong?

Opportunity

Corona General Hospital ordered 25 new hospital beds to replace aging ones. Which leadership function is used to determine which departments these beds are allocated to?

Organizing

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? Patient assessment instrument Minimum data set for long-term care Resident assessment protocol Outcomes and Assessment Information Set

Outcomes and Assessment Information Set

A gallbladder removal patient presents with uncontrolled type 1 diabetes, COPD, and morbid obesity. What physical status modifier should the anesthesiologist assign?

The Corona General Hospital wants to keep its photo storage separate from its relational database to increase database query speed. What could the hospital use to manage the photo archive?

PACS

When implementing a new laboratory resulting software system that is interoperable with the EHR, each step of implementation is dependent on the previous step. A project manager scheduling the project should use which chart to determine an estimated timeline?

PERT chart

A healthcare facility has the right to deny patient's access to their medical records if the:

PHI may cause the patient to injure himself.

In processing a bill under the Medicare outpatient prospective payment system (OPPS), where a patient had three surgical procedures performed during the same operative session, which of the following would apply? Bundling of services Outlier adjustment Pass-through payment Discounting of procedures

Pass-through payment

Identify the acute care record report where the following information would be found:Microscopic: Sections are of squamous mucosa with no atypia. Medical history Medical laboratory report Pathology report Physical examination

Pathology report

Accompanied by her mother and husband, a 16-year-old woman presents in the emergency room for treatment of stomach pain. She is conscious, alert, and oriented. Who is the appropriate individual to sign the consent for treatment?

Patient

Physican orders for DNR and DNI should be consistent with: Patient's advance directive Patient bill of rights Notice of privacy practices Authorization for release of information

Patient bill of rights

In almost every hospital, the largest clinical department in terms of staffing, budgeting, specialized services offered, and clinical expertise required is which of the following? Diagnostic services Patient care services Occupational therapy services Rehabilitation services

Patient care services

Which of the following health information management activities are used in the quality assessment process?

Patient chart analysis

A class action suit is filed against a pharmaceutical company because of lasting side effects that its product caused. Who is the lead plaintiff?

Patient who originally filed the claim against the pharmaceutical company

Which of the following best represents the definition of the term data? Patient's laboratory value is 50 Patient's SGOT is over 50 and is outside of normal limits Patient's resting heart beat is 70 which is within normal range Patient's laboratory value is consistent with liver disease

Patient's laboratory value is 50

George is a popular coding manager. He takes an interest in all of his employees and motivates each one individually. He appreciates the contributions each make for his team. According to behavior theory, what character type does George have?

People-oriented

Which of the following statements does not represent a principle of contemporary performance improvement? Success must be celebrated to encourage more success. All systems demonstrate variation. Performance improvement works by identifying the individuals responsible for quality problems and retraining them. Performance improvement relies on the collection and analysis of data to increase knowledge.

Performance improvement works by identifying the individuals responsible for quality problems and retraining them.

A statewide cancer surveillance system is an example of which of the NHII dimensions? Personal Provider Community Payer

Personal

A home health agency plans to implement a computer system whereby its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect laptop and network data from a virus introduced from an external device? Session terminations Encryption Biometrics Personal firewall software

Personal firewall software

Identify the acute care record report where the following information would be found:HEENT: Reveals the tympanic membranes, nares, and pharnyx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds. Discharge summary Medical history Medical laboratory report Physical examination

Physical examination

According to The Joint Commission documentation standards, which of the following medical records do not require healthcare provider signature, even though it is highly advised?

Physician's progress notes

A patient has a placenta previa with delivery of twins. The patient has two prior Cesarean sections. This was an emergent C-section due to hemorrhage. The appropriate principal diagnosis would be: Normal delivery Placenta previa Twin gestation Vaginal hemorrhage

Placenta previa

The following is documented in the physician's progress note: "Prescribing statins to reduce inflammation and cholesterol. Recommending a low-fat and low-sodium diet. Reevaluate cholesterol levels in 3 months." Which section of the SOAP note will this be documented?

Plan

A third-party vendor was requested by the hospital to measure and analyze outcomes due to the implementation of a new CPOE software system. The vendor determines that there are some gaps that can benefit from additional improvements. What would be the next step in the system's life-development cycle?

Planning

City of Hope Cancer Hospital is developing a budget for patient care for the following year by examining the patient care expenses for this year. Which type of analytics explains why the events occurred?

Predictive analytics

The healthcare facility COO conducts a meeting every Monday with only the male supervisors on his staff because he feels that women are distracting during the operational meeting. What type of ethical violation is occurring?

Prejudice

Which of the following terms is used for the amount charged for a medical insurance policy? Fee schedule Premium Claim Deductible

Premium

The national average of employee turnover in the healthcare sector is 15 percent. The HIM department at Community Hospital employs an average of 75 FTEs. The total number of employees leaving the department in the past 12 months was 23. What was the turnover in the HIM department compared to the national average? Approximately the same as the national average Approximately 8 percent greater than the national average Approximately 15 percent less than the national average Approximately 30 percent greater than the national average

Approximately 30 percent greater than the national average

A HIM supervisor is revising job descriptions for record scanning positions. These positions have been in existence for just over one year. Which of the following would be the most appropriate action to take to ensure that all tasks being performed are incorporated into the new job descriptions? Ask current staff members to keep a diary for a certain period of time on how they spend their time. Review job descriptions from other hospitals. Make random observations of job tasks. Refer the matter to the human resources department.

Ask current staff members to keep a diary for a certain period of time on how they spend their time.

The Happy Home Healthcare Facility has 12 beds for its patients. What category would this be recorded under in the balance sheet?

Asset

Which of the following equations is the accounting equation used by the balance sheet?

Assets - Liabilities = Owners' Equity

After appropriate diagnostic and procedural codes are assigned, which of the following must be performed in order for the provider to be reimbursed in a fee-for-service payment arrangement? Assign a fee to each service from the provider's standard fee schedule Discount the fee for each service Determine bundled services Bill the third-party payer the capitated premium amount

Assign a fee to each service from the provider's standard fee schedule

In 1928, the American College of Surgeons established the health information profession by sponsoring the:

Association of Record Librarians of North America.

Hospital administration wants to know how many surgeons admitted patients into the hospital. How can this data be extracted from the EHR?

Audit patient records.

A patient presents to the ER with stroke-like symptoms, including numbness in the left arm, slurred words, and elevated blood pressure. How should the patient be treated first?

Automated disease protocols for stroke should be followed.

A visitor to the hospital looks at the screen of the admitting clerk's computer work-station when she leaves her desk to copy some admitting documents. What security mechanism would best have minimized this security breach? Access controls Audit controls Automatic logoff controls Device and media controls

Automatic logoff controls

A hospital is planning on allowing coding professionals to work at home. The hospital is in process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended? User name and password Automatic session terminations Cable locks Encryption

Automatic session terminations

In designing a database for collection of patient information, which of the following would be the best choice as the primary key for the table holding patient demographic information? Autonumber Patient last name Patient last name plus first name Patient date of birth

Autonumber

A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? Avoid displaying the number on any document, screen, or data collection field. Allow the information in both electronic and paper forms since a variety of people need this data. Require employees to sign confidentiality agreements if they have access to social security numbers. Contact legal counsel for advice.

Avoid displaying the number on any document, screen, or data collection field.

Tim Thompson was admitted for a possible left hip fracture. The X-ray performed in the hospital confirmed the physician's initial diagnosis. Which of the following codes will the hospital use to code the X-ray?

BQ01ZZZ - Imaging, nonaxial lower bones, plain radiography, left hip, no contrast, no qualifiers

Which of the following activities is considered an unethical practice? Backdating progress notes Performing quantitative analysis Verifying that an insurance company is one that is authorized to receive patient information Determining what information is required to fulfill an authorized request for information

Backdating progress notes

When comparing individual team member productivity, which of the following will be the most effective data presentation tool?

Bar chart

Which of the following records should be maintained separately from the patient medical record?

Behavior health patient file

What of the following terms means "promoting good"? Autonomy Beneficence Justice Nonmaleficence

Beneficence

Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? Autonomy Beneficence Justice Nonmaleficence

Beneficence

When a hospital uses many different vendors to support its information system needs, the information technology (IT) strategy being used is called: Best of breed Best of fit Hospital information system Legacy architecture

Best of breed

Who is primarily responsible for setting the overall direction of an acute care hospital? Chief executive officer Medical staff Board of directors Organization's stockholders

Board of directors

Which of the following is a technique used to generate a large number of creative ideas from a group? Affinity grouping Brainstorming Multivoting technique Nominal group technique

Brainstorming

Essential patient information, such as patient allergies, needs to be highlighted to each member of the healthcare team. Which of the following EHR feature best highlights this?

Bright color alert on the EHR dashboard

Which of the following best describes strategic decision making? Broad-based information Detailed data requirements Structured decisions Periodic reports

Broad-based information

In the ICD-10-CM code set, which of the following cases is an example of an external cause of injury?

Broken wrist due to vehicle accident

Behavioral health and rehabilitation healthcare facilities are accredited by the which of the following organizations?

CARF

A physician wants an automated system that allows input of signs, symptoms, and results of laboratory tests and provides a list of provisional diagnoses. Which of the following would best meet the physician's needs? CDSS DSS EIS MIS

CDSS

Sandra is a single mother of two children. She earns enough money to support her family, so she makes above the poverty level. However, she cannot afford to pay for health insurance coverage for her two children. Which plan may her children be eligible for?

CHIP

What component of the budget would include money for the purchase of an EHR? Revenue budget Expense budget Capital budget Cash budget

Capital budget

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? Catheter-associated urinary tract infection Cerebral vascular accident COPD Hypertension

Catheter-associated urinary tract infection

Which of the following data elements are commonly collected and analyzed in the National Vital Statistics Reports?

Cause of death

Before purchasing an electronic health record (EHR) system, a clinical office practice should consult which of the following to ensure that the system meets HL7 standards for EHR system functionality? Certification Commission on Health Information Technology (CCHIT) Health Information Exchange (HIE) Centers for Medicare and Medicaid Services (CMS) National Committee on Vital and Health Statistics (NCVHS)

Certification Commission on Health Information Technology (CCHIT)

Which of the following users of the healthcare record is considered a secondary user?

Certified cancer registrar

The project team is working on assembling priorities for the project. In which phase of the project management life cycle would this activity be included?

Change control

_____ is the formal process of introducing a new technology, getting it adopted, and diffusing if through the organization. Analysis and design Change management Management Implementation

Change management

In the project management meeting to implement a new Bar Code Medication Administration software, the HIM department invited representatives for various disciplines. Which of the following groups should have priority input because they will be using the software of a regular basis?

Charge nurses

When a healthcare facility submits insurance claims for reimbursements, all medical products and drugs must be listed on the facility _____.

Chargemaster

In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit? Admission diagnosis and complaints Chargemaster description and medical necessity Clinical laboratory results Radiology orders

Chargemaster description and medical necessity

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? Chart deficiency system Chart tracking system Chart abstracting system Chart encoder

Chart tracking system

A famous musician's child is admitted through the ER. The ER nurse on duty starts sharing what happened to the child in the breakroom. Sally overheard the conversation and recognized the HIPAA breach. Which organizational officer should the incident be reported?

Chief Privacy Officer (CPO)

A patient is admitted to the hospital with abdominal pain. The principal diagnosis is cholecystitis. The patient also has a history of hypertension and diabetes. In the DRG prospective payment system, which of the following would determine the MDC assignment for this patient? Abdominal pain Cholecystitis Hypertension Diabetes

Cholecystitis

Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation which of the following should the HIM director advise? There are no barriers prescribed by HIPAA for this arrangement. Community Hospital needs to expand their Organized Health Care Arrangement to include the other hospital. City Hospital should obtain a business associate agreement with Community Hospital. Community Hospital should obtain a business associate agreement with City Hospital.

City Hospital should obtain a business associate agreement with Community Hospital.

A hospital's C-section rate is an example of a: Clinical standard Clinical guideline Clinical performance measure Clinical protocol

Clinical performance measure

A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents "skin lesion" in the health record. Prior to billing the pathology report returns with a diagnosis of basal cell carcinoma. Which of the following actions should the coding professional do for claim submission? Code skin lesion Code benign skin lesion Code basal cell carcinoma Query the dermatologist

Code basal cell carcinoma

The HIT coding supervisor is conducting a coding productivity study. The data in this figure show the average number of health records coded per hour per day by each of the department's four coders. The coding supervisor has also calculated the average records coded per hour for a departmental coding benchmark. Given this data what do the coding audit results show? (Insert chart) All coders are meeting the departmental average of records coded per hour. Coder C codes the most records per hour. Coder A consistently exceeds the departmental average. Coder D is significantly below the departmental average.

Coder A consistently exceeds the departmental average.

During orientation, Amora was presented with an organizational chart. Amora works in the coding department, and she reports to her coding supervisor. The coding supervisor reports to the director of Health Information and the director of Health Information reports to the COO of the healthcare facility. The COO then directly reports to the CEO. Based on the unity of control principle, if Amora has an issue, which of the following would she ask?

Coding supervisor

The right of an individual to keep information about themselves from being disclosed to anyone is a definition of: Confidentiality Privacy Integrity Security

Privacy

in the ER triage area, the doctor informed the patient that the results of the stat lab test were positive for Hepatitis B. The doctor did not close the curtain nor did he lower his voice while delivering the news. He then proceeded to discuss the patient's case at the nurse's station out loud. Which of the following HIPAA elements were compromised?

Privacy

What is (are) the format problems with the following table? Variable names are missing Title of the table is missing Column headings are missing Column totals are inaccurate

Column headings are missing

Based on the adjustment percentage in this table, which payer proportionately reimburses the facility the most? BC/BS Commercial Medicaid Medicare

Commercial

There are two hospitals in the community that perform gallbladder stone removal. One hospital uses the DaVinci surgical system, whereas the other hospital uses the standard laparoscopic procedure. Researchers are interested in results from both surgical techniques. Which type of study would they use?

Comparative

Which type of law defines the rights and duties among people and private businesses? Public law Private law Corporate law Administrative law

Private law

Which of the following elements of coding quality represent the degree to which the codes capture all the diagnoses and procedures documented in the patient's health record? Reliability Validity Completeness Timeliness

Completeness

Dr. Joseph Johnson is a new physician at the San Antonio Community Hospital. On his first day, the director of Health Information paged him to review documentation standards for the facility. Why is this training essential?

Compliance purposes

Which of the following is a condition that arises during hospitalization? Case mix Complication Comorbidity Principal diagnosis

Complication

Which of the following technologies has been demonstrated to significantly reduce medication administrative errors?

Computer physician order entry (CPOE)

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 in order to become certified for these programs? Joint Commission Accreditation Standards Conditions for Coverage Conditions for Participation Outcomes and Assessment Information Set

Conditions for Coverage

A new coding supervisor sees that the coding division is not working together as a team. The supervisor recognizes that several of the employees have a bias against team work. Given this situation which of the following would be one of the first actions the supervisor should take? Call a meeting to discuss workers' biases. Conduct teambuilding exercises to overcome worker biases. Talk with the director of HIM. Give a verbal notice to workers who do not want to cooperate.

Conduct teambuilding exercises to overcome worker biases.

Angie purchased black glass screens for all tablets used in the healthcare facility to prevent unauthorized information viewing. Which ethical principle is she applying?

Confidentiality

Which of the following ethical principles focuses on keeping a patient's information safe and preventing unauthorized access?

Confidentiality

Which of the following is the approved method for conducting business in an organization? Hierarchy chart Organizational chart Policy Procedure

Procedure

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case how should the director of HIM advise the CFO? Confirm that a formal letter of termination meets HIPAA requirements and no further action is required. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned. Inform the CFO that business associate agreements cannot be terminated.

Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned.

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed during 2008. Given this data, which procedure should the Council scrutinize in evaluating performance? Procedures 1,4 Procedures 2,3,5 Procedures 6,7 Procedures 1, 4, 6, 7

Procedures 1, 4, 6, 7

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. Which of the following would be the correct sequencing and coding of this case? Congestive heart failure, respiratory failure Respiratory failure Respiratory failure, congestive heart failure Shortness of breath, congestive heart failure, respiratory failure

Congestive heart failure, respiratory failure

Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? Consent for operative procedure, anesthesia report, surgical report Consent for operative procedure, history, physical examination History, physical examination, anesthesia report Problem list, history, physical examination

Consent for operative procedure, history, physical examination

The HIM director is having difficulty with the on-call physicians in the emergency services department completing their health records. Currently, three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? Routinely send out a fourth notice. Post the hospital policy in the emergency department. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to current notices. Call the Joint Commission.

Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to current notices.

A family practitioner requests the opinion of a physician specialist in endocrinology who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report? Consultation Medical history Physical examination Progress notes

Consultation

Medical record completion compliance is a problem at Community Hospital. The number of incomplete charts often exceed the standard set by the Joint Commission, risking a type I violation. Previous HIM committee chairpersons had tried multiple methods to improve compliance, including suspension of privileges and deactivating the parking garage key of any physician in bad standing. To improve compliance which of the following would be a next step to overcoming the problem of noncompliance? Discuss the problem with the hospital CEO. Call the Joint Commission. Contact other hospitals to see what methods they use to ensure compliance. Drop the issue because non-compliance is always a problem.

Contact other hospitals to see what methods they use to ensure compliance.

Southern California is experiencing a swarm of mini earthquakes that have interrupted power and radio communications for the past couple of weeks. Which plan will the facility refer to in case the loss of power and communication affects the delivery of quality patient care?

Contingency plan

Sara has noticed an increase in medical records delinquency. So, she schedules a meeting for her HIM staff to emphasize the standards and requirements to maintain a low delinquency rate. Which function of leadership is she employing?

Controlling

In performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis and procedure codes specifically for the purpose of obtaining a higher level of payment. The coder believes that this practice is helping the hospital in increasing revenue. Which of the following should be done in this case? Complement the coder for taking initiative in helping the hospital Report the coder to the FBI for coding fraud Counsel the coder and stop the practice immediately Provide the coder with incentive pay for her actions

Counsel the coder and stop the practice immediately

Which of the following identification types cannot be accepted for release of information purposes?

Credit card with a photo picture

Which of the following is the approved method for conducting business in an organization? D23 Other benign neoplasms of skin D17.0 Benign lipomatous neoplasm of skin D23.12 Other benign neoplasm of skin of left eyelid, including canthus D23.11 Other benign neoplasm of skin of right eyelid, including canthus

D23.12 Other benign neoplasm of skin of left eyelid, including canthus

When coding a nevus, which is a benign neoplasm of the skin, the coder should select: D23.5 Other benign neoplasm of skin of trunk D23.9 Other benign neoplasm of skin, unspecified D48.5 Neoplasm of uncertain behavior of skin D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin

D23.9 Other benign neoplasm of skin, unspecified

Which of the following data sets would be most helpful in developing a hosptial trauma data registry? DEEDS UACDS MDS Version 2.0 OASIS

DEEDS

A HIM director is requesting the purchase of a document imaging system. However, the Hospital Budget Committee is reluctant to approve the request because of the expense. The Committee feels that the money is better spent pursuing implementation of CPOE and other EHR applications. Which of the following might the HIM director use as a cost-benefit justification? The EHR system will take too long to implement. The Joint Commission requires that the hospital move to digital scanning. DNFB and AR days can be improved because of workflow efficiencies. HIPAA requires the use of digital tracking of release of information.

DNFB and AR days can be improved because of workflow efficiencies.

In one city near the Rio Grande River, there is a high incidence of birth defects linked to the contaminated drinking water, according to the birth defects registry. What data in the birth defects registry can be used to promote legislation to improve the drinking water in this community?

Data collected through the assessment of maternal health during the prenatal period

The medical offices of Patrick Hall, MD, would like to participate in the Lower Salt Lake City Health Information Exchange (HIE). The patient name data element from Dr. Hall's office looks like LNAME_MI_FNAME; however, the patient name data element in the HIE is LAST_MI_FIRST. Which of the following data characteristics can be applied to enhance interoperability?

Data currency

The director of health information would like to follow how data is collected through the admission to the discharge process. Which of the following tools can he use?

Data flow diagram

Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? Client-server computer Data warehouse Local area network Internet

Data warehouse

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, type of records coded and other data, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use to develop this type of database? Database management system Paper log book Spreadsheet Word-processing documents

Database management system

The aging report lists five accounts that are 90 days. What date does this time start?

Date of encounter

Which of the following information systems will be most useful for diagnosing patients for an internal medicine office?

Decision support system

Which of the following cases is an example of quality improvement?

Decrease in medical record percent delinquency

Which of the following is not a key focus of healthcare information standards development? Linking data from disparate computer systems Providing common definitions for data elements Responding to the information needs of users Defining data for paper-based health record systems

Defining data for paper-based health record systems

What is the information identifying the patient (such as name, health record number, address, and telephone number) called? Accession data Indicator data Reference data Demographic data

Demographic data

In processing a bill for healthcare services which of the following would be excluded under Medicare Part A? Dental services Home health services Hospice services Hospitalization services

Dental services

The Healthy People 2020 initiative is sponsored by the:

Department of Health and Human Services.

Physicians have not been using the e-script feature of the EHR. Which department in the hospital helps train the staff on documentation standards?

Department of health information

Which of the following is NOT true about a primary key in a database table? Usually a unique number Does not change in value Dependent on the data in the table Uniquely identifies each row in a table

Dependent on the data in the table

If a judge asks a record custodian to attest to the permanence of an EHR, the custodian should: Attest to a retention schedule Describe contingency plans Produce paper back-ups Request IT support

Describe contingency plans

The project to implement the upgraded EHR system is in place. However, the lab department feels that their module in the HER does provide enough detail. They would prefer that each entry be time stamped; this project idea was not part of the original project plan. Which phase of the project management life cycle would this update be a part of?

Design

Which of the following information presentation format is best for operational decision making? Detailed, scheduled reports Summarized, ad hoc reports Background data External data

Detailed, scheduled reports

As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all of the divisions within the HIM department. The following table shows sample productivity benchmarks for record assembly that the director found through a literature search. Given this information, how should be director proceed in establishing benchmarks for the department? Use the average benchmark example as a beginning point for implementation. Use the low benchmark example as a beginning point for implementation. Determine if the source of the benchmark data is from a comparable institution. Contact the hospital statistician to determine if the data were relevant.

Determine if the source of the benchmark data is from a comparable institution.

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? Alert the Joint Commission that the hospital has not met its quality goal. Determine if there was a medical or other reason why patients were not given aspirin. Institute an in-service training program for clinical staff on the importance of administering aspirin within 24 hours. Determine which physicians did not order aspirin.

Determine if there was a medical or other reason why patients were not given aspirin.

Community Hospital files its inpatient medical records using terminal digit filing. An audit of medical record misfiles reveals that the misfile rate is 15 percent. This is 14 percent higher than the standard quality level. Which of the following should the HIM director do immediately to rectify the filing problem? Determine the reasons for the high number of misfiles Institute an educational program in terminal digit filing for the file clerks Give a verbal warning to the file clerks Fire the file clerks responsible for the misfiles

Determine the reasons for the high number of misfiles

A HIM department performed an audit of a random sample of filed medical records to determine the accuracy of its filing system. The audit revealed that the department had a 9 percent error rate. What should the HIM director do in this instance? Monitor the error rate to see if it increases Monitor the error rate to see if it decreases Determine the reasons why there are misfiles Do nothing at this time since the error rate is within the national average

Determine the reasons why there are misfiles

The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation? a. Contact CMS for assistance b. Determine the type and volume of documentation problems c. Change the medical staff bylaws to require improved documentation practice d. Implement a documentation score card for each medical specialty

Determine the type and volume of documentation problems

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case what should the supervisor do? Reprimand the employee Fire the employee Determine what information was printed and why Revoke the employee's access privileges

Determine what information was printed and why

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? Immediately stop the practice of changing transcribed reports Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form Conduct a verification audit Alert hospital legal counsel of the practice

Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional advise be done first for identifying the components of the legal health record? Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records. Perform a quality check on all health record systems in the practice. Develop a listing and categorize all information requests for health information over the past two years.

Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records.

A HIM professional is the leader of the quality improvement team. To ensure that all team members understand the mission and goals of the team and expectations of the team members, which of the following actions should be taken? Develop project definition document. Record minutes of the first team meeting. Develop a team charter. Develop a Gantt chart.

Develop a team charter.

During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste function of the hospital's new EHR system for documenting nursing notes. In some cases nurses are copying and pasting the objective data from the lab system and intake-output records as well as the patient's subjective complaints and symptoms originally documented by another practitioner. Which of the following should the HIM director do to ensure that the nurses are following acceptable documentation practices? Inform the nurses that "copy and paste" is not acceptable and to stop this practice immediately Determine how many nurses are involved in this practice Institute an in-service training session on documentation practices Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system

Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system

Several members of the hospital's quality improvement team arrive late for most team meetings. This practice hinders the efficiency of the team. Which of the following would be the best action to take to remedy this situation? Reprimand the offenders. Ignore the individuals who come late to meetings. Develop team ground rules for meeting attendance. Make sure that the individuals who come late are given extra teamwork

Develop team ground rules for meeting attendance.

A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach? Access controls Device and media controls Facility access controls Workstation controls

Device and media controls

The Corona Regional Hospital had an increase in patient admission intake time because the server was running much slower. Which type of analytics explains why the events occurred?

Diagnostic analytics

Which of the following provides a means to record information about patients treated for substance abuse and mental disorders? Current Procedural Terminology (CPT) Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Systemized Nomenclature of Medicine Clinical Terminology

Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision

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 medical record. Retrieval of the complete record after discharge is difficult. The HIM director feels that the integrity of the record is at risk since it is harder to control addendums and updates when the record is spread between electronic and paper systems. Furthermore, clinicians, physicians, and others are often challenged to find all of the documentation to provide patient care if the patient is readmitted at a later date. Given these circumstances which of the following should the HIM director implement to alleviate these problems while at the same time preserving the efficiences of an electronic record? Print out all electronic data post-discharge and file with the rest of the paper record. Microfilm all electronic data and link to the paper record. Digitally scan all paper records post-discharge and integrate and index these into the existing digital documentation system. Digitally scan all paper records.

Digitally scan all paper records post-discharge and integrate and index these into the existing digital documentation system.

Anthem Blue Cross offers Dr. William Harrison a capitation agreement in which he agrees to accept 1,000 patients for reasonable primary care at a monthly stipend of $12 per patient in January. However, by March, Dr. Harrison tells his staff to offer limited appointments to Anthem Blue Cross patients who are in this capitation group and to make room for patients with other private health insurance plans, even though Anthem Blue Cross pays Dr. Harrison the $12,000 monthly stipend to provide patients primary care. As a result, the Anthem Blue Cross patients are waiting more than six weeks for an appointment. Who is at fault, if anyone, and why?

Dr. Harrison is in breach of the capitation contract because he agreed to provide reasonable primary care to these patients.

In designing an input screen for an electronic health record, which of the following would be best to capture discrete data? Drop-down menus Speech recognition Natural language processing Document imaging

Drop-down menus

Which of the following is an example of the overhandling of patient care?

Duplicating medical testing

Which of the following are examples of computer software systems?

EPIC EHR

Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing for launching this service the HIM director is asked if a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? Each physician practice obtain a business associate agreement with the hospital The hospital obtain a business associate agreement with each physician practice Since the physicians all have medical staff privileges no business associate agreement is necessary Since the physicians are part of an Organized Health Care Arrangement (OHCA) with the hospital, no business associate agreement is necessary

Each physician practice obtain a business associate agreement with the hospital

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What security measures should be in place to minimize this security breach? Access controls Audit trail Edit checks Password controls

Edit checks

Which of the following best describes e-RX? Electronic radiology reporting system Electronic medication prescribing system Electronic health record system Electronic interchange system

Electronic medication prescribing system

Which of the following statements represents a barrier to implementing change? Management demonstrates a high and visible commitment to change. Change must be based on good diagnosis. Change must be directed by line managers. Employees should not be notified of the change in advance.

Employees should not be notified of the change in advance.

The HIM department is implementing a document scanning process to scan all paper-related documents in the health record. The goal of this process is to increase record availability and decrease record storage. Which of the following should the department have in place to ensure timely availability of the scanned records? Maintain paper records as a back-up, but store off site Microfilm records as backup to the scanning system Ensure that appropriate back-up procedures are in place Keep paper back up for 120 days to be sure scanning is correct

Ensure that appropriate back-up procedures are in place

As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed that more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the Committee's first action? Conduct another study to reverify the data Establish a data dictionary policy with associated standards Develop an in-service training program on data dictionary use Distribute a memorandum to all department heads on the value of a data dictionary

Establish a data dictionary policy with associated standards

When a healthcare facility realizes that there has been a breach of health information, who gets involved to review possible ethical violations to determine how to remedy the situation?

Ethics committee

Which of the following statements is true about the chain of command in a bureaucratic organization? Every employee is accountable to only one boss. An employee may report to multiple managers. All employees share in authority and responsibility. Employees can belong to many cross-functional teams.

Every employee is accountable to only one boss.

The following are examples of high-level computer programming languages except:

Excel

The hospital is in need of a new CT Scanner, but it needs to determine if it should purchase, lease, or rent the new equipment. Which information system supports this type of decision making?

Executive information system

Which of the following information systems supports strategic decision making? Transaction processing system Management information system Executive information system Expert system

Executive information system

Which of the following is used to support the work of professionals engaged in the design, diagnosis, or evaluation of complex situations requiring special knowledge in a limited area? Decision support system Executive information system Expert system Management information system

Expert system

When applying the principle of data relevancy, which of the following data would apply?

Eye color

The orientation supervisor asked the new employee to watch the HR compliance videos during spare time. The employee would not be on the clock to complete these requirements. This is a violation of:

Fair Labor Standards Act.

Catherine Johnson is filing a wrongful death suit against the VA hospital in Virginia. The VA Hospital lost the case and is filing an appeal. Which court will hear the case?

Federal Appellate Court

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? Flowchart Fishbone diagram Pareto chart Scatter diagram

Fishbone diagram

The leader of the coding performance improvement team wants all of her team members to clearly understand the coding process. Which of the following would be the best tool for accomplishing this objective? Flowchart Force-field analysis Pareto chart Scatter diagram

Flowchart

Which of the following strategies would be best to use to ensure that all stakeholders are engaged in the planning and development of an organization EHR system? Form an EHR steering committee Put out a press release Distribute an organization-wide memorandum from the CEO Put out a notice on the organization's intranet

Form an EHR steering committee

Which of the following statements best describes the sequence of stages in teamwork development? Forming, informing, norming, performing Forming, storming, norming, performing Information, norming, storming, reforming Forming, storming, performing, norming

Forming, storming, norming, performing

Cynthia needs a hysterectomy. However, the physician needs to obtain approval for the procedure from the insurance company. Which stage of the revenue cycle will this be?

Front-end cycle

Which of the following statements most accurately describes funding for the Medicaid program? Funding comes from the federal government. Funding comes from each state government. Funding is a joint federal and state initiative. Funding is from private sources.

Funding is a joint federal and state initiative.

Community Hospital has been collecting quarterly data on the average monthly medical record delinquency rate for the hospital. This graph depicts the trend in the delinquency rate. The hospital has established a 35 percent benchmark. Given this data what should the hospital's Performance Improvement Council recommend?graph60 Maintain tracking the delinquency rate to see if the last two quarter trend continues. Establish a higher benchmark to accommodate an increase in delinquent records. Further analyze the data to determine why the benchmark is not being met. Take an average of all the data points to arrive at a new benchmark.

Further analyze the data to determine why the benchmark is not being met.

Which of the following help to facilitate the integration of work processes and team work? DSS Groupware Kiosks MIS

Groupware

The charge nurses have noticed that the biohazard needle boxes in the patient rooms have not been emptied on a regular basis. Which HR function should be employed to address this situation?

Handling grievance

What types of covered entity health records are subject to the HIPAA privacy regulations? Only health records in paper format Only health records in electronic format Health records in paper or electronic format Health records in any format

Health records in any format

Which of the following promotes uniform reporting and statistical data collection for medical procedures, supplies, products, and services? Current Procedural Terminology Healthcare Common Procedure Coding System International Classification of Diseases, Ninth Revision, Clinical Modification International Classification of Diseases for Oncology, Third Edition

Healthcare Common Procedure Coding System

Which of the following is an advantage offered by computer-based clinical decision support tools? Give physicians instant access to pharmaceutical formularies, referral databases, and reference literature. Review structured electronic data and alert practitioners to out-of-range laboratory values or dangerous trends. Help support physicians as they consider diagnostic and treatment alternatives by recalling relevant diagnostic criteria and treatment options on the basis of data in the health record. Automatically transcribes medical reports.

Help support physicians as they consider diagnostic and treatment alternatives by recalling relevant diagnostic criteria and treatment options on the basis of data in the health record.

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed, but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case? Poisoning due to Coumadin Unspecified adverse reaction to Coumadin Hematuria; poisoning due to Coumadin Hematuria; adverse reaction to Coumadin

Hematuria; adverse reaction to Coumadin

Which of the following procedures would require the healthcare provider to obtain a written consent before the procedure was performed on an inpatient? Chest x-ray Hernia repair EKG EEG

Hernia repair

The right-handed patient was discharged with the following diagnoses: embolic stroke in the left middle cerebral artery, , hemiplegia of right side-no longer present, asphasia-still present, and hypertension. Which of the following code assignments would be appropriate for this case? I66.9; G81.90; I10; R47.01 I63.412; G81.91; I10; R47.01 I63.9; I10; R47.01 I63.412; G81.93; R47.01

I63.412; G81.91; I10; R47.01

In developing a monitoring program for coding compliance, which of the following should be regularly audited? ICD-10 and CPT coding CPT/HCPCS and LOINC coding ICD-10 and SNOMED coding CPT/HCPCS and SNOMED coding

ICD-10 and CPT coding

Franklin Cho was admitted through the emergency room due to difficulty breathing. Which information collected during the encounter is considered primary care data?

ICD-10-CM code explaining the reason for the visit

Which of the following is NOT one of the purposes of ICD-10-CM? Classification of morbidity for statistical purposes Classification of mortality for statistical purposes Reporting of diagnoses by physicians Identification of the supplies, products, and services provided to patients

Identification of the supplies, products, and services provided to patients

Which of the following actions would be best to determine if present on admission (POA) indicators for the conditions selected by CMS are having a negative impact on the hospital's Medicare reimbursement? Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnosis present on the claim that will lead that will lead to higher payment. Identify all records for a period that have these indicators for these conditions. Identify all records for a period that have these indicators for these conditions and determine whether or not additional documentation can be submitted to Medicare to increase reimbursement. Take a random sample of records for a period of records having these indicators for these conditions and extrapolate the negative impact on Medicare reimbursement.

Identify all records for a period having these indicators for these conditions and determine if these conditions are the only secondary diagnosis present on the claim that will lead that will lead to higher payment.

A new HIM director has been asked by the hospital CIO to ensure that 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? Call the EHR vendor and ask to review the system's data dictionary. Identify data content requirements for all areas of the organization. Call a meeting of all department directors to get their input. Contact CMS to determine what data sets are required to be collected

Identify data content requirements for all areas of the organization.

Which of the following is the biggest challenge of using a regional health information exchange?

Identifying the correct patient

Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to insure that everyone understands the importance of this program? Request that the CEO write a memorandum to all hospital staff. Give the chairperson of the CDI committee authority to fire employees who don't improve clinical documentation. Include ancillary clinical and medical staff in the process. Request a letter from the Joint Commission.

Include ancillary clinical and medical staff in the process.

Which of the following plans reimburses patients up to a specified amount? Health insurance Coinsurance Indemnity Major medical plan

Indemnity

The hospital is revising its policy on medical record documentation. Currently, all entries in the medical record must be legible, complete, dated, and signed. The committee chairperson wants to add that in addition all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct since personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest? Suggest that only hospital clock time be noted in clinical documentation. Suggest that only electronic documentation have time notated. Inform the committee that according to the COP all documentation must include date and time. Inform the committee that according to the COP only medication orders must include date and time.

Inform the committee that according to the COP all documentation must include date and time.

An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should have been implemented that could minimize this security breach? Audit controls Information access controls Facility access controls Workstation security

Information access controls

Which of the following statements is true regarding HIPAA security? All institutions must implement the same security measures Institutions are allowed flexibility in the way they implement HIPAA standards All institutions must implement all HIPAA implementation specifications A security risk assessment must be performed every year

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 seven employees from the analysis, transcription, release of information, and coding sections. Specifically, the team is heterogeneous. 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? Too many team members Unspecific team charge Insufficient knowledge of team members Too homogeneous a team

Insufficient knowledge of team members

Which of the following provides a full range of healthcare services along a continuum of care to ensure that patients get the right care at the right time from the right provider? Subacute Care Integrated Delivery Systems (IDS) Community of Care Quality of Care Managers

Integrated Delivery Systems (IDS)

Which of the following plans can reduce the number of additional document requests (ADRs) by maintaining coding compliance?

Internal coding audit

Which of the following allows corporations to supply Internet services over their LANs? Extranet Intranet Internet WAN

Intranet

Which of the following statements does not apply in ICD-10? It can be used as the basis for epidemiological research. It can be used in the evaluation of medical care planning for healthcare delivery systems. It can be used to facilitate data storage and retrieval. It can be used to collect data about nursing care.

It can be used to collect data about nursing care.

Which of the following statements does not apply to ICD-10-CM? It can be used as the basis for epidemiological research. It can be used in the evaluation of medical care planning for healthcare delivery systems. It can be used to facilitate data storage and retrieval. It can be used to collect data about nursing care.

It can be used to collect data about nursing care.

Which of the following is NOT true of zero-based budgeting? It is done by projecting a percentage increase from historical results. It is based on work colume and unit cost. It is an option for budget preparation. It is useful in budgeting some supply costs.

It is done by projecting a percentage increase from historical results.

Judy Thompson has lived in the Green Hills Long-Term Care Facility for the past three years. Her daughter's 25th wedding anniversary is on January 26, so Judy would like to leave the facility for five days and then return on February 1. How does the long-term care facility address her leaving the facility? Judy will be discharged on January 26 and readmitted on February 1. The long-term care facility will not report that she has discharged. Judy's room will be put on hold status until she returns on February 1. Judy is not allowed to leave the long-term care facility.

Judy's room will be put on hold status until she returns on February 1.

Dr. Howard Chung advertises that he accepts most health insurance types, including Medicaid. In his medical office, there are two different treatment room types. The one for private insurance patients are state-of-the-art rooms, and the other room type is a much smaller room with basic medical treatment amenities. Which ethical principle is Dr. Chung violating?

Justice

Which of the following ethical principles is being followed when a HIT professional applies rules fairly to all? Autonomy Beneficence Justice Nonmaleficence

Justice

A hospital CEO wants to organize the organization's policies, procedures, and business expertise to increase overall effectiveness and efficiency. Which of the following systems would be best to accomplish this task? Data warehouse DSS KMS MIS

KMS

Which of the following statements does not represent a fundamental principle of performance improvement? Teamwork is an optional element in performance improvement. Communication must be open and honest. Success must be celebrated to encourage more success. Leaders and employees must know and share the organization's mission and vision.

Teamwork is an optional element in performance improvement.

Dr. Henderson is a pain management physician. There has been an increase in competition in his local area, and his medical practice has been more cash strapped. He decides to bill patient insurance for services that he didn't provide to help him get caught up with the healthcare facility finances. He reasons that Medicare reimbursement rates are decreasing every year, and they should really pay him more for the care that is delivered. Could Dr. Henderson be found guilty under the False Claims Act?

The False Claims Act legislation evaluates the intent of facility's coding practices that deliberately deceive the federal government insurance plans, so Dr. Henderson can be found guilty because he filed the claims even though he knew he didn't deliver these services.

Molly Harrison has health insurance coverage from both her parents. How will the medical office determine the primary insurance?

The child's primary coverage always comes from the parent with the birthday earliest in the year.

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? The cost of training will deliver a 46 percent return on investment over one year and can be justified. The results of training will be minimal reflecting only $400 per day and cannot be justified. The cost of training will be recouped in less than half a year and can be justified. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.

The cost of training will deliver a 46 percent return on investment over one year and can be justified.

The hospital requires that all job descriptions be reviewed on a yearly basis to determine if they need to be updated. In which of the following situations would a supervisor not be required to update a job description? The current employee is requesting a raise. The job includes new work from the last update. Technology has substantially changed the job. New tasks are being performed as a result of new workflow patterns.

The current employee is requesting a raise.

A 16-year-old patient visits her pediatrician and shares that she is pregnant, but she doesn't want to tell her parents, and she would like a referral to a clinic to have an abortion. The physician knows the girl's parents are from a strong religious background, so the doctor reasons that the patient-physician's privilege is not valid when the patient is a minor. Does the doctor have the right to contact the girl's parents?

The doctor would be violating the patient-physician privilege by calling the parents, regardless of the patient being a minor; this is her patient.

Which of the following definitions best describes the concept of confidentiality? The right of individuals to control access to their personal health information The protection of healthcare information from damage, loss, and unauthorized alteration The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose

When healthcare facilities use a hybrid health record, what is the best strategy for discharge analysis? The discharge audit should only include the documentation in the her. The discharge audit should only include the documentation in the paper records. The healthcare facility should identify the minimum discharge data elements both in the EHR and the hybrid records to develop a process to incorporate analysis of both types of records. The healthcare facility should follow guidance by the accrediting agency as to the essential analytics in discharge data

The healthcare facility should identify the minimum discharge data elements both in the EHR and the hybrid records to develop a process to incorporate analysis of both types of records.

Given NCCI edits, if the placement of a catheter is billed along with the performance of an infusion procedure for the same date of service for an outpatient beneficiary, Medicare will pay for: The placement of the catheter The placement of the catheter and the infusion procedure The infusion procedure Neither the placement of the catheter nor the infusion procedure

The infusion procedure

Which of the following statements is NOT correct about the PDSA model? One or two of the proposed changes should be tested first to determine whether the planned changes are working toward the project's final goal. The last step in the model involves collecting data on the effects of the changes implemented. Improvement efforts should start out slowly. Planning the proposed changes requires the most effort.

The last step in the model involves collecting data on the effects of the changes implemented.

Marjory Hanson had bunionectomy surgery on her left foot. She needed a copy of the medical record to apply for disability. Ms. Hanson was not able to drive herself to the Ambulatory Surgery Center to request a copy, so the center emailed her a copy of the release of health information form. Marjory completed the form, included her date of birth, the date of service, the surgeon, and the medical record number and attached a copy of her state driver's license. However, the Ambulatory Surgery Center denied her request for information. Why?

The release of information form was most likely not signed.

The orthopedic surgeon billed Blue Shield of California $7,325 for a broken ankle surgery. The reimbursement check was sent to the patient in full. Why would a health insurance company send the check to the patient and not the physician?

The surgeon is not in-network with the health insurance plan.

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 of 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 the committee? HIPAA does not allow a patient's name to be announced in the waiting room. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. HIPAA allows only the use of the patient's first name. HIPAA requires that patients be given numbers and only the number be announced.

There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.

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 of 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 the committee? HIPAA does not allow a patient's name to be announced in a waiting room. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. HIPAA allows only the use of the patient's first name. HIPAA requires that patients be given numbers and only the number be announced.

There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.

Simon was admitted through the ER for a burst appendix. He is extremely afraid of needles. In fact, he has needed an epidural injection for back pain for a while, but he has put it off because he is so afraid. He asks the physician if he can perform both the appendectomy and the epidural at the same time. His staff has determined that the two procedure codes, the appendectomy and the epidural, have an NCCI edit modifier 0. What does this mean?

These two procedures cannot be performed at the same time according to the NCCI modifier.

Ms. Smith is a 75-year-old patient who only has Medicare's Part A insurance. Using the following information, how many benefit periods did the patient use during this calendar year? One Two Three Four

Three

Medicare provides 18 months from the date of service to submit claims for its members. Harry Gomez, M.D., is a new physician, and although he is a Medicare participating provider, he didn't have the knowledgeable staff to bill for Medicare patients. When he was organized enough to submit the insurance claims to Medicare, 24 months had passed. Which data quality characteristic did Dr. Gomez miss?

Timeliness

How do accreditation organizations such as the Joint Commission, use the health record? To serve as a source for case study information To determine whether the documentation supports the provider's claim for reimbursement To provide healthcare services To determine whether standards of care are being met

To determine whether standards of care are being met

Which of the following projects are common for the HIM department?

Training physicians on accurate documentation standards and practices for all consultations

Which of the following information systems manages the day-to-day operations of a business? Transaction processing system Management information system Decision-processing system Expert system

Transaction processing system

Traumatic injury may result from all of the following except:

The following would most probably not be on the healthcare facility data analysis team.

Triage nurse

An outpatient clinic is reviewing the functionality of a computer system it is considering purchasing. Which of the following datasets should the clinic consult to ensure that the all federally required data elements for Medicare and Medicaid outpatients are collected by the system? DEEDS EMEDS UACDS UHDDS

UACDS

A health record technician has been asked to review the discharge patient abstracting portion of a proposed new computer system. Which of the following datasets would the technician consult to ensure the system collects all the federally required data elements for discharged Medicare and Medicaid inpatients? DEEDS CARF UACDS UHDDS

UHDDS

The UB-04 or the CMB1450 form is based on which of the following data sets?

UHDDS

What does an audit trail check for? Unauthorized access to a system Loss of data Presence of a virus Successful completion of a backup

Unauthorized access to a system

In the annual budget, the supervisor or release of information supervisor estimated that receipts from copy fees would be $45,000. At the end of the fiscal year, the receipts to date were $40,000. Given this data which of the following would the supervisor be asked to explain? Favorable variance of $5,000 Unfavorable variance of $5,000 Favorable revenue of $40,000 Unfavorable revenue of $5,000

Unfavorable variance of $5,000

Which of the following numbering systems is best for maintaining the encounters of a patient together? Unit Serial-unit Serial Alphabetic

Unit

Which of the following would be categorized as a voluntary hospital? U.S. Air Force hospital University hospital Investor-owned hospital Proprietary hospital

University hospital

The HIM director is on the design team for the CPOE system. During a user interface design session a sample of the electronic system is demonstrated. Two of the physicians are concerned about the overuse of alerts that are unnecessary. What problem could this feature pose in the new system? Unnecessary alerts can lead to clinicians ignoring other important alerts. Alerts make order entry difficult. Physicians don't like to be reminded how to treat patients. Joint Commission discourages an alert system.

Unnecessary alerts can lead to clinicians ignoring other important alerts.

When correcting erroneous information in a health record, which of the following is NOT appropriate? Print "error" above the entry Enter the correction in chronological sequence Add the reason for the change Use black pen to obliterate the entry

Use black pen to obliterate the entry

Which of the following is a key characteristic of the POMR? Uses an itemized list of the patient's past and present medical problems Uses laboratory reports and other diagnostic tools to determine medical problems Allows all providers to document in the health record Provides electronic documentation in the health record

Uses an itemized list of the patient's past and present medical problems

Which of the following statements does not apply to systems thinking? Problems in patient care are usually symptoms of shortcomings that are part of a system or process. Systems thinking is a vital part of performance improvement. Variations in the way a system works are always caused by factors outside the system. Every system has inputs and outputs, and the processing of inputs eventually produces outputs.

Variations in the way a system works are always caused by factors outside the system.

Which of the following end users would normally use a management information system in their day-to-day work? Clerical staff Supervisors Admissions Staff Vice Presidents

Vice Presidents

Which of the following would NOT be found in a medical history? Chief complaint Vital signs Present illness Review of symptoms

Vital signs

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medicine unit within a two-week period. What clinical report would be the best source to gather this information? Admission record Initial nursing assessment record Physician progress notes Vital signs record

Vital signs record

With the decline of Medicaid reimbursements, the Happy Kids Pediatrics Clinic is struggling to keep up with the required technology to meet Meaningful Use Standards. In which category of SWOT does this case belong?

Weakness

Which of the following computer architectures would be best for implementing an EHR for a healthcare system that needs to transmit data to its various campuses that are located across a wide geographic area? Client/server Local area network Wide area network Wireless network

Wide area network

A laboratory employee forgot his user ID badge at home and uses another lab employee's badge to access the computer system. What controls should have been in place to minimize this security breach? Access controls Security incident procedures Security management process Workforce security awareness training

Workforce security awareness training

The following regulatory agency is not managed by the Department of Human and Health Services (DHHS)?

World Health Organization (WHO)

A universal language to aid storage and transmission of Web-based data is _____. XML HTML E1384 SQL

XML

Dr. Kamath is opening his office over the weekend to sponsor a health fair in an effort to attract additional patients. He offers free blood pressure screenings and basic physical exams. Is Dr. Kamath abiding by the federal anti-kickback laws?

Yes, because the patients he is offering free services to are obligated to become his new patients.

Donna and Joe Scott are going through a divorce. During this time, Joe Scott was involved in a car accident. When he was admitted to the hospital, he requested that his wife didn't visit him. Can the healthcare facility respect Joe's wishes?

Yes. Because Joe is the patient, he has the right to deny any visitors.

Sally Jensen is upset because when she requested her medical record from San Antonio Community Hospital Department of Health Information, she was asked to pay $20. According to HIPAA, is this fair?

Yes. HIPAA allows for healthcare organizations to charge a reasonable copy fee to offset the costs or printing.

Nancy Walsh presented with a family history of colon cancer. The gastroenterologist performed the colonoscopy. Which of the following procedure codes will be used for the surgeon services? <Insert table 10 T01>

Z12.11, 45378

An HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient records at the time of discharge, providing a 24-hour turnaround time. The hospital has an average daily discharge of 120 patients, and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time?

a. 100 hours

a. 82

Coding accuracy is best determined by: a. A predefined audit process b. Medicare Conditions of Participation c. Payer audits d. Joint Commission Standards for Accreditation

a. A predefined audit process

To use a data element for aggregation and reporting, that data element must be: a. Abstracted or indexed b. Searched c. Subject to case finding d. Registered

a. Abstracted or indexed

An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit controls c. Contingency controls d. Security incident controls

a. Access controls

The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments

a. Accusations of fraud and abuse

Which of the following is true regarding the development of health record destruction policies? a. All applicable laws must be considered b. The organization must find a way not to destroy any health records c. Health records involved in pending or ongoing litigation may be destroyed d. Only state laws must be considered

a. All applicable laws must be considered

How is the patient registration department assisted by the HIM department? a. Assigns the health record number b. Processes the healthcare claim c. Implements the information systems used by the HIM department d. Maintains the information systems used by the HIM department

a. Assigns the health record number

A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): a. Audit trail b. Facility access control c. Forensic scan d. Security management plan

a. Audit trail

Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: a. By the hospital b. By the patient c. By the attending and consulting physician d. Jointly by the hospital, physician, and patient

a. By the hospital

Clinical documentation improvement (CDI) programs use metrics to evaluate the effectiveness of their program. Which of the following is the most widely used key indicator for a CDI program? a. Case-mix index b. Severity of illness score c. Accounts receivable index d. Risk mortality score

a. Case-mix index

Continuing coding education is required for: a. Certified coders b. Inpatient coders c. All coders d. Inpatient and ambulatory surgery coders

a. Certified coders

A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter? a. Code skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist

a. Code skin lesion

What formatting problem is found in the following table? a. Column headings are missing b. Title of the table is missing c. Column totals are inaccurate d. Variable names are missing

a. Column headings are missing

An alternative to the retrospective coding model is the __________ coding model in which records are coded while the patient is still an inpatient. a. Concurrent b. Analytical c. Prospective d. Auxiliary

a. Concurrent

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations? a. Consultation b. Medical history c. Physical examination d. Progress notes

a. Consultation

A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis? a. Dehydration b. Chemotherapy c. Liver carcinoma d. Complication of chemotherapy

a. Dehydration

As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all the divisions within the HIM department. The following table shows sample productivity benchmarks for record analysis the director found through a literature search. Given this information, how should the director proceed in establishing benchmarks for the department? a. Determine whether the source of the benchmark data is from a comparable institution b. Use the low benchmark example as a beginning point for implementation c. Contact the hospital statistician to determine whether the data are relevant d. Use the average benchmark example as a beginning point for implementation

a. Determine whether the source of the benchmark data is from a comparable institution

What types of covered entity health records are subject to the HIPAA privacy regulations? a. Health records in any format b. Only health records in electronic format c. Only health records from hospitals d. Only health records in paper format

a. Health records in any format

A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of: a. Healthcare fraud b. Payment optimization c. Payment reduction d. Healthcare creativity

a. Healthcare fraud

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: a. Healthcare fraud b. Optimization c. Upcoding d. Healthcare abuse

a. Healthcare fraud

Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. Identification of the record as the one subpoenaed b. The care provided to the patient c. The qualifications of the treating physician d. Identification of the standard of care used to treat the patient

a. Identification of the record as the one subpoenaed

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 seven employees from the analysis, transcription, release of information, 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? a. Insufficient knowledge of team members b. Too many team members c. Unspecific team charge d. Too few team members

a. Insufficient knowledge of team members

Which of the following is the first step in analyzing data? a. Knowing your objectives or purpose of the data analysis b. Starting with basic types of data analysis and work up to more sophisticated analysis c. Utilizing a statistician to analyze the data d. Presenting your findings to administration

a. Knowing your objectives or purpose of the data analysis

The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration

a. Laboratory

Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: a. Legitimate need for access b. Password to access the EHR c. Report development program d. Signed confidentiality agreement

a. Legitimate need for access

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways? a. Makes it lower than warranted by the actual service and resource intensity of the facility b. Makes it higher than warranted by the actual service and resource intensity of the facility c. Hospital's MS-DRG case mix is never monitored so there is no impact d. Coding has nothing to do with a hospital's MS-DRG case mix

a. Makes it lower than warranted by the actual service and resource intensity of the facility

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 department records without a written authorization from the patient. Was this action in compliance? a. No; the records are needed for continued care of the patient, so no authorization is required b. Yes; the release of all records requires written authorization from the patient c. No; permission of the ER physician was not obtained d. Yes; one covered entity cannot request the records from another covered entity

a. No; the records are needed for continued care of the patient, so no authorization is required

A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. b. Yes; this is hospital policy for which HIPAA has no control. c. No; the records from the previous hospital are not included in the designated record set but should be released anyway. d. Yes; HIPAA only requires that current records be produced for the patient.

a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to 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? a. Notice of privacy practices is required on the first provision of service. b. Notice of privacy practices is required every time the patient is provided service. c. Notice of privacy practices is only required for inpatient admissions. d. Notice of privacy practices is required on the first inpatient admission but for every outpatient encounter.

a. Notice of privacy practices is required on the first provision of service.

Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching? a. Obliterating or deleting errors b. Leaving existing entries intact c. Labeling late entries as being late d. Ensuring the legal signature of an individual making a correction accompanies the correction

a. Obliterating or deleting errors

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? a. Operative and other invasive procedures, medication management, and blood and blood product use b. Blood and blood product use, medication management, and appointment to the board of directors c. Medication management, marketing strategy, and blood use d. Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use

a. Operative and other invasive procedures, medication management, and blood and blood product use

Which of the following best represents the definition of the term data? a. Patient's laboratory value is 50. b. Patient's SGOT is higher than 50 and outside of normal limits. c. Patient's resting heartbeat is 70, which is within normal range. d. Patient's laboratory value is consistent with liver disease.

a. Patient's laboratory value is 50.

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically

a. Provide the records in paper format only

The clinical forms committee: a. Provides oversight for the development, review, and control of forms and computer screens b. Is responsible for the EHR implementation and maintenance c. Is always a subcommittee of the quality improvement committee d. Is an optional function for the HIM department

a. Provides oversight for the development, review, and control of forms and computer screens

What factor is medical necessity based on? a. The beneficial effects of a service for the patient's physical needs and quality of life b. The cost of a service compared with the beneficial effects on the patient's health c. The availability of a service at the facility d. The reimbursement available for a given service

a. The beneficial effects of a service for the patient's physical needs and quality of life

An employee views a patient's electronic health record. It is a trigger event if: a. The employee and patient have the same last name b. The patient was admitted through the emergency department c. The patient is over 89 years old d. A dietitian views a patient's nutrition care plan

a. The employee and patient have the same last name

Which of the following definitions best describes the concept of confidentiality? a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The right of individuals to control access to their personal health information d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer

a. The template was defined

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? a. Training will provide $146,000 savings in help desk support and can be justified. b. The results of training will provide $365,000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.

a. Training will provide $146,000 savings in help desk support and can be justified. Current cost: $50 × 40 calls per day = $2,000 per day × 365 days = $730,000. Cost with reduced number of help desk calls: $50 × (40 × 0.80) calls per day = $1,600 per day × 365 days = $584,000, or a savings of $146,000. Training costs of $100,000 will be recouped and a savings of $46,000 realized (Gordon and Gordon 2016b, 548).

Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following? a. Validity of hospital diagnosis and procedure coding data completeness b. Appropriateness of EHR used c. Policies, procedures and standards of conduct d. Professional standards

a. Validity of hospital diagnosis and procedure coding data completeness

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record

a. Vital signs record

Recently, a local professional athlete was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine: a. Whether access by employees is appropriate b. If the patient is satisfied with their stay c. If it is necessary to order prescriptions for the patient d. Whether the care to the patient meets quality standards

a. Whether access by employees is appropriate

The primary goals of __________ are to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. a. the National Health Information Network b. the National Committee on Vital and Health Statistics c. Health Level Seven (HL7) International d. the EHR Collaborative

a. the National Health Information Network

The traditional approach to assuring quality was to view quality as the _____. execution of an activity absence of defects absence of corrective action application of interpersonal skills

absence of defects

In Dr. Patel's pediatric practice, every returning patient office visit is coded to 99214, regardless of the medical decision-making, patient history, or problem complexity. Dr. Patel's medical coding practices are an example of:

abuse.

An EHR system can provide better security than a paper record for protected health information system due to _____. handling by fewer clinical practitioners access controls, audit trails, and authentication systems easier data entry safer storage

access controls, audit trails, and authentication systems

What is the name of the team of healthcare providers that work together to coordinate and improve care for Medicare patients?

accountable care organizations

The goal of coding compliance programs is to prevent _____. accusations of fraud and abuse delays in claims processing billing errors inaccurate code assignments

accusations of fraud and abuse

When Sheila Ramos underwent surgery for the first time, she had a bad reaction to anesthesia. This is known as a(n):

adverse event.

Data that are collected on large populations of individuals and stored in databases are referred to as _____. statistics information aggregate data standard

aggregate data

The primary purpose of the Continuity of Care Record (CCR) is to _____. provide a platform for personal health record development communicate with payers to facilitate reimbursement allow healthcare providers to readily access information about a patient's healthcare at any point in time enhance the quality of coding

allow healthcare providers to readily access information about a patient's healthcare at any point in time

Grievance procedures _____. do not concern the supervisor vary with each individual are defined in the union contract are the same in every work setting

are defined in the union contract

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital? a. $40,300 b. $39,375 c. $26,250 d. $13,125

b. $39,375

A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure? a. 0QB60ZZ b. 0Q860ZZ c. 0SB90ZZ d. 0SN90ZZ

b. 0Q860ZZ The Section is Medical and Surgical—character 0; Body System is Lower Bones—character Q; Root Operation is Division—character 8; Body Part is Femur, Right—character 6; Approach is Open—character 0; No Device—character Z; and No Qualifier —character Z

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2? a. 240 b. 242 c. 280 d. 320

b. 242

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? a. 30 b. 31.5 c. 32 d. 35

b. 31.5

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? a. 49320, 58662 b. 58670 c. 58671 d. 49320

b. 58670

Which of the following individuals may authorize release of health information? a. An 86-year-old patient with a diagnosis of advanced dementia b. A married 15-year-old father c. A 15-year-old minor d. The parents of an 18-year-old student

b. A married 15-year-old father

Which of the following situations is considered a breach of PHI? a. A nurse views the record of a patient that she is not caring for b. A patient's attorney is sent records not authorized by that patient c. A nurse starts to place PHI in a public area where a patient is standing and immediately picks it up d. An HIM employee keys in the incorrect health record number but closes it out as soon as it is realized

b. A patient's attorney is sent records not authorized by that patient

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 with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare: a. The full DRG amount, and Big Medical Center will receive a per diem rate for the three-day stay b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment c. The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the three-day stay d. No payment; Community Hospital must bill Big Medical Center a per diem rate for the twoday stay

b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment

In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis and complaints b. Chargemaster description c. Clinical laboratory results d. Radiology orders

b. Chargemaster description

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Call the Joint Commission and notify them of non-compliant physicians b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices c. Post the hospital policy in the emergency department d. Routinely send out a fourth notice to remind each physician of his or her documentation obligations

b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices

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? a. Benchmark b. Dashboards c. Pareto chart d. Time ladder

b. Dashboards

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: a. Data comprehensiveness b. Data consistency c. Data currency d. Data granularity

b. Data consistency

When data has been lost in an EHR, which action is taken to remedy this problem? a. Build a firewall b. Data recovery c. Review the audit trail d. Develop data integrity plan

b. Data recovery

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record

b. Delinquent record

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? a. Alert the Joint Commission that the hospital has not met its quality goal b. Determine whether there was a medical or other reason why patients were not given aspirin c. Institute an in-service training program for clinical staff on the importance of administering aspirin within 24 hours d. Determine which physicians did not order aspirin

b. Determine whether there was a medical or other reason why patients were not given aspirin

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records c. Perform a quality check on all health record systems in the practice d. Develop a listing and categorize all information requests for health information over the past two years

b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records

Which of the following practices is an appropriate coding compliance activity? a. Reviewing all accurately paid claims b. Developing procedures for identifying coding errors c. Providing a financial incentive for coding claims improperly d. Instructing coders to code diagnoses and submit the bill before all applicable information is documented in the health record

b. Developing procedures for identifying coding errors

In designing an input screen for an EHR, which of the following would be best to capture structured data? a. Speech recognition b. Drop-down menus c. Natural language processing d. Document imaging

b. Drop-down menus

Patient care managers use the data documented in the health record to: a. Determine the extent and effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care

b. Evaluate patterns and trends of patient care

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? a. Destruction b. Extirpation c. Extraction d. Fragmentation

b. Extirpation

The HIM improvement team wants to identify the causes of poor documentation compliance in the health record. Which of the following tools would best aid the team in identifying the root cause of the problem? a. Flowchart b. Fishbone diagram c. Pareto chart d. Scatter diagram

b. Fishbone diagram

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit

b. Focused audit

A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to get their input d. Contact CMS to determine what data sets are required to be collected

b. Identify data content requirements for all areas of the organization

Which of the following statements is true regarding HIPAA security? a. All institutions must implement the same security measures. b. Institutions are allowed flexibility in the way they implement HIPAA standards. c. All institutions must implement all HIPAA specifications. d. A security risk assessment must be performed every year.

b. Institutions are allowed flexibility in the way they implement HIPAA standards.

Which of the following is considered the authoritative resource in locating a health record? a. Disease index b. Master patient index c. Patient directory d. Patient registry

b. Master patient index

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family conditions? a. Problem list b. Medical history c. Physical examination d. Clinical observation

b. Medical history

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits

b. Medical necessity

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Minimum data set for long-term care b. Outcomes and Assessment Information Set c. Patient assessment instrument d. Resident assessment protocol

b. Outcomes and Assessment Information Set

An HIM technician was alerted by registration that the system has a record for John Smith with two different birthdates. After an investigation the technician determined the documentation was for two different patients, both named John Smith, who have the same health record number in the EHR. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge

b. Overlay

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: a. Normal delivery b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa

Sometimes data do not follow a normal distribution and are pulled toward the tails of the curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it is called a __________. a. Negatively skewed distribution b. Positively skewed distribution c. Bimodal distribution d. Normal distribution

b. Positively skewed distribution

A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is: a. K21.9, Gastro-esophageal reflux disease without esophagitis b. R07.9, Chest pain, unspecified c. R10.11, Right upper quadrant pain d. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out

b. R07.9, Chest pain, unspecified

The Department of Health and Human Services has identified that Community Hospital is guilty of fraud. It was determined that the facility tried to comply with standards, but their efforts failed. What category of fraud and abuse prevention does this fall into? a. Reasonable cause b. Reasonable diligence c. Willful neglect d. Willful defiance

b. Reasonable diligence

Which of the following is true about health information retention? a. Retention depends only on accreditation requirements b. Retention periods differ among healthcare facilities c. The operational needs of a healthcare facility cannot be considered d. Retention periods are frequently shorter for health information about minors

b. Retention periods differ among healthcare facilities

To comply with the Joint Commission standards, the HIM director wants to ensure the 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? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to ensure the history and physicals are present c. Retrospectively review each patient's health record to ensure the history and physicals are present d. Write a memorandum to all physicians relating the Joint Commission requirements for documenting history and physical examinations

b. Review each patient's health record concurrently to ensure the history and physicals are present

Which tool is used to display performance data over time? a. Status process control chart b. Run chart c. Benchmark d. Time ladder

b. Run chart

Which of the following is true regarding the reporting of communicable diseases? a. They must be reported by the patient to the health department. b. The diseases to be reported are established by state law. c. The diseases to be reported are established by HIPAA. d. They are never reported because it would violate the patient's privacy.

b. The diseases to be reported are established by state law.

Which of the following is a true statement about the content of the legal health record? a. The legal health record contains only clinical data b. The legal health record may contain metadata c. The legal health record should not include e-mail d. The legal health record should not include diagnostic images

b. The legal health record may contain metadata

Which of the following is a positive aspect of using employee self-appraisal as a source of data for performance appraisal? a. Employees are in the best position to provide objective review without overstatement b. The supervisor is kept informed of the employee's accomplishments c. Appraiser and employee training on the purpose and procedures of this process is essential d. Peer pressure of evaluation can motivate team members to be more productive

b. The supervisor is kept informed of the employee's accomplishments

Each healthcare organization must identify and prioritize which processes and outcomes (in other words, which types of data) are important to monitor. This data collection should be based on the scope of care and services they provide and: a. The number of employees they employ b. Their mission c. The QI methodology used d. Their accreditation status

b. Their mission

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 the clinic's practice of 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 the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. 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. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced

b. 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.

Copies of personal health records (PHRs) are considered part of the legal health record when: a. Consulted by the provider to gain information on a consumer's health history b. Used by the organization to provide treatment c. Used by the provider to obtain information on a consumer's prescription history d. Used by the organization to determine a consumer's DNR status

b. Used by the organization to provide treatment

Comparing automobile-related deaths between five different states can be best presented by:

bar graphs.

The study and application of health informatics includes all of the following except:

barcode scanners.

The Joint Commission voluntary accreditation is required to:

be a participating facility for Medicare and Medicaid.

A local hospital has been awarded for highest-quality healthcare delivery. Your hospital is a similar size, and you would like to implement some of the same standards to reach the same levels of quality. This process is known as:

benchmarking.

The hospital acquired infection rate for San Antonio Community hospital is 0.24%, whereas the same rate for Riverside Community Hospital is 0.33%. This comparison is an example of:

benchmarking.

The level of management that develops strategic goals for the healthcare facility is the:

board of governors.

A structured decision is made _____. without using a prescribed method by following a formula or step-by-step process by executive officers of the company by consultants

by following a formula or step-by-step process

Hospital physical documents relating to the delivery of patient care such as medical records, x-rays, laboratory reports, and consultation reports are owned: by the hospital by the patient by the attending and consulting physician jointly by the hospital, physician, and patient

by the hospital

How many identifiers must be removed for a data to be considered de-identified under the Safe Harbor Method? a. 12 b. 15 c. 18 d. 20

c. 18

Based on this output table, what is the average coding test score for the beginner coder? a. 93 b. 6.4 c. 73 d. 90

c. 73

c. 76 pages Productivity standards should be based on both accuracy and volume. In this situation, 114 / 0.60 = 190; 190 − 114 = 76 more pages will need to be indexed to meet the productivity standard (Kelly and Greenstone 2016, 161).

Data elements collected on large populations of individuals and stored in databases are referred to as: a. Statistics b. Information c. Aggregate data d. Standard

c. Aggregate data

Community Hospital wants to compare its hospital-acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. Of these individuals, 200,000 were admitted with a principal diagnosis of UTI; another 300,000 were admitted with a principal diagnosis of infectious disease, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital? a. All individuals in the MEDPAR database b. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease d. All individuals in the MEDPAR database except those admitted with a diagnosis of hypertension

c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease

The organization that employs you just concluded an investigation of a laptop computer that was lost and contained a file with the information of 765 patients on it, including names, addresses, telephone numbers, and social security numbers. As the privacy officer, you are required to manage the notification process for the data breach. All of the following would need to be notified of this data breach within 60 days of the discovery except: a. Individual patients b. Local media c. Attending physicians of the patients d. Department of Health and Human Services

c. Attending physicians of the patients

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses would be reported as POA? a. Catheter-associated urinary tract infection, COPD, Hypertension b. Cerebral vascular accident, COPD, Catheter-associated urinary tract infection c. Cerebral vascular accident, COPD, Hypertension d. Hypertension, Catheter-associated urinary tract infection, Cerebral vascular accident

c. Cerebral vascular accident, COPD, Hypertension

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? a. Minimum Data Set b. National Commission on Correctional Health Care Valley High, a skilled nursing facility, wants to become certified to c. Conditions of Participation d. Outcomes and Assessment Information Set

c. Conditions of Participation

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? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set

c. Conditions of Participation

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Determine that a formal letter of termination meets HIPAA requirements and no further action is required b. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned d. Inform the CFO that business associate agreements cannot be terminated

c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned

For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it: a. Contains only Medicare data b. Is used to determine pay for performance c. Contains data on all payer types d. Contains bibliographic listings from medical journals

c. Contains data on all payer types

Which of the following is a risk of copy and pasting documentation in the electronic health record? a. Reduction in the time required to document b. System may not save data c. Copying the note in the wrong patient's record d. System thinking that the information belongs to the patient from whom the content is being copied

c. Copying the note in the wrong patient's record

When performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis and procedure codes specifically for the purpose of obtaining a higher level of reimbursement. The coder believes that this practice helps the hospital increase its revenue. Which of the following should be done in this case? a. Compliment the coder for taking initiative in helping the hospital b. Report the coder to the FBI for coding fraud c. Counsel the coder and stop the practice immediately d. Provide the coder with incentive pay for her actions

c. Counsel the coder and stop the practice immediately

When coding a benign neoplasm of skin of the left upper eyelid, which of the following codes should be used? a. D23.12 b. D17.0 c. D23.121 d. D23.122

c. D23.121

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? a. Reprimand the employee b. Terminate the employee c. Determine what information was printed and why d. Revoke the employee's access privileges

c. Determine what information was printed and why

The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management

c. Federal and state confidentiality laws

What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? a. Risk management analysis b. Qualitative analysis c. Gap analysis d. Document management analysis

c. Gap analysis

Which of the following is a function of the outpatient code editor? a. Validate the patient's age on a claim b. Validate the patient's encounter number c. Identify unbundling of codes d. Identify cases that don't meet medical necessity

c. Identify unbundling of codes

The accounts not selected for the billing report is a daily report used to track accounts that are: a. Awaiting payment in accounts receivable b. Paid at different rates c. In bill hold or in error and awaiting billing d. Pulled for quality review

c. In bill hold or in error and awaiting billing

Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request d. It includes a patient's personal health record

c. It is the record disclosed upon request

Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located. a. Accreditation b. Certification c. Licensure d. Permission

c. Licensure

Which of the following is an example of a physical safeguard that should be provided for in a data security program? a. Using password protection b. Prohibiting the sharing of passwords c. Locking computer rooms d. Annual employee training

c. Locking computer rooms

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? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports

c. Medication administration record and clinical laboratory reports

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? a. Regional health information organizations b. Corporate compliance plans c. OIG workplans d. Federal register

c. OIG workplans

The risk manager's principal tool for capturing the facts about potentially compensable events is the: a. Accident report b. RM report c. Occurrence report d. Event report

c. Occurrence report

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? a. PHI related to treatment, payment, and operations b. PHI provided to meet national security or intelligence requirements c. PHI sent to a physician who has not treated Sally d. PHI released to Sally's attorney upon her request

c. PHI sent to a physician who has not treated Sally

Which of the following is the approved method for implementing an organization's formal position? a. Hierarchy chart b. Organizational chart c. Policy and procedure d. Mission statement

c. Policy and procedure

The utilization manager's role is essential to: a. Analyze the estimate of benefits (EOBs) received b. Capture all relevant charges for the patient's account c. Prevent denials for inappropriate levels of service d. Verify the patient has insurance

c. Prevent denials for inappropriate levels of service

The first step in an inpatient record review is to verify correct assignment of the: a. Record sample b. Coding procedures c. Principal diagnosis d. MS-DRG

c. Principal diagnosis

The right of an individual to keep personal health information from being disclosed to anyone is a definition of: a. Confidentiality b. Integrity c. Privacy d. Security

c. Privacy

Which policy ensures that the minimum penalty appropriate to the level of employee offense is applied? a. Employment at will b. Downsizing c. Progressive penalties d. Discipline without punishment

c. Progressive penalties

Carolyn works as an inpatient coder in a hospital HIM department. She views a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? a. Assign a code for the staph infection b. Put a note in the chart c. Query the physician d. Tell her supervisor

c. Query the physician

A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? a. Review the subpoena to determine what documents must be produced b. Review the subpoena and notify the hospital administrator c. Review the subpoena and appear at the time and place supplied to give testimony d. Review the subpoena and alert the hospital's risk management department

c. Review the subpoena and appear at the time and place supplied to give testimony

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? a. Drop-down menus b. Point and click fields c. Speech recognition d. Structured templates

c. Speech recognition

Which of the following is a secondary purpose of the health record? a. Support for provider reimbursement b. Support for patient self-management activities c. Support for research d. Support for patient care delivery

c. Support for research

When a staff member 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? a. There is no impact. b. The person making the entry in the health record may not be called as a witness in trial. c. The incident report likely becomes discoverable because it is mentioned in a discoverable document. d. The incident report cannot be discovered even though it is mentioned in a discoverable document.

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

An external security threat can be caused by which of the following? a. Employees who steal data during work hours b. A facility's water pipes bursting c. Tornadoes d. The failure of a facility's software

c. Tornadoes

The objective of the National Cancer Registrars Association (NCRA) is to:

capture a complete patient health history and health status for cancer patients.

Dr. Williams wants to update his service charges for 20XX. He can find the current list of service charges for his practice from the:

chargemaster.

All of the following represents the purpose of the planning management function except:

classifying and dividing work into separate units.

According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a _____. proctosigmoidoscopy sigmoidoscopy colonoscopy protoscopy

colonoscopy

The utilization management process in which patient records are reviewed after discharge to ensure appropriate care was delivered is known as:

concurrent.

The quality of healthcare services is regulated by state health department regulations and:

conditions of participation.

When patients share their collected health information with the her, it is called:

consumer-mediated exchange.

All of the following are idea-generating techniques except:

continuous process improvement.

The significance of accurate data and collection, vision and support of executive leadership, and the value of teamwork are all part of the six essential principles of:

continuous quality improvement.

The one aspect of managed care that has had the greatest impact on healthcare organizations during the past 25 years is _____. quality control cost control risk management utilization management

cost control

Elena works as a charge nurse on the med-surg ward of the Corona Regional Hospital. According to HITECH classifications, Elena is a:

covered entity.

From the information provided in this table below, what percentage will the facility be paid for procedure 25500? a. 0% b. 50% c. 75% d. 100%

d. 100% Procedure 25500 has a "T" status indicator, which indicates that it is a significant procedure and multiple procedure reductions will apply. In this case, there is only one CPT procedure code that is a status "T" indicator, so 100 percent of the fee-based APC will be paid (Casto 2018, 159-160).

The RHIT supervisor for the scanning and quality control 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 scanning records is 50 records per hour. The standard for quality control of scanning of records is 40 records per hour. Given these standards, how many productive hours will be required daily to scan and quality control records for each clinic day? a. 10 hours per day b. 11.11 hours per day c. 12.5 hours per day d. 22.5 hours per day

d. 22.5 hours per day

Based on a productivity log, a coder completed 23 charts during a 7.5-hour workday. The performance standard is 4 charts per hour. How many charts did he code per hour? Round to the nearest whole number. a. 2.06 b. 4.1 c. 23 d. 3

d. 3

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? a. 36578 b. 36580 c. 36582, 36597 d. 36582

d. 36582

Community Hospital's HIM department conducted a random sample of 200 inpatient health records to determine the timeliness of the history and physicals completion. Nine records were found to be out of compliance with the 24-hour requirement. Which of the following percentages represents the H&P timeliness rate at Community Hospital? a. 4.5% b. 21.2% c. 66.7% d. 95.5%

d. 95.5%

Which of the following is an example of how an internal user utilizes secondary data? a. State infectious disease reporting b. Birth certificates c. Death certificates d. Benchmarking with other facilities

d. Benchmarking with other facilities

After the types of cases to be included in a cancer registry have been determined, what is the next step in data acquisition? a. Case registration b. Case definition c. Case abstracting d. Case finding

d. Case finding

The national patient safety goals score organizations on areas that: a. Affect the financial stability of the organization b. Commonly lead to overpayment c. Affect compliance with state law d. Commonly lead to patient injury

d. Commonly lead to patient injury

An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: a. American Health Information Management Association b. American Medical Association c. Centers for Medicare and Medicaid Services d. Cooperating Parties

d. Cooperating Parties

What should be done when the HIM department's chart analysis error rate is too high, or its accuracy rate is too low based on policy? a. Re-audit the problem area b. The problem should be treated as an isolated incident c. The formula for determining the rate may need to be adjusted d. Corrective action should be taken to meet the department standards

d. Corrective action should be taken to meet the department standards

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. This process creates a: a. Data chargemaster report b. Data dictionary c. Database management system d. Data map

d. Data map

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? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system

d. Database management system

What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived

d. Derived

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? a. BC/BS b. Commercial c. TRICARE d. Medicare

d. Medicare

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? a. Two CPT codes, one for each laceration b. One CPT code for the largest laceration c. One CPT code for the most complex closure d. One CPT code, adding the lengths of the lacerations together

d. One CPT code, adding the lengths of the lacerations together

If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient: a. For the balance due after Medicare has paid b. Only if both Medicare and any supplemental insurance have been billed and settled c. Never—providers may not bill Medicare patients for amounts unpaid by Medicare d. Only if a properly executed ABN was obtained before the service was provided

d. Only if a properly executed ABN was obtained before the service was provided

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? a. Serial work division b. Job sharing c. Job rotation d. Parallel work division

d. Parallel work division

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? a. Wait until Susan is 18 years old b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed

d. Present an authorization that at least one of them (Ted or Mary) has signed

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance. a. Procedures 1, 4 b. Procedures 2, 3, 5 c. Procedures 6, 7 d. Procedures 1, 4, 6, 7

d. Procedures 1, 4, 6, 7

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. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations? a. Provide copies of the records within 15 days b. Provide copies of the records within 30 days c. Provide copies of the records within 45 days d. Provide copies of the records within 60 days

d. Provide copies of the records within 60 days

The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following? a. Reporting of claims, initiating an investigation of claims, protecting the primary and secondary health records, negotiating settlements, managing litigations, and using information for claim's resolution in performance management activities b. Risk acceptance, risk avoidance, risk reduction or minimization, and risk transfer c. Safety management, security management, claims management, technology management, and facilities management d. Risk identification and analysis, loss prevention and reduction, and claims management

d. Risk identification and analysis, loss prevention and reduction, and claims management

How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met

d. To determine whether standards of care are being met

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (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? a. CARF b. DEEDS c. UACDS d. UHDDS

d. UHDDS

Which of the following is true about a primary key in a database table? a. Usually is not a unique number b. Changes in value c. Is dependent on the data in the table d. Uniquely identifies each row in a table

d. Uniquely identifies each row in a table

Which of the following is a key characteristic of the problem-oriented health record? a. Allows all providers to document in the health record b. Uses laboratory reports and other diagnostic tools to determine health problems c. Provides electronic documentation in the health record d. Uses an itemized list of the patient's past and present health problems

d. Uses an itemized list of the patient's past and present health problems

When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following? a. Performance measurement b. Workforce planning c. Work observation study d. Variance analysis

d. Variance analysis

Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: a. Content and structure standards b. Security standard c. Transaction standards d. Vocabulary standards

d. Vocabulary standards

As part of your job responsibilities, you are responsible for reviewing audit trails of access to patient information. The following are all types of activities that you would monitor except: a. Every access to every data element or document type b. Whether the person viewed, created, updated, or deleted the information c. Physical location on the network where the access occurred d. Whether the patient setup an account in the patient portal

d. Whether the patient setup an account in the patient portal

Ms. Smith's date of birth is recorded as 3/25/1948 in her admission data and populated electronically throughout her electronic record. An audit of the electronic health record system discovers that the numbers in the date of birth are transposed in different health record reports. This situation reflects a problem in _____. data comprehensiveness data consistency data currency data granularity

data consistency

In a database the LAST_NAME column in a table would be considered a _______. data element record primary key row

data element

The admissions intake form asked patients if their health insurance plan was sponsored by someone else and, if so, to provide the sponsor's date of birth. For the month of June 20XX, out of the 320 admissions who were sponsored by someone else, only 43% provided their sponsor's date of birth. This is an example of poor:

data exchange.

The process of identifying common elements in two or more data sets is known as:

data mapping.

A hospital's electronic health system defines the expected values of the data element "gender" as female, male, and unknown. This type of specificity is known as _____. data comprehensiveness data consistency data granularity data precision

data precision

Which of the following is defined as an organized collection of data? information database DBMS spreadsheet

database

An information system that alerts a physician when a laboratory value is outside of the normal range is called a(n) _____. decision support system enterprise-wide system management information system transaction processing system

decision support system

When a hospital accredited by the Joint Commission is considered to be in compliance with Medicare's Conditions of Participation, this is called _____. adjuvant accreditation deemed status conditional accreditation dual accreditation

deemed status

Setting a clear deadline is an important step in _____. budgeting delegation strategic planning schedule development

delegation

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _____. suspended record delinquent record pending record illegal record

delinquent record

The phase of the Systems Development Life Cycle that answer the "how" questions is:

design.

A new thermometer cover is used for each patient encounter. The costs for these covers are considered __________ because they are included for every patient.

direct costs

The objective of the Office of the National Coordinator (ONC) is to:

encourage all healthcare facilities to implement information systems.

The goal of Patient-Centered Outcomes Research Organization (PCORI) is to:

ensure patients feel engaged and informed through all stages of healthcare delivery.

The primary goal of the American Hospital Association (AHA) is to:

ensure that patients have appropriate access to quality hospital care.

Due to extreme flooding in third-world countries, a larger than usual number of cases of cholera appear in the geographical area. This is an example of:

epidemic.

The study of disease and determinants of disease is known as:

epidemiology.

On the announcement board, the Director of Health Information lists five professional behaviors that all HIM department employees should maintain when speaking to a patient. Which of the seven AHIMA Code of Ethics purposes would this represent?

establish a framework for professional behavior and responsibilities when professional obligations conflict or ethical uncertainties arise

The first and most fundamental strategy for minimizing security threats is to _____. establish access controls implement an employee security awareness program establish a security organization conduct a risk analysis

establish a security organization

The American Medical Association (AMA) is a regulatory agency that is involved in all of the following except:

establishing documentation standards to ensure quality care is delivered.

The primary goal of Joint Commission standards is to:

evaluate and promote the quality of care delivered.

Patient care managers use the data documented in the health record to: evaluate the performance of individual patient care providers communicate vital information among departments and across disciplines and settings generate patient bills and/or third-party payer claims for reimbursement determine the extent and effects of occupational hazards

evaluate the performance of individual patient care providers

The cost of labor needed to deliver care to patients is categorized as:

expense

Aetna denied the physician's claim. The medical biller can find the reason for the denial in the:

explanation of benefits.

The release of information function requires the HIM professional to have knowledge of _____. clinical coding principals database development federal and state confidentiality laws human resource management

federal and state confidentiality laws

Monitoring ongoing revenues and expenses and verifying actual expenses are important steps in _____. the hiring process personnel management financial control leadership

financial control

The strategic project management team is discussing priority projects for the next fiscal year. All of the hospital departments submitted two project they would like implemented, and the project management team needs to determine the top five within their budget constraints. All of the suggestions from the different departments were put on the board, and the project management team members were assigned to rank each one. The project team will then calculate the ranks and determine the highest-priority projects. This is an example of:

fishbone diagram.

A major employee benefit of a flexible benefit account is:

funds are set aside for healthcare purposes on a pretax basis.

Dana Hansen is participating in a prospective study on sickle cell disease. This means Dana:

has the risk factor for the disease, but the disease has not manifested.

In the following figure, the _____.graph59 higher the age of the patient, the higher the diastolic pressure lower the diastolic pressure, the higher the age of the patient lower the age of the patient, the higher the diastolic pressure higher the diastolic pressure, the lower the age of the patient

higher the age of the patient, the higher the diastolic pressure

Within an organization, it is the supervisor's role to determine _____. how staff will be organized strategic priorities the overall budget assumptions how the work will be accomplished by the team

how the work will be accomplished by the team

The National Provider Identifier (NPI):

identifies the types of healthcare specialty that Medicare approves for a provider.

Items such as buildings, equipment, furniture, and computers are generally _____. considered revenue part of the operating budget included in the capital budget not budgeted

included in the capital budget

All of the following are benefits of business process redesign and re-engineering except:

increased costs of production.

The practice of management is _____. not affected by new technologies the same all over the world the same as it was 50 years ago influenced by the context of the organization

influenced by the context of the organization

The paper-based health record format that organizes all forms in chronological order is known as a(n) _____. problem-oriented health record integrated health record patient-oriented health record source-oriented health record

integrated health record

The three elements of a security program are ensuring data availability, protection, and _____. suitability integrity flexibility robustness

integrity

A disgruntled worker accessed hundreds of patient records without authorization. This is an example of a(n):

intentional breach.

Sandra is an RN who works for Parkview Community Hospital. She received notice a few months ago that she needs to recertify for her license, so she needs to complete some continuing education units. Sandra doesn't have time to complete this, so her license expires. Parkview Community Hospital finds out that Sandra's nursing license expired and suspends her. and it is now short staffed. This is an example of:

internal force.

An example of data collected by the Joint Commission for the ORYX initiatives is _____. intrahospital mortality data financial data health plan performance data patient demographic data

intrahospital mortality data

Systems thinking _____. is an objective way of looking at ideas and processes is outdated and no longer applied in management involves planning for computers and technology can only be effectively applied to the budget process

is an objective way of looking at ideas and processes

An organization's budget ______. is the financial plan for the coming time period. always begins January 1. is prepared every six months. usually is completed by the finance department.

is the financial plan for the coming time period.

An organization's mission statement _____. is updated regularly as part of the strategic planning process never changes as it describes what the organization does is the same for every healthcare facility does not contain information about the organization's customers

is updated regularly as part of the strategic planning process

The discharge record for a long-term care facility should be labeled with all of the following information except: last date of physician consultation. date of admission. discharge date. patient date of service.

last date of physician consultation.

Strengthening others by sharing information and power is a characteristic of _____. supervision management the organizational chart leadership

leadership

Before healthcare organizations can provide services, they usually must obtain _____ by government entities such as the state or county in which they are located. accreditation certification licensure permission

licensure

The Joyful Mother Obstetrics Group would like to implement advanced technologies into its practice, including a 4D ultrasound machine. It does not want to have the lease payment every month, so the group made it a goal to purchase the new machine in four years. This is an example of a __________ goal.

long-term

Data analysis is the method used to:

measure quality and effectiveness of healthcare delivery.

Internal promotion is best used to _____. motivate current employees to do a good job and learn new skills save money on advertising ensure that there is not too much change in the department fill positions quickly

motivate current employees to do a good job and learn new skills

Henry works at the Betty Ford Center, a rehabilitation facility that is famous for treating a variety of celebrities. Henry was working when a famous actress was admitted, but she is not Henry's patient. Henry should not access the actress' medical records on the principle of:

need-to-know principle.

The supervisor of the document scanning function needs to prepare a budget for the next fiscal year. Which of the following would the supervisor suggest for the capital budget? salaries of employees new scanning equipment paper supplies professional meeting dues

new scanning equipment

Nancy is working about 50 hours a week, is paid hourly, and gets paid time and a half for overtime. This must mean that she is a(n):

nonexempt employee.

The success of organizational efforts at change depends on the _____. organization's culture of shared vision, responsibility, and accountability chief executive officer's ability to get the administrative and clinical staff's buy-in for the change employee's immediate acceptance of the need for change traditional leadership skills of the organization's governing board

organization's culture of shared vision, responsibility, and accountability

A valid consent for release of information form collects all of the following data elements except the:

patient's marital status.

Tom is a respiratory therapist on staff at Parkview Community Hospital. He works about 20 hours per week, except when the patient census drops below 200 patients. At that point he is not scheduled. Tom must be a(n):

per-diem employee.

AHIMA's retention standards recommend that the master patient index be maintained _____. for at least 5 years for at least 10 years for at least 25 years permanently

permanently

An individual who brings a lawsuit is called the _____. defendant plaintiff arbitrator complainant

plaintiff

The phase of the Systems Development Life Cycle that answer the "what" questions is:

planning.

The physician monitored Stacey's fluid input and output over several days to ensure she was hydrated. The use of the collected data is an example of: primary data. secondary data. research data. clinical data.

primary data.

An individual's right to control access to his or her personal information is known as _____. security confidentiality privacy access control

privacy

Lisa, the head of the Department of Health Information, wants to reduce the time it takes to intake emergency room patients by opening an admissions clerk in the department. This is an example of:

process improvement.

A software interface is a _____. device to enter data protocol for describing data program to exchange data standard vocabulary

program to exchange data

The primary function of the American Health Information Management Association is to _____. ensure that accurate and complete medical records are written for every hospital patient standardize the content and format of the health records maintained by acute and emergency care facilities promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting provide support for two- and four-year health information management educational programs

promote the accuracy, confidentiality, and accessibility of health records in every healthcare setting

An audit of all operative records should at the minimum include all of the following records except:

psychological evaluations.

In a health information exchange, patients would most likely be identified using a(n) _____. master person index medical record number record locator service unique patient identifier

record locator service

The National Practitioner Data Bank (NPDB) provides a database of:

records of malpractice award amounts to patients.

When filing an appeal with Medicare, the first step is:

redetermination by a Medicare Administration Contractor.

The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is _____ coding. proactive prospective concurrent retrospective

retrospective

Monies collected through cafeteria sales are reported on the balance sheet as:

revenue.

A score assigned that is used to predict a patient's chances of death from illness is known as a:

risk of mortality score.

A critical element of data retrieval planning is designing a _____. clinical data repository controlled vocabulary screen layout source systems

screen layout

A woman died in labor last week. The patient had no indications of any preexisting conditions. This event is an example of a(n):

sentinel event.

There has been an influx of refugee moving to Utah. As a result, the general practice has been inundated with new patients. The practice is considering adding another general physician to its practice in the next three to six months. This is an example of a __________ goal.

short-term

In the State of California, Medi-Cal claims must be submitted within 90 days of the date of service. After this period, Medi-Cal will deny all new claims. This is an example of the principle of:

statutes of limitations.

An example of a retrospective study is a:

study in review of patient records over the past three months to ensure quality patient care delivery.

Problems in patient care and other areas of the healthcare organization are usually symptoms inherent in a(n) _____. infrastructure output principle system

system

The work of performance improvement is accomplished through _____. teamwork process analysis change management quality indicators

teamwork

Credentialing is the process of verifying:

that healthcare professionals possess appropriate licensing and accreditation needed to deliver healthcare services.

Which section of ICD-10-CM contains the chronological list of codes divided into chapters based on body system or condition? the Tabular List the Index of Diseases and Injury the Index of External Causes of Injury the Table of Neoplasms

the Tabular List

Teams often fail to succeed when _____. the leader dominates the team the team has chosen an effective leader the team members care about the outcomes differences of opinion exist within the group

the leader dominates the team

While Medicare is a federally sponsored government insurance plan, it uses Medicare Administrative Contractors (MACs), which determine coverage and benefits for:

the local region.

The BMAR Code tool in the EHR is used:

to administer medications according to the EHR provider notes.

In the annual budget, the transcription supervisor estimated that receipts from transcription of physician office reports would be $200,000. At the end of the fiscal year, the receipts to date were $175,000. Given this data which of the following would the supervisor be asked to explain? favorable variance of $25,000 unfavorable variance of $25,000 favorable revenue of $175,000 unfavorable revenue of $25,000

unfavorable variance of $25,000

When the physician enters orders in the EHR, the software automatically confirms the authentication to ensure that the individual who entered the data is authorized to do so (that is, that the authentication is correct). This is an example of a computer being used to ensure data:

validity.

Expenses that change from month to month, such as labor and utilities, are known as:

variable costs.

The secure and private internet connection to the hospital HER that is needed by remote medical coders is also known as:

virtual private network.

Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of _____. transaction standards content and structure standards vocabulary standards security standards

vocabulary standards

The Happy Hills Long-Term Care Facility staff shops at a grocery warehouse. They purchased 20 gallons of orange juice that will expire in seven days. About half of the orange juice was consumed, and the staff threw the rest away. This is an example of:

waste.

Before beginning to budget at the department level, it is important to understand _____. when monthly reports will become available who will give the budget presentation how much each supply will cost during the upcoming year what the organization's budget assumptions are

what the organization's budget assumptions are

All of the following represent the essential purposes of the health record except:

when used to evaluate the bedside manner of the healthcare team.

In a managed fee-for service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? Prospectively precertify the necessity of inpatient services Determined what services can be bundled Pay only 80 percent of the inpatient bill Require the patient to pay 20 percent of the inpatient bill

Prospectively precertify the necessity of inpatient services

Which of the following is a core ethical obligation of HITs? Coding diseases and operations Protecting patients' privacy and confidential communications Transcribing medical reports Performing quanitative analysis on record content

Protecting patients' privacy and confidential communications

A hospital HIM department wants to move five years of medical records to a remote storage location. The records will be stored in boxes and the boxes will be filed on open shelves at the remote location. Which of the following should be done so that record location can be easily indentified in the remote storage area? Provide a unique identifier for each box and prepare a log of the records that each contains. Prepare a sequential list of all records sent to remote storage. Provide a listing of records by medical record number on the outside of the box. File the records in terminal digit order in each box.

Provide a unique identifier for each box and prepare a log of the records that each contains.

Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record? Make admission date a required field Provide an input mask for entering data in the field Make admission date a numeric field Provide sufficient space for input of data

Provide an input mask for entering data in the field

A patient requests a copy of his medical records. When the request is received, the HIM clerk finds that the records are stored off-site. Which of the following actions must the hospital take to be in compliance with HIPAA regulations? Provide copies of the records within 15 days. Provide copies of the records within 30 days. Provide copies of the records within 45 days. Provide copies of the records within 60 days.

Provide copies of the records within 60 days.

What was the primary objective of the original Social Security Act, which became a law in 1935? Provide healthcare insurance to the elderly. Finance construction of new hospitals and modernization of exisitng facilities. Provide retirement income to the elderly. Provide supplementary income to the disabled.

Provide retirement income to the elderly.

A patient requests copies of her medical records on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the records in paper format. How should the hospital respond? Provide the records in paper format. Burn another CD since this is hospital policy. Provide the patient with both paper and CD copies of the record. Review the CD copies with the patient on a hospital computer.

Provide the records in paper format.

Which of the following is an example of unstructured data?

Provider notes

Which of the following practices is not an appropriate coding compliance activity? Reviewing all rejected claims Developing procedures for identifying coding errors Providing a financial incentive for coding claims properly Coding diagnoses only when all applicable information is documented in the health record

Providing a financial incentive for coding claims properly

Which of the following is NOT a function of the discharge summary? Providing information about the patient's insurance coverage Ensuring the continuity of care Providing information to support the activities of the medical staff review committee Providing concise information that can be used to answer information requests

Providing information about the patient's insurance coverage

Which federal legislation enacted the Medicare and Medicaid programs? Public Law 92-603 of 1972 Public Law 89-97 of 1965 Public Law 98-21 of 1983 Utilization Review Act of 1977

Public Law 89-97 of 1965

The active storage area for medical records at Community Hospital is almost filled. In order to create more space in the storage area which of the following should be done? Discard the oldest records Purge oldest records to another location Remove nursing notes from the oldest records Remove the file folders from all the records

Purge oldest records to another location

In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatement or further evaluation is provided. Which of the following actions should the coder take in this case? Query the attending physician and ask if the patient has the COPD Code the COPD becuase the documentation substantiates it Query the radiologist to determine if the patient has the COPD Assign a code from the abnormal findings to reflect the condition

Query the attending physician and ask if the patient has the COPD

Tiffany is coding for reposition of the scapula. Although the report does not indicate any comorbidities, she did notice that the lab results indicate the patient may have diabetes. What should Tiffany do?

Query the physician to have the documentation clarified and updated, including the review of the lab results, to include the comorbidity.

A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM code is: Z03.89, Encounter for observation for other suspected diseases and conditions ruled out R10.11, Right upper quadrant pain K21.9, Gastro-esophageal reflux disease without esophagitis R07.9, Chest pain, unspecified

R07.9, Chest pain, unspecified

Which of the following is associated with Medicare SNF prospective payment? CMGs DRGs RBRVS RUG-III

RUG-III

Blue Cross Blue Shield of Texas sent an EOB that contained five claims. Three of the claims were paid according to the fee schedule, but two of the claims were not paid. By reviewing the EOB, which of the following provides the medical biller the reason for denial?

Reason code

Which of the following elements of coding quality represent consistency of code assignments among different coders? Reliability Validity Completeness Timeliness

Reliability

In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. What would be the best course of action in this case? Request that the physician dictate another discharge summary. Have the record analyst note the date discrepancy. Request the physician dictate an addendum to the discharge summary. File the record as complete since the discharge summary includes all of the pertinent patient information.

Request the physician dictate an addendum to the discharge summary.

A consumer non-profit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. A HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. What advice should the HIT professional provide? Billing data is easy to obtain and a good source to conduct quality studies The low number of data elements included in billing data allows for easy data analysis Results based on billing data have significant limitations Billing data is a good choice because of its high degree of integrity

Results based on billing data have significant limitations

To comply with the Joint Commission standards, the HIM director wants to ensure 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? Retrospectively review each patient's medical record to make sure that history and physicals are present. Review each patient's medical record concurrently to make sure that history and physicals are present and meet the accreditation standards. Establish a process to review medical records immediately on discharge. Write a memorandum to all physicians relating the Joint Commission requirements for documenting history and physical examinations

Review each patient's medical record concurrently to make sure that history and physicals are present and meet the accreditation standards.

A health information technician receives a subpoena duces tecum for the records of a discharged patient. To respond to the subpoena, which of the following should the technician do? Review the subpoena to determine what documents must be produced Review the subpoena and notify the hospital administrator Consult with the legal counsel for the hospital Review the subpoena and alert the hospital risk management department

Review the subpoena to determine what documents must be produced

Which of the following methods do not meet the standards of AHIMA patient record destruction?

Ripping them and throwing in an unsecure trash bin

Community Hospital uses a unit filing system and wants to archive its oldest records on microfilm. Which type of microfilm will NOT accommodate the hospital's needs to maintain a unit filing system? COM microfiche Jacket microfiche Microfiche Roll microfilm

Roll microfilm

Which of the following is the traditional manner of planning and implementing an information system? CPRI UML Database Management SDLC

SDLC

Which of the following is an example of secondary data collected from a structured query?

SNOMED code for patient aged between 20 and 29 years

Databases are typically written in which of the following programming languages?

SQL

A patient is admitted for chest pain with cardiac dysrhythmia to Hosptial A. The patient is found to have an acute inferior myocardial infarction with atrial fibrillation. After the atrial fibrillation was controlled and the patient was stabilized, the patient was transferred to Hospital B for a CABG X3. What are the correct diagnoses for Hospital B? Subsequent ST elevation (S TEMI) myocardial infarction of inferior wall; Unspecified atrial fibrillation ST elevation (STEMI) myocardial infarction of unspecified site; Unspecified atrial fibrillation ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall; Unspecified atrial fibrillation Chest pain; cardiac dysrhythmia; ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall; Unspecified atrial fibrillation

ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall; Unspecified atrial fibrillation

Which law requires the reporting of deaths and severe complications due to devices? Medical Implantation and Transplantation Act of 1986 Medical Devices Reporting Act of 1972 Food and Drug Modernization Act of 1997 Safe Medical Devices Act of 1990

Safe Medical Devices Act of 1990

Which of the following is used as sketch of the user interface during system development? Screen prototype System testing System debugging System object

Screen prototype

Last night, someone broke into the Department of Health Information office and stole some paper records from the archive. The perpetrators broke the locks on the door. Which of the following HIPAA elements were compromised?

Security

Community Hospital has more than 100 clinical databases. The Data Quality Committee is launching a project to determine the level of comparability among the databases. The data elements and associated data definitions have been catalogued for each database. What would be the next logical step to determine the degree of data comparability among the databases? Identify the operating system for each database to determine if they are similar to each other. Select a representative set of data elements and track these across the databases to identify consistencies and differences. Identify the network capability of each of the databases so that data can be exchanged. Determine the volume and type of data stored within each database so that a data repository can be developed of similar data.

Select a representative set of data elements and track these across the databases to identify consistencies and differences.

Which of the following have powers to govern outlined by the Constitution of the United States?

Senate

City Hospital had a fiscal year end of June 30. For this hospital the first quarter ends on: September 30 December 31 March 31 June 30

September 30

City Hospital has a fiscal year end of June 30. For this hospital the first quarter ends on: September 30 December 31 March 31 June 30

September 30

A HIM department is planning to implement virtual teams for the coding and the data analytics areas. Some in the facility are skeptical of this arrangement, feeling that offsite employees cannot be managed. Given this work format, how can the supervisor best gauge productivity of the virtual staff? Require staff to call in to the office every morning. Require a daily conference call with staff. Set clear goals and productivity standards and see that these are met. Install camcorders on each team's computer to ensure that they are at their workstations.

Set clear goals and productivity standards and see that these are met.

Andrew Johnson, MD, was the only gastroenterology office in the city. Then, a new medical school graduate, Howard Nyguen, MD, opened a gastroenterology center with advanced technologies that Dr. Johnson could not afford. Dr. Johnson started telling his patients that the new physician did not speak English clearly and that he didn't score high marks in medical school. Which of the following legal recourses can Dr. Nyguen take?

Slander

Which of the following lists of names is in correct order for alphabetical filing? Smith, Carl J.Smith, Mary A.Smith, Paul M.Smith, Thomas Carl J. SmithMary A. SmithPaul M. SmithThomas Smith Smith, A. MarySmith, J. CarlSmith, M. PaulSmith, Thomas Smith, ThomasSmith, Carl M.Smith, Mary A.Smith, Paul M.

Smith, Carl J.Smith, Mary A.Smith, Paul M.Smith, Thomas

Which of the following information is not found on the facility MPI records?

Social Security number

In the design phase of the system development life cycle, which tool is used to break down problems into source interoperability issues that need to be addressed?

Software relationship diagram

Eric was hired for his extensive experience in MS-DRG assignment. However, when he started working for San Antonio Community Hospital, the hospital's ICD-10-PCS coder was on leave, so the coding supervisor assigned Eric to that position. Which principles of organization did the coding supervisor fail to apply?

Specialization

San Antonio Community Hospital is developing procedures to collect information on patient outcomes to improve the quality of care delivered. Which Meaningful Use stage is the hospital working on?

Stage 3

Health information exchange is a standard met in which stage of Meaningful Use implementations?

Stage II

Which of the following entities administer the Medicaid program? Federal government State governments County governments Peer review organizations

State governments

Which of the following should be considered first when establishing health record retention policies? State retention requirements Accreditation standards AHIMA's retention guidelines Federal requirements

State retention requirements

Parkview Community Hospital paid off the long-term loan that was used for its EHR implementation. What financial statement would reflect the large payoff of debt?

Statement of retained earnings

The COO of Riverside Community Hospital has implemented a challenge to all surgical staff to eliminate medical errors as much as possible. Where in the SWOT analysis category would this effort fall into?

Strength

A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena? Inform defense and plaintiff lawyers that the records no longer exist Submit a certification of destruction in response to the subpoena Refuse the subpoena since no records exist Contact the clert of the court and explain the situation

Submit a certification of destruction in response to the subpoena

Which of the following occupations is not usually considered to be an allied health professional? Dietician Physical Therapist Emergency medical technician Surgeon

Surgeon

In preparing a bill for Mr. Smith's healthcare services, the health record technician needs to determine those services to be paid under Medicare Part A and those under Medicare Part B. Which of the following services should be process under Part B? Inpatient hospitalization care Inpatient laboratory and radiology services Skilled nursing facility care Surgeon's services

Surgeon's services

Which of the following can be defined as a collection of related components that interact to perform a task in order to accomplish a goal? Information Data System Process

System

Which of the following health information professionals would have a Certified Health Data Analyst (CHDA) credential?

Systems data analyst

A 65-year old patient is admitted with pain and loosening of a previous right total hip arthroplasty. The acetabular component has loosened and become painful. The patient was admitted for revision of the hip replacement. The acetabular component uses a metal-on-metal bearing surface. Which of the following codes would be the principal diagnosis for this admission? T84.020 Dislocation of internal right hip prosthesis T84.84 Pain due to internal orthopedic prosthetic devices, implants and grafts Z44.10 Encounter for fitting and adjustment of unspecified artificial leg Z98.89 Other specified postprocedural states

T84.020 Dislocation of internal right hip prosthesis

Development of a departmental budget would be considered: Strategic decision making Tactical decision making Operational decision making Unstructured decision making

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