HITT Test 2 Review

Which of the following provides a set of codes used for collecting data about substance abuse and mental health disorders? a. CPT b. DSM-IV-TR c. HCPCS d. SNOMED CT

b. DSM-IV-TR

The data set designed to organize data for public release about the outcomes of care is ___. a. UHDDS. b. DEEDS. c. MDE. d. HEDIS.

b. HEDIS.

Which of the following provides the most comprehensive controlled vocabulary for coding the contents of a patient record? a. CPT b. HCPCS c. ICD-9-CM d. SNOMED CT

d. SNOMED CT

Instructions: For questions 33-40, match the data set in column A with the applicable type of care setting, facility, or program in column B. Column A Column B 33. ___ UHDDS a. Long-term care facilities 34. ___ UACDS b. Health plans 35. ___ MDS c. Emergency services 36. ___ DEEDS d. Outpatient services 37. ___ HEDIS e. Acute inpatient care 38. ___ RAP f. Home health care 39. ___ EMDS 40. ___ OASIS

33. E 34. D 35. A 36. C 37. B 38. A 39. C 40. F

Instructions for questions 6-10: In the following questions, answer "a" if the provider should submit a CMS-1500 to a third-party payer or "b" if the provider should submit a UB-92/UB-04 to a third-party payer. 6. __ Physician who sees a patient in the office 7. __ Hospital that treats a patient as a hospital inpatient 8. __ Ambulance company that responds to a motor vehicle accident and transports the patient to the closest trauma center 9. __ DMERC supplier that provides services to the patient 10. __ Ambulatory surgery center that performs same-day surgery on the patient

6. a 7. b 8. b 9. a 10. b

Which volume of ICD-9-CM contains the numerical listing of codes that represent diseases and injuries? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

a. Volume 1

A recent breakthrough in the development of a universal language to aid storage and transmission of Web-based data is ___. a. XML. b. HTML. c. E1384. d. SQL.

a. XML.

e. to provide a system for coding the clinical procedures and services provided by physicians and other clinical professionals

__ Current Procedural Terminology

d. to provide a means to record information about patients treated for substance abuse and mental disorders

__ Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision

b. to promote uniform reporting and statistical data collection for medical procedures, supplies, products and services

__ Healthcare Common Procedure Coding System Modification

c. to provide a detailed classification system for coding the histology, topography, and behavior of neoplasms

__ International Classification of Diseases for Oncology, Third Edition

a. the planned replacement for ICD-9-CM Volumes 1 and 2

__ International Classification of Diseases, 10th Revision, Clinical Modification

g. to provide a system for classifying morbidity and mortality information for statistical purposes

__ International Classification of Diseases, Ninth Revision, Clinical

f. to provide a standardized vocabulary for facilitating the development of computer-based patient records

__ Systematized Nomenclature of Medicine Clinical Terminology

Which of the following is a standard terminology used to code medical procedures and services? a. CPT b. HCPCS c. ICD-9-CM d. SNOMED CT

a. CPT

Which term is used in reference to the electronic transmission of information from a provider to a health plan to determine a patient's eligibility for services? a. Claims transaction b. Coordination of benefits transaction c. Electronic data interchange d. Remittance advise

a. Claims transaction

After an episode of emergency care, data is entered into a specialized database for the purpose of developing a health history for the patient. This data is part of ___. a. EMDS. b. DEEDS. c. HEDIS. d. ORYX.

a. EMDS. ???

Which of the following explains Medicare payments and denials? a. ERA b. HCC c. HIPAA d. Payment transaction

a. ERA

Messaging standards for electronic data interchange in healthcare have been developed by ___. a. HL7 b. IEE c. JCAHO d. CMS

a. HL7

Of the following resources, the best resource to use in defining the structure of the EHR is the ___. a. HL7 Functional Model. b. HIPAA privacy standards. c. UHDDS. d. IEEE .

a. HL7 Functional Model.

Which organizations enter into contracts with the CMS to process claims for Part B professional physician services? a. Medicare carriers b. Medicare fiscal intermediaries c. Quality improvement organizations d. Integrated provider organization

a. Medicare carriers

Which of the following terms can be defined as the combination of certain items (such as anesthesia, supplies, and drugs) for the purposes of reimbursement? a. Packaging b. Discounting c. Prospective payment d. Global surgery payment

a. Packaging

Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ___. a. UHDDS. b. UACDS. c. MDS. d. ORYX.

a. UHDDS.

Which of the following lists of names is in correct order for alphabetical filing? a. Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas b. Carl J. Smith Mary A. Smith Paul M. Smith Thomas Smith c. Smith, A. Mary Smith, J. Carl Smith, M. Paul Smith, Thomas d. Smith, Thomas Smith, Carl J. Smith, Mary A. Smith Paul M.

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

Critique this statement: Skilled nursing facilities are no longer paid under a system based on reasonable cost but, rather, through per-diem prospective casemix- adjusted payment rates. a. This is a true statement. b. This is a false statement as skilled nursing facilities are paid on a per visit rate. c. This is a false statement as skilled nursing facilities are paid based on a schedule d. This is a false statement as skilled nursing facilities are paid based on charges.

a. This is a true statement.

Once hospital discharge abstract systems were developed and their ability to provide comparative data to hospitals was established, it became necessary to develop ___. a. data sets. b. data elements. c. electronic data interchange. d. bills of mortality.

a. data sets.

OASIS data is used to assess the ___ of home health services. a. outcomes b. financial performance c. utilization d. core measures

a. outcomes

The first point of data collection and the area where the health record number is most commonly assigned in an acute care hospital is the ___. a. patient registration department b. patient care unit c. billing department d. HIM department

a. patient registration department

In healthcare, data sets serve two purposes. The first purpose is to identify data elements to be collected about each patient. The second is to ___. a. provide uniform data definitions. b. guide efforts toward computerization. c. determine statistical formulas. d. provide a research database.

a. provide uniform data definitions.

Reviewing the health record for missing signatures, missing medical reports and ensuring that all documents belong in the health record is an example of ___ review. a. quantitative b. qualitative c. statistical d. outcomes

a. quantitative

Which of the following is not a knowledge source for users of the Unified Medical Language System? a. the concept table b. the semantic network c. the metathesaurus d. the specialist lexicon

a. the concept table

__ validity

a. the degree to which codes accurately reflect the patient's diagnoses and procedures

The Joint Commission on requires that the medical record delinquency rate quarter averaged from the last four quarterly measurements is not greater than ___ of the average monthly discharge rate. a. 25% b. 50% c. 75% d. 100%

b. 50%

In designing an electronic health record, one of the best resources to use in helping to define the content of the record as well as to standardize data definitions is the E1384 standard promulgated by the ___. a. CMS. b. American Society for Testing and Measurement. c. Joint Commission on Accreditation of Healthcare Organizations. d. National Centers for Health Statistics.

b. American Society for Testing and Measurement.

Which of the following organizations is responsible for updating the procedure classification of ICD-9-CM? a. Centers for Disease Control b. Centers for Medicare and Medicaid Services c. National Center for Health Statistics d. World Health Organization

b. Centers for Medicare and Medicaid Services

The exchange of digitized images such as X rays, CT scans, and MRIs is supported by ___. a. UHDDS b. DICOM c. X12 d. NCPDP

b. DICOM

Which of the following ICD-9-CM codes classify environmental events and circumstances as the cause of an injury, poisoning, or other adverse effect? a. category codes b. E codes c. subcategory codes d. V codes

b. E codes

Which of the following statements describes alphabetical filing? a. File the record alphabetically by first name, followed by the middle initial, and then the last name. b. File the record alphabetically by the last name, followed by the first name, and then the middle initial. c. File the record alphabetically by the last name, followed by the middle initial and then the first name. d. File the record alphabetically by last name only.

b. File the record alphabetically by the last name, followed by the first name, and then the middle initial.

Which of the following is used to report the healthcare supplies, products, and services provided to patients by healthcare professionals? a. CPT b. HCPCS c. ICD-9-CM d. SNOMED CT

b. HCPCS

A corporation is evaluating several health plans for its benefits package. The data set that provides comparison information about health plan performance is ___. a. ORYX. b. HEDIS. c. UHDDS. d. MDS.

b. HEDIS.

What is the term used to describe the process of checking individual data elements, reports, or files against each other to resolve discrepancies in accuracy of data and information? a. Repudiation b. Reconciliation c. Legal health record d. Analysis

b. Reconciliation

Data collected to evaluate facility performance in designated core measure areas in order to achieve accreditation is ___. a. HEDIS. b. ORYX. c. DEEDS. d. OASIS.

b. ORYX.

Our hospital wants to partner with local physicians so that we can be viewed as a single entity in negotiating managed care contracts. Which of the following model should we develop? a. MSO b. PHO c. Medical foundation d. ASO

b. PHO

Which of the following is not a characteristic of the common healthcare data sets such as UHDDS and UACDS? a. They define minimum data elements to be collected. b. They provide a complete and exhaustive list of data elements that must be collected. c. They provide a framework for data collection to which an individual facility can add data items. d. The federal government recommends, but does not mandate, implementation of most of the data sets.

b. They provide a complete and exhaustive list of data elements that must be collected.

Which volume of ICD-9-CM contains the alphabetic index for the diagnostic codes? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

b. Volume 2

__ International Classification of Diseases, Ninth Revision

b. World Health Organization

What component of the departmental budget would include the expense of purchasing new reference books for clinical coding staff? a. revenue budget b. expense budget c. capital budget d. cash budget

b. expense budget

Using a hospital discharge database, a physician does a study of diabetes mellitus comparing age of onset with response to a specific drug regimen. The physician has gathered ___ from the database. a. data elements b. information c. informatics standards d. data sets

b. information

Which of the following indexes is considered to be the authoritative key to locating a health record? a. disease index b. master patient index c. operation index d. physician index

b. master patient index

The services provided by HIM departments in acute care hospitals usually include all the following except ___. a. medical transcription b. medical billing c. clinical coding d. release of information.

b. medical billing

Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long roll? a. document scanning system b. microfilm roll c. microfilm jacket d. microfiche

b. microfilm roll

Which of the following terms refers to the incidence of disease? a. classification b. morbidity c. mortality d. vocabulary

b. morbidity

In which of the following systems does an individual receive a unique numerical identifier for each encounter with a healthcare facility? a. alphabetic filing system b. serial numbering system c. terminal digit filing system d. unit numbering system

b. serial numbering system

Information standards that provide clear descriptors of data elements to be included in computer-based patient record systems are called ___ standards: a. vocabulary b. structure and content c. transaction d. security

b. structure and content

Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 37-45-99 38-45-99 36-45-99 a. straight numerical b. terminal digit c. middle digit d. unit

b. terminal digit

__ timeliness

b. the time frame in which health records are coded

When did CMS implement the Correct Coding Initiative for physician claims? a. 1983 b. 1990 c. 1996 d. 2000

c. 1996

The annual volume statistics for New Town Hospital are noted below. How many shelving units will be required to store this year's inpatient discharge records? Average inpatient discharges = 12,000 Average inpatient record thickness = ¾ inch Shelving units shelf width = 36 inches Number of shelves per unit = 6 a. 41 b. 41.67 c. 42 d. 74

c. 42

In the 1980s, which of the following trends necessitated the development of data sets in addition to the UHDDS? a. Inpatient admissions dramatically increased. b. Inpatient lengths of stay increased. c. Ambulatory services and procedures proliferated. d. Ambulatory lengths of stay increased.

c. Ambulatory services and procedures proliferated.

__ CPT Assistant

c. American Medical Association

Which term is used in reference to the transfer of health claims using electronic media? a. ANSI b. ASC X12 c. EDI d. Optical scanning

c. EDI

Which classification system is established for the prospective reimbursement of covered home care services to Medicare beneficiaries during a sixty-day episode of care? a. OASIS b. HAVEN c. HHRGs d. HH PPS

c. HHRGs

The ___ mandated the development of standards for electronic medical records. a. Medicare and Medicaid legislation of 1965 b. Prospective Payment Act of 1983 c. Health Insurance Portability and Accountability Act of 1996 d. Balanced Budget Act of 1997

c. Health Insurance Portability and Accountability Act of 1996

11. The ___ data set is mandated for use in facilities that participate in the Medicare and Medicaid programs. a. DEEDS b. UACDS c. MDS d. ORYX

c. MDS

The ___ is used as an assessment tool to determine a care plan at the time of admission. a. DEEDS b. UHDDS c. MDS d. HEDIS

c. MDS

ADLs are components of ___. a. UACDS and MDS. b. UHDDS and EMDS. c. MDS and OASIS. d. ORYX and RAPs.

c. MDS and OASIS.

Which of the following organizations is responsible for updating the diagnosis classification of ICD-9-CM? a. Centers for Disease Control b. Centers for Medicare and Medicaid Services c. National Centers for Health Statistics d. World Health Organization

c. National Centers for Health Statistics

As a health information professional, you've become involved in developing an RHIO in your region. The agency that would provide the best resources for RHIO development is ___. a. NCVHS b. HL7 c. ONC d. ASTM

c. ONC

The ambulatory payment classification system is based on the categorization of which services? a. Inpatient care b. Home care c. Outpatient care d. Skilled care

c. Outpatient care

Which of the following statements best describes the situation for a provider that agrees to accept assignment for Medicare services? a. Reimbursed at 15 percent above the allowed charge b. Paid according to the MFS plus 10 percent c. Prohibited from balance billing patients d. Referred to as a nonparticipating provider

c. Prohibited from balance billing patients

Which of the following classification systems uses resident assessment data to assign residents to one of forty-four groups, with each assessment applying to specific days within a resident's stay? a. MS-DRG b. APC c. RUG d. HH PPS

c. RUG

Which volume of ICD-9-CM contains the tabular and alphabetic lists of procedures? a. Volume 1 b. Volume 2 c. Volume 3 d. Volume 4

c. Volume 3

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

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

Which of the following tasks would the HIM department not perform in an electronic health record system? a. document imaging b. analysis c. assembly d. indexing

c. assembly

A record not completed within the time frame specified in the medical staff rules and regulations is called a ____. a. suspended record b. completed record c. delinquent record d. purged record

c. delinquent record

Computer software programs that assist in the assignment of codes used with diagnostic and procedural classifications are called ___. a. natural language processing systems b. monitoring/audit programs c. encoders d. concept, description, and relationship tables

c. encoders

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

c. federal and state confidentiality laws

An example of data collected by the JCAHO for the ORYX initiatives is ___. a. intrahospital mortality data. b. financial data. c. health plan performance data. d. patient demographic data.

c. health plan performance data. ???

Which of the following terms refers to the incidence of death? a. classification b. morbidity c. mortality d. vital statistics

c. mortality

Which of the following tools is usually used to track health records that have been removed from their permanent storage locations? a. deficiency slips b. master patient indexes c. outguides d. requisition slips

c. outguides

A statement or guideline that directs decision making or behavior is called a ____. a. directive b. procedure c. policy d. process

c. policy

Which of the following practices is not an appropriate coding compliance activity? a. reviewing all rejected claims b. developing procedures for identifying coding errors c. providing a financial incentive for coding claims improperly d. coding diagnoses only when all applicable information is documented in the health record

c. providing a financial incentive for coding claims improperly

What are four-digit ICD-9-CM diagnosis codes referred to as? a. category codes b. section codes c. subcategory codes d. subclassification codes

c. subcategory codes

__ reliability

c. the degree to which the same results are achieved consistently

The key data element for linking data about an individual who is seen in a variety of care settings is the ___. a. facility medical record number. b. facility identification number. c. unique patient identifier. d. patient birth date.

c. unique patient identifier. ???

In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters? a. alphabetic filing system b. serial numbering system c. unit numbering system d. none of the above

c. unit numbering system

__ Coding Clinic

d. American Hospital Association

Which of the following classifications is used exclusively for classifying cases of malignant disease? a. CPT b. HCPCS c. ICD-9-CM d. ICD-O-3

d. ICD-O-3

An example of clinical data representation is a(n) ___. a. DRG. b. HL7 standard. c. Social Security number. d. ICD-9-CM code.

d. ICD-9-CM code.

Which of the following statements does not apply to ICD-9-CM? a. It can be used as the basis for epidemiological research. b. It can be used in the evaluation of medical care planning for healthcare delivery systems. c. It can be used to facilitate data storage and retrieval. d. It can be used to collect data about nursing care.

d. It can be used to collect data about nursing care. ???

The organization that coordinates the collection of performance data for managed care plans is the ___. a. Joint Commission on the Accreditation of Healthcare Organizations. b. CMS. c. NCVHS d. NCQA.

d. NCQA.

The governmental agency most closely involved in the development of healthcare data sets and information standards is the ___. a. CMS. b. DHHS c. Johns Hopkins University. d. NCVHS.

d. NCVHS.

10. A ___ during the data collection process in long-term care identifies a resident issue or the need for further assessment. a. quality indicator b. performance improvement alert c. care conference monitor d. RAP trigger

d. RAP trigger

AHIMA strongly opposes the use of which of the following as a patient identifier in an electronic environment? a. enterprise master patient index record number b. patient's full name c. national healthcare identification number d. Social Security number

d. Social Security number

Which of the following ICD-9-CM codes are always alphanumeric? a. category codes b. procedure codes c. subcategory codes d. V codes

d. V codes

Which organization originally published ICD-9? a. American Medical Association b. Centers for Disease Control c. United States federal government d. World Health Organization

d. World Health Organization

The master patient index ___. a. is the most important index maintained by the HIM department b. contains basic demographic information about the patient c. is commonly part of the admission, discharge, and transfer computer system d. all of the above

d. all of the above

To avoid fraudulent behaviors in coding, healthcare providers need to ___. a. develop written standards of conduct b. designate a chief compliance officer c. develop effective training programs for coders d. all of the above

d. all of the above

Which entity(ies) have established documentation standards? a. Medicare b. Joint Commission c. American Osteopathic Association d. all of the above

d. all of the above

Which of the following should be taken into consideration when designing a health record form? a. assigning a unique identifying number to the form b. using a concise title that identifies the form's purpose c. including original and revised dates for tracking purposes d. all of the above

d. all of the above

Nosology can be defined as the branch of medical science that deals with ___. a. cosmetic surgery b. hospital-acquired infections c. nursing diagnoses d. classification systems

d. classification systems

Which of the following is not a key focus of healthcare information standards development? a. linking data from disparate computer systems b. providing common definitions for data elements c. responding to the information needs of users d. defining data for paper-based health record systems

d. defining data for paper-based health record systems ???

The increased collection and use of healthcare data was most profoundly influenced in the 1960s by the ___. a. passage of Medicare/Medicaid legislation. b. expansion of insurance coverage by third party payers. c. increase in technical knowledge of HIM professionals. d. development of computers capable of storing and processing large amounts of data.

d. development of computers capable of storing and processing large amounts of data.

What committee oversees the development and approval of new forms for the health record? a. quality review committee b. medical staff committee c. executive committee d. forms committee

d. forms committee

Which of the following is not one of the purposes of ICD-9-CM? a. classification of morbidity for statistical purposes b. classification of mortality for statistical purposes c. reporting of diagnoses by physicians d. identification of the supplies, products, and services provided to patients

d. identification of the supplies, products, and services provided to patients

If the vice president of marketing requested information regarding the number of cardiac catheterizations performed in 2004, what index would you consult? a. master patient index b. physician index c. disease index d. operations/procedures index

d. operations/procedures index

The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is ____ review. a. proactive b. prospective c. concurrent d. retrospective

d. retrospective

What are five-digit ICD-9-CM diagnosis codes referred to as? a. category codes b. section codes c. subcategory codes d. subclassification codes

d. subclassification codes

At which level of the classification system are the most specific ICD-9-CM codes found? a. category level b. section level c. subcategory level d. subclassification level

d. subclassification level

Which of the following filing methods is considered the most efficient? a. alphabetical filing b. alphanumeric filing c. straight numeric filing d. terminal digit filing

d. terminal digit filing

__ completeness

d. the degree to which the codes capture all the diagnoses and procedures documented in the patient's health record

__ Standards of Ethical Coding

e. American Health Information Management Association