RHIT Mock Exam
Dr Gray has applied for medical staff privileges at your hospital. What database would you research to determine if he has been denied medical staff privileges at another hospital? a. National Practitioner Data Bank b. Healthcare Integrity and Protection Data Bank c. MEDPAR file d. State Administrative Data Bank
a
Dr. Sam Vineyard improperly performed a knee replacement surgery, which causes the patient to develop an infection that led to the amputation of the leg and thigh. The best term to describe the action performed is a. Misfeasance b. Malpractice c. Nonfeasance d. Malfeasance
a
Engaging patients and their families in health care decisions is one of the core objectives for a. Achieving meaningful use of EHRs b. The Joint Commission's National Patient Safety goals c. HIPAA 5010 regulations d. Establishing flexible clinical pathways
a
Fetal monitoring strips are part of the ____________ record and should be maintained _____________. a. Newborns; 10 years past the age of majority b. Mother's; according to the length of time required for a minor's records c. Newborn's; according to the time period specified in the state's statute of limitations d. Mother's; 10 years
b
During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed does of insulin. What type of review is this clerk performing? a. Utilization review b. Quantitative review c. Legal review d. Qualitative review
d
Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are a. Geographic index, wage index, and cost of living index b. Fee-for-service, per diem payment, and capitation c. Conversion factor, CMS weight, and hospital-specific rate d. Physician work, practice expense, and malpractice insurance expense
d
This is the amount collected by the facility for the services it bills. a. Costs b. Charges c. Reimbursement d. Contractual allowance
c
A new Health Information department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? a. 6 b. 8 c. 10 d. 12
200 units x 6 shelves per unit = 1,200 shelves total 1200 shelves divided by 100 primary numbers (00-99) = 12 shelves per primary number
Barbara is being seen at a physician's office that she has never been to before. This physician practice is independently owned and is not associated with a hospital or other physician practice. She did not have to request copies of her health records, but the physician has everything that she needs. They physician must be part of a(n) a. Integrated health network b. Corporation c. Health information exchange d. Electronic health record
c
Contingency planning includes which of the following processes? a. Data quality b. Systems analysis c. Disaster planning d. Hiring practices
c
Discharge summary documentation must include a. A detailed history of the patient b. A note from social services or discharge planning c. Significant findings during hospitalization d. Correct codes for significant procedures
c
Dr. Smith has a practice in Macon, Georgia. He is treating a patient who is physically located in Soperton, Georgia, which is about 70 miles away. Dr. Smith, however, treats the patient while remaining in his Macon office. What technology is required for Dr. Smith to treat the patient? a. EHR b. Clinical data repository c. Telehealth d. Cloud computing
c
For inpatients, the first data item collected of a clinical nature is usually a. Principal diagnosis b. Expected payer c. Admitting diagnosis d. Review of systems
c
Historically, individually identifiable information for deceased individuals regardless of the time of death was covered under the HIPAA privacy rule. However, under HITECH individually identifiable information for deceased individuals is no longer covered after ______ years. a. 30 b. 40 c. 50 d. 60
c
ICD-10-PCS utilized the third character in the Medical and Surgical section to identify the "root operation." The name of the root operation that describes "cutting out or off, without replacing a portion of a body part" is a. Destruction b. Extirpation c. Excision d. Removal
c
In Creating a new form or computer view, the designer should be most driven by a. QIO standards b. Medical staff bylaws c. Needs of the users d. Flow of data on the page or screen
c
In preparing a capital budget request, the first priority will be to document a. The specific type of equipment requested b. Where the new equipment will be located c. The need for the new equipment d. The cost of the new equipment
c
Information found in which of the following would not be considered secondary data? a. Disease index b. Implant registry c. Health record d. National Practitioner Data
c
Maria has received a request to update a patient's address. What system should she use? a. Executive information system b. Clinical decision support system c. Admission-discharge-transfer system d. Laboratory information system
c
Mary is designing a computer screen that will be used to collect patient demographic information. What input design should be utilized for the state field? a. An icon b. A dialog box c. The drop-down menu d. Free form text
c
Measurements within Sample A are assumed to be more variable than measurements within sample B when a. Sample A and sample B have the same mean b. Individuals within sample A are more alike than individuals within sample B c. Individuals within sample A differ more from one another than individuals within sample B d. Sample A and sample B have the same standard deviation
c
Needlesticks, patient or employee falls, medication errors, or any event not consistent with routine patient care activities would require risk reporting documentation in the form of an a. Operative report b. Emergency room report c. Incident report d. Insurance claim
c
One of the major functions of the cancer registry is to ensure that patients receive regular and continued observation and management. How long should patient follow-up be continued? a. Until remission occurs b. 10 years c. For the life of the patient d. 1 year
c
Reviewing a medical record to ensure that all diagnoses are justified by documentation throughout the chart is an example of a. Peer review b. Quantitative review c. Qualitative review d. Legal analysis
c
The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for? a. Release of information b. Coding c. Chart tracking d. Transcription
c
Which of the following disclosures would require patient authorization? a. Law enforcement activities b. Workers compensation c. Release to patient's family d. Public health activities
c
Which of the following is NOT a benefit of the electronic document management system in the HIM Department? a. Online availability of information b. Multiuser simultaneous access c. Decreased use of computer technology d. System security and confidentiality
c
Which of the following is NOT considered a challenge in the adoption of an electronic health record system? a. Design of the work flow and processes b. Physician willingness to adopt c. Contribution to the quality of patient care d. Individual state legal and regulatory issues
c
Which of the following is the term used to identify who made an entry into a health record? a. Access control b. Authentication c. Authorship d. Accessibility
c
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "with the patient in the supine position, the right side of the neck was appropriately prepped with betadine solution and draped. I was able to pass the central line, which was taped to skin and used for administration of drugs during resuscitation." a. Physical progress notes b. Operative report c. Nursing progress notes d. Physical examination
b
CMS-identified "Hospital-Acquired Conditions" mean that when a particular diagnosis is not "present on admission," CMS determines it to be a. Medically necessary b. Reasonably preventable c. A valid comorbidity d. The principal diagnosis
b
Dr. Smith is entering a medication order in a CPOE. A window pops up with the following message: Patient is on beta-blocker, which is contraindication for this medication. Do you want to order this medication Yes or No. This is an example of a(n) a. Reminder b. Alert c. Allergy d. Structured entry
b
Electronic health record built-in tools that can make data capture easier include all but which one of the following? a. Data dictionaries b. Flow process charts c. Automated quality measures d. Clinical decision support systems
b
Federal legislation has a significant impact ton the workplace. Which of the following requires employers to make reasonable accommodations for individuals to perform essential job functions? a. Age Discrimination Act b. Americans with Disabilities Act c. Rehabilitation Act d. Equal Opportunity Employment act
b
Given a positively skewed frequency distribution a. The frequencies are identical between the mean, median and mode b. Larger frequencies are concentrated at the low end of the variable c. Larger frequencies are concentrated at the high end of the variable d. Largest frequencies occur at both low and high ends of the variable
b
How many years does the CMS regulations require that health records be maintained? Medicare's Conditions of Participation for Hospitals requires that patient health records be retained for at least ______ years unless a longer period is required by state or local laws. a. 3 b. 5 c. 7 d. 10
b
If a consent is added to all measurements within a sample a. The mean remains the same b. The standard deviation remains the same c. The mean remains the same and the standard deviation remains the same d. Neither the mean nor the standard deviation remains the same
b
If a participating provider's usual fee for a service is $700.00 and Medicare's allowed amount is $450.00, what amount is written off by the physician? a. None of it is written off b. $250.00 c. $340.00 d. $391.00
b
In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the a. UHDDS b. MDS c. Uniform Clinical Data Set d. Uniform Ambulatory Core Data
b
In ICD-10-PCS, to code "removal of thumbnail," the root operation would be a. Removal b. Extraction c. Fragmentation d. Extirpation
b
In general, all three key components (history, physical examination, and MDM) for the E/M codes in CPT should be met or exceeded when a. The patient is established b. A new patient is seen in the office c. The patient is given subsequent care in the hospital d. The patient is seen for a follow-up inpatient consultation
b
In order to use the inpatient CPT consultation codes, the consulting physician must a. Order diagnostic tests b. Document his finding in the patient's medical record c. Communicate orally his opinion to the attending physician d. Use the term "referral" in his report
b
Julian supervises the department's coding section. He notices that the coding technician is working 30 additional minutes each day before clocking in at her schedule starting time. After discussing her timecard with her, he discovers that she is starting work early in order to check the unbilled account report. Under which act are you required to pay her for all hours worked? a. ERISA b. Fair Labor Standards Act c. National Labor Relations Act d. Equal Pay Act
b
A covered entity must act on a request for accounting disclosures no later than ______ days after its receipt and within _____ days of extension, as long as it notifies the individual in writing of the reasons for the delay and when the accounting will be made available. a. 60, 30 b. 45, 30 c. 45, 60 d. 30, 60
a
Which of the following can be released without consent or authorization? a. Summary of patient care for the latest discharge b. De-identified health information c. Personal health information d. Protected health information
b
Which of the following is an example of administrative safeguards under the security rule? a. Encryption b. Monitoring the computer access activity of the user c. Assigning unique identifiers d. Monitoring traffic on the network
b
I have been asked if I want to be in the directory. The admission clerk explains that if I am in the directory, a. My friends and family can find out my room number b. My condition can be discussed with any caller in detail c. My condition can be released to news media d. My condition can be released to hospital staff only
a
ICD-10-PCS procedure codes are used on which of the following forms to report services provided to a patient a. UB-04 b. CMS-1500 c. CMS-1491 d. MCD 02
a
ICD-10-PCS was implemented in the United States to code a. Hospital inpatient procedures b. Physician office procedures c. Hospital inpatient diagnoses d. Hospital outpatient diagnoses
a
In CPT, Category III codes include codes a. To describe emerging technologies b. To measure performance c. For use by nonphysician practitioners d. For supplies, drugs, and durable medical equipment
a
In performing a "what if" query to determine whether the facility should expand the emergency department, which of the following systems would be used? a. Decision support system b. Financial information system c. Clinical decision support system d. Knowledge-based system
a
Jason, an HIM educator, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. Which of the following legal issues will he describe? a. OSHA b. Wagner Act c. Taft-Hartley Law d. Labor Management Relations Act
a
Mandatory reporting requirements for vital statistics generally a. Do not require authorization by the patient b. Require authorization by the physician c. Require authorization by the payer d. Do not apply to health facilities
a
Mapping between ICD-9-CM and ICD-10-CM were developed and released by the National Center for Health Statistics (NCHS) to facilitate the transition from one code set to another. They are called a. GEMS (General Equivalency Mappings) b. Medical Mappings c. Code Maps d. ICD Code Maps
a
Ms. Thomas was a patient at your facility. She has been told that there are some records that she cannot have access to. These records are most likely a. Psychotherapy notes b. Alcohol and drug records c. AIDS records d. Mental health assessment
a
Of the following, which is a hospital-acquired condition (HAC)? a. Air embolism b. Stage 1 pressure ulcer c. Traumatic wound infection d. Breach birth
a
One of the ways that an EHR is distinguished from a clinical data repository is that the EHR a. Has clinical decision support capabilities b. Has data from multiple information systems c. Can have digital images d. Aggregates data
a
Public health informatics is used for: a. Epidemiology b. Fraud and abuse monitoring c. Billing and reimbursement d. Request for information
a
The ability to obtain the same results from different studies using different methodologies and different populations is a. Reliability b. Validity c. Confidence d. Specificity
a
The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with a. Completeness b. Validity c. Reliability d. Timeliness
a
The doctrine that the decisions of the court should stand as precedents for future guidance is a. Res ipsa loquitur b. Respondent superior c. Stare decisis d. Statute of limitations
a
Which of the following agencies is empowered to implement the law governing Medicare and Medicaid? a. Centers for Medicare and Medicaid Services (CMS) formerly known as Health Care Financing Administration (HCFA) b. Joint Commission c. Institutes of Health d. Department of Health and Human Services
a
Which of the following classification systems was designed with electronic systems in mind currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and images? a. SNOMED CT b. SNDO c. ICDPC-2 d. GEM
a
Which of the following would be a business associate? a. Release of information company b. Bulk food service provider c. Childbirth class instructor d. Security guards
a
Which of the following is an example of the breach of confidentiality? a. A nurse speaking with the physician in the patient's room b. Staff members discussing patients in the elevator c. The admission clerk verifying over the phone that the patient is in-house d. The hospital operator paging code blue in room 3 north
b
Which of the following statements is FALSE in regard to departmental reengineering? a. It is mainly done to reduce departmental costs b. It is intended to make small or minor changes in order to improve a function or process c. It is intended to improve departmental productivity d. It is intended to ensure satisfied customers
b
Which of the following systems would provide a snapshot of information about the patient's condition? a. EHR b. Continuity of care record c. Personal health record d. SMART card1
b
Which of the following would be an inappropriate procedure for the custodian of the medical record to perform prior to taking a medical record from a health care facility to court? a. Number each of the record in ink b. Document in the file folder the total number of pages in the record c. Remove any information that might prove detrimental to the hospital or physician d. Prepare an itemized list of sheets contained in the medical record
b
Which security measure utilizes fingerprints or retina scans? a. Audit trail b. Biometrics c. Authentication d. Encryption
b
Which system is a classification of health and health-related domains that describe body functions and structures, domains of activities and participation, and environmental factors that interact with all of these components? a. International Classification of Primary Care (ICPC-2) b. International Classification on Functioning Disability, and Health (ICF) c. National Drug Codes d. Clinical Care Classification (CCC)
b
Who is legally responsible for obtaining the patient's informed consent for surgery? a. The admission clerk b. The surgeon performing the surgery c. The nurse d. Medical records personnel
b
You are reviewing your privacy and security policies, procedures, training program, and so on, and comparing them to the HIPAA and ARRA regulations You are conducting a a. Policy assessment b. Risk assessment c. Compliance audit d. Risk management
b
You need to know the structures in the database, the types of records stored, and the fields used. In which component of database design will you find this information? a. Data dictionary b. Data model c. Database design specification d. Database management
b
Your release of information system has part of the computing on the workstation and part on the file server. What type of technology is being used? a. Internet b. Client server c. LAN d. Operating system
b
Your state regulation requires health records to be kept for a statute of limitations period of 7 years. Federal law requires records to be retained for 5 years. The minimum retention period for health records in your facility should be a. 5 years b. 7 years c. 10 years d. Either 5 or 7 years, as determined by the facility
b
A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare Fee Schedule amount for this service is $200.00. The non-PAR Medicare Fee Schedule amount for this service is $190.00 If the physician is a participating physician who accepts assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is a. $200.00 b. $40.00 c. $160.00 d. $30.00
b 80% of 200= 160. 20% of 200=
Mr. McDonaldson was admitted to your hospital at 10:45 PM on January 1. He died at 4:22 Am on January 3. How many inpatient service days did Mr. McDonaldson receive? a. 1 b. 2 c. 3 d. 4
b The day of admission is counted as inpatient service day, but the day of discharge is not
Selena works 40 hours per week at Rio Grande Radiology, which pays time-and-a-half for overtime and double-time for holidays. During this past week, Selena took 6 hours of unpaid personal leave and worked an 8-hour holiday. How many hours will Selena be paid? a. 34 b. 42 c. 48 d. 50
b Selena took 6 hours' unpaid leave 40-6=34, but worked a holiday at double time (8*2=16). Because 8 hours of the holiday are already figured in the work week, add an additional 8 hours for holiday pay. So 34+ 8=42
Which of the following statements describes a method of following a procedure? a. Medical records requested by the emergency room will be retrieved and delivered within 30 minutes b. Multiple-page discharge summaries are stapled together in the left-hand corner c. Transcription turnaround time is established as 24 hours following completion of dictation by the physician d. Only HIM personnel have access to the medical record filing area
b"Medical records requested by the emergency room will be retrieved and delivered within 30 minutes" and "transcription turnaround time is established as 24 hours following completion of dictation byu the physician" describe a standard. "Only HIM personnel have access to the medical record filing area" describes a rule"
According to the American Medical Association, medical decision making is measured by all of the following except the a. Number of diagnoses or management options b. Amount and complexity of data reviewed c. Risk of complications d. Specialty of the treating physician
d
All of the following items mean the same thing, EXCEPT a. Inpatient service day b. Daily inpatient census c. Daily census d. Inpatient census
d
An example of a primary data source for health care statistics is the a. Disease index b. Accession register c. MPI d. Health record
d
As HIM director, you must ensure a means to regulate access and ensure preservation of data in the health care facility's computer system. Which of the following is NOT a security measure that can be implemented to prevent privacy violations in this computer system? a. Authentication b. Encryption c. Disaster recovery plan d. Stonewall
d
As an HIM supervisor, one of your employees reports that a coworker has returned from lunch on numerous occasions with the smell of alcohol on his breath. What is the best approach in handling this problem? a. Confront the employee and place him on suspension for 1 week b. Terminate the employee immediately c. Ignore the report because it is hearsay d. Handle the situation as you would any other disease that affects an employee's work
d
Before a user is allowed to access protected health information, the system confirms that this is a valid user. This is known as a. Access control b. Notification c. Authorization d. Authentication
d
CMS adjusts the Medicare Severity DRGs and the reimbursement rates every a. Calendar year beginning January 1 b. Quarter c. Month d. Fiscal year beginning October 1
d
Case definition is important for all types of registries. Age will certainly be an important criterion for accessing a case in a(n) _____________ registry. a. Implant b. Trauma c. HIV/AIDS d. Birth defects
d
Cheryl is the director of the Health Information Services Department and Suzanne is the assistant director. Cheryl notices one of Suzanne's subordinates leaving the department for an unscheduled break. When the employee returns, Cheryl immediately asks the employee to step into her office and begins discussing the unauthorized break. Which organizational principle is this director violating? a. Organizational function b. Grievance procedure c. Span of control d. Unity of command
d
In a hospital, a document that contains a computer generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a (n) a. Encounter form b. Superbill c. Revenue master d. Chargemaster
d
In assigning E/M codes, three key components are used. There are a. History, examination, counseling b. History, examination, time c. History, nature of presenting problem, time d. History, examination, medical decision making
d
In selecting a messaging standard for use in a picture archival communication system, the BEST choice would be a. Consolidating Health Informatics Initiatives b. National Drug Code c. HL7 d. DICOM
d
One of the patients at your physician group practice has asked for an electronic copy of her medical record. Your electronic computer system will not allow you to accommodate this request. Chances are, you are NOT in compliance with a. Joint Commission standards b. Conditions of Coverage rules c. The HIPAA privacy rule d. Meaningful use requirements
d
Puget Sound Health System has set hiring goals and taken steps to guarantee equal employment opportunities for members of protected groups (e.g., American Indians, veterans). It is complying with a. Affirmative Action b. Equal Pay Act c. Minority Hiring Act d. Civil Rights Act
d
The best example of a point-of-care service and documentation is a. Using an automated tracking system to locate a record b. Using occurrence screens to identify adverse events c. Doctors using voice recognition to dictate radiology reports d. Nurses using bedside terminals to record vital signs
d
The function of a (an) _________ Is limited to data retrieval. a. Electronic health record b. Executive information system c. Database management system d. Clinical data repository
d
The health record states that the patient is a female, but the registration record has the patient listed as male. Which of the following characteristics of data quality has been compromised in this care? a. Data comprehensiveness b. Data granularity c. Data precision d. Data accuracy
d
The manager of the quality department is listing various sources of data. Which of the following data sources would be an example of an external source? a. Emergency room logs b. Incident reports c. Patient registration and admission, discharge and transfer (ADT) information d. Quality improvement organization (QIO) information
d
The medical malpractice crisis of the 1970's prompted the development of __________________ in health care facilities. a. Utilization management b. Financial analysis programs c. Quality improvement programs d. Risk management
d
The most important consideration in planning the office layout for a Health Information Service department is the a. Number of employees b. Cost c. Types of furniture to be purchased d. Workflow
d
The patient has the right to agree or object in which of the following situations? a. Disclosing information to patient's attorney b. Disclosing information to minister c. Disclosing information to family member who is not directly involved in the care d. Disclosing information to family member who is directly involved in care
d
The utilization review coordinator reviews inpatient records at regular intervals to justify necessary and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed? a. Admission review b. Preadmission c. Retrospective review d. Continued stay review
d
There are seven criteria for high quality clinical documentation. All of these elements are included EXCEPT a. Precise b. Complete c. Consistent d. Covered (by third-party payer)
d
This is a 10-digit, intelligence-free, numeric identifier designed to replace all previous provider legacy numbers. This number identifies the physician universally to all payers. This number is issued to all HIPAA-covered entities. It is mandatory on the CMS-1500 and UB-04 claim forms. a. National Practitioner Databank (NPD) b. Universal Physician Number (UPN) c. Master Patient Index (MPI) d. National Provider Identifier (NPI)
d
What component of the history and physical examination includes an inventory designed to uncover current or past subjective symptoms? a. Past medial history b. Social and personal history c. Chief complaints d. Review of systems
d
What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future? a. Risk management b. Quality control c. Utilization management d. Performance improvement
d
Which of the following is NOT a major management challenge in the storage and retention of electronic health record systems? a. Following state and federal laws and accreditation requirements when developing retention and destruction policies b. Keeping technology updated in order to retrieve data c. Ensuring that health information can be retrieved in a timely manner d. Maintaining the paper-based storage system
d
Which of the following is NOT a technical security control employed by electronic health record systems? a. Audit trails b. Data encryptions protocols c. User-based access controls d. Automatic logon
d
Which of the following is an example of two-factor authentication? a. Username and password b. Token and smart card c. Fingerprint and retinal scan d. Password and token
d
Which of the following is considered confidential information if the patient is seeking treatment in substance abuse facility? a. Patient's name b. Patient's address c. Patient's diagnosis d. All of these answers apply
d
Which of the following should NOT be included in the documentation of record destruction? a. A statement that records were destroyed in the normal course of business b. Method of destruction c. Signature of the individuals supervising and witnessing the destruction. d. Dates not covered in destruction
d
Which one of the following is NOT an advantage of computerized master patient index? a. It allows access to data alphabetically, phonetically, or by date of birth, social security number, medical record, or billing number. b. It solves most space and retrieval problems c. It provides other departments with immediate access to the information maintained in the master patient index. Duplication of patient registration can never occur
d
With data exchange standards, the ability to transfer data from one system to another system is called a. Data sets b. Messaging standards c. Interfaces d. Interoperability
d
With the passage of Medicare (Title XVIII of Social Security Act) in 1965, which of the following functions became mandatory? a. Quality improvement b. Risk management c. Quality assessment d. Utilization review
d
You have been asked by a peer review committee to print a list of medical record numbers of all patient who had CABGs performed in the past year at your acute care hospital. Which secondary data source could be used to quickly gather this information? a. Disease index b. Physician index c. Master patient index d. Operation index
d
You sit on the quality improvement team for the Nursing department that meets to generate ideas to address verbal order documentation problems about the "Read Back Verbal Order" policy. What QI tool would prove useful in sharing input and various recommendations for solving this problem? a. Flowchart b. Scatter diagram c. Check sheet d. Brainstorming
d
You use the Internet to log in to a system and from there you are able to access several systems. This technology is known a(n): a. Authentication b. Application c. Link d. Portal
d
_____________ refers to the flatness or peakedness of one distribution in relation to another distribution. a. Skewness b. Correlation c. Central tendency d. Kurtosis
d
The inpatient census at midnight is 67. Two patients were admitted in the morning; one died 2 hours later; the second patient was transferred to another facility that same afternoon. The inpatient service days for that day will be a. 65 b. 67 c. 68 d. 69
d 67+2= 69 admissions/discharges same day. (transfers to other facilities and death are forms of discharges.)
Assume the patient has already met his or her deductible and that the physician is a nonparticipating Medicare provider but does not accept assignment. The standard fee for the services provided is $120.00. Medicare's PAR fee is $60.00 and Medicare's non-PAR fee is $57.00. What is the amount Medicare will pay the beneficiary on this claim? a. $120.00 b. $60.00 c. $57.00 d. $45.60
d 80% of 57.00
Changes in case-mix index (CMI) may be attributed to all of the following factors EXCEPT a. Changes in medical staff composition b. Changes in coding rules c. Changes in services offered d. Changes in coding productivity
d Coding productivity will not directly affect CMI. Inaccuracy or poor coding quality can affect the CMI
Gerda Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gerda has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's a. EDMS system b. CPOE c. Expert system d. RIO
d EDMS-electronic data management system
The staff in the Human Resource Department is proposing a cloud training program for 200 employees and needs to prepare a budget for the time and cost of the training. · The training program will be 30 minutes in length · The employees can take the training online at any time · There are 200 employees to be trained · The rate of pay for 50 of the employees is $15.50 per hour · The rate of pay for 50 employees is $12.00 per hour · The rate of pay for the other 100 employees is $18.00 per hour How much should the training staff request in the budget for doing the computer-based training program? a. $3,175.00 b. $1,975.00 c. $1,887.50 d. $1,587.50
d 50 employees x $15.50 per hour x ½ hour =387.50 50 employees x $12.00 per hour x ½ hour =300.00 100 employees x $18.00 per hour x ½ hour= 900.00 387.50 + 300.00 + 900.00 =1,587.50
The average number of transcribed lines per month at Bent Tree Hospital is 142,500. The daily production standard is 950 lines per day. With 20 workdays in the month, calculate the minimum number of FTEs needed for this volume. a. 13 b. 8 c. 6 d. 7.5
d 950 x 20= 19,000; 142,500/19,000=7.5 FTEs
Case Study 2 A 73-year-old male was admitted to the Sunset Nursing Facility with senility, cataracts, and S/P cerebrovascular accident with right-side hemiplegia. On his second day at the facility, the resident was discovered to have extensive thermal burns on his buttocks and legs by one of the facility's attendants. 1. Referring to case study 2, the resident's family brought legal action against the nursing facility for a. Medical abandonment b. Vicarious liability c. Assault and battery d. Negligence 2. Referring to case study 2, which of the following can the attorney of the resident's family also use as a basis for the lawsuit, and why? a. The doctrine of res ipsa loquitur because it allows the plaintiff to shift the burden of proof to the defendant because direct evidence is available b. The doctrine of charitable immunity because the nursing facility is a private institution and is shielded for liability for any torts committed on its property. c. The Good Samaritan Statues because they protect the director of nursing, an employee of the nursing facility, who was not present when the injury occurred. d. The failure to warn theory because the doctor did not inform the resident's family that the resident was in danger at the nursing facility. 3. What source or document is considered the "supreme law of the land"? a. Bill of rights b. Supreme court decisions c. Presidential power d. Constitution of the United States 4. All of the following require the patient to sign a consent for EXCEPT a. To release information to the emergency room physician b. To refuse treatment c. For the physician to perform an invasive procedure d. For the surgeon to perform surgery
d, a, d, a
Out of 2543 records requested from the HIM Department 2375 were located. What is the filing accurate rate? a. 6.61% b. 75.33% c. 89.01% d. 93.39%
(2,375 records retrieved from proper locations x 100) divided by 2,543 records requested= 93.39% filing accuracy
A method that has been developed for representing a variety of data on a single display in a easy-to-read format is called a a. Dashboard b. Pareto chart c. Line chart d. Textual summary
a
A patient is admitted for a diagnostic workup for cachexia. The final diagnosis is malignant neoplasm of lung with metastasis. The present on admission (POA) indicator is a. Y= Present at the time of inpatient admission b. N=Not present at the time of inpatient admission c. U=Documentation is insufficient to determine if condition was present at the time of admission d. W=Provider is unable to clinically determine if condition was present at the time of admission
a
A radiologist is asked to review a patient's CPT scan that was taken at another facility. The modifier -26 is attached to the code indicates that the physician is billing for what components of the procedure? a. Professional b. Technical c. Global d. Confirmatory
a
A valid authorization for the disclosure of health information should not be a. Dated prior to discharge of the patient b. In writing c. Addressed to the health care provider d. Signed by the patient
a
A work environment that is not ergonomically sound could lead to a. Injuries b. Conflict among departments c. Employee arguments d. Increases in department equipment budgets
a
According to AHINA's recommended retention standards, which of the following types of health information does NOT need to be retained permanently? a. Physician index b. Register of births c. Register of surgical procedures d. Register of deaths
a
All of the following statements are true of MS-DRGs, EXCEPT a. A patient claim may have multiple MS-DRGs b. The MS-DRG payment received by the hospital may be lower than the actual cost of providing the services c. Special circumstances can result in a cost outlier payment to the hospital d. There are several types of hospitals that are excluded from the Medicare inpatient PPS
a
An employee in the admission department stole the patient's name, social security number and other information and used it to get a charge card in the patient's name. This is an example of a. Identify theft b. Mitigation c. Disclosure d. Release of information
a
An improper disclosure of patient information to unauthorized individuals, agencies or news media may be considered a(n) a. Invasion of privacy b. Libel c. Slander d. Defamation
a
As a trauma registrar working in an emergency department, you want to begin comparing your trauma care services to other hospital-based emergency departments. To ensure that your facility is collecting the same data as other facilities, you review elements from which data set? a. DEEDS b. UHDDS c. MDS d. ORYX
a
As a working HIM professional, you are investigating the workforce development projections of electronic health records specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of this governmental agency. a. ONC b. CMS c. OSHA d. CDC
a
As director of the HIM department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to a. Install a computerized access control panel. b. Hire a security guard to monitor entrance to the file area c. Convert form a terminal digit filing system to serial unit filing d. Utilize a sign-in and sign-out log for admittance to file area
a
As the Chair of a Forms Review Committee, you need to tract the field name of a particular data field and the security levels applicable to that field. Your best source for this information would be the a. Facility's data dictionary b. MDS c. Glossary of health care terms d. UHDDS
a
Based on the following documentation in an acute care record, where would you expect this excerpt to appear? "The patient is alert and in no acute distress. Initial vital signs: T 98, P102 and regular, R 20 and BP 120/69..." a. Physical exam b. Past medial history c. Social history d. Chief complaint
a
Continuous quality improvement is best described by the following statements EXCEPT a. Corrective action targets clinicians more so that processes b. Standards are defined, measured, and systematically applied c. Monitoring is ongoing with periodic feedback d. All personal support quality improvement efforts, including top management and the governing body.
a
Currently, the enforcement of HIPAA Privacy and Security Rules is the responsibility of the a. Office for Civil Rights b. FBI c. Office of Inspector General d. Department of Recovery Audit Coordinators
a
DSM-5 is used most frequently in what type of healthcare setting? a. Behavioral health centers b. Ambulatory surgery centers c. Home health agencies d. Nursing homes
a
Darling vs. Charleston Community Memorial Hospital is considered one of the benchmark cases in health care because it was with this case that the doctrine of ______________ was eliminated for nonprofit hospitals. a. Charitable immunity b. Corporate negligence c. Professional negligence d. Contributory negligence
a
The health care providers at your hospital do a very thorough jo1b of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding. a. The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. b. Whether a postoperative infection occurred and how it was treated. c. The quality of follow-up care d. Whether the severity of illness and/or intensity of service warranted acute level of care
a
The health care providers at your hospital do a very thorough job of periodic open record review to ensure the completeness of record documentation. A qualitative review of surgical records would likely include checking for documentation regarding. a. The presence or absence of such items as preoperative and postoperative diagnosis, description of findings, and specimens removed. b. Whether a postoperative infection occurred and how it was treated. c. The quality of follow-up care d. Whether the severity of illness and/or intensity of service warranted acute level of care
a
The health care providers in a n acute care hospital require access to paper health records 24 hours a day, 7 days a week. To secure the area and continue to maintain accessibility, the Director of the HIM Department should a. Staff the department with personnel 24 hours a day b. Be on call every evening and weekends for emergency requests c. Train security guards to retrieve records after the department closes. d. Arrange for records to retrieved at 7:00AM every morning.
a
The research coordinator viewed 10 patients' record for a research study being conducted. Select the term used for this practice a. Use b. Disclosure c. Discovery d. Release
a
The standard claim used by hospitals to request reimbursement for inpatient and outpatient procedures performed or services provided is called the a. UB-04 b. CMS-1500 c. CMS-1491 d. CMS-1600
a
The type of documentation that uses drop boxes, radio buttons, and pick lists is called a. A structured data entry b. Free text c. Natural language processing d. Unstructured data entry
a
There is a problem with the data dictionary. The drop-down fields do not have all the options that are needed. This type of field is known as a: a. Structured data entry b. Unstructured data entry c. Direct data capture d. Patient data entry
a
Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long? a. Age of minority plus statute of limitations b. 10 years after the most recent encounter c. 10 years after the age of majority d. Permanently
a
What type of system would be purchased to provide information on the census, update the master patient index and distribute demographic data? a. Admission, discharge, transfer b. Executive information system c. Clinical information system d. Financial information system
a
When the third-part payer refuses to grant payment to the provider, this is called a a. Denied claim b. Clean claim c. Rejected claim d. Unprocessed claim
a
Which of the following is NOT included as a part of the minimum data maintained in the MPI? a. Principal diagnosis b. Patient medical record number c. Full name (last, first, and middle) d. Date of birth
a
Which of the following is a secondary data source that would be used to quickly gather the health records of all juvenile patients treated for diabetes within the past 6 months? a. Disease index b. Patient register c. Pediatric census sheet d. Procedure index
a
You are looking at statistics for your facility that include average length of stay (ALOS) and discharge data by DRG. What type of data are you reviewing? a. Aggregate data b. Patient-identifiable data c. MPI data d. Protocol data
a
You have been asked to give an example of a clinical information system. Which one of the following would you cite? a. Laboratory information system b. Financial information system c. Billing system d. Admission, discharge, transfer
a
______ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which no entitlement would otherwise exist. a. Fraud b. Whistle-blowing c. Abuse d. Assault
a
Bayside Hospital has 275 adult beds, 30 pediatric beds, and 40 bassinets. In a non-leap year, inpatient service days were 75, 860 for adults, 7,100 for pediatrics, and 11,800 for newborns. What was the average daily census for the year? a. 227 b. 208 c. 207 d. 259
a (75,860 + 7100)/ 365=227 (Note: average daily census includes A & P but NOT newborns)
A patient admitted to the hospital on January 24 and discharged on February 9 has a length of stay of a. 16 days b. 15 days c. 17 days d. 14 days
a 1/24-31= 8 days + 2/1 through 2/8 =8 days, so 8+8=16 (count the day of admission but not discharge)
A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare Fee Schedule amount for this service is $200.00. The non-PAR Medicare Fee Schedule amount for this service is $190.00 If this physician is a nonparticipating physician who does NOT accept assignment for this claim, the total amount of the patient's financial liability (out-of-pocket expense) is a. $66.50 b. $38.00 c. $190.00 d. $152.00
a 20% of 190=38 patient liable for 20% coinsurance 190 x0.15=28.50 (15% limiting charge) over NON-par. 28.50+38=
Sea Crest Hospital has 200 beds and 20 bassinets. There was a sudden increase in the birth rate in the town in November. The hospital set up five additional bassinets for the entire month. Total bed count days for Sea Credit Hospital in a nonleap year would be a. 73,000 b. 80,300 c. 80,450 d. 80,455
a 200 beds x 365 days in a nonleap year = 73,000 (note: bassinets are excluded)
2. If there are 150,000 medical records and the Health Information Department received 3,545 requests for records in a week, what percentage of the records are requested weekly? a. 2.4% b. 3.5% c. 4.6% d. 5.1%
a 3,545 requested records x 100 / 150,000 total records 354,500/150,000=2.36= 2.4%
According to the following table, the most serious record delinquency problem occurred in which of the following months? Record Delinquency for Second Quarter April May June Percentage in complete records 70% 88% 79% Percentage delinquent records 51% 43% 61% Percentage delinquent due to missing H&P 3% 1.4% 0.5% a. April b. May c. June d. Cannot determine from this data
a A recommendation for improviment from JC is indicated if the number of delinquent records is greater than 50% or if the % of records with delingquent records due to missing H&P's exceeds 2% of the average monthly discharges. In the month of April, both of these delinquence problems are reflected. The % of imomplete records is not relevant
A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captures on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data a. Reliability b. Accessibility c. Legibility d. Completeness
a Data reliability implies that data are consistent no matte rhow many times the same data are collected and entered into a system. Accessibility-data avaliabnle to authorize people. Completeness all required data in system.
Stage I of meaningful use focused on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? a. Use CPOE for medications orders b. Smoking cessation counseling for MI patients c. Appropriate use of HL-7 standards d. Establish critical pathway for complex, high-dollar cases
a Healthit.hhs.gov has the complete list
A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare Fee Schedule amount for this service is $200.00. The non-PAR Medicare Fee Schedule amount for this service is $190.00 If this physician is a participating physician who accepts assignment for this claim, the total amount the physician will receive is a. $200.00 b. $250.00 c. $218.50 d. $190.00
a If a physician is participating physician who accepts assignment he will receive the lessor of the "total charges" of "the PAR Medicare fee schedule amount" in this case the Medicare fee schedule amount is less; therefore, the total received by the physician is 200.00
If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? a. 2.4% b. 3.5% c. 4.6% d. 5.1%
a 3454 x 100 / 150,000= 2.36% = 2.4%
The staff in the Human Resource Department is proposing a cloud training program for 200 employees and needs to prepare a budget for the time and cost of the training. · The training program will be 30 minutes in length · The employees can take the training online at any time · There are 200 employees to be trained · The rate of pay for 50 of the employees is $15.50 per hour · The rate of pay for 50 employees is $12.00 per hour · The rate of pay for the other 100 employees is $18.00 per hour What would be the average cost for training an individual employee? a. $7.94 b. $9.00 c. $15.50 d. $15.87
a Calculate by time : $1,587.50 total cost for training/ 100 hours needed to train =$15.88 per hour/2 to get cost for ½ hour of training = 7.938 = $7.94 OR Calculate by employee: $1,587.50/200 employees = 7.938 = $7.94
Gregg is a recent graduate who has applied for a Trauma Registry position at a Chicago hospital while he prepares to apply to graduate school. In making the decision, he considers the offer of $15 per hour for a 40-hour week, benefits of 27.5% of his salary, and tuition waivers of six credits per year at $145. He calculated that his total compensation, rounded to the nearest dollar, would be a. $40,650 b. $39,563 c. $38,599 d. $31,030
a Calculation: $15.00 x 2080 hours per year=$31,200 x 27.5%= $8,580 Tuition waiver = 6 credits at $145 = $870 Therefore, $31,200 + $8,580 +$870= $40,650
A 16-year-old female delivers a stillborn infant in Mercy Hospital. The clinical documentation on the stillborn infant would a. Be filed in a health record created for the infant b. Be filed in the mother's record c. Be retained in a separate file in the administrative offices d. Not be retained in hospital records
b
A coder notes that a patient is taking prescription Pilocarpine. The final diagnosis on the discharge summary are congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of a. Arthritis b. Glaucoma c. Bronchitis d. Laryngitis
b
A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued. a. -52 b. -53 c. -73 d. -74
b
A physician excises a 3.1 cm malignant lesion of the scalp that requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded? a. Full-thickness skin graft to the scalp b. Excision of lesion; full-thickness skin graft to the scalp c. Excision of lesion; full-thickness skin graft to the scalp; excision of skin from thigh d. Code 15004 for surgical preparation of recipient site; full-thickness skin graft to scalp
b
According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a. Principal procedure b. Significant procedure c. Operating room procedure d. Therapeutic procedure
b
Administrative, financial, and other systems supply the EHR with much of its data. What are these various systems known as? a. Application b. Source systems c. Administrative information systems d. Point-of-care charting
b
All of the following are examples of intentional torts EXCEPT a. Medical abandonment b. Failure to warn c. Invasion of privacy d. Breach of contract
b
An example of a primary data source is the a. Physician index b. Health record c. Cancer registry d. Hospital statistical report
b
Organizations collect statistics to increase their knowledge of a specified population. The knowledge does not come automatically-it is developed in the following sequence: a. Data-facts-information-knowledge b. Data-information-facts-knowledge c. Facts-data-information-knowledge d. Facts-information-data-knowledge
b
Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS but NOT the UHDDS would be a. A personal identification b. Cognitive patterns c. Procedures and dates d. Principal diagnosis
b
The HIM Department at General Hospital has been experiencing an average 30-minute delay in the retrieval of records requested by the Emergency Department. Which of the following corrective actions would be most effective in reducing the delay in retrieval of requested records? a. Offer a prize to the employee who locates the requested records first. b. Review and possibly reengineer the retrieval process to decrease retrieval time. c. Allow the requesters to retrieve the record themselves. d. Increase file area staff to include one additional file clerk devoted to pulling records for the emergency room.
b
The HIM supervisor uses many of the advanced functions of the EHR. This use of advanced features is an example of which of the following: a. Governance b. Optimization c. Adoption d. Meaningful use
b
The ideal consent for medical treatment obtained by the physician is a. Expressed b. Informed c. Implied d. Verbal
b
The improvement process of comparing the collection and coding of POA indicators at your facility with those of comparable departments of superior performance of other health care facilities is referred to as a. Focused review b. Benchmarking c. Peer review d. Occurrence screening
b
The minimum record retention period for patients who are minors is a. Age of majority b. Age of majority plus the statute of limitations c. 5 years past treatment d. 2 years past treatment
b
The prospective payment system used to reimburse home health agencies for patient with Medicare utilizes data from the a. MDS b. OASIS c. UHDDS d. UACDS
b
The three components of data security program are protecting the privacy of data, ensuring the integrity of data, and ensuring the ________. a. Validity of data b. Availability of data c. Security of hardware d. Security of data
b
Which of the following lists in in correct alphabetical order? a. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Phillip; Ferlazzo J. b. Ferlazzo, J.; Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, Joshua Philip c. Ferlazzo, Joshua; Ferlazzo, Joshua P.; Ferlazzo, J.; Ferlazzo, Joshua Philip d. Ferlazzo, Joshua A.; Ferlazzo, B.; Ferlazzo, Joshua; Ferlazzo, Joshua Philip
b
As chief privacy officer for Premier Medical Center, you are responsible for which of the following? a. Backing up data b. Developing a plan for reporting privacy complaints c. Writing policies on protecting hardware d. Writing policies on encryption standards
b. Developing a plan for reporting privacy complaints
A fetal death occurring during the 21stweek of pregnancy, weighing 1,000 g is considered to be a(n) a. Early fetal death b. Preterm neonate c. Intermediate fetal death d. Late fetal death
c
A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare Fee Schedule amount for this service is $200.00. The non-PAR Medicare Fee Schedule amount for this service is $190.00 The patient is financially liable for the coninsurance amount, which a. 80% b. 100% c. 20% d. 15%
c
A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a(n) a. Disease index b. Master patient index c. Disease registry d. Admissions register
c
As part of the Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for a. Including the primary caregiver in surgery consults b. Including the surgeon in the paranesthesia assessment c. Marking the surgical site d. Apprising the patient of all complications that might occur Requirement of the joint commission
c
A system of preferred terminology for naming, disease processes is known as a a. Set of categories b. Classification system c. Medical nomenclature d. Diagnosis listing
c
According to CPT, in which of the following cases would an established E/M code be used? a. A home visit with a 45-year-old male with a long history of drug abuse and alcoholism. The man is seen at the request of Adult Protective Services for an assessment of his mental capabilities. b. John and his family have just moved to town. John has asthma and requires medication to control the problem. He has an appointment with Dr. You and will bring his records from his previous physician. c. Tom is seen by Dr. X for a sore throat. Dr. C is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple years ago. d. A 78-year-old female with weight loss and progressive agitation over the past two months is a seen by her physician for drug therapy. She has not seen her primary care physician in 4 years.
c
As an HIM coding supervisor, you are asked to compare the current coding process with a proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure? a. Decision matrix b. Cause and effect diagram c. Flowchart d. Check sheet
c
The body of law founded on custom, natural justice and reason, and sanctioned by usage and judicial decision is known as a. Common law b. Lien law c. Constitutional law d. Statutory law
c
The case-mix management system that utilized information from the minimum data set (MDS) in long-term care settings is called a. Medicare Severity Diagnosis Related Groups (MS-DRGs) b. Resource Based Relative Value Systems (RBRVS) c. Resource Utilization Groups (RUGs) d. Ambulatory Patient Classifications (APCs)
c
The director of the Health Information Services Department has asked that the supervisor of coding institute a method to monitor the accuracy of coding. What method would be the most effective approach? a. Perform a 100% review of one of the employees' work each day b. Review a sample of each employee's work annually c. Review a random sample of each employee's work monthly d. Have each employee check each other's work and report any problems to the supervisor
c
The foundation for communicating all patient care goals in long-term care settings is the a. Legal assessment b. Cognitive assessment c. Interdisciplinary plan of care d. Uniform Hospital Discharge Data Set
c
The legislation that required all federally funded facilities to inform patients of their rights under state law to accept or refuse medical treatment is known as a. Advanced directives b. Living wills c. Patient self-determination act d. Durable power of attorney
c
The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct. a. CPT code b. Standard Nomenclature of Injuries codes c. ICD-10-CM codes d. HCPCS level II codes
c
The master patient index must, at a minimum, include sufficient information to a. Summarize the patient's medical history b. List all physicians who have every treated the patient c. Uniquely identify the patient d. Justify the patient's hospital bill
c
The most widely discussed and debated unique patient identifier is the a. Patient's date of birth b. Patient's first and last names c. Patient's social security number d. Unique Physician Identification Number (UPIN)
c
The organizing process determines how the work in a particular department will be divided and accomplished. In order to be in the best position to organize the work effectively, the manager must first engage in which management function? a. Staffing b. Directing c. Planning d. Controlling
c
The patient has requested an amendment to her health record. The facility, after review with the physician, has decided to deny the request. According to HIPAA, the patient must be notified within how many days? a. 90 b. 30 c. 60 d. 45
c
The patient has the right to control access to his or her health information. This is known as a. Security b. Confidentiality c. Privacy d. Disclosure
c
The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called a. APGs b. RBRVS c. APCs d. MS-DRGs
c
The standard deviation of a particular set of measures was found to be 20.00. The sample variance would then be a. 20 b. 5 c. 400 d. 10
c
Twelve new cases of a certain disease occurred during the month of August. If 4,000 persons were at risk during August, then the a. Prevalence was 3 per 1,000 persons b. Prevalence was 6 per 1,000 persons c. Incidence was 3 per 1,000 persons d. Incidence was 6 per 1,000 persons
c
What follow-up rate does the American College of Surgeons mandate for all cancer cases to meet approval requirements as a cancer problem? a. 70% b. 80% c. 90% d. 100%
c
You are trying to improve communication with your staff by posting graphs of significant statistics on the employee bulletin board. You recently calculated the percentage of time employees spend on each of six major tasks. Because you would like the employees to appreciate each task as a percentage of their whole day, you will post these figures using a a. Line graph b. Bar graph c. Scatter diagram d. Pie graph
c
You just completed a process through which you reviewed a patient record and entered the required elements into a database. What is this process called? a. Case finding b. Staging c. Abstracting d. Nomenclature
c
______ is a joint federal and state program that provides health care coverage to low-income populations and certain aged and disable individuals a. TRICARE b. Medicare Part A c. Medicaid d. Medicare Part B
c
The statistics reported for a 300-bed hospital for 1 year were 20,932 discharges with 136,651 discharge days and 3,699 consultations performed. What was the consultation rate for the year? a. 16.5% b. 17.0% c. 17.7% d. 18.0%
c (3,699 x 100) / 20,932= 17.7%
Sandy Beach Hospital reports 1,652 discharges for September. The infection control report documents 21 nosocomial infections and 27 community-acquired infections for the same month. What is the community-acquired infection rate? a. 1.3 b. 1.4 c. 1.6 d. 2.9
c (27 x 100)/1652=1.6%
The first patient with cancer seen in your facility on January 1, 2018, was diagnosed with colon cancer with no known history of previous malignancies. The accession number assigned to this patient is a. 18-0000/00 b. 18-0000/01 c. 18-0001/00 d. 18-0001/01
c 18 represents the year the pt entered the database. 0001 indicates first case entered that year. 00 indicates pt only has one known neoplasm
A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the a. Doctors' progress notes b. Integrated progress notes c. Incident report d. Nurses' notes
c Factual summaries investigating unexpected facility events should not be treated as part of a patient' health information and therefore would not be records in the health record
A patient with Medicare is seen in the physician's office. The total charge for this office visit is $250.00. The patient has previously paid his deductible under Medicare Part B. The PAR Medicare Fee Schedule amount for this service is $200.00. The non-PAR Medicare Fee Schedule amount for this service is $190.00 If this physician is a nonparticipating physician who does NOT accept assignment for this clam, the total amount the physician will receive is a. $250.00 b. $200.00 c. $218.50 d. $190.00
c IF a physician is nonparticipating physician who does not accept assignment, he can collect a max of 15% (the limiting charge) over the non-PAR Medicare fee schedule amount. 15% of 190 28.50. 190+28.50=
Setting up a drop-down menu to make sure that the registration clerk collects "gender" as "male, female, or unknown" is an example of ensuring data a. Reliability b. Timeliness c. Precision d. Validity
c Precision refers to data values that are just large enough to support the application of the process.
As part of the Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for a. Including the primary caregiver in surgery consults b. Including the surgeon in the paranesthesia assessment c. Marking the surgical site d. Apprising the patient of all complications that might occur
c Requirement of the joint commission
Lake City Health Center has 200 beds and 20 bassinets. In a non-leap year, Styles Hospital admitted 16,437 adults and children; 16,570 adults and children were discharged. There were 1,764 live births and 1,798 newborns discharged. The bed turnover rate for the year was a. 82.2 b. 82.7 c. 82.9 d. 93.5
c Use the direct method, bed turnover. 16,570 adult and peds discharge/200 adult and peds beds = 82.85=82.9%
A health information manager develops a formal plan or record retention schedule for the automatic transfer of records to inactive storage and potential destruction based on all but which one of the following factors? a. Statute of limitations b. Volume of research c. Readmission rate d. Department staffing
d
The staff in the Human Resource Department is proposing a cloud training program for 200 employees and needs to prepare a budget for the time and cost of the training. · The training program will be 30 minutes in length · The employees can take the training online at any time · There are 200 employees to be trained · The rate of pay for 50 of the employees is $15.50 per hour · The rate of pay for 50 employees is $12.00 per hour · The rate of pay for the other 100 employees is $18.00 per hour How many employee clock hours will be needed to complete the training? a. 200 hours b. 150 hours c. 100 hours d. 50 hours
c 200 x 30/60= 100 hours total
As the director of the Health Information Department, you are preparing a request for approval for the purchase of an encoding system. Because this is considered a capital request, you are required to submit the cost-benefit ratio. The software and license cost $6,000, hardware maintenance is $1,500, and the training of two employees will cost $500. It is expected that the encoding system will increase reimbursement by $10,000. The cost-benefit ratio is a. 0.8 b. 1.7 c. 1.25 d. 1.33
c Costs= $6,000 + $1,500 +$500 = $8,000 Benefits = $10,000 (that is the increase in reimbursement) 10,000/8,000 =1.25. Benefits/Costs ratio = 1.25 (this also known as the cost-benefit figure.) IN other words, for every dollar invested in the encoding system, it will have a return of $1.25 after 1 year.
A Mechanism to ensure that PHI has not been altered or destroyed inappropriately has been established. This process is called a. Entity authentication b. Audit controls c. Access controls d. Integrity
d
Case Study 1 You are the director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. 1. Referring to the case study 1, Barbara Masters is the _____________ in this case. a. Appellant b. Appellee c. Defendant d. Plaintiff 2. Referring to the case study 1, Bayshore Hospital is the ______________ in this case. a. Appellant b. Appellee c. Defendant d. Plaintiff 3. Referring to the case study 1, the sworn verbal testimony you are asked to provide is called a(n) a. Interrogatory b. Deposition c. Physical and mental examination d. Court order 4. Referring to the case study 1, the written answers to questions you have been asked to provider are known as a(n) a. Interrogatory b. Deposition c. Physical and mental examination d. Court order 5. Referring to case study 1, what phase of the lawsuit are you involved in? a. Pretrial conference b. Trial c. Discovery d. Appeal 6. The failure to obtain written consent of the patient before performing a surgical procedure may constitute a. Battery b. Contempt c. Libel d. Malpractice
d, c, b, a, c, a
Case Study 3 William is a 16-year-old male who lives at home with his parents and works part-time as a dishwasher at one of the local restaurants. While emptying the dishwasher, William is severely scaled and rendered unconscious. He is taken to the emergency room of the local acute care hospital for emergency treatment. 1. Referring to case study 3, given the emergency of the situation, who should the health care provider seek consent from in order to provide treatment to William? a. The employer b. The parents c. The patient d. No consent is needed for emergency care 2. Referring to case study 3, in order to release information to his employer, the hospital must receive a a. Consent signed by the patient b. Court order c. Consent signed by the doctor d. Consent signed by the patient's parent
d, d
