RHIT Practice Exam 2020

A celebrity injured while on vacation was admitted to the local community hospital for treatment of a fracture. On day two of the admission, the hospital was contacted by several media agencies stating that they were aware the patient was at the facility and requesting information about the current medical condition of this high profile celebrity patient. The CEO is concerned that an employee has shared information to the media regarding the patient. The facility privacy officer was tasked with determining if a facility employee leaked this information to the press. How would the privacy officer begin with analysis? A. Create a new policy about high-profile patient privacy B. Start by discussing the situation with the media to resovle their inquiries C. Make contact with employees in the facility D. Review audit trail information to determine which employees have accessed this patient's information

Review audit trail information to determine which employees have accessed this patient's information The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. Often they record time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred. Reviewing the audit trail information would be the first step to identify all employees who have accessed this patient's information.

The Information Services Department has requested information about the electronic signature system being used in your facility. they would like to know the locations where physicians are accessing the system. Review the information in the table below. What is the percentage of physicians not using the electronic signature system? ***Graph is needed to answer Q 81.*** A. 2.2% B. 2.45% C. 18.81% D. 99.99%

2.2% The ratio of a part to the whole is often expressed as a percentage. Percentages are a useful way to make fair comparisons. The percentage of physicians not using the system is 2.2%. (11 physicians not using the system x 100) / 500 = 1,100 / 500 = 2.2%.

The acute care hospital discharges an average of 55 patients per day. The HIM department is open during normal business hours only. The volume of productivity standard is six records per hour when coding 4.5 hours per day. Assuming that standards are met, how many FTE coders does the facility need to have on staff in order to ensure that there is no backlog? A. 2.85 B. 5 C. 14.26 D. 27

2.85 385 charts per week / 5 days/ 27 standard charts per day = 2.85.

Community Hospital had 25 inpatient deaths, including newborns, for the moth of June. The hospital performed five autopsies for the same period. What was the gross autopsy rate for the hospital for June? A. 0.02% B. 5% C. 20% D. 200%

20% The gross autopsy rate is the proportion or percentage of deaths that are followed by the performance of autopsy. In this case, (5/25)x100=20%.

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 600 clinic visits per day. The standard for filing records is 60 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day? A. 6 hours per day B. 10 hours per day C. 15 hours per day D. 25 hours per day

25 hours per day Timeliness of the storage and retrieval processes can be monitored. In this situation, each clinic visit represents a patient record that will need to be retrieved (or pulled) and stored (filed back), 600/60 = 10; 600/40 = 15; 10 + 15 = 25 hours per day.

The coding department at Community Physician's Clinic developed the following report for the denials committee at the clinic. The billing report shows the following information. How many hours will it take to reconcile these denials if each denial takes 1.5 hours to review and resubmit the bill? ***Graph is needed to answer Q 78.*** A. 11.46 hours B. 264 hours C. 3450 hours D. Unable to determine

264 hours A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be grouped into tables. Columns allow you to read data up and down, and rows allow you to read data across. The columns and rows should be labeled. In order to determine the amount of time it will take to reconcile all of the denials the number of denials is multiplied by the amount of time it takes to complete each denial (1.5 hours). 1.5 hours x 176 denials = 264 hours.

Angela's annual performance appraisal is scheduled for the next month. She has been asked by her supervisor to provide the names of two peers and one person in another department with who she regularly interacts. These individuals will contribute to Angela's evaluation. This is an example of what type of performance appraisal method? A. 360 performance appraisal B. Critical incident method C. Essay evaluation D. Graphic rating scale

360 performance appraisal Performance appraisal refers to the formal system of review and evaluation methods used to assess employee and team performance. The 360 performance appraisal method utilizes team members as part of the appraisal process. Some of the pros of this method are that bias is reduced by including multiple perspectives from inside and outside the organization (that is, manager, subordinates, peers, customers; may also include self-appraisal); it is development-focused; less useful for promotion, compensation; and it emphasizes team and customer relationships.

Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. A. 32405, Biopsy, Lung or Mediastinum, percutaneous needle B. 37609, Ligation or biopsy, temporal artery C. 20206, Biopsy, muscle, percutaneous needle D. 31629, Bronchoscopy, rigid and flexible, including fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i)

37609, Ligation or biopsy, temporal artery Begin with the main term Biopsy, artery, temporal.

A family practitioner in your local physician's clinic saw 150 adults in one week for their annual physical examinations. Sixty-seven received the flu vaccine and three patients received the pneumococcal pneumonia vaccine. What is the rate of the flue vaccine administration for this physician? A. 44.7% B. 67.0% C. 20.0% D. 447%

44.7% A rate is a ratio in which there is a distinct relationship between the numerator and the denominator and the denominator often implies a large base population. (67/150) x 100 = 44.66 = 44.7%.

Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was: A. 0.05% B. 2% C. 5% D. 20%

5% The gross death rate is the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. The gross death rate is calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including deaths, for the same period: 25/500 = 0.05 x 100 = 5%.

The HIM professional reported to the quality improvement committee at Community Hospital that there were 58 patients with influenza discharged from the hospital in January. Of those, 3 died. What is the case fatality rate for influenza for January? A. 1.60% B. 5.17% C. 0.10% D. 94.8%

5.17% The case fatality rate is the total number of deaths due to a specific illness during a given time period divided by the total number of cases during the same period. (3 x 100) / 58 = 300 / 58 = 5.17%.

Per the HITECH breach notification requirements, what is the threshold for the immediate notification of each individual? A. 1,00 individuals affected B. 500 individuals affected C. 250 individuals affected D. Any number of individuals affected requires individual notification.

500 individuals affected All individuals whose information has been breached must be notified without unreasonable delay, and not more than 60 days, by first-class mail or a faster method (such as telephone) if there is the potential for imminent misuse. If 500 or more individuals are affected, they must be individually notified immediately and media outlets must be used as a notification mechanism as well. The Secretary of HHS must specifically be notified of the breach.

What is the correct CPT code assignment for hysteroscopy with lysis of intrauterine adhesions? ***Graph is needed to answer Q 84.*** A. 58555, 58559 B. 58559 C. 58559, 58740 D. 58555, 58559, 58740

58559 Main term: Hysteroscopy; lysis; adhesions. It should be noted that a surgical laparoscopy always includes a diagnostic laparoscopy.

The physician performs an exploratory laparotomy with bilateral salpingo-oophrectomy. What is the correct CPT code assignment for this procedure? ***Graph is needed to answer Q 79.*** A. 4900, 58940, 58700 B. 58940, 58720-50 C. 49000, 58720 D. 58720

58720 In the abdomen, peritoneum, and omentum subsection, the exploratory laparotomy is a separate procedure and should not be reported when it is part of a larger procedure. The code of 49000 is often used incorrectly because laparotomy is the approach to many abdominal surgeries. The code 58720 includes bilateral and so the-50 modifier is not necessary.

What is the procedure code for a patient who had ventilator management for more than 96 hours in ICD-10-PCS? ***Graph is needed to answer Q 45.*** A. 5A1955Z B. 5A1945Z C. 5A09557 D. 5A09458

5A1955Z The root operation Performance is used to code the mechanical ventilation for greater than 96 hours. Section-Extracorporeal Assistance and Performance-character 5; Physiological Systems-character A; Root Operation is Performance-Character 1; Body System is Respiratory-character 9; Duration is greater than 96 hours-character 5; Function Value Ventilation-character 5; and No Qualifier-character Z.

HIPAA requires that data security policies and procedures be maintained for a minimum of: A. 3 years from date of creation B. 5 years from the date of creation C. 5 years from date of creation or the date when last in effect, whichever is later D. 6 years from date of creation or the date when last in effect, whichever is later

6 years from date of creation or the date when last in effect, whichever is later Covered entities must maintain their security policies and procedures in written form. This includes formats that may be electronic. Any actions, assessments, or activities of the HIPAA Security Rule also must be documented in a written format. Documentation must be retained for six years from the date of its creation or the date when it last was in effect, whichever is later.

Analyze the following report of physician deficiency rates and determine which physician has the lowest deficiency rate for H&Ps completed within 24 hours of admission. ***Graph is needed to answer Q 68.*** A. 102 B. 237 C. 391 D. 637

637 A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be grouped into tables. Columns allow you to read data up and down, and rows allow you to read data across. The columns and rows should be labeled. IN this, table the physician with the lowest rate of deficiency is number 637.

Using the information in the table below, calculate the vaginal delivery rate at University Hospital for the semiannual period. ***Graph is needed to answer Q 76.*** A. 20.04% B. 59.97% C. 84.13% D. 79.96%

79.96% Vaginal delivery rate: (403 x 100) / 504 = 40,300 / 504 = 79.96%.

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

8 days The median is the midpoint of a frequency distribution. It is the point at which 50 percent of observations fall above and 50 percent fall below. Eight is the mid-point of the distribution where 50 percent of the observations fall above and below eight.

The pathologist performed a gross and microscopic examination of a kidney biopsy. What is the correct CPT code assignment? ***Graph is needed to answer Q 77.*** A. 88300, 88305 B. 88305 C. 88307 D. 88300, 88307

88305 Codes 88320-88309 are assigned based on the specific specimen examined. The type of specimen included in each code is listed alphabetically under the code. A kidney biopsy specimen examination, both gross and microscopic is coded to 88305.

Date of service: 1/3/17. Last date of treatment: 2/12/16. The patient is seen in the physician's office for a cough and sore throat. The physician performs a problem-focused history, expanded problem-focused examination, and medical decision making is straightforward. What is the correct E/M code for this service? A. 99213, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: expanded problem focused history and expanded problem focused examination, medical decision making of low complexity. B. 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: Problem focused history and examination, straightforward medical decision. C. 99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: detailed history and examination, medical decision making of moderate complexity D. 99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other health care professional.

99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: Problem focused history and examination, straightforward medical decision. Code 99212 is used because the history is problem-focused, the examination is problem-focused, and the medical decision making is straightforward.

A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin-susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? ***Graph is needed to answer Q 29.*** A. A41.1, K57.32, R10.9 B. A41.01. K57.32 C. A41.1, K57.32, B95.61 D. A41.2, K57.32

A41.01, K57.32 Sepsis is a serious medical condition caused by the body's immune response to an infection. Code A41.01 is for sepsis with methicillin-susceptible Staphylococcus aureus. Because abdominal pain is a symptom of diverticulitis, only the diverticulitis of the colon is coded.

When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with a(n)__________ indicating that Medicare might not pay and that the patient might be responsible for the entire charge. A. OIG B. ABN C. LOS D. EOB

ABN An Advanced Beneficiary Notice (ABN) should be provided to a patient when a service is not considered medically necessary, indicating that Medicare might not pay and that the patient may be responsible for the entire charge.

Coding policies should include which of the following elements? A. Lunch or break schedule B. How to access the computer system C. AHIMA Standards of Ethical Coding D. Nonofficial coding guidelines

AHIMA Standards of Ethical Coding Coding policies should include the following components: AHIMA Code of Ethics, AHIMA Standards of Ethical Coding, Official Coding Guidelines, applicable federal and state regulations, internal documentation policies requiring the presence of physician documentation to support all coded diagnosis and procedure code assignments.

Which of the following is a legal concern regarding the EHR? A. Ability to subpoena audit trails B. Template design C. ANSI standards D. Data sets

Ability to subpoena audit trails There are a number of legal issues facing the electronic health record (EHR). State laws vary as to what is and is not acceptable in a court of law regarding EHRs. Healthcare providers frequently receive subpoenas requesting the production of the health record. The subpoenas may require the production of audit trails.

Information that has been taken from the health records of injured patients and entered into the trauma registry database has been: A. Aggregated B. Mapped C. Abstracted D. Queried

Abstracted After trauma cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database.

After the types of cases to be included in a trauma registry have been determined, what is the next step in data acquisition? A. Registering B. Defining C. Abstracting D. Reporting

Abstracting After the cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database. The data elements collected in the abstracting process vary from registry to registry but usually include: demographic information on the patient; information on the injury; care the patient received before hospitalizations (such as care at another transferring hospital or care from an emergency medical technician who provided care at the scene of the accident or in transport from the accident site to the hospital); status of the patient at the time of admission; patient's course in the hospital; and diagnosis and procedure codes. 1. Case Definition/Case Finding: Case definition for the trauma registry varies but frequently involves inclusion of cases with diagnosis from the trauma diagnosis codes from the ICD. Case finding, to find cases with trauma diagnosis, the trauma registrar can access the disease indexes looking for cases with codes from this section of ICD. 2. Abstracting/Data Collection: After the cases have been identified, information is abstracted from the health records of the injured patients and entered into the trauma registry database. abstracting can be either the process of extracting information from a document to create a brief summary of a patient's illness, treatment, and outcome, or extracting elements of data from a source document or database. 3. Reporting and Follow-up: An annual report is often develop to show the activity of the trauma registry. Other reports may be generated as part of the performance improvement process, such as self extubation and delays in abdominal surgery or patient complications. Follow-up may or may not happen in trauma registries. When follow-up is done, emphasis is frequently on the patient's quality of life after a period of time.

The "discharged", not final billed" report (also known as "discharged, no final bill" or "accounts not selected for billing") includes what types of accounts? A. Accounts that have been discharged and have not been billed for a variety of reasons B. Only discharged inpatient accounts awaiting generation of the bill C. Only uncoded patient records D. Accounts that are within the system hold days and not eligible to be billed

Accounts that have been discharged and have not been billed for a variety of reasons Discharged not final billed (DNFB) refers to accounts where the patient has been discharged but the charges have not been processed or billed. The DNFB report is usually "owned" by the health information management (HIM) department. Because the HIM department codes the health records, any uncoded records, for whatever reason, become the responsibility of the HIM department. Unfortunately, the reason why an account cannot be coded has little to do with HIM operations. More often, uncoded accounts are the result of untimely documentation, misposted charges, registration or the wrong service area, services provided under an incorrect revenue code, or lost paperwork.

A physician query may not be appropriate in which of the following instances? A. Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae B. Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay. C. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis D. Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI

Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis. A query may not be appropriate because the clinical information or clinical picture does not appear to support the documentation of a condition or procedure. In situations where the provider's documented diagnosis does not appear to be supported by clinical findings, a healthcare entity's policies can provide guidance on a process for addressing the issue without querying the attending physician.

The Medical Staff Executive Committee has requested a report that identifies all medical staff members who have been suspended in the last six months due to delinquent health records. This is an example of what type of report? A. Ad hoc or demand B. Annual report C. Exception D. Periodic scheduled

Ad hoc or demand As opposed to periodic and exception reports, demand reports, also known as ad hoc reports, are produced as needed, whenever a manager demands or asks for it. Usually, demand reports are produced through report generators or database query languages and are customized by the manager.

The following data were derived from a comparative discharge database for hip and femur procedures: These data can be described as: ***Graph is needed to answer Q 12.*** A. Aggregate B. Identifiable C. Patient specific D. Primary

Aggregate Aggregate data include data on groups of people or patients without identifying any particular patient individually. Secondary data are considered aggregate data. Examples of aggregate data are statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis-related group (DRG).

Which of the following is a good question for a supervisor of coding to ask when evaluating potential fraud or abuse risk areas in the coding area? A. Are the assigned codes supported by the health record documentation? B. Does the hospital have a compliance plan? C. How many claims have not been coded? D. Which members of the medical staff have the most admissions to the hospital?

Are the assigned codes supported by the health record documentation? Codes are used to determine reimbursement, therefore code assignment is critical. Assigning the incorrect codes with the intent of receiving more money is fraudulent. The coding supervisor should regularly compare assigned codes to health record documentation to ensure compliance.

A patient is scheduled for an outpatient colonoscopy, but due to a sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given general anesthetic prior to the procedure. How should this procedure be coded? A. Assign the code for colonoscopy with modifier -74, Discontinued outpatient procedure after anesthesia administration. B. Assign the code for colonoscopy with modifier -52, Reduced services. C. Assign no code because no procedure was performed. D. assign an anesthesia code only.

Assign the code for colonoscopy with modifier -74, Discontinued outpatient procedure after anesthesia administration. Per CPT Coding Guidelines, when a planned procedure is terminated prior to completed for cause, the intended procedure is coded with a modifier. Because general anesthesia was used, modifier-74 is appropriate in the case.

A Clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid: A. NCCI edits B. Upcoding C. Coding without a completed face sheet D. Assumption coding

Assumption coding A CDI program provides a mechanism for the coding staff to communicate with the physician regarding nonspecific diagnostic statements or when additional diagnoses are suspected but not clearly stated in the record, which helps to avoid assumption coding.

A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? A. Acute bronchitis B. Acute bronchitis with chronic obstructive pulmonary disease. C. Asthma with status asthmaticus D. Chronic obstructive asthma

Asthma with status asthmaticus The patient has the signs and symptoms and responded to treatment that would be given because of asthma with status asthmaticus. The physician can be queried based on the clinical indicators of a diagnosis when no documentation of the condition is present.

A Recovery Auditing Contractor (RAC) is conducting a review of claims for improper payment at Wildcat Hospital. The review is performed electronically utilizing a software program that analyzes claims data to identify proper payments. This type of review is referred to as: A. Automated review B. Complex REview C. Semi-automated review D. Semi-complex review

Automated review Recovery Audit Contractor (RAC) is a governmental program whose goal is to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Automated reviews are performed electronically rather than by humans. A software program analyzes claims data to identify improper payments.

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

Automatic logoff controls Provisions must also be made to protect workstations that are more exposed to the public. For example, locking devices can be used to prevent removal of computer equipment and other devices. Automatic logouts can be used to prevent access by unauthorized.

Suppose that five patients stayed in the hospital for a total of 27 days. Which term would be used to describe the result of the calculation 27 divided by 5? A. Average length of stay B. Total length of stay C. Patient length of stay D. Average patient census

Average length of stay The average length of stay (ALOS) is calculated from the total length of stay (LOS). The total LOS divided by the number of patients discharged is the ALOS.

A patient known to have AIDS is admitted to the hospital for treatment of pneumocystis carinii pneumonia. Assign the principal diagnosis for this patient. A. B20, Human immunodeficiency virus HIV disease B. J18.9, Pneumonia, unspecified organism C. B59, Pneumocystosis D. Z21, Asymptomatic human immunodeficiency virus HIV infection status

B20, Human immunodeficiency virus HIV disease AIDS stands for acquired immunodeficiency syndrome, frequently called human immunodeficiency infection (HIV). According to coding guideline I.C.1.a.2)(a), when a patient is treated for a complication associated with HIV infection, the B20 code is assigned as the principal diagnosis, followed by the code for the complication. Patients who are admitted for an HIV-related illness should be assigned a minimum of two codes in the following order: B20 to identify the HIV disease and additional codes to identify other diagnoses.

When interviewing candidates for a job, Angela likes to get a feel for how their experiences will shape their future actions. She likes to ask the question, "Tell me about a time when you had to prioritize three or four courses of action, what they were, and how you decided to prioritize each one. Did you choose correctly? How did it work out?" This is what type of interview question? A. Behavior B. Job Knowledge C. Situational D. Work requirement

Behavior One way hiring managers can improve effectiveness of job interview includes using job-related situational or behavioral questions based on job description. An example of a behavioral question would be to ask a candidate to relate behavior from the past to a job situation (for example, describe a situation where you had to deal with a subordinate's chronic tardiness, and explain how you handled it).

Charles is a supervisor of the imaging section of the HIM department. In trying to update scanning productivity standards, Charles calls around to other area hospitals to ask what their scanning standards are. This is an example of what source of performance data? A. Benchmarking B. Job Appraisal C. Observation D. Work Sampling

Benchmarking Comparing an organization's performance to the performance of other organizations that provide the same types of service is known as benchmarking. Internal benchmarking is also important to establish a baseline for the organization to find ways to improve effectiveness.

Which of the following is an example of how an internal user utilizes secondary data? A. State infectious disease reporting B. Birth certificates C. Death certificates D. Benchmarking with other facilities

Benchmarking with other facilities Internal users of secondary data are individuals located within the healthcare facility. Internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful in patient care, long-term planning, budgeting, and benchmarking with other facilities.

An overarching limitation or maximum dollar plan limit on an insurance plan is also known as a: A. Benefit cap B. Formulary C. Copayment D. Limitation

Benefit cap A benefit cap is an overarching limitation and is also known as a maximum dollar plan limit. A benefit cap is the total dollar amount that the healthcare insurance policy will pay for the policyholder and each covered dependent for covered healthcare services during a specified period, such as a year or lifetime.

The period of time between discharge and claim submission, which a facility defines by policy, is called the: A. AR days B. Bill hold C. Cash flow days D. Denial period

Bill Hold Sometimes facilities adopt a bill hold policy. This policy dictates a waiting period between the patient's discharge date and claim submission.

Which of the following is an example of a common form of healthcare fraud and abuse? A. Billing for services not furnished to patients B. Clinical documentation improvement C. Refiling claims after denials D. Use of a claim scrubber prior to submitting bills

Billing for services not furnished to patients Healthcare fraud is defined as an intentional representation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefits to himself or herself or some other person. An example of fraud is billing for a service that was not furnished. The other three options are acceptable practices for healthcare organizations to use to effectively manage their revenue cycles.

Review of disease indexes, pathology reports, and radiation therapy reports are parts of which function in the cancer registry? A. Case definition B. Case finding C. Follow-up D. Reporting

Case finding Cancer registries were developed as an organized method to collect these data. Case Finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry. After cases have been identified, extensive information is abstracted from the patients' paper-based health records into the registry database or extracted from other databases and automatically entered into the registry database. 1. Case Definition/Case Finding: Case definition is the process of deciding which cases should be entered into the registry. IN A CANCER REGISTRY THE FIRST STEP IS CASE-FINDING. One way to find cases is through the discharge process in the HIM department. Another case finding method is using the facility-specific disease index to identify patients with diagnoses of cancer. Additional methods may include reviews of pathology reports and list of patients receiving radiation therapy or other Cancer treatments to determine cases that have not been found by other methods. 2. Abstracting/Data Collection: Data are nationally obtained by reviewing and collecting them from the patient's health record. demographic information, type and site of cancer, diagnostic methodologies, treatment methodologies, stage at the time of diagnosis are all information that would be abstracted. 3. Reporting and Follow-up: Reporting of cancer registries are done through an annual report. The annual report includes aggregate data on the number of cases in the past year by sight and type of cancer. It also includes information on patients by gender, age, and ethnic group. Often a particular site or type of cancers featured with more in-depth data provided. For follow up, on an annual basis the registry attempts to obtain information about each patient in the registry, including whether he or she is still alive, status of the cancer, and treatment received during the period.

Which of the following is an investigational technique that facilitates the identification of the various factors that contribute to a problem? A. Affinity grouping B. Cause-and-effect diagram C. Force-field analysis D. Nominal group technique

Cause-and-effect diagram A cause-and-effect diagram is an investigational technique that facilitates the identification of the various factors that contribute to a problem.

What term is used for the number of inpatients present at any one time in a healthcare facility? A. Average daily census B. Census C. Inpatient service day D. Length of stay

Census Even though much of the data collection process has been automated, an ongoing responsibility of the HIM professional is to verify the census data that are collected daily. The census reports patient activity for a 24-hour reporting period. Included in the census report are the number of inpatients admitted and discharged for the previous 24-hour period and the number of intrahospital transfers. An intrahospital is a patient who is moved from one patient care unit (for example, the intensive care unit) to another (for example, the surgical unit). The usual 24-hour reporting period begins at 12:01 a.m. and ends at 12:00 am (midnight). In the census count, adults and children are reported separately from newborns.

The number of inpatients present in a healthcare facility at any given time is called a_______________. A. Survey B. Census C. Sample D. Enumeration

Census Healthcare facilities have a census, which is the count of patients present at a specific time and in a particular place.

The National Patient Safety Goals (NPSGs) have effectively mandated all healthcare organizations to examine care processes that have a potential for error that can cause injury to patients. Which of the following process are included in the NPSGs? A. Identify patients correctly, prevent infection, and file claims for reimbursement B. Check patient medicines, prevent infection, and identify patients correctly C. File claims for reimbursement, check patient medicines, and improve staff communication D. Improve staff communication, process claims timely, and prevent infection

Check patient medicines, prevent infection, and identify patients correctly The National Patient Safety Goals (NPSGs) have effectively mandated all healthcare organizations examine care processes that have a potential for error and can cause injury to patients. The NPSGs include identifying patients correctly, improving staff communication, using medicines safely, preventing infection, checking patient medicines, preventing patients from falling, preventing bed sores, and identifying patient safety risks.

You are the coding supervisor, and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." What should have been coded as the patient's diagnosis? A. Chronic cough B. Observation and evaluation without need for further medical care C. Diagnosis of unknown etiology D. Lung cancer

Chronic cough Outpatient coding guidelines do not allow coding of possible conditions as a diagnosis for the patient. Do not code diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis," or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter or visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

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

City Hospital should obtain a business associate agreement with Community Hospital In this situation, the smaller hospital should obtain a business associate agreement with the facility providing the information services.

In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area? A. Preclaims submission B. Claims processing C. Accounts receivable D. Claims reconciliation and collections

Claims reconciliation and collections The last component of the revenue cycle is reconciliation and collections. The healthcare facility uses the EOB, MSN, and RA to reconcile accounts. These are monitored in the claims reconciliation and collections area of the revenue cycle.

Each year when coding updates are published, Amy plans a face-to-face seminar training program for coders, business office employees, and physician office personnel involved in coding and billing. It generally takes her three weeks to complete the training of all necessary personnel. Which method of employee training is being described? A. Self-directed learning B. On-the-job training C. Classroom-based learning D. Online training

Classroom-based learning Classroom-based learning refers to instructor-led, face-to-face training such as traditional lectures, workshops, and seminars. This method is commonly used by managers because it is familiar and content is relatively quick, easy, and inexpensive to develop.

As part of the clinic's performance improvement program, and HIM director wants to implement benchmarking for the transcription division at a large physician clinic. The clinic has 21 transcriptionists who average about 140 lines per hour. The transcription unit supports 80 physicians at a cost of 15 cents per line. What should be the first step that the supervisor takes to establish benchmarks for the transcription division? A. Clearly define what is to be studied and accomplished by instituting benchmarks. B. Hold a meeting with the transcriptionists to announce the benchmark program. C. Obtain benchmarks from other institutions. D. Hire a consultant to assist with the process.

Clearly define what is to be studied and accomplished by instituting benchmarks. The first step in benchmarking is to determine the performance measure to be studied and what is to be accomplished. Once a benchmark for a performance measure is determined, analyzing data collection results becomes more meaningful.

The supervisor over the coding division in the HIM Department at Community Hospital reviewed the productivity logs of four newly hired coders after their first month. Using the information below, which employee will require additional assistance in order to meet the standard of 20 medical records coded per day? ***Question needs a graph Q 40*** A. Coder 1 B. Coder 2 C. Coder 3 D. Coder 4

Coder 3 Productivity is defined as a unit of performance defined by management in quantitative standards. Productivity allows organizations to measure how well the organization converts input into output or labor into a product or service. 20 records per day x 5 days x 4 weeks = 400 records required to be coded. Coder 1 coded 400 records; Coder 2 Coded 405 records; Coder 3 coded 345 records; Coder 4 coded 400 records.

Continuing education is vital to ensure accurate coding. Which of the following is NOT true about continuing education for coders? A. Physicians from the medical staff can be asked to present clinical topics to coders. B. Coding managers can use member resources from AHIMA to educate coders. C. Coding education is best accomplished by sending staff to external seminars. D. Coding managers can have coders research clinical topics to present to each other.

Coding education is best accomplished by sending staff to external seminars. Continuing education can be accomplished without sending staff to costly external seminars or workshops. The coding manager should consider the following few suggestions for internal continuing education (this is not a complete list): Ask physicians from the medical staff to present short clinical topics pertinent to the patient population in a particular setting; have coders research pertinent clinical topics and make a presentation to their colleagues; and use resources available to members of AHIMA.

In all positions it is important to develop requirements for employee success to perform their job. For the release information technician position, the statement, "apply policies and procedures for disclosure of health information to process requests with 98% accuracy," would be considered a: A. Procedure B. Mission C. Policy D. Competency

Competency Competencies are "do" statements identifying measurable skills, abilities, behaviors, or other characteristics required of an individual in order to complete the work required in a successful manner. This example provides competencies for a release of information specialist.

According to CPT, a repair of a laceration that includes retention sutures would be considered what type of closure? A. Complex B. Intermediate C. Not specified D. Simple

Complex A complex repair of a wound goes beyond layer closure and requires scar revision, debridement, extensive undermining, stents, or retention sutures.

Which of the following is the process of establishing an organizational culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies? A. corporate integrity B. meaning use C. benchmarking D. compliance

Compliance Compliance is the process of establishing an organization culture that promotes the prevention, detection, and resolution of instances of conduct that do not conform to federal, state, or private payer healthcare program requirements or the healthcare organization's ethical and business policies. In other words, compliance actively prevents fraud and abuse.

Which of the following groups are included in the feedback loop between denials, management, and clinical documentation improvement (CDI) program staff? A. Compliance B. Office of the Inspector General C. Center for Medicare and Medicaid Services D. Payers

Compliance The clinical documentation improvement (CDI) manager should coordinate a feedback look with functional managers that involved reporting data from the department to CDI and then from CDI back to the department. The three areas for CDI best practices include operationalizing feedback loops with denials management, compliance, and HIM.

The clinical documentation improvement (CDI) staff might create a feedback loop in which department to prevent disgruntled physicians from filing claims against them? A. Billing or finance B. Health information management C. Compliance D. Case Management

Compliance The clinical documentation improvement (CDI) manager should see the compliance function as an opportunity to discuss concerns about physicians who may not be cooperating with program staff of who are ignoring queries. If not managed appropriately, these physicians may become disgruntled with the CDI process and file complaints with CMS, the state's attorney general, or even the OIG.

The clinical documentation improvement (CDI) program must keep high-quality records of the query process for: A. Revenue cycle analysis B. Compliance issues C. Chart deficiency tracking D. Reducing the workload on HIM

Compliance issues Every organization should apply the same criteria for high-quality clinical documentation to the recording of clinical documentation improvement (CDI) program activities (queries and case notes) as it does to the review of clinical documentation. Maintaining thorough query documentation is necessary for compliance purposes.

What is the goal of the clinical documentation improvement (CDI) compliance review? A. To ensure adequate CDI improvement B. Compliant query generation and physical responses C. To ensure corrective action for any compliance concerns D. To ensure compliance between CDI program staff

Compliant query generation and physician responses Clinical documentation improvement (CDI) should be part of the organizational compliance program. The goal of a CDI compliance review is to monitor compliant query generation and physician responses.

Community Hospital has launched a clinical documentation improvement (CDI) initiative. Currently, clinical documentation does not always adequately reflect the severity of illness of the patient or support optimal HIM coding accuracy. Given this situation, which of the following would be the best action to validate that the new program is achieving its goals? A. Hire clinical documentation specialists to review records prior to coding B. Ask coders to query physicians more often C. Provide physicians the opportunity to add addenda to their reports to clarify documentation D. Conduct a retrospective review of all query opportunities for the year.

Conduct a retrospective review of all query opportunities for the year Facilities may design the CDI program based on several different models. Improvement work can be done with retrospective record review and queries, which concurrent record review and queries, or with concurrent coding. Staffing models may include the involvement of the CDS discussed previously or could be done by enhancing the role of the utilization review staff or case mangers or a communication of these models. Retrospective review of all query opportunities for the year would help to validate the effectiveness of the new program.

Sarah, a new graduate of a health information technology program, sits for the registered health information technician (RHIT) exam and fails. She does not want her employer to know she failed and tells her coworker she passed the examination. Sarah then starts using the RHIT credential after her name in work correspondence. A coworker, Nancy, discovers that Sarah is using the RHIT credential fraudulently and notifies the supervisor, Joan. What is the responsibility of Nancy and Joan in this situation? A. Contact AHIMA and report the abuse B. Contact the state licensing division C. Contact the office of inspector general D. Contact the HIT program

Contact AHIMA and report the abuse HIM professionals should be guided by the AHIMA Code of Ethics in making ethical decisions that relate to the HIM profession. In this situation, Joan and Nancy should contact AHIMA and report the abuse.

If a patient notices an unknown item in the explanation of benefits they receive from an insurance company and they do not recognize the service being paid for, the patient should: A. Not do anything B. Contact the insurer and the provider who billed for the services to correct the information C. Contact the police D. Contact human resources and let them know there has been a mistake

Contact the insurer and the provider who billed for the services to correct the information Patients should review and monitor the information found within their explanation of benefits (EOBs). Patients should not assume that their healthcare services have been accurately submitted to and paid by their insurance companies as claims submission is an error-prone process.

A record is considered a primary data source when it: A. Contains data about a patient and has been documented by the professionals who provided care to the patient B. contains data abstracted from a patient record C. Includes data stored in a computer system D. Contains data that are entered into a disease-oriented database

Contains data about a patient and has been documented by the professionals who provided care to the patient. The health record is considered a primary data source because it contains data about a patient that has been documented by the professionals who provided care or services to that patient. Data taken from the primary health record and entered into registries and databases are considered a secondary data source.

The Joint Commission and CMS have identified sets of patient care characteristics that they have determined reflect the quality of care an organization can provide for important diagnoses. These sets are called: A. Core measures B. Conditions of Participation C. Case mix D. Cost outliers

Core Measures Sets of patient care characteristics that the Joint Commission and CMS have determined to reflect the quality of care an organization can provide for important diagnoses are core measures.

Which plan should be devised to respond to issues arising from the clinical documentation improvement (CDI) compliance and operational audit process? A. CDI response plan B. Quality assurance plan C. CDI plan D. Corrective action plan

Corrective action plan Most audits should identify some issues, either operational or compliance, in the clinical documentation improvement (CDI) process, even if they are minor issues. An organization needs to develop a corrective action plan for any identified issues.

Community Hospital performed a cost-savings analysis between its current paper-based, on-site coding processes and an e-WebCoding telecommuting model. Given the graph here, what does the cost analysis show? ***Graph is needed to answer Q 43.*** A. The current system saves more than the e-WebCoding system would. B. The current system reduces DNFB significantly. C. Cost comparison reflects a net reduction in overall expenses on a monthly basis for the e-WebCoding system. D. There is not enough information to make a determination.

Cost comparison reflects a net reduction in overall expenses on a monthly basis for the e-Webcoding system. The data on the graph show there is a net reduction in overall expenses on a monthly basis for the e-WebCoding system. Learning to use data analysis tools and data aggregation techniques is important for improvement decisions. Making decisions based on actual experience and aggregate data is much better than making decisions based on intuition or gut feelings.

What is the benefit to comparing the coding assigned by coders to the coding appearing on the claim? A. May find that more codes are required to support the claim B. May find that the charge description master soft coding is inaccurate C. Servers as a way for HIM to take over the management of patient financial services D. Could find claim generation issues that cannot be found other ways

Could find claim generation issues that cannot be found other ways When the claim is submitted, the reviewer should compare all the diagnoses and procedures included on the bill with the coded information in the health record system. This process will help identify whether the communication software between the health record system and the billing system is functioning correctly. The HIM department should share the results of this comparison with patient financial services and the information technology department.

A coding audit shows that an inpatient coder is using multiple codes that describe the individual components of a procedure rather than using a single code that describes all the steps of the procedure performed. Which of the following should be done in this case? A. Require all coders to implement this practice B. Report the practice to the OIG C. Counsel the coder and stop the practice immediately D. Put the coder on unpaid leave of absence

Counsel the coder and stop the practice immediately Unbundling is the practice of using multiple codes that describe individual components of a procedure rather than an appropriate single code that describes all steps of the procedure performed. Unbundling is a component of the NCCI and is what the coder in the example was doing. The use of audits or other evaluation techniques to monitor compliance and assist in the reduction of identified problem areas and corporate compliance is necessary to become aware of coding issues and stop them.

As an HIM manager, Chelsea documents both positive and negative examples of her employee's work throughout the year. She refers back to these examples during annual evaluations. This is an example of what type of performance appraisal method? A. 360 performance appraisal B. Critical incident method C. Essay evaluation D. Graphic rating scale

Critical incident method The critical incident method is a method of performance appraisal that includes an ongoing written log of examples of an employee's job-related behavior during the appraisal period is used. It offers specific examples for development and is important that a manager documents both positive actions and negative incidents. This method can be used to supplement rating methods.

Which of the following procedures or services could NOT be assigned a code with CPT? A. Gastroscopy B. Anesthesia C. Glucose tolerance test D. Crutches

Crutches Healthcare Common Procedure Coding System (HCPCS) Level II codes were developed by CMS for use in reporting health services not covered in CPT. Level II codes are provided for injectable drugs, ambulance services, prosthetic devices, and selected providers services. Crutches are classified as durable medical equipment and would be coded with a HCPCS Level II code.

When coding a benign neoplasm of skin of the vermilion border of the lip, which of following codes should be used? ***Graph is needed to answer Q 22.*** A. D23 B. D10.0 C. D23.0 D. D17.0

D10.0 The excludes 1 note is found in the Tabular List, the Excludes 1 note indicates that the conditions listed after it cannot ever be used at the same time as the code above the excludes 1 note. The benign neoplasm on the vermillion border of the lip (D10.0) is not coded in category D23.

When coding a hydrocystoma of the right eyelid, which of the following codes should be used? ***Graph is needed to answer Q 32.*** A. D23 B. D17.0 C. D23.12 D. D23.11

D23.11 Assign codes to their highest level of specificity. Diagnosis is of eyelid, D23.11 is the correct code.

Which of the following is a technique for graphically depicting the structure of a computer database? A. Data model B. Data flow diagram C. Foreign key D. Primary key

Data model Data models provide a contextual framework and graphical representation that aid in the definition of data elements.

The evaluation of coders is recommended at least quarterly for the purpose of measurement and assurance of: A. Speed B. Data quality and integrity C. Accuracy D. Effective relationships with physicians and facility personnel

Data quality and integrity Coders should be evaluated at least quarterly, with appropriate training needs identified, facilitated, and reassessed over time. Only through this continuous process of evaluation can data quality and integrity be accurately measured and ensured.

Which HIM role works with patients to help them understand health data? A. Resource manager B. Data translator C. Data analyst D. Data security, data privacy, and confidentiality manager

Data translator A data translator works as the liaison between the patient and his or her health data. Data translators assist the patient in understanding their rights, such as the right to control access to their protected health information. They work with patients to help overcome barriers such as translating medical terminology into understandable terms.

The purpose of the present on admission indicator is to: A. Differentiate between conditions present on admission and conditions that develop during an inpatient admission B. Track principal diagnoses C. Distinguish between principal and primary diagnoses D. Determine principal diagnosis

Differentiate between conditions present on admission and conditions that develop during an inpatient admission Present on admission (POA) is defined as a condition present at the time the order for inpatient admission occurs-conditions that develop during an outpatient encounter, including the emergency department, observation or outpatient surgery, are considered as present on admission. A POA indicator is assigned to principal and secondary diagnoses and the external cause of injury codes.

In a recent documentation quality audit, the HIM manager discovered that the orthopedic surgeons have a high rate of noncompliance with history and physical examinations being available in the patient's record prior to surgery. Which of the follwoing is the best action for the HIM manager to take to address this noncompliance issue? A. Discuss this issue and the important of compliance with the chief of surgery B. Report the noncompliance to the OIG C. Post the names of noncompliant physicians on the door of the physician's lounge D. Discuss this issue and the importance compliance with the HIM staff

Discuss this issue and the important of compliance with the chief of surgery A complete history and physical report represents the attending physician's assessment of the patient's current health status, and accreditation standards require it to be completed within 24 hours of admission. In this case, the HIM manager should provide the chief of surgery with information on non-compliant physicians and work together with the chief of surgery to resolve this issue.

What is one key component of a compliant clinical documentation improvement program? A. Detailed review of Joint Commission findings B. Documented, mandatory physician education C. Revenue cycle team involvement D. Exceeding query response targets

Documented, mandatory physician education There are three components an organization should include early in the implementation of a compliant clinical documentation improvement (CDI ) program. These include: documented, mandatory physician education; detailed query documentation; CDI policies and procedures with annual sign-off from all program staff.

In ICD-10-PCS, the root operation defined as taking or letting out fluids and/or gases from a body part is: A. Control B. Drainage C. Excision D. Release

Drainage The root operation Drainage is defined as taking, or letting out fluids and/or gases from a body part. The value of 9 is used for Drainage. Examples are incision and drainage and arthrotomy for fluid drainage.

A postoperative patient was prescribed Lortab prn. Nurse Jones documented in the patient record that she administered one does of Lortab to the patient, but never actually administered this medication. Nurse Jones then took the Lortab herself. This action would be called? A. Drug prescribing B. Adverse drug reaction C. Sentinel event D. Drug diversion

Drug diversion Drug diversion is the removal of a medication from its usual stream of preparation, dispensing, and administration by personnel involved in those steps in order to use or sell the medication in non-healthcare settings. An individual might take the medication for personal use, to sell on the street, to sell directly to a user as a dealer or to sell to others who will redistribute for the diverting individual.

A Joint Commission-accredited organization must review its formulary annually to ensure a medication's continued: A. Safety and dose B. Efficiency and efficacy C. Efficacy and safety D. Dose and efficiency

Efficacy and safety The formulary is composed of medications used for commonly occurring conditions or diagnoses treated in the healthcare organization. Organizations accredited by the Joint Commission are required to maintain a formulary and document that they review it at least annually for a medication's continued safety and efficacy.

A patient is admitted with abdominal pain. The physician states that the discharge diagnosis is pancreatitis and noncalculus cholecystitis. Both diagnoses are equally treated. The correct coding and sequencing for this case would be: A. Either the pancreatitis or noncalculus cholecystitis sequenced as principal diagnosis B. Pancreatitis; noncalculus cholecystitis; abdominal pain C. Noncalculus cholecystitis; pancreatitis; abdominal pain D. Abdominal pain; pancreatitits; noncalculus cholecystitis

Either the pancreatitis or noncalculus cholecystitis sequenced as principal diagnosis In the unusual instance when tow or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, or the therapy provided, and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing in such cases, any one of the diagnoses may be sequenced first.

Community Hospital has compared its admission-type patient-profile data for two consecutive years. From a performance improvement standpoint, which admission types should the hospital examine for possible changes in capacity handling? ***Graph is needed to answer Q 39*** A. Elective B. Emergency C. Newborn D. Urgent

Emergency A pie chart is used to show the relationship of each part to the whole, in other words, how each part contributes to the total product or process. The 360 degrees of the circle, or pie, represent the total, or 100 percent. The pie is divided into "slices" proportionate to each component's percentage of the whole. Review of the pie chart shows that the emergency department has had significant patient growth over the five-year period. By using this patient profile data for performance improvement, the hospital should examine capacity changes for this department.

At Community Hospital, each full-time employee is required to work 2,080 hours annually. The table shows the amount of time that four employees were absent from work over the past year. Which employee had the highest absentee rate? ***Graph is needed for question 11.*** A. Employee A B. Employee B C. Employee C D. Employee D

Employee D A rate is a ratio in which there is a distinct relationship between the numerator and the denominator and the denominator often implies a large base population. Coder D had the highest absentee rate. In this situation the vacation hours used is added to the sick leave hours used and multiplied by 100 divided by 2,080 hours (for a full time employee). The absentee rate for each employee is calculated as follows: Coder A: [(40+6)x100]/2,080=4,600/2080=2.21%; Coder B: [(22+16)x100]/2,080=3,800/2,080=1.83%; Coder C [(36+8) x100]/2,080=4,400/2,080=2.115=2.12%; Coder D: [(80+32)x100]/2,080=11,200/2,080=5.38%.

The nursing staff routinely sends text messages to attending physicians to clarify orders during the night shift. The HIM professional should recommend which of the following to refine the policy as the best practice for protection information that is text messaged. A. Send a text message to more than one person B. Enter a person's telephone number each time a text message is sent to him C. Encrypt text messages during transmission D. Presume that telephone numbers stored in memory remain valid

Encrypt text messages during transmission Although text messaging is often used in healthcare it presents privacy and security risks. One best practice for text messaging in healthcare is to use encryption during transmission.

A statewide data base is used by your performance improvement department each month to compare other facilities' readmission rates to your facility's rates. This is an example of __________. A. Internal data B. External data C. Ration data D. Nominal data

External data External data sources refers to data collected outside an organization. For example, a census, reports from the Centers for Medicare and Medicaid Services (CMS) or the Centers for Disease Control (CDC), economic databases, journals, even social media have links to outside data.

Which of the follwoing would be classified in ICD-10-CM with an external cause code? A. Echocardiogram B. Call from curb C. Adenocarcinoma D. Admission for plastic surgery

Fall from curb External cause of injury codes provide a means to classify environmental events, circumstances, and conditions, as the cause of injury, poisoning, and other adverse effect. These codes are used in addition to codes from the main chapters of ICD-10-CM: in this case the external cause code for fall from a curb is used to describe how the patient was injured.

A physician orders a chest x-ray for an office patient who presents with fever, productive cough, and shortness of breath. The physician indicates in the progress notes: "Rule out pneumonia." What should the coder report for the visit when the results have not yet been received? A. Pneumonia B. Fever, cough, shortness of breath C. Cough, shortness of breath D. pneumonia, cough, shortness of breath, fever

Fever, cough, shortness of breath Signs, symptoms, abnormal test results, or other reasons for the outpatient visit are used when a physician qualifies a diagnostic statement as "possible", "probable", "suspected", "questionable", "rule out", or "working diagnosis", or other similar terms indicating uncertainty.

A quality review based on specific problem areas that comes after an initial baseline review has been completed in a hospital is called a: A. Compliance initiative B. Concurrent review C. Focused review D. Internal audit

Focused review The HIM department can plan focused reviews based on specific problem areas after the initial baseline review has been completed. This would be called a focused review.

When an obstetric patient enters the hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the final character in ICD-10-CM selected for the antepartum condition should be: A. For the trimester in which the complication developed B. For the trimester in which the patient delivered C. For the trimester in which the patient was discharged D. Any trimester as long as the same character is used for all complications

For the trimester in which the complication developed ICD-10-CM Coding Guideline I.C.15.a.4 states in the instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester the complication developed, not the trimester of the discharge.

The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data? ***Graph is needed to answer Q 42.*** A. Part-time coders are more productive than full-time coders. B. Full-time coders are more productive than part-time coders. C. All coders produce more than the departmental average. D. Part-time coders exceed the departmental average.

Full-time coders are more productive than part-time coders. Reading this graph, the full-time coder productivity is higher than part-time coder productivity. The cause for this difference must be identified before any solution can be developed to increase the productivity of the part-time coders.

The physician documents that she changed the cardiac pacemaker battery. In CPT, the battery is called a(n): A. Generator B. Electrode C. Dual system D. Cardioverter

Generator Cardiac pacemakers are devices that send a small current through a lead (wire) to stimulate the heartbeat. There are two components to a pacemaker: generator (battery) and, attached to the generator, one or two leads.

Which autopsy rate compares the number of autopsies performed on hospital inpatients to the total number of inpatient deaths for the same period of time? A. Net B. Gross C. Hospital D. Average

Gross A gross autopsy rate is the proportion or percentage of deaths that are followed by the performance of autopsy.

Which rate is used to compare the number of inpatient deaths to the total number of inpatient deaths and discharges? A. Net hospital death rate B. Fetal/newborn/maternal hospital death rate C. Gross hospital death rate D. Adjusted hospital death rate

Gross hospital death rate The gross hospital death rate is the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. The gross death rate is calculated by dividing the total number of death occurring in a given time period by the total number of discharges, including deaths, for the same time period.

To be reliable, statistical data must: A. Have some consistency B. Be applicable to what is being measured C. Be collected from one source only D. Have multiple meanings

Have some consistency The data used in the statistics must be valid and reliable. Validity answers the question of whether one measured what one intended to measure, and reliability means that there is some consistency of results.

Privacy awareness and training must be provided to all employees in order to prevent privacy breaches. This requirement is covered under which of the following laws? A. Civil Rights Act of 1991 B. Consolidated Omnibus Budget Reconciliation Act C. Fair Labor Standards Act D. Health Insurance Portability and Accountability Act

Health Insurance Portability and Accountability Act HIPAA provides standards regarding administrative requirements that are important to the health information professional, including requirements for privacy training. Every member of the covered entity's workforce must be trained in PHI policies and procedures to include maintaining the privacy of patient information, upholding individual rights guaranteed by the Privacy Rule, and reporting alleged breaches and other Privacy Rule violations.

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

Healthcare Common Procedure Coding System HCPCS is a collection of codes and descriptors used to represent healthcare procedures, supplies, products, and services.

A select group of reasonably preventable conditions for which hospitals should not receive additional payment when one of the conditions was not present on admission is called a: A. Charge code B. Hospital-acquired condition C. Principal diagnosis D. Value-based purchasing list

Hospital-acquired condition A hospital-acquired condition (HAC) is a select group of reasonably preventable conditions for which hospitals should not receive additional payment when one of the conditions was not present on admission (POA).

What is the most constant threat to health information integrity? A. Natural threats B. Environmental threats C. Internal threats D. Humans

Humans Health information can be threatened by humans as well as by natural and environmental factors. Threats posed by humans can be either unintentional or intentional. Threats to health information can result in compromised integrity (that is alteration of information, either intentional or unintentional), theft (intentional by nature), loss (unintentional) or intentional misplacement, other wrongful uses or disclosures (either intentional or unintentional), and destruction (intentional or unintentional).

A coder might find which of the following on a patient's problem list if the medication list contains the drug procardia? A. Esophagitis B. Hypertension C. Schizophrenia D. AIDS

Hypertension Procardia is an antianginal, antihypertensive, calcium channel blocker that is used to treat stable angina pectoris, vasopastic angina, and hypertension.

Given the following information, which of the following has the lowest work RVU? ***Graph is needed to answer Q 83.***. A. Office visit B. I&D of pilonidal cyst, simple C. Colonoscopy with biopsy D. TURP, complete

I&D of pilonidal cyst, simple When analyzing this table one is able to determine that 1.22 is the lowest relative value unit.

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

Identify all records for a period having these indicators for these conditions and determine whether these conditions are the only secondary diagnoses present on the claim that will lead to higher payment. Present on admission (POA) is defined as a condition present at the time the order for the inpatient admission occurs-conditions that develop during an outpatient encounter, including the emergency department, observation, or outpatient surgery, are considered as present on admission. A POA indicator is assigned to principal and secondary diagnoses and the external cause of injury codes based on physician documentation.

Case finding is a method used to: A. Identifying patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry B. Define which cases are to be included in a registry C. Identify trends and changes in the incidence of disease D. Identify facility-based trends

Identify patients who have been seen or treated in a facility for a particular disease or condition for inclusion in a registry Case finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry. After cases have been identified, extensive information is abstracted from the patients' paper-based health records into the registry database or extracted from other databases and automatically entered into the registry database.

The function of the NCCI editor is to: A. Report poor performing physicians B. Identify procedures and services that cannot be billed together on the same day of service for a patient C. identify poor performing coders D. Identify problems in the national coding system

Identify procedures and services that cannot be billed together on the same day of service for a patient The NCCI edits (which most providers have built into their claims software) explain what procedures and services cannot be billed together on the same day of service for a patient. The mutually exclusive edit applies to improbable or impossible combinations of codes.

Which of the following should be the first step in any quality improvement process? A. Analyzing the problem B. Identifying the performance measures C. Developing an alternative solution D. Deciding on the best solution

Identifying the performance measures Most quality improvement methodologies recognize that the organization must identify and continuously monitor the important organizational and patient-focused functions that they perform. The first step in this process is to identify performance measures.

Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations? A. Use biometrics for access to the system. B. Implement firewall and virus protection. C. Implement automatic session terminations. D. Install encryption and similar devices.

Implement automatic session terminations. Automatic log-off is a security procedure that causes a computer session to end after a predetermined period of inactivity, such as 10 minutes. Multiple software products are available to allow network administrators to set automatic log-off parameters.

Which rate describes the probability or risk of illness in a population over a period of time? A. Mortality B. Incidence C. Morbidity D. Prevalence

Incidence An incidence rate is used to compare the frequency of disease in different populations. Populations are compared using rates instead of raw numbers because rates adjust for differences in population size. The incidence rate is the probability or risk of illness in a population over a period of time.

Which of the following would be and example of a reviewable sentinel event? A. Incidence of hospital acquired infection B. Incidence of an unruly patient C. Incidence of infant abduction D. Incidence of blood transfusion reaction

Incidence of infant abduction A sentinel event includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. Examples of sentinel events include infant abduction from the nursery or a foreign body left in a patient from surgery.

NCCI edits prevent improper payments in which of the following cases? A. Medical Necessity has not been justified by a diagnosis. B. The account is potentially upcoded. C. The claim contains any of a variety of errors. D. Incorrect code combinations are on the claim.

Incorrect code combination are on the claim. National Correct Coding Initiative (NCCI) is a predefined set of edits created by Medicare to prevent improper payment when incorrect code combinations are reported. The NCCI contains two types of edits, one of which are mutually exclusive edits that consist of code pairs that should not be reported together for a number of reasons.

After an outpatient review, individual audit results by coder should become part of the: A. Individual employee's performance evaluation B. Patient's health record C. Coding compliance review summary D. Mission of the coding team

Individual employee's performance evaluation Individual audit results by coder may identify that certain coders are ready to be cross trained in another category of coding. Regardless of the corrective actions taken, the results should become part of each employee's performance evaluation.

A local nonprofit community hospital is looking to do a fundraiser to add to their surgical center. HIPAA rules restrict activities related to fundraising for healthcare organizations. Which of the following must the hospital do to comply with the HIPAA requirements for fundraising? A. Fundraising materials do not have to include opt-out instructions B. Prior authorization is only required if individuals are not targeted based on diagnosis C. Individuals must be informed in the notice of privacy practices that their information may be used for fundraising purposes D. Authorization is required for fundraising solicitations.

Individuals must be informed in the notice of privacy practices that their information may be used for fundraising purposes For fundraising activities that benefit the covered entity, the covered entity may use or disclose to a BA or an institutionally related foundation, without authorization, demographic information and dates of healthcare provided to an individual. However, the covered entity must inform individuals in its notice of privacy practices that PHI may be used for this purpose. It must also include in its fundraising materials instructions on how to opt out of receiving materials in the future.

The process that involves ongoing surveillance and prevention of infections so as to ensure the quality and safety of healthcare for patients and employees is known as: A. Case management B. Infection control C. Risk management D. Utilization management

Infection control Infection control is a system for the prevention of communicable diseases that concentrates on protecting healthcare workers and patients against exposure to disease causing organisms and promotes compliance with applicable legal requirements through early identification of potential sources of contamination and implementation of policies and procedures that limit the spread of disease.

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also has angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? A. Abdominal pain; affectious gastroenteritis; chronic obstructive pulmonary disease; angina B. Infectious gastroenteritis; chronic obstructive pulmonary disease; angina C. Gastroenteritis; abdominal pain; angina D. Gastroenteritis; abdominal pain; diarrhea; chronic obstructive pulmonary disease; angina

Infectious gastroenteritis; chronic obstructive pulmonary disease; angina The principal diagnosis is designated and defined as the condition established after study chiefly responsible for occasioning the admission of the patient to the hospital for care. The abdominal pain would not be coded as it is a symptom of the gastroenteritis.

The type of statistics that makes a best guess about a larger group of data by drawing conclusions from a smaller group of data is called: A. Descriptive statistics B. Inferential statistics C. Generalized statistics D. Mathematical statistics

Inferential statistics Inferential statistics help make inferences or guesses about a larger group of data by drawing conclusion from a small group of data.

Which unit of measure is used to indicate the services received by one inpatient in a 24 hour period? A. Inpatient service day B. Volume of services C. Average occupancy charges D. Length of services provided

Inpatient service day A unit of measure that reflects the services received by one inpatient during a 24-hour period is an inpatient service day (IPSD). The number of inpatient service days for a 24-hour period is equal to the daily inpatient census, that is, one service day for each patient treated.

Organizations use of audits in data analysis in order to ensure compliance with policies and procedures is a component of: A. Internal monitoring B. Benchmarking C. Corrective action D. Educating staff

Internal monitoring As part of an effective compliance plan organizations must perform internal monitoring. These organizations must be diligent to ensure compliance with policies and procedures, such as through the use of audits and data analysis.

A physician takes the medical records of a group of HIV positive patients out of the hospital to complete research tasks at home. The physician mistakenly leaves the records in a restaurant, where they are read by a newspaper reporter who publishes an article that identifies the patients. The physician can be sued for: A. Slander B. Willful infliction of mental distress C. Libel D. Invasion of privacy

Invasion of privacy A person's right to privacy is the right to be left alone and protected against physical or psychological invasion. It includes freedom from intrusion into one;s private affairs to include their healthcare diagnoses.

An HIM director reviews the departmental scanning productivity reports for the past three months and sees that productivity is below that of the national average. Which of the following actions should the director take? A. Reduce the salary of the nonproductive workers. B. Investigate whether there are factors contributing to the low productivity that are not reflected in the national benchmarks. C. Meet with departmental supervisors to discuss the issue. D. Assess whether or not the current economy is affecting productivity.

Investigate whether there are factors contributing to the low productivity that are not reflected in the national benchmark Comparing an organization's performance of other organizations that provide the same type of service is known as benchmarking. Internal benchmarking is also important to establish a baseline for the organization to find ways to improve effectiveness. Benchmark averages can be helpful in setting productivity standards, but do not necessarily reflect variations in procedures from organization to organization. Investigating what factors may be contributing to the low productivity for this organization will give a better understanding of the variation.

Which of the following statements best defines utilization management? A. It is the process of determining whether the medical care provided to a patient is necessary. B. It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. C. It is a process that determines whether a planned service or a patient's condition warrants care in an inpatient setting. D. It is an ongoing infection surveillance program.

It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care. Utilization review (UR) is the process of determining whether the healthcare provided to a specific patient is necessary. Preestablished objective screening criteria are used as the basis of UR, which is performed according to time frames specified in the organizations UM plan.

Why is the MEDPAR file limited in terms of being used for research purposes? A. It only provides demographic data about patients. B. It only contains medicare patients. C. It uses diagnoses and procedure codes. D. It breaks charges down by specific types of service.

It only contains Medicare patients. The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients.

What document outlines the work to be performed by a specific employee or group of employees with the same responsibilities? A. Union contract B. Policy and Procedure Manual C. Job evaluation D. Job description

Job description A job description, sometimes called a position description, is a written explanation of a job and the duties it emails and is based on information provided by the job analysis. A job description helps the human resources department, hiring manager, the employee's direct supervisor and the employee understand the job duties and expectations.

A tornado touched down in the community and multiple patients were brought to the hospital. The HIM director has asked all department personnel to report to the emergency staging area to help with record management. The HIM director is performing which function of management? A. Planning B. Organizing C. Leading D. Controlling

Leading Leading is the function in which people are directed and motivated to achieve the goals of the healthcare organization. In this scenario, the HIM director is performing the leading function of management.

A notice that the suspends the process or destruction of paper or electronic records is called: A. Subpoena B. Consent form C. Rule D. Legal hold

Legal hold A legal hold (also known as a preservation order, preservation notice, or litigation hold) basically suspends the processing or destruction of paper or electronic records. It may be initiated by a court if there is concern that information may be destroyed in cases of current or anticipated litigation, audit, or government investigation. Or, it may be initiated by the organization as part of their pre-litigation planning and duty to preserve information in anticipation of litigation.

Which term is used to describe the number of calendar days that a patient is hospitalized? A. Average length of stay B. Length of stay C. Occupancy rate D. Level of service

Length of stay Length of stay (LOS) is calculated for each patient after he or she is discharged from the hospital. It is the number of calendar days from the day of patient admission to the day of discharge. When the patient is admitted and discharged in the same month, the LOS is determined by subtracting the date of admission from the date of discharge.

Risk determination considers the factors of: A. Likelihood and impact B. Risk prioritization and control recommendations C. Risk Prioritization and impact D. Likelihood and control recommendations

Likelihood and impact Risk determination considers how likely it is that a particular threat will actually occur and , if it does occur, how great its impact or severity will be. Risk determination quantifies and organization's threats and enables it to both prioritize its risks and appropriately allocate its limited resources (namely, people, time, and money) accordingly.

Which of the following is made up of claims data from Medicare claims submitted by acute-care hospitals and skilled nursing facilities? A. NPDB B. MEDPAR C. HIPDB D. UHDDS

MEDPAR The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care hospital and SNF claims data for all Medicare claims. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients.

In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? A. Account level B. MS-DRG level C. MDC level D. MS-DRG triples, pairs, and singles

MS-DRG triples, pairs, and singles A review of the distribution between MS-DRG triples, pairs and singles against patient record documentation would provide information to support coding and billing of appropriate CCs and MCCs. The appropriateness of assigning CCs and MCCs will impact the organizations case-mix index and must be monitored. The CMI is a measure of the average revenue received per case. Many hospitals closely monitor the movement of their CMI for inpatient populations for which payment is based on DRGs.

Diagnosis-related groups are organized into: A. Case-mix classifications B. Geographic practice cost indices C. Major diagnostic categories D. Resource-based relative values

Major diagnostic categories To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into 1 of 25 major diagnostic categories, or MDCs.

In ICD-10-PCS, what is the root operation for left heart catheterization with sampling and pressure measurement? A. Insertion B. Introduction C. Measurement D. Monitoring

Measurement The heart catheterization is a percutaneous approach to the circulatory system of the body, not a definitive procedure. Code the actual root operations or root types that were performed through the catheter. In this case, the diagnostic test of heart catheterization was the percutaneous approach to the circulatory system of the body to take sampling and pressure measurements. The root operation would be measurement.

Given the following information, from which the payer does the hospital proportionately receive the least amount of payment? ***Graph is needed to answer Q 44.*** A. BC/BS B. TRICARE C. Medicare D. Medicaid

Medicaid Medicaid charges are larger than the charges to commercial insurance and TRICARE; however, the facility receives a smaller payment from Medicaid. There is an adjustment of 36 percent, meaning that the facility had to adjust their charges 36 percent from the actual amount billed and the amount they receive in payment.

Which type of identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits? A. Medical B. Financial C. Criminal D. Health

Medical Medical identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits. Most often this is done so a person can receive healthcare with an insurance benefit and pay less or nothing for the care received.

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostatic carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay? A. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion B. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy C. Metastatic carcinoma of the brain; history of the carcinoma of the prostate D. Carcinoma of the prostate; metastatic carcinoma to the brain

Metastatic carcinoma of the brain; history of carcinoma of the prostate A patient may have a history of a primary site of malignancy but later develop a secondary neoplasm or a metastatic site at another location. When this occurs, the treatment is likely to be directed to the secondary site. The secondary site code is assigned first with a category Z85 code used as an additional diagnosis code.

The people within the organization who oversee the operation of a broad scope of functions such as coding, transcriptions, and release of information at the department level are referred to as: A. Senior managers B. The board of directors C. Supervisory managers D. Middle manager

Middle manager Middle management involves the people within the organization who oversee the operation of a broad scope of functions; for example, the HIM manager may oversee coding, transcription, and release of information at the departmental level or they may oversee a defined product or line of service, such as in the case of a radiology department manager.

In a management sense, controlling means: A. Directing people carry out tasks B. Monitoring performance C. Providing little choice in job descriptions D. Making people do what a manager wants

Monitoring performance Controlling is the function in which performance is monitored according to policies and procedures. In HIM, controlling includes monitoring the performance of employees for quality, accuracy, and timeliness of completion of duties.

Code the following scenario: Patient with flank pain was admitted and found to have a calculus of the left kidney. Ureteroscopy with placement of bilateral ureteral stents was performed. ***Graph is needed to answer Q 80.*** A. N20.0, 0T788DZ, 0TH983Z B. N20.2, N20.9, 0T788DZ C. N20.0, 0TH983Z D. N20.0, 0T788DZ

N20.0, 0T788DZ Codes for symptoms, signs, and ill-defined conditions are not to be used as the principal diagnosis when a related definitive diagnosis has been established. The flank pain would not be coded because it is a symptom of the calculus. For the ICD-10-PCS procedure code, a dilation procedure was performed using a stent inserted using ureteroscopy, so 0T788DZ is the correct code. The section is Medical and Surgical-character 0: Body system is Urinary System-character T; Root Operation is Dilation-character 7; Body part is Ureters, Bilateral-character 8; Approach-via Natural or Artificial Opening Endoscopic-character 8, No Device-character Z, and the procedure was for diagnostic reasons-character X.

Patient admitted with chronic cycstitis. A cystoscopy and biopsy of the bladder were performed. What diagnosis and procedure codes would be assigned for this patient? ***Graph is needed to answer Q 82.*** A. N30.30, 0TBB8ZX B. N30.20, 0TBB8ZX, 0TJB8ZZ C. N30.20, 0TBB8ZX D. N39.0, 0TBB8ZX

N30.20, 0TBB8ZX Main term for diagnosis: Cystitis; subterm: chronic N30.20 is the correct code. For the ICD-10-PCSk procedure code, an excision procedure was performed, so 0TBB8ZX is correct code. The Section is Medical and Surgical-character 0; Body System is Urinary System-character T; Root Operation is Exicision-character B;Body Part is Bladder-character B; Approach-Via Natural or Artificial Opening Endoscopic-character 8, No device-character Z, and the procedure was for diagnostic reasons-character X.

Assign codes for the following scenario: A female patient is admitted for stress incontinence. A urethral suspension is performed. A. N39.3, 0TUD0JZ B. N23, 0TSD0ZZ C. N39.3, 0TSD0zz D. R32, 0TUD0JZ

N39.3, 0TSD0ZZ Main term for diagnosis: Incontinence, subterm: stress N39.3 is correct code. For the ICVD-10-PCS procedure code a reposition procedure was performed, )TSD0ZZ is the correct code. The section is Medical and Surgical-character 0; Body System is Urinary System-character T; Root operation is Reposition-character s; Body Part is Urethra-character D; Approach-Open-character 0; No device character Z; and No Qualifier-character Z.

Which of the following would generally be found in a query to a physician? A. Health record number and demographic information B. Name and contact number of the individual initiating the query and account number C. Date query initiated and date query must be completed. D. Demographic information and name and contact number of individual initiating the query

Name and contact number of the individual initiating the query and account number It is recommended that the healthcare entity's policy address the query format. A query generally includes the following information: patient name, admission date or date or service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the charge (e.g., history and physical states urosepsis, lab reports WBC of 14,400, emergency department report fever of 102 degrees fahrenheit).

Certificates, such as those for births and fetal-deaths, are reported by hospitals to the individual state registrars and maintained permanently. State vital statistics registrars then compile the data and report them to which of the following: A. National Center for Health Statistics B. Agency for Healthcare Research and Quality C. Health Services Research D. National Statistics Research

National Center for Health Statistics Healthcare facilities are interested in births and deaths, fetal deaths, and induced terminations of pregnancy; facilities generally are responsible for completing certificates for births, fetal deaths, abortions, and occasionally, deaths. All states have laws that require this data. The certificates are reported to the individual state registrars and maintained permanently. State vital statistics registrars compile the data and report them to the NCHS.

Events that occur in a healthcare organization that do not necessarily affect an outcome but carry significant chance of being a serious adverse event if they were to recur are: A. Time-out B. Serious events C. Sentinel events D. Near misses

Near Misses Near misses include occurrences that do not necessarily affect an outcome but if they were to recur they would carry significant chance of being a serious adverse event. Near misses fall under the definition of a sentinel event, but are not reviewable by The joint Commission under its current sentinel event policy.

The HIM manager is also the facility privacy officer. In this role, she is required to provide her expertise in regard to HIPAA privacy and security regulations. She oversees initial training of the workforce for the organization. Which of the following is the best setting to accomplish this initial training to ensure all workforce members are trained? A. College coursework B. New employee orientation C. On-the-job training D. Local HIM association meeting

New employee orientation New employee orientation includes a group of activities to help the employee feel knowledgeable and competent. Educational programs required for employee organizational-wide (such as HIPAA, Privacy, etc.) are training with new employee orientation.

Which of the following types of data does not have a natural order? A. Nominal B. Ordinal C. Ratio D. Interval

Nominal Qualitative data are divided into the nominal scale and ordinal scale. Nominal data observations are organized into categories in which there is no recognition of order, and ordinal data are types of data where the values are in ordered categories and the order of the numbers is meaningful, but no the numbers themselves.

Which of the following is a problem-solving technique that focuses on working with individuals to find a mutually acceptable solution? A. Nominal group technique B. Change management C. Brainstorming D. New beginnings

Nominal group technique Using the nominal group technique, the group writes down their suggestions anonymously and then votes on which ideas are the most appropriate for the context of the discussion. This technique focuses on finding a communally acceptable solution.

In the relational database shown here, the patient table and the visit table are related by: ***Graph is needed to answer Q 61.*** A. Visit number B. Date of visit C. Patient number D. Practitioner number

Patient number Relations are established in a relational database by the primary key of one table becoming a foreign key in another table. In this case, the patient number is the primary key in the patient table and used as the foreign key in the visit table.

Which of the following is the unique identifier in the relational database patient table? ***Graph is needed to answer Q 34*** A. Patient last name B. Patient last and first name C. Patient date of birth D. Patient number

Patient number The unique identifier in the patient table is the patient number. It is unique to each patient. Patient last name, first name, and date of birth can be shared with other patients, but the identifier will not be shared.

Which of the following would NOT be a focus area of claims auditing for healthcare services provided in the emergency department? A. Ensuring claims are not submitted more than once B. Procedures are reported at the appropriate level C. Ensuring documentation supports services reported on the claim D. Patients are satisfied with their services

Patients are satisfied with their services The data elements collected during the audit vary based on the audit objective. As in this example, auditing a claim for healthcare services in the emergency department could consider the following areas: procedures that are reported at the appropriate level, claims are not submitted more than once, documentation supports services reported on the claim. Patient satisfaction with their services would not be an area of claim audit.

What type of value-based purchasing program is Hospital-Acquired Conditions Reduction Program? A. Quality consumer assessment B. Pay for reporting C. Quality incentive program D. Paying for value

Paying for value To move to a mature value based purchasing (VBP) program, CMS desires to pay for value, that is to promote efficiency in resources use while providing high-quality care. As the first step, CMS established the hospital-acquired conditions provision in the acute-care inpatient setting.

Every healthcare organization's risk management plan should include the following components except: A. Loss prevention and reduction B. Safety and security management C. Peer review D. Claims management

Peer review Risk management programs have three functions: risk identification and analysis, loss prevention and reduction, and claims management.

What do the wedges or divisions in a pie graph represent? A. Frequency groups B. Various data C. Percentages D. Classes

Percentages Pie charts are best to use when you want to show each category's percentage of the total. They do not show changes over time. A circle is divided into sections such as wedges or slices. These represent percentages of the total (100 percent).

Before the actual job analysis process begins, an HIM manager must complete the following: A. Collect primary data to support the job analysis B. Execute a workflow analysis C. Perform a needs assessment D. Write a job description

Perform a needs assessment A needs analysis is a procedure performed by collecting and analyzing data to determine what is required, lacking, or desired by an employee, group, or organization. A needs assessment is a process for determining how to close a learning or performance gap as it relates to jobs performed in a particular department.

If you want to display the parts of a whole in graphic form, what graphic technique would you use? A. Table B. Histogram C. Line graph D. Pie chart

Pie chart A pie chart is an easily understood chart in which the sizes fot the slices of the pie show the proportional contribution of each part. Pie charts can be used to show the component parts of a single group or variable.

Which of the following items on Abigail's to do list is most likely to require a critical conversation? A. Ask Thomas to act as a coach for the new scanning clerk scheduled to start next week. B. Meet with the director for a discussion on whether I should consider going back to school for my master's degree C. Tell Patricia she has been selected for promotion to lead transcriptionist to fill the vacancy left when Sara retired. D. Place Daniel on probation due to continuing problems with decreasing coding productivity and coding accuracy.

Place Daniel on probation due to continuing problems with decreasing coding productivity and coding accuracy. While managing conflict, there are time when difficult or critical conversations need to take place in order for resolution to occur to move change to the next level. Poor communication creates obstacles for managing critical conversations in conflict situations. Critical or crucial conversations are about challenging issues where emotions are involved and the outcomes of the conversation have a large impact on relationships or workplace dynamics.

The HIM department at Memorial hospital will install a computer-assisted coding (CAC) system next month. Meetings were held with all coders so they had input into the process and could address any concerns. HIM managers are working together to ensure the process is as smooth as possible. This is an example of what kind of change? A. Emergent B. Open-ended C. Planned D. Strategic

Planned Planned change is a formal process that is introduced methodically and is actively influenced by manager or change agents.

One of the first steps in this managerial function is to perform an environmental scan of internal organization and external industry. This is which managerial function? A. Planning B. Organizing C. Leading D. Controlling

Planning Planning is the examination of the future and preparation of action strategies to attain goals of the department of healthcare facility; for example, a director in the HIM department may use the planning function to prepare for the future state of the department after the implementation of a new release of information software system installation.

A governing principle that describes how a department or an organization is supposed to handle a specific situation or execute a specific process is a: A. Position statement B. Policy C. Procedure D. Performance appraisal

Policy A policy is a governing principle that describe how a department or an organization is supposed to handle a specific situation or execute a specific process.

A statement or guideline that directs decision making or behavior is called a: A. directive B. procedure C. policy D. rule

Policy A policy is a statement that describes general guidelines that direct behavior or direct and constrain decision making in the organization.

The coding staff at University Hospital has access to the Internet for research purposes while performing their job duties. The coding manager has noticed an increase in use and distraction by her coders who are using social media while on the job. In this situation, what should the coding manager develop and use to handle the inappropriate use of the Internet by her coding staff? A. Policy B. Standard C. Procedure D. Benchmark

Policy Policies are the principles describing how a department or an organization will handle a specific situation or execute a specific process. They are clear, simple statements. of how an HIM department will conduct its services, actions, or business; and set of guidelines and steps to help with decision making.

A risk manager is called in to evaluate a situation in which a visitor to the hospital slipped on spilled water, fell, and fractured his femur. This situation was referred to the risk manager because it involves a: A. Medical error B. Claims management issue C. Potentially compensable event D. Sentinel event

Potentially compensable event Risk management systems today are sophisticated programs that function to identify, reduce, or eliminate potentially compensable events (PCEs), thereby decreasing the financial liability of injuries or accidents to patients, staff, or visitors.

What practice do HIM departments use to protect themselves from RAC identifying coding and billing errors? A. Prebilling coding audits B. Postbilling coding audits C. Complex reviews D. Semi-automated reviews

Prebilling coding audits Good professional practice is to perform prebilling audits in RAC focus areas in hopes to prevent errors being identified by RAC audits.

The business office at community hospital is looking at software that can help them with decreasing their fraud and abuse cases. The software claims to be able to flag those patients that would most likely be involved in fraud by examining many data bases at the same time and finding those patients with demographic discrepancies. This is an example of______________. A. Descriptive analytics B. Predictive analytics C. Inferential statistics D. Descriptive statistics

Predictive analytics Predictive analytics is a branch of data mining concerned with the prediction of future probabilities and trends, also called forecasting. PREDICTIVE ANALYTICS answers "what will happen." DESCRIPTIVE ANALYTICS answers the question "what happened." DIAGNOSTIC ANALYTICS answers the question "why did it happen." PRESCRIPTIVE ANALYTICS answers "how can we make it happen."

A managed care organization is using a system that examines the past healthcare behaviors of their patients to determine their future costs for their healthcare. This is an example of_____________. A. Descriptive analytics B. Predictive modeling C. Prescriptive analytics D. Real-time analysis

Predictive modeling Predictive modeling is a process used in predictive analysis to identify patterns that can be used to determine the odds of a particular outcome based on the observed data. That is, statistics from the past are reviewed to determine what is likely to happen in the future. Predictive modeling is used by many companies that want to predict future trends.

Which of the following uniquely identifies each record in a database table? A. Data definition B. Data element C. Foreign key D. Primary key

Primary key Primary keys ensure that each row in a table is unique. A primary key must not change in value. Typically a primary key is a number that is a one-up counter or a randomly generated number in large databases.

Which of the following is the condition established after study to be the reason for hospitalization? A. Principal procedure B. Complication C. Comorbidity D. Principal diagnosis

Principal diagnosis Principal diagnosis is defined as the condition which, after study, is determined to have occasioned the admission of the patient to the hospital for care.

In the inpatient prospective payment system, the calculation of the DRG begins with the: A. Principal diagnosis B. Primary diagnosis C. Secondary diagnosis D. Surgical procedure

Principal diagnosis To determine the appropriate MS-DRG, a claim for a healthcare encounter is first classified into 1 of 25 major diagnostic categories, or MDCs. The principal diagnosis determines the MDC assignment.

Suppose that 6 males and 14 females are in a class of 20 students with the data reported as 3/1. What term could be used to describe the comparison? A. Average B. Percentage C. Proportion D. Rate

Proportion A proportion is a particular type of ratio in which x is portion of the whole (x + y).

Detailed query documentation can be used to: A. Protect the hospital from lawsuits B. Protect the hospital against claims from physicians about leading queries C. show the effects of follow-up training D. Protect the auditor from corrective action

Protect the hospital against claims from physicians about leading queries Healthcare organization should keep detailed query data. Ther should be documented evidence of all queries the clincial documentation improvement (CDI) specialists ask, to whom they ask them, the clinical documentation or information supporting the query, and responses to queries. Detailed query documentation can also protect the hospital when against claims from physicians about leading queries.

One of the questions on the patient satisfaction survey that is sent to the patient after discharge asks for the number of times the nurses checked the patient's vital sign in a day. This is an example of which type of data? A. Nominal B. Interval C. Qualitative D. Quantitative

Quantitative Healthcare data are divided into two broad categories of quantitative and qualitative data. Quantitative data are numeric while qualitative data describe observations. Quantitative data can be numerically counted. They deal with measurements.

When the physician does not specify the method used to remove a lesion during an endoscopy, what is the appropriate procedure? A. Assign the removal by snare technique code B. Assign the removal by hot biopsy forceps code C. Assign the ablation code D. Query the physician as to the method used

Query the physician as to the method used It is not appropriate for the coder to assume that the removal was done by either snare or hot biopsy forceps. The coding professional must query the physician to assign the appropriate code.

An 80 year old female is admitted with fever, lethargy, hypertension, tachycardia, oliguria, and elevated WBC. the patient has more than 100, 000 organisms of Edcherichia coli per cc of urine. The attending physician documents "urosepsis." How should this case be coded? A. Code sepsis as the principal diagnosis with urinary tract infection due to E. coli as secondary diagnosis. B. Code urinary tract infection with sepsis as the principal diagnosis C. Query the physician to ask if the patient has septicemia because of the symptomatology. D. Query the physician to ask if the patient had septic shock so that this may be used as the principal diagnosis.

Query the physician to ask if the patient has septicemia because of the symptomatology As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity.

Which of the following is the whistleblower provision of the False Claims Act that provides a means for individuals to report healthcare information non-compliance? A. Quid pro quo B. Query C. Qui tam D. Quasi reporting

Qui tam One of the key components of the False Claims Act is qui tam. Qui tam is the whistleblower provision of the False Claims Act-private persons, known as realtors, may enforce the Act by filing a complaint, under seal, alleging fraud committed against the government. For example, if a coder is told to assign codes in violation of coding rules, then he or she can report the facility for fraud.

Community Hospital is using a system that will help them detect when intracranial pressure becomes high in patients with a recent CVA that will quickly send an alert to the physician. This is an example of___________. A. Descriptive analytics B. Predictive analytics C. Prescriptive analytics D. Real-time analysis

Real-time analysis Unlike retrospective analytical tools, such as predictive modeling, real-time analytics refers to data that can be accessed as they come into a computer system. Real-time analytics, also referred to as streaming analytics, implies instantaneous results; however, the data may not be immediately available, but rather available within a few minutes. The most valuable data in this category are those that are collected and analyzed during the customer interaction, not the review afterward.

A coder with a vision impairment may need additional workspace lighting and a larger computer monitor installed with adjustments to screen contrast and magnification. This would an example of a(n): A. Unreasonable accommodation B. Essential job function C. Reasonable accommondation D. Discrimination

Reasonable accommodation Reasonable accommodations are actions taken by an employer to allow a disabled applicant or employee access to work opportunity. The disabled person is typically expected to request the accommodation. Examples of accommodation might include altering their work schedule modifying office equipment or software.

If a patient receives a ____________ from a healthcare organization it indicated that the patient's protected health information was involved in a data breach. A. Notice of Breach B. Release of Information C. Protected Health Breach Notice D. Receipt of Breach Notice

Receipt of Breach Notice If a patient receives a Receipt of Breach Notice from a healthcare organization it indicates that the patient's protected health information was involved in a data breach

A report that lists the ICD-10-CM codes associated with each physician in a healthcare facility can be used to assess the quality of the physician's services before he or she is: A. Scheduled for a coding audit B. Subjected to corrective action C. recommended for staff reappointment D. Involved in an in-house training program

Recommended for staff reappointment The medical staff department is particularly interested in the ICD-10-CM codes associated with each physician. Because diagnostic codes can identify untoward events that occur during hospitalization, the quality of a physician's services can identified through reports called physician reappointment summaries. These summaries outline the number of cases by diagnosis and procedure type, LOS, and infection and mortality statistics. At reappointment to a facility's medical staff, code-based reports are required. The medical staff department accumulates these reports and works with the elected or appointed medical staff leadership to ensure that a thorough analysis of each physician's activities takes place before he or she is reappointed to the staff.

All of the following are measures used to track and assess clinical documentation improvement (CDI) programs EXCEPT: A. Record review rate B. Physician query rate C. Record agreement rate D. Query agreement rate

Record agreement rate Each of these percentages should be tracked within the first few months of program operation. The target percentage may need adjustment over time as the CDS staff members become more familiar with their responsibilities and physician documentation improves. These percentages are record review rate, physician query rate and query agreement rate.

An accuracy calculation method that divides the number of records where there was not change in APC or DRG assignment by the total number of cases reviewed is considered: A. Code over code method B. Record over record method C. Code over record method D. Code determination method

Record over record method The record -over-record method of calculating errors considers each health record coded incorrectly as one error. The advantages of this method are that it allows for benchmarking with other hospitals that frequently use it, permits reviewers to track errors by case type, enables reviewer to relate productivity with quality errors on a case-by-case basis, and is much quicker to calculate. The disadvantages to this method are that it lacks specificity because it does not identify the coder's ability to assign codes that must be reported, and it does not identify the number of secondary diagnoses or procedures missed by the coder.

The HIM data analytics professional is reviewing a chart on nosocomial infections presented by the hospitals infection control committee. The committee is reporting that the decrease in infection rate has accelerated during the past 10 years. What comments should the data analytics professional make? ***Graph is needed to answer Q 4.*** A. Concur with the conclusion of the committee B. State that the greatest decrease in infection rate in a year took place in 2005 C. State that the greatest decrease in infection rate occurred in 1960 and 1970 D. Request a new data chart be presented that accurately reflects the trend of infection rate

Request a new data chart be presented that accurately reflects the trend of infection rate Both x and y axes are in unequal measures, so data are not accurately represented. Line graphs are used to display time trends as opposed to a histogram or bar chart.

The benefits of a coding compliance plan include the following: A. Improving patient care B. Identifying those who participate in fraud and abuse C. Retention of high standard of coding D. Increasing the number of denials of healthcare services reimbursement based on coding errors

Retention of high standard of coding There are a number of benefits of a coding compliance plan including retention of high standard of coding.

Patient has been discharged prior to an administrative utilization review being conducted. Which of the following should be performed? A. Continued stay utilization review B. Discharge plan C. Retrospective utilization review D. Case management

Retrospective utilization review Retrospective utilization review is conducted after the patient has been discharged. Retrospective review examines the medical necessity of the services provided to the patient while in the hospital.

Examples of high-risk billing practices that create compliance risks for healthcare organizations include all EXCEPT which of the following? A. Altered claim forms B. Returned overpayments C. Duplicate billings D. Unbundled procedures

Returned overpayments Fraudulent billing practices represent a major compliance risk for healthcare organizations. High-risk billing practices include: billing for noncovered services, altered claim forms, duplicate billing, misrepresentation of facts on a claim form, failing to return overpayments, unbundling, billing for medically unnecessary services, overcoding and upcoding, billing for items or services not rendered, and false cost reports.

An HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning, such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process? A. Scanning all documents at the time of patient discharge B. Scanning all documents after physicians have completed any record deficiencies C. Begin remote work only after all deficiencies have been corrected in the paper record D. Using scanners with the maximum amount of output

Scanning all documents at the time of patient discharge Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files. The data can be interfaced in the current EHR with document scanning system. Using scanned images solves many of the problems associated with traditional paper-based health records and hybrid records. Scanning at patient discharge allows the all of the contents of the record to be available in a timely manner for other functions such as remote coding and cancer registry.

Which of the following is used to plot the points for two variables that may be related to each other in some way? A. Force-field analysis B. Pareto chart C. Root cause analysis D. Scatter diagram

Scatter diagram Scatter diagrams are used to plot the points for two continuous variables that may be related to each other in some way. For example, one might want to look at whether age and blood pressure are related. One variable, age, would be plotted on the vertical axis of the graph, and the other variable, blood pressure, would be plotted on the horizontal axis.

As the assistant director of the HIM department, Judy is responsible for creating a job description for the new application specialist position. As part of the data collection phase, Judy researches the AHIMA Body of Knowledge to locate similar job descriptions already on file. The body of knowledge is what source of data? A. Primary B. Secondary C. Tertiary D. The Body of Knowledge should not be used as a source of data

Secondary Secondary data sources for job analysis are information obtained from subject matter experts, human resource consultants, job data banks, or competency models. The AHIMA Body of Knowledge would be considered data from subject matter experts.

A patient was taken into surgery at a local hospital for treatment of colon cancer. A large section of the colon was removed during surgery and the patient was taken to the medical floor after surgery. Within the first 24 hours post-op, the patient developed fever, chills, and abdominal pain. An abdominal CT scan revealed the presence of a foreign body. This situation describes a: A. Near miss B. Sentinel event C. Security incident D. Time out

Sentinel event A sentinel event includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. Examples of sentinel events include infant abduction from the nursery or a foreign body left in a patient from surgery.

NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for: A. Services that cannot reasonably be billed together B. Services that are components of a more comprehensive procedure C. Unnecessary procedures D. Comprehensive procedures

Services that cannot reasonably be billed together The NCCI edits (which most providers have built into their claims software) explain what procedures and services cannot be billed together on the same day of service for a patient. The mutually exclusive edit applies to improbable or impossible combinations of codes.

A supervisor wants to determine whether the release-of-information staff members are working at optimal output. Which of the following would be most useful to determine this? A. Review work attendance records to see who is absent from work the most. B. Walk through the work area at random times of the day to make sure that employees are at their desks and working. C. Set productivity standards for the area, and review results on a regular basis. D. Determine the backlog of work not performed each day.

Set productivity standards for the area, and review results on a regular basis. Managers must be able to report on the amount, efficiency, and quality of work being done in a unit. Employees need to know what is expected of them, and how they are doing relative to expectations. Setting performance standards and measuring performance can address the needs of both.

How many basic elements are included in an effective compliance program? A. Five B. Seven C. Nine D. three

Seven Each healthcare facility should have a compliance program. There are seven basic elements that should be included in an effective compliance program. These include: policies, procedures, and standards of conduct; identifying a compliance officer and committee; educating staff; establish communication channels; perform internal monitoring; penalties for noncompliance with standards; and taking immediate corrective action when a problem is identified.

From an evidentiary standpoint, incident reports: A. Are universally nonadmissible during trial proceedings B. May be referenced in the patient's health record C. Should not be placed in a patient's health record D. Are universally nondiscoverable during litigation

Should not be placed in a patient's health record Incident reports involving patient care are not created to treat the patient, but rather to provide a basis for investigating the incident. From an evidentiary standpoint, incident reports should not be placed in a patient's health record, nor should the record refer to an incident report.

Position descriptions, policies and procedures, training checklists, and performance standards are all examples of: A. Staffing tools B. organizational policies C. Strategic plans D. Items on a training checklist

Staffing tools Staffing tools may be used to plan and manage staff resources. Staffing tools include: position descriptions, which outline the work and qualifications required by the job; performance standards, which establish expectations for how well the job will be done and how much work will be accomplished; and written policies and procedures explaining staffing requirements and scheduling, which assist the supervisor in being fair and objective and help the staff understand the rules.

Which of the following services is most likely to be considered medically necessary? A. Caregivers' convenience or relief B. Cosmetic improvement C. Investigational cancer prevention D. Standard of care for health condition

Standard of care for health condition Medical necessity review is a cost control method to evaluate the need for and the intensity of the service prior to it being provided. Services that are cosmetic, elective, and investigational are much less likely to be consider medically necessary. Standard of care for health condition would be much more likely to be considered medically necessary.

Hospital A discharges 10,000 patients per year. Hospital B is located in the same town and discharges 5,000 patients per year. At Hospital B's medical staff committee meeting, a physician reports that he is concerned about the quality of care at Hospital B because the hospital has double the number of deaths per year than hospital A. The HIM director is attending the meeting in a staff position. Which of the following actions should the director take? A. Make no comment since this is a medical staff meeting. B. Agree with the physician that the data suggest a quality issue. C. Suggest that the data be adjusted for possible differences in type and volume of patients treated. D. Suggest that an audit be done immediately to determine the cause of deaths within the hospital.

Suggest that the data be adjusted for possible differences in type and volume of patients treated. When doing external benchmarking, the other organizations need not be in the same region of the country, but they should be comparable in terms of patient mix and size. The data from the two hospitals are not comparable because Hospital A discharges more patients than Hospital B. In addition, data on the comparability of severity of illness between the two hospitals is lacking and an informed decision cannot be made.

Which step of risk analysis identifies information assets that need protection? A. identifying vulnerabilities B. Control Analysis C. System characterization D. Likelihood determination

System characterization The first step of risk analysis is system characterization. It focuses on what the organization possesses by identifying which information assets need protection. The assets may be identified either because they are critical to business operations (for example, the data itself, such as e-PHI) or because critical data is processed and stored on the system (such as hardware).

The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what immediate action should the coding supervisor take? A. Counsel Tim and Jane because they have the highest error rates. B. Encourage Tim and Jane to get additional training. C. Provide Bob and Susan with incentive pay for low coding error rate. D. Take no action because not enough information is given to make a judgment.

Take no action because not enough information is given to make a judgement The error rates are not comparable because there is no data about the number or records coded during the period by each coder.

Incorporating a workflow function in an electronic information system would help support: A. Tasks that need to be performed in a specific sequence B. Moving patients from point to point C. Registration of patients D. Making computer output available on laser disk

Task that need to be performed in a specific sequence Workflow and process designs ensure the most efficient and effective use of electronic information systems.

The Medical Record Committee wants to determine if the hospital is in compliance with medical staff rules and regulations for medical record delinquency rates. The HIM director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the committee conclude? A. Delinquency rate is within medical staff rules and regulations B. All physicians are performing at optimal levels C. The chart deficiency process is working well D. The data are insufficient to determine whether the hospital is in compliance.

The data are insufficient to determine whether the hospital is in compliance. When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. Generally, an incomplete record is considered delinquent after it haws been available to the physician for completion for 15-30 days. This question does not provide enough information on the standard as the medical staff rules and regulations on delinquent records are not defined.

What is (are) the format problem(s) with the following table? ***Graph is needed to answer Q 16.*** A. The title is missing B. Variable names are missing. C. There are blank cells. D. Row totals are inaccurate

There are blank cells A table should contain all the information the user needs to understand the data in it. A table should not have blank cells. When no information is available for a particular cell, the cell should contain a zero.

Which of the following is one of the five best practices for management of financial measures in the CDI program. A. Track and report on CC capture rates across the organization and by service B. Build relationships with QIO and primary insurers C. Publish data to benchmarking organizations D. Document corrective actions

Track and report on CC capture rates across the organization and by service. Because the financial impact of a clinical documentation improvement (CDI) program in important and because many programs may lose their continued funding without the ability to demonstrate economic value, every organization should have a best practices approach to managing the financial measurement of the CDI program. One of these best practices is to track and report on MCC and CC capture rates across the organization and by service.

Healthcare fraud is all except which of the following? A. Damage to another party that reasonably relied on misrepresentation B. False representation of fact C. Failure to disclose a material fact D. Unnecessary costs to a program

Unnecessary costs to a program Healthcare fraud is the intentional deception or misrepresentation that an individual knows (or should know) to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s). Unnecessary costs to a program, in and of itself, would not be healthcare fraud, there would need to be some intentional deception for it to be considered fraud.

The breach notification requirement applies to: A. All PHI B. Unsecured PHI only C. Electronic PHI only D. PHI on paper only

Unsecured PHI only Breach notification requirements only apply to unsecured PHI that technology has not made unusable, unreadable, or indecipherable to unauthorized person. This PHI is considered to be the most at-risk.

The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: A. Unbundling B. Billing for services not provided C. Medically unnecessary services D. Upcoding

Upcoding Upcoding is the practice of using code that results in a higher payment to the provider that actually reflects the service of item provided.

Unbundling refers to: A. Use of a comprehensive code to appropriately maximize reimbursement B. Use of multiple procedure codes when a comprehensive code is available C. Combined billing for pre and postsurgery physician services D. Using the incorrect DRG code

Use of multiple procedure codes when a comprehensive code is available Unbundling refers to a billing practice in which providers use multiple procedure codes for a group of procedures instead of the appropriate combination code.

Medical identity theft includes which of the following: A. Using another person's name to obtain durable medical equipment B. Purchasing an EHR C. Purchasing surgical equipment D. Using another healthcare provider's national provider identifier to submit a claim

Using another person's name to obtain durable medical equipment Medical identity theft is a crime that challenges healthcare organizations and the health information profession. A type of healthcare fraud that includes both financial fraud and identity theft, it involves either (a) the inappropriate or unauthorized misrepresentation of one's identity (for example, the use of one's name and Social Security number) to obtain medical services or good, or (b) the falsifying of claims for medical services in an attempt to obtain money.

Jane is responsible for developing the positions needed for scanning inactive records in anticipation of EHR implementation. Since she has no scanning experience, Jane called the supervisors of the scanning function at three different facilities to pick their brains in regards to scanning jobs, This is an example of what type of data collection in the job analysis process: A. Using external sources B. Diary method C. Observation method D. Work imaging

Using external sources Managers can collect information about a job from a variety of sources. One of these is to use external sources' data for job analysis. In this scenario, Jane contacts other external sources at other facilities in order to use their information to create the scanning function requirements.

The policies and procedures section of a coding compliance plan should include all EXCEPT which of the following? A. Physician query process B. Unbundling C. Assignment of discharge disposition codes D. Utilization review

Utilization review The policies and procedures section of a coding compliance plan should include physician query process, coding diagnosis not supported by health documentation, upcoding, correct use of encoder software, unbundling, coding health records without complete documentation, assignment of discharge destination codes, and complete process for using scrubber software. Utilization review would not be part of the policies and procedures section of a Coding Compliance Plan.

What is the term that means evaluating the appropriateness of the setting for the healthcare service and the level of service? A. Coordination of service benefits B. Community rating C. Outcomes assessment D. Utilization review

Utilization review Utilization review assesses the appropriateness of the setting for the healthcare service in the continuum of care and the level of service. Also factored in are patients' severity of illness and other medical conditions and illnesses.

What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified? A. Case management B. Continuum of care C. Quality improvement D. Utilization review

Utilization review Utilization review is the process to determine if medical care meets objective screening criteria.

The overutilization or inappropriate utilization of services and misuse of resources, typically not a criminal or intentional act is called which of the following? A. Fraud B. Abuse C. Waste D. Audit

Waste Waste is the overutilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act. Waste includes practice like over prescribing and ordering tests inappropriately.

Helen is the HIM department head, and has been asked to share a SWOT analysis of her department with her new boss. One aspect of Helen's SWOT analysis indicates that the chart tracking software is over 10 years old and is not compatible with the digital dictation system. In a SWOT analysis, this would be a(n): A. Strength B. Weakness C. Opportunity D. Threat

Weakness The process to develop a strategic and operational plan begins with a SWOT (acronym for strengths, weaknesses, opportunities, and threats) analysis. In a SWOT analysis, key leadership personnel determine the strengths of the organization (what the company does well), the weakness (needs for improvement), and establishes future opportunities (and evaluates threats to those opportunities). This scenario is an example of weakness in a SWOT analysis.

Recently, a state senator was admitted to your facility for a serious medical condition. The facility privacy officer has been tasked with reviewing access logs daily to determine which of the following? A. Whether or not the patient is fit to continue public service. B. What information should be shared with the media. C. that the patient has received adequate care. D. Whether all access by hospital employees was appropriate

Whether all access by hospital employees was appropriate In order to maintain patient privacy certain audits may need to be completed daily. If a high profile patient is currently in a facility, for example, access logs may need to be checked daily to determine whether all access to this patient's information by workforce is appropriate.

The HIM manager at Community Hospital is responsible for reviewing audit trails detailing potential access issues within the EHR. Which one of the following would be a type of activity that the manager would want to review? A. Every access to every data element or document type that occurred within the facility B. Whether the person viewed, created, updated, or deleted information belonging to a patient with the same last name. C. Physical location of the redundant servers used for back up. D. Whether all patients setup accounts in the patient portal

Whether the person viewed, created, updated, or deleted information belonging to a patient with the same last name The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. Often they record time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred. Reviewing the audit trail information would be the first step to identify all employees who have accessed this patient's information.

The facility privacy officer is visited at the hospital by a recent patient that is concerned that her nosy neighbor, who happens to be a hospital employee, accessed her electronic health record inappropriately in order to tell other neighbors about the patient's health conditions. In order to determine this occurred, the privacy officer requests and audit log of activity within the patient's health record. What part of the audit log would the privacy officer need to first analyze to determine if this patient complaint is valid? A. The physician documentation from her recent stay regarding the patient's health conditions B. Whether the patient had requested any amendments to her record. C. If the record has any deficiencies that would cause the record to be deliquent D. Which employees viewed, created, updated, or deleted information

Which employees viewed, created, updated, or deleted information It is a requirement of the HIPAA Security Rule to implement ways that document access to information systems that contain electronic PHI. One of the ways to do this is to review the individuals that have viewed, created, updated, or deleted information within a health record. In this instance the Privacy Officer should review this information to determine if the patient complaint is valid.

Kevin is responsible for updating all job descriptions in the HIM department. In order to gather information about the data analyst position to establish standards, he spends time interviewing and observing Sophie, Who has held this job for three years. What type of study is Kevin conducting on the data analyst position? A. Coaching B. Recruiting C. Work imaging D. Job sharing

Work imaging Work imaging occurs when the supervisor gets a snapshot of the current process and then use that data, along with benchmarking data, to establish standards for a position within their department.

Joe is a supervisor of the imaging section of the HIM department. In trying to update scanning productivity standards, Joe asked the current scanners to track their tasks on an activity log. Each scanner logs in the time it takes to scan a specific amount of records. This is an example of what source of performance data? A. Benchmarking B. Job appraisal C. Observation D. Work sampling

Work sampling Work sampling is a statistical method that reviews a select portion of tasks performed and provides baseline data for further job performance assessment. Work sampling takes into account the quantity of activities that can be completed within a certain timeframe.

The coding department at Community Physician's Clinic developed the following report for the denials committee at the clinic. The billing report shows the following information. Using the information below, identify which payment source has the highest denial rate. ***Graph is needed to answer Q 75.*** A. Medicare B. Commercial payers C. Worker's Compensation D. Tricare/Military

Workers Compensation A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be grouped into tables. Columns allow you to read data up and down, and rows allow you to read data across. The columns and rows should be labeled. In this table, the payment source with the highest denial rate is Worker's Compensation.

A laboratory employee forgot his password to the computer system while trying to record the results for a STAT request. He asked his coworker to log in for him so that he could record the results and said he would then contact technical support to reset his password. What controls should have been in place to minimize this security breach? A. Access controls B. Security incident procedures C. Security management process D. Workforce security awareness training

Workforce security awareness training A strategy included in a good security program is employee security awareness training. Employees are often responsible for threats to data security. Consequently, employee awareness is a particularly important tool in reducing security breaches.

The ICD-10-CM utilizes a placeholder character at certain codes to allow for future expansion of the classification system. What letter is used to represent this placeholder character? A. A B. G C. U D. X

X Certain ICD-10-CM categories have applicable seventh characters. The applicable seventh character is required for all codes within the category, or as he notes in the Tabular List instruct. The seventh character must always be the seventh character in the data field. If a code that requires a seventh character does not contain six characters, a placeholder X must be used to fill in the empty characters.

When reporting an encounter for a patient who is HIV positive but has never had any symptoms, the following code would be assigned: A. B20, Human immunodeficiency virus HIV disease B. Z21, Asymptomatic human immunodeficiency virus HIV infection status C. R75, Inconclusive laboratory evidence of human immunodeficiency virus HIV D. Z20.6, Contact with and (suspected) exposure to human immunodeficiency virus HIV

Z21, Asymptomatic human immunodeficiency virus HIV infection status Z21, Asymptomatic HIV infection status is to be used when the patient without any documentation of symptoms is listed as being "HIV positive", "known HIV," "HIV test positive," or terminology. Do not use this code if the term "AIDS" is used or if the patient is treated for any HIV-related illness or is described as having any condition(s) resulting from HIV positive status; use B20 in these cases.

A patient is seen as an outpatient to receive chemotherapy for distal esophageal carcinoma. What is the appropriate first-listed diagnosis? A. Z48.3, Aftercare following surgery for neoplasm B. Z51.11, Encounter for antineoplastic chemotherapy C. C15.5, Malignant neoplasm of lower third of esophagus D. C15.3, Malignant neoplasm of upper third of esophagus

Z51.11, Encounter for antineoplastic chemotherapy If the treatment is directed at the malignancy, designate the malignancy as the first-listed diagnosis. The only exception to this guideline is if a patient admission or encounter is for the purpose of radiotherapy, immunotherapy, or chemotherapy. When the purpose of the encounter or hospital admission is for radiotherapy, or for antineoplastic chemotherapy, use the Z code as the first-listed diagnosis.

An HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient records at the time of discharge, providing a 24-hour turnaround time. The hospital has an average daily discharge of 120 patients, and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time? National Benchmarks for Document Scanning Processes: Function: Expectations per Worked Hour Prepping: 340-500 images Scanning: 1,200-2,400 images Quality Control: 1,600-2,000 images Indexing: 600-800 images a. 100 hours b. 146 hours c. 1,000 hours d. 3,740 hours

a. 100 hours The question is asking for the least amount of hours needed to meet the 24-hour turnaround time. The average discharge in a 24-hour period is 120 patients, and the average number of pages for each patient chart is 200. So, 120 × 200 = 24,000 pages in a 24-hour period. Each chart must be prepped, scanned, checked for quality, and indexed. The highest number of pages that can go through all these processes in an hour would be: 500 images in prepping; 2,400 images in scanning; 2,000 images in quality control; and 800 images in indexing. 24,000 / 500 = 48 hours needed for prepping 24,000 / 2,400 = 10 hours for scanning 24,000 / 2,000 = 12 hours for quality control 24,000 / 800 = 30 hours for indexing 48 + 10 + 12 + 30 = 100 hours, at least, needed each day to meet a 24-hour turnaround time.

A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used? Coder & Work Output Coder A: 500 Coder B: 480 Coder C: 300 Coder D: 360 a. 82 b. 156 c. 820 d. 1,550

a. 82 Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data. In this case, 82 records would be a sufficient number to review for coding quality. The calculation is: (500 × 0.05) + (480 × 0.05) + (300 × 0. 05) + (360 × 0.05) = 25 + 24 + 15 + 18 = 82 records OR (500 + 480 + 300 + 360) × 0.05 = 1640 × 0.05 = 82 records

Which of the following administrative safeguards includes policies and procedures for responding to emergencies or failures in systems that contain e-PHI? a. A contingency plan b. Security training c. Workforce security d. Information access management

a. A contingency plan A contingency plan is a standard that requires the establishment and implementation of policies and procedures for responding to emergencies or failures in systems that contain e-PHI. It includes a data backup plan, disaster recovery plan, emergency mode of operation plan, testing and revision procedures, and applications and data criticality analysis to prioritize data and determine what must be maintained or restored first in an emergency.

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

a. A predefined audit process Accuracy of coding is best determined by a predefined audit process. The audits allow the facility to confirm that the policies and procedures of the organization are being met and to identify problems that need to be addressed and corrected.

The use of the health record by a clinician to facilitate quality patient care is considered: a. A primary purpose of the health record b. Patient care support c. A secondary purpose of the health record d. Patient care effectiveness

a. A primary purpose of the health record The primary purposes of the health record are related to providing care to the patient. Patient care includes the direct care provided and the day-to-day business of the organization.

Which of the following is an institutional user of the health record? a. A third-party payer b. Patient c. Physician d. Employer

a. A third-party payer Institutional users of the health record are organizations that need access to health records in order to accomplish their mission. These institutional users include healthcare delivery organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, and policy-making bodies.

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

a. Abstracted or indexed Abstracting is the process of extracting elements of data from a source document and entering them into an automated system. The purpose of this endeavor is to make those data elements available for later use. After a data element is captured in electronic form, it can be aggregated into a group of data elements to provide information needed by the user.

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

a. Access controls Establishing access controls is a fundamental security strategy. Basically, the term access Control means being able to identify which employees should have access to what data. The general practice is that employees should have access only to data they need to do their jobs. For example, an admitting clerk and a healthcare provider would not have access to the same kinds of data.

Within the context of electronic health records, protecting data privacy means defending or safeguarding: a. Access to information b. Data availability c. Health record quality d. System implementation

a. Access to information Within the context of data security, protecting data privacy means safeguarding access to information. Only those individuals who need to know information should be authorized to access it.

The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards is called: a. Accreditation b. Licensure c. Acceptance d. Approval

a. Accreditation Accreditation is the act of granting approval to a healthcare organization. The approval is based on whether the organization has met a set of voluntary standards that were developed by the accreditation agency. Voluntary reviews are conducted at the request of the healthcare facility seeking accreditation or certification. The Joint Commission is an example of an accreditation agency.

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

a. Accusations of fraud and abuse The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance.

Which of the following is an example of clinical data? a. Admitting diagnosis b. Date and time of admission c. Insurance information d. Health record number

a. Admitting diagnosis The health record generally contains two types of data: clinical and administrative. Clinical data document the patient's health condition, diagnosis, and procedures performed as well as the healthcare treatment provided. Administrative data include demographic and financial information as well as various consents and authorizations related to the provision of care and the handling of confidential patient information.

Which of the following is not an identifier under the Privacy Rule? a. Age 75 b. Vehicle license plate BZ LITYR c. Street address 265 Cherry Valley Road d. Visa account 2773 985 0468

a. Age 75 One of the most fundamental terms in the Privacy Rule is protected health information (PHI), defined by the rule as "individually identifiable health information that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium" (45 CFR 160.103). To meet the individually identifiable element of PHI, information must meet all three portions of a three-part test. It must either identify the person or provide a reasonable basis to believe the person could be identified from the information given. It must relate to one's past, present, or future physical or mental health condition; the provision of healthcare; or payment for the provision of healthcare. It must be held or transmitted by a covered entity or its business associate.

A physician is reviewing lab results on a patient in his office. The EHR screen displays one set of results in red with a flashing asterisk and also shows that this result is three times higher than the expected value. This is an example of a(n) _______. a. Alert b. Reminder c. Structured data d. Unstructured data

a. Alert These alerts and reminders are controlled by clinical decision support built into the system, which is able to help prevent medication errors, notification of abnormal test results, and improve the quality of care through its validation mechanisms.

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

a. All applicable laws must be considered Not all information must be kept forever. Just as the HIM professional must consider multiple factors when determining retention, many factors must also be taken into consideration with regard to health record destruction. These include applicable federal and state statutes and regulations; accreditation standards; pending or ongoing litigation; storage capabilities; and cost.

A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the HIM department and requests to review her health record. Of the options here, what is the best course of action? a. Allow her to review her record after obtaining authorization from her. b. Refer the patient to her physician for the information. c. Tell her to go through her supervisor for the information. d. Tell her that hospital employees cannot access their own medical records.

a. Allow her to review her record after obtaining authorization from her. Review of records by the patient is permitted after the authorization for use and disclosure is verified. Usually hospital personnel should be present during on-site reviews to assist the requester with the paper record or working with the EHR if necessary. Assistance would not be needed if the people requesting on-site review work for the facility.

Under the HIPAA Privacy rule, which of the following statements is true? a. An authorization must contain an expiration date or event. b. A consent for use and disclosure of information must be obtained from every patient. c. An authorization must be obtained for uses and disclosures for treatment, payment, and operations. d. A notice of privacy practices must give 10 examples of a use or disclosure for healthcare operations.

a. An authorization must contain an expiration date or event. In order for an authorization to be valid, it must contain an expiration date or event that relates to the individual or the purpose of the use or disclosure.

The member had gastric bypass surgery three years prior. As a result of an over 200-pound weight loss, loose skin hung from the member's arms, thighs, and belly. The member, upon referral from her general surgeon, was scheduled to have a plastic surgeon to remove the excess skin. The member called for prior approval as required by the plan. The clinical review resulted in a denial of the surgery as cosmetic. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. The peer clinician denied the case. What is the next step the member can take to have the surgery paid for by her insurance company? a. Appeal to an expert clinician in the same specialty b. Disenroll from the plan and enroll with indemnity healthcare insurance c. File a lawsuit d. Schedule the surgery with her original general surgeon as that surgeon was paid

a. Appeal to an expert clinician in the same specialty An appeal is a request for reconsideration of denial of coverage for healthcare services or rejection of a claim. Second and third opinions are cost-containment measures to prevent unnecessary tests, treatments, health devices, or surgical procedures. These second and third opinions are particularly sought when test, treatment, health device, or surgical procedure is high risk or high cost; diagnostic evidence is contradictory or equivocal; or experts' opinions are mixed about efficacy.

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

a. Ask current staff members to keep a diary for a certain period of time on how they spend their time Collecting data on current performance and tasks allows the HIM supervisor to include all tasks that are being performed in the new job descriptions. When more than one person is performing a task, the data could be collected over time and averaged. One method of doing this is to keep a diary for a period of time on how they spend their time. The experience and overall performance of each person must be considered in setting the standard.

A healthcare provider organization, when defining its legal health record must: a. Assess the legal environment, system limitations, and standards of care b. Determine what other healthcare provider organizations are doing c. Determine if a legal health record is needed d. Include only the paper components of the health record

a. Assess the legal environment, system limitations, and standards of care As part of the process to identify the legal health record, the facility should assess the legal environment, system limitations, and standards of care.

A notation for a hypertensive patient in a physician ambulatory care progress note reads: "Blood pressure adequately controlled." In which part of a problem-oriented health record progress note would this be written? a. Assessment b. Objective c. Plan d. Subjective

a. Assessment Some providers also use a SOAP format for their problem-oriented progress notes. Professional conclusions reached from evaluation of the subjective or objective information make up the assessment.

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

a. Assigns the health record number The health record typically begins in patient registration with the capture of patient demographic information. The health record is assigned to new patients during the patient registration process. The HIM department works with patient registration to ensure the quality of the data collected and to correct duplicate and other issues with the MPI.

Secondary data is used for multiple reasons including: a. Assisting researchers in determining effectiveness of treatments b. Assisting physicians and other healthcare providers in providing patient care c. Billing for services provided to the patient d. Coding diagnoses and procedures treated

a. Assisting researchers in determining effectiveness of treatments Secondary data is used in research. Data taken from health records and entered into disease oriented databases can help researchers determine the effectiveness of alternate treatment methods. They also can quickly demonstrate survival rates at different stages of diseases.

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

a. Audit trail An audit trail is a record of system and application activity by users. It can track when an employee has accessed the system, the actions taken, and how long the employee has been logged into a system.

A coding compliance manager is reviewing a tool that identifies when a user logs in and out, what he or she does, and more. What is the manager reviewing? a. Audit trail b. Facility access control c. Forensics d. Security management plan

a. Audit trail Audit controls are required by HIPAA. One method of monitoring is the use of audit trails. Audit trails are a recording of activities occurring in an information system. Audit trails can monitor system level controls such as login, logout, unsuccessful logins, print, query, and other actions. It also records user-identification information and the date and time of the activity. Audits should be scheduled periodically, but can also be performed when a problem is suspected.

Which of the following is the best definition of system of record (SOR)? a. Authoritative source for data about an entity b. Master entity application c. Exact match logic d. Primary data about an entity

a. Authoritative source for data about an entity Once the organization identifies sources, it lists the most trusted ones. Usually these are the sources with the most volume of master data records associated with a specific entity. In some instances, the master data will have their own unique system of record. A system of record is usually a specialized application system and the authoritative source for data about an entity.

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

a. Avoid displaying the number on any document, screen, or data collection field It is generally agreed that Social Security numbers (SSNs) should not be used as patient identifiers. The Social Security Administration is adamant in its opposition to using the SSN for purposes other than those identified by law. AHIMA is in agreement on this issue due to privacy, confidentiality, and security issues related to the use of the SSN.

What makes the indexing of scanned health record more efficient because it can enter metadata automatically? a. Barcodes b. Interoperability c. Scanning d. Deficiency management

a. Barcodes The barcode makes indexing more efficient because the barcode can enter metadata automatically. Standards for the use of barcodes must be established to facilitate scanning. These standards should include the size of the barcode, the standardized location of the barcode, and the amount of white space between the barcode and any text.

What type of health records may contain family and caregiver input? a. Behavioral health records b. Ambulatory surgery health records c. Emergency department health records d. Obstetric health record

a. Behavioral health records Behavioral health records are more commonly referred to as mental health records and contain much of the same content as a non-behavioral health record such as discharge summary, H&P, or physician's orders. Behavioral health records contain a treatment plan that often includes family and caregiver input and information as well as assessments geared toward the transition to outpatient, nonacute treatment.

The hospital-acquired infection rate for our hospital is 0.2%, whereas the rate at a similar hospital across town is 0.3%. This is an example of a: a. Benchmark b. Check sheet c. Data abstract d. Run chart

a. Benchmark A benchmark is a systematic comparison of one organization's measurement characteristics to those of another similar organization. When an organization compares its current performance to its own internal historical data, or uses data from similar external organizations, it helps establish an organization benchmark.

To develop performance standards for release of information turnaround time, the manager conducted a literature search and contacted peer institutions. Which method did she use? a. Benchmarking b. Workflow analysis c. Productivity analysis d. Work measurement

a. Benchmarking Comparing an organization's performance to the performance of other organizations that provide the same types of service is known as benchmarking. Internal benchmarking is also important to establish a baseline for the organization to find ways to improve effectiveness.

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

a. By the hospital Health records, x-rays, laboratory reports, consultation reports, and other physical documents relating to the delivery of patient care are owned by the healthcare organization.

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

a. Case-mix index CDI metrics are key indicators used to monitor the effectiveness of CDI programs. One of the most widely used key indicators for a CDI program is the case-mix index. A strong CDI program will strengthen the case-mix index because the quality and specificity of the documentation help the coders to choose the appropriate codes.

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

a. Certified coders A well-trained coding staff helps ensure complete and accurate coding, which is essential for the integrity of the data collected. All coders in the facility should receive continuing education, but certified coders must demonstrate that they are continuing to maintain their knowledge and skill base. To maintain their certification, individuals must complete a designated set of continuing education units.

A PI Team is concerned with the time it is taking for patients to get through the registration process. To better understand the causes or reasons for the delay in this process the PI Team would like to gather observational data. What data collection tool would be appropriate for this team to develop for their observation data? a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool

a. Check sheet A check sheet is used to gather data based on sample observations in order to detect patterns. When preparing to collect data, a team should consider the four W questions: Who will collect the data? What data will be collected? Where will the data be collected? When will the data be collected?

Which of the following is part of qualitative analysis review? a. Checking that only approved abbreviations are used b. Checking that all forms and reports are present c. Checking that documents have patient identification information d. Checking that reports requiring authentication have signatures

a. Checking that only approved abbreviations are used Qualitative analysis is about the quality of the documentation including the use of approved abbreviations.

What committee usually oversees the development and approval of new forms for the health record? a. Clinical forms committee b. Executive committee c. Medical staff committee d. Quality review committee

a. Clinical forms committee Every healthcare organization should have a clinical forms or design (for EHR systems) committee. This committee should provide oversight for the development, review, and control of all enterprise-wide information capture tools, including paper forms and design of computer screens.

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

a. Code skin lesion In the outpatient setting, do not code a diagnosis documented as "probable." Rather, code the conditions to the highest degree of certainty for the encounter.

What formatting problem is found in the following table? Community Hospital Admissions by Gender, 20XX Male 3,546 42.4 Female 4,825 57.6 Total 8,371 100 a. Column headings are missing b. Title of the table is missing c. Column totals are inaccurate d. Variable names are missing

a. Column headings are missing A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be organized into tables. Tables are useful for demonstrating patterns and other kinds of relationships. Tables need headings for columns and rows, and they need to be specific and understandable.

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission

a. Commission on Accreditation of Rehabilitation Facilities The Commission on Accreditation of Rehabilitation Facilities (CARF) is a private, not-for-profit organization committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs. CARF accreditation is based on an organization's commitment to continually enhance the quality of its services and programs and to focus on customer satisfaction.

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

a. Concurrent Concurrent coding is the type of coding that takes place in the hospital while the patient is still receiving care.

What is the general name for Medicare rules affecting healthcare organizations? a. Conditions of Participation b. Regulations for licensure c. Requirements for service d. Terms of accreditation

a. Conditions of Participation Called the Medicare Conditions of Participation, these rules are set forth by CMS. Facilities that must meet the standards in the Conditions of Participation include hospitals, home health agencies, ambulatory surgical centers, and hospices.

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

a. Congestive heart failure, respiratory failure, ventilator management, intubation CHF is the principal diagnosis and must be sequenced first.

The statement, "the unique patient identifier must be numeric," is an example of which of the following business rule categories? a. Constraint b. Definition c. Derivation d. Relational

a. Constraint A constraint is a condition that determines what values an attribute or relationship can or must have which is one of the business rule categories.

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

a. Consultation The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record.

Which of the following is an example of a business associate? a. Contract coder b. Environmental services department c. Hospital security officer d. Employee with access to e-PHI

a. Contract coder Although business associates are not directly regulated by the Privacy Rule, they do come under the Privacy Rule's requirements by virtue of their association with one or more covered entities. Some examples of business associates are contract coder, billing companies, consultants, accounting firms, and the like.

Which of the following is necessary to ensure that each term used in an EHR has a common meaning to all users? a. Controlled vocabulary b. Data exchange standards c. Encoded vocabulary d. Proprietary standards

a. Controlled vocabulary The vocabulary used in an electronic health record (EHR) system should, at a minimum, be a controlled vocabulary, which is essential in ensuring a common meaning for all users. A controlled vocabulary means that a specific set of terms in the EHR's data dictionary may be used and that a central authority approves any additions or changes.

A(n) __________ is imposed on providers by the OIG when fraud and abuse is discovered through an investigation. a. Corporate Integrity Agreement b. OIG Workplan c. Red Flags Rule d. Resource Agreement

a. Corporate Integrity Agreement A corporate integrity agreement (CIA) is essentially a compliance program imposed by the government, with substantial government oversight and outside expert involvement in the organization's compliance activities. The OIG negotiates CIAs with health care providers and other entities as part of the settlement of federal health care program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other federal healthcare programs.

Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS

a. DEEDS In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.

Which of the following are clear guidelines for the acceptable values of specific data fields and makes it possible to exchange health information using electronic networks? What type of standards provide clear descriptors of data elements to be included in an electronic health record system? a. Data content standard b. Messaging standards c. Interoperability standards d. Vocabulary standards

a. Data content standard Data and content standards are clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks.

Managing an organization's data and those who enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following? a. Data dictionary b. Data warehouse c. Data mapping d. Data set

a. Data dictionary A data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology.

Multiple users entering data may have different definitions or perceptions about what goes into a data field, thereby confounding the data. For example, one department may use the term "PATIENT" while another department my use the term "CLIENT" to define the same entity. Which of the following would be used to provide standardization? a. Data dictionary b. Data mining c. Data model d. Database

a. Data dictionary The data dictionary is a central building block that supports communication across business processes. Defining a data dictionary supports the creation of well-structured and defined data sets by creating standardized definitions of data elements to help ensure consistency of collection and use of the data. For example, the data element "PATIENT" would have the same field length and definition across all applications in the organization.

In a database the LAST_NAME column in a table would be considered a: a. Data element b. Record c. Primary key d. Row

a. Data element A data element is an individual fact or measurement that is the smallest unique subset of a database.

Patient name, zip code, and health record number are typical: a. Data elements b. Data sources c. Aggregate data d. Data monitors

a. Data elements The types of data elements that are abstracted, or defined as indexed fields in an automated system, vary from facility to facility. Generally, however, any data elements that are needed for selecting cases for reports must be abstracted or indexed. Some of the typical data fields that can be searched for the purpose of finding and reporting include: patient name, zip code, health record number, patient account number, attending physician, and the like.

Which of the following Enterprise Information Management (EIM) functions is the overarching authority for managing an organization's data assets? a. Data governance b. Clinical quality management c. Data security management d. Master data management

a. Data governance Data governance is the overarching authority that ensures the cohesive operation and integration of all EIM domains. Data governance includes a formal organizational structure with both authority and responsibility for managing an organization's data assets

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors is called: a. Data mining b. Data warehouse c. Data searching d. Big data

a. Data mining Data mining is the process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors.

A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as: a. Data precision b. Data consistency c. Data granularity d. Data comprehensiveness

a. Data precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For example, a precise data definition related to gender would include three values: male, female, and unknown.

What is the term used to identify a separate database or system within a department that does not integrate into the main organizational system nor can it be accessed by others outside that specific department? a. Data silo b. Information system c. Information technology d. Data architecture

a. Data silo A data silo is a separate database or system within a department that does not integrate into the main organizational system nor can others access it outside of that specific department.

Which of the following individuals would serve as a bridge between information technology and business and clinical areas while managing each key area? a. Data steward b. Systems analyst c. Data scientist d. Systems administrator

a. Data steward Data stewards serve as the bridge between information technology, and business and clinical areas. They are assigned to manage key data areas and are responsible for tasks such as data definition and information quality activities.

What is it called when accrediting bodies, such as the Joint Commission, rather than the government can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals? a. Deemed status b. Licensure c. Subpoena d. Credentialing

a. Deemed status Hospitals accredited through the Joint Commission or another accrediting body may participate in the Medicare program because the accrediting agency has been granted deemed status by the Medicare program. Deemed status means accrediting bodies such as the Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for Hospitals instead of the government.

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

a. Determine whether the source of the benchmark data is from a comparable institution Comparing an organization's performance to the performance of other organizations that provide the same types of services is known as external benchmarking. The other organizations need not be in the same region of the country, but they should be comparable organizations in terms of patient mix and size.

Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health? a. Document name, media type, source system, electronic storage start date, stop printing start date b. Document name, media type c. Document name, medical record number, source system d. Document name, source system

a. Document name, media type, source system, electronic storage start date, stop printing start date Create a matrix that defines each document type in the legal health record and determine the medium in which each element will appear. Such a matrix could include a column indicating the transition date of a particular document from the paper-based to the electronic environment. It is important that specific state guidelines are incorporated when a facility matrix is developed.

Which of the following is a primary purpose of the health record? a. Document patient care delivery b. Regulation of healthcare facilities c. Aid in education of nurses and physicians d. Assist in process redesign

a. Document patient care delivery Patient care delivery is a primary purpose of the health record. Other primary purposes are patient care management, patient care support processes, financial and other administrative processes, and patient self-management.

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

a. Each physician practice should obtain a business associate agreement with the hospital. If physicians were to dictate information regarding patients they are treating in the facility, the disclosure of protected health information within the voice recognition system would be considered healthcare operations and, therefore, permitted under the HIPAA Privacy Rule. If physicians, who are separate covered entities, are dictating information on their private patients, however, it would be necessary for physicians to obtain a business associate agreement with the facility. It is permitted by the Privacy Rule for one covered entity to be a business associate of another covered entity.

The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: a. Enterprise master patient index (EMPI) b. Audit trail c. Case-mix management d. Electronic document management system (EDMS)

a. Enterprise master patient index (EMPI) The EMPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility. When a healthcare enterprise as more than one facility and the patient is seen at two or more places, the enterprise master patient index (EMPI) links the patient's information at the different facilities.

Authentication of a record refers to: a. Establishment of its baseline trustworthiness b. The type of electronic operating system on which it was created c. The identity of the individual who notarized it d. Its relevance

a. Establishment of its baseline trustworthiness Even if evidence appears to be relevant, it must also be authenticated. As with health records, the evidence itself must be shown to have a baseline authenticity or trustworthiness.

How do patient care managers use the data documented in the health record? a. Evaluate the services provided by their employees b. Communicate vital information among departments and across disciplines and settings c. Generate patient bills or third-party payer claims for reimbursement d. Determine the extent and effects of occupational hazards

a. Evaluate the services provided by their employees It is the role of the patient care managers and support staff to evaluate the services provided by their employees.

With regard to training in PHI policies and procedures: a. Every member of the covered entity's workforce must be trained b. Only individuals employed by the covered entity must be trained c. Training only needs to occur when there are material changes to the policies and procedures d. Documentation of training is not required

a. Every member of the covered entity's workforce must be trained Every member of the covered entity's workforce must be trained in PHI policies and procedures to maintain the privacy of patient information, uphold individual rights guaranteed by the Privacy Rule, and report alleged breaches and other Privacy Rule violations.

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

a. Form an EHR steering committee Most organizations create an electronic health records (EHR) steering committee to engage all the various stakeholders in EHR planning and development. This ensures that the EHR planning is comprehensive and also starts the process of introducing change and gaining buy-in.

This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans: a. HEDIS b. UHDDS c. UACDS d. ORYX

a. HEDIS Healthcare Effectiveness Data and Information Set (HEDIS) is overseen by the National Committee for Quality Assurance. HEDIS is a standardized set of performance measures designed to allow purchasers to compare the performance of managed-care plans.

Which of the following statements represents an example of nonmaleficence? a. HITs must ensure that patient-identifiable information is not released to unauthorized parties. b. HITs must apply rules fairly and consistently to every case. c. HITs must ensure that patient-identifiable information is released to the parties who need it to provide services to their patients. d. HITs must ensure that patients themselves, and not other parties, are authorizing access to the patients' individual health information.

a. HITs must ensure that patient-identifiable information is not released to unauthorized parties. Nonmaleficence would require the HIM professional to ensure that the information is not released to someone who does not have authorization to access it and who might harm the patient if access were permitted (for example, a newspaper seeking information about a famous person).

Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Health information management b. Patient access c. Patient accounts d. Utilization management

a. Health information management Resolving failed edits is one of many duties of the health information management (HIM) department. Various hospital departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues.

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

a. Health records in any format One of the most fundamental terms used in the Privacy Rule is protected health information (PHI). The Privacy Rule defines PHI as individually identifiable health information that is transmitted by electronic media, maintained in any electronic medium, or maintained in any other form or medium.

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

a. Healthcare fraud Healthcare fraud is an intended and deliberate deception or misrepresentation by a provider, or by representative of a provider, that results in a false or fictitious claim. These false claims then result in an inappropriate payment by Medicare or other insurers.

The deception or misrepresentation by a healthcare provider that may result in a false or fictitious claim for inappropriate payment by Medicare or other insurers for items or services either not rendered or rendered to a lesser extent than described in the claim is: a. Healthcare fraud b. Optimization c. Upcoding d. Healthcare abuse

a. Healthcare fraud Healthcare fraud is defined as an intentional misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself or herself or some other person. An example of fraud is billing for a service that was not furnished.

In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited? a. ICD-10-CM and ICD-10-PCS coding b. CPT/HCPCS and LOINC coding c. ICD-10-CM and SNOMED coding d. CPT/HCPCS and ICD-10-PCS coding

a. ICD-10-CM and ICD-10-PCS coding The corporate compliance program addresses the coding function. Because the accuracy and completeness of ICD-10-CM and ICD-10-PCS for inpatient code assignment determine the provider payment, the coding compliance program should regularly audit these codes. It is important that healthcare organizations have a strong coding compliance program.

When an individual requests a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may: a. Impose a reasonable cost-based fee b. Not charge the individual c. Impose any fee authorized by state statute d. Charge only for the cost of the paper on which the information is printed

a. Impose a reasonable cost-based fee HIPAA gives individuals the right to request access to their PHI, but the covered entity may require that requests be in writing. HIPAA allows a reasonable cost-based fee when the individual requests a copy of PHI or agrees to accept summary or explanatory information.

Which of the following should be taken into consideration when designing a health record form? a. Including original and revised dates b. Number of clicks to access data c. Choosing the field type such as radio buttons d. Difference between paper and screen

a. Including original and revised dates One example of effective form design principles is that each form should include original and revised dates for the tracking and purging of obsolete forms.

Which of the following statements about the directory of patients maintained by a covered entity is true? a. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory. b. Individuals must provide a written authorization before information about them can be placed in the directory. c. The directory may contain only identifying information such as the patient's name and birth date. d. The directory may contain private information as long as it is kept confidential.

a. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory. A patient has the opportunity to agree or disagree with being placed in a patient directory. They must be given the opportunity to determine if they want to be placed in the directory or not, but it does not need to be in writing.

Which of the following is true about information assets? a. Information considered to add value to an organization b. Data entered into a patient's health record by a provider c. Clearly defined elements required to be documented in the health record d. A list of all data elements added within a record

a. Information considered to add value to an organization Information assets refer to the information collected during day-to-day operations of a healthcare organization that has value within an organization. For example, patient data collected to support patient care is an example of information assets for the organization.

The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team? a. Insufficient knowledge of team members b. Too many team members c. Unspecific team charge d. Too few team members

a. Insufficient knowledge of team members Whether selecting a permanent staff team or members of a team for a short-term project, making the right choice is fundamental to the team's success. Putting together a team involves understanding the challenges to be faced and considering all of the perspectives, experience, and knowledge that will be needed. The members of the team should be selected for what they can contribute to the team. Member selection should not be based purely on job title; rather, team members should be selected for the tasks that they actually can perform and the responsibilities they can carry out.

Mary's PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the physician office's required action? a. It must report the breach to HHS within 60 days after the end of the calendar year in which the breach occurred b. It must report the breach to HHS within 60 days of the breach c. It must notify all local media outlets and HHS immediately d. It is not required to take any action since the breach affected only one person

a. It must report the breach to HHS within 60 days after the end of the calendar year in which the breach occurred Since this breach applies to one patient, it must be reported to HHS within 60 days after the end of the calendar year.

Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed. K20.9 Esophagitis, unspecified K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis 0 Section - Medical and Surgical D Body System - Gastrointestinal System J RootOperation - Inspection 0 Body Part - Upper Intestinal Tract 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device Z Qualifier - No qualifier 0 Section - Medical and Surgical D Body System - Gastrointestinal System B RootOperation - Excision 5 Body Part - Esophagus 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device X Qualifier - Diagnostic 0 Section - Medical and Surgical D Body System - Gastrointestinal System B RootOperation - Excision 5 Body Part - Esophagus 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device Z Qualifier - No qualifier a. K21.9, 0DB58ZX b. K20.9, 0DB58ZZ c. K21.0, 0DB58ZX d. K21.9, 0DJ08ZZ, 0DB58ZX

a. K21.9, 0DB58ZX The patient has esophageal reflux with no esophagitis mentioned, so K21.9 is the correct diagnosis code. For the ICD-10-PCS procedure code, a closed biopsy of the esophagus was performed via esophagoscopy, so 0DB58ZX is the correct code. The Section is Medical and Surgical—character 0; Body System is Gastrointestinal—character D; Root Operation is Excision—character B; Body Part is Esophagus—character 5; Approach—Via Natural or Artificial Opening Endoscopic—character 8; No Device—character Z; and the procedure was for diagnostic reasons (biopsy)—character X

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

a. Laboratory As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected. This creates new challenges for organizations because merge functionality could be different in each system or module, which in turn creates data redundancy. When duplicates are identified, the department managers need to be notified. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare.

Identify where the following documentation would be found in the acute-care record: "CBC: WBC 12.0, RBC 4.65, HGB 14.8, HCT 43.3, MCV 93." a. Laboratory report b. Pathology report c. Physical examination d. Physician orders

a. Laboratory report The results of all diagnostic and therapeutic procedures become part of the patient's health record. The laboratory report includes tests performed on blood, urine, and other samples from the patient.

Which of the following would be considered a security vulnerability? a. Lack of laptop encryption b. Workforce employees c. Tornado d. Electrical outage

a. Lack of laptop encryption A security threat is anything that can exploit a security vulnerability. Vulnerability is a weakness or gap in security protection. In this situation the lack of encryption for the laptop would be considered a security vulnerability as the contents could be more easily accessed.

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

a. Legitimate need for access The access controls standard requires implementation of technical procedures to control or limit access to health information. The procedures would be executed through some type of software program. This requirement ensures that individuals are given authorization to access only the data they need to perform their respective jobs.

A patient has liver metastasis due to adenocarcinoma of the rectum. The rectum was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is: a. Liver metastasis b. Adenocarcinoma of the rectum c. Anemia d. Admission for radiotherapy

a. Liver metastasis When an admission or encounter is for the management of anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced first as the principal or first listed diagnosis followed by the appropriate code for the anemia (such as D63.0, Anemia in neoplastic disease) according to ICD-10-CM Coding Guideline I.C.2.c.1

If a patient wants to amend his or her health record, the covered entity may require the individual to: a. Make an amendment request in writing and provide a rationale for the amendment. b. Ask the attending physician for his or her permission to amend their record. c. Require the patient to wait 30 days before their request will be considered and processed. d. Provide a court order requesting the amendment.

a. Make an amendment request in writing and provide a rationale for the amendment. The covered entity may require the individual to make an amendment request in writing and provide a rationale for their amendment request. Such a process must be communicated in advance to the individual.

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

a. Makes it lower than warranted by the actual service and resource intensity of the facility Medicare severity diagnosis-related group (MS-DRG) sets exist where the listings of diagnoses used to drive the grouping are the same, but the presence or absence of a complication or comorbidity (CC) diagnosis or major complication or comorbidity (MCC) diagnosis assigns the case to a higher or lower MS-DRG. MS-DRG sets may contain two or three MS-DRGs. These MS-DRG relationships and sets pose a compliance concern because the health record documentation used to support the coding of principal diagnosis, complications, and comorbidities may not always be clear or used appropriately by the coder (such as undercoding). Therefore, inaccurate coding can lead to incorrect MS-DRG assignment and thus inappropriate reimbursement and can affect a hospital's case mix.

A nurse is responsible for which of the following types of acute-care documentation? a. Medication administration record b. Radiology report c. Operative report d. Therapy assessment

a. Medication administration record Nurses maintain chronological records of the patient's vital signs (blood pressure, heart rate, respiration rate, and temperature) and separate logs that show what medications were ordered and when they were administered on the medication administration record (MAR).

An audit log is an example of: a. Metadata b. Encryption c. Admissibility d. Data integrity

a. Metadata Metadata are data about data and include information that track actions such as when and by whom a document was accessed or changed, such as in an audit log.

A provider's office calls to retrieve emergency room records for a patient's follow-up appointment. The HIM professional refused to release the emergency department records without a written authorization from the patient. Was this action in compliance? a. No; the records are needed for continued care of the patient, so no authorization is required b. Yes; the release of all records requires written authorization from the patient c. No; permission of the ER physician was not obtained d. Yes; one covered entity cannot request the records from another covered entity

a. No; the records are needed for continued care of the patient, so no authorization is required Treatment, payment, and operations (TPO) is an important concept because the Privacy Rule provides a number of exceptions for PHI that is being used or disclosed for TPO purposes. Treatment means providing, coordinating, or managing healthcare or healthcare-related services by one or more healthcare providers.

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

a. Obliterating or deleting errors To correct errors or make changes in the paper health record, a single line should be drawn in ink through the incorrect entry. The word error should be printed at the top of the entry along with a legal signature or initials, date, time, and discipline of the person making the change.

The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas? a. Operative and other invasive procedures, medication management, and blood and blood product use b. Blood and blood product use, medication management, and appointment to the board of directors c. Medication management, marketing strategy, and blood use d. Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use

a. Operative and other invasive procedures, medication management, and blood and blood product use Appointments to the Board of Directors is important information, but the Joint Commission requires detailed information on the responsibilities and actions of the Board, not necessarily its composition. The Joint Commission requires healthcare organizations to collect data on each of these areas: medication management, blood and blood product use, restraint and seclusion use, behavior management and treatment, operative and other invasive procedures, and resuscitation and its outcomes.

Physician orders for DNR should be consistent with: a. Patient's advance directive b. Patient's bill of rights c. Notice of privacy practices d. Authorization for release of information

a. Patient's advance directive An advanced directive is a written document that provides directions about a patient's desires in relation to care decisions for use by health care workers if the patient is incapacitated or not capable of communication. Physician orders for "do not resuscitate" (DNR) should be consistent with the patient's advanced directives.

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

a. Patient's laboratory value is 50. Although sometimes used interchangeably, the terms data and information do not mean the same thing. Data represent the basic facts about people, processes, measurements, conditions, and so on. They can be collected in the form of dates, numerical measurements and statistics, textual descriptions, checklists, images, and symbols. After data have been collected and analyzed, they are converted into a form that can be used for a specific purpose. This useful form is called information. In other words, data represent facts and information represents meaning.

How long should the MPI be retained? a. Permanently b. 25 years c. 50 years d. 10 years

a. Permanently The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information.

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? Personnel: Cost User's time—30 minutes: $15 Telephone cost—30 minutes: $2 Call Desk time—30 minutes: $16 Call Desk IS facilities time: $17 Total Cost: $50 a. Training will provide $146,000 savings in help desk support and can be justified. b. The results of training will provide $365,000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.

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

Our computer system just notified us that Mary Burchfield has just looked up another patient with the same last name. This notification is called a(n): a. Trigger b. Audit reduction tool c. Integrity d. Audit control

a. Trigger The security audit process should include triggers that identify the need for a closer inspection. These trigger events cannot be used as the sole basis of the review, but they can significantly reduce the amount of reviews performed. An example of a trigger is when a user has same last name as patient.

An audit trail may be used to detect which of the following? a. Unauthorized access to a system b. Loss of data c. Presence of a virus d. Successful completion of a backup

a. Unauthorized access to a system An audit trail is a software program that tracks every single access or attempted access of data in the computer system. It logs the name of the individual who accessed the data, terminal location or IP address, the date and time accessed, the type of data, and the action taken (for example, modifying, reading, or deleting data).

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

a. Validity of hospital diagnosis and procedure coding data completeness The responsibilities of the quality improvement organizations include reviewing health records to confirm the validity of hospital diagnosis and procedure coding data completeness.

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

a. Vital signs record The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information.

Mary's PHI has been breached. She must be informed of all of the following EXCEPT: a. Who committed the breach b. Date the breach was discovered c. Types of unsecured PHI involved d. What she may do to protect herself

a. Who committed the breach Individuals who are notified that their PHI has been breached must be given a description of what occurred (including date of breach and date that breach was discovered); the types of unsecured PHI that were involved (such as name, Social Security number, date of birth, home address, account number); steps that the individual may take to protect himself or herself; what the entity is doing to investigate, mitigate, and prevent future occurrences; and contact information for the individual to ask questions and receive updates.

A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure? -Section: 0 Med/Surg -Body System: Q Lower Bones -Root Operation: B Excision -Body Part: 6 Upper Femur, Right -Approach: 0 Open -Device: Z No Device -Qualifier: Z No Device -Section: 0 Med/Surg -Body System: Q Lower Bones -Root Operation: B Division -Body Part: 6 Upper Femur, Right -Approach: 0 Open -Device: Z No Device -Qualifier: Z No Device -Section: 0 Med/Surg -Body System: S Lower Bones -Root Operation: B Excision -Body Part: 9 Hip Joint, Right -Approach: 0 Open -Device: Z No Device -Qualifier: Z No Device -Section: 0 Med/Surg -Body System: S Lower Bones -Root Operation: N Release -Body Part: 9 Hip Joint, Right -Approach: 0 Open -Device: Z No Device -Qualifier: Z No Device a. 0QB60ZZ b. 0Q860ZZ c. 0SB90ZZ d. 0SN90ZZ

b. 0Q860ZZ The root operation performed was division—cutting into a body part without drawing fluids and/or gases from the body part in order to separate or transect a body part. The intent of the operation was to separate the femur. 0Q860ZZ is the correct code. The Section is Medical and Surgical—character 0; Body System is Lower Bones—character Q; Root Operation is Division—character 8; Body Part is Femur, Right—character 6; Approach is Open—character 0; No Device—character Z; and No Qualifier —character Z

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

b. 242 A unit of measure that reflects the services received by one inpatient during a 24-hour period is called an inpatient service day. The number of inpatient service days for a 24-hour period is equal to the daily inpatient census—that is, one service day for each patient treated. The calculation is: [(250 + 30) − 40] + 2 = 242 [(patients at midnight on May 1 + patients admitted on May 2) - discharged patients] + patient deaths = total number of inpatient days for May 2

In May, 270 women were admitted to the obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculating the C-section rate? a. 33 b. 263 c. 270 d. 296

b. 263 The denominator (the number of times an event could have occurred) in this case would be 263 as 263 women delivered.

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

b. 31.5 The median is the midpoint of a frequency distribution. It is the point at which 50 percent of observations fall above and 50 percent fall below. If an even number of observations is in the frequency distribution, the median is the midpoint between the two middle observations. It is found by averaging the two middle scores, (x + y) / 2. In the example, the median is 31.5: ([30 + 33] / 2) Data set in order from least to greatest: 11, 20, 30, 30, 33, 35, 47, 50

City Hospital's Revenue Cycle Management team has established the following benchmarks: (1) The value of discharged not final billed cases should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. The net average daily revenue is $1,000,000. The following data indicate that City Hospital's DNFB cases met its benchmarks: [Graph: Value of DFNB Days on Y axis, DFNB Days on X Axis; DNFB-Jan 1000000, DNFB-Feb 2000000, DNFB-Mar 3000000, DNFB-Apr 5000000, DNFB-May 3000000, DNFB-Jun 1000000] a. 25 percent of the time b. 50 percent of the time c. 75 percent of the time d. 100 percent of the time

b. 50 percent of the time In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 percent of the time.

Which of the following statements is true in regard to responding to requests from individuals for access to their protected health information (PHI)? a. A cost-based fee may be charged for retrieval of the PHI. b. A cost-based fee may be charged for making a copy of the PHI. c. No fees of any type may be charged. d. A minimal fee may be charged for retrieval and copying of PHI.

b. A cost-based fee may be charged for making a copy of the PHI. HIPAA allows the covered entity to impose a reasonable cost-based fee when the individual requests a copy of PHI or agrees to accept summary or explanatory information. The fee may include the cost of: copying, including supplies, labor, and postage. HIPAA does not permit "retrieval fees" to be charged to patients.

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

b. A patient's attorney is sent records not authorized by that patient There are three exceptions to a breach. All of these answers fall into one of these categories with the exception of the records sent to the patient's attorney. He does not work for the covered entity and an authorization is required.

The Patient Accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills? a. Accounts receivable aging report b. Accounts not selected for billing report c. Case-mix index report d. Discharge summary report

b. Accounts not selected for billing report The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged not final billed (DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list.

You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide to the physician? a. Patient-specific data b. Aggregate data c. Operating room data d. Nothing—you cannot obtain this data after the fact

b. Aggregate data Aggregate data is data extracted from individual health records and combined to form de- identified information about groups of patients that can be compared and analyzed.

Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to the physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: a. Never allowed b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment c. Allowed only if Jennifer's mother is declared incompetent by a court of law d. Any family member is always allowed access to PHI

b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment The Privacy Rule lists two circumstances where protected health information (PHI) can be used or disclosed without the individual's authorization (although the individual must be informed in advance and given an opportunity to agree or object). One of these circumstances is disclosing PHI to a family member or a close friend that is directly relevant to his or her involvement with the patient's care or payment. Likewise, a covered entity may disclose PHI, including the patient's location, general condition, or death, to notify or assist in the notification of a family member, personal representative, or some other person responsible for the patient's care.

What is the legal term used to define the protection of health information in a patient-provider relationship? a. Access b. Confidentiality c. Privacy d. Security

b. Confidentiality Confidentiality, as recognized by law and professional codes of ethics, stems from a relationship such as physician and patient, and pertains to the information resulting from that relationship. Privileged communication is a legal concept designed to protect the confidentiality between two parties.

Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which quality element is missing from Mrs. Smith's health record? a. Data completeness b. Data consistency c. Data accessibility d. Data comprehensiveness

b. Data consistency Data consistency means that the data are reliable. Reliable data do not change no matter how many times or in how many ways they are stored, processed, or displayed. Data values are consistent when the value of any given data element is the same across applications and systems. Related data items also should be reliable.

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

b. Data recovery Data recovery is the process of recouping lost data or reconciling conflicting data after the system fails. These data may be from events that occurred while the system was down or from backed-up data.

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

b. Developing procedures for identifying coding errors Coding compliance activities would not include a financial incentive for coders to commit fraud, to code diagnoses and procedures before documentation is complete, or to spend resources reviewing accurately paid claims. Providing a financial incentive to coders for coding claims improperly would be against any coding compliance plan and would also be a violation of AHIMA's Standards of Ethical Coding. One of the basic elements of a coding compliance program includes developing policies and procedures for identifying coding errors.

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

b. Device and media controls Device and media controls require the facility to specify proper use of electronic media and devices (external drives, backup devices, etc.). Included in this requirement are controls and procedures regarding the receipt and removal of electronic media that contain protected health information and the movement of such data within the facility. The entity must also address procedures for the transfer, removal, or disposal, including reuse or redeployment, of electronic media.

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

b. Identify data content requirements for all areas of the organization Data content standards allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes.

What does the term access control mean? a. Identifying the greatest security risks b. Identifying which data employees should have a right to use c. Implementing safeguards that protect physical media d. Restricting access to computer rooms and facilities

b. Identifying which data employees should have a right to use The term access control means being able to identify which employees should have access to what data. The general practice is that employees should have access only to data they need to do their jobs. For example, an admitting clerk and a healthcare provider would not have access to the same kinds of data.

Which of the following are data that have been filtered and put into context? a. Data b. Information c. Knowledge d. System

b. Information Information moves beyond data and consists of sets of data that are related and have been placed in context, are filtered, manipulated, or formatted in some way and are useful to a particular task.

When a user keys in 10101963, the computer displays it as 10/10/1963. What enables this? a. Toolkit b. Input mask c. Check box d. Radio button

b. Input mask Data is collected in a number of ways. The information system should have measures in place to control the data entered into the EHR. In this example, the birth date of 10101963 is displayed in the computer as 10/10/1963 because an input mask was used in the information system to show the format in which the data will be displayed.

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

b. Institutions are allowed flexibility in the way they implement HIPAA standards. HIPAA allows a covered entity to adopt security protection measures that are appropriate for its organization as long as they meet the minimum HIPAA security standards. Security protections in a large medical facility will be more complex than those implemented in a small group practice.

Why is the MEDPAR file limited in terms of being used for research purposes? a. It only provides demographic data about patients b. It only contains Medicare patients c. It uses ICD-10-CM diagnoses and procedure codes d. It breaks charges down by specific type of service

b. It only contains Medicare patients The MEDPAR file is frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients.

Which of the following represents documentation of the patient's current and past health status? a. Physical exam b. Medical history c. Physician orders d. Patient consent

b. Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician.

When served with a court order directing the release of health records, an individual: a. May ignore it b. Must comply with it c. Must request patient authorization before disclosing the records d. May determine whether or not to comply with it

b. Must comply with it A court order is a document issued by a judge that compels a certain action, such as testimony or the production of documents such as health records. If a document requesting the production of health records is determined to be a court order, it must be complied with regardless of the presence or absence of patient authorization.

Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is: a. Protected by the Privacy Rule because it is individually identifiable b. Not protected by the Privacy Rule because it is part of a personnel record c. Protected by the Privacy Rule because it contains his physical exam results d. Protected by the Privacy Rule because it is in the custody of a covered entity

b. Not protected by the Privacy Rule because it is part of a personnel record Although a person or organization may, by definition, be subject to the Privacy Rule by virtue of the type of organization it is, not all information that it holds or comes into contact with is protected by the Privacy Rule. For example, the Privacy Rule has specifically excluded from its scope employment records held by the covered entity in its role as employer (45 CFR 160.103). Under this exclusion, employee physical examination reports contained within personnel files are specifically exempted from this rule.

To comply with HIPAA regulations, a hospital would make its membership in an HIE known to its patients through which of the following? a. Press release b. Notice of Privacy Practices c. Consent form d. Website notice

b. Notice of Privacy Practices The Privacy Rule introduced the standard that individuals should be informed how covered entities use or disclose protected health information (PHI). Section 164.520 requires that, except for certain variations or exceptions for health plans and correctional facilities, an individual has the right to a notice explaining how his or her PHI will be used and disclosed. This is the notice of privacy practices.

The home health prospective payment system uses the ________ data set for patient assessments. a. HEDIS b. OASIS-C c. MDS d. UHDDS

b. OASIS-C The Outcomes and Assessment Information Set (OASIS-C) is a standardized data set designed to gather data about Medicare beneficiaries who are receiving services from a home health agency. OASIS-C includes a set of core data items that are collected on all adult home health patients.

To ensure relevancy, an organization's security policies and procedures should be reviewed at least: a. Once every six months b. Once a year c. Every two years d. Every five years

b. Once a year All data security policies and procedures should be reviewed and evaluated annually to make sure they are up-to-date and still relevant to the organization.

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

b. Outcomes and Assessment Information Set (OASIS-C) Medicare-certified home healthcare uses a standardized patient assessment instrument called the Outcomes and Assessment Information Set (OASIS-C). OASIS-C items are components of the comprehensive assessment that is the foundation for the plan of care

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

b. Overlay An issue with the quality of the MPI is an overlay, where a patient is erroneously assigned another person's health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient as well.

In which department or unit is the health record number typically assigned? a. HIM b. Patient registration c. Nursing d. Billing

b. Patient registration The health record number is a key data element in the MPI. It is used as a unique personal identifier and is also used in paper-based numerical filing systems to locate records and in electronic systems to link records. Although it is typically assigned at the point of patient registration, the HIM department is usually responsible for the integrity of health record number assignment and for ensuring that no two patients receive the same number.

Which of the following are security safeguards that protect equipment, media, and facilities? a. Administrative controls b. Physical safeguards c. Audit controls d. Role based safeguards

b. Physical safeguards Physical safeguards protect physical equipment, media, or facilities. For example, doors leading to the areas that house mainframes and other principal computing equipment should have locks on them.

A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be: a. Normal delivery b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa In cases of a cesarean delivery, the selection of the principal diagnosis should be the condition established after study that was responsible for the patient's admission. If the patient was admitted with a condition that resulted in the performance of the cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission or encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission or encounter should be selected as the principal diagnosis even if a cesarean was performed.

Placenta previa with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergent C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be: a. Third-degree perineal laceration b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa Placenta previa is the reason for the C-section and therefore is the principal diagnosis.

The EHR may have multiple versions of the same document; for example, a signed and unsigned copy. How can a healthcare organization manage version control of documents in the EHR? a. The deletion of old versions and the retention of the most recent b. Policies and procedures to control which version(s) is displayed c. Signed and unsigned documents not to be considered two versions d. Previous versions to be accessible to administration only

b. Policies and procedures to control which version(s) is displayed The health record may have multiple versions of the same document; for example, a signed and an unsigned copy of a document. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed.

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

b. Positively skewed distribution When the tail is pulled toward the right side, it is called a positively skewed distribution; when the tail is pulled toward the left side of the curve it is called a negatively skewed distribution.

Health departments use the health record to monitor outbreaks of diseases. In this situation what type of use of the health record does this represent? a. Educational b. Public health and research c. Medical review organization d. Patient care

b. Public health and research Public health and research uses data in the health record for many reasons including monitoring disease outbreaks.

HIM departments may be the hub of identifying, mitigating, and correcting MPI errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems with admitting patients that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems? a. Administration b. Registration c. Risk Management d. Radiology and Laboratory

b. Registration A review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. Although health information management (HIM) departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors, that information may never be shared with the registration department. If the registration staff is not aware of the errors, how can they begin to proactively prevent the errors from occurring in the first place? Registration process improvement activities can eventually reduce work for HIM departments. In addition, monitoring new duplicates is a critical process, and tracking reports should be created and implemented. Identifying and reporting MPI errors is important; however, tracking who made the error and why will decrease the number of duplicates.

Which of the following is considered a clinical documentation best practice? a. Allowing clinicians to backdate physician orders b. Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, rules, and regulations c. Allowing clinicians to delete documentation errors in an electronic record d. Prohibiting all verbal orders

b. Restricting use of abbreviations to a list approved by hospital and medical staff bylaws, rules, and regulations Clinical documentation best practices establish policies and guidelines that ensure uniformity of both content and format of the patient record. One example of a clinical documentation best practice would be to stipulate abbreviations and symbols in the patient record to be permitted only when approved according to hospital and medical staff bylaws, rules, and regulations.

The process that is followed to mitigate and fix issues that arise during a review of systems that contain PHI to reduce vulnerabilities is called: a. Risk analysis b. Risk management c. Results documentation d. Recommendations for controls

b. Risk management One strategy in protecting the organization's data is to establish a risk management program. Risk management encompasses the identification, evaluation, and control of risks that are inherent in unexpected and inappropriate events.

Which of the following would be considered a derivation business rule? a. Upon admission a patient must be assigned to a clinical service b. The average length of stay is the sum of inpatient days for a period divided by the number of discharges for a period c. Date of birth must be documented as DD/MM/YYYY d. The hospital census is taken at midnight each day

b. The average length of stay is the sum of inpatient days for a period divided by the number of discharges for a period Derivation is an attribute that is derived through a mathematical calculation of inference from other attributes or systems variables.

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

b. Their mission Each healthcare organization must identify and prioritize which processes and outcomes are important to monitor on the basis of its mission and the scope of care and services it provides.

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? 49560 Repair initial incisional or ventral hernia; reducible 49565 Repair recurrent incisional or ventral hernia; reducible 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft-tissue infection 49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible a. 49565 b. 49565, 49568 c. 49656 d. 49560, 49568

c. 49656 Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope, and is reducible makes the answer 49656. Notice that the use of mesh is included in the code.

Based on this output table, what is the average coding test score for the beginner coder? Coding Test Score: Coder Status /Mean / N / Standard Deviation Advanced / 93.0000 / 3 / 5.00000 Intermediate / 89.5000 / 2 / 0.70711 Beginner / 73.3333 / 3 / 6.42910 Total / 84.7500 / 8 / 10.51190 a. 93 b. 6.4 c. 73 d. 90

c. 73 Since the mean is the average and the value next to the "beginner" under coder status is 73.3333, round the value to a whole number and the best answer is 73.

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

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

Which of the following represents an example of data granularity? a. A progress note recorded at or near the time of the observation b. An acceptable range of values defined for a clinical characteristic c. A numerical measurement carried out to the appropriate decimal place d. A health record that includes all of the required components

c. A numerical measurement carried out to the appropriate decimal place Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data. For example, numerical values for laboratory results should be recorded to the appropriate decimal place as required for the meaningful interpretation of test results—or in the collection of demographic data, data elements should be defined appropriately to determine the differences in outcomes of care among various populations.

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data

c. Administrative data Administrative describes patient identification, diagnosis, procedures, and insurance. Patient registration information would be considered administrative data as would patient account information. A significant portion of administrative data is demographic data.

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

c. Aggregate data Data about patients can be extracted from individual health records and combined as aggregate data. Aggregate data are used to develop information about groups of patients. For example, data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database.

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

c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients. Community Hospital is excluding MEDPAR data of those patients with a principal diagnosis of UTI or infectious disease because these would not represent a hospital acquired condition (HAC) because the patients were admitted with those diagnoses. Community Hospital is looking for comparative secondary diagnosis data of Medicare patients from the MEDPAR file to compare their HAC rate for UTIs to the national average from the MEDPAR data.

St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year-old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the past two months. These records are not psychotherapy notes. Of the options here, what is the best course of action? a. Prohibit the patient from accessing his record, as it contains psychiatric diagnoses that may greatly upset him. b. Allow the patient to access his record. c. Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patient. d. Deny access because HIPAA prevents patients from reviewing their psychiatric records.

c. Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patient. The HIPAA Privacy Rule provides patients with significant rights that allow them to have some measure of control over their health information. As long as state laws or regulations or the physician do not state otherwise, competent adult patients have the right to access their health record.

City Hospital's HIPAA committee is considering a change in policy to allow hospital employees who are also hospital patients to access their own patient information in the hospital's EHR system. A committee member notes that HIPAA provides rights to patients to view their own health information. However, another member wonders if this action might present other problems. In this situation, what information should the HIM director provide? a. HIPAA requires that employees have access to their own information, so grant privileges to the employees to perform this function. b. HIPAA does not allow employees to have access to their own information, so the procedure should not be implemented. c. Allowing employees to access their own records using their job-based access rights appears to violate HIPAA's minimum necessary requirement; therefore, allow employees to access their records through normal procedures. d. Employees are considered a special class of people under HIPAA and the procedure should be implemented.

c. Allowing employees to access their own records using their job-based access rights appears to violate HIPAA's minimum necessary requirement; therefore, allow employees to access their records through normal procedures. Allowing employees of a covered entity to access their own protected health information electronically results in a situation in which the covered entity may be in compliance with parts of the HIPAA Privacy Rule but in violation of other sections of the Privacy Rule. An ideal situation would be to establish a patient portal through which all patients may view their own records in a secure manner and for which an employee has neither more or less rights than any other patient.

Which of the following statements is false with regard to the HIPAA Privacy Rule? a. A notice of privacy practices must be written in plain language. b. A notice of privacy practices must have a statement that other uses and disclosures will be made only with the individual's written authorization and that the individual may revoke such authorization. c. An authorization must be obtained for uses and disclosures for treatment, payment, and operations. d. A notice of privacy practices must give an example of a use or disclosure for healthcare operations.

c. An authorization must be obtained for uses and disclosures for treatment, payment, and operations. Under the Privacy Rule, healthcare providers are not required to obtain patient consent to use or disclose personal identifiable information for treatment, payment, and healthcare operations.

Which of the following security controls are built into a computer software program? a. Physical safeguards b. Administration safeguards c. Application safeguards d. Media safeguards

c. Application safeguards One security strategy is to implement application safeguards. These are controls contained in the application software or computer programs. One common application control is password management. It involves keeping a record of end users' identifications and passwords and then matching the passwords to each end user's privileges.

The HIM supervisor suspects that a departmental employee is accessing the EHR for personal reasons, but has no specific data to support this suspicion. In this case, what should the supervisor do? a. Confront the employee. b. Send out a memorandum to all department employees reminding them of the hospital policy on Internet use. c. Ask the security officer for audit trail data to confirm or disprove the suspicion. d. Transfer the employee to another job that does not require computer usage.

c. Ask the security officer for audit trail data to confirm or disprove the suspicion. The HIM supervisor should determine if a breach has occurred before action is taken. This can be done using an audit trail, which is a software program that tracks access to data in the EHR. It logs the name of the individual who accessed the data, the date and time, and the action taken (for example, modifying, reading, or deleting data).

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

c. Attending physicians of the patients All individuals whose information has been breached must be notified without unreasonable delay, and not more than 60 days, by first-class mail or a faster method such as by telephone if there is the potential for imminent misuse. If 500 or more individuals are affected, they must be individually notified immediately and media outlets must be used as a notification mechanism as well. The Secretary of HHS must specifically be notified of the breach. The attending physicians of the patients do not need to be notified of the breach.

Which of the following is an example of data security? a. Contingency planning b. Fire protection c. Automatic logoff after inactivity d. Card key for access to data center

c. Automatic logoff after inactivity Data security includes insuring that workstations are protected from unauthorized access. If a workstation is inactive for a period of time specified by the organization, it should log itself off automatically. The automatic log off helps prevent unauthorized users from accessing e-PHI when an authorized user walks away from the computer without logging out of the system.

What term describes the processing of scanning past health records into the information system so there is an existing database of patient information, making the information system valuable to the user from the first day of implementation? a. CPOE b. Analysis c. Backscanning d. Barcoding

c. Backscanning Backscanning is the process of scanning past health records into the document management system (DMS) so there is an existing database of patient information, making the DMS valuable to the user from the first day of implementation.

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps? a. Flow record b. Vital signs record c. Care plan d. Surgical note

c. Care plan A care plan is a summary of the patient's problems from the nurse or other professional's perspective with a detailed plan for interventions that may follow the assessment.

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

c. Cerebral vascular accident, COPD, Hypertension Present on admission (POA) is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission. This patient was not admitted with a catheter-associated urinary infection and so that condition cannot be coded as POA. The patient was admitted with symptoms of a stroke and diagnoses of COPD and hypertension. The CVA was documented after admission, but the symptoms of the stroke were POA, so this condition would be coded as POA.

Which of the following is an individual user of the health record? a. Public health department b. State data bank c. Coding and billing staff d. Third-party payer

c. Coding and billing staff Individual users are those who depend on the health record in order to complete their job. Documentation in the health record is the basis for reimbursement or payment for the care provided. The coding and billing staff use patient specific information in their day-to-day work.

According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy

c. Colonoscopy Colonoscopy includes examining the transverse colon. Proctosigmoidoscopy involves examining the rectum and sigmoid colon. Sigmoidoscopy involves examining the rectum, sigmoid colon, and may include portions of the descending colon.

Which of the following is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis

c. Comorbidity A comorbidity is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay.

A record that fails quantitative analysis is missing the quality criterion of: a. Legibility b. Reliability c. Completeness d. Clarity

c. Completeness Quantitative analysis is used by health information management professionals as a method to detect whether elements of the patient's health record are missing, or not complete.

Which of the following data quality characteristics means all data items are included within the information collected? a. Accuracy b. Consistency c. Comprehensiveness d. Relevancy

c. Comprehensiveness Data comprehensiveness means that all the required data elements are included in the health record. In essence, comprehensiveness means that the record is complete. In both paper-based and computer-based systems, having a complete health record is critical to the organization's ability to provide excellent patient care and to meet all regulatory, legal, and reimbursement requirements.

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set

c. Conditions of Participation Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and, thus, must follow the Medicare Conditions of Participation.

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

c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned The HIPAA Privacy Rule requires the covered entity to have business associate agreements in place with each business associate. This agreement must always include provisions regarding destruction or return of protected health information (PHI) upon termination of a business associate's services. Upon notice of the termination, the covered entity needs to contact the business associate and determine if the entity still retains any protected health information from, or created for, the covered entity. The PHI must be destroyed, returned to the covered entity, or transferred to another business associate. Once the PHI is transferred or destroyed, it is recommended that the covered entity obtain a certification from the business associate that either it has no PHI, or all PHI it had has been destroyed or returned to the covered entity .

Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule? a. Identifies an individual b. In the custody of or transmitted by a CE or its BA c. Contained within a personnel file d. Relates to one's health condition

c. Contained within a personnel file To meet the individually identifiable element of PHI, the information must meet all three portions of a three-part test: it must either identify the person or provide a reasonable basis to believe the person could be identified from the information given; it must relate to one's past, present, or future physical or mental health condition, the provision of healthcare, or payment for the provision of healthcare; and it must be held or transmitted by a covered entity or its business associate.

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

c. Contains data on all payer types Healthcare Cost and Utilization Project (HCUP) consists of a set of databases that are unique because they include data on inpatients whose care is paid for by all types of payers, including Medicare, Medicaid, private insurance, self-paying, and uninsured patients. Data elements include demographic information, information on diagnoses and procedures, admission and discharge status, payment sources, total charges, length of stay, and information on the hospital or freestanding ambulatory surgery center.

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

c. Copying the note in the wrong patient's record In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes propagation of false information in the record.

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

c. Counsel the coder and stop the practice immediately Ethical coding practices must be followed with appropriate employee counseling and remediation.

When coding a benign neoplasm of skin of the left upper eyelid, which of the following codes should be used? D23 - Other benign neoplasms of skin D23.0 - Other benign neoplasm of skin of lip D23.1 - Other benign neoplasm of skin of eyelid, including canthus D23.10 - Other benign neoplasm of skin of unspecified eyelid, including canthus D23.11 - Other benign neoplasm of skin of right eyelid, including canthus D23.111 - Other benign neoplasm of skin of right upper eyelid, including canthus D23.112 - Other benign neoplasm of skin of right lower eyelid, including canthus D23.12 - Other benign neoplasm of skin of left eyelid, including canthus D23.121 - Other benign neoplasm of skin of left upper eyelid, including canthus D23.122 - Other benign neoplasm of skin of left lower eyelid, including canthus D23.2 - Other benign neoplasm of skin of ear and external auricular canal D23.20 - Other benign neoplasm of skin of unspecified ear and external auricular canal D23.21 - Other benign neoplasm of skin of right ear and external auricular canal D23.22 - Other benign neoplasm of skin of left ear and external auricular canal a. D23.12 b. D17.0 c. D23.121 d. D23.122

c. D23.121 When subcategory codes are provided, they must be used. Codes are to be assigned to the highest level of specificity based on provider documentation. In this situation, code D23.121 is the most specific code for this diagnosis.

Dr. Jones entered a progress note in a patient's health record 24 hours after he visited the patient. Which quality element is missing from the progress note? a. Data completeness b. Data relevancy c. Data currency d. Data precision

c. Data currency Data currency and data timeliness mean that healthcare data should be up-to-date and recorded at or near the time of the event or observation. Because care and treatment rely on accurate and current data, an essential characteristic of data quality is the timeliness of the documentation or data entry.

Which of the following best describes data comprehensiveness? a. Data are correct. b. Data are easy to obtain. c. Data include all required elements. d. Data are reliable.

c. Data include all required elements. Data comprehensiveness means that all the required data elements are included in the health record. In essence, comprehensiveness means that the record is complete. In both paper-based and computer-based systems, having a complete health record is critical to the organization's ability to provide excellent patient care and to meet all regulatory, legal, and reimbursement requirements.

Which of the following is the best definition of a data governance framework? a. Lists successive steps of growth to measure a program's progression b. Supports high level business imperatives c. Describes a real or conceptual structure that organizes a system or concept d. Targets an end point to achieve

c. Describes a real or conceptual structure that organizes a system or concept A data governance framework is a real or conceptual structure that organizes a system or concept. A framework typically describes and shows the synergy and interrelation among different part of an approach.

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

c. Determine what information was printed and why Audit trails are usually examined by system administrators who use special analysis software to identify suspicious or abnormal system events or behavior. Because the audit trail maintains a complete log of system activity, it can also be used to help reconstruct how and when an adverse event or failure occurred.

One way for a hospital to demonstrate compliance with OIG guidelines is to: a. Designate a privacy officer b. Continuously monitor PEPPER reports c. Develop, implement, and monitor written policies and procedures d. Obtain ABNs for all Medicare registrations

c. Develop, implement, and monitor written policies and procedures Over the past several years, the OIG has published several documents to help providers develop internal programs that include elements for ensuring compliance. One of the elements included is written policies and procedures.

The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record? a. Print out all electronic data postdischarge and file with the rest of the paper record b. Microfilm all electronic data and link to the paper record c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system d. Do not scan any of the paper records

c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system Many hospitals incorporate documents into their EHR systems. Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files in their electronic document management system (EDMS). Using scanned images solves many of the problems associated with traditional paper-based health records and hybrid records.

Which one of the following indexes contains a list maintained in diagnosis code number order for patients who are discharged from a facility during a particular time period? a. Physician b. Master patient c. Disease d. Operation

c. Disease The disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period. Each patient's diagnosis is converted from a verbal description to a numerical code, usually using the International Classification of Diseases. The patient's diagnosis codes are entered into the facility's health information system as part of the discharge processing of the patient's health record.

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error? a. Access controls b. Audit trail c. Edit checks d. Password controls

c. Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer.

What is the biggest threat to the security of healthcare data? a. Natural disasters b. Fires c. Employees d. Equipment malfunctions

c. Employees Employees are the biggest threat to the security of healthcare data. Whether it is disgruntled employees destroying computer hardware, snooping employees accessing information without authorization to do so, or employees accessing information for fraudulent purposes, employees are a real threat to data security.

Which of the following is not a recommended guideline for maintaining integrity in the health record? a. Specifying consequences for the falsification of information b. Requiring periodic training covering the falsification of information and information security c. Ensuring documentation that is being changed is permanently deleted from the record d. Prohibiting the entry of false information into any of the organization's records

c. Ensuring documentation that is being changed is permanently deleted from the record Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy. Assuring documentation that is being changed is permanently deleted from the record would not be a guideline for maintaining the integrity of the health record.

Covered entities must do which of the following to comply with HIPAA security provisions? a. Appoint an individual who has the title of chief security officer who is responsible for security management b. Conduct employee security training sessions every six months for all employees c. Establish a contingency plan d. Conduct technical and nontechnical evaluations every six years

c. Establish a contingency plan Administrative safeguards are documented, formal practices to manage data security measures throughout the organization. Basically, they require the facility to establish a security management process. The administrative provisions detail how the security program should be managed from the organization's perspective. Administrative safeguards have nine standards, including the development and testing of a contingency plan. This is to ensure that procedures are in place to handle an emergency response in the event of an untoward event such as a power outage.

The primary goal of the Hospital Standardization Program, established in 1918 by the American College of Surgeons, was to: a. Standardize the educational curricula of American medical schools b. Train physicians and nurses for American hospitals c. Establish minimum quality standards for hospitals d. Force substandard hospitals to close

c. Establish minimum quality standards for hospitals In 1918, the hospital standardization movement was inaugurated by the American College of Surgeons (ACS). The purpose of the Hospital Standardization Program was to raise the standards of surgery by establishing minimum quality standards for hospitals. The ACS realized that one of the most important items in the care of any patient was a complete and accurate report of the care and treatment provided during hospitalization.

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

c. Federal and state confidentiality laws Release of information (ROI) is the process of providing PHI access to individuals or entities that are deemed to be authorized to either receive or review it. Protecting the security and privacy of patient information is one of a healthcare organization's top priorities, and the HIM department is usually responsible for determining appropriate access to and ROI from patient health records. Knowledge of state and federal confidentiality laws is critical to the ROI function.

Community Hospital has been collecting quarterly data on the average monthly health record delinquency rate for the hospital. This graph depicts the trend in the delinquency rate. The hospital has established a 35 percent benchmark. Given this data, what should the hospital's Performance Improvement Council recommend? [Graph of Average Monthly Medical Record Deficiency Rate: Y axis is percentage, X axis is quarter; plots are: 40% at 2016 Q1, 35% at 2016 Q2, 32% at 2016 Q3, 25% at 2016 Q4, 21% at 2017 Q1, 35% at 2017 Q2, 51% at 2017 Q3, 55% at 2017 Q4.] a. Continue tracking the delinquency rate to see if the last two quarters' trend continues b. Establish a higher benchmark to accommodate an increase in delinquent records c. Further analyze the data to determine why the benchmark is not being met d. Take an average of all the data points to arrive at a new benchmark

c. Further analyze the data to determine why the benchmark is not being met Once a benchmark for each performance measure is determined, analyzing data collection results becomes more meaningful. Often, further study or more focused data collection on a performance measure is triggered when data collection results fall outside the established benchmark. When variation is discovered or when unexpected events suggest performance problems, members of the organization may decide there is an opportunity for improvement.

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

c. Gap analysis The gap analysis process compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis. Once complete, the HIM professional would analyze the data and develop a plan for correction.

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

c. Identify unbundling of codes The latest version of the Medicare integrated outpatient code editor (OCE) should be installed to review claims prior to releasing billed data to the Medicare program. OCE software contains the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT). The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to control improper coding leading to inappropriate payment and unbundling on the Part B claims. They also identify component codes that were used instead of the appropriate comprehensive code, as well as other types of coding errors.

Which of the following is the goal of the quantitative analysis performed by HIM professionals? a. Ensuring that the health record is legible b. Verifying that health professionals are providing appropriate care c. Identifying deficiencies early so they can be corrected d. Ensuring bills are correct

c. Identifying deficiencies early so they can be corrected Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record.

The function used to provide access controls, authentication, and audit logging in an HIE is: a. Patient identification b. Record location service c. Identity management d. Consent management

c. Identity management Identity management provides security functionality, including determining who (or what information system) is authorized to access information, authentication services, audit logging, encryption, and transmission controls.

What is the key piece of data needed to link a patient's information who is seen in a variety of care settings? a. Facility medical record number b. Facility identification number c. Identity matching algorithm d. Patient birth date

c. Identity matching algorithm Because the United States does not have a national patient identifier, an identity matching algorithm process must be used by organizations to identify any patient for whom data are to be exchanged. This algorithm uses sophisticated probability equations to identify patients.

In which of the following examples does the gender of the patient constitute information rather than a data element? a. As an entry to be completed on the face sheet of the health record b. In the note "50-year-old white male" in the patient history c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females d. In a study of the age distribution of lung cancer patients

c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combined to produce value) and enhance that information with experience and trial-and-error that produces knowledge. In this example, the gender is tied to race in the data collection that constitutes information and not a data element.

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

c. In bill hold or in error and awaiting billing The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged not final billed (DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list. Some accounts are held because the patient has not signed the consents and authorizations required by the insurer. Still others are not billed because the primary and secondary insurance benefits have not been confirmed .

Which of the following would be an example of a sentinel event? a. Incidence of hospital acquired infection b. Incidence of an unruly patient c. Incidence of infant abduction d. Incidence of blood transfusion reaction

c. Incidence of infant abduction Sentinel events usually involve significant injury to, or the death of, a patient or an employee through avoidable causes. Hospital acquired infections, blood transfusion reactions, or incidences of an unruly patient are monitored processes, but in and of themselves would not be considered sentinel events. An infant abduction would be considered an avoidable occurrence and therefore a sentinel event.

The term used to describe controlling information is ________. a. Information power b. Information authority c. Information governance d. Information policy

c. Information governance Information governance is the accountability framework and decision rights to achieve enterprise information management. In other words, the information must be controlled to ensure the needs of the organization are met.

Which of the following statements best describes the difference between a hospital inpatient and a hospital outpatient? a. Outpatients are treated in the emergency department; inpatients receive services in the regular clinical departments of the hospital. b. Inpatients always stay in the hospital overnight; outpatients never do. c. Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services. d. Outpatients primarily receive diagnostic services; inpatients receive mostly therapeutic services.

c. Inpatients receive room, board, and continuous nursing services in areas of the hospital where patients generally stay overnight; outpatients receive ambulatory diagnostic and therapeutic services. A hospital inpatient is a person who is provided room, board, and continuous general nursing service in an area of the hospital where patients generally stay at least overnight. A hospital outpatient is a hospital patient who receives services in one or more of the outpatient facilities when not currently an inpatient or home care patient.

Release of birth and death information to public health authorities: a. Is prohibited without patient consent b. Is prohibited without patient authorization c. Is a public health activities disclosure that does not require patient authorization d. Requires both patient consent and authorization

c. Is a public health activities disclosure that does not require patient authorization There are circumstances where PHI can be used or disclosed without the individual's authorization and without granting the individual the opportunity to agree or object. Some of these circumstances include preventing or controlling diseases, injuries, and disabilities, and reporting disease, injury, and vital events such as births and deaths.

Which of the following is a characteristic of breach notification? a. It is only required when 500 or more individuals are affected b. It applies to both secured and unsecured PHI c. It applies when one person's PHI is breached d. Is only applies when 20 or more individuals are affected

c. It applies when one person's PHI is breached Breaches by covered entities and BAs (both governed by HHS breach notification regulations) are deemed discovered when the breach is first known or reasonably should have been known. All individuals whose information has been breached must be notified without unreasonable delay, and within 60 days, by first-class mail or a faster method, such as by telephone, if there is the potential for imminent misuse.

Spoliation can be defined as which of the following? a. It is required after a legal hold is imposed b. It is the negligent destruction or changing of information c. It is destroying, changing, or hiding evidence intentionally d. It can only be performed on records that are involved in a court proceeding

c. It is destroying, changing, or hiding evidence intentionally To preserve discoverable data, they must also ensure that records involved in litigation or potential litigation are preserved through a legal hold, which is generally a court order to preserve a health record if there is concern about destruction. A legal hold supersedes routine destruction procedures. It also prevents spoliation—the act of destroying, changing, or hiding evidence intentionally.

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

c. It is the record disclosed upon request The legal health record distinction is important for several reasons. First, it is important to an organization's business and legal processes. Second, because the legal health record is the record that is produced upon request, including legal requests, it becomes important to ensure that the legal health record is legally sound and defensible as a valid document in legal situations.

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

c. Licensure Licensure is the state's act of granting a healthcare organization or individual practitioner the right to provide healthcare services of a defined scope in a limited geographic area. It is illegal in all 50 states to operate healthcare facilities and practice medicine without a license.

Suppose you want to display the number of deaths due to breast cancer for the years 2005 through 2015. What is the best graphic technique to use? a. Table b. Histogram c. Line graph d. Bar chart

c. Line graph A line graph may be used to display time trends. A line graph is especially useful for plotting a large number of observations. It also allows several sets of data to be presented on one graph.

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

c. Locking computer rooms Physical safeguards refer to the physical protection of information resources from physical damage, loss from natural or other disasters, and theft. This includes protection and monitoring of the workplace, computing facilities, and any type of hardware or supporting information system infrastructure such as wiring closets, cables, and telephone and data lines. To protect from intrusion, there should be proper physical separation from the public. Doors, locks, audible alarms, and cameras should be installed to protect particularly sensitive areas such as data centers.

long-term care, the resident's care plan is based on data collected in the: a. UHDDS b. OASIS-C c. MDS d. HEDIS

c. MDS The data collected by the Minimum Data Set (MDS) are used to develop care plans for residents and to document placement at the appropriate level of care. The MDS provides a structured way to organize resident information and develop a resident care plan

Which of the following systems is the key to identifying a patient's multiple hospitalizations? a. CDR b. CPOE c. MPI d. R-ADT

c. MPI The master patient index assigns a unique patient identifier to a patient. This facilitates managing a patient's multiple encounters as a "unit" over the course of a lifetime.

Which of the following would be the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in an EHR? a. Add validation edits on all essential fields b. Provide an input mask for essential data fields c. Make all essential data fields required d. Provide sufficient space for all essential fields

c. Make all essential data fields required Standardization of the collection of patient data is essential to collect the proper information and reach data quality levels needed to support the enhancement of patient care and the healthcare industry. Templates can be created for common types of notes, visits, and procedures.

A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports

c. Medication administration record and clinical laboratory reports Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed.

Which of the following is not true of Notices of Privacy Practices? a. Must be made available at the site where the individual is treated b. Must be posted in a prominent place c. Must contain content that may not be changed d. Must be prominently posted on the covered entity's website when the entity has one

c. Must contain content that may not be changed Healthcare providers with a direct treatment relationship with an individual must provide the notice of privacy practices no later than the date of the first service delivery (for example, first visit to a physician's office, first admission to a hospital, or first encounter at a clinic), including service delivered electronically. Notices must be available at the site where the individual is treated and must be posted in a prominent place where patients can reasonably be expected to read it. If the facility has a website with information on the covered entity's services or benefits, the notice of privacy practices must be prominently posted to it.

Dr. Hall is an orthopedic surgeon performing a knee replacement on Mary. Mary was seen in Dr. Hall's office two months before the surgery and Dr. Hall documented her history and physical (H&P) at that point. Does this H&P meet documentation requirements for the surgery? a. No, the first H&P must be documented within 60 days before admission, and another H&P must be documented within 48 hours after admission to the hospital b. Yes, there are no requirements on when an H&P must be performed c. No, the H&P must be documented within 30 days before admission with an update within 24 hours after admission d. Yes, because the H&P was documented within 60 days

c. No, the H&P must be documented within 30 days before admission with an update within 24 hours after admission Dr. Hall must document a new history and physical for Mary because the last history and physical was completed 60 days ago. A history and physical must be completed within 30 days of admission or within 24 hours after admission. If a history and physical is completed within 30 days of a surgery, an updated exam must be documented within 24 hours of admission and prior to the surgery or procedure.

The following data fields comprise a database table: patient last name, patient first name, street address, city, state, zip code, patient date of birth. Given this information, which of the following is a true statement about maintaining the data integrity of the database table? a. Patient last name should be used as the primary key for the table. b. Patient date of birth should be used as the primary key for the table. c. None of the data fields are adequate to use as a primary key for the table. d. Patient last and first name should be used as the primary key for the table.

c. None of the data fields are adequate to use as a primary key for the table. A primary key must uniquely identify a record. None of the options provided will uniquely identify a record. Multiple individuals may have the same name and birth dates.

What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services? a. Regional health information organizations b. Corporate compliance plans c. OIG workplans d. Federal register

c. OIG workplans The resource that the facility compliance officer should consult to provide information on ongoing reviews and audits each year in programs administered by the department of Health and Human Services (HHS) is the OIG workplan.

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

c. Occurrence report An occurrence report is a structured data collection tool that risk managers use to gather information about potentially compensable events. Effective occurrence reports carefully structure the collection of data, information, and facts in a relatively simple format.

Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report

c. Operative report The operative report describes the surgical procedures performed on the patient. Each report typically includes the name of the surgeon and assistants; date, duration, and description of the procedure; preoperative and postoperative diagnosis; estimated blood loss; descriptions of any unusual or unique events during the course of the surgery, normal and abnormal findings, as well as any specimens that were removed.

OASIS-C data are used to assess the ________ of home health services. a. Core measure b. Financial performance c. Outcome d. Utilization

c. Outcome The Outcomes and Assessment Information Set (OASIS-C) consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement

Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request? a. PHI related to treatment, payment, and operations b. PHI provided to meet national security or intelligence requirements c. PHI sent to a physician who has not treated Sally d. PHI released to Sally's attorney upon her request

c. PHI sent to a physician who has not treated Sally Maintaining some type of accounting procedure for monitoring and tracking PHI disclosures has been a common practice in departments that manage health information. However, the Privacy Rule has a specific standard with respect to such record keeping. Disclosures for which an accounting is not required, and which are therefore exempt include some of the following examples: TPO disclosures, pursuant to an authorization, and to meet national security or intelligence requirements. PHI sent to a physician that has not treated the patient would need to be accounted for.

Which of the following is considered a two-factor authentication system? a. User ID with a password b. User ID with voice scan c. Password and swipe card d. Password and PIN

c. Password and swipe card Strong authentication requires providing information from two of the three different types of authentication information. The three methods are something you know such as a password or PIN; something you have, such as an ATM card, token, swipe card, or smart card; and something you are, such as a biometric fingerprint, voice scan, iris, or retinal scan. An individual who provides something he knows (password) and something he has (swipe card) is called two-factor authentication.

A secure method of communication between the healthcare provider and the patient is a(n): a. Personal health record b. E-mail c. Patient portal d. Online health information

c. Patient portal A secure patient portal allows for the communication between the provider and the patient and is not just a site for patients to access information. This is part of the effort to engage patients in their care.

Which of the following materials is not documented in an emergency medical care record? a. Patient's instructions at discharge b. Time and means of the patient's arrival c. Patient's complete medical history d. Emergency care administered before arrival at the facility

c. Patient's complete medical history Information typically included in the patient's health record for an emergency visit includes: patient's instructions at discharge, time and means of patient's arrival, emergency care administered before arrival at the facility, clinical observations, and the like. The patient's complete health history would not be included in the record.

Healthcare abuse relates to practices that may result in: a. False representation of fact b. Failure to disclose a fact c. Performing medically unnecessary services d. Knowingly submitting altered claim forms

c. Performing medically unnecessary services Abuse occurs when a healthcare provider unknowingly or unintentionally submits an inaccurate claim for payment. Abuse generally results from unsound medical, business, or fiscal practices that directly or indirectly result in unnecessary costs to the Medicare program. The performance of medically unnecessary services and submitting them for payment would be an example of healthcare abuse.

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

c. Personal firewall software A firewall is a part of a computer system or network that is designed to block unauthorized access while permitting authorized communications. It is a software program or device that filters information between two networks, usually between a private network like an intranet and a public network like the Internet.

Placing locks on computer room doors is considered what type of security control? a. Access control b. Workstation control c. Physical safeguard d. Security breach

c. Physical safeguard Physical safeguards protect physical equipment, media, or facilities. For example, doors leading to the areas that house mainframes and other principal computing equipment should have locks on them.

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

c. Policy and procedure Policies and procedures also can be considered organizational tools. Policies are written descriptions of the organization's formal positions. Procedures are the approved methods for implementing those positions. Together, they spell out what the organization expects employees to do and how they are expected to do it.

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

c. Prevent denials for inappropriate levels of service Front-end utilization management (UM) is essential to the prevention of denials for inappropriate levels of care. UM staff work with the physician to ensure that the requested services meet medical necessity requirements and are provided in the most appropriate setting. When the insurer denies the claim, an appeal may be possible.

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

c. Principal diagnosis To begin the review, the coding supervisor checks the inpatient health record to ensure that the diagnosis billed as principal meets the official Uniform Hospital Discharge Data Set (UHDDS) definition for principal diagnosis. The principal diagnosis must have been a principal reason for admission, and the patient received treatment or evaluation during the stay. When several diagnoses meet all of those requirements, any of them could be selected as the principal diagnosis.

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

c. Privacy In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information.

The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as: a. Access b. Confidentiality c. Privacy d. Security

c. Privacy Privacy is when a patient has the right to maintain control over certain health information.

An individual's right to control access to his or her personal information is known as: a. Security b. Confidentiality c. Privacy d. Access control

c. Privacy Privacy, confidentiality, and security are related, but distinct, concepts. In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information. Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose. Security is the protection of the privacy of individuals and the confidentiality of health records.

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

c. Progressive penalties Progressive penalties ensure that the minimum penalty appropriate to the level of offense is applied. Penalties may include but are not limited to oral warning for first unexcused tardiness and written warning for the second instance; serious rule violations, such as bringing a weapon to work, may result in immediate dismissal.

George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of: a. Data mining b. Qualitative analysis c. Quantitative analysis d. Data warehousing

c. Quantitative analysis Quantitative analysis is used by health information management technicians as a method to detect whether elements of the patient's health record are missing.

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

c. Query the physician As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries may be made in situations where there are clinical indicators of a diagnosis but no documentation of the condition.

The HIM Department has been receiving complaints about the turnaround time for release of information (ROI) requests. A PI team is created to investigate this issue. What data source would be appropriate to use to investigate this issue further? a. ROI employee evaluations b. Survey requestors c. ROI tracking system d. ADT system

c. ROI tracking system The supervisor is responsible for ensuring turnaround times are met. Turnaround time is the time between receipt of the request and when the request is sent to the requester. The ROI system tracks requests for the information.

What is the primary purpose of structured data entry? a. Provide providers with as many options as possible b. Speed up data entry c. Reduce documentation variability d. Comply with regulatory rules

c. Reduce documentation variability Structured data entry techniques constrain data capture into a common format or vocabulary. A purpose of structured data entry is to reduce variability in terminology, allowing for standardization.

The sister of a patient requests the HIM department to release copies of her brother's health record to her. She states that because the physician documented her name as her brother's caregiver that HIPAA regulations apply and that she may receive copies of her brother's health record. In this case, how should the HIM department proceed? a. Provide the copies as requested since the sister was a caregiver. b. Provide only copies of the reports where the sister's name is mentioned. c. Refuse the request. d. Refer the individual to legal counsel.

c. Refuse the request. The Privacy Rule addresses the issue of personal representatives. Personal representatives are those who are legally authorized to make healthcare decisions on an individual's behalf or to act on behalf of a deceased individual or that individual's estate. Under the Privacy Rule, then, a personal representative must be treated the same as the individual regarding the use and disclosure of the individual's PHI. In this instance, the fact that the sister is listed in the health record as the caregiver does not make her legally authorized as a personal representative under the Privacy Rule. Her request should be refused.

Two HIM professionals are abstracting data for the same case for a registry. When their work is checked, discrepancies are found. Which data quality component is lacking? a. Completeness b. Validity c. Reliability d. Timeliness

c. Reliability Reliability refers to the degree to which a selection test produces consistent scores on a test and retest. Reliability is frequently checked by having more than one person abstract data for the same case. The results are then compared to identify any discrepancies.

A secondary purpose of the health record is to provide support for which of the following? a. Provider reimbursement b. Education for patients c. Research activities d. Delivery of patient care

c. Research activities The secondary purposes of the health record are not associated with specific encounters between patient and healthcare professional. Rather, they are related to the environment in which patient care is provided. Some secondary purposes are: support for research, to serve as evidence in litigation, to allocate resources, to plan market strategy, and the like.

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

c. Review the subpoena and appear at the time and place supplied to give testimony Sometimes HIM professionals are subpoenaed to testify as to the authenticity of the health records by confirming that they were compiled in the normal course of business and have not been altered in any way. A subpoena that is issued to elicit testimony is a subpoena ad testificandum.

General Hospital is performing peer reviews of their medical providers for quality outcomes of care. The hospital has more than 500 providers on its medical staff. The process to peer review even 10 cases for each provider is quite extensive. The quality department has concluded that to accomplish this review process, they will review 20 percent of each provider's inpatient admissions to the hospital every other year. In this situation, the quality department has applied to their review process. a. Benchmarking b. Data analysis c. Sampling d. Skewing

c. Sampling Sometimes the organizational characteristic or parameter about which data are being collected occurs too frequently to measure every occurrence. In this case, those collecting the data might want to use sampling techniques. Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data.

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

c. Set clear goals and productivity standards and see that these are met Managing remote staff presents new considerations. It is not necessarily more difficult to manage remote staff; rather, it presents different challenges. In the remote environment, managers may need to rely on productivity and coding accuracy reports to determine the success of remote employees. When allowing coders to work from home or contracting with remote coders, work expectations must be established in advance.

During user acceptance testing of a new EHR system, physicians are complaining that they must use multiple log-on screens to access all the system modules. For example, they must use one log-on for CPOE and another log-on to view laboratory results. One physician suggests having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide? a. Single sign-on is not supported by HIPAA security measures. b. Single sign-on is discouraged by the Joint Commission. c. Single sign-on is less frustrating for the end user and can provide better security. d. Single sign-on is not possible given today's technology.

c. Single sign-on is less frustrating for the end user and can provide better security. Single sign-on allows sign-on to multiple related, but independent, software systems. With this property a user logs in once and gains access to all systems without being prompted to log in again at each of them. Single sign-off is the reverse property whereby a single action of signing out terminates access to multiple software systems.

In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited? a. Drop-down menus b. Point and click fields c. Speech recognition d. Structured templates

c. Speech recognition Speech recognition can be very effective in certain situations when data entry is fairly repetitive and the vocabulary used is fairly limited. As speech recognition improves, it is becoming a replacement for other forms of dictation. In some cases, the user reviews the speech as it is being converted to type and makes any needed corrections; in other cases, the speech is sent to a special device where it generates type for another individual to review and edit.

Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system? a. Congestive heart failure b. Acute myocardial infarction c. Stage III or IV pressure ulcers d. Diabetic retinopathy

c. Stage III or IV pressure ulcers The hospital-acquired conditions (HAC) provision is an additional component of pay-forperformance utilizing reported ICD-10-CM diagnosis codes and the present-on-admission (POA) indicator to identify quality issues. A Stage III or IV pressure ulcer not present on admission or identified with the POA indicator on the claim would not be paid for as a CC or MCC because it would be considered an HAC.

What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors? a. HIPAA because it has strict rules regarding minors b. Hospital attorneys because they know the rules of the hospital c. State law because HIPAA defers to state laws on matters related to minors d. Federal law because HIPAA overrides state laws on matters related to minors

c. State law because HIPAA defers to state laws on matters related to minors Because HIPAA defers to state laws on the issue of minors, applicable state laws should be consulted regarding appropriate authorization. In general, the age of maturity is 18 years or older. This is the legal recognition that an individual is considered responsible for, and has control over, his or her actions.

Which document directs an individual to bring originals or copies of records to court? a. Summons b. Subpoena ad testificandum c. Subpoena duces tecum d. Deposition

c. Subpoena duces tecum A subpoena duces tecum means to bring documents and other records with oneself. Such subpoenas may direct the heath information technology (HIT) professional to bring originals or copies of health records, laboratory reports, x-rays, or other records to a deposition or to court. Each state has different rules governing the production of health records in litigation. Often, the component state HIM association of AHIMA has a legal handbook that outlines the various conditions and how HITs should respond to a subpoena.

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

c. Support for research Healthcare is a sophisticated industry and information from the health record is used for many purposes not related specifically to patient care. These secondary purposes include support for public health and research.

Community Hospital is discussing restricting the access that physicians have to electronic health records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available, whereas others maintain that HIPAA restricts access. The HIM director is part of the committee. Which of the following should the director advise the committee? a. HIPAA restricts the access of physicians to all information. b. The "minimum necessary" concept does not apply to disclosures made for treatment purposes; therefore, physician access should not be restricted. c. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role. d. The "minimum necessary" concept applies only to attending physicians, and therefore, restriction of access must be implemented.

c. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role. The HIPAA Privacy Rule concept of "minimum necessary" does not apply to disclosures made for treatment purposes. However, the covered entity must define, within the organization, what information physicians need as part of their treatment role.

Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event an amendment, addendum, or deletion needs to be made, which following should occur? a. The EHR should retain only the latest version of the document in order to avoid confusion as documenting who made a change and when is never necessary. b. The EHR should not allow any amendments, addendums, or deletions of electronic documents as this violates accreditation standards. c. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made. d. The EHR is not capable of allowing documentation changes. If a document needs to be amended, it must printed, redlined, and scanned into the EHR

c. The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made the EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made.

Central City Clinic has requested that Ghent Hospital send its hospital records for Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? a. The Privacy Rule requires that Susan Hall complete a written authorization. b. The hospital may send only the discharge summary, history and physical, and operative report. c. The Privacy Rule's minimum necessary requirement does not apply. d. This "public interest and benefit" disclosure does not require the patient's authorization.

c. The Privacy Rule's minimum necessary requirement does not apply. There are certain circumstances where the minimum necessary requirement does not apply, such as to healthcare providers for treatment; to the individual or his personal representative; pursuant to the individual's authorization to the secretary of the HHS for investigations, compliance review, or enforcement; as required by law; or to meet other Privacy Rule compliance requirements.

For HIPAA implementation specifications that are addressable, which of the following statements is true? a. The covered entity must implement the specification. b. The covered entity may choose not to implement the specification if implementation is too costly. c. The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment. d. If the covered entity is a small hospital, the specification does not have to be implemented.

c. The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment. Implementation specifications define how standards are to be implemented. Implementation specifications are either "required" or "addressable." Covered entities must implement all implementation specifications that are "required." For those implementation specifications that are labeled addressable, the covered entity must conduct a risk assessment and evaluate whether the specification is appropriate to its environment.

When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected? a. There is no impact. b. The person making the entry in the health record may not be called as a witness in trial. c. The incident report likely becomes discoverable because it is mentioned in a discoverable document. d. The incident report cannot be discovered even though it is mentioned in a discoverable document.

c. The incident report likely becomes discoverable because it is mentioned in a discoverable document. Hospitals strive to keep incident reports confidential, and in some states, incident reports are protected under statutes protecting quality improvement studies and activities. Incident reports themselves should not be considered a part of the health record. Because the staff member mentioned in the record that an incident report was completed, it will likely be discoverable as the health record is already a discoverable document.

The HIM manager was asked by the medical director to present the hospital's policy on deletion of erroneous information from the electronic health record to the medical staff. This policy requires that the original documentation is retained in the EHR along with the corrected documentation. Which of the following is a key component of this policy? a. The new documentation must be reviewed by the chief of the medical staff b. Natural language processing would be utilized to delete erroneous information c. The new and old documentation would be included in the same document with a comment section. d. The new documentation needs to be reviewed by the risk manager.

c. The new and old documentation would be included in the same document with a comment section. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made the EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made.

In the scatter chart below what can be concluded about the relationship between age and income. [Graph: X axis is income in dollars, Y axis is age, graph direction looks like "/"] a. There is a strong negative relationship between age and income b. There is no relationship between age and income c. There is a strong positive relationship between age and income d. There is not enough information to determine the relationship

c. There is a strong positive relationship between age and income The scatter chart is showing a strong positive relationship between age and income because as age increases so does income. A negative relationship would show that as age increases income decreases, and that is not the case in this scatter chart example.

As CIO, you have initiated discussions of information governance (IG) with your C-suite colleagues. Since your background is in HIM, you stress the importance of information protection and data quality. You mention all of the following in your discussion as to why quality data is important to data governance (DG) and IG, but as an HIM professional, you feel the most important is __________. a. To make informed decisions b. To evaluate patient care and population health c. To decrease security breaches d. To evaluate business processes

c. To decrease security breaches Data governance and information governance programs rely on quality data and information for all the reasons listed in the question. However, confidentiality, privacy and security are the cornerstones of HIM. Therefore, to decrease security breaches is the most important reason.

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

c. Tornadoes All threats can be categorized as either internal threats (threats that originate within an organization) or external threats (threats that originate outside an organization). People are not the only threats to data security. Natural disasters such as earthquakes, tornadoes, floods, and hurricanes can demolish physical facilities and electrical utilities.

Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients? a. Priority focus process review b. Periodic performance review c. Tracer methodology d. Performance improvement

c. Tracer methodology The Joint Commission uses tracer methodology for on-site surveys. The tracer methodology incorporates the use of the priority focus process (PFP) review, follows the experience of care through the organization's entire healthcare process, and allows the surveyor to identify performance issues.

What type of registry maintains a database on patients injured by an external physical force? a. Implant registry b. Birth defects registry c. Trauma registry d. Transplant registry

c. Trauma registry Trauma registries maintain databases on patients with severe traumatic injuries. A traumatic injury is a wound or other injury caused by an external physical force such as an automobile accident, a shooting, a stabbing, or a fall.

Which of the following is not true of good electronic forms design? a. Minimizes keystrokes by using pop-up menus b. Performs completeness check for all required data c. Uses radio buttons to select multiple items from a set of options d. Uses text boxes to enter text

c. Uses radio buttons to select multiple items from a set of options Good forms design is needed within an EHR to create ease of use. The use of a selection box allows the user to select a value from a predefined list. Check boxes are used for multiple selections and radio buttons are used for single selections

Which of the following is NOT a true statement about a hybrid health record system? a. Development of processes for both manual and computer processes is a challenge. b. Creation of a definition of what constitutes a health record in manual and electronic format must be developed. c. Version control is easy to implement. d. Security safeguards must be developed for both paper and electronic processes.

c. Version control is easy to implement. As the electronic system develops, different versions of documents may exist, and these also must be monitored and logged for both legal and practice purposes. Version control in a hybrid record environment is challenging as both the paper and electronic documents must be controlled.

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

d. 100 patients The average daily census is the average number of inpatients treated during a given period of time. There are 30 days in September, so 3,000 / 30 = 100

From the information provided in this table below, what percentage will the facility be paid for procedure 25500? Billing Number / Status Indicator / CPT/HCPCS / APC 998323/ V/ 99285-25 / 0612 998323 / T / 25500 / 0044 998323 / X / 72050 / 0261 998323 / S / 72128 / 0283 998323 / S / 70450 / 0283 a. 0% b. 50% c. 75% d. 100%

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

The RHIT supervisor for the scanning and quality control section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for scanning records is 50 records per hour. The standard for quality control of scanning of records is 40 records per hour. Given these standards, how many productive hours will be required daily to scan and quality control records for each clinic day? a. 10 hours per day b. 11.11 hours per day c. 12.5 hours per day d. 22.5 hours per day

d. 22.5 hours per day Timeliness of the scanning and quality control processes should be monitored. In this situation, each clinic visit represents a patient record that will need to be scanned and quality control completed. The calculation is: (500 / 50) + (500 / 40) = 22.5 hours per day.

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

d. 3 Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work. Employees log what they do and the time spent on tasks in units of work received and processed each day. 23 charts/7.5 hours = 3.06, which is rounded to 3 charts per hour.

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578 - Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580 - Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36582 - Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access 36597 - Repositioning of previous placed central venous catheter under fluoroscopic guidance a. 36578 b. 36580 c. 36582, 36597 d. 36582

d. 36582 A complete replacement of the entire device by the same venous access site is being performed. It is a tunneled catheter inserted within the same venous access point. Code 36582 is the correct code.

HIPAA requires a covered entity to establish policy to ensure that protected health information could not identify a specific individual. One method used to meet this deidentification standard is the expert determination model. The expert determination model requires these four steps: 1. Determine the statistical and scientific method to be used to determine the risk of reidentification 2. Analyze and assess the risk to the deidentified data 3. The expert applies the method to the deidentified data 4. The facility should choose the expert for the deidentification analysisWhat is the correct order in which these steps should be performed? a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 4, 3, 1 d. 4, 1, 3, 2

d. 4, 1, 3, 2 The process for expert determination of de-identification has four recommended steps that include: Step 1: The facility should choose the expert for the deidentification analysis; Step 2: Determine the statistical and scientific method to be used to determine the risk of reidentification; Step 3: The expert applies the method to the deidentified data; and Step 4: Analyze and assess the risk to the deidentified data

Community Hospital's HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timeliness rate. Thirteen discharges were determined to be out of compliance with completion standards. Which of the following percentages represents the timeliness rate for discharge summaries at Community Hospital? a. 8.7% b. 9.5% c. 41.5% d. 91.3%

d. 91.3% Hospitals set completion standards based on this requirement. Record completion would include the discharge summary (137/150) × 100 = 91.3%

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

d. 95.5% A complete history and physical report represents the attending physician's assessment of the patient's current health status, and accreditation standards require it to be completed within 24 hours of admission. In this case, 191 instances of timely H&Ps out of 200 sampled is 95.5% accuracy. The calculation is (191/200) × 100 = 95.5%

An HIT using her password can access and change data in the hospital's master patient index. A billing clerk, using his password, cannot perform the same function. Limiting the class of information and functions that can be performed by these two employees is managed by: a. Network controls b. Audit trails c. Administrative controls d. Access controls

d. Access controls Determining what data to make available to an employee usually involves identifying classes of information based on the employee's role in the organization. Every role in the organization should be identified, along with the type of information required to perform it. This is often referred to as role-based access. Although there are other types of access control strategies, role-based access is probably the one used most often in healthcare organizations. Access to information and information resources (such as computers) must be restricted to those authorized to access the information or the associated resources.

Which of the following are components of AHIMA's principles of information governance? a. Accountability and accessibility b. Integrity and safeguards c. Safeguards and accessibility d. Accountability and integrity

d. Accountability and integrity AHIMA defined the following principles to support proper information governance across an organization: accountability, transparency, integrity, protection, compliance, availability, disposition, and retention.

Cancer registries receive approval as part of the facility cancer program from which of the following agencies? a. American Cancer Society b. National Cancer Registrar's Association c. National Cancer Institute d. American College of Surgeons

d. American College of Surgeons Several organizations have developed standards or approval processes for cancer programs. The American College of Surgeons (ACS) Commission on Cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program.

Written business associate agreements are required with: a. Every company where work is outsourced b. Any outside company that handles electronic data c. Every outside company d. Any outside company that handles electronic PHI

d. Any outside company that handles electronic PHI Covered entities must obtain a written contract with business associates or other entities who handle e-PHI. The written contract must stipulate that the business associate will implement HIPAA administrative, physical, and technical safeguards and procedures and documentation requirements that safeguard the confidentiality, integrity, and availability of the e-PHI that it creates, receives, maintains, or transmits on behalf of the covered entity.

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

d. Automatic session log-off In the HIPAA Security Rule, one of the technical safeguards standards is access control. This includes automatic log-off, which ensures processes that terminate an electronic session after a predetermined time of inactivity.

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

d. Benchmarking with other facilities Internal users of secondary data are individuals located within the healthcare facility. For example, internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities.

A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at trial d. Bring records to a legal proceeding

d. Bring records to a legal proceeding A subpoena duces tecum instructs the recipient to bring documents and other records with himself or herself to a deposition or to court.

The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: a. Admissibility exception b. Discovery exception c. Direct evidence exception d. Business records exception

d. Business records exception The Business Records Exception is the rule under which a record is determined not to be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge; it was kept in the course of a regularly conducted business activity; and it was the regular practice of that business activity to make the record.

Which group focuses on accreditation of rehabilitation programs and services? a. HFAP b. Joint Commission c. AAAHC d. CARF

d. CARF The Joint Commission accredits rehabilitation programs and services but they do not focus on it like CARF does.

Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity: a. Must always provide access b. Can always deny access c. Can demand that the individual pay to see his or her record d. Can deny access to psychotherapy notes

d. Can deny access to psychotherapy notes Section 164.524 of the Privacy Rule states that an individual has a right of access to inspect and obtain a copy of his or her own protected health information (PHI) that is contained in a designated record set, such as a health record. The individual's right extends for as long as the PHI is maintained. However, there are exceptions to what PHI may be accessed. For example, psychotherapy notes; information compiled in reasonable anticipation of a civil, criminal, or administrative action or proceeding; or PHI subject to the Clinical Laboratory Improvements Act (CLIA) are all exceptions.

A hospital can monitor its performance under the MS-DRG system by monitoring its: a. Accounts receivable b. Operating costs c. RBRVS payments d. Case-mix index

d. Case-mix index A hospital can monitor its performance under the MS-DRG system by monitoring its case-mix index (CMI). The CMI is the average of the relative MS-DRG weights of all cases treated at a given hospital. The CMI can be used to make comparisons between hospitals and to assess the quality of documentation and coding at a particular hospital.

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

d. Commonly lead to patient injury The national patient safety goals outline for healthcare organizations the areas of organizational practice that most commonly lead to patient injury or other negative outcomes that can be prevented when staff utilize standardized procedures.

When all required data elements are included in the health record, the quality characteristic for data ________ is met. a. Security b. Accessibility c. Flexibility d. Comprehensiveness

d. Comprehensiveness Data comprehensiveness means that all the required data elements are included in the health record. In essence, comprehensiveness means that the record is complete. In both paper-based and computer-based systems, having a complete health record is critical to the organization's ability to provide excellent patient care and to meet all regulatory, legal, and reimbursement requirements.

Two coders have found the same abbreviation in two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation in another patient's record was used to mean "overdose" in an abuse record. What data quality component is lacking here? a. Timeliness b. Completeness c. Security d. Consistency

d. Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Data must have definitions and be uniform to prevent information inconsistencies.

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

d. Cooperating Parties Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the Cooperating Parties and any other official coding rules and guidelines established for use with mandated standard code sets.

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

d. Corrective action should be taken to meet the department standards Each function should have its own acceptable level of performance and monitoring should be performed to confirm the standards are met. If not, corrective actions should be taken.

A consumer nonprofit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. An HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. Which of the following would not be a quality consideration in using billing data? a. Accuracy of the data b. Consistency of the data c. Appropriateness of the data elements d. Cost to process the data

d. Cost to process the data Several factors must be addressed when assessing data quality. These include: data accuracy, consistency, comprehensiveness, and timeliness. Cost to process the data does not influence the quality.

What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice? a. Degree b. Certificate c. License d. Credential

d. Credential Credentials are the recognition by healthcare organizations of previous professional practice responsibilities and experiences commonly accorded to licensed independent practitioners and are usually conferred by a national professional organization dedicated to a specific area of healthcare practice.

Which of the following is not a characteristic of high-quality healthcare data? a. Data relevancy b. Data currency c. Data consistency d. Data accountability

d. Data accountability The data quality model applies the following quality characteristics: data accuracy, data accessibility, data comprehensiveness, data consistency, data currency, data definition, data granularity, data precision, data relevancy, and data timeliness.

A crucial early step in designing an electronic health record (EHR) is to develop a(n) ________ in which the characteristics of each data element are defined. a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary

d. Data dictionary A data dictionary improves data validity and reliability within, across, and outside the enterprise because it ensures that each piece of data can only mean one thing. A critical early step in implementing the EHR is to develop a data dictionary.

The patient's address is the same in the master patient index, electronic health record, laboratory information system, and other systems. This means that the data values are consistent and therefore indicative of which of the following? a. Data availability b. Data accessibility c. Data privacy d. Data integrity

d. Data integrity Data integrity means that data are complete, accurate, consistent, and up-to-date so it is reliable.

The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a: a. Data chargemaster report b. Data dictionary c. Database management system d. Data map

d. Data map Data mapping is a process that allows for connections between two systems. For example, mapping two different coding systems to show the equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose.

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system

d. Database management system The database management system is the best option to collect, store, manipulate, and retrieve data for this situation. Paper and word-processing documents cannot sort and store the data in a meaningful way for this purpose. Spreadsheets should be used for accounting-type functions and not for data storage.

This type of data identifies the patient (such as name, health record number, address, and telephone number) and is called? a. Accession data b. Indicator data c. Reference data d. Demographic data

d. Demographic data Demographic data is used to identify an individual, such as name, address, gender, age, and other information linked to a specific person.

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

d. Derived Derived data consist of factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients. These data should have the same level of confidentiality as the legal health record.

During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste functionality of the hospital's EHR system for documenting nursing notes. Which of the following should the HIM director do to ensure that the nurses are following acceptable documentation practices? a. Inform the nurses that copy and paste is not acceptable and to stop this practice immediately b. Determine how many nurses are involved in this practice c. Institute an in-service training session on documentation practices d. Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system

d. Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system The ability to copy previous entries and paste into a current entry leads to a record in which a clinician may, upon signing the documentation, unwittingly swear to the accuracy and comprehensiveness of substantial amounts of duplicated or inapplicable information as well as the incorporation of misleading or erroneous documentation. The HIM professional plays a critical role in developing policies and procedures to ensure the integrity of patient information.

Which HIPAA-required tracking system can be queried to determine the percentage of responses to ROIs that are sent to attorneys, insurance companies, and covered entities? a. Chart locator system b. CDI system c. Encoder/grouper d. Disclosure management system

d. Disclosure management system A disclosure management system tracks the disclosures made throughout the healthcare facility for reporting purposes. Disclosure is the release, transfer, provision of access to, or divulging tin any manner of information outside the healthcare facility holding the information.

The removal of medication from its usual stream of preparation, dispensing, and administration by personnel involved in those steps in order to use or sell the medication in nonhealthcare settings is called: a. Prescribing b. Adverse drug reaction c. Sentinel event d. Diversion

d. Diversion Diversion is the removal of a medication from its usual stream of preparation, dispensing, and administration by personnel involved in those steps in order to use or sell the medication in non-healthcare settings. An individual might take the medication for personal use, to sell on the street, to sell directly to a user as a dealer or to sell to others who will redistribute for the diverting individual.

Dr. Smith wants to use a lot of free text in his EHR. What should be your response? a. Good idea, Dr. Smith. This allows you to customize the documentation for each patient. b. Dr. Smith, we recommend that you do not use any free text in the EHR. c. Dr. Smith, we recommend that you should use free text only in your more complex cases. d. Dr. Smith, we recommend that you use little, if any, free text in the EHR.

d. Dr. Smith, we recommend that you use little, if any, free text in the EHR. Free-text data is the unstructured narrative data that is the result of a person typing data into an information system. It is undefined, unlimited, and unstructured, meaning that the typist can type anything into the field or document. The amount of free-text in the EHR should be limited as the ability to manipulate data is diminished.

Electronic systems used by nurses and physicians to document assessments and findings are called: a. Computerized provider order entry b. Electronic document management systems c. Electronic medication administration record d. Electronic point-of-care charting

d. Electronic point-of-care charting There are important applications that support electronic health record (EHR) functionality. Many hospitals begin their EHR implementation with point-of-care (POC) charting systems. These might include nursing admission assessments, nursing progress notes, vital signs charting, intake and output records, and the like.

Which of the following would be used to track data movement from one system to another? a. Administrative metadata b. Business metadata c. Context metadata d. Embedded metadata

d. Embedded metadata Embedded metadata are most often associated with automated records of operations (such as audit trails) and are stored with the date themselves. If data move from a source system to another system, then the system can attach metadata that identify where the data originated. In this way, metadata helps track data movement from one system to another.

What is the primary benefit of point-of-care charting? a. Eases duplicate data entry burden b. Eliminates intermediary paper forms c. Eliminates the need for provider documentation d. Ensures that appropriate data are collected timely

d. Ensures that appropriate data are collected timely Many hospitals begin their EHR implementation with point of care (POC) charting systems. These might include nursing admission assessments, nursing progress notes, vital signs charting, intake and output records, and the like.

Which of the following is not a guideline for maintaining integrity in the health record? a. Specifying consequences for the falsification of information b. Requiring periodic training covering the falsification of information and information security c. Prohibiting the entry of false information into any of the organizations' records d. Ensuring documentation that is being changed is permanently deleted from the record

d. Ensuring documentation that is being changed is permanently deleted from the record Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy.

Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle? a. Errors by coding guideline b. Percentage of cases that could have been improved if queried c. Errors by coder d. Errors that produced changes in MS-DRG assignment

d. Errors that produced changes in MS-DRG assignment Coding errors can affect the Medicare severity diagnosis-related group (MS-DRG) assignment, thus impacting the revenue cycle. Ultimately, the coding supervisor should determine whether the frequency of errors identified demonstrates a trend.

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

d. Flow chart When a team examines a process with the intention of making improvements, it must first understand the process thoroughly. Each team member has a unique perspective and significant insight about how a portion of the process works. Flow charts help all the team members understand the process in the same way.

The data set designed to organize data about public health issues to inform purchasers and consumers about the performance of healthcare plans is: a. UHDDS b. DEEDS c. MDS d. HEDIS

d. HEDIS The Healthcare Effectiveness Data and Information Set (HEDIS) is sponsored by the National Committee for Quality Assurance (NCQA). HEDIS is a set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of healthcare plans

This type of chart plots all data points as a cell for two given variables of interest and, depending on frequency of observations in each cell, provides color to visualize high or low frequency. a. Barplot b. Scatter plot c. Boxplot d. Heatmap

d. Heatmap A heat map plots all data points as a cell for two given variables or interest, and depending on frequency of observations in each cell, provides color to visualize high or low frequency.

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

d. Hematuria; adverse reaction to Coumadin Hematuria is an adverse effect as opposed to a poisoning because it was correctly prescribed and correctly taken.

Ensuring data are not altered during transmission across a network or during storage is called: a. Media control b. Audit controls c. Mitigation d. Integrity

d. Integrity Technology has advanced to a point at which an unauthorized user can capture data in transit and alter it. Therefore, CEs must confirm the integrity of data passed across a network. Integrity is the security principle that protects data from inappropriate modification or corruption. This includes both unintentional and intentional modifications and destructions. Unintentional modifications and destruction could occur if the wrong data are destroyed, the wrong backup is used to restore data, or an electrical fire destroys the computer.

When a patient revokes authorization for release of information after a healthcare facility has already released the information, the facility in this case: a. May be prosecuted for invasion of privacy b. Has become subject to civil action c. Has violated the security regulations of HIPAA d. Is protected by the Privacy Act

d. Is protected by the Privacy Act An individual may revoke an authorization at any time, provided that he or she does so in writing. However, the revocation does not apply when the covered entity has already taken action on the authorization.

Which of the following is not true about the Notice of Privacy Practices? a. It must include a description of the patient's right to amend PHI. b. It must include a description of the right to request restrictions on certain uses and disclosures. c. It must explain the patient's right to inspect and copy PHI. d. It must include at least two examples of how information is used for both treatment and operations.

d. It must include at least two examples of how information is used for both treatment and operations. AHIMA outlines the requirements for the content of the notice of privacy practices. One requirement is that a description (including at least one example) is to be given of the types of uses and disclosures the covered entity is permitted to make for treatment, payment, and healthcare operations.

A patient's registration forms, personal property list, RAI, care plan, and discharge or transfer documentation would be found most frequently in which type of health record? a. Rehabilitative care b. Ambulatory care c. Behavioral health d. Long-term care

d. Long-term care The following list identifies some of the most common components of long-term care records: registration forms including resident identification data, personal property list, history and physical and hospital records, advance directives, bill of rights, and other legal records, and RAI and care plan.

Which of the following statements represents knowledge? a. Hematocrit is 48 today b. Mary Jones had a blood pressure of 120/100 c. The hospital has an 89 percent occupancy rate d. Mary Jones's hemoglobin of 13 is within normal range

d. Mary Jones's hemoglobin of 13 is within normal range Knowledge consists of a combination of rules, relationships, ideas, and experiences applied to information. The statement "Mary Jones's hemoglobin of 13 is within normal range" identifies the patient, specific information about that patient and how it relates to normal parameters which makes it knowledge rather than information.

Which of the following describe criteria with specific objectives and measures that hospitals must meet to demonstrate they are using EHRs that positively affect patient care? a. Approved certified EHR technology b. Hospital standardization program c. Interoperability standards d. Meaningful use

d. Meaningful use Meaningful use is criteria with specific objectives and measures to be met by hospitals to demonstrate they are using EHRs that positively affect patient care.

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? Payer/Charges/Payments/Adjustment/Charges/Payments BCBS/$450,000/$360,000/$90,000/23%/31%/12% Commercial/$250,000/$200,000/$50,000/13%/17%/6% Medicaid/$350,000/$75,000/$275,000/18%/6%/36% Medicare $750,000 $495,000 $255,000 39% 42% 33% TRICARE/$150,000/$50,000/$100,000/7%/4%/13% Total/$1,950,000/$1,180,000/$770,000/100%/100% a. BC/BS b. Commercial c. TRICARE d. Medicare

d. Medicare In the "Payments" column, Medicare has the highest payment percentage (42 percent) of any of the payers; therefore, Medicare contributes more to the hospital's overall payments

In which type of distribution are the mean, median, and mode equal? a. Bimodal distribution b. Simple distribution c. Nonnormal distribution d. Normal distribution

d. Normal distribution The normal distribution is where data follows a symmetrical curve. The normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. In a normal distribution, the mean, median, and mode are equal.

Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linens for off-site laundering. Ready-Clean is: a. A business associate because Lane Hospital has a contract with it b. Not a business associate because it is a local company c. A business associate because its employees may see PHI d. Not a business associate because it does not use or disclose individually identifiable health information

d. Not a business associate because it does not use or disclose individually identifiable health information Vendors who have a presence in a healthcare facility, agency, or organization will often have access to patient information in the course of their work. If the vendor meets the definition of a business associate (that is, it is using or disclosing an individual's PHI on behalf of the healthcare organization), a business associate agreement must be signed. If a vendor is not a business associate, employees of the vendor should sign confidentiality agreements because of their routine contact with and exposure to patient information. In this situation, Ready-Clean is not a business associate.

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

d. One CPT code, adding the lengths of the lacerations together The length of multiple laceration repairs located in the same classification are added together and one code is assigned.

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

d. Only if a properly executed ABN was obtained before the service was provided Medicare does have a provision that a patient may be billed for a test that is not medically necessary if he or she receives an advance beneficiary notice (ABN) before the test is performed. Therefore, not only must the registration staff determine whether the sign or symptom is sufficient, they also may contact the patient's physician to obtain a new order or, if a new order is not provided, to issue an ABN. Success in the patient registration process involves a thoroughly educated staff with the tools to determine medical necessity, the processes in place to clarify orders, and the ability to obtain signatures on ABNs.

Which one of the following indexes contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period? a. Physician b. Master patient c. Disease d. Operation

d. Operation The Operation Index is similar to the Disease Index except that it is arranged in numerical order by the patient's procedure code(s) using International Classification of Diseases or Current Procedural Terminology (CPT) codes.

Under HIPAA, which of the following is not named as a covered entity? a. Attending physician b. Healthcare clearinghouse c. Health plan d. Outsourced transcription company

d. Outsourced transcription company An outsourced transcription company and vendor would be business associates of a covered entity (CE). Although business associates are not directly regulated by the Privacy Rule, they do come under the Privacy Rule's requirements by virtue of their association with one or more CEs. A business associate is a person or organization other than a member of a CE's workforce that performs functions or activities on behalf of or affecting a CE that involve the use or disclosure of individually identifiable health information.

One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following? a. Serial work division b. Job sharing c. Job rotation d. Parallel work division

d. Parallel work division In parallel work division, the same tasks are handled simultaneously by several workers; each completes all steps in the process from beginning to end, working independently of the other employees.

Bob Smith is a 56-year-old white male. This is an example of what type of data? a. Secondary b. Primary c. Aggregate d. Patient-identifiable

d. Patient-identifiable Data also are categorized as either patient identifiable data, or aggregate data. With patient identifiable data, the patient is identified within the data either by name or number. The health record consists entirely of patient-identified data.

Which of the following is a principle of contemporary performance improvement? a. Success must never be celebrated as this does not encourage more success. b. Systems never demonstrate variation. c. Performance improvement works by identifying the individuals responsible for quality problems and reprimanding them. d. Performance improvement relies on the collection and analysis of data to increase knowledge.

d. Performance improvement relies on the collection and analysis of data to increase knowledge. Performance improvement (PI) is based on several fundamental principles, including: the structure of a system determines its performance; all systems demonstrate variation; improvements rely on the collection and analysis of data that increase knowledge; PI requires the commitment and support of top administration; PI works best when leaders and employees know and share the organization's mission, vision, and values.

Typically, healthcare facilities should retain the master patient index: a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently

d. Permanently Record retention should only be done in accordance with federal and state law and written retention and destruction policies of the organization. AHIMA's recommended retention standards for the master patient index (MPI) is permanent retention.

Clara maintains and updates an individual health record for herself as a tool she can use to collect, track, and share her past and current information about her health with providers. What is this tool called? a. Hybrid health record b. Paper health record c. Duplicate health record d. Personal health record

d. Personal health record The tool that Clara is using is a personal health record. Personal health records are a tool that an individual can use to collect, track, and share past and current information about their health.

The following is documented in an acute-care record: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." In which of the following would this documentation appear? a. Medical history b. Pathology report c. Operation report d. Physical examination

d. Physical examination Information usually documented in the physical examination includes vital signs and examinations of the head, eyes, ears, nose, throat (HEENT).

Identify the report where the following information would be found: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds." a. Discharge summary b. Health history c. Medical laboratory report d. Physical examination

d. Physical examination Review of body systems is typically documented in the report of a physical examination. This would include documentation regarding the HEENT (head, eyes, ears, nose, and throat) and the chest.

A special web page that offers secure access to data is a(n): a. Internet b. Home page c. Intranet d. Portal

d. Portal A portal is a special application to provide secure remote access to specific applications.

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 years old b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed

d. Present an authorization that at least one of them (Ted or Mary) has signed Because minors are, as a general rule, legally incompetent and unable to make decisions regarding the use and disclosure of their own health information, this authority belongs to the minor's parent(s) or legal guardian(s) unless an exception applies. Because privacy, security, and confidentiality of minor records are extremely regulated, HIM professionals should also consult state regulations or legal counsel for specific questions. Generally, only one parent signature is required to authorize the use or disclosure of the minor's PHI.

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance. Bar graph showing volume of procedures performed with the approximate values of: Procedure 1: 990 Procedure 2: 300 Procedure 3: 340 Procedure 4: 960 Procedure 5: 350 Procedure 6: 40 Procedure 7: 60 Procedure 8: 340 a. Procedures 1, 4 b. Procedures 2, 3, 5 c. Procedures 6, 7 d. Procedures 1, 4, 6, 7

d. Procedures 1, 4, 6, 7 Performance measurement in healthcare provides an indication of an organization's performance in relation to a specified process or outcome. Healthcare performance improvement philosophies most often focus on measuring performance in the areas of systems, processes, and outcomes. Outcomes should be scrutinized whether they are positive and appropriate or negative and diminishing.

Which of the following is not part of data governance? a. Ensuring control and accountability for enterprise data b. Establishing and monitoring data policies c. Assigning data decision rights and accountabilities for data d. Promoting the sale of enterprise data

d. Promoting the sale of enterprise data Data governance is the enterprise authority that ensures control and accountability for enterprise data through the establishment of decision rights and data policies and standards that are implemented and monitored through a formal structure of assigning roles, responsibilities, and accountabilities. Promoting the sale of data would not be a role of data governance.

Which of the following is a core ethical obligation of health information management professionals? a. Coding diseases and operations b. Performing quantitative analysis on record content c. Transcribing health reports d. Protecting patients' privacy and confidential communications

d. Protecting patients' privacy and confidential communications The HIM professional's core ethical obligations are to protect patient privacy and confidential information and communication and to assure security of that information.

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations? a. Provide copies of the records within 15 days b. Provide copies of the records within 30 days c. Provide copies of the records within 45 days d. Provide copies of the records within 60 days

d. Provide copies of the records within 60 days The HIPAA Privacy Rule requires that records be produced within 30 days to a patient or their personal representative, with a one-time extension of an additional 30 days if necessary. If such an additional 30 days is needed, the covered entity must notify the patient in writing of the need for additional time.

The process of releasing health record documentation originally created by a different provider is called: a. Privileged communication b. Subpoena c. Jurisdiction d. Redisclosure

d. Redisclosure The process of releasing health record documentation originally created by a different provider is called redisclosure. Federal and state regulations provide specific redisclosure guidelines; however, when in doubt, follow the same principles as the release and disclosure guidelines for other types of health record information.

A competent individual has the following rights concerning his or her healthcare: a. Right to consent to treatment and the right to destroy their original health record b. Right to destroy their original health record and the right to refuse treatment c. Right to access his or her own PHI and the right to take the original record with them d. Right to consent to treatment and the right to access his or her own PHI

d. Right to consent to treatment and the right to access his or her own PHI Competent adults have a general right to consent to or refuse medical treatment. In general, a competent adult has the right to request, receive, examine, copy, and authorize disclosure of the patient's healthcare information.

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

d. Risk identification and analysis, loss prevention and reduction, and claims management The purpose of the risk management program is to link risk management functions to related processes of quality assessment and PI. The basic functions of healthcare risk management programs are similar for most organizations and include: risk identification and analysis, loss prevention and reduction, and claims management.

An individual designated as an inpatient coder may have access to an electronic health record to code the record. Under what access security mechanism is the coder allowed access to the system? a. Situation based b. User based c. Context based d. Role based

d. Role based Access to e-PHI can be controlled through the use of the following: user-based access, role- based access, and context-based access. Role-based access control decisions are based on the roles individual users have as part of an organization. Each user is given various privileges to perform their role or function.

Which of the following is not an automatic control that helps preserve data confidentiality and integrity in an electronic system? a. Edit checks b. Audit trails c. Password management d. Security awareness program

d. Security awareness program Security awareness requires entities to provide security training for all staff. They must address security reminders, detection and reporting of malicious software, login monitoring, and password management. Edit checks, audit trails, and password management can all be programmed to be automatic controls where a security awareness program cannot.

The role of the HIM professional in medical identity theft protection programs includes all of the following except: a. Ensure safeguards are in place to protect the privacy and security of PHI b. Balance patient privacy protection with disclosing medical identity theft to victims c. Identify resources to assist patients who are victims of medical identity theft d. Send all issues related to medical identity theft to the in-house attorney

d. Send all issues related to medical identity theft to the in-house attorney Medical identity theft is distinguished from other types of identity theft because it creates negative consequences to both the victim's financial status and health information. The HIM professional should ensure safeguards are in place to protect PHI and provide resources to assist victims of medical identity theft. It is important to balance patient privacy protection with disclosure of medical identity theft to victims.

The HIPAA Privacy Rule: a. Protects only medical information that is not already specifically protected by state law b. Supersedes all state laws that conflict with it c. Is federal common law d. Sets a minimum (floor) of privacy requirements

d. Sets a minimum (floor) of privacy requirements With the passage of the Privacy Rule, a minimum amount of protection (that is, a floor) was achieved uniformly across all the states through the establishment of a consistent set of standards that affected providers, healthcare clearinghouses, and health plans.

Which of the following should be avoided when designing forms for an electronic document management system (EDMS)? a. Color borders around the edge of a form b. Mnemonic descriptor used for nonbarcode recognition engine c. Quarter-inch border on each side of document without bar code d. Shading of bars or lines that contain text

d. Shading of bars or lines that contain text The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images.

The following is documented in an acute-care record: "Spoke to the attending re: my assessment. Provided adoption and counseling information. Spoke to CPS re: referral. Case manager to meet with patient and family." In which of the following would this documentation appear? a. Admission note b. Dietary note c. Physician progress note d. Social service note

d. Social service note This documentation would typically be found in social service notes.

Which of the following provides a standardized vocabulary for facilitating the development of computer-based patient records? a. Current Procedural Terminology b. Healthcare Common Procedure Coding System c. International Classification of Diseases, Tenth Revision, Clinical Modification d. Systematized Nomenclature of Medicine Clinical Terminology

d. Systematized Nomenclature of Medicine Clinical Terminology Standardized vocabulary is needed to facilitate the indexing, storage, and retrieval of patient information in an electronic health record (EHR). Systematized Nomenclature of Medicine Clinical Terminology (SNOMED CT) creates a standardized vocabulary. The Computerbased Patient Record Institute (CPRI) has studied the ability of current nomenclatures to capture information for EHRs. The institute has determined that SNOMED CT is the most comprehensive controlled vocabulary for coding the contents of the health record and facilitating the development of computerized records.

The "custodian of health records" refers to the individual within an organization who is responsible for all except which of the following actions? a. Authorized to certify records b. Supervising inspection and copying of record c. Testifying to the authenticity of records d. Testifying regarding the care of the patient

d. Testifying regarding the care of the patient The custodian of health records is the individual who has been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records for such persons or institutions that prepare and maintain records of healthcare. The custodian of the health record does not have the responsibility or expertise to testify regarding the care of the patient.

Which of the following is the healthcare industry's leading standards-setting body in the country? a. Agency for Healthcare Research and Quality b. National Guideline Clearinghouse c. National Committee for Quality Assurance d. The Joint Commission

d. The Joint Commission Although there are many high quality accreditation organizations in existence today, all with the common goals of patient safety and the delivery of high quality healthcare to patients, the Joint Commission has been an industry leader in the area of healthcare provider organization accreditation.

Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided? a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission

d. The Joint Commission The Joint Commission has been the most visible organization responsible for accrediting healthcare organizations since the mid-1950s. The primary focus of the Joint Commission at this time is to determine whether organizations seeking accreditation are continually monitoring the quality of the care they provide. The Joint Commission requires that this continual improvement process be in place throughout the entire organization, from the governing body down, as well as across all department lines.

Which accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits? a. Accreditation Association for Ambulatory Healthcare b. Commission on Accreditation of Rehabilitation Facilities c. American Osteopathic Association d. The Joint Commission

d. The Joint Commission The Joint Commission requires healthcare organizations to conduct in-depth investigations of occurrences that resulted—or could have resulted—in life-threatening injuries to patients, medical staff, visitors, and employees. The Joint Commission uses the term sentinel event for such occurrences.

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

d. To determine whether standards of care are being met Every participating healthcare organization is subject to a periodic accreditation survey. Surveyors visit each facility and compare its programs, policies, and procedures to a prepublished set of performance standards. A key component of every accreditation survey is a review of the facility's health records. Surveyors review the documentation of patient care services to determine whether the standards for care are being met.

A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is: a. ORYX b. UACDS c. MDS d. UHDDS

d. UHDDS The purpose of the UHDDS is to list and define a set of common, uniform data elements. The data elements are collected from the health records of every hospital inpatient and later abstracted from the health record and included in national databases.

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital? a. CARF b. DEEDS c. UACDS d. UHDDS

d. UHDDS (Uniform Hospital Discharge Data Set) The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient.

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

d. Uniquely identifies each row in a table Primary keys ensure that each row in a table is unique. A primary key must not change in value. Typically, a primary key is a number that is a one-up counter or a randomly generated number in large databases. A number is used because a number processes faster than an alphanumeric character. In large tables, this makes a difference. In the PATIENTS table, the PATIENT_ID is the primary key. It is good programming practice to create a primary key that is independent of the data in a table.

Which of the following would be the best course of action to take to ensure continuous availability of electronic data? a. Acquire storage management software. b. Send data to a remote site using the Internet. c. Store data on RAID. d. Use redundant servers.

d. Use redundant servers. Data must be available continuously. When paper as a backup no longer exists in a paperless electronic health record (EHR) environment, users must be assured that the computer system is available to them at all times. To achieve such availability, an EHR should have server redundancy. This means that as data are entered and processed by one server, they are entered and processed simultaneously by a second server. Should the primary server crash, the system should be designed to "fail over" to the second server and can continue processing as if, at least from the user's point of view, nothing had happened.

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

d. Variance analysis Reported performance data are regularly analyzed for variance. Variance—where actual performance does not meet, varies, or is significantly different from the standard—should be further assessed.

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

d. Vocabulary standards Vocabulary standards are a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field, such as to provide consistent descriptions of medical terms for an individual's condition in the health record.

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

d. Whether the patient setup an account in the patient portal The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. Often they record: time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred. Creation of an account through the patient portal by the patient is appropriate use.

Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n): a. Business associate b. Covered entity c. Employee d. Workforce member

d. Workforce member Covered entities (CEs) are responsible for their workforce, which consists not only of employees but also volunteers, student interns, and trainees. Workforce members are not limited to those who receive wages from the CE.

Which of the following can assist managers with the tasks of monitoring productivity and forecasting budgets? a. Intermediary bulletins b. Mapping errors c. Revenue codes d. Workload statistics

d. Workload statistics Workload statistics can assist managers with the tasks of monitoring productivity and provide data regarding resources used, such as equipment, personnel, services, and supplies.

The legal health record (LHR) is a(n): a. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information b. Entire set of information created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information c. Set of patient-specific data created or accumulated by a healthcare provider that is defined to be legal by the local, state, or federal authorities d. Set of patient-specific data that is defined to be legal by state or federal statute and that is legally permissible to provide in response to requests for patient information

a. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information The legal health record is a defined subset of all patient-specific data. The legal health record is the record that will be disclosed upon request by third parties. It includes documentation about health services provided and stored on any media.

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

a. Dehydration When the admission or encounter is for management of dehydration due to the malignancy and only the dehydration is being treated, the dehydration is sequenced first, followed by the code(s) for the malignancy.

What are the patient data such as name, age, and address called? a. Demographic data b. Secondary data c. Aggregate data d. Identification data

a. Demographic data Information about a patient is collected during the course of receiving healthcare services. This includes demographic data used to identify an individual.

The HIPAA Security Awareness and Training administrative safeguard requires all of the following addressable implementation programs for an entity's workforce except: a. Disaster recovery plan b. Log-in monitoring c. Password management d. Security reminders

a. Disaster recovery plan Another administrative safeguard specification requires that a covered entity implement a security awareness and training program for all members of its workforce. Special protections must be taken to ensure information is not inappropriately released or accessed. These protections include log-in monitoring, password management, and security reminders.

The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue.

b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification.

Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an EHR? a. Make admission date a required field b. Provide a template for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data

b. Provide a template for entering data in the field Templates are a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date.

Who owns the health record? a. Patient b. Provider who generated the information c. Insurance company who paid for the care recorded in the record d. No one

b. Provider who generated the information Ownership of the health record has traditionally been granted to the provider who generates the record.

Which of the following has access to personally identifiable data without authorization or subpoena? a. Insurance company for life insurance eligibility b. Public health department for disease reporting purposes c. The patient's attorney d. Workers' compensation for disability claim settlement

b. Public health department for disease reporting purposes Covered entities may disclose PHI to public health entities even if the law does not specifically require the disclosure is for the purpose of preventing or controlling disease; injury; or disability; including, but not limited to, the reporting of disease; injury; vital events such as birth or death; and the conduct of public health surveillance.

At the time a hospital implemented an electronic health record, the Health Record Committee determined that all records of patients who have not been treated at the facility in the past two years would be moved to an inactive file area. These patient records are considered ________ from the active filing area. a. Inactivated b. Purged c. Cleared d. Reactivated

b. Purged Files of patients who have not been at the facility for a specified period, such as two years, may be purged or removed from the active filing area. The time period and frequency of purging depends on the space available, patient readmission rate, and the need for access to the health record.

Joan reviewed the health record of Sally Williams and found the physician stated on her post-op note, "examined after surgery." This review process would be an example of: a. Quantitative analysis b. Qualitative analysis c. Data mining d. Data warehousing

b. Qualitative analysis Qualitative analysis is a detailed review of a patient's health record for the quality of the documentation contained therein.

A patient's birth date and gender documented in the health record are examples of a data ________. a. Element b. Map c. Dictionary d. Definition

a. Element A data element can be a single or individual fact that represents the smallest unique subset of a larger database, sometimes referred to as the raw facts and figures.

Specific performance expectations, structures, and processes that provide detailed information and the intent for each of the Joint Commission standards are called: a. Elements of performance b. Fact sheets c. Ad hoc reports d. Registers

a. Elements of performance Within each chapter, the standards associated with each topic are cited and then elaborated upon with "elements of performance" (EP) that directly communicate the intent of the Joint Commission with respect to each standard. In addition, a scoring guideline is provided that allows the organization to score itself on each EP and thus get a sum total on each standard.

In this experimental study, blood pressure is taken before and after an experimental medication is used as the intervention in a sample of participants that were previously unable to control their blood pressure with other medications. In this example, the independent variable is the __________ and the dependent variable is the__________. a. Experimental medication; blood pressure b. Blood pressure; experimental medication c. Blood pressure; heart disease d. Experimental medication; heart disease

a. Experimental medication; blood pressure The independent variable in this example is the intervention used (medication) and the dependent variable is the disease that is being assessed (blood pressure).

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

a. Identification of the record as the one subpoenaed Original health records may be required by subpoena to be produced in person and the custodian of records is required to authenticate those records through testimony.

An electronic health record risk analysis is useful to: a. Identify security threats b. Identify which employees should have access to data c. Establish password controls d. Establish audit controls

a. Identify security threats Risk management begins by conducting a risk analysis. Identifying security threats or risks, determining how likely it is that any given threat may occur, and estimating the impact of an untoward event are all parts of a risk assessment.

Which of the following is an argument against the use of the copy and paste function in the EHR? a. Inability to identify the author b. Inability to print the data out c. The time that it takes to copy and paste the documentation d. The users will not know how to perform the copy and paste function

a. Inability to identify the author In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes the inability to identify the author of the documentation.

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

a. Knowing your objectives or purpose of the data analysis The first step in analyzing data is to know your objective or the purpose of the data analysis.

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of? a. Minimum necessary b. Notice of privacy practices c. Authorization d. Consent

a. Minimum necessary The Privacy Rule introduced the standard of minimum necessary to limit the amount of PHI used, disclosed, and requested. This means that healthcare providers and other covered entities must limit uses, disclosures, and requests to only the amount needed to accomplish the intended purpose. For example, for payment purposes, only the minimum amount of information necessary to substantiate a claim for payment should be disclosed.

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

a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. When other healthcare providers provide records, it is done to ensure the continuity of care for the individual. Many covered entities either include the whole file or copies of the file as part of the covered entity's record, with the assumption that the treating physician has used some or all of the records to decide how to treat the patient. Any copies that are included with the records of the individual are, therefore, considered part of the individual's designated record set and should be released.

The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond? a. Notice of privacy practices is required on the first provision of service. b. Notice of privacy practices is required every time the patient is provided service. c. Notice of privacy practices is only required for inpatient admissions. d. Notice of privacy practices is required on the first inpatient admission but for every outpatient encounter.

a. Notice of privacy practices is required on the first provision of service. A patient has a right to a notice of privacy practices as defined in the HIPAA Privacy Rule. A healthcare provider has to provide the notice no later than the first service delivery. After that first provision of service, there is no requirement to provide a notice every time a patient receives service.

The Breach Notification Rule requires covered entities to do which of the following: a. Notify affected individuals when a breach occurs b. Establish a policy on minimum necessary c. Provide each patient with a new notice of privacy practices d. Assign a new patient record number

a. Notify affected individuals when a breach occurs When a breach occurs, facilities must notify affected individuals. Facilities do not need to create a new health record number for each patient, provide a new copy of the Notice of Privacy Practices, or establish a policy on minimum necessary.

Which of the following is most likely to be used in performing an outpatient coding review? a. OCE b. MS-DRG c. CMI d. MDS

a. OCE The outpatient code editor (OCE) is a software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided.

Which of the following represents the required documentation elements needed to be included in a patient's health record when a surgical procedure is performed? a. Operative report, anesthesia report, recovery room report b. Discharge summary, anesthesia report, operative report c. Recovery room report, physical therapy notes, operative report d. Operative report, discharge summary, anesthesia report

a. Operative report, anesthesia report, recovery room report Any surgical procedure requires special documentation. The entire process is recorded with an anesthesia report, operative report, and recovery room report.

Amanda uploads her diet and fitness log from her smartwatch to her record. She also adds information about her previous medical history. What type of system is Amanda using? a. PHR b. CCR c. CPOE d. DMS

a. PHR The personal health record (PHR) is an electronic or paper health record maintained and updated by individuals that can be used to collect, track, and share past and current information about their health or the health of someone in their care. PHR information includes a wide range of data including allergies, diagnoses, medications, health status tracking (such as a diet, nutrition, and fitness activities, blood pressure or glucose monitoring), healthcare provider contact information, and social and family history.

A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst include in the database? a. Patient date of birth b. Name of attending physician c. Patient room number d. Admitting diagnosis

a. Patient date of birth In the context of healthcare, demographic information includes the following elements: patient's full name; patient's facility identification or account number; patient's address; patient's telephone number; patient's date and place of birth; patient's gender; patient's race or ethnic origin; patient's marital status; name and address of patient's next of kin; date and time of admission; hospital's name, address, and telephone number.

Which of the following contains the physician's findings based on an examination of the patient? a. Physical exam b. Discharge summary c. Medical history d. Patient instructions

a. Physical exam The physical examination report represents the attending physician's assessment of the patient's current health status. This report should document data on all the patient's major organ systems.

This individual assists in educating medical staff members on the documentation needed for accurate coding. a. Physician champion b. Compliance officer c. Chargemaster coordinator d. Data monitor

a. Physician champion The health information manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion. Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement.

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

a. Prospectively precertify the necessity of inpatient services Utilization controls include the prospective and retrospective review of the healthcare services planned for, or provided to, patients. For example, a prospective utilization review of a plan to hospitalize a patient for minor surgery might determine that surgery could be safely performed less expensively in an outpatient setting. Prospective utilization review—often called precertification—is done in managed fee-for-service reimbursement.

Which of the following is the principal goal of a corporate compliance program? a. Protect providers from sanctions or fines b. Increase revenues c. Improve patient care d. Limit unnecessary changes to the chargemaster

a. Protect providers from sanctions or fines Implementation of an effective corporate compliance program significantly reduces the risk of unlawful or improper conduct, criminal or civil liability, and the risk of a government audit, and also promotes an ethical organizational culture.

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed? a. Note the condition as present on admission. b. Query the physician to determine if the condition was present on admission. c. Note the condition as unknown on admission. d. Note the condition as not present on admission.

b. Query the physician to determine if the condition was present on admission. As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity.

Community Hospital has implemented an EHR and is no longer retaining paper health records. The hospital HIM department director has determined that the facility needs the file room space where the paper health records that are not yet eligible for destruction. The HIM director wants to move these health records to a remote storage location. The records will be stored in boxes and will be filed on open shelves at the remote location. Which of the following should be done so that record location can be easily identified in the remote storage area? a. Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier b. Prepare a sequential list of all records sent to remote storage c. Provide a unique box identifier and list the records by health record number on the outside of each box d. File the records in terminal digit order in each box

a. Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier An off-site storage company is usually a contracted service that provides long-term storage of health records. The off-site storage company must be able to return the records to the healthcare facility within a predetermined time. For easy record retrieval it would be important to have records labeled. Because the records are filed in boxes, each box needs a unique identifier so it can be located.

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

a. Provide the records in paper format only The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be provided in that format.

In healthcare, data sets serve two purposes. The first 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 Healthcare data sets have two purposes. The first is to identify the data elements that should be collected for each patient. The second is to provide uniform definitions for common terms. The use of uniform definitions ensures that data collected from a variety of healthcare settings will share a standard definition. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities.

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

a. Provides oversight for the development, review, and control of forms and computer screens Every healthcare facility should have a clinical forms committee to establish standards for design and to approve new and revised forms. The committee should also have oversight of computer screens and other data capture tools.

Community Hospital has a storage facility with older records that must be retained to meet retention laws and guidelines. The HIM professional has been tasked with removing health records from an associated clinic of patients who have not been treated for a specific period of time and sending those records to the storage area. This process is called: a. Purging records b. Assembling records c. Logging records d. Cycling records

a. Purging records Files of patients who have not been at the facility for a specified period, may be purged or removed and sent to the storage facility.

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

a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results This is an example of a circumstance in which the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS, and whether the COPD does is not clear.

The primary purpose of a data set in healthcare is to: a. Recommend common data elements to be collected in health records b. Mandate all data that must be contained in a health record c. Define reportable data for federally funded programs d. Standardize medical vocabulary

a. Recommend common data elements to be collected in health records A data set is a recommended list of data elements that have defined and uniformed definitions that are relevant for a particular use or are specific to a type of healthcare industry.

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

b. R07.9, Chest pain, unspecified Because this patient was seen only in the emergency department, he or she would be classified as an outpatient. Diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms in the outpatient setting indicate uncertainty and would not be coded as if existing. Rather, code the condition to the highest degree of certainty for that encounter or visit, such as signs, symptoms, abnormal test results, or other reason for the visit. In this case, unspecified chest pain would be coded.

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

b. Reasonable diligence Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements.

Which of the following can be used to develop a focused inpatient coding review? a. Controversial issues identified in CPT Assistant b. Recent data quality issues identified by external review agencies c. Analysis of HCPCS comparative data d. Top 25 APC groups by volume and charges

b. Recent data quality issues identified by external review agencies The HIM department can plan focused review based on specific problem areas after the initial baseline review has been completed.

In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. Because of unexpected complications; however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case? a. Request that the physician dictate an addendum to the discharge summary b. Have the record analyst note the date discrepancy c. Request that the physician dictate another discharge summary d. File the record as complete because the discharge summary includes all the pertinent patient information

a. Request that the physician dictate an addendum to the discharge summary If during record analysis, missing or incomplete information is identified, HIM personnel can issue deficiency notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a supplement to a signed report that provides additional health information within the health record. In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident.

If steps in a revenue cycle process are handled separately in sequence by individual workers, the method of organizing work is called which of the following? a. Serial work division b. Parallel work division c. Processing d. Benchmarking

a. Serial work division One of two major ways to organize process work is serial work division, assembly line fashion, where tasks or steps are handled separately in sequence by multiple individuals.

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

a. State retention requirements Health record retention policies depend on a number of factors. They must comply with state and federal statutes and regulations. Retention regulations vary by state and possibly by organization type. Health records should be retained for at least the period specified by the state's statute of limitations for malpractice, and other claims must be taken into consideration when determining the length of time to retain records as evidence.

A notation for a diabetic patient in a physician progress note reads: "Occasionally gets hungry. No insulin reactions. She says she is following her diabetic diet." In which part of a problem-oriented health record progress note would this be written? a. Subjective b. Objective c. Assessment d. Plan

a. Subjective Some providers also use a SOAP format for their problem-oriented progress notes. A subjective (S) entry relates significant information in the patient's words or from the patient's point of view.

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

a. Submit a certification of destruction in response to the subpoena If the paper health record is destroyed, the imaging record would be the legal health record. This may not be the case if the paper record is retained. State laws typically view the original health record as the legal record when it is available. Those who choose to destroy the original health record may do so within weeks, months, or years of scanning. If the record was destroyed according to guidelines for destruction and no scanned record exists, the certificate of destruction should be presented in lieu of the record.

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

a. The beneficial effects of a service for the patient's physical needs and quality of life Medical necessity is based on the effects of a service for the patient's physical needs and quality of life.

Why should the copy and paste function not be used in the electronic health record? a. The content may contain outdated information b. Joint Commission standards prevent this practice c. This feature is never found in the electronic health record d. Medicare has a regulation against this practice

a. The content may contain outdated information In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied and information can be outdated.

Which events must occur in order to maintain patient identity data integrity? a. The data must be accurately queried b. The data must be accurately analyzed c. The data must be accurately normalized d. The data must be accurately coded

a. The data must be accurately queried Maintenance of data integrity is a key aspect of data quality management. When it comes to patient identity and HIE, integrity is of prime importance to linking the patient to the correct information. Three events must occur in order to maintain patient identity data integrity. The data must be accurately collected, entered, and queried.

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

a. The employee and patient have the same last name With appropriate policies and procedures in place, it is the responsibility of the organization and its managers, directors, CSO, and employees with audit responsibilities to review access logs, audit trails, failed logins, and other reports. One type of event that would be a trigger event would include employees viewing records of patients with the same last name or address of the employee.

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

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

The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric; field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element? a. The field type should be changed to alphanumeric. b. The input mask should be changed from None to Required. c. The field length should be shortened. d. A default value should be Required.

a. The field type should be changed to alphanumeric. The data element PATIENT_LAST_NAME must be stored as alphanumeric data because the data are character-based.

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

a. The template was defined A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry.

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

b. Retention periods differ among healthcare facilities The HIM professional must consider multiple factors when developing health record retention policies that determine how long health records are to be kept. These factors include applicable federal and state statutes and regulations; accreditation standards; operational needs of the organization; and the type of organization, thus retention policies differ among healthcare facilities.

To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to ensure the history and physicals are present c. Retrospectively review each patient's health record to ensure the history and physicals are present d. Write a memorandum to all physicians relating the Joint Commission requirements for documenting history and physical examinations

b. Review each patient's health record concurrently to ensure the history and physicals are present. The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital.

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

b. Run chart A run chart displays data points over a period of time to provide information about performance. The measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time.

Which of the following technologies would reduce the risk that information is not accessible during a server crash? a. RAID b. Server redundancy c. Storage area network d. Tape or disk backup

b. Server redundancy As EHRs are being implemented without paper backup, contingency planning and disaster recovery is becoming increasingly important. Not only must a healthcare organization be able to replace data if a server or storage device is destroyed in some manner, but organizations need to be able to instantaneously failover to another server during a server crash. Back up of stored data has been routinely performed by most healthcare organizations. To reduce the risk of downtime, healthcare organizations now must also have server redundancy with server failover.

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

b. The diseases to be reported are established by state law. All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department.

When creating requirements of documentation for the hospital bylaws, which of the following should be evaluated? a. The personal preferences of the healthcare practitioner b. The documentation needs based on accrediting bodies c. Information taught in the local nursing programs d. The wants of the department chairs in a hospital

b. The documentation needs based on accrediting bodies Outside of the medical staff bylaws, hospital bylaws are written documents that govern the staff members who create data within the record for additional support of patient care and reimbursement. Since providers are not the sole authors in the creation of clinical documentation, it is important for hospitals to define who can document within the record, the type of documentation that can occur, and the timeliness and completeness of that documentation. The documentation must also be based on accrediting bodies' expectations.

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

b. The legal health record may contain metadata Organizations should develop and maintain an inventory of all documents and data that could comprise the legal health record, considering all locations in the organization (for example, separate departments or servers) where such information could be housed. Organizations should also carefully consider whether to include data such as pop-up reminders, alerts, and metadata. Metadata are data about data and include information that track actions such as when and by whom a document was accessed or changed.

Which of the following is a correct statement regarding DNR orders? a. A DNR is a form of advance directive and only requires the patient's desire for the withholding of care. b. The record should be clearly marked to indicate the presence of a DNR order. c. A DNR replaces the need for an advance directive since it is the ultimate in advance directive notifications. d. The Patient Self-Determination Act is federal so there are no differences in state law that need to be consulted.

b. The record should be clearly marked to indicate the presence of a DNR order. A do-not-resuscitate order is a physician's order documenting a patient's (or a substitute decision maker's) desire for no desired resuscitation attempts. Although a DNR order results from a desire expressed in an advanced directive, it does not replace the need for that directive. The health record should contain documentation indicating the presence of a DNR order.

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

b. The supervisor is kept informed of the employee's accomplishments Employee self-appraisal provides the opportunity for the employee to keep the supervisor informed of accomplishments and issues.

As the corporate director of HIM services and enterprise privacy officer, you are asked to review a patient's health record in preparation for a legal proceeding for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. Health information contains a summary of two procedures that were dictated 95 days after the procedure. The physician in question has a longstanding history of being lackadaisical with record completion practices. Previous concerns regarding this physician's record maintenance practices had been reported to the facility's Credentialing Committee. Is this information admissible in court? a. This information could be rejected because the physician dictated the procedure note after the malpractice suit was filed. b. This information will be admissible in court because it is part of the patient's health record. c. This information could be rejected because it is not relevant to the malpractice case. d. This information will be rejected because the patient did not authorize its release.

a. This information could be rejected because the physician dictated the procedure note after the malpractice suit was filed. The health record may be valuable evidence in a legal proceeding. To be admissible, the court must be confident that the record is: complete, accurate, and timely (recorded at the time the event occurred); was documented in the normal course of business; and was made by healthcare providers who have knowledge of the "acts, events, conditions, opinions, or diagnoses appearing in it".

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

a. To determine whether standards are being met In order to be granted and maintain accreditation, a healthcare organization must show compliance with the accrediting body standards. This frequently requires review of the health record to determine compliance with documentation and patient care standards.

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

a. Whether access by employees is appropriate In order to maintain patient privacy certain audits may need to be completed daily. If a high profile patient is currently in a facility, for example, access logs may need to be checked daily to determine whether all access to this patient's information by workforce is appropriate.

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

a. the National Health Information Network The National Health Information Network is a group of federal agencies and no-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

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

b. $39,375 Unbundling is the practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure code. In this situation, the penalty is the overpayment of the $75 for all 175 claims overpaid as well as 3 times the total amount of the overpayment (175 × $75 = $13,125 then; $13,125 × 3 = $39,375).

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? 49320 - Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662 - Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670 - Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 - Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320

b. 58670 No mention is made of biopsy, excision of lesion, or occlusion, so following proper steps for coding in CPT, the correct code is 58670.

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

b. 6 days The average length of stay is the mean length of stay of hospital inpatients discharged during a given period of time. Add the total days for each patient (for a total of 54 days) and divide by 9 patients = 6 days.

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

b. A married 15-year-old father Emancipated minors generally may authorize the access and disclosure of their own PHI. If the minor is married or previously married, the minor may authorize the disclosure or use of his or her information. If the minor is under the age of 18 and is the parent of a child, the minor may authorize the access and disclosures of his or her own information as well as that of his or her child.

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced.

b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice. The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is to not interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure, and therefore, allowed in the Privacy Rule.

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. A data set is a list of recommended data elements with uniform definitions that are relevant for a particular use. The contents of data sets vary by their purpose. However, data sets are not meant to limit the number of data elements that can be collected. Most healthcare organizations collect additional data elements that have meaning for their specific administrative and clinical operations. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities. A number of data reporting requirements come from federal initiatives.

A healthcare system wants to map ICD-10-CM to ICD-9-CM. Which of the following would be true about this effort? a. ICD-10-CM would be considered the target system b. This is an example of reverse mapping c. This is an example of forward mapping d. This is an example of bidirectional mapping

b. This is an example of reverse mapping A reverse map links two systems in the opposite direction, from the newer version of a code set to an older version.

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

b. Used by the organization to provide treatment Organizational policy should address how personal health information provided by the patient will or will not be incorporated into the patient's health record. Copies of personal health records (PHRs), created, owned, and managed by the patient, are considered part of the legal health record when the organization uses them to provide treatment; however, the PHR does not replace the legal health record.

The director of health information services is allowed access to the health record tracking system when providing the proper log-in and password. What is this access security mechanism called? a. Context based b. User-based c. Situation based d. Role based

b. User-based User-based access is a security mechanism that grants users of a system access based on their identity.

Which of the following elements of coding quality represent the degree to which codes accurately reflect the patient's diagnoses and procedures? a. Reliability b. Validity c. Completeness d. Timeliness

b. Validity Validity is the degree to which codes accurately reflect the patient's diagnoses and procedures.

Cancer registries are maintained by hospitals: a. By federal law or state law b. Voluntarily or by state law c. Voluntarily or by federal law d. By mandate from the American College of Surgeons

b. Voluntarily or by state law Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central state-wide registry or incidence surveillance program who in turn reports the data to the Centers for Disease Control (CDC).

The facility privacy officer receives a phone call from a patient who is concerned that her former sister-in-law who is a hospital employee has accessed her health record. The privacy officer requests an audit log of activity within the patient's health record. What part of the audit log must be analyzed to determine if this complaint has merit? a. The patient demographic information b. Which employees viewed, created, updated, or deleted information c. The ownership of the record d. Whether the patient had requested to be omitted from the facility patient directory

b. Which employees viewed, created, updated, or deleted information It is a requirement of the HIPAA Security Rule to implement ways that document access to information systems that contain electronic PHI. One of the ways to do this is to review the individuals that have viewed, created, updated, or deleted information within a health record. In this instance, the Privacy Officer should review this information to determine if the patient complaint is valid.

An HIM director is requesting the purchase of a document imaging system. However, the Hospital Budget Committee is reluctant to approve the request because of the expense. The committee thinks that the money is better spent implementing CPOE and other EHR applications. Which of the following might the HIM director use as a cost-benefit justification? a. The EHR system will take too long to implement. b. The Joint Commission requires that the hospital move to digital scanning. c. "Discharged, not final billed" and accounts receivable days can be improved because of workflow efficiencies. d. HIPAA requires the use of digital tracking of release of information.

c. "Discharged, not final billed" and accounts receivable days can be improved because of workflow efficiencies. Typical performance statistics maintained by the accounts receivable department include days in accounts receivable and aging of accounts. Facilities typically set performance goals for this standard. Understanding the workflow within a department is crucial for the supervisor in managing the departmental resources. To understand and control the workflow, the supervisor can perform a workflow analysis and then design the process to be more effective and efficient.

The HIM manager recently performed an audit of health record documentation in the EHR looking for reports that had been indexed incorrectly. The audit showed that for the 100 records reviewed there was a 4 percent error rate. Given that the national average labor cost of each misindexed report is $200, what is the labor cost for the department for handling these misindexed reports? a. $8,000 b. $500 c. $800 d. $500,000

c. $800 Indexing in the EHR can be checked by conducting a random audit. To conduct a study, a subsection of the EHR reports can be checked for mislabeled reports. Any mislabeled reports that are found are noted, and an accuracy rate can be determined and compared against the established standard. In this scenario, there was a 4 percent error rate for the 100 records in the sample. If the cost of each misfile is $200, this would cost the facility $800 (100 x 0.04) x $200= $800

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

c. 1 FTE The productivity increase with telecommuting is 20 percent. The facility has five coders who are currently coding a total of 100 charts a day. With this 20 percent increase, each of the existing five coders can code four records more per day each (a 20 percent increase). This amounts to 120 charts: 24 × 5 = 120. If the discharges increase by 44 charts, the facility would need one more FTE in the telecommuting staffing model, since each coder can code 24 records per day.

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

c. 18 The safe harbor method of deidentification requires the removal of 18 specific identifiers from the protect health information.

Given the information here, which of the following MS-DRGs would have the highest payment rate? MS-DRG / MDC / Type / MS-DRG Title / Weight / Discharges / Geometric Mean 191 / 04 / MED / Chronic obstructive pulmonary disease w CC / 0.9139 / 10 / 3.1 / 3.7 192 / 04 / MED / Chronic obstructive pulmonary disease w/o CC/MCC / 0.7241 / 20 / 2.5 / 3.0 193 / 04 / MED / Simple pneumonia & pleurisy w MCC / 1.3167 / 10 / 4.2 / 5.2 194 / 04 / MED / Simple pneumonia & pleurisy w CC / 0.9002 / 20 / 3.3 / 3.9 195 / 04 / MED / Simple pneumonia & pleurisy w/o CC/MCC / 0.6868 / 10 / 2.6 / 3.1 a. 191 b. 192 c. 193 d. 194

c. 193 MS-DRG 193 has the highest weight and therefore would have the highest payment

To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within ________ days. a. 10 b. 20 c. 30 d. 60

c. 30 A covered entity must act on an individual's request for review of PHI no later than 30 days after the request is made, extending the response period by no more than 30 additional days if it gave the individual a written statement within the 30-day time period explaining the reasons for the delay and the date by which the covered entity will complete its action on the request. The covered entity may extend the time for action on a request for access only once.

From the information provided, how many APCs would this patient have? Billing Number / Status Indicator / CPT/HCPCS / APC 998323 / V / 99285-25 / 0612 998323 / T / 25500 / 0044 998323 / X / 72050 / 0261 998323 / S / 72128 / 0283 998323 / S / 70450 / 0283 a. 1 b. 4 c. 5 d. Unable to determine

c. 5 Each HCPCS code is assigned to one and only one ambulatory payment classification (APC). The APC assignment for a procedure or services does not change based on the patient's medical condition or the severity of illness. There may be an unlimited number of APCs per encounter for a single patient. The number of APC assignments is based on the number of reimbursable procedures or services provided for that patient. In this instance, the patient has five APCs.

Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare: a. The full DRG amount, and Big Medical Center will receive a per diem rate for the three-day stay b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment c. The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the three-day stay d. No payment; Community Hospital must bill Big Medical Center a per diem rate for the twoday stay

b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment There are two types of transfer cases under the inpatient prospective payment system (IPPS). The first category is a patient transfer between two IPPS hospitals. A type 1 transfer is when a patient is discharged from an acute IPPS hospital (Community Hospital in this case) and is admitted to another acute IPPS hospital (Big Medical Center) on the same day. Payment is altered for the transferring hospital and is based on a per diem rate methodology. The transferring facility receives double the per diem rate for the first day plus the per diem rate for each day thereafter for the patient LOS. The receiving facility receives the full PPS payment rate for the case.

Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security? a. Access controls b. Administrative safeguards c. Audit safeguards d. Role-based controls

b. Administrative safeguards Administrative safeguards include policies and procedures that address the management of computer resources. For example, one such policy might direct users to log off the computer system when they are not using it or employ automatic logoffs after a period of inactivity.

General documentation guidelines apply to: a. Only electronic health records b. All categories of health records c. All emergency health records d. Only paper-based health records

b. All categories of health records General documentation guidelines apply to all categories of health records.

Under HIPAA regulations, how many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHI is stored off-site? a. 10 days beyond the original requirement b. 30 days c. 60 days d. 90 days

c. 60 days A covered entity must act on an individual's request for review of protected health information (PHI) no later than 30 days after the request is made, extending the response period by no more than 30 additional days if it gave the individual a written statement within the 30-day time period explaining the reasons for the delay and the date by which the covered entity will complete its action on the request. The covered entity may extend the time for action on a request for access only once. If PHI is not maintained or located on-site, the covered entity is given within 60 days of receipt to respond to a request.

Which of the following laws created the HITECH act? a. Health Insurance Portability and Accountability Act b. American Recovery and Reinvestment Act c. Consolidated Omnibus Budget Reconciliation Act d. Healthcare Quality Improvement Act

b. American Recovery and Reinvestment Act The American Recovery and Reinvestment Act of 2009 (ARRA) is considered one of the major health information technology laws that provided stimulus funds to the US economy in the midst of a major economic downturn. A substantial portion of the bill, Title XIII of the Act entitled the Health Information Technology for Economic and Clinical Health (HITECH) Act, was part of ARRA.

Which of the following is a software program that tracks every access to data in the computer system? a. Access control b. Audit trail c. Edit check d. Risk assessment

b. Audit trail The audit trail is a software program that tracks every single access to data in the computer system. It logs the name of the individual who accessed the data, the date and time, and the action taken (for example, modifying, reading, or deleting data). Review of audit trails can help detect whether a breach of security has occurred.

Which of the following ethical principles is being followed when a health information management professional ensures that patient information is only released to those who have a legal right to access it? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

b. Beneficence Beneficence would require the HIM professional to ensure that the information is released only to individuals who need it to do something that will benefit the patient (for example, to an insurance company for payment of a claim).

Which of the following is considered a secondary data source? a. Urinalysis laboratory report b. Cancer registry c. Pathology report d. Patient problem list

b. Cancer registry Secondary data sources are data collected or extracted from a primary data source and used for purposes other than their original intended use. Secondary data sources are frequently maintained in registries, databases or indexes, such a cancer registry.

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

b. Chargemaster description One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description for accuracy.

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

b. Chargemaster description and medical necessity An auditing process identifies risk areas such as chargemaster description, medical necessity, MS-DRG coding accuracy, variations in case mix, and the like. Admission diagnosis and complaints, clinical laboratory results, and radiology orders are not risk areas that should be targeted for audit.

In planning a compliance training session, you want to allow adult learners the flexibility to proceed at their own pace. Which would be the best choice among the following training methods? a. On-the-job training b. Computer-based c. Classroom lecture d. Seminar with break-out groups

b. Computer-based Computer-based training is a form of self-directed learning, an approach that allows learners to control their own education at their own pace.

Which of the following best describes the function of kiosks? a. A computer station that physicians can use to order medications b. A computer station that unlocks workstations c. A computer station that facilitates integrated communications within the healthcare organization d. A computer station that promotes the healthcare organization's services

c. A computer station that facilitates integrated communications within the healthcare organization A kiosk is a special form of input device geared to people less familiar with computers that is located in a provider's waiting room allowing patients to have access to some of their health information and other services.

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

b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices A coding manager or physician champion should present documentation issues to educate the medical staff. General areas of concern regarding documentation should be included.

Which of the following is an organization's planned response to protect its information in the case of a natural disaster? a. Administrative controls b. Contingency plan c. Audit trail d. Physical controls

b. Contingency plan Disaster planning occurs through a contingency plan—a set of procedures, documented by the organization to be followed when responding to emergencies. It encompasses what an organization and its personnel need to do both during and after events that limit or prevent access to facilities and patient information.

A core data set developed by ASTM to communicate a patient's past and current health information as the patient transitions from one care setting to another is: a. Ambulatory Care Data Set b. Continuity of care record c. Minimum Data Set d. Uniform Hospital Discharge Data Set

b. Continuity of care record The continuity of care record (CCR) standard (ASTM E2369-05) is a core data set of relevant administrative, demographic, and clinical information elements about a patient's health status and healthcare treatment. It was created to help communicate that information from one provider to another for referral, transfer, or discharge of the patient.

What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system? a. Administrator of records b. Custodian of records c. Director of records d. Supervisor of records

b. Custodian of records Associated with ownership of health records is the legal concept of the custodian of records. The custodian of health records is the individual who has been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records.

Performance monitoring is data driven and the HIM department needs access to data in order to make important decisions. One way to provide real-time data and important information that can be monitored at a glance is to use which of the following? a. Benchmark b. Dashboards c. Pareto chart d. Time ladder

b. Dashboards Performance monitoring is data driven. The organization's leadership uses the information displayed on the dashboard to guide operations and determine improvement projects. Having real-time data in an easily assessable format like a dashboard allows leaders to keep track of high-impact, high-risk, or high-value processes and make adjustments on a daily basis if needed.

Which of the following best describes data accessibility? a. Data are correct. b. Data are easy to obtain. c. Data include all required elements. d. Data are reliable.

b. Data are easy to obtain. Data accessibility means that the data are obtainable. Any organization that maintains health records for individual patients must have systems in place that identify each patient and support efficient access to information on each patient. Authorized users of the health record must be able to access information easily when and where they need it.

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

b. Data consistency Consistency means ensuring the patient data is reliable and the same across the entire patient encounter. In other words, patient data within the record should be the same and should not contradict other data also in the patient record.

The protection measures and tools for safeguarding information and information systems is a definition of: a. Confidentiality b. Data security c. Informational privacy d. Informational access control

b. Data security Data security can be defined as the protection measures and tools for safeguarding information and information systems.

Which of the following is the best example of a data governance business case? a. Improves processes and productivity by reducing rework b. Data silos and fragmented data inhibit data integration c. Reduces organizational risk by providing better data d. Improves business intelligence by providing consistent data

b. Data silos and fragmented data inhibit data integration The case for data governance is compelling if we look at the degree to which business processes are dependent on access to good data. The best example for a data governance business case is data in silos or fragmented data which inhibit data integration.

The evaluation of data collected based on business needs and strategy is part of ________. a. Data ownership b. Data stewardship c. Data quality d. Data modeling

b. Data stewardship Data stewardship is the evaluation of the data collection based on business need and strategy to ensure the data meets the requirements of patient care and organizational needs. Data stewardship and data ownership are closely connected.

Which of the following would be a discriminating attribute used to disqualify two or more similar records? a. Phone number b. Date of birth c. E-mail address d. Last name

b. Date of birth Discriminating attributes are used to disqualify two or more similar records, rather than match them. These should be static attributes that do not normally change such as date of birth.

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

b. Delinquent record When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards.

Which of the following describes incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies? a. Suspended records b. Delinquent records c. Loose records d. Default records

b. Delinquent records Physicians and other practitioners are notified when they have incomplete health records requiring their attention. If a health record remains incomplete for a specified number of days, as defined in the medical staff rules and regulations, the record is considered to be a delinquent record.

Community Hospital is planning implementation of various elements of the EHR in the next six months. Physicians have requested the ability to access the EHR from their offices and from home. What advice should the HIM director provide? a. HIPAA regulations do not allow this type of access. b. This access would be covered under the release of PHI for treatment purposes and poses no security or confidentiality threats. c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. d. Access can be permitted because the physicians are on the medical staff of the hospital and are covered by HIPAA as employees.

c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. The HIPAA Privacy Rule permits healthcare providers to access protected health information for treatment purposes. However, there is also a requirement that the covered entity provide reasonable safeguards to protect the information. These requirements are not easy to meet when the access is from an unsecured location, although policies, medical staff bylaws, confidentiality or other agreements, and a careful use of new technology can mitigate some risks.

City Hospital has implemented a procedure that allows inpatients to decide whether they want to be listed in the hospital's directory. The directory information includes the patient's name, location in the hospital, and general condition. If a patient elects to be in the directory, this information is used to inform callers who know the patient's name. Some patients have requested that they be listed in the directory, but information is to be released to only a list of specific people the patient provides. A hospital committee is considering changing the policy to accommodate these types of patients. In this case, what type of advice should the HIM director provide? a. Approve the requests because this is a patient right under HIPAA regulations. b. Deny these requests because screening of calls is difficult to manage and if information is given in error, this would be considered a violation of HIPAA. c. Develop two different types of directories—one directory for provision of all information and one directory for provision of information to selected friends and family of the patient. d. Deny these requests and seek approval from the Office for Civil Rights.

b. Deny these requests because screening of calls is difficult to manage and if information is given in error, this would be considered a violation of HIPAA. The HIPAA Privacy Rule allows individuals to decide whether they want to be listed in a facility directory when they are admitted to a facility. If the patient decides to be listed in the facility directory, the patient should be informed that only callers who know his or her name will be given any of this limited information. Covered entities generally do not, however, have to provide screening of visitors or calls for patients because such an activity is too difficult to manage with the number of employees and volunteers involved in the process of forwarding calls and directing visitors. If the covered entity agreed to the screening and could not meet the agreement, it could be considered a violation of this standard of the Privacy Rule.

Burning, shredding, pulping, and pulverizing are all acceptable methods in which process? a. Deidentification of electronic documents b. Destruction of paper-based health records c. Deidentification of records stored on microfilm d. Destruction of computer-based health records

b. Destruction of paper-based health records Because of cost and space limitations, permanently storing paper and microfilm-based health record documents is not an option for most hospitals. Acceptable destruction methods for paper documents include burning, shredding, pulping, and pulverizing.

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

b. Determine whether there was a medical or other reason why patients were not given aspirin Patient care outcomes are reviewed to improve the safety and quality of care as well as to identify issues related to medical necessity for treatment and appropriateness of care. Accrediting and licensing entities expect that healthcare organizations will choose appropriate measures for the services they offer. In this situation is it important to determine whether there was a medical or other reason why patients b. Determine whether there was a medical or other reason why patients were not given aspirin Patient care outcomes are reviewed to improve the safety and quality of care as well as to identify issues related to medical necessity for treatment and appropriateness of care. Accrediting and licensing entities expect that healthcare organizations will choose appropriate measures for the services they offer. In this situation is it important to determine whether there was a medical or other reason why patients were not given aspirin within 24 hours of arrival at the hospital. This determination is critical to assess compliance with the quality goal.were not given aspirin within 24 hours of arrival at the hospital. This determination is critical to assess compliance with the quality goal.

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. To remedy this situation, the HIM director should recommend which of the following? a. Immediately stop the practice of changing transcribed reports b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form c. Conduct a verification audit d. Alert hospital legal counsel of the practice

b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form An example of unethical documentation in healthcare is retrospective documentation—when healthcare providers add documentation after care has been given, possibly for the purpose of increasing reimbursement or avoiding a medical legal action. The HIM professional is responsible for maintaining accurate and complete records and is able to identify the occurrence and either correct the error or indicate that the entry is a late entry into the health record.

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

b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record as the first step in determining the components of the legal health records.

A newborn is treated for pulmonary valve stenosis, with stretching of the valve opening accomplished via a percutaneous balloon pulmonary valvuloplasty. In ICD-10-PCS, what root operation would be coded for this procedure? a. Alteration b. Dilation c. Repair d. Restriction

b. Dilation Though the term valvuloplasty in the index leads to Repair, Replacement, or Supplement, this procedure was performed as a percutaneous Dilation. The root operation Dilation is expanding an orifice or the lumen of a tubular body part.

The attending physician is responsible for which of the following types of acute-care documentation? a. Consultation report b. Discharge summary c. Laboratory report d. Pathology report

b. Discharge summary The discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged (officially released) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or his or her caregiver at the time of discharge. It provides an overview of the entire health encounter. The discharge summary is the responsibility of, and must be signed by, the attending physician.

What is the function of a consultation report? a. Provides a chronological summary of the patient's medical history and illness b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care c. Concisely summarizes the patient's treatment and stay in the hospital d. Documents the physician's instructions to other parties involved in providing care to a patient

b. Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The consultation is requested by the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record.

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

b. Drop-down menus Structured data are data that are able to be read and interpreted by a computer. Examples of structured data include check boxes, drop-down boxes, and radio buttons.

A transition technology used by many hospitals to increase access to health record content is: a. Electronic health record b. Electronic document management system c. Electronic signature authentication d. Electronic data interchange

b. Electronic document management system When electronic document management systems (EDMSs) are well indexed, certain content within the documents can be uniquely retrieved making EDMS a good transition for the healthcare organization on their way to a fully interactive EHR.

Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient? a. Ambulatory care b. Emergency care c. Long-term care d. Rehabilitative care

b. Emergency care The emergency department record is a health record that is generated when a patient visits an emergency department (ED) seeking treatment. Documentation in the emergency department records includes the means by which the patient arrived at the healthcare facility and documentation of care provided to stabilize the patient.

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

b. Evaluate patterns and trends of patient care Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place.

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation

b. Extirpation The root operation extirpation is defined as taking or cutting out solid material from a body part. The matter may have been broken into pieces during the lithotripsy previous to this encounter, but at this time the pieces of the calculus are being removed.

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

b. Fishbone diagram A cause-and-effect diagram, also known as a fishbone diagram because of its characteristic fish shape, is an investigation technique that facilitates the identification of the various factors that contribute to a problem. It facilitates root-cause analysis, in order to determine the cause of the problem.

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

b. Focused audit Focused selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-risk areas or other areas of specific concern, such as a focused audit of cases with no CC/MCC to determine why the case-mix is dropped.

A pharmacist who submits Medicaid claims for reimbursement on brand name drugs when less expensive generic drugs were dispensed has committed the crime of: a. Criminal negligence b. Fraud c. Perjury d. Products' liability

b. Fraud Fraud in healthcare is defined as a deliberate false representation of fact, a failure to disclose a fact that is material (relevant) to a healthcare transaction, damage to another party that reasonably relies on the misrepresentation, or failure to disclose.

Which of the following provide the objective and scope for the HIPAA Security Rule as a whole? a. Administrative provisions b. General rules c. Physical safeguards d. Technical safeguards

b. General rules The General Rules provide the objective and scope for the HIPAA Security Rule as a whole. They specify that covered entities must develop a security program that includes a range of security safeguards that protect individually identifiable health information maintained or transmitted in electronic form.

An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: a. Consistency b. Granularity c. Comprehensiveness d. Relevancy

b. Granularity Data granularity requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data.

When meeting with the HIM professional during an on-site review, the surveyor would be looking for what type of information? a. Written policies and procedures on document imaging b. HIM department's success in documentation compliance c. Document type matrix d. Attendance policy

b. HIM department's success in documentation compliance An on-site review by experienced surveyor from the accrediting organization would meet with the HIM leader to review their written policies and procedures and ask for some examples of the HIM department's successes in areas of quality improvement and patient safety. The type of successes the surveyor would be looking for might be that the signing, dating, and timing of physician verbal orders went from 95 percent compliance to 99 percent. Another success would be the reduction of duplicate or overlaid medical record numbers (MRN).

Which of the following is not an individual user of the health record? a. Clinical professionals who provide direct patient care b. Insurance companies that cover healthcare expenses c. Billers in the healthcare facility's business office d. Patient care managers

b. Insurance companies that cover healthcare expenses Individual users are those who depend on the health record in order to complete their job. Documentation in the health record is the basis for reimbursement or payment for the care provided. Patient care providers and the coding and billing staff use patient specific information in their day-to-day work. An insurance company would be considered an institutional user of the health record and only needs access to process the claim.

Which of the following refers to guarding against improper information modification or destruction? a. Confidentiality b. Integrity c. Privacy d. Security

b. Integrity Data integrity means that data should be complete, accurate, consistent, and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules.

The three elements of a security program are ensuring data availability, protection, and: a. Suitability b. Integrity c. Flexibility d. Robustness

b. Integrity Data security embodies three basic concepts: protecting the privacy of data, ensuring the integrity of data, ensuring the availability of data.

The ability to electronically send data from one information system to another while maintaining the original meaning is called: a. Data comparability b. Interoperability c. National data exchange d. Data architecture

b. Interoperability Interoperability refers to the use of standard protocols to enable two different computer systems to share data with each other.

In a cancer registry, the accession number: a. Identifies all the cases of cancer treated in a given year b. Is the number assigned to each case as it is entered into a cancer registry c. Identifies the pathologic diagnosis of an individual cancer d. Is the number assigned for the diagnosis of a cancer patient that is entered into the cancer registry treatments and at different stages of cancer

b. Is the number assigned to each case as it is entered into a cancer registry When a case is first entered in the registry, an accession number is assigned. This number consists of the first digits of the year the patient was first seen at the facility, and the remaining digits are assigned sequentially throughout the year. The first case in the year, for example, might be 10-0001. The accession number may be assigned manually or by the automated cancer database used by the organization.

Which of the following statements is NOT true about a business associate agreement? a. It prohibits the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity. b. It allows the business associate to maintain PHI indefinitely. c. It prohibits the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule. d. It requires the business associate to make available all of its books and records relating to PHI use and disclosure to the Department of Health and Human Services or its agents.

b. It allows the business associate to maintain PHI indefinitely. Agreements between the covered entity and a business associate include: requiring the business associate to make available all of its books and records relating to protected health information (PHI) use and disclosure to the Department of Health and Human Services or its agent; prohibiting the business associate from using or disclosing PHI in any way that would violate the HIPAA Privacy Rule; and prohibiting the business associate from using or disclosing PHI for any purpose other than that described in the contract with the covered entity; and other agreements. But it does not allow the business associate to maintain PHI indefinitely.

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? a. Autopsy report b. Laboratory findings c. Pathology report d. Surgical report

b. Laboratory findings The results of all diagnostic and therapeutic procedures become part of the patient's health record. Diagnostic procedures include laboratory tests performed on blood, urine, and other samples from the patient which would be documented in the laboratory findings.

Which of the following is the best definition of a forward map in data mapping? a. Linking of two systems in the opposite direction b. Linking an older version of a code set to a newer version c. Linking a newer version of a code set to an older version d. Linking a source system to a target system

b. Linking an older version of a code set to a newer version In a forward map, an older version of a code set is mapped to a newer version.

An RAI/MDS and care plan are found in records of patients in what setting? a. Home healthcare b. Long-term care c. Behavioral healthcare d. Rehabilitative care

b. Long-term care The long-term care health record contains the patient's registration forms, personal property list, RAI/MDS, care plan and discharge or transfer information.

Patient is admitted with prepatellar bursitis following a crushing injury to the left knee as a result of being hit by a car two years ago. What diagnosis codes would be assigned for this patient? M70.40 Prepatellar bursitis, unspecified knee M70.42 Prepatellar bursitis, left knee S87.02xA Crushing injury of left knee, initial encounter S87.02xD Crushing injury of left knee, subsequent encounter S87.02xS Crushing injury of left knee, sequela a. M70.40, S87.02xA b. M70.42, S87.02xS c. M70.42, S87.02xD d. M70.40, S87.02xS

b. M70.42, S87.02xS The bursitis was the result of the previous crush injury and should be coded as sequela with the seventh character coded as "S" for sequela. The code for the left knee is also used to identify laterality.

Which of the following indexes is an important source of patient health record numbers? a. Physician index b. Master patient index c. Operation index d. Disease index

b. Master patient index The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information.

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

b. Master patient index (MPI) The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information.

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

b. Medical history A complete medical history documents the patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician.

Under Outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Mr. Smith had a minor procedure performed in the hospital outpatient department at a charge of $85. In addition, Mr. Smith has paid his deductible for the year. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case? A. $15 B. $17 C. $68 D. $85

$15 Coinsurance refers to the amount the insured pays as a requirement of the insurance policy. The coinsurance amount is $85 x 0.20 = $17. A $15 copay is lower than the 20 percent ($17) coinsurance.

The HIM department at Community Hospital has three full time coders. One is considered the lead coder and his salary is $20.35 per hour. One coder is a new graduate who makes $15.50 per hour and the third coder is an experienced employee who earns $18.90 per hour. The lead coder codes four records per hour; the new coder codes three records per hour and their experienced coder codes six records per hour. Using a 7.5 hour productive day, what is the unit cost for the lead coder? A. $3.36 per record B. $4.49 per record C. $5.43 per record D. $5.51 per record

$5.43 per record The lead coder's annual salary is $20.35 x 2,080 (hours per year) = 42,328. The lead Coder's productivity is 7.5 hours per day x 4 records per hour = 30 records per day. 30 records per day x 5 days a week x 52 weeks per year = 7,800 records per year. Yearly salary of $42,328 / 7,800 records per year = $2.556 = $5.43 per record.

The HIM department at Community Hospital has three full time coders. One is considered the lead coder and his salary is $20.35 per hour. One coder is a new graduate who makes $15.50 per hour and the third coder is an experienced employee who earns $18.90 per hour. The lead coder codes four records per hour; the new coder codes three records per hour and their experienced coder codes six records per hour. Using a 7.5 hour productive day, what is the unit cost for the new graduate coder? A. $3.36 per record B. $4.49 per record C. $5.43 per record D. $5.51 per record

$5.51 per record The new graduate coder's salary is $15.50 x 2,080 (hours per year) = 32,240. Productivity is 7.5 hours per day x 3 records per hour = 22.5 records per day. 22.5 records x 5 days per week x 52 weeks per year = 5,850 records per year. $32,240 / 5,850 = $5.51 per record.

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

b. Medical necessity Local coverage determination (LCD) is used to determine coverage on a Medicare Administrative Contractor-wide, intermediary-wide, or carrier-wide basis (rather than nationwide, as with a NCD). LCDs are educational materials that assist facilities and providers with correct billing and claims processing. Within the LCD is a listing of ICD-10-CM codes that indicate what is covered and what is not covered. For example, a procedure may be covered by Medicare, but is not reimbursed by Medicare because it does not meet medical necessity.

Identify the two-digit modifier that may be reported to indicate a physician performed the postoperative management of a patient but another physician performed the surgical procedure. A. -22, Increased procedural services B. -54, Surgical care only C. -32, Mandated service D. -55, Postoperative management only

-55, Postoperative management only Modifiers are appended to the code to provide more information or alert the payer that a payment change is required. Modifier - 55 is used to identify that the physician provided only postoperative care services for a particular procedure.

The credentialing process of independent practitioners within a healthcare organization must be defined in: a. Hospital policies and procedures b. Medical staff bylaws c. Accreditation regulations d. Hospital licensure rules

b. Medical staff bylaws The credentialing and privileging process for the initial appointment and reappointment of independent practitioners should be defined in the healthcare organization's medical staff bylaws and should be uniformly applied.

In the community clinic Dr. Simpson, an interventional cardiologist, saw 270 patients last quarter. Of those, he performed stent procedures on 182 patients and angioplasty procedures on 88 patients. What is the proportion of Dr. Simpson's patients who have had stent procedures? A. 0.67 B. 0.45 C. 0.33 D. Unable to determine

0.67 A proportion is a type of ratio in which x is a portion of the whole (x+y). In a proportion, the numerator is always included in the denominator. 182 / 270 = 0.67.

At Community Hospital, each full-time employee is required to work 2,080 hours annually. The table below shows the amount of time that five employees were absent from work over the past year. ***Graph is needed to answer Q 30.*** What is the total sick leave rate for this group of employees for the year? A. 0.29% B. 0.98% C. 1.29% D. 1.54%

0.98% A ratio is a ration in which there is a distinct relationship between the numerator and denominator and the denominator often implies a large base population. Add each employee's sick leave hours together to get a total of 102. Multiplying 2,080 (full-time equivalent) by 5 (number of employees) equals 10,400. Take the total sick leave hours (102) and multiply by 100, then divide it by the total hours for the 5 full time employees (10,400). Calculations: (6 + 16 + 8 + 32 + 40) = 102 hours total sick leave time; (2,080 x 5) = 10,400 total hours for the 5 coders; (102 x 100)/10,400 = 10,200/10,400 = 0.98% total sick leave rate.

Dr. Green discharged 30 patients from Medicine Service during the month of August. The table above presents the number of patients discharged by MS-DRG. Calculate the CMI for Dr. Green. ***Graph is needed to answer Q 9.*** A. 32.219 B. 30 C. 1.074 D. 2.3055

1.074 When calculating case-mix using MS-DRGs, the case-mix (CMI) is the average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group in a relation to the other groups in the classification system. The calculation for this data set is 32.219/30 = 1.074.

Given the information here, how much of the APC payment would the facility receive for the status T procedure? ***Graph is needed to answer Q 30.*** A. 0% B. 50% C. 75% D. 100%

100% Code T for APC 0044 designates that the APC payment is subject to payment reduction when multiple procedures are performed during the same visit. In the case, there were no additional procedures so the status indicator does not affect payment. If both CPT codes have a 'T' status indicator, the one with the highest relative weight will be paid at 100% APC payment. Any additional procedures with a status indicator 'T' will be discounted 50% of their APC payment. Remember that with status indicator 'T', there is no limit the number of CPT codes that you can report, as long as you follow CPT rules and guidelines and include complete medical record documentation.

Mr. Jones was admitted to the hospital on March 21 and discharged on April 1. What was the length of stay for Mr. Jones? A. 5 days B. 10 days C. 11 days D. 15 days

11 days Length of stay (LOS) is calculated for each patient after he or she is discharged from the hospital. It is the number of calendar days from the day of patient admission to the day of discharge (31-21)+1=11 days.

In a frequency distribution, the lowest value is 5, and the highest value is 20. What is the range? A. 5 to 20 B. 15 C. 7.5 D. 20 to 5

15 The range is the simplest measure of spread. It is difference between the smallest and largest values in a frequency distribution. 20-5=15

Which of the following would be an indicator of process problems in a health information department? A. 5% decline in the number of patients who indicate satisfaction with hospital care B. 10% increase in the average length of stay C. 15% reduction in bed turnover rate D. 18% error rate on abstracting data

18% error rate on abstracting data Performance measurement compares work outcome to the established performance standards and results are typically expressed in quantifiable terms, such as rates. An 18% error rate on abstracting data would be indicative of a process problem in the HIM department. The other three options are process problems for other areas of the hospital.

What is the mean for the following frequency distribution: 10, 15, 20, 25, 25? A. 47.5 B. 20 C. 19 D. 95

19 The mean is the arithmetic average of frequency distribution. Put simply, it is the sum of all the values in a frequency distribution divided by the frequency: (10 + 15 + 20 + 25 + 25) / 5 = 19.

Using the information in the table below, calculate the C-section rate at University Hospital for the semiannual period. ***Graph is needed to answer Q 49.*** A. 15.03% B. 19.24% C. 20.04% D. 25.06%

20.04% C-section rate: (101 x 100) / 504 = 10,100/504 = 20.039=20.04%.

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the mode? A. 30 B. 32 C. 32.5 D. 35

30 The mode is the simplest measure of central tendency. It is used to indicate the most frequent observation in a frequency distribution. The most frequent observation is 30.

The patient was admitted to the outpatient department and had a bronchoscopy with bronchial brushings performed. What is the appropriate code assignment? ***Graph is needed to answer Q 53.*** A. 31622, 31640 B. 31622, 31623 C. 31623 D. 31625

31623 A bronchoscopy with brushings and washings is considered a diagnostic bronchoscopy and not a biopsy. Code 31623 specifies brushings, and 31622 is selected for washings.

Assign the correct CPT code for the following procedure: Revision of the pacemaker skin pocket. A. 33223, Relocation of skin pocket for implantable defibrillator B. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) C. 33212, Insertion of pacemaker pulse generator only; with exsisting single lead D. 33222, Relocation of skin pocket for pacemaker

33222, Relocation of skin pocket for pacemaker Begin with the main term Revision; pacemaker site; chest.

On October 1st, a hurricane hit a small coastal community, which has a community hospital licensed for 50 beds and two treatment room beds in order to help take care of patients. Which of the following would be the denominator used to determine the percentage of occupancy for October 1st? A. 50 B. 60 C. 63 D. 65

50 A bed count, also called an inpatient bed count, is the number of available hospital inpatient beds, both occupied and vacant, on any given day. Temporary beds are not included in the bed count for percentage of occupancy.

A patient who has been diagnosed with hypertension visits her physician on a monthly basis. The nurse conducted the blood pressure check under the physician's supervision. Code the office visit. A. 99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. B. 99201, Office or other outpaqtient visit for the evaluation and management of a new patient, which requires these three key components: problem focused history and examination, straightforward medical decision. C. 99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: detailed history and examination, low complexity medical decision. D. 99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: problem focused history and examination, straightforward medical decision.

99211, Office or other outpatient visit of the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional. For established patients, the requirements differ depending on the level of service. Code 99211 does not require a history, examination, medical decision making, or presence of a physician.

Mrs. Bolton is an angry patient who resents her physicians "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is: a. Mean b. Noncompliant and hostile toward staff c. Belligerent and out of line d. A pain in the neck

b. Noncompliant and hostile toward staff When entries are made in the health record regarding a patient who is particularly hostile or irritable, general documentation principles apply, such as charting objective facts and avoiding the use of personal opinions, particularly those that are critical of the patient. The degree to which these general principles apply is heightened because a disagreeable patient may cause a provider to use more expressive and inappropriate language. Further, a hostile patient may be more likely to file legal action in the future if the hostility is a personal attribute and not simply a manifestation of his or her medical condition.

An HIM technician is paid an hourly rate and is eligible for overtime pay, consistent with the Fair Labor Standards Act. Her position would be classified as which of the following? a. Exempt b. Nonexempt c. Full-time d. Professional

b. Nonexempt Nonexempt employees are covered by FLSA overtime provisions; this includes hourly-paid jobs.

A group practice has hired an HIT as its chief compliance officer. The current compliance program includes written standards of conduct and policies, and procedures that address specific areas of potential fraud. It also has audits in place to monitor compliance. Which of the following should the compliance officer also ensure are in place? A. A bonus program for coders who code charts with higher paying MS-DRGs B. A hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation C. Procedures to adequately identify individuals who make complaints so that appropriate follow-up can be conducted D. A corporate compliance committee that reports directly to CFO

A hotline to receive complaints and adoption of procedures to protect whistleblowers from retaliation The OIG has outlined seven elements as the minimum necessary for a comprehensive compliance program. One of the seven elements is the maintenance of a process, such as a hotline, to receive complaints and the adoption of procedures to protect the anonymity of complaints and to protect whistleblowers from retaliation.

All of the following are steps in medical necessity and utilization review, except: A. Initial clinical review B. Peer clinical review C. Access consideration D. Appeals consideration

Access consideration The three steps in medical necessity and utilization review are: clinical review, peer review, and appeals consideration.

The patient was admitted with nausea, vomiting, and abdominal pain. The physician documents the following on the discharge summary: acute cholecystitis, nausea, vomiting, and abdominal pain. Which of the following would be the correct coding and sequencing for this case? A. Acute cholecystitis, nausea, vomiting, abdominal pain B. Abdominal pain, vomiting, nausea, acute cholecystitis C. Nausea, vomiting, abdominal pain D. Acute cholecystitis

Acute cholecystitis Signs and symptoms integral to the disease process should not be coded. In this case the nausea, vomiting, and abdominal pain are integral to the acute cholecystitis.

A comprehensive retrospective review should be conducted at least once a year of what aspect of the clinical documentation improvement program? A. Proficiency statistics B. Compliance issues C. All query opportunities D. Core key measures

All query opportunities A standard should be set that all query opportunities within a CDI program should undergo comprehensive review retrospectively at least once a year.

Per the Fair and Accurate Credit Transactions Act (FACTA), which of the following is not a red flag category? A. An account held by a person who is over 80 years old B. Warnings from a consumer-reporting agency C. Unusual activity relating to a covered account D. Suspicious documents

An account help by a person who is over 80 years old The federal Fair and Accurate Credit Transactions Act (FACTA) requires financial institutions and creditors to develop and implement written identity theft programs that identify, detect, and respond to red flags that may signal the presence of identity theft. There are five categories of red flags that are used as triggers to alert the organization to a potential identity theft (16 CFR Part 681). The categories are: Alerts, notifications, or warnings from a consumer reporting agency; Suspicious documents; Suspicious personally identifying information such as a suspicious address; Unusual use of , or suspicious activity relating to, a covered account; Notices from customers, victims of identity theft, law enforcement authorities, or other businesses about possible identity theft in connection with an account.

Calling out patient names in a physician's office is: A. An incidental disclosure B. Not subject to the minimum necessary requirement C. A disclosure for payment purposes D. An automatic violation of the HIPAA Privacy Rule

An incidental disclosure Calling out patient's name in a physician office is an incidental disclosure because it occurs as part of office operations. It is permitted as long as the information disclosed is the minimum necessary.

City Hospital's HIM department made a decision to discontinue outsourcing its release of information (ROI) function and perform the function in house. Because of HIPAA implementation, the department wanted better control over tracking release of information. Given the graph shown here. How would you evaluate the ROI revenue growth? ***Graph is needed for question 5.*** A. The ROI function continues to cost more than revenue generated. B. Annualized revenue for YR-7 is more than the costs. C. The ROI function costs are inversely related to revenue generated. D. The ROI costs for YR-7 are greater than the revenue.

Annualized revenue for YR-7 is more than the costs. Line graphs are used to display time trends in data. A line graph is useful for plotting data to make observations. In analyzing the chart, the revenue exceeds the costs.

The coding staff should be updated at least__________ on compliance requirements. A. Weekly B. Monthly C. Every six months D. Annually

Annually It is imperative that all staff be trained in compliance policies, procedures, and standards of conduct as it applies to their position in the organization. This training should occur, at a minimum, in their initial orientation training and on and annual basis.

Community hospital is looking for ways to increase physician referrals. One board member suggested that they offer local physician $100 for every patient referred to the hospital for care. If the hospital goes ahead with the board member's suggestion, what statute is the hospital violating? A. Anti-Kickback statute B. False Claims Act C. Health Insurance Portability and Accountability Act D. Red Flags Rule

Anti-Kickback Statute The Anti-Kickback Statute dictates that physicians cannot receive money or other benefits for referring patients to a healthcare facility. In this example, a hospital cannot give a physician $100 for every patient referred to the hospital for care.

Quality standards for coding accuracy should be: A. At least 80 percent B. At least 90 percent C. As close to 100 percent as possible D. No specific standards are possible

As close to 100 percent as possible Quality coding is an important component of coding compliance. Standards for coding accuracy should be as close to 100 percent as possible.

Using data mining, an RAC makes a claim determination at the system-level without a human review of the health record. This type of review is called: A. Automated review B. Complex review C. Detailed review D. Systematic review

Automated review RACs conduct three types of audits: automated reviews, semi-automated reviews, and complex reviews. An automated review occurs when an RAC makes a claim determination at the system level without human review of the health record, such as data mining. Errors found must be clearly non-covered services or incorrect applications of coding rules and must be supported by Medicare policy, approved article, or coding guidance.

To date, the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? A. HIPAA does not allow charges for copying of medical records. B. Use the state formula because HIPAA allows hospitals to use the state formula C. Base charges on the cost of labor and supplies for copying and postage if copies are mailed while following the state copy fee schedule D. Because HIPAA allows for reasonable and customary charges, charge only for the paper used for copying the record.

Base charges on the cost of labor and supplies for copying and postage if copies are mailed while following the state copy fee schedule The HIPAA Privacy Rule intent is to allow an individual to obtain copies of records for a fee that is reasonable enough that an individual could pay for it. The Privacy Rule requires that the copy fee for the individual be reasonable and cost based. It can only include the cost of labor for copying and postage, when mailed. The commentary to the Privacy Rule expands upon this standard. If paper copies are made, the fee can include the cost of the paper. If electronic copies are made, the fee can include copies of the media used.

Clinical documentation policies and procedures should: A. Dictate the practices and procedures for medical treatment B. Encompass nationally recognized guidelines C. Meet all the requirements of physician leaders D. Be created by and specifically for each organization

Be created by and specifically for each organization In order to be both effective and efficient, each organization must be guided by policies and procedures that are created and specific to the organization. This includes policies and procedures regarding clinical documentation.

A standard of performance or best practice for a particular process or outcome is called a(n): A. Performance measure B. Benchmark C. Improvement opportunity D. Data measure

Benchmark When an organization compares its current performance measure to its own internal historical data, or uses data from similar external organizations across the country, it helps establish a benchmark also known as a standard of performance or best practice, for particular process or outcome.

Which of the following is the average relative weight of all cases treated at a given facility or by a given physician? A. Case mix index B. Sampling C. Hospital-acquired condition D. Present on admission indicator

Case-mix index Case-mix index is a weighted average of the sum of the RWs of all patients treated during a specified time period.

The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on: A. Case-mix index B. Query rate C. Principal diagnosis D. Record review rate

Case-mix index The appropriateness of assigning CCs and MCCs will impact the organization's case-mix index and must be monitored. The CMI is a measure of the average revenue received per case. Many hospitals closely monitor the movement of their CMI for inpatient populations for which payment is based on DRGs.

Managing the adoption and implementation of new processes is called: A. Management by design B. Change management C. Process flow implementation D. Visioning

Change management Change management is the formal process of introducing change, getting it adopted, and diffusing it throughout the organization.

What is the formal process of introducing change, adopting the change, and diffusing it throughout the organization? A. SWOT B. Change management C. Supply management D. Workflow

Change management Change management is the formal process of introducing change, getting it adopted, and diffusing it throughout the organization.

Which of the follwoing could be a focus of a coding quality review program? A. CC and MCC coding rates (MS-DRGs) B. Outpatient Code Editor failure rates C. Coding completed by new coders D. New coding guidelines

Coding completed by new coders Any new coder should have his or her coded records reviewed prior to releasing the claim for accuracy and quality review.

Performance standards are used to: A. Communicate performance expectations B. Assign daily work C. Describe the elements of a job D. Prepare a job advertisement

Communicate performance expectations Managers must be able to report on the amount, efficiency, and quality of work being done in a unit. Employees need to know what is expected of them, and how they are doing relative to expectations. Setting performance standards and measuring performance can address the needs of both.

Data found on sites such as Hospital Compare use aggregated data to describe the experiences of unique types of patients with one or more aspects of their care. This data collection is called? A. Patient-specific B. Aggregated C. Comparative D. Detailed

Comparative Comparative data uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care.

Elizabeth prepares a weekly dashboard report with key performance indicators of the HIM department to send to the chief executive officer. Preparation of this report falls under what managerial function? A. Planning B. Organizing C. Leading D. Controlling

Controlling Controlling is the function in which performance is monitored according to policies and procedures. In HIM, controlling includes monitoring the performance of employees for quality, accuracy, and timeliness of completion of duties.

What is the official count of inpatients taken at midnight called? A. Average daily census B. Census C. Daily inpatient census D. Inpatient service days

Daily inpatient census The result of the official count taken at midnight is the daily inpatient census.

Which term is used to describe the number of inpatients present at the census-taking time each day plus the number of inpatients who were both admitted and discharged after the census-taking time the previous day? A. Inpatient bed occupancy rate B. Bed count C. Average daily census D. Daily inpatient census

Daily inpatient census The result of the official count taken at midnight is the daily inpatient census. This is the number of inpatients present at the official census-taking time each day. Also included in the daily inpatient census are any patients who were admitted and discharged the same day.

A recent HIM trend is instituting a clinical documentation improvement program. This is not a small undertaking. Which of the following can be used by the HIM manager to assist in measuring whether or not the program is successful? A. Dashboard B. Policy C. Procedure D. Benchmark

Dashboard A dashboard is a management report of process measures. Dashboards can assist in measuring whether or not the program is successful. A monthly dashboard might show the number of clarifications requested by a CDI specialist that impacted a diagnosis-related group based on a benchmark.

One of the pediatricians at Community Physician's Clinic worked with a software vendor to get a display of the patients she currently has in the hospital on her smart phone that lets her know current information such as lab results, vital signs, medications given. This is called a ________. A. Big data B. Descriptive analytics screen C. Dashboard D. Descriptive tablet

Dashboard A dashboard is a visual display of the most important information that a physician would need to see about his patients. These can usually be customized by facility or an individual.

As the director of HIM services, Mitch receives a weekly report form his coding supervisor. The report graphically displays inpatient and outpatient coding volume data, employee turnover rates, and the number of claim denials due to coding errors. This snapshot report is called a: A. Benchmark report B. Budget C. Dashboard D. Performance appraisal

Dashboard Performance monitoring is data driven. The organization's leadership uses the information displayed on the dashboard to guide operations and determine improvement projects. Having real-time data in an easily assessable format like a dashboard allows leaders to keep track of high-impact, high-risk, or high-value processes and make adjustments on a daily basis if needed.

The results of a recent coding audit show that wo of the inpatient coders are missing the correct principal dianosis selection that affects MS-DRG payment for the hospital. As the coding manager, your are tasked to provide coding education to the coders to correct this problem. What should be included in this training? A. How to use the CPT index B. Definitions of root operations C. How to calculate the case-mix D. Definitions of principal diagnosis

Definitions of principal diagnosis Training provides new or current employees with knowledge, skills, and abilities related to specific competencies needed to perform their current job. Coding education must be provided in this situation in order to improve the accuracy of principal diagnosis assignment. Accurate assignment of principal diagnosis is a critical part of the inpatient coding process as this assignment has direct impact on the MS-DRG assignment.

When the Medicare Recovery Audit Contractor has determined that incorrect payment has been made to an organization, which document is sent to the provider notifying them of this determination? A. Appeal request B. Claims denial C. Demand letter D. Medicare Summary Notice

Demand letter The provider will be notified of RAC determination in a demand letter, which includes the providers identification, reason for the review, list of claims, reasons for any denials, and amount of the overpayment for each claim. The demand letter is the equivalent of a denial letter.

Your administrator has asked you to generate a report that gives the number of hypertension patients last year. This is an example of_______________. A. Descriptive analytics B. Predictive analytics C. Prescriptive analytics D. Real-time analysis

Descriptive analytics Data analytics is the science of examining raw data with the purpose of drawing conclusions about that information. Analytics can be descriptive, predictive, or prescriptive. Descriptive analytics is just the summarization of data. DESCRIPTIVE ANALYTICS answers the question "what happened."PREDICTIVE ANALYTICS answers "what will happen." DIAGNOSTIC ANALYTICS answers the question "why did it happen." PRESCRIPTIVE ANALYTICS answers "how can we make it happen."

A patient admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a comorbid condition? A. Acute appendicitis B. Appendectomy C. Diabetes D. Wound infection

Diabetes A comorbid condition is a condition that existed at admission and is thought to increase the patient stay at least one day for approximately 75 percent of the patients. Diabetes existed at the time of admission.

If a patient has an excision of a malignant lesion of the skin, the CPT code is determined by the body area from which the excision occurs and which of the following? A. Length of the lesion as described in the pathology report B. Dimension of the specimen submitted as described in the pathology report. C. Width times the length of the lesion as described in the operative report. D. Diameter of the lesion as well as the margins excised as described in the operative report

Diameter of the lesion as well as the margins excised as described in the operative report During surgery, physicians may take some normal-looking skin around the growth. Removal of the normal-looking skin is known as taking margins. This is done to be sure no cancer cells are left behind. The total size of the excised area, including margins, is needed for accurate coding. Usually, this information is provided in the operative report.

In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures with the payment status indicator-T performed during the same operative session, which of the following would apply? A. Bundling of services B. Discounting of procedures C. Outlier adjustment D. Pass-through payment

Discounting of procedures Discounting applies to multiple surgical procedures that have a payment status T indicator and are performed during the same operative session. For discounted procedures, the full ambulatory payment classification (APC) rate is paid for the surgical procedure with the highest rate, and other surgical procedures performed at the same time are reimbursed at 50 percent of the APC rate.

Patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? ***Graph is needed to answer Q 31.*** A. E10.52 B. E10.9, I96 C. E10.52, E10.9, I96 D. E11.52`

E10.52 Diabetes would be referenced in the Index, subterm Type I, with gangrene which directs the coder to E10.52.

Dr. Jones is the first physician in the practice to adopt the e-prescribing application. He says he likes to try out new technologies and to be a role model for other physicians. Dr. Jones is at what step in the innovation adoption life cycle? A. Early adopter B. Early majority C. Laggard D. Late majority

Early adopter Early adopters are a little more cautious than the innovators but these individuals are the change leaders within the organization. These individuals do not require information to change but they like to have how-to-manuals and information sheets on how to participate within the change, which can be provided by the change agents. In this situation, Dr Jones is an early adopter of the e-prescribing application.

After implementing a new EHR, the HIM department is noticing that documents are occasionally found in the wrong health record or are mislabeled. Which of the following would be the best approach to manage these errors in the EHR? A. Ignore them because it does not matter B. Establish an error-management team to receive notice of these instances and correct them C. Establish a policy of HIM staff to be more careful D. Report these issues to the IT department to resolve them

Establish and error-management team to receive notice of these instances and correct them Error management is part of data integrity which means that data should be complete, accurate, consistent, and up-to-date. Ensuring the integrity of healthcare data is important because providers use data in making decisions about patient care.

Large population-based studies are used to identify the care processes or interventions that achieve the best healthcare outcomes in different types of medical practice. This research concept is called? A. Clinical pathway B. Evidence-based medicine C. Patient-centered care D. Morbidity indicators

Evidence-based medicine Evidence-based medicine attempts to identify the care processes or interventions that achieve the best outcomes in different types of medical practice. Researchers perform large population-based studies. Such studies are difficult to do without a well developed information infrastructure to provide data for analysis.

The Joint Commission is conducting an audit at Community Hospital to determine the hospital's compliance with the Joint Commission standards regarding patient rights. This is an example of a(n): A. Complex review B. External audit C. Internal Audit D. Casefinding review

External audit External audits are conducted by accreditation, insurance companies, or other organizations monitoring the healthcare provider for compliance with their standards and regulations. In this scenario The Joint Commission is doing an external audit to determine compliance with The Joint Commission standards regarding patients' rights.

The following table compares Community Hospital's pneumonia length of stay (observed LOS) to the pneumonia LOS of similar hospitals (expected LOS). Given this data, where might Community Hospital want to focus on its pneumonia LOS? ***Graph is needed to answer Q 41.*** A. Cardiology B. Endocrinology C. Family practice D. Internal medicine

Family practice Family practice has the largest variance with the potential for the most savings.

Corporate compliance programs became common after adoption of which of the following? A. False Claims Act. B. Federal Sentencing Guidelines C. Office of the Inspector General for HHS D. Federal Physician Self-Referral Statute

Federal Sentencing Guidelines The U.S. Federal Sentencing Guidelines outline seven steps as the hallmark of an effective program to prevent and detect violations of law. These seven steps were the basis for the OIG's recommendations regarding the fundamental elements of an effective compliance program.

Which of the following is a data collection tool that records the workflow of current processes? A. Flow chart B. Force-field analysis C. Pareto chart D. Scatter diagram

Flow chart Flow charts help all the team members understand the process in the same way. The work involved in developing the flow chart allows the team to thoroughly understand every step in the process as well as the sequence of steps. The flow chart provides a visual picture of each decision point and each event that must be completed. It readily points out places where there are redundancy and complex and problematic areas.

If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing: A. Abuse B. Fraud C. Malpractice D. Kickbacks

Fraud Medicare defines fraud as an intentional representation that an individual knows to be false or does not believe to be true but makes, knowing that the representation could result in some unauthorized benefit to himself or herself or some other person. Disregard for official coding guidelines would be considered fraud.

Which of the following issues compliance program guidance? A. AHIMA B. CMS C. Federal Register D. HHS Office of Inspector General

HHS Office of Inspector General From February 1998 until the present, the Office of Inspector General (OIG) continues to issue compliance program guidance for various types of healthcare organizations. The OIG website (www.oig.hhs.gov) posts the documents that most healthcare organizations need to develop fraud and abuse compliance plans.

Clinical documentation improvement staff members must work directly with this department to obtain data about retrospective physician queries: A. Coding B. Health information managment C. Compliance D. Case management

Health information management A feedback loop between clinical documentation improvement (CDI) and health information management (HIM) should be in place as a best practice. It is necessary to ensure the CDI manager works directly with the HIM manager to obtain data about retrospective physician queries.

When multiple burns are present, the first sequenced diagnosis is the: A. Burn that is treated surgically B. Burn that is closest to the head C. Highest-degree burn D. Burn that is treated first

Highest-degree burn Treatment and anatomic location are not factors in the sequencing of burn conditions. Code all burns with the highest degree of burn sequenced first.

In Medicare, the most common forms of fraud and abuse include all except which of the following? A. Billing for services not furnished B. Misrepresenting the diagnosis to justify payment C. Unbundling or exploding charges D. Implementing a clinical documentation improvement program

Implementing a clinical documentation improvement program In Medicare, the most common forms of fraud and abuse include billing for services not furnished; misrepresenting the diagnosis to justify payment; soliciting, offering, or receiving a kickback; unbundling; falsifying certificates of medical necessity; and billing for a service not furnished as billed, known us upcoding.

Given the information her, which of the following statements is correct? ***Graph is needed to answer Q 31*** A. In each MS-DRG, the geometric mean is lower than the arithmetic mean. B. In each MS-DRG, the arithmetic mean is lower than the geometric mean. C. The higher the number of patients in each MS-DRG, the greater the geometric mean for that MS-DRG. D. The geometric means are lower in MS-DRGs that are associated with a CC or MCC.

In each MS-DRG, the geometric mean is lower than the arithmetic mean. The geometric mean LOS is defined as the total days of service, excluding any outliers or transfers, divided by the total number of patients. Given the examples, the geometric means are lower than the arithmetic means.

The present on admission indicator is a requirement for: A. Inpatient Medicare claims submitted by hospitals B. Inpatient Medicare and Medicaid claims submitted by hospitals C. Medicare claims submitted by all entities D. Inpatient skilled nursing facility Medicare claims

Inpatient Medicare claims submitted by hospitals Inpatient hospitals were required to submit POA information on diagnoses for inpatient Medicare discharges.

The HIM director conducted an analysis of the coding department that revealed that 10 of the coders are credentialed and have at least 10 years of experience. However, the top five coders are leaving their employment within the next three months. This is an example of which type of analysis? A. External B. Internal C. Market D. Workflow

Internal An internal analysis involves reviewing the inner working of the healthcare organization to determine strengths and weaknesses of the business practice and process. The scenario is an example of internal analysis.

Medicare inpatient reimbursement levels are based on: A. CPT codes reported during the encounter B. MS-DRG calculated for the encounter C. Charges accumulated during the episode of care D. Usual and customary charges reported during the encounter

MS-DRG calculated for the encounter Medicare inpatients are reimbursed through MS-DRGs calculated for each hospital encounter. These are assigned with the help of a grouper.

Which of the following reportable diseases usually requires telephone reporting as opposed to other methods of reporting? A. Chicken pox B. Influenza C. Measles D. Pertussis

Measles All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the healthcare organization must notify the public health department. Measles usually requires immediate notification to the public health department. The other three need to be reported, but not necessarily immediately.

A 65-year-old patient with a history of lung cancer is admitted to a healthcare facility with ataxia and syncope and a fractured arm as a result of falling. The patient undergoes a closed reduction of the fracture in the emergency department as well as a complete workup for metastatic carcinoma of the brain. The patient is found to have metastatic carcinoma of the lung to the brain and undergoes radiation therapy to the brain. Which of the following would be the principal diagnosis in this case? A. Ataxia B. Fractured arm C. Metastatic carcinoma of the brain D. Carcinoma of the lung

Metastatic carcinoma of the brain The principal diagnosis is designated and defined as the condition established after study chiefly responsible for occasioning the admission of the patient to the hospital for care.

A patient is admitted with spotting. She had been treated two weeks previously for a miscarriage with sepsis. The sepsis had resolved, and she is afebrile at this time. She is treated with an aspiration dilation and curettage. Products of conception are found. Which of the following should be the principal diagnosis? A. Miscarriage B. Complications of spontaneous abortion with sepsis C. Sepsis D. Spontaneous abortion with sepsis

Miscarriage This patient's sepsis has resolved before being admitted to the hospital and would be considered a previous condition. She is treated with an aspiration dilation and curettage with products of conception found. The patient's principal diagnosis would be the miscarriage.

Which of the following behaviors is an early indicator of resistance to change that an employee might exhibit when presented with a new project? A. Asking repeated questions during a department meeting about the new project B. Missing planning meetings to determine the implementation schedule for the new project C. Reading industry articles on the new project to gain knowledge prior to installation D. Volunteering to be on an implementation committee for the new project

Missing planning meetings to determine the implementation schedule for the new project The underlying tenet is all human beings prefer doing things that have the most meaning for themselves. When people believe change is going to be harmful to themselves or their career they are resistant to change. To overcome this resistance, leaders need to patiently sell the idea of change by educating their team and carefully disseminating information. Missing planning meetings would be perceived as being resistant to the change.

Which of the following is one of the four criteria describing the basics of the best practice clinical documentation improvement (CDI) programs? A. Intangible best practices in middle revenue cycle B. Practices must be central to only one area C. Must be supported by research and actual application by multiple healthcare systems D. Best practices with high validity are included

Must be supported by research and actual application by multiple healthcare systems The four criteria describing the basics of best practice in CDI programs are: remain constant over time; be supported by research or actual application by more than one healthcare system; affect at least two out of three management areas; and provide some measurable value to the organization.

In developing a coding compliance program, which of the following would NOT be ordinarily included as participants in coding compliance education? A. Current coding personnel B. Medical staff C. Newly hired coding personnel D. Nursing staff

Nursing staff In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff.

A 27-year-old female has a vaginal delivery with single liveborn female at 40 weeks gestation with episiotomy and repair. What diagnosis and procedure codes would be assigned for this patient? ***Graph is needed to answer Q 67.*** A. O70.0, Z37.0, Z3A.40, 0WQNXZZ B. O80, Z37.0, Z3A.40, 0W8NXZZ, 0WQNXZZ C. O80, Z37.0, Z3A.40, 0W8NXZZ D. O70.9, Z37.0, 0WQNXZZ

O80, Z37.0, Z3A.40, 0W8NXZZ This is an example of normal delivery, full-term, single, healthy liveborn infant with an episiotomy. No other procedures or manipulation needed to aid in delivery. The Z3A code is used to indicate the 40 weeks of gestation of pregnancy. The correct ICD-10-PCS procedure code is 0W8NXZZ, division of the female perineum.

The risk manager's principal tool for capturing the facts about potentially compensable events is the: A. Accident report B. RM report C. Occurrence report D. Event report

Occurrence report The risk manager's principal tool for capturing the facts about potentially compensable events is the occurrence report, sometimes called the incident report. Effective occurrence reports carefully structure the collection of data, information, and facts in a relatively simple format.

A coding supervisor who makes up the weekly work schedule would engage in what type of planning? A. Long range B. Operational C. Tactical D. Strategic

Operational Operational planning is the specific day-to-day tasks required in operating a healthcare organization or an HIM department. Making up the weekly work schedule would be part of operational planning.

Delegation is a skill that managers develop to show employees that they trust them with authority to perform certain projects on their own. Delegation falls under what managerial function? A. Planning B. Organizing C. Leading D. Controlling

Organizing Organization is coordinating all of the tasks and responsibilities of a department to guarantee the work to be accomplished is completed correctly. A director or supervisor is responsible for the decisions concerning the division of labor for the HIM department.

A facility recently submitted two claims for the same service for a patient's recent encounter for chemotherapy. If the third-party payer pays both of these claims, the facility will receive a higher reimbursement than deserved. This is called: A. Appropriate payment B. Overpayment C. Unbundling D. Waste

Overpayment An overpayment occurs when a facility receives higher reimbursement than the facility deserves. One example of this is when a facility submits two or more claims for the same service.

The National Correct Coding Initiative (NCCI) was developed to control improper coding leading to inappropriate payment for: A. Part A Medicare claims B. Part B Medicare claims C. Medicare claims D. Medicare and Medicaid claims

Part B Medicare claims CMS implemented the National Correct Coding Initiative (NCCI) in 1996 to develop correct coding methodologies to improve the appropriate payment of Medicare Part B claims.

The hospital-acquired conditions provision of the Medicare PPS is an example of which type of value-based purchasing system? A. Paying for value B. Penalty based C. Reward based D. Penalty for value

Paying for value To move to a mature value-based purchasing program, Centers for Medicare and Medicaid Services (CMS) desires to pay for value-that is, to promote efficiency in resource use while providing high-quality care. To achieve this goal, CMS, as a first step, established the hospital-acquired conditions provision in the acute-care inpatient setting.

The Medicare Integrity Program was established to battle fraud and abuse and is charged with which of the following responsibilities? A. Audit of expense reports and notifying beneficiaries of their rights B. Payment determinations and audit of cost reports. C. Publishing of new coding guidelines and code changes D. Monitoring of physician credentials and payment determinations

Payment determinations and audit of cost reports The Medicare Integrity Program was established under the HIPAA legislation to battle healthcare fraud and abuse. Not only did medicare continue to review provider claims for fraud and abuse, but the focus expanded to cost reports, payment determinations and the need for ongoing compliance education.

The Information Services Department has requested information about the electronic signature system being used in our facility. They would like to know the locations where physicians are accessing the system. Review the information in the table below and determine which site has the highest percentage of use. ***Graph is needed to answer Q 71.*** A. HIM department B. Obstetrics, 1 West C. Personal mobile device D. Physician home

Personal mobile device A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be grouped into tables. Columns allow you to read data up and down, and rows allow you to read data across. The columns and rows should be labeled. In this table, personal mobile device has the highest percent of physicians using the system.

Dr. Smith always orders the same 10 things when a new patient is admitted to the hospital in addition to some patient-specific orders. What would assist in assuring that the specific patient is not allergic to a drug being ordered? A. Clinical decision support B. Electronic medication administration record system C. Pharmacy information system D. Standard order set

Pharmacy information system When the pharmacy information system receives an order for a drug, it will aid the pharmacist in checking for contraindications, directs staff in compounding any drugs requiring special preparation, and aids in dispensing the drug in the appropriate dose and route of administration. Indication of an allergy would be considered a contraindication.

Which item below is NOT recommended by the HHS and the OIG for minimum compliance with clinical documentation regulations? A. Physicians should include vaccination records B. Progress, response, and changes are to be documented C. Health record should be completely legible D. Past and present diagnosis should be easily accessible

Physicians should include vaccination records Progress, response, and changes to the patient's condition must be documented. All health records should be completely legible and accessible to patient and present diagnosis information. These are all required elements of the Medicare Conditions of Participation. Physician inclusion of vaccination records is not mandated.

Which of the following is a written description of an organization's formal position? A. Hierarchy chart B. Policy C. Organizational chart D. Procedure

Policy A policy is clearly stated and comprehensive statement that establishes the parameters for decision making and action and is the written description of the organizations's formal position. Policies are developed at both the institutional and departmental levels. In both cases, policies should be consistent within the organization. They must be developed in accordance with applicable laws and reflect actual practice.

This type of analytics allows users to prescribe a number of different possible actions: A. Descriptive analytics B. Predictive analytics C. Prescriptive anaytics D. Real-time analytics

Prescriptive analytics Prescriptive analytics is a relatively new field of analytics that allows users to prescribe a number of different possible actions. This type of analytics predicts what will happen, but also provides recommendations that will take advantage of the predictions.

Community Hospital recently implemented a fully integrated electronic health record EHR system. The process for record analysis will be significantly different with this new system. The process is changing from the hybrid to a fully electronic analysis process. Which of the following should the HIM manager modify to reflect this process change? A. Policy B. Standard C. Procedure D. Benchmark

Procedure A procedure is a document that describes the steps involved in performing a specific function that define the processes by which the policies are put into action.

A document that describes the steps involved in performing a specific function is a: A. Position statement B. Policy C. Procedure D. Performance appraisal

Procedure A procedure is a document that describes the steps involved in performing a specific function.

HIM managers set different types of standards to evaluate employee performance for functions such as coding, analysis, and release of information. These standards are called: A. Productivity standards B. Accreditation standards C. Privacy standards D. Regulatory standards

Productivity standards Productivity is denied as a unit of performance defined by management in quantitative standards. Productivity allows organization to measure how well the organization converts input into output, or labor into a product or service. Most HIM departments have productivity standards in the department, such a coding, analysis, and release of information.

The quality improvement organizations (QIOs) under contract with CMS conduct audits on high-risk and hospital-specific data from claims data in this report: A. Hospital Payment Monitoring Program B. Payment Error Prevention Program C. Program for Evaluation Payment Patterns Electronic Report D. Compliance Program Guidance for Hospitals

Program for Evaluation Payment Patterns Electronic Report QIOs are currently under contract with CMS to perform a Hospital Payment Monitoring Program. This program targets specific DRGs and discharges that have been identified as at high-risk for payment errors. The high-risk hospital specific data are identified in an electronic report called Program for Evaluating Payment Patterns Electronic Report (PEPPER).

Coding productivity is measured by: A. Quantity B. Quality C. Quantity and Quality D. Volume

Quantity and Quality Coding productivity is measured by two indicators of a coder's skill which are the types of errors he or she makes and the speed at which he or she can work.

When documentation in the health record is not clear, the coding professional should: A. Submit the question to the coding clinic B. Refer to dictation from other encounters for the patient to get clarification. C. Query the physician who originated the progress note or other report in question. D. Query a physician who consistently responds to queries in a timely manner.

Query a physician who originated the progress note or other report in question. A healthcare entity's query policy should address the question of whom to query. The query is directed to the provider who originated the progress note or other report in question. This could include the attending physician, consulting physician, or the surgeon. In most cases a query for abnormal test results would be direct to the attending physician.

In order to determine the hospital's expected MS-DRG payment, the hospital's blended rate is multiplied by the MS-DRGs____________ to determine the dollar amount paid. A. Length of stay B. Case mix number C. Relative weight D. Major diagnostic category

Relative weight Each diagnosis-related group (DRG) is assigned a relative weight (RW). The RW is a multiplier that determines reimbursement. For example, a DRG with a relative weight of 2.0000 would pay twice as much as a DRG with a RW of 1.0000.

Exceptions to the Federal Anit-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are: A. Qui tam practices B. Safe practices C. Safe harbors D. Exclusions

Safe harbors A common theme runs through safe harbors and that is the intent to protect certain arrangements in which commercially reasonable items or services are exchanged for fair market value compensation. Safe harbors are an exception to the Federal Anti-Kickback Statue. Congress authorized HHS to establish additional safe harbors by regulation. These safe harbors are activities that are not subject to prosecution and protect the organization from civil or criminal penalties.

Given the following information, in which city is the GPCI the highest for practice expense? ***Graph is needed to answer Q 32.*** A. St. Louis B. Dallas C. Seattle D. Philadelphia

Seattle Geographic practice cost index (GPCI) is the number used to multiply each RVU so that it better reflects a geographical area's relative costs. The practice expense GPCI is higher in Seattle at 1.098.

A patient requested a copy of a payment made by her insurance company for a surgery she had last month. The business office copied the remittance advice (RA) notice the organization received from the insurance company but failed to delete or remove the PHI for 10 patients listed on the same RA. This is an example of: A. Double billing B. Stereotyping C. Retrospective review D. Security breach

Security breach A security breach of PHI has occurred in this scenario because business office provided the patient with not only her information on the remittance advice, but also that the 10 other patients.

Which of the following types of information include areas like genetics, adoption, and drug use that require special attention? A. Special information B. Scientific information C. Sensitive information D. Super information

Sensitive information All health information must be protected; however, there is some information that requires special attention because it is considered sensitive health information such as genetic, adoptive, drug, alcohol, sexual health, and behavioral information. This type of information not only has strict rules and regulations, but also providers and ethical gray area when it comes to releasing and providing records.

A hospital employee destroyed a health record so that its contents-which would be damaging to the employee-could not be used at trial. In legal terms, the employee's action constitutes: A. Mutilation B. Destriction C. Spoilation D. Spoilage

Spoliation Spoliation is a legal concept applicable to both paper and electronic records. When evidence is destroyed that relaters to a current or pending civil or criminal proceeding, it is reasonable to infer that the party had a consciousness of guilt or another motive to avoid the evidence.

What kind of planning addresses long-term needs and sets comprehensive plans of action? A. Tactical B. Operational C. Strategic D. Administrative

Strategic A strategic plan is the document in which the leadership of a healthcare organization identifies the organization's overall mission, vision, and goals to help define the long-term direction of the organization.

Which of the following is an alternate work schedule option that has been made possible by the growth and development of technology? A. Compressed workweek B. Flextime C. Open systems D. Telecommuting

Telecommuting Telecommuting, also called remote or virtual work, allows employees to use technology to perform work and link with the organization from home or another out-of office location. The organization usually provides a computer and the required software.

University medical center would like to give access to the EHR to referring physicians for their patients' information for continuing care. The HIM manager should recommend which of the following: A. That access be granted that is view-only B. That unlimited access be granted C. Deny any access to the EHR D. Deny access unless the patient gives written consent

That access be granted that is view-only Organizations that allow referral providers access to their EHRs should determine which information will be accessible. Steps should be taken to ensure that this is a view-only access. It should be tested at each upgrade to ensure the view-only status continues.

Which of the following can be used to discover current risk or focused areas of compliance? A. The OIG workplan B. AHA newsletter C. HIPAA Privacy Rule D. Local medical review policy

The OIG Workplan The OIG workplan should be reviewed each year. This document provides insight into the directions the OIG is taking , as well as highlights hot areas of compliance.

When assigning evaluation and management codes for hospital outpatient services, the coder should follow: A. AHA guidelines B. AHIMA guidelines C. CMS guidelines D. The hospital's own internal guidelines

The hospital's own internal guidelines Medical visits present several interesting aspects of the ambulatory payment classification (APC). For the most part, APCs follow the CPT coding rules as set forth by the AMA. However, for medical visits, hospitals have been able to develop their own criteria for assigning E/M codes that determine the level of the visit. In addition, hospitals do not follow the same guidelines as physicians.

Identify where the following information would be found in the acute-care record: "Following induction of an adequate general anesthesia, and with the patient supine on the padded table, the left upper extremity was prepped and draped in the standard fashion." a. Anesthesia report b. Physician progress notes c. Operative report d. Recovery room record

The operative report describes the surgical procedures performed on the patient. The operative report should be written or dictated by the surgeon immediately after surgery and become part of the health record.

A secondary data source includes______________. A. Vital statistics B. The medical record C. The physician's index D. A videotape of a counseling session

The physician's index Secondary data sources are data derived from primary sources and may be collected by someone other than the primary user. Secondary data sources are facility specific. The physician index is an example of a secondary data source.

A patient was admitted to the hospital for treatment of a myocardial infarction (heart attack) and the MS-DRG assigned was 236 Coronary bypass w/o cardiac cath w/o MCC. During the patient's admission, a bypass procedure was performed on day 2; on day 4, the patient was diagnosed with sepsis, which was not present on admission. Sepsis is a major complication. This case was identified as coded incorrectly in a recent audit by the coding manager. What was the error that was made by the coder? A. The sepsis was not coded, and so an MCC was missed. B. The coronary bypass procedure was coded incorrecty. C. The claim was coded correctly; no error was made. D. The cardiac catheterization procedure was not coded.

The sepsis was not coded, and so an MCC was missed. Complication and comorbidities (CCs) and major complications and comorbidities (MCCs) also play a part in determining the Medicare severithy diagnosis-related group (MS-DRG). CCs and MCCs are additional, or secondary, diagnoses that ordinarily extend the length of stay. A complication is a secondary condition that arises during hospitalization; comorbidity is one that exists at the time of admission. CCs affect many but not all MS-DRG categories. MS-DRGs are often found in sets of two or three depending on whether CCs or MCCs affect the DRG assignment. In such groupings, a case with a CC would represent a higher severity level and thus would result in a higher payment than a case without a CC. A case with an MCC would be an even higher level of severity and would pay more than a case with a CC.

Within the context of the inpatient prospective payment system, how is the case-mix index calculated? A. The sum of all relative weights divided by the total number of discharges B. The total number of inpatient service days divided by the total number of discharges C. The sum of all MDCs divided by the total number of discharges D. The total number of inpatient beds divided by the total number of discharges

The sum of all relative weights divided by the total number of discharges To determine the case-mix index, take the sum of all relative weights and divide by the total number of discharges. The formula for computing case-mix is: The sum of the weights of MS-DRGs for patients discharged during a given period divided by the total number of patients discharged. A facility's case mix index (CMI) is calculated as the sum of the relative weights of the facility's DRGs divided by the number of admissions for the period of time (often 1 year).

One element of Helen's SWOT analysis mentions the hospital across town recently sent all their coders home to work remotely. Currently all coding done at Helen's hospital is done in-house. In a SWOT analysis, remote coding done by the other hospital would be a(n): A. Strength B. Weakness C. Opportunity D. Threat

Threat The process to develop a strategic and operational plan begins with a SWOT (acronym for strengths, weaknesses, opportunities, and threats) analysis. In a SWOT analysis, key leadership personnel determine the strengths of the organization (what the company does well), the weaknesses (needs for improvement), and establishes future opportunities (and evaluates threats to those opportunities). This scenario is an example of threat in the SWOT analysis.

MS-DRGs may be split into a maximum of__________ payment tiers based on severity as determined by the presence of a major complication/comorbidity, a CC or no CC. A. Two B. Three C. Four D. Five

Three Each base Medicare severity diagnosis-related group (MS-DRG) can be subdivided in one of three possible alternatives: Major Complication/Comorbidity (MCC); Complication/Comorbidity (CC); and Non-CC.

Why is it essential for members of the compliance team to be involved in the entire EHR implementation process? A. To ensure HIPAA compliance B. Evolving regulatory guidelines C. To monitor cut and past documentation D. Reimbursement risk

To monitor cut and past documentation Because of compliance concerns, such as cutting and pasting documentation in the EHR, it is essential to ensure that a member of the compliance team is involved in the entire EHR implementation process, as well as the part of the process involving clinical documentation practice.

The HIM supervisor has set a key performance standard for the release of information (ROI) staff related to the time between receipt of a request and when the request is sent to the requestor. This standard is considered the ROI: A. Control workflow B. Overlap C. Duplicate rate D. Turnaround time

Turnaround time Turnaround time is the time between receipt of the release of information (ROI) request and when the request is sent to the requestor. The supervisor is responsible for insuring that release of information ROI turnaround times are met.

The main purpose of National Correct Coding Initiative edits to prohibit: A. ICD-10-CM procedure code errors B. DRG assignment errors C. Unbundling of procedures D. Incorrect POA assignment

Unbundling of procedures The National Correct Coding Initiative (NCCI or CCI) edits also apply to the APC system. The main purpose of CCI edits is to prohibit unbundling or procedures. CCI edits are updated quarterly.

When a meaningful _______________ is developed, an organization is more likely to achieve its goals and be profitable. A. Physician education B. Organizational value statement C. Vision statement D. CDI mission statement

Vision statement Every clinical documentation improvement (CDI) needs a strong vision that is both compelling and consistent with the organization's overall values, vision, and mission statement. This allows the organization to increase their likelihood of meeting their goals and being profitable.

If an employee produces 2,080 hours of work in the course of one year, how many employees will be required for the coding area if the coding time on average for one record is 30 minutes and there are 12,500 records that must be coded each year? a. 3 b. 6 c. 36 d. 69

a. 3 The number of records per FTE is 2 (number of records per hour) × 2,080 = 4,160. Therefore, three employees per year are required: 12,500 / 4,160 = 3.0

Dr. Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list? a. A disease index b. A master patient index c. An operative index d. A physician index

a. A disease index A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period.

What number is assigned to a case when it is first entered in a cancer registry? a. Accession number b. Patient number c. Health record number d. Medical record number

a. Accession number Accession number is a number assigned to each case as it is entered in a cancer registry.

What type of health record policy dictates how long individual health records must remain available for authorized use? a. Disclosure policies b. Legal policies c. Retention policies d. Redisclosure policies

c. Retention policies Hospitals and other healthcare facilities develop health record retention policies to ensure that health records comply with all applicable state and federal regulations, accreditation standards, as well as meet future patient care needs. Most states have established regulations that address how long health records and other healthcare-related documents must be maintained before they can be destroyed.

In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information? a. Any time access is requested b. When the covered entity is a correctional institution c. When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual d. When the covered entity is unable to produce the health record

c. When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual The HIPAA Privacy Rule provides patients with significant rights that allow them to have some measure of control over their health information. As long as state laws or regulations or the physician does not state otherwise (such as when a licensed healthcare professional has determined that access would likely endanger the life or safety of the individual) competent adult patients have the right to access their health record.

In data matching which of the following best describes an overlap? a. When one entity in a database has multiple unique identifiers b. When one entity is assigned another entity's unique identifier c. When one entity has different unique identifiers in different databases d. When one database overlaps with another database

c. When one entity has different unique identifiers in different databases An overlap is when one entity has different unique identifiers in different databases.

The manager calculated a unit and time productivity statistic based on employee self-reported data. He used the method to develop this performance standard. a. Benchmarking b. Work distribution analysis c. Work measurement d. Workflow analysis

c. Work measurement Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work.

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

d. 1.45 The weight of each diagnosis-related group (DRG) is multiplied by the number of discharges for that DRG to arrive at the total weight for each DRG—in this situation 15,192. The total weights are summed and divided by the number of total discharges to arrive at the case-mix index for a hospital: 15,192 / 10,471 = 1.45

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

d. Case finding After the cases to be included have been determined, the next step is usually case finding. Case finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry, such as cancer in the case of a cancer registry.

The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following? a. Upcoding b. Complex coding c. Query d. Unbundling

d. Unbundling Unbundling occurs when individual components of a complete procedure or service are billed separately instead of using a combination code.

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

d. Uses an itemized list of the patient's past and present health problems The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems.

Which of the following is true about the legal health record: a. Is inadmissible into evidence b. May not be hybrid c. Must consist in part on paper d. Will be disclosed upon request

d. Will be disclosed upon request One of the major purposes of a health record is to serve as the legal business record of an organization and as evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request.