RHIT Study Guide

Clinical documentation improvement staff members must work directly with this department to obtain data about retrospective physician queries: a. Coding b. Health information management c. Compliance d. Case management

b. 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 (Hess 2015, 245).

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 (Brodnik 2017b, 341-342).

willful neglect

"conscious, intentional failure or reckless indifference to the obligation to comply with the administrative simplification provision violated."

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 (Hess 2015, 174-175).

Policy

1. Governing principals that describe how a department or an organization is supposed to handle a specific situation 2.Binding contracts issued by a healthcare insurance company to an individual or group in which the company promises to pay for healthcare to treat illness or injury

Statistics

A branch of mathematics concerned with collecting, organizing, summarizing, and analyzing data

Autonomy

A core ethical principal centered on the individuals right to self determination that includes respect for the individual in clinical applications the patients right to determine what does or does not happen to him/her in terms of healthcare

benefience

A legal term that means promoting good for others or providing services that benefit others, such as releasing health information that will help a patient receive care or will ensure payment for services received

primary key

A primary key is a special relational database table column (or combination of columns) designated to uniquely identify all table records. A primary key's main features are: It must contain a unique value for each row of data. It cannot contain null values.

Lean

A quality improvement technique involving a systematic method to streamline processes to eliminate waste. Successful implementation of Lean techniques in a healthcare organization must include attention to the customer (patient-centered care) and their perspective while attempting to reduce unnecessary waste.

Nominal group technique

A quality improvement technique that allows groups to narrow the focus of discussion or to make decisions without becoming involved in extended circular discussions

Run chart

A type of graph that shows data points collected over time and identifies emerging trends or patterns

Statistical process control chart

A type of run chart that includes both upper and lower control limits and indicates whether a process is stable or unstable

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

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 (Rinehart-Thompson 2016c, 264-265).

Benchmarking

An analysis process that is based on comparison

Planning

An examination of the future and preparation of action plans to attain goals; of the four traditional management functions, planning must be done first because it is the foundation on which the other functions operate.

fishbone diagram / Cause and effect diagram

An investigational technique that facilitates the identification of the various factors (that is, manpower, material, methods, and machinery) that contribute to a problem

Systems Thinking

An objective way of looking at work-related ideas and processes with the goal of allowing people to think to uncover ineffective patterns of behavior and thinking and then finding ways to make lasting improvements.

flowchart

Analytical tools used to illustrate the sequence of activities in a complex process

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 (Rinehart-Thompson 2016c, 262-263).

CARF

Commission on Accreditation for Rehab Facilities A private, not-for-profit organization that develops customer-focused standards for behavioral healthcare and medical rehab programs and accredits such programs on the basis of its standards

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.

Correct Answer: A 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 (Thomason 2013, 113).

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

Correct Answer: A 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 (Brinda 2016, 141; Sayles and Gordon 2016, 675).

To clarify documentation, the preferred method of contact between a coder and a physician is: a. Face-to-face communication b. E-mail transmission c. Fax transmission d. Telephone conversation

Correct Answer: A Although physicians may be contacted by phone to clarify documentation, both documentation and coding are most accurate when physicians review the health records face-to-face with coders and then document findings. At the time of the review and discussion, the physician should be asked to add or modify documentation in the record. Codes should be modified, changed, or deleted only after—or when—the physician documents in the health record (Schraffenberger and Kuehn 2011, 21).

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

Correct Answer: A Medical necessity is based on the effects of a service for the patient's physical needs and quality of life (Fahrenholz 2013a, 81).

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. Health records in paper or electronic format d. Only health records in paper format

Correct Answer: A 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 (Rinehart-Thompson 2016b, 220, 222).

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

Correct Answer: B 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 (Shaw and Carter 2015, 27-28).

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

Correct Answer: B 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 (Sayles 2016b, 54).

HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into? a. Reasonable cause b. Reasonable diligence c. Willful neglect d. Abuse

Correct Answer: B Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements (Foltz et al. 2016, 451).

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

Correct Answer: C 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 (Sharp 2016, 173).

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

Correct Answer: C In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information (Rinehart-Thompson 2016b, 214).

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

Correct Answer: C The safe harbor method of deidentification requires the removal of 18 specific identifiers from the protect health information (Marc and Sandefer 2016, 22).

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

Correct Answer: C Compliance with state licensing laws is required in order for healthcare organizations to begin or remain in operation within their states. To continue licensure, organizations must demonstrate their knowledge of, and compliance with, documentation regulations (Fahrenholz 2013a, 84)

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

Correct Answer: D 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 (Sharp 2016, 175).

What should be done when the HIM department's 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

Correct Answer: D 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 (Sayles 2016b, 66).

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

Correct Answer: D 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 (Brinda 2016, 146).

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

Correct Answer: D 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 (Prater 2016, 588).

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

D. 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 (Gordon and Gordon 2016b, 534).

DEEDS

Data Elements For Emergency Department Systems A data set designed to support the uniform collection of information in hospital-based emergency departments

Aggregate data

Data extracted from individual health records and combined to form deidentified information about groups of patients that can be compared and analyzed

EMEDS

Expeditionary Medical Support System (EMEDS) is a modular field hospital system developed by the U.S. military for mobile deployment of medical treatment facilities in any location.

Information

Factual data that have been collected, combined, analyzed, interpreted, and or converted into a form that can be used for a specific purpose

HEDIS

Healthcare Effectiveness Data and Information Set A set of performance measures developed by the National Commission for Quality Assurance that are designed to provide purchasers and consumers of healthcare with the information they need to compare the performance of managed care plans

Leading

Influencing others to meet the goals and objectives of the organization by motivating subordinates, communicating effectively, and effectively using power; it is sometimes referred to as actuating, directing or influencing

abuse

Means incidents or practices by physicians, not usually considered fraudulent, that are inconsistent with accepted sound medical business or fiscal practices

reasonable diligence

Reasonable diligence is an alternate term for due diligence. It means the care and attention that is expected from and is ordinarily exercised by a reasonable and prudent person under the circumstances

The primary purpose of a minimum data set in healthcare is to:

Recommend common data elements to be collected in health records In 1969, a conference on hospital discharge abstract systems was sponsored jointly by NCHS, the National Center for Health Services Research and Development, and Johns Hopkins University. Conference participants recommended that all short-term general hospitals in the United States collect a minimum set of patient-specific data elements. They also recommended that these data elements be included in all databases compiled from hospital discharge abstract systems (Brinda 2016, 142).

Who was the ICD-10-CM and ICD-10-PCS guidelines established by

The WHO established them & the NCHS maintains it

Efficacy

The ability to produce a desired or intended result. Synonyms: effectiveness, success, productiveness, potency, power;

data granularity

The attributes and values of data should be defined at the correct level of detail.

In long-term care, the resident's care plan is based on data collected in the: a. UHDDS b. OASIS-C c. MDS d. HEDIS

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 (James 2013b, 535-537).

Data

The dates, numbers, images, symbols, letters, and words that represent basic facts and observations about people, processes, measurements, and conditions

data comprehensiveness

The extend to which healthcare data are complete

data consistency

The extent to which healthcare data are reliable

data precision

The extent to which healthcare-related data are useful for the purpose for which they were collected

justice

The impartial administration of policies or laws that takes into consideration the competing interest and limited resources of the individual or groups involved.

Performance Measure

The indication of a healthcare organization's performance in relation to a specified process or outcome.

performance measurement

The indicator of a healthcare organization's performance in relation to a specified process or outcome.

Controlling

The monitoring and correcting of organizational, departmental, and individual performance so goals and objects are met; controlling is dependent on goals, objectives, and key indicators being set during the planning phase

Procedure

The steps taken to implement a policy

Benchmark

The systematic comparison of the products, services, and outcomes of one organization with those of a similar organization; or the systematic comparison of one organization's outcome with regional or national standards.

variance analysis

Variance analysis is the quantitative investigation of the difference between actual and planned behavior. This analysis is used to maintain control over a business. For example, if you budget for sales to be $10,000 and actual sales are $8,000, variance analysis yields a difference of $2,000.

Reasonable cause

To have knowledge of facts which, although not amounting to direct knowledge, would cause a reasonable person, knowing the same facts, to reasonably conclude the same thing.

UACDS

Uniform Ambulatory Care Data Set a data set developed by the national committee on Vital and Health Statistics consisting of a minimum data set of patient/client specific data elements to be collected in ambulatory care settings

UHDDS

Uniform Hospital Discharge Data Set A core set of data elements adopted by the US dept of health, education, and welfare in 1974 that are collected by hospitals on all discharges and all discharge abstract systems

Six Sigma

Uses statistics for measuring variation in a process with the intent of producing error-free results.

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

Validity Validity is the degree to which codes accurately reflect the patient's diagnoses and procedures (Prater 2016, 573)

workforce planning

Workforce planning is a continual process used to align the needs and priorities of the organization with those of its workforce to ensure it can meet its legislative, regulatory, service and production requirements and organizational objectives.

pareto chart

a bar graph used to determine priories in problem solving

Guidelines

a general rule, principle, or piece of advice

scatter diagram

a graph in which the values of two variables are plotted along two axes, the pattern of the resulting points revealing any correlation present.

Foreign Key

a key attribute used to link one entity/table to another

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 outpatient 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 key components: problem focused history and examination, straightforward medical decision.

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 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 (Kuehn 2017, 41-42).

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 (A) (Brickner 2016, 106).

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

a. 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 (Foltz et al. 2016, 453-454).

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

a. 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 (Schraffenberger and Palkie 2017, 123).

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

a. Behavior One way hiring managers can improve effectiveness of job interviews 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) (Prater 2016, 574).

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 (Brickner 2016, 104).

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 (Johns 2015, 153).

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 for coverage c. Case mix d. Cost outliers

a. 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 (Shaw and Carter 2015, 497)

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

a. 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 (Giannangelo 2016b, 324-325).

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

a. Data model Data models provide a contextual framework and graphical representation that aid in the definition of data elements (Amatayakul 2016, 301).

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 (Johns 2015, 83).

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 Registered Health Information Technician (RHIT) Exam Preparation, Seventh Edition

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 (Rinehart-Thompson 2016a, 206).

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 (Reynolds and Brodnik 2017, 274)

Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment? 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 A definition of what constitutes a record in each hybrid system must be developed. It is also important to regularly update system descriptions to include the location of all care documents so that patient health information remains readily available to users. A matrix that includes the report or document type, media type, source system, electronic storage start date, and stop printing start date should be maintained by the healthcare organization (Russo 2013b, 334-335, 361).

How do patient care managers use the data documented in the health record? a. Evaluate the performance of 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 performance of employees It is the role of the patient care managers and support staff to evaluate the performance of employees (Sayles 2016b, 54)

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

a. 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 (Carter and Palmer 2016, 513).

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

a. 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 (Schraffenberger and Palkie 2017, 472-474).

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 (Sayles and Trawick 2014, 35).

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) (Gordon and Gordon 2016c, 604)

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

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 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 based on physician documentation (Gordon and Gordon 2016a, 437; Foltz et al. 2016, 465).

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

a. Inpatient Medicare claims submitted by hospitals Inpatient hospitals were required to submit POA information on diagnoses for inpatient Medicare discharges (Rinehart-Thompson 2016b, 237).

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 (Rinehart-Thompson 2016b, 240).

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

a. Lists successive steps of growth to measure a program's progression 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 (Johns 2015, 82).

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

a. 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 (Schraffenberger and Palkie 2017, 97, 488-491).

Which of the following types of data does not have a natural order? a. Nominal b. Ordinal c. Ratio d. Interval

a. 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 not the numbers themselves (Horton 2016a, 322-323).

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

a. 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 hospitalacquired conditions provision in the acute-care inpatient setting (Casto and Forrestal 2015, 306).

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 (Brinda 2016, 142).

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

a. 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 the 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 (Russo 2013b, 335).

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

a. 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 (Casto and Forrestal 2015, 269).

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 checklis

a. 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 (Prater 2016, 568, 584-592).

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 Character. 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 Character. The data element PATIENT_LAST_NAME must be stored as character data because the data are character-based (Brinda 2016, 141).

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" (Klaver 2017a, 78-79).

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

b- 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 (Gordon and Gordon 2016a, 441).

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

b. 15 The range is the simplest measure of spread. It is the difference between the smallest and largest values in a frequency distribution (Watzlaf 2016, 360).

Per the HITECH breach notification requirements, what is the threshold for the immediate notification of each individual? a. 1,000 individuals affected b. 500 individuals affected c. 250 individuals affected d. Any number of individuals affected requires individual notification.

b. 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 (AHIMA 2009; Rinehart-Thompson 2016b, 240).

. 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 (Rinehart-Thompson 2016b, 225).

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 (Rinehart-Thompson 2016b, 234-235).

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

b. Benchmark When an organization compares its current performance 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 a particular process or outcome (Shaw and Carter 2015, 29)

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

b. Bill hold Sometimes facilities adopt a bill hold policy. This policy dictates a waiting period between the patient's discharge date and claim submission (dropping the bill) (Schraffenberger and Kuehn 2011, 460).

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 deny access to psychotherapy notes c. Can demand that the individual pay to see his or her record d. Can always deny access

b. 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 (Rinehart-Thompson 2016b, 225).

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 (Johns 2015, 232).

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

b. 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 (Carter and Palmer 2016, 515).

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 processes 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

b. 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 (Shaw and Carter 2015, 174).

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

b. 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 (Schraffenberger and Kuehn 2011, 270).

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

b. 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 (Sayles and Trawick 2014, 244-245).

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

b. Discounting of procedures Discounting applies to multiple surgical procedures that have a payment status T indictor 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 (Casto and Forrestal 2015, 175).

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 (Johns 2015, 193).

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 for HIM staff to be more careful d. Report these issues to the IT department to resolve them

b. Establish an 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 (Johns 2015, 211).

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

b. 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 (Bowman 2017, 463).

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 (Rinehart-Thompson 2016c, 271).

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

b. Gross A gross autopsy rate is the proportion or percentage of deaths that are followed by the performance of autopsy (Horton 2016b, 395-396).

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

b. Healthcare Common Procedure Coding System HCPCS is a collection of codes and descriptors used to represent healthcare procedures, supplies, products, and services (Casto and Forrestal 2015, 31).

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

b. 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 (Shaw and Carter 2015, 45).

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

b. 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 (AHIMA 2014, 78).

A patient was admitted for abdominal pain with diarrhea and was diagnosed with infectious gastroenteritis. The patient also had angina and chronic obstructive pulmonary disease. Which of the following would be the correct coding and sequencing for this case? a. Abdominal pain; infectious 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

b. 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 (Schraffenberger and Palkie 2017, 91).

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

b. Inferential statistics Inferential statistics help make inferences or guesses about a larger group of data by drawing conclusions from a small group of data (Horton 2016a, 3-4).

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 (Rinehart- Thompson 2016b, 220-222).

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

b. 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 (Horton 2016b, 390).

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 (Brickner 2016, 102-103).

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 (Rinehart-Thompson 2017c, 215).

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

b. 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 (Gordon and Gordon 2016b, 534).

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. Medicaid claims d. Medicare and Medicaid claims

b. 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 (Casto and Forrestal 2015, 269).

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

b. 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 (Casto and Forrestal 2015, 37).

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

b. 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 (Sayles and Gordon 2016, 666).

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

b. 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 (Horton 2016a, 324).

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 (Foltz et al. 2016, 466).

An accuracy calculation method that divides the number of records where there was no 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

b. 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 reviewers 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 (Schraffenberger and Kuehn 2011, 319-320).

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 a source of data

b. 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 (Kelly and Greenstone 2016, 117).

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 (Brinda 2016, 142).

The breach notification requirement applies to: a. All PHI b. Unsecured PHI only c. Electronic PHI only d. PHI on paper only

b. Unsecured PHI only Breach notification requirements only apply to unsecured PHI that technology has not made unusable, unreadable, or indecipherable to unauthorized persons. This PHI is considered to be the most at-risk (Rinehart-Thompson 2016b, 240).

When reporting an encounter for a patient who is HIV positive but has never had any symptoms, the following code is 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]

b. 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 similar 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 (ICD-10-CM Coding Guideline I.C.1.a.2.d.; Schraffenberger and Palkie 2017, 123-124).

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

c. $5.43 per record The lead coder's annual salary is $20.35 × 2,080 (hours per year) = $42,328. The lead coder's productivity is 7.5 hours per day × 4 records per hour = 30 records per day. 30 records per day × 5 days per week × 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 (Horton 2016a, 174-175).

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

c. Planned Planned change is a formal process that is introduced methodically and is actively influenced by manager or change agents (Kellogg 2016b, 481-482; Kelly and Greenstone 2016, 75)

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. Finding

c. 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 hospitalization (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 (Sharp 2016, 178).

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

c. 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 (Brinda 2016, 163).

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 last 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 (Rinehart-Thompson 2017d, 243-244).

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

c. 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 (Schraffenberger and Palkie 2017, 344-345; Brinda 2016, 163).

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 records.

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 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 costs 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 (Thomason 2013, 96).

Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise? 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.

c. 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 (Thomason 2013, 25).

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

c. 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 (Prater 2016, 593).

Which of the following 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

c. 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 (Foltz et al. 2016, 459).

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 (Brinda 2016, 158).

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 (Rinehart-Thompson 2017c, 213).

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

c. 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 (Shaw and Carter 2015, 246).

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 (Rinehart-Thompson 2016c, 256).

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

c. 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 deaths occurring in a given time period by the total number of discharges, including deaths, for the same time period (Horton 2016b, 392-393).

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 Correct Answer: C 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 (Foltz et al. 2016, 450; AHIMA 2014, 110).

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 (Amatayakul 2016, 307).

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

c. 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 (Shaw and Carter 2015, 189).

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

c. 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 (Schraffenberger and Palkie 2017, 91).

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

c. Peer review Risk management programs have three functions: risk identification and analysis, loss prevention and reduction, and claims management (Carter and Palmer 2016, 522).

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

c. 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 (Amatayakul 2016, 292).

A statement or guideline that directs decision making or behavior is called a: a. Directive b. Procedure c. Policy d. Rule

c. Policy A policy is a statement that describes general guidelines that direct behavior or direct and constrain decision making in the organization (Gordon and Gordon 2016b, 537)

which of the following is the approved method for implementing an organizations 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 organization tools. Policies are written descriptions of the organizations 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.

This type of analytics allows users to prescribe a number of different possible actions: a. Descriptive analytics b. Predictive analytics c. Prescriptive analytics d. Real-time analysis

c. 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 (Horton 2016a, 325).

The quality improvement organizations (QIOs) under contract with CMS conduct audits on highrisk 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

c. 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) (Schraffenberger and Kuehn 2011, 32).

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

c. Qui tam One of the key components of the False Claims Act is qui tam. Qui tam is the whistleblower provisions of the False Claims Act—private persons, known as relators, 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 (Foltz et al. 2016, 449).

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

c. 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 be 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 (Schraffenberger and Kuehn 2011, 443).

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

c. Retention of high standard of coding There are a number of benefits of a coding compliance plan including retention of high standard of coding (Foltz et al. 2016, 461).

Which of the following technologies would reduce the risk that information is not accessible during a server crash? a. RAID b. Storage area network c. Server redundancy d. Tape or disk backup

c. 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 (Sayles and Trawick 2014, 212-213).

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

c. Should not be placed in a patient's health record

During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all the system modules. For example, they have to 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 (Rinehart-Thompson 2016c, 263).

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.

c. 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 (Shaw and Carter 2015, 46).

Which step of risk analysis identifies information assets that need protection? a. Identifying vulnerabilities b. Control analysis c. System characterization d. Likelihood determination

c. 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) (Rinehart-Thompson 2013, 117).

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 (Rinehart-Thompson 2016c, 271).

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 paste documentation d. Reimbursement risk

c. To monitor cut and paste 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 (Hess 2015, 269).

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

c. 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 (Foltz et al. 2016, 448).

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 (Johns 2015, 177).

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 menues 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.

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

d. $5.51 per record The new graduate coder's salary is $15.50 × 2,080 (hours per year) = $32,240. Productivity is 7.5 hours per day × 3 records per hour = 22.5 records per day. 22.5 records × 5 days per week × 52 weeks per year = 5,850 records per year. $32,240 / 5,850 = $5.51 per record (Horton 2016a, 174-175).

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

d. 18% error rate on abstracting data Performance measurement compares work outcomes 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 (Prater 2016, 588).

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

d. 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 (Horton 2016a, 185-186).

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 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

d. 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 (Rinehart-Thompson 2016c, 274).

The coding staff should be updated at least ________ on compliance requirements. a. Weekly b. Monthly c. Every six months d. Annually

d. 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 an annual basis (Foltz et al. 2016, 457).

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. 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 (Sharp 2016, 173).

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 (Klaver 2017a, 80).

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

d. 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 (Casto and Forrestal 2015, 256).

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

d. Competency Competencies are "do" statements identifying measureable 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 (Prater 2016, 568-569).

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. Meaningful Use c. Benchmarking d. Compliance

d. Compliance Compliance 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. In other words, compliance actively prevents fraud and abuse (Foltz et al. 2016, 448).

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 issues d. Conduct a retrospective review of all query opportunities for the year

d. 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, with 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 managers or a combination of these models. Retrospective review of all query opportunities for the year would help to validate the effectiveness of the new program (Schraffenberger and Kuehn 2011, 363).

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

d. 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 (Hess 2015, 214).

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 (Shaw and Carter 2015, 336).

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

d. 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 (Horton 2016b, 386).

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 (Brinda 2016, 148).

The data set designed to organize data for public release about the outcomes of care 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 managed healthcare plans (Shaw and Carter 2015, 179).

What is the most constant threat to health information integrity? a. Natural threats b. Environmental threats c. Internal threats d. Humans

d. 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) (Rinehart-Thompson 2013, 118).

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.

d. Incorrect code combinations 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 (Casto and Forrestal 2015, 269).

A notice that suspends the process or destruction of paper or electronic records is called: a. Subpoena b. Consent form c. Rule d. Legal hold

d. 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 (Klaver 2017a, 86-87).

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

d. 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 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 (Gordon and Gordon 2016a, 441).

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 (45 CFR 160.103(1); Rinehart- Thompson 2017c, 210-211).

What type of value-based purchasing program is the Hospital-Acquired Conditions Reduction Program? a. Quality consumer assessment b. Pay for reporting c. Quality incentive program d. Paying for value

d. 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 resource use while providing high-quality care. As the first step, CMS established the hospital-acquired conditions provision in the acute-care inpatient setting (Casto and Forrestal 2015, 306-307).

Which of the following uniquely identifies each record in a database table? a. Data definition b. Data element c. Foreign key d. Primary key

d. 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 (Johns 2015, 127-128).

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

d. 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 (Gordon and Gordon 2016c, 613).

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 a low coding error rate. d. Take no action because not enough information is given to make a judgment.

d. Take no action because not enough information is given to make a judgment The error rates are not comparable because there is no data about the number of records coded during the period by each coder (Schraffenberger and Kuehn 2011, 319-320).

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 (Shaw and Carter 2015, 406).

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

d. 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 (Schraffenberger and Kuehn 2011, 206).

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 (45 CFR 160.103; Rinehart-Thompson 2017c, 210-211).

Security Standards

ensure that patient-identifiable health information remains confidential and protected from unauthorized disclosure, alteration, or destruction

Content and structure standards

establish and provide clear and uniform definitions of the data elements to be included in the EHR systems. They specify the type of data to be collected in each data field and the attributes and values of each data field, all of which are captured in data dictionaries

Standard

fixed rules that must be followed

Vocabulary Standards

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 condition in the health record

nonmaleficence

means do no harm

nonfeasance

negligence meaning failure to act

oryx measurement

requirements are intended to support Joint Commission-accredited organizations in their quality improvement efforts. Performance measures are essential to the credibility of any modern evaluation activity for health care organizations.

Transaction Standards

standards that support the uniform format and sequence of data during transmission from one healthcare entity to another

the responsibilities of the quality improvement organizations include reviewing health records to confirm ______

the validity of hospital diagnosis and procedure coding data completeness

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 ______

their mission

what is the purpose of the risk management program

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