Mock exam 1

How long will it take to complete the project described below? 12 days 20 days 17 days 29 days

20 Days It will take 20 days to complete the task. The rewire occurs during the 10 days to receive the order. The Install takes 6 days. Then the traning takes 4 days. The supervisor training occurs the same time the clerks are trained.

Patient was seen for excision of two interdigital neuromas from the left foot. 28080 Excision, interdigital (Morton) neuroma, single, each 64774 Excision of neuroma; cutaneous nerve, surgically identifiable 64776 Excision of neuroma; digital nerve, one or both, same digit 64774 28080 64776 28080, 28080

28080, 28080 Look up in CPT codebook index under foot, neuroma.

As the information security officer at your facility, you have been asked to provide examples of the physical safeguards used to manage data security measures throughout the organization. Which of the following would you provide? proof of organizational firewalls chain-of-trust partner agreements acceptable policies regarding workstation use and location audit controls

acceptable policies regarding workstation use and location The Security Rule defines physical safeguards as "physical measures, policies, and procedures to protect a covered entity's electronic information systems and related buildings and equipment from natural and environmental hazards and unauthorized intrusions. Physical safeguards include measures that affect facility access control or workstation use such as automatic log offs and the use of privacy screens.

Which of the following responsibilities would you expect to find on the job description of a facility's chief security officer but NOT on the job description of chief privacy officer? Conduct audit trails to monitor inappropriate access to system information. Oversee the patient's right to inspect, amend, and restrict access to protected health information. Monitor the facility's business associate agreements. Cooperate with the Office of Civil Rights in compliance investigations.

Conduct audit trails to monitor inappropriate access to system information. While a privacy officer would likely be involved with facility training in privacy and security standards, a security officer is more likely to be responsible for the technical aspects of monitoring the security of protected health information.

Establishing a data strategy and policies for managing structured and unstructured data within the organization are a component of: Information Governance EHR Governance Documentation Governance Data Governance

Data Governance Information Governance is the framework to manage information through its life-cycle within an organization. This framework focuses on the proper use and application of information. Data governance is the overarching authority that ensures the cohesive operation and integration of all information. This includes the formal structure with the authority and responsibility to establish a data structure and policies for managing structured and unstructured data within the organization.

A newly hired HIM Director has been asked to review the organization's Legal Health Record policy and verify the documentation that needs to be included in and excluded from the legal health record. To complete this process the HIM Director should do which of the following first? Determine all statutes, regulations, rules, and guidelines that contain requirements affecting the release of information Meet with all department directors to verify the forms and types of documents created within their departments Develop a list of all forms and types of documentation for patient care and their source-systems Review all requests for copies of the legal health record from the past year

Determine all statutes, regulations, rules, and guidelines that contain requirements affecting the release of information Determining all statutes, regulations, rules, and guidelines that contain requirements affecting the release of information is the first step in the process. Then, all forms and documentation that are created need to be identified and reviewed to determine what needs to be included in and excluded from the legal health record.

The Release of Information function of the HIM Department is contracted to a release of information company. This is an example of what type of contracting arrangement? Full-service contracting Functional contracting Partial contracting Specialized contracting

Full-service contracting Full-service contracting involves outsourcing or handing-off an entire function to a contract company.

Make Me Better Clinic (MMBC) provides well child visits and childhood immunizations for four insurance companies. Data on the services they provided and the reimbursement they received from the four companies are listed in the two tables below. MMBC receives the best reimbursement for well-child visits from SureHealth. Lifecare. BeHealthy. Getwell.

Getwell.

Incomplete abortion complicated by excessive hemorrhage; dilation and curettage performed. Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS. {D62 Acute posthemorrhagic anemia O03.1 Delayed or excessive hemorrhage following incomplete spontaneous abortion O03.6 Delayed or excessive hemorrhage following complete or unspecified spontaneous abortion O03.4 Incomplete spontaneous abortion without complication 10D17ZZ Extraction, retained products of conception, via natural opening 0UDB7ZZ Extraction, endometrium, via natural opening} O03.1, D62, 0UDB7ZZ O03.1, 10D17ZZ​ O03.6, 0UDB7ZZ O03.4, 10D17ZZ

O03.1, 10D17ZZ​ O03 is reported for a spontaneous abortion. A spontaneous abortion may be complete or incomplete. The coding manual needs to be referenced for the assigning codes according to the types of complications.

A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? "W" "Y" "U" "N"

N

Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound site that was treated with antibiotics. When making decisions about sequencing the codes for this case, the coder should rely on definitions found in the Federal Register. Coding Clinic. CMS Coding Guidelines. UHDDS.

UHDDS. The Uniform Hospital Discharge Data Set (UHDDS) is a required data set for acute care facilities. This data set gives specific definitions of principal diagnosis and secondary diagnoses that must be followed when sequencing codes. The purpose of the UHDDS is to improve uniformity and comparability of data.

When analyzing records in the EHR, the HIM Specialist notices there are two of the same scanned documents within a patient record. One is completed and signed, the other is blank. She refers to the Analysis policy and procedure and it states to use the hide function for the unsigned document. This function allows the unsigned document to stay in the EHR but is only visible to those with administrator rights. The Analysis policy and procedure addresses which of the following? Analysis control Documentation maintenance Version control Documentation integrity

Version control Version control identifies which version(s) of the document(s) is available to the user. A health record may have multiple versions of the same document, such as a signed and unsigned copy of the same document. Addendums, corrections, or amendments can also create multiple versions of the same document. There must be policies and procedures to address version control.

Mary is 6 weeks post-mastectomy for carcinoma of the breast. She is admitted for chemotherapy. What is the correct sequencing of the codes? {C50.911 Malignant neoplasm of unspecified site of right female breast Z85.3 Personal history of malignant neoplasm of breast Z51.11 Encounter for antineoplastic chemotherapy Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm} Z08, Z51.11 Z51.11, Z85.3 Z85.3 Z51.11, C50.911

Z51.11, C50.911 The cancer is coded as a current condition as long as the patient is receiving adjunct therapy.See the Official Guidelines for Coding and Reporting 2018, Section 1.c.2.d. Primary malignancy previously excised "When a primary malignancy has been previously excised or eradicated from its site and there is no further treatment directed to that site and there is no evidence of any existing primary malignancy, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy."

Which of the following is a voluntary process of institutional or organizational review in which a quasi-independent body periodically evaluates the quality of the entity's work against pre-established criteria, such as Information Management or Environment of Care criteria? Accreditation Conditions for coverage Licensing Regulatory authorization

Accreditation Accreditation is a voluntary process or institutional or organizational review that evaluates the quality of the entity's work against preestablished criteria. Organizations seek accreditation to prove that they meet the standards of legitimate and appropriate medical practice.

In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to nationally known facilities. larger facilities. facilities with superior performance. facilities within your corporation.

facilities with superior performance. Benchmarking occurs when an organization uses comparative data between organizations to judge performance and identify improvements to be successful in other organizations.

Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with regular in-service presentations on the importance of accurate clinical documentation and tips for improvement. a copy of the facility coding guidelines, along with written information on improved documentation. feedback on specific instances when improved documentation would improve coding. the UHDDS and information on where each data element is collected and/or verified in your facility.

feedback on specific instances when improved documentation would improve coding. Providing feedback to physicians in concurrent and, as appropriate, retrospective reviews is the purpose of Clinical Documentation Improvement (CDI)

Which of the following is coded as an adverse effect in ICD-10-CM? rejection of transplanted kidney nonfunctioning pacemaker due to defective soldering mental retardation due to intracranial abscess tinnitus due to allergic reaction after administration of eardrops

tinnitus due to allergic reaction after administration of eardrops An allergic reaction is an adverse effect to medication properly administered.

Annual costs for the only Release of Information Clerk at Jacksonville Beach Healthcare Center (salary and benefits) are $36,429. The monthly cost for the copier used solely for ROI is $89 (supplies and repairs). It costs the department $0.95 on average for ROI mailings (envelopes and postage). There were 687 requests filled for ROI last month. The cost per request for release of information last month was $4.55. $4.63. $5.50. $4.42.

$5.50. Calculations:• $36,429 annual labor costs / 12 = $3,035.75 cost per month• $3,035.75 + $89 copier cost = $3,124.75 monthly costs/687• ROI last month = 4.548 or $4.55 unit cost (not counting mailing)• $4.55 + 0.95 average mailing cost = $5.50 per ROI

Provide the CPT code for anesthesia services for the transvenous insertion of a pacemaker. 00530 Anesthesia for permanent transvenous pacemaker insertion 00560 Anesthesia for procedures on heart, pericardial sac, and great vessels of chest; without pump oxygenator 33202 Insertion of epicardial electrode(s); open incision 33206 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 00530 33202, 00530 00560 33206, 00560

00530 Code 00530 for the anesthesia for the permanent transvenous pacemaker insertion.

During the work sampling of a file clerk's activity, it is noted that the employee is speaking on the telephone during 76 of 300 observations. How much of the employee's time is spent on the phone if the employee works 7 hours a day? 3.94 hours 1.77 hours 3.28% 9.2%

1.77 hours 76 / 300 = 0.253 0.253 x 7 hours = 1.77 hours

The performance standard for coders is 28-33 workload units per day. Workload units are calculated as follows: Inpatient record = 1 workload unit Outpatient surgical procedure records = 0.75 workload units Outpatient observation/emergency records = 0.50 workload units One week's productivity information is shown in the table above. What percentage of the coders is meeting the productivity standards? 25% 50% 75% 100%

100% employee # 425: 120 + (35 × 0.75) + (16 × 0.5) = 154.25154.25/5 = 30.85 average work units per dayemployee # 426: 48 + (89 × 0.75) + (95 × 0.5) = 162.25162.25/5 = 32.45 average work units per dayemployee # 427: 80 + (92 × 0.75) + (4 × 0.5) = 151151/5 = 30.2 average work units per dayemployee # 428: 65 + (109 × 0.75) + (16 × 0.5) = 154.75154.75 = 30.95 average work units per day

An HIM Department Budget Report for May shows a payroll budget of $25,000 and an actual payroll expense of $22,345. The percentage of budget variance for the month is $265. $2,655. 11%. 0.9%.

11%. A budget variance is the difference between the budgeted amount and the amount actually spent. To determine the percent variance, subtract the budgeted amount from the actual amount and then divide the difference by the budgeted amount. Calculation: 25,000 - 22,345 = 2,655 2,655 / 25,000 = 0.1062 x 100 = 10.62%, rounds to 11%

Patient was seen in the Emergency Department with lacerations on the left arm. Two lacerations, one 7 cm and one 9 cm, were closed with layered sutures. {12002 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 2.6-7.5 cm 12004 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk, and/or extremities (including hands and feet); 7.6-12.5 cm 12035 Repair, intermediate, of wounds of scalp, axillae, trunk, and/or extremities (excluding hands and feet); 12.6-20.0 cm 12045 Repair, intermediate, of wounds of neck, hands, feet, and/or external genitalia; 12.6-20.0 cm} 12002, 12004 12045 12035 12004

12035 The sizes of the layered wound repairs of the same body area are added together in order to select the correct CPT code.

A 335-bed hospital opened a new wing on June 1 of a nonleap year, increasing its bed count to 350 beds. The total bed count days for the year at the hospital was 122,275. 127,750. The answer cannot be calculated with the information provided. 125,485.

125,485. (335 x 151) + (350 x 214) = 125,485

The coder works 7.5 hours per day. If a time standard is determined from sample observations to be 2.50 minutes per record for coding emergency room records, what is the daily standard for the number of records coded when a 15% fatigue factor is allowed? 192 records per day 180 records per day 153 records per day 200 records per day

153 records per day Calculation:7.5 hours x 60 minutes per hour = 450 minutes per day450 x 15% = 67.5450 − 67.5 = 382.5382.5/2.5 = 153

RECORD COMPLETION INFORMATION FOR DECEMBER: 604 INCOMPLETE RECORDS: 604 DELINQUENT RECORDS: 304 AVERAGE MONTHLY DISCHARGES: 845 AVERAGE MONTHLY OPERATIVE PROCEDURES: 526 DELINQUENT OPERATIVE REPORTS: 14 What is the percentage of delinquent missing OP records from operative procedures? 2.7% cannot be determined from the information given 4.6% 1.7%

2.7% Calculation: (14 / 526) = 0.02661 x 100 = 2.66%, rounds to 2.7%.

A 1.234 12 B 3.122 10 C. 2.165 19 D 5.118 16 Based on the MS-DRG report above, what is the case-mix index for this facility? 57 11.639 0.2042 2.9658

2.9658 The case-mix index is calculated by multiplying the volume of patients in each category by the DRG weight (e.g., 1.234 DRG weight x 12 patients) and then dividing the total Medicare Severity-Diagnosis Related Group (MS-DRG) relative weights by the total number of discharges for a group. Calculation: 1.234 x 12 = 14.808 3.122 x 10 = 31.22 2.165 x 19 = 41.135 5.118 x 16 = 81.888 14.808 + 31.22 + 41.135 + 81.788 = 169.051 12 + 10 + 19 + 16 = 57 169.051 / 57 = 2.9658

You supervise five clerical employees who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for 200 square feet of space for your clerical staff. 350 square feet of space for your clerical staff. 300 square feet of space for your clerical staff. 250 square feet of space for your clerical staff.

300 square feet of space for your clerical staff. Generally, allow 60 sq ft per employee. However, as time progresses, less area is being allotted for personal space.

The patient had a thrombectomy, without catheter, of the peroneal artery, by leg incision. Provide correct CPT code for the procedure. 34203 Embolectomy or thrombectomy, with or without catheter; popliteal-tibioperoneal artery, by leg incision 35226 Repair blood vessel, direct; lower extremity 35302 Thromboendarterectomy, including patch graft if performed; superficial femoral artery 37799 Unlisted procedure, vascular surgery 35302 35226 37799 34203

34203 Code 34203 for the thrombectomy without catheter for the peroneal artery by making an incision in the leg. No mention of repairing a blood vessel or thromboendarterectomy.

The correspondence section of your department receives an average of 50 requests per day for release of information. It takes an average of 30 minutes to fulfill each request. Using 6.5 productive hours per day as your standard, calculate the staffing needs for the correspondence section. 2.5 FTE 3.5 FTE 3 FTE 4 FTE

4 FTE Calculation: 50 x 30 = 1,5001,500/60 = 2525/6.5 = 3.8Round up to 4.

A 4-year-old child had a repair of an incarcerated inguinal hernia. This is the first time this child had been treated for this condition. 49496 Repair initial inguinal hernia full-term infant, under age 6 months, or preterm infant over 50 weeks' post conception age and under 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated 49501 Repair initial inguinal hernia, age 6 months to under 5 years, with or without hydrocelectomy; incarcerated or strangulated 49521 Repair recurrent inguinal hernia, any age; incarcerated or strangulated 49553 Repair initial femoral hernia, any age; incarcerated or strangulated 49521 49553 49501 49496

49501 Code 49501 for the initial inguinal hernia repair for a 4-year-old child.

A patient with lung cancer and bone metastasis is seen for complex treatment planning by a radiation oncologist. {77263 Therapeutic radiology treatment planning; complex 77290 Therapeutic radiology simulation-aided field setting; complex 77315 Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77334 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds, or casts)} 77315 77263 77334 77290

77263 Code 77263 for complex therapeutic radiology treatment planning. No indication of simulation-aided field, teletherapy, or treatment devices.

A quantitative drug assay was performed for a patient to determine digoxin level. 80050 General health panel 80101 Drug screen, qualitative; single drug class method (e.g., immunoassay and enzyme assay), each drug class 80162 Digoxin (therapeutic drug assay, quantitative examination) 80166 Doxepin (therapeutic drug assay, quantitative examination) 80162 80101 80050 80166

80162 A quantitative drug assay was performed for a patient to determine digoxin level would be coded to 80162.

The file clerks in your department's main file area report that they are able to locate 400 out of 450 requested records during the past month. There are a total of 4,500 records in the main file. What is the area's accuracy rate? 1.1% 88.9% 8.9% 10.0%

88.9% 400 / 450 = 0.888888 x 100 = 88.9%

An established patient was seen by the physician in the office for DTaP vaccine and Hib. 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use 90748 Hepatitis B and Hemophilus influenza B vaccine (HepB-Hib), for intramuscular use 99211 Office or other outpatient visit for the evaluation and management of an established patient, which may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. 90700 90700, 90748, 99211 90748, 90471 90471, 90748

90471, 90748 If the immunization is the only service that the patient receives, then two codes are used to report the service. The immunization administration code is first and then the code for the vaccine/toxoid.

Patient was seen today for regular hemodialysis. No problems reported, tolerated procedure well. 90935 Hemodialysis procedure with single physician evaluation 90937 Hemodialysis procedure requiring repeated evaluations(s) with or without substantial revision of dialysis prescription 90945 Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation +99354 Prolonged physician service in the office or other outpatient setting requiring direct (face-to-face) contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient Evaluation and Management service) 90935 90937 99354 90945

90935 Dialysis is the main term to be referenced in the CPT manual index.

Office visit for 43-year-old male, new patient, with no complaints. Patient is applying for life insurance and requests a physical examination. A detailed health and family history was obtained and a basic physical was done. Physician completed life insurance physical form at patient's request. Blood and urine were collected. 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; infant (age under 1 year) 99386 Initial comprehensive preventive medicine evaluation and management of an individual including a comprehensive history, a comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; 40-64 years 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 40-64 years 99450 Basic life and/or disability examination that includes completion of a medical history following a life insurance pro forma 99450 99386 99396 99381

99450 The codes in this subsection are used to report evaluations for life or disability insurance baseline information.

Your HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report? 0-2 years 3-4 years 5 years >12 months 12-24 months 25-37 months 38-50 months <51 months 0-1 year 1-2 years 2-3 years 3-4 years 4-5 years <12 months 12-24 months 25-37 months 38-50 months 51-63 months

<12 months 12-24 months 25-37 months 38-50 months 51-63 months A grouped frequency distribution shows the values that a variable can take and the number of observations associated with each value. The data are sorted and separated into groups called classes. There are typically 5 to 20 classes are used, but in any case, make sure that you use enough classes to give a good description of the data. The classes must be mutually exclusive (non-overlapping). This means that there is no way that any of the data could fall into two different classes at once. The classes must be continuous—this means that there can be no gaps in the classes. The classes must be exhaustive, meaning that there must be a class for every data value in the data set. Lastly, the classes must be of equal width, otherwise the distribution would give a distorted view of the data. This frequency distribution is mutually exclusive, continuous, exhaustive, and equal.

Which of the following demonstrates the primary purpose for documenting and maintaining health records? Data source for public health and research A communication tool between health care professionals providing care to the patient Protect the organization from medical malpractice Monitor compliance with laws, regulations, and accreditation standards

A communication tool between health care professionals providing care to the patient One of the most important uses of the health record for patient care is the documentation of care by health care professionals to serve as a tool between health care professionals. All of the other examples are secondary purposes of the health record.

Four patients were discharged from Crestview Hospital yesterday. A final progress note is an appropriate discharge summary for Jackson, who had no comorbidities or complications during this admission for replacement of a pacemaker battery. Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. Fieldstone, who was admitted for 5 days following a heart attack for the acute onset of chest pain. Howard, who died within 24 hours after his admission for a second heart attack in 2 weeks.

Babson, who delivered a healthy 8-pound boy without complications for either mother or child, and was discharged within 36 hours of admission. Joint Commission standards allow a final progress note to substitute for a discharge summary in the following three cases: uncomplicated OB patient, normal newborn, and a minor stay of less than 48 hours. The Babson admission is the only one that qualifies.

CDI programs have been traditionally measured by financial data from DRG shifts and the shift in the organization's case-mix index. As CDI has grown, additional measures of success have been utilized. Which of the following items is not a measure of success for a CDI program? Reduction of coding queries Claims denials Bed occupancy rate Patient safety indicators and hospital-acquired infections

Bed occupancy rate Trending denial rates and query rates over time is another method of demonstrating the effectiveness of a Clinical Doumentation Improvement (CDI) program. Many CDI programs report a reduction in claims denials and physician queries due to the proactive collaboration of CDI and physicians for accurate and complete documentation. Patient safety indicators (PSIs) were developed by the Agency for Healthcare Research and Quality (AHRQ) to reflect quality of care by measuring potentially avoidable in-hospital complications and adverse events. CDI programs need to be on the lookout for certain PSIs that are used to measure a facility's quality scores and help ensure hospital-acquired conditions and their related present on admission (POA) indicators are reported correctly.

An 11-year-old female is brought to the emergency room with a compound, comminuted fracture of the right tibia and fibula. Her mother was very seriously injured in the same accident and is unconscious. What should be done? The hospital should quickly seek a court-appointed guardian for the child. Nothing, until consent can be obtained from the nearest relative. The mother can be treated under implied consent but not the child. Both patients can be treated under implied consent.

Both patients can be treated under implied consent. Even though the mother is not able to give expressed consent for treatment, permission is implied when the provider is acting in the patient's best interest to prevent death or preserve a limb.

Four people were seen in your emergency department yesterday. Which one will be coded as a poisoning? • Josh was diagnosed with digitalis intoxication. • Ben had an allergic reaction to a dye administered for a pyelogram. • Bryan developed syncope after taking Contac pills with a double scotch. • Matthew had an idiosyncratic reaction between two properly administered prescription drugs. Josh Ben Matthew Bryan

Bryan The condition should be coded as a poisoning when there is an interaction of an over-the-counter drug and alcohol (Bryan). Josh, Ben, and Matthew have adverse effects of a correctly administered prescription drug.

Which organizational document defines who can document within the health record, the type of documentation that can occur, and the timeliness and completeness of the documentation within the organization's health record? Strategic plan Bylaws Regulations Statute

Bylaws The bylaws are written documents that govern the staff members, both medical providers and non-physician providers, who create data within the health records for support of patient care and reimbursement. The bylaws define who can document within the health record, the type of documentation that can occur, and the timeliness and completeness of the documentation.

Your HIS Department receives an authorization for Sara May's medical history to be sent to her attorney, but the expiration date noted on the authorization has passed. What action is appropriate according to HIPAA Privacy Rules? Honor the authorization since the patient obviously approves of the release. Contact the patient to get permission to respond. Contact the attending physician for permission to respond. Do not honor because the authorization is invalid.

Do not honor because the authorization is invalid. Once an expiration date has passed on an authorization, it becomes invalid.

Your hospital takes advantage of the 8/80 exemption for health care facilities. Assuming that no employee worked more than 8 hours in a day, which of the employees listed in the table below will be paid overtime this pay period? Employees 101, 103, 104, and 105 Employees 101 and 105 Employees 101, 102, and 105 Employees 101, 104, and 105

Employees 101, 104, and 105 The 8/80 exception allows employers to pay one and one-half times the employee's regular rate for all hours worked in excess of 8 in a workday and 80 in a 14-day period. Although employees 103 and 104 worked more hours than scheduled, they still did not work overtime using the 8/80 rules.

The physician has documented the final diagnoses as acute myocardial infarction, COPD, CHF, hypertension, atrial fibrillation, and status post cholecystectomy. The following conditions should be reported: I10 Essential hypertensionI11.0Hypertensive, heart disease, with heart failure I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I48.91 Unspecified atrial fibrillationI 50.9 Heart failure, unspecified J44.9 Chronic obstructive pulmonary disease, unspecified Z90.49 Acquired absence of other specified parts of digestive tract I11.0, J44.9, I50.9, I10, Z90.49 I21.3, J44.9, I50.9, I11.0, I48.91 I11.0, J44.9, I50.9, I10, I48.91, Z90.49 I21.3, J44.9, I48.91, Z90.49

I21.3, J44.9, I50.9, I11.0, I48.91 Category Z90.49, acquired absence of other specified parts of digestive tract, is intended to be used for patient care where the absence of an organ affects treatment.

An Electronic Document Management Systems (EDMS) allows you to digitize paper patient records so that they can be viewed within the EHR or in a separate viewing platform. Documents are scanned in to the EDMS and indexing is completed through recognitions systems. Which of the following recognition systems utilizes artificial intelligence to allow the system to "learn" the form type through the handwriting or information on the form? OMR OCR ICR IWR

IWR Intelligent Character Recognition (ICR) is an advanced form of OCR in which the system "learns through artificial intelligence or artificial neural networks. Optical Mark Recognition (OMR) is the oldest form of optical recognition and requires pre-printed forms to contain locations for marking specific, limited information that is then read by a scanning system, and the content is incorporated into the EDMS. Optical Character Recognition (OCR) is the scanning of printed or type written text in structured locations on forms into machine-editable text. Intellegent Word Recognition (IWR) allows for the recognition of unconstrained handwritten words.

Patient was admitted from the nursing home in acute respiratory failure due to congestive heart failure. Chest x-ray also showed acute pulmonary edema. Patient was intubated and placed on mechanical ventilation for less than 24 hours and expired the day after admission. Code diagnoses using ICD-10-CM and procedures using ICD-PCS. I50.9 Heart failure, unspecified I50.1 Left ventricular failure J81.0 Acute edema of lung, unspecified J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia J96.20 Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia 0BH17EZ Insertion of endotrachial device, via natural or artificial opening via trachea 5A1935Z Ventilation, respiratory system, less than 24 consecutive hours I50.9, J96.20, J81.0, 0BH17EZ, 5A1935Z I50.9, J81.0, 0BH17EZ, 5A1935Z I50.9, J96.00, J81.0, 0BH17EZ, 5A1935Z J96.00, I50.1, 5A1935Z

J96.00, I50.1, 5A1935Z Acute pulmonary edema is included in the code for congestive heart failure (CHF). Insertion of endotracheal tube is included in the ventilation code.

Diverticulitis large bowel with ascending colon abscess was the diagnosis for a patient who was admitted with abdominal pain. Right hemicolectomy with colostomy performed. Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS. K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding K57.90 Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding K57.92 Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding K62.0 Anal polyp 0DTK0ZZ Resection, ascending colon, open approach 0DTL0ZZ Resection of transverse colon, open approach 0D1K0Z4 Bypass, ascending colon to cutaneous, open approach, no device K57.20, 0D1K0Z4 K57.92, 0DTK0ZZ, 0D1K0Z4 K57.90, 0DTL0ZZ, 0D1K0Z4 K57.92, K62.0, 0DTL0ZZ

K57.20, 0D1K0Z4 See ICD-10-PCS Official Guidelines for Bypass procedures (B3.6a): "Bypass procedures are coded by identifying the body part bypassed 'from' and the body part bypassed 'to.' The fourth character body part specifies the body part bypassed from, and the qualifier specifies the body part bypassed to."

Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes. {I66.9 Occlusion and stenosis of unspecified cerebral artery K80.10 Chronic cholecystitis with chronic cholelithiasis without obstruction Z53.09 Procedure and treatment not carried out because of other contraindication I97.821 Postprocedural cerebrovascular infarction during other surgery 0FT40ZZ Resection of gallbladder, open approach (cholecystectomy)} K80.10, I66.9, Z53.09 I66.9, Z53.09 I97.821, K80.10, 0FT40ZZ I97.821, I66.9, Z53.09

K80.10, I66.9, Z53.09 The INCLUDES notation beneath I66 informs you that cerebral thrombosis is reported with a code from this code category.

You have received a valid patient authorization and subpoena duces tecum requesting the custodian of records to appear in court with all records kept in the normal course of business. In reviewing the request and the master patient index, you validate that the patient was treated at your facility on the date referenced in the request. When preparing the records, you must consider the organization's definition of: Hybrid Record Legal Health Record Designated Record Set Metadata

Legal Health Record The legal health record is released upon a valid request and the contents may vary based on how the organization defines it. It may include information other than clinical documents, such as radiological images, videos, or photographs. The designated record set is defined by HIPAA as a covered entity's health records and records involved in billing, insurance, enrollment, coverage and any other documents used to make decisions about individuals. All documents and data must be evaluated for designation as the legal health record and/or designated record set.

The Systems Development Life Cycle (SDLC) consists of four primary phases. Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of which phase? Design Implementation Planning and Analysis Maintenance and Evaluation

Maintenance and Evaluation Defining system goals, defining project objectives and scope, and determining and prioritizing the system requirements are part of the Design phase. The Systems Development Life Cycle (SDLC) consists of four primary phases: Planning and Analysis: In this phase the organization first defines the goals and scope of the project. The focus on this phase is on defining the organization's business problem and the resources that may be needed to develop the project, along with an in-depth assessment of user needs and functional requirements. Design: During this phase the system goals, project objectives and scope, determination and prioritization of system requirements, screening for vendors, development of an RFI or RFP, evaluation of vendors, and contract negotiations are completed. Implementation: Implementation and training occur in this phase. Maintenance and Evaluation: This phase focuses on responding to identified problems and concerns and the ongoing maintenance of the system.

You are the office manager at a large group practice. One of the physicians at your practice has asked you to research and supply her with information about Medicare's newest payment incentives and how to comply with the quality reporting requirements. You will bring this inquisitive physician facts from CMS regarding Merit-based Incentive Payment System (MIPS) Physician Quality Reporting System (PQRS) diagnosis related groups (DRGs) Stage 2 of meaningful use requirements

Merit-based Incentive Payment System (MIPS) The Merit-Based Incentive Payment System (MIPS) is one of two tracks under the Quality Payment Program, which moves Medicare Part B providers to a performance-based payment system. MIPS streamlines three historical Medicare programs—the Physician Quality Reporting System (PQRS), the Value-Based Payment Modifier (VM) Program, and the Medicare Electronic Health Record (EHR) Incentive Program ( Meaningful Use)—into a single payment program. All Medicare Part B providers who meet the definition of a MIPS Eligible Clinician should plan to participate in MIPS in 2017, or they will be subject to a negative 4% payment adjustment on Medicare Part B reimbursements in 2019.

Vaginal delivery with episiotomy of full-term live-born infant. Patient undergoes repair of delivery episiotomy and postdelivery elective vaginal endoscopic ligation of fallopian tubes bilaterally. Code the diagnoses using ICD-10-CM and procedures using ICD-10-PCS. O80 Encounter for full-term uncomplicated delivery Z30.2 Encounter for sterilization Z37.0 Single live-born 0UL74ZZ Occlusion, bilateral fallopian tubes, percutaneous endoscopic approach, no device 10E0XZZ Delivery of products of conception, external, no device 0W8NXZZ Division, perineum, female (episiotomy) Z37.0, 0W8NXZZ, 0UL74ZZ O80, Z37.0, 0UL74ZZ O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ O80, Z37.0, 10E0XZZ, 0UL74ZZ

O80, Z37.0, Z30.2, 10E0XZZ, 0W8NXZZ, 0UL74ZZ Whenever there is a delivery, there must also be an Outcome of Delivery code. Each of these procedures is reported separately: the delivery, the episiotomy, and the occlusion of the fallopian tubes.

As the director of a Health Information Technology Program, you are reviewing the workforce development forecast for electronic health record specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the website of which governmental agency? CMS OSHA CDC ONC

ONC The Office of the National Coordinator for Health Information Technology (ONC) produced a federal Health IT Strategic Plan that includes three major focus areas with the intent to collect patient-generated data, share information more effectively with patients, and use technology and data to improve population health.

The rate of surgical complications or rate of hospital-acquired infections are examples of: Structural Measures Process Measures Outcome Measures Risk Measures

Outcome Measures Structural measures are those that give consumers a sense of a health care provider's capacity, systems, and processes to provide high-quality care. This can include the number of board-certified physicians or the ratio of patients to providers.Process measures are those that are done to maintain or improve health for either healthy people or those diagnosed with a condition. This can include the percentage of patients receiving preventive care services such as mammograms or immunizations. Outcome measures reflect the impact of the health care service on the health status of patients. This can include mortality rates, surgical infection rates and the rate of hospital-acquired infections.

You are implementing a quality improvement plan that utilizes the PDSA cycle. If you correctly implement PDSA, which phase of the project will take the most of your time? D P S A

P The PDSA cycle is a process for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). It is a four-step cycle that allows you to implement change, solve problems, and continuously improve processes. Its cyclical nature allows it to be utilized in a continuous manner for ongoing improvement. The planning step usually takes the most amount of time.

The transcriptionists have collected data on the number and types of problems with the dictation equipment. The best tool to display the data they collected is a PERT chart. Pareto chart. flowchart. Gantt chart.

Pareto chart. Pareto charts are graphs that display bars arranged in descending order to indicate, which issues or problems should be considered first. A Pareto chart would provide the best format for organizing the number and types of problems with the dictation equipment. A flowchart displays a picture of a process. PERT and Gantt charts are project management tools.

The Quality Payment Program consists of four categories for the measures and activities that providers must report data for the year. Which of the following is not one of the required categories? Quality measures Cost measures Promoting interoperability Physician satisfaction

Physician satisfaction Quality measures 45% Promoting interoperability 25% Improvement activities 15% Cost measures 15%

What are the four functions of management utilized by HIM Directors, Managers and Supervisors use on a day-to-day and long-term basis to ensure the organization is complying with the laws and regulations that mandate the management of HIM functions? Strategizing, organizing, controlling, and managing Planning, controlling, leading, and organizing Planning, maintaining, leading and organizing Strategizing, maintaining, controlling, and leading

Planning, controlling, leading, and organizing Planning, controlling, leading, and organizing are the four functions of management. Planning is the examination of the future and preparation of action strategies to attain goals for the department or the organization. Controlling is the function in which performance is monitored according to policies and procedures. Leading is the function in which people are directed and motivated to achieve the goals of the organization. Organization is coordinating all the tasks and responsibilities to guarantee the work to be completed correctly and in a timely manner.

Which of the following is an example of unstructured data? ICD-10 codes Vitals Date of birth Progress note

Progress note Unstructured data is data that does not have a predefined data model or is not stored in a traditional database. Unstructured data is typically found in documents, emails, and images. ICD-10 codes, date of birth, and vitals are all examples of structured data. This is data that is organized and easily retrievable and interpreted by traditional databases and data models.

Gail Smith has presented to the ER in a coma with injuries sustained in a motor vehicle accident. According to her sister, Gail has had a recent medical history taken at the public health department. The physician on call is grateful that she can access this patient information using the area's RHIO. CPOE. EDMS system. expert system.

RHIO. A Regional Health Information Organization (RHIS) is a group of organizations within a specific area that share health information electronically, according to accepted health information technology standards. A RHIO typically oversees the health information exchange among various provider settings, payers, and government agencies. The RHIO is one model toward achieving the proposed National Health Information Network (NHIN).

Upon the discharge of a patient, an HIM specialist reviews each record in the EHR to verify all documentation is in the correct location. For example, they will verify all physician progress notes are in the progress note section, lab results are in the laboratory section, and radiology results are in the radiology section. The EMR uses which of the following formats? Source-oriented Integrated Practice-oriented System-oriented

Source-oriented Source-oriented records are organized based on the source of the documentation or department that rendered the service. Integrated records are organized in strict chronological order. Practice-oriented and System-oriented are not recognized formats.

You are assisting the HIM Director with the review and update of health record retention policies. You want to determine how long the health records should be retained by the organization. Which of the following sources will you utilize? Medical staff bylaws Joint Commission accreditation standards State statute AHIMA record retention toolkit

State statute The first resource must be the state statutes to determine if there is a statute that states how long health records must be retained and how they can be destroyed. All states may not have statutes regarding the retention and destruction of health records. AHIMA provides professional practice guidelines for the retention of records to assist HIM professionals in determining their policies and procedures for record retention.

Generally, CMS requires the submission of a claim (CMS 1450) for inpatient services provided to a Medicare beneficiary for inpatient services. An exception to this requirement would be when -attempts are made to charge a beneficiary for a service that is covered by Medicare. -the physician furnishes a covered service to the beneficiary. -the beneficiary refuses to authorize the submission of a bill to Medicare. -an ABN was given to the beneficiary for services unlikely to be covered by Medicare.

The beneficiary refuses to authorize the submission of a bill to Medicare When a beneficiary refuses to authorize the submission of a bill to Medicare, the Medicare provider is not required to submit a claim to Medicare

RHIT Mock Examination (Untimed) Your Score: 58%87 Correct out of 150Question 35 of 150 The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to let the administrative departmental staff get training. If you can talk him into training his staff, you can let him skip the training. This level of involvement is enough to meet Joint Commission standards. This will not do because it violates Joint Commission standards and CQI philosophy. The Joint Commission only expects involvement from clinical staff.

This will not do because it violates Joint Commission standards and CQI philosophy Acceptance of the CQI philosophy must funnel down from the top to truly permeate the organization's culture. Executive leadership must communicate a clear vision and mission statement that every employee can understand and share.

The electronic system at your physician practice allows for e-prescribing and the exchange of data to a centralized immunization registry, and lets your physicians report on key clinical quality measures. In all likelihood, your practice has succeeded in implementing a Joint Commission-approved system. an AMA-approved product. a functional EMR. a certified EHR.

a certified EHR. The Certified Electronic Health Record Technology standards (CEHRT) are used to inform technology vendors and providers about the functionality required to receive incentive payments for the implementation of EHR technology in the Centers for Medicare and Medicaid Services (CMS) EHR incentive program.

The discharge diagnosis for this inpatient encounter is rule out myocardial infarction. The coder would assign no code for this condition. a code for a myocardial infarction. a code for an impending myocardial infarction. a code for the patient's symptoms.

a code for a myocardial infarction. When a diagnosis is preceded by the phrase "rule out" in the inpatient setting, code the condition as a present diagnosis for that visit.

The ER staff has collected the data on the number of visits and corresponding wait times in the ER. The data are displayed on the chart shown above. Based on this information, what kind of correlation do you see between the number of visits (Variable X) and the wait times (Variable Y)? a negative correlation between Variable X and Variable Y a positive correlation between Variable X and Variable Y a causative correlation between Variable X and Variable Y a conjunctive correlation between Variable X and Variable Y

a positive correlation between Variable X and Variable Y Scatter diagrams display the strength of relationship between two variables. A strong relationship is seen as the data come closer to forming a straight line. When both variables increase and decrease at the same time, and the line progresses from the lower left toward the upper right corner, a positive relationship is demonstrated.

A major drug company wants to promote a fundraiser targeting patients with congestive heart failure. The drug company representative has requested a list of patients treated at your facility. As privacy and security officer, you tell them that you will need to confer with the medical director. they just need to send a written request for the list. a prior authorization is required before any PHI can be released. if the fundraising was conducted by a business associate without authorization, and the funds were to benefit your facility (the covered entity), that you could disclose the information.

a prior authorization is required before any PHI can be released. The use of patient information for marketing strategies, such as fundraising, requires authorization. There are certain exceptions when marketing services to patients.

You have been asked to report the registry's annual caseload to administration. The most efficient way to retrieve this information would be to use patient index. patient abstracts. accession register. follow-up files.

accession register. When a case is first entered into the cancer registry, an accession number is assigned. The unique number is assigned to the patient (not the tumor). The accession number provides a unique identifier for the patient consisting of the year in which the patient was first seen at the reporting facility and the consecutive order in which the patient was abstracted. The first four numbers specify the year, and the last five numbers are the numeric order the patient was entered into the registry database. There is only one accession number per patient, per facility, and per lifetime. A patient's accession number is never reassigned.

The patient's family asked the attending physician to keep the patient in the hospital for a few days more until they could make arrangements for the patient's home care. Because the patient no longer meets criteria for continued stay, if the physician complies with the family's request, this would be considered the best utilization of the hospital's resources. an underutilization of the hospital's resources appropriate provided it is limited to a few days. an inappropriate use of hospital resources.

an inappropriate use of hospital resources. The necessity for inpatient hospitalizations and continued stays are strictly regulated by intensity of service and severity of illness criteria which indicate services that can be provided only at an acute level of care. To keep a patient hospitalized for reasons not tied to these criteria would indicate an overutilization of hospital resources and likely, a denial of reimbursement.

Reviewing the health record to ensure required reports are completed and authenticated is called indexing. coding. abstracting. analysis.

analysis. Analysis is a review of the health record to ensure completeness. Analysis can also be completed to review the quality of the health record; for example, reviewing the quality of physician or nursing documentation, timeliness of documentation, and other documentation standards.

A Clinical Documentation Specialist performs many duties. These include reviewing the data, and looking for trends or patterns over time, as well as noting any variances that require further investigation. In this role, the CDS professional is acting as a(n) ambassador. reviewer. educator. analyst.

analyst. The CDS professional may act as a reviewer and educator, but the duties described are most representative of his or her role as an analyst. Ambassador is a distractor. A CDI analyst conduct ongoing analyses of clinical documentation while providing extensive collaboration with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded.

Your facility has a team that has been working to develop a strong performance improvement model, and they have come up with the model shown above. The team asks if you see anything missing from the model. You tell them they are missing a step requiring regular employee input into the process. are missing a step requiring ongoing monitoring and reassessment. aren't missing any steps; the model is a good one. are missing a step requiring reporting to the board of directors.

are missing a step requiring ongoing monitoring and reassessment. Performance improvement includes evaluating and continuously monitoring performance measures to ensure expectations are being met.

Postage charges in the health information department have increased during the last quarter. The department director has seen metered envelopes in the mail bin that do not appear to be those used for departmental business. The best course of action for the director would be to assign responsibility for the postage meter to one employee. issue employee warnings at the next departmental meeting. keep a watchful eye on the meter and who uses it. remove the postage meter from the department.

assign responsibility for the postage meter to one employee. Delegating responsibility for the postage meter allows for control over the process and ensures appropriate monitoring of the task.

As the information security officer at your facility, you have been asked to provide examples of technical security safeguards as required of HIPAA Security Rule. Which of the following would you provide? audit controls surge protectors workstation use and location evidence of security awareness training

audit controls Under the Security Rule, technical safeguards include automatic log off and unique user identification to protect access and control of ePHI.

A patient was treated for meningitis at age 3 (18 years ago). The patient is now 21. The patient's attorney is requesting information on the admission. You tell the clerk the information is available, but the patient's parents will have to sign a consent for you to release it. available, and the patient may sign consent to release the information in the record. available, but the attorney will have to obtain a court order before you will release it. no longer available because your facility retains information for 10 years after the last patient visit.

available, and the patient may sign consent to release the information in the record. Once a patient has reached the age of majority, he/she has the right to access his/her own health information.

A(n) ___________ addresses how patient information should be documented in the event the EHR is down or during a catastrophic event. documentation plan business continuity plan emergency response plan risk analysis

business continuity plan The business continuity plan is a set of policies and procedures to direct the organization on how to continue its business operations during an information shut-down.

A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc.). The quality improvement tool most likely to help collect these data would be flowchart. force field analysis. check sheet. decision matrix.

check sheet. A checksheet is a data collection tool permitting the recording and compiling of observations or occurrences. It consists of a simple listing of categories, issues, or observations on the left side of the chart and a place on the right for individuals to record checkmarks next to the item when it is observed or counted.

The Pharmacy and Therapeutics Committee has asked you to find out more about a computerized order entry system that calculates drug dosages based on patient parameters (weight, age, etc.) and even suggests the best drug given the patient's diagnosis and current treatment. The committee is asking for information on a(n) clinical decision support system. practice parameters system. ordering system. application system.

clinical decision support system. Knowledge-based components of a clinical decision system include: (1) a knowledge-based system that provides facts, or evidence, concerning a domain of knowledge; (2) production rules that are a generic set of "if..then.." structures, or rules that draw from the knowledge base; (3) an inference engine, which is the software that controls how the rules are applied to specific facts about the patient; and (4) the user interface.

You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM-5 for billing purposes. You find this "theoretically" reasonable because DSM-5 codes are also valid ICD-10-CM codes. is the industry standard for psychiatric billing systems. is a widely used system for coding injury in ambulatory care systems. codes are also valid CPT codes.

codes are also valid ICD-10-CM codes. DSM-5 standardizes the clinician's diagnostic process for patients with mental disorder. The codes incorporated into the classification are ICD-10-CM.

Each month, the staff of the clinic with the lowest overall waiting time is awarded a free dessert in the Gulfside Healthcare Center cafeteria. Take a look at the information listed above. The winner will be selected based on objective individual data. demonstrative clinical data. duplicate thematic data. comparative aggregate data.

comparative aggregate data. The data displayed is best described as aggregate data, or data extracted from individual health records and then grouped to form de-identified information about a population of patients. Aggregated information can be analyzed and compared in a way that individual health records cannot. Aggregate data can help care providers see patient data from a completely new angle. While it may not provide specific details needed to treat patients, it can offer crucial insight for strategic planning.

Which of the following scenarios identifies a pathologic fracture? compression fracture of the vertebrae as a result of bone metastasis compression fracture of the skull after being hit with a baseball bat greenstick fracture secondary to fall from a bed vertebral fracture with cord compression following a car accident

compression fracture of the vertebrae as a result of bone metastasis A pathologic fracture is one caused by a diseased condition. In this case, the bone cancer is the underlying cause of the fracture.

Which of these conditions are always considered "present on admission" (POA)? acute conditions congenital conditions possible, probable, or suspected conditions E codes

congenital conditions As required by the Deficit Reduction Act of 2005 (DRA), the HAC-POA Indicator Reporting provision requires a quality adjustment in Medicare Severity-Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions (HACs). IPPS hospitals must submit present on admission (POA) information on principal and all secondary diagnoses for inpatient discharges. IPPS hospitals do not receive the higher payment for cases when one of the selected conditions is acquired during hospitalization (i.e., the condition was not POA). The case is paid as though the secondary diagnosis is not present. Hospitals must identify the conditions that are present on admission to receive appropriate reimbursement. A congenital condition is present at birth and would therefore be present on any subsequent admission.

Sunset Beach Clinic allows patients to communicate by email to ask questions regarding their treatment and request appointment changes. Emails and text messages are not typically maintained or documented as patient encounters. generally maintained in a facility's electronic mail system until the next face-to-face patient encounter. considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters. considered proof of patient contact and should be summarized in a progress note in the patient record.

considered health care business records and are subject to the same regulations as records created in face-to-face patient encounters Best practice for handling a patient's email and/or text questions is to treat the information as protected health information and to apply the same security safeguards as other PHI.

The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure the level of software support will be considered in the decision. consistent criteria are used to evaluate the alternatives/vendors. the personalities of individual vendors will not influence the decision. all alternatives/vendors are evaluated subjectively.

consistent criteria are used to evaluate the alternatives/vendors. A data matrix analysis helps organize information to make a decision by listing options as rows in a table and the factors as columns. Then a ratings scale is established to assess the value of each option/factor combination to determine a score for each option.

A patient has written to request a copy of his own record. When the clerk checked the record, it was noted that the patient was last admitted to the psychiatric unit of the facility. You advise the clerk to contact the patient's attending physician before complying. ignore the request and to advise you if it is repeated. comply with the request immediately. ask the patient to send the required fee prior to the release.

contact the patient's attending physician before complying. When releasing information to a patient in a behavioral health setting, it is typical to contact the physician to make sure that releasing the information would not hinder the patient's course of treatment. Under the HIPAA privacy rule, if the physician has determined that access requested is reasonably likely to endanger the life or physical safety of the individual or another person, the organization can or may refuse the request. If release of the information is not in the best interest of the patient, then the physician may prepare a summary of the visit to provide to the patient. The patient may appeal the decision to refuse access.

Your organization's medical staff rules and regulations require that physicians complete all health record documentation within thirty days of discharge. If the documentation is not completed within thirty days then the record is considered delinquent. suspended. partially complete. unfinished.

delinquent. If a health record remains incomplete for the specified number of days as defined within the medical staff rules and regulations, then the record is considered delinquent. The specific number of days can vary by health care organization but is typically fifteen to thirty days.

Which of the following best describes a goal of a CDI program? -Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnosis and procedures -Utilize open-ended or multiple-choice queries as a communication tool with providers to obtain clinical clarification, documentation alert, or ask additional questions. -Utilize computer-assisted coding (CAC) software to search and evaluate clinical documentation to identify potential areas for documentation integrity -Complete audits to determine if the documentation in the health record meets the expectation of the codes being billed to the insurance company

dentify and clarify missing, conflicting, or nonspecific provider documentation related to diagnosis and procedures The goals of a CDI program are: -Obtain specific documentation that can be used to identify the patient's severity of illness. -Identify and clarify missing, conflicting, or nonspecific provider documentation related to diagnosis and procedures. -Support accurate diagnostic and procedural coding, and Medicare Severity Diagnosis Related Group (MS-DRG) assignment, leading to appropriate reimbursement. -Promote health record completion during the patient's course of care, which promotes patient safety. -Improve communication between physicians and other members of the health care team. -Provide awareness and education. -Improve documentation to reflect quality and outcome scores. -Improve coding professional's clinical knowledge.

A supervisor reviews a job to determine the required content, skills, knowledge, abilities, and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job analysis. detail. description. process.

description. A job description outlines the work to be performed by a specific employee or group of employees with the same responsibilities. This generally consists of three parts: (1) a summary of the position's requirements and purpose, (2) its functions, and (3) the qualifications needed to perform the job.

An effective means of protecting the security of electronic health information would be to write detailed procedures for the entry of data into the computerized information system. install a system that would require fingerprint scanning and recognition for data access. develop clear policies on data security that are supported by the top management of the facility. require all facility employees to change their passwords at least once a month.

develop clear policies on data security that are supported by the top management of the facility. Data security management includes developing, implementing, and enforcing data security policies and procedures.

In preparation for conversion to an electronic health record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data feasibility. edits. dictionary. reasonableness.

dictionary. A data dictionary describes all the primitive level data structures and data elements within a system.

You are the Director of Coding and Billing at a large group practice. The practice manager stops by your office on his way to a planning meeting to ask about the timeline for complying with HITECH requirements to adopt Promoting Interoperability (formerly Meaningful Use) technology. You reply that the incentives began in 2011 and ended in 2014. You remind him that in 2015, sanctions for noncompliance began to appear in the form of a mandatory action plan for implementing a meaningful use EHR. monetary fines up to $100,000. downward adjustments to Medicare reimbursement. withdrawal of permission to treat Medicare and Medicaid patients.

downward adjustments to Medicare reimbursement. EHR incentive program penalties will apply specifically to Medicare eligible professionals (EPs) who do not demonstrate and attest to Promoting Interoperability (formerly Meaningful Use). However, Medicaid EPs who see patients under the Medicare Physician Fee Schedule (PFS) are also subject to a payment reduction.

An HIM specialist has noticed that a patient has two medical record numbers. The patient has an ER visit from one month ago that is listed under one number and is currently an inpatient under a second number. This is an example of a(n) __________ record.\ overlay deficiency overlap duplicate

duplicate A duplicate record results when the patient has two or more medical record numbers issued. This results in some of their health information being stored under one medical record number and some stored under another medical record number. An overlay is when a patient is erroneously assigned another person's medical record number. With an overlay, patient information for both patients is stored within the same medical record number. An overlap is when a patient has more than one medical record number at different locations within an enterprise or health care organization.

Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is consistent formatting of each page of each form. giving each form or view an identifiable name, number, and revision date. capturing every data item required by UHDDS. providing instructions when necessary for appropriate data fields.

giving each form or view an identifiable name, number, and revision date. Forms management requires the development of guidelines and processes for forms control, this includes guiding the design of forms and including elements that identify the patient, the form type, and the version of the form.

In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to quality review committees within the hospital. In this case, the PHI is being used as part of the facility's treatment. payment. documentation improvement plan. health care operations.

health care operations. The HIPAA Privacy Rule allows covered entities to use and disclose protected health information for the purpose of treatment, payments, or health care operations

The facility's policy for physician's verbal orders in accordance with state law and regulations needs updating. The first area of investigation is the qualifications of those individuals who have been authorized to record verbal orders. For this information, you will consult the policy and procedure manual. data dictionary. hospital's Quality Management Plan. hospital bylaws, rules, and regulations.

hospital bylaws, rules, and regulations. Accreditation standards require a hospital's staff bylaws, rules, and regulations to address who is authorized to accept verbal orders.

Authentication is one of the components necessary to produce a legal document in an EHR. This means identifying who created a document and when. using the data dictionary for accuracy in entering information into the health care record. creating audit trails. providing the medical history and review of systems for the patient health care record.

identifying who created a document and when. Authentication is the process of identifying the source of entries in the EHR through an electronic signature.

You are conducting an educational session on benchmarking. You tell your audience that the key to benchmarking is to use the comparison to implement your QI process. compare your department with another. improve your department's processes. make recommendations for improvement.

improve your department's processes. Benchmarking involves comparing your department to other departments or organizations known to be excellent in one or more areas. The success of benchmarking involves finding out how the other department functions and then incorporating their ideas into your department.

According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is percutaneous. punch. excisional. incisional.

incisional. An incisional biopsy is cutting of breast tissue where a small portion or slice of a lesion is removed.

Patient data is collected to support patient care. Without patient data, the health care organization would not be able to support the continuity of patient care or billing of services provided to the patient. This is an example of a(n) data asset. company asset. information asset. strategic asset.

information asset. An information asset is the information collected during the day-to-day operations of a health care organization that has value within the health care organization.

The special form or view that plays the central role in planning and providing care at skilled nursing, psychiatric, and rehabilitation facilities is the medical history and review of systems. interval summary. interdisciplinary patient care plan. problem list.

interdisciplinary patient care plan. The interdisciplinary patient care plan is the foundation around which patient care is organized. It contains input from the unique perspective of each discipline involved. It includes an assessment, statement of goals, identification of specific activities, or strategies to achieve those goals and periodic assessment of goal attainment. The care plan is initiated when a patient begins care or is admitted, and it is updated periodically. It is reviewed and revised as often as the organization, regulatory agencies, and accrediting bodies require when goals change, or when the patient circumstances have changed. The interdisciplinary care plan is required for most patient care sites. Exceptions are a physician's office or clinic and an acute care hospital where the physician plan and other practitioner's plans are documented separately.

A patient's husband slipped and fell in your HIM reception area and now he is suing the facility. You have been asked to prepare detailed written answers to a long list of questions and send them to your hospital attorney. You will spend the afternoon working on allocutions. affidavits. interrogatories. depositions.

interrogatories. Interrogatories are a list of questions used in the discovery stage of a trial to obtain information from other parties in a lawsuit. A deposition is sworn verbal testimony that is obtained during the discovery phase of a trial. An allocution, or elocutus, is a formal statement made to the court by the defendant who has been found guilty prior to being sentenced. An affidavit is a written statement confirmed by oath or affirmation for use as evidence in court.

INCOMPLETE RECORDS: 604 DELINQUENT RECORDS: 304 AVERAGE MONTHLY DISCHARGES: 845 AVERAGE MONTHLY OPERATIVE PROCEDURES: 526 DELINQUENT OPERATIVE REPORTS: 14 Use the information provided in the table above to calculate the delinquent rate. The delinquent rate is 50%. is 36%. cannot be determined. is 71%.

is 36%. To calculate the delinquency rate, the formula for a rate can be applied. A rate is a fraction that is formulated to express the relationship between the numerator and denominator. The basic rule of thumb for calculating rates is to divide the number of times something actually happened in relation to the number of times it could have happened.

Johnston City was set upon by a swarm of killer bees. All 5,000 residents are at risk of a bee attack. If 25 residents were attacked by the bees, the incidence of bee attacks is 25 in 1,000. cannot be determined at this time. is 5 in 5,000. is 5 in 1,000.

is 5 in 1,000. 25 / 5000 = 0.005 0.005 x 1000 = 5 per 1,000

As a CTR, you know that staging designates the degree of differentiation of cells. is a system for documenting the extent or spread of cancer. refers to the monitoring of incidence and trends associated with a disease. is continued medical surveillance of a case.

is a system for documenting the extent or spread of cancer. The staging of the cancer refers to the extent of the spread of the cancer. At the time of initial diagnosis and treatment, the stage of the cancer is recorded and included in the registry. Pathology reports on cancerous tissue typically include the stage of the neoplasm that provides information on the size and extent of spread of a tumor throughout the body.

In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post-surgery. There is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the lab report. pathology report. operative report. nurses' notes.

lab report. The administration of an antibiotic such as Keflex implies that the patient has an infection. The coder can verify this by checking the patient's white blood count in the lab report.

Which of the following diagnoses or procedures would prevent the normal delivery code, O80, from being assigned? episiotomy occiput presentation low forceps single live-born

low forceps See the ICD-10-CM Official Guidelines for 2018, Section 1.c.15.n Encounter for full-term uncomplicated delivery Code O80 should be assigned when a woman is admitted for a full-term normal delivery and delivers a single, healthy infant without any complications antepartum, during the delivery, or postpartum during the delivery episode. Code O80 is always a principal diagnosis. It is not to be used if any other code from Chapter 15 is needed to describe a current complication of the antenatal, delivery, or perinatal period. Additional codes from other chapters may be used with code O80 if they are not related to or are in any way complicating the pregnancy.

You stop by the office to meet a friend for lunch. Looking on her desk, you see the grid above. Your friend is trying to design a system. plan a conversion. make a decision. analyze a workflow.

make a decision. A data matrix analysis helps organize information to make a decision by listing options as rows in a table and the factors as columns. Then a ratings scale is established to assess the value of each option/factor combination to determine a score for each option.

Which of the following is considered a late effect regardless of time? nonunion poisoning nonhealing fracture congenital defect

nonunion See the ICD-10-CM Official Guidelines 2018, Section 1. a. Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth, or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

A patient initially consulted with Dr. Vasseur at the request of Dr. Meche, the patient's primary care physician. Dr. Vasseur examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vasseur's office for continuing care would be assigned from which E/M section? office or other outpatient consultations, new or established patient office and other outpatient services, established patient office and other outpatient services, new patient confirmatory consultations, new or established patient

office and other outpatient services, established patient Consultation codes can no longer be coded when the physician has taken an active part in the continued care of the patient. Under a referral, the care of the patient is passed by the referring physician to the provider to whom he or she is referred. In contrast, consultants provide an opinion and then return the patient to the requesting doctor's care.

A portion of a deficiency slip is reproduced below. This patient was discharged yesterday. Your greatest concern regarding deficiencies on this record would be the missing signature on the physical exam. operative report. diagnoses and procedures. signature on the discharge summary.

operative report. All patients who undergo surgery must have an operative report included in their record. The operative report must be documented either in writing or dictated by the surgeon immediately after surgery.

In a research study that includes a patient questionnaire, five of the questions will be answered using the following scale: 1 Strongly disagree 2 Disagree 3 No opinion 4 Agree 5 Strongly agree The data collected using this scale are commonly referred to as nominal data. continuous data. ordinal data. cardinal data.

ordinal data Ordinal data ranks from lowest to highest according to a criterion. Ordinal data can include responses to questionnaires or interviews. The number assigned to each rank does not necessarily indicate an equal difference between each category.

The state is considering the closure of the Arcadia Hospital. In reviewing the hospital statistics, which indicator will best help state officials determine whether closure is warranted? daily census average length of stay inpatient service days percentage of occupancy

percentage of occupancy The inpatient bed occupancy rate measures the percentage of beds that are occupied by inpatients in relation to the total number of beds within the facility for a specific period of time. This metric is used to assess the functionality degree of a hospital and the institution's ability to efficiently manage its resources. Market data on occupancy rates as a key performance indicator shows that 85-90% is the ideal range for bed occupancy. A rate higher than 90% may cause the danger of overcrowding, indicating that hospitals may have to turn away patients and postpone the provision of needed, possibly crucial, health care. If occupancy is below 85%, this might indicate that resources are managed inefficiently and inequitably. An extremely low percentage of occupancy may reflect a duplication of hospital services in a geographic area.

At your meeting with the clerical staff on the stat report concerns, one clerk suggests a possible reason for the delays is a lack of training concerning the nature of stat reports. On the cause and effect diagram, this would most appropriately be listed under materials. equipment. personnel. methods.

personnel. A cause and effect diagram helps to determine the root causes of the problem. A horizontal line is drawn with diagonal bones, pointing to the boxes above and below the line. The boxes represent broad classifications of the problem area such as personnel, methods, equipment, materials, and procedures. Example:

The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. This crisis manager is particularly weak in which management function? controlling budgeting organizing planning

planning Management functions can be divided into four different functions: planning, organizing, leading, and controlling. Planning is the first step in management and involves determining what should be accomplished and how. It is an ongoing step and can be highly specialized based on organizational, department, or team goals. Organizing involves the determination of how to distribute resources and organize employees according to the plan. Leading involves communicating, motivating, inspiring, and encouraging employees. Controlling involves checking the progress of achieving objectives and giving feedback.

The HIM Director is responsible for overseeing amendments and corrections to the EHR. As part of this role, they have advised the organization's leadership that it is important to have ______________ addressing how to deal with corrections made to erroneous entries in the EHR. a documentation committee a charter training sessions policies and procedures

policies and procedures It is important for the facility to have policies and procedures that address how corrections for erroneous entries are completed. Generally, the HIM director is included in a documentation committee to create these policies and procedures. There is usually a charter that is an official document setting out the policies and procedures to be followed by members of an organization. These policies and procedures are part of the training sessions for all that document in the EHR and includes a section on how to make corrections.

Your facility is engaged in a research project concerning patients newly diagnosed with type 2 diabetes. The researchers notice older patients have a longer length of stay than younger patients. They have seen a causal relationship between age and length of stay. positive correlation between age and length of stay. homologous relationship between age and length of stay. negative correlation between age and length of stay.

positive correlation between age and length of stay. Scatter charts are graphs that visually display the linear relationships that exist between two variables. When the variables of age and length of stay go up correspondingly, a direct or positive relationship is indicated.

You are creating an inventory of all template forms within the electronic health record. You come across an unnamed template in the OB section that includes a checklist for assessing an obstetric patient's lochia, fundus, and perineum. The document type you give to this form is prenatal record. delivery room record. postpartum record. labor record.

postpartum record. A postpartum flow sheet is the most logical name for this template. The type of medical information is specific to the postpartum period of treatment.

Health records contain patient specific data and information that is documented by a professional that provided care or services for the patient; therefore, it is considered a(n) ___________ data source. aggregate critical secondary primary

primary The health record is considered a primary data source because it contains information about a patient that has been documented by the professional that provided the care or services to the patient. Data that is derived from the health record, such as an index or registry is a secondary data source. Critical information is used for the direct delivery by a physician for a critically ill or critically injured patient. Aggregate information is information about groups or categories of health care consumers which does not contain information that can identify the user. It serves to provide "anonymous information".

Which of the following is the unique identifier in the database illustrated in the table above? record number date of birth patient's last name date of service

record number The record number is a unique identifier assigned to each patient. The Department of Health and Human Services explains that a unique patient identifier "is required to manage the various clinical and administrative functions relating to the delivery of care."

Improving clinical outcomes and optimal continuity of care for patients are common goals of clinical documentation improvement programs in acute care hospitals. Additionally, CDI programs may work together with UM programs to report sentinel events to the Joint Commission. increase patient engagement through patient portals. reduce clinical denials for medical necessity. decrease medication errors through CPOE systems.

reduce clinical denials for medical necessity. "Decrease medication errors through CPOE systems" and "report sentinel events to the Joint Commission" are more closely associated with patient safety programs than CDI programs. The answer, "increase patient engagement through patient portals" relates to HITECH goals for physician practices. Clinical documentation improvement programs are designed to improve clinical documentation specificity, thus supporting the medical necessity requirement for inpatient level care as well as the intensity of service and severity of illness for each inpatient.

A clerk's work performance has diminished dramatically during the past 2 weeks. The supervisor initiates a discussion with the clerk, during which the clerk reveals that he recently accepted that he has an alcohol addiction. The clerk states an intention to quit drinking completely. The supervisor should terminate the clerk if it can be proved that alcohol was used on the job. suspend the clerk if alcohol has diminished the clerk's job performance. give the clerk a leave of absence until these problems can be resolved. refer the clerk to the facility's employee assistance program.

refer the clerk to the facility's employee assistance program. An employee assistance program is an employee benefit program that assists employees with personal problems and/or work-related problems that may impact their job performance, health, mental, and emotional well-being.

Which means of data modeling is illustrated in the table shown above? entity-relationship model object-oriented model relational data model data management model

relational data model This is a relational data model. The relational database model consists of a database with a set of formally described tables, related to each other by a shared reference. Object-oriented data models are databases that represent data in the form of objects and classes. In object-oriented terminology, an object is a real-world entity, and a class is a collection of objects. Entity data model refers to a set of concepts that describe data structure, regardless of its stored form. This model uses three key concepts to describe data structure: entity type, association type, and property. An entity-relationship model describes interrelated things of interest in a specific domain of knowledge. A basic ER model is composed of entity types (which classify the things of interest) and specifies relationships that can exist between entities (instances of those entity types).

A pharmacist at your facility was caught running a drug ring. The pharmacist filled orders of valuable medications with cheap outdated ones purchased on the Internet and then sold the good drugs for profit. Patients have been injured, and the lawsuits are starting. Unfortunately, your facility is going to be held responsible for the pharmacist's negligent acts under the doctrine of adjudicus res. respondeat superior. res ipsa loquitur. stare decisis.

respondeat superior. Respondeat superior means "let the master answer" for the actions of the servant—the doctrine of the "agency." Under the doctrine of respondeat superior, the courts hold employers responsible for the acts of their employees or agents that are acting within the scope of employment. For example, a hospital can be held responsible for the actions of a physical therapist while they are performing the aspects of their position.

Identification of threats and vulnerabilities, security measures, and implementation priorities are part of a health care organization's security plan. identity management plan. intrusion detection plan. risk management plan.

risk management plan. A risk management plan includes identification of threats and vulnerabilities, security measures, and implementation priorities. It is used to identify and evaluate risks as a means to reduce injury to patients, staff members, and visitors within an organization. Risk managers work proactively and reactively to either prevent incident or to minimize the damages following an event.

Everyone in the health information department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not temporary employees. salaried exempt employees. salaried nonexempt employees. hourly employees.

salaried exempt employees. Salaried exempt employees are paid a set salary per pay period.

A 19-year-old former patient has completed an authorization requesting all of his medical records be released to the army. The release of information clerk should deny the request. send the records as requested. inform the young man that specific reports must be identified in his request. send a letter informing him that faxed requests are not accepted.

send the records as requested. Records can be sent with a valid authorization (request) for use and disclosure.

The final HITECH Omnibus Rule expanded some of HIPAA's original requirements, including changes in immunization disclosures. As a result, where states require immunization records of a minor prior to admitting a student to a school, a covered entity is permitted to allow school officials to authorize immunization disclosures on behalf of a child attending their school. require written authorization from a custodial parent before disclosing proof of the child's immunization to the school. simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school. allow the minor to authorize the disclosure of the proof of immunization to the school.

simply document a written or oral agreement from a parent or guardian before releasing the immunization record to the school. The "Disclosure of Student Immunizations to Schools" provision of the final rule permits a covered entity to disclose proof of immunization to a school (where state law requires it prior to admitting a student) without written authorization of the parent. An agreement must still be obtained and documented, but no signature by the parent is required.

Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be space considerations. professional standards. statutory requirements. provider preferences.

statutory requirements The length of retention depends on laws, regulation, and the use of health records for care and for other purposes such as research and education.

As a new HIM manager, you recognize that employee development is a necessary investment for the long-term survival and growth of the organization. Your goal is to design and implement a staff development program for your employees, so one of your first steps is to implement training programs that emphasize teamwork. establish HIPAA training programs hospital-wide. establish a budget for all hospital employee training. survey the HIM employees to assess their need for new skills or knowledge.

survey the HIM employees to assess their need for new skills or knowledge. The first step in developing a training program is to perform a needs analysis to determine the deficiencies in knowledge and skills between the desired level and the current level of each employee.

If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level only the acute condition should be coded. they should both be coded, chronic sequenced first. only the chronic condition should be coded. they should both be coded, acute sequenced first.

they should both be coded, acute sequenced first. If the same condition is described as both acute and chronic and separate subentries exist in the ICD-10-CM alphabetic index at the same indentation level, they should both be coded, acute sequenced first.

The difference between an Institutional Review Board (IRB) and a hospital's Ethics Committee is that -the Ethics Committee reviews ethics complaints, and the IRB focuses on developing policies and procedures. -the IRB focuses on patient care only, and the Ethics Committee addresses both patient care and business practices. -the IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary. -the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues.

the IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. The Institutional Review Board (IRB) is a committee established to protect the rights and welfare of human subjects involved in research activities. The ethics committee is a committee of the organization tasked with reviewing ethics violations and determining the course of action required to remedy the violations.

As a coder for a large physician practice, you have reason to believe that several physicians are involved in charging Medicare for services not rendered. Regulatory oversight for complaints regarding this fraudulent activity lies with the Recovery Audit Contractor. the Office for Civil Rights. the Office of the Surgeon General. the FDA.

the Recovery Audit Contractor. The Recovery Audit Contractor (RAC) program is a government program with a goal of identifying improper payments on claims of health care services already provided to Medicare beneficiaries. The medical reviews consist of the Medicare contractors collecting information and performing a review to determine whether Medicare's coverage, coding, and medical necessity requirements are met.

Release of information has increased its use of part-time PRN clerical support in order to respond to increased requests for release of information in a timely manner. For the line item projecting costs for ROI, this quarter's budget variance report will reflect the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support. neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports. the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. both the increases in revenue and increased costs for clerical support in ROI.

the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area. Budget variance reflects the difference between projected or budgeted costs and actual costs. In this case, the budget variance report will compare the costs projected for ROI and the actual cost based on volume.

A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? the patient's wife the patient the patient's parent or legal guardian either of the patient's parents

the patient The patient must authorize the release of his records since he is an emancipated minor by marriage.

In your state, it is legal for minors to seek medical treatment for a sexually transmitted disease without parental consent. When this occurs, who would be expected to authorize the release of the medical information documented in this episode of care? the patient the patient's doctor on behalf of the patient the custodial parent of the patient a court-appointed guardian on behalf of the patient

the patient When the law allows a minor to seek treatment without parental permission, the right to control access to the protected health information also belongs to the minor.

After your coders helped you rank the reasons for coding errors in the order of their importance, you then plotted the results on the chart above. The results of your work surprise you because you expected the coders to put more emphasis on time pressure. the rankings show surprising disagreement on the issue. the results appear to violate the Pareto principle. you thought limited training was the primary reason for the errors.

the results appear to violate the Pareto principle. The Pareto principle states that 20% of the problem are responsible for 80% of the actual problem. This allows for a concentration of vital resources to address a large number of the actual problems.

When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis. the primary neoplasm is coded as the principal diagnosis, and the secondary neoplasm is coded as an additional diagnosis. code only the primary neoplasm as the principal diagnosis. code only the secondary neoplasm as the principal diagnosis.

the secondary neoplasm is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis. When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary site only, the secondary neoplasm is designated as the principal diagnosis even though the primary malignancy is still present.

In preparing the retention schedule for health records, the most concrete guidance in determining when records may be destroyed will be the average readmission rate for the facility. the statute of limitations in your state. the available options for inactive records. best practice standards.

the statute of limitations in your state. Although readmission rates, best practice guidelines, and record archival options may affect the retention period for a facility, the minimum retention period will be mandated by the length of time a patient may bring a lawsuit against the facility.

Community Hospital reported an average LOS in December of 3.7 days with a standard deviation of 23. This information indicates that there was a small variation in the LOS at Community Hospital. patients stay longer at Community than at most hospitals. there was a large variation in the LOS at Community Hospital. most of the patients at Community Hospital stay 3-4 days.

there was a large variation in the LOS at Community Hospital. The standard deviation is the measure of variability often used to show how data are related to the mean. A large standard deviation implies great variability in the data.

In the past, Joint Commission standards have focused on promoting the use of a facility-approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations. use of abbreviations used in the final diagnoses. prohibited use of any abbreviations. flagrant use of specialty-specific abbreviations.

use of prohibited or "dangerous" abbreviations. The Joint Commission requires hospitals to prohibit abbreviations that have caused confusion or problems in their handwritten form (e.g., "U" for unit, which can be mistaken for "0" (zero) or "4"). Spelling out "unit" is preferred.

A number of key elements for your facility's electronic patient record are still input by clerical staff from handwritten data entry sheets. You are concerned about the transfer of data. If the vital signs stored in the database are not what were originally recorded, the impact on patient care could be severe. You are concerned about the granularity of the data. stability of the data. validity of the data. timeliness of the data.

validity of the data. Validity refers to the credibility of the data.There is concern of the validity because of the transfer of data.

A piece of objective data collected upon initial assessment of the patient is the chief complaint. review of systems. vital signs. history of present illness.

vital signs. Objective data are observable and measurable data (signs) obtained through observation, physical examination, and laboratory and diagnostic testing. The vital signs are objective data that is collected during the initial assessment.

A run or line chart would be most useful for collecting data on waiting time in the Pediatrics Clinic over a 6-month period. a possible relationship between 2 variables. medication errors and their causes. patient satisfaction with the food.

waiting time in the Pediatrics Clinic over a 6-month period. Run charts are best used to track data points over time, such as wait time in a Pediatrics Clinic over several months.

You are providing an educational session to new hires at your hospital. You tell the new employees that health records may be used as evidence in court even though hearsay laws bar the use of most evidence that does not represent personal knowledge of the witness. That is because the hospital medical record is written rather than spoken. is impervious to tampering was kept in the regular course of business. is accurate and complete.

was kept in the regular course of business. A health record kept in the normal course of business is considered an exception to the hearsay rule.

A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that you need the names of those involved in union activities. you are opposed to the union. wages will increase if the union is defeated. a strike is inevitable if the union wins.

you are opposed to the union. Management has both the right and obligation to tell employees that the organization does not believe that union representation is in their best interest and to encourage them to vote no on the ballot. They also should answer employee's questions honestly and assure the commitment of the organization to provide high quality care in a desirable working environment and culture for employees. They should also explain that if they choose to recognize the union, any improvements in wages, benefits, and working conditions will be subject to negotiation and are not guaranteed. Management is not permitted to interrogate individual employees about their union activities. They cannot threaten, coerce, or intimidate employees because of their union support. They may not make specific promises contingent on the outcome of the election or offer unilateral improvements in wages, benefits, or working conditions during the election campaign.Management has both the right and obligation to tell employees that the organization does not believe that union representation is in their best interest and to encourage them to vote no on the ballot. They also should answer employee's questions honestly and assure the commitment of the organization to provide high quality care in a desirable working environment and culture for employees. They should also explain that if they choose to recognize the union, any improvements in wages, benefits, and working conditions will be subject to negotiation and are not guaranteed. Management is not permitted to interrogate individual employees about their union activities. They cannot threaten, coerce, or intimidate employees because of their union support. They may not make specific promises contingent on the outcome of the election or offer unilateral improvements in wages, benefits, or working conditions during the election campaign.