RHIA State Test Prep #9

Rootkit

- a program that hides in a computer and allows someone from a remote location to take full control of the computer. -is a computer program designed to gain unauthorized access to a computer and assume control of and modify the operating system.

Pareto Chart

A Pareto chart is a type of chart that contains both bars and a line graph, where individual values are represented in descending order by bars, and the cumulative total is represented by the line. The chart is named for the Pareto principle, which, in turn, derives its name from Vilfredo Pareto, a noted Italian economist. The purpose of the Pareto chart is to highlight the most important among a (typically large) set of factors. In quality control, Pareto charts are useful to find the defects to prioritize in order to observe the greatest overall impact. It often represents the most common sources of defects, the highest occurring type of defect, or the most frequent reasons for customer complaints. The chart visually depicts which situations are more significant. The Pareto Chart is a very powerful tool for showing the relative importance of problems. It contains both bars and lines, where individual values are represented in descending order by bars, and the cumulative total of the sample is represented by the curved line. An 80% cut-off line is also included to indicate where the 80/20 rule applies i.e. the vital few factors that warrant the most attention sit under the 80% cut-off line. The ordering in a Pareto Chart helps identify the 'vital few' (the factors that warrant the most factors whose cumulative percent (dots) fall under the 80% cut-off line) from the 'trivial many' ( while useful to know about, have a relatively smaller effect i.e. cumulative percent dots that fall above the 80% cut off line). Using a Pareto diagram helps a team concentrate its efforts on the factors that have the greatest It also helps a team communicate the rationale for focusing on certain areas.

Run Chart

A run chart, also known as a run-sequence plot, is a graph that displays observed data in a time sequence. It is a form of line chart and is used to study collected data for trends or patterns over a specific period of time. A run chart helps in monitoring data over time to detect trends, shifts, or cycles, comparing a measure before and after the implementation of a solution to measure impact, and focusing attention on vital changes. It is a basic graph that displays data as they evolve over time, making it easy to identify trends or shifts in a process. Run charts are useful for visually depicting how a process is performing, tracking and communicating improvements, identifying process variation, and avoiding unbiased actions. They are easy to construct, interpret, and can be used to identify changes or trends over time.

A new patient arrives at a doctor's office for his first appointment. He provided a notice explaining how and when his PHI can be used or disclosed. This patient has been asked to sign a form stating that he has received the notice. What type of document was this patient provided? a. Notice of privacy practices b. Advance Beneficiary Notice of Non-coverage form c. Business associate agreement d. Medicare summary notice

A: A notice of privacy practices is a document that describes the duty the healthcare entity has to protect healthcare information privacy, informs patients of their own privacy rights, and notifies them of how their PHI may be used or shared by their health plan or provider under the HIPAA Privacy Rule. The notice of privacy practices must provide examples of PHI uses/disclosures that are permitted or required for treatment, payment, and healthcare operations and for other purposes. Patients will be asked to sign an acknowledgment of receipt of this notice.

Which of the following would NOT be information necessary to define in a data dictionary for data fields or columns? a. An entity relationship diagram b. The name, type, and length of each data field c. Clear definitions of each data field d. Allowed values that can be used in each data field

A: A quality data dictionary should define the name, type (date, text, number, etc.) length, and values allowed to be used in each data field. Clear definitions for each data field or column should also be incorporated. Some other descriptors that may be included are data format, whether the field is required, and edits placed on the data fields. Although data dictionaries can be used during the process of database design, it is not necessary to include entity relationship diagrams regarding the data fields/columns in the data dictionary.

A healthcare organization wants to solicit a small group of prescreened potential EHR vendors. A structured document is used to compare the functionality and feasibility of each system so the organization can make an informed decision on which bid best fits its requirements. Which of the following best describes this process? a. Request for proposal b. Request for information c. Request for quotation d. Request for services

A: A request for proposal (RFP) involves carefully researching specifications of technology desired by an organization. Because health IT systems are significant investments, organizations must exercise due diligence and ensure that potential vendors can meet their contractual specifications. The RFP uses a structured document that compels candidates to answer various questions that will be scored. RFPs are typically sent to four to six vendors. After scoring questions and conducting an internal review of potential vendors, the list will usually be narrowed down to three to four vendors. Internal interviews will outline clear expectations by the requesting organization, demonstrations of vendors' products, and reference checks. Site visits provide a better understanding of the vendors and their products. This allows an organization to compare primary functionality, user-friendliness, and potential downfalls of multiple systems before making a decision.

A coding supervisor wants to display the entire coding process from start to finish to highlight relevant variables, such as steps associated with the process and individuals responsible for each step. Which visualization tool would be most appropriate to display this information? a. Swimlane diagram b. Force-field analysis c. Run chart d. Affinity grouping

A: A swimlane diagram is very similar to a flowchart, except the diagram is broken up into lanes that delineate the individual(s) or group(s) responsible for a specific task. Each task is connected by arrows that signify the order of information or flow of a process. This cross-sectional flowchart allows for simultaneous viewing of everyone involved in a process. Swimlane diagrams are used to troubleshoot problems, standardize work processes, improve efficiency, and clarify accountability.

Healthcare facilities collect, process, and store various data to help support organizational operations. This information can identify patients, providers, and the location of encounters, among other things. What kind of data is this information considered? a.Administrative data b.Operational data c.Clinical data d.Financial data

A: Administrative data are crucial for healthcare organizational operations that are associated with healthcare encounters. In order to run smoothly and efficiently, organizations must ensure that accurate documentation is kept on all patients and encounters. Administrative data may consist of patient demographics, enrollment, claims/eligibility data, and more.

Trevor has been tracking patients' recent lengths of stay to see if there are any trends. Trevor decides to present his summary report to the admissions department and uses the mean length of stay as a facility statistic. After examining the table below, what would be the biggest problem with using this measure of central tendency? a.The mean can be sensitive to extreme values falling outside the normal range and can distort the portrayal of the data set's measure of central tendency. b.There is no problem; Trevor used the appropriate measure of central tendency based on the information provided. c.It would be mathematically incorrect to use the mean length of stay. d.Using the mode of the data set would be the most accurate representation of the length of stay's measure of central tendency.

A: After reviewing the data set, one disadvantage of using the mean length of stay as a facility statistic in this scenario is that it contains an outlier. Outliers that are present in a data set can skew the mean. For example, the values 3, 3, 4, 5, 6, 7, and 28 result in an average of 8. However, this value is on the high end of the dataset because the outlier (28) has skewed the mean value. Therefore, based on the data presented, the median (5) would provide a more accurate measure of the facility's length of stay.

All of the following would typically be included in an HIM department's operational budget EXCEPT: a. Computers b. Benefits c. Payroll d. Office supplies

A: Benefits, payroll, and office supplies cover some of the day-to-day expenses and focus on projected income statement activity spanning 1 fiscal year. On the other hand, large-dollar purchases/investments such as office equipment (computers, printers, office furniture, etc.) would be included in a capital budget. Capital acquisitions may span from 1 to 3 years.

Which healthcare professionals must determine whether an individual or entity can rightfully access PHI? a. HIM professionals b. Attending physicians c. IT professionals d. Healthcare administrators

A: HIM professionals are responsible for validating ROI requests and determining whether access and disclosures of PHI are appropriate. HIM professionals apply their extensive knowledge of state and federal laws to ensure that ROI processes promote patient access rights while balancing the protection of their privacy.

Who has the responsibility of guaranteeing healthcare record documentation quality? a.Provider b.Data steward c.Health information professional d.Quality manager

A: In general, healthcare providers (i.e., attending physicians) who are treating patients bear the responsibility of ensuring the quality of medical documentation. These individuals record the diagnoses, treatment, medical history, procedures performed, and other pertinent details that could be used in future medical decision-making processes.

A data analyst has asked you to help collect information about the effects that alcohol consumption has on people when they have the flu. You have been asked to collect the following information: •Whether or not a person has consumed any alcohol throughout the duration of their flu •How many hours of sleep occurred the night before •The person's temperature during the day that alcohol was consumed What are the levels of measurement used for each data point? a. Nominal, ordinal, interval b. Ratio, interval, ordinal c. Interval, nominal, ratio d. Ordinal, interval, nominal

A: In this scenario, the first question would be answered with a simple yes or no option, which is considered nominal because they are categorical data with no natural order. However, a numbering system may be used for calculation purposes (e.g., no = 0, yes = 1). The total number of hours spent sleeping on the same day that alcohol was consumed is considered ordinal. These options have a natural order (e.g., 0-3 = little sleep, 4-6 = a moderate amount of sleep, 7-9 = a full night's rest). The temperature of an individual is considered interval data because it is continuous data that does not have a true zero value.

A coding specialist uses computer-assisted coding software to code a patient's medical documentation. After reviewing the selected codes, the coder notices that two different codes (20612-RT and 20612-LT) have been generated for the procedure aspiration of a ganglion cyst of the wrist. The coder closely examined the medical record and found that the provider documented that this procedure was to be performed on the right wrist in the office note. However, the operative note stated that this procedure was performed on the left wrist. What is the best course of action for the coder to take based on these circumstances? a. Query the patient's provider to clarify if the procedure was performed on the left or right wrist before selecting a code. b. Call the floor the patient was on and ask the nurse which wrist the procedure was performed on. c. The coder should report both codes because each appears at least once i

A: Inconsistencies in clinical documentation often result in poor patient outcomes, improper reimbursement, medical errors, and much more. Therefore, when medical records consist of conflicting information, the best way to request clarification is to use the communication tool known as a physician query. In this situation, the coders should query the provider who created the documentation before reporting any codes.

Who contracts with CMS and serves as financial agents between the federal government and providers by performing prepayment reviews of locally administered Medicare Parts A and B medical claims? a. Medicare administrative contractor (MACs) b. HHS Office of Inspector General c. Recovery audit contractor d. Document integrity specialist

A: Medicare administrative contractors (MACs) are awarded geographic jurisdiction to process Medicare Parts A and B claims. They perform prepayment reviews to ensure services are considered medically necessary and are covered. Other MAC duties include but are not limited to, educating providers, establishing local coverage determinations, coordinating with CMS and other contractors, and handling the appeals process.

Mrs. Davis is preparing to undergo bariatric surgery but is required to obtain permission from her health insurer before receiving the procedure. What is the term used to describe this concept? a. Prior authorization b. Pre-approval c. Pre-clearance d. Prior acceptance

A: Prior authorization, or pre-certification, occurs when a physician obtains permission from the patient's insurance carrier to provide certain services. This process is often done to ensure that the services provided meet medical necessity standards and would be covered under the beneficiary's healthcare plan.

A healthcare facility offers real-time,instructor-led online training that employees attend through an online learning platform. Which of the following best describes the training method offered? a. Synchronous b. Asynchronous c. Informal training d. E-learning

A: Synchronous training refers to real-time gatherings of instructors and learners that can occur virtually or physically. This type of training allows instantaneous communication, collaboration, and the ability for instructors to address questions or concerns as they arise. Although disadvantages can include scheduling conflicts, learning is set at the instructor's pace, and students may not receive individual attention.

An established patient arrives at a doctor's office for their visit. During the check-in process, the patient provides the receptionist with her driver's license. The receptionist notices that it is different than what is on file. The patient has the same name, but her date of birth and address have changed. The patient also looks quite different from the photo on her ID. The receptionist ignores these inconsistencies and sends the patient to see the physician. Later, it was discovered that this individual had committed medical identity theft. A detailed training on which fraud statute should occur to prevent situations like this from happening again. a. Red Flag Rule b. Healthcare Fraud Statute c. Exclusion Provisions d. False Claims Act

A: The Federal Trade Commission (FTC) created the Red Flag Rule to help organizations detect and prevent fraud. This rule requires organizations to implement an identity theft prevention program with corresponding policies and procedures to identify red flags. The ability to detect suspicious activities quickly during day-to-day operations can help mitigate damage and combat fraudulent actions. Information that does not match what your practice has on file suchas a person's date of birth, social security number, or differences in a person's physical appearance would be considered a red flag and should be more closely examined.

A patient was recently discharged from a psychiatric unit at a local hospital. A few weeks later, the patient called the medical records department to request access to the psychotherapy notes created during their stay. What is the appropriate way to respond to this patient's request? a. Inform the patient that psychotherapy notes are not released to patients. b. The release of psychotherapy notes to a patient must be approved by a licensed healthcare professional. c. Deny the request because it is too soon following the patient's discharge date. d. Allow the request only after an authorization ROI form is signed by the patient.

A: The HIPAA Privacy Rule requires special protections for psychotherapy notes. Psychotherapy notes are a treating provider's personal notes kept separate from the medical record that contains sensitive information regarding a provider's opinion on a patient. These notes are often used to help the therapist recall details of sessions and are not typically shared with other healthcare professionals. The exceptions for disclosures of psychotherapy notes (when required by law) include reporting abuse or instances of duty to warn when a patient makes threats to harm another individual. However, patients have the right to access their mental health records, and an ROI specialist could release the records after confirming with the physician that it would not be considered harmful to the patient.

What clinical terminology is used to facilitate a universal method of reporting laboratory observations? a. LOINC b. CPT c. SNOMED CT d. RxNorm

A: The Logical Observations Identifier Names and Codes (LOINC) is a clinical terminology used to provide a common language, exchange standard, and mapping mechanism for laboratory test orders and results. Each LOINC code provides a detailed description of the laboratory tests ordered/completed, and the resulting data are displayed in a structured format.

Given the following table, which facility would be considered to have a tier 3 violation according to the HIPAA Omnibus Rule? a.Facility1 b.Facility2 c.Facility3 d.Facility4

A: The breach at facility 1 would be considered a tier 3 violation because the category falls under willful neglect,but the facility corrected the violation within 30 days after its discovery. The penalty for this type of breach can range from $10,000 to $50,000 per violation. If the facility had not corrected the violation after 30 days, it would be considered a tier 4 violation.

A patient had undergone a cryoablation of a skin lesion on her right breast. Which of the following is the correct ICD-10-PCS code for this procedure? a. 0H5TXZZ b. 0H9TX0Z c. 0HBT3ZX d. 0HCTXZZ

A: The correct ICD-10-PCS code for cryoablation of the skin lesion on the right breast would be 0H5TXZZ. The section is medical and surgical, the body system is skin and breast, the root operation is destruction, the body part is the right breast, an external approach would be used, and no device or qualifier is required

The legal doctrine established by the landmark case Tarasoff v. Regents of the University of California of 1976 resulted in the Tarasoff Rule. What legal health concept does this rule enforce? a. Duty to warn b. Corporate negligence c. Need for advance directives d. Implicit right to privacy

A: The ruling on the Tarasoff v. Regents of the University of California case of 1976, held that mental health professionals have a duty to protect those threatened with bodily harm by a patient and have a responsibility to warn of the potential dangers that their patients could pose to others. The duty to warn can also extend to sexually transmitted diseases. Physicians may be held liable if they fail to warn third parties of any potential serious threats that could place them at risk.

During an accreditation survey, a technique was used to assess operational systems and processes by closely examining the experiences of selected patients. Which of the following approaches best describes this procedure? a. Tracer methodology b. Audit trail c. Content analysis d. Historical research

A: The tracer methodology is a technique used by on-site Joint Commission surveyors that can identify performance or process issues. The tracer methodology is often conducted by following the experience of care, treatment, and services rendered to selected patients. It can also be used to assess operational systems.

Accession number 04-0056 has been assigned to a patient in a cancer registry. What do the first two digits of this accession number represent? a. The year a patient was first seen b. The type of cancer a patient is diagnosed with c. The patient's stage of cancer d. The facility's unique ID number

A:: The accession number is used to identify patients in a cancer registry; the list of cases is arranged in the order in which they were entered. The first two digits represent the year when the patient was first seen at the facility. The remaining digits would be assigned sequentially throughout the year. In this example, the accession number reveals that the patient was first seen in 2004.

Breach Notification Requirements

All individuals whose information has been breached must be notified without unreasonable delay, and not more than 60 days, by first-class mail or a faster method such as by telephone if there is a potential for imminent misuse. If 500 or more individuals are affected, they must be individually notified immediately, and media outlets must be used as a notification mechanism as well. The Secretary of HHS must specifically be notified of the breach All breaches affecting fewer than 500 people must be logged by the CE in an HHS online reporting system and submitted annually as a report not later than 60 days after the end of the calendar year. Individuals who are notified that their PHI has been breached must be given a description of what occurred (including the date of breach and date that breach was discovered); the types of unsecured PHI that were involved (such as name, Social Security number, date of birth, home address, account number); steps that the individual may take to protect himself or herself; what the CE is doing to investigate, mitigate, and prevent future occurrences; and contact information for the individual to ask questions and receive updates. Companion breach notification regulations by the FTC protects individuals whose information has been breached by non-covered entities and non-BAs that are PHR vendors, third-party service providers of PHR vendors, or other non-HIPAA covered entities or BAs that are affiliated with PHR vendors. In addition to notifying the individuals affected by the breach, these entities must also notify the FTC of the breach. Third-party PHR service providers shall notify the PHR vendor or entity of the breach. Other notification requirements, such as the content and nature of breach notices, parallel HHS requirements.

Object Oriented Database

An object-oriented database (OODB) is designed to store different types of data including images, audio files, documents, videos, and data elements. OODBs are useful for storing fetal monitoring strips, electrocardiograms, PACs, and more. The OODB is dynamic because it provides the data as well as the object (image and document).

Which of the following systems allows patient access to all or a portion of their health records that are maintained by their physician? a. EHR b. Patient portal c. Clinical web portal d. Personal health record

B: A patient portal offers individuals 24-hour access to all or part of their medical records maintained by their healthcare provider. These portals are secure and require users to enter a username and password to view information from anywhere with an internet connection. Patient portals can also be used for requesting prescription refills, scheduling appointments, and accessing educational material.

Unlike the traditional fee-for-service reimbursement method, in which providers are paid for each service that they perform, what do value-based purchasing programs consider? a. Expenses of medical treatments b. Quality measures c. Procedures performed d. Quantity measures

B: A value-based purchasing program reimburses quality instead of the quantity of care provided. The goal is to promote the triple aim (improving individuals experiences, enhancing population health, and reducing healthcare costs). A hospital's performance will be based on quality measures that impact reimbursement rates.

Which of the following is a valuable data dictionary that serves as a resource for information system development? a. Passive data dictionary b. Organization-wide data dictionary c. DBMS data dictionary d. MPI data dictionary

B: An organization-wide data dictionary helps drive data standards while promoting consistency and quality across the entire organization. This data dictionary serves as a valuable resource for information system development because it can assist technologists and organizational leaders in understanding the enterprise terms and their definitions to better use consumer data.

The following graph was created by tracking the number of productive hours logged by the facility's coding department. What change could be made to make this visualization of the productivity report more effective? a. Use a different title to describe the graph. b. Present the data as a line plot. c. Present the data as a pie chart. d. Increase the number of productive hours per month.

B: Bar graphs can be used to compare various groups or track significant changes over time. Data that are being tracked over a period of time would usually be better presented on a line plot.

Of the options listed, which of the following would NOT be considered malware? a.Rootkits b.Bugs c.Keyloggers d.Trojans

B: Bugs are programming mistakes or source code errors that could affect a software application's performance by causing a program to crash or produce unexpected results. Although computer bugs could be considered a vulnerability to the facility's systems, they would not be considered malware

Covered entities must notify the secretary of the Department of Health and Human Services (HHS) on PHI breaches that affect up to 500 individuals no later than which of the following? a. 30 days after the breach was discovered b. 60 days after the end of the calendar year in which the breach was discovered c. 1 year after the breach was discovered d. 3 years after the end of the calendar year in which the breach was discovered

B: Covered entities must report breaches of PHI to the secretary of HHS, in addition to informing the affected individuals. According to HIPAA's Breach Notification Rule, for breaches affecting up to 500 individuals, a covered entity must notify the secretary of HHS no later than 60 days after the end of the calendar year when the breach was discovered. A breach report form can be found on the HHS website and should be filled out and submitted by the covered entity.

All of the following statistical techniques can be used to determine the probability of claims being fraudulent EXCEPT: a. Decision trees b. Flowcharts. c. Logistic regressions d. Cluster analyses

B: Flowcharts Statistical techniques such as decision trees, logistic regressions, and cluster analyses are all visualization tools used in predictive modeling to create models to assess the probability of fraudulent claims. • Decision trees can create characteristics or profiles of fraudulent behaviors so these cases can be extracted and examined more closely. •. Logistic regressions help predict expected claim values and identify cases that fall outside the expected range. •. Cluster analyses can be used to group a provider's transactions and perform outlier identification by using association algorithms.

A coding specialist has been assigning codes straight from the charge description master without using any human intervention. What is the term used to describe the actions of this coding specialist? a. Assumption coding b. Hard coding c. Soft coding d. Computer-assisted coding

B: Hard coding refers to the coding of repetitive or noncomplex services using the CDM without human intervention. Hard coding could also include delegating coding responsibilities to individuals who are not coding specialists and are not familiar with coding guidelines. Soft coding requires the knowledge and intervention of a coding professional who assesses the clinical documentation to assign diagnosis or procedure codes. Although both methods may be used in healthcare facilities, soft coding is the recommended practice—hard coding should be avoided.

An HIM director is currently determining how long medical records should be kept according to the Medicare Conditions of Participation requirements. A health record created on March 10, 2010, should have been retained until at least which of the following dates? a. March 10, 2013 b. March 10, 2015 c. March 10, 2016 d. March 10, 2020

B: If the HIM director is only considering the retention period required by Medicare's Conditions of Participation (CoP), it would be most appropriate to retain this record until at least March 10, 2015. According to the CoP, medical records must be retained and be legally reproducible for at least 5 years.

As part of the EMPI's ongoing maintenance program, the MPI coordinator must resolve duplicates, overlays, and overlap errors found within the EMPI. What is the term used to describe this maintenance process? a. Identification b. Cleanup c. Reduction d. Declutter

B: It is essential to conduct an ongoing maintenance program to ensure low rates of MPI quality issues. This process is often referred to as MPI or EMPI cleanup, which consists of using algorithms to detect dirty patient data. MPI cleanup efforts result in a reduction of redundant and inconsistent entries, help standardize data, and ensure data integrity.

A hospital requires that all patient phone numbers be displayed in the following format: (XXX) XXX-XXXX. This format is an example of which of the following? a. Data definition b. Mask c. Structured data d. Wildcard

B: Mask A data dictionary controls whether or not an input mask should be used and tells a database the format that should be used to display the number. For example, a mask for phone numbers may appear in the system or may be entered as (123) 456-7890. Masks are commonly used to format social security numbers(XXX-XX-XXXX)and dates (MM/DD/YY).

Which part of the revenue management life cycle includes clinical documentation, charge capture, case management, and coding? a. Front end b. Middle process c. Back end d. Closing end

B: Middle Process The revenue cycle has three distinct phases, including front-end, middle, and back-end processes. Front-end processes include scheduling, prior authorization, insurance verification, financial counseling, and more. The middle process involves charge capture, coding, clinical documentation, and case management. Back-end processes include claims processing, denial management, follow-ups, posting of payments, and collections.

Which of the following is a standardized set of performance measures used to make comparisons of various managed health plans? a. UACDS b. HEDIS c. DEEDS d. RAVEN

B: The Healthcare Effectiveness Data and Information Set (HEDIS) was developed by the National Committee for Quality Assurance. HEDIS supplies healthcare consumers and purchasers with the information that is required to compare the performance of managed healthcare plans. More than 70 measures—compared to national or regional benchmarks—are used to assess the quality of healthcare plan services delivered.

What Latin term describes decisions made on landmark cases that set a precedence that lower courts in the same jurisdiction are expected to follow regarding similar legal cases? a. Respondeat superior b. Stare decisis c. Res ipsa loquitur d. Subpoena ad testificandum

B: The Latin term stare decisis means "let the decision stand." This principle refers to the legal doctrine of judicial precedence, in which state courts look at similar past issues that have been ruled on to guide decisions. Considering the ruling in previous historical cases helps to ensure uniform justice and fairness in similar legal cases or closely related issues.

A patient has requested copies of their medical records and was informed by the ROI specialist that there will be charges associated with this ROI request. Is the statement that the ROI specialist has relayed to the patient true? Why or why not? a. No, patients should never be charged for copies of their own PHI. b. Yes, cost-based fees can be charged for copying the PHI. c. No, charges for PHI can only occur when someone else makes the request. d. Yes, patients are always charged for receiving copies of their PHI.

B: The Privacy Rule allows covered entities to charge reasonable cost-based fees associated with the function of release of PHI. These charges consider costs of labor, supplies used for making photocopies, and postage if the records are to be mailed (the price for these activities varies from state to state). However, patients are not always charged these fees. Typically, the covered entity will provide copies of PHI free of charge.

The admissions department has implemented a new patient registration system to mitigate an increase in registration errors. A few months after the new system was first implemented, similar errors continued occurring. Based on these facts, what is the most likely cause of this issue? a. The old system was infected by malware. b. There were underlying human registration processes that were not addressed and corrected first. c. The new system had not been properly installed. d. Both patient registration systems had the same defects.

B: The information provided in this scenario—persistent registration errors despite implementing a new patient registration system—would infer that underlying human processes were not addressed and corrected beforehand. It is unlikely that both the new and old systems would result in the same registration errors. A closer examination of the department's workflow might uncover problems that could be addressed before implementing new health IT systems to solve the issue.

A small medical practice is in the process of implementing an EHR system. The HIM director and IT department have agreed to use a strategy that allows everyone to go live at once and halt paper processing promptly after implementation. Based on this information, which rollout strategy does this describe? a. Parallel processing b. Straight turnover c. Phased rollout d. Go-live

B: The most common form of EHR turnover is straight turnover. This rollout method takes a big-bang approach and is typically used by smaller organizations. Straight turnover is designed so everyone in the designated group will go live at one time. Immediately after the go-live date, the processing of paper documents should cease because it can be time-consuming and veers away from meaningful use of the EHR system. However, temporary paper processing might be necessary for a short time until users can process electronic information correctly.

A provider performed a sigmoidoscopy with the removal of polyps. The clinical documentation does not specify whether hot biopsy forceps, the snare technique, or the ablation method were used to remove the polyps. Based on this information, what would be the most appropriate action to take regarding code selection? a.Select the code of the most common polyp removal method. b.Query the physician regarding the method that was used in this encounter. c.Select the code that would result in the highest reimbursement. d.The removal technique does not matter, and the selection of any polyp removal code will have the same impact.

B: The removal method should not be assumed, and the best course of action would be to ask the physician who performed the procedure about which method wasused. It could be possible that multiple techniques were used to remove multiple polyps. In this case, modifier 59 (distinct procedural service) could be attached to bundled codes to receive appropriate reimbursement.

During the e-discovery process, the director of HIM at your facility has advised that the patient records involved with the litigation be specially tracked and handled to avoid any alteration or destruction of these documents. What is the most appropriate term used to describe the HIM director's request? a. Preservation of evidence b. Spoliation c. Legal hold d. Disposition

C: A legal hold requires carefully tracked handling of patient records involved in litigation. The special care and attention given to these records ensure that no changes can be made to these documents and protect them from being improperly destroyed or tampered with. This documentation must be preserved because it may serve as evidence in legal proceedings.

A CDI specialist has begun reviewing documentation from patient's records weeks or even months after patients have been discharged to gather data for decisions and to identify trends. What type of chart review is the CDI specialist performing? a.Prospective review b.Medical necessity review c.Retrospective review d.Complex review

C: A retrospective review is a cost-effective way to collect and analyze data after a patient is discharged from a healthcare facility. The goal of retrospective reviews is to determine if the patient's health benefits and member eligibility are correct and whether coverage after treatment has been given.

Johnathan is an HIM analyst who inspects the medical records of Jane Smith while she is still a patient in the facility to ensure that all entries are complete and authenticated. What is this process called? a. Quantitative analysis b. Predictive analysis c. Concurrent review d. Retrospective review

C: A review of records completed while the patient is still in the facility is referred to as a concurrent, or open-record, review. This process is done to ensure that medical documentation is complete and that the signatures of providers are present; it also helps determine if the diagnosis codes selected accurately support what is found in the medical record documentation. Any problems revealed during this process can be corrected immediately, thereby contributing to a better quality of care and improved health outcomes.

What portion of a medical record is displayed below? a. Family history b. Present illness c. Review of systems d. Diagnosis

C: A review of systems is a structured technique that physicians use to keep an inventory of a patient's body systems by asking the individual a series of questions to identify any possible symptoms the patient may be experiencing. CMS recognizes 14 body systems that include but are not limited to, gastrointestinal, genitourinary, musculoskeletal, neurological, psychiatric, endocrine, and allergic/immunologic.

A covered entity has released information requested by a patient's insurance company after ensuring that an authorization form for the ROI was signed by the patient. Later that day, the patient presented to the HIM department to revoke the authorization for the ROI. What actions will result from the information being released earlier that day? a. The covered entity would have to pay a fine for committing a breach violation b. The covered entity would be placed on probation and lose access rights for 6 months. c. The covered entity would be protected under the Privacy Rule. d. The covered entity would face legal repercussions.

C: All individuals have the right to revoke their consent for use and disclosure (in writing). However, if a covered entity has already released PHI in good faith based on the prior authorization of the patient, it would be covered under the Privacy Rule.

What character and symbol recognition technology has the potential to reduce medication errors? a. Computerized provider order entry b. Scanning c. Barcoding d. Vector graphic data

C: Barcoded medication administration (BCMA) technology has been implemented to assist in reducing human errors. Barcodes consist of arrangements of parallel dark bars and light spaces that can be located on patient wristbands, medication labels, specimen containers, or other records/items. Barcoding interpretsdata for identification and data collection purposes. In addition to reducing medication errors, barcoding technology can streamline billing and can be used to manage inventory.

A new patient presents to your office for an appointment and provides two healthcare insurance carrier cards (Medicare and Medicaid). What is the most appropriate action to take in this situation? a. Create claims for both insurance carriers. b. Do not create claims for either insurance carrier. c. Determine which insurance carrier is primary and which one is secondary. d. Ask the patient which one they would prefer to be billed.

C: Coordination of benefits is a term used to describe the method used in determining which health insurance carrier is the primary payer and which one is the secondary payer when an individual has coverage through multiple insurers. (Medicaid will always be considered the payer of last resort.)

Edward has been tasked with bringing data from multiple sources into a centralized database. He wants to apply the most widely used data integration technique to manage big data. Based on this information, which of the following techniques should Edward choose? a. Manual data integration b. Change data capture c. Extract, transform, and load d. A record locator service

C: Extract, transform, and load is the most widely used data integration technique for big data systems. This integration technique pulls data from its source systems, copies them, and then converts them by duplication or combining them into other data. After data are extracted and transformed, they can be loaded into the target database.

Which of the following is an itemized list with details of services provided to a patient that is sent to a patient's healthcare insurance company to calculate reimbursement? a. Remittance advice b. Chargemaster c. Superbill d. Advanced beneficiary notice

C: Healthcare providers send out superbills (detailed, itemized receipts distributed to patients and their insurance carriers). Other names used for this document include claim form, encounter form, charge slip, and fee ticket. The information on a superbill includes but is not limited to, a patient's name, insurance information, diagnosis and procedure codes, date(s) of service, the provider's National Provider Identifier number, and any associated charges.

William Jones has presented to a physician's office requesting medical records on behalf of his wife, Bethany. He tells the ROI specialist that his wife is at home sick with the flu and she has sent him to receive a copy of her medical records. How should the ROI specialist proceed in this situation? a. Release a copy of the medical records to Mr. Jones. b. Request that Mr. Jones sign an authorization for the ROI form before releasing any records. c. Inform Mr. Jones that his wife will have to sign an authorization for the ROI form, and she must specify that her husband can receive her medical records. d. Allow Mr. Jones to view a copy of his wife's medical record, but deny him from taking the copy home.

C: In this scenario, Mr. Jones will be denied access to his wife's medical records. Generally, HIPAA does not allow the release of PHI to any individuals except for the patient without proper authorization. This includes the patient's friends, family members, spouse, or other loved ones. The exception to this rule is if the individual requesting PHI is the patient's caregiver or the patient has signed a HIPAA-compliant authorization form that specifies the individual to receive copies of medical records on behalf of the patient. Therefore, in this scenario, the office will require written authorization for the release of medical records signed by Bethany that designates her husband as being authorized to obtain a copy of her medical record. This should identify the range of approved disclosure,for example, if her spouse only receives copies of PHI in this instance or all records over a given period of time.It is recommended that this form be updated often to avoid breaches of privacy.

Over the past 6 months, a hospital's pediatric floor has reported 45 new cases of respiratory syncytial virus. These 45 cases represent 25% of this hospital's pediatric population. This rate represents the: a. Prevalence b. Frequency c. Incidence d. Density

C: Incidence rates are used to compare the number of new cases of specific diseases over a given period to the population at risk for the disease during the same period. In this scenario, the 45 new cases of respiratory syncytial virus, compared to the entire pediatric population during a specific time, represent the incidence rate.

Today, Olivia will undergo a hip replacement at Silver Pine Hospital. Who is responsible for obtaining Olivia's informed consent before the procedure is performed? a. An HIM professional b. Any medical professional c. The surgeon d. The administrative staff

C: Invasive procedures or treatments that may be considered risky should not be performed until informed consent is obtained from the patient. The provider responsible for performing the procedure should obtain the patient's consent. The surgeon should attempt to answer any questions from the patient regarding the procedure and must detail the nature of the service, outline the expected benefits and risks, provide alternative treatment options, and explain the possible consequences of not performing the procedure.

A hospital has initiated peer reviews of medical providers' documentation to assess quality outcomes of care. This task can be overwhelming because the hospital currently employs more than 300 providers. It is eventually decided that 30% of each provider's discharge reports will be reviewed on an every-other-year basis. Which of the following techniques has this hospital applied to conduct its review process? a. Predictive methods b. Descriptive statistical analysis c. Sampling d. Benchmarking

C: It would be a difficult and time-consuming task to assess even a handful of records from each provider. The hospital can, however, use the sampling technique to randomly select and examine a small subset of the discharge reports from each provider over an extended period of time. The results from the samples can be useful in drawing conclusions about the quality outcomes of care for each provider.

An organization is in the process of determining appropriate productivity standards for the billing department. The billing department's productivity standards must reflect what elements of the organization? a. Values and ethics b. Structure and finances c. Mission and goals d. Vision and values

C: Mission and goals Productivity standards should be aligned with an organization's mission and goals and can be used to guide the actions and behaviors of the workforce. Goals should be specific, measurable, actionable, realistic, and timely to increase the likelihood of reaching and even boosting productivity standards.

When an individual suspects being a victim of medical identity theft, which agency should the person file a complaint with? a. Office of Civil Rights (OCR) b. Centers for Disease Control and Prevention(CDC) c. Federal Trade Commission (FTC) d. Centers for Medicare and Medicaid Services (CMS)

C: Patients who suspect that they are victims of identity theft can file a complaint with the FTC. This agency is responsible for the oversight of identity theft regulations. It offers support and comprehensive educational materials for consumers and victims.

During a recent follow-up appointment, a patient discusses their medical condition with their provider. What is the legal term that best represents this type of communication occurring between the patient and their physician? a.Clinical communication b.Private communication c.Privileged communication d.Open communication

C: Privileged communication, or physician-patient privilege, is a concept often delineated by state law, which is designed to protect confidentiality between two parties. Providers have an ethical duty to keep the communications between themselves and their patients private and must not improperly disclose details of an individual's private affairs.

Which of the following is NOT a component of a records retention program? a.Determine the location and format of record storage. b.Conduct an inventory of the facility's records. c.Destroy records when they are close to the end of the retention period. d.Assign each record a specific time for preservation.

C: Record retention programs generally consist of conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a specific time for preservation, and destroying records only after they have reached the end of their retention period.

Six Sigma's DMAIC method used for business transformation consists of five phases including define, measure, analyze, improve, and __________. a. calculate b. confirm c. control d. coordinate

C: Six Sigma encompasses a set of management techniques intended to improve business processes. Define, measure, analyze, improve, and control (DMAIC) is the standard data-driven Six Sigma methodology used to reduce the number of defects in processes. The five phases are described below. • Define the problem and the improvement opportunity. • Measure performance. • Analyze performance to determine the root causes of variances. • Improve the process by addressing the root causes. • Control the improved process.

A patient requested a copy of her medical records on March 3. Her request should be responded to by what date? a. March 16 b. March 24 c. April 1 d. April 30

C: The HIPAA Privacy Rule addresses timely responses to requests for PHI. Covered entities and the individual(s) responsible for the release of medical records must respond to an individual's request no later than 30 days after the request has been made. In the event that medical records would take longer to retrieve—possibly due to being stored at an off-site location—the covered entity may be allowed to extend the request to 60 days. The requestor should be informed of the reason for the delay and should be provided with the date that the request will be fulfilled.

A general practitioner recently saw a patient who complained of fatigue and dizziness. The general practitioner requests that the patient get blood work done and decides to send the patient to a clinical laboratory owned by his brother because he has a financial relationship with this entity and will be compensated. What law did this doctor violate? a. Right-to-know laws b. Good Samaritan laws c. The Stark Law d. Private law

C: The Stark Law, also known as the physician self-referral statute, prohibits physicians from referring patients for designated health services to any entities that the physician has a financial relationship with or who is an immediate family member. Designated health services can include, but are not limited to, clinical laboratory services, physical or occupational therapy, durable medical equipment, home health services, and outpatient prescription drugs.

Which of the following payment methods reimburses providers using a fixed amount for each of their patients enrolled in a managed care plan? a. Fee-for-service b. Bundled rate c. Capitated rate d. Pay for performance

C: The capitated rate is also known as per member per month (PMPM) or per patient per month (PPPM). This payment method refers to physicians providing all contracted healthcare services to a group of patients and reimbursing a fixed amount for each individual. For example, a doctor could be reimbursed $150 per patient per month. A practice with 50 enrolled members would be compensated a total of $7,500 per month regardless of whether all patients were seen during this period.

Which of the following is considered the most recognizable component of the problem-oriented health record? a. Source-oriented record b. Integrated format c. SOAP format d. Legal health record

C: The problem-oriented medical record (POMR) is comprised of a problem list, initial plan, and progress notes so other professionals can easily follow the course of a person's treatment. The most recognizable component of the POMR is the use of the subjective, objective, assessment, plan (SOAP) format to document progress notes. This record format is commonly used by physicians or other healthcare providers who furnish treatment services to patients.

A hospital recently purchased a computerized provider order entry system for $150,000. The hospital has a liability from a long-term bank loan of $100,000 for this purchase. The revenue generated from this purchase was $36,000. Using this information, calculate the return on investment. a. 43% b. 67% c. 24% d. 36%

C: The return on investment for an individual purchase can be calculated by dividing the earnings from the purchase by the total asset amount. Step1—Divide the earnings by the total assets: $36,000÷$150,000=0.24 Step 2—Multiply the decimal by 100 to get a percentage: ROI=0.24×100=24%

After implementing a new EHR system, the performance improvement team notices that many physicians are reluctant to use the system. The majority claim they are frustrated, stating that it is challenging to navigate the interface and that it seems time-consuming to explore its functionalities. The performance improvement team was not prepared for these project dependencies. Of the options listed, what is the most appropriate course of action to address the physician's concerns? a. Install a system that the providers feel more comfortable using. b. Allow the physicians to figure out the EHR system at their own pace. c. Provide support staff and implement training programs for the physicians. d. Have super users perform the physician's data entry and actions in the EHR system.

C: The success of an EHR system can be dependent on physicians adopting and properly using this technology. If physicians complain that the system's interface is not user-friendly and exploring all its functionalities would be too time-consuming, it would be best to provide support staff and implement training programs for physicians. Explaining how healthcare technologies can improve patient care, help meet compliance standards, and make workflows more efficient might help influence physicians. Interfaces can be configured to make the navigation of EHRs easier. Also, providing support staff can aid throughout the training period and beyond.

A quality improvement team performs an internal and external assessment of its organization. It has determined that it has an emerging market and increased access to interns. How would these be classified in a SWOT analysis? a. Strength b. Weakness c. Opportunity d. Threat

C: When conducting a SWOT analysis, opportunities may include ways to improve the business. An organization may assess its internal and external environments to try and determine how it may expand its operations, better leverage technology, or discover how other resources can be taken advantage of to enhance business operations or outcomes.

Which of the following is a process whereby government-associated agencies grant legal authorization for a healthcare professional to practice an occupation? a. Credentialization b. Accreditation c. Licensure d. Authorization

C: When healthcare professionals are granted licensure(which is issued on a statewide level), they have legal authorization to practice their occupation. Licensure is awarded to individuals when they show that they can meet industry state-approved quality standards by passing an examination. This ensures that professionals are proficient by meeting specific qualifications and continuing to maintain competencies in that given content area.

Willfull neglect

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

The image below is an example of what kind of data analysis tool? a.Radar chart b.Line graph c.Histogram d.Scatterplot

D: A scatterplot is a data analysis tool used to uncover relationships between two continuous variables. A line of best fit can be drawn between the middle of the points on the plot and is used to represent trends in the data. An ascending line is interpreted as a positive association, and a descending line represents a negative association. Therefore, this scatterplot shows a positive correlation between the increase of a patient's age and their likelihood of falling.

A 65-year-old patient presented to the emergency department with meningitis due to African trypanosomiasis. Based on this information, what would be the correct code selection? a. B56.0 b. G02 c. [G02], B56.0 d. B56.0, [G02]

D: According to the official ICD-10-CM coding guidelines, codes presented in brackets should always be sequenced second. This coding convention instructs coders to first code any underlying disease or condition followed by the etiology or manifestations.

For a contract to be considered valid and legally enforceable, it must contain all of the following EXCEPT: a.Contractual offer b.Contract acceptance c.Contractual consideration d.Contract payment

D: Although contracts can vary in length, complexity, and terms, they all must contain essential elements that make them valid and legally enforceable. These elements often include but are not limited to, an offer, acceptance, consideration, a mutual obligation, capacity, and legality.

What is the term used to describe the process of furnishing proof of authorship of medical record documentation? a. Standardization b. Identification c. Authorization d. Authentication

D: Authentication is the process of identifying the author who created an entry in a medical record and attesting that it is genuine. The use of a password, a handwritten or digital signature, or biometric identifiers can establish the user who originated the documentation. All entries in health records must be authenticated to provide verification of the author's identity.

One way to prepare and support end users in EHR applications is to determine if they have any prior experience using these systems and to assess any experiences they have had or opinions they hold on the organization's systems. What data collection method would be the most appropriate to use to obtain this information? a. Sampling methods b. Interviews c. Observations d. Questionnaire surveys

D: Deploying questionnaire surveys is a way to query end users about their current use of EHR applications. Participants' responses can be used to make adjustments or improvements. Questionnaire surveys are a more cost-effective and time-effective option compared to conducting interviews. The survey may ask if users thoughtthey were adequately trained, ifthey receive technical support when necessary, if they find the EHR easy to navigate, and ifthey are satisfied with their overall experience.The survey can also ask for users'opinionsand comments on what changes could be made to improve the EHRsystem's effectiveness.

Important considerations for data governance do NOT include which of the following? a. The mapping of data flow b. The needs of data consumers c. The classification and categorization of data d. The application of internal regulations only

D: Every healthcare organization should closely examine internal and external regulations to help shape its data governance programs. Considering external regulations helps ensure that data will be kept, maintained, and used in accordance with federal and state laws and can avoid noncompliance issues

Which of the following is NOT a component of the Resident Assessment Instrument in long-term care settings? a. Utilization Guidelines b. Care Area Assessments c. The Minimum Data Set d. Healthcare-associated infections

D: Healthcare-associated infections The Minimum Data Set, Care Area Assessments, and Utilization Guidelines are all components of the Resident Assessment Instrument in long-term care settings. Together, these three elements furnish information regarding a resident's preferences and functional status, while providing additional guidance concerning future assessments after issues have been identified. Although healthcare-associated infections may be tracked in long-term care, they are not a component of the Resident Assessment Instrument.

What is the standardized programming language used to communicate with and manage relational databases? a. Java b. Object-oriented languages c. Python. d. Structure Query Language

D: Structured Query Language (SQL) is the formal programming language used to sort, process, retrieve, update, and delete information in relational databases. Various SQL commands can be used to communicate with databases and assist with creating, manipulating, and accessing data across numerous tables

A patient has presented to the emergency department in critical condition after being struck by a car while riding his bicycle. After registering the patient, the department discovered that the patient does not have health insurance and would be unable to pay for their treatment. It is suggested to transfer the patient to a hospital 12 miles away to avoid treating a patient without insurance coverage. What section of the Consolidated Omnibus Budget Reconciliation Act (COBRA) obliges a hospital that participates in Medicare to stabilize and treat patients regardless of their insurance status? a. NCCI b. ERISA c. FMLA d. EMTALA

D: The Emergency Medical Treatment and Active Labor Act (EMTALA) is also referred to as the antidumping statute. EMTALA ensures that the public can receive emergency medical services regardless of ability to pay. EMTALA applies to hospitals that have provider agreements and accept payments from the Centers for Medicare and Medicaid Services (CMS) under the Medicare program. This act requires a patient's condition to be stabilized before transferring them to another facility.

An HIM professional has received an ROI request from a patient's employer. The employer is seeking medical records about a patient's recent work-related injury. From the options listed here, what would be the most appropriate action for the HIM professional to take? a. Contact the workers' compensation specialist and ask for advice. b. Release the minimum necessary PHI to the employer for workers' compensation purposes. c. Require the employer to sign an authorization form first. d. Inform the employer that written authorization from the patient will be required first.

D: The HIM professional should inform the employer that signed authorization from the patient is required before any medical records can be released. To protect the patient's privacy, only the minimum necessary information should be released to the employer to accomplish their intended purposes. Be aware that in some states, employers, their attorneys, or their insurers may not require patient authorization to obtain the minimum necessary PHI of that individual for workers' compensation purposes.

A patient was recently admitted to a hospital and has elected to opt out of the facility directory. What would be the most appropriate action to take in this situation? a. .Inform the patient that they cannot opt out of the facility directory. b. Ask the patient why they want to opt out of the facility directory before removing them. c. Assure the patient that only family members will be provided information about their health. d. Have the patient sign an opt-out form before removing them.

D: The HIPAA Privacy Rule allows healthcare facilities to maintain facility directories that can disclose basic information including a patient's location in the facility, and it can describe their condition in general terms to anyone who specifically asks for a patient by name. Patients have the right to opt out of a facility directory by filling out a form and can opt back in at any time. When a patient opts out of the directory, staff must not share any information regarding the patient's condition or location within the facility even if a family member is asking.

What program was developed by CMS to promote accurate coding and prevent improper reporting of incorrect code combinations? a. NCHS b. HIPAA c. AAMT d. NCCI

D: The National Correct Coding Initiative (NCCI) is a program developed by CMS that is designed to promote correct coding methods and reduce improper Medicare Part B and Medicaid payments. Outpatient code editors are software programs linked to NCCI that apply logical rules to determine various combinations of procedures and services that cannot be billed together on the same day.

A 60-year-old female patient was admitted to the hospital complaining of a severe headache. The nurse measuring her vital signs has alerted the provider that the patient has a low blood pressure reading. The provider requested a CT scan and urinalysis (UA). The UA showed a decrease in the glomerular filtration rate, and the CT showed a ruptured brain aneurysm. The patient was taken to emergency surgery for microvascular clipping. What was the chief complaint? a.Brain aneurysm b.Dehydration c.Low blood pressure d.Severe headache

D: The chief complaint refers to the principal reason or symptoms that a patient is experiencing that caused the patient to seek medical care as told in the patient's own words. In this scenario, the patient presented to the facility complaining of a severe headache. Therefore, this would be considered the chief complaint.

Many medical claims submitted by one coding specialist have been denied due to incorrect code assignments. The coding compliance officer decided to review a random sample of 50 cases coded by the specialist over the past month. What kind of audit is the compliance officer conducting? a. Random audit b. External audit c. IRS audit d. Focused audit

D: The compliance officer is conducting a focused audit of this specific coder's claims, on a retrospective basis. The only way to determine why these claims were denied is to compare the assigned codes to the medical documentation to verify the information. Performing this focused audit can better uncover error patterns, can be used to educate the coder, and will ultimately result in code/reimbursement optimization by decreasing instances of denied claims.

An HIM manager wants to resolve an issue between two employees using a specific conflict management solution. The manager has decided to let one of the employees have their way because the other employee does not care as strongly about the issue of concern. What is the conflict management style used in this scenario? a.Compromising b.Avoiding c.Collaborating d.Accommodating

D: The conflict management style used by the HIM manager in this scenario is accommodation. This resolution can occur when one party sacrifices a desired outcome to satisfy the other party. The accommodating style only works when one party is not invested as strongly in the conflict/outcome as the other. This allows the issue to be resolved more quickly and avoids prolonged conflict.

Robert is the custodian of health records at his medical practice and has been called on to appear for a legal proceeding of a malpractice suit. What role is Robert responsible for regarding the medical documentation presented in the case? a.Determine if the provider authenticated the record. b.Determine if the principal diagnosis of a patient was accurately assigned. c.Testify that medical care was appropriately documented. d.Testify to the admissibility of the record.

D: The custodian of medical records has various responsibilities related to legal proceedings such as appropriately releasing information to a designated recipient (typically an attorney), ensuring that requests for PHI are valid, and determining which portions of the medical record may be released. Another role that the custodian would be responsible for is testifying as to whether the records are admissible to admit as evidence.

What type of analysis is conducted to determine how vital the information in health information systems is with regard to day-to-day operations and patient care? a. Classification analysis b. Perspective analysis c. Requirements analysis d. Criticality analysis

D: The goal of performing a criticality analysis is to recognize how valuable an asset is to a business. An addressable requirement of the HIPAA Security Rule is to evaluate all systems/applications used by an organization to assess potential risks and determine the impacts that they could have on the business. This process is vital to data management and can be helpful in quickly restoring critical systems following expected or unexpected downtime

Which of the following standards is implemented to avoid confusion and variations in the naming of medical procedures and conditions? a. Transaction standards b. Privacy standards c. Data structure and content standards d. Vocabulary standards

D: Vocabulary standards support data integrity by implementing common and consistent definitions for medical concepts or characterization of a patient's condition. Using uniform vocabulary standards helps enhance reporting, improve quality, and assist with interoperability for the effective exchange of health information.

Remittence Advice

Remittance advice is a document that provides details about a payment being made. In the context of healthcare, the Centers for Medicare & Medicaid Services (CMS) provides Electronic Remit Advice (ERA) and Standard Paper Remit (SPR) to communicate claim adjudication and payment information to providers, physicians, and suppliers. The remittance advice includes itemized information for each claim and/or line, the reason for each adjustment, and the value of each adjustment. It is an important tool for providers to reconcile their accounts and understand the payments received for the services they have rendered. Businesses also use remittance advice to add an extra layer of clarity to complex transactions and keep accountants informed about payments. It can help with allocating payments and simplifying the vendor's record-keeping process. Remittance advice is not mandatory for businesses to send, but it is seen as a courtesy. It can be sent via email or snail mail, and it comes in several different forms, such as basic remittance advice, removable invoice advice, and scannable remittance advice.

FTC Federal Trade Commission

The Federal Trade Commission (FTC) is an independent agency of the United States government, established in 1914 by the Federal Trade Commission Act. The FTC is tasked with promoting consumer protection and eliminating and preventing anticompetitive business practices. It works to prevent fraudulent, deceptive, and unfair business practices, and provides information to help consumers spot, stop, and avoid scams and fraud.

HIPAA's Tiered Penalty Structure

The Health Insurance Portability and Accountability Act (HIPAA) establishes a tiered penalty structure for violations. The penalties are divided into four tiers, each representing a different level of culpability. The tiers are as follows: Tier 1: Violations that the covered entity was unaware of and could not have realistically avoided, with a minimum penalty of $100 per violation and a maximum penalty of $50,000 per violation. Tier 2: Violations that the covered entity should have been aware of but could not have avoided, with a minimum penalty of $1,000 per violation and a maximum penalty of $50,000 per violation. Tier 3: Violations suffered as a direct result of "willful neglect" of HIPAA rules, with a minimum penalty of $10,000 per violation and a maximum penalty of $50,000 per violation. Tier 4: Violations of HIPAA attributable to willful neglect, with a minimum penalty of $50,000 per violation.

Minimum Data Set (MDS)

The Minimum Data Set (MDS) is a standardized assessment tool used in clinical settings, particularly in nursing homes, to measure the health and functional status of residents. It is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid-certified nursing homes. The MDS provides a comprehensive assessment of each resident's functional capabilities and is completed every 3 months or more often, depending on circumstances. It includes information on various domains such as functional, cognitive, psychosocial functioning, and geriatric syndromes. The data collected through MDS assessments is used for care planning, research, and policy development. The MDS can be a valuable resource for understanding the health status of individuals in long-term care facilities and for conducting research on function and disability in aging populations

True or False: For inpatients, a diagnosis is described as possible, probable, and so on is considered to be an established diagnosis. In outpatient settings, you cannot use possible, probable, and so on. In outpatient, code for signs and symptoms instead.

True

A patient who was recently treated in your facility has paid in full for all services out of pocket (this patient does have insurance). The patient has requested that all information regarding this visit remain private and not be shared with their insurance company. Is this an appropriate request, and should the healthcare facility comply with this patient's request? a. Yes, because the patient paid out of pocket (in full), the insurance company has no responsibility for payment. b. Yes, patient can withhold any treatment information from their insurance company at any time. c. No, because the insurance company may cover the costs of these services. d. No, because this individual has insurance and healthcare services should never be kept from their insurer.

a. Covered entities are obligated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA)to allow individuals to make specific privacy requests; however, they are not always required to honor the patient's request. For example, if a patient pays for a service in full out of pocket, they have the right to restrict disclosures of PHI regarding this service. This special request must be in writing, and a signed copy should be kept if the covered entity agrees to the request.

What is the time frame for completing an operative report for a high-risk procedure? a. Whenever the provider has enough time to dedicate to documentation b. No more than 1 week following the procedure c. Immediately after a procedure is completed d. Within 30 days of the procedure

c. According to the Joint Commission, operative reports must be written, dictated, and entered into the medical record immediately after surgery of a high-risk procedure. If an operative report cannot be completed, a progress note must be entered before the patient is transferred to the next level of care to ensure that pertinent information is available to subsequent caregivers.

A manager has created an image to help her visualize a defined workspace as well as functions or other related tasks performed in that designated area to determine how they are related. What kind of visualization tool has the manager created? a. Work distribution chart b. Dashboard c. Movement diagram d. Heat map

c. Movement Diagrams Movement diagrams visually depict a workspace layout that includes doorways, furniture, equipment workstations, and more. The movements of daily work can be traced to examine inefficiencies in workflow processes. Equipment and workstations can be rearranged for process improvement purposes that could result in smoother and more effective office workflows.

A famous celebrity was recently admitted to your hospital for emergency surgery. It has been recommended that during this patient's stay, audit logs be conducted to determine if inappropriate access to the patient's protected health information (PHI)has occurred. What type of measure is this? a. Administrative safeguard b. Physical safeguard c. Addressable safeguard d. Technical safeguard

d. Performing audit trails helps to reconstruct electronic events to maintain the privacy of patients. Audit controls are considered a category of technical safeguards that include the technology and policies/procedures used to protect electronic protected health information (ePHI). Curious workforce members may conduct unauthorized searches of the celebrity patient's medical records and may even leak or try to sell this information for attention or personal gain. Therefore, healthcare organizations must ensure that additional security precautions are taken to protect the confidentiality of public figures.

Relational Database

type of database that stores data in predefined tables made up of rows and columns. (usually 2 dimensional)