Health Info Processes Final Exam pt. 2

When the final deadline for EHR implementation arrives, physicians not using a certified EHR see their Medicare reimbursement revenue reduced. How much will they be penalized?

1% with a maximum of 5% penalty

A patient admitted to the emergency department was later transferred to another patient care unit. Upon discharge, the patient was transferred to a rehabilitation facility. Which administrative system would be used to track the patient from admission to discharge?

ADT system

________ require all medical record documentation to be legible, dated, timed, and authenticated.

CMS and Joint commision

Meaningful use requires providers to input their own lab and medication orders into the ________ system.

CPOE

What code system identifies medical, surgical, and diagnostic procedures provided in an outpatient setting?

CPT

_______ provide order and meaning to patient record data.

Clinical terminologies Nomenclatures Classification systems

Computer-assisted coding (CAC) software is expensive and has the potential to create upcoding and downcoding errors. What is another disadvantage of CAC?

Coders are still needed to review the output.

Which of the following populates the ADT?

EHR registrar MPI

________ is one of the meaningful use objectives established by the ONC for the use of EHRs.

Engaging patients Improving efficiency Improving public health

________ require healthcare organizations to keep records safe from fire, water damage, and theft.

HIPAA and the Joint Commission

_______ are standards for interoperability.

HL7

What coding system makes it possible to identify the disease etiology, the anatomic site, and the severity of the disease or the condition?

ICD-10-PCS

What is the purpose of a business associate (BA) agreement?

It specifies the safeguards the BA must have in place to protect patient health information.

What is the benefit of a dictionary-driven encoder?

It takes less time to code since the coder does not have to look up codes in the manual.

________ software assists coders in identifying the correct codes by posing a series of questions.

Logic-based encoder

This clinical system allows the storage and retrieval of radiology images.

PACS

What system does a patient maintain?

PHR

Which of the following is true regarding the PHR?

The PHR should include a confidentiality clause. A strong password should be applied. The patient should audit the record to determine who accessed the record.

________ specify(ies) the required data elements for each patient and the format in which the data must be recorded.

a data dictionary

"Red flags" are specific activities that might indicate fraud. Which of the following choices are examples of red flags?

a fraud alert on a credit card transaction the use of a social security number that is listed on the Social Security Administration Death Master File an insurance card containing information that is inconsistent with the other information provided by the person seeking care

A report is ________ if it is legally subject to release of information.

a part of the legal record

ethics is

a set of principles of right conduct. a system of moral values.

A blank document detailing all data elements required to transcribe a report is known as ________

a template

________ is assigned to an individual and/or job title establishing the amount of access to the electronic record.

access level

A patient has requested a list of all facilities where his or her healthcare information has been released. This is an example of ________

accounting of disclosures

A staff training plan, a contingency plan, and a disaster recovery plan are all examples of

administrative safeguards

Providing a patient with a list of the information released from his or her chart along with the identity of the person(s) who requested the information is ________

an accounting of PHI disclosures.

When ordering medication, a pop-up appears indicating a possible contraindication between a previously prescribed medication and the newly prescribed medication. This is an example of ________

an alert

Which of the following choices is a digital signature?

an electronic signature

In the ICD-10 coding system, what does the underlined numeral 5 in the code S52.521 represent?

anatomical site

The IT department had detected suspicious attempts to access PHI on a famous patient. What would the IT department look at to determine which members of the hospital staff have accessed the patient's EHR?

audit trail

The following password, A#1456bg, is an example of ________

authentication

Which system monitors bed turnover rate?

bed control system

When using an encoder, what should the coder do first?

begin by typing in a keyword or a code

This registry tracks patients diagnosed with a tumor from the date of the diagnosis until the patient's death.

cancer

________ is the process of identifying all the services provided to a patient for reimbursement purposes.

charge capture

A ________ organizes medical terms into categories.

classification ssytem

What program ensures complete documentation, supports accurate diagnostic and procedural coding, and improves communication between physicians and other members of the healthcare team?

clinical documentation improvement

Which of the following choices means "to act in accordance with established guidelines or requirements"?

compliance

A patient admitted for the surgical repair of a fracture develops pneumonia following the surgery. This is an example of a ________

complication

To improve accuracy and increase speed, the ________ system identifies diagnoses and procedure codes. The coder then determines if the codes are accurate and can be used.

computer-assisted coding

________ generates code numbers automatically based on terms and phrases from documentation in the patient record.

computer-assisted coding

When a patient gives formal approval to receive care within a facility, what has the patient provided?

consent

The ________ is referred to as the central system; it may be purchased from the vendor or developed internally.

core EHR system

Health plans, healthcare clearinghouses, and healthcare providers are all considered ________

covered entities

This person is responsible for the care, custody, and control of the patient record in the normal course of business.

custodian of the record

HHS defines ________ as data or information that has not been altered or destroyed in an authorized manner.

data integrity

As the physician is charting, a pop-up appears indicating that due to lab values and signs and symptoms, the patient may have pneumonia. This an example of ________

decision support

Which of the following is related to a prospective payment system?

diagnosis-related groups (DRGs)

A physician speaks into a ________ so that a transcriptionist can listen to the recording.

dictation system

A broken water pipe, fire, downed system, and the policies and procedures regarding these are all examples of ________

disaster-preparedness and downtime procedures.

A physician received an image of a patient's chest X-ray via email. The physician opened the image and transferred it to the patient's electronic record. Which system did the physician use?

document management system

A patient's name and medical record number are entered at registration. The same data elements are entered again by many healthcare providers during the same encounter. This is an example of ________

documentation redundency

When admitting a patient to your facility you need to determine if the patient has had any previous admissions. You search the database by the patient's current and previous name, social security number, and date of birth. In doing so, what are you are trying to eliminate?

duplicate records

A prescription has been sent electronically by the prescribing provider to the patient's pharmacy of choice. This is an example of ________

e-prescribing

Coders input diagnoses and procedures into a(n) ________ for the purpose of generating codes.

encoder software

Providing patients with access to their health information via a portal is an example of ________

engaging patients

Hospitals track the case mix index to ________

estimate further reimbursement

________ integrates the provider's expertise with external evidence, such as medical research or clinical trials, to support clinical decision-making.

evidence-based medicine

When an explanation or instructions are given to a patient who then expresses that he or she understands the information, what type of consent has the patient provided?

express

________ is used to facilitate the sharing of patient health information between physicians located in two different states.

health information exchange

When a patient is re-admitted, the Northstar hospital scans pre-determined documents from prior encounters into the EHR. The patient record then consists of information stored both electronically and on paper. Which term describes this type of patient record?

hybrid record

In what circumstance is authorization for the release of information not required?

if the information is part of a coroner's investigation if the information is reported to state driver and licensing agencies to determine an individual's fitness to drive if it is in public interest to protect the patient and others from harm

Which of the following is an advantage of the EHR?

improved patient safety ease of access quicker access to lab results

________ is when the custodian of the record requests that the judge review the patient record in chambers away from the courtroom.

in-camera view

A whistle-blower is someone who ________

informs law or regulatory agencies about potential fraudulent activity.

Two systems communicating through the exchange of data is accomplished through ________

interoperability

An unauthorized use or disclosure of PHI ________

is a breach

In the EHR, you will find information regarding the patient's recent acute care episode of care, information on an acute care episode of care from the previous year, a consultation report, and the patient's primary care records. Which of the following describes this?

longitudinal record

________ requires the use of a certified EHR to help improve patient care.

meaningful use

When personal information is stolen and used for personal gain, such as securing medical care, purchasing drugs, or falsifying medical claims for payment, this is considered ________

medical identity theft

Medical transcriptionists are now sometimes referred to as ________

medical language editors

________ provides justification that the care provided to a patient is reasonable, necessary, and/or appropriate based on evidence-based clinical standards of care.

medical neccessity

Meaningful use provides incentives for qualified providers who treat ________ patients.

medicare and medicaid

The ICD-O-3 code set is used for ________

oncology coding

________refers to a claim for reimbursement in which the actual cost of providing care is much higher or much lower than the majority of claims for that specific diagnostic category.

outlier

When the HIM department hires a vendor to perform the ROI function, it is referred to as ________

outsourcing

Who maintains a cloud-based application?

patient

A patient can access physician progress notes, lab results, and medications prescribed through the ________

patient portal

________ is a unique identifier? Patient's date of birth Patient's last name Patient's admitting physician patient's medical identification number

patient's medical identification number

How many years must the MPI be retained?

permanantly

Facility access controls and records located in a locked facility are examples of ________

physical safeguards

A nurse documenting in a patient's record is using a terminal located in the patient's room. This is an example of ________

point of care

Which of the following systems is used most often in physician offices?

practice management system

The ________ established standards to ensure that PHI is protected.

privacy rule

Information about the health status, provision of care, or payment for healthcare that can be linked to a specific patient is considered part of ________

protected health information

A patient's name, social security number, medical record number, and home address are all examples of ________

protected health information.

Your job is to look through the electronic record and identify missing reports, dates, times, and signatures. This is accomplished using what system?

record analysis

Which of the following terms describes the removal of all patient identifying information?

reflect

You receive a request for patient information in the mail. You log it into the system, process the request, and then update the system. What system are you using?

release of information

What does the chief financial officer need to consider before determining whether the purchase of an EHR is financially feasible?

return on investment training costs maintenance costs

Which of the following provides administrative, physical, and technical safeguards to protect patient's electronic records?

security rule

Coding classification systems provide ________ for the care providers, payers, and others who use the information.

standarization

A ________ is a type of legal directive that instructs the custodian of the patient record to produce the record in court.

subpoena duces tecum

Individual access controls and transmission security are examples of ________

technical safeguards

Who investigates potential Privacy Rule violations?

the Office for Civil Rights

What information can be accessed through a patient portal?

the information varies depending on the individual site

________ addresses the physical and administrative safeguards that must be in place to protect patient health information.

the security rule

The term ________ refers to side effects or problems that may result from a medical procedure.

unintended consequences

What factors must be considered to determine if a document is protected health information under HIPAA?

whether the document is related to direct patient care whether the information would be released in response to a legal request