Missed RHIA Questions
A coding service had 400 discharged records to code in March. The service coded 200 within 3 days, 100 within 5 days, 50 within 8 days, and 50 within 10 days. The average turnaround time (TAT) for coding in March was: a. 3 days b. 5 days c. 6.5 days d. 9 days
(200 × 3) + (100 × 5) + (50 × 8) + (50 × 10) / 400 = 5 days (LaTour et al. 2013, 815).
Per HITECH, an accounting of disclosures must include disclosures made during the previous: a. 10 years b. 6 years c. 3 years d. 1 year
. 3 years
The correct sequence of steps when evaluating an ethical problem is: a. Consider the values and obligations of others, consider the choices that are both justified and not justified, determine the facts, and identify prevention options b. Consider the choices that are both justified and not justified, consider the values and obligations of others, identify prevention options, and determine the facts c. Determine the facts, consider the choices that are both justified and not justified, consider the values and obligations of others, and identify prevention options d. Determine the facts, consider the values and obligations of others, consider the choices that are both justified and not justified, and identify prevention options
. Determine the facts, consider the values and obligations of others, consider the choices that are both justified and not justified, and identify prevention options
. With what agency may patients file a complaint if they suspect medical identity theft violations? a. Internal Revenue Service b. Office of Civil Rights c. Centers for Medicare and Medicaid Services d. Federal Trade Commission
. Federal Trade Commission
Which of the following is a characteristic of an organized medical staff as recognized by the Joint Commission? a. Peer review activities are optional unless requested by a physician. b. Fully licensed physicians are permitted by law to provide patient care services. c. Delineation of clinical privileges is not necessary. d. The medical staff is not subject to medical staff bylaws or rules, regulations, and policies, and is subject to their professional code of ethics.
. Fully licensed physicians are permitted by law to provide patient care services.
The MPI includes which of the following? a. Patient's date of birth, height, and gender b. Patient's health record number, blood pressure reading, and age c. Patient's gender, height, and weight d. Patient's date of birth, gender, and health record number
. Patient's date of birth, gender, and health record number
According to the Privacy Rule, which of the following statements must be included in the notice of privacy practices? a. A description (including at least one example) of the types of uses and disclosures the physician is permitted to make for marketing purposes. b. A description of each of the other purposes for which the covered entity is permitted or required to use or disclose PHI without the individual's written consent or authorization. c. A statement that other uses and disclosures will be made without the individual's written authorization and that the individual may not revoke such authorization. d. A statement that all disclosures will be prohibited from future redisclosures.
A description of each of the other purposes for which the covered entity is permitted or required to use or disclose PHI without the individual's written consent or authorization.
Which of the following is a component of the resident assessment instrument? a. The resident's health record b. A standard Minimum Data Set (MDS) c. Preadmission Screening Assessment d. Annual Resident Review
A standard Minimum Data Set (MDS)
HIPAA mandated that healthcare business partners and covered entities implement a common standard for data and information transfer. That standard is: a. ICD-10-CM b. HL7 c. ASC X12 N d. CPT
ASC X12n
Identifying appropriate users of specific information is a function of: a. Access control b. Nosology c. Data modeling d. Workflow modeling
Access control
Which of the following must be reported to the medical examiner?
Accidental deaths
The patient accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills? a. Accounts receivable aging report b. Accounts not selected for billing report c. Case-mix index report d. Discharge summary report
Accounts not selected for billing report
. In a typical acute-care setting, aging of accounts reports are monitored in which revenue cycle area? a. Pre-claims submission b. Claims processing c. Accounts receivable d. Claims reconciliation or collections
Accounts receivable
During the voluntary review process, the performance of a healthcare entity is measured against: a. Accreditation standards b. Clinical practice guidelines c. Core measures d. Conditions of Participation
Accreditation Standards
Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards
Accreditation standards
Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors
Achieving legitimate optimization
. Long-term care hospitals must meet state requirements for ________ and have an agreement with ________ in order to receive payments. a. Acute care hospitals, Medicare b. Medicare, acute care hospitals c. Fiscal intermediaries, Medicare d. Medicare, fiscal intermediaries
Acute care hospitals, Medicare
The accounts receivable collection cycle involves the time from: a. Discharge to receipt of the money b. Admission to billing the account c. Admission to deposit in the bank d. Billing of the account to deposit in the bank
Admission to deposit in the bank
Fifty percent of patients treated at our facilities have Medicare as their primary payer. This is an example of what type of information? a. Patient-specific b. Expert knowledge c. Comparative d. Aggregate
Aggregate
. An alteration of the health information by modification, correction, addition, or deletion is known as a(n): a. Change b. Amendment c. Copy and paste d. Deletion
Amendment
Identifying user information needs is part of the ________ phase of the systems development life cycle. a. Analysis b. Design c. Implementation d. Evaluation
Analysis
In data quality management, the process of translating data into information to be utilized by an application is called: a. Analysis b. Warehousing c. Collection d. Application
Analysis
In which stage of the system life cycle would data be collected from system users regarding their needs? a. Implementation b. Design c. Analysis d. Initiation
Analysis
Which of the following are phases of the systems development life cycle (SDLC)? a. Design, analysis, and alignment b. Maintenance, implementation, and improvement c. Analysis, design, and implementation d. Analysis, alignment, and improvement
Analysis, design, and implementation
Which of the following is an effective method of evaluating responses to a request for proposal (RFP)? a. Testing the new system b. Negotiating contracts with all vendors and assessing the best price c. Attending user group meetings d. Visiting sites that use the systems of product competitors
Attending user group meetings
Which of the following is a mechanism that records and examines activity in information systems?
Audit controls
A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity breach risk and wants the information removed. The physicians and others in the hospital are not cooperating, saying they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? a. Avoid displaying the number on any document, screen, or data collection field b. Allow the information in both electronic and paper forms since a variety of people need this data c. Require employees to sign confidentiality agreements if they have access to social security numbers d. Contact legal counsel for advice
Avoid displaying the number on any document, screen, or data collection field
Which graph is the best choice to use when comparing lengths of stay across three hospitals? a. Line graph b. Bar chart c. Pie chart d. Scatter diagram
Bar chart
The Medicare programs that encourage patients to review provider bills carefully and to report any discrepancies to the Secretary of HHS are called: a. Beneficiary incentive programs b. OIG work plans c. Compliance initiatives d. Operation Restore Trust programs
Beneficiary incentive programs
An evaluation of the benefits that have accrued from the EHR investment that is performed at specific milestones in the life of the project and used to help in future systems planning, designing, and implementing is called a: a. Benefits realization study b. Goal-setting exercise c. Cost-benefit feasibility study d. Productivity improvement study
Benefits realization study
To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? a. Brain injury b. Chronic myelogenous leukemia c. Acute myocardial infarction d. Cancer
Brain injury
A subpoena duces tecum compels the recipient to:
Bring records to a legal proceeding
All computers on this type of network receive the same message at the same time, but only one computer at a time can transfer information; and if one segment of the network goes down, the entire network is affected. a. Star topology b. Ring topology c. Bus topology d. Logical topology
Bus topology
Barcoding technology is an example of: a. Character or symbol recognition technology b. Artificial intelligence c. Voice recognition d. Vector graphic data
Character or symbol recognition technology
What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user? a. Clinical data repository b. Data exchange standard c. Central processor d. Digital system
Clinical data repository
In today's healthcare entity, physicians use the ________ to access multiple sources of patient information within the entity's network. a. Data repository b. Clinical information system c. Data warehouse d. Clinician portal
Clinician portal
Community Hospital has launched a clinical documentation improvement (CDI) initiative. Currently, clinical documentation does not always adequately reflect the severity of illness of the patient or support optimal HIM coding accuracy. Given this situation, which of the following would be the best action to validate that the new program is achieving its goals? a. Hire clinical documentation specialists to review records prior to coding b. Ask coders to query physicians more often c. Provide physicians the opportunity to add addenda to their reports to clarify documentation issues d. Conduct a retrospective review of all query opportunities for the year
Conduct a retrospective review of all query opportunities for the year
. Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required b. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned d. Inform the CFO that business associate agreements cannot be terminated
Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned
For a contract to be valid, it must include three elements. Which of the following is one of those elements? a. Assumption of risk b. Consideration c. Statute of limitations d. Notice of liability
Consideration
Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? a. Compromise b. Collaborative confrontation c. Control d. Constructive confrontation
Constructive confrontation
Which of the following interoperability standards defines specific standards needed to assist patients in making decisions regarding care and healthy lifestyles, specifically to enable the exchange of data between patients and their caregivers via networks? a. Consumer empowerment b. Quality c. Medication management d. Personalized healthcare
Consumer empowerment
Under what access security mechanism would an individual be allowed access to ePHI if he or she has a proper login and password, belongs to a specified group, and his or her workstation is located in a specific place within the facility? a. Role-based b. User-based c. Context-based d. Job-based
Context based
The relationship between patient gender and readmission to the hospital is best displayed using a: a. Frequency chart b. Contingency table c. Bar chart d. Pie chart
Contingency table
Which of the following is a concept designed to help standardize clinical content for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED
Continuity of care record
This type of chart is used to focus attention on any variation in a process and helps the team to determine whether that variation is normal or a result of special circumstances. a. Pareto chart b. Pie chart c. Control chart d. Line chart
Control chart
It is the year 201X. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? a. Conversion factor b. RVU c. GPCI d. Weighted discount
Conversion factor
Determining costs associated with EHR hardware and software acquisition, implementation, and ongoing maintenance represents which type of analysis? a. Benefits realization study b. Goal-setting exercise c. Cost-benefit feasibility study d. Productivity improvement study
Cost-benefit feasibility study
Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? a. Deemed status b. Judicial decision c. Subpoena d. Credentialing
Credentialing
A current key function in the health information field whereby data is turned into useful information is: a. Data mining b. Decision analysis c. Clinical decision support d. Data analytics
Data analytics
Community Hospital just added a new system that changed the way data move throughout the facility. Which of the following would need to be updated to reflect this change? a. Data dictionary b. Entity relationship diagram c. Data flow diagram d. Semantic object model
Data flow diagram
In which of the following does an analyst perform exploratory data analysis to determine trends and identify patterns in the data set? a. Data quality b. Data mining c. Record analysis d. Inferential statistics
Data mining
The process of recouping lost data or reconciling conflicting data after a system failure is called: a. Data backup b. Data mapping c. Data recovery d. Data warehouse
Data recovery
What is it called when accrediting bodies such as the Joint Commission or American Osteopathic Association can survey facilities for compliance with the Medicare Conditions of Participation for hospitals instead of the government? a. Deemed status b. Judicial decision c. Subpoena d. Credentialing
Deemed status
Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called: a. Default records b. Delinquent records c. Loose records d. Suspended records
Delinquent records
Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived
Derived
Which of the following is required in a risk analysis according to the Security Rule? a. Determine the likelihood of threat occurrence and the potential impact b. Focus on improved efficiency c. Implement successful system migration and interoperability d. Develop a sustainable business plan
Determine the likelihood of threat occurrence and the potential impact
The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies would be most likely to correct this problem in the long term? a. Focused reviews on changes in MS-DRGs b. Facility top 10 to 15 DRGs by volume and charges c. Contracting with a larger consulting firm to do audits and education d. Development and implementation of a CDI program
Development and implementation of a CDI program
A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important set of standards to implement in order to transmit images is: a. X12N b. LOINC c. IEEE 1073 d. DICOM
Digital imaging and communication in medicine (DICOM)
Dr. Jones comes into the HIM department and requests that the HIM director pull all of his records from the previous year in which the principal diagnosis of myocardial infarction was indicated. Where would the HIM director begin to pull these records? a. Disease index b. Master patient index c. Operative index d. Physician index
Disease index
The personal health record model that maintains provider control of content while allowing online access to the authorized patient is the: a. Shared data record model b. EHR extension model c. Provider-sponsored information management model d. Smart card model
EHR extension model
A Joint Commission accredited organization must review their formulary annually to ensure a medication's continued: a. Safety and dose b. Efficiency and efficacy c. Efficacy and safety d. Dose and efficiency
Efficacy and safety
Which of the following are technologies and methodologies for rendering protected health information unusable, unreadable, or indecipherable to unauthorized individuals as a method to prevent a breach of PHI? a. Encryption and destruction b. Recovery and encryption c. Destruction and redundancy d. Interoperability and recovery
Encryption and destruction
Which of the following best describes the intent of strategic information systems planning? a. Provide the potential for growth and expansion b. Ensure that all information technology initiatives are integrated and aligned with the healthcare entity's overall strategy c. Assess community or market needs and resources d. Ensure ongoing accreditation
Ensure that all information technology initiatives are integrated and aligned with the healthcare entity's overall strategy
The process of integrating healthcare facility systems requires the creation of: a. Data warehouses b. E-health initiatives c. Enterprise master patient indexes d. Electronic data interchange
Enterprise master patient indexes
A visitor walks through the work area and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? a. Device and media controls b. Facility access controls c. Workstation use controls d. Workstation security controls
Facility access control
Which of the following requires financial institutions to develop written medical identity theft programs? a. HIPAA Security Rule b. HITECH Act c. Fair and Accurate Credit Transactions Act d. HIPAA Privacy and Security Rule
Fair and Accurate Credit Transactions Act
E-discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended which legislation? a. Federal Rules of Evidence b. State Rules of Evidence c. Federal Rules of Civil Procedure d. State Rules of Civil Procedure
Federal Rules of Civil Procedure
In which type of health information exchange architectural model does the entity operate much like an application service provider (ASP) or bank vault? a. Consolidated b. Federated—consistent databases c. Federated—inconsistent databases d. Switch
Federated—consistent databases
Which of the following is a kind of technology that focuses on data security? a. Clinical decision support b. Bitmapped data c. Firewalls d. Smart cards
Firewalls
A quality data review that is based on specific problems after an initial baseline review that has been completed in a hospital is called a(n): a. Focused inpatient review b. Compliance initiative c. Internal audit d. Concurrent review
Focused inpatient review
How do healthcare providers use the administrative data they collect? a. For regulatory, operational, and financial purposes b. For statistical data purposes c. For electronic health record tracking purposes d. For continuity of patient care purposes
For regulatory, operational, and financial purposes
Dr. Smith, an OB-GYN specialist, has just become a staff member at Medical Center Hospital, where she may offer care and treatment related to obstetrics and gynecology including performing deliveries and gynecological surgery. The process of defining what services she may perform is called: a. Outcomes management b. Care mapping c. Granting privileges d. Retrospective review
Granting privileges
Bob Jones is considering contractors for his company's medical benefits, and he is reviewing health plans from two different entities. Which of the following databases should he consult to compare the performance of the two health plans? a. HEDIS b. OASIS c. ORYX d. UHDDS
HEDIS
Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Utilization management b. Patient access c. Health information management d. Patient accounts
Health information management
This type of data display tool is used to illustrate frequency distributions of continuous variables, such as age or length of stay (LOS).
Histogram
Which data collection program is the basis for the CMS value-based purchasing program? a. Leapfrog b. HEDIS c. Hospital Compare d. HCUP
Hospital compare
What is the most constant threat to health information integrity? a. Natural threats b. Environmental threats c. Internal disaster d. Humans
Humans
If parties to a contract agree to hold each other harmless for each other's actions or inactions, this is referred to as a(n): a. Indemnification b. Liability c. Offer d. Warranty
Indemnification
What must be in place to enhance the retrieval process for scanned documents? a. Electronic signature b. Indexing system c. RFID device d. Table of contents
Indexing system
The original HIPAA legislation required adoption of four identifiers: employers, providers, health plans, and individuals. Three of these identifiers have been implemented and one is on hold. Which unique identifier has not been implemented? a. Employers b. Health plans c. Individuals d. Providers
Individuals
The process of preventing the spread of communicable diseases in compliance with applicable legal requirements is performed in this quality management function. a. Infection control b. Clinical quality assessment c. Utilization management d. Risk management
Infection control
Which health record format is arranged in chronological order with documentation from various sources intermingled? a. Electronic b. Source-oriented c. Problem-oriented d. Integrated
Integrated
A protocol to pass data from the R-ADT system of one vendor to the laboratory information system of another vendor is called: a. OLAP b. Integration c. TCP/IP d. Interface
Interface
Allowing different health information systems to work together within and across organizational boundaries is referred to as: a. Telehealth b. Interoperability c. Informatics d. Interfaces
Interoperability
To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of reliability check is called: a. Precision b. Recheck c. Interrater d. Construct
Interrater
Which of the following statements is true of structured query language (SQL)? a. It is both a data manipulation and data back-up mechanism. b. It defines data elements and manipulates and controls data. c. It is the computer language associated with document imaging. d. Users are not able to query a relational database.
It defines data elements and manipulates and controls data.
What is the biggest problem with using mean length of stay as a facility statistic? a. It is not accurate. b. It is influenced by outlier values. c. It is mathematically incorrect. d. It is a dependent variable.
It is influenced by outlier values.
Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? a. X12N b. LOINC c. RxNorm d. DICOM
LOINC
Successful strategic managers understand that three competencies are common to all successful change and that these competencies can and must be developed. These three competencies are: a. Leadership, change management, and strategic development b. Organizational learning, visioning, and leadership c. Visioning, managing, and change management d. Improvement, visioning, and managing
Leadership, change management, and strategic development
This type of data display tool is a plotted chart of data that shows the progress of a process over time. a. Bar graph b. Histogram c. Pie chart d. Line graph
Line graph
This data mining technique discovers relationships between attributes within data sets and displays them in a linked network graph to enable the user to better visualize the patterns. a. Machine learning b. Linkage analysis c. Neural networks d. Logistic regression
Linkage analysis
Working with the healthcare entity's integration team to ensure that ADT interfaces are properly built and tested is the responsibility of the: a. MPI manager b. EHR analyst c. IT manager d. Electronic forms manager
MPI Manager
In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? a. Account level b. MS-DRG level c. MDC level d. MS-DRG triples, pairs, and singles
MS-DRG triples, pairs, and singles
What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts approved by Medicare, amount Medicare paid, and amount the patient must pay? a. EOB b. MSN c. EOMB d. ABN
MSN Medicare summary notices
The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways?
Makes it lower than warranted by the actual service or resource intensity of the facility
Which type of identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits?
Medical
Protocols that support communication between applications are often referred to as: a. Application program b. Interface code c. Messaging standards d. Source code
Messaging standards
Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date element terminated from system, and system of origin are all examples of: a. Autoauthentication fields b. Metadata c. Data d. Information fields
Metadata
The baby of a mother who is 15 years old was recently discharged from the hospital. The mother is seeking access to the baby's health record. Who must sign the authorization for release of the baby's health record? a. Both mother and father of the baby b. Maternal grandfather of the baby c. Maternal grandmother of the baby d. Mother of the baby
Mother of the baby
Which tool is used to determine the most critical areas for training and education for a group of employees? a. Performance evaluation b. Needs assessment c. Orientation assessment d. Job specification
Needs assessment
Today, Janet Kim had her first appointment with a new dentist. She was not presented with a Notice of Privacy Practices. Is this acceptable?
No; it is a violation of the HIPAA Privacy Rule.
Using the information provided, if this is a participating physician who accepts assignment, how much can he or she expect to be reimbursed by Medicare? Physician's normal charge = $340 Medicare fee schedule = $300 Patient has met his deductible
Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians). For example, if the MFS amount is $200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider receives only $152 (95 percent of $160). In this case, the physician is participating so he or she will receive 80 percent of the MFS or $240 (80 percent of $300) (LaTour et al. 2013, 449).
The practices or methods that defend against charges questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation
Nonrepudiation
The term used to describe breaking data elements into the level of detail needed to retrieve the data is: a. Normalization b. Data definitions c. Primary key d. A database management system
Normalization
Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all the facility's linens for off-site laundering. Ready-Clean is: a. A business associate because Lane Hospital has a contract with it b. Not a business associate because it is a local company c. A business associate because its employees may see PHI d. Not a business associate because it does not use or disclose individually identifiable health information
Not a business associate because it does not use or disclose individually identifiable health information
The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure.
Object-oriented database
Phil White had coronary artery bypass graft surgery. Unfortunately, during the surgery, Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care: acutecare hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled?
One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers
Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN
Password and swipe card
. What is the most common method for implementing entity authentication? a. Personal identification number b. Biometric identification systems c. Token systems d. Password systems
Password systems
What term is used to represent a difference between the budgeted amount and the actual amount of a line item that is not expected to reverse itself during a subsequent period? a. Permanent variance b. Fixed cost c. Temporary variance d. Flexible cost
Permanent variance
Which of the following basic services provided by a health information exchange (HIE) entity matches identifying information to an individual? a. Consent management b. Person identification c. Record locator d. Identity management
Person identification
Under the HIPAA Security Rule, these types of safeguards have to do with protecting the environment: a. Administrative b. Physical c. Security d. Technical
Physical
In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation? a. Accuracy b. Granularity c. Precision d. Currency
Precision
Which application uses statistical techniques to determine the likelihood of certain events occurring together? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering
Predictive modeling
Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed
Present an authorization that at least one of them (Ted or Mary) has signed
Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time? a. Prevalence b. Incidence c. Frequency d. Distributio
Prevalence
Which of the following are used to report information about mortality and morbidity at local, state, and national levels? a. Rates, populations, and ratios b. Ratios, proportions, and continuous variables c. Proportions, populations, and continuous variables d. Proportions, ratios, and rates
Proportions, ratios, and rates
Generally, policies addressing the confidentiality of quality improvement (QI) committee data (minutes, actions, and so forth) state that this kind of data is: a. Protected from disclosure b. Subject to release with patient authorization c. Generally available to interested parties d. May not be reviewed or released to external reviewers such as the Joint Commission
Protected from disclosure
The best reason for implementing IS technology in healthcare is to: a. Provide effective and efficient patient care services b. Keep up with rapid technological change c. Provide a competitive edge in marketing the healthcare entity d. Support all IS initiatives identified by managers in the healthcare entity
Provide effective and efficient patient care services
A nurse administrator who is not typically on call to cover staffing shortages gets called in over the weekend to staff the emergency department. She does not have access to enter notes since this is not a part of her typical role. In order to meet the intent of the HIPAA Security Rule, the hospital policy should include a: a. Requirement for her to attend training before accessing ePHI b. Provision for another nurse to share his or her password with the nurse administrator c. Provision to allow her emergency access to the system d. Restriction on her ability to access ePHI
Provision to allow her emergency access to the system
What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met? a. Qualitative analysis b. Legal record review c. Utilization analysis d. Ongoing record review
Qualitative analysis
The statement "Coding of inpatient records must be completed at a 98 percent accuracy rate" is an example of a: a. Goal b. Vision statement c. Qualitative standard d. Quantitative standard
Qualitative standard
A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? a. Code congestive heart failure, respiratory failure, mechanical ventilation, and intubation b. Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis c. Query the attending physician about the adding the symptom of shortness of breath as a secondary diagnosis d. Code shortness of breath, congestive heart failure, mechanical ventilation, and intubation
Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis
When documentation in the health record is not clear, the coding professional should: a. Query the physician who originated the progress note or other report in question b. Refer to dictation from other encounters with the patient to get clarification c. Submit the question to the coding clinic d. Query a physician who consistently responds to queries in a timely manner
Query the physician who originated the progress note or other report in question
Which of the following would be used to determine what the users need in an information system?
Questionnaire
Which of the following is a rule established by an administrative agency of government? a. Municipal code b. Statute c. Subpoena d. Regulation
REgulation
Which of the following lists contains only entities that have roles in the various Medicare Improper Payment Review processes? a. MAC, RAC, and QIO b. AMA, AHA, and RAC c. MAC, AMA, and QIO d. ACS, MAC, and RAC
Rac , MAc qio
A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed? a. Randomly audit EHR documentation for patients readmitted within 30 days. b. Survey practitioners to determine if they are following hospital policy. c. Institute an in-service program for all hospital personnel. d. Observe the documentation practices of all clinical personnel.
Randomly audit EHR documentation for patients readmitted within 30 days.
In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n): a. Primary key interface (PKI) b. Application programming interface (API) c. Continuity of care record (CCR) d. Record locator service (RLS)
Record locator service (RLS)
Which of the following healthcare entities' mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments?
Recovery audit contractor
providers who do not implement an EHR will eventually be penalized through: a. Reduction in Medicare payments b. Reduction in amount of reimbursement from private insurance programs c. Increased administrative costs to process claims d. Restrictions from providing some patient care services
Reduction in Medicare payments
What could an analysis of a flowchart identify? a. Productivity levels b. Customer needs c. Key performance measures d. Redundancies in a process
Redundancies in a process
Which of the following basic services provided by an HIE entity identifies participating users and systems? a. Identity management b. Person identification c. Registry and directory d. Secure data transport
Registry and directory
Which of the following are considered dimensions of data quality? a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency
Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency (RGTCAcPC)
Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service.
Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service.
As an EHR implementation project proceeds, additional hospital departments add requirements for the system, and the project becomes more complex. This is known as:
Scope creep
When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source
Secondary data source
Which of the following basic services provided by an HIE entity ensures that information can be retrieved as needed? a. Consent management b. Person identification c. Registry and directory d. Secure data transport
Secure datat transport
This process provides covered entities and business associates with the structural framework upon which to build their HIPAA Security Plan. a. Security Rule Evaluation b. Security Rule Assessment c. Security Incident Analysis d. Security Risk Analysis
Security Risk Analysis
According to the Joint Commission, the unanticipated death of a full-term infant should be reported as a(n): a. Sentinel event b. Violation of clinical practice guideline c. Unfortunate accident d. Medical accident
Sentinel event
What is the purpose of the project charter or statement of work in project management? a. Detail the tasks to be performed b. Set expectations for the what, when, and how of the project c. Document project issues d. Provide detailed estimates for work effort and start and finish dates
Set expectations for the what, when, and how of the project
An electronic document management system (EDMS) would enable which of the following changes to occur in an HIM department? a. Change record retention schedule to one year b. Eliminate transcription c. Reduce coding errors d. Shift release of information to point of service
Shift release of information to point of service
A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the: a. Mean b. Mode c. Standard deviation d. Standard variance
Standard deviation
For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary
Structured data
The purpose of Regional Extension Centers is to: a. Implement meaningful use b. Support providers in adopting EHR and with technical assistance c. Develop standards for HI systems d. Provide funding for expanding the adoption of HI technology
Support providers in adopting EHR and with technical assistance
A health information exchange entity that has no access to personal health information is an example of this kind of architectural model:
Switch
If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? a. Survey sampling b. Systematic sampling c. Cluster sampling d. Stratified sampling
Systematic sampling
When an entity relational diagram is implemented as a relational database, an entity will become a(n): a. Query b. Form c. Object d. Table
Table
The technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: a. Administrative safeguards b. Technical safeguards c. Physical safeguards d. Integrity controls
Technical safeguards
The HIPAA Privacy Rule permits charging patients for labor and supply costs associated with copying health records. Mercy Hospital is located in a state where state law allows charging patients a $100 search fee associated with locating records that have been requested. Which of the following statements is true when applied to this scenario? a. State law will not be preempted in this situation. b. The Privacy Rule will preempt state law in this situation. c. The Privacy Rule never preempts existing state law. d. The Privacy Rule always preempts existing state law.
The Privacy Rule will preempt state law in this situation.
An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis? a. The average wait time is shorter on weekends. b. The average wait time is longer on weekends. c. The average wait time is different on weekends and weekdays. d. The average wait time is the same on weekends and weekdays.
The average wait time is longer on weekends.
Which of the following statements about new technology items included on the charge description master (CDM) is false ? a. The CDM maintenance committee should review new technology items for FDA approval. b. The CDM maintenance committee should review new technology items for OPPS pass-through assignment. c. The CDM maintenance committee should have a professional coder review code assignments even if codes are suggested by the manufacturer. d. The codes for new technology should not be included in the CDM until coverage has been determined.
The codes for new technology should not be included in the CDM until coverage has been determined.
Which of the following is the definition of revenue cycle management? a. The regularly repeating set of events that produce revenue or income b. The method by which patients are grouped together based on a set of characteristics c. The systematic comparison of the products, services, and outcomes of one healthcare entity with those of a similar entity d. The coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
The coordination of all administrative and clinical functions that contribute to the capture, management, and collection of patient service revenue
In the APC system, a high-cost outlier payment is paid when which of the following occurs? a. The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount. b. The LOS is greater than expected. c. The charges for the services provided are greater than the expected payment. d. The total cost of all the services is greater than the sum of APC payments by a fixed ratio and exceeds the sum of APC payments plus a threshold amount.
The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount.
n original goal of HIPAA Administrative Simplification was to standardize: a. Privacy notices given to patients b. The electronic transmission of health data c. Disclosure of information for treatment purposes d. The definition of PHI
The electronic transmission of health data
A patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond? a. The hospital must accept the request but does not have to agree to it. b. The hospital must honor the request. c. The hospital must guarantee that the request will be followed. d. The hospital must agree to the request, providing that state or federal law does not prohibit it.
The hospital must accept the request but does not have to agree to it.
The confidentiality of incident reports is generally protected in cases when the report is filed in: a. The nursing notes b. The patient's health record c. The physician's progress notes d. The hospital risk manager's office
The hospital risk manager's office
What is the first consideration in determining how long records must be retained? a. The amount of space allocated for record filing b. The number of records c. The most stringent law or regulation in the state d. The cost of filing space
The most stringent law or regulation in the state
he following table shows the LOS for a sample of 11 discharged patients. Using the data listed, calculate the range. Patient Length of Stay 1 1 2 3 3 5 4 3 5 2 6 29 7 3 8 4 9 2 10 1 11 2 a. 29 b. 1 c. 5 d. 28
The range is the simplest measure of spread. It is the difference between the smallest and largest values in a frequency distribution: Range = Xmax - Xmin For this scenario, the range is 1 to 29 (29 - 1) or 28 (LaTour et al. 2013, 520).
If a health plan analyst wanted to determine if the readmission rates for two hospitals were statistically different, what is the null hypothesis? a. The readmission rates are not equal. b. The readmission rates are equal. c. The readmission rate for one hospital is larger than the other. d. The readmission rate for one hospital is smaller than the other.
The readmission rates are equal.
The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and that only the number be announced.
There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice.
An analyst wishes to use the CMI for a set of MS-DRGs to determine if a documentation improvement program is having an impact. Use the MS-DRG volumes and weights in the table below to calculate the CMI for the three MS-DRGs. MS-DRG Description Weight Volume 034 CAROTID ARTERY STENT PROCEDURE W MCC 3.6918 100 035 CAROTID ARTERY STENT PROCEDURE W CC 2.1965 52 036 CAROTID ARTERY STENT PROCEDURE W/O CC/MCC 1.6610 36 a. 2.3234 b. 2.8893 c. 2.5164 d. 3.6918
To calculate the case mix index from the volume of cases from MS-DRG calculate the weighted average MS-DRG weight by completing these steps: (1) Multiply the number of discharges in each MS-DRG by the relative weight of that MS-DRG; (2) Sum the relative weights from step 1; (3) Sum the number of discharges in the MS-DRGs chosen to be evaluated; (4) Divide the total relative weights from step 2 by the total number of discharges from step 3. Step 1: 3.6918 × 100= 369.18 2.1965 × 52= 114.218 1.6610 × 36= 59.796 Step 2: 369.18 + 114.218 + 59.796 = 543.194 Step 3: 100 + 52 + 36= 188 Step 4: 543.194/ 188= 2.8893 (White 2016, 155-156).
Generally, substantial performance by one party to a contract will obligate the other party: a. To perform their contractual obligations b. Not to perform their contractual obligations c. To void the contract d. To invalidate the contract
To perform their contractual obligations
Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use? a. UHDDS b. UACDS c. MDS d. ORYX
UHDDS
A hospital is undergoing a major reconstruction project and a new director of nursing has been hired. At the same time, the nursing documentation component of the EHR has been implemented. The fact that nursing staff satisfaction scores have risen is: a. A result of anecdotal benefits of EHR b. A result of qualitative benefits of EHR c. A result of reconfiguration of the nursing units d. Uncertain due to existence of confounding variables
Uncertain due to existence of confounding variables
In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? a. Unit numbering b. Index unit numbering c. Serial-unit numbering d. Serial numbering
Unit numbering
A set of scenarios that describes an interaction between a user and a system is called a(n): a. Use case b. RHIO c. Test case d. Use description
Use case
Which request for proposal (RFP) component would fit the following description: Describe how your product supports the ability to register a patient in the clinic, admit the patient using the same health record number and demographic information, and share the medication list for medication reconciliation with the nursing home to which the patient is discharged. a. Application support b. Operational requirements c. Technical specifications d. Use case
Use case
Copies of personal health records (PHRs) are considered part of the legal health record when: a. Consulted by the provider to gain information on a consumer's health history b. Used by the healthcare entity to provide treatment c. Used by the provider to obtain information on a consumer's prescription history d. Used by the healthcare entity to determine a consumer's DNR status
Used by the healthcare entity to provide treatment
Which of the following is a statement made by one party to induce another party to enter into a contract? a. Ultra vires b. Warranty c. Agreement d. Indemnification
Warranty
When should an e-discovery response team be formed? a. When a healthcare entity can reasonably anticipate litigation b. The team should be rebuilt yearly c. Well in advance of any litigation d. At least 30 days before the court date
Well in advance of any litigation
The Health Information Services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. The manager has each employee complete a form identifying the amount of time he or she spends each day on various tasks. What is this tool called? a. Serial work distribution tool b. Work distribution chart c. Check sheet d. Flow process chart
Work Distribution Chart
Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems
Work value and practice expenses
It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. a. Training sessions b. Written procedures c. Verbally communicated instructions d. A supervisory committee
Written procedures
Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? a. Each physician practice should obtain a business associate agreement with the hospital. b. The hospital should obtain a business associate agreement with each physician practice. c. Because the physicians all have medical staff privileges, no business associate agreement is necessary. d. Because the physicians are part of an Organized Health Care Arrangement (OHCA) with the hospital, no business associate agreement is necessary.
a. Each physician practice should obtain a business associate agreement with the hospital.
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is: a. Protected by the Privacy Rule because it is individually identifiable b. Not protected by the Privacy Rule because it is part of a personnel record c. Protected by the Privacy Rule because it contains his physical exam results d. Protected by the Privacy Rule because it is in the custody of a covered entity
b. Not protected by the Privacy Rule because it is part of a personnel record
Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical? a. When the patient is readmitted a second time for the same condition b. When the patient is readmitted within 30 days of the initial treatment for a different condition c. When the patient is readmitted a third time for the same condition d. When the patient is readmitted within 30 days of the initial treatment for the same condition
d. When the patient is readmitted within 30 days of the initial treatment for the same condition
An employee forgot his user ID badge at home and uses another employee's badge to access the computer system. What controls should have been in place to minimize this security breach? a. Access controls b. Security incident procedures c. Security management process d. Workforce security awareness training
d. Workforce security awareness training
Per the HITECH breach notification requirements, which of the following is the threshold in which the media and the Secretary of Health and Human Services should be notified of the breach? a. more than 1,000 individuals affected b. more than 500 individuals affected c. more than 250 individuals affected d. Any number of individuals affected requires notification
more than 500 individuals affected
