RHIA Practice Questions

Coding accuracy is best determined by: A. a predefined audit process B. medicare conditions of participation C. Payer audits D. Joint commission Standards for Accreditation

A a predefined audit process Coders should be evaluated at least quarterly with appropriate training needs identified facilitated and reassessed over time. Only through this continuous process of evaluation can data quality and integrity be accurately measured and ensured. Accuracy of coding is best determined by a predefined audit process

A secretary in the nursing office was recently hospitalized with ketoacidosis. She comes to the HIM department and requests to review her health record. Of the options listed, what is the best course of action? A. Allow her to review her record after obtaining authorization from her B. Refer the patient to her physician for the information C. tell her to go through her supervisor for the information D. tell her the hospital employees cannot access their own health records

A. Allow her to review her record after obtaining authorization from her Review of records by the patient is permitted after the authorization for use and disclosure is verified. Usually hospital personnel should be present during on-site reviews to assist the requester with the paper record or ehr if necessary

In its payment notice (remittance advice), the healthcare plan lists that the payment for the individual laboratory test is $39.00. The bill that the pathologist's office submitted for the laboratory test was $45.00. What does the amount of $39.00 represent? A. Allowable charge B. Capitated rate C. cost D. Premium

A. Allowable charge In a fee-for-service environment, third-party payers establish a fee schedule. A fee schedule is a predetermined list of fees that the third-party payer allows for payment for all healthcare services. The allowable charge represents the average or maximum amount the third-party payer will reimburse providers for the service.

A physician takes the health records of a group of HIV positive patients out of the hospital to complete research tasks at home. The physician mistakenly leaves the records in a restaurant where they are read by a newspaper reporter who publishes an article that identifies patients. The physician can be sued for: A. Invasion of privacy B. Libel C. Slander D. Willful infliction of mental distress

A. Invasion of privacy Invasion of privacy is the intrusion upon one's solitude, another major concern in healthcare. A persons right to privacy is "the right to be let alone." This includes the rights of individuals to be free from surveillance and interference, as well as the right to keep one's information from being disclosed. One major actionable offense of concern is healthcare involving invasion of privacy is the unlawful disclosure of patient's health information.

Which dimension of data quality is defines as "data that is free of errors?" A. accuracy B. currency c. granularity d. precision

A. accuracy (no explanation given in practice test)

The device and media controls standard requires organizations to implement polices and procedures to: A. address the final disposition of ephi, hardware, and electronic media B. restrict the types of media that can be used in an organization C. restrict the type of hardware that can be used in an organization D. address the hardware for business associates

A. address the final disposition of ephi, hardware, and electronic media Organizations must address the final disposition of ePHI, hardware, and electronic media. There are four implementation specifications within this standard: disposal, media reuse, accountability, and data backup and storage

Which of the following fields of informatics largely focuses on developing tools and processes to empower patients? A. consumer B. health C. medical D. nursing

A. consumer Consumer informatics focused on empowering patients by communicating effectively with them using a variety of methods, including health information in various formats. The communication of health information whether in verbal or written format relies on the ability of the individual to understand the information to achieve its desired purpose

A security breach has been reported. What concept describes the process to gather evidence? A. forensics B. risk assessment C. security incident D. security event

A. forensics Forensics is the process used to gather intact and validated evidence and should be used to gather evidence of the security incident

If a patient is readmitted ti a facility, after a recent admission, CMS allows the facility to use the existing history and physical from the first admission if it is for a related condition and was completed with _______ of the second admission and if an interval note updating any changes to the patient's condition has been documented. A. 7 days B. 30 days C. 48 hours D. 72 hours

B. 30 days If the history and physcial have been completed with the 30 days prior to admission it can still be used as long as an updated entry (interval note) is made in the medical record that documents an examination and any changes in the patients condition since the original history and physical was completed. this entry must be included in the record within the first 24 hours of admission

Facility based cancer registries receive approval as part of the facility cancer program form which of the following agencies? A. American Cancer Society B. American College of Surgeons C. National Cancer Institute D. National Cancer Registrars Association

B. American College of Surgeons The american college of surgeons (ACS) commission on cancer has an approval process for cancer programs. One of the requirements of this process is the existence of a cancer registry as part of the program. When the ACS surveys the cancer program part of the survey process is a review of cancer registry activities

When managing the master patient index (MPI) which of the following would be the biggest concern for the health information professional? A. Physical space to house the server B. Duplicate record numbers C. Maintaining the database D. Number of computers in registration

B. Duplicate record numbers A duplicate medical record number results in the creation of new medical record for the patient. This duplicate number and the associated records results in a patient having medical information in disparate medical records that could impeded proper care. Proper management of the MPI is critical to reduce or eliminate the assignment of duplicate medical record numbers.

Which of the following is an example of a 1:M relationship? A. Patients to consulting physicians B. Patients to hospital admissions C. Patients to hospital health records D. Primary care physicians to patients

B. Patients to hospital admissions The one to many (1:M) relationship exists when one instance of an entity is associated with many instances of another entity. In this case the relationship between patient and hospital admissions is one to many. For each instance patient in the database there could be many instances of hospital admission. In other words each patient may have many hospital admissions, but each hospital admission is associated with only one patient

Which of the following is NOT an element of the external environmental assessment that should be part of a managers routine scanning? A. The opinions of industry experts B. The opinions of employees C. Changes in healthcare policy and regulation D. What is happening in similar organizations

B. The opinions of employees Knowledge of the internal and external environment is essential to vision and strategy formulation. Elements of an external environmental assessment include: opinions of industry experts, changes in healthcare policy and regulation, and what is happening in similar organizations in the community. The opinions of employees would not be considered an external environment

The joint commission requires a varying number of safety functions and plans depending on the license or services provided by an organization. The standards require the assessment of safety features for patients, staff, and visitors. Which of the following lists are required safety standard plans for the environment of care? A. emergency management, security management, and patient management B. medical equipment management, life safety management, and emergency management C. employment management, hazardous materials and waste management, and life safety management D. utilities management, employment management, and medical equipment management

B. medical equipment management, life safety management, and emergency management The seven written safety standards or plans for the environment of care cover the following areas: safety management, security management, hazardous materials and waste management, emergency management, life or fire safety management, medical equipment management, and utilities management

Which of the following describes the EHR product's data architecture analytical processes supported, necessary interfaces, reliability and security features, system capacity, expansion capabilities, response time, downtime, and other issues associated with system maintenance? A. functional specifications B. operational requirements C. organizational profile D. vendor information

B. operational requirements The operational requirements elicit information on the EHR product's data architecture analytical processes supported, necessary interfaces, reliability and security features, system capacity, expansion capabilities, response time, downtime, and other issues associated with system maintenance

The incidence of postoperative wound infections occurring in ORIF procedures in which antibiotics were and were not utilized is an example of which type of performance measure? A. data measure B. outcome measure C. process measure D. system measure

B. outcome measure Performance measurement in healthcare provides an indivation of an organization's performance in relation to a specified process or outcome. An outcome measure may be the effect of care, treatment, or services on a customer

When the Medicare Recovery Audit Contractor has determined that incorrect payment has been made to an organization, what document is sent to the provider notifying them of this determination? A. appeal request B. claims denial C. demand letter D. medicare summary notice

C demand letter The provider will be notified of RAC or MAC determination in a demand letter, which includes the providers identification, reason for the review, list of claims, reasons for any denials, and amount of the over payment for each claim. The demand letter is equivalent to a denial letter

Medical identity theft includes all of the following except use of another person's A. Name to obtain durable medical equipment B. Insurance policy number to undergo reconstructive surgery C. Financial information to purchase expensive handbags D. Identity to falsify claims for medical services

C. Financial information to purchase expensive handbags Medical identity theft occurs when a patient uses another patients name and insurance information to receive healthcare benefits. Most often this is done so a person can receive medical care with an insurance benefit and pay less or nothing for the care received

What work measurement tool uses random sample observations to obtain information about the performance of an entire department? A. Performance measurement B. Work distribution C. Work sampling D. Performance controls

C. Work sampling Work sampling is a technique that involves using statistical probability (determined through random sample observations) to characterize the performance of the department and its functional work units

HIPAA allows what form of signature? A. automatic B. digitized C. electronic D. wet

C. electronic The federal electronic signatures in global and national commerce act of 200 (ESIGN) permits an electornic signature to be any electronic sound, symbol, or process attached to or logically associated with a contract or other record that is executed or adopted by the person with the intent to sign the record

In a normal distribution 99.7% of the observations fall within which of the following standard deviations? A. +- 1 s.d. of the mean B. +- 1.5 s.d. of the mean C. +- 2 s.d. of the mean D. +- 3 s.d. of the mean

D. +- 3 s.d. of the mean In the normal distribution the standard deviation indicates how many observations fall within a certain range of the mean. The areas under the distribution curve corresponding to 1,2,3 standard deviations are respectively 68.3%, 95.4%, and 99.7%

Urban clinic is establishing a new Women's Breast Center at an initial investment cost of $2,000,000. Monthly operating expenses are expected to be $100,000 and the center is expected to generate $20,000 in profits each month. What is the estimated return on investment of this project in one year? A. 5% B.10% C. 15% D. 12%

D. 12% Return on investment measures the increase in the value of an asset. Return on investment for one year can be calculated for the acquisition of the Women's Breast Center in this manner: $20,000 X 12 = $240,000; $240,000/ $2,000,000 X 100 = 12%; Return on investment:earnings (after taxes)/ total assets

Which of the following is a continuous quality improvement (CQI) tool frequently used to display data? A. brainstorming B. multi voting C. nominal group technique D. scatter diagram

D. scatter diagram A scatter diagram is a data analysis tool used to plot points of two variables suspected of being related to each other in some way

What project management tool focuses on the percentage of completion of a task but does not show a link between one or more tasks? A. PERT chart B. Project management C. Planning and design D. Gantt

D. Gantt Scheduling the project is commonlu planned and managed through a gantt chart. The Gantt chart captures each of the work packages identified in the work breakdown structure (WBS) as tasks for the project team, assigns each task to a project team member identifies the dates when the work begins and when it will be completed, and identifies any scheduling dependencies/ The Gantt chart can be used to display the schedule in a hierarchical form similar to the WBS. The resulting Gantt chart is used to communicate the schedule and monitor the progress of the project during execution

The HIM manager is conducting a study that compares ICD-9-CM and ICD-10-CM diabetes mellitus codes and documents variations in order to access the impact of the organization. This creates a: A. data chargemaster report B. data dictionary C. database management system D. data map

D. data map a data map descibes the connections or paths between classifications and vocabularies. To help the HIM manager ensure the study validity and integrity the manager will rely on the data map or crosswalk that cnnects the ICD-9-CM codes across the span of the study to ensure that an ICD-9-CM code has in essense the same meaning as the ICD-10-CM code it is mapped or cross-walked to

Site surveyors always look for evidence of three trigger issues including very high percentages of patients suffering from dehydration decubitus ulcers in low-risk residents and fecal impaction within which type of healthcare setting? A. acute care hospital B. ambulatory surgery center C. behavioral health facility D. skilled nursing facility

D. skilled nursing facility Long-term care site surveyors always look for evidence of three trigger issues: very high percentages of patient suffering from dehydration, decubitus ulcers in low risk residents, and fecal impaction. Current federal regulations mandate the primary importance of these issues in a long-term care setting. Whether the facility has very high percentages is determined on the basis of the Facility Quality Indicator Survey

The health information manager is conducting a patient satisfaction survey in an outpatient clinic. Because the clinic typically sees about 300 people per day the manager decides to have the interviewers administer the questionnaire on every tenth patient. This is an example of what type of sampling: A. cluster sampling B. convenience sampling C. stratified sampling D. systemic sampling

D. systemic sampling A systemic random sample is a simple random sample that may be generated by selecting every fifth or tenth member of the sampling framework

Emphasis on group rather than individual achievement is stress in the training topic called: A. ethics B. diversity C. offshoring D. team-building

D. team-building Team-building training helps employees learn to work in groups that have the authority to make decisions. Emphasis is on the group rather than individual achievement

The director of health information services is allowed access to the health record tracking system when providing the proper login and password. Under what kind of access security mechanism is the director allowed access to the system? A. context-based B. role-based C. situation-based D. user-based

D. user-based User-based access is a security mechanism used to grant users of a system access based on the identity of the user

It is important to evaluate a health information systems implementation. All of the following are recommended as measures to determine appropriate performance except for the A. Amount of electricity used B. Percentage of system downtime C. Unintended consequences D. Number of alerts triggered

A. Amount of electricity used The implementation committee for a new information system should establish a formal process to collect data regarding all reported problems to identify patterns, trends, and opportunities to improve the system. The percentage of downtime, unintended consequences and number of alerts triggered would all be appropriate measures to monitor the performance of the new system. The amount of electricity used should not impact users or patients and does not need to be monitored

Detailed procedures should be able to: A. Create consistent outcomes for tasks done B. Eliminate the need for process improvement C. Eliminate the need to train a new employee D. Replace policies

A. Create consistent outcomes for tasks done A procedure describes how work is to be done and how policies are to be carried out. Procedures are instructions that ensure high quality consistent outcomes

The process of reviewing and validating a physicians education and experiences prior to granting medical staff membership is called: A. Credentialing B. Outcomes management C. Surveillance D. utilization review

A. Credentialing Credentialing is the process of reviewing and validating qualifications, granting professional or medical staff membership and awarding delineated privileges. Specific policies and procedures are used by healthcare organizations to accomplish this process. The credentialing process verifies the education, training, experience, current competence, and ability to perform the privileges requires as wall as many other background information pertinent to an individual requesting medical staff membership

A hospital is reviewing the quantity and type of resources being used in the provision of chemotherapy treatment. This is an example of: A. FOCUS-PDCA review B. Accreditation review C. Medication reconciliation D. Utilization management review

A. FOCUS-PDCA review Like other continuous quality improvement (CQI) models FOCUS-PDCA applies to plan, do, check, act process, which is a cycle of trial, measurement, and learning

When the Entity Relationship Diagram (ERD) is implemented as a relational database, an attribute will become a(n): A. Field B. Table C. Object D. Query

A. Field Attributes are the characteristics or data elements to be collected about each entity. They can be depicted in an erd as an oval shape coming off as entity. attributes become the field or column headings withing the data tables of a relational database

A patinet was admitted to the hospital for treatment of myocardial infarction (heart attack) and the MS-DRG assigned was 236 Coronary bypass without cardiac cath without MCC. During the patient's admission a bypass procedure was performed on day 2. On day 4 the patients was diagnosed with sepsis that was not present on admission. Sepsis is a major complication. This case was identified as coded incorrectly in a recent audit by the coding manager. What error was made by the coder? A. The sepsis was not coded and so an MCC was missed B. The coronary bypass procedure was coded incorrectly C. The claim was coded correctly and no error was made D. The cardiac catheterization procedure was not coded.

A. The sepsis was not coded and so an MCC was missed Complications and comorbidity (CCs) and major complication and commodities (MCCs) also play a part in determining the MS-DRGs. CCs and MCCs are additional or secondary diagnoses that ordinarily extend the length of stay. A complication is a secondary condition that arises during hospitalization. a comorbidity is one that exists at the time of admission. CCs affect many but not all MS-DRG categories. MS-DRGs are often found in sets of two or three depending on whether ccs or mccs affect the drg assignment. In such groupings a case with a CC would represent higher severity level and would result in higher payment than a case without a cc. A case with an MCC would be an even higher level of severity and would pay more than a case with a cc

Who may sign an authorization for use and disclosure when the patient is a minor? A. the minor's parents or legal guardian B. the patient C. the physician D. the social worker

A. the minor's parents or legal guardian As a general rule, minors are legally incompetent and unable to make decisions regarding the use and disclosure of their own healthcare information. This authority belongs to the minors parent(s) or legal guardian(s) unless an exception applies

The MPI is necessary to physically locate health records within the paper-based storage system for all types of filing systems except which of the following: A. alphabetical B. middle-digit C. terminal-digit D. straight numerical

A. alphabetical The MPI includes information for all patients who have been registered or treated at any locations in a facility. regardless of the format of the MPI it associates the patient with the particular number under which patient treatment information can be located. In an alphabetical filing system you would be able to locate the patient information without having access to the MPI

Which of the following is an example of a technical safeguard? A. assigning passwords that limit access to information stored electronically B. a policy that states that only authorized people can access the data center C. a policy that states that passwords cannot be shared D. locking the door of the data center

A. assigning passwords that limit access to information stored electronically The security rule defines technical safeguards as the technology and the policy and procedures for its use that protect ephi and controls access to it. a covered entity must determine which security measures and technologies are reasonable and appropriate for implementation. A password fulfills the unique user identification requirement of this specification

A medical staff committee wants ti compare long-term survival rates for breast cancer by comparing outcomes for the mastectomy versus lumpectomy approaches. The best source of this information is the: A. cancer registry B. operative registry C. disease index D. master patient index

A. cancer registry A cancer registry collects demographic information (such as name, health record number, address) type and site of the cancer, diagnostic methodologies, treatment methodologies, and stage at the time of diagnosis as well as periodically collects follow-up information on the patients survival status

The physical safeguards standards of the security rule requires organizations to: A. consider all aspects of physical access to an organization's ePHI B. Have a security consultant test their physical access C. Secure access during transmission of data D. utilize specific locks on all computer and physical assets

A. consider all aspects of physical access to an organization's ePHI All aspects of physical access (physical measures, policies and procedures to protect a covered entity's electronic protected health information buildings and equipment from natural and environmental hazards, and unauthorized intrusion) to ephi are included in the physical safeguards standards

The joint commission measures that are standardized metric tools that provide and indication of an organizations performance are called: A. core performance measures B. measures of central tendency C. performance improvement measures D. vital statistics measures

A. core performance measures Core measures are defined as standardized sets of valid, reliable, and evidence-based measures implemented by the Joint-Commission. The hospital quality measures currently utilized by the joint commission and CMS are acute myocardial infarction; heart failure; pneumonia; asthma care for children; and surgical infection prevention or the Surgical Care Improvement Project

Highland Hospital requires all dates be recorded in its clinical information system as MM/DD/YYYY. This required data definition and format should be part of the________. A. data dictionary B. database administration system C. decision support system D. tacit information system

A. data dictionary A data dictionary is like a map of the database. Whenever a set of data is created it should have an accompanying data dictionary. A data dictionary can ensure consistency by standardizing definitions. A typical data dictionary allows for the format of each attribute such as MM/DD/YYYY for the data

The most important information to include in an informed consent in biomedical research is the: A. description of risk B. name of the sponsor C. specific names of the drugs and substances used D. timeline for the project

A. description of risk Federal regulations require that certain information be provided to each human subject in a research study. The subjects must be given a description of reasonably foreseeable risks or discomfort. The description must be accurate and reasonable, and subjects must be informed of previously reported adverse events

The HIPAA security awareness and training administrative safeguards require all but one of the following addressable implementation programs for an entity's workforce. A. disaster recovery plan B. login monitoring C. password management D. security reminders

A. disaster recovery plan HIPAA administrative safeguards require that a covered entity implements a security awareness and training program for all members of its workforce. Special protections must be taken to ensure information is not inappropriately released or accessed. These protections include login monitoring password management and security reminders

If a physician coerces a patient into undergoing experimental treatments the contract between them may be void based on which defense for nonperformance? A. duress B. fraud C. illegality D. mistake of fact

A. duress duress is when unlawful threats or pressure are used to force a party to execute the contract. In this situation the physician placed under pressure on the patient to undergo the experimental treatment so the contract may be voided based on this

At the end of March the HIM department has a year to date (YTD) payroll budget of $100,000. The actual YTD amount paid in $95,000 because a coder resigned in Feb. For the past two months the position has been filled through outsourcing. Therefore the actual YTD amount for consulting services is $5,000 although no money was budgeted for consulting services. The reporting threshold for variances is 4%. The fiscal year end is December. What is the best description of the payroll variance for this year? A. favorable. permanent B. unfavorable, permanent C. favorable, temporary D. unfavorable, temporary

A. favorable. permanent The money that is in the payroll budget may not be spent by the end of the fiscial year. therefore it is a permanent variance ($100,000 - $95,000 = $5,000. The payroll budget is the positive amount, so it is a favorable

A pharmacist who submits medicaid claims for reimbursement of brand name drugs when less expensive generic drugs were actually dispensed has committed the crime of: A. fraud B. criminal negligence C. perjury D. products liability

A. fraud fraud in healthcare is defined independently by a number of legal authorities but all definitions share common elements: a false representation of fact, a failure to disclosure a fact that is material (relevant) to a healthcare transaction, damage to another party that reasonably relies on the misrepresentation or failure to disclose. This situation would fall under the second category

A patient who was admitted for treatment of an intervertebral disk injury developed a urinary tract infection and fever several days after undergoing surgery. In this situation the urinary tract infection would be classified as: A. healthcare associated infection B. hospital sickness C. community acquired infection D> community sickness

A. healthcare associated infection a healthcare associated infection is one that occurs in a patient in a hospital or healthcare setting in whom it was not present or incubating at the time of the admission nor is it the remainder of an infection acquired during previous admission

Which of the following basic services provided by an HIE organization provides authentication? A. identity management B. person identification C. registry and directory D. secure data transport

A. identity management Identity management is a process that operates to ensure the individuals who have bee identifies are who they say they are, that they have authority to do what they want to do, and that their actions are tracked. This process is essentially the typical security functions of authorization, authentication, access control, and audit control

Which of the following statements is true of data quality management? A. it affects the collection, application, warehousing, and analysis of data to improve information quality B. It analyzes and interprets disease and procedure classifications and terminologies C. It includes system design screen design and report and forms design D. it involves appropriately responding to requests for information based on laws and policy

A. it affects the collection, application, warehousing, and analysis of data to improve information quality Data quality management is the collection, application, warehousing, and analysis of data to improve information quality

The EHR implementation strategy identifies the sequence of implementing the EHR with regard to various inpatient units, departments, physicians, or other categories of users or sites. A. phased roll out B. big bang roll out C. pilot D. straight turnover

A. phased roll out Implementation of an EHR component or functions of a component in one or a few organizational units at a time with a plan to follow with full roll out in the same manner is called a phased roll out

What factor is medical necessity based on? A. the beneficial effects of service for the patients physical needs and quality of life B. The cost pf a service compared with the beneficial effects on the patients health C. the availability of a service at the facility D. the reimbursement available for a given service.

A. the beneficial effects of service for the patients physical needs and quality of life Part of utilization review is to determine the medical necessity of services provided to or planned for an individual patient. Determination of medical necessity is based on whether the services can be expected to have a reasonably beneficial effect on the patients physical needs and quality of life.

Community hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on may 2. The hospital discharged 40 patients, including deaths on May 2. two patients were both admitted and discharged on may 2. What was the total number of inpatient service days for May 2? A. 240 B. 242 C. 280 D. 320

B. 242 (no explanation given) (seems off to me if two patients were admitted and discharged same day) 250+ 30= 280 280-40= 240 240+2= 242

In a typical acute-care setting, which revenue cycle are uses an internal auditing system (scrubber) to ensure that error-free claims (clean claims) are submitted to third-party payers? A. Accounts receivable B. Claims processing C. Claims reconciliation or collections D. Pre-claims submission

B. Claims processing The claims process are uses an internal auditing system to ensure claims are error free. Once all the data have been posted to a patient's account , the claim can be reviewed for accuracy and completeness. Many facilities have an internal auditing system known as scrubbers. The auditing system runs each claim through a set of edits specifically designed for the third-party payer, identifies data that has failed the edits, and flags the claim for correction.

A visitor walks through the IT department and picks up a flash drive from an employees 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

B. Facility access controls The facility access control standard states that organizations should consider methods such as lock and key controls, security tagging equipment, using video camera surveillance, monitoring identification badges, and employing human workforce to perform facility security controls

Which of the following statements is true regarding HIPAA security? A. All institutions must implement the same security measures B. HIPAA allows flexibility in the way an institution implements the security standards C. All institutions must implement all HIPAA Implementation specifications D. A security risk assessment must be performed every year

B. HIPAA allows flexibility in the way an institution implements the security standards Covered entities and business associates must decide which security measures to implement using a risk analysis to determine the circumstances that lead them to unauthorized access and disclosure of ephi. security is not a one-time project but an ongoing process that requires constant analysis as the business practices of the ce and ba change, technologies advance, and new systems are implemented

What is the term to describe whether a person can obtain,process, and understand basic health information and services needed to make suitable health decisions? A. patient literacy B. health literacy C. activation D. HealthyPeople 2020

B. Health literacy Health literacy is the ability to understand instructions on prescription drug bottles, appointment cards, medical education brochures, doctor's directions, and consent forms; it also includes the ability to navigate complex healthcare systems; it requires a complex group of reading, listening, analytical, and decision-making skills and the ability to apply these skills to health situations

Consumer education about the PHR must include which of the following items in order for consumers to embrace it? A. Direct electronic tie-in with the consumers insurance provider B. Information about security and confidentiality C. Standardized form and presentation D. Web-based tools

B. Information about security and confidentiality PHR are popular outside of patients and physicians. The office of the national cordinator for health information technology includes PHRs as part of its strategy for implementing EHRs and the National Helath Information Network (NHIN). Vendors have introduced a proliferation of PHR products. For consumers to embrace PHRs the healthcare industry must providde education on their proper use including secuirty and confidentiality and the technical standards that facilitate the exchange of PHR information

A patient was admitted for cellulitis of the right palm of the hand following a non-venomous insect bite three days prior to the encounter. How would this encounter be coded? L03.011 Cellulitis of right finger L03.113 Cellulitis of right upper limb S60.561A Insect bite (nonvenomous) of right hand initial encounter S60.561D Insect bite (nonvenomous) of right hand, subsequent encounter S60.571A Other superficial bite of the hand of right hand, initial encounter W57.XXXA Bitten or stung by nonvenomous insect and other nonvenomous arthropods initial encounter W57.XXXD Bitten or stung by nonvenomous insect and other nonvenomous arthropods subsequent encounter A. S60.561A, W57.XXXA B. L03.113, S60.561A, W57.XXXA C.L03.011, S60.561A, W57.XXXD D.L03.113, S60.561D, W57.XXXD

B. L03.113, S60.561A, W57.XXXA The cellulitis of the palm should be coded first as the reason for the encounter. Additional codes are also used to represent the insect bite. The seventh character A for initial encounter is used while the patient is receiving active treatment for the injury

A 27 year-old female has a vaginal delivery with a single liveborn female as 40 weeks gestation. Episiotomy and repair. What diagnosis and procedure codes would be assigned to this patient? O70.0 First degree perinal laceration during delivery O70.9 Perineal laceration during delivery, unspecified O80 Encounter for full-term uncomplicated delivery Z37.0 Single live birth Z3A.40 40 weeks of gestation of pregnacy 0W8NXZZ (Med/Surg, General Anatomical regions, Divison, Perineum Female, External, no device, no qualifier) 0WQNXZZ (Med/Surg, General Anatomical regions, Repair, Perineum Female, External, no device, no qualifier) A. O70.0, O37.0, Z3A.40, 0WQNXZZ B. O80, Z37.0, Z3A.40, 0W8NXZZ C. O80, Z37.0, Z3A.40, 0W8NXZZ, 0WQNXZZ D. O70.0, O37.0, 0WQNXZZ

B. O80, Z37.0, Z3A.40, 0W8NXZZ This is an example of a normal delivery, full term, single, health liveborn infant with episiotomy. No other procedures or manipulation to aid in delivery. The Z3A code is used to idicate the 40 weeks gestation od the pregnancy. The correct PCS procedure code is 0W8NXZZ, division of the female perineum

Which of the following clinicians would use the DSM-V system to assist with establishing a diagnosis? A. Physical Therapists B. Practicing Psychiatrists C. Registered dietitians D. Registered nurses

B. Practicing Psychiatrists DSM-V is a multiaxial coding system with five axes. Axis I includes the mental disorders or illnesses comparable to general medical illnesses. Axis 2 includes personality disorders. Axis 3 includes general mental illnesses. Axis 4 covers life events or social problems that affect the patient. Axis 5 is the overall level of the patient's functioning, usually as determined by the Global Assessment of FUnctioning (GAF) The american psychiatric association (APA) states two general uses for DSM: as a source of diagnostic information that enhances clinical practice, research, and education

Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete medical records form accreditation surveyors are unethical behaviors for the following Code of Ethics principle _______. A. Advocate and uphold the right to privacy B. Put service before self-interest C. Represent the profession accurately to the public D. Respect the inherent dignity and worth of every person

B. Put service before self-interest The ethical obligations of the HIM professional include placing service before self-interest. The HIM professional must ensure the honor of the profession before personal advantage as well as the health and welfare of patients before all other interests

The project management terminology, what is the definition of variance? A. the scope limiting statements B. The difference between the original project plan (in terms of work, cost, and schedule estimates) and the actual progress or revised estimates C. the process of making actual progress and remaining efforts from project team members D. the requests for changes to the original project scope

B. The difference between the original project plan (in terms of work, cost, and schedule estimates) and the actual progress or revised estimates After updating the project schedule with the task progress, the project manager compares the task start date, expected finish date, estimated work effort, estimated cost, and estimated duration to what was originally planned. All projects do not progress as originally planned. The project manager must concentrate on those variances that are substantially affecting the project's timeline budget and objectives

Which of the following statements most accurately characterizes the primary reason why today's managers must be able to think and act strategically? A. Traditional strategic planning has been very effective B. The pace of change has compressed organizational response times C. Senior management has more important things to do D. Competitors are doing it

B. The pace of change has compressed organizational response times Strategic planning was developed to prevent organizations from "crisis planning" when they realized that their competitors outpaced them in innovation and they quickly had to develop reactive strategies to keep this from happening again.

In data quality management the purpose for which data are collected is: A. analysis B. application C. collection D. warehousing

B. application Data quality management functions involve continuous improvement for data quality throughout an organization. this includes the application process that is the purpose for which data are collected.

The period of time between discharge and claim submission, which a facility defines by policy is called the: A. AR days B. bill hold C. cash flow days D. denial period

B. bill hold Each facility has a defined number of days during the bill hold period. These are the number of days in which accounts will be held from billing so charges can be entered after the patient is discharged. Bill hold assumes that there will be a delay in accumulating the charges incurred by the patient

If a nurse uses the abbreviation CPR to mean cardiopulmonary resuscitation one time and computer-based patient record another time, which leads to confusion, what would be a concern when applying this dimension of data quality? A. accuracy B. consistency C. currency D. precision

B. consistency Data quality needs to be consistent. A difference in the use of abbreviations provides a good example of how the lack of consistency can lead to problems

Extracting data from a data set to determine trends and identify patterns is referred to as______ A. access control B. data mining C. portal entry D. e-commerce

B. data mining In data mining, the analyst performs exploratory analysis to determine trends and identify patterns in the data set. Those trends and patterns are then used in business planning or process

Which activity would typically occur during the analysis phase of the systems development life cycle? A. building interfaces B. defining deficiencies in the current system C. researching vendor qualifications D. submitting RFI to vendors

B. defining deficiencies in the current system In the analysis phase the new system requirements are defined. In particular deficiencies in the existing system are addressed with specific proposals for improvement

Allowing employees to solve problems within the scope of their job is a characteristic of: A. adult learning B. empowerment C. flexing D. outsourcing

B. empowerment Empowerment is the concept of providing employees with the tools and resources to solve problems themselves. Employees obtain power over their work situation by assuming responsibility.

The medical transcription improvement team wants to identify the cause of poor transcription quality. Which tool could help them accomplish this objective? A. flow chart B. fishbone diagram C. Pareto chart D. force field analysis

B. fishbone diagram When a team first identifies a problem, it may use a fishbone diagram, also known as a cause-and-effect diagram, to help determine the root cuases of the problem. the problem is placed in a box on the right side of the paper. A horizontal line i sdrawn somewhat like a backbone with diagonal bones like ribs pointing to the boxxes above and below the backbone. Each box contains a categoru. the categories may be names that represent broad classification problem areas (for example, people, methods, equipment, policies and procedures, environment, measurement, and so on)

In this level of interoperability the receiving computer has some information regarding the nature of the information being exchanged but does not have complete and shared understanding with the sending system. A. basic B. functional C. semantic D. process

B. functional functional interoperability refers to sending messages between computers with a shared understanding of the structure and format of the message. with functional interoperability the receiving computer can store information in a similar data field because of the nature (context) of the data being sent is understood. For example, the receiving computer could recognize the information being sent is a lab result and can store it accordingly

Which of the following is a retention concern with electronic health records? A. durability B. hardware obsolescence C. storage space D. statute of limitations

B. hardware obsolescence planning for the eventual obsolescence of technology is often not given high enough priority. Hardware obsolescence is a retention concern with electronic health records. record managers need to understand how long data will need to be migrated to ensure compliance with the long retention periods (years to decades) required for EHR systems

A 65 year old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper-GI series and laboratory evaluation of CBC and urinalysis. The x-ray revealed possible cholelithiasis and the urinalysis showed an elevated wbc. the patient was taken to surgery for an exploratory laparaotomy and a ruptured appendix was discovered. After an appendectomy was performed and appropriate postoperative care given. The patient was discharged from the hospital on 1/20. According to Joint commission standards the surgeons operative report must be written or dictated and filed on the patients health record: A. before discharge B. immediately after surgery C. withing 24 hours D. within 48 hours

B. immediately after surgery

If the agreement rate on retrospective queries for a physician is 100 percent, this could be a sign of: A. a lack of responsiveness B. leading queries C. cooperation D. exceptionally well-written queries

B. leading queries It is important to collect the agreement rate because if it is too high or too low this may represent a systemic problem with the documentation process. For example if the agreement rate is 100% the physician is agreeing with CDI specialists on all queries. This may be evidence of either leading queries or physicians who did not receive proper training in clinical documentation practices

What is the term for the record of care in any health-related setting that is used by healthcare professionals while providing patient-care services or for administrative, business or payment purposes? A. minimum data record B. legal health record C. mixed-media health record D. electronic health record

B. legal health record the legal health record can be defined as official business records and for evidentiary purposes created by or for healthcare organizations. The legal health record included documentation of health care services provided to an individual during any aspect pf healthcare delivery in any type of healthcare organization as well as the source of the documentation

A hospitals utilization review committee would like to see data that show the monthly admissions to five different units over the past year. Which of the following techniques for data display would work best? A. histogram B. line chart C. pie chart D. stem and leaf plot

B. line chart A line chart or plot may be used to display time trends. The x-axis shows the unit of time from left to right and the y axis measures the values of the variables being plotted

Which of the following healthcare information systems is most likely to use barcoding technology for patient safety purposes? A. CPOE B. medication administration C. PACS D. telemedicine

B. medication administration The bar code symbol was standardized for the healthcare industry, making it easier to adopt bar-coding technology and to realize its potential. Since then, bar-coding application have been adopted for labels; patient wristbands, specimen containers; business, employee, and patient records; library reference materials; medication packagers; dietary items, paper documents and more

Which work design tool uses an office layout to visualize the interaction of various work procedures? A. job procedure B. movement diagram C. work distribution chart D. workflow process

B. movement diagram A movement diagram is a visual depiction of the layout of the workspace with all the furniture, equipment, doorways, and other elements sketched in. Superimposed on the layout are the movements of either individuals or things (for example documents files and such) the movement diagram can be used to evaluate the workflow and to redesign one that is more efficient

A hospital has experienced an increase in third-party payer denials for lack of pre-authorization for certain services. Which of the following departments should hospital administration scrutinize to ensure that proper procedures are in place? A. health information management B. patient registration C. patient accounting D. utilization management

B. patient registration The patient registration department for admitting encompasses all of the front end process including obtaining information before the patient arrives at the facility for services. Insurance verification is essential to determine whether the patient actually has insurance coverage, whether the insurance covers the service the patient will have, and whether the patient must pay a deductible or co-payment. Notification of some or all of this information can result in claims either being sent to an insurance company that will not pay then being returned to staff in the patient accounts department to try to determine the actual insurance or claims reverting to the patient for payment

The HIM manager at Anywhere hospital has contracted with an outside vendor to handle the complete cancer registry function for the facility. This type of contract for services would be considered: A. full service B. project based C. temporary D. specialty function

B. project based In this situation, contracting for staffing to handle a complete function (cancer registry) within the HIM department would be considered a full service contract

There are instances under the HIPAA Privacy Rule in which a person can informally agree or object to the release of their protected health information. All of the following are examples except: A. When the patient name is included in a facility directory B. When releasing information for public health purposes C. when family and friends are with the patient being treated D. when releasing information for disaster relief

B. when releasing information for public health purposes Use or disclosure is permitted even without patient authorization for public health interest and benefits. As required by law, public health interest and benefits may be public health activities or activities essential for government functions

A child's prescription drug is not on the healthcare plan's formulary. The pharmacist states that the drugs cost is $113.45. Using the information provided on the patients coverage how much should the guarantor expect to pay for this prescription? A. $10 B. $25 C. $40 D. $113.45

C. $40 The copayment is a fixed dollar amount or flat fee. The fixed amount may vary by type or service such as a visit or a prescription. In this situation the childs prescription is not on the healthcare plans formulary (list of prefered drugs) so it would fall to the Tier 4 rate of $40 for the copayment

Refer to the OCQ table. Which of the following would be considered invalid ? A. 0CQ3XZZ B. 0CQ80ZZ C. 0CQ9XZZ D. 0CQWXZ2

C. 0CQ9XZZ PCS coding guidline A9 emphasizes that the code building process has to take place by selecting values from a given row in a table. It is not permissible to pick values for a given character in one row and select a value form a different row for the next character. in this case the body part character 9 paratoid gland left does not correspond to a row with the approach character of X external

How many days does a covered entity have to respond to an individuals request for access to his or her PHI when the PHI is stored off-site? A. 10 days B. 30 days C. 60 days D. 90 days

C. 60 days If the PHI is not maintained or located on-site the covered entity must respond to the request within 60 days of receiving it

The designated record set: A. Must be maintained outside a covered entity B. Includes incident reports C. Includes medical and billing records D. Is not used to make decisions about an individual

C. Includes medical and billing records A designated record set (DRS) is defined as a group of records maintained by or for a covered entity that is (1) the health records and billing records about individuals maintained by or for a covered healthcare provider; (2) the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; (3) or used, in whole or in part by or for the covered entity to make decisions about individuals

An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should have been implemented that could minimize this security breach? A. audit controls B. Facility access controls C. Information access controls D. Workstation security

C. Information access controls The information access management standard restricts access to electronic protected health information (ephi) only to those that need it to perform their jobs. In this scenario the physical therapist needs access to PHI for the job but is violating that privilege by access ephi on individuals that are not under the therapists care

The HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to the lease amount necessary to accomplish the intended purpose. What concept is this an example of? A. Authorization B. Consent C. Minimum Necessary D. Notice of Privacy Practices

C. Minimum Necessary The privacy rule introduced the standard of minimum necessary which is a "need to know" filter applied to limit access to a patients protected health information (PHI) as well as the amount of PHI used, disclosed, and requested

How does mentoring differ from coaching as a career development practice? A. offers specific job-related training B. reviews the work of the employee C. Most often performed by a senior employee D. Involves performance appraisal

C. Most often performed by a senior employee Mentoring is a form of coaching. A mentor is a senior employee who works with employees early in their careers, giving them advice on developing skills and career options.

The technology that allows a healthcare organization to logically (or conceptually) link multiple physical data repositories is: A. MPI B. OLAP C. OTLP D. EMPI

C. OTLP Online or real time transactional processing (OLTP) is a technology that allows an organization to logically link their physical data repositories. The data are entered into the repositores by the organizations' various "feeder" applications, and the users must be able to manipulate, update, retrieve, and otherwise act on the data in real time while the data are stored in the repositories. This requires data repositories to include tools like OLTP, which are designed to perform intricate data searches and retrievals

Coding compliance programs focus on preventing accusations of fraud and abuse in healthcare. Which organization from the department of health and human services provides guidance for healthcare organizations in developing compliance programs? A. Joint Commission B. AHIMA C. Office of Inspector General (OIG) D. CMS

C. Office of Inspector General (OIG) The OIG continues to issue compliance program guidance for various types of healthcare organizations. The goal of the compliance programs is to prevent accusations of fraud and abuse, make operations run more smoothly, improve services and contain costs.

The performance standard to "Deliver the record to the requester of a STAT request within 10 minutes of receiving the request is an example of a: A. Compliance standard B. Join Commission standard C. Quality standard D. Quantity standard

C. Quality standard Quantity standards (also called productivity standards) and quality standards (also known as service standards) are generally used by managers to monitor individual employee performance and the performance of a functional unity or the department as a whole. To properly communicate performance standards, managers need to make the distinction between quantitative and qualitative standards and identify examples of each for the HIS function. In this scenario delivery of the record to the requester of STAT request within 10 minutes of receiving the request is identifying the quality or how well the work is being performed rather than by how much work is being performed so it is a quality standard

An 80- year old female is admitted with fever, lethargy, hypotension, tachycardia, oliguria, and elevated WBC. The patient has more than 100,000 organisms of Escherichia coli per cc of urine. The attending physician documents "urosepsis." How should the coder proceed to code this case? A. code sepsis as the principal diagnosis with urinary tract infection due to e. coli as secondary diagnosis B. code urinary tract infection with sepsis as the principal diagnosis C. Query the physician to ask of the patient has septicemia because of the symptomatology D. Query the physician to ask if the patient had septic shock so this may be used as the principal diagnosis

C. Query the physician to ask of the patient has septicemia because of the symptomatology As a result of disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity. In this case, a diagnosis of urosepsis is ambiguous and needs to be clarified by the physician for correct coding

The primary purpose of minimum data set in healthcare is to: A. define reportable data for federally funded programs B. mandate all data that must be contained in a health record C. Recommend common data elements to be collected in health records D. Standardize medical vocabulary

C. Recommend common data elements to be collected in health records The need for standardized data definitions was recognized in the 1960s and the national committee on vital and health statistics took the lead developing uniform minimum data sets for various sites of care. As technology has driven the development of the data or information systems, the early data sets have been supplemented with healthcare information standards that focus on EHR system. A number of standards-setting organizations are involved in developing uniform definitions, data fields, and views for health record content and structure

. An analyst was testing the hypothesis that there is an association between physician gender (M/F) and the willingness to use/not use CPOE. The value of the chi-square test statistic is 7.23. If the acceptable level of type I error was set to 0.01, what is the conclusion of the hypothesis test? A. Accept the null hypothesis B. Reject the alternative hypothesis C. Reject the null hypothesis D. Accept the alternative hypothesis

C. Reject the null hypothesis In testing a hypothesis using statistical inference the decision is to reject or not reject the null hypothesis at the present alpha level. If the test statistic value is greater the the cutoff, reject the null hypothesis. In this scenario the chi-square test statistic is 7.23 and is greater than the type 1 error rate of 0.01 so the null hypothesis would be rejected

The Uniform Health-Care Decision Act ranks the next-of-kin in the following order for medical decision making purposes: A. Adult sibling, adult child, spouse, parent B. Parent, spouse, adult child, adult sibling C. Spouse, adult child, parent, adult sibling D. Spouse, parent, adult sibling, adult child

C. Spouse, adult child, parent, adult sibling The Uniform Health-Care Decision Act suggests that decision-making priority for an individual's next of kin be as follows: Spouse, adult child, parent, adult sibling. If no one is available who is related to the individual authority may be granted to "an adult who exhibited special care and concern for the individual."

In most cases, minors are deemed legally incompetent to access, use, or disclose their health information. What resource should be consulted in terms of who may authorize the ability to access, use, or disclose the health records of minors? A. HIPAA, because there are strict HIPAA rules regarding minors B. A hospital attorney, since they know the rules of the hospital C. State law, since HIPAA defers to state laws on matters related to minors D. State rules of evidence related to minors

C. State law, since HIPAA defers to state laws on matters related to minors Because HIPAA defers to state law on the issue of minors applicable state laws should be consulted regarding appropriate authorization. Generally speaking age of majority is 18 years or older. This is the legal recognition that an individual is considered responsible for and has control over his or her actions

A database rule that states "patient gender must be recorded as M=male, F=female, and U=unknown is referred to as: A. authorization management B. data map C. application control D. knowledge management

C. application control databases contain rules known as application controls that must be satisfied by the stored data. Data integrity happens when all of the data in the database conform to all rules. Certain fields such as dates must be entered in a certain format such as MM/DD/YYYY. Application controls such as edit checks help ensure that the originally-entered data and changes to these data follow certain rules

A visitor to the hospital looks at the screen of the admitting clerks computer workstation when the clerk leaves her desk to copy some documents. What security mechanism would best have minimized the security breach? A. access controls B. audit controls C. automatic log off controls D. device and media controls

C. automatic log off controls The workstation use standard requires organizations to set policies and procedures that specify the proper functions to be performed and the manner in which those functions are to be performed. Examples of this kind of safeguard are the timeouts and logouts that break the system connection if the workstation remains idle for a specified period of time

The standard that required covered entities and business associates to have an agreement regarding use, disclosure, and security of protected health information is the: A. business associate agreement standard B. covered entity contracts and other arrangement standard C. business associate contracts and other arrangements standard D. covered entity and business associate agreement standard

C. business associate contracts and other arrangements standard the final standard in the administrative safeguard section of the security rule is the business associate contracts and other arrangements standard. Specific items that were addressed are that business associates follow the security rule for electronic phi , have business associate agreements with their subcontractors who must follow the security rule for ephi and obtain authorization prior to marketing

In a recent coding audit the coding manager discovered the following issue: A skin lesion was removed from a patient's cheek in the dermatologists office. The dermatologist documented skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take in order to correctly code this encounter? A. code basal cell carcinoma B. code benign skin lesion C. code skin lesion D. query the dermatologist

C. code skin lesion In the outpatient setting, do not code a diagnosis documented as probable. Rather code the conditions to the highest degree of certainty for the encounter

The distinguishing feature of a results management application is that it: A. captures charges for diagnostic studies and sends them to a billing system B. directs the work of the departments that produce results of diagnostic studies C. enables results of a diagnostic study to be compared and displayed with other data D. Provides diagnostic study information viewable form

C. enables results of a diagnostic study to be compared and displayed with other data The result management application enables the results of diagnostic studies to be compared and displayed with other data

Problems that would be faced by an HIM professional responsible for ___ include curious employees who should not have access to health information failures to log off electronic systems, and inappropriate data being stored on a personal laptop. A. data resource management B. e-health systems C. information security D. software development and implementation

C. information security the health information management professionals are trained in the ethical issues related to EHR systems such as information security because staff have access to more information that what is needed to do their job. Employees accessing the records should not explore information out of curiosity as this would be unethical

Placing a condition about the award of a contract for laboratory services on the provision of an "under the table" percentage payback to a physician who has the ability to influence the decision about who is awarded the contract is called a(n): A. arbitration B. criminal bribery C. kickback D. solicitation

C. kickback the federal anti-kickback statute establishes criminal penalties for individuals and entities that knowingly and willfully offer, pay, solicit, or receive remuneration in order to induce business for which payment may be made under any federal healthcare program, including kickback, bribes, and rebates.

A health record that includes all the health-related information generated for an individual during his or her lifetime is called: A. electronic health record B. latitudinal health record C. longitudinal health record D. personal health record

C. longitudinal health record The longitudinal health record is a health record that may include all health-related information generated for an individual during his or her lifetime. These records have many benefits for consumers. However, maintaining such records for every American will be impossible until every healthcare provider in the country has implemented an EHR system

Which of the following tracks patient, person, or member activity within healthcare organizations and accross patient care settings? A. bechmarking B. case-mix management C. master patient index D. OIG work plan

C. master patient index The MPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient who has never been admitted or treated in the facility

Which of the following is the key to identification and location of a patient's health record in a numerical filing system? A. deficiency slip B. disease index C. master patient index D. outguide

C. master patient index The MPI functions as the primary guide to locating pertinent demographic data about the patient and his or her health record number. Without the information contained in the MPI it would be almost impossible to locate the patient's health record in most organizations that use a numeric filing system. The MPI is the permanent record of every patient ever seen in the healthcare entity

The HIM manager at community hospital needs to choose a database model that allows the facility to store images, video, and data. Which of the following should the manager choose? A. hierarchical database B. network database C. object-oriented database D. relational databse

C. object-oriented database the object-oriented database is a database model that handles text, images, audio, video, and other objects. In the model these images and other non-text items are stored as objects with hierarchy and a navigational style of programming

The CPT codes for Emergency Department visits are: 99281- Level 1 Emergency Department Visit 99282- Level 2 Emergency Department Visit 99283- Level 3 Emergency Department Visit 99284- Level 4 Emergency Department Visit 99285- Level 5 Emergency Department Visit This set of CPT codes is an example of: A. interval data B. nominal data C. ordinal data D. ratio data

C. ordinal data Oridnal data are discreate categories or groups within a natural or inferred order. Examples of ordinal data include patient satisfaction responses on a five point scale, patient severity scores, or CPT codes for emergency department visits

This type of data tool is used to show the relationship of each part the the whole. A. bar graphs B. histogram C. pie charts D. line graphs

C. pie charts A pie chart is an easily understood chart in which the sizes of the slices of pie show the proportional contributions of each part. Pie charts can be used to show the component parts of a single group or variable and are intended for interval or ratio data

The SOAP format is an example of a structured progress note commonly used with the ______ health record. A. integrated system B. patient-oriented C. problem-oriented D. source-oriented

C. problem-oriented The subjective, objective, assessment, and plan (SOAP) format is an example of structured progress note commonly used with the problem-oriented health record

Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patients health record that is positive for staph infection. However there is no mention of staph in the physician documentation. What should Carolyn do? A. assign a code for the staph infection B. put a note in the chart C. query the physician D. tell her supervisor

C. query the physician as a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries may be made in situations in which there are clinical indicators of a diagnosis but no documentation of the condition

Violations of the need-to-know principal and misuse of blanket authorizations are ethical problems pertaining to ______. A. data resource management B. genetic discrimination C. release of information D. requests for proposals

C. release of information Two primary ethical problems pertinent to the release of information include: violations of the need-to-know principle and misuse of blanker authorizations. The need-to-know principle is based on the minimum necessary standard. Another common ethical problem is misuse of blanket authorizations, which is when the patient signs an authorization allowing the ROI specialist to release any and all information from that point forward

The process of prescreening vendors before detailed vendor proposals are requested is called? A. outsourcing analysis B. proposal framing C. request for information D. systematic design

C. request for information A request for information (RFI) is generally sent to a list of vendors that known to offer products or systems that meet the organization's needs. The RFI is used to obtain general product information and to prescreen vendors

Which of the following is a solution to the problem of staff recruitment for coding and transcription? A. cross-training B. job rotation C. telecommuting D. web-based training

C. telecommuting Alternative staffing structures (flextime, telecommuting, and job sharing) offer flexibility in hours location and job responsibilities as a method to attract and retain employees

Use the attached custom revenue production report to determine which of the following evaluations is apparent to the practice coding manager about the consultation codes (99241-99245) Revenue Production Report Code, QTY, fee, Projected Rev, Actual Insurance Rev 99201, 0, 50, 0, 0 99202, 3, 75, 224, 164.10 99203, 4, 90, 360, 267.94 99204, 0, 120, 0, 0 99205, 0, 150, 0, 0 99211, 703, 28, 19684, 14988.32 99212, 489, 47, 22983, 18092.65 99213, 1853, 63, 116739, 92890.38 99214, 41, 89, 3649, 2799.11 99215, 7, 135, 945, 722.87 99241, 3, 100, 300, 52.50 99242, 9, 125, 1125, 156.23 99243, 27, 150, 4050, 610.45 99244, 10, 175, 1750, 124.32 99245, 1, 200, 200, 53.10 A. the consultation codes are being used more frequently that expected B. the consultation codes appear clustered C. the charges are not being paid appropriately D. the charges appear to be much lower than expected

C. the charges are not being paid appropriately The projected revenue is considerably higher than the actual revenue for consultation in the report, which indicates the practice group is not being paid what they are expecting for their consultation services. A revenue production report contains the total revenue produced by CPT or HCPCS code and the average reimbursement rate for that code. This report is sorted by the amount of revenue produced. Usually 80% of revenue is produced by 20% of the CPT codes used by the practice

In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals who want to see their own health information? A. when access to psychotherapy notes is requested B. when the covered entity is a correctional institution C. when a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual D. when the covered entity has acted under the direction of a correctional institution

C. when a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual The HIPAA Privacy rule provides patients with significant rights that allow them to have some measure of control over their health information. As long as state laws or the physician does not state otherwise (it might endanger the life or safety of the individual or another person), competent adult patients have the right to access their record

Which of the following is an example of demographic data? A. History of appendectomy at age 4 B. Mother died of heart disease C. Temperature: 100 degrees F D. 125 Oak Street, Smallville, KS

D. 125 Oak Street, Smallville, KS Demographic data includes basic factual details about the individual patient. The main purpose of collecting demographic data is to confirm the patients identity. Hospitals and other healthcare related organizations use the demographic data collected from patients as the basis of statistical records, research, and resource planning

What is the correct cpt code assignment for electrosurgical removal of three nevi of the arm (size approx 2.0 cm, 1.5 cm, 0.5 cm)? 11056-Paring or cutting a benign hyperkeratotic lesion (e.g. corn or callus; 2 to 4 lesions 11200- Removal of skin tags, multiple fibrocutaneous tags, any area, up to and including 15 lesions 11400- Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs, excised diameter 0.5 cm or less 11402- Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs, excised diameter 1.1 cm to 2.0 cm 17000- Destruction (e.g. laser surgery, electrosurgery, cruyosurgery, chemosurgery, surgical curettement), premailignant lesions (eg actinic keratoses); first lesion + 17003- Destruction (e.g. laser surgery, electrosurgery, cruyosurgery, chemosurgery, surgical curettement), premailignant lesions (eg actinic keratoses); second through 14 lesions each (List seperatelt in addition to code for first lesion) A. 14000, 11402, 11402 B. 11056 C. 11200 D. 1700, 17003, 17003

D. 1700, 17003, 17003 The plus symbol + indicates the code following the symbol is an add on code. In this situation there are three lesions; therefore 17000 is coded for the first lesion and then 17003 is coded twice for lesions 2 and 3

During the month of June, Community Hospital had 149 discharges and 47 patients had consultations from specialty physicians. What was the consultation rate for June? A. 0.31% B. 9.46% C. 9.7% D. 31.5%

D. 31.5% The consultation rate calculation for this scenario is (47X100)/149 or 4,700/149= 31.5%. A consultation occurs when two or more physicians collaborate on a particular patient diagnosis or treatment. The attending physician requests the consultation and explainsthe reason for doing so. The consultant then examines the patient and the patient's health record and makes recommendations in a written report. the formula for calculating the consultation rate is: total number of patients receiving consulations for a given period/ total number of discharges and eaths for the same period X 100 47 / 149= 0.3154 X 100 = 31.54%

Compliance with the conditions of participation allow a hospital to achieve: A. Joint commission accreditation B. Commercial insurance reimbursement C. State licensure D. Medicare certification

D. Medicare certification The regulations for health record content and documentation were originally established in the conditions of participation. CMS is responsible for developing and enforcing regulations regarding the participation of healthcare providers in the Medicare program

The EMTALA regulations include all of the following except which? A. transfers of non-stabilized patients must only occur under specific conditions B. Every patient arriving at the ED must receive an appropriate "medical screening exam" C. If an emergency medical condition exists the hospital must treat and stabilize that condition or transfer the patient D. Non-Medicare indigent patients must be transferred to the nearest level 1 trauma center

D. Non-Medicare indigent patients must be transferred to the nearest level 1 trauma center Under the EMTALA regulations hospitals must comply with the following: an appropriate: "medical screening exam" must be provided to anyone coming into the emergency department who is seeking medical care; if an emergency condition is found the hospital must treat and stabilize that condition or transfer the individual; and transfers of non-stabilized patients are not allowed unless several specific conditions have been met

Electronic prescribing is used: A. computerized provider order entry B. hospital order entry systems C. pharmacy systems D. Physicians office prescription writing

D. Physicians office prescription writing electronic prescribing (e-Rx) is the protocol used for a physicians office to send prescriptions electronically to retail pharmacy

Competent individuals have which of the following rights in regard to healthcare? A. Right to consent to treatment and right to destroy their original health record B. Right to destroy their original health record and the right to refuse treatment C. Right to access his or her own PHI and the right to take the original record with them D. Right to consent to treatment and the right to access his or her own PHI

D. Right to consent to treatment and the right to access his or her own PHI Competent adults have the general right to consent to or refuse medical treatment. In general the competent adult has the right to request, receive, examine, copy, and authorize disclosure of the patient's healthcare information

Disciplinary action: A. Should vary based on whom the employee reports B. Cannot be taken when employees are unionized C. Should be taken whenever there is a performance problem D. Should be documented at each step in the process

D. Should be documented at each step in the process Regardless of the counseling and disciplinary actions mandated by the organization, managers should take some key steps of their own such as documenting the steps taken to improve performance

A leader who was using path-goal theory and determined that a worker was not performing well because of lack of self-confidence would most likely use which of the following leadership behaviors to correct the situation? A. Achievement-oriented leadership B. Directive leadership C. Participative leadership D. Supportive leadership

D. Supportive leadership Path-goal theory identifies four different situations, each requiring a different facilitative response from leadership. When workers lack self-confidence, leaders provide support by being friendly, approachable, concerned about needs and equitable. This increases the workers' confidence to achieve the work outcome

Which of the following statements about compiling a directory of patients being treated in the hospital is true? A. A written authorization from the patient is required before any information about him or her is placed in a hospital directory of patients B.Because this is considered a normal hospital operation, an individual may not restrict or prohibit any uses of the directory C. Only the patient's last and first name may be placed in the directory without his or her consent or authorization D. The covered entity must inform the individual what information is maintained in a directory and whom this information may be disclosed.

D. The covered entity must inform the individual what information is maintained in a directory and whom this information may be disclosed. When a healthcare facility id compiling a directory of patients the facility must inform the individual what information is maintained in the directory and to whom is may be disclosed. Once the individual has agreed to be included in the directory the Privacy Rule permits the facility to maintain in its directory the following information about an individual: name, location in the facility, condition described in general terms, and religious affiliation. This information may be disclosed to persons who ask for the individual by name. A patient has the rig to "opt-out" of inclusion in the directory

What information does not have to be included in a covered entity's notice of privacy practice? A. a description with one example of disclosures made for treatment, payment and healthcare operations B. a description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization C. a statement of individuals rights with respect to PHI and how the individual can exercise these rights D. The signature of the patient and date the notice was given to the patient

D. The signature of the patient and date the notice was given to the patient The Notice of Privacy Practices (NPP) is a statement mandadted by the HIPAA Privacy rule that is issued by a healthcare organization to inform individuals of the uses and disclosures of patient-identifiable health information that may be made by the organization as well as to inform the individuals of tights and the organizations legal duties with respect to that information. The actual signature of the patient and the date the notice was given to the patient does not need to be included in the statement, but all other items (examples of TPO, other disclosures permitted without authorization, individual rights) must be included in the NPP

A drug interaction alert would be a typical feature of a _____ A. data warehouse B. data repository C. data mart D. decision support system

D. decision support system The clinical decision support may be active which means that it has alerts or reminders the user must address or passive which means the user may choose to utilize or ignore these alerts. Alerts may notify the care provider of patient allergies contraindications for the medication or other treatment. It may notify the user that the drug being ordered is off-formulary

The Contingency Plan Standard includes all of the following as required implementation standards except for which plan? A. data backup plan B. disaster recovery plan C. emergency mode operation plan D. environmental risk plan

D. environmental risk plan The contingency plan standard is central to being able to ensure availability of data. The standard requires covered entities to establish and implement as needed policies and procedures for responding to an emergency or other occurrence. These policies and procedures include a data backup plan, disaster recovery plan, and emergency mode operation plan. An environmental risk plan is not part of the implementation specifications

Providers should be queried regarding information in the health record for all of the following except: A. conflicting documentation B. ambiguous documentation C. incomplete information D. insignificant information

D. insignificant information Queries are not necessary for every discrepancy or unaddressed issues in physician documentation. healthcare entities should develop policies and procedures to clarify which clinical conditions and documentation situation warrant a request for physician clarification. Insignificant or irrelevant findings may not warrant a query regarding the assignment of an additional diagnosis code for example. entities must balance the value of collecting marginal data against the administrative burden of obtaining the additional documentation

Which term describes the ability of one information system to exchange data with another information system? A. certified B. deterministic C. integrated D. interoperable

D. interoperable Many healthcare organizations have used a closed-system approach to designing healthcare information systems (ISs) that has resulted in a lack of interoperability among systems. Interoperability refers to the capability of one IS to exchange data with another

Securing the authorization of the attending physician, in addition to the patient's authorization, for the release of medical information to the patient's insurance company is: A. a legal requirement under the privileged communication statute B. a legal requirement under common law C. necessary only if the patient is a minor D. not legally required

D. not legally required An authorization to use or disclose information is required if the requester is a third party to the patient such as an insurance company or attorney. But the attending physician does not need to provide any authorization to release the information

Which of the following provides a complete description to patients about the PHI is used in a healthcare facility? A. authorization B. consent for treatment C. minimum necessary D. notice of privacy practices

D. notice of privacy practices The notice of privacy practices explaines how protected health information is used or disclosed. this document explains patients rights and the covered entities legal duties with respect to PHI

What application of data mining is used to identify potential fraudulent medicare claims? A. database modeling B. knowledge management C. total quality management D. predictive modeling

D. predictive modeling Predictive modeling applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are applied to historical data to learn the patterns in the data. These patterns are used to create models of what is most likely to occur. CMS uses predictive modeling to identify potential fraudulent Medicare claims

In order to determine the hospitals expected MS-DRG payment the hospitals blended rate is multiplied by the MS-DRGs______ to determine the dollar amount paid A. case mix number B. length of stay C. major diagnostic category D. relative weight

D. relative weight each DRG is assigned a relative wight. the rw is a multiplier that determines reimbursement. For example a DRG with a relative weight of 2.0000 would pay twice as much as a DRG with a relative wieght of 1.0000

The charge description master relieves the HIM department of _______ that does not require documentation analysis. A. duplicate coding B. manual coding C. procedure coding D. repetitive coding

D. repetitive coding The principal purpose of the charge description master (CDM) is to allow the healthcare facility to efficiently and accurately charge repetitive services and routine supplies to the patient's bill. Through the process of order entry services located in the CDM are "charges" that are hard coded to the patients account

Which of the following would likely head the list of important performance measures for evaluating the results of strategic change? A. Satisfaction and attitudes B. Relationship of cost to benefits achieved C. relative competitive advantage D. results compared to performance targets

D. results compared to performance targets Any time strategic change is undertaken the measures by which its success will be judged should be made part of the performance measures data set

An activity useful in diversity training that involves learners acting out a response to a hypothetical situation is known as: A. classroom lecture B. keyboarding C. programmed learning D. role playing

D. role playing Role playing is an activity where learners are presented with a hypothetical situation they may encounter on the job, and they act out the response. It is useful for tasks such as interviewing, grievance handling, team problem solving, or communication difficulties

The management of a high quality error free MPI requires constant maintenance. A comprehensive MPI management program would include all of the following except: A. ongoing processes to identify and address existing errors B. mechanisms for efficiently detecting, reviewing and resolving potential errors C. reliable links to different health record numbers and other identifies for the same person D. ways to find out where the patients health information has been shared for purposes other than care

D. ways to find out where the patients health information has been shared for purposes other than care The management of high quality error free mpi requires constant maintenance which includes oversight, evaluation, and correction of errors. the responsibility for MPI maintenance should be centralized under the direction of a qualified professional. employees responsible for MPI management must be carefully trained have adequate tools and procedures and be supervised to ensure they are consistently compliant with established guidelines. A comprehensive program should include: *ongoing processes to identify and address existing errors * advanced person search capabilities for minimizing the creation of new errors *mechanisms for efficiently detecting, reviewing and resolving potential errors *reliable links to different health record numbers and other identifies for the same person *consideration of the types of physical merges (such as files and film) and the interfaces and correction routines to other electronic systems that are population or updated by the MPI

What data set provides the underpinning of the home health prospective payment system (HHPPS)? a. UHDDS b. MHDS c. OASIS d. HAVEN

c. OASIS The HHPPS is based on a predetermined rate for a 60-day episode of home healthcare. OASIS data are essential to a home health agency's reimbursement under the HHPPS. Oasis data drive the determination of case-based adjustment. There are three components in the structure of payment under the HHPPS: the national standardized episode rate, the HHA case-mix group, and adjustments