RHIT: CORRECTED/UPDATED Multiple choice Purple Book 2016 Practice EXAM 1
*??)* A critical element of data retrieval planning is designing a: a.
*?* Screen Layout
*???)* Which of the following is a retention concern with health records?
*??* Hardware Obsolescence
*29) The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required daily to retrieve and file records for each clinic day? a. 10 hours/day b. 11.11 hours/day c. 12.5 hours/day d. 22.5 hours/day
22.5 hours/day
*7)* Community Hospital's data elements and data definitions are cataloged for each database. What would be the next logical step to determine the degree of data comparability among the databases?
Select a representative set of data elements and track these across the databases to identify consistencies and differences
*84)* The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approxomately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? *COSTS ASSOCIATED: Per IT desk call on PW issues* *Personnel | Cost* User time-30 min. | $15.00 Teleph. Cost-30 min. | $02.00 CallDsk Time-30 min. | $16.00 CallDsk IS facilities time | $17.00 *TOTAL | $50.00* a. Training will provide $146.00 savings in help desk support and can be justified. b. The results of training will provide $365, 000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualititative results cannot be measured to calculate a return on investment.
Training will provide $146,000 savings in help desk support and can be justified
A HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient records at the time of discharge, providing a 24-hour turnaround time. The hospital has an average daily discharge of 120 patients and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time? NAT'L BENCHMARK for DOCUMENT SCANNING __________________________________________________________ Function | Expectations per Worked Hour ---------------------------------------------- Prepping | 340-500 images Scanning | 1200-2400 images Qual Cntrl | 1600-2000 images Indexing | 600-800 images a. 100 hrs b. 146 hrs c. 1,000 hrs d. 3,740 hrs
a. 100 hours
*49)* The patient was admitted to the hospital for treatment of a myocardial infarction (heart attack). A bypass procedure was performed on day two. On admission the patient was diagnosed with sepsis. Sepsis is a major complication. Based solely on this information, which of the following is the correct MS-DRG assignment for this case? a. 235, Coronary bypass w/o cardiac cath w MCC b. 236, Coronary bypass w/o cardiac cath w/o MCC c. 280, Acute myocardial infarction, discharged alive w MCC d. 282, Accute myocardial infarction discharged alive w/0 cc/MCC
a. 235, Coronary bypass w/o cardiac cath w/MCC
*40)* Coding accuracy is best determined by: a. A predefined audity porcess b. Medicare Conditions of Participation c. Payer Audits d. Joint Commision Standards for Accreditation
a. A predefined audit process
*85)* The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date: field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: a. A template was defined b. The data type was numeric c. The field was not required d. The field length was longer
a. A template was defined
*50)* To use a data element for aggregation and reporting, that data element must be: a. Abstracted and indexed b. Searched c. Subject to case finding d. Registered
a. Abstracted or indexed
*95)* An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit Controls c. Contingency controls d. Security incident controls
a. Access controls
*70)* The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments
a. Accusations of fraud and abuse
*80)* A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): a. Audit trail b. Facility access control c. Forensic scan d. Security management plan
a. Audit Trail
*91)* When a hospital uses many different vendors to support its information system needs, the information technology strategy being used is called: a. Best of breed b. Best of fit c. Hospital information system d. Legacy architecture
a. Best of breed
*37)* The APC payment system is based on what system? a. CPT/HCPCS b. ICD-1-CM Dx and Px codes c. CPT and ICD-10-CM procedure codes d. Only CPT codes
a. CPT/HCPCS codes
*55)* A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA (present on admission)? a. Catheter-associated inurinary tract infection b. Cerebral vacular accident c. COPD d. Hypertension
a. Catheter-associated urinary tract infection
*92)* Before purchasing an EHR system, a clinical office practice should consult which of the following to ensure the system meets HL7 standards for EHR system functionality? a. Certification Commission on Health Information Technology (CCHIT) b. Health information exchange (HIE) c. Centers for Medicare and Medicaid (CMS) d. National Committee on Vital and Health Statistics (NCVHS)
a. Certification Commission on Health Information Technology (CCHIT)
*48)* A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cess carcinoma. Which of the following actions should the coding professional do to code this encounter? a. Code the skin lesion b. Code benign skin lesion c. Code basal cell carcinoma d. Query the dermatologist
a. Code the skin lesion
*10)* A family practitioner request the opinion of a physician specialist, who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report? *a. Consultation b. Medical history c. Physical examinataion d. Progress notes*
a. Consultation
*24)* The HIM manager is conducting a study in which she is comparing 1CD-9-CM AND ICD-10-CM diabtes mellitis codes and documenting variations in order to assess the impact on the organization. This process creates a: a. Data map b. Data dictionary c. Data chargemaster report d. Database managemet system
a. Data Map
*32)* The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, medical record ID, type of records coded and other data, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Database management system b. Paper log book c. Spreadsheet d. Word-processing documents
a. Database Management System
*89)* In designing an input screen for an EHR, which of the following would be best to capture discrete data? a. Drop-down menus b. Speech recognition c. Natural Language processing d. Document imaging
a. Drop-down menus
*4)* Patient care managers use the data documented in the health record to: *a. Evaluate patterns and trends of patient care b. Provide direct patient care c. Generate patiend bills and third-party payer claims for reimbursement d. Determine the extend and effects of occupational hazards*
a. Evaluate patters and trends of patient care
*74)* If the coder misrepresents the patient's clinical picture through intentional incorrect coding or the omission or addition of diagnosis or procedure codes, this would be an example of: a. Healthcare fraud b. Payment optimization c. Payment reduction d. Healthcare creativity
a. Healthcare fraud
*63)* In developing a monitoring program for coding compliance, which of the following should be regularly audited? a. ICD-10-CM & ICD-10-PCS b. CPT/HCPCS & LOINC coding c. ICD-10-CM & SNOMED D. CPT/HCPCS & ICD-10-PCS
a. ICD-10-CM & ICD-10-PCS
*21)* An example of data collected by the Joint Commission for the ORYX initiatives is: a. Intrahospital mortality rate b. Financial data c. Health plan performance data d. Patient demographic data
a. Intrahospital mortality data
*81)* This database maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers. a. National Practitioner Data Bank b. National Pysician Database c. Healthcare Integrity and Protection Data Bank d. Healthcare security of Physicians Data Bank
a. National Practitioner Data Bank
*88)* Which of the following best represents the definition of the term data? a. Patient's laboratory value is 50 b. Patient's SCOT is highte than 50 and outside of the normal limits c. Patient's resting heartbeat is 70, which is within the normal range d. Patient's laboratory value is consitent with liver disease
a. Patient's laboratory value is 50
*33)* Which of the following is the goal of ICD-10-PCS? a. Reduce inconsistency due to overlapping terms b. Eliminate the need to communicate with physicians c. Assign diagnosis codes d. Assign diagnosis and procedures
a. Reduce inconsistency due to overlapping terms
*28)* Which of the following lists of names is correct order for alphabetical filing? a. Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas b. Carl J. Smith Mary A. Smith Paul M. Smith Thomas Smith c. Smith, A Mary Smith, J. Carl Smith, M. Paul Smith, Thomas d. Smith Thomas Smith, Carl J. Smith, Mary A. Smith, Paul M.
a. Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas
*60)* What factor is medical necessity based on? a. The beneficial effects of a service for the patient's physical needs and quality of life b. The cost of a service compared wth the beneficial effects on the patient's self c. The availability of a service at the facility d. The reimbursement available for a given service
a. The beneficial effects of a service for the patient's physical needs and quality of life
*23)* Which of the following numbering systems is best for maintaining the encounters of a patient together? a. Unit b. Serial-unit c. Serial d. Alphabetical
a. Unit
*11)* Which of the following is a key characteristic of the problem-oriented health record? *a. Uses an itemized list of the patient's past and present health problems b. Uses laboratory reports and other diagnostic tools to determine health problems c. Allows all providers to document in the helath record d. Provides electronic documentation in the health record*
a. Uses an itemized list of the patient's past and present medical problems
*57)* A patient has a malunion of an intertronchateric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PDS cosse for this procedure? (See chart p. 14) a. 0QB60ZZ lower bones excision b. 0Q860ZZ lower bones division c. 0SB90ZZ lower joints excision d. 0SN90ZZ lower jionts release
b. 0Q860ZZ lower bones division
*20)* 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
*42)* A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? *49320* Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) *58662* Laparoscopy, surgial; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method *58670* Laparoscopy, surgial; with fulguration of oviducts (with or without transection) *58671* Laparoscopy, surgial; with occlusions of oviducts by device (e.g., band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320
b. 58670
*65)* In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis and complaints b. Chargemaster description c. Clincal laboratory results d. Radiology orders
b. Chargemaster description
*31)* Which of the following provides a means to record information about patients treated for substance abuse and mental disorders? a. CPT Current Procedural Terminology b. DSM Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision c. ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification d. SNOMED Systemized Nomenclature of Medicine Clinical Terminology
b. DSM Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision
*82)* When data has been lost in an electronic health record, which action is taken to remedy this problem? a. Develop data integrity plan b. Data recovery c. Build a firewall d. Review the audit trail
b. Data Recovery
*9)* At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the electronic health record system discovers that the numbers in the date of birth are transposed in different record reports. This situation reflects a problem in: *a. Data comrehensiveness b. Data consistency c. Data currency d. Data granularity*
b. Data consistency
*97)* Which of the following is defined as an organized collection of data? a. Information b. Database c. DBMS d. Spreadsheet
b. Database
*72*) A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n): a. Susended record b. Delinquent record c. Pending record d. Illegal record
b. Delinquent record
*6)* As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the committee's first action? *a. Disregard the data b. Establish a data dictionary policy with asociated standards c. Develop an in-service training program on the data dictionary use. d. Distribute a memorandum to all department heads on the value of a data dictionary*
b. Establish a data dictionary policy with associated standards
*38)* A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy an is now removed via a percutaneous neprostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation
b. Extirpation
*8)* A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, and implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? *a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas fo the organization c. Call a meeting of all department directors to get their imput d. Contact CMS to determine what data sets are required to be collected*
b. Identify data content requirements for all areas of the organization
*73)* Which of the following statements is true regarding HIPAA security? a. All institutions must implement the same security measures b. Institutions are allowed flexibility in the way they implement HIPAA standards c. All institutions must implemnet all HIPAA specifications d. A security reisk assessment must be perfromed every year.
b. Institutions are allowed flexibility in the way they implement HIPAA standards
*26)* The paper-based health record format that organizes all forms in chronological order is known as a(n): a. Problem-oriented health record b. Integrated health record c. Patient-oriented health record d. Source-oriented health record
b. Integrated Health Record
*25)* Which of the following is considered the authoritative key in locating a health record? a. Disease index b. Master patient index c. Patient directory d. Patient registry
b. Master Patient Index
*15)* A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? *a. Pysician proress notes and medication record b. Medication reocrd and clinical laboratory reports c. Nursing and physiciam progress notes d. Physician orders and laboratory reports*
b. Medication record and clinical laboratory reports
*43)* A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergent C-section due to hemorrhage. The appropriate principal diagnosis would be: a. Normal delivery b. Placenta previa c. Twin gestation d. Vagninal Hemorrhage
b. Placenta Previa
*5)* The active storage area for medical records at Community Hospital is almost filled. To create more space in the storage area, which of the following should be done? *a. Discard the oldest records b. Purge oldest record to another location c. remove nursing notes from the oldest records d. Remove the file folders from all the records*
b. Purge oldest records to another location
*46)* Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? a. Tell her supervisor b. Query the physician c. Assign a code for hte staph infection d. Put a note in the chart
b. Query the physician
*58)* To comply with the Joint Commission standards, the HIM director wants to be sure that history and physician examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Retrospecitively review each patiends helath record to make sure that history adn physicals are present b. Review each patient's medical record concurrently to make sure that history and physicals are present c. Establish a process to review health record immediately on discharge d. Write a memorandum to all physicians relating the Joint Commission requriements for documenting history and physical examinations.
b. Review each patient's medical record concurrently to make sure that history and physicals are present
*13)* Which of the following is true regarding the reporting of communicable diseases? *a They must be reported by the patient to the health department b. The diseases to be reported are established by state law c. The disease to be reported are established by HIPAA d. They are never reported because it would violate the patient's privacy*
b. The diseases to be reported are established by state law
*93)* A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose? a. Chart deficiency system b. Chart tracking system c. Chart abstracting system d. Chart encoder
b. chart tracking system
*18)* Given the numbers 47, 20, 11, 33, 30, 30 35, and 50, what is the median? a. 30 b. 32 c. 31.5 d. 35
c. 31.5
*41)* Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9cm, 6.0cm) are undertaken. Which of the following CPT codes would be most appropriate? *52000* Cystourethroscopy (separate procedure) *52224* Cystourethroscopy with fulguration (inclding cryosurgury or laser surgery) or treatment of minor (less than .5 cm) lesion(s) with our without biopsy *52234* Cystourethroscopy with fulgeration (including criosurgery or laser surger) and /or resection of; small bladder tumor(s) (0.5 cm to 2.0 cm) *52235* Cystourethroscopy with fulgeration (including criosurgery or laser surger) and /or resection of; medium bladder tumor(s) (2.0 cm to 5.0 cm) *52240* Cystourethroscopy with fulgeration (including criosurgery or laser surger) and /or resection of; large bladder tumor(s) a. 52234, 52240 b. 52235 c. 52240 d. 52000, 52234, 52240
c. 52240
*14)* Data that are collected on large populations of individuals and stored in databases are referred to as: *a. Statistics b. Information c. Aggregate data d. Standard*
c. Aggregate data
Continuing coding education is required for: a. Credentialed coders b. Inpatient Coders c. All coders d. Inpatient and abmulatory coders
c. All coders
*16)* Community Hospital wants to compare its hospital-acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. 200,000 of these individuals were admitted with a principal diagnosis of UTI, 300,000 were admited with the principal diagnosis of infectious disease, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital? *(Full explanation follows: http://perspectives.ahima.org/using-medpar-data-as-a-measure-of-urinary-tract-infection-rates-implications-for-the-medicare-inpatient-drg-payment-system/)* a. All indvividuals in the MEDPAR database b. All individuals in the MEDPAR database except those with the diangnosis of UTI c. All individuals in the MEDPAR database except those admitted with a principal diagnosis UTI or infectious disease d. All individuals in the MEDPAR database except those admitted with the diagnosis of hypertension
c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease
*34)* Which of the following elements of coding quality represent the degree to which the codes capture all the dagnoses and procedures documented in the patient's health record? a. Relibility b. Validity c. Completeness d. Timeliness
c. Completeness
*53)* An alternative to the retrospective coding model is the __ coding model in which records are coded while the patient is still an inpatient in the hospital. a. Prospecitve b. Analytical c. Concurrent d. Auxiliary
c. Concurrent
*19)* What is (are) the format problem(s) with the following table? *Community Hospital Admission by Sex, 20XX* _______________ | ___________ |_____________| MALE | 3546 | 42.4 | FEMALE | 4825 | 57.6 | TOTAL | 8371 | 100.0 | a. Variable names are missing b. Title of the table is missing c. Column headings are missing d. Column totals are inaccurate
c. Column headings are missing
*76)* Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? a. Joint Commission b. National Commision on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set
c. Conditions of Participation
*61)* The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Routinely send out a fourth notice b. Post the hospital policy in the emergency department c. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices d. Call the Joint Commission
c. Consult with the physician in charge of the on-call doctors for suggestions on how to improve response to the current notices
*67)* In performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis and procedure codes specifically for the purpose of obtaining a higher level of reimbursement. The coder believes that this practice helps the hospital in increasing revenue. Which of the following should be done in this case? a. Compliment the coder for taking initiative in helping the hosptial b. report the coder to the FBI for coding fraud c. Counsel the coder and stop the practice immediately d. Provide the coder with incentive pay for her actions
c. Counsel the coder and stop the practice immediately
*44)*When coding a benign neoplasm of skin of the left eyelid, which of the following codes should be used? *D23 Other benign neoplasms of skin* *Incudes* benign neoplasm of hair follicles benign neoplasm of sebaeous glands benign neoplasm of sweat glands *Excludes1*: benign lipomatous neoplasm of skin (D17.0-D17.3) *D23.0 Other benign neoplasm of skin of lip *Excludes1*: benign neoplasm of vermillion border of lip (D10.0) *D23.1: Other benign neoplasm of skin of eyelid including canthus* *D23.10 Other benign neoplam of skin of unspecified eyelid, including canthus* *D23.11 Other benign neoplasm of skin of right eyelid, including canthus* *D23.12 Other benign neoplasm of skin of left eyelid, including canthus* *D23.3 Other benighn neoplasm of skin of ear and external aurcular canal* *D23.20cOther benign neoplasm of skin of unspecified ear and external auricular canal* *D23.21 Other benign neoplasm of skin of right ear and external auricular canal* *D23.22 Other benign neoplasm of skin of left ear and external auricular canal* a. D23 b. D17.0 c. D23.12 d. D23.11
c. D23.12
*86)* Which of the following would be used to control user access in an electronic health record? a. Data definition b. Relational database c. Database management system d. The field length was longer
c. Database managment system
*36)* A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Which of the following should be sequenced as the principal diagnosis? a. Liver carcinoma b. Chemotherapy c. Dehydration d. Complication of chemotherapy
c. Dehydration
*98)* Which of the following is NOT true about a primary key in a database table? a. Usually a unique number b. Does not change in value c. Dependent on the data in the table d. Uniquely identifies each row in a table
c. Dependent on the data in the table
*62)* Which of the following are basic functions of the utilization management process? a. Preadmission review, claims management, and restrospecitive review b. Discharge planning, review for potentially compesnable events, and losss prevention c. Discharge planning, retrospective review, and preadmission review d. Retrospecitive review, discharge planning and review for potentially compensable events
c. Discharge planning, retrospective review, and preadmission review
*83)* Which of the following is used to support the work of professionals engaged in the design, diagnosis, or evaluation of complex situations requiring special knowledge in a limited area? a. Decision support system b. Executive information system c. Expert system d. Management information system
c. Expert System
*79)* The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principals b. Database development c. Federal and State confidentiality laws d. Human resource management
c. Federal and state confidentiality laws
*78)* Before healthcare organizations can provide services, they usually must obtain __ by government entities such as the state or county in which they are located. a. Accreditation b. Database development c. Licensure d. Permission
c. Licensure
*12)* Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? BC/CS-Commercial-Medicaid-Medicare-TRICARE *IN $1000.00:* PAYER: CHRG PAY ADJ BC/BS: 450 360 90 Comrcl: 250 200 50 Medcd: 350 75 275 Medcr: 750 495 255 TRICR: 150 50 100 *Total: 1,950 1,180 770* *AS PERCENT:* PAYER: CHRG PAY ADJ BC/BS: 23 31 12 Comrcl: 13 17 6 Medcd: 18 6 36 Medcr: 39 42 33 TRICR: 7 4 13 *Total: 100* 100 100 *a. BC/BS b. Commercial c. Medicare d. TRICARE*
c. Medicare
*45)* In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? a. Two CPT codesone fore each laceration b. Once CPT code for the largest laceration c. Once CPT code, adding the lengths of the lacerations together d. Once CPT code for the most complex closure
c. One CPT code, adding the lengths of the lacerations together
*69)* The utilization manager's role is essential to: a. Capture all relevant charges for the patient's account b. Verify the patient actually has infurance c. Prevent denials for inappropriate levels of service d. Analyze the estimate of benefits (EOBs) recieved
c. Prevent denials for inappropriate levels of service
*56)* The first step in an inpatient record review is to verify correct assignment of the: a. Record sample b. Coding procedures c. Principal diagnosis d. DRG
c. Principal diagnosis
*90)* A software interface is a: a. Device to enter data b. Protocol for describing data c. Program to exchange data d. Standard vocabulary
c. Program to exchange data
*66)* Which of the following practices is NOT an appropriate coding compliance activity? a. Reviewing all rejected claims b. Developing procedures for identfying coding erros c. Providing a financial incentive for coding claims improperly d. Coding diagnoses only when all applicalble information is documented in the health record
c. Providing a financial incentive for coding claims improperly
*2)* An outpatient clinic is reviewing the functionality of an EHR it is condisering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system? *a. DEEDS b. EMEDS c. UACDS d. UHDDS*
c. UACDS
*3)* Standardizing medical terminology to avoid differences in naming various medical conditions and procedures is one purpose of: (prevention of confusion such as the use of these synonyms: bunionectomy, McBride procedure, and/or repair of hallux valgus) *a. Transaction Standards b. Content and Structure Standards c. Vocabulary Standards d. Security standards*
c. Vocabulary Standards
*94)* Which of the following computer architectures would be best for implementing an EHR for a healthcare system that needs to transmit data to its various campuses that are located across a wide geographic area? a. Client/server b. Local area network LAN c. Wide area network WAN d. Wireless network
c. Wide area network WAN
*22)* Community Hospital HIM department conducted a random sample of 600 health records to determine the rate of filing accuracy. Nine misfiles were identified. Which of the following percentages represents the filing accuracy at Community Hospital? a. 15% b. 34% c. 66.7% d. 98.5%
d. 98.5%
*87)* Which of the following is NOT an advantage offered by computer-based clinical decision support tools? a. Give physicians instant access to pharmaceutical formularies, referral databases, and reference literature b. Review structured electronic data and alert practitioners to out-of range laboratory values or dangerous trends. c. Help support physcicians' as they consider diagnostic and treatment alternatives by recalling diagnostic criteria and treatment options on the basis of data in the health record. d. Automatically transcribe medical reports.
d. Automatically transcribes medical reports.
*54)* An inpatient, acute-care coder must follow official ICD-10-CM/PCS coding guidelines established by the: a. AHIMA b. AMA c. CMS d. Cooperating Parties
d. Cooperating Parties
*47)* To clarify documentation, the preferred method of contact between a coder and a physician is: a. Telephone conversation b. e-mail transmission c. Fax transmission d. Face-to-face communication
d. Face-to-face communication
*51)* Which of the following record types is most likely to impair an exceptional coder's productivity? a. 100% EHR b. 100% paper record c. Source-oriented record d. Hybrid record
d. Hybrid Record
*35)* All of the following are functions of the Outpatient Code Editor, except: a. Evaluated the relationshsip between CPT codes on the bill b. Control improper coding c. Identify unbundling codes d. Identifiy cases that don't meet medical necessity
d. Identify cases that don't meet medical necessity
*27)* The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? a. Registration b. Radiology c. Quality Management d. Laboratory
d. Laboratory
*64)* Access to reports based on protected health information within a healthcare facility should be limited to employees who have a: a. Report development program b. Password c. Signed confidentialiy agreement d. Legitimate need for access
d. Legitimate need for access
*59)* Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. Proper administation of benefits b. MACs c. NCD's d. Medical Necessity
d. Medical necessity
*68)* If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient: a. For the balance due after Medicare has paid b. Only if both Medicare and any supplemental insurance have been billed settled c. Never-- providers may not bill Medicare patients for amounts unpaid by Medicare d. Only if a properly executed ABN was obtained before the service was provided
d. Only if a properly executed ABN was obtained before the service was provided
*77)* Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Patient assessment instrument b. Minimum data set for long-term care c. Resident assessment protocol d. Outcomes and Assessment Information Set
d. Outcomes and Assessment Information Set
*71)* Which of the following is the approved method for *implementing* an organization's formal position? a. Hierarchy chart b. Organizational chart c. Policy d. Procedure
d. Procedure
*39)* A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is: a. Z03.89 Encounter for observation for other suspected diseases and conditions ruled out b. R10.11 Right upper quadrant pain c. K21.9 Gastro-esophogeal reflux disease without esophagitits d. R07.9 Chest pain, unspecified
d. R07.9 Chest pain, unspecified
*96)* Which of the following is the traditional manner of planning and implementing an information system (IS)? a. CPRI b. UML c. Database managent d. SDLC system development life cycle
d. SDLC
*75)* How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for the case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met
d. To determine whether standards of care are being met
*1)* A healh record technician has been asked to review the discharge patient abstracting module of a proposed new EHR. Which of the following data sets would the technician consult to ensure the system collects all the federally required data elements for discharged Medicare and Medicaid inpatients in an acute-care hospital? *a. DEEDS b. CARF c. UACDS d. UHDDS*
d. UHDDS
*17)*A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension that were treated on the medicine unit within a two-week period. What clinical report would be the best source to gather this information? a. Admission record b. Initial nursing assessment record c. Physician progress notes d. Vital signs record
d. Vital Signs record