RHIT Exam

Data elements collected on large populations of individuals and stored in databases are referred to as:

Aggregate data

You are the director of HIM at Community Hospital. A physician has asked for the total number of appendectomies that he performed at your hospital last year. What type of data will you provide to the physician?

Aggregate data

Which of the following is true regarding the development of health record destruction policies?

All applicable laws must be considered

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. Of these individuals, 200,000 were admitted with a principal diagnosis of UTI; another 300,000 were admitted with a 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?

All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease

An HIM director is requesting the purchase of a document imaging system. However, the Hospital Budget Committee is reluctant to approve the request because of the expense. The committee thinks that the money is better spent implementing CPOE and other EHR applications. Which of the following might the HIM director use as a cost-benefit justification?

"Discharged, not final billed" and accounts receivable days can be improved because of workflow efficiencies.

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital?

$39,375

The HIM manager recently performed an audit of health record documentation in the EHR looking for reports that had been indexed incorrectly. The audit showed that for the 100 records reviewed there was a 4 percent error rate. Given that the national average labor cost of each misindexed report is $200, what is the labor cost for the department for handling these misindexed reports?

$800

A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure?

0Q860ZZ

The HIM director is part of the revenue cycle management team. The discharged-not-final-billed days are increasing because discharges are increasing. The number of coding staff is five. In an effort to increase productivity, the HIM director is researching staffing alternatives. With the implementation of an electronic document storage system, telecommuting has been suggested as an alternative. Studies report that coding productivity can increase as much as 20 percent with telecommuting. Given that discharges have increased from 100 per day to 144, how many more FTEs would need to be hired if the department went to telecommuting?

1 FTE

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment?

58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection)

Dr. Jones comes into the HIM department and requests that the HIM director provide a list of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director use to provide this list?

A disease index

The sum of a hospital's relative DRG weights for a year was 15,192, and the hospital had 10,471 discharges for the year. Given this information, what would be the hospital's case-mix index for that year?

1.45

An 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?

100 hours

Community Hospital had a total of 3,000 inpatient service days for the month of September. What was the average daily census for the hospital during September?

100 patients

How many identifiers must be removed for a data to be considered de-identified under the Safe Harbor Method?

18

The RHIT supervisor for the scanning and quality control 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 scanning records is 50 records per hour. The standard for quality control of scanning of records is 40 records per hour. Given these standards, how many productive hours will be required daily to scan and quality control records for each clinic day?

22.5 hours per day

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?

242

In May, 270 women were admitted to the obstetrics service. Of these, 263 women delivered; 33 deliveries were by C-section. What is the denominator for calculating the C-section rate?

263

Based on a productivity log, a coder completed 23 charts during a 7.5-hour workday. The performance standard is 4 charts per hour. How many charts did he code per hour? Round to the nearest whole number.

3

If an employee produces 2,080 hours of work in the course of one year, how many employees will be required for the coding area if the coding time on average for one record is 30 minutes and there are 12,500 records that must be coded each year?

3

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median?

31.5

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate?

36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access

HIPAA requires a covered entity to establish policy to ensure that protected health information could not identify a specific individual. One method used to meet this deidentification standard is the expert determination model. The expert determination model requires these four steps: Determine the statistical and scientific method to be used to determine the risk of reidentification Analyze and assess the risk to the deidentified data The expert applies the method to the deidentified data The facility should choose the expert for the deidentification analysis What is the correct order in which these steps should be performed?

4, 1, 3, 2

City Hospital's Revenue Cycle Management team has established the following benchmarks: (1) The value of discharged not final billed cases should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. The net average daily revenue is $1,000,000. The following data indicate that City Hospital's DNFB cases met its benchmarks:

50 percent of the time

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment?

49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible

Community Hospital discharged 9 patients on April 1. The length of stay for each of the patients was as follows: for patient A, 1 day; for patient B, 5 days; for patient C, 3 days; for patient D, 3 days; for patient E, 8 days; for patient F, 8 days; for patient G, 8 days; for patient H, 9 days; for patient I, 9 days. What was the average length of stay for these nine patients?

6 days

An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard?

76 pages

Community Hospital's HIM department conducted a random sample of 150 inpatient health records to determine the discharge summary completion timeliness rate. Thirteen discharges were determined to be out of compliance with completion standards. Which of the following percentages represents the timeliness rate for discharge summaries at Community Hospital?

91.3%

Community Hospital's HIM department conducted a random sample of 200 inpatient health records to determine the timeliness of the history and physicals completion. Nine records were found to be out of compliance with the 24-hour requirement. Which of the following percentages represents the H&P timeliness rate at Community Hospital?

95.5%

Which of the following individuals may authorize release of health information?

A married 15-year-old father

Which of the following situations is considered a breach of PHI?

A patient's attorney is sent records not authorized by that patient

Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare:

A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment

Coding accuracy is best determined by:

A predefined audit process

Which of the following is an institutional user of the health record?

A third-party payer

An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the:

Cooperating Parties

Which of the following is a risk of copy and pasting documentation in the electronic health record?

Copying the note in the wrong patient's record

To use a data element for aggregation and reporting, that data element must be:

Abstracted or indexed

Community Hospital is planning implementation of various elements of the EHR in the next six months. Physicians have requested the ability to access the EHR from their offices and from home. What advice should the HIM director provide?

Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security.

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?

Access controls

What number is assigned to a case when it is first entered in a cancer registry?

Accession number

Which of the following are components of AHIMA's principles of information governance?

Accountability and integrity

The Patient Accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills?

Accounts not selected for billing report

The goal of coding compliance programs is to prevent:

Accusations of fraud and abuse

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data?

Administrative data

City Hospital's HIPAA committee is considering a change in policy to allow hospital employees who are also hospital patients to access their own patient information in the hospital's EHR system. A committee member notes that HIPAA provides rights to patients to view their own health information. However, another member wonders if this action might present other problems. In this situation, what information should the HIM director provide?

Allowing employees to access their own records using their job-based access rights appears to violate HIPAA's minimum necessary requirement; therefore, allow employees to access their records through normal procedures.

The accounts not selected for the billing report is a daily report used to track accounts that are:

In bill hold or in error and awaiting billing

The member had gastric bypass surgery three years prior. As a result of an over 200-pound weight loss, loose skin hung from the member's arms, thighs, and belly. The member, upon referral from her general surgeon, was scheduled to have a plastic surgeon to remove the excess skin. The member called for prior approval as required by the plan. The clinical review resulted in a denial of the surgery as cosmetic. The member requested a peer review and submitted documentation from her physician that the excess skin was causing skin infections and exacerbating her eczema. The peer clinician denied the case. What is the next step the member can take to have the surgery paid for by her insurance company?

Appeal to an expert clinician in the same specialty

An HIM supervisor is revising job descriptions for record scanning positions. These positions have been in existence for just over one year. Which of the following would be the most appropriate action to take to ensure all tasks being performed are included in the new job descriptions?

Ask current staff members to keep a diary for a certain period of time on how they spend their time

How is the patient registration department assisted by the HIM department?

Assigns the health record number

Secondary data is used for multiple reasons including:

Assisting researchers in determining effectiveness of treatments

The organization that employs you just concluded an investigation of a laptop computer that was lost and contained a file with the information of 765 patients on it, including names, addresses, telephone numbers, and social security numbers. As the privacy officer, you are required to manage the notification process for the data breach. All of the following would need to be notified of this data breach within 60 days of the discovery except:

Attending physicians of the patients

A coding compliance manager is reviewing a tool that identifies when a user logs in and out, what he or she does, and more. What is the manager reviewing?

Audit trail

A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n):

Audit trail

A hospital is planning to allow coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended?

Automatic session log-off

A hospital currently uses the patient's Social Security number as their patient identifier. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say they need the information for identification and other purposes. Given this situation, what should the HIM director suggest?

Avoid displaying the number on any document, screen, or data collection field

The hospital-acquired infection rate for our hospital is 0.2%, whereas the rate at a similar hospital across town is 0.3%. This is an example of a:

Benchmark

To develop performance standards for release of information turnaround time, the manager conducted a literature search and contacted peer institutions. Which method did she use?

Benchmarking

Which of the following is an example of how an internal user utilizes secondary data?

Benchmarking with other facilities

Which of the following ethical principles is being followed when a health information management professional ensures that patient information is only released to those who have a legal right to access it?

Beneficence

Our computer system just notified us that Mary Burchfield has just looked up another patient with the same last name. This notification is called a(n):

Trigger

A subpoena duces tecum compels the recipient to:

Bring records to a legal proceeding

Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:

By the hospital

After the types of cases to be included in a cancer registry have been determined, what is the next step in data acquisition?

Case finding

A hospital can monitor its performance under the MS-DRG system by monitoring its:

Case-mix index

Clinical documentation improvement (CDI) programs use metrics to evaluate the effectiveness of their program. Which of the following is the most widely used key indicator for a CDI program?

Case-mix index

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 would be reported as POA?

Cerebral vascular accident, COPD, Hypertension

Continuing coding education is required for:

Certified coders

According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a:

Colonoscopy

In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit?

Chargemaster description

In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit?

Chargemaster description and medical necessity

A PI Team is concerned with the time it is taking for patients to get through the registration process. To better understand the causes or reasons for the delay in this process the PI Team would like to gather observational data. What data collection tool would be appropriate for this team to develop for their observation data?

Check sheet

Which of the following is part of qualitative analysis review?

Checking that only approved abbreviations are used

A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter?

Code skin lesion

The national patient safety goals score organizations on areas that:

Commonly lead to patient injury

Which of the following is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay?

Comorbidity

In planning a compliance training session, you want to allow adult learners the flexibility to proceed at their own pace. Which would be the best choice among the following training methods?

Computer-based

An alternative to the retrospective coding model is the __________ coding model in which records are coded while the patient is still an inpatient.

Concurrent

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?

Conditions of Participation

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO?

Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned

A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient subsequently develops respiratory failure. The patient undergoes intubation with ventilator management. Which of the following would be the correct sequencing and coding of this case?

Congestive heart failure, respiratory failure, ventilator management, intubation

Two coders have found the same abbreviation in two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation in another patient's record was used to mean "overdose" in an abuse record. What data quality component is lacking here?

Consistency

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system 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?

Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations?

Consultation

For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it:

Contains data on all payer types

A(n) __________ is imposed on providers by the OIG when fraud and abuse is discovered through an investigation.

Corporate Integrity Agreement

Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence?

Identification of the record as the one subpoenaed

What should be done when the HIM department's chart analysis error rate is too high, or its accuracy rate is too low based on policy?

Corrective action should be taken to meet the department standards

The release of information function requires the HIM professional to have knowledge of:

Federal and state confidentiality laws

The role of the HIM professional in medical identity theft protection programs includes all of the following except:

Send all issues related to medical identity theft to the in-house attorney

A consumer nonprofit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. An HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. Which of the following would not be a quality consideration in using billing data?

Cost to process the data

Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following?

Validity of hospital diagnosis and procedure coding data completeness

When 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 increase its revenue. Which of the following should be done in this case?

Counsel the coder and stop the practice immediately

What is the term used most often to describe the individual within an organization who is responsible for protecting health information in conjunction with the court system?

Custodian of records

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, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose?

Database management system

A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as:

Data precision

Which of the following data sets would be most helpful in developing a hospital trauma data registry?

DEEDS

Performance monitoring is data driven and the HIM department needs access to data in order to make important decisions. One way to provide real-time data and important information that can be monitored at a glance is to use which of the following?

Dashboards

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in:

Data consistency

Managing an organization's data and those who enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following?

Data dictionary

In a database the LAST_NAME column in a table would be considered a:

Data element

Patient name, zip code, and health record number are typical:

Data elements

The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a:

Data map

The process of extracting and analyzing large volumes of data from a database for the purpose of identifying hidden and sometimes subtle relationships or patterns and using those relationships to predict behaviors is called:

Data mining

A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis?

Dehydration

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n):

Delinquent record

Which of the following describes incomplete records that are not completed by the physician within the time frame specified in the healthcare facility's policies?

Delinquent records

This type of data identifies the patient (such as name, health record number, address, and telephone number) and is called?

Demographic data

The removal of medication from its usual stream of preparation, dispensing, and administration by personnel involved in those steps in order to use or sell the medication in nonhealthcare settings is called:

Diversion

City Hospital has implemented a procedure that allows inpatients to decide whether they want to be listed in the hospital's directory. The directory information includes the patient's name, location in the hospital, and general condition. If a patient elects to be in the directory, this information is used to inform callers who know the patient's name. Some patients have requested that they be listed in the directory, but information is to be released to only a list of specific people the patient provides. A hospital committee is considering changing the policy to accommodate these types of patients. In this case, what type of advice should the HIM director provide?

Deny these requests because screening of calls is difficult to manage and if information is given in error, this would be considered a violation of HIPAA.

What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients?

Derived

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do?

Determine what information was printed and why

As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all the divisions within the HIM department. The following table shows sample productivity benchmarks for record analysis the director found through a literature search. Given this information, how should the director proceed in establishing benchmarks for the department?

Determine whether the source of the benchmark data is from a comparable institution

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best?

Determine whether there was a medical or other reason why patients were not given aspirin

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. To remedy this situation, the HIM director should recommend which of the following?

Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?

Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records

During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste functionality of the hospital's EHR system for documenting nursing notes. Which of the following should the HIM director do to ensure that the nurses are following acceptable documentation practices?

Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system

One way for a hospital to demonstrate compliance with OIG guidelines is to:

Develop, implement, and monitor written policies and procedures

Which of the following practices is an appropriate coding compliance activity?

Developing procedures for identifying coding errors

A dietary department donated its old laptop to a school. Some old patient data were still on the computer. What controls would have minimized this security breach?

Device and media controls

Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an EHR?

Provide a template for entering data in the field

The hospital currently has a hybrid health record. Nurses and clinicians are recording bedside documentation electronically in a clinical documentation system, while most other documentation, such as physician progress notes and orders, are paper based and stored in a paper health record, making retrieval of the complete record after discharge difficult and risking the record's integrity. Given these circumstances, which of the following should the HIM director implement to alleviate these problems and preserve the efficiencies of an electronic record?

Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system

A newborn is treated for pulmonary valve stenosis, with stretching of the valve opening accomplished via a percutaneous balloon pulmonary valvuloplasty. In ICD-10-PCS, what root operation would be coded for this procedure?

Dilation

Which HIPAA-required tracking system can be queried to determine the percentage of responses to ROIs that are sent to attorneys, insurance companies, and covered entities?

Disclosure management system

Dr. Smith wants to use a lot of free text in his EHR. What should be your response?

Dr. Smith, we recommend that you use little, if any, free text in the EHR.

In designing an input screen for an EHR, which of the following would be best to capture structured data?

Drop-down menus

Community Hospital wants to provide voice recognition services for office notes of the private patients of physicians. All these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise in order to comply with HIPAA regulations?

Each physician practice should obtain a business associate agreement with the hospital.

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What measures should be in place to minimize this data entry error?

Edit checks

Which of the following is not a recommended guideline for maintaining integrity in the health record?

Ensuring documentation that is being changed is permanently deleted from the record

The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as:

Enterprise master patient index (EMPI)

Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle?

Errors that produced changes in MS-DRG assignment

Patient care managers use the data documented in the health record to:

Evaluate patterns and trends of patient care

With regard to training in PHI policies and procedures:

Every member of the covered entity's workforce must be trained

In this experimental study, blood pressure is taken before and after an experimental medication is used as the intervention in a sample of participants that were previously unable to control their blood pressure with other medications. In this example, the independent variable is the __________ and the dependent variable is the__________.

Experimental medication; blood pressure

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure?

Extirpation

The HIM improvement team wants to identify the causes of poor documentation compliance in the health record. Which of the following tools would best aid the team in identifying the root cause of the problem?

Fishbone diagram

The leader of the coding performance improvement team wants all her team members to clearly understand the coding process. Which of the following would be the best tool for accomplishing this objective?

Flow chart

The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?

Focused audit

Which of the following strategies would be best to ensure that all stakeholders are engaged in the planning and development of an organization EHR system?

Form an EHR steering committee

A pharmacist who submits Medicaid claims for reimbursement on brand name drugs when less expensive generic drugs were dispensed has committed the crime of:

Fraud

Community Hospital has been collecting quarterly data on the average monthly health record delinquency rate for the hospital. This graph depicts the trend in the delinquency rate. The hospital has established a 35 percent benchmark. Given this data, what should the hospital's Performance Improvement Council recommend?

Further analyze the data to determine why the benchmark is not being met

What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis?

Gap analysis

Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue?

Health information management

What types of covered entity health records are subject to the HIPAA privacy regulations?

Health records in any format

A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of:

Healthcare fraud

The deception or misrepresentation by a healthcare provider that may result in a false or fictitious claim for inappropriate payment by Medicare or other insurers for items or services either not rendered or rendered to a lesser extent than described in the claim is:

Healthcare fraud

This type of chart plots all data points as a cell for two given variables of interest and, depending on frequency of observations in each cell, provides color to visualize high or low frequency.

Heatmap

A physician correctly prescribes Coumadin. The patient takes the Coumadin as prescribed but develops hematuria as a result of taking the medication. Which of the following is the correct way to code this case?

Hematuria; adverse reaction to Coumadin

A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?

Identify data content requirements for all areas of the organization

Which of the following is a function of the outpatient code editor?

Identify unbundling of codes

Which of the following is the goal of the quantitative analysis performed by HIM professionals?

Identifying deficiencies early so they can be corrected

In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited?

ICD-10-CM and ICD-10-PCS coding

When an individual requests a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may:

Impose a reasonable cost-based fee

Which of the following is an argument against the use of the copy and paste function in the EHR?

Inability to identify the author

Which of the following would be an example of a sentinel event?

Incidence of infant abduction

Which of the following is true about information assets?

Information considered to add value to an organization

Which of the following statements is true regarding HIPAA security?

Institutions are allowed flexibility in the way they implement HIPAA standards.

The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team?

Insufficient knowledge of team members

The three elements of a security program are ensuring data availability, protection, and:

Integrity

Which of the following refers to guarding against improper information modification or destruction?

Integrity

Release of birth and death information to public health authorities:

Is a public health activities disclosure that does not require patient authorization

Which of the following is a characteristic of breach notification?

It applies when one person's PHI is breached

Spoliation can be defined as which of the following?

It is destroying, changing, or hiding evidence intentionally

Which of the following is characteristic of the legal health record?

It is the record disclosed upon request

Why is the MEDPAR file limited in terms of being used for research purposes?

It only contains Medicare patients

Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed.

K21.9, 0DB58ZX

Which of the following would be considered a security vulnerability?

Lack of laptop encryption

Which of the following is the first step in analyzing data?

Knowing your objectives or purpose of the data analysis

The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data?

Laboratory

Access to health records based on protected health information within a healthcare facility should be limited to employees who have a:

Legitimate need for access

Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located.

Licensure

Suppose you want to display the number of deaths due to breast cancer for the years 2005 through 2015. What is the best graphic technique to use?

Line graph

A patient has liver metastasis due to adenocarcinoma of the rectum. The rectum was resected two years ago. The patient has been receiving radiotherapy to the liver with some relief of pain. The patient is being admitted at this time for management of severe anemia due to the malignancy. The principal diagnosis listed on this admission is:

Liver metastasis

Which of the following is an example of a physical safeguard that should be provided for in a data security program?

Locking computer rooms

Patient is admitted with prepatellar bursitis following a crushing injury to the left knee as a result of being hit by a car two years ago. What diagnosis codes would be assigned for this patient?

M70.42, S87.02xS Prepatellar bursitis, left knee Crushing injury of left knee, sequela

Which of the following would be the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in an EHR?

Make all essential data fields required

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways?

Makes it lower than warranted by the actual service and resource intensity of the facility

Which of the following is considered the authoritative resource in locating a health record?

Master patient index

Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family conditions?

Medical history

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met:

Medical necessity

The credentialing process of independent practitioners within a healthcare organization must be defined in:

Medical staff bylaws

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?

Medication administration record and clinical laboratory reports

The Breach Notification Rule requires covered entities to do which of the following:

Notify affected individuals when a breach occurs

Which of the following represents the required documentation elements needed to be included in a patient's health record when a surgical procedure is performed?

Operative report, anesthesia report, recovery room report

A provider's office calls to retrieve emergency room records for a patient's follow-up appointment. The HIM professional refused to release the emergency department records without a written authorization from the patient. Was this action in compliance?

No; the records are needed for continued care of the patient, so no authorization is required

A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?

No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.

The following data fields comprise a database table: patient last name, patient first name, street address, city, state, zip code, patient date of birth. Given this information, which of the following is a true statement about maintaining the data integrity of the database table?

None of the data fields are adequate to use as a primary key for the table.

An HIM technician is paid an hourly rate and is eligible for overtime pay, consistent with the Fair Labor Standards Act. Her position would be classified as which of the following?

Nonexempt

In which type of distribution are the mean, median, and mode equal?

Normal distribution

The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond?

Notice of privacy practices is required on the first provision of service.

Which of the following is most likely to be used in performing an outpatient coding review?

OCE

What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services?

OIG workplans

Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching?

Obliterating or deleting errors

The risk manager's principal tool for capturing the facts about potentially compensable events is the:

Occurrence report

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?

One CPT code, adding the lengths of the lacerations together

If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient:

Only if a properly executed ABN was obtained before the service was provided

The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas?

Operative and other invasive procedures, medication management, and blood and blood product use

Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?

Operative report

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

Outcomes and Assessment Information Set

An HIM technician was alerted by registration that the system has a record for John Smith with two different birthdates. After an investigation the technician determined the documentation was for two different patients, both named John Smith, who have the same health record number in the EHR. This is an example of:

Overlay

Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request?

PHI sent to a physician who has not treated Sally

One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following?

Parallel work division

A health data analyst has been asked to abstract patient demographic information into an electronic database. Which of the following would the analyst include in the database?

Patient date of birth

Physician orders for DNR should be consistent with:

Patient's advance directive

Which of the following best represents the definition of the term data?

Patient's laboratory value is 50.

Which of the following is a principle of contemporary performance improvement?

Performance improvement relies on the collection and analysis of data to increase knowledge.

Healthcare abuse relates to practices that may result in:

Performing medically unnecessary services

Typically, healthcare facilities should retain the master patient index:

Permanently

A home health agency has plans to implement a computer system where its nurses document home care services on a laptop computer taken to the patient's home. The laptops will connect to the agency's computer network. The agency is in the process of identifying strategies to minimize the risks associated with the practice. Which of the following would be the best practice to protect laptop and network data from a virus introduced from an external device?

Personal firewall software

Clara maintains and updates an individual health record for herself as a tool she can use to collect, track, and share her past and current information about her health with providers. What is this tool called?

Personal health record

Identify the report where the following information would be found: "HEENT: Reveals the tympanic membranes, nares, and pharynx to be clear. No obvious head trauma. CHEST: Good bilateral chest sounds."

Physical examination

This individual assists in educating medical staff members on the documentation needed for accurate coding.

Physician champion

A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be:

Placenta previa

Placenta previa with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergent C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be:

Placenta previa

The EHR may have multiple versions of the same document; for example, a signed and unsigned copy. How can a healthcare organization manage version control of documents in the her?

Policies and procedures to control which version(s) is displayed

Which of the following is the approved method for implementing an organization's formal position?

Policy and procedure

Sometimes data do not follow a normal distribution and are pulled toward the tails of the curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it is called a __________.

Positively skewed distribution

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services?

Prospectively precertify the necessity of inpatient services

Which of the following is the principal goal of a corporate compliance program?

Protect providers from sanctions or fines

Which of the following is a core ethical obligation of health information management professionals?

Protecting patients' privacy and confidential communications

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report?

Present an authorization that at least one of them (Ted or Mary) has signed

The utilization manager's role is essential to:

Prevent denials for inappropriate levels of service

The first step in an inpatient record review is to verify correct assignment of the:

Principal diagnosis

An individual's right to control access to his or her personal information is known as:

Privacy

The right of an individual to keep personal health information from being disclosed to anyone is a definition of:

Privacy

Which policy ensures that the minimum penalty appropriate to the level of employee offense is applied?

Progressive penalties

Community Hospital has implemented an EHR and is no longer retaining paper health records. The hospital HIM department director has determined that the facility needs the file room space where the paper health records that are not yet eligible for destruction. The HIM director wants to move these health records to a remote storage location. The records will be stored in boxes and will be filed on open shelves at the remote location. Which of the following should be done so that record location can be easily identified in the remote storage area?

Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations?

Provide copies of the records within 60 days

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond?

Provide the records in paper format only

The clinical forms committee:

Provides oversight for the development, review, and control of forms and computer screens

Health departments use the health record to monitor outbreaks of diseases. In this situation what type of use of the health record does this represent?

Public health and research

Community Hospital has a storage facility with older records that must be retained to meet retention laws and guidelines. The HIM professional has been tasked with removing health records from an associated clinic of patients who have not been treated for a specific period of time and sending those records to the storage area. This process is called:

Purging records

In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case?

Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results

Carolyn works as an inpatient coder in a hospital HIM department. She views 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?

Query the physician

In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?

Query the physician to determine if the condition was present on admission.

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:

R07.9, Chest pain, unspecified

The HIM Department has been receiving complaints about the turnaround time for release of information (ROI) requests. A PI team is created to investigate this issue. What data source would be appropriate to use to investigate this issue further?

ROI tracking system

The Department of Health and Human Services has identified that Community Hospital is guilty of fraud. It was determined that the facility tried to comply with standards, but their efforts failed. What category of fraud and abuse prevention does this fall into?

Reasonable diligence

Which of the following can be used to develop a focused inpatient coding review?

Recent data quality issues identified by external review agencies

In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/20XX. Because of unexpected complications; however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case?

Request that the physician dictate an addendum to the discharge summary

Which of the following is true about health information retention?

Retention periods differ among healthcare facilities

To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical 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?

Review each patient's health record concurrently to ensure the history and physicals are present

A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do?

Review the subpoena and appear at the time and place supplied to give testimony

The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following?

Risk identification and analysis, loss prevention and reduction, and claims management

The process that is followed to mitigate and fix issues that arise during a review of systems that contain PHI to reduce vulnerabilities is called:

Risk management

Which tool is used to display performance data over time?

Run chart

General Hospital is performing peer reviews of their medical providers for quality outcomes of care. The hospital has more than 500 providers on its medical staff. The process to peer review even 10 cases for each provider is quite extensive. The quality department has concluded that to accomplish this review process, they will review 20 percent of each provider's inpatient admissions to the hospital every other year. In this situation, the quality department has applied to their review process.

Sampling

If steps in a revenue cycle process are handled separately in sequence by individual workers, the method of organizing work is called which of the following?

Serial work division

An HIM department is planning to implement virtual teams for the coding and data analytics areas. Some in the facility are skeptical of this arrangement, believing that off-site employees cannot be managed. Given this work format, how can the supervisor best gauge productivity of the virtual staff?

Set clear goals and productivity standards and see that these are met

Which of the following should be avoided when designing forms for an electronic document management system (EDMS)?

Shading of bars or lines that contain text

A hospital HIM department receives a subpoena duces tecum for records of a former patient. When the health record technician goes to retrieve the patient's health records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?

Submit a certification of destruction in response to the subpoena

In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited?

Speech recognition

Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system?

Stage III or IV pressure ulcers

Which of the following should be considered first when establishing health record retention policies?

State retention requirements

Which of the following is a secondary purpose of the health record?

Support for research

Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event an amendment, addendum, or deletion needs to be made, which following should occur?

The EHR should retain the previous version of the document and identify who made the change along with the date and time that the change was made.

What factor is medical necessity based on?

The beneficial effects of a service for the patient's physical needs and quality of life

Which events must occur in order to maintain patient identity data integrity?

The data must be accurately queried

Which of the following is true regarding the reporting of communicable diseases?

The diseases to be reported are established by state law.

An employee views a patient's electronic health record. It is a trigger event if:

The employee and patient have the same last name

Which of the following definitions best describes the concept of confidentiality?

The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose

When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected?

The incident report likely becomes discoverable because it is mentioned in a discoverable document.

Which of the following is a true statement about the content of the legal health record?

The legal health record may contain metadata

The HIM manager was asked by the medical director to present the hospital's policy on deletion of erroneous information from the electronic health record to the medical staff. This policy requires that the original documentation is retained in the EHR along with the corrected documentation. Which of the following is a key component of this policy?

The new and old documentation would be included in the same document with a comment section.

Which of the following is a correct statement regarding DNR orders?

The record should be clearly marked to indicate the presence of a DNR order.

Which of the following is a positive aspect of using employee self-appraisal as a source of data for performance appraisal?

The supervisor is kept informed of the employee's accomplishments

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:

The template was defined

Each healthcare organization must identify and prioritize which processes and outcomes (in other words, which types of data) are important to monitor. This data collection should be based on the scope of care and services they provide and:

Their mission

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice.

As CIO, you have initiated discussions of information governance (IG) with your C-suite colleagues. Since your background is in HIM, you stress the importance of information protection and data quality. You mention all of the following in your discussion as to why quality data is important to data governance (DG) and IG, but as an HIM professional, you feel the most important is __________.

To decrease security breaches

How do accreditation organizations such as the Joint Commission use the health record?

To determine whether standards of care are being met

An external security threat can be caused by which of the following?

Tornadoes

A health record technician has been asked to review the discharge patient abstracting module of a proposed new electronic health record (EHR). Which of the following data sets would the technician consult to ensure the system collects all federally required discharge data elements for Medicare and Medicaid inpatients in an acute-care hospital?

UHDDS

The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following?

Unbundling

Which of the following is true about a primary key in a database table?

Uniquely identifies each row in a table

Copies of personal health records (PHRs) are considered part of the legal health record when:

Used by the organization to provide treatment

Which of the following is a key characteristic of the problem-oriented health record?

Uses an itemized list of the patient's past and present health problems

When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following?

Variance analysis

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information?

Vital signs record

Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:

Vocabulary standards

Cancer registries are maintained by hospitals:

Voluntarily or by state law

Recently, a local professional athlete was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine:

Whether access by employees is appropriate

As part of your job responsibilities, you are responsible for reviewing audit trails of access to patient information. The following are all types of activities that you would monitor except:

Whether the patient setup an account in the patient portal

The facility privacy officer receives a phone call from a patient who is concerned that her former sister-in-law who is a hospital employee has accessed her health record. The privacy officer requests an audit log of activity within the patient's health record. What part of the audit log must be analyzed to determine if this complaint has merit?

Which employees viewed, created, updated, or deleted information

Mary's PHI has been breached. She must be informed of all of the following except:

Who committed the breach

Which of the following is true about the legal health record:

Will be disclosed upon request

The manager calculated a unit and time productivity statistic based on employee self-reported data. He used the method to develop this performance standard.

Work measurement

Which of the following can assist managers with the tasks of monitoring productivity and forecasting budgets?

Workload statistics

The primary goals of __________ are to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange.

the National Health Information Network