RHIT Practice Exam 2 - 150 Questions

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? a. 3 b. 6 c. 36 d. 69

a. 3 The number of records per FTE is 2 (number of records per hour) × 2,080 = 4,160. Therefore, three employees per year are required: 12,500 / 4,160 = 3.0

Which of the following is an institutional user of the health record? a. A third-party payer b. Patient c. Physician d. Employer

a. A third-party payer Institutional users of the health record are organizations that need access to health records in order to accomplish their mission. These institutional users include healthcare delivery organizations, third-party payers, medical review organizations, research organizations, educational organizations, accreditation organizations, government licensing agencies, and policy-making bodies.

Which of the following is part of qualitative analysis review? a. Checking that only approved abbreviations are used b. Checking that all forms and reports are present c. Checking that documents have patient identification information d. Checking that reports requiring authentication have signatures

a. Checking that only approved abbreviations are used Qualitative analysis is about the quality of the documentation including the use of approved abbreviations.

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? a. Congestive heart failure, respiratory failure, ventilator management, intubation b. Respiratory failure, intubation, ventilator management c. Respiratory failure, congestive heart failure, intubation, ventilator management d. Shortness of breath, congestive heart failure, respiratory failure, ventilator management

a. Congestive heart failure, respiratory failure, ventilator management, intubation CHF is the principal diagnosis and must be sequenced first.

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? a. Appeal to an expert clinician in the same specialty b. Disenroll from the plan and enroll with indemnity healthcare insurance c. File a lawsuit d. Schedule the surgery with her original general surgeon as that surgeon was paid

a. Appeal to an expert clinician in the same specialty An appeal is a request for reconsideration of denial of coverage for healthcare services or rejection of a claim. Second and third opinions are cost-containment measures to prevent unnecessary tests, treatments, health devices, or surgical procedures. These second and third opinions are particularly sought when test, treatment, health device, or surgical procedure is high risk or high cost; diagnostic evidence is contradictory or equivocal; or experts' opinions are mixed about efficacy.

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? a. Audit trail b. Facility access control c. Forensics d. Security management plan

a. Audit trail Audit controls are required by HIPAA. One method of monitoring is the use of audit trails. Audit trails are a recording of activities occurring in an information system. Audit trails can monitor system level controls such as login, logout, unsuccessful logins, print, query, and other actions. It also records user-identification information and the date and time of the activity. Audits should be scheduled periodically, but can also be performed when a problem is suspected.

A(n) __________ is imposed on providers by the OIG when fraud and abuse is discovered through an investigation. a. Corporate Integrity Agreement b. OIG Workplan c. Red Flags Rule d. Resource Agreement

a. Corporate Integrity Agreement A corporate integrity agreement (CIA) is essentially a compliance program imposed by the government, with substantial government oversight and outside expert involvement in the organization's compliance activities. The OIG negotiates CIAs with health care providers and other entities as part of the settlement of federal health care program investigations arising under a variety of civil false claims statutes. Providers or entities agree to the obligations, and in exchange, OIG agrees not to seek their exclusion from participation in Medicare, Medicaid, or other federal healthcare programs.

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? a. Data dictionary b. Data warehouse c. Data mapping d. Data set

a. Data dictionary A data dictionary is a descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology.

In a database the LAST_NAME column in a table would be considered a: a. Data element b. Record c. Primary key d. Row

a. Data element A data element is an individual fact or measurement that is the smallest unique subset of a database.

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: a. Data mining b. Data warehouse c. Data searching d. Big data

a. Data mining Data mining is 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.

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? a. Each physician practice should obtain a business associate agreement with the hospital. b. The hospital should obtain a business associate agreement with each physician practice. c. Because the physicians all have medical staff privileges, no business associate agreement is necessary. d. Because the physicians are part of an Organized Health Care Arrangement with the hospital, no business associate agreement is necessary.

a. Each physician practice should obtain a business associate agreement with the hospital. If physicians were to dictate information regarding patients they are treating in the facility, the disclosure of protected health information within the voice recognition system would be considered healthcare operations and, therefore, permitted under the HIPAA Privacy Rule. If physicians, who are separate covered entities, are dictating information on their private patients, however, it would be necessary for physicians to obtain a business associate agreement with the facility. It is permitted by the Privacy Rule for one covered entity to be a business associate of another covered entity.

The link that tracks patient, person, or member activity within healthcare organizations and across patient care settings is known as: a. Enterprise master patient index (EMPI) b. Audit trail c. Case-mix management d. Electronic document management system (EDMS)

a. Enterprise master patient index (EMPI) The EMPI is a list or database created or maintained by a healthcare facility to record the name and identification number of every patient and activity that has ever been admitted or treated in the facility. When a healthcare enterprise as more than one facility and the patient is seen at two or more places, the enterprise master patient index (EMPI) links the patient's information at the different facilities.

With regard to training in PHI policies and procedures: a. Every member of the covered entity's workforce must be trained b. Only individuals employed by the covered entity must be trained c. Training only needs to occur when there are material changes to the policies and procedures d. Documentation of training is not required

a. Every member of the covered entity's workforce must be trained Every member of the covered entity's workforce must be trained in PHI policies and procedures to maintain the privacy of patient information, uphold individual rights guaranteed by the Privacy Rule, and report alleged breaches and other Privacy Rule violations.

Patient accounting is reporting an increase in national coverage decisions (NCDs) and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? a. Health information management b. Patient access c. Patient accounts d. Utilization management

a. Health information management Resolving failed edits is one of many duties of the health information management (HIM) department. Various hospital departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues.

Which of the following is an argument against the use of the copy and paste function in the EHR? a. Inability to identify the author b. Inability to print the data out c. The time that it takes to copy and paste the documentation d. The users will not know how to perform the copy and paste function

a. Inability to identify the author In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes the inability to identify the author of the documentation.

Which of the following is true about information assets? a. Information considered to add value to an organization b. Data entered into a patient's health record by a provider c. Clearly defined elements required to be documented in the health record d. A list of all data elements added within a record

a. Information considered to add value to an organization Information assets refer to the information collected during day-to-day operations of a healthcare organization that has value within an organization. For example, patient data collected to support patient care is an example of information assets for the organization.

Assign codes for the following scenario: A 35-year-old male is admitted with esophageal reflux. An esophagoscopy and closed esophageal biopsy were performed. K20.9 Esophagitis, unspecified K21.0 Gastro-esophageal reflux disease with esophagitis K21.9 Gastro-esophageal reflux disease without esophagitis 0 Section - Medical and Surgical D Body System - Gastrointestinal System J RootOperation - Inspection 0 Body Part - Upper Intestinal Tract 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device Z Qualifier - No qualifier 0 Section - Medical and Surgical D Body System - Gastrointestinal System B RootOperation - Excision 5 Body Part - Esophagus 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device X Qualifier - Diagnostic 0 Section - Medical and Surgical D Body System - Gastrointestinal System B RootOperation - Excision 5 Body Part - Esophagus 8 Approach - Via natural or artificial opening Endoscopic Z Device - No device Z Qualifier - No qualifier a. K21.9, 0DB58ZX b. K20.9, 0DB58ZZ c. K21.0, 0DB58ZX d. K21.9, 0DJ08ZZ, 0DB58ZX

a. K21.9, 0DB58ZX The patient has esophageal reflux with no esophagitis mentioned, so K21.9 is the correct diagnosis code. For the ICD-10-PCS procedure code, a closed biopsy of the esophagus was performed via esophagoscopy, so 0DB58ZX is the correct code. The Section is Medical and Surgical—character 0; Body System is Gastrointestinal—character D; Root Operation is Excision—character B; Body Part is Esophagus—character 5; Approach—Via Natural or Artificial Opening Endoscopic—character 8; No Device—character Z; and the procedure was for diagnostic reasons (biopsy)—character X

Which of the following would be considered a security vulnerability? a. Lack of laptop encryption b. Workforce employees c. Tornado d. Electrical outage

a. Lack of laptop encryption A security threat is anything that can exploit a security vulnerability. Vulnerability is a weakness or gap in security protection. In this situation the lack of encryption for the laptop would be considered a security vulnerability as the contents could be more easily accessed.

The Breach Notification Rule requires covered entities to do which of the following: a. Notify affected individuals when a breach occurs b. Establish a policy on minimum necessary c. Provide each patient with a new notice of privacy practices d. Assign a new patient record number

a. Notify affected individuals when a breach occurs When a breach occurs, facilities must notify affected individuals. Facilities do not need to create a new health record number for each patient, provide a new copy of the Notice of Privacy Practices, or establish a policy on minimum necessary.

Physician orders for DNR should be consistent with: a. Patient's advance directive b. Patient's bill of rights c. Notice of privacy practices d. Authorization for release of information

a. Patient's advance directive An advanced directive is a written document that provides directions about a patient's desires in relation to care decisions for use by health care workers if the patient is incapacitated or not capable of communication. Physician orders for "do not resuscitate" (DNR) should be consistent with the patient's advanced directives.

This individual assists in educating medical staff members on the documentation needed for accurate coding. a. Physician champion b. Compliance officer c. Chargemaster coordinator d. Data monitor

a. Physician champion The health information manager must continuously promote complete, accurate, and timely documentation to ensure appropriate coding, billing, and reimbursement. This requires a close working relationship with the medical staff, perhaps through the use of a physician champion. Physician champions assist in educating medical staff members on documentation needed for accurate billing. The medical staff is more likely to listen to a peer than to a facility employee, especially when the topic is documentation needed to ensure appropriate reimbursement.

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): a. Trigger b. Audit reduction tool c. Integrity d. Audit control

a. Trigger The security audit process should include triggers that identify the need for a closer inspection. These trigger events cannot be used as the sole basis of the review, but they can significantly reduce the amount of reviews performed. An example of a trigger is when a user has same last name as patient.

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? a. Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier b. Prepare a sequential list of all records sent to remote storage c. Provide a unique box identifier and list the records by health record number on the outside of each box d. File the records in terminal digit order in each box

a. Provide a unique identifier for each box and prepare a log of the records that is cross-indexed by box identifier An off-site storage company is usually a contracted service that provides long-term storage of health records. The off-site storage company must be able to return the records to the healthcare facility within a predetermined time. For easy record retrieval it would be important to have records labeled. Because the records are filed in boxes, each box needs a unique identifier so it can be located.

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? a. 5 days b. 6 days c. 8 days d. 9 days

b. 6 days The average length of stay is the mean length of stay of hospital inpatients discharged during a given period of time. Add the total days for each patient (for a total of 54 days) and divide by 9 patients = 6 days.

Why is the MEDPAR file limited in terms of being used for research purposes? a. It only provides demographic data about patients b. It only contains Medicare patients c. It uses ICD-10-CM diagnoses and procedure codes d. It breaks charges down by specific type of service

b. It only contains Medicare patients The MEDPAR file is frequently used for research on topics such as charges for particular types of care and MS-DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients.

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? M70.40 Prepatellar bursitis, unspecified knee M70.42 Prepatellar bursitis, left knee S87.02xA Crushing injury of left knee, initial encounter S87.02xD Crushing injury of left knee, subsequent encounter S87.02xS Crushing injury of left knee, sequela a. M70.40, S87.02xA b. M70.42, S87.02xS c. M70.42, S87.02xD d. M70.40, S87.02xS

b. M70.42, S87.02xS The bursitis was the result of the previous crush injury and should be coded as sequela with the seventh character coded as "S" for sequela. The code for the left knee is also used to identify laterality.

The credentialing process of independent practitioners within a healthcare organization must be defined in: a. Hospital policies and procedures b. Medical staff bylaws c. Accreditation regulations d. Hospital licensure rules

b. Medical staff bylaws The credentialing and privileging process for the initial appointment and reappointment of independent practitioners should be defined in the healthcare organization's medical staff bylaws and should be uniformly applied.

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: a. Third-degree perineal laceration b. Placenta previa c. Twin gestation d. Vaginal hemorrhage

b. Placenta previa Placenta previa is the reason for the C-section and therefore is the principal diagnosis.

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 EHR? a. The deletion of old versions and the retention of the most recent b. Policies and procedures to control which version(s) is displayed c. Signed and unsigned documents not to be considered two versions d. Previous versions to be accessible to administration only

b. Policies and procedures to control which version(s) is displayed The health record may have multiple versions of the same document; for example, a signed and an unsigned copy of a document. To address the issues that result from having multiple versions of the same document, policies and procedures addressing version control must be developed.

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? a. Make admission date a required field b. Provide a template for entering data in the field c. Make admission date a numeric field d. Provide sufficient space for input of data

b. Provide a template for entering data in the field Templates are a cross between free text and structured data entry. The user is able to pick and choose data that are entered frequently, thus requiring the entry of data that change from patient to patient. Templates can be customized to meet the needs of the organization as data needs change by physician specialty, patient type (surgical/medical/newborn), disease, and other classification of patients. In this situation a template would provide structured data entry for the admission date.

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? a. Note the condition as present on admission. b. Query the physician to determine if the condition was present on admission. c. Note the condition as unknown on admission. d. Note the condition as not present on admission.

b. Query the physician to determine if the condition was present on admission. As a result of the disparity in documentation practices by providers, querying has become a common communication and educational method to advocate proper documentation practices. Queries can be made in situations when there is clinical evidence for a higher degree of specificity or severity.

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: a. Risk analysis b. Risk management c. Results documentation d. Recommendations for controls

b. Risk management One strategy in protecting the organization's data is to establish a risk management program. Risk management encompasses the identification, evaluation, and control of risks that are inherent in unexpected and inappropriate events.

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? a. The patient demographic information b. Which employees viewed, created, updated, or deleted information c. The ownership of the record d. Whether the patient had requested to be omitted from the facility patient directory

b. Which employees viewed, created, updated, or deleted information It is a requirement of the HIPAA Security Rule to implement ways that document access to information systems that contain electronic PHI. One of the ways to do this is to review the individuals that have viewed, created, updated, or deleted information within a health record. In this instance, the Privacy Officer should review this information to determine if the patient complaint is valid.

Patient had a laparoscopic incisional herniorrhaphy for a recurrent reducible hernia. The repair included insertion of mesh. What is the correct code assignment? 49560 Repair initial incisional or ventral hernia; reducible 49565 Repair recurrent incisional or ventral hernia; reducible 49568 Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh for closure of debridement for necrotizing soft-tissue infection 49656 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible a. 49565 b. 49565, 49568 c. 49656 d. 49560, 49568

c. 49656 Begin with the main term of Hernia repair; incisional. The fact that the hernia is recurrent, done via a laparoscope, and is reducible makes the answer 49656. Notice that the use of mesh is included in the code.

A patient's gender, phone number, address, next of kin, and insurance policy holder information would be considered what kind of data? a. Clinical data b. Authorization data c. Administrative data d. Consent data

c. Administrative data Administrative describes patient identification, diagnosis, procedures, and insurance. Patient registration information would be considered administrative data as would patient account information. A significant portion of administrative data is demographic data.

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? a. Access controls b. Audit trail c. Edit checks d. Password controls

c. Edit checks Edit checks assist in ensuring data integrity by allowing only reasonable and predetermined values to be entered into the computer.

Which of the following is not a recommended guideline for maintaining integrity in the health record? a. Specifying consequences for the falsification of information b. Requiring periodic training covering the falsification of information and information security c. Ensuring documentation that is being changed is permanently deleted from the record d. Prohibiting the entry of false information into any of the organization's records

c. Ensuring documentation that is being changed is permanently deleted from the record Data integrity is the assurance that the data entered into an electronic system or maintained on paper are only accessed and amended by individuals with the authority to do so. Data integrity includes data governance, patient identification, authorship validation, amendments and record correction, and audit validation for reimbursement purposes. These functions ensure that the data is protected and altered by authorized individuals as per policy. Assuring documentation that is being changed is permanently deleted from the record would not be a guideline for maintaining the integrity of the health record.

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? [Graph of Average Monthly Medical Record Deficiency Rate: Y axis is percentage, X axis is quarter; plots are: 40% at 2016 Q1, 35% at 2016 Q2, 32% at 2016 Q3, 25% at 2016 Q4, 21% at 2017 Q1, 35% at 2017 Q2, 51% at 2017 Q3, 55% at 2017 Q4.] a. Continue tracking the delinquency rate to see if the last two quarters' trend continues b. Establish a higher benchmark to accommodate an increase in delinquent records c. Further analyze the data to determine why the benchmark is not being met d. Take an average of all the data points to arrive at a new benchmark

c. Further analyze the data to determine why the benchmark is not being met Once a benchmark for each performance measure is determined, analyzing data collection results becomes more meaningful. Often, further study or more focused data collection on a performance measure is triggered when data collection results fall outside the established benchmark. When variation is discovered or when unexpected events suggest performance problems, members of the organization may decide there is an opportunity for improvement.

Which of the following is the goal of the quantitative analysis performed by HIM professionals? a. Ensuring that the health record is legible b. Verifying that health professionals are providing appropriate care c. Identifying deficiencies early so they can be corrected d. Ensuring bills are correct

c. Identifying deficiencies early so they can be corrected Reviewing for deficiencies is an example of quantitative analysis. The goal of quantitative analysis is to make sure there are no missing reports, forms, or required signatures in a patient record. Timely completion of this process ensures a complete health record.

An individual's right to control access to his or her personal information is known as: a. Security b. Confidentiality c. Privacy d. Access control

c. Privacy Privacy, confidentiality, and security are related, but distinct, concepts. In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information. Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose. Security is the protection of the privacy of individuals and the confidentiality of health records.

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? a. ROI employee evaluations b. Survey requestors c. ROI tracking system d. ADT system

c. ROI tracking system The supervisor is responsible for ensuring turnaround times are met. Turnaround time is the time between receipt of the request and when the request is sent to the requester. The ROI system tracks requests for the information.

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? a. Require staff to call in to the office every morning b. Require a daily conference call with all staff c. Set clear goals and productivity standards and see that these are met d. Install camcorders on each team's computer to ensure that they are at their workstations

c. Set clear goals and productivity standards and see that these are met Managing remote staff presents new considerations. It is not necessarily more difficult to manage remote staff; rather, it presents different challenges. In the remote environment, managers may need to rely on productivity and coding accuracy reports to determine the success of remote employees. When allowing coders to work from home or contracting with remote coders, work expectations must be established in advance.

In the scatter chart below what can be concluded about the relationship between age and income. [Graph: X axis is income in dollars, Y axis is age, graph direction looks like "/"] a. There is a strong negative relationship between age and income b. There is no relationship between age and income c. There is a strong positive relationship between age and income d. There is not enough information to determine the relationship

c. There is a strong positive relationship between age and income The scatter chart is showing a strong positive relationship between age and income because as age increases so does income. A negative relationship would show that as age increases income decreases, and that is not the case in this scatter chart example.

Which of the following are components of AHIMA's principles of information governance? a. Accountability and accessibility b. Integrity and safeguards c. Safeguards and accessibility d. Accountability and integrity

d. Accountability and integrity AHIMA defined the following principles to support proper information governance across an organization: accountability, transparency, integrity, protection, compliance, availability, disposition, and retention.

A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at trial d. Bring records to a legal proceeding

d. Bring records to a legal proceeding A subpoena duces tecum instructs the recipient to bring documents and other records with himself or herself to a deposition or to court.

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? a. Timeliness b. Completeness c. Security d. Consistency

d. Consistency Characteristics for data entry should be uniform throughout the health record to ensure consistency. Data must have definitions and be uniform to prevent information inconsistencies.

This type of data identifies the patient (such as name, health record number, address, and telephone number) and is called? a. Accession data b. Indicator data c. Reference data d. Demographic data

d. Demographic data Demographic data is used to identify an individual, such as name, address, gender, age, and other information linked to a specific person.

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? a. Inform the nurses that copy and paste is not acceptable and to stop this practice immediately b. Determine how many nurses are involved in this practice c. Institute an in-service training session on documentation practices d. Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system

d. Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system The ability to copy previous entries and paste into a current entry leads to a record in which a clinician may, upon signing the documentation, unwittingly swear to the accuracy and comprehensiveness of substantial amounts of duplicated or inapplicable information as well as the incorporation of misleading or erroneous documentation. The HIM professional plays a critical role in developing policies and procedures to ensure the integrity of patient information.

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? a. Poisoning due to Coumadin b. Unspecified adverse reaction to Coumadin c. Hematuria; poisoning due to Coumadin d. Hematuria; adverse reaction to Coumadin

d. Hematuria; adverse reaction to Coumadin Hematuria is an adverse effect as opposed to a poisoning because it was correctly prescribed and correctly taken.

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? a. Hybrid health record b. Paper health record c. Duplicate health record d. Personal health record

d. Personal health record The tool that Clara is using is a personal health record. Personal health records are a tool that an individual can use to collect, track, and share past and current information about their health.

Which of the following is true about the legal health record: a. Is inadmissible into evidence b. May not be hybrid c. Must consist in part on paper d. Will be disclosed upon request

d. Will be disclosed upon request One of the major purposes of a health record is to serve as the legal business record of an organization and as evidence in lawsuits or other legal actions, and as such, it would be the record released upon a valid request.

Patient name, zip code, and health record number are typical: a. Data elements b. Data sources c. Aggregate data d. Data monitors

a. Data elements The types of data elements that are abstracted, or defined as indexed fields in an automated system, vary from facility to facility. Generally, however, any data elements that are needed for selecting cases for reports must be abstracted or indexed. Some of the typical data fields that can be searched for the purpose of finding and reporting include: patient name, zip code, health record number, patient account number, attending physician, and the like.

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. A disease index b. A master patient index c. An operative index d. A physician index

a. A disease index A disease index is a listing in diagnosis code number order for patients discharged from the facility during a particular time period.

What number is assigned to a case when it is first entered in a cancer registry? a. Accession number b. Patient number c. Health record number d. Medical record number

a. Accession number Accession number is a number assigned to each case as it is entered in a cancer registry.

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? a. Ask current staff members to keep a diary for a certain period of time on how they spend their time b. Review job descriptions from other hospitals c. Make random observations of job tasks d. Refer the matter to the human resources department

a. Ask current staff members to keep a diary for a certain period of time on how they spend their time Collecting data on current performance and tasks allows the HIM supervisor to include all tasks that are being performed in the new job descriptions. When more than one person is performing a task, the data could be collected over time and averaged. One method of doing this is to keep a diary for a period of time on how they spend their time. The experience and overall performance of each person must be considered in setting the standard.

Secondary data is used for multiple reasons including: a. Assisting researchers in determining effectiveness of treatments b. Assisting physicians and other healthcare providers in providing patient care c. Billing for services provided to the patient d. Coding diagnoses and procedures treated

a. Assisting researchers in determining effectiveness of treatments Secondary data is used in research. Data taken from health records and entered into disease oriented databases can help researchers determine the effectiveness of alternate treatment methods. They also can quickly demonstrate survival rates at different stages of diseases.

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? a. Avoid displaying the number on any document, screen, or data collection field b. Allow the information in both electronic and paper forms since a variety of people need this data c. Require employees to sign confidentiality agreements if they have access to Social Security numbers d. Contact legal counsel for advice

a. Avoid displaying the number on any document, screen, or data collection field It is generally agreed that Social Security numbers (SSNs) should not be used as patient identifiers. The Social Security Administration is adamant in its opposition to using the SSN for purposes other than those identified by law. AHIMA is in agreement on this issue due to privacy, confidentiality, and security issues related to the use of the SSN.

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: a. Benchmark b. Check sheet c. Data abstract d. Run chart

a. Benchmark A benchmark is a systematic comparison of one organization's measurement characteristics to those of another similar organization. When an organization compares its current performance to its own internal historical data, or uses data from similar external organizations, it helps establish an organization 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? a. Benchmarking b. Workflow analysis c. Productivity analysis d. Work measurement

a. Benchmarking Comparing an organization's performance to the performance of other organizations that provide the same types of service is known as benchmarking. Internal benchmarking is also important to establish a baseline for the organization to find ways to improve effectiveness.

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? a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool

a. Check sheet A check sheet is used to gather data based on sample observations in order to detect patterns. When preparing to collect data, a team should consider the four W questions: Who will collect the data? What data will be collected? Where will the data be collected? When will the data be collected?

Which of the following data sets would be most helpful in developing a hospital trauma data registry? a. DEEDS b. MDS c. OASIS d. UACDS

a. DEEDS In 1997, the Centers for Disease Control and Prevention (CDC), through its National Center for Injury Prevention and Control (NCIPC), published a data set called Data Elements for Emergency Department Systems (DEEDS). The purpose of this data set is to support the uniform collection of data in hospital-based emergency departments and to reduce incompatibilities in emergency department records.

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: a. Data precision b. Data consistency c. Data granularity d. Data comprehensiveness

a. Data precision Data precision is the term used to describe expected data values. As part of data definition, the acceptable values or value ranges for each data element must be defined. For example, a precise data definition related to gender would include three values: male, female, and unknown.

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__________. a. Experimental medication; blood pressure b. Blood pressure; experimental medication c. Blood pressure; heart disease d. Experimental medication; heart disease

a. Experimental medication; blood pressure The independent variable in this example is the intervention used (medication) and the dependent variable is the disease that is being assessed (blood pressure).

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? a. Form an EHR steering committee b. Put out a press release c. Distribute an organization-wide memorandum from the CEO d. Put out a notice on the organization's intranet

a. Form an EHR steering committee Most organizations create an electronic health records (EHR) steering committee to engage all the various stakeholders in EHR planning and development. This ensures that the EHR planning is comprehensive and also starts the process of introducing change and gaining buy-in.

In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited? a. ICD-10-CM and ICD-10-PCS coding b. CPT/HCPCS and LOINC coding c. ICD-10-CM and SNOMED coding d. CPT/HCPCS and ICD-10-PCS coding

a. ICD-10-CM and ICD-10-PCS coding The corporate compliance program addresses the coding function. Because the accuracy and completeness of ICD-10-CM and ICD-10-PCS for inpatient code assignment determine the provider payment, the coding compliance program should regularly audit these codes. It is important that healthcare organizations have a strong coding compliance program.

When an individual requests a copy of the PHI or agrees to accept summary or explanatory information, the covered entity may: a. Impose a reasonable cost-based fee b. Not charge the individual c. Impose any fee authorized by state statute d. Charge only for the cost of the paper on which the information is printed

a. Impose a reasonable cost-based fee HIPAA gives individuals the right to request access to their PHI, but the covered entity may require that requests be in writing. HIPAA allows a reasonable cost-based fee when the individual requests a copy of PHI or agrees to accept summary or explanatory information.

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: a. Liver metastasis b. Adenocarcinoma of the rectum c. Anemia d. Admission for radiotherapy

a. Liver metastasis When an admission or encounter is for the management of anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced first as the principal or first listed diagnosis followed by the appropriate code for the anemia (such as D63.0, Anemia in neoplastic disease) according to ICD-10-CM Coding Guideline I.C.2.c.1

Which of the following is most likely to be used in performing an outpatient coding review? a. OCE b. MS-DRG c. CMI d. MDS

a. OCE The outpatient code editor (OCE) is a software program linked to the Correct Coding Initiative that applies a set of logical rules to determine whether various combinations of codes are correct and appropriately represent the services provided.

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? a. Operative report, anesthesia report, recovery room report b. Discharge summary, anesthesia report, operative report c. Recovery room report, physical therapy notes, operative report d. Operative report, discharge summary, anesthesia report

a. Operative report, anesthesia report, recovery room report Any surgical procedure requires special documentation. The entire process is recorded with an anesthesia report, operative report, and recovery room report.

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? a. Patient date of birth b. Name of attending physician c. Patient room number d. Admitting diagnosis

a. Patient date of birth In the context of healthcare, demographic information includes the following elements: patient's full name; patient's facility identification or account number; patient's address; patient's telephone number; patient's date and place of birth; patient's gender; patient's race or ethnic origin; patient's marital status; name and address of patient's next of kin; date and time of admission; hospital's name, address, and telephone number.

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services? a. Prospectively precertify the necessity of inpatient services b. Determine what services can be bundled c. Pay only 80% of the inpatient bill d. Require the patient to pay 20% of the inpatient bill

a. Prospectively precertify the necessity of inpatient services Utilization controls include the prospective and retrospective review of the healthcare services planned for, or provided to, patients. For example, a prospective utilization review of a plan to hospitalize a patient for minor surgery might determine that surgery could be safely performed less expensively in an outpatient setting. Prospective utilization review—often called precertification—is done in managed fee-for-service reimbursement.

Which of the following is the principal goal of a corporate compliance program? a. Protect providers from sanctions or fines b. Increase revenues c. Improve patient care d. Limit unnecessary changes to the chargemaster

a. Protect providers from sanctions or fines Implementation of an effective corporate compliance program significantly reduces the risk of unlawful or improper conduct, criminal or civil liability, and the risk of a government audit, and also promotes an ethical organizational culture.

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: a. Purging records b. Assembling records c. Logging records d. Cycling records

a. Purging records Files of patients who have not been at the facility for a specified period, may be purged or removed and sent to the storage facility.

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? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code the COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has the COPD d. Assign a code from the abnormal findings to reflect the condition

a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results This is an example of a circumstance in which the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS, and whether the COPD does is not clear.

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? a. Request that the physician dictate an addendum to the discharge summary b. Have the record analyst note the date discrepancy c. Request that the physician dictate another discharge summary d. File the record as complete because the discharge summary includes all the pertinent patient information

a. Request that the physician dictate an addendum to the discharge summary If during record analysis, missing or incomplete information is identified, HIM personnel can issue deficiency notification(s) to the appropriate caregiver to assure the completeness of the health record. An addendum is a supplement to a signed report that provides additional health information within the health record. In this type of correction, a previous entry has been made and the addendum provides additional information to address a specific situation or incident.

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? a. Serial work division b. Parallel work division c. Processing d. Benchmarking

a. Serial work division One of two major ways to organize process work is serial work division, assembly line fashion, where tasks or steps are handled separately in sequence by multiple individuals.

Which of the following should be considered first when establishing health record retention policies? a. State retention requirements b. Accreditation standards c. AHIMA's retention guidelines d. Federal requirements

a. State retention requirements Health record retention policies depend on a number of factors. They must comply with state and federal statutes and regulations. Retention regulations vary by state and possibly by organization type. Health records should be retained for at least the period specified by the state's statute of limitations for malpractice, and other claims must be taken into consideration when determining the length of time to retain records as evidence.

The Patient Accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills? a. Accounts receivable aging report b. Accounts not selected for billing report c. Case-mix index report d. Discharge summary report

b. Accounts not selected for billing report The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged not final billed (DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list.

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? a. Submit a certification of destruction in response to the subpoena b. Inform defense and plaintiff lawyers that the records no longer exist c. Refuse the subpoena since no records exist d. Contact the clerk of the court and explain the situation

a. Submit a certification of destruction in response to the subpoena If the paper health record is destroyed, the imaging record would be the legal health record. This may not be the case if the paper record is retained. State laws typically view the original health record as the legal record when it is available. Those who choose to destroy the original health record may do so within weeks, months, or years of scanning. If the record was destroyed according to guidelines for destruction and no scanned record exists, the certificate of destruction should be presented in lieu of the record.

Which events must occur in order to maintain patient identity data integrity? a. The data must be accurately queried b. The data must be accurately analyzed c. The data must be accurately normalized d. The data must be accurately coded

a. The data must be accurately queried Maintenance of data integrity is a key aspect of data quality management. When it comes to patient identity and HIE, integrity is of prime importance to linking the patient to the correct information. Three events must occur in order to maintain patient identity data integrity. The data must be accurately collected, entered, and queried.

Mary's PHI has been breached. She must be informed of all of the following EXCEPT: a. Who committed the breach b. Date the breach was discovered c. Types of unsecured PHI involved d. What she may do to protect herself

a. Who committed the breach Individuals who are notified that their PHI has been breached must be given a description of what occurred (including date of breach and date that breach was discovered); the types of unsecured PHI that were involved (such as name, Social Security number, date of birth, home address, account number); steps that the individual may take to protect himself or herself; what the entity is doing to investigate, mitigate, and prevent future occurrences; and contact information for the individual to ask questions and receive updates.

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? a. 33 b. 263 c. 270 d. 296

b. 263 The denominator (the number of times an event could have occurred) in this case would be 263 as 263 women delivered.

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: [Graph: Value of DFNB Days on Y axis, DFNB Days on X Axis; DNFB-Jan 1000000, DNFB-Feb 2000000, DNFB-Mar 3000000, DNFB-Apr 5000000, DNFB-May 3000000, DNFB-Jun 1000000] a. 25 percent of the time b. 50 percent of the time c. 75 percent of the time d. 100 percent of the time

b. 50 percent of the time In this example, DNFB met the benchmark in January, February, and June, which is 3/6 or 50 percent of the time.

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? a. Patient-specific data b. Aggregate data c. Operating room data d. Nothing—you cannot obtain this data after the fact

b. Aggregate data Aggregate data is data extracted from individual health records and combined to form de- identified information about groups of patients that can be compared and analyzed.

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? a. Autonomy b. Beneficence c. Justice d. Nonmaleficence

b. Beneficence Beneficence would require the HIM professional to ensure that the information is released only to individuals who need it to do something that will benefit the patient (for example, to an insurance company for payment of a claim).

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 and medical necessity c. Clinical laboratory results d. Radiology orders

b. Chargemaster description and medical necessity An auditing process identifies risk areas such as chargemaster description, medical necessity, MS-DRG coding accuracy, variations in case mix, and the like. Admission diagnosis and complaints, clinical laboratory results, and radiology orders are not risk areas that should be targeted for audit.

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? a. On-the-job training b. Computer-based c. Classroom lecture d. Seminar with break-out groups

b. Computer-based Computer-based training is a form of self-directed learning, an approach that allows learners to control their own education at their own pace.

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? a. Administrator of records b. Custodian of records c. Director of records d. Supervisor of records

b. Custodian of records Associated with ownership of health records is the legal concept of the custodian of records. The custodian of health records is the individual who has been designated as having responsibility for the care, custody, control, and proper safekeeping and disclosure of health records.

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? a. Suspended records b. Delinquent records c. Loose records d. Default records

b. Delinquent records Physicians and other practitioners are notified when they have incomplete health records requiring their attention. If a health record remains incomplete for a specified number of days, as defined in the medical staff rules and regulations, the record is considered to be a delinquent record.

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? a. Approve the requests because this is a patient right under HIPAA regulations. b. 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. c. Develop two different types of directories—one directory for provision of all information and one directory for provision of information to selected friends and family of the patient. d. Deny these requests and seek approval from the Office for Civil Rights.

b. 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. The HIPAA Privacy Rule allows individuals to decide whether they want to be listed in a facility directory when they are admitted to a facility. If the patient decides to be listed in the facility directory, the patient should be informed that only callers who know his or her name will be given any of this limited information. Covered entities generally do not, however, have to provide screening of visitors or calls for patients because such an activity is too difficult to manage with the number of employees and volunteers involved in the process of forwarding calls and directing visitors. If the covered entity agreed to the screening and could not meet the agreement, it could be considered a violation of this standard of the Privacy Rule.

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? a. Immediately stop the practice of changing transcribed reports b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form c. Conduct a verification audit d. Alert hospital legal counsel of the practice

b. Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in draft form An example of unethical documentation in healthcare is retrospective documentation—when healthcare providers add documentation after care has been given, possibly for the purpose of increasing reimbursement or avoiding a medical legal action. The HIM professional is responsible for maintaining accurate and complete records and is able to identify the occurrence and either correct the error or indicate that the entry is a late entry into the health record.

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? a. Access controls b. Device and media controls c. Facility access controls d. Workstation controls

b. Device and media controls Device and media controls require the facility to specify proper use of electronic media and devices (external drives, backup devices, etc.). Included in this requirement are controls and procedures regarding the receipt and removal of electronic media that contain protected health information and the movement of such data within the facility. The entity must also address procedures for the transfer, removal, or disposal, including reuse or redeployment, of electronic media.

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? a. Alteration b. Dilation c. Repair d. Restriction

b. Dilation Though the term valvuloplasty in the index leads to Repair, Replacement, or Supplement, this procedure was performed as a percutaneous Dilation. The root operation Dilation is expanding an orifice or the lumen of a tubular body part.

A pharmacist who submits Medicaid claims for reimbursement on brand name drugs when less expensive generic drugs were dispensed has committed the crime of: a. Criminal negligence b. Fraud c. Perjury d. Products' liability

b. Fraud Fraud in healthcare is defined as a deliberate false representation of fact, a failure to disclose a fact that is material (relevant) to a healthcare transaction, damage to another party that reasonably relies on the misrepresentation, or failure to disclose.

Which of the following refers to guarding against improper information modification or destruction? a. Confidentiality b. Integrity c. Privacy d. Security

b. Integrity Data integrity means that data should be complete, accurate, consistent, and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules.

The three elements of a security program are ensuring data availability, protection, and: a. Suitability b. Integrity c. Flexibility d. Robustness

b. Integrity Data security embodies three basic concepts: protecting the privacy of data, ensuring the integrity of data, ensuring the availability of data.

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? a. Exempt b. Nonexempt c. Full-time d. Professional

b. Nonexempt Nonexempt employees are covered by FLSA overtime provisions; this includes hourly-paid jobs.

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? a. Educational b. Public health and research c. Medical review organization d. Patient care

b. Public health and research Public health and research uses data in the health record for many reasons including monitoring disease outbreaks.

Which of the following can be used to develop a focused inpatient coding review? a. Controversial issues identified in CPT Assistant b. Recent data quality issues identified by external review agencies c. Analysis of HCPCS comparative data d. Top 25 APC groups by volume and charges

b. Recent data quality issues identified by external review agencies The HIM department can plan focused review based on specific problem areas after the initial baseline review has been completed.

Which of the following is a correct statement regarding DNR orders? a. A DNR is a form of advance directive and only requires the patient's desire for the withholding of care. b. The record should be clearly marked to indicate the presence of a DNR order. c. A DNR replaces the need for an advance directive since it is the ultimate in advance directive notifications. d. The Patient Self-Determination Act is federal so there are no differences in state law that need to be consulted.

b. The record should be clearly marked to indicate the presence of a DNR order. A do-not-resuscitate order is a physician's order documenting a patient's (or a substitute decision maker's) desire for no desired resuscitation attempts. Although a DNR order results from a desire expressed in an advanced directive, it does not replace the need for that directive. The health record should contain documentation indicating the presence of a DNR order.

Cancer registries are maintained by hospitals: a. By federal law or state law b. Voluntarily or by state law c. Voluntarily or by federal law d. By mandate from the American College of Surgeons

b. Voluntarily or by state law Cancer registries are typically maintained by hospitals on a voluntary basis or as mandated by state law. Many states require that hospitals report their data to a central state-wide registry or incidence surveillance program who in turn reports the data to the Centers for Disease Control (CDC).

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? a. The EHR system will take too long to implement. b. The Joint Commission requires that the hospital move to digital scanning. c. "Discharged, not final billed" and accounts receivable days can be improved because of workflow efficiencies. d. HIPAA requires the use of digital tracking of release of information.

c. "Discharged, not final billed" and accounts receivable days can be improved because of workflow efficiencies. Typical performance statistics maintained by the accounts receivable department include days in accounts receivable and aging of accounts. Facilities typically set performance goals for this standard. Understanding the workflow within a department is crucial for the supervisor in managing the departmental resources. To understand and control the workflow, the supervisor can perform a workflow analysis and then design the process to be more effective and efficient.

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? a. $8,000 b. $500 c. $800 d. $500,000

c. $800 Indexing in the EHR can be checked by conducting a random audit. To conduct a study, a subsection of the EHR reports can be checked for mislabeled reports. Any mislabeled reports that are found are noted, and an accuracy rate can be determined and compared against the established standard. In this scenario, there was a 4 percent error rate for the 100 records in the sample. If the cost of each misfile is $200, this would cost the facility $800 (100 x 0.04) x $200= $800

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? a. 0.5 FTE b. 0.75 FTE c. 1 FTE d. 2 FTEs

c. 1 FTE The productivity increase with telecommuting is 20 percent. The facility has five coders who are currently coding a total of 100 charts a day. With this 20 percent increase, each of the existing five coders can code four records more per day each (a 20 percent increase). This amounts to 120 charts: 24 × 5 = 120. If the discharges increase by 44 charts, the facility would need one more FTE in the telecommuting staffing model, since each coder can code 24 records per day.

Given the information here, which of the following MS-DRGs would have the highest payment rate? MS-DRG / MDC / Type / MS-DRG Title / Weight / Discharges / Geometric Mean 191 / 04 / MED / Chronic obstructive pulmonary disease w CC / 0.9139 / 10 / 3.1 / 3.7 192 / 04 / MED / Chronic obstructive pulmonary disease w/o CC/MCC / 0.7241 / 20 / 2.5 / 3.0 193 / 04 / MED / Simple pneumonia & pleurisy w MCC / 1.3167 / 10 / 4.2 / 5.2 194 / 04 / MED / Simple pneumonia & pleurisy w CC / 0.9002 / 20 / 3.3 / 3.9 195 / 04 / MED / Simple pneumonia & pleurisy w/o CC/MCC / 0.6868 / 10 / 2.6 / 3.1 a. 191 b. 192 c. 193 d. 194

c. 193 MS-DRG 193 has the highest weight and therefore would have the highest payment

From the information provided, how many APCs would this patient have? Billing Number / Status Indicator / CPT/HCPCS / APC 998323 / V / 99285-25 / 0612 998323 / T / 25500 / 0044 998323 / X / 72050 / 0261 998323 / S / 72128 / 0283 998323 / S / 70450 / 0283 a. 1 b. 4 c. 5 d. Unable to determine

c. 5 Each HCPCS code is assigned to one and only one ambulatory payment classification (APC). The APC assignment for a procedure or services does not change based on the patient's medical condition or the severity of illness. There may be an unlimited number of APCs per encounter for a single patient. The number of APC assignments is based on the number of reimbursable procedures or services provided for that patient. In this instance, the patient has five APCs.

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? a. HIPAA regulations do not allow this type of access. b. This access would be covered under the release of PHI for treatment purposes and poses no security or confidentiality threats. c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. d. Access can be permitted because the physicians are on the medical staff of the hospital and are covered by HIPAA as employees.

c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. The HIPAA Privacy Rule permits healthcare providers to access protected health information for treatment purposes. However, there is also a requirement that the covered entity provide reasonable safeguards to protect the information. These requirements are not easy to meet when the access is from an unsecured location, although policies, medical staff bylaws, confidentiality or other agreements, and a careful use of new technology can mitigate some risks.

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? a. HIPAA requires that employees have access to their own information, so grant privileges to the employees to perform this function. b. HIPAA does not allow employees to have access to their own information, so the procedure should not be implemented. c. 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. d. Employees are considered a special class of people under HIPAA and the procedure should be implemented.

c. 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. Allowing employees of a covered entity to access their own protected health information electronically results in a situation in which the covered entity may be in compliance with parts of the HIPAA Privacy Rule but in violation of other sections of the Privacy Rule. An ideal situation would be to establish a patient portal through which all patients may view their own records in a secure manner and for which an employee has neither more or less rights than any other patient.

According to CPT, an endoscopy that is undertaken to the level of the midtransverse colon would be coded as a: a. Proctosigmoidoscopy b. Sigmoidoscopy c. Colonoscopy d. Proctoscopy

c. Colonoscopy Colonoscopy includes examining the transverse colon. Proctosigmoidoscopy involves examining the rectum and sigmoid colon. Sigmoidoscopy involves examining the rectum, sigmoid colon, and may include portions of the descending colon.

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? a. Case mix b. Complication c. Comorbidity d. Principal diagnosis

c. Comorbidity A comorbidity is a medical condition that coexists with the primary cause of the hospitalization and affects the patient's treatment and length of stay.

One way for a hospital to demonstrate compliance with OIG guidelines is to: a. Designate a privacy officer b. Continuously monitor PEPPER reports c. Develop, implement, and monitor written policies and procedures d. Obtain ABNs for all Medicare registrations

c. Develop, implement, and monitor written policies and procedures Over the past several years, the OIG has published several documents to help providers develop internal programs that include elements for ensuring compliance. One of the elements included is written policies and procedures.

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? a. Print out all electronic data postdischarge and file with the rest of the paper record b. Microfilm all electronic data and link to the paper record c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system d. Do not scan any of the paper records

c. Digitally scan all paper records postdischarge, and integrate and index these into the existing electronic document management system Many hospitals incorporate documents into their EHR systems. Digital scanners create images of handwritten and printed documents that are then stored in health record databases as electronic files in their electronic document management system (EDMS). Using scanned images solves many of the problems associated with traditional paper-based health records and hybrid records.

Which of the following would be an example of a sentinel event? a. Incidence of hospital acquired infection b. Incidence of an unruly patient c. Incidence of infant abduction d. Incidence of blood transfusion reaction

c. Incidence of infant abduction Sentinel events usually involve significant injury to, or the death of, a patient or an employee through avoidable causes. Hospital acquired infections, blood transfusion reactions, or incidences of an unruly patient are monitored processes, but in and of themselves would not be considered sentinel events. An infant abduction would be considered an avoidable occurrence and therefore a sentinel event.

Release of birth and death information to public health authorities: a. Is prohibited without patient consent b. Is prohibited without patient authorization c. Is a public health activities disclosure that does not require patient authorization d. Requires both patient consent and authorization

c. Is a public health activities disclosure that does not require patient authorization There are circumstances where PHI can be used or disclosed without the individual's authorization and without granting the individual the opportunity to agree or object. Some of these circumstances include preventing or controlling diseases, injuries, and disabilities, and reporting disease, injury, and vital events such as births and deaths.

Which of the following is a characteristic of breach notification? a. It is only required when 500 or more individuals are affected b. It applies to both secured and unsecured PHI c. It applies when one person's PHI is breached d. Is only applies when 20 or more individuals are affected

c. It applies when one person's PHI is breached Breaches by covered entities and BAs (both governed by HHS breach notification regulations) are deemed discovered when the breach is first known or reasonably should have been known. All individuals whose information has been breached must be notified without unreasonable delay, and within 60 days, by first-class mail or a faster method, such as by telephone, if there is the potential for imminent misuse.

Spoliation can be defined as which of the following? a. It is required after a legal hold is imposed b. It is the negligent destruction or changing of information c. It is destroying, changing, or hiding evidence intentionally d. It can only be performed on records that are involved in a court proceeding

c. It is destroying, changing, or hiding evidence intentionally To preserve discoverable data, they must also ensure that records involved in litigation or potential litigation are preserved through a legal hold, which is generally a court order to preserve a health record if there is concern about destruction. A legal hold supersedes routine destruction procedures. It also prevents spoliation—the act of destroying, changing, or hiding evidence intentionally.

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? a. Table b. Histogram c. Line graph d. Bar chart

c. Line graph A line graph may be used to display time trends. A line graph is especially useful for plotting a large number of observations. It also allows several sets of data to be presented on one graph.

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? a. Add validation edits on all essential fields b. Provide an input mask for essential data fields c. Make all essential data fields required d. Provide sufficient space for all essential fields

c. Make all essential data fields required Standardization of the collection of patient data is essential to collect the proper information and reach data quality levels needed to support the enhancement of patient care and the healthcare industry. Templates can be created for common types of notes, visits, and procedures.

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? a. Patient last name should be used as the primary key for the table. b. Patient date of birth should be used as the primary key for the table. c. None of the data fields are adequate to use as a primary key for the table. d. Patient last and first name should be used as the primary key for the table.

c. None of the data fields are adequate to use as a primary key for the table. A primary key must uniquely identify a record. None of the options provided will uniquely identify a record. Multiple individuals may have the same name and birth dates.

Which of the following reports includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed? a. Anesthesia report b. Laboratory report c. Operative report d. Pathology report

c. Operative report The operative report describes the surgical procedures performed on the patient. Each report typically includes the name of the surgeon and assistants; date, duration, and description of the procedure; preoperative and postoperative diagnosis; estimated blood loss; descriptions of any unusual or unique events during the course of the surgery, normal and abnormal findings, as well as any specimens that were removed.

Healthcare abuse relates to practices that may result in: a. False representation of fact b. Failure to disclose a fact c. Performing medically unnecessary services d. Knowingly submitting altered claim forms

c. Performing medically unnecessary services Abuse occurs when a healthcare provider unknowingly or unintentionally submits an inaccurate claim for payment. Abuse generally results from unsound medical, business, or fiscal practices that directly or indirectly result in unnecessary costs to the Medicare program. The performance of medically unnecessary services and submitting them for payment would be an example of healthcare abuse.

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? a. Biometrics b. Encryption c. Personal firewall software d. Session terminations

c. Personal firewall software A firewall is a part of a computer system or network that is designed to block unauthorized access while permitting authorized communications. It is a software program or device that filters information between two networks, usually between a private network like an intranet and a public network like the Internet.

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. a. Benchmarking b. Data analysis c. Sampling d. Skewing

c. Sampling Sometimes the organizational characteristic or parameter about which data are being collected occurs too frequently to measure every occurrence. In this case, those collecting the data might want to use sampling techniques. Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data.

Which of the following is on the list of the hospital-acquired conditions provision of the inpatient prospective payment system? a. Congestive heart failure b. Acute myocardial infarction c. Stage III or IV pressure ulcers d. Diabetic retinopathy

c. Stage III or IV pressure ulcers The hospital-acquired conditions (HAC) provision is an additional component of pay-forperformance utilizing reported ICD-10-CM diagnosis codes and the present-on-admission (POA) indicator to identify quality issues. A Stage III or IV pressure ulcer not present on admission or identified with the POA indicator on the claim would not be paid for as a CC or MCC because it would be considered an HAC.

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? a. The EHR should retain only the latest version of the document in order to avoid confusion as documenting who made a change and when is never necessary. b. The EHR should not allow any amendments, addendums, or deletions of electronic documents as this violates accreditation standards. c. 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. d. The EHR is not capable of allowing documentation changes. If a document needs to be amended, it must printed, redlined, and scanned into the EHR

c. 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. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made 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.

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? a. The new documentation must be reviewed by the chief of the medical staff b. Natural language processing would be utilized to delete erroneous information c. The new and old documentation would be included in the same document with a comment section. d. The new documentation needs to be reviewed by the risk manager.

c. The new and old documentation would be included in the same document with a comment section. Policies and procedures need to be in place to address amendments and corrections in the EHR. In the event that an amendment, addendum, or deletion needs to be made 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.

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 __________. a. To make informed decisions b. To evaluate patient care and population health c. To decrease security breaches d. To evaluate business processes

c. To decrease security breaches Data governance and information governance programs rely on quality data and information for all the reasons listed in the question. However, confidentiality, privacy and security are the cornerstones of HIM. Therefore, to decrease security breaches is the most important reason.

The manager calculated a unit and time productivity statistic based on employee self-reported data. He used the method to develop this performance standard. a. Benchmarking b. Work distribution analysis c. Work measurement d. Workflow analysis

c. Work measurement Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work.

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? a. 0.689 b. 0.689 × 100 c. 1.45 × 100 d. 1.45

d. 1.45 The weight of each diagnosis-related group (DRG) is multiplied by the number of discharges for that DRG to arrive at the total weight for each DRG—in this situation 15,192. The total weights are summed and divided by the number of total discharges to arrive at the case-mix index for a hospital: 15,192 / 10,471 = 1.45

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? a. 10 patients b. 96.77 patients c. 97 patients d. 100 patients

d. 100 patients The average daily census is the average number of inpatients treated during a given period of time. There are 30 days in September, so 3,000 / 30 = 100

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: 1. Determine the statistical and scientific method to be used to determine the risk of reidentification 2. Analyze and assess the risk to the deidentified data 3. The expert applies the method to the deidentified data 4. The facility should choose the expert for the deidentification analysisWhat is the correct order in which these steps should be performed? a. 4, 1, 2, 3 b. 1, 2, 3, 4 c. 2, 4, 3, 1 d. 4, 1, 3, 2

d. 4, 1, 3, 2 The process for expert determination of de-identification has four recommended steps that include: Step 1: The facility should choose the expert for the deidentification analysis; Step 2: Determine the statistical and scientific method to be used to determine the risk of reidentification; Step 3: The expert applies the method to the deidentified data; and Step 4: Analyze and assess the risk to the deidentified data

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? a. 8.7% b. 9.5% c. 41.5% d. 91.3%

d. 91.3% Hospitals set completion standards based on this requirement. Record completion would include the discharge summary (137/150) × 100 = 91.3%

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? a. User name and password b. Encryption c. Cable locks d. Automatic session log-off

d. Automatic session log-off In the HIPAA Security Rule, one of the technical safeguards standards is access control. This includes automatic log-off, which ensures processes that terminate an electronic session after a predetermined time of inactivity.

A hospital can monitor its performance under the MS-DRG system by monitoring its: a. Accounts receivable b. Operating costs c. RBRVS payments d. Case-mix index

d. Case-mix index A hospital can monitor its performance under the MS-DRG system by monitoring its case-mix index (CMI). The CMI is the average of the relative MS-DRG weights of all cases treated at a given hospital. The CMI can be used to make comparisons between hospitals and to assess the quality of documentation and coding at a particular hospital.

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? a. Accuracy of the data b. Consistency of the data c. Appropriateness of the data elements d. Cost to process the data

d. Cost to process the data Several factors must be addressed when assessing data quality. These include: data accuracy, consistency, comprehensiveness, and timeliness. Cost to process the data does not influence the quality.

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? a. Chart locator system b. CDI system c. Encoder/grouper d. Disclosure management system

d. Disclosure management system A disclosure management system tracks the disclosures made throughout the healthcare facility for reporting purposes. Disclosure is the release, transfer, provision of access to, or divulging tin any manner of information outside the healthcare facility holding the information.

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: a. Prescribing b. Adverse drug reaction c. Sentinel event d. Diversion

d. Diversion Diversion is the removal of a 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 non-healthcare settings. An individual might take the medication for personal use, to sell on the street, to sell directly to a user as a dealer or to sell to others who will redistribute for the diverting individual.

Dr. Smith wants to use a lot of free text in his EHR. What should be your response? a. Good idea, Dr. Smith. This allows you to customize the documentation for each patient. b. Dr. Smith, we recommend that you do not use any free text in the EHR. c. Dr. Smith, we recommend that you should use free text only in your more complex cases. d. Dr. Smith, we recommend that you use little, if any, free text in the EHR.

d. Dr. Smith, we recommend that you use little, if any, free text in the EHR. Free-text data is the unstructured narrative data that is the result of a person typing data into an information system. It is undefined, unlimited, and unstructured, meaning that the typist can type anything into the field or document. The amount of free-text in the EHR should be limited as the ability to manipulate data is diminished.

Which of the following coding error classifications is most valuable in determining the impact on overall revenue cycle? a. Errors by coding guideline b. Percentage of cases that could have been improved if queried c. Errors by coder d. Errors that produced changes in MS-DRG assignment

d. Errors that produced changes in MS-DRG assignment Coding errors can affect the Medicare severity diagnosis-related group (MS-DRG) assignment, thus impacting the revenue cycle. Ultimately, the coding supervisor should determine whether the frequency of errors identified demonstrates a trend.

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? a. Scatter diagram b. Force-field analysis c. Pareto chart d. Flow chart

d. Flow chart When a team examines a process with the intention of making improvements, it must first understand the process thoroughly. Each team member has a unique perspective and significant insight about how a portion of the process works. Flow charts help all the team members understand the process in the same way.

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. a. Barplot b. Scatter plot c. Boxplot d. Heatmap

d. Heatmap A heat map plots all data points as a cell for two given variables or interest, and depending on frequency of observations in each cell, provides color to visualize high or low frequency.

In which type of distribution are the mean, median, and mode equal? a. Bimodal distribution b. Simple distribution c. Nonnormal distribution d. Normal distribution

d. Normal distribution The normal distribution is where data follows a symmetrical curve. The normal distribution is actually a theoretical family of distributions that may have any mean or any standard deviation. In a normal distribution, the mean, median, and mode are equal.

Which of the following is a principle of contemporary performance improvement? a. Success must never be celebrated as this does not encourage more success. b. Systems never demonstrate variation. c. Performance improvement works by identifying the individuals responsible for quality problems and reprimanding them. d. Performance improvement relies on the collection and analysis of data to increase knowledge.

d. Performance improvement relies on the collection and analysis of data to increase knowledge. Performance improvement (PI) is based on several fundamental principles, including: the structure of a system determines its performance; all systems demonstrate variation; improvements rely on the collection and analysis of data that increase knowledge; PI requires the commitment and support of top administration; PI works best when leaders and employees know and share the organization's mission, vision, and values.

Typically, healthcare facilities should retain the master patient index: a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently

d. Permanently Record retention should only be done in accordance with federal and state law and written retention and destruction policies of the organization. AHIMA's recommended retention standards for the master patient index (MPI) is permanent retention.

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." a. Discharge summary b. Health history c. Medical laboratory report d. Physical examination

d. Physical examination Review of body systems is typically documented in the report of a physical examination. This would include documentation regarding the HEENT (head, eyes, ears, nose, and throat) and the chest.

Which of the following is a core ethical obligation of health information management professionals? a. Coding diseases and operations b. Performing quantitative analysis on record content c. Transcribing health reports d. Protecting patients' privacy and confidential communications

d. Protecting patients' privacy and confidential communications The HIM professional's core ethical obligations are to protect patient privacy and confidential information and communication and to assure security of that information.

The role of the HIM professional in medical identity theft protection programs includes all of the following except: a. Ensure safeguards are in place to protect the privacy and security of PHI b. Balance patient privacy protection with disclosing medical identity theft to victims c. Identify resources to assist patients who are victims of medical identity theft d. Send all issues related to medical identity theft to the in-house attorney

d. Send all issues related to medical identity theft to the in-house attorney Medical identity theft is distinguished from other types of identity theft because it creates negative consequences to both the victim's financial status and health information. The HIM professional should ensure safeguards are in place to protect PHI and provide resources to assist victims of medical identity theft. It is important to balance patient privacy protection with disclosure of medical identity theft to victims.

Which of the following should be avoided when designing forms for an electronic document management system (EDMS)? a. Color borders around the edge of a form b. Mnemonic descriptor used for nonbarcode recognition engine c. Quarter-inch border on each side of document without bar code d. Shading of bars or lines that contain text

d. Shading of bars or lines that contain text The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated because the color can adversely affect the quality of scanned images.

The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following? a. Upcoding b. Complex coding c. Query d. Unbundling

d. Unbundling Unbundling occurs when individual components of a complete procedure or service are billed separately instead of using a combination code.

Which of the following can assist managers with the tasks of monitoring productivity and forecasting budgets? a. Intermediary bulletins b. Mapping errors c. Revenue codes d. Workload statistics

d. Workload statistics Workload statistics can assist managers with the tasks of monitoring productivity and provide data regarding resources used, such as equipment, personnel, services, and supplies.