exam
54.How is the patient registration department assisted by the HIM department? a. Assigns the health record number b. Processes the healthcare claim c. Implements the information systems used by the HIM department d. Maintains the information systems used by the HIM department
a. Assigns the health record number
52.Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: a. By the hospital b. By the patient c. By the attending and consulting physician d. Jointly by the hospital, physician, and patient
a. By the hospital
20.An alternative to the retrospective coding model is the __________ coding model in which records are coded while the patient is still an inpatient. a. Concurrent b. Analytical c. Prospective d. Auxiliary
a. Concurrent
38.A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. Intravenous (IV) fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis? a. Dehydration b. Chemotherapy c. Liver carcinoma d. Complication of chemotherapy
a. Dehydration
11.A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. b. Yes; this is hospital policy for which HIPAA has no control. c. No; the records from the previous hospital are not included in the designated record set but should be released anyway. d. Yes; HIPAA only requires that current records be produced for the patient.
a. No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.
17.Which of the following is true regarding the reporting of communicable diseases? a. They must be reported by the patient to the health department. b. The diseases to be reported are established by state law. c. The diseases to be reported are established by HIPAA. d. They are never reported because it would violate the patient's privacy.
b. The diseases to be reported are established by state law.
18.Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request d. It includes a patient's personal health record
c. It is the record disclosed upon request
89.Which of the following is an example of a physical safeguard that should be provided for in a data security program? a. Using password protection b. Prohibiting the sharing of passwords c. Locking computer rooms d. Annual employee training
c. Locking computer rooms
1.A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used? Fixed Percentage Random Sample Audit ExampleCoderWork OutputRecords for 5% AuditA500B480C300D360 a. 82 b. 156 c. 820 d. 1,550
82 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. In this case, 82 records would be a sufficient number to review for coding quality. The calculation is: (500 × 0.05) + (480 × 0.05) + (300 × 0. 05) + (360 × 0.05) = 82 records
10.Community Hospital's HIM department conducted a random sample of 200 inpatient health records to determine the timeliness of the history and physicals completion. Nine records were found to be out of compliance with the 24-hour requirement. Which of the following percentages represents the H&P timeliness rate at Community Hospital? a. 4.5% b. 21.2% c. 66.7% d. 95.5%
95.5% 200-9=191 191/200=95.5%
70.Which of the following is a function of the outpatient code editor? a. Validate the patient's age on a claim b. Validate the patient's encounter number c. Identify unbundling of codes d. Identify cases that don't meet medical necessity
c. Identify unbundling of codes
73.An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit controls c. Contingency controls d. Security incident controls
a. Access controls
8.The risk manager's principal tool for capturing the facts about potentially compensable events is the: a. Accident report b. RM report c. Occurrence report d. Event report
a. Accident report
99.The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claims processing c. Billing errors d. Inaccurate code assignments
a. Accusations of fraud and abuse
91.The accounts not selected for the billing report is a daily report used to track accounts that are: a. Awaiting payment in accounts receivable b. Paid at different rates c. In bill hold or in error and awaiting billing d. Pulled for quality review
c. In bill hold or in error and awaiting billing
61.Which of the following is true regarding the development of health record destruction policies? a. All applicable laws must be considered b. The organization must find a way not to destroy any health records c. Health records involved in pending or ongoing litigation may be destroyed d. Only state laws must be considered
a. All applicable laws must be considered
5.To use a data element for aggregation and reporting, that data element must be: a. Abstracted or indexed b. Searched c. Subject to case finding d. Registered
a. Abstracted or indexed
43.As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all the divisions within the HIM department. The following table shows sample productivity benchmarks for record analysis the director found through a literature search. Given this information, how should the director proceed in establishing benchmarks for the department? Sample Productivity BenchmarksProductivity BenchmarksPer HourFunctionLowAverageHighAnalysis (charts per hour)Inpatient820Observation/outpatient surgery/newborn/maternity51460Other outpatient20120 a. Determine whether the source of the benchmark data is from a comparable institution b. Use the low benchmark example as a beginning point for implementation c. Contact the hospital statistician to determine whether the data are relevant d. Use the average benchmark example as a beginning point for implementation
a. Determine whether the source of the benchmark data is from a comparable institution
48.A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of: a. Healthcare fraud b. Payment optimization c. Payment reduction d. Healthcare creativity
a. Healthcare fraud
53.The deception or misrepresentation by a healthcare provider that may result in a false or fictitious claim for inappropriate payment by Medicare or other insurers for items or services either not rendered or rendered to a lesser extent than described in the claim is: a. Healthcare fraud b. Optimization c. Upcoding d. Healthcare abuse
a. Healthcare fraud
82.Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. Identification of the record as the one subpoenaed b. The care provided to the patient c. The qualifications of the treating physician d. Identification of the standard of care used to treat the patient
a. Identification of the record as the one subpoenaed
19.The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark development. What fundamental team leadership mistake is the HIM director making with composition of the team? a. Insufficient knowledge of team members b. Too many team members c. Unspecific team charge d. Too few team members
a. Insufficient knowledge of team members
69.The master patient index (MPI) manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. The MPI manager merged the patient information and corrected the duplicates in the patient information system. After this merging process, which department should the MPI manager notify to correct the source system data? a. Laboratory b. Radiology c. Quality Management d. Registration
a. Laboratory
6.Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: a. Legitimate need for access b. Password to access the EHR c. Report development program d. Signed confidentiality agreement
a. Legitimate need for access
88.The admissions director maintains that a notice of privacy practices must be provided to the patient on each admission. How should the HIM director respond? a. Notice of privacy practices is required on the first provision of service. b. Notice of privacy practices is required every time the patient is provided service. c. Notice of privacy practices is only required for inpatient admissions. d. Notice of privacy practices is required on the first inpatient admission but for every outpatient encounter.
a. Notice of privacy practices is required on the first provision of service
41.Erin is an HIM professional. She is teaching a class to clinicians about proper documentation in the health record. Which of the following is an example of improper teaching? a. Obliterating or deleting errors b. Leaving existing entries intact c. Labeling late entries as being late d. Ensuring the legal signature of an individual making a correction accompanies the correction
a. Obliterating or deleting errors
83.The leaders of a healthcare organization are expected to select an organization-wide performance improvement approach and to clearly define how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas? a. Operative and other invasive procedures, medication management, and blood and blood product use b. Blood and blood product use, medication management, and appointment to the board of directors c. Medication management, marketing strategy, and blood use d. Operative and other invasive procedures, appointments to the board of directors, and restraint and seclusion use
a. Operative and other invasive procedures, medication management, and blood and blood product use
87.Which of the following best represents the definition of the term data? a. Patient's laboratory value is 50. b. Patient's SGOT is higher than 50 and outside of normal limits. c. Patient's resting heartbeat is 70, which is within normal range. d. Patient's laboratory value is consistent with liver disease.
a. Patient's laboratory value is 50.
24.A patient requests copies of her medical records in an electronic format. The hospital does not maintain all the designated record set in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically
a. Provide the records in paper format only
56.The clinical forms committee: a. Provides oversight for the development, review, and control of forms and computer screens b. Is responsible for the EHR implementation and maintenance c. Is always a subcommittee of the quality improvement committee d. Is an optional function for the HIM department
a. Provides oversight for the development, review, and control of forms and computer screens
59.What factor is medical necessity based on? a. The beneficial effects of a service for the patient's physical needs and quality of life b. The cost of a service compared with the beneficial effects on the patient's health c. The availability of a service at the facility d. The reimbursement available for a given service
a. The beneficial effects of a service for the patient's physical needs and quality of life
7.An employee views a patient's electronic health record. It is a trigger event if: a. The employee and patient have the same last name b. The patient was admitted through the emergency department c. The patient is over 89 years old d. A dietitian views a patient's nutrition care plan
a. The employee and patient have the same last name
92.Which of the following definitions best describes the concept of confidentiality? a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The right of individuals to control access to their personal health information d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information
a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose
45.The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if: a. The template was defined b. The data type was numeric c. The field was not required d. The field length was longer
a. The template was defined
35.The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified? Costs Associated with Each IT Help Desk Call to Resolve Password IssuesPersonnelCostUser's time—30 minutes$15Telephone cost—30 minutes$2Call Desk time—30 minutes$16Call Desk IS facilities time$17Total$50 a. Training will provide $146,000 savings in help desk support and can be justified. b. The results of training will provide $365,000 savings in help desk support and can be justified. c. The cost of training will be recouped in less than half a year and can be justified. d. The cost of training is not justified because qualitative results cannot be measured to calculate a return on investment.
a. Training will provide $146,000 savings in help desk support and can be justified. Current cost: $50 x 40 calls per day = $2,000 per day x 365 days = $730,000. Cost with reducednumber of help desk calls: $50 x (40 x 0.80) calls per day = $1,600 per day x 365 days =3584.000. or a saVings of $146000. Training costs of $100000 will be recouped and a savin0f$46.000 realized
50.Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following? a. Validity of hospital diagnosis and procedure coding data completeness b. Appropriateness of EHR used c. Policies, procedures and standards of conduct d. Professional standards
a. Validity of hospital diagnosis and procedure coding data completeness
95.A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record
a. Vital signs record
62.Recently, a local professional athlete was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine: a. Whether access by employees is appropriate b. If the patient is satisfied with their stay c. If it is necessary to order prescriptions for the patient d. Whether the care to the patient meets quality standards
a. Whether access by employees is appropriate
28.The HIM improvement team wants to identify the causes of poor documentation compliance in the health record. Which of the following tools would best aid the team in identifying the root cause of the problem? a. Flowchart b. Fishbone diagram c. Pareto chart d. Scatter diagram
b. Fishbone diagram
25.The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit
b. Focused audit
32.Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both admitted and discharged on May 2. What was the total number of inpatient service days for May 2? a. 240 b. 242 c. 280 d. 320
b) 242 250+30=280 280-40=240 240+2=242
27.A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure? SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalLowerBonesExcisionUpperFemur, RightOpenNo DeviceNo Qualifier0QB60ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalLowerBonesDivisionUpperFemur, RightOpenNo DeviceNo Qualifier0QB60ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalLowerBonesExcisionHip Joint,RightOpenNo DeviceNo Qualifier0SB90ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalLowerBonesReleaseHip Joint,RightOpenNo DeviceNo Qualifier0SN90ZZ a. 0QB60ZZ b. 0Q860ZZ c. 0SB90ZZ d. 0SN90ZZ
b. 0Q860ZZ
44.Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare: a. The full DRG amount, and Big Medical Center will receive a per diem rate for the three-day stay b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment c. The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the three-day stay d. No payment; Community Hospital must bill Big Medical Center a per diem rate for the twoday stay
b. A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment
90.In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis and complaints b. Chargemaster description c. Clinical laboratory results d. Radiology orders
b. Chargemaster description
34.At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: a. Data comprehensiveness b. Data consistency c. Data currency d. Data granularity
b. Data consistency
3.A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record
b. Delinquent record
84.Which of the following practices is an appropriate coding compliance activity? a. Reviewing all accurately paid claims b. Developing procedures for identifying coding errors c. Providing a financial incentive for coding claims improperly d. Instructing coders to code diagnoses and submit the bill before all applicable information is documented in the health record
b. Developing procedures for identifying coding errors
9.In designing an input screen for an EHR, which of the following would be best to capture structured data? a. Speech recognition b. Drop-down menus c. Natural language processing d. Document imaging
b. Drop-down menus
80.Which of the following is considered the authoritative resource in locating a health record? a. Disease index b. Master patient index c. Patient directory d. Patient registry
b. Master patient index
75.Which of the following is the health record component that addresses the patient's current complaints and symptoms and lists that patient's past medical, personal, and family conditions? a. Problem list b. Medical history c. Physical examination d. Clinical observation
b. Medical history
49.Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits
b. Medical necessity
100.Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers? a. Minimum data set for long-term care b. Outcomes and Assessment Information Set c. Patient assessment instrument d. Resident assessment protocol
b. Outcomes and Assessment Information Set
72.A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be: a. Normal delivery b. Placenta previa c. Twin gestation d. Vaginal hemorrhage
b. Placenta previa
30.Sometimes data do not follow a normal distribution and are pulled toward the tails of the curve. When this occurs, it is referred to as having a skewed distribution. Because the mean is sensitive to extreme values or outliers, it gravitates in the direction of the extreme values thus making a long tail when a distribution is skewed. When the tail is pulled toward the right side, it is called a __________. a. Negatively skewed distribution b. Positively skewed distribution c. Bimodal distribution d. Normal distribution
b. Positively skewed distribution
66.The Department of Health and Human Services has identified that Community Hospital is guilty of fraud. It was determined that the facility tried to comply with standards, but their efforts failed. What category of fraud and abuse prevention does this fall into? a. Reasonable cause b. Reasonable diligence c. Willful neglect d. Willful defiance
b. Reasonable diligence
71.Which of the following is true about health information retention? a. Retention depends only on accreditation requirements b. Retention periods differ among healthcare facilities c. The operational needs of a healthcare facility cannot be considered d. Retention periods are frequently shorter for health information about minors
b. Retention periods differ among healthcare facilities
21.To comply with the Joint Commission standards, the HIM director wants to ensure the history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record? a. Establish a process to review health records immediately on discharge b. Review each patient's health record concurrently to ensure the history and physicals are present c. Retrospectively review each patient's health record to ensure the history and physicals are present d. Write a memorandum to all physicians relating the Joint Commission requirements for documenting history and physical examinations
b. Review each patient's health record concurrently to ensure the history and physicals are presen
74.Which tool is used to display performance data over time? a. Status process control chart b. Run chart c. Benchmark d. Time ladder
b. Run chart
68.How many identifiers must be removed for a data to be considered de-identified under the Safe Harbor Method? a. 12 b. 15 c. 18 d. 20
c. 18
60.Which of the following is a positive aspect of using employee self-appraisal as a source of data for performance appraisal? a. Employees are in the best position to provide objective review without overstatement b. The supervisor is kept informed of the employee's accomplishments c. Appraiser and employee training on the purpose and procedures of this process is essential d. Peer pressure of evaluation can motivate team members to be more productive
b. The supervisor is kept informed of the employee's accomplishments
81.Each healthcare organization must identify and prioritize which processes and outcomes (in other words, which types of data) are important to monitor. This data collection should be based on the scope of care and services they provide and: a. The number of employees they employ b. Their mission c. The QI methodology used d. Their accreditation status
b. Their mission
4.The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and only the number be announced.
b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing a change that might reduce this practice.
97.Copies of personal health records (PHRs) are considered part of the legal health record when: a. Consulted by the provider to gain information on a consumer's health history b. Used by the organization to provide treatment c. Used by the provider to obtain information on a consumer's prescription history d. Used by the organization to determine a consumer's DNR status
b. Used by the organization to provide treatment
36.Based on this output table, what is the average coding test score for the beginner coder? Coding Test ScoreCoder StatusMeanNStandard DeviationAdvanced93.000035.00000Intermediate89.50002.70711Beginner73.333336.42910Total84.7500810.51190 a. 93 b. 6.4 c. 73 d. 90
c. 73
13.The organization that employs you just concluded an investigation of a laptop computer that was lost and contained a file with the information of 765 patients on it, including names, addresses, telephone numbers, and social security numbers. As the privacy officer, you are required to manage the notification process for the data breach. All of the following would need to be notified of this data breach within 60 days of the discovery except: a. Individual patients b. Local media c. Attending physicians of the patients d. Department of Health and Human Services
c. Attending physicians of the patients
22.Which of the following is a risk of copy and pasting documentation in the electronic health record? a. Reduction in the time required to document b. System may not save data c. Copying the note in the wrong patient's record d. System thinking that the information belongs to the patient from whom the content is being copied
c. Copying the note in the wrong patient's record
55.When coding a benign neoplasm of skin of the left upper eyelid, which of the following codes should be used?
c. D23.121
58.The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management
c. Federal and state confidentiality laws
63.A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to prepare this report? a. Physician progress notes and medication record b. Nursing and physician progress notes c. Medication administration record and clinical laboratory reports d. Physician orders and clinical laboratory reports
c. Medication administration record and clinical laboratory reports
51.Which of the following is the approved method for implementing an organization's formal position? a. Hierarchy chart b. Organizational chart c. Policy and procedure d. Mission statement
c. Policy and procedure
98.The utilization manager's role is essential to: a. Analyze the estimate of benefits (EOBs) received b. Capture all relevant charges for the patient's account c. Prevent denials for inappropriate levels of service d. Verify the patient has insurance
c. Prevent denials for inappropriate levels of service
40.The first step in an inpatient record review is to verify correct assignment of the: a. Record sample b. Coding procedures c. Principal diagnosis d. MS-DRG
c. Principal diagnosis
12.Which policy ensures that the minimum penalty appropriate to the level of employee offense is applied? a. Employment at will b. Downsizing c. Progressive penalties d. Discipline without punishment
c. Progressive penalties
93.Carolyn works as an inpatient coder in a hospital HIM department. She views a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do? a. Assign a code for the staph infection b. Put a note in the chart c. Query the physician d. Tell her supervisor
c. Query the physician
31.A health information technician receives a subpoena ad testificandum. To respond to the subpoena, which of the following should the technician do? a. Review the subpoena to determine what documents must be produced b. Review the subpoena and notify the hospital administrator c. Review the subpoena and appear at the time and place supplied to give testimony d. Review the subpoena and alert the hospital's risk management department
c. Review the subpoena and appear at the time and place supplied to give testimony
67.In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited? a. Drop-down menus b. Point and click fields c. Speech recognition d. Structured templates
c. Speech recognition
77.Which of the following is a secondary purpose of the health record? a. Support for provider reimbursement b. Support for patient self-management activities c. Support for research d. Support for patient care delivery
c. Support for research
57.When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected? a. There is no impact. b. The person making the entry in the health record may not be called as a witness in trial. c. The incident report likely becomes discoverable because it is mentioned in a discoverable document. d. The incident report cannot be discovered even though it is mentioned in a discoverable document.
c. The incident report likely becomes discoverable because it is mentioned in a discoverable document.
94.An external security threat can be caused by which of the following? a. Employees who steal data during work hours b. A facility's water pipes bursting c. Tornadoes d. The failure of a facility's software
c. Tornadoes
65.The RHIT supervisor for the scanning and quality control section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for scanning records is 50 records per hour. The standard for quality control of scanning of records is 40 records per hour. Given these standards, how many productive hours will be required daily to scan and quality control records for each clinic day? a. 10 hours per day b. 11.11 hours per day c. 12.5 hours per day d. 22.5 hours per day
d. 22.5 hours per dayTimeliness of the scanning and quality control processes should be monitored. In this situation, each clinic visit represents a patient record that will need to be scanned and quality control completed.The calculation is: (500 / 50) + (500 / 40) = 22.5 hours per day.
29.Based on a productivity log, a coder completed 23 charts during a 7.5-hour workday. The performance standard is 4 charts per hour. How many charts did he code per hour? Round to the nearest whole number. a. 2.06 b. 4.1 c. 23 d. 3
d. 3 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. Employees log what they do and the time spent on tasks in units of work received and processed each day.23 charts/7.5 hours = 3.06, which is rounded to 3 charts per hour.
2.A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site36580Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access36582Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access36597Repositioning of previous placed central venous catheter under fluoroscopic guidance a. 36578 b. 36580 c. 36582, 36597 d. 36582
d. 36582
78.Which of the following is an example of how an internal user utilizes secondary data? a. State infectious disease reporting b. Birth certificates c. Death certificates d. Benchmarking with other facilities
d. Benchmarking with other facilities
64.After the types of cases to be included in a cancer registry have been determined, what is the next step in data acquisition? a. Case registration b. Case definition c. Case abstracting d. Case finding
d. Case finding
26.The national patient safety goals score organizations on areas that: a. Affect the financial stability of the organization b. Commonly lead to overpayment c. Affect compliance with state law d. Commonly lead to patient injury
d. Commonly lead to patient injury
96.An inpatient, acute-care coder must follow official ICD-10-CM and ICD-10-PCS coding guidelines established by the: a. American Health Information Management Association b. American Medical Association c. Centers for Medicare and Medicaid Services d. Cooperating Parties
d. Cooperating Parties
76.The HIM manager is conducting a study in which she is comparing the current year's diagnosis codes to the proposed new codes for the next fiscal year and documenting variations in order to assess the impact on the organization. This process creates a: a. Data chargemaster report b. Data dictionary c. Database management system d. Data map
d. Data map
15.What is data called that consists of factual details aggregated or summarized from a group of health records the provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived
d. Derived
85.Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? PayerChargesPaymentsAdjustmentChargesPaymentsAdjustmentsBC/BS$450,000$360,000$90,00023%31%12%Commercial$250,000$200,000$50,00013%17%6%Medicaid$350,000$75,000$275,00018%6%36%Medicare$750,000$495,000$255,00039%42%33%TRICARE$150,000$50,000$100,0007%4%13%Total$1,950,000$1,180,000$770,000100%100%100% a. BC/BS b. Commercial c. TRICARE d. Medicare
d. Medicare
39.If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient: a. For the balance due after Medicare has paid b. Only if both Medicare and any supplemental insurance have been billed and settled c. Never—providers may not bill Medicare patients for amounts unpaid by Medicare d. Only if a properly executed ABN was obtained before the service was provided
d. Only if a properly executed ABN was obtained before the service was provided
46.Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 years old b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed
d. Present an authorization that at least one of them (Ted or Mary) has signed
33.The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance. a. Procedures 1, 4 b. Procedures 2, 3, 5 c. Procedures 6, 7 d. Procedures 1, 4, 6, 7
d. Procedures 1, 4, 6, 7
37.The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following? a. Reporting of claims, initiating an investigation of claims, protecting the primary and secondary health records, negotiating settlements, managing litigations, and using information for claim's resolution in performance management activities b. Risk acceptance, risk avoidance, risk reduction or minimization, and risk transfer c. Safety management, security management, claims management, technology management, and facilities management d. Risk identification and analysis, loss prevention and reduction, and claims management
d. Risk identification and analysis, loss prevention and reduction, and claims management
16.How do accreditation organizations such as the Joint Commission use the health record? a. To serve as a source for case study information b. To determine whether the documentation supports the provider's claim for reimbursement c. To provide healthcare services d. To determine whether standards of care are being met
d. To determine whether standards of care are being met
23.Which of the following is a key characteristic of the problem-oriented health record? a. Allows all providers to document in the health record b. Uses laboratory reports and other diagnostic tools to determine health problems c. Provides electronic documentation in the health record d. Uses an itemized list of the patient's past and present health problems
d. Uses an itemized list of the patient's past and present health problems
14.Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of: a. Content and structure standards b. Security standard c. Transaction standards d. Vocabulary standards
d. Vocabulary standards
47.As part of your job responsibilities, you are responsible for reviewing audit trails of access to patient information. The following are all types of activities that you would monitor except: a. Every access to every data element or document type b. Whether the person viewed, created, updated, or deleted the information c. Physical location on the network where the access occurred d. Whether the patient setup an account in the patient portal
d. Whether the patient setup an account in the patient portal