RHIT EXAM

Fishbone diagram

A cause-and-effect diagram, also known as a fishbone diagram because of its characteristic fish shape, is an investigation technique that facilitates the identification of the various factors that contribute to a problem. It facilitates root-cause analysis, in order to determine the cause of the problem

positive correlation

A correlation where as one variable increases, the other also increases, or as one decreases so does the other. Both variables move in the same direction.

NCCI Edits

(most providers have built into their claims software) explain what procedures and services cannot be billed together on the same day of service for a patient. The mutually exclusive edit applies to improbable or impossible combinations of codes

Health record retention policies

The HIM professional must consider multiple factors when developing health record retention policies that determine how long health records are to be kept. These factors include applicable federal and state statutes and regulations; accreditation standards; operational needs of the organization; and the type of organization, thus retention policies differ among healthcare facilities

What are the requirements in the HIPAA Privacy Rule to produce records when requested?

HIPAA Privacy Rule requires that records be produced within 30 days to a patient or their personal representative, with a one-time extension of an additional 30 days if necessary. If such an additional 30 days is needed, the covered entity must notify the patient in writing of the need for additional time

The National Correct Coding Initiative consists of: A. Automated edits to evaluate Medicare outpatient claim submissions for certain code combinations for services for the same beneficiary on the same date of service B. Manual edits to evaluate Medicare and Medicaid outpatient claim submissions for more than one service for the same beneficiary on the same date of service C. Rules for CPT and ICD coding for outpatient services D. Rules for HCPCS and ICD coding for outpatient services

A. Automated edits to evaluate Medicare outpatient claim submissions for certain code combinations for services for the same beneficiary on the same date of service

If you want to display the average length of stay by gender and service for the month of August, what graphic technique would you choose? A. Bar chart B. Histogram C. Line graph D. Table

A. Bar chart

One tool that a manager can use to evaluate productivity requirements is: A. Benchmarking surveys B. Budget analysis C. Salary surveys D. Satisfaction surveys

A. Benchmarking surveys

The HIM director has been asked to monitor the hospitalâ s â Do Not Useâ abbreviation policy for health record documentation. Which of the following monitoring actions would best ensure that a medication error would be caught before an adverse incident occurs? A. Concurrent monitoring by pharmacy staff for medication orders B. Retrospective assessment of all medication orders from the past month C. Instituting an educational program on the hospitalâ s policy D. Placement of policy notices at each nursing station

A. Concurrent monitoring by pharmacy staff for medication orders

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a: A. Concurrent review B. Peer review C. Prospective review D. Retrospective review

A. Concurrent review

HIPPA Security

HIPAA allows a covered entity to adopt security protection measures that are appropriate for its organization as long as they meet the minimum HIPAA security standards. Security protections in a large medical facility will be more complex than those implemented in a small group practice

A patient belonged to a managed care plan and had an elective surgery. Prior approval for the elective surgery had not been obtained. What should the patient expect? A. Denial of reimbursement for the surgery B. Delay in scheduling the postoperative visit C. Increase in the premium for the next enrollment period D. Reduction in future coverage of surgical services

A. Denial of reimbursement for the surgery

Your administrator has asked you to generate a report that gives the number of hypertension patients last year. This is an example of _____. A. Descriptive analytics B. Predictive analytics C. Prescriptive analytics D. Real-time analysis

A. Descriptive analytics

A patient requests that disclosures made from her health record are limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond? A. The hospital must accept the request but does not have to agree to it. B. The hospital must honor the request. C. The hospital must guarantee that the request will be followed. D. The hospital must agree to the request, providing that state or federal law does not prohibit it.

A. The hospital must accept the request but does not have to agree to it.

HIPAA Privacy rule in regards to charge a fee for copying of medical records.

Allow an individual to obtain copies of records for a fee that is reasonable enough that an individual could pay for it. The Privacy Rule requires that the copy fee for the individual be reasonable and cost based. It can only include the costs of labor for copying and postage, when mailed. The commentary to the Privacy Rule expands upon this standard. If paper copies are made, the fee can include the cost of the paper. If electronic copies are made, the fee can include copies of the media used

Can an individual revoke an authorization for release of information?

An individual may revoke an authorization at any time, provided that he or she does so in writing. However, the revocation does not apply when the covered entity has already taken action on the authorization

What are the two purposes of Healthcare data sets?

The first is to identify the data elements that should be collected for each patient. The second is to provide uniform definitions for common terms. The use of uniform definitions ensures that data collected from a variety of healthcare settings will share a standard definition. Standardizing data elements and definitions makes it possible to compare the data collected at different facilities

Querying

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

Calculating Case Mix Index using MS-DRGs

Average relative weight of all cases treated at a given facility or by a given physician, which reflects the resource intensity or clinical severity of a specific group. Add all relative weight and divide by number of cases. For example 33.446/30=1.115

If an HIM department receives gifts from vendors in exchange for purchasing specific encoder software, this is considered: A. Abuse B. A kickback C. Malpractice D. Negligence

B. A kickback

Which of the following is the best definition of a security vulnerability? A. Something that can exploit a security weakness B. A weakness or gap in security protection C. Lack of consistency in data D. Exposure to danger

B. A weakness or gap in security protection

Training programs on data security should be conducted at least: A. Semi-annually B. Annually C. Every two years D. Quarterly

B. Annually

William is the director of HIM at a large acute-care facility. He is concerned because the coders in his department never seem to be able to keep up with the number of discharges. The chief financial officer (CFO) is questioning the cost of hiring consultants to cover the backlog, because William is in danger of exceeding his consulting budget very soon. William is not sure whether he needs to hire another coder or work more closely with his existing coders to increase productivity. Which of the following activities will be most helpful for William to understand whether his coders are appropriately productive? A. Brainstorming B. Benchmarking C. Needs assessment D. Quality improvement

B. Benchmarking

Data-mining efforts of RAC contractors allow them to deny payments without ever reviewing a health record based on the information they gather without having access to the record. Which of the following would be an example of a potential denial based on information the RAC contractor would have without the health record? A. A coder assigning the wrong DRG for a patient B. Billing for two colonoscopies on the same day for the same Medicare beneficiary C. An inaccurate principal diagnosis D. A principal procedure code

B. Billing for two colonoscopies on the same day for the same Medicare beneficiary

In determining the data collection requirements for Medicare and Medicaid patients in a long-term care facility, the health information technician would consult standards from: A. CARF B. CMS C. The Joint Commission D. NCQA

B. CMS

When a physician is appointed to the medical staff of a healthcare organization, their scope of practice is determined by: A. Clinical knowledge B. Clinical privileges C. Credential D. Position on the staff

B. Clinical privileges

The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module, and release of information module with the electronic health record. This is an example of what data strategy method? A. Data standardization and integration B. Data ownership C. Data management D. Data stewardship

B. Data ownership

A ______ is an examination of health records to determine the level of coding accuracy and to identify areas of coding problems. A. Data quality improvement program B. Data quality review C. Payment error prevention program D. Process analysis

B. Data quality review

A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would be the best application to perform this function? A. Database B. Data warehouse C. Spreadsheet D. WAN

B. Data warehouse

Who is responsible for resolving failed edits?

Health Information Management

Policies and procedures regarding clinical documentation

In order to be both effective and efficient, each organization must be guided by policies and procedures that are created and specific to the organization.

Are Incident Reports part of the health record?

Incident reports themselves should not be considered a part of the health record. Because the staff member mentioned in the record that an incident report was completed, it will likely be discoverable as the health record is already a discoverable document

SWOT

The process to develop a strategic and operational plan begins with a SWOT (acronym for strengths, weaknesses, opportunities, and threats) analysis. In a SWOT analysis, key leadership personnel determine the strengths of the organization (what the company does well), the weaknesses (needs for improvement), and establishes future opportunities (and evaluates threats to those opportunities). The scenario not having coders being remote compared to another hospital that does have coders remote is an example of threat in the SWOT analysis

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. Developed in 1977 by CDC through its National Center for Injury Prevention and Control (NCIPC).

Appropriate sequence for Anemia admission for Malignancy

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

Is the health record considered primary data source?

Yes, because it contains data about a patient that has been documented by the professionals who provided care or services to that patient. Data taken from the primary health record and entered into registries and databases are considered a secondary data source

MPI

Master patient index

What can Individual audit results by coder be used for?

May identify that certain coders are ready to be cross trained in another category of coding. Regardless of the corrective actions taken, the results should become part of each employee's performance evaluation

Audit logs are a requirement by HIPPA Security rule which includes:

Often they record: time stamps that record access and use of the data elements and documents; what was viewed, created, updated, or deleted; the user's identification; the owner of the record; and the physical location on the network where the access occurred.

Accounting of PHI disclosures

PHI sent to a physician that has not treated the patient would need to be accounted for. Privacy Rule has a specific standard with respect to such record keeping. Disclosures for which an accounting is not required, and which are therefore exempt include some of the following examples: TPO disclosures, pursuant to an authorization, and to meet national security or intelligence requirements.

What is documented in the patients compete medical history?

Patient's current complaints and symptoms and lists his or her past health, personal, and family history. In acute care, the health history is usually the responsibility of the attending physician

The Medical Record Committee is assessing various strategies to improve documentation in the health record. Concerns have been raised that current documentation practices may be insufficient to support diagnoses or reflect the progress and clinical findings in patient care. Which of the following would be the best first step to help improve physician documentation? A. Contact CMS for assistance B. Determine the type and volume of documentation problems C. Change the medical staff bylaws to require improved documentation practice D. Implement a documentation score card for each medical specialty

B. Determine the type and volume of documentation problems

The HIM transcription supervisor has instituted a performance improvement program that includes the use of benchmarks. Benchmarks have been established for total lines per hour of production, and the program was instituted two weeks ago. What should the supervisor do to determine if the benchmark is being met? A. Ask transcriptionists for their feedback on the benchmarks B. Prepare a report of the number and type of reports transcribed C. Compare individual transcriptionist line production per hour to the benchmark D. Measure the number of reports transcribed by each transcriptionist to the benchmark

C. Compare individual transcriptionist line production per hour to the benchmark

Which of the following CPT coding guidelines is true when a reduction of a fracture is performed with cast application? A. Use the terminology â manipulationâ rather than â reductionâ B. Include internal fixation in all codes C. Do not code the application of a cast separately D. Do not differentiate between open and closed treatmentâ "CPT only specifies the site of the fracture

C. Do not code the application of a cast separately

Which of the following entities owns the physical hospital health record? A. Attending physician B. Health information management department C. Hospital that maintains the record D. Patient

C. Hospital that maintains the record

A physician does not agree with the number of patients attributed to her for recredentialing purposes. Of the following, which report will be most useful in validating the data? A. Discharge Register B. Disease Index C. Physician Index D. Procedure Index

C. Physician Index

A coding supervisor wants to compare the work productivity between coders over time as part of the overall hospital performance improvement program. The coding supervisor has compared each coderâ s productivity by counting the number of records each coder has coded during the past month. Which of the following would best describe the process followed by the coding supervisor? A. The process provides an adequate measure of each coderâ s performance. B. The process would be improved by measuring coder productivity per hour. C. The process would be improved by calculating averages rather than comparing record counts. D. The process is inadequate because it does not look at external benchmarks.

B. The process would be improved by measuring coder productivity per hour.

If a healthcare provider is accused of breaching the privacy and confidentiality of a patient what resource may a patient rely on to substantiate the providerâ s responsibility for keeping health information private? A. Federal Code of Fair Practice and Ethics B. Federal Code of Silence C. Professional Code of Ethics D. State Code of Fair Practice

C. Professional Code of Ethics

The process in which a healthcare organization addresses the provider documentation issues that are conflicting, ambiguous, or incomplete is called: A. Casefinding B. Coding C. Querying D. Releasing information

C. Querying

Comparing Benchmarking

Comparing an organization's performance to the performance of other organizations that provide the same types of services is known as external benchmarking. The other organizations need not be in the same region of the country, but they should be comparable organizations in terms of patient mix and size

Risk determination

Considers how likely is it that a particular threat will actually occur and, if it does occur, how great its impact or severity will be. Risk determination quantifies an organization's threats and enables it to both prioritize its risks and appropriately allocate its limited resources (namely, people, time, and money) accordingly

Derived data

Consist of factual details aggregated or summarized from a group of health records that provide no means of identifying specific patients. These data should have the same level of confidentiality as the legal health record

aggregate data

Data extracted from individual health records and combined to form de-identified information about groups of patients that can be compared and analyzed

When does a healthcare provider required to provide the patient with notice of privacy practices?

A healthcare provider has to provide the notice no later than the first service delivery. After that first provision of service, there is no requirement to provide a notice every time a patient receives service

Patients options for Patient Directory

A patient has the opportunity to agree or disagree with being placed in a patient directory. They must be given the opportunity to determine if they want to be placed in the directory or not, but it does not need to be in writing

Patient history questionnaires, problem lists, diagnostic test results, and immunization records are commonly found in which type of record? A. Ambulatory record B. Emergency department record C. Long-term care record D. Rehabilitative care record

A. Ambulatory record

Procedures should be complete enough so that: A. Anyone generally competent can perform the task B. There is never a need to improve the process C. There is no need to train a new employee D. There is no need for policies

A. Anyone generally competent can perform the task

What are Risk management systems?

Sophisticated programs that function to identify, reduce, or eliminate potentially compensable events (PCEs), thereby decreasing the financial liability of injuries or accidents to patients, staff, or visitors

What is HEDIS: Healthcare Effectiveness Data and Information Set?

Sponsored by the National Committee for Quality Assurance (NCQA). HEDIS is a set of standard performance measures designed to provide healthcare purchasers and consumers with the information they need to compare the performance of healthcare plans

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

A. Assisting researchers in determining effectiveness of treatments

At Wildcat Hospital, charts are scanned at the time of discharge. The record is then stored for six months before being destroyed. Which of the following statements is true? A. The scanned record is the legal record effective from the moment of scanning. B. The scanned record becomes the legal record as soon as the original chart is destroyed. C. The scanned record can never be the legal record so we should not destroy the paper record. D. The paper health record must be retained for the statute of limitations.

B. The scanned record becomes the legal record as soon as the original chart is destroyed.

The HIPAA-recognized consent is a patients agreement to: A. A specific disclosure B. Use or disclosure of PHI for treatment, payment, or operations C. Treatment D. Disclosure for fundraising purposes

B. Use or disclosure of PHI for treatment, payment, or operations

A small counseling center received notification that a laptop that contained PHI was stolen out of a workforce memberâ s car. Upon investigation, it was determined that information on the workforce memberâ s laptop contained information on approximately 980 individuals. The laptop that was stolen was password protected; however, it did not contain any encryption software. While no reports of identity theft have been reported, it is unknown what has been done with the laptop or the information on the laptop. How long does this counseling center have to notify these patients of this breach? A. Immediately B. Within 60 days of the discovery C. Within 90 days of the discovery D. No notification is needed

B. Within 60 days of the discovery

Legal health record

a defined subset of all patient-specific data that will be disclosed upon request by third parties. It includes documentation about health services provided and stored on any media

Computer based training

a form of self-directed learning, an approach that allows learners to control their own education at their own pace

The national Health Information Network

a group of federal agencies and no-federal organizations that came together under a common mission and purpose to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange

z-score

a measure of how many standard deviations you are away from the norm (average or mean)

Comorbidity

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

What is a Needs analysis?

a procedure performed by collecting and analyzing data to determine what is required, lacking, or desired by an employee, group, or organization. It is a process for determining how to close a learning or performance gap as it relates to jobs performed in a particular department

What is Data governance framework

a real or conceptual structure that organizes a system or concept. A framework typically describes and shows the synergy and interrelation among different part of an approach

How are errors corrected in the paper health record?

a single line should be drawn in ink through the incorrect entry. The word error should be printed at the top of the entry along with a legal signature or initials, date, time, and discipline of the person making the change.

What is a kiosk?

a special form of input device geared to people less familiar with computers that is located in a provider's waiting room allowing patients to have access to some of their health information and other services

What is a policy?

a statement that describes general guidelines that direct behavior or direct and constrain decision making in the organization

Under outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20 percent) or a fixed copayment amount, whichever is less. Mr. Smith had a minor procedure performed in the hospital outpatient department at a charge of $85. In addition, Mr. Smith has paid his deductible for the year. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case? a. $15 b. $17 c. $68 d. $85

a. $15

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

The use of the health record by a clinician to facilitate quality patient care is considered: a. A primary purpose of the health record b. Patient care support c. A secondary purpose of the health record d. Patient care effectiveness

a. A primary purpose of the health record

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

a. A third-party payer

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

Which of the following is a good question for a supervisor of coding to ask when evaluating potential fraud or abuse risk areas in the coding area? a. Are the assigned codes supported by the health record documentation? b. Does the hospital have a compliance plan? c. How many claims have not been coded? d. Which members of the medical staff have the most admissions to the hospital?

a. Are the assigned codes supported by the health record documentation?

Which of the following are clear guidelines for the acceptable values of specific data fields and makes it possible to exchange health information using electronic networks? What type of standards provide clear descriptors of data elements to be included in an electronic health record system? a. Data content standard b. Messaging standards c. Interoperability standards d. Vocabulary standards

a. Data content standard

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

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

Which of the following statements about the directory of patients maintained by a covered entity is true? a. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory. b. Individuals must provide a written authorization before information about them can be placed in the directory. c. The directory may contain only identifying information such as the patient's name and birth date. d. The directory may contain private information as long as it is kept confidential.

a. Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory.

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

The present on admission indicator is a requirement for: a. Inpatient Medicare claims submitted by hospitals b. Inpatient Medicare and Medicaid claims submitted by hospitals c. Medicare claims submitted by all entities d. Inpatient skilled nursing facility Medicare claims

a. Inpatient Medicare claims submitted by hospitals

Which unit of measure is used to indicate the services received by one inpatient in a 24-hour period? a. Inpatient service day b. Volume of services c. Average occupancy charges d. Length of services provided

a. Inpatient service day

. 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

Which of the following is the first step in analyzing data? a. Knowing your objectives or purpose of the data analysis b. Starting with basic types of data analysis and work up to more sophisticated analysis c. Utilizing a statistician to analyze the data d. Presenting your findings to administration

a. Knowing your objectives or purpose of the data analysis

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

Risk determination considers the factors of: a. Likelihood and impact b. Risk prioritization and control recommendations c. Risk prioritization and impact d. Likelihood and control recommendations

a. Likelihood and impact

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

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

In healthcare, data sets serve two purposes. The first is to identify data elements to be collected about each patient. The second is to: a. Provide uniform data definitions b. Guide efforts toward computerization c. Determine statistical formulas d. Provide a research database

a. Provide uniform data definitions

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

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

Vocabulary standards

are a list or collection of clinical words or phrases with their meanings; also, the set of words used by an individual or group within a particular subject field, such as to provide consistent descriptions of medical terms for an individual's condition in the health record

Embedded metadata

are most often associated with automated records of operations (such as audit trails) and are stored with the date themselves. If data move from a source system to another system, then the system can attach metadata that identify where the data originated. In this way, metadata helps track data movement from one system to another

Primary purposes of the health record

are related to providing care to the patient. Patient care includes the direct care provided and the day-to-day business of the organization

An audit of a hospital's electronic health system shows that diagnostic codes are not being reported at the correct level of detail. This indicates a problem with data: a. Consistency b. Granularity c. Comprehensiveness d. Relevancy

b. Granularity

When meeting with the HIM professional during an on-site review, the surveyor would be looking for what type of information? a. Written policies and procedures on document imaging b. HIM department's success in documentation compliance c. Document type matrix d. Attendance policy

b. HIM department's success in documentation compliance

A new health information management (HIM) director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? a. Call the EHR vendor and ask to review the system's data dictionary b. Identify data content requirements for all areas of the organization c. Schedule a meeting with all department directors to get their input d. Contact CMS to determine what data sets are required to be collected

b. Identify data content requirements for all areas of the organization

Which of the following would generally be found in a query to a physician? a. Health record number and demographic information b. Name and contact number of the individual initiating the query and account number c. Date query initiated and date query must be completed d. Demographic information and name and contact number of the individual initiating the query

b. Name and contact number of the individual initiating the query and account number

Mrs. Bolton is an angry patient who resents her physicians "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is: a. Mean b. Noncompliant and hostile toward staff c. Belligerent and out of line d. A pain in the neck

b. Noncompliant and hostile toward staff

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

. 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

b. OIG Workplan

To ensure relevancy, an organization's security policies and procedures should be reviewed at least: a. Once every six months b. Once a year c. Every two years d. Every five years

b. Once a year

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

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

b. Overlay

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

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

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.

Which of the following is a true statement about the content of the legal health record? a. The legal health record contains only clinical data b. The legal health record may contain metadata c. The legal health record should not include e-mail d. The legal health record should not include diagnostic images

b. The legal health record may contain metadata

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.

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.

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

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

How to calculate 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 and divide by the number of patients. (for a total of 54 days) and divide by 9 patients = 6 days

Waste

is the overutilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act. Waste includes practice like over prescribing and ordering tests inappropriately

Sampling Techniques

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

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

Licensure

is the state's act of granting a healthcare organization or individual practitioner the right to provide healthcare services of a defined scope in a limited geographic area. It is illegal in all 50 states to operate healthcare facilities and practice medicine without a license

Quantitative analysis

is used by health information management professionals as a method to detect whether elements of the patient's health record are missing, or not complete

The Joint Commission requires healthcare organizations to collect data on each of these areas

medication management, blood and blood product use, restraint and seclusion use, behavior management and treatment, operative and other invasive procedures, and resuscitation and its outcomes

How does a CDI program help coding staff?

provides a mechanism for the coding staff to communicate with the physician regarding nonspecific diagnostic statements or when additional diagnoses are suspected but not clearly stated in the record, which helps to avoid assumption coding

Data granularity

requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data

Safe harbor method of deidentification

requires the removal of 18 specific identifiers from the protect health information

The basic functions of healthcare risk management programs are similar for most organizations and include

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

Extirpation

taking or cutting out solid material from a body part.

In cases of a cesarean delivery, the selection of the principal diagnosis should be?

the condition established after study that was responsible for the patient's admission. If the patient was admitted with a condition that resulted in the performance of the cesarean procedure, that condition should be selected as the principal diagnosis. If the reason for the admission or encounter was unrelated to the condition resulting in the cesarean delivery, the condition related to the reason for the admission or encounter should be selected as the principal diagnosis even if a cesarean was performed

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

Before healthcare organizations can provide services, they usually must obtain this from government entities such as the state or county in which they are located. a. Accreditation b. Certification c. Licensure d. Permission

c. Licensure

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

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

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

George reviewed the patient record of Mr. Brown and found there was no H&P on the record at seven hours past this patient's admission time. This review process would be an example of: a. Data mining b. Qualitative analysis c. Quantitative analysis d. Data warehousing

c. Quantitative analysis Quantitative analysis is used by health information management technicians as a method to detect whether elements of the patient's health record are missing

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

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

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

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

Which of the following types of information include areas like genetics, adoption, and drug use that require special attention? a. Special information b. Scientific information c. Sensitive information d. Super information

c. Sensitive information

From an evidentiary standpoint, incident reports: a. Are universally nonadmissible during trial proceedings b. May be referenced in the patient's health record c. Should not be placed in a patient's health record d. Are universally nondiscoverable during litigation

c. Should not be placed in a patient's health record

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

The HIPAA Privacy Rule concept of "minimum necessary for treatment purposes.

concept of "minimum necessary" does not apply to disclosures made for treatment purposes. However, the covered entity must define, within the organization, what information physicians need as part of their treatment role

Workforce members

consists not only of employees but also volunteers, student interns, and trainees. Workforce members are not limited to those who receive wages from the CE

Healthcare Cost and Utilization Project (HCUP)

consists of a set of databases that are unique because they include data on inpatients whose care is paid for by all types of payers, including Medicare, Medicaid, private insurance, self-paying, and uninsured patients. Data elements include demographic information, information on diagnoses and procedures, admission and discharge status, payment sources, total charges, length of stay, and information on the hospital or freestanding ambulatory surgery center

primary data

consumer's health record is a primary type of data source. contain information specifically entered into the medical record by the healthcare professional providing the care or services; this could be a physician, nurse, technician, or others.

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

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 day 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

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

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

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

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which is the longest timeframe the hospital can take to remain in compliance with HIPAA regulations? a. Provide copies of the records within 15 days b. Provide copies of the records within 30 days c. Provide copies of the records within 45 days d. Provide copies of the records within 60 days

d. Provide copies of the records within 60 days

A celebrity injured while on vacation was admitted to the local community hospital for treatment of a fracture. On day two of the admission, the hospital was contacted by several media agencies stating that they were aware the patient was at the facility and requesting information about the current medical condition of this high profile celebrity patient. The CEO is concerned that an employee has shared information to the media regarding this patient. The facility privacy officer was tasked with determining if a facility employee leaked this information to the press. How would the privacy officer begin this analysis? a. Create a new policy about high-profile patient privacy b. Start by discussing the situation with the media to resolve their inquiries c. Contact employees in the facility d. Review audit trail information to determine which employees have accessed this patient's information

d. Review audit trail information to determine which employees have accessed this patient's information

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

Which of the following has been responsible for accrediting healthcare organizations since the mid-1950s and determines whether the organization is continually monitoring and improving the quality of care provided? a. Commission on Accreditation of Rehabilitation Facilities b. American Osteopathic Association c. National Committee for Quality Assurance d. The Joint Commission

d. The Joint Commission

One element of Helen's SWOT analysis mentions the hospital across town recently sent all their coders home to work remotely. Currently, all coding done at Helen's hospital is done in-house. In a SWOT analysis, remote coding done by the other hospital would be a(n): a. Strength b. Weakness c. Opportunity d. Threat

d. Threat

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

The HIM supervisor has set a key performance standard for the release of information (ROI) staff related to the time between receipt of a request and when the request is sent to the requestor. This standard is considered the ROI: a. Control workflow b. Overlap c. Duplicate rate d. Turnaround time

d. Turnaround time

What are policies?

the principles describing how a department or an organization will handle a specific situation or execute a specific process. They are clear, simple statements of how an HIM department will conduct its services, actions, or business; and a set of guidelines and steps to help with decision making

Backscanning

the process of scanning past medical records into the document management system (DMS) so that there is an existing database of patient information, making the document management system valuable to the user from the first day of implementation

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

d. UHDDS (Uniform Hospital Discharge Data Set)

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

Which of the following is true about a primary key in a database table? a. Usually is not a unique number b. Changes in value c. Is dependent on the data in the table d. Uniquely identifies each row in a table

d. Uniquely identifies each row in a table

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

When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following? a. Performance measurement b. Workforce planning c. Work observation study d. Variance analysis

d. Variance analysis

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

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

Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n): a. Business associate b. Covered entity c. Employee d. Workforce member

d. Workforce member Covered entities (CEs) are responsible for their workforce, which consists not only of employees but also volunteers, student interns, and trainees. Workforce members are not limited to those who receive wages from the CE

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

GPCI

geographic practice cost indices

What is Sensitive health information

health information such as genetic, adoptive, drug, alcohol, sexual health, and behavioral information. This type of information not only has strict rules and regulations, but also providers an ethical gray area when it comes to releasing and providing records

What is included in the National Patient Safety Goals?

identifying patients correctly, improving staff communication, using medicines safely, preventing infection, checking patient medicines, preventing patients from falling, preventing bed sores, and identifying patient safety risks

Sentinel event

includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response. Examples of sentinel events include infant abduction from the nursery or a foreign body left in a patient from surgery

Predictive modeling

is a process used in predictive analysis to identify patterns that can be used to determine the odds of a particular outcome based on the observed data. That is, statistics from the past are reviewed to determine what is likely to happen in the future. Used by many companies that want to predict future trends

Business records exception

the rule under which a record is determined not to be hearsay if it was made at or near the time by, or from information transmitted by, a person with knowledge; it was kept in the course of a regularly conducted business activity; and it was the regular practice of that business activity to make the record

Parallel work division

the same tasks are handled simultaneously by several workers; each completes all steps in the process from beginning to end, working independently of the other employees

no correlation

there does not appear to be a relationship between two sets of data

What is the first step in benchmarking?

to determine the performance measure to be studied and what is to be accomplished. Once a benchmark for a performance measure is determined, analyzing data collection results becomes more meaningful

What is a check sheet used for?

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?

Compliance Education

In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff

Which of the following is a documentation issue? A. Copy and paste functionality B. Key indicator C. Query D. Case mix index

A. Copy and paste functionality

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

A. Duplicate health record numbers

The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term? A. Focused reviews on lower weighted MS-DRGs from triples and pairs B. Facility top 10 to 15 APCs by volume and charges C. Contracting with a larger consulting firm to do audits and education D. Focused reviews on surgical complications

A. Focused reviews on lower weighted MS-DRGs from triples and pairs

The purpose of the POA indicator is to identify: A. Hospital-acquired conditions B. Medical fraud and abuse C. Hospital claim denials D. DRG creep

A. Hospital-acquired conditions

The HIM professional is arguing against the use of the copy/paste function in the EHR. Which of the following would be the position for this argument? A. I am unable to identify the author. B. I am unable to print the data out. C. I am concerned about the time that it takes to copy/paste the documentation. D. I am concerned that the users will not know how to perform the copy/paste function.

A. I am unable to identify the author.

Which of the following electronic record technological capabilities would allow paper-based health records to be incorporated into a patientâ s EHR? A. Database management B. Documentation-imaging technology C. Text processing D. Vocabulary standards

B. Documentation-imaging technology

Which of the following would be used to encode textual material and convert it to scrambled data that must be decoded in order for the recipient to understand it? A. Encoding B. Encryption C. Firewall D. Virtual private network

B. Encryption

A visitor walks through the IT department and picks up a flash drive from an employeeâ s desk. What security controls should have been implemented to prevent this security breach? A. Device and media controls B. Facility access controls C. Workstation use controls D. Workstation security controls

B. Facility access controls

In performing quantitative analysis of an emergency room health record, which of the following data elements would the health information technician look for to be present in the record? A. Advance directive, correspondence, anesthesia report B. Patient identification, time and means of patient arrival, pertinent history of illness C. Consent for treatment, advance directive, consent to disclose information D. Results of tests, consent for treatment, anesthesia report

B. Patient identification, time and means of patient arrival, pertinent history of illness

Why is only the most current version of a document displayed? A. All previous versions are deleted B. To ensure there is no confusion on the correct document C. Only the physician has access to previous versions of a document D. The user decides which version to see

B. To ensure there is no confusion on the correct document

Safeguards established to support the data being available when and where is it needed under the data quality model is called: A. Approachability B. Timeliness C. Accessibility D. Relevancy

C. Accessibility

Reviewing a health record for missing signatures and medical reports is called: A. Assembly B. Indexing C. Analysis D. Coding

C. Analysis

The performance appraisal method that links specific job-related performance to each rating level is the: A. Graphic rating scale B. Critical incident method C. Behaviorally-anchored rating scale D. Ranking method

C. Behaviorally-anchored rating scale

When a healthcare organization evaluates the Joint Commission core measure data with a similar organization, they are using: A. Data repository B. Information warehouse C. Comparative performance data D. PI database

C. Comparative performance data

This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation. A. Data reliability B. Data accuracy C. Data integrity D. Data completeness

C. Data integrity

Analysis of data to find trends and patterns is called: A. Data warehousing B. Data governance C. Data mining D. Data transfer

C. Data mining

A health record technician is preparing a bill for a patient who has two different third-party payers. Verification of the payers has been performed. Before either of the payers can be billed, the health record technician has to: A. Contact the attending physician B. Contact the patient C. Determine which policy is primary and which is secondary D. Determine who is the primary policy holder

C. Determine which policy is primary and which is secondary

The medical staff at University Medical Center is nationally renowned for its skill in performing cardiac procedures. The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: A. Nursing staff B. Admissions department C. Physician D. Administration

C. Physician

Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patientâ s health record that is positive for staph infection; however, there is no mention of staph in the physicianâ 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

Which of the following would not be considered a HIPAA data breach? A. The use of a patients name and social security number by an employee to get a credit card B. Lost laptop that contains patient names, addresses, and ICD codes C. Release of employee salary data D. Unauthorized use of PHI by a hospital employee

C. Release of employee salary data

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

negative correlation

as one variable increases, the other decreases

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

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

The National Patient Safety Goals (NPSGs) have effectively mandated all healthcare organizations to examine care processes that have a potential for error that can cause injury to patients. Which of the following processes are included in the NPSGs? a. Identify patients correctly, prevent infection, and file claims for reimbursement b. Check patient medicines, prevent infection, and identify patients correctly c. File claims for reimbursement, check patient medicines, and improve staff communication d. Improve staff communication, process claims timely, and prevent infection

b. Check patient medicines, prevent infection, and identify patients correctly

The clinical documentation improvement (CDI) program must keep high-quality records of the query process for: a. Revenue cycle analysis b. Compliance issues c. Chart deficiency tracking d. Reducing the workload on HIM

b. Compliance issues

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

What is the legal term used to define the protection of health information in a patient-provider relationship? a. Access b. Confidentiality c. Privacy d. Security

b. Confidentiality

Which of the following is an organization's planned response to protect its information in the case of a natural disaster? a. Administrative controls b. Contingency plan c. Audit trail d. Physical controls

b. Contingency plan

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

Keith is the supervisor of the MPI and chart deficiency review staff in the HIM department, which also included being the liaison for the billing department and the R-ADT staff. He frequently meets with Michael, the R-ADT supervisor, to discuss methods to combat healthcare fraud and the process of verifying that the patients are truly who they say they are and that these patients have the appropriate documentation for verification. This process is called: a. Consent management b. Identity management c. Identity matching d. Patient identification

b. Identity management

Which of the following are data that have been filtered and put into context? a. Data b. Information c. Knowledge d. System

b. Information

Which of the following statements is true regarding HIPAA security? a. All institutions must implement the same security measures. b. Institutions are allowed flexibility in the way they implement HIPAA standards. c. All institutions must implement all HIPAA specifications. d. A security risk assessment must be performed every year.

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

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

b. Integrity

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record? a. Autopsy report b. Laboratory findings c. Pathology report d. Surgical report

b. Laboratory findings

Which term is used to describe the number of calendar days that a patient is hospitalized? a. Average length of stay b. Length of stay c. Occupancy rate d. Level of service

b. Length of stay

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

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

Which of the following represents documentation of the patient's current and past health status? a. Physical exam b. Medical history c. Physician orders d. Patient consent

b. Medical history

A managed care organization is using a system that examines the past healthcare behaviors of their patients to determine their future costs for their healthcare. This is an example of ________. a. Descriptive analytics b. Predictive modeling c. Prescriptive analytics d. Real-time analysis

b. Predictive modeling

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

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

Is Retrospective documentation considered unethical?

Yes, 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

Run chart

displays data points over a period of time to provide information about performance. The measured points of a process are plotted on a graph at regular time intervals to help team members see whether there are substantial changes in the numbers over time

The Joint commission

has been the most visible organization responsible for accrediting healthcare organizations since the mid-1950s. The primary focus of the Joint Commission at this time is to determine whether organizations seeking accreditation are continually monitoring the quality of the care they provide. The Joint Commission requires that this continual improvement process be in place throughout the entire organization, from the governing body down, as well as across all department lines

Performance measurement

in healthcare provides an indication of an organization's performance in relation to a specified process or outcome. Healthcare performance improvement philosophies most often focus on measuring performance in the areas of systems, processes, and outcomes. Outcomes should be scrutinized whether they are positive and appropriate or negative and diminishing

subpoena duces tecum

instructs the recipient to bring documents and other records with himself or herself to a deposition or to court

Accession number

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

Data mapping

is a process that allows for connections between two systems. For example, mapping two different coding systems to show the equivalent codes allows for data initially captured for one purpose to be translated and used for another purpose

Focused audit

Focused selections of coded accounts are necessary for deeper understanding of patterns of error or change in high-risk areas or other areas of specific concern, such as a focused audit of cases with no CC/MCC to determine why the case-mix is dropped

What should a query format include?

A query generally includes the following information: patient name, admission date or date of service, health record number, account number, date query initiated, name and contact information of the individual initiating the query, and statement of the issue in the form of a question along with clinical indicators specified from the chart (for example, history and physical states urosepsis, lab reports WBC of 14,400, emergency department report fever of 102°F)

What tool must be used by Medicare-Certified home health providers?

A standardized patient assessment instrument called the Outcomes and Assessment Information Set (OASIS-C). OASIS-C items are components of the comprehensive assessment that is the foundation for the plan of care

Inpatient service day (IPSD)

A unit of measure that reflects the services received by one inpatient during a 24-hour period. The number of inpatient service days for a 24-hour period is equal to the daily inpatient census, that is, one service day for each patient treated

Last year, your community experienced 4 deaths due to the Zika virus. There were 130,968 people in your community. What is the cause-specific mortality rate? A. 3.05 per 100,000 population B. 4.00 per 100,000 population C. 6.10 per 100,000 population D. 30.05 per 100,000 population

A. 3.05 per 100,000 population

Statistics on the average length of stay (ALOS) for patients discharged within a particular diagnosis-related group (DRG) would be considered which of the following type of data? A. Aggregate B. Continuous C. Index D. Accession

A. Aggregate

Healthcare facilities must have processes in place to maintain and correct the master patient index (MPI) against the quality issues of duplicates, overlays, and overlaps on a continuous basis. Which of the following is used to match patients so that patient information can be merged? A. Algorithm B. Outguide C. Encoder D. Audit trail

A. Algorithm

A patient was admitted with an acute non-ST anterior wall myocardial infarction and atrial fibrillation and discharged to home three days later. This same patient presented to the emergency department two weeks later and was diagnosed with an acute inferior wall myocardial infarction. The patient is still being monitored following an MI two weeks earlier. What codes are assigned for this patient? I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I21.4 Non-ST elevation (NSTEMI) myocardial infarction I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall I25.2 Old myocardial infarction A. I22.1, I21.4 B. I21.19, I25.2 C. I21.19, I21.4 D. I22.1

A. I22.1, I21.4

A patient is discharged with right sided hemiplegia and aphasia associated with an infarction of the middle cerebral artery of the left side of the brain. Which of the following code assignments would be appropriate for this case? G81.91 Hemiplegia, unspecified affecting right dominant side G81.93 Hemiplegia, unspecified affecting right nondominant side I63.512 Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery I69.951 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side I69.953 Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right nondominant side I69.920 Aphasia following unspecified cerebrovascular disease R47.01 Aphasia A. I63.512, G81.91, R47.01 B. I69.951, I69.920 C. I69.953, I69.920 D. I63.512, G81.93, R47.01

A. I63.512, G81.91, R47.01

Which of the following is true about the Joint Commissions Do Not Use abbreviation list? A. It applies to orders and medication-related documentation B. It applies to only medication-related orders C. It applies to all documentation in the health record D. It applies to only preprinted forms

A. It applies to orders and medication-related documentation

Which of the following is a key feature of a problem-oriented health record? A. Itemized list of patients present and past conditions B. Itemized list of patients present conditions C. Sequential list of patients confirmed diagnoses D. Chronological list of solved problems

A. Itemized list of patients present and past conditions

To stay current with new technologies and pioneering procedures, CPT is revised each year, with changes going into effect the following: A. January 1st B. April 1st C. July 1st D. October 1st

A. January 1st

Where would you expect to find the following documentation in the health record: BUN 14, Creatinine 0.9, H&H 8.8 and 25.4?â A. Laboratory report B. Pathology report C. Physical exam D. Physician order

A. Laboratory report

A hospital interested in finding out if a physician has any adverse licensure actions should review data from: A. NPDB B. OASIS-C C. ORYX D. UHDDS

A. NPDB (National Practitioner Data Bank)

The Health Insurance Portability and Accountability Act (HIPAA): A. Provides a federal floor for healthcare privacy B. Preempts all state laws C. Applies to anyone who collects health information D. Duplicates the Joint Commission standards

A. Provides a federal floor for healthcare privacy

A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which approach would be the best for conducting a retrospective analysis to determine if hospital copy policies are being followed? A. Randomly audit EHR documentation for patients readmitted within 30 days B. Survey practitioners to determine if they are following hospital policy C. Institute an in-service program for all hospital personnel D. Observe the documentation practices of all clinical personnel

A. Randomly audit EHR documentation for patients readmitted within 30 days

What term would be applied to a comparison of the number of female patients to the number of male patients who were discharged from DRG 326? A. Ratio B. Percentage C. Proportion D. Rate

A. Ratio

A healthcare organization received notification that a hospital employeeâ s laptop that contained PHI was inadvertently left at a local restaurant and was stolen. The laptop was password protected; however, it did not contain any encryption software. While no reports of identity theft have been reported, it is unknown what has been done with the laptop or the information on the laptop. Which of the following could the organization do to prevent this from happening in the future? A. Refine organizational procedures to require encryption software on all laptops containing PHI B. Refine organizational procedures to not allow any laptops to contain PHI C. Refine organizational procedures to prevent the use of any laptops D. Refine organizational procedures to require patients to sign a waiver to allow their PHI to be loaded on a laptop

A. Refine organizational procedures to require encryption software on all laptops containing PHI

When coding a health record that contains the final diagnosis as pneumonia, what documentation should the coder look for to support the diagnosis? A. Results from progress notes and sputum culture B. Results from electrocardiogram C. Results from MRI D. Results from EEG

A. Results from progress notes and sputum culture

A high-profile patient was admitted to community hospital. On day two of the admission, the hospital was contacted regarding a news story about the medical condition this high profile patient was being treated for. The facility privacy officer was tasked with determining if a facility employee leaked this information to the press. How would the privacy officer begin this analysis? A. Review audit trail information to determine which employees have accessed this patients information B. Interview all employees who have had contact with this patient C. Discuss the situation with the local paper D. Create a new policy about high-profile patient privacy

A. Review audit trail information to determine which employees have accessed this patients information

The Medicare outpatient code editor (OCE) should be installed on a healthcare facilityâ s computer system to perform which of the following functions? A. Review claims for errors prior to releasing information to the Medicare program B. Post charges C. Identify items that are reimbursed on a fee schedule D. Track changes made to the CDM over time

A. Review claims for errors prior to releasing information to the Medicare program

The outpatient clinic of a large hospital is reviewing its patient sign-in procedures. The registration clerks say it is essential that they know if the patient has health insurance and the reason for the patientâ s visit. The clerks maintain having this information on a sign-in sheet will make their jobs more efficient and reduce patient waiting time in the waiting room. What should the HIM director advise in this case? A. To be HIPAA compliant, sign-in sheets should contain the minimum information necessary such as patient name only. B. Patient name, insurance status, and diagnoses are permitted by HIPAA. C. Patient name, insurance status, and the reason for the visit would be considered incidental disclosures if another patient saw this information. D. Any communication overheard by another patient is considered an incidental disclosure.

A. To be HIPAA compliant, sign-in sheets should contain the minimum information necessary such as patient name only.

Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support the quality of care, data, and HIM coding accuracy. Which of the following would be the best approach to justify the funding and continuation of a CDI program? A. Tracking, measuring, and reporting the impact of the CDI program B. A statement and endorsement from the hospital CEO C. A statement of need by the HIM director D. Opinions by surveying the medical staff

A. Tracking, measuring, and reporting the impact of the CDI program

This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry. A. Unstructured data B. Structured data C. Formatted data D. Unformatted data

A. Unstructured data

This type of healthcare organization review is conducted at the request of the healthcare facility seeking accreditation. A. Voluntary review B. Complimentary review C. Vocational review D. Compulsory review

A. Voluntary review

Code T

APC payment is subject to payment reduction when multiple procedures are performed during the same visit. IF there were no additional procedures the status indicator does not affect payment

Coding for AIDS acquired immunodeficiency syndrome (HIV)

According to coding guideline I.C.1.a.2)(a), when a patient is treated for a complication associated with HIV infection, the B20 code is assigned as the principal diagnosis, followed by the code for the complication. Patients who are admitted for an HIV-related illness should be assigned a minimum of two codes in the following order: B20 to identify the HIV disease and additional codes to identify other diagnoses

The HIM professional was asked by her facility administration to assess the impact of the proposed rule changes for the next fiscal year to the organizationâ s Medicare reimbursement. What should the HIM professional reference to assess any changes to the relative weights for the new fiscal year? A. AHA Coding Clinic B. Federal Register C. AMAs CPT Assistant D. Federal Code of Regulations

B. Federal Register

Which of the following actions by a physician requires the patients authorization? A. Giving a patient a pen with the name of a pharmaceutical product on it B. Giving the name of an expectant mother to a baby formula manufacturer C. Giving a sample product to a patient to use for a diagnosed condition D. Recommending acupuncture as an alternative treatment for a patientâ s condition

B. Giving the name of an expectant mother to a baby formula manufacturer

The paper health record has been scanned and is now available digitally. What is this known as? A. It is still known as the paper record since it was originally paper. B. It is known as imaging. C. It is known as the EHR. D. It is known as the problem-oriented health record.

B. It is known as imaging.

Shirley Denton has written to request an amendment to her PHI from Bon Voyage Hospital, stating that incorrect information is present on the document in question. The document is an incident report from Bon Voyage Hospital, which was erroneously placed in Ms. Dentonâ s health record. The covered entity declines to grant her request based on which privacy rule provision? A. It was not created by the covered entity. B. It is not part of the designated record set. C. It is her PHI and she can remove it from the record. D. None. The covered entity must grant her request.

B. It is not part of the designated record set.

The hospitals public relations department in conjunction with the local high school is holding a job-shadowing day. The purpose of this event is to give high school seniors an opportunity to observe the various jobs in the hospital and help them with career planning. The public relations department asks for event input from the standpoint of HIPAA compliance. In this case, what should the HIM department advise? A. Job shadowing is allowed by HIPAA under the provision allowing students and trainees to practice. B. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is very limited, such as administrative areas. C. Job shadowing is allowed by HIPAA under the provision of volunteers. D. Job shadowing is specifically prohibited by HIPAA.

B. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is very limited, such as administrative areas.

Which database must a healthcare facility query as part of the credentialing process when a physician initially applies for medical staff privileges? A. UHDDS B. NPDB C. MEDPAR D. HEDIS

B. NPDB National Practitioner Data Bank

When coding, what is the best source of documentation to determine the size of a removed malignant lesion? A. Laboratory report B. Operative report C. Pathology report D. Physical examination

B. Operative report

_______ seeks the most accurate documentation, coded data, and resulting payment in the amount the provider is rightly and legally entitled to receive. A. Unbundling B. Optimization C. Maximization D. Upcoding

B. Optimization

An internal coding audit at Community Hospital shows that the cause of improper coding is lack of proper physician documentation to support reimbursement at the appropriate level. Coders have found that coding issues are a result of physician documentation needing clarification. The HIM department staff has met periodically with each clinical specialty to improve communication and provide targeted education, but documentation problems still persist. Which of the following actions would be the most reliable and consistent method to improve communication and documentation? A. Revise medical staff bylaws to include documentation requirements B. Suspend medical staff privileges after a specified number of documentation problems have occurred C. Implement a standardized physician query form so that coders can request clarification from physicians about documentation issues D. Allow coders to make clinical judgments in absence of physician documentation

C. Implement a standardized physician query form so that coders can request clarification from physicians about documentation issues

Which of the following controls would be used to monitor the information system for abnormalities that might indicate a security breach is occurring? A. Encryption B. Firewall C. Incident detection D. Virtual private network

C. Incident detection

Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be the best approach to ensure that everyone understands the importance of this program? A. Request that the CEO write a memorandum to all hospital staff. B. Give the CDI committee chairperson the authority to fire employees who don't improve their clinical documentation. C. Include clinical and medical staff in the process. D. Request a letter from The Joint Commission.

C. Include clinical and medical staff in the process.

An admitting clerk arrives early every morning to snoop through the EHR for information about neighbors and friends. What security mechanisms could minimize this security breach? A. Audit controls B. Facility access controls C. Information access controls D. Workstation security

C. Information access controls

What concept refers to the process of creating management and oversight of data assets to support the organizationâ s mission, vision, and values? A. Enterprise information management B. Outcomes and Assessment Information Set (OASIS) C. Information governance D. Data governance

C. Information governance

A patient is undergoing a laparoscopic cholecystectomy. Following the insertion of the laparoscope into the abdominal cavity, the patient experienced a cardiac arrhythmia and the procedure was terminated. What root operation(s) would be coded for this procedure? A. Excision B. Resection C. Inspection D. Excision and Inspection

C. Inspection

A patient is discharged with a diagnosis of abdominal pain, probable irritable bowel syndrome. Which of the following would be the correct sequencing and coding for this case? A. Abdominal pain B. Abdominal pain, irritable bowel syndrome C. Irritable bowel syndrome D. Irritable bowel syndrome, abdominal pain

C. Irritable bowel syndrome

Under the HIPAA Privacy Rule, an impermissible use or disclosure should be presumed to be a breach unless the covered entity or business associate demonstrates that the probability the PHI has been compromised is ___________. A. High B. Moderate C. Low D. Non-existent

C. Low

Coding managers should have a complete understanding of current coding processes before they start which of the following process improvement tasks? A. Brainstorming B. Collecting and analyzing data C. Making recommendations for process change D. Establishing ground rules

C. Making recommendations for process change

Which of the following is the key to the identification and access of a patients health record? A. Deficiency slip B. Disease index C. Master patient index D. Outguide

C. Master patient index

In performing an internal audit for coding compliance, which of the following would be suitable case selections for auditing? A. Infrequent diagnosis and procedure codes B. Medical and surgical MS-DRGs by low dollar and low volume C. Medical and surgical MS-DRGs by high dollar and high volume D. Low admission diagnoses

C. Medical and surgical MS-DRGs by high dollar and high volume

What is the term that describes the data that defines and characterizes other data within an electronic system? A. Data quality B. Data element C. Metadata D. Source data

C. Metadata

Employees in the Hospital Business Office may have legitimate access to patient health information without patient authorization based on what HIPAA principle? A. Accounting of disclosures B. Compound authorization C. Minimum necessary D. Preemption

C. Minimum necessary

Deficiencies in a health record include which of the following? A. Mistake in the patients age B. Contradictory content C. Missing document D. Illegible content

C. Missing document

Which of the following is an example of individual user of the health record? A. Policy-making body B. Government licensing agency C. Patient D. Accreditation organization

C. Patient

Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her health record in person. She has requested to review them by herself in a private room. Which of the following is true based on this scenario? A. Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule. B. Sally owns the information in her record, so she must be granted her request. C. Sallys request does not have to be granted because the hospital is responsible for the integrity of the health record. D. Patients should never be given access to their actual health records.

C. Sallys request does not have to be granted because the hospital is responsible for the integrity of the health record.

Protection of healthcare information from damage, loss, and unauthorized alteration is also known as: A. Privacy B. Results management C. Security D. Data accuracy

C. Security

In regard to data security, what is the purpose of a red flag? A. Elevate security protection levels B. Increase audit trail reporting C. Sound an alert to a potential identify theft D. Raise concerns over security awareness

C. Sound an alert to a potential identify theft

This law prohibits a physician from referring patients to a business in which he or she or a member of the physicianâ s immediate family has financial interests A. False Claims B. Anti-Kickback C. Stark Law D. Health Insurance Portability and Accountability Act

C. Stark Law

After a claim has been filed with Medicare, a healthcare organization had late charges posted to a patientâ s outpatient account that changed the calculation of the APC. What is the best practice for this organization to receive the correct reimbursement from Medicare? A. Do nothing because the claim has already been submitted. B. Bill the patient for any remaining balance after payment from Medicare is received. C. Submit an adjusted claim to Medicare. D. Return the account to coding for review.

C. Submit an adjusted claim to Medicare.

A health information management professional may attend legal proceedings and testify as to: A. The reason a patient was treated B. Reasons a defendant health care provider should not be sued C. The authenticity of the patients health record D. The medical necessity of any procedures performed

C. The authenticity of the patients health record

The hospital is revising its policy for postanesthesia documentation. One member of the committee wants to retain the current policy that requires the postanesthesia evaluation be performed by the individual who administered the anesthesia. Another committee member argues that Hospital Conditions of Participation allow the postanesthesia evaluation to be completed and documented by any individual qualified to administer anesthesia. Given this discussion, which of the following might the HIM director suggest? A. Because of patient safety issues only the individual who administered the anesthesia should do the postanesthesia evaluation. B. Documentation will be hindered if two individuals are involved in documenting anesthesia evaluation. C. The change in policy would provide more flexibility and would decrease the burden for anesthesia personnel. D. The Conditions of Participation do not allow the change in policy being suggested.

C. The change in policy would provide more flexibility and would decrease the burden for anesthesia personnel.

An addendum to the health record should be dated _____. A. The day the error was identified B. The day the care provided occurred C. The day the addendum was created D. The day the patient was discharged

C. The day the addendum was created

Which of the following statements about compiling a directory of patients being treated in the hospital is true? A. A written authorization from the patient is required before any information about him or her is placed in a hospital directory of patients. B. Only the patients first and last names may be placed in a directory without his or her consent or authorization. C. The patient must be informed that certain information is maintained in a directory and to whom this information may be disclosed. D. An individual may not restrict or prohibit any uses of the directory.

C. The patient must be informed that certain information is maintained in a directory and to whom this information may be disclosed.

A patient contacts the HIM manager at Wildcat Hospital with a privacy complaint about another covered entity. What should the HIM manager recommend to the patient? A. The patient should first complain to the Office of Civil Rights B. The patient should first complain to the CEO of Wildcat Hospital C. The patient should first be encouraged to complain to the covered entity whose actions generated the complaint. D. The patient should first complain to their insurance company

C. The patient should first be encouraged to complain to the covered entity whose actions generated the complaint.

A patient is discharged from the hospital with a diagnosis of peptic ulcer versus cholecystitis, which are both equally treated and well documented. What should the coder assign as the principal diagnosis? A. The principal diagnosis must be peptic ulcer B. The principal diagnosis must be cholecystitis C. The principal diagnosis can be either peptic ulcer or cholecystitis D. The coder must query the physician for clarification

C. The principal diagnosis can be either peptic ulcer or cholecystitis

Determining if data follow a normal distribution is important because certain statistics can be computed on data that is normally distributed. Which of the following is one type of these statistics? A. Mean B. Median C. Z-score D. Mode

C. Z-score

Which of the following is an example of abuse? A. Billing for services not provided to the patient B. Misrepresentation of procedures performed to obtain payment for non-covered services C. Falsifying a patients diagnosis to justify tests D. A pattern of coding errors

D. A pattern of coding errors

The staff member who is responsible for evaluating and monitoring education action plans for individual coders within a coding department is the: A. Compliance officer B. Data quality specialist C. Attending physician D. Coding manager

D. Coding manager

An audit trail is a good tool for all of the following except? A. Holding an individual employee accountable for actions B. Reconstructing electronic events C. Detecting a hacker D. Determining revenue from a particular DRG

D. Determining revenue from a particular DRG

The overall goal of documentation standards is to: A. Ensure physicians have access to the health record information they need to care for the patient. B. Ensure the healthcare provider organization is reimbursed appropriately by payers. C. Ensure that CMS does not find reason to fine the healthcare provider organization. D. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.

D. Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient.

All of the following represent criteria for medical necessity and utilization review except: A. Intensity of service, Severity of illness, and Discharge screens B. Appropriateness Evaluation Protocol C. Truven Length of Stay Benchmarks D. Federal Register Index and Ratings

D. Federal Register Index and Ratings

What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization? A. Forms standardization system B. Forms distribution system C. Forms quality management system D. Form tracking system

D. Form tracking system

___________________________ are the information collected within a healthcare organization during the normal day-to-day operations that support patient care and business operations. A. Data assets B. Information elements C. Data elements D. Information assets

D. Information assets

A patients registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record? A. Rehabilitative care B. Ambulatory care C. Behavioral health D. Long-term care

D. Long-term care

Which of the following ethical principles is being followed when an HIM professional refuses to participate in a fraudulent act? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence

D. Nonmaleficence

If the nursing director requested information, regarding the number of cardiac catheterizations performed in the previous fiscal year, which index would the HIT use to access this information? A. Master patient index B. Physician index C. Disease index D. Operations/procedures index

D. Operations/procedures index

Where in an acute care health record would the documentation â Admit to 3C. Diet: NPO. Meds: Compazine 10mg IV Q 6 PRN.â be found? A. Laboratory report B. Pathology report C. History and Physical D. Physician order

D. Physician order

What application of data mining is used to identify potential fraudulent Medicare claims? A. Database modeling B. Knowledge management C. Total quality management D. Predictive modeling

D. Predictive modeling

A legal hold serves to: A. Confine a person in jail B. Subject records to a search warrant C. Create information D. Preserve information

D. Preserve information

Which of the following is an external user of data? A. Director of the clinical laboratory B. Hospital administrator C. Medical staff D. Public health department

D. Public health department

A patient is admitted to the hospital with back pain. The principal diagnosis is pyelonephritis. The patient also has depression, diverticulosis, and diabetes. In the inpatient prospective payment system, which of the following would determine the MDC assignment for this patient? A. Depression B. Diabetes C. Diverticulosis D. Pyelonephritis

D. Pyelonephritis

Joe Smith, RHIA, works for an outsourcing company as interim health information department director in a large hospital. By the terms of the contract, the hospital pays the company for Joeâ s services based on a 40-hour workweek with overtime for any hours exceeding 40. Joe typically works 9 hours per day, Monday through Thursday, and 4 hours on Friday. He then flies home for the weekend. After several months, he discovers the hospital is billed for 44 to 48 hours per week almost every week. Joe confronts the company billing department because this practice conflicts with the tenet of the AHIMA Code of Ethics that states that health information management professionals: A. Respect the rights and dignity of all individuals B. Adhere to the vision, mission, and values of the association C. Promote and protect the confidentiality and security of health records and health information D. Refuse to participate in or conceal unethical practices or procedures

D. Refuse to participate in or conceal unethical practices or procedures

Part of the coding supervisors responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? A. Delete the code from the CDM because it shouldnâ t be there B. Refer the case to the chargemaster coordinator C. Force a final bill on the accounts, since the duplication wonâ t affect the UB-04 D. Remove the code from the abstract and counsel the coder regarding CDM hard codes for this service.

D. Remove the code from the abstract and counsel the coder regarding CDM hard codes for this service.

Lisa is a coder at General Hospital. She has been told by her supervisor to assign codes that are in violation of coding rules. Lisa has reported her concerns with this request to the compliance officer at her facility. The compliance officer has advised her to follow the directions from her supervisor. What is Lisaâ s next step? A. Nothing as she could lose her job B. Continue to assign the codes even though this violates coding rules C. Attend continuing education courses D. Report the fraud to OIG hotline

D. Report the fraud to OIG hotline

An employee observes a non-employee putting some computer disks in a bag. The employee does not report this security breach. What security measures should have been in place to help ensure that such a case is reported? A. Access controls B. Audit controls C. Authentication controls D. Security incident procedures

D. Security incident procedures

Which of the following does not have to be included in a covered entitys notice of privacy practices? A. Description with one example of disclosures made for treatment, payment, and healthcare operations B. Description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization C. Statement of individuals rights with respect to PHI and how the individual can exercise these rights D. Signature of the patient and date the notice was given to the patient

D. Signature of the patient and date the notice was given to the patient

Optimum workflow for coders is dependent not only on the efficient sequence of record-processing functions, but also on: A. Cooperative relationships between staff members B. Proper lighting C. Coder productivity D. The physical location in which coding is performed

D. The physical location in which coding is performed

HIM professionals working with a hybrid record often find this record format challenging because: A. They are focusing on the EHR. B. They have to maintain all of the traditional HIM functions. C. HIM professionals do not have the skills to manage the EHR. D. They have to manage both the electronic and paper media.

D. They have to manage both the electronic and paper media.

The compliance officer was made aware that a user accessed the PHI of a patient with the same last name through a computer alert. This is the example of a(n): A. Authentication B. Integrity C. Transmission security D. Trigger

D. Trigger

Information collected in a cancer registry typically includes: A. Type and stage of cancer, total charges, and claims reconciliation B. Stage of cancer, patient demographic information, and total charges C. Patient demographic information, claims reconciliation, and type of cancer D. Type and stage of cancer and patient demographic information

D. Type and stage of cancer and patient demographic information

The policies and procedures section of a coding compliance plan should include all of the following except: A. Physician query process B. Unbundling C. Assignment of discharge disposition codes D. Vendor selection process

D. Vendor selection process

A coder uses an LCD or an NCD to identify: A. What services require documentation to be submitted to Medicare B. What services need prior approval before payment is made C. What procedure codes justify the medical necessity of a test or service D. What diagnosis codes justify the medical necessity of a test or service

D. What diagnosis codes justify the medical necessity of a test or service

The technique that provides a snapshot of an existing process and can identify potential areas for change is: A. Time ladder B. Benchmarking C. Needs assessment D. Work-imaging study

D. Work-imaging study

An employee forgot his password and uses another employeeâ s user ID and password to access the EHR. What controls should have been in place to minimize this security breach? A. Access controls B. Security incident procedures C. Security management process D. Workforce security awareness training

D. Workforce security awareness training

secondary data analysis

Data, be it research data or administrative data, when used for purposes that go beyond the original intent. refers to data that was collected by another agency for some other purpose. Common sources of secondary data for health and social science include censuses, information collected by government departments, organizational records and data that was originally collected for other research purposes. When data is taken from the health record and then used for purposes such as databases and registries, it is considered a secondary data source. It is when this data or information is taken from the primary source, the medical record, and used in registries (cancer, trauma, birth defect, implant, transplant, immunizations, etc.), indexes (master population or master patient index [MPI], diseases, physician, operation, or procedures indexes, etc.), or databases (CDC, National Practitioner Data Bank, Health Integrity and Protection Data Bank [HIPDB], clinical trials, vital statistics, etc.) that it can be considered a secondary data source.

What are the first steps for a HIM Professional in determining the components of the legal health records?

Develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record

Congingency plan

Disaster planning-a set of procedures, documented by the organization to be followed when responding to emergencies. It encompasses what an organization and its personnel need to do both during and after events that limit or prevent access to facilities and patient information

What are three components that an organization should include in the implementation of a compliant clinical documentation (CDI) program?

Documented, mandatory physician education; detailed query documentation; CDI policies and procedures with annual sign-off from all program staff

What does Accreditation organizations such as the Joint Commission do?

Every participating healthcare organization is subject to a periodic accreditation survey. Surveyors visit each facility and compare its programs, policies, and procedures to a prepublished set of performance standards. A key component of every accreditation survey is a review of the facility's health records. Surveyors review the documentation of patient care services to determine whether the standards for care are being met

Health care fraud

Healthcare fraud is defined as an intentional misrepresentation that an individual knows to be false or does not believe to be true and makes, knowing that the representation could result in some unauthorized benefit to himself or herself or some other person. An example of fraud is billing for a service that was not furnished

Secondary data enables internal users such as medical staff, administrative, and management staff to?

Identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities

What is data that consists of sets of data that are related and have been placed in context, are filtered, manipulated, or formatted in some way and are useful to a particular task?

Information

What are the HIPAA Privacy rules in regards to providing record requests electronically?

The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be provided in that format

Discharge summary

The discharge summary is a concise account of the patient's illness, course of treatment, response to treatment, and condition at the time the patient is discharged (officially released) from the hospital. The summary also includes instructions for follow-up care to be given to the patient or his or her caregiver at the time of discharge. It provides an overview of the entire health encounter. The discharge summary is the responsibility of, and must be signed by, the attending physician

Outpatient code editor (OCE)

The latest version of the Medicare integrated outpatient code editor (OCE) should be installed to review claims prior to releasing billed data to the Medicare program. OCE software contains the National Correct Coding Initiative (NCCI) edits for Current Procedural Terminology (CPT). The NCCI edits were created to evaluate the relationships between CPT codes on the bill and to control improper coding leading to inappropriate payment and unbundling on the Part B claims. They also identify component codes that were used instead of the appropriate comprehensive code, as well as other types of coding errors

An HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient records at the time of discharge, providing a 24-hour turnaround time. The hospital has an average daily discharge of 120 patients, and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time? National Benchmarks for Document Scanning Processes Function Expectations per Worked Hour Prepping 340-500 images Scanning 1,200-2,400 images Quality Control 1,600-2,000 images Indexing 600-800 images a. 100 hours b. 146 hours c. 1,000 hours d. 3,740 hours

The question is asking for the least amount of hours needed to meet the 24-hour turnaround time. The average discharge in a 24-hour period is 120 patients, and the average number of pages for each patient chart is 200. So, 120 × 200 = 24,000 pages in a 24-hour period. Each chart must be prepped, scanned, checked for quality, and indexed. The highest number of pages that can go through all these processes in an hour would be: 500 images in prepping; 2,400 images in scanning; 2,000 images in quality control; and 800 images in indexing. 24,000 / 500 = 48 hours needed for prepping 24,000 / 2,400 = 10 hours for scanning 24,000 / 2,000 = 12 hours for quality control 24,000 / 800 = 30 hours for indexing 48 + 10 + 12 + 30 = 100 hours, at least, needed each day to meet a 24-hour turnaround time (Prater 2016, 587-588).

Community Hospital had 100 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 daily inpatient census at midnight on May 2? A. 90 B. 92 C. 130 D. 132

The result of the official count taken at midnight is the daily inpatient census. This is the number of inpatients present at the official census-taking time each day ([100 + 30] - 40) = 90 A. 90

What are Application safeguards?

These are controls contained in the application software or computer programs. One common application control is password management. It involves keeping a record of end users' identifications and passwords and then matching the passwords to each end user's privileges

Given the information here, the case-mix index would be

To arrive at the case-mix index for a hospital, multiply the weight of each Medicare severity diagnosis-related group (MS-DRG) by the number of discharges for that MS-DRG to arrive at the total weight for each MS-DRG. Then the total weights are summed and divided by the number of total discharges, as in the equations that follow: 0.9184 x 10 = 9.184 0.7234 x 20 = 14.468 1.3860 x 10 = 13.860 0.9469 x 20 = 18.938 0.7028 x 10 = 7.028 9.184 + 14.468 + 13.860 + 18.938 + 7.028 = 63.478/70 discharges= 0.9068

Coding Sequencing for burn conditions

Treatment and anatomic location are not factors. Code all burns with the highest degree of burn sequenced first.

What does a on-site surveyor reviewer meet with HIM department to review.

Would meet with the HIM leader to review their written policies and procedures and ask for some examples of the HIM department's successes in areas of quality improvement and patient safety. The type of successes the surveyor would be looking for might be that the signing, dating, and timing of physician verbal orders went from 95 percent compliance to 99 percent. Another success would be the reduction of duplicate or overlaid medical record numbers (MRN)

A patient is scheduled for an outpatient colonoscopy, but due to a sudden drop in blood pressure, the procedure is canceled just as the scope is introduced into the rectum. Because of moderately severe mental retardation, the patient is given general anesthetic prior to the procedure. How should this procedure be coded? a. Assign the code for colonoscopy with modifier −74, Discontinued outpatient procedure after anesthesia administration. b. Assign the code for a colonoscopy with modifier −52, Reduced services. c. Assign no code because no procedure was performed. d. Assign an anesthesia code only.

a. Assign the code for colonoscopy with modifier −74, Discontinued outpatient procedure after anesthesia administration. Per CPT Coding Guidelines, when a planned procedure is terminated prior to completed for cause, the intended procedure is coded with a modifier. Because general anesthesia was used, modifier −74 is appropriate in this case

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

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

A patient known to have AIDS is admitted to the hospital for treatment of Pneumocystis carinii pneumonia. Assign the principal diagnosis for this patient. a. B20, Human immunodeficiency virus [HIV] disease b. J18.9, Pneumonia, unspecified organism c. B59, Pneumocystosis d. Z21, Asymptomatic human immunodeficiency virus [HIV] infection status

a. B20, Human immunodeficiency virus [HIV] disease

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

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? 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 b. Workflow analysis c. Productivity analysis d. Work measurement

a. Benchmarking

Clinical documentation improvement (CDI) programs use metrics to evaluate the effectiveness of their program. Which of the following is the most widely used key indicator for a CDI program? a. Case-mix index b. Severity of illness score c. Accounts receivable index d. Risk mortality score

a. Case-mix index

Continuing coding education is required for: a. Certified coders b. Inpatient coders c. All coders d. Inpatient and ambulatory surgery coders

a. Certified coders

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

As part of the clinic's performance improvement program, an HIM director wants to implement benchmarking for the transcription division at a large physician clinic. The clinic has 21 transcriptionists who average about 140 lines per hour. The transcription unit supports 80 physicians at a cost of 15 cents per line. What should be the first step that the supervisor takes to establish benchmarks for the transcription division? a. Clearly define what is to be studied and accomplished by instituting benchmarks. b. Hold a meeting with the transcriptionists to announce the benchmark program. c. Obtain benchmarks from other institutions. d. Hire a consultant to assist with the process.

a. Clearly define what is to be studied and accomplished by instituting benchmarks.

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

a. Code skin lesion

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

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

A record is considered a primary data source when it: a. Contains data about a patient and has been documented by the professionals who provided care to the patient b. Contains data abstracted from a patient record c. Includes data stored in a computer system d. Contains data that are entered into a disease-oriented database

a. Contains data about a patient and has been documented by the professionals who provided care to the patient

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

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 recent HIM trend is instituting a clinical documentation improvement program. This is not a small undertaking. Which of the following can be used by the HIM manager to assist in measuring whether or not the program is successful? a. Dashboard b. Policy c. Procedure d. Benchmark

a. Dashboard

The legal health record (LHR) is a(n): a. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information b. Entire set of information created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information c. Set of patient-specific data created or accumulated by a healthcare provider that is defined to be legal by the local, state, or federal authorities d. Set of patient-specific data that is defined to be legal by state or federal statute and that is legally permissible to provide in response to requests for patient information

a. Defined subset of all patient-specific data created or accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information

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 When the admission or encounter is for management of dehydration due to the malignancy and only the dehydration is being treated, the dehydration is sequenced first, followed by the code(s) for the malignancy

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 Benchmarks Productivity Benchmarks Per Hour Function Low Average High Analysis (charts per hour) Inpatient 8 20 Observation/outpatient surgery/newborn/maternity 5 14 60 Other outpatient 20 120 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

Which of the following is a primary purpose of the health record? a. Document patient care delivery b. Regulation of healthcare facilities c. Aid in education of nurses and physicians d. Assist in process redesign

a. Document patient care delivery

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 facillities

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

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

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

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

After an outpatient review, individual audit results by coder should become part of the: a. Individual employee's performance evaluation b. Patient's health record c. Coding compliance review summary d. Mission of the coding team

a. Individual employee's performance evaluation

A provider's office calls to retrieve emergency room records for a patient's follow-up appointment. The HIM professional refused to release the emergency department records without a written authorization from the patient. Was this action in compliance? a. No; the records are needed for continued care of the patient, so no authorization is required b. Yes; the release of all records requires written authorization from the patient c. No; permission of the ER physician was not obtained d. Yes; one covered entity cannot request the records from another covered entity

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

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

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.

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

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

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

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

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. Correct Answer: A Although sometimes used interchangeably, the terms data and information do not mean the same thing. Data represent the basic facts about people, processes, measurements, conditions, and so on. They can be collected in the form of dates, numerical measurements and statistics, textual descriptions, checklists, images, and symbols. After data have been collected and analyzed, they are converted into a form that can be used for a specific purpose. This useful form is called information. In other words, data represent facts and information represents meaning

The coding staff at University Hospital has access to the Internet for research purposes while performing their job duties. The coding manager has noticed an increase in use and distraction by her coders who are using social media while on the job. In this situation, what should the coding manager develop and use to handle the inappropriate use of the Internet by her coding staff? a. Policy b. Standard c. Procedure d. Benchmark

a. Policy

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

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

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

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

a. Request that the physician dictate an addendum to the discharge summary

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

NCCI edit files contain code pairs, called mutually exclusive edits, that prevent payment for: a. Services that cannot reasonably be billed together b. Services that are components of a more comprehensive procedure c. Unnecessary procedures d. Comprehensive procedures

a. Services that cannot reasonably be billed together

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

Incorporating a workflow function in an electronic information system would help support: a. Tasks that need to be performed in a specific sequence b. Moving patients from point to point c. Registration of patients d. Making computer output available on laser disk

a. Tasks that need to be performed in a specific sequence

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

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 Issues Personnel/Cost User's time—30 minutes $15 Telephone cost—30 minutes $2 Call Desk time—30 minutes $16 Call Desk IS facilities time $17 Total $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. $50 x 40 calls per day=2000x365 days=73000 x .2(20%)=146,000 Savings

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 Issues Personnel Cost User's time—30 minutes $15 Telephone cost—30 minutes $2 Call Desk time—30 minutes $16 Call Desk IS facilities time $17 Total $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 × 40 calls per day = $2,000 per day × 365 days = $730,000. Cost with reduced number of help desk calls: $50 × (40 × 0.80) calls per day = $1,600 per day × 365 days = $584,000, or a savings of $146,000. Training costs of $100,000 will be recouped and a savings of $46,000 realized (Gordon and Gordon 2016b, 548).

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

Medical identity theft includes which of the following: a. Using another person's name to obtain durable medical equipment b. Purchasing an EHR c. Purchasing surgical equipment d. Using another healthcare provider's national provider identifier to submit a claim

a. Using another person's name to obtain durable medical equipment

. 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

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

The primary goals of __________ are to improve patient care, streamline disability benefit claims, and improve public health reporting through secure, trusted, and interoperable health information exchange. a. the National Health Information Network b. the National Committee on Vital and Health Statistics c. Health Level Seven (HL7) International d. the EHR Collaborative

a. the National Health Information Network

What are Data content standards?

allow organizations to collect data once and use it many times in many ways. They also assist in data storage and mining as well as sharing data with external organizations for use in benchmarking and other purposes

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital? a. $40,300 b. $39,375 c. $26,250 d. $13,125

b. $39,375 Unbundling is the practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps of the comprehensive procedure code. In this situation, the penalty is the overpayment of the $75 for all 175 claims overpaid as well as 3 times the total amount of the overpayment (175 × $75 = $13,125 then; $13,125 × 3 = $39,375)

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 A unit of measure that reflects the services received by one inpatient during a 24-hour period is called an inpatient service day. The number of inpatient service days for a 24-hour period is equal to the daily inpatient census—that is, one service day for each patient treated. The calculation is: [(250 + 30) − 40] + 2 = 242

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median? a. 30 b. 31.5 c. 32 d. 35

b. 31.5 The median is the midpoint of a frequency distribution. It is the point at which 50 percent of observations fall above and 50 percent fall below. If an even number of observations is in the frequency distribution, the median is the midpoint between the two middle observations. It is found by averaging the two middle scores, (x + y) / 2. In the example, the median is 31.5: ([30 + 33] / 2)

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

Which of the following individuals may authorize release of health information? a. An 86-year-old patient with a diagnosis of advanced dementia b. A married 15-year-old father c. A 15-year-old minor d. The parents of an 18-year-old student

b. A married 15-year-old father Emancipated minors generally may authorize the access and disclosure of their own PHI. If the minor is married or previously married, the minor may authorize the disclosure or use of his or her information. If the minor is under the age of 18 and is the parent of a child, the minor may authorize the access and disclosures of his or her own information as well as that of his or her child

Which of the following situations is considered a breach of PHI? a. A nurse views the record of a patient that she is not caring for b. A patient's attorney is sent records not authorized by that patient c. A nurse starts to place PHI in a public area where a patient is standing and immediately picks it up d. An HIM employee keys in the incorrect health record number but closes it out as soon as it is realized

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

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

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

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)

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

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best? a. Alert the Joint Commission that the hospital has not met its quality goal b. Determine whether there was a medical or other reason why patients were not given aspirin c. Institute an in-service training program for clinical staff on the importance of administering aspirin within 24 hours d. Determine which physicians did not order aspirin

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

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

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record? a. Develop a list of all data elements referencing patients that are included in both paper and electronic systems of the practice b. Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records c. Perform a quality check on all health record systems in the practice d. Develop a listing and categorize all information requests for health information over the past two years

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

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

The attending physician is responsible for which of the following types of acute-care documentation? a. Consultation report b. Discharge summary c. Laboratory report d. Pathology report

b. Discharge summary

In processing a bill under the Medicare outpatient prospective payment system (OPPS) in which a patient had three surgical procedures with the payment status indicator -T performed during the same operative session, which of the following would apply? a. Bundling of services b. Discounting of procedures c. Outlier adjustment d. Pass-through payment

b. Discounting of procedures Discounting applies to multiple surgical procedures that have a payment status T indictor and are performed during the same operative session. For discounted procedures, the full ambulatory payment classification (APC) rate is paid for the surgical procedure with the highest rate, and other surgical procedures performed at the same time are reimbursed at 50 percent of the APC rate

What is one key component of a compliant clinical documentation improvement program? a. Detailed review of Joint Commission findings b. Documented, mandatory physician education c. Revenue cycle team involvement d. Exceeding query response targets

b. Documented, mandatory physician education

In ICD-10-PCS, the root operation defined as taking or letting out fluids and/or gases from a body part is: a. Control b. Drainage c. Excision d. Release

b. Drainage

Patient care managers use the data documented in the health record to: a. Determine the extent and effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care

b. Evaluate patterns and trends of patient care

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

b. Extirpation

The HIM improvement team wants to identify the causes of poor documentation compliance in the health record. Which of the following tools would best aid the team in identifying the root cause of the problem? a. Flowchart b. Fishbone diagram c. Pareto chart d. Scatter diagram

b. Fishbone diagram

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

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

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

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

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

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.

A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is: a. K21.9, Gastro-esophageal reflux disease without esophagitis b. R07.9, Chest pain, unspecified c. R10.11, Right upper quadrant pain d. Z03.89, Encounter for observation for other suspected diseases and conditions ruled out

b. R07.9, Chest pain, unspecified

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

HIM departments may be the hub of identifying, mitigating, and correcting MPI (Master Patient Index) errors, but that information often is not shared with other departments within the healthcare organization. After identifying procedural problems with admitting patients that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems? a. Administration b. Registration c. Risk Management d. Radiology and Laboratory

b. Registration A review of the identified duplicates and overlays often reveals procedural problems that contribute to the creation of errors. Although health information management (HIM) departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors, that information may never be shared with the registration department. If the registration staff is not aware of the errors, how can they begin to proactively prevent the errors from occurring in the first place? Registration process improvement activities can eventually reduce work for HIM departments. In addition, monitoring new duplicates is a critical process, and tracking reports should be created and implemented. Identifying and reporting MPI errors is important; however, tracking who made the error and why will decrease the number of duplicates

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

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 present

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 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. The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is to not interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure, and therefore, allowed in the Privacy Rule

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

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

Helen is the HIM department head, and has been asked to share a SWOT analysis of her department with her new boss. One aspect of Helen's SWOT analysis indicates that the chart tracking software is over 10 years old and is not compatible with the digital dictation system. In a SWOT analysis, this would be a(n): a. Strength b. Weakness c. Opportunity d. Threat

b. Weakness The process to develop a strategic and operational plan begins with a SWOT (acronym for strengths, weaknesses, opportunities, and threats) analysis. In a SWOT analysis, key leadership personnel determine the strengths of the organization (what the company does well), the weaknesses (needs for improvement), and establishes future opportunities (and evaluates threats to those opportunities). This scenario is an example of weakness in a SWOT analysis

A new mother placed her baby in the bassinet in her hospital room while she used the restroom in her room. When she returned, she went to pick up her baby and found the bassinet empty. She immediately called the nurse to inquire as to the whereabouts of her child. The nurse replied that she had not taken the baby and immediately issued a hospital-wide security alert for a possible infant abduction. Although all procedures were followed to locate the baby, the baby was not found within the hospital. This situation describes a ________. a. near miss b. sentinel event c. security incident d. time out

b. sentinel event

Why is treatment, payment, and operations (TPO) an important concept?

because the Privacy Rule provides a number of exceptions for PHI that is being used or disclosed for TPO purposes. Treatment means providing, coordinating, or managing healthcare or healthcare-related services by one or more healthcare providers

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

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.

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

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

Community Hospital had 25 inpatient deaths, including newborns, for the month of June. The hospital performed five autopsies for the same period. What was the gross autopsy rate for the hospital for June? a. 0.02% b. 5% c. 20% d. 200%

c. 20%

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

c. 5

An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard? a. 45.6 pages b. 68.4 pages c. 76 pages d. 190 pages

c. 76 pages Productivity standards should be based on both accuracy and volume. In this situation, 114 / 0.60 = 190; 190 − 114 = 76 more pages will need to be indexed to meet the productivity standard

Which of the following best describes the function of kiosks? a. A computer station that physicians can use to order medications b. A computer station that unlocks workstations c. A computer station that facilitates integrated communications within the healthcare organization d. A computer station that promotes the healthcare organization's services

c. A computer station that facilitates integrated communications within the healthcare organization

All of the following are steps in medical necessity and utilization review, except: a. Initial clinical review b. Peer clinical review c. Access consideration d. Appeals consideration

c. Access consideration

A physician query may not be appropriate in which of the following instances? a. Diagnosis of viral pneumonia noted in the progress notes and sputum cultures showing Haemophilus influenzae b. Discharge summary indicates chronic renal failure but the progress notes document acute renal failure throughout the stay c. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis d. Diagnosis of chest pain and abnormal cardiac enzymes indicative of an AMI

c. Acute respiratory failure in a patient whose lab report findings appear not to support this diagnosis

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

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 record that fails quantitative analysis is missing the quality criterion of: a. Legibility b. Reliability c. Completeness d. Clarity

c. Completeness

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? a. Minimum Data Set b. National Commission on Correctional Health Care c. Conditions of Participation d. Outcomes and Assessment Information Set

c. Conditions of Participation

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

Community Hospital wants to compare its hospital-acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. Of these individuals, 200,000 were admitted with a principal diagnosis of UTI; another 300,000 were admitted with a principal diagnosis of infectious disease, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital? a. All individuals in the MEDPAR database b. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease d. All individuals in the MEDPAR database except those admitted with a diagnosis of hypertension

c. All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease The Medicare Provider Analysis and Review (MEDPAR) file is made up of acute care hospital and skilled nursing facility (SNF) claims data for all Medicare claims. The MEDPAR file is frequently used for research on topics such as charges for particular types of care and DRGs. The limitation of the MEDPAR data for research purposes is that the file contains only Medicare patients. Community Hospital is excluding MEDPAR data of those patients with a principal diagnosis of UTI or infectious disease because these would not represent a hospital acquired condition (HAC) because the patients were admitted with those diagnoses. Community Hospital is looking for comparative secondary diagnosis data of Medicare patients from the MEDPAR file to compare their HAC rate for UTIs to the national average from the MEDPAR data

A comprehensive retrospective review should be conducted at least once a year of which aspect of the clinical documentation improvement program? a. Proficiency statistics b. Compliance issues c. All query opportunities d. Core key measures

c. All query opportunities

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

Which of the following security controls are built into a computer software program? a. Physical safeguards b. Administration safeguards c. Application safeguards d. Media safeguards

c. Application safeguards

A seven-year-old patient was admitted to the emergency department for treatment of shortness of breath. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unabated following treatment. What diagnosis should be suspected? a. Acute bronchitis b. Acute bronchitis with chronic obstructive pulmonary disease c. Asthma with status asthmaticus d. Chronic obstructive asthma

c. Asthma with status asthmaticus

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

A visitor to the hospital looks at the screen of the admitting clerk's computer workstation when she leaves her desk to copy some admitting documents. What security mechanism would best have minimized this security breach? a. Document controls b. Audit controls c. Automatic logoff controls d. Device and media controls

c. Automatic logoff controls

What term describes the processing of scanning past health records into the information system so there is an existing database of patient information, making the information system valuable to the user from the first day of implementation? a. CPOE b. Analysis c. Backscanning d. Barcoding

c. Backscanning

To date, the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? a. HIPAA does not allow charges for copying of medical records. b. Use the state formula because HIPAA allows hospitals to use the state formula. c. Base charges on the cost of labor and supplies for copying and postage if copies are mailed while following the state copy fee schedule. d. Because HIPAA allows for reasonable and customary charges, charge only for the paper used for copying the records.

c. Base charges on the cost of labor and supplies for copying and postage if copies are mailed while following the state copy fee schedule.

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses would be reported as POA? a. Catheter-associated urinary tract infection, COPD, Hypertension b. Cerebral vascular accident, COPD, Catheter-associated urinary tract infection c. Cerebral vascular accident, COPD, Hypertension

c. Cerebral vascular accident, COPD, Hypertension

Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant, all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Determine that a formal letter of termination meets HIPAA requirements and no further action is required b. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned d. Inform the CFO that business associate agreements cannot be terminated

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

Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule? a. Identifies an individual b. In the custody of or transmitted by a CE or its BA c. Contained within a personnel file d. Relates to one's health condition

c. Contained within a personnel file

For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it: a. Contains only Medicare data b. Is used to determine pay for performance c. Contains data on all payer types d. Contains bibliographic listings from medical journals

c. Contains data on all payer types

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

When performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis and procedure codes specifically for the purpose of obtaining a higher level of reimbursement. The coder believes that this practice helps the hospital increase its revenue. Which of the following should be done in this case? a. Compliment the coder for taking initiative in helping the hospital b. Report the coder to the FBI for coding fraud c. Counsel the coder and stop the practice immediately d. Provide the coder with incentive pay for her actions

c. Counsel the coder and stop the practice immediately

One of the pediatricians at Community Physician's Clinic worked with a software vendor to get a display of the patients she currently has in the hospital on her smart phone that lets her know current information such as lab results, vital signs, medications given. This is called a ________. a. Big data b. Descriptive analytics screen c. Dashboard d. Descriptive tablet

c. Dashboard

Which of the following is the best definition of a data governance framework? a. Lists successive steps of growth to measure a program's progression b. Supports high level business imperatives c. Describes a real or conceptual structure that organizes a system or concept d. Targets an end point to achieve

c. Describes a real or conceptual structure that organizes a system or concept

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

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

What type of analysis compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis? a. Risk management analysis b. Qualitative analysis c. Gap analysis d. Document management analysis

c. Gap analysis

When multiple burns are present, the first sequenced diagnosis is the: a. Burn that is treated surgically b. Burn that is closest to the head c. Highest-degree burn d. Burn that is treated first

c. Highest-degree burn

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

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

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

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

The right of an individual to keep personal health information from being disclosed to anyone is a definition of: a. Confidentiality b. Integrity c. Privacy d. Security

c. Privacy

A patient is admitted with a history of prostate cancer and with mental confusion. The patient completed radiation therapy for prostate carcinoma three years ago and is status post a radical resection of the prostate. A CT scan of the brain during the current admission reveals metastasis. Which of the following is the correct coding and sequencing for the current hospital stay? a. Metastatic carcinoma of the brain; carcinoma of the prostate; mental confusion b. Mental confusion; history of carcinoma of the prostate; admission for chemotherapy c. Metastatic carcinoma of the brain; history of carcinoma of the prostate d. Carcinoma of the prostate; metastatic carcinoma to the brain

c. Metastatic carcinoma of the brain; history of carcinoma of the prostate

Dr. Hall is an orthopedic surgeon performing a knee replacement on Mary. Mary was seen in Dr. Hall's office two months before the surgery and Dr. Hall documented her history and physical (H&P) at that point. Does this H&P meet documentation requirements for the surgery? a. No, the first H&P must be documented within 60 days before admission, and another H&P must be documented within 48 hours after admission to the hospital b. Yes, there are no requirements on when an H&P must be performed c. No, the H&P must be documented within 30 days before admission with an update within 24 hours after admission d. Yes, because the H&P was documented within 60 days

c. No, the H&P must be documented within 30 days before admission with an update within 24 hours after admission

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.

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

What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services? a. Regional health information organizations b. Corporate compliance plans c. OIG workplans d. Federal register

c. OIG workplans

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

c. Occurrence report

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

Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request? a. PHI related to treatment, payment, and operations b. PHI provided to meet national security or intelligence requirements c. PHI sent to a physician who has not treated Sally d. PHI released to Sally's attorney upon her request

c. PHI sent to a physician who has not treated Sally

A secure method of communication between the healthcare provider and the patient is a(n): a. Personal health record b. E-mail c. Patient portal d. Online health information

c. Patient portal

Before the actual job analysis process begins, an HIM manager must complete the following: a. Collect primary data to support the job analysis b. Execute a workflow analysis c. Perform a needs assessment d. Write a job description

c. Perform a needs assessment

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

A statement or guideline that directs decision making or behavior is called a: a. Directive b. Procedure c. Policy d. Rule

c. Policy

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

A risk manager is called in to evaluate a situation in which a visitor to the hospital slipped on spilled water, fell, and fractured his femur. This situation was referred to the risk manager because it involves a: a. Medical error b. Claims management issue c. Potentially compensable event d. Sentinel event

c. Potentially compensable event

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

Community Hospital is discussing restricting the access that physicians have to electronic health records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available, whereas others maintain that HIPAA restricts access. The HIM director is part of the committee. Which of the following should the director advise the committee? a. HIPAA restricts the access of physicians to all information. b. The "minimum necessary" concept does not apply to disclosures made for treatment purposes; therefore, physician access should not be restricted. c. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role. d. The "minimum necessary" concept applies only to attending physicians, and therefore, restriction of access must be implemented.

c. The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role.

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.

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.

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

What type of registry maintains a database on patients injured by an external physical force? a. Implant registry b. Birth defects registry c. Trauma registry d. Transplant registry

c. Trauma registry

The overutilization or inappropriate utilization of services and misuse of resources, typically not a criminal or intentional act is called which of the following? a. Fraud b. Abuse c. Waste d. Audit

c. Waste

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

Speech recognition

can be very effective in certain situations when data entry is fairly repetitive and the vocabulary used is fairly limited. As speech recognition improves, it is becoming a replacement for other forms of dictation. In some cases, the user reviews the speech as it is being converted to type and makes any needed corrections; in other cases, the speech is sent to a special device where it generates type for another individual to review and edit

What are Data and content standards

clear guidelines for the acceptable values for specified data fields. These standards make it possible to exchange health information using electronic networks

What are OASIS-C items

components of the comprehensive assessment that is the foundation for the plan of care

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

d. 95.5% 200-9=191 In this case, 191 instances of timely H&Ps out of 200 sampled is 95.5% accuracy. The calculation is (191/200) × 100 = 95.5%

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 Clinical Documentation Improvement (CDI) program facilitates accurate coding and helps coders avoid: a. NCCI edits b. Upcoding c. Coding without a completed face sheet d. Assumption coding

d. Assumption coding

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

Clinical documentation policies and procedures should: a. Dictate the practices and procedures for medical treatment b. Encompass nationally recognized guidelines c. Meet all the requirements of physician leaders d. Be created by and specifically for each organization

d. Be created by and specifically for each organization

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

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

The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: a. Admissibility exception b. Discovery exception c. Direct evidence exception d. Business records exception

d. Business records exception

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

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

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

What should be done when the HIM department's chart analysis error rate is too high, or its accuracy rate is too low based on policy? a. Re-audit the problem area b. The problem should be treated as an isolated incident c. The formula for determining the rate may need to be adjusted d. Corrective action should be taken to meet the department standards

d. Corrective action should be taken to meet the department standards

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

The patient's address is the same in the master patient index, electronic health record, laboratory information system, and other systems. This means that the data values are consistent and therefore indicative of which of the following? a. Data availability b. Data accessibility c. Data privacy d. Data integrity

d. Data integrity

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

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

. 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

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

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

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 would be used to track data movement from one system to another? a. Administrative metadata b. Business metadata c. Context metadata d. Embedded metadata

d. Embedded metadata

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

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

The data set designed to organize data about public health issues to inform purchasers and consumers about the performance of healthcare plans is: a. UHDDS b. DEEDS c. MDS d. HEDIS

d. HEDIS

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 Answer: D 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

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

When a patient revokes authorization for release of information after a healthcare facility has already released the information, the facility in this case: a. May be prosecuted for invasion of privacy b. Has become subject to civil action c. Has violated the security regulations of HIPAA d. Is protected by the Privacy Act

d. Is protected by the Privacy Act

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

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff

d. Nursing staff

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? a. Two CPT codes, one for each laceration b. One CPT code for the largest laceration c. One CPT code for the most complex closure d. One CPT code, adding the lengths of the lacerations together

d. One CPT code, adding the lengths of the lacerations together

One release of information (ROI) specialist handles requests from insurance and managed care companies. Another handles requests from attorneys and courts. Each completes all steps in the business process from beginning to end. This is an example of which of the following? a. Serial work division b. Job sharing c. Job rotation d. Parallel work division

d. Parallel work division

Insufficient documentation is the highest risk area for Physician Services. Which of the following is the best approach for the coding supervisor at Family Physicians group to combat this issue? a. Ensure medical record documentation is submitted for every single CERT record request. b. Work with billing to ensure only valid CPT and HCPCS codes are reported on Medicare claims. c. Design and execute a physician documentation assessment. d. Perform a root cause analysis of records denied for insufficient documentation and then develop a plan based on the findings.

d. Perform a root cause analysis of records denied for insufficient documentation and then develop a plan based on the findings.

Primary Keys

ensure that each row in a table is unique. A primary key must not change in value. Typically, a primary key is a number that is a one-up counter or a randomly generated number in large databases. A number is used because a number processes faster than an alphanumeric character. In large tables, this makes a difference. In the PATIENTS table, the PATIENT_ID is the primary key. It is good programming practice to create a primary key that is independent of the data in a table

Identity management

ensures that the individual who has been identified is who they say they are, that they have the authority to do what they want to do, and that their actions are tracked

Clinical forms committee

establishes standards for design and to approve new and revised forms. The committee should also have oversight of computer screens and other data capture tools

What are the circumstances where PHI can be used or disclosed without the individuals authorization and without granting the individual the opportunity to agree or object?

preventing or controlling diseases, injuries, and disabilities, and reporting disease, injury, and vital events such as births and deaths