RHIT Exam 1

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.

Correct Answer: A A patient has a right to a notice of privacy practices as defined in the HIPAA Privacy Rule. 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 (Thomason 2013, 113).

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

Correct Answer: A A pattern used in computer-based patient records to capture data in a structured manner is called a template. One benefit of using a template is to ensure data integrity upon data entry (Brickner 2016a, 83).

What formatting problem is found in the following table? See Graph a. Column headings are missing b. Title of the table is missing c. Column totals are inaccurate d. Variable names are missing

Correct Answer: A A table is an orderly arrangement of values that groups data into rows and columns. Almost any type of quantitative information can be organized into tables. Tables are useful for demonstrating patterns and other kinds of relationships. Tables need headings for columns and rows, and they need to be specific and understandable (Watzlaf 2016, 347).

To use a data element for aggregation and reporting, that data element must be: a. Abstracted or indexed b. Searched c. Subject to case finding d. Registered

Correct Answer: A Abstracting is the process of extracting elements of data from a source document and entering them into an automated system. The purpose of this endeavor is to make those data elements available for later use. After a data element is captured in electronic form, it can be aggregated into a group of data elements to provide information needed by the user (Sayles 2016b, 74).

A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n): a. Audit trail b. Facility access control c. Forensic scan d. Security management plan

Correct Answer: A An audit trail is a record of system and application activity by users. It can track when an employee has accessed the system, the actions taken, and how long the employee has been logged into a system (Rinehart-Thompson 2016c, 265).

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

Correct Answer: A As the HIM department merges two duplicates together, the source system (laboratory) also must be corrected. This creates new challenges for organizations because merge functionality could be different in each system or module, which in turn creates data redundancy. When duplicates are identified, the department managers need to be notified. Addressing ongoing errors within the MPI means an established quality measurement and maintenance program is crucial to the future of healthcare (Sayles 2016b, 58).

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

Correct Answer: A CDI metrics are key indicators used to monitor the effectiveness of CDI programs. One of the most widely used key indicators for a CDI program is the case-mix index. A strong CDI program will strengthen the case-mix index because the quality and specificity of the documentation help the coders to choose the appropriate codes (Foltz et al. 2016, 464).

*An alternative to the retrospective coding model is the __________ coding model in which records are coded while the patient is still an inpatient. a. Concurrent b. Analytical c. Prospective d. Auxiliary

Correct Answer: A Concurrent coding is the type of coding that takes place in the hospital while the patient is still receiving care (AHIMA 2017, 56).

Hospital documentation related to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned: a. By the hospital b. By the patient c. By the attending and consulting physician d. Jointly by the hospital, physician, and patient

Correct Answer: A Health records, x-rays, laboratory reports, consultation reports, and other physical documents relating to the delivery of patient care are owned by the healthcare organization (Rinehart- Thompson 2016a, 205).

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

Correct Answer: A In order to maintain patient privacy certain audits may need to be completed daily. If a high profile patient is currently in a facility, for example, access logs may need to be checked daily to determine whether all access to this patient's information by workforce is appropriate (Thomason 2013, 173).

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

Correct Answer: A In the outpatient setting, do not code a diagnosis documented as "probable." Rather, code the conditions to the highest degree of certainty for the encounter (Schraffenberger and Palkie 2019, 105).

What factor is medical necessity based on? a. The beneficial effects of a service for the patient's physical needs and quality of life b. The cost of a service compared with the beneficial effects on the patient's health c. The availability of a service at the facility d. The reimbursement available for a given service

Correct Answer: A Medical necessity is based on the effects of a service for the patient's physical needs and quality of life (Gordon and Gordon 2016a, 426; Sayles and Gordon 2016, 659).

What types of covered entity health records are subject to the HIPAA privacy regulations? a. Health records in any format b. Only health records in electronic format c. Only health records from hospitals d. Only health records in paper format

Correct Answer: A One of the most fundamental terms used in the Privacy Rule is protected health information (PHI). The Privacy Rule defines PHI as individually identifiable health information that is transmitted by electronic media, maintained in any electronic medium, or maintained in any other form or medium (Rinehart-Thompson 2016b, 220, 222).

A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used? See Graph a. 82 b. 156 c. 820 d. 1,550

Correct Answer: A Sampling is the recording of a smaller subset of observations of the characteristic or parameter, making certain, however, that a sufficient number of observations have been made to predict the overall configuration of the data. In this case, 82 records would be a sufficient number to review for coding quality. The calculation is: (500 × 0.05) + (480 × 0.05) + (300 × 0. 05) + (360 × 0.05) = 82 records (Shaw and Carter 2019, 72).

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

Correct Answer: A 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 (Thomason 2013, 102).

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

Correct Answer: B 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 (Carter and Palmer 2016, 515).

Which tool is used to display performance data over time? a. Status process control chart b. Run chart c. Benchmark d. Time ladder

Correct Answer: B A 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 (Carter and Palmer 2016, 509-510).

*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

Correct Answer: B Consistency means ensuring the patient data is reliable and the same across the entire patient encounter. In other words, patient data within the record should be the same and should not contradict other data also in the patient record (Brinda 2016, 158).

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

Correct Answer: B Organizational policy should address how personal health information provided by the patient will or will not be incorporated into the patient's health record. Copies of personal health records (PHRs), created, owned, and managed by the patient, are considered part of the legal health record when the organization uses them to provide treatment; however, the PHR does not replace the legal health record (Fahrenholz 2017c, 57).

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

Correct Answer: B Organizations should develop and maintain an inventory of all documents and data that could comprise the legal health record, considering all locations in the organization (for example, separate departments or servers) where such information could be housed. Organizations should also carefully consider whether to include data such as pop-up reminders, alerts, and metadata. Metadata are data about data and include information that track actions such as when and by whom a document was accessed or changed (Rinehart-Thompson 2016a, 206).

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

Correct Answer: B Reasonable diligence is when the healthcare provider has taken reasonable actions to comply with the legislative requirements (Foltz et al. 2016, 451).

*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

Correct Answer: B The HIM professional should advise the medical group practice to develop a list of statutes, regulations, rules, and guidelines regarding the release of the health record as the first step in determining the components of the legal health records (Rinehart-Thompson 2017b, 170-171).

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.

Correct Answer: B 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 (Thomason 2013, 37).

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

Correct Answer: B The root operation extirpation is defined as taking or cutting out solid material from a body part. The matter may have been broken into pieces during the lithotripsy previous to this encounter, but at this time the pieces of the calculus are being removed (Kuehn and Jorwic 2019, 85-86).

A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): a. Suspended record b. Delinquent record c. Pending record d. Illegal record

Correct Answer: B When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards (Sayles 2016b, 64-65).

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

Correct Answer: C Administered by the federal government Centers for Medicare and Medicaid Services (CMS), the Medicare Conditions of Participation or Conditions for Coverage apply to a variety of healthcare organizations that participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and, thus, must follow the Medicare Conditions of Participation (Brickner 2016, 84).

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

Correct Answer: C All individuals whose information has been breached must be notified without unreasonable delay, and not more than 60 days, by first-class mail or a faster method such as by telephone if there is the potential for imminent misuse. If 500 or more individuals are affected, they must be individually notified immediately and media outlets must be used as a notification mechanism as well. The Secretary of HHS must specifically be notified of the breach. The attending physicians of the patients do not need to be notified of the breach (Rinehart-Thompson 2016b, 240).

An external security threat can be caused by which of the following? a. Employees who steal data during work hours b. A facility's water pipes bursting c. Tornadoes d. The failure of a facility's software

Correct Answer: C All threats can be categorized as either internal threats (threats that originate within an organization) or external threats (threats that originate outside an organization). People are not the only threats to data security. Natural disasters such as earthquakes, tornadoes, floods, and hurricanes can demolish physical facilities and electrical utilities (Rinehart-Thompson 2016c, 256-257).

*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

Correct Answer: C An occurrence report is a structured data collection tool that risk managers use to gather information about potentially compensable events. Effective occurrence reports carefully structure the collection of data, information, and facts in a relatively simple format (Shaw and Carter 2019, 200).

Data elements collected on large populations of individuals and stored in databases are referred to as: a. Statistics b. Information c. Aggregate data d. Standard

Correct Answer: C Data about patients can be extracted from individual health records and combined as aggregate data. Aggregate data are used to develop information about groups of patients. For example, data about all patients who suffered an acute myocardial infarction during a specific time period could be collected in a database (Sharp 2016, 173).

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

Correct Answer: C In the context of healthcare, privacy can be defined as the right of individuals to control access to their personal health information (Gordan and Gordan 2016c, 610).

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

Correct Answer: C 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 (Fahrenholz 2017a, 82).

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

Correct Answer: C Maintaining some type of accounting procedure for monitoring and tracking PHI disclosures has been a common practice in departments that manage health information. However, the 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. PHI sent to a physician that has not treated the patient would need to be accounted for (Rinehart-Thompson 2017d, 247-248).

*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

Correct Answer: C 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 (Kelly and Greenstone 2016, 161).

Based on this output table, what is the average coding test score for the beginner coder? Mean (average) Advanced = 93.0000 Intermediate = 89.5000 Beginner = 73.3333 Total = 84.7500 a. 93 b. 6.4 c. 73 d. 90

Correct Answer: C Since the mean is the average and the value next to the "beginner" under coder status is 73.3333, round the value to a whole number and the best answer is 73 (Watzlaf 2016, 359)

*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

Correct Answer: C Sometimes HIM professionals are subpoenaed to testify as to the authenticity of the health records by confirming that they were compiled in the normal course of business and have not been altered in any way. A subpoena that is issued to elicit testimony is a subpoena ad testificandum (Rinehart-Thompson 2016b, 198).

*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

Correct Answer: C To begin the review, the coding supervisor checks the inpatient health record to ensure that the diagnosis billed as principal meets the official Uniform Hospital Discharge Data Set (UHDDS) definition for principal diagnosis. The principal diagnosis must have been a principal reason for admission, and the patient received treatment or evaluation during the stay. When several diagnoses meet all of those requirements, any of them could be selected as the principal diagnosis (Schraffenberger and Kuehn 2011, 315).

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

Correct Answer: D 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 (Sayles 2016b, 55).

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

Correct Answer: D In 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 (Prater 2016, 584).

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments? See Graph a. BC/BS b. Commercial c. TRICARE d. Medicare

Correct Answer: D In the "Payments" column, Medicare has the highest payment percentage (42 percent) of any of the payers; therefore, Medicare contributes more to the hospital's overall payments (Watzlaf 2016, 347).

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed. Given this data, which procedures should the council scrutinize in evaluating performance. See Graph a. Procedures 1, 4 b. Procedures 2, 3, 5 c. Procedures 6, 7 d. Procedures 1, 4, 6, 7

Correct Answer: D 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 (Shaw and Carter 2019, 40-41).

From the information provided in this table below, what percentage will the facility be paid for procedure 25500? V T = 100% X S S a. 0% b. 50% c. 75% d. 100%

Correct Answer: D Procedure 25500 has a "T" status indicator, which indicates that it is a significant procedure and multiple procedure reductions will apply. In this case, there is only one CPT procedure code that is a status "T" indicator, so 100 percent of the fee-based APC will be paid (Casto 2018, 159-160).

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

Correct Answer: D The 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 (Thomason 2013, 98).

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

Correct Answer: D The HIPAA Security Rule requires that access to electronic PHI in information systems is monitored. Included in the same standard is the requirement that covered entities examine the activity using access audit logs. 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. Creation of an account through the patient portal by the patient is appropriate use (Thomason 2013, 177).

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system

Correct Answer: D The database management system is the best option to collect, store, manipulate, and retrieve data for this situation. Paper and word-processing documents cannot sort and store the data in a meaningful way for this purpose. Spreadsheets should be used for accounting-type functions and not for data storage (Sayles and Kavanaugh-Burke 2018, 28).

The national patient safety goals score organizations on areas that: a. Affect the financial stability of the organization b. Commonly lead to overpayment c. Affect compliance with state law d. Commonly lead to patient injury

Correct Answer: D The national patient safety goals outline for healthcare organizations the areas of organizational practice that most commonly lead to patient injury or other negative outcomes that can be prevented when staff utilize standardized procedures (Carter and Palmer 2016, 520).

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

Correct Answer: A Treatment, payment, and operations (TPO) is 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 (Rinehart-Thompson 2016b, 223).

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

Correct Answer: D 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 (Sayles and Kavanaugh-Burke 2018, 207).

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

Correct Answer: A A well-trained coding staff helps ensure complete and accurate coding, which is essential for the integrity of the data collected. All coders in the facility should receive continuing education, but certified coders must demonstrate that they are continuing to maintain their knowledge and skill base. To maintain their certification, individuals must complete a designated set of continuing education units (Sayles 2016a, 14).

Coding accuracy is best determined by: a. A predefined audit process b. Medicare Conditions of Participation c. Payer audits d. Joint Commission Standards for Accreditation

Correct Answer: A Accuracy of coding is best determined by a predefined audit process. The audits allow the facility to confirm that the policies and procedures of the organization are being met and to identify problems that need to be addressed and corrected (Foltz et al. 2016, 459).

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.

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 (Sayles 2016b, 52).

*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

Correct Answer: A Appointments to the Board of Directors is important information, but the Joint Commission requires detailed information on the responsibilities and actions of the Board, not necessarily its composition. 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 (Shaw and Carter 2019, 304, 313).

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? 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

Correct Answer: A 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 (Shaw and Carter 2019, 70).

Which of the following definitions best describes the concept of confidentiality? a. The expectation that personal information shared by an individual with a healthcare provider during the individual's care will be used only for its intended purpose b. The protection of healthcare information from damage, loss, and unauthorized alteration c. The right of individuals to control access to their personal health information d. The expectation that only individuals with the appropriate authority will be allowed to access healthcare information

Correct Answer: A Confidentiality refers to the expectation that the personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose (Rinehart-Thompson 2016b, 214).

*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? 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.

Correct Answer: A 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).

An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit controls c. Contingency controls d. Security incident controls

Correct Answer: A Establishing access controls is a fundamental security strategy. Basically, the term access Control means being able to identify which employees should have access to what data. The general practice is that employees should have access only to data they need to do their jobs. For example, an admitting clerk and a healthcare provider would not have access to the same kinds of data (Rinehart-Thompson 2016c, 273).

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

Correct Answer: A Every healthcare facility should have a clinical forms committee to establish standards for design and to approve new and revised forms. The committee should also have oversight of computer screens and other data capture tools (Sayles 2016b, 66).

A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of: a. Healthcare fraud b. Payment optimization c. Payment reduction d. Healthcare creativity

Correct Answer: A Healthcare fraud is an intended and deliberate deception or misrepresentation by a provider, or by representative of a provider, that results in a false or fictitious claim. These false claims then result in an inappropriate payment by Medicare or other insurers (Foltz et al. 2016, 448).

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

Correct Answer: A 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 (Casto 2018, 34).

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways? a. Makes it lower than warranted by the actual service and resource intensity of the facility b. Makes it higher than warranted by the actual service and resource intensity of the facility c. Hospital's MS-DRG case mix is never monitored so there is no impact d. Coding has nothing to do with a hospital's MS-DRG case mix

Correct Answer: A Medicare severity diagnosis-related group (MS-DRG) sets exist where the listings of diagnoses used to drive the grouping are the same, but the presence or absence of a complication or comorbidity (CC) diagnosis or major complication or comorbidity (MCC) diagnosis assigns the case to a higher or lower MS-DRG. MS-DRG sets may contain two or three MS-DRGs. These MS-DRG relationships and sets pose a compliance concern because the health record documentation used to support the coding of principal diagnosis, complications, and comorbidities may not always be clear or used appropriately by the coder (such as undercoding). Therefore, inaccurate coding can lead to incorrect MS-DRG assignment and thus inappropriate reimbursement and can affect a hospital's case mix (Gordon and Gordon 2016a, 441).

Typically, the record custodian can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. Identification of the record as the one subpoenaed b. The care provided to the patient c. The qualifications of the treating physician d. Identification of the standard of care used to treat the patient

Correct Answer: A Original health records may be required by subpoena to be produced in person and the custodian of records is required to authenticate those records through testimony (Rinehart-Thompson 2016a, 198).

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

Correct Answer: A The National Health Information Network is 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 (Fahrenholz 2017c, 62).

Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: a. Legitimate need for access b. Password to access the EHR c. Report development program d. Signed confidentiality agreement

Correct Answer: A The access controls standard requires implementation of technical procedures to control or limit access to health information. The procedures would be executed through some type of software program. This requirement ensures that individuals are given authorization to access only the data they need to perform their respective jobs (Rinehart-Thompson 2016c, 273).

A family practitioner requests the opinion of a physician specialist who reviews the patient's health record and examines the patient. In what type of report would the physician specialist record findings, impressions, and recommendations? a. Consultation b. Medical history c. Physical examination d. Progress notes

Correct Answer: A The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The report is based on the consulting physician's examination of the patient and a review of his or her health record (Brickner 2016, 96).

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

Correct Answer: A The first step in analyzing data is to know your objective or the purpose of the data analysis (Watzlaf 2016, 363-364).

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

Correct Answer: A The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance (Foltz et al. 2016, 461-462).

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

Correct Answer: A The health record typically begins in patient registration with the capture of patient demographic information. The health record is assigned to new patients during the patient registration process. The HIM department works with patient registration to ensure the quality of the data collected and to correct duplicate and other issues with the MPI (Sayles 2016b, 74).

*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? 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

Correct Answer: A 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).

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

Correct Answer: A The responsibilities of the quality improvement organizations include reviewing health records to confirm the validity of hospital diagnosis and procedure coding data completeness (Foltz et al. 2016, 454).

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medical unit within a two-week period. What clinical report would be the best source to gather this information? a. Vital signs record b. Initial nursing assessment record c. Physician progress notes d. Admission record

Correct Answer: A The vital signs record is comprised of blood pressure readings, temperature, respiration, and pulse, making it the best source to gather this type of information (Brickner 2016, 94).

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

Correct Answer: A To correct errors or make changes 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. (Sayles 2016b, 65).

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.

Correct Answer: A When other healthcare providers provide records, it is done to ensure the continuity of care for the individual. Many covered entities either include the whole file or copies of the file as part of the covered entity's record, with the assumption that the treating physician has used some or all of the records to decide how to treat the patient. Any copies that are included with the records of the individual are, therefore, considered part of the individual's designated record set and should be released (Thomason 2013, 99).

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

Correct Answer: A 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 (Schraffenberger and Palkie 2019, 142).

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

Correct Answer: A Whether selecting a permanent staff team or members of a team for a short-term project, making the right choice is fundamental to the team's success. Putting together a team involves understanding the challenges to be faced and considering all of the perspectives, experience, and knowledge that will be needed. The members of the team should be selected for what they can contribute to the team. Member selection should not be based purely on job title; rather, team members should be selected for the tasks that they actually can perform and the responsibilities they can carry out (Kellogg 2016b, 487).

An employee views a patient's electronic health record. It is a trigger event if: a. The employee and patient have the same last name b. The patient was admitted through the emergency department c. The patient is over 89 years old d. A dietitian views a patient's nutrition care plan

Correct Answer: A With appropriate policies and procedures in place, it is the responsibility of the organization and its managers, directors, CSO, and employees with audit responsibilities to review access logs, audit trails, failed logins, and other reports. One type of event that would be a trigger event would include employees viewing records of patients with the same last name or address of the employee (Rinehart-Thompson 2016c, 275).

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Currently, three deficiency notices are sent to the physicians through the EHR system including an initial notice, a second reminder, and a final notification. Which of the following would be the best first step in trying to rectify the current situation? a. Call the Joint Commission and notify them of non-compliant physicians b. Consult with the medical director who has authority over the on-call physicians for suggestions on how to improve response to the current notices c. Post the hospital policy in the emergency department d. Routinely send out a fourth notice to remind each physician of his or her documentation obligations

Correct Answer: B A coding manager or physician champion should present documentation issues to educate the medical staff. General areas of concern regarding documentation should be included (Schraffenberger and Kuehn 2011, 386-387).

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

Correct Answer: B A complete medical history documents the 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 (Brickner 2016, 90).

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

Correct Answer: B 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 (Horton 2016, 386).

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.

Correct Answer: B All states have a health department with a division that is required to track and record communicable diseases. When a patient is diagnosed with one of the diseases from the health department's communicable disease list, the facility must notify the state public health department (Shaw and Carter 2019, 177).

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

Correct Answer: B An issue with the quality of the MPI is an overlay, where a patient is erroneously assigned another person's health record number. When this happens, patient information from both patients becomes commingled and care providers may make medical decisions based on erroneous information, increasing the legal risks to the healthcare organization and quality of care risks to the patient as well (Sayles 2016b, 58).

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

Correct Answer: B Because this patient was seen only in the emergency department, he or she would be classified as an outpatient. Diagnoses documented as "probable," "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms in the outpatient setting indicate uncertainty and would not be coded as if existing. Rather, code the condition to the highest degree of certainty for that encounter or visit, such as signs, symptoms, abnormal test results, or other reason for the visit. In this case, unspecified chest pain would be coded (Schraffenberger and Palkie 2019, 98).

Which of the following practices is an appropriate coding compliance activity? a. Reviewing all accurately paid claims b. Developing procedures for identifying coding errors c. Providing a financial incentive for coding claims improperly d. Instructing coders to code diagnoses and submit the bill before all applicable information is documented in the health record

Correct Answer: B Coding compliance activities would not include a financial incentive for coders to commit fraud, to code diagnoses and procedures before documentation is complete, or to spend resources reviewing accurately paid claims. Providing a financial incentive to coders for coding claims improperly would be against any coding compliance plan and would also be a violation of AHIMA's Standards of Ethical Coding. One of the basic elements of a coding compliance program includes developing policies and procedures for identifying coding errors (Foltz et al. 2016, 461-462).

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

Correct Answer: B 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 (Sayles and Kavanaugh-Burke 2018, 206).

When data has been lost in an EHR, which action is taken to remedy this problem? a. Build a firewall b. Data recovery c. Review the audit trail d. Develop data integrity plan

Correct Answer: B Data recovery is the process of recouping lost data or reconciling conflicting data after the system fails. These data may be from events that occurred while the system was down or from backed-up data (Sayles and Kavanaugh-Burke 2018, 228).

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

Correct Answer: B Each healthcare organization must identify and prioritize which processes and outcomes are important to monitor on the basis of its mission and the scope of care and services it provides (Shaw and Carter 2019, 25).

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

Correct Answer: B 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 (Brodnik 2017b, 343-344).

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

Correct Answer: B Employee self-appraisal provides the opportunity for the employee to keep the supervisor informed of accomplishments and issues (Prater 2016, 575-576).

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

Correct Answer: B 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 (Schraffenberger and Kuehn 2011, 271).

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.

Correct Answer: B 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 (Rinehart-Thompson 2016c, 271).

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

Correct Answer: B 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 (Schraffenberger and Palkie 2019, 483).

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met: a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits

Correct Answer: B Local coverage determination (LCD) is used to determine coverage on a Medicare Administrative Contractor-wide, intermediary-wide, or carrier-wide basis (rather than nationwide, as with a NCD). LCDs are educational materials that assist facilities and providers with correct billing and claims processing. Within the LCD is a listing of ICD-10-CM codes that indicate what is covered and what is not covered. For example, a procedure may be covered by Medicare, but is not reimbursed by Medicare because it does not meet medical necessity (Casto 2018, 255).

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

Correct Answer: B Medicare-certified home healthcare uses 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 (Selman-Holman 2017, 345).

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment? 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 58662 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring) a. 49320, 58662 b. 58670 c. 58671 d. 49320

Correct Answer: B No mention is made of biopsy, excision of lesion, or occlusion, so following proper steps for coding in CPT, the correct code is 58670 (Kuehn 2019, 22).

*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

Correct Answer: B One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description for accuracy (Foltz et al. 2016, 458-459).

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

Correct Answer: B Patient care managers are responsible for the overall evaluation of services rendered for their particular area of responsibility. To identify patterns and trends, they take details from individual health records and put all the information together in one place (Sayles 2016b, 54).

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

Correct Answer: B Patient care outcomes are reviewed to improve the safety and quality of care as well as to identify issues related to medical necessity for treatment and appropriateness of care. Accrediting and licensing entities expect that healthcare organizations will choose appropriate measures for the services they offer. In this situation is it important to determine whether there was a medical or other reason why patients were not given aspirin within 24 hours of arrival at the hospital. This determination is critical to assess compliance with the quality goal (Shaw and Carter 2019, 160).

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

Correct Answer: B Performance monitoring is data driven. The organization's leadership uses the information displayed on the dashboard to guide operations and determine improvement projects. Having real-time data in an easily assessable format like a dashboard allows leaders to keep track of high-impact, high-risk, or high-value processes and make adjustments on a daily basis if needed (Carter and Palmer 2016, 502).

In designing an input screen for an EHR, which of the following would be best to capture structured data? a. Speech recognition b. Drop-down menus c. Natural language processing d. Document imaging

Correct Answer: B Structured data are data that are able to be read and interpreted by a computer. Examples of structured data include check boxes, drop-down boxes, and radio buttons (Brinda 2016, 159-160).

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

Correct Answer: B 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 (Rinehart-Thompson 2016a, 206-207).

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

Correct Answer: B The master patient index (MPI) is the permanent record of all patients treated at a healthcare facility. It is used by the HIM department to look up patient demographics, dates of care, the patient's health record number, and other information (Sayles 2016b, 56).

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

Correct Answer: B 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) (Watzlaf 2016, 359).

*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

Correct Answer: B The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this method, personnel from the HIM department go to the nursing unit daily (or periodically) to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital (Sayles 2016b, 64).

A patient has a malunion of an intertrochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure? a. 0QB60ZZ, excision b. 0Q860ZZ, division c. 0SB90ZZ d. 0SN90ZZ

Correct Answer: B The root operation performed was division—cutting into a body part without drawing fluids and/or gases from the body part in order to separate or transect a body part. The intent of the operation was to separate the femur; 0Q860ZZ is the correct code. The Section is Medical and Surgical—character 0; Body System is Lower Bones—character Q; Root Operation is Division—character 8; Body Part is Femur, Right—character 6; Approach is Open—character 0; No Device—character Z; and No Qualifier —character Z (Kuehn and Jorwic 2019, 27-28, 93).

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

Correct Answer: B There are three exceptions to a breach. All of these answers fall into one of these categories with the exception of the records sent to the patient's attorney. He does not work for the covered entity and an authorization is required (Rinehart-Thompson 2016b, 240).

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

Correct Answer: C Ethical coding practices must be followed with appropriate employee counseling and remediation (Foltz et al. 2016, 458).

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

Correct Answer: B There are two types of transfer cases under the inpatient prospective payment system (IPPS). The first category is a patient transfer between two IPPS hospitals. A type 1 transfer is when a patient is discharged from an acute IPPS hospital (Community Hospital in this case) and is admitted to another acute IPPS hospital (Big Medical Center) on the same day. Payment is altered for the transferring hospital and is based on a per diem rate methodology. The transferring facility receives double the per diem rate for the first day plus the per diem rate for each day thereafter for the patient LOS. The receiving facility receives the full PPS payment rate for the case (Casto 2018, 125).

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

Correct Answer: B 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) (Foltz et al. 2016, 450).

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

Correct Answer: B When the tail is pulled toward the right side, it is called a positively skewed distribution; when the tail is pulled toward the left side of the curve it is called a negatively skewed distribution (Watzlaf 2016, 361-362).

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

Correct Answer: C 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 (Brinda 2016, 163).

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do? a. Reprimand the employee b. Terminate the employee c. Determine what information was printed and why d. Revoke the employee's access privileges

Correct Answer: C Audit trails are usually examined by system administrators who use special analysis software to identify suspicious or abnormal system events or behavior. Because the audit trail maintains a complete log of system activity, it can also be used to help reconstruct how and when an adverse event or failure occurred (Rinehart-Thompson 2016c, 265).

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

Correct Answer: C Clinical laboratory reports should be reviewed to determine if a partial thromboplastin time (PTT) test was performed. Medication Administration Records (MAR) should be reviewed to determine if heparin was given after the PTT test was performed (Brickner 2016, 94).

*The utilization manager's role is essential to: a. Analyze the estimate of benefits (EOBs) received b. Capture all relevant charges for the patient's account c. Prevent denials for inappropriate levels of service d. Verify the patient has insurance

Correct Answer: C Front-end utilization management (UM) is essential to the prevention of denials for inappropriate levels of care. UM staff work with the physician to ensure that the requested services meet medical necessity requirements and are provided in the most appropriate setting. When the insurer denies the claim, an appeal may be possible (Schraffenberger and Kuehn 2011, 467).

*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

Correct Answer: C 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 (Sharp 2016, 188).

Which of the following is a secondary purpose of the health record? a. Support for provider reimbursement b. Support for patient self-management activities c. Support for research d. Support for patient care delivery

Correct Answer: C Healthcare is a sophisticated industry and information from the health record is used for many purposes not related specifically to patient care. These secondary purposes include support for public health and research (Sayles 2016b, 52-53).

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.

Correct Answer: C Hospitals strive to keep incident reports confidential, and in some states, incident reports are protected under statutes protecting quality improvement studies and activities. 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 (Carter and Palmer 2016, 522).

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

Correct Answer: C In the EHR, the user is able to copy and paste free text from one patient or patient encounter to another. This practice is dangerous as inaccurate information can easily be copied. One of the risks to documentation integrity of using copy functionality includes propagation of false information in the record (Sayles 2016b, 69).

Which of the following is an example of a physical safeguard that should be provided for in a data security program? a. Using password protection b. Prohibiting the sharing of passwords c. Locking computer rooms d. Annual employee training

Correct Answer: C Physical safeguards refer to the physical protection of information resources from physical damage, loss from natural or other disasters, and theft. This includes protection and monitoring of the workplace, computing facilities, and any type of hardware or supporting information system infrastructure such as wiring closets, cables, and telephone and data lines. To protect from intrusion, there should be proper physical separation from the public. Doors, locks, audible alarms, and cameras should be installed to protect particularly sensitive areas such as data centers (Rinehart-Thompson 2016c, 264).

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

Correct Answer: C Policies and procedures also can be considered organizational tools. Policies are written descriptions of the organization's formal positions. Procedures are the approved methods for implementing those positions. Together, they spell out what the organization expects employees to do and how they are expected to do it (Gordon and Gordon 2016b, 537-538).

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 d. Hypertension, Catheter-associated urinary tract infection, Cerebral vascular accident

Correct Answer: C Present on admission (POA) is defined as present at the time the order for inpatient admission occurs. Conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered present on admission. This patient was not admitted with a catheter-associated urinary infection and so that condition cannot be coded as POA. The patient was admitted with symptoms of a stroke and diagnoses of COPD and hypertension. The CVA was documented after admission, but the symptoms of the stroke were POA, so this condition would be coded as POA (Gordon and Gordon 2016, 437).

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

Correct Answer: C Progressive penalties ensure that the minimum penalty appropriate to the level of offense is applied. Penalties may include but are not limited to oral warning for first unexcused tardiness and written warning for the second instance; serious rule violations, such as bringing a weapon to work, may result in immediate dismissal (Prater 2016, 581).

The release of information function requires the HIM professional to have knowledge of: a. Clinical coding principles b. Database development c. Federal and state confidentiality laws d. Human resource management

Correct Answer: C Release of information (ROI) is the process of providing PHI access to individuals or entities that are deemed to be authorized to either receive or review it. Protecting the security and privacy of patient information is one of a healthcare organization's top priorities, and the HIM department is usually responsible for determining appropriate access to and ROI from patient health records. Knowledge of state and federal confidentiality laws is critical to the ROI function (Rinehart-Thompson 2016b, 243-245).

*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

Correct Answer: C 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 (Sayles and Kavanaugh-Burke 2018, 16).

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

Correct Answer: C The HIPAA Privacy Rule requires the covered entity to have business associate agreements in place with each business associate. This agreement must always include provisions regarding destruction or return of protected health information (PHI) upon termination of a business associate's services. Upon notice of the termination, the covered entity needs to contact the business associate and determine if the entity still retains any protected health information from, or created for, the covered entity. The PHI must be destroyed, returned to the covered entity, or transferred to another business associate. Once the PHI is transferred or destroyed, it is recommended that the covered entity obtain a certification from the business associate that either it has no PHI, or all PHI it had has been destroyed or returned to the covered entity (Thomason 2013, 18).

*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

Correct Answer: C 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 (Gordon and Gordon 2016a, 437; Sharp 2016, 185).

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

Correct Answer: C The accounts not selected for billing report is a daily report used to track the many reasons that accounts may not be ready for billing. This report is also called the discharged not final billed (DNFB) report. Accounts that have not met all facility-specified criteria for billing are held and reported on this daily tracking list. Some accounts are held because the patient has not signed the consents and authorizations required by the insurer. Still others are not billed because the primary and secondary insurance benefits have not been confirmed (Schraffenberger and Kuehn 2011, 436; AHIMA 2017, 81).

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

Correct Answer: C The gap analysis process compares omitted clinical information received from external providers with the needed clinical information to make a correct diagnosis. Once complete, the HIM professional would analyze the data and develop a plan for correction (Rossiter 2017, 279).

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

Correct Answer: C 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 (Foltz et al. 2016, 450; AHIMA 2017, 168).

*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

Correct Answer: C The legal health record distinction is important for several reasons. First, it is important to an organization's business and legal processes. Second, because the legal health record is the record that is produced upon request, including legal requests, it becomes important to ensure that the legal health record is legally sound and defensible as a valid document in legal situations (Rinehart-Thompson 2016a, 206).

*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

Correct Answer: C The resource that the facility compliance officer should consult to provide information on ongoing reviews and audits each year in programs administered by the department of Health and Human Services (HHS) is the OIG workplan (Foltz et al. 2016, 457).

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

Correct Answer: C The safe harbor method of deidentification requires the removal of 18 specific identifiers from the protect health information (Marc and Sandefer 2016, 22).

When coding a benign neoplasm of skin of the left upper eyelid, which of the following codes should be used? D23 Other benign neoplasms of skin Includes: benign neoplasm of hair folliclesbenign neoplasm of sebaceous glandsbenign neoplasm of sweat glands Excludes1: benign lipomatous neoplasm of skin (D17.0-D17.3)melanocytic nevi (D22.-) D23.0 Other benign neoplasm of skin of lipExcludes1: benign neoplasm of vermilion border of lip (D10.0) D23.1 Other benign neoplasm of skin of eyelid, including canthus D23.10 Other benign neoplasm of skin of unspecified eyelid, including canthus D23.11 Other benign neoplasm of skin of right eyelid, including canthus D23.111 Other benign neoplasm of skin of right upper eyelid, including canthus D23.112 Other benign neoplasm of skin of right lower eyelid, including canthus D23.12 Other benign neoplasm of skin of left eyelid, including canthus D23.121 Other benign neoplasm of skin of left upper eyelid, including canthus D23.122 Other benign neoplasm of skin of left lower eyelid, including canthus D23.2 Other benign neoplasm of skin of ear and external auricular canal D23.20 Other benign neoplasm of skin of unspecified ear and external auricular canal D23.21 Other benign neoplasm of skin of right ear and external auricular canal D23.22 Other benign neoplasm of skin of left ear and external auricular canal

Correct Answer: C When subcategory codes are provided, they must be used. Codes are to be assigned to the highest level of specificity based on provider documentation. In this situation, code D23.121 is the most specific code for this diagnosis (Schraffenberger and Palkie 2019, 35, 43).

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%

Correct Answer: D A complete history and physical report represents the attending physician's assessment of the patient's current health status, and accreditation standards require it to be completed within 24 hours of admission. 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% (Brickner 2016, 84; Horton 2016, 383).

A patient received a complete replacement of tunneled centrally inserted central venous catheter with subcutaneous port; replacement performed through original access site (45-year-old patient). Which of the following CPT codes would be most appropriate? 36578 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580 Replacement, complete, on a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36582 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access 36597 Repositioning of previous placed central venous catheter under fluoroscopic guidance a. 36578 b. 36580 c. 36582, 36597 d. 36582

Correct Answer: D A complete replacement of the entire device by the same venous access site is being performed. It is a tunneled catheter inserted within the same venous access point. Code 36582 is the correct code (Smith 2019, 126-127).

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

Correct Answer: D After the cases to be included have been determined, the next step is usually case finding. Case finding is a method used to identify the patients who have been seen or treated in the facility for the particular disease or condition of interest to the registry, such as cancer in the case of a cancer registry (Sharp 2016, 175).

*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

Correct Answer: D Reported performance data are regularly analyzed for variance. Variance—where actual performance does not meet, varies, or is significantly different from the standard—should be further assessed (Prater 2016, 588).

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 years old b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed

Correct Answer: D Because minors are, as a general rule, legally incompetent and unable to make decisions regarding the use and disclosure of their own health information, this authority belongs to the minor's parent(s) or legal guardian(s) unless an exception applies. Because privacy, security, and confidentiality of minor records are extremely regulated, HIM professionals should also consult state regulations or legal counsel for specific questions. Generally, only one parent signature is required to authorize the use or disclosure of the minor's PHI (Brodnik 2017b, 342).

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

Correct Answer: D Coding professionals shall adhere to the ICD coding conventions, official coding guidelines approved by the Cooperating Parties and any other official coding rules and guidelines established for use with mandated standard code sets (Casto 2018, 26).

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

Correct Answer: D 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 (Brinda 2016, 148).

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

Correct Answer: D 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 (Fahrenholz 2017c, 56).

*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

Correct Answer: D Each function should have its own acceptable level of performance and monitoring should be performed to confirm the standards are met. If not, corrective actions should be taken (Sayles 2016b, 66).

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

Correct Answer: D Internal users of secondary data are individuals located within the healthcare facility. For example, internal users include medical staff and administrative and management staff. Secondary data enable these users to identify patterns and trends that are helpful in patient care, long-range planning, budgeting, and benchmarking with other facilities (Sharp 2016, 173).

If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient: a. For the balance due after Medicare has paid b. Only if both Medicare and any supplemental insurance have been billed and settled c. Never—providers may not bill Medicare patients for amounts unpaid by Medicare d. Only if a properly executed ABN was obtained before the service was provided

Correct Answer: D Medicare does have a provision that a patient may be billed for a test that is not medically necessary if he or she receives an advance beneficiary notice (ABN) before the test is performed. Therefore, not only must the registration staff determine whether the sign or symptom is sufficient, they also may contact the patient's physician to obtain a new order or, if a new order is not provided, to issue an ABN. Success in the patient registration process involves a thoroughly educated staff with the tools to determine medical necessity, the processes in place to clarify orders, and the ability to obtain signatures on ABNs (Schraffenberger and Kuehn 2011, 467).

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

Correct Answer: D 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 (Sayle and Kavanaugh-Burke 2018, 35).

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

Correct Answer: D The Uniform Hospital Discharge Data Set (UHDDS) data characteristics include patient-specific items on every inpatient (Brinda 2016a, 142-143).

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

Correct Answer: D The length of multiple laceration repairs located in the same classification are added together and one code is assigned (Smith 2019, 29-30, 80-81).

*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

Correct Answer: D The problem-oriented health record is better suited to serve the patient and the end user of the patient's information. The key characteristic of this format is an itemized list of the patient's past and present social, psychological, and health problems. (Brickner 2016, 106).

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

Correct Answer: D The purpose of the risk management program is to link risk management functions to related processes of quality assessment and PI. 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 (Carter and Palmer 2016, 522).

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

Correct Answer: D Timeliness of the scanning and quality control processes should be monitored. In this situation, each clinic visit represents a patient record that will need to be scanned and quality control completed. The calculation is: (500 / 50) + (500 / 40) = 22.5 hours per day (Horton 2017, 187; Sayles 2016b, 66-67).

Based on a productivity log, a coder completed 23 charts during a 7.5-hour workday. The performance standard is 4 charts per hour. How many charts did he code per hour? Round to the nearest whole number. a. 2.06 b. 4.1 c. 23 d. 3

Correct Answer: D Work measurement is based on assessment of internal data collected on actual work performed within the organization and the calculation of time it takes to do the work. Employees log what they do and the time spent on tasks in units of work received and processed each day. 23 charts/7.5 hours = 3.06, which is rounded to 3 charts per hour (Prater 2016, 587-588).

Which of the following is true regarding the development of health record destruction policies? a. All applicable laws must be considered b. The organization must find a way not to destroy any health records c. Health records involved in pending or ongoing litigation may be destroyed d. Only state laws must be considered

Not all information must be kept forever. Just as the HIM professional must consider multiple factors when determining retention, many factors must also be taken into consideration with regard to health record destruction. These include applicable federal and state statutes and regulations; accreditation standards; pending or ongoing litigation; storage capabilities; and cost (Rinehart-Thompson 2016a, 208).