Week 5: Domain 4 Compliance Quiz

You recommend that the staff at your home health agency routinely check to verify that a summary on each patient is provided to the attending physician so that they can review, update, and recertify the patient as appropriate. The time frame for requiring this summary is at least every 60 days. week. 90 days. month.

60 days. This 60-day time frame is often referred to as the patient's certification period. Recertification can continue every 62 days until the patient is discharged from home health services.

One excellent source to guide you to perform ethical coding is ________. DHHS AMA AHIMA NEC

AHIMA AHIMA publishes the Standards for Ethical Coding, a set of guidelines that all AHIMA members must follow.

____ is knowingly making false statements or representation of material facts to obtain a benefit or payment for which a lesser amount or no amount at all was actually earned. Whistle-blowing Fraud Assault Abuse

Fraud Fraud is the act of submitting claims with untrue information with the intent of collecting monies that have not been earned. This is the correct answer. Incorrect answers: Abuse—errors that occur by mistake, without intent to defraud Assault—a physical attack Whistle-blowing—a courageous staff member informing authorities of a professional and/or facility is using fraudulent practices

Sylvia Dean received ablation therapy at Hematology Associates USA on May 20, 2020. She later visited her dental hygienist, Dr. Meadows, who performed a root canal on July 18 2020. Given the above scenario, who owns the medical record that captures the ablation therapy procedure? Dr. Meadows Hematology Associates and Sylvia Dean Hematology Associates USA Sylvia Dean

Hematology Associates USA In general, ownership of the medical record belongs to the health care provider who created the record. However, the patient has a right to access his or her medical record and to control or determine how his or her information is used or disclosed. INCORRECT ANSWERS:Sylvia Dean is the patient and did not generate or create the medical record. Therefore, she does not own the medical record, which is a legal record as well as a business record. However, she does have access and control over how he patient information is used and disclosed. Dr. Meadows, the dental hygienist, does not own the medical record because he did perform the ablation therapy treatment and did not create the medical record. The medical record is not owned by Hematology Associates USA and Sylvia Dean, it was generated only by Hematology Associates USA. They do not share ownership of the medical record.

Before submitting a query, stop and consider the appropriateness. Which of the following would be considered inappropriate in a query? Including ICD-10-CM/PCS codes, code details, or coding guidelines Being direct in what is being asking without being leading Always include an "out" such as "unable to be determined" Always provide the provider with multiple answer options

Including ICD-10-CM/PCS codes, code details, or coding guidelines Before submitting a query, stop and consider the appropriateness. If there is an issue in the patient documentation that needs clarity, a physician query is necessary, and you should not be afraid of it. Queries are not the time to educate physicians about coding. ICD-10-CM/PCS codes, code details, or coding guidelines should never be included. Remember, the goal of a query is to make the record clearer, nothing more. A query should be direct in what is being asking without being leading, always provide the provider with multiple answer options and always include an "out" such as "unable to be determined."

Lady Dada is a well known singer, but would like to use the name Samantha Sheard when receiving medical care and treatment. Which statement best describes Lady Dada's situation? Lady Dada will be permitted to use an alias in compliance with the providers' procedures. Lady Dada will be permitted to use an alias because she has enough money to pay for all of her medical needs for she is self-insured and does not need to meet the criteria of a third-party insurance provider. Lady Dada will not be permitted to use an alias. Currently there aren't any laws or regulations that permit providers to use an alias for patients.

Lady Dada will be permitted to use an alias in compliance with the providers' procedures. Most state statutes and regulations grant patients the right to request the use of an alias instead of their legal name as a mechanism of providing additional privacy protection. This is permitted as long as the provider has the appropriate policies and procedures in place. INCORRECT ANSWERS:Lady Dada will be permitted to use an alias as long as the provider has the appropriate policy and procedure in place.Most states have statutory and regulatory laws that permit patients to request additional privacy protections including the use of an alias.The request for additional privacy protections is extended to all patients as a right, and is not based upon the amount of money a patient may have.

An organization that reviews the facility's provision of health care services, respond to Medicare beneficiary complaints that have been filed, and take action by implementing quality of care improvements is known as a(n) ______________ Lean Management Model Total Quality Management Program HVBP program Quality Improvement Organization (QIO)

Quality Improvement Organization (QIO) HVBP program stands for Hospital Value-Based Purchasing, a program that rewards hospitals with incentives from the CMS. Lean management model ensures that all employees are empowered to speak-up about problems affecting patient care and create patient-centered processes. Quality Improvement Organization (QIO) reviews the facility's provision of healthcare services, responds to Medicare beneficiary complaints that have been filed, and takes action by implementing quality of care improvements. This is the correct answer. Total Quality Management Program aims to improve the competitiveness of an organization through employee participation, customer-driven quality, and continuous quality improvement.

Which feature is a trademark of an effective PI program? a one-time cure-all for a facility's problems an unmanageable project that is too expensive a cost-containment effort a continuous cycle of improvement projects over time

a continuous cycle of improvement projects over time PI stands for Performance Improvement. An effective PI program should have a continuous cycle of improvement projects over time. Wronganswers: A PI program includes systematic activities that are organized to monitor, assess, and improve quality of care. Therefore, the followingwould not help achieve the goal of PI: 1) an unmanageable project that is too expensive 2) A one-time cure-all for a facility's problems 3) A costcontainmenteffort.

Which of the following is less likely to be considered a covered entity under the HIPAA Privacy Rule? a managed care organization a primary physician in a local practice a third-party administrator that is responsible for transmitting medical claims a locally family-owned drug store

a locally family-owned drug store The HIPAA rules apply to specific organizations that are referred to as covered entities and business associates. A covered entity is defined as a health plan, health care clearinghouse, or a health care provider that transmits information in electronic form in connection with a transaction. Incorrect answers: A managed care organization is considered a covered entity under the HIPAA Privacy Rule. A third-party administrator that is responsible for transmitting medical claims is considered a covered entity under the HIPAA Privacy Rule. A primary physician in a local practice is considered a covered entity under the HIPAA Privacy Rule.

An ethical physician's query cannot include ________. the diagnosis or procedure in question a recommendation for an answer the patient's name suggested "answer by" date

a recommendation for an answer A recommendation for an answer cannot be included in an ethical physician's query because it implies leading the physician toward a response that may constitute fraud.

HIM professionals have a duty to maintain health information that complies with state statutes. federal statutes. all of these answers apply. accreditation standards.

all of these answers apply. HIM professionals have a duty to maintain health information that complies with federal and state statutes; accreditation standards; conditions of participation; licensure requirements; professional practices as established by AHIMA's code of ethics; and other rules and regulations as established by the organization. Incorrect answers: Federal statutes: health information management professionals must be knowledgeable of and adhere to federal statutes in order to be competent and effective health professionals. Accreditation standards: health information management professionals must be knowledgeable of and adhere to Accreditation Standards in order to be competent and effective health professionals. State statutes: health information management professionals must be knowledgeable of and adhere to state statutes in order to be competent and effective health professionals.

External audits may be conducted by several organizations in the federal government as well as the private sector, including ________. RAC Humana Fraud Department OIG any of these

any of these External audits are also known as fraud investigations and can be conducted by any third-party payer to whom the facility submits a claim.

The failure to obtain the written consent of the patient before performing a surgical procedure may constitute malpractice. libel. battery. contempt.

battery. Battery is the intentional touching of another person's body without his or her consent. In this scenario, the surgeon performed a surgical procedure on the patient's body without first obtaining the patient's consent. Health care professionals must obtain consent from the patient in order to perform any medical and surgical procedures on a patient. Incorrect answers: Libel is defamation in written form. Contempt is any willful disobedience to, or disregard of, a court order or any misconduct in the presence of a court. Malpractice is the misconduct of professional persons, including health care providers, attorneys, accountants, and others.

The Joint Commission has a standard stating that a hospital must plan and design information management processes to meet _____________ information needs. both internal and external patient record internal external

both internal and external Both internal and external needs must be met. This is the correct answer. External needs are insufficient to wholly protect the information. Internal needs are insufficient to wholly protect the information. Patient record is only one aspect of health information management responsibilities.

The coding supervisor notices that the coders are routinely failing to code all possible diagnoses and procedures for a patient encounter. This indicates to the supervisor that there is a problem with validity. timeliness. completeness. reliability.

completeness It is very important to have experienced, well-trained coders in order to ensure accurate and complete code assignment and optimum reimbursement. Coders must be skilled at reading through documentation on a variety of different forms and formats and interpreting that documentation to arrive at the correct code assignment. Incorrect answers: Validity assesses relevance, completeness, accuracy, and correctness—it measures how well a data collection instrument measures what it should measure. Timeliness of documentation is linked to accurate documentation—individual documents in the patient health record must be created in a timely manner according to standards used by the facility. Reliability refers to consistency between users of a given instrument or method. Reliability is the extent in which two or more independent coders agree on the coding of the content of interest with an application of the same coding scheme.

You are the director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to the case study above, Bayshore Hospital is the __________________ in this case. appellee defendant appellant plaintiff

defendant The defendant is the individual, or party against whom the lawsuit is brought. Incorrect answers: Plaintiff is the individual who initiates a lawsuit to enforce either his or her right's or another's obligations. Appellant is the party appealing a case, also known as the petitioner. Appellee is the party against whom a case is appealed, also known as the respondent.

The purpose of the Correct Coding Initiative is to teach coders how to unbundle codes. restrict Medicare reimbursement to hospitals for ancillary services. increase fines and penalties for bundling services into comprehensive CPT codes. detect and prevent payment for improperly coded services.

detect and prevent payment for improperly coded services. The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims.

A coder notices that some patient records contain incomplete documentation. The coder brings these records to the attention of the coding supervisor who will implement the next stage of the coding compliance program. What stage of coding compliance is being described in this scenario? prevention correction verification detection

detection Detection is the process of identifying potential coding compliance problems. Incorrect answers: Correction is based on the review of patient records that contain potential coding compliance problems, during which specific compliance issues are identified and problem solving methods are used to implement necessary improvements/corrections. Prevention involves educating coders and providers so as to prevent coding compliance problems from recurring. Verification provides an audit trail that the detection, correction, and prevention functions of the coding compliance program are being actively performed.

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain telephone orders. discharge order. stop orders. standing orders.

discharge order. Although many patient health records may feasibly contain all of the orders listed, only the discharge order is required to document the formal release of a patient from the facility. Absence of a discharge order would indicate that the patient left against medical advice, and this event should be thoroughly documented as well. Wrong answers: You should not expect to see completed inpatient health record with 1) telephone order which are verbal instructions given over a phone by a healthcare provider, 2) stop order or 3) standing orders are based on national clinical guidelines and allow communication between non-clinician members of the term for example a nurse.

One of the greatest threats to the confidentiality of health data is when medical information is reviewed as a part of quality assurance activities. disclosure of information for purposes not authorized in writing by the patient. when medical information is used for research or education. lack of written authorization by the patient.

disclosure of information for purposes not authorized in writing by the patient. Patients generally understand that, with consent, information in their medical records will be shared widely within a hospital and for insurance and reimbursement purposes. They also expect that data collected about them will be used only for the purpose of the initial collection and that such data will be shared with others only for that same purpose.A covered entity must obtain the individual's written authorization for any use or disclosure of protected health information that is not for treatment, payment, or health care operations or otherwise permitted or required by the Privacy Rule. All authorizations must contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data. See https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html. Incorrect answers: Lack of written authorization by the patient: this answer is incorrect and is not considered a major threat to the confidentiality of health data. When medical information is reviewed as a part of quality assurance activities: this answer is incorrect and is not considered a major threat to the confidentiality of health data. When medical information is used for research or education: this answer is incorrect and is not considered a major threat to the confidentiality of health data.

Audits are conducted to find ________ between the determined codes to be reported and the clinical documentation. agreement rationales misspellings discrepancies

discrepancies Audits are conducted to find discrepancies between the determined codes and the supporting documentation.

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave documented in both the progress notes and the discharge summary. reported as a potentially compensable event. reported to the Executive Committee. documented in an incident report and filed in the patient's health record.

documented in both the progress notes and the discharge summary. Incident reports are written accounts of unusual events that have an adverse effect on a patient, employee, or facility visitor and should never be filed with the patient's record. PCEs are occurrences that could result in financial liability at some future time. A patient leaving AMA does not in itself suggest a PCE. It is not typical to report AMAs to the Executive Committee. Documenting the event is crucial in protecting the legal interests of the health care team and facility.

AHIMA and HIMSS recommend that organizations participating in HIE take all of the following steps to reduce the risk of unauthorized disclosures EXCEPT conduct a risk analysis to evaluate potential risks. create a policy and procedure to manage HIE within the organization. educate/train the workforce. ensure that all HIE participants have full access to patient information.

ensure that all HIE participants have full access to patient information. American Health Information Management Association (AHIMA) and Health Information Management Systems Society (HIMSS) have recommended the following steps to reduce the risks to the privacy and security for a health information exchange (HIE): (1) conduct a risk analysis to evaluate the potential risks; (2) the organization should develop a policy and procedure for how to manage HIE within the organization; (3) the organization should have a dedicated person or team responsible for the internal management of the HIE; and (4) provide education and training to the workforce. The answer, to ensure that all HIE participants have full access to patient information, is a contradiction to the intent of ensuring the privacy and security of patients' health information as established in the guidelines set forth by AHIMA and HIMSS.

All of these are quality improvement strategies EXCEPT computer-based reminder alerts error-based penalties providing patient education performance-based bonuses

error-based penalties Error-based penalties are negative-oriented actions. Quality improvement strategies use positive reinforcement and support to increase productivity and accuracy.

When writing a query to a physician regarding ambiguous details in the documentation, one must be careful to never let the question include the name and patient number for the individual whose record is questioned. be open-ended so the physician can answer however he or she wants. imply an answer that will lead to a higher reimbursement rate. include clinical indicators from the health record.

imply an answer that will lead to a higher reimbursement rate. A query should never imply an answer that may lead to a higher reimbursement rate. A legal query should be open-ended or provide multiple answers for the physician to choose what is most accurate. The query should provide the clinical indicators from the chart and must include the name and patient number so the physician can connect the query response to the correct patient.

Traditionally, the medical record is accepted as being the property of the institution. patient. court. patient's guardian.

institution The organization that created and maintained the physical record is responsible for the integrity and security of the record and thus is the custodian, owner, of the record. However, the information in the record belongs to the patient. Incorrect answers: Patient: this answer is incorrect because the institution established the record and, therefore, is the owner of the record. Only the information within the record belongs to the patient. Court: this answer is incorrect because the court did not generate the record and, therefore, is not the owner of the record. Patient's guardian: this answer is incorrect because the court did not generate the record and, therefore, is not the owner of the record.

Adrienne, a disgruntled nurse was fired from East Care Hospital after it was discovered that she accessed a local celebrity's medical record. The celebrity was being treated for communicable disease at a satellite clinic under East Care's operational umbrella. In this scenario, Adrienne can best be described as an ________ for East Care Hospital. internal privacy threat external privacy threat internal security threat external security threat

internal security threat Internal human threats are caused by individuals within the organization, such as employees, whereas external human threats are caused by individuals outside the organization. Incorrect answers: External privacy threat: this answer is incorrect because the security of the information was jeopardized in this scenario due to unauthorized access to the patient's information housed in an electronic system. External security threat is a security threat caused by individuals or forces outside the organization. Internal privacy threat: this answer is incorrect because the security of the information was jeopardized in this scenario due to unauthorized access to the patient's information housed in an electronic system.

Patient health care records can be released for research purposes or education, without patient permission, if they have been de-identified. This means all details have been removed that may identify the attending physician. describe any procedures, services, or treatments that had been performed. confirm a diagnosis or diagnoses. lead to one specific person.

lead to one specific person. De-identification of a medical record means that there is no individually identifiable information - anything that might lead to one specific person.

You want to review one document in your facility that will spell out the documentation requirements for patient records, designate the time frame for completion by the active medical staff, and indicate the penalties for failure to comply with these record standards. Your best resource will be Joint Commission accreditation manual. medical staff rules and regulations. quality management plan. medical staff bylaws.

medical staff rules and regulations. Although the medical staff bylaws reflect general principles and policies of the medical staff, the rules and regulations outline the details for implementing these principles, including the process and time frames for completing records, and the penalties for failure to comply. Wrong answers: 1) Quality management plan (QMP) establishes quality policies as related to organization, maintenance and improvement in the quality of care through effective treatment and improved patient satisfaction. 2) Medical staff bylaws is a document that addresses and can be considered a contract that establishes requirements of how the medical staff will perform their duties. It is a standard of performance that has been approved by the hospital's board. 3) Joint Commission accreditation manual include standards on objective evaluation process that can aid healthcare facilities measure, assess and improve performance.

William is a 16-year-old male who lives at home with his parents and works part-time as a dishwasher at one of the local restaurants. While emptying the dishwasher, William is severely scalded and rendered unconscious. He is taken to the emergency room of the local acute care hospital for emergency treatment. Referring to the case study above, what must the hospital receive in order to release information to William's employer? consent signed by the patient court order nothing; no consent is needed consent signed by the patient's parent

nothing; no consent is needed The HIPAA Privacy Rule permits the disclosure of PHI relating to work-related illness or injury, or workplace-related medical surveillance to the extent such disclosure complies with workers' compensation laws. The Privacy Rule permits covered entities to disclose protected health information to workers' compensation insurers, State administrators, employers, and other persons or entities involved in workers' compensation systems, without the individual's authorization. Incorrect answers: Consent signed by the patient is not required for worker's compensation claims. Court order: the scenario does not meet the criteria for issuing a court order. Consent signed by the patient's parent is not required for worker's compensation claims.

A coding supervisor trained the employees that they should code signs and symptoms in addition to the established diagnosis code. This is an example of: upcoding. jamming. unbundling. overcoding.

overcoding Overcoding is reporting codes for signs and symptoms in addition to the established diagnosis code. Incorrect answers: Unbundling is reporting multiple codes to increase reimbursementwhen a single combination code should be reported. Upcoding is reporting codes that are not supported by documentation in the patient record for the purpose of increasing reimbursement. Jamming is routinely assigning an unspecified ICD-9-CM or ICD-10-CM disease code instead of reviewing the coding manual to select the appropriate code.

The ownership of the information contained in the physical medical/health record is considered to belong to the patient. insurance company. hospital. physician.

patient. The organization that created and maintained the physical record is responsible for the integrity and security of the record and thus is the custodian, owner, of the record. However, the information in the record belongs to the patient. Incorrect answers: Hospital: this answer is incorrect, because the hospital does not own the information within the record. Physician: this answer is incorrect, because the physician does not own the information within the record. Insurance company: this answer is incorrect, because the insurance company does not own the information within the record.

You are the director of the Health Information Management Department for Bayshore Hospital. A former patient of the hospital, Barbara Masters, is suing the hospital for negligent care of an infected decubitus ulcer. You are asked by Barbara's attorney to provide sworn verbal testimony and/or written answers to questions. Referring to the case study above, Barbara Masters is the _____________ in this case. appellant plaintiff appellee defendant

plaintiff The plaintiff is the party that initiates a lawsuit to enforce his or her rights and or another party's obligations. Incorrect answers: Defendant is the individual or the organization that is the object of the lawsuit and against whom a law suit is brought: wrongdoer. Appellant is the party appealing a case, also known as the petitioner. Appellee is the party against whom a case is appealed, also known as the respondent.

It is September 15th, and you have just received the upcoming year's ICD-10-PCS code set updates. The next step is to ________. notify the physicians so they are aware immediately work to memorize new codes put in a change ticket for the hospital's chargemaster to be updated wait until the codes come into effect on October 1st

put in a change ticket for the hospital's chargemaster to be updated Hospital chargemasters list all billable services provided in the facility. ICD-10-PCS procedure codes update as of October 1st each year.

A powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment is called a query. SOR. POA. halo effect.

query. A query can be a powerful communication tool used to clarify documentation in a health record and achieve accurate code assignment. Querying has become a common communication and educational tool for clinical documentation improvement (now integrity, or CDI) and coding departments. An effective query process aids the hospital's compliance with billing/coding rules and serves as an educational tool for providers, CDI professionals, and coding professionals, on the physician side. Present on Admission (POA) is defined as being present at the time the order for inpatient admission occurs. Halo effect is a form of bias that should be avoided during the performance appraisal process. Example: Supervisor Sally Shields may assign high performance ratings to an employee based solely on the fact that she likes the employee. Source Oriented Record (SOR) Traditional patient record format that maintains reports according to source of the document.

A qualitative analysis of OB records reveals a pattern of inconsistent data entries when comparing documentation of the same data elements captured on both the prenatal form and labor and delivery form. The characteristic of data quality that is being compromised in this case is data accessibility. completeness. reliability. legibility.

reliability Data reliability implies that data are consistent no matter how many times the same data are collected and entered into the system. Accessibility implies that data are available to authorized people when and where needed. Legibility implies data that are readable. Completeness implies that all required data are present in the information system.

In regard to quality of coding, the degree to which the same results (same codes) are obtained by different coders or on multiple attempts by the same coder refers to timeliness. completeness. reliability. validity.

reliability. Coding is the labeling of words or word groups (segments) or images with annotations or scales. To assess reliability, the agreement between and among coders may be checked. Incorrect answers: Validity assesses relevance, completeness, accuracy, and correctness—it measures how well a data collection instrument measures what it should measure. Completeness refers to the patient health record being complete according to standards adhered to by the facility. Timeliness of documentation is linked to accurate documentation—individual documents in the patient health record must be created in a timely manner according to standards used by the facility.

What term refers to the wrongful destruction of evidence or the failure to preserve property? deposition spoliation litigation triggers interrogatories

spoliation Spoliation is the intentional destruction, mutilation, alteration, or concealment of evidence relevant to a legal proceeding. It is a legal concept applicable to both paper and electronic information. When evidence is destroyed that relates to a current or pending civil or criminal proceeding, it is reasonable that the party had consciousness of guilt or another motive to avoid the evidence. Incorrect answers: Interrogatories are discovery devices consisting of written questions given to a party, witness, or other person who has information needed in a legal case. Deposition is a formal proceeding by which the oral testimonies of individuals are obtained as part of the discovery process. Litigation triggers are untoward events that the facility/organization believes may lead to a litigation.

When managers work to keep staff members feeling appreciated and valued for their contributions to the job and the organization, this is known as __________. extrinsic motivation continuing education risk calculation staff satisfaction

staff satisfaction Continuing education: Additional classes, seminars, and other educational events outside of a formal certificate or degree program. Extrinsic motivators are those that offer a reward or an acknowledgement from an outside source. Risk calculation is the determination of opportunities for injury and other liabilities. Staff satisfaction includes management ensuring that staff members feel appreciated and valued for their contributions to their job and the organization. This is the correct answer.

As the chair of the Forms Committee at your hospital, you are helping to design a template for house staff members to use while collecting information for the history and physical. When asked to explain how "review of systems" differs from "physical exam," you explain that the review of systems is used to document objective symptoms observed by the physician. subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant. a chronological description of patient's present condition from time of onset to present. past and current activities, such as smoking and drinking habits.

subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant. "Objective symptoms observed by the physician" refers to the physical exam. "Past and current activities, such as smoking and drinking habits" refers to the social history. "A chronological description of patient's present condition from time of onset to present" refers to the history of present illness. The correct answer is "subjective symptoms that the patient may have forgotten to mention or that may have seemed unimportant."

HIM personnel charged with the responsibility of bringing a medical record to court would ordinarily do so in answer to a subpoena duces tecum. personal subpoena. deposition. judgment.

subpoena duces tecum HIM professionals are more than likely served with a subpoena duces tecum, which instructs the recipient to personally appear at a deposition or in court, with documents in hand. A subpoena duces tecum may also direct the recipient to produce and bring originals or copies of health records, laboratory reports, x-rays, or other records. Incorrect answers: Personal subpoena: this term is incorrect and is not a valid standard term. Deposition is a formal proceeding by which the oral testimonies of individuals are obtained as part of the discovery process. Judgment is a decision of a court regarding the rights and liabilities of parties in a legal action or proceeding.

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse investigations for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS's website. the OIG's Evaluation and Management Documentation Guidelines the OIG's Model Compliance Plan the Federal Register the OIG's Work Plan

the OIG's Work Plan The OIG's Work Plan is published annually, itemizes specific services that are, or will be, under investigation during that fiscal year. This is the correct answer. Incorrect answers: Evaluation and Management Documentation Guidelines are the details that help physicians understand what must be documented to qualify for a specific evaluation and management code. The Federal Register is the official journal of the federal government of the United States that contains government agency rules, proposed rules, and public notices. Model Compliance Plan is a document that provides examples to help health care facilities create their own compliance plans.

A valid authorization for the disclosure of health information is considered defective if the expiration date has passed or the expiration event has occurred. a description of the purpose is provided. it is signed by the patient. it is addressed to the health care provider.

the expiration date has passed or the expiration event has occurred. An authorization is considered to be defective under the HIPAA Privacy Rule if: the expiration date has passed or the expiration event has occurred; the authorization is not completely filled out; the authorization has been revoked; the authorization is combined with any other documentation to create a compound authorization except where permitted; or the facility knows that the material information included in the authorization is false. Incorrect answers: It is addressed to the health care provider: this is an element of a valid authorization for disclosure. It is signed by the patient: this is an element of a valid authorization for disclosure. A description of the purpose is provided: this is an element of a valid authorization for disclosure.

A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT a physician requesting copies from another physician. the patient's attorney. the hospital attorney for the facility where the patient is treated. an insurance company.

the hospital attorney for the facility where the patient is treated. The HIPAA Privacy Rule permits covered entities to use and disclose protected health information for the purpose of treatment, payments, or health care operations. Incorrect answers: An insurance company: this answer is incorrect because a patient's written authorization is required in order to release the patient's medical records to the insurance company. A physician requesting copies from another physician: this answer is incorrect because a patient's written authorization is required in order to release the patient's medical records to another physician not responsible for the provision of treatment for that specific encounter of service. The patient's attorney: this answer is incorrect because a patient's written authorization is required in order to release the patient's medical records to the insurance company.

Mr. Blake was admitted to Allcare Hospital for scheduled cholecystectomy and was discharged within 48 hours. However, after 72 hours following the procedure, Mr. Blake complained of continued intensifying pain in the abdominal region. Mr. Blake was readmitted to the hospital and an x-ray revealed that a sponge had been left within his abdominal cavity. As a result, Mr. Blake filed a lawsuit against Allcare Hospital, and his medical records were subpoenaed by the courts. Which of the following documentation should be provided by Allcare Hospital in response to the subpoena? the legal health record the personal health record the longitudinal health record the medical record excluding the x-ray

the legal health record The "legal" health record as defined by the organization should be the record that is provided in response to a valid subpoena. It is the organization's responsibility to define the contents of a legal health record for its facility. Incorrect answers: Personal health record is an electronic or a paper health record maintained and updated by an individual for himself or herself. Longitudinal health record is a health record that documents health services from birth to death. Medical record excluding x-ray, this answer is incorrect because the facility determines/defines what constitutes their legal health record, and the legal health record is used in court proceedings.

Patient self-reported documentation may also be used to assign codes for social determinants of health, with the requirement that a nurse or other clinician witness the patient's story. the patient has the report notarized. lab reports confirm that patient's story. the physician includes these details in the encounter documentation.

the physician includes these details in the encounter documentation. The physician includes these details in the encounter documentation. As per ICD-10-CM 2023 Official Guidelines, B.14. Patient self-reported documentation may also be used to assign codes for social determinants of health if the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.

Internal disclosures of patient information for patient care purposes should not be granted to the attending physician. to the facility's legal counsel. to a family member who is a registered nurse at the facility. on a need-to-know basis.

to a family member who is a registered nurse at the facility Patient information should only be released to health care professionals within an organization who are directly responsible for the care of the patient. Patient information may also be disclosed to carry out health care operations, but only to those who have been assigned to carry out those operations. Only the minimum amount of information that is necessary to carry out treatment, payment, or other health care operations should be disclosed. Patient information should not be released to family members without prior written authorization from the patient.

All of the following require the patient to sign a consent form EXCEPT to refuse treatment. to release information to the emergency room physician. for the physician to perform an invasive procedure. for the surgeon to perform surgery.

to release information to the emergency room physician. Consent may not be required for treatment in the case of emergency. Emergency, in this situation, is when immediate treatment is required in order to prevent death or serious health impairment. Obviously, if the physician is aware that the patient would not want the procedure, then treatment may not be provided. Incorrect answers: For the surgeon to perform surgery requires an informed consent form signed by patient. To refuse treatment requires a "against medical advice" form signed by the patient and/or "informed refusal of care" form signed by the patient. For the physician to perform an invasive procedure requires an informed consent form signed by patient.

Ms. Juanita Smith has been hired as the new Health Information Management director at the Sunny Capital City Medical Health System. This organization was created by the merging of two smaller facilities that had hybrid medical records. One of Ms. Smith's first responsibilities is to define what constitutes a legal health record for the Sunny Capital City Medical Health System. All of the following should be considered in developing the definition for the legal health record EXCEPT the purpose of the health records. state and federal laws. type of software application used for the electronic health record. standards defining health record content.

type of software application used for the electronic health record. The purpose of the health record; state and federal laws; regulations and standards defining health record content; internal documents; risks the organization faces if its health record does not meet business record or legal health record requirements or the rules of evidence are all factors that should be considered by an organization when defining its legal health record. Incorrect answers: Purpose of the health records should be considered in the development of the definition of the legal health record. Standards defining health record content should be considered in the development of the definition of the legal health record. State and federal laws should be considered in the development of the definition of the legal health record.

There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by calling the physician's office. e-mailing physicians. leaving notes in the chart. using established physician query protocols.

using established physician query protocols. An established query process is the legal and proper way to communicate with physicians regarding documentation. Emailing physicians, leaving notes on the chart [which is difficult when using EHR], and just phoning may waste time and energy because the physician may not see them. An established query process has everyone in agreement where the questions will be located.