EXAM ACTUAL QUESTIONS AND ANSWERS -
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1. A health information manager is developing a data governance program.
Which element is most critical to ensure data integrity across the enterprise?
A. User satisfaction surveys
B. Clearly defined data ownership and stewardship roles
C. Increased data storage capacity
D. Vendor-specific data dictionaries
Rationale: Clearly defined ownership and stewardship establish
accountability for data accuracy, consistency, and integrity across systems.
2. A hospital transitions from ICD-9-CM to ICD-10-CM. Which impact is
most significant for HIM operations? A. Reduction in documentation
requirements
B. Elimination of clinical documentation improvement programs
C. Increased specificity in coding and documentation
D. Decreased need for coder education
Rationale: ICD-10-CM requires greater specificity, increasing
documentation and coding precision needs.
3. Which federal regulation primarily governs the privacy of individually
identifiable health information?
A. HITECH Act
B. HIPAA Privacy Rule
C. False Claims Act
D. Stark Law
, Rationale: The HIPAA Privacy Rule establishes national standards for
protecting PHI.
4. A coder notes inconsistent documentation that affects code assignment.
What is the most appropriate action?
A. Assign the most common diagnosis
B. Initiate a clinical documentation query
C. Omit the unclear diagnosis
D. Delay coding indefinitely
Rationale: A compliant query clarifies provider intent and supports accurate
coding.
5. Which data quality characteristic ensures data are recorded only once and
used consistently across systems?
A. Timeliness
B. Consistency
C. Accessibility
D. Granularity
Rationale: Consistency prevents conflicting data values across systems.
6. In an EHR environment, structured data are preferred over unstructured data
primarily because they: A. Require less clinician input
B. Enable reporting, analytics, and interoperability
C. Reduce storage costs
D. Eliminate privacy risks
Rationale: Structured data support standardized reporting and data
exchange.
7. Which reimbursement methodology is based on patient acuity and resource
utilization for inpatient care?
, A. Fee-for-service
B. Diagnosis-Related Groups (DRGs)
C. Capitation
D. Bundled payments
Rationale: DRGs classify inpatient stays to determine payment based on
diagnoses and procedures.
8. A breach involving unsecured PHI affects 600 patients. What is the required
action under HIPAA?
A. Notify only affected individuals
B. Document internally with no reporting
C. Notify HHS and affected individuals without unreasonable delay
D. Notify the media only
Rationale: Breaches affecting more than 500 individuals require notification
to HHS and individuals.
9. Which role is primarily responsible for ensuring clinical documentation
supports quality reporting and reimbursement?
A. Privacy officer
B. Health information technician
C. Clinical Documentation Improvement (CDI) specialist
D. Compliance auditor
Rationale: CDI specialists bridge clinical care and documentation accuracy.
10. Which standard enables semantic interoperability between
health information systems? A. ASCII
B. SNOMED CT
C. PDF
D. JPEG
, Rationale: SNOMED CT provides standardized clinical terminology for
shared meaning.
11. A patient requests access to their medical record. Under HIPAA, the
provider must respond within:
A. 10 days
B. 14 days
C. 30 days
D. 60 days
Rationale: HIPAA allows up to 30 days to provide access, with one possible
extension.
12. Which committee typically oversees data governance initiatives in
a healthcare organization? A. Infection control committee
B. Data governance council
C. Medical executive committee
D. Ethics board
Rationale: A data governance council coordinates data policies and
standards.
13. Which coding system is used to report inpatient procedures in U.S.
hospitals?
A. CPT
B. HCPCS Level II
C. ICD-10-PCS
D. LOINC
Rationale: ICD-10-PCS is designated for inpatient hospital procedures.
14. An HIM director evaluates record completion rates. This activity supports
which core HIM function?