CCA Exam Preparation |229 Questions and Answers(A+ Solution guide)

During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? - Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in a draft form. What is the basic formula for calculating each MS-DRG hospital payments? - Hospital payment = DRG relative weight x hospital base rate Which of the following activities would be in violation of AHIMA's Code of Ethics? - Coding an intentionally inappropriate level of service What is abstracting? - Compiling the pertinent information from the medical record based on predetermined data sets ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth. - 28th What healthcare organization collects UHDDS data? -All non-outpatient settings including acute care, short term care, long term care, an psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing home. A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in place to minimize this security breach? - Edit checks Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1). They will also be sending her records to her physician for continuity of care (2). Under HIPAA, these two functions are: - Use and disclosureWho is responsible for writing and signing discharge summaries and discharge instructions? - Attending physician Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? - Psychotherapy notes