CIC EXAM PREP CHAPTER 4 –
DOCUMENTATION EXAM QUESTIONS
WITH COMPLETE ANSWERS
Conditions of Participation CoP - Answer-Health and safety standards developed by
CMS that healthcare organizations must meet. The conditions were created for the
purpose of quality improvement and protecting the health and safety of beneficiaries.
Medicare Cost Reports - Answer-Forms submitted by institutional Providers on an
annual basis that collect descriptive' financial, and statistical data to determine if
Medicare over or underpaid the provider.
Medicare Severity Diagnosis Related Groups - Answer-Payment groups designed for
the Medicare beneficiaries. Patients who have similar clinical characteristics and similar
treatment costs are assigned to a MS-DRG. The MS-DRG is linked to a fixed payment
amount based on the average treatment cost of Patients in the group.
Patient Dumping - Answer-A statutorily imposed liability that occurs if a hospital capable
of providing the necessary medical care transfers a patient to another facility, Or turns
the patient away because of the patient's inability to pay. Hospitals that knowingly,
willingly, Or negligently fall to comply with legislation prohibiting this practice are subject
to monetary penalties and suspension of their Medicare provider agreements.
Unbundling - Answer-Expanding into individual units a group of diagnostic or procedural
test codes that might have been previous included as a panel to maximize
reimbursement from third Party Payers.
Uniform Hospital Discharge Data Set (UHDDS) - Answer-Used for reporting inpatient
data in acute care, Short-term Care, and long-tem Care hospitals. Includes a minimum
set of items based on standard definitions to provide consistent data for multiple users.
Who can make entries in the medical record? - Answer-Physicians, nurse practitioners,
nurses, and other members of the healthcare team.
Uniform Hospital Discharge Data Set
The data elements required by UHDDS include: - Answer-Personal Patient identifier
date of birth
Sex
race
ethnicity
residence
hospital identification
admission date
, type of admission
discharge date
the attending physician's identification
Operating physician identification
PRINCIPAL diagnosis
OTHER diagnoses
external cause of injury codes
birth weight of neonates
Procedures and dates
disposition of patient
expected payment source
total charges
Regardless of setting, Or regulatory or accreditation requirements, the healthcare
record must support the ________ and subsequent treatment of the patient. - Answer-
condition (diagnosis)
The documentation found in the healthcare record justifies the _______ and _______
the patient receives, and therefore must be adequate. - Answer-treatment and services
MDS: The minimum data set is required by CMS for ______ ________. - Answer-
nursing facilities
The __________ is a tool that can be used to implement standardized assessments
and management of care and is a mandated process for all residents in a Medicare or
Medicaid Certified nursing facility. - Answer-MDS
The process to identify trends and patterns in a database. It can be useful in many
ways, including detecting fraud and abuse and identifying effective treatments and
efficiencies. - Answer-Data mining
The health record/documentation pertaining to patient care is the property of the
_____________. - Answer-hospital or healthcare provider (professional setting)
responsible for creating the record
The information contained in the medical record belongs to the individual _________. -
Answer-patient
The _________ must maintain control of the record to insure accuracy and maintain the
patient's privacy. - Answer-facility
The Institute of Medicine defines the users of the health record as, - Answer-"those
individuals who enter, verify, correct, analyze, or obtain information from the record
either directly or indirectly."
DOCUMENTATION EXAM QUESTIONS
WITH COMPLETE ANSWERS
Conditions of Participation CoP - Answer-Health and safety standards developed by
CMS that healthcare organizations must meet. The conditions were created for the
purpose of quality improvement and protecting the health and safety of beneficiaries.
Medicare Cost Reports - Answer-Forms submitted by institutional Providers on an
annual basis that collect descriptive' financial, and statistical data to determine if
Medicare over or underpaid the provider.
Medicare Severity Diagnosis Related Groups - Answer-Payment groups designed for
the Medicare beneficiaries. Patients who have similar clinical characteristics and similar
treatment costs are assigned to a MS-DRG. The MS-DRG is linked to a fixed payment
amount based on the average treatment cost of Patients in the group.
Patient Dumping - Answer-A statutorily imposed liability that occurs if a hospital capable
of providing the necessary medical care transfers a patient to another facility, Or turns
the patient away because of the patient's inability to pay. Hospitals that knowingly,
willingly, Or negligently fall to comply with legislation prohibiting this practice are subject
to monetary penalties and suspension of their Medicare provider agreements.
Unbundling - Answer-Expanding into individual units a group of diagnostic or procedural
test codes that might have been previous included as a panel to maximize
reimbursement from third Party Payers.
Uniform Hospital Discharge Data Set (UHDDS) - Answer-Used for reporting inpatient
data in acute care, Short-term Care, and long-tem Care hospitals. Includes a minimum
set of items based on standard definitions to provide consistent data for multiple users.
Who can make entries in the medical record? - Answer-Physicians, nurse practitioners,
nurses, and other members of the healthcare team.
Uniform Hospital Discharge Data Set
The data elements required by UHDDS include: - Answer-Personal Patient identifier
date of birth
Sex
race
ethnicity
residence
hospital identification
admission date
, type of admission
discharge date
the attending physician's identification
Operating physician identification
PRINCIPAL diagnosis
OTHER diagnoses
external cause of injury codes
birth weight of neonates
Procedures and dates
disposition of patient
expected payment source
total charges
Regardless of setting, Or regulatory or accreditation requirements, the healthcare
record must support the ________ and subsequent treatment of the patient. - Answer-
condition (diagnosis)
The documentation found in the healthcare record justifies the _______ and _______
the patient receives, and therefore must be adequate. - Answer-treatment and services
MDS: The minimum data set is required by CMS for ______ ________. - Answer-
nursing facilities
The __________ is a tool that can be used to implement standardized assessments
and management of care and is a mandated process for all residents in a Medicare or
Medicaid Certified nursing facility. - Answer-MDS
The process to identify trends and patterns in a database. It can be useful in many
ways, including detecting fraud and abuse and identifying effective treatments and
efficiencies. - Answer-Data mining
The health record/documentation pertaining to patient care is the property of the
_____________. - Answer-hospital or healthcare provider (professional setting)
responsible for creating the record
The information contained in the medical record belongs to the individual _________. -
Answer-patient
The _________ must maintain control of the record to insure accuracy and maintain the
patient's privacy. - Answer-facility
The Institute of Medicine defines the users of the health record as, - Answer-"those
individuals who enter, verify, correct, analyze, or obtain information from the record
either directly or indirectly."
