1. During an audit of health records, the HIM
Develop a facility
director finds that transcribed reports are
policy that defines
being changed by
the accept-
the author up to a week after initial transcription. The able period of
time al-
director is concerned that changes occurring this long lowed for a
transcribed
after transcription jeopardize the legal principle that document to
remain in a
documentation must occur near the time of the event.
draft form. To remedy this situation, the HIM director
should rec- ommend which of the following?
2. What is the basic formula for calculating each MS-DRG Hospital
payment = DRG
hospital payments? relative weight x hospital
base rate
3. Which of the following activities would be in Coding an intentionally in-
violation of AHIMA's Code of Ethics? appropriate level of
ser- vice
4. What is abstracting? Compiling the
pertinent
information from
the medical record
based on
predetermined data
sets
5. ICD-9-CM defines the "newborn period" as 28th
birth through the day following birth.
6. What healthcare organization collects UHDDS data? All non-outpatien
, CCA Exam Preparation Study Guide Test.
settings
including acute care,
short term care, long
term care, an psychiatric
hospitals, home health
agencies, re- habilitation
facilities, and nursing
home.
, CCA Exam Preparation Study Guide Test.
7. A coding analyst consistently enters the wrong Edit checks
code for patient gender in the electronic
billing system. What security measures
should be in place to mini- mize this
security breach?
Use and disclosure
8. 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
physi- cian for continuity of care (2). Under
HIPAA, these two functions are:
Attending physician
9. Who is responsible for writing and signing
discharge summaries and discharge
instructions?
10. Although the HIPAA Rule allows patient access to per- Psychotherapy
notes
sonal health information about themselves,
which of the following cannot be disclosed to
patients?
11. Identify the punctuation mark that is used to required
sup- plement words or explanatory to use?
information that may or may not be present
in the statement of diagnosis or procedure in 13. Which of
ICD-9-CM coding. The punctuation does not the
affect the code number assigned to the case. The following
punctuation is considered a nonessential ethical
modifi- er, and all three volumes of ICD-9-CM principles
use them. is being
fol- lowed
12. What is the name of the organization that when an
develops the billing form that hospitals are HIT
, CCA Exam Preparation Study Guide Test.
professional ensures that patient information is Parentheses ( )
only released to those who have a legal right to
access it?
National Uniform Billing
Committee (NUBC)
Beneficence