RHIA Exam 292 Questions with Verified Answers,100% CORRECT

RHIA Exam 292 Questions with Verified Answers An audit trail is a good tool for which of the following? - CORRECT ANSWER Reconstructing electronic events The kids foundation related to children's hospital is mailing fundraising information to the families of all patients who have been treated at children's in the past three years. based on the facts given: - CORRECT ANSWER children's hospital must have notified the patients or patients guardians of this disclosure in the notice of privacy practices A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes: - CORRECT ANSWER Spoliation A breach occurs when unsecured protected health information is accessed or released. The secretary of HHS and local media must be notified if this threshold of patient records breached has been met or exceeded - CORRECT ANSWER 500 The security rule leaves the method for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be - CORRECT ANSWER its own characteristics and environment Mary Smith has been asked to work on the development of a hospital trauma data registry. Which of the following data sets would be most helpful in developing this registry? - CORRECT ANSWER DEEDS- Data Elements for ER Department Who owns the health records of patients treated in a healthcare facility? - CORRECT ANSWER the facility In figuring a drug dosage, it is unacceptable to round up to the nearest gram if the drug is to be dosed in milligrams. Which dimension of data quality is being applied in this situation? - CORRECT ANSWER Precision The HIM manager is concerned with a backlog in transcription of surgical reports. The medical staff rules and regulations stipulate that the surgeon should: - CORRECT ANSWER Write a detailed postoperative progress note about the procedure performed. The discharge summary must be completed within _ after discharge for most patients but within _ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for less than _ hours. - CORRECT ANSWER 30 days, 24 hours, 48 hours Which of the following statements does not pertain to paper-based health records? - CORRECT ANSWER They have a built in access control mechanism. A number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year (for ex 03-0001) is a _ number - CORRECT ANSWER Accession Two clerks are abstracting data for a registry. When their work is checked, discrepancies are found between similar data abstracted by the two clerks. Which data quality component is lacking? - CORRECT ANSWER Reliability In ICD 10 CM this note means "not coded here"? - CORRECT ANSWER Excludes 1 When an entity relational diagram is implemented as a relational database, an entity will become an: - CORRECT ANSWER Table A procedure that attempts to obstruct the blood flow to a malignant tumor would be coded to which root operation in ICD 10 PCS? - CORRECT ANSWER Occlusion Under what access security mechanism would an individual be allowed access to ePHI if he or she has a proper login and password, belongs to a specified group, and his or her workstation is located in a specific place within the facility? - CORRECT ANSWER Context-based Which of the following is a rule established by an administrative agency of government? - CORRECT ANSWER Regulation The computer notified the compliance officer that a user accessed the PHI of a patient with the same last name as the user. This is an example of a - CORRECT ANSWER Trigger The Security Incident Procedures Standard has one required implementation specification centered on: - CORRECT ANSWER Identifying and responding to security events Dr. Smith an OB-GYN specialist has just become a staff member at Medical Center Hospital, where she may offer care and treatment related to obstetrics and gynecology including performing deliveries and gynecological surgery. The process of defining what services she may perform is called: - CORRECT ANSWER Granting privileges Under the HIPAA privacy standard, which of the following types of protected health information PHI must be specifically identified in an authorization? - CORRECT ANSWER Psychotherapy notes If a data breach caused by willful neglect is corrected within 30 days from the date of the covered entity or business associate becoming aware of it, what level of violation of the HIPAA Omnibus Rule is this breach? - CORRECT ANSWER Tier 3 Per the HIPAA Privacy Rule, which of the following requires authorization for research purpose? - CORRECT ANSWER Use of Mary's individually identifiable information related to her asthma treatments City Hospitals HIPAA committee is considering a change in policy to allow hospital employees who are also hospital patients to access their own patient information in the hospitals EHR system. A committee member notes that HIPAA provides rights to patients to view their own health information. However, another member wonders if this action might present other problems. In this situation what suggestion should the HIM director provide? - CORRECT ANSWER Allowing employees to access their own records using their job-based access rights appears to violate HIPAAs minimum necessary requirement; therefore, allow employees to access their records through normal procedures. An employee forgot his user ID badge at home and uses another employees badge to access the computer system. What control should have been in place to minimize this security breach? - CORRECT ANSWER Security incident procedures A visitor walks through the work area and picks up a flash drive from an employees desk. What security controls should have been implemented to prevent this security breach? - CORRECT ANSWER Facility access controls The nursing staff in the cardiac unit has noticed that a significant number of health records do not have informed consents prior to the performance of procedures. Obtaining informed consent is the responsibility of the: - CORRECT ANSWER Physician Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, Susan is a - CORRECT ANSWER Workforce member Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremys medical information is: - CORRECT ANSWER Not protected by the NPP because it is part of a personnel record If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must: - CORRECT ANSWER Comply with the patients request and keep the information private (omnibus rule) The Person or entity authentication standard requires methods for verifying that a person is who he or she claims to be. Any of the following meets this standard except: - CORRECT ANSWER Unit level password When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a: - CORRECT ANSWER Health record matrix Which of the following is used by a long term care facility to gather information about specific health status factors and includes information about specific risk factors in the residents care? - CORRECT ANSWER Minimum Data Set Which of the following is an example an example of a M:M relationship? - CORRECT ANSWER Patients to consulting physicians Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of potential breach of: - CORRECT ANSWER Authorship integrity The legal health record for disclosure consists of: - CORRECT ANSWER The data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings A clinic has a contract with the city government to perform all new employee physicals and work injury evaluations. Is it appropriate that a patients family history of cancer be reported to the employer? - CORRECT ANSWER Yes, unless the employer has allowed for such exclusion. Mary Smith has gone to her doctor to discuss her current medical condition. What is the legal term that best describes the type of communication that has occurred between Mary and her physician? - CORRECT ANSWER Privileged communication An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system? - CORRECT ANSWER Role-based The privacy rule generally requires documentation related to its requirements to be retained: - CORRECT ANSWER 6 years Mrs Davis is preparing to undergo hernia repair surgery at Deconess Hospital. Select the best statement of the following options. - CORRECT ANSWER The surgeon should obtain Mrs. Davis informed consent Which legal doctrine was established by the Darling v. Charleston Community hospital case of 1965? - CORRECT ANSWER Corporate negligence Which national database was created to collect information on the legal actions (both civil and criminal) taken against licensed healthcare providers? - CORRECT ANSWER National Practitioner Data Bank Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room. - CORRECT ANSWER Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record. The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as: - CORRECT ANSWER Confidentiality Which of the following is an identifier under the Privacy Rule? - CORRECT ANSWER Vehicle license plate Which type of identity theft occurs when a patient uses another persons name and insurance information to receive healthcare benefits? - CORRECT ANSWER medical The term "hard coding" refers to: - CORRECT ANSWER ICD-10 codes that appear in the hospitals chargemaster The relationship between patient gender and readmission to the hospital is best displayed using a: - CORRECT ANSWER Contingency table This analytic technique is being used by CMS to assist in prepayment audits? - CORRECT ANSWER Predictive modeling Which of the following is included in a request for proposal (RFP)? - CORRECT ANSWER The timeline for implementation Which data collection program is the basis for the CMS value-based purchasing program? - CORRECT ANSWER Hospital Compare HIPPA mandated that healthcare business partners and covered entities implement a common standard for data and information transfer. That standard is: - CORRECT ANSWER ASC X12 N Physician use the _ to access multiple sources of patient information within the healthcare organizations network. - CORRECT ANSWER clinician portal The key to an effective retention and retrieval system of health records in a facility is: - CORRECT ANSWER Master patient index Which of the following health record numbers are in correct terminal digit order? - CORRECT ANSWER 12-25-62, 11-25-68, 18-20-69, 00-24-69 As a preliminary step in designing an IS strategy, it is important for the steering committee to conduct a scan of the external environment and to: - CORRECT ANSWER Conduct an internal environment assessment If an analyst wishes to determine the root cause of claim denials during June via a random sample, what is the sampling unit? - CORRECT ANSWER Claims In which stage of the system life cycle would data be collected from system users regarding their needs? - CORRECT ANSWER Analysis What architectural model of health information exchange allows participants to access data in point to point exchange? - CORRECT ANSWER Federated- inconsistent databases Which of the following represents the correct sequence from low to high of levels of interoperability? - CORRECT ANSWER Basic, functional, semantic There were 25 inpatient deaths, including newborns, at Community Memorial Hospital during the month of June. The hospital performed five autopsies during the same period. The gross autopsy rate for the hospital for June was: - CORRECT ANSWER 20% (5/25= 0.2*100) In purchasing an EHR system from a vendor, what does due diligence refer to? - CORRECT ANSWER Checking references The MPI includes which of the following? - CORRECT ANSWER Patients date of birth, gender, and health record number The director of the health information department wanted to determine the level of the physicians satisfaction with the departments services. The director surveyed the physicians who came to the department. What type of sample is this? - CORRECT ANSWER Convenience Working with the healthcare entity's integration team to ensure that ADT interfaces are properly built and tested is the responsibility of the: - CORRECT ANSWER MPI Manager In which of the following examples does the gender of the patient constitute information rather than a data element? - CORRECT ANSWER In a study comparing the incidence of myocardial infarctions in black males as compared to white females The HIPAA methods titled Expert Determination and Safe Harbor are ways in which the following can be achieved legally - CORRECT ANSWER Deidentification large hospital is planning for an EHR but wants to ensure it has adequate source systems in place to support it. Each of the ancillary departments has a separate information system, and each has claimed that the product is the best on the market and that the vendor has promised the system will interface with any EHR on the market. Identify the PM mistake in this situation - CORRECT ANSWER Lack of sponsorship An HIM professional who accurately reports HIV status of an audit that indicates health problems meets the ethical standards for: - CORRECT ANSWER Public health A distance learning method in which groups of employees in multiple classroom locations may listen to and see the material presented at the same time via satellite or telephone is called: - CORRECT ANSWER Videoconferencing As an EHR implementation project proceeds, additional hospital departments add requirements for the system, and the project becomes more complex. This is known as - CORRECT ANSWER Scope creep Fifty percent of our HIM staff have a nationally recognized credential. This is an example of what type of indicator? - CORRECT ANSWER System Based on the financial data listed what was Triads total net assets before posting net income for the year? - CORRECT ANSWER (assets-liability=net assets) (cash+A/R+building+land)-(A/R+mortgage)= 1,500,000 Based on the financial data, what was Triads net income? - CORRECT ANSWER Revenue - Expenses = 250,000 For a contract to be valid, it must include three elements. Which of the following is one of those elements? - CORRECT ANSWER Consideration Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? - CORRECT ANSWER Constructive confrontation Distributing work duties to others along with the right to make decisions and take action is called - CORRECT ANSWER Delegation The performance standard to assign the correct health record number to a returning patient with 99 percent accuracy is an example of a - CORRECT ANSWER Quality standard The process icon symbol (rectangle) is used in flowcharting to indicate: - CORRECT ANSWER A process in which actions are being performed by humans Outpatient programs designed to provide employees immediate access to psychological counseling on a limited basis that may be provided on site or through local providers are called - CORRECT ANSWER Employee Assisted programs In order to expedite basic performance improvement team functioning, the team should: - CORRECT ANSWER Establish ground rules The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called - CORRECT ANSWER Environmental assessment 1000 records per day, 3 FTE, 88% productive, 12% unproductive PFD - CORRECT ANSWER 1000 rpd * 3 88%*8= 7 333/7 = 48 records per hour A comprehensive retrospective review should be conducted at least once a year of what aspect of CDI program? - CORRECT ANSWER All query opportunities The facilities Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding audit review should be performed? - CORRECT ANSWER Focused audit A polyp was removed from a patients colon during a colonoscopy procedure. The physician and pathologist document the polyp as probable adenocarcinoma of the colon. Which of the following actions should the coding professional take to code this encounter? - CORRECT ANSWER Code "polyp" All of the following are goals for a clinical documentation improvement program except - CORRECT ANSWER Preventing billing for bundled services What type of organization works under contract with CMS to conduct Medicare and Medicaid certification surveys for hospitals? - CORRECT ANSWER State licensure agencies Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER Date the claim drops Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) is available for - CORRECT ANSWER Spouses or widowers of veterans meeting specific criteria Which of the following accreditation categories would the JC assign to a hospital that did not meet all of the standards at the time of initial on site survey, had a level of standards in noncompliance, had requirements for improvements (RFIs) in excess of the published level for a year and subsequently underwent an additional onsite follow-up survey? - CORRECT ANSWER Contingent accrediation Which of the following lists contains only entities that have roles in the various Medicare improper payment review processes? - CORRECT ANSWER MAC (Medicare Audit Contactor), RAC (Recovery Audit Contractors), and QIO (Quality improvement Organization) Physician normal charge $340 Medicare fee schedule $300 Patient has met his deductible - CORRECT ANSWER $240 (80% of 300) What is the benefit of comparing the coding assigned by coders to the coding that appears on the claim? - CORRECT ANSWER May find claim generation issues that cannot be found in other ways Which of the following is not true of a PHR? - CORRECT ANSWER It will replace the legal records of providers How are hospital compare measures used by CMS - CORRECT ANSWER Hospitals that report all measures receive the full payment update Technology that electronically stores, manages, and distributes documents that are generated in a digital format and whose output data are report-formatted and print stream originated is called - CORRECT ANSWER Computer output laser disk (COLD) technology What type of authentication is created when a person signs his or her name on a pen pad and the signature is automatically converted and affixed to a computer document? - CORRECT ANSWER Digital signature It is impossible to have health information interoperability or health information exchange without the following: - CORRECT ANSWER Complete, publicity available standards The JC and CMS identify core measures that provide an indication of a healthcare facility's performance. Some of the core measure data sets include which of the following? - CORRECT ANSWER Pneumonia, congestive heart failure, and myocardial infarction Medical identity thefts are situations in which the following occurs: - CORRECT ANSWER When demographic and financial information is used to acquire medical services The technology commonly utilized for automated claims processing (sending bills directly to third party payers) is: - CORRECT ANSWER Electronic data interchange Which of the following healthcare entities mission is to reduce medicare improper payments through detection and collection of overpayments, identification, identification of underpayments, and implementation of actions that will prevent future improper payments? - CORRECT ANSWER Recovery audit contractor Which of the following conditions would be the most likely to fall into the category of notifiable diseases as defined by the National Notifiable Diseases Surveillance System? - CORRECT ANSWER HIV infection A technique for measuring healthcare entity performance across the four perspective of customer, financial, internal process, and learning and growth is called: - CORRECT ANSWER Balanced scorecard methodology A set of activities designed to familiarize new employees with their jobs, the healthcare entity, and work culture is called: - CORRECT ANSWER Orientation Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? - CORRECT ANSWER Derived What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? - CORRECT ANSWER Clinical practice guidelines The patient has a biopsy of the colon followed by a hemicolectomy. In the ICD 10 PCS coding system, which procedure(s) are coded? - CORRECT ANSWER Both the biopsy and the hemicolectomy What is the first step a healthcare entity should take when developing a data dictionary? - CORRECT ANSWER Design a plan Which of the following processes is an ancillary function of the health record? - CORRECT ANSWER Biomedical research While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on: - CORRECT ANSWER Reason for encounter Unstructured data may be preferred over structured data because: - CORRECT ANSWER It provides greater detail Inadequate functions that make it impossible to detect when an entry was modified or borrowed from another source and misrepresented as an original entry by an authorized user is an example of a potential breach of ____________. - CORRECT ANSWER Auditing integrity Which health record format is arranged in chronological order with documentation from various sources intermingled? - CORRECT ANSWER Integrated To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following? - CORRECT ANSWER Resident Assessment Instrument A barrier to effective computer-assisted coding is the: - CORRECT ANSWER Poor quality of documentation A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is the correct root operation? - CORRECT ANSWER Extirpation Changes and updates to ICD-9-CM are managed by the ICD-9-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and who? - CORRECT ANSWER CMS Who is responsible for ensuring the quality of health record documentation? - CORRECT ANSWER Provider Which of the following is an example of a 1:1 relationship? - CORRECT ANSWER Patients to hospital beds According to the UHDDS definition, ethnicity should be recorded on a patient record as: - CORRECT ANSWER Spanish origin/Hispanic, non-Spanish origin/non-Hispanic, unknown Which of the following is a component of the resident assessment instrument? - CORRECT ANSWER A standard Minimum Data Set (MDS) HIM professionals sometimes monitor the records of current inpatients as well as closed records after the patients have been discharged or transferred. What is this process called? - CORRECT ANSWER Ongoing record review Which of the following is a graphical display of the relationship between tables in a database? - CORRECT ANSWER ERD (Entity Relationship Diagram) Which of the following keywords precedes the listing of variables to be returned from an SQL query? - CORRECT ANSWER SELECT The process of providing proof of the authorship of health record documentation is called: - CORRECT ANSWER Authentication Regardless of the healthcare setting, accreditation and Regulatory standards require a separate Healthcare record for each: - CORRECT ANSWER Individual patient Which of the following is a business role with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? - CORRECT ANSWER Data definition steward Record consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: - CORRECT ANSWER Hybrid health records Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered: - CORRECT ANSWER Patient data source What is the traditional paper format for a hospital patient care record? - CORRECT ANSWER Source-oriented Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of a patient to the acute care hospital in which she works. The first resource that she should use is ______. - CORRECT ANSWER UHDDS Quality has several components, including appropriateness, technical excellence, acceptability, and: - CORRECT ANSWER Accessibility Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons? - CORRECT ANSWER Physician What tool is used to sort data in a variety of ways to assist in the study of certain data elements? - CORRECT ANSWER Indexes In a long-term care, the resident's care plan is based on data collected in the: - CORRECT ANSWER MDS- Minimum Data Set The name of the government agency that has led the development of basic data sets for health records and computer databases is the: - CORRECT ANSWER National Committee on Vital and Health Statistics Which of the following is a concept designed to help standardize clinical content for sharing between providers? - CORRECT ANSWER Continuity of care record A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR_ - CORRECT ANSWER maintenance plan Why is it important to extract individual patient information and enter it into a database? - CORRECT ANSWER To reveal patterns Where can you find guidelines for the retention and destruction of healthcare information? - CORRECT ANSWER Accreditation standards Community hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? - CORRECT ANSWER Each physcian practice should obtain a business associate agreement with the hospital. A patient requests copies of her medical records in an electronic format. The hospital maintains a portion of the designated record set in a paper format and a portion of the designated record set in an electronic format. How should the hospital respond? - CORRECT ANSWER Provide the patient with both paper and electronic copies of the record The federal physician self-referral statute is also known as the: - CORRECT ANSWER Stark law The medical record committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinics practice of calling out a patients full name in the waiting room is not in compliance with HIPAA regulations and that only the patients first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? - CORRECT ANSWER There is no violation of HIPAA in announcing a patients name, but the committee may want to consider implementing practices that might reduce this practice. A hospital currently includes the patients social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity breach risk and wants the information removed. The physicians and others in the hospital are not cooperating, saying they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? - CORRECT ANSWER Avoid displaying the number on any document, screen, or data collection field Which of the following is NOT an identifier under the Privacy Rule? - CORRECT ANSWER Age 75 Which of the following must be reported to the medical examiner? - CORRECT ANSWER Accidental deaths Which of the following is an administrative safeguard action? - CORRECT ANSWER Documentation retention guidelines Which of the following does NOT have to be included in a covered entity's notice of privacy practices? - CORRECT ANSWER Patients signature and email address Health Insurance Portability and Accountability Act states that "__ used for the purposes of treatment, payment, or healthcare operations foes not require patient authorization to allow providers access, use , or disclosure." However, only the __ information needed to satisfy the specified purpose can be used or disclosed. - CORRECT ANSWER Protected health informaiton, minimum necessary Per HITECH, as accounting of disclosure must include disclosures made during the previous: - CORRECT ANSWER 3 years In the case of behavioral healthcare information a healthcare provider may disclose health information on a patient without the patients authorization in which of the following situations? - CORRECT ANSWER Court order, duty to warn, and involuntary commitment proceeding Covered entities must retain documentation of their security policies for at least: - CORRECT ANSWER Six years from the date when last in effect According to the Privacy Rule, which of the following is true about authorization? - CORRECT ANSWER A description of each of the other purposes for which the covered entity is premitted or required to use or disclose PHI without the individuals written consent or authorizaiton Regarding an individuals right of access per HIPAA, a covered entity: - CORRECT ANSWER May require individuals to make their requests in writing Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? - CORRECT ANSWER The privacy rule minimum necessary requirement does not apply. The confidentiality of incident reports is generally protected in cases when the report is filed in: - CORRECT ANSWER The hospital risk manager's office Which one of the following has access to personally identifiable data without authorization or subpoena? - CORRECT ANSWER Public health departments for disease reporting purposes An original goal of HIPAA Administrative Simplification was to standardize - CORRECT ANSWER The electronic transmission of health data To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? - CORRECT ANSWER Base charges on the cost of labor and supplies for copying and postage if copies are mailed. Under the Privacy Rule which of the following must be included in a patient accounting of disclosures? - CORRECT ANSWER State-mandated report of a sexually trasmitted disease The Administrative Simplification portion of Title II of HIPAA addresses which of the following? - CORRECT ANSWER Uniform standards for transactions and code sets The HIPAA Privacy Rule permits charging patients for labor and supply costs associated with copying health records. Mercy Hospital is located in a state where state law allows charging following statements is true when applied to this scenario? - CORRECT ANSWER The Privacy Rule will preempt state law in this situation Lane Hospital has a contact with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linen for off-site laundering, Ready-Clean is: - CORRECT ANSWER Not a business associate because it does not use or disclose individually identifiable health information Automated registration entries that generate erroneous patient identification—possibly leading to patient safety and quality of care issues, enabling fraudulent activity involving patient identity theft, or providing unjustified care for profit—is an example of a potential breach of ____________. - CORRECT ANSWER Patient identification and demographic accuracy A patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond? - CORRECT ANSWER The hospital must accept the request but does not have to agree to it. When should an e-discovery response team be found? - CORRECT ANSWER Well in advance of any litigation John Smith was seen in his primary care physician's office. When the provider attempted to call him with his laboratory results, he advertently called the incorrect John Smith and verbally provided him the lab result. Which of the following would apply to this situation in the context of breach notification? - CORRECT ANSWER Even though the results were discussed with the incorrect patient, no hard copy results were sent to the wrong person, so because the wrong John Smith could not keep the PHI, no reporting is necessary. What is the most common method for implementing entity authentication? - CORRECT ANSWER Password systems The health record of Kathy smith, the plaintiff, has been subpoenaed for a deposition. The plaintiffs attorney wants to use the records as evidence to prove his clients case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: - CORRECT ANSWER Business records exception Which of the following would be included in an accounting of disclosure? - CORRECT ANSWER Patient information faxed to the bank Which standard in the Security Rule provides guidance for covered entities to secure laptops and other small portable mobile technologies used within the healthcare facility? - CORRECT ANSWER Device and media controls standard A valid subpoena duces tecum seeking health records does not have to: - CORRECT ANSWER Be signed by the plaintiff and defendant Which of the following fundraising solicitations violates HIPAA? - CORRECT ANSWER One sent to cardiac patients only When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against the: - CORRECT ANSWER Governments interests in protecting human life A nurse administrator who is not typically on call to cover staffing shortages gets called in over the weekend to staff the emergency department. She does not have access to enter notes since this is not a part of her typical role. In order to meet the intent of the HIPAA Security Rule, the hospital policy should include a: - CORRECT ANSWER Provision to allow her emergency access to the system Which of the following presents the greatest risk of large-scale health information breaches? - CORRECT ANSWER Laptop theft Which of the following statements is true with regard to responding to requests from individuals for access to their PHI? - CORRECT ANSWER A cost-based fee may be charged for making a copy of the PHI. What type of safeguards comprise over half of all the safeguards included in the security rule? - CORRECT ANSWER Administrative safeguards What is the most constant threat to health information integrity? - CORRECT ANSWER Humans In order to effectively transmit healthcare data between a provider and payer, both parties must adhere to which electronic data interchange standards? - CORRECT ANSWER X12N This data collection tool is used when one needs to gather data on sample observations in order to detect patterns - CORRECT ANSWER Check Sheet To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of reliability check is called: - CORRECT ANSWER Interrater Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specific period of time? - CORRECT ANSWER Prevalence This type of chart is used to focus attention on any variation in a process and helps the team to determine whether that variation is normal or a result of special circumstances. - CORRECT ANSWER Control chart The process of process of preventing the spread of communicable disease is compliance with applicable legal requirements is performed in this quality management function. - CORRECT ANSWER Infection control A _ is a range of values, such that the probability of that range covering the true value of a parameter is a set probability or confidence. - CORRECT ANSWER Confidence interval What is the term for health records maintained by patients or their families? - CORRECT ANSWER Personal health records A current key function in the health information field whereby data is turned into useful information is: - CORRECT ANSWER Data analytics In which phase of the Systems Development Life Cycle does initial training on a new information system generally occur? - CORRECT ANSWER Implementation The _ is a standardized assessment of consumer perspectives regarding healthcare access and quality in hospitals. - CORRECT ANSWER HCAHPA (Hospital Consumer Assessment of Healthcare Providers) Which of the following statements about new technology items included on the charge description master (CDM) is false? - CORRECT ANSWER The code for new technology should not be included in the CDM until coverage has been determined. Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? - CORRECT ANSWER Health Information Management The "discharged, not final billed" report (also known as "discharged, no final bill" or "accounts not selected for billing") includes what type of accounts? - CORRECT ANSWER Accounts that have been discharged and have not been billed for a variety of reasons Patient accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should: - CORRECT ANSWER Write off the failed charges to bad debt and bill Medicare for the clean charges The following are the most common reasons for claim denials except_. - CORRECT ANSWER Coverage not in effect for date of service Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? - CORRECT ANSWER 95% of 240 (80% of 300) = 228 From the figure determine which entity that has purchased the insurance policy - CORRECT ANSWER STATE (under group) Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to Joint Commission standards, which statement applies to this situation? a. The record is not in compliance because the physical examination must be completed within 24 hours of admission. b. The record is not in compliance because the physical examination must be completed within 48 hours of admission. c. The record is in compliance because the physical examination must be completed within 48 hours. d. The record is in compliance because the physical examination was completed within 72 hours of admission. - CORRECT ANSWER The record is not in compliance as the physical exam must be completed within 24 hours of admission A clinical documentation program facilitates accurate coding and helps coders avoid: - CORRECT ANSWER Assumption coding Reviewing claims to ensure appropriate coding for deserved payments is one method of ___. - CORRECT ANSWER Achieving legitimate optimization It is the year 201X. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? - CORRECT ANSWER Conversion factor A JC accredited organization must review their formulary annually to ensure a medications continued: - CORRECT ANSWER Efficacy and safety In the HHPS system, which home healthcare services are consolidated into a single payment to home health agencies? - CORRECT ANSWER Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following? - CORRECT ANSWER Unbundling Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? - CORRECT ANSWER Include ancillary clinical staff and medical stagg in this process The AR collection cycle involves the time from: - CORRECT ANSWER Admission to deposit in the bank In a typical acute-care setting, aging of accounts reports are monitored in which revenue cycle area? - CORRECT ANSWER Accounts receivable The lead coder in the HIM department is an acknowledged coding expert and is the go-to person in the organization for coding guidance. As the HIM director you learn that she is not following proper coding guidelines and her coding practices are not compliant. As the HIM director, the best steps to take would be which of the following? - CORRECT ANSWER Review the coding errors and counsel the employee Which of the following items are packaged under the Medicare hospital outpatient prospective payment system(OPPS)? - CORRECT ANSWER Supplies (other than pass-through) and recovery room In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar? - CORRECT ANSWER Based on principle diagnosis Which of the following elements is found in a charge description master? - CORRECT ANSWER Procedure or service charge In a typical acute-care setting, the explanation of benefits, Medicare summary notice, and remittance advice documents (provided by the payer) are monitored in which revenue cycle area? - CORRECT ANSWER Claims reconciliation and collections This statistical inference measures both the strength of a relationship between two variable and the functional relationship between them - CORRECT ANSWER Simple linear regression Which index, often considered the most important resource in a healthcare facility, is a database of patients within a facility or associated group of facilities? - CORRECT ANSWER Master Patient Index One strategy for acquiring EHR components from various vendors and interfacing them is: - CORRECT ANSWER Best of breed This EHR implementation strategy stops its paper processing immediately after the go-live of the system - CORRECT ANSWER Straight turnover Protocols that support communication between applications are often referred to as: - CORRECT ANSWER Messaging standards Which of the following basic services provided by an HIE entity identifies participating users and systems? - CORRECT ANSWER Registry and directory An EKG tracing is an example of _____ data. - CORRECT ANSWER Vector graphic Providers who do not implement an EHR will eventually be penalized through: - CORRECT ANSWER Reduction in Medicare payments Which type of architecture has one powerful central computer that performs all processing and storage functions while sending and receiving data to or from various terminals and printers? - CORRECT ANSWER Mainframe The term used to describe breaking data elements into the level of detail needed to retrieve the data is: - CORRECT ANSWER Normalization A protocol to pass data from the system of one vendor to the information system of another vendor is called: - CORRECT ANSWER Interface All computers on this type of network receive the same message at the same time, but only one computer at a time can transfer information; and if one segment of the network goes down, the entire network is affected. - CORRECT ANSWER Bus topology When describing the typical length of stay for patients admitted for congestive heart failure, which is the most appropriate measure of central tendency when there are a number of long stay outliers? - CORRECT ANSWER Median In addition to bar codes on medical record documents, what other forms of recognition characteristics enhance the accuracy of forms indexing features? - CORRECT ANSWER OCR An evaluation of the benefits that have accured from the EHR investment that is performed at specific milestones in the life of the project and used to help in future systems planning, designing, and implementing is called a: - CORRECT ANSWER Benefits realization study In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? - CORRECT ANSWER Unit numbering The process of integrating healthcare facility systems requires the creation of: - CORRECT ANSWER Enterprise master patient indexes Which of the following is NOT a statistical technique used to create a model to access the probability that current Medicare claims are fraudulent? - CORRECT ANSWER Database warehousing In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a - CORRECT ANSWER Record locator service (RLS) Which of the following is an organization that develops standards related to the interoperability of health information technology? - CORRECT ANSWER Health Level 7 Network made accessible to trusted individuals outside of the organization - CORRECT ANSWER Extranet The JC requirement regarding delinquent records is that the number of delinquent records in a facility cannot exceed ________. - CORRECT ANSWER 50 percent of the average number of discharges Which of the following are used by an organization or enterprise to determine the probability of a duplicate data element to identify potential duplicate MPI entries? - CORRECT ANSWER Algorithms Which of the following lists represents recommended care data elements for the master patient index? - CORRECT ANSWER Name, gender, address, and DOB An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis? - CORRECT ANSWER The average wait time is longer on the weekends Which graph is the best choice to use when exploring the relationship between length of stay and charge for a set of patients? - CORRECT ANSWER Scatter diagram Charges for items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures are called: - CORRECT ANSWER Exploding charges A quality data review that is based on specific problems after an initial baseline review that has been completed in a hospital is called an - CORRECT ANSWER Focused inpatient review With what agency may patients file a complaint if they suspect medical identity theft violations? - CORRECT ANSWER Federal Trade Commission Which of the following can be a tool for recovery audit contractors (RAC) preparation because they outline the hospitals Medicare payment patterns compared to other hospitals in the state? - CORRECT ANSWER PEPPER In the APC system, a high cost outlier payment is paid when which of the following occurs? - CORRECT ANSWER The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts by Medicare, amount Medicare paid, and amount the patient must pay? - CORRECT ANSWER MSN (Medicare Summary Notice) Which of the following requires financial institutions to develop written medical identity theft programs? - CORRECT ANSWER Fair and Accurate Credit Transactions Act A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? - CORRECT ANSWER Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis You are the coding manager and are completing a review of a new coder's work. The case facts are that the patient was admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. The new coder sequenced the principal diagnosis as liver carcinoma. Which of the following would be the correct principal diagnosis? - CORRECT ANSWER Admission for chemotherapy The most recent coding audit has revealed a tendency to miss secondary diagnoses the would have increased the reimbursement for the case. Which of the following strategies would be most likely to correct this problem in the long term? - CORRECT ANSWER Development and implementation of a CDI program Which of the following are alternate work scheduling techniques? - CORRECT ANSWER Flextime, telecommuting, and compressed workweek One of the most common issues that healthcare organizations fail to do well in the strategic process is: - CORRECT ANSWER Execute the implantation plan Change management includes: - CORRECT ANSWER Being available to listen to staff. When implementing health information management training, determining who needs to be trained, who should do the training, how much training is required, and how the training will be accomplished is the responsibility of: - CORRECT ANSWER the implementation team Coders at the medical center hospital are expected to do a high volume of coding. Their department also includes a clerical support person who handles phone calls, pulls and files records to be coded, and maintains productivity logs. An abstract clerk enters coded data into the health information system. This is an example of ____ work division. - CORRECT ANSWER Serial The predefined process icon (rectangle with lines on sides) is used in flowcharting to indicate: - CORRECT ANSWER Formal procedures that participants are expected to carry out the same way every time. An analysis of a company's liquidity attempts to measure the company's ability to? - CORRECT ANSWER Meet current debt payments What actions might be taken to reduce the risks of groupthink? - CORRECT ANSWER Monitoring the degree of consensus and disagreement Which of the following is considered a viable solution to a staff recruitment problem for coding and transcription shortages? - CORRECT ANSWER Telecommuting Which of the following are attributes of both projects and daily operations? - CORRECT ANSWER Roles and responsibilities Ethical obligation to the _ include advocating change when patterns or system problems are not in the best interest of patients, reporting violation of practice standards to the proper authorities. - CORRECT ANSWER Public The manual input icon (square with diagonal top) is used in flowcharting to indicate: - CORRECT ANSWER A point in the process at which the participants must record data in paper-based or computer-based formats The financial statement that communicates the financial position of an organization at a certain point in time is called the: - CORRECT ANSWER Balance sheet When a computer-assisted coding product was installed at Community Memorial Hospital, coders initially found the new system overwhelming and were frustrated because their productivity decreased significantly. This experience represents the first stages of a - CORRECT ANSWER Learning curve Which tool is used to determine the most critical areas for training and education for a group of employees? - CORRECT ANSWER Needs analysis Which of the following is a statement made by one party to induce another party to enter into a contract? - CORRECT ANSWER Warranty The correct sequence of steps when evaluating an ethical problem is: - CORRECT ANSWER Determine the facts, who are the stakeholders, what are the options, what is the decision, what justifies the choice, and identify prevention options The three level of communication important to successful EHR implementation among internal stakeholders include all of the following except: - CORRECT ANSWER Between stakeholders and standard-setting organizations Which of the following would not be included in a healthcare entity's strategic profile? - CORRECT ANSWER Nature of its threats and opportunities Which of the following is a common outcome of conflict in the workplace? - CORRECT ANSWER Decreased productivity Which of the following materials are required elements in an emergency care record? - CORRECT ANSWER Time and means of the patients arrival, treatment rendered, and instructions at discharge The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as: - CORRECT ANSWER Privacy In carrying out the strategic plan for health IT, the step that describes what is needed to achieve the plans goal is : - CORRECT ANSWER Requirement ananlysis Case mix index - CORRECT ANSWER (total of weight * discharges) divided by (total discharges) At medical center hospital, the MPI systems is not meeting facility needs. There are duplicate numbers and errors in patient identification information. The IS director replaces the system with a newer system from a different vendor. After several months, the new system is exhibiting many of the same problems as the old systems, and the facility staff is frustrated and angry. What is most likely the cause of the problem? - CORRECT ANSWER Underlying human and process problems were not identified and corrected prior to making a system change. Using the following custom revenue production report, which coding error may be demonstrated in the report? - CORRECT ANSWER Clustering The slightly higher wage paid to an employee who works a less desirable shift is called a: - CORRECT ANSWER Shift differential The director of health information services in a hospital wants to implement a computer based patient record system over the next 2 years. She gets support from the CIO who advocates for the project with the administrative team. The CIO has become the projects - CORRECT ANSWER Champion A_ assists in educating medical staff members on documentation needed for accurate billing - CORRECT ANSWER Physician advisor Once all data are posted to a patient's account, the claim can be reviewed for accuracy and completeness. Many facilities have internal auditing systems. The auditing systems run each claim through a set of edits specifically designed for the various third-party payers. The auditing system identifies data that have failed edits and flags the claim for correction. These "internal" auditing systems are called a. scrubbers. b. groupers. c. pricers. d. encoders - CORRECT ANSWER Scrubbers The coding supervisor has complied a report on the number of coding errors made each day by the coding staff. The report data shows that Tim makes an average of six errors per day , Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what action should the coding supervisor take? - CORRECT ANSWER Take no action since not enough information is given to make a judgement Which of the following statements is most accurate regarding the relationship between levels of management and managerial skills? - CORRECT ANSWER Conceptual skills are greatest at the top level of management The following information was abstracted from Community Hospital balance sheet. A vendor selling a large dollar amount of goods to this hospital on credit would: - CORRECT ANSWER Be somewhat concerned because the curent ratio is less than one Contracting for staffing to handle a complete function within the HIM department, such as the Cancer Registry function, would be considered what type of contracting arrangement? - CORRECT ANSWER Full-Service Which of the following would be the best approach in starting a data governance program? - CORRECT ANSWER Focus on one or a few small business imperatives The original HIPAA legislation required adoption of four identifiers; employers, providers, health plans, and individuals. Three of these identifiers have been implemented and one is on hold. Which unique identifier has NOT been implemented? - CORRECT ANSWER Individuals Which of the following lists contains only entities that have roles in the various Medicare Improper Payment Review processes? - CORRECT ANSWER MAC, RAC, and QIO A patient was admitted for removal of the left lobe of the liver via laparotomy due to metastasis from a colon carcinoma. What is the correct ICD-10 PCS procedure code for this operation> - CORRECT ANSWER 0FT20ZZ (MEDICAL AND SURGICAL, HEPATOBILIARY SYSTEM AND PANCREAS, RESECTION, LIVER LEFT LOBE, OPEN, NO DEVICE, NO QUALIFIER - CORRECT ANSWER