Health records and information
management (EXAM 1) UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Supporting the current and continuing care of patients, the institutions administrative
processes, maintains records for billing and accounting are all functions of ? - CORRECT
ANSWER✔✔- Health information departments
What does ICD-10-CM stand for? - CORRECT ANSWER✔✔- International Classification
of Diseases, 10th Revision, Clinical Modification
What does CPT-4 stand for? - CORRECT ANSWER✔✔- Current Procedural Terminology,
4th edition
What does APC stand for? - CORRECT ANSWER✔✔- Ambulatory Payment Classification
What's does DRG stand for? - CORRECT ANSWER✔✔- Diagnosis-related group
What does TJC stand for? - CORRECT ANSWER✔✔- The Joint Commission
What does HFAP stand for ? - CORRECT ANSWER✔✔- Healthcare Facilities Accreditation
Program
What does PPS stand for? - CORRECT ANSWER✔✔- Prospective Payment System
What does EHR/EMR stand for? - CORRECT ANSWER✔✔- Electronic Health Record
Electronic Medical Record
What is the ICD-10-CM? - CORRECT ANSWER✔✔- System that is used for DIAGNOSIS
coding in all health care settings in the United States
, What is the CPT-4? - CORRECT ANSWER✔✔- listing of medical terms and codes for
diagnostic and therapeutic PROCEDURES used for coding for physician reimbursement
What is APC? - CORRECT ANSWER✔✔- Based on ICD-10-CM codes for diagnosis and
CPT codes used for REIMBURSEMENT to health care in an OUTPATIENT setting
What is DRG? - CORRECT ANSWER✔✔- Categorized into PAYMENT GROUPS, patients
who are MEDICALLY RELATED with respect to diagnosis and treatment and statistically
similar with regard to length of stay
What is the TJC and what do they do? - CORRECT ANSWER✔✔- Organization that
ACCREDITS hospitals and other health care institutions in the United States
What does HFAP do? - CORRECT ANSWER✔✔- Performs functions similar to TJC, can
also accredit hospitals
What is PPS and what does it do? - CORRECT ANSWER✔✔- System for MEDICARE
PATIENTS whereby payment groups are established in advance, hospitals get PAID UP
FRONT (inpatient setting)
What is EHR? - CORRECT ANSWER✔✔- Electronic Health Record, where all patient
health information is able to be accessed by patients and physicians
According to the TJC a medical record must contain sufficient info to? - CORRECT
ANSWER✔✔- Identify patient, support diagnosis, justify treatment, document the course &
results, and promote care among health care providers
According to Medicare, a medical record must contain what? - CORRECT ANSWER✔✔-
Info to justify admission and hospitalization, support diagnosis, and describe patients
progress as well as response to medication and services
When should documenting/ charting be done? - CORRECT ANSWER✔✔- When a patient
receives either diagnostic or therapeutic radiologic services
management (EXAM 1) UPDATED
ACTUAL Exam Questions and CORRECT
Answers
Supporting the current and continuing care of patients, the institutions administrative
processes, maintains records for billing and accounting are all functions of ? - CORRECT
ANSWER✔✔- Health information departments
What does ICD-10-CM stand for? - CORRECT ANSWER✔✔- International Classification
of Diseases, 10th Revision, Clinical Modification
What does CPT-4 stand for? - CORRECT ANSWER✔✔- Current Procedural Terminology,
4th edition
What does APC stand for? - CORRECT ANSWER✔✔- Ambulatory Payment Classification
What's does DRG stand for? - CORRECT ANSWER✔✔- Diagnosis-related group
What does TJC stand for? - CORRECT ANSWER✔✔- The Joint Commission
What does HFAP stand for ? - CORRECT ANSWER✔✔- Healthcare Facilities Accreditation
Program
What does PPS stand for? - CORRECT ANSWER✔✔- Prospective Payment System
What does EHR/EMR stand for? - CORRECT ANSWER✔✔- Electronic Health Record
Electronic Medical Record
What is the ICD-10-CM? - CORRECT ANSWER✔✔- System that is used for DIAGNOSIS
coding in all health care settings in the United States
, What is the CPT-4? - CORRECT ANSWER✔✔- listing of medical terms and codes for
diagnostic and therapeutic PROCEDURES used for coding for physician reimbursement
What is APC? - CORRECT ANSWER✔✔- Based on ICD-10-CM codes for diagnosis and
CPT codes used for REIMBURSEMENT to health care in an OUTPATIENT setting
What is DRG? - CORRECT ANSWER✔✔- Categorized into PAYMENT GROUPS, patients
who are MEDICALLY RELATED with respect to diagnosis and treatment and statistically
similar with regard to length of stay
What is the TJC and what do they do? - CORRECT ANSWER✔✔- Organization that
ACCREDITS hospitals and other health care institutions in the United States
What does HFAP do? - CORRECT ANSWER✔✔- Performs functions similar to TJC, can
also accredit hospitals
What is PPS and what does it do? - CORRECT ANSWER✔✔- System for MEDICARE
PATIENTS whereby payment groups are established in advance, hospitals get PAID UP
FRONT (inpatient setting)
What is EHR? - CORRECT ANSWER✔✔- Electronic Health Record, where all patient
health information is able to be accessed by patients and physicians
According to the TJC a medical record must contain sufficient info to? - CORRECT
ANSWER✔✔- Identify patient, support diagnosis, justify treatment, document the course &
results, and promote care among health care providers
According to Medicare, a medical record must contain what? - CORRECT ANSWER✔✔-
Info to justify admission and hospitalization, support diagnosis, and describe patients
progress as well as response to medication and services
When should documenting/ charting be done? - CORRECT ANSWER✔✔- When a patient
receives either diagnostic or therapeutic radiologic services
