CEHRS Review Chapter 2 HER
questions with complete solutions
The Legal Medical Records, or charts - correct answer ✔✔are created by physicians and other providers
in physician practices, hospitals, surgery centers, clinics and other healthcare facilities. They are created
and shared to help make accurate diagnoses of patients' conditions and to trace the course of care
Patient medical records are legal documents - correct answer ✔✔physicians own the physical record
(although patients own the information about themselves), and properly documented patient care is
part of the physician's defense against accusations that patients were not treated correctly. Medical
records should clearly state who performed what service and describe why, where, when, and how it
was done. The concept of it is based on rationale of medical necessity. The clinically logical link between
a patient's condition and the treatment provided.
Documentation means organizing a patient's health record in chronological order, using a systematic,
logical, and consistent method - correct answer ✔✔the patient's health history, examinations, tests, and
results of treatments are all documented. Complete and comprehensive documentation is important to
show that physicians have followed the medical standards of care that apply in their state.
An unwritten law of medical insurance - correct answer ✔✔is that if it was not documented, it was not
done. And if it was not done, it cannot be billed
Federal Regulation:
Main federal government agency is Centers of Medicare and Medicaid Services (CMS) - correct answer
✔✔CMS runs Medicare, Medicaid, clinical laboratories, and other government health programs. They
are also responsible for enforcing all HIPAA standards other than the privacy and security standards
Health and Human Services (HHS):
When a change is made in Medicare rules - correct answer ✔✔private payers often adopt a similar rule
State Regulations:
, Operating an insurance company without a license is illegal in all states - correct answer ✔✔State
commissioners of insurance investigate consumer complaints about the quality and financial aspects of
health care. State laws ensure the solvency of insurance companies and managed care organizations, so
that they will be able to pay enrollees' claims
Electronic Data Interchange (EDI) - correct answer ✔✔is the computer-to-computer exchange of routine
business information using publicly available electronic standards. Practice staff members use EDI to
exchange health information about their practices' patients with payers and clearinghouses
3 parts to HIPAA's Administrative Simplification Provisions: - correct answer ✔✔1. HIPAA Privacy Rule,
the privacy requirements cover patients' health information, whether paper, electronic or otherwise 2.
HIPAA Security Rule, the security requirements state the administrative, technical and physical
safeguards that are required to protect patients' electronic health information 3. HIPAA Electronic
Transactions and Code Sets standards, the standards require every provider who does business
electronically to use the same health care transactions, code sets and identifiers
HITECH ACT - correct answer ✔✔prevents breaches of health information, the HITECH ACT requires
keeping patients' protected health information secure by making it "unusable, unreadable, or
indecipherable to unauthorized individuals" using specified technologies and methods. In the case of
breaches of unsecured health information by covered entities or their business associates, HITECH
requires health care providers, health plans, and other entities covered by HIPAA to notify individuals
that their health information has been compromised
covered entitiy - correct answer ✔✔under HIPAA health plans, clearinghouses, or providers who
transmit any health information in electronic form in connection with a HIPAA transaction
clearinghouse - correct answer ✔✔company that processes electronic health information and executes
electronic transactions such as insurance verification and claim submission for providers
business associates - correct answer ✔✔individuals or businesses whose services involve the use of
disclosure of personal health information (PHI) to perform a function or activity on behalf of a covered
entity but who are not part of the covered entity's workforce
protected health information (PHI) - correct answer ✔✔individually identifiable health information
transmitted or maintained by electronic media or in any other form or medium
questions with complete solutions
The Legal Medical Records, or charts - correct answer ✔✔are created by physicians and other providers
in physician practices, hospitals, surgery centers, clinics and other healthcare facilities. They are created
and shared to help make accurate diagnoses of patients' conditions and to trace the course of care
Patient medical records are legal documents - correct answer ✔✔physicians own the physical record
(although patients own the information about themselves), and properly documented patient care is
part of the physician's defense against accusations that patients were not treated correctly. Medical
records should clearly state who performed what service and describe why, where, when, and how it
was done. The concept of it is based on rationale of medical necessity. The clinically logical link between
a patient's condition and the treatment provided.
Documentation means organizing a patient's health record in chronological order, using a systematic,
logical, and consistent method - correct answer ✔✔the patient's health history, examinations, tests, and
results of treatments are all documented. Complete and comprehensive documentation is important to
show that physicians have followed the medical standards of care that apply in their state.
An unwritten law of medical insurance - correct answer ✔✔is that if it was not documented, it was not
done. And if it was not done, it cannot be billed
Federal Regulation:
Main federal government agency is Centers of Medicare and Medicaid Services (CMS) - correct answer
✔✔CMS runs Medicare, Medicaid, clinical laboratories, and other government health programs. They
are also responsible for enforcing all HIPAA standards other than the privacy and security standards
Health and Human Services (HHS):
When a change is made in Medicare rules - correct answer ✔✔private payers often adopt a similar rule
State Regulations:
, Operating an insurance company without a license is illegal in all states - correct answer ✔✔State
commissioners of insurance investigate consumer complaints about the quality and financial aspects of
health care. State laws ensure the solvency of insurance companies and managed care organizations, so
that they will be able to pay enrollees' claims
Electronic Data Interchange (EDI) - correct answer ✔✔is the computer-to-computer exchange of routine
business information using publicly available electronic standards. Practice staff members use EDI to
exchange health information about their practices' patients with payers and clearinghouses
3 parts to HIPAA's Administrative Simplification Provisions: - correct answer ✔✔1. HIPAA Privacy Rule,
the privacy requirements cover patients' health information, whether paper, electronic or otherwise 2.
HIPAA Security Rule, the security requirements state the administrative, technical and physical
safeguards that are required to protect patients' electronic health information 3. HIPAA Electronic
Transactions and Code Sets standards, the standards require every provider who does business
electronically to use the same health care transactions, code sets and identifiers
HITECH ACT - correct answer ✔✔prevents breaches of health information, the HITECH ACT requires
keeping patients' protected health information secure by making it "unusable, unreadable, or
indecipherable to unauthorized individuals" using specified technologies and methods. In the case of
breaches of unsecured health information by covered entities or their business associates, HITECH
requires health care providers, health plans, and other entities covered by HIPAA to notify individuals
that their health information has been compromised
covered entitiy - correct answer ✔✔under HIPAA health plans, clearinghouses, or providers who
transmit any health information in electronic form in connection with a HIPAA transaction
clearinghouse - correct answer ✔✔company that processes electronic health information and executes
electronic transactions such as insurance verification and claim submission for providers
business associates - correct answer ✔✔individuals or businesses whose services involve the use of
disclosure of personal health information (PHI) to perform a function or activity on behalf of a covered
entity but who are not part of the covered entity's workforce
protected health information (PHI) - correct answer ✔✔individually identifiable health information
transmitted or maintained by electronic media or in any other form or medium
