C810 FOUNDATIONS IN HEALTHCARE
DATA MANAGEMENT - STUDY GUIDE
QUESTIONS & ANSWERS 100%
CORRECT
C-CDA - ANSWERAllows interop of health information exchange between hospitals
DEEDS - ANSWERData set for uniform collection of information in hospital-based
emergency departments. Used by Trauma Registrar in ED.
UHDDS - ANSWERStandard data dictionary terms for commonly collected data in
acute care hospitals. Required data set for acute care hospitals.
Data Element Requirements UHDDS - ANSWERIncludes Personal Identification,
Procedures, Dates, and Principal Diagnosis
MDS - ANSWERMinimum Data Set for SNF patient assessment data and
reimbursement.
MDS Minimum Data Set - ANSWEROBRA mandates comprehensive functional
assessments of long-term care residents.
ICD-10-CM-PCS - ANSWERInternational Classification of Diseases, Clinical
Modification/Procedure Coding Systems
SNOMED CT (Systemized Nomenclature of Medicine - Clinical Terms) - ANSWERis
a controlled medical terminology that encompasses diseases, clinical findings,
etiologies, procedures, and health
outcomes. Is a comprehensive clinical terminology that provides clinical
content and expressivity for clinical documentation and reporting. Is basically
comprised of concepts, descriptions,
and relationships in order to accurately represent clinical information in healthcare.
can be used to support direct patient care, clinical audit, research, epidemiology, and
service planning.
LOINC (Logical Observation Identifiers Names and Codes) - ANSWERa clinical
terminology, provides a common language for clinical and laboratory observations
RxNorm - ANSWERStandardized nomenclature for clinical drugs detailing
ingredients, strengths, and forms of administration
DSM-5 - ANSWERDiagnostic and Statistical Manual of Mental Disorders
ORYX - ANSWERJoint Commission Core Measure Sets; Initiative to enhance
healthcare safety and quality
,OASIS - ANSWEROutcome and Assessment Information Set for home healthcare
NQF - ANSWERNational Quality Forum focusing on patient protection and
healthcare quality
NCQA - ANSWERNational Committee for Quality Assurance accrediting managed
care organizations and assessing quality
HEDIS - ANSWERHealthcare Effectiveness Data and Information Set
Meaningful Use - EHR Incentive program - ANSWERIncentivizes EHR adoption with
defined core and menu sets in healthcare
Components of long-term care federal mandated RAI - ANSWER1. New Care Area
Assessment
2. Utilization Guidelines
3. MDS - Minimum Data Set for LTC facilities
COP - ANSWERRegulations for health care institutions to receive Medicare
Reimbursement.
Immunization Registry - ANSWERMonitors children from birth in a geographical
area.
Implant Registry - ANSWERCollects data on recipients of heart valves and
pacemakers.
NPDB - ANSWERUsed in the credentialing process by healthcare organizations.
Must be queried by hospitals for physician privileges.
HIPDB - ANSWERCentral repository for healthcare fraud and abuse information.
Mandated by HIPAA. Types of items reported include adverse actions.
Reporting to NPDB - ANSWERProviders must report medical malpractice payments,
licensure actions, adverse clinical privileges actions, and more to NPDB.
Trauma Registry - ANSWERUsed for performance improvement and research in
trauma care. Can be facility-based or regional.
The Injury Severity Score (ISS) - ANSWEROverall severity measurement calculated
from the three most severe injuries of a patient.
is an overall severity measurement calculated from the AIS scores for the three most
severe injuries of the patient. classify and describe the severity of injuries and can be
used for reporting registry activity.
Current Procedural Terminology (CPT). - ANSWERMost commonly used system of
procedure codes. Provides a uniform language that accurately describes medical,
surgical, and diagnostic services, and thereby serves as an effective means for
reliable nationwide communication among physicians, patients, and third parties
, Healthcare Common Procedure Coding System (HCPCS) - ANSWERis used to
report services and supplies primarily for reimbursement purposes in the outpatient
or ambulatory setting.
Level I of HCPCS is composed of the CPT codes as published by the (AMA) and
represents medical services and procedures performed by physicians and other
healthcare providers.
Level II of HCPCS contains codes that represent products, supplies, and services
not included in the CPT codes.
Hospital Based Cancer Registry - ANSWERAims to improve patient care.
Unified Medical Language System UMLS - ANSWERIntegrates biomedical concepts
from various sources to show relationships; includes medical classifications like ICD-
10-CM, CPT, and HCPCS.
MEDLINE - ANSWERBest-known database from the National Library of Medicine;
used to locate articles on HIM issues and medical topics for quality improvement and
research.
Disease Index - ANSWERMajor source of case findings for cancer registry
programs; lists diagnosis codes in number order.
Number Control Index - ANSWERIdentifies new health record numbers and the
assigned patients.
Physicians Index - ANSWERIdentifies all patients treated by each doctor; lists cases
in order by physician name or number.
Patient Index - ANSWERLinks each patient treated in a facility with the health
number for clinical information retrieval.
MPI: Master Patient Index - ANSWERCross-references patient's name and medical
record number; key locator in numerical filing system.
Operation Index - ANSWERLists medical record numbers of patients who had
CABGs performed in acute care hospital.
3 Major Types of Events Requiring Contingency Disaster Planning - ANSWER1.
Natural threats (floods)
2. Technical/Man-made (mechanical, biological)
3. Intentional acts (computer security)
Core Principles of HIM Recording Management at Risk During Disaster - ANSWER1.
Disclosing Health Information
2. Retention
3. Confidentiality
DATA MANAGEMENT - STUDY GUIDE
QUESTIONS & ANSWERS 100%
CORRECT
C-CDA - ANSWERAllows interop of health information exchange between hospitals
DEEDS - ANSWERData set for uniform collection of information in hospital-based
emergency departments. Used by Trauma Registrar in ED.
UHDDS - ANSWERStandard data dictionary terms for commonly collected data in
acute care hospitals. Required data set for acute care hospitals.
Data Element Requirements UHDDS - ANSWERIncludes Personal Identification,
Procedures, Dates, and Principal Diagnosis
MDS - ANSWERMinimum Data Set for SNF patient assessment data and
reimbursement.
MDS Minimum Data Set - ANSWEROBRA mandates comprehensive functional
assessments of long-term care residents.
ICD-10-CM-PCS - ANSWERInternational Classification of Diseases, Clinical
Modification/Procedure Coding Systems
SNOMED CT (Systemized Nomenclature of Medicine - Clinical Terms) - ANSWERis
a controlled medical terminology that encompasses diseases, clinical findings,
etiologies, procedures, and health
outcomes. Is a comprehensive clinical terminology that provides clinical
content and expressivity for clinical documentation and reporting. Is basically
comprised of concepts, descriptions,
and relationships in order to accurately represent clinical information in healthcare.
can be used to support direct patient care, clinical audit, research, epidemiology, and
service planning.
LOINC (Logical Observation Identifiers Names and Codes) - ANSWERa clinical
terminology, provides a common language for clinical and laboratory observations
RxNorm - ANSWERStandardized nomenclature for clinical drugs detailing
ingredients, strengths, and forms of administration
DSM-5 - ANSWERDiagnostic and Statistical Manual of Mental Disorders
ORYX - ANSWERJoint Commission Core Measure Sets; Initiative to enhance
healthcare safety and quality
,OASIS - ANSWEROutcome and Assessment Information Set for home healthcare
NQF - ANSWERNational Quality Forum focusing on patient protection and
healthcare quality
NCQA - ANSWERNational Committee for Quality Assurance accrediting managed
care organizations and assessing quality
HEDIS - ANSWERHealthcare Effectiveness Data and Information Set
Meaningful Use - EHR Incentive program - ANSWERIncentivizes EHR adoption with
defined core and menu sets in healthcare
Components of long-term care federal mandated RAI - ANSWER1. New Care Area
Assessment
2. Utilization Guidelines
3. MDS - Minimum Data Set for LTC facilities
COP - ANSWERRegulations for health care institutions to receive Medicare
Reimbursement.
Immunization Registry - ANSWERMonitors children from birth in a geographical
area.
Implant Registry - ANSWERCollects data on recipients of heart valves and
pacemakers.
NPDB - ANSWERUsed in the credentialing process by healthcare organizations.
Must be queried by hospitals for physician privileges.
HIPDB - ANSWERCentral repository for healthcare fraud and abuse information.
Mandated by HIPAA. Types of items reported include adverse actions.
Reporting to NPDB - ANSWERProviders must report medical malpractice payments,
licensure actions, adverse clinical privileges actions, and more to NPDB.
Trauma Registry - ANSWERUsed for performance improvement and research in
trauma care. Can be facility-based or regional.
The Injury Severity Score (ISS) - ANSWEROverall severity measurement calculated
from the three most severe injuries of a patient.
is an overall severity measurement calculated from the AIS scores for the three most
severe injuries of the patient. classify and describe the severity of injuries and can be
used for reporting registry activity.
Current Procedural Terminology (CPT). - ANSWERMost commonly used system of
procedure codes. Provides a uniform language that accurately describes medical,
surgical, and diagnostic services, and thereby serves as an effective means for
reliable nationwide communication among physicians, patients, and third parties
, Healthcare Common Procedure Coding System (HCPCS) - ANSWERis used to
report services and supplies primarily for reimbursement purposes in the outpatient
or ambulatory setting.
Level I of HCPCS is composed of the CPT codes as published by the (AMA) and
represents medical services and procedures performed by physicians and other
healthcare providers.
Level II of HCPCS contains codes that represent products, supplies, and services
not included in the CPT codes.
Hospital Based Cancer Registry - ANSWERAims to improve patient care.
Unified Medical Language System UMLS - ANSWERIntegrates biomedical concepts
from various sources to show relationships; includes medical classifications like ICD-
10-CM, CPT, and HCPCS.
MEDLINE - ANSWERBest-known database from the National Library of Medicine;
used to locate articles on HIM issues and medical topics for quality improvement and
research.
Disease Index - ANSWERMajor source of case findings for cancer registry
programs; lists diagnosis codes in number order.
Number Control Index - ANSWERIdentifies new health record numbers and the
assigned patients.
Physicians Index - ANSWERIdentifies all patients treated by each doctor; lists cases
in order by physician name or number.
Patient Index - ANSWERLinks each patient treated in a facility with the health
number for clinical information retrieval.
MPI: Master Patient Index - ANSWERCross-references patient's name and medical
record number; key locator in numerical filing system.
Operation Index - ANSWERLists medical record numbers of patients who had
CABGs performed in acute care hospital.
3 Major Types of Events Requiring Contingency Disaster Planning - ANSWER1.
Natural threats (floods)
2. Technical/Man-made (mechanical, biological)
3. Intentional acts (computer security)
Core Principles of HIM Recording Management at Risk During Disaster - ANSWER1.
Disclosing Health Information
2. Retention
3. Confidentiality
