AHIMA RHIA Exam Prep (7th Edition) 158 Questions with Verified Answers,100% CORRECT

AHIMA RHIA Exam Prep (7th Edition) 158 Questions with Verified Answers 17. 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? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically - CORRECT ANSWER c. Provide the patient with both paper and electronic copies of the record The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be delivered electronically (Thomason 2013, 102). 15. For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - CORRECT ANSWER If an EHR is to provide clinical decision support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364). 14. Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card d. Password and PIN - CORRECT ANSWER c. Password and swipe card The three methods of two-factor authentication are something you know, such as a password or PIN; something you have, such as an ATM card, token, or swipe/smart card; and something you are, such as a biometric fingerprint, voice scan, iris, or retinal scan (Sayles and Trawick 2014, 219). Under RBRVS, which elements are used to calculate a Medicare payment? a. Work value and extent of the physical exam b. Malpractice expenses and detail of the patient history c. Work value and practice expenses d. Practice expenses and review of systems - CORRECT ANSWER Each Resource-Based Relative Value Scale (RBRVS) comprises three elements: physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register (Casto and Forrestal 2015, 150). 12. The predefined process icon is used in flowcharting to indicate: a. A process in which actions are being performed by humans b. A point in the process at which participants must evaluate the status of the process c. Formal procedures that participants are expected to carry out the same way every time d. A point in the process at which the participants must record data in paper-based or computer- based formats - CORRECT ANSWER The rectangle with double lines on the side in a flowchart is a predefined process icon. This symbol represents the formal procedure that participants are expected to carry out the same way every time (Shaw and Carter 2015, 198). . A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? a. Content analysis b. Effect size review c. Psychometric assay d. Secondary analysis - CORRECT ANSWER Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586). In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has COPD d. Assign a code from the abnormal findings to reflect the condition - CORRECT ANSWER A query is routine communication and education tool used to advocate for complete and compliant documentation. The intent is to clarify what has been recorded, not to call into question the provider's clinical judgment or medical expertise. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS and whether the COPD does is not clear (Hunt 2016, 276-277). Per the HITECH breach notification requirements, which of the following is the threshold in which the media and the Secretary of Health and Human Services should be notified of the breach? a. more than 1,000 individuals affected b. more than 500 individuals affected c. more than 250 individuals affected d. Any number of individuals affected requires notification - CORRECT ANSWER Reporting requirements mandate notification to the individual whose information was breached, and in the case of breaches of more than 500 individuals' information, to the media and the Secretary of Health and Human Services (Biedermann and Dolezel 2017, 401). Determining costs associated with EHR hardware and software acquisition, implementation, and ongoing maintenance represents which type of analysis? a. Benefits realization study b. Goal-setting exercise c. Cost-benefit feasibility study d. Productivity improvement study - CORRECT ANSWER Cost-benefit feasibility is used to determine if an EHR initiative is appropriate for the organization at this time; it measures the costs associated with acquisition of hardware and software, installation, implementation, and ongoing maintenance (Amatayakul 2016, 104-105). Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service. - CORRECT ANSWER If a service is hard-coded into the charge description master (CDM), it is important that this decision is communicated to the coding staff. If the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and Forrestal 2015, 253). Which health record format is arranged in chronological order with documentation from various sources intermingled? a. Electronic b. Source-oriented c. Problem-oriented d. Integrated - CORRECT ANSWER The integrated health record is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse-chronological order. The advantage of the integrated format is that it is easy for caregivers to follow the course of the patient's diagnosis and treatment (Russo 2013b, 305). 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 clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room. b. There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice. c. HIPAA allows only the use of the patient's first name. d. HIPAA requires that patients be given numbers and that only the number be announced. - CORRECT ANSWER The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is not to interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure and, therefore, allowed in the Privacy Rule (Thomason 2013, 37). 4. Which of the following is a graphical display of the relationships between tables in a database? a. RDMS b. SQL c. ERD d. SAS - CORRECT ANSWER An entity relationship diagram (ERD) is used to describe how the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool (White 2016a, 46). What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options? a. Core measures b. Enhanced discharge planning c. Data mining d. Clinical practice guidelines - CORRECT ANSWER Clinicians use health record information to develop clinical pathways and other clinical practice guidelines, which help clinicians make knowledge- and experience-based decisions on medical treatment. These guidelines make it easier to coordinate multidisciplinary care and services (Fahrenholz 2013b, 78). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). Which of the following is a kind of technology that focuses on data security? a. Clinical decision support b. Bitmapped data c. Firewalls d. Smart cards - CORRECT ANSWER Firewalls are hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders (Sandefer 2016a, 366). 9. What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts approved by Medicare, amount Medicare paid, and amount the patient must pay? a. EOB b. MSN c. EOMB d. ABN - CORRECT ANSWER Correct Answer: B For Medicare patients, the fiscal intermediary and carriers prepare Medicare summary notices or MSNs. The MSN details amounts billed by the provider, amounts approved by Medicare, how much Medicare reimbursed the provider, and what the patient must pay the provider by way of deductible and copayments (Casto and Forrestal 2015, 256). 20. Secondary data sources provide information that is ________ available by looking at individual health records. a. not easily b. easily c. often d. never - CORRECT ANSWER Correct Answer: A Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2013c, 159). Use of a variety of content delivery methods to accommodate different types of learners is called: a. Blended learning b. Programmed learning c. Classroom learning d. Online learning - CORRECT ANSWER Correct Answer: A Blended learning uses several delivery methods thereby gaining the advantages and reducing the disadvantages of each method alone (Patena 2016, 772). 22. In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? a. DICOM b. IEEE 1073 c. LOINC d. X12N - CORRECT ANSWER Correct Answer: D X12N refers to standards adopted for electronic data interchange. In order for transmission of healthcare data between a provider and payer, both parties must adhere to these standards (Sayles and Trawick 2014, 175). 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 specified period of time? a. Prevalence b. Incidence c. Frequency d. Distribution - CORRECT ANSWER Correct Answer: A The prevalence rate is the proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time. The prevalence rate describes the magnitude of an epidemic and can be an indicator of the medical resources needed in a community for the duration of the epidemic (Edgerton 2016, 503). 15 8 Correct15 Wrong8 Unanswered 1. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel d. Nursing staff - CORRECT ANSWER Correct Answer: D In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff. Coding is based primarily on physician documentation, so nursing staff would not be included in the education process (Hunt 2016, 288). 18 5 Correct18 Wrong5 Unanswered 2. A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a: a. Problem-oriented health record b. Patient-centric record c. Longitudinal health record d. Health record - CORRECT ANSWER Correct Answer: C A longitudinal health record maintains information throughout the lifespan of the patient, ideally from birth to death (Fahrenholz 2013a, 45). 3. In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. This data is called a(n): a. Indicator b. Measurement c. Assessment d. Outcome - CORRECT ANSWER Correct Answer: A An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2015, 153). The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue? a. Have coders continue to query the attending physician for this documentation. b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines. c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue. - CORRECT ANSWER Correct Answer: B The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Hunt 2016, 275). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Correct Answer: B Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). For a contract to be valid, it must include three elements. Which of the following is one of those elements? a. Assumption of risk b. Consideration c. Statute of limitations d. Notice of liability - CORRECT ANSWER Correct Answer: B The elements of a contract must be stated clearly and specifically. A contract cannot exist unless all the following elements exist: there must be an agreement between two or more persons or entities and the agreement must include a valid offer, acceptance, and exchange of consideration (Rinehart-Thompson 2016, 56). For Medicare patients, how often must the home health agency's assessment and care plan be updated? a. At least every 60 days or as often as the severity of the patient's condition requires b. Every 30 days c. As often as the severity of the patient's condition requires d. Every 60 days - CORRECT ANSWER Correct Answer: A Home health agencies are expected to conduct an assessment that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires (White 2013, 558). Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: a. Never allowed b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment c. Allowed only if Jennifer's mother is declared incompetent by a court of law d. Allowed access to PHI; any family member is always allowed access to PHI - CORRECT ANSWER Correct Answer: B The Privacy Rule lists two circumstances where protected health information (PHI) can be used or disclosed without the individual's authorization (although the individual must be informed in advance and given an opportunity to agree or object). One of these circumstances is disclosing PHI to a family member or a close friend that is directly relevant to his or her involvement with the patient's care or payment. Likewise, a covered entity may disclose PHI, including the patient's location, general condition, or death, to notify or assist in the notification of a family member, personal representative, or some other person responsible for the patient's care (Rinehart-Thompson 2017d, 225-226). 10. Using the data in the following graph, we can see changes in this hospital's profile. What concerns might the hospital's quality council need to address based on these changes in their customer base? a. Staffing changes might be necessary to accommodate patients who have cultural differences. b. Data collection has improved. c. No changes in staffing are necessary because the patient mix is appropriate. d. The quality council should ask for more detailed data. - CORRECT ANSWER Correct Answer: A The graph shows that the Asian population has increased in the last five years, so the organization may need to adjust staffing, offer a wider variety in dietary choices, and ensure patient rights and safety are appropriate in the face of possible language barriers and cultural differences (Shaw and Carter 2015, 95-97) A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called: a. Strategy map b. Process innovations c. Balanced scorecard methodology d. SWOT analysis - CORRECT ANSWER Correct Answer: C Balanced scorecard methodology is a technique for measuring organization performance across the four perspectives of customer, financial, internal processes, and learning and growth (McClernon 2016, 951). The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of: a. Assisting coders to read physician handwriting b. Preventing potential medication errors due to misinterpretation c. Making terminology consistent in preparation for electronic records d. Identifying physicians who are dispensing large quantities of drugs - CORRECT ANSWER Correct Answer: B Healthcare organizations need to be very clear about which abbreviations are not acceptable to use when writing or communicating medication orders. The organization's policy should also define whether or when the diagnosis, condition, or indication for use is included on a medication order (Shaw and Carter 2015, 248-249). Which of the following is true of the median? a. It is a measure of variability. b. It is difficult to calculate. c. It is based on the whole distribution. d. It is sensitive to extreme values. - CORRECT ANSWER Correct Answer: C The median offers the following three advantages: relatively easy to calculate; based on the whole distribution and not just a portion of it, as is the case with the mode; and unlike the mean, it is not influenced by extreme values or unusual outliers in the frequency distribution (Horton 2016, 222). 4. This type of data display tool is a plotted chart of data that shows the progress of a process over time. a. Bar graph b. Histogram c. Pie chart d. Line graph or plot - CORRECT ANSWER Correct Answer: D A line graph or plot may be used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the values of the variable being plotted (Marc 2016, 546). Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given: a. No information due to the highly sensitive nature of his illness b. Admission date and location in the facility c. General condition and acknowledgment of admission d. Location in the facility and diagnosis - CORRECT ANSWER Correct Answer: C A facility may maintain a facility directory of patients being treated. HIPAA's Privacy Rule permits the facility to maintain in its directory the following information about an individual if the individual has not objected: name, location in the facility, and condition described in general terms. This information may be disclosed to persons who ask for the individual by name (Rinehart-Thompson 2017d, 227). 17. If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? a. Survey sampling b. Systematic sampling c. Cluster sampling d. Stratified sampling - CORRECT ANSWER Correct Answer: B A systematic random sample is a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample (White 2016a, 140). . 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: a. Release the information to the health insurance provider b. Get special patient consent to release the information c. Comply with the patient's request and keep the information private d. Request permission from HHS to release the information - CORRECT ANSWER Correct Answer: C The 2013 HIPAA Omnibus Rule finalized regulations give patients the right to request that their PHI not be disclosed to a health plan if they pay out of pocket in full for the services or items. A provider who accepts the payment and provides the service is compelled to abide by this request (Rinehart-Thompson 2017d, 220-221). Which of the following would be the best approach in starting a data governance program? a. Focus on one or a few small business imperatives b. Begin with developing policies and procedures c. Identify HIPAA requirements d. Establish success metrics - CORRECT ANSWER Correct Answer: A Data governance is an iterative process. It initially prioritizes initiatives and focuses on small select business imperatives that quickly deliver value and expand as the program matures (Johns 2016, 88). 18 5 Correct18 Wrong5 Unanswered 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? a. Utilization management b. Patient access c. Health information management d. Patient accounts - CORRECT ANSWER Correct Answer: C Resolving failed edits is one of many duties of the health information management (HIM) department. Various medical departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Schraffenberger and Kuehn 2011, 237-238). The legal health record for disclosure consists of: a. Any and all protected health information data collected or used by a healthcare entity when delivering care b. Only the protected health information requested by an attorney for a legal proceeding c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings d. All of the data and information included in the HIPAA Designated Record Set - CORRECT ANSWER Correct Answer: C The concept of legal health records was created to describe the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings. Understanding legal health records requires knowledge of not only what comprises business records used as legal health records, but also the processes as well as the physical and electronic systems used to manage these records (Biedermann and Dolezel 2017, 424). 22. In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions): a. Resident Assessment Protocols (RAPs) b. Resident Assessment Instrument (RAI) c. Utilization Guidelines (UG) d. Minimum Data Sets (MDS) - CORRECT ANSWER Correct Answer: A Resident assessment protocols (RAPs) form a critical link to decisions about care planning and provide guidance on how to synthesize assessment information within a comprehensive assessment. The triggers target conditions for additional assessment and review, as warranted by Minimum Data Set (MDS) item responses. The RAPs guidelines help facility staff evaluate triggered conditions (CMS 2010; James 2013b, 538). Which of the following is a true statement about business process reengineering? a. It is intended to make small incremental changes to improve a process. b. It seeks to reevaluate and redesign organizational processes to make dramatic performance improvements. c. It implies making few changes to achieve significant improvements in cost, quality, service, and speed. d. Its main focus is to reduce services. - CORRECT ANSWER Correct Answer: B In reengineering, the entire manner and purpose of a work process is questioned. The goal is to achieve the desired process outcome in the most effective and efficient manner possible. The results expected from reengineering efforts include increased productivity, decreased costs, improved quality, maximized revenue, and more satisfied customers. However, it should be clearly understood that the main focus is on reducing costs (Oachs 2016, 819). 1. In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute-care MS-DRGs similar? a. Relative weights b. Based on principal diagnosis c. Categorization of low-volume groups into quintiles d. Classification of short-stay outliers - CORRECT ANSWER Correct Answer: B Both the MS-LTC-DRGs and the acute care MS-DRGs are based on the principal diagnosis in terms of grouping and reimbursement (Casto and Forrestal 2015, 217-218). . The process of conducting a thorough review of the internal and external conditions in which a healthcare entity operates is called: a. Environmental assessment b. Operations improvement planning c. Strategic management d. Employment assessment - CORRECT ANSWER Correct Answer: A Knowledge of the internal and external environment is essential to vision and strategy formulation. An environmental assessment is defined as a thorough review of the internal and external conditions in which an organization operates. This data-intensive process is the continuous process of gathering and analyzing intelligence about trends that are—or may be—affecting an organization and industry. IBM did not see the market demands and change in the personal home computing environment quickly enough, so their competitors were out to market ahead of them (McClernon 2016, 933). 3. Ensuring that data have been accessed or modified only by those authorized to do so is a function of: a. Data integrity b. Data quality c. Data granularity d. Logging functions - CORRECT ANSWER Correct Answer: A Data integrity means that data should be complete, accurate, consistent and up-to-date. With respect to data security, organizations must put protections in place so that no one may alter or dispose of data in a manner inconsistent with acceptable business and legal rules (Johns 2015, 211) 5. Conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a time period for preservation, and destroying records that are no longer needed are all components of a: a. Case mix index b. Master patient index c. Health record matrix d. Retention program - CORRECT ANSWER Correct Answer: D The health information management (HIM) director is generally responsible for implementing the retention program; however, other individuals may be charged with the shared responsibility of implementing the program in some facilities. Some facilities establish a task force to oversee the record retention program, and this is sometimes chaired by the HIM professional. The steps in developing a record retention program include: conducting an inventory of the facility's records, determining the format and location of record storage, assigning each record a retention period, and destroying records that are no longer needed (Reynolds and Sharp 2016, 133-135). 15 8 Correct15 Wrong8 Unanswered What must be in place to enhance the retrieval process for scanned documents? a. Electronic signature b. Indexing system c. RFID device d. Table of contents - CORRECT ANSWER Correct Answer: B To enhance retrieval of scanned documents, some form of indexing needs to take place in order to organize the documents. Ideally, each form that is scanned or otherwise created should have a bar code or some other forms recognition feature, or features, associated with it (Amatayakul 2017, 285). 7. Which of the following statements is most accurate regarding effective communication? a. Use passive listening b. Monitor others' nonverbal behaviors for cues that they are following or confused c. Make sure all parties are distracted to better communicate your message d. Message content is more important than how it is delivered - CORRECT ANSWER Correct Answer: B To communicate effectively, managers must pay just as much attention to how their message is received and interpreted as they do to its content. In order to enhance the accuracy and acceptance of communication, the communicator needs to monitor others' nonverbal behaviors for cues that they are following or confused. Passive listening and distracted parties would not enhance effective communication (Kelly and Greenstone 2016, 36). A visitor walks through the work area and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? a. Device and media controls b. Facility access controls c. Workstation use controls d. Workstation security controls - CORRECT ANSWER Correct Answer: B Facility access controls include establishing safeguards to prohibit the physical hardware and computer system itself from unauthorized access while ensuring that proper authorized access is allowed (Reynolds and Brodnik 2017a, 275-276) In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed? a. Initial study b. Design c. Testing d. Operation - CORRECT ANSWER Correct Answer: C Running a mock query would be part of application testing that ensures every function of the new computer system works. Application testing also ensures the system meets the functional requirements and other required specifications in the RFP or contract (Sayles and Trawick 2014, 95). Decision making and authority over data-related matters is known as a. Data management b. Data administration c. Data governance d. Data modeling - CORRECT ANSWER Correct Answer: C Data governance is an emerging practice in the healthcare industry. Decision making and authority over data-related matters is data governance. It is clear that any industry as reliant on data as healthcare needs a plan for managing this asset (Biedermann and Dolezel 2017, 163). Data management is an administrative process that includes acquiring, validating, storing, protecting, and processing required data to ensure the accessibility, reliability, and timeliness of the data for its users. A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach? a. Access controls b. Device and media controls c. Facility access controls d. Workstation controls - CORRECT ANSWER Correct Answer: B HIPAA requires the implementation of policies and procedures for the removal of hardware and electronic media that contain ePHI into and out of a facility. There are four implementation specifications within this standard: disposal, media reuse, accountability, and data backup and storage. In this case the organization did not follow policies for the removal of hardware and electronic media (Theodos 2017, 276). A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This coding auditing process addresses the data quality element of: a. Granularity b. Reliability c. Timeliness d. Accuracy - CORRECT ANSWER Correct Answer: D The quality of coded clinical data depends on a number of factors, including accuracy. Accuracy is ensuring that the coded data is free from error and a correct representation of the patient's diagnosis and procedures (Sharp and Madlock-Brown 2016, 197). Medical identity thefts are situations in which the following occurs: a. When health information on the wrong patient is put in the incorrect record b. When financial information is used to purchase nonmedical items c. When demographic and financial information is used to acquire medical services d. When demographic information is used to purchase nonmedical items - CORRECT ANSWER Correct Answer: C Medical identity theft occurs when a patient uses another person's name and insurance information to receive healthcare benefits. Most often this is done so a person can receive medical care with an insurance benefit and pay less or nothing for the care he or she receives (Rinehart-Thompson 2016, 71). Under which circumstances may an interval note be added to a patient's health record in place of a complete history and physical? a. When the patient is readmitted a second time for the same condition b. When the patient is readmitted within 30 days of the initial treatment for a different condition c. When the patient is readmitted a third time for the same condition d. When the patient is readmitted within 30 days of the initial treatment for the same condition - CORRECT ANSWER Correct Answer: D An interval note may be used for the patient's history and physical when the patient is readmitted within 30 days of the initial treatment for the same condition (Russo 2013a, 207). 16. In which of the following examples does the gender of the patient constitute information rather than a data element? a. As an entry to be completed on the face sheet of the health record b. In the note "50-year-old white male" in the patient history c. In a study comparing the incidence of myocardial infarctions in black males as compared to white females d. In a study of the age distribution of lung cancer patients - CORRECT ANSWER Correct Answer: C Data are the raw elements that make up our communications. Humans have the innate ability to combine data they collect and, through all their senses, produce information (which is data that have been combined to produce value) and enhance that information with experience and trial-and-errors that produce knowledge. In this example, the gender is tied to race in the data collection that constitutes information and not a data element (Amatayakul 2017, 284). 17. Code the following scenario: Patient admitted with major depression, recurrent, severe. F32.9 Major depressive disorder, single episode, unspecified F33.2 Major depressive disorder, recurrent, severe, without psychotic features F33.3 Major depressive disorder, recurrent, severe, with psychotic symptoms F33.9 Major depressive disorder, recurrent, unspecified a. F33.3 b. F33.2 c. F32.9 d. F33.9 - CORRECT ANSWER Correct Answer: B Main term: Depression, subterm: recurrent; see Disorder, depressive, recurrent. Follow the cross reference to Disorder, depressive, recurrent, severe F33.2 (Schraffenberger and Palkie 2017, 34). Which of the following keywords precedes the listing of variables to be returned from an SQL query? a. SELECT b. SET c. DATA d. BY - CORRECT ANSWER Correct Answer: A A simple query statement using the data manipulation language has three parts. The "select" statement is always first. This determines the label, or field name, of the data that is being retrieved (White 2016a, 48). The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan? a. Traditional retrospective b. Capitated rate c. Relative value d. Discounted fee schedule - CORRECT ANSWER Correct Answer: B Capitated rate is a method of payment for health services in which the third-party payer reimburses providers a fixed, per capita amount for a period. Per capita means per head or per person. A common phrase in capitated contracts is per member per month (PMPM). The PMPM is the amount of money paid each month for each individual enrolled in the health insurance plan. Capitation is characteristic of HMOs (Casto and Forrestal 2015, 11). 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. a. Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule. b. Sally owns the information in her record, so she must be granted her request. c. Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record. d. Patients should never be given access to their actual medical records. - CORRECT ANSWER Correct Answer: C The covered entity may require the individual to make an amendment request in writing and provide a rationale for it. Such a process must be communicated in advance to the individual through the organization's notice of privacy practices. Therefore, an individual cannot review his or her physical record without an authorized HIM staff member present to maintain the integrity of the record (Rinehart-Thompson 2017e, 245-246). The Security Incident Procedures Standard has one required implementation specification centered on: a. Performing the Security Risk Analysis b. Identifying and responding to security events c. Preventing workforce security risks d. Complying with breach notification processes - CORRECT ANSWER Correct Answer: B The identification of and response to security incidents (or events) is the required implementation specification. Response and reporting is the single required implementation specification that states covered entities must identify and respond to suspected or known security incidents; mitigate, to the extent practicable, harmful events of security incidents that are known to the covered entity; and document security incidents and their outcomes (Biedermann and Dolezel 2017, 387). 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: a. The vendor b. Information systems c. Health information management d. The implementation team - CORRECT ANSWER Correct Answer: D Training is essential to the successful implementation of each new system. The implementation team must define who needs to be trained, who should do the training, how much training is required, and how the training will be accomplished (Biedermann and Dolezel 2017, 260). The integrity of the MPI is key to accurate storage and retrieval of patient-related information. Errors are possible in the MPI for various reasons. Errors in the MPI database can lead to which of the following? a. Billing problems b. Accurate record location c. Necessary patient testing d. Efficiency in the HIM department - CORRECT ANSWER Correct Answer: A Whether the master patient index (MPI) is at a local, enterprise, or HIE level, its primary purpose is to facilitate the link between clinical and administrative information between disparate systems. With so many patient care and industry initiatives at stake, the quality of MPI data can no longer be considered a back-end function. Errors in MPI databases can lead to billing problems, unnecessary duplicate tests, and potential legal exposure. In addition, duplicates contribute to HIM operational workload and create inefficiencies as each new patient receives a new medical record number, file folder (in the paper world), and staff time in MPI maintenance activities (Fahrenholz 2013c, 171). 1. 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: a. Bill the patients for these accounts b. Contact the patients to obtain an ABN c. Write off the accounts to contractual allowances d. Write off the failed charges to bad debt and bill Medicare for the clean charges - CORRECT ANSWER Correct Answer: D The Integrated Outpatient Code Editor (IOCE) is a predefined set of edits created by Medicare to check outpatient claims for compliance with the Medicare outpatient prospective payment system (OPPS). The IOCE will review a coded claim for accuracy and send back an edit flag if an error has been detected in the claim. Most organizations run all their claims through the IOCE prior to sending out to any payer to look for errors, correct them, and then send out a clean claim. A portion of the NCCI edits are embedded in the IOCE edits (Schraffenberger and Kuehn 2011, 465). An NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs. If an NCD does not specifically exclude/limit an indication or circumstance, or if the item or service is not mentioned at all in an NCD or in a Medicare manual, it is up to the Medicare contractor to make the coverage decision (see LMRP). Prior to an NCD taking effect, CMS must first issue a Manual Transmittal, CMS ruling, or Federal Register Notice giving specific directions to our claims-processing contractors. The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as: a. Unbundling b. Billing for services not provided c. Medically unnecessary services d. Upcoding - CORRECT ANSWER Correct Answer: D Upcoding is the practice of using a code that results in a higher payment to the provider that actually reflects the service or item provided (Hunt 2016, 286). 3. An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s). a. A list of newborns to the local newspaper for publication in the birth announcements section b. Data about cancer patients to the state health department cancer surveillance program c. Birth information to the country registrar d. Information about patients with sexually transmitted infections to the county health department - CORRECT ANSWER Correct Answer: A The Privacy Rule provides patients an opportunity to agree or object to specific types of disclosure. These do not require a written authorization; verbal authorization is acceptable. However, communication with the patient regarding these types of disclosures and the patient's decision should be documented in the health record or other appropriate manner of documentation (Brinda and Watters 2016, 317). 4. Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? a. X12N b. LOINC c. RxNorm d. DICOM - CORRECT ANSWER Correct Answer: B LOINC is a well-accepted set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results (Palkie 2016a, 155). According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed? a. Admission record b. Physician's order c. Report of history and physical examination d. Discharge summary - CORRECT ANSWER Correct Answer: C Except in emergency situations, every surgical patient's chart must include a report of a complete history and physical conducted no more than seven days before the surgery is to be performed (Russo 2013a, 238). A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena? a. Inform defense and plaintiff lawyers that the records no longer exist b. Submit a certification of destruction in response to the subpoena c. Refuse the subpoena since no records exist d. Contact the clerk of the court and explain the situation - CORRECT ANSWER Correct Answer: B Those who choose to destroy the original health record may do so within weeks, months, or years of scanning. If the record was destroyed according to guidelines for destruction and no scanned record exists, the certificate of destruction should be presented in lieu of the record (Reynolds and Sharp 2016, 137). . Who is responsible for the content, quality, and signing of the discharge summary? a. Attending physician b. Head nurse c. Consulting physician d. Admitting nurse - CORRECT ANSWER Correct Answer: A The physician principally responsible for the patient's hospital care generally dictates the discharge summary. However, a resident, physician assistant, or nurse practitioner who is being supervised by the attending physician may complete this task. Regardless of who documents it, the attending physician is responsible for the content and quality of the summary and must date and sign it (Russo 2013a, 284). 8. What is the process of finding, soliciting, and attracting new employees called? a. Recruitment b. Retention c. Orientation d. Hiring - CORRECT ANSWER Correct Answer: A Recruitment is the process of finding, soliciting, and attracting new employees. However, the manager should be sure to understand the organization's recruitment and hiring policies and to seek the assistance of the HR department before the vacancy is publicized (LeBlanc 2016, 732). Which of the following is a "public interest and benefit" exception to the authorization requirement? a. Payment b. PHI regarding victims of domestic violence c. Information requested by a patient's attorney d. Treatment - CORRECT ANSWER Correct Answer: B Pursuant to the Privacy Rule, the hospital may disclose health information to law enforcement officials without authorization for law enforcement purposes for certain situations, including situations involving a crime victim. Disclosure is made in response to law enforcement officials' request for such information about an individual who is, or is suspected to be, a victim of a crime (Brinda and Watters 2016, 315). . The Health Information Services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. The manager has each employee complete a form identifying the amount of time he or she spends each day on various tasks. What is this tool called? a. Serial work distribution tool b. Work distribution chart c. Check sheet d. Flow process chart - CORRECT ANSWER Correct Answer: B Basic work distribution data can be collected in a work distribution chart, which is initially filled out by each employee and includes all responsible task content. Task content should come directly from the employee's current job description. In addition to task content, each employee tracks each task's start time, end time, and volume or productivity within a typical workweek. The results of a work distribution analysis can lead a department to redefine the job descriptions of some employees, redesign the office layout, or establish new or revised procedures for some department functions in order to gain improvements in staff productivity or service quality (Oachs 2016, 792). . A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This coding auditing process addresses the data quality element of: a. Granularity b. Reliability c. Timeliness d. Accuracy - CORRECT ANSWER Correct Answer: D The quality of coded clinical data depends on a number of factors, including accuracy. Accuracy is ensuring that the coded data is free from error and a correct representation of the patient's diagnosis and procedures (Sharp and Madlock-Brown 2016, 197). Verbal orders by telephone or in person are discouraged. For cases in which verbal orders are necessary, which of the following is the most effective method for lessening the risk of miscommunication? a. The person receiving the order should read it back to ensure the order is correct. b. The order should be signed after the patient is discharged from the facility. c. The order should be signed by another provider. d. The person receiving the order should authenticate the order after it is entered into the record. - CORRECT ANSWER Correct Answer: A Because of the risks associated with miscommunication, verbal orders are strongly discouraged. To reduce miscommunication, the person receiving the order should read it back to ensure the order is correct. Verbal orders should be authenticated as soon as possible after they are given (Rinehart-Thompson 2017c, 178-179). 3. Which of the following would be an indicator of process problems in a health information department? a. 5% decline in the number of patients who indicate satisfaction with hospital care b. 10% increase in the average length of stay c. 15% reduction in bed turnover rate d. 18% error rate on abstracting data - CORRECT ANSWER Correct Answer: D Performance measurement is the process of comparing the outcomes of an organization, work unit, or employee to pre-established performance standards. The results of performance measurement are usually expressed as percentages, rates, ratios, averages, or other quantitative assessment. It is used to assess quality and productivity in clinical and administrative services. An 18 percent error rate on abstracting data is an indicator of a process problem in the health information management (HIM) department because it is an HIM function. The other items are not under the control of the HIM department and would not indicate a process problem in HIM (Oachs 2016, 803). To reduce the effect of a server crash in an EHR environment, it is advisable to: a. Set up redundant systems b. Have a storage area network c. Store data in RAID d. Have an inventory of all systems - CORRECT ANSWER Correct Answer: A To achieve availability, an EHR must have full redundancy as well as backup and network redundancy. This means that there is a duplication of all data, hardware, cables, or other components of the system. Should the primary server crash, the system switches over to the second server and can continue processing (Sayles and Trawick 2014, 212). RAID (Redundant Array of Independent Disks, originally Redundant Array of Inexpensive Disks) is a data storage virtualization technology that combines multiple physical disk drive components into one or more logical units for the purposes of data redundancy, performance improvement, or both. 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: a. Case mix index b. Master patient index c. Health record matrix d. Retention schedule - CORRECT ANSWER Correct Answer: C The documentation that comprises the legal health record (LHR) may physically exist in separate and multiple paper-based or electronic systems. This complicates the process of pulling the entire legal record together in response to authorized requests to produce the complete patient record. Once the LHR is defined, it is best practice to create a health record matrix that identifies and tracks the physical location of each paper document and the source of each electronic document that constitutes the LHR. In addition to defining the content of the LHR, it is best practice to establish a policy statement on the maintenance of it (Rinehart-Thompson 2016, 61). The medical staff at Regency Health is nationally renowned for its skill in performing cardiac procedures. 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: a. Nursing staff b. Admissions department c. Physician d. Administration - CORRECT ANSWER Correct Answer: C When obtaining consent for treatment, the physician is the healthcare provider who would discuss the treatment with the patient. The basic elements of an informed consent should include the purpose of the proposed procedure, any risks associated with the procedure, and if any noninvasive treatment alternatives are available (Klaver 2017c, 141). 17. This analytic technique is being used by CMS to assist in prepayment audits? a. Descriptive statistics b. Graphical analysis c. Exploratory data analysis d. Predictive modeling - CORRECT ANSWER Correct Answer: D Predictive modeling applies statistical techniques to determine the likelihood of certain events occurring together. Statistical methods are applied to historical data to learn the patterns in the data. These patterns are used to create models of what is most likely to occur (White 2016a, 7; White 2016b, 531). Which of the following is not true of a PHR? a. Individuals own and manage their PHR b. It is a life-long resource c. Individuals determine rights of access d. It will replace the legal records of providers - CORRECT ANSWER Correct Answer: D Organizational policy should address how personal health information provided by the patient will or will not be incorporated into the patient's health record. Copies of personal health records (PHR), created, owned, and managed by the patient are considered part of the legal health record when the organization uses them to provide treatment; however, the PHR does not replace the legal health record (Fahrenholz 2013a, 40). Before Central Hospital is permitted to open and provide medical services in a particular state, the healthcare entity must first go through which of the following processes? a. Accreditation b. Licensure c. Qualification d. Certification - CORRECT ANSWER Correct Answer: B Licensure is the state's act of granting a healthcare organization or individual practitioner the right to provide healthcare services of a defined scope in a limited geographic area. State governments establish licensure requirements, which vary from state to state. Unlike accreditation, which is a voluntary process, licensure is mandatory. Licensure is required prior to a hospital's opening and providing medical services (Fahrenholz 2013b, 84). A transcription manager is assigned to a project team that is implementing a voice recognition system. He reports to the director of health information services for regular job functions and to the project manager for tasks related to the project. This is an example of which type of project management structure? a. Strong matrixed b. Projectized c. Functional d. Weak matrixed - CORRECT ANSWER Correct Answer: A The strong matrix organization is very similar to the balanced matrix but includes a department of project managers. In these organizations, project managers are not functional staff members assuming the role of project manager but rather project manager specialists reporting to a manager of project management. The strong matrix organizations provide the project manager a moderate to high level of authority over the project and project resources (Olson 2016, 885). A matrix organization is defined as an organization where people have to report to more than one boss. ... In a projectized organization, the project manager has all authority and power while in a functional organization, the functional manager has the authority. In this form of organization, the functional manager retains most of the power; they "own" the people and resources. In a weak / functional matrix, the project manager is not very powerful. Usually they carry out an administrative or coordinating role and rely on the functional manages to get things done. Name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date element terminated from system, and system of origin are all examples of: a. Autoauthentication fields b. Metadata c. Data d. Information fields - CORRECT ANSWER Correct Answer: B Examples of metadata include name of element, definition, application in which the data element is found, locator key, ownership, entity relationships, date first entered system, date terminated from system, and system of origin (Russo 2013b, 321-322). Copies of personal health records (PHRs) are considered part of the legal health record when: a. Consulted by the provider to gain information on a consumer's health history b. Used by the healthcare entity to provide treatment c. Used by the provider to obtain information on a consumer's prescription history d. Used by the healthcare entity to determine a consumer's DNR status - CORRECT ANSWER Correct Answer: B Only when copies of the personal health record (PHR) are used for treatment can they be considered part of the facilities' legal health record; however, the PHR does not replace the legal health record (Fahrenholz 2013a, 40). Online or real-time transaction processing (OLTP) is a functional requirement for a: a. Data repository b. Data mart c. Data display d. Data dictionary - CORRECT ANSWER Correct Answer: A Data repositories in healthcare organizations require tools designed to perform intricate data searches and retrievals using online or real-time transaction processing (OLTP) (Amatayakul 2017, 306-307). A ________ helps a healthcare entity proactively ensure that the information they store and maintain is only being accessed in the normal course of business. a. Contingency plan b. Workflow analysis c. Documentation audit d. Security audit - CORRECT ANSWER Correct Answer: D Security audits can help a healthcare organization proactively ensure that the information it stores and maintains is only being accessed for the normal course of business (Brinda and Watters 2016, 322). 2. What does an audit trail check for? a. Loss of data b. Presence of a virus c. Successful completion of a backup d. Unauthorized access to a system - CORRECT ANSWER Correct Answer: D An audit trail is a chronological set of computerized records that provides evidence of a computer system utilization (log-ins and log-outs, file accesses) used to determine security violations (Sandefer 2016a, 366). 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: a. Health benefits fair b. Employee assistance programs c. Outpatient employee care d. Employee crisis lines - CORRECT ANSWER Correct Answer: B Employers acknowledge the need for mental health services for their employees by providing access to employee assistance programs (EAPs). These outpatient programs are designed to provide employees with immediate access to psychological counseling on a limited basis and may be provided on-site or through local providers (Munn 2013, 609). While the focus of inpatient data collection is on the principal diagnosis, the focus of outpatient data collection is on the: a. Reason for admission b. Activities of daily living c. Discharge diagnosis d. Reason for encounter - CORRECT ANSWER Correct Answer: D The Uniform Ambulatory Care Data Set (UACDS) includes data elements specific to ambulatory care such as the reason for the encounter with the healthcare provider (Johns 2015, 280). 30 15 Correct30 Wrong15 The term "hard coding" refers to: a. ICD-10-CM codes that are coded by the coders b. CPT codes that appear in the hospital's chargemaster c. CPT codes that are coded by the coders d. ICD-10-CM codes that appear in the hospital's chargemaster - CORRECT ANSWER Correct Answer: B During order-entry a unique identifier for each service is entered. This unique identifier triggers a charge from the chargemaster to be posted on the patient's account. This process is known as hard coding (Casto and Forrestal 2015, 253). Which of the following accreditation categories would the Joint Commission assign to a hospital that did not meet all of the standards at the time of the initial on-site survey, had a level of standards in noncompliance, had Requirements for Improvements (RFIs) in excess of the published level for the year, and subsequently underwent an additional on-site, follow-up survey? a. Accr