RHIA Exam Prep 116 Questions with Verified Answers,100% CORRECT

RHIA Exam Prep 116 Questions with Verified Answers Data Set - CORRECT ANSWER A group of data items or elements and their definitions. Each element can have its own defined value. Clinical or Medical Vocabulary - ...

RHIA Exam Prep 116 Questions with Verified Answers Data Set - CORRECT ANSWER A group of data items or elements and their definitions. Each element can have its own defined value. Clinical or Medical Vocabulary - CORRECT ANSWER A formally-recognized list of preferred medical terms and their corresponding definitions. They assist in standardizing the language within the health record. Clinical Terminology - CORRECT ANSWER A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement Nomenclature - CORRECT ANSWER A system of naming, especially in the arts or sciences Data Mapping - CORRECT ANSWER The process of identifying relationships between two distinct data models. MS-DRG - CORRECT ANSWER Medicare-severity diagnosis-related group. Medicare restructuring of reimbursement of inpatient hospital admissions. UHDDS - CORRECT ANSWER Uniform Hospital Discharge Data Set. Used by federal and state agencies to collect data on inpatients. NCVHS - CORRECT ANSWER National Committee on Vital and Health Statistics An advisory body to HHS that deals with health data, statistics and national health information policy. UACDS - CORRECT ANSWER Uniform Ambulatory Care Data Set. Collects data about ambulatory care patients HIPAA - CORRECT ANSWER Health Insurance Portability and Accountability Act. Legislation in 1996 enacted to focus on health insurance and health information privacy and security ANSI - CORRECT ANSWER American National Standards Institute. Oversees and accredits private standards development for organizations in the US. DEEDS - CORRECT ANSWER Data Elements for Emergency Department Systems. Uniform specifications for data entered in ED patient records. MDS - CORRECT ANSWER Minimum Data Set (Look up further - is this for long term care?) OASIS - CORRECT ANSWER Outcome and Assessment Information Set. Standardized reproducible assessment instrument used to monitor home health care. CDC - CORRECT ANSWER Centers for Disease Control. Concerned with communicable diseases and environmental health. DHHS (HHS) - CORRECT ANSWER Department of Health and Human Services. Branch of the federal government responsible for regulatory programs affecting the healthcare industry. TJC (JCAHO) - CORRECT ANSWER The Joint Commission. Private accrediting organization whose goal is to improve the quality of patient care through the development and assessment of standards of performance by healthcare organizations. NCQA - CORRECT ANSWER National Committee for Quality Assurance. Accrediting agency for managed care organizations (MCOs). HEDIS - CORRECT ANSWER Healthcare Effectiveness Data and Information Set. Standardized set of performance measures designed to allow consumers of managed care plans to compare performance. NEDSS - CORRECT ANSWER National Electronic Disease Surveillance System. Web-based strategy intended to monitor and assess disease trends, guide prevention and intervention programs, inform public health makers, and identify issues of concern. ASTM - CORRECT ANSWER American Society for Testing and Materials. National standards development body. AMIA - CORRECT ANSWER American Medical Informatics Association. Provides leadership in the development/implementation of information systems to improve patient care. HIMSS - CORRECT ANSWER Healthcare Information and Management Systems Society. Focuses on optimal use of healthcare information technology and management systems for the betterment of human health. AAMT - CORRECT ANSWER American Association for Medical Transcription. Committed to the creation of quality health record reports from dictation by healthcare providers. AHRQ - CORRECT ANSWER Agency for Healthcare Research and Quality. Focuses on production and dissemination of information which improves quality, reduces cost, and enhances the effectiveness of healthcare. Interviews, Surveys, and Questionnaires - CORRECT ANSWER Data collection tools. CLIA - CORRECT ANSWER Clinical Laboratory Improvement Amendments. Legislature mandating certification of clinical laboratories prior to obtaining billing privileges for tests conducted. LOINC - CORRECT ANSWER Logical Observation Identifiers Names and Codes. Database designed to perform the exchange and aggregation of laboratory tests. Flowchart - CORRECT ANSWER Provides a graphical depiction of the sequencing of the steps in a process. Organizational Chart - CORRECT ANSWER Illustrates hierarchical relationships between entities. Timelines - CORRECT ANSWER Presents projected indications for achievements of deadlines. PERT Chart - CORRECT ANSWER Used to provide likely completion times for projects, using smaller projects to accomplish larger goals. Gantt Chart - CORRECT ANSWER Project scheduling tool used to emphasize the work time needed to meet an identified goal. Work Simplification - CORRECT ANSWER A method used to find a better and easier way of performing a function. Its focus is on eliminating wasted time, energy, materials, and cost without compromising safety, while enhancing quality. Accuracy and Integrity - CORRECT ANSWER Two characteristics of data quality. Education, Training, Communication, and Timeliness - CORRECT ANSWER Four components that help ensure data accuracy. Quantitative Health Record Analysis - CORRECT ANSWER All tests ordered by the physician are present and authenticated by comparing the test result reports with the physician orders. Qualitative Health Record Analysis - CORRECT ANSWER A review for documentation inconsistencies related to the diagnosis on various forms and comparison of the medical administration record (MAR) with the patient's pharmacy profile. Legal Health Record Analysis - CORRECT ANSWER Errors in documentation are corrected in a legal manner. Statistical Health Record Analysis - CORRECT ANSWER The abstracting of select data items from the patient record to both clinical and administrative decisions. Metadata - CORRECT ANSWER Data about data. Descriptive, Structural, and Administrative - CORRECT ANSWER Three types of metadata. Classification System - CORRECT ANSWER A method of grouping similar items in a logical way based on common characteristics. ICD-10-CM - CORRECT ANSWER Diagnosis Codes ICD-10-PCM - CORRECT ANSWER Procedure codes Encoders - CORRECT ANSWER Computer programs that assist coding professionals in assigning the appropriate codes to natural language words and phrases contained in the health record. Logic-based and Automated Code Books - CORRECT ANSWER Two types of encoders. Logic-based Encoders - CORRECT ANSWER Allow the coding professional to enter partial words and providing options to choose from, while building and arriving at a code. Automated Code Books - CORRECT ANSWER Requires the coding professional to apply coding guidelines exactly in the same manner as if they were using the coding manual. Groupers - CORRECT ANSWER Software tools that apply logic to assign a particular payment group. MUE - CORRECT ANSWER Medical Unlikely Edits. US Medicare unit of service claim edit applied to Medical claims against a procedure code for medical services rendered by one provider/supplier to one patient on one day OCE - CORRECT ANSWER Outpatient Code Editor Software that combines editing logic with the new Ambulatory Payment Classification (APC) assignment program designed to meet the mandated OPPS implementation. APC - CORRECT ANSWER Ambulatory Payment Classification. Government's method of paying for facility outpatient services for the Medicare program OPPS - CORRECT ANSWER Outpatient Prospective Payment System The system through which Medicare decides how much money a hospital or community mental health center will get for outpatient care to patients with Medicare. PDX - CORRECT ANSWER Principal Diagnosis Code of Ethics - CORRECT ANSWER A tool that guides individuals of a specific profession by defining what acceptable behavior is by setting values and principles those professionals abide by. 3M - CORRECT ANSWER A logic-based encoder that allows the coding professional to enter the diagnosis as documented into the chart to locate the correct code. Database - CORRECT ANSWER A collection of interrelated data stored together in one or more computerized files. SDLC - CORRECT ANSWER System Development Life Cycle DBLC - CORRECT ANSWER Database Life Cycle Database Life Cycle Phases - CORRECT ANSWER 1. Database initial study 2. Database Design 3. Database implementation 4. Testing and Evaluation 5. Database operation 5. Database maintenance and evolution Database Initial Study - CORRECT ANSWER First phase in the database life cycle. Key users are consulted regarding their needs and technical requirements. Database Design - CORRECT ANSWER Second phase in the database life cycle. The developer determines the type of database, and data models that are developed. A user interface is created. The user continues to be consulted as to the requirements of the completed database. Database Implementation - CORRECT ANSWER Third phase in the database life cycle. The database is loaded onto the network or workstation where it will be housed. Testing and Evaluation - CORRECT ANSWER Fourth phase in the database life cycle. Users test the database in its current state and evaluate the results of their testing. Problems are identified and resolved and any needed modifications to the initial design are made. Database Operation - CORRECT ANSWER Fifth phase in the database life cycle. The database is moved from the test phase to the live environment. Database Maintenance and Evolution - CORRECT ANSWER Sixth and last phase in the database life cycle. Ongoing maintenance is performed. The database is continually evaluated for its usefulness. Updates and enhancements are added. As the need for changes in the database are identified, the life cycle begins to repeat. Relational Database - CORRECT ANSWER Consist of a collection of tables (relations) with rows and columns. Each row represents a record and each column (attribute) represents a data field that corresponds to the row. DML - CORRECT ANSWER Data Manipulation Language SQL - CORRECT ANSWER Structured Query Language (the most popular data manipulation language or DML) Object-Oriented Database - CORRECT ANSWER Composed of objects where each object is a separate entity, application, or program with a specific task to perform. These databases can process complex data types such as video, graphics, and sound. Data Model - CORRECT ANSWER A picture or abstraction of real conditions used to describe the definitions of fields and records and their relationships in a database. Components of a Data Model - CORRECT ANSWER 1. Data Model Diagram 2. Data Dictionary 3. Narratives explaining what the diagrams and dictionary mean Data Model Diagram - CORRECT ANSWER A pictorial representation of the proposed database. It is most often a flowchart of the data flow, symbols of the relationships to be developed among the database entities, and drawings of tables representing the records and attributes in a relational database. Data Flow Diagram - CORRECT ANSWER A data flow diagram is used to visually demonstrate the relationship between the inputs to the database and the outputs from the database. There is a separate data flow diagram for each process represented in the database. Types of Data Models - CORRECT ANSWER 1. Conceptual 2. Logical 3. Physical Conceptual Data Model - CORRECT ANSWER The highest level of data model, representing the highest level of abstraction, independent of hardware and software. Logical Data Model - CORRECT ANSWER Shows the organization of data without indicating how it is stored, created, or manipulated. Physical Data Model - CORRECT ANSWER Shows how the data will actually be stored in databases or files. Data Dictionary - CORRECT ANSWER A descriptive list of names, definitions, and attributes of data elements to be collected in an information system database whose purpose is to standardize definitions and ensure consistent use. Types of Data Dictionaries - CORRECT ANSWER 1. Database Management System (DBMS) 2. Organization-Wide DBMS DD - CORRECT ANSWER Database Management System Data Dictionary. A type of data dictionary that contains all of the information about the database and its related elements. Organization-Wide Data Dictionary - CORRECT ANSWER Applies the concept of the DBMS data dictionary and applies it at the organizational level to assure all definitions across the organization are consistent. Database Administrator (DBA) - CORRECT ANSWER Responsible for overseeing all technical aspects of database management. Data Administrator - CORRECT ANSWER Oversees the managerial functions of database management, including planning for the database, training users, developing and implementing policies and procedures, and managing the organization-wide data dictionary. Data Resource Manager (DRM) - CORRECT ANSWER Responsible for retrieving data from an organization's information systems to ensure that the end users' needs are met and guarantee that the organization's data resources are secure, accessible, accurate, and reliable. Data Analyst - CORRECT ANSWER Responsible for collecting and analyzing data from the database. Data Mining - CORRECT ANSWER The process of abstracting data from a database to identify hidden trends that are then used for decision-making. Data Integrity - CORRECT ANSWER Controlling the consistency and correctness of data throughout a database. Data Integrity Constraints - CORRECT ANSWER Rules that must be followed when entering and/or changing data in a database (restrict values that may be entered). Data Security - CORRECT ANSWER Ensuring that the confidentiality, integrity, and availability of the data are in place. Data Migration - CORRECT ANSWER The process of moving data from one computer or information system to another. Data Translation Tables - CORRECT ANSWER Include specific information about files that are being migrated to a new system. Steps for Data Migration - CORRECT ANSWER 1. Data Extraction 2. Data Loading 3. Data Verification LHR - CORRECT ANSWER Legal Health Record. This is the business record generated at or for a healthcare organization that would be released upon receipt of a request. It is the officially-declared record of healthcare services provided to an individual delivered by a provider. Designated Record Set - CORRECT ANSWER A group of records maintained by or for a covered entity that is the medical and billing records about individuals; enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health plan; information used in whole or in part by or for the HIPAA covered entity to make decisions about individuals. AAAASF - CORRECT ANSWER American Association for Accreditation of Ambulatory Surgery Facilities AAAHC - CORRECT ANSWER Accreditation Association for Ambulatory Health Care AAHP - CORRECT ANSWER American Association of Health Plans AAMC - CORRECT ANSWER Association of American Medical Colleges AAMRL - CORRECT ANSWER American Association of Medical Record Librarians AAPC - CORRECT ANSWER American Academy of Professional Coders AAPPO - CORRECT ANSWER American Association of Preferred Provider Organizations Abbreviated Injury Scale (AIS) - CORRECT ANSWER An anatomically-based, consensus-derived global severity scoring system that classifies each injury by region according to its relative importance on a 6-point ordinal scale (1=minor and 6=maximal). ABC - CORRECT ANSWER Activity-based costing ABC Codes - CORRECT ANSWER Codes that consist of five-character, alphabetic strings that identify services, remedies, or supplies. Codes are followed by a two-character code modifier, which identifies the practitioner type who delivered the care. Aberrancy - CORRECT ANSWER Services in medicine that deviate from what is typical in comparison to the national norm ABN - CORRECT ANSWER Advance beneficiary notice Abnormal Involuntary Movement Scale (AIMS) - CORRECT ANSWER A standardized form that can be used in facilities to document involuntary movements Absolute Frequency - CORRECT ANSWER The number of times that a score of value occurs in a data set Abstract - CORRECT ANSWER A brief summary of the major parts of a research study Abstracting - CORRECT ANSWER 1. The process of extracting information from a document to create a brief summary of a patient's illness, treatment and outcome; 2. The process of extracting elements of data from a source document or database and entering them into an automated system. Abuse - CORRECT ANSWER Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare Program. This includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and are fairly priced. Accept Assignment - CORRECT ANSWER A term used to refer to a provider's or a supplier's acceptance of the allowed charges (from a fee schedule) as payment in full for services or materials provided Acceptance Theory of Authority - CORRECT ANSWER A management theory based on the principle that employees have the freedom to choose whether they will follow managerial directions. Accession Number - CORRECT ANSWER A number assigned to each case as it is entered in a cancer registry