RHIA Exam 393 Questions with Verified Answers,100% CORRECT

RHIA Exam 393 Questions with Verified Answers Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditatio ...

RHIA Exam 393 Questions with Verified Answers Where can you find guidelines for the retention and destruction of healthcare information? a. Institute of Medicine b. Municipal regulations c. HIPAA d. Accreditation standards - CORRECT ANSWER d. Accreditation standards This functionality can result in confusion from incessant repetition of irrelevant clinical data. a. Change b. Amendment c. Copy and paste d. Deletion - CORRECT ANSWER c. Copy and paste Which of the following indexes would be used to compare the number and quality of treatments for patients who underwent the same operation with different surgeons? a. Physician b. Master patient c. Procedure d. Disease and operation - CORRECT ANSWER a. Physician A diagnosis described as "possible," "probable," "likely," or "rule out" is reported as if present for which type of patient records? a. Outpatient b. Emergency room c. Physician office d. Inpatient - CORRECT ANSWER d. Inpatient Who is responsible for ensuring the quality of health record documentation? a. Board of directors b. Administrator c. Provider d. Health information management professional - CORRECT ANSWER c. Provider Which of the following represents data flow for a hospital inpatient admission? a. Registration > diagnostic and procedure codes assigned > services performed > charges recorded b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned c. Services performed > charges recorded > registration > diagnostic and procedure codes assigned d. Diagnostic and procedure codes assigned > registration > services performed > charges recorded - CORRECT ANSWER b. Registration > services performed > charges recorded > diagnostic and procedure codes assigned Which of the following is the goal of quantitative analysis performed by health information management (HIM) professionals? a. Ensuring the record is legible b. Identifying deficiencies early so they can be corrected c. Verifying that health professionals are providing appropriate care d. Checking to ensure bills are correct - CORRECT ANSWER b. Identifying deficiencies early so they can be corrected The process of providing proof of the authorship of health record documentation is called: a. Identification b. Standardization of data capture c. Standardization of abbreviations d. Authentication - CORRECT ANSWER d. Authentication Which of the following data sets would be most useful in developing a matrix for identification of components of the legal health record? a. Document name, media type, source system, electronic storage start date, stop printing start date b. Document name, media type c. Document name, medical record number, source system d. Document name, source system - CORRECT ANSWER a. Document name, media type, source system, electronic storage start date, stop printing start date According to the UHDDS definition, ethnicity should be recorded on a patient record as: a. Race of mother b. Race of father c. Hispanic, non-Hispanic d. Free-text descriptor as reported by patient - CORRECT ANSWER c. Hispanic, non-Hispanic 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 c. ERD The purpose of the data dictionary is to ________ definitions and ensure consistency of use. a. Identify b. Standardize c. Create d. Organize - CORRECT ANSWER b. Standardize It is important for a healthcare entity to have ________ addressing how to deal with corrections made to erroneous entries in health records. a. Training sessions b. Policies and procedures c. Verbally communicated instructions d. A supervisory committee - CORRECT ANSWER b. Policies and procedures Quality has several components, including appropriateness, technical excellence, ________, and acceptability. a. Accuracy of diagnosis b. Continuous improvement c. Connectivity d. Accessibility - CORRECT ANSWER d. Accessibility Assign the correct CPT code for the following procedure: Patient is admitted to move the skin pocket for their pacemaker. a. 33223, Relocation of skin pocket for implantable defibrillator b. 33210, Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) c. 33212, Insertion of pacemaker pulse generator only; with existing single lead d. 33222, Relocation of skin pocket for pacemaker - CORRECT ANSWER d. 33222, Relocation of skin pocket for pacemaker Bloodwork results from the laboratory information system, mammogram reports and films from the radiology information system, and a listing of chemotherapy agents administered to the patient from the pharmacy information system are all delivered into the patient's EHR. These different information systems that feed information into the EHR are known as: a. Interoperability b. Source systems c. Continuity of care records d. Clinical decision support systems - CORRECT ANSWER b. Source systems Of the following, what is the most likely to happen to the health records of a physician's patient when that physician leaves an office practice? a. It will be sent to the state department of health. b. It will be sent to outside storage. c. It will be destroyed. d. It will be retained by the practice. - CORRECT ANSWER d. It will be retained by the practice. Reviewing a health record for missing signatures and medical reports is called: a. Analysis b. Coding c. Assembly d. Indexing - CORRECT ANSWER a. Analysis A barrier to effective computer-assisted coding is the: a. Resistance of physicians b. Resistance of HIM professionals c. Poor quality of documentation d. Reduction of consistency without human coders - CORRECT ANSWER c. Poor quality of documentation To complete a comprehensive assessment and collect information for the Minimum Data Set for Long-Term Care, the coordinator must use which of the following? a. Core measure b. Resident Assessment Instrument c. Precertification d. Record of transfer - CORRECT ANSWER b. Resident Assessment Instrument What is a legal document that is used to specify whether the patient would like to be kept on artificial life support if they become permanently unconscious or is otherwise dying and unable to speak for themselves? a. Durable power of attorney b. Living consent form c. Informed consent d. Advance directive - CORRECT ANSWER d. Advance directive A patient with a diagnosis of ventral hernia is admitted to undergo a laparotomy with ventral hernia repair. The patient undergoes a laparotomy and develops bradycardia. The operative site is closed without the repair of the hernia. What is the correct code assignment? I97.191 Other postprocedural cardiac functional disturbances following other surgery K43.9 Ventral hernia without obstruction or gangrene R00.1 Bradycardia, unspecified Z53.09 Procedure and treatment not carried out because of other contraindication SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralRepairAbdominalWallOpenNo DeviceNo Qualifier 0WQF0ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalAnatomicalRegions,GeneralInspectionPeritonealCavityOpenNo DeviceNo Qualifier 0WJG0ZZ a. K43.9, R00.1, Z53.09, 0WJG0ZZ b. K43.9, I97.191, R00.1, 0WJG0ZZ c. K43.9, 0WQF0ZZ d. K43.9, Z53.09, 0WQF0ZZ - CORRECT ANSWER a. K43.9, R00.1, Z53.09, 0WJG0ZZ A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of chronic obstructive pulmonary disease (COPD) and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA? a. Catheter-associated urinary tract infection b. Cerebral vascular accident c. COPD d. Hypertension - CORRECT ANSWER a. Catheter-associated urinary tract infection A pediatrician would report the fact that he or she administered the MMR vaccine to a toddler on a(n): a. Diabetes registry b. Cancer registry c. Immunization registry d. Trauma registry - CORRECT ANSWER c. Immunization registry A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of? a. Data collection b. Edit check c. Data reliability d. Hot spot - CORRECT ANSWER b. Edit check Which of the following are considered dimensions of data quality? a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency b. Relevancy, granularity, timeliness, currency, atomic, precision, and consistency c. Relevancy, granularity, timeliness, concurrent, atomic, precision, and consistency d. Relevancy, granularity, equality, currency, precision, accuracy, and consistency - CORRECT ANSWER a. Relevancy, granularity, timeliness, currency, accuracy, precision, and consistency The statement "All patients admitted with a diagnosis falling into ICD-10-CM code numbers S00 through T88" represents a possible case definition for what type of registry? a. Birth defect registry b. Cancer registry c. Diabetes registry d. Trauma registry - CORRECT ANSWER d. Trauma registry Mrs. Bolton is an angry patient who resents her physician "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physician orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient health record is: a. Mean b. Noncompliant and hostile toward staff c. Belligerent and out of line d. A pain in the neck - CORRECT ANSWER b. Noncompliant and hostile toward staff When data is taken from the health record and entered into registries and databases, the data in the registries or databases is then considered a(n): a. Secondary data source b. Reliable data source c. Primary data source d. Unreliable data source - CORRECT ANSWER a. Secondary data source Because a health record contains patient-specific data and information about a patient that has been documented by the professionals who provided care or services to that patient, it is considered: a. Secondary data source b. Aggregate data source c. Primary data source d. Reliable data source - CORRECT ANSWER c. Primary data source A 65-year-old woman was admitted to the hospital. She was diagnosed with sepsis secondary to methicillin susceptible Staphylococcus aureus and abdominal pain secondary to diverticulitis of the colon. What is the correct code assignment? A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus A41.89 Other specified sepsis A41.9 Sepsis, unspecified organism B95.61 Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding R10.9 Unspecified abdominal pain a. A41.89, K57.32, R10.9 b. A41.01, K57.32 c. A41.89, K57.32, B95.61 d. A41.9, K57.32 - CORRECT ANSWER b. A41.01, K57.32 A patient had a radical resection of soft tissue sarcoma of the left thigh. In ICD-10-PCS what would the root operation be for this procedure? a. Excision b. Repair c. Resection d. Destruction - CORRECT ANSWER a. Excision The data that describe other data in order to facilitate data quality are found in the: a. Data definition language b. Data dictionary c. Data standards d. Data definition - CORRECT ANSWER b. Data dictionary A patient returns during a 90-day postoperative period from a ventral hernia repair; the patient is now complaining of eye pain. What modifier would you use with the evaluation and management code for professional fee reporting? a. -79, Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period b. -25, Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service c. -59, Distinct procedural service d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period - CORRECT ANSWER d. -24, Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period A computer software program that supports a coder in assigning correct codes is called a(n): a. Encoder b. Grouper c. Automated coder d. Decision support system - CORRECT ANSWER a. Encoder The name of the government agency that has led the development of basic data sets for health records and computer databases is: a. The Centers for Medicare and Medicaid Services b. The National Committee on Vital and Health Statistics c. The American National Standards Institute d. The National Institute of Health - CORRECT ANSWER b. The National Committee on Vital and Health Statistics A regular review of LHR policies and procedures to ensure a healthcare entity remains in compliance with legal requirements is generally called an LHR ________. a. maintenance plan b. management plan c. attribute plan d. strategic plan - CORRECT ANSWER a. maintenance plan An alteration of the health information by modification, correction, addition, or deletion is known as a(n): a. Change b. Amendment c. Copy and paste d. Deletion - CORRECT ANSWER b. Amendment A patient born with a neural tube defect would be included in which type of registry? a. Birth defects b. Cancer c. Diabetes d. Trauma - CORRECT ANSWER a. Birth defects The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called: a. Information asset management b. Information management c. Information governance d. Enterprise information management - CORRECT ANSWER c. Information governance Dr. Jones dies while still in active medical practice. He leaves incomplete records at Medical Center Hospital. The best way for the HIM department to handle these incomplete records is to: a. Have the administrator of the hospital complete them b. Have the charge nurse on the respective nursing units complete them c. Ask the chief of staff to complete them d. File the incomplete records with a notation about the physician's death - CORRECT ANSWER d. File the incomplete records with a notation about the physician's death What is a primary purpose for documenting and maintaining health records? a. Effective communication among caregivers for continuity of care b. Substantiate claims for reimbursement c. Provide evidence for malpractice lawsuits d. Contribute to medical science - CORRECT ANSWER a. Effective communication among caregivers for continuity of care The inpatient data set incorporated into federal law and required for Medicare reporting is the: a. Ambulatory Care Data Set b. Uniform Hospital Discharge Data Set c. Minimum Data Set for Long-term Care d. Health Plan Employer Data and Information Set - CORRECT ANSWER b. Uniform Hospital Discharge Data Set A database contains two tables: physicians and patients. If a physician may be linked to many patients and patients may only be related to one physician, what is the cardinality of the relationship between the two tables? a. One-to-one b. One-to-many c. Many-to-many d. One-to-two - CORRECT ANSWER b. One-to-many 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 b. Preventing potential medication errors due to misinterpretation Unstructured data may be preferred over structured data because: a. It does not require processing b. It provides greater detail c. Clinicians know how to enter it d. It is more complete - CORRECT ANSWER b. It provides greater detail A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: a. Spreadsheet b. Database c. File d. Data table - CORRECT ANSWER b. Database Regardless of the healthcare setting, accreditation and regulatory standards require a separate healthcare record for each: a. Family b. Individual patient c. Encounter with the facility d. Day of treatment - CORRECT ANSWER b. Individual patient A patient has HIV with disseminated candidiasis. What is the correct code assignment? B20 Human immunodeficiency virus [HIV] disease B37.0 Candidal stomatitis Oral thrush B37.7 Candidal sepsis Disseminated candidiasis Systemic candidiasis B37.89 Other sites of candidiasisCandidal osteomyelitis a. B20, B37.0 b. B37.7, B20 c. B20, B37.7 d. B20, B37.89, B37.7 - CORRECT ANSWER c. B20, B37.7 In long-term care, the resident's comprehensive assessment is based on data collected in the: a. UHDDS b. OASIS c. MDS d. HEDIS - CORRECT ANSWER c. MDS Changes and updates to ICD-10-CM are managed by the ICD-10-CM Coordination and Maintenance Committee, a federal committee cochaired by representatives from the NCHS and: a. AMA b. OIG c. CMS d. WHO - CORRECT ANSWER c. CMS What document is a snapshot of a patient's status and includes everything from social issues to disease processes as well as critical paths and clinical pathways that focus on a specific disease process or pathway in a long-term care hospital (LTCH)? a. Face sheet b. Care plan c. Diagnosis plan d. Flow sheet - CORRECT ANSWER b. Care plan Which of the following is an example of a 1:1 relationship? a. Patients to hospital admissions b. Patients to consulting physicians c. Patients to clinics d. Patients to hospital beds - CORRECT ANSWER d. Patients to hospital beds 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 d. Clinical practice guidelines Which document is used in the long-term care setting that is not used in the acute-care setting? a. Progress notes b. Monthly summary c. Physician consultations d. Physician orders - CORRECT ANSWER b. Monthly summary Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? a. Case definition b. Case finding c. Follow-up d. Reporting - CORRECT ANSWER b. Case finding Which of the following personnel should be authorized, per hospital policy, to take a physician's verbal order for the administration of medication? a. Unit secretary working on the unit where the patient is located b. Nurse working on the unit where the patient is located c. Health information director d. Admissions registrars - CORRECT ANSWER b. Nurse working on the unit where the patient is located 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 d. Reason for encounter 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 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 Records that are not completed by the physician within the time frame specified in the healthcare organization policies are called: a. Default records b. Delinquent records c. Loose records d. Suspended records - CORRECT ANSWER b. Delinquent records When a healthcare entity destroys health records after the acceptable retention period has been met, a certificate of destruction is created. How long must the healthcare entity maintain the certificate of destruction? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER d. Permanently A critical early step in designing an EHR in which the characteristics of each data element are defined is to develop a(n): a. Accreditation manual b. Core content c. Continuity of care record d. Data dictionary - CORRECT ANSWER d. Data dictionary What term is used in reference to the systematic review of sample health records to determine whether documentation standards are being met? a. Qualitative analysis b. Legal record review c. Utilization analysis d. Ongoing record review - CORRECT ANSWER a. Qualitative analysis A patient was admitted to the hospital and diagnosed with Type 1 diabetic gangrene. What is the correct code assignment? E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene E10.52 Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.8 Type 1 diabetes mellitus with unspecified complications I96 Gangrene, not elsewhere classified a. E08.52, I96 b. E10.52, I96 c. E10.8 d. E10.52 - CORRECT ANSWER d. E10.52 How do healthcare providers use the administrative data they collect? a. For regulatory, operational, and financial purposes b. For statistical data purposes c. For electronic health record tracking purposes d. For continuity of patient care purposes - CORRECT ANSWER a. For regulatory, operational, and financial purposes Which of the following is not an appropriate method for destroying paper-based health records? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing To ensure authentication of data entries, which type of signature is the most secure? a. Digital b. Electronic c. Handwritten d. Virtual - CORRECT ANSWER a. Digital Which of the following is the appropriate method for destroying electronic data? a. Burning b. Shredding c. Pulverizing d. Degaussing - CORRECT ANSWER d. Degaussing Personal information about patients such as their names, ages, and addresses is considered what type of information? a. Clinical b. Administrative c. Operational d. Accreditation - CORRECT ANSWER b. Administrative 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 a. SELECT Which data set would be used to document an elective surgical procedure that does not require an overnight hospital stay? a. Uniform Hospital Discharge Data Set b. Data Elements for Emergency Department Systems c. Uniform Ambulatory Care Data Set d. Essential Medical Data Set - CORRECT ANSWER c. Uniform Ambulatory Care Data Set Assign the correct CPT code for the following: A 58-year-old male was seen in the outpatient surgical center for insertion of a self-contained inflatable penile prosthesis for impotence. a. 54401, Insertion of penile prosthesis; inflatable (self-contained) b. 54405, Insertion of multicomponent, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir c. 54440, Plastic operation of penis for injury d. 54400, Insertion of penile prosthesis, non-inflatable (semi-rigid) - CORRECT ANSWER a. 54401, Insertion of penile prosthesis; inflatable (self-contained) What tool is used to sort data in a variety of ways to assist in the study of certain data elements? a. Registries b. Indexes c. Clinical trials d. Statistical reports - CORRECT ANSWER b. Indexes Which type of data consists of factual details aggregated or summarized from a group of health records that provides no means to identify specific patients? a. Original b. Source c. Protected d. Derived - CORRECT ANSWER d. Derived Data content standards are used to: a. Share data in the same way the users interpret data b. Share data is a unique way c. Share data between disparate systems d. Modify data - CORRECT ANSWER a. Share data in the same way the users interpret data What is the first consideration in determining how long records must be retained? a. The amount of space allocated for record filing b. The number of records c. The most stringent law or regulation in the state d. The cost of filing space - CORRECT ANSWER c. The most stringent law or regulation in the state Which of the following is a concept designed to help standardize clinical content for sharing between providers? a. Continuity of care record b. Interoperability c. Personal health record d. SNOMED - CORRECT ANSWER a. Continuity of care record A strategic plan that identifies applications, technology, and operational elements needed for the overall information technology program in a healthcare entity is a(n): a. Implementation plan b. Information technology plan c. Migration path d. Transition strategy - CORRECT ANSWER c. Migration path Identify the level in the data model that describes how the data is stored within the database: a. Conceptual data model b. Physical data model c. Logical data model d. Data manipulation language - CORRECT ANSWER b. Physical data model According to the Medicare Conditions of Participation, how long must health records be retained? a. Two years b. Five years c. Ten years d. Permanently - CORRECT ANSWER b. Five years Which of the following data management domains would be responsible for establishing standards for data retention and storage? a. Data architecture management b. Metadata management c. Data life cycle management d. Master data management - CORRECT ANSWER c. Data life cycle management Ensuring that only the most recent report is available for viewing is known as: a. Documentation integrity b. Authorship c. Validation d. Version control - CORRECT ANSWER d. Version control Which of the following makes the indexing of scanned health records more efficient by entering metadata automatically? a. Barcodes b. Backscanning c. OCE d. CPOE - CORRECT ANSWER a. Barcodes Assign the correct CPT code for the following: A 63-year-old female had a temporal artery biopsy completed in the outpatient surgical center. a. 32405, Biopsy, lung or mediastinum, percutaneous needle b. 37609, Ligation or biopsy, temporal artery c. 20206, Biopsy, muscle, percutaneous needle d. 31629, Bronchoscopy, rigid or flexible, including fluoroscopic guidance when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) - CORRECT ANSWER b. 37609, Ligation or biopsy, temporal artery The practices or methods that defend against charges questioning the integrity of the data and documents are called: a. Authentication b. Security c. Accuracy d. Nonrepudiation - CORRECT ANSWER d. Nonrepudiation The EHR indicates that Dr. Anderson wrote the January 12 progress note at 11:04 a.m. We know Dr. Anderson wrote this progress note due to which of the following? a. Authorship b. Validation c. Integrity d. Identification - CORRECT ANSWER a. Authorship What are LOINC codes used for? a. Identifying test results b. Reporting test results c. Identifying tests unique to a specific company d. Reporting a code for reimbursement - CORRECT ANSWER a. Identifying test results 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 are all examples of: a. Auto-authentication fields b. Metadata c. Data d. Information fields - CORRECT ANSWER b. Metadata Appropriate documentation of health record destruction must be maintained permanently no matter how the process is carried out. This documentation usually takes the form of a: a. Policy of destruction b. Retention schedule c. Regulation schedule d. Certificate of destruction - CORRECT ANSWER d. Certificate of destruction Which of the following plans address how information can be documented in the health record during down time or a catastrophic event? a. Disaster b. E-discovery response c. Business continuity d. Emergency documentation - CORRECT ANSWER a. Disaster Which of the following is a component of the resident assessment instrument? a. The resident's health record b. A standard Minimum Data Set (MDS) c. Preadmission Screening Assessment d. Annual Resident Review - CORRECT ANSWER b. A standard Minimum Data Set (MDS) A patient was admitted for removal of the left lobe of the liver via laparotomy due to metastasis from a colon carcinoma. What is the correct ICD-10-PCS procedure code for this operation? SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalHepatobiliarySystem andPancreasExcisionLiver, LeftLobeOpenNo DeviceNo Qualifier 0FB20ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalHepatobiliarySystem andPancreasExcisionLiver, LeftLobePercutaneousEndoscopicNo DeviceNo Qualifier 0FB24ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalHepatobiliarySystem andPancreasResectionLiver, LeftLobeOpenNo DeviceNo Qualifier 0FT20ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedicalandSurgicalHepatobiliarySystem andPancreasResectionLiver, LeftLobePercutaneousEndoscopicNo DeviceNo Qualifier 0FT24ZZ a. 0FB20ZZ b. 0FB24ZZ c. 0FT20ZZ d. 0FT24ZZ - CORRECT ANSWER c. 0FT20ZZ The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure. a. Object-oriented database b. Relational database c. Access database d. Structured database - CORRECT ANSWER a. Object-oriented database 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 a. not easily A staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy. The patient returns now for removal of the calculus via a percutaneous nephrostomy tube. What is the correct root operation? a. Destruction b. Extirpation c. Fragmentation d. Release - CORRECT ANSWER b. Extirpation What term is used in reference to raw facts generally stored as characters, words, symbols, measurements, or statistics? a. Data b. Information c. Knowledge d. Notices - CORRECT ANSWER a. Data The first deliverable from a legal health record (LHR) definition project is a: a. List of LHR stakeholders b. Document matrix of LHR components c. Letter of support from management d. Master source system matrix - CORRECT ANSWER a. List of LHR stakeholders The patient has a biopsy of the colon followed by a hemicolectomy. In the ICD-10-PCS coding system, which procedure(s) are coded? a. The hemicolectomy only b. The biopsy only c. Both the biopsy and the hemicolectomy d. It depends on the results of the biopsy - CORRECT ANSWER c. Both the biopsy and the hemicolectomy Which of the following processes is an ancillary function of the health record? a. Admitting and registration information b. Billing and reimbursement c. Patient assessment and care planning d. Biomedical research - CORRECT ANSWER d. Biomedical research 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 d. Integrated Mary Smith, RHIA, has been charged with the responsibility of designing a data collection form to be used on admission of patients to the acute-care hospital in which she works. What is the first resource she should use? a. UHDDS b. UACDS c. MDS d. ORYX - CORRECT ANSWER a. UHDDS Automated insertion of clinical data using templates or similar tools with predetermined components using uncontrolled and uncertain clinical relevance is an example of a potential breach of: a. Patient identification and demographic accuracy b. Authorship integrity c. Documentation integrity d. Auditing integrity - CORRECT ANSWER c. Documentation integrity Which of the following is a business role with major responsibilities that include identifying the specific data needed to operate business processes, recording metadata, and identifying and enforcing quality standards? a. Chief data officer b. Data definition steward c. Data production steward d. Subject matter expert - CORRECT ANSWER b. Data definition steward Which of the following terms is used for the process of scanning past health records into the information system so there is an existing database of patient information, making the information system valuable to the user from the first day of implementation? a. CPOE b. OCR c. Backscanning d. Barcoding - CORRECT ANSWER c. Backscanning Records consisting of multiple electronic systems that do not communicate or are not logically architected for record management are called: a. Electronic medical records b. Electronic health records c. Hybrid health records d. Computerized health records - CORRECT ANSWER c. Hybrid health records What is the most constant threat to health information integrity? a. Natural threats b. Environmental threats c. Internal disaster d. Humans - CORRECT ANSWER d. Humans Lane Hospital has a contract with Ready-Clean, a local company, to come into the hospital to pick up all the facility's linens for off-site laundering. Ready-Clean is: a. A business associate because Lane Hospital has a contract with it b. Not a business associate because it is a local company c. A business associate because its employees may see PHI d. Not a business associate because it does not use or disclose individually identifiable health information - CORRECT ANSWER d. Not a business associate because it does not use or disclose individually identifiable health information Which standard in the Security Rule provides guidance for covered entities to secure laptops and other small portable mobile technologies used within the healthcare facility? a. Workstation security standard b. Technical safeguard standard c. Device and media controls standard d. Facility access control standard - CORRECT ANSWER c. Device and media controls standard The Latin phrase meaning "let the master answer" that puts responsibility for negligent actions of employees on the employer is called: a. Res ipsa locquitor b. Res judicata c. Respondeat superior d. Restitutio in integrum - CORRECT ANSWER c. Respondeat superior The Privacy Rule establishes that a patient has the right of access to inspect and obtain a copy of his or her PHI: a. For as long as it is maintained b. For six years c. Forever d. For 12 months - CORRECT ANSWER a. For as long as it is maintained Many states have mandatory reporting requirements for suspected abuse or mistreatment of the following categories of individuals: a. Children, competent adults, and nursing home residents b. Competent adults, residents of mental health facilities, and nursing home residents c. Nursing home residents, the elderly, and residents of state mental health facilities d. Residents of state mental health facilities, the elderly, and competent adults - CORRECT ANSWER c. Nursing home residents, the elderly, and residents of state mental health facilities Debbie, an HIM professional, was recently hired as the privacy officer at a large physician practice. She observes the following practices. Which is a violation of the HIPAA Privacy Rule? a. Dr. Graham recommends a medication to a patient with asthma. b. Dr. Herman gives a patient a pen with the name of a pharmaceutical company on it. c. Dr. Martin recommends acupuncture to a patient. d. Dr. Lawson gives names of asthma patients to a pharmaceutical company. - CORRECT ANSWER d. Dr. Lawson gives names of asthma patients to a pharmaceutical company. According to HIPAA standards, designated individuals responsible for data security: a. Must be identified by every covered entity b. Are only required in large facilities c. Are only required in hospitals d. Are not required in small physician practices - CORRECT ANSWER a. Must be identified by every covered entity Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? a. The Privacy Rule requires that Susan Hall complete a written authorization. b. The hospital may send only discharge summary, history, and physical and operative report. c. The Privacy Rule's minimum necessary requirement does not apply. d. This "public interest and benefit" disclosure does not require the patient's authorization. - CORRECT ANSWER c. The Privacy Rule's minimum necessary requirement does not apply. Identifying appropriate users of specific information is a function of: a. Access control b. Nosology c. Data modeling d. Workflow modeling - CORRECT ANSWER a. Access control An original goal of HIPAA Administrative Simplification was to standardize: a. Privacy notices given to patients b. The electronic transmission of health data c. Disclosure of information for treatment purposes d. The definition of PHI - CORRECT ANSWER b. The electronic transmission of health data Health Insurance Portability and Accountability Act's Privacy Rule states that "________ used for the purposes of treatment, payment, or healthcare operations does not require patient authorization to allow providers access, use, or disclosure." However, only the ________ information needed to satisfy the specified purpose can be used or disclosed. a. Demographic information, minimum necessary b. Protected health information, minimum necessary c. Protected health information, diagnostic d. Demographic information, diagnostic - CORRECT ANSWER b. Protected health information, minimum necessary Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO? a. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required b. Confirm that a formal letter of termination meets HIPAA requirements and no further action is required except that the termination notice needs to be retained for seven years c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned d. Inform the CFO that business associate agreements cannot be terminated - CORRECT ANSWER c. Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned E-discovery rules were created in response to the tremendous volume of evidence maintained in electronic format that is pertinent to lawsuits and amended which legislation? a. Federal Rules of Evidence b. State Rules of Evidence c. Federal Rules of Civil Procedure d. State Rules of Civil Procedure - CORRECT ANSWER c. Federal Rules of Civil Procedurec. Federal Rules of Civil Procedure The federal physician self-referral statute is also known as the: a. Sherman Anti-Trust Act b. Deficit Reduction Act c. False Claims Act d. Stark Law - CORRECT ANSWER d. Stark Law 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 c. Firewalls Under HIPAA, when is the patient's written authorization required to release his or her healthcare information? a. For purposes related to treatment b. For purposes related to payment c. For administrative healthcare operations d. For any purpose unrelated to treatment, payment, or healthcare operations - CORRECT ANSWER d. For any purpose unrelated to treatment, payment, or healthcare operations Which of the following must be reported to the medical examiner? a. Burns b. Accidental deaths c. Causes of injury d. Morbidity - CORRECT ANSWER b. Accidental deaths A federal confidentiality statute specifically addresses confidentiality of health information about ________ patients. a. Developmentally disabled b. Elderly c. Drug and alcohol recovery d. Cancer - CORRECT ANSWER c. Drug and alcohol recovery Regarding an individual's right of access to their own PHI, per HIPAA, a covered entity: a. Must act on the request within 90 days b. May extend its response by 60 days if it gives the reasons for the delay c. May require individuals to make their requests in writing d. Does not have limits regarding what it can charge individuals for copies of their health records - CORRECT ANSWER c. May require individuals to make their requests in writing The HIM manager received notification that a user accessed the PHI of a patient with the same last name as the user. This is an example of a(n): a. Encryption b. Trigger flag c. Transmission security d. Redundancy - CORRECT ANSWER b. Trigger flag In Medical Center Hospital's clinical information system, nurses may write nursing notes and may read all parts of the patient health record for patients on the unit in which they work. This type of authorized use is called: a. Password limitation b. Security clearance c. Role-based access d. User grouping - CORRECT ANSWER c. Role-based access A subpoena duces tecum compels the recipient to: a. Serve on a jury b. Answer a complaint c. Testify at a trial d. Bring records to a legal proceeding - CORRECT ANSWER d. Bring records to a legal proceeding Per HITECH, an accounting of disclosures must include disclosures made during the previous: a. 10 years b. 6 years c. 3 years d. 1 year - CORRECT ANSWER c. 3 years When a patient revokes authorization for release of information after a healthcare entity has already released the information, the healthcare entity in this case: a. May be prosecuted for invasion of privacy b. Has become subject to civil action c. Has violated the security regulations of HIPAA d. Is protected by the Privacy Act - CORRECT ANSWER d. Is protected by the Privacy Act The hospital's public relations department in conjunction with the local high school is holding a job shadowing day. The purpose of this event is to allow high school seniors an opportunity to observe the various jobs in the hospital and to help the students with career planning. The public relations department asks for input on this event from the standpoint of HIPAA compliance. In this case, what should the HIM department advise? a. Job shadowing is allowed by HIPAA under the provision of allowing students and trainees to practice. b. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is very limited, such as administrative areas. c. Job shadowing is allowed by HIPAA under the provision of volunteers. d. Job shadowing is specifically prohibited by HIPAA. - CORRECT ANSWER b. Job shadowing should be limited to areas in which the likelihood of exposure to PHI is very limited, such as administrative areas. When a competent adult refuses treatment, a court may be required to balance the individual's privacy interests against the: a. Patient's level of pain b. Physician's right to keep the patient alive c. Government's interests in protecting human life d. Provider's liability concerns - CORRECT ANSWER c. Government's interests in protecting human life A patient requests that disclosures made from her medical record be limited to specific clinical notes and reports. Given HIPAA requirements, how must the hospital respond? a. The hospital must accept the request but does not have to agree to it. b. The hospital must honor the request. c. The hospital must guarantee that the request will be followed. d. The hospital must agree to the request, providing that state or federal law does not prohibit it. - CORRECT ANSWER a. The hospital must accept the request but does not have to agree to it. Which of the following is a best practice for protecting information that is text messaged? a. Send a text message to more than one person b. Enter a person's telephone number each time a text message is sent c. Encrypt text messages during transmission d. Presume that telephone numbers stored in memory remain valid - CORRECT ANSWER c. Encrypt text messages during transmission City Hospital has implemented a procedure that allows inpatients to decide whether they want to be listed in the hospital's directory. The directory information includes the patient's name, location in the hospital, and general condition. If a patient elects to be in the directory, this information is used to inform callers who know the patient's name. Some patients have requested that they be listed in the directory but information is to be released to only a list of specific people the patient provides. A hospital committee is considering changing the policy to accommodate these types of patients. In this case, what type of advice should the HIM director provide? a. Approve the requests because this is a patient right under HIPAA regulations b. Deny these requests because screening of calls is difficult to manage and if information is given in error, this would be considered a violation of HIPAA c. Develop two different types of directories—one directory for provision of all information and one directory for provision of information to selected friends and family of the patient d. Deny these requests and seek approval from the Office of Civil Rights - CORRECT ANSWER b. Deny these requests because screening of calls is difficult to manage and if information is given in error, this would be considered a violation of HIPAA Which of the following is a mechanism that records and examines activity in information systems? a. eSignature laws b. Security audits c. Minimum necessary rules d. Access controls - CORRECT ANSWER b. Security audits Which of the following statements is true with regard to responding to requests from individuals for access to their PHI? a. A cost-based fee may be charged for retrieval of the PHI. b. A cost-based fee may be charged for making a copy of the PHI. c. No fees of any type may be charged. d. A minimal fee may be charged for retrieval and copying of PHI. - CORRECT ANSWER b. A cost-based fee may be charged for making a copy of the PHI. Authorization management involves: a. The process used to protect the reliability of a database b. Limiting user access to a database c. Allowing unlimited use of the database d. Developing definitions for database elements - CORRECT ANSWER b. Limiting user access to a database Which landmark legal case established the responsibility of the hospital for the quality of care given by its physicians? a. Roe v. Wade b. Darling v. Charleston Community Memorial Hospital c. Brown v. Board of Education d. Marbury v. Madison - CORRECT ANSWER b. Darling v. Charleston Community Memorial Hospital An employee accesses ePHI that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach? a. Access controls b. Audit controls c. Contingency controls d. Security incident controls - CORRECT ANSWER a. Access controls Which of the following is an administrative safeguard action? a. Facility access control b. Documentation retention guidelines c. Maintenance record d. Media reuse - CORRECT ANSWER b. Documentation retention guidelines 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 a. Data integrity An employee received an email that he thought was from the information technology department. He provided his personal information at the sender's request. The employee was tricked by: a. Phishing b. Ransomware c. Virus d. Bot - CORRECT ANSWER a. Phishing Caitlin has been experiencing abdominal pain. Removal of her gallbladder was recommended. Who is responsible to obtain Caitlin's informed consent? a. The anesthesiologist who will be administering general anesthesia b. The surgical nurse who will assist during surgery c. The physician who will be performing the surgery d. The administrator in the surgery department - CORRECT ANSWER c. The physician who will be performing the surgery Which of the following statements about a firewall is false? a. It is a system or combination of systems that supports an access control policy between two networks. b. The most common place to find a firewall is between the healthcare entity's internal network and the Internet. c. Firewalls are effective for preventing all types of attacks on a healthcare system. d. A firewall can limit internal users from accessing various portions of the Internet. - CORRECT ANSWER c. Firewalls are effective for preventing all types of attacks on a healthcare system. Which of the following statements is true in regard to training in protected health information (PHI) policies and procedures? a. Every member of the covered entity's workforce must be trained. b. Only individuals employed by the covered entity must be trained. c. Training only needs to occur when there are material changes to the policies and procedures. d. Documentation of training is not required. - CORRECT ANSWER a. Every member of the covered entity's workforce must be trained. The age of majority in most states is: a. 16 and older b. 17 and older c. 18 and older d. 21 and older - CORRECT ANSWER c. 18 and older An employer has contacted the HIM department and requested health information on one of his employees. Of the options listed here, what is the best course of action? a. Provide the information requested b. Refer the request to the attending physician c. Request the employee's written authorization for release of information d. Request the employer's written authorization for release of the employee's information - CORRECT ANSWER c. Request the employee's written authorization for release of information Kay Denton wrote to Mercy Hospital requesting an amendment to her PHI. She states that her record incorrectly lists her weight at 180 lbs. instead of her actual 150 lbs., and amending it would look better on her record. The information is present on a copy of a history and physical that General Hospital sent to Mercy Hospital. Mercy Hospital may decline to grant her request based on which privacy rule provision? a. Individuals do not have the right to make amendment requests. b. The history and physical was not created by Mercy Hospital. c. A history and physical is not part of the designated record set. d. Mercy Hospital must grant her request. - CORRECT ANSWER b. The history and physical was not created by Mercy Hospital. Notices of privacy practices must be available at the site where the individual is treated and: a. Must be posted next to the entrance b. Must be posted in a prominent place where it is reasonable to expect that patients will read them c. May be posted anywhere at the site d. Do not have to be posted at the site - CORRECT ANSWER b. Must be posted in a prominent place where it is reasonable to expect that patients will read them A visitor sign-in sheet to a computer area is an example of what type of control? a. Administrative b. Audit c. Facility access d. Workstation - CORRECT ANSWER c. Facility access The confidentiality of incident reports is generally protected in cases when the report is filed in: a. The nursing notes b. The patient's health record c. The physician's progress notes d. The hospital risk manager's office - CORRECT ANSWER d. The hospital risk manager's office Mary Jones has been declared legally incompetent by the court. Mrs. Jones's sister has been appointed her legal guardian. Her sister requested a copy of Mrs. Jones's health records. Of the options listed here, what is the best course of action? a. Comply with the sister's request but first request documentation from the sister that she is Mary Jones's legal guardian b. Provide the information as requested by the sister c. Require that Mary Jones authorize the release of her health information to the sister d. Refer the sister to Mary Jones's doctor - CORRECT ANSWER a. Comply with the sister's request but first request documentation from the sister that she is Mary Jones's legal guardian Which of the following would be included in an accounting of disclosures? a. Incidental to an otherwise permitted or required use disclosure b. Disclosures to the individual about whom the information pertains c. Disclosures made pursuant to an authorization d. Patient information faxed to the bank - CORRECT ANSWER d. Patient information faxed to the bank 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 b. more than 500 individuals affected HITECH specifically includes all of the following as business associates except: a. Patient safety organizations b. Health information exchanges c. E-prescribing gateways d. Facility housekeeping staff - CORRECT ANSWER d. Facility housekeeping staff In all of the following situations PHI may be disclosed without providing the opportunity for an individual to object or to provide an authorization except: a. For disclosures for public health purposes as required by law b. For disclosures to health oversight agencies as required by law c. For reporting certain types of wounds or other physical injuries as required by law d. For including the individual's name in the facility directory - CORRECT ANSWER d. For including the individual's name in the facility directory HIPAA was designed to accomplish all of the following except: a. Designate HIM professionals as privacy officers b. Establish a consistent set of privacy and security rules for healthcare information nationwide c. Simplify the sharing of health information for legitimate purposes d. Authorize that only the minimum necessary should be released upon proper authorization - CORRECT ANSWER a. Designate HIM professionals as privacy officers The outpatient clinic of a large hospital is reviewing its patient sign-in procedures. The registration clerks say it is essential that they know if the patient has health insurance and the reason for the patient's visit. The clerks maintain that having this information on a sign-in sheet will make their jobs more efficient and reduce patient waiting time in the waiting room. What should the HIM director advise in this case? a. To be HIPAA compliant, sign-in sheets should contain the minimal information necessary such as patient name. b. Patient name, insurance status, and diagnoses are permitted by HIPAA. c. Patient name, insurance status, and reason for visit would be considered incidental disclosures if another patient saw this information. d. Any communication overheard by another patient is considered an incidental disclosure. - CORRECT ANSWER a. To be HIPAA compliant, sign-in sheets should contain the minimal information necessary such as patient name. Which of the following is not an identifier under the Privacy Rule? a. Visa account 2773 985 0468 b. Vehicle license plate BZ LITYR c. Age 75 d. Street address 265 Cherry Valley Road - CORRECT ANSWER c. Age 75 Community Hospital is planning implementation of various elements of the EHR in the next six months. Physicians have requested the ability to access the EHR from their offices and from home. What advice should the HIM director provide? a. HIPAA regulations do not allow this type of access. b. This access would be covered under the release of PHI for treatment purposes and poses no security or confidentiality threats. c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. d. Access cannot be permitted because the physicians would not be accessing information for treatment purposes. - CORRECT ANSWER c. Access can be permitted providing that appropriate safeguards are put in place to protect against threats to security. Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? a. Wait until Susan is 18 b. Present an authorization signed by the court that granted the adoption c. Present an authorization signed by Susan's natural (birth) parents d. Present an authorization that at least one of them (Ted or Mary) has signed - CORRECT ANSWER d. Present an authorization that at least one of them (Ted or Mary) has signed What is the legal term used to define the protection of health information in a patient-provider relationship? a. Access b. Confidentiality c. Privacy d. Security - CORRECT ANSWER b. Confidentiality Mr. Martin has asked his physician's office to review a copy of his PHI. His request must be responded to no later than ________ after the request was made. a. 90 days b. 60 days c. 30 days d. 6 weeks - CORRECT ANSWER c. 30 days Which of the following does not have to be included in a covered entity's notice of privacy practices? a. Description with one example of disclosures made for treatment purposes b. Description of all the other purposes for which a covered entity is permitted or required to disclose PHI without consent or authorization c. Statement of individual's rights with respect to PHI and how the individual can exercise those rights d. Patient's signature and e-mail address - CORRECT ANSWER d. Patient's signature and e-mail address The privacy officer was conducting training for new employees and posed the following question to the trainees to help them understand the rule regarding breach notification: "If a breach occurs, which of the following must be provided to the individual whose PHI has been breached?" a. The facility's notice of privacy practices b. An authorization to release the individual's PHI c. The types of unsecured PHI that were involved d. A promise to never do it again - CORRECT ANSWER c. The types of unsecured PHI that were involved A valid subpoena duces tecum seeking health records does not have to: a. Be signed by the plaintiff and defendant b. Include the date, time, and place of the requested appearance c. Include the case docket number d. The name of the issuing attorney - CORRECT ANSWER a. Be signed by the plaintiff and defendant The process that encodes textual material, converting it to scrambled data that must be decoded is a(n): a. Audit trail b. Encryption c. Password d. Physical safeguard - CORRECT ANSWER b. Encryption The technology, along with the policies and procedures for its use, that protects and controls access to ePHI are: a. Administrative safeguards b. Technical safeguards c. Physical safeguards d. Integrity controls - CORRECT ANSWER b. Technical safeguards Which of the following is required in a risk analysis according to the Security Rule? a. Determine the likelihood of threat occurrence and the potential impact b. Focus on improved efficiency c. Implement successful system migration and interoperability d. Develop a sustainable business plan - CORRECT ANSWER a. Determine the likelihood of threat occurrence and the potential impact Community Hospital wants to provide transcription services for transcription of office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise to comply with HIPAA regulations? a. Each physician practice should obtain a business associate agreement with the hospital. b. The hospital should obtain a business associate agreement with each physician practice. c. Because the physicians all have medical staff privileges, no business associate agreement is necessary. d. Because the physicians are part of an Organized Health Care Arrangement (OHCA) with the hospital, no business associate agreement is necessary. - CORRECT ANSWER a. Each physician practice should obtain a business associate agreement with the hospital. Dr. Williams is on the medical staff of Sutter Hospital, and he has asked to see the health record of his wife, who was recently hospitalized. Dr. Jones was the patient's physician. Of the options listed here, which is the best course of action? a. Refer Dr. Williams to Dr. Jones and release the record if Dr. Jones agrees b. Inform Dr. Williams that he cannot access his wife's health information unless she authorizes access through a written release of information c. Request that Dr. Williams ask the hospital administrator for approval to access his wife's record d. Inform Dr. Williams that he may review his wife's health record in the presence of the privacy officer - CORRECT ANSWER b. Inform Dr. Williams that he cannot access his wife's health information unless she authorizes access through a written release of information The privacy officer was conducting training for new employees and posed the following question to the trainees to help them understand the rule regarding protected health information (PHI): "Which of the following is an element that makes information 'PHI' under the HIPAA Privacy Rule?" a. Identifies an attending physician b. Specifies the insurance provider for the patient c. Contained within a personnel file d. Relates to one's health condition - CORRECT ANSWER d. Relates to one's health condition Which of the following controls external access to a network? a. Access controls b. Alarms c. Encryption d. Firewall - CORRECT ANSWER d. Firewall A competent adult female has a diagnosis of ovarian cancer and while on the operating table suffers a stroke and is in a coma. Her son would like to access her health records from a clinic she recently visited for pain in her right arm. The patient is married and lives with her husband and two grown children. According to the Uniform Health Care Decisions Act (UHCDA), who is the logical person to request and sign an authorization to access the woman's health records from the clinic? a. Adult child making request b. Oldest adult child c. Patient d. Spouse - CORRECT ANSWER d. Spouse John Smith was seen in his primary care physician's office. When the provider attempted to call him with his laboratory results, he inadvertently called the incorrect John Smith and verbally provided him the lab result. Which of the following would apply to this situation in the context of breach notification? a. The provider would be required to report the breach to the media. b. No reporting is necessary because the laboratory results are not considered PHI and no breach can occur based on this fact. c. Even though the results were discussed with the incorrect patient, no hard copy results were sent to the wrong person, so because the wrong John Smith could not keep the PHI, no reporting is necessary. d. The provider would be required to report the breach to the Secretary of HHS. - CORRECT ANSWER c. Even though the results were discussed with the incorrect patient, no hard copy results were sent to the wrong person, so because the wrong John Smith could not keep the PHI, no reporting is necessary. To practice medicine, medical school students must pass a test before they can obtain a: a. Degree b. License c. Residency d. Specialty - CORRECT ANSWER b. License Which of the following fundraising solicitations violates HIPAA? a. One sent to cardiac patients only b. One that includes opt-out instructions c. One sent to all patients treated at a facility in the previous year d. One preceded by a Notice of Privacy Practices that informed individuals about fundraising activity - CORRECT ANSWER a. One sent to cardiac patients only What is the most common method for implementing entity authentication? a. Personal identification number b. Biometric identification systems c. Token systems d. Password systems - CORRECT ANSWER d. Password systems To date, the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide? a. HIPAA does not allow charges for copying medical records. b. Use the state formula because HIPAA allows hospitals to use the state formula. c. Base charges on the cost of labor and supplies for copying and postage if copies are mailed. d. Because HIPAA restricts charges to the cost of paper, charge only for the paper used for copying the records. - CORRECT ANSWER c. Base charges on the cost of labor and supplies for copying and postage if copies are mailed. An inherent weakness or absence of a safeguard that could be exploited by threat is a: a. Security incident b. Breach c. Vulnerability d. Threat - CORRECT ANSWER c. Vulnerability If a healthcare provider is accused of breaching the privacy and confidentiality of a patient, what resource may a patient rely on to substantiate the provider's responsibility for keeping health information private? a. Professional Code of Ethics b. Federal Code of Fair Practice c. Federal Code of Silence d. State Code of Fair Practice - CORRECT ANSWER a. Professional Code of Ethics A hospital releases information to an insurance company with proper authorization by the patient. The insurance company forwards the information to a medical data clearinghouse. This process is referred to as: a. Admissibility b. Civil release c. Privileging process d. Redisclosure - CORRECT ANSWER d. Redisclosure 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 d. Security audit 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). Under the HIPAA Security Rule, these types of safeguards have to do with protecting the environment: a. Administrative b. Physical c. Security d. Technical - CORRECT ANSWER b. Physical Mrs. Guindon is requesting every piece of health information that exists about her from Garrett Hospital. The Garrett Hospital privacy officer must explain to her that, under HIPAA privacy regulations, she does not have the right to access her: a. History and physical report b. Operative report c. Discharge summary d. Psychotherapy notes - CORRECT ANSWER d. Psychotherapy notes Data security management involves defending or safeguarding: a. Access to information b. Data availability c. Health record quality d. System implementation - CORRECT ANSWER a. Access to information The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence? a. The care provided to the patient b. Identification of the record as the one subpoenaed c. The qualifications of the treating physician d. Identification of the standard of care used to treat the patient - CORRECT ANSWER b. Identification of the record as the one subpoenaed Under the HIPAA Privacy Rule, a hospital may disclose health information without authorization or subpoena in which of the following cases? a. The patient has been involved in a crime that may result in death. b. The patient has celebrity status and requires protection. c. The father of a 22-year-old is requesting the records. d. An attorney requests records. - CORRECT ANSWER a. The patient has been involved in a crime that may result in death. Which of the following are technologies and methodologies for rendering protected health information unusable, unreadable, or indecipherable to unauthorized individuals as a method to prevent a breach of PHI? a. Encryption and destruction b. Recovery and encryption c. Destruction and redundancy d. Interoperability and recovery - CORRECT ANSWER a. Encryption and destruction Generally, policies addressing the confidentiality of quality improvement (QI) committee data (minutes, actions, and so forth) state that this kind of data is: a. Protected from disclosure b. Subject to release with patient authorization c. Generally available to interested parties d. May not be reviewed or released to external reviewers such as the Joint Commission - CORRECT ANSWER a. Protected from disclosure According to the Privacy Rule, which of the following statements must be included in the notice of privacy practices? a. A description (including at least one example) of the types of uses and disclosures the physician is permitted to make for marketing purposes. b. A description of each of the other purposes for which the covered entity is permitted or required to use or disclose PHI without the individual's written consent or authorization. c. A statement that other uses and disclosures will be made without the individual's written authorization and that the individual may not revoke such authorization. d. A statement that all disclosures will be prohibited from future redisclosures. - CORRECT ANSWER b. A description of each of the other purposes for which the covered entity is permitted or required to use or disclose PHI without the individual's written consent or authorization. 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 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. Employees in the hospital business office may have legitimate access to patient health information without patient authorization based on what HIPAA standard or principle? a. Minimum necessary b. Compound authorization c. Accounting of disclosures d. Preemption - CORRECT ANSWER a. Minimum necessary The HIPAA Privacy Rule permits charging patients for labor and supply costs associated with copying health records. Mercy Hospital is located in a state where state law allows charging patients a $100 search fee associated with locating records that have been requested. Which of the following statements is true when applied to this scenario? a. State law will not be preempted in this situation. b. The Privacy Rule will preempt state law in this situation. c. The Privacy Rule never preempts existing state law. d. The Privacy Rule always preempts existing state law. - CORRECT ANSWER b. The Privacy Rule will preempt state law in this situation. 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 ________ established the right of patients to access and amend their own health records. a. HIPAA b. Medicare c. Medicaid d. AHIMA - CORRECT ANSWER a. HIPAA Covered entities must retain documentation of their security policies for at least: a. Five years b. Five years from the date of origination c. Six years from the date when last in effect d. Six years from the date of the last incident - CORRECT ANSWER c. Six years from the date when last in effect According to the HIPAA Security Rule, how should a covered entity instruct a physician who needs a new smartphone when her current smartphone contains ePHI? a. Keep her old smartphone b. Turn in her old smartphone to have the memory wiped c. Recycle the old smartphone by giving it to a charity d. Do what she wants since IT is too busy with other projects - CORRECT ANSWER b. Turn in her old smartphone to have the memory wiped Training in PHI policies and procedures means that: a. Every member of the covered entity's workforce must be trained b. Only individuals employed by the covered entity must be trained c. Training only needs to occur when there are material changes to the policies and procedures d. Documentation of training is not required - CORRECT ANSWER a. Every member of the covered entity's workforce must be trained In the case of behavioral healthcare information, a healthcare provider may disclose health information on a patient without the patient's authorization in which of the following situations? a. Court order, duty to warn, and involuntary commitment proceedings b. Duty to warn, release of psychotherapy notes, and court order c. Involuntary commitment proceedings, court order, and substance abuse treatment records d. Release of psychotherapy notes, substance abuse treatment records, and duty to warn - CORRECT ANSWER a. Court order, duty to warn, and involuntary commitment proceedings What type of safeguards comprise over half of all of the safeguards included in the Security Rule? a. Physical safeguards b. Technical safeguards c. Administrative safeguards d. Security safeguards - CORRECT ANSWER c. Administrative safeguards 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 Which one of the following has access to personally identifiable data without authorization or subpoena? a. Law enforcement in a criminal case b. The patient's attorney c. Public health departments for disease reporting purposes d. Workers' compensation for disability claim settlement - CORRECT ANSWER c. Public health departments for disease reporting purposes Which professional has the responsibility of determining when an individual or entity has the right to access healthcare information in a hospital setting? a. Physicians b. Nurses c. Health information management professionals d. Hospital administrators - CORRECT ANSWER c. Health information management professionals The Administrative Simplification portion of Title II of HIPAA addresses which of the following? a. Creating standardized forms for release of information throughout the industry b. Computer memory requirements for health plans maintaining patient health information c. Security regulations for personal health records d. Uniform standards for transactions and code sets - CORRECT ANSWER d. Uniform standards for transactions and code sets A nurse administrator who is not typically on call to cover staffing shortages gets called in over the weekend to staff the emergency department. She does not have access to enter notes since this is not a part of her typical role. In order to meet the intent of the HIPAA Security Rule, the hospital policy should include a: a. Requirement for her to attend training before accessing ePHI b. Provision for another nurse to share his or her password with the nurse administrator c. Provision to allow her emergency access to the system d. Restriction on her ability to access ePHI - CORRECT ANSWER c. Provision to allow her emergency access to the system 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 b. PHI regarding victims of domestic violence Community Memorial Hospital is developing a new trauma center. The administrative team asks the director of HIM to ensure that hospital policies are in compliance with all regulations regarding acceptance and transfer of emergency patients. The legislation that the HIM director should review is the: a. Prospective Payment Act b. Health Insurance Portability and Accountability Act c. Emergency Medical Treatment and Active Labor Act d. Tax Equity and Fiscal Responsibility Act - CORRECT ANSWER c. Emergency Medical Treatment and Active Labor Act Under the Privacy Rule, which of the following must be included in a patient accounting of disclosures? a. State-mandated report of a sexually transmitted disease b. Disclosure pursuant to a patient's signed authorization c. Disclosure necessary to meet national security or intelligence requirements d. Disclosure for payment purposes - CORRECT ANSWER a. State-mandated report of a sexually transmitted disease One of the four general requirements a covered entity must adhere to in order to be in compliance with the HIPAA Security Rule is to: a. Ensure the confidentiality, integrity, and addressability of ePHI b. Ensure the confidentiality, integrity, and accuracy of ePHI c. Ensure the confidentiality, integrity, and availability of ePHI d. Ensure the confidentiality, integrity, and accountability of ePHI - CORRECT ANSWER c. Ensure the confidentiality, integrity, and availability of ePHI A healthcare entity that is governed by the HIPAA regulations is called a(n): a. Authorized entity b. Covered entity c. Privacy entity d. Regulated entity - CORRECT ANSWER b. Covered entity Which of the following presents the greatest risk of large-scale health information breaches? a. Unlocked rooms b. Computer monitors positioned toward high-traffic areas c. Unattended computer workstations d. Laptop theft - CORRECT ANSWER d. Laptop theft Which process requires the verification of the educational qualifications, licensure status, and other experience of healthcare professionals who have applied for the privilege of practicing within a healthcare facility? a. Deemed status b. Judicial decision c. Subpoena d. Credentialing - CORRECT ANSWER d. Credentialing Which of the following is a direct command that requires an individual or a representative of a healthcare entity to appear in court or to present an object to the court? a. Judicial decision b. Subpoena c. Credential d. Regulation - CORRECT ANSWER b. Subpoena The baby of a mother who is 15 years old was recently discharged from the hospital. The mother is seeking access to the baby's health record. Who must sign the authorization for release of the baby's health record? a. Both mother and father of the baby b. Maternal grandfather of the baby c. Maternal grandmother of the baby d. Mother of the baby - CORRECT ANSWER d. Mother of the baby The health record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wants to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the: a. Admissibility exception b. Discovery exception c. Direct evidence exception d. Business records exception - CORRECT ANSWER d. Business records exception What information process must the legal counsel of Smithville Hospital perform in order to prepare for a lawsuit against the hospital? a. Information governance b. E-Discovery c. Transparency d. Enterprise information management - CORRECT ANSWER a. Information governance A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity breach risk and wants the information removed. The physicians and others in the hospital are not cooperating, saying they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? a. Avoid displaying the number on any document, screen, or data collection field b. Allow the information in both electronic and paper forms since a variety of people need this data c. Require employees to sign confidentiality agreements if they have access to social security numbers d. Contact legal counsel for advice - CORRECT ANSWER a. Avoid displaying the number on any document, screen, or data collection field Per the Privacy Rule, which of the following requires authorization for research purposes? a. Use of Mary's deidentified information about her myocardial infarction b. Use of Mary's information about her asthma in a limited data set c. Use of Mary's individually identifiable information related to her asthma treatments d. Use of medical information about Jim, Mary's deceased husband - CORRECT ANSWER c. Use of Mary's individually identifiable information related to her asthma treatments Which of the following is the statistic that would be used to explore the relationship between length of stay and patient age? a. Mean b. Correlation c. Predictive modeling d. Variance - CORRECT ANSWER b. Correlation 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 b. LOINC Fifty percent of patients treated at our facilities have Medicare as their primary payer. This is an example of what type of information? a. Patient-specific b. Expert knowledge c. Comparative d. Aggregate - CORRECT ANSWER d. Aggregate Last year, 73,249 people died from diabetes mellitus in the United States. The total number of deaths from all causes was 2,443,387, and the total population was 288,356,713. Calculate the proportionate mortality ratio for diabetes mellitus. a. 0.003 b. 10.94 c. 0.09 d. 3.0 - CORRECT ANSWER d. 3.0 The purpose of Regional Extension Centers is to: a. Implement meaningful use b. Support providers in adopting EHR and with technical assistance c. Develop standards for HI systems d. Provide funding for expanding the adoption of HI technology - CORRECT ANSWER b. Support providers in adopting EHR and with technical assistance An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis? a. The average wait time is shorter on weekends. b. The average wait time is longer on weekends. c. The average wait time is different on weekends and weekdays. d. The average wait time is the same on weekends and weekdays. - CORRECT ANSWER b. The average wait time is longer on weekends. Which graph is the best choice to use when exploring the relationship between length of stay and charge for a set of patients? a. Line graph b. Bar chart c. Pie chart d. Scatter diagram - CORRECT ANSWER d. Scatter diagram A scatter diagram is a data analysis tool used to plot points of two variables suspected of being related to each other in some way (Oachs 2016, 816-817). A database will be created solely for use in a research study that is being conducted. Which of the following is best suited for this scenario? a. Relational database model b. Data repository c. Data mart d. Data warehouse - CORRECT ANSWER c. Data mart A data mart is a subset of the data warehouse designed for a single purpose or specialized use. The data mart performs the same type of analysis as a data warehouse; however, the scope of the data is narrower (Sayles and Kavanaugh-Burke 2018, 38). Which of the following best describes the intent of strategic information systems planning? a. Provide the potential for growth and expansion b. Ensure that all information technology initiatives are integrated and aligned with the healthcare entity's overall strategy c. Assess community or market needs and resources d. Ensure ongoing accreditation - CORRECT ANSWER b. Ensure that all information technology initiatives are integrated and aligned with the healthcare entity's overall strategy Protocols that support communication between applications are often referred to as: a. Application program b. Interface code c. Messaging standards d. Source code - CORRECT ANSWER c. Messaging standards Which of the following statements is true of structured query language (SQL)? a. It is both a data manipulation and data back-up mechanism. b. It defines data elements and manipulates and controls data. c. It is the computer language associated with document imaging. d. Users are not able to query a relational database. - CORRECT ANSWER b. It defines data elements and manipulates and controls data. What is the average of the sum of the relative weights of all patients treated during a specified time period? a. Case-mix index b. Outlier pool c. Share d. Mean qualifier - CORRECT ANSWER a. Case-mix index Case-mix index is the weighted average of the sum of the relative weights of all patients treated during a specified time period (Casto 2018, 116). A single point of personalized web access through which to find and deliver information, applications, and services is called a(n): a. Keyhole b. Entry way c. WWW d. Portal - CORRECT ANSWER d. Portal When describing the typical length of stay for patients admitted for congestive heart failure, which is the most appropriate measure of central tendency when there are a number of long stay outliers? a. Minimum b. Mean c. Median d. Mode - CORRECT ANSWER c. Median Which model for health information exchange stores patient records in a single database built to allow queries into the system? a. Federated b. Hybrid c. Centralized d. Decentralized - CORRECT ANSWER c. Centralized What is the term for health records maintained by patients or their families? a. Electronic health records b. Mixed-media records c. Personal health records d. Longitudinal health records - CORRECT ANSWER c. Personal health records The most common architecture used in EHRs in hospitals today is: a. Client or server b. Mainframe c. Network computers d. Web-based - CORRECT ANSWER a. Client or server 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 b. Indexing system Which of the following basic services provided by a health information exchange (HIE) entity matches identifying information to an individual? a. Consent management b. Person identification c. Record locator d. Identity management - CORRECT ANSWER b. Person identification Because there is no mandated unique patient identifier, ensuring that the HIE organization can identify the right patient as it seeks to exchange information is a process of identity matching (Amatayakul 2017, 419). A protocol to pass data from the system of one vendor to the information system of another vendor is called: a. OLAP b. Integration c. TCP/IP d. Interface - CORRECT ANSWER d. Interface Which type of architecture has one powerful central computer that performs all processing and storage functions while sending and receiving data to or from various terminals and printers? a. Client or server b. Mainframe c. Super computer d. Web-based - CORRECT ANSWER b. Mainframe Mainframe computers use a single large computer with many terminals directly connected to it and sharing the resources of the single computer (Amatayakul 2017, 333). A current key function in the health information field whereby data is turned into useful information is: a. Data mining b. Decision analysis c. Clinical decision support d. Data analytics - CORRECT ANSWER d. Data analytics The term data analytics is used to describe a variety of approaches to using data to make business decisions. Healthcare data analytics is therefore the practice of using data to make business decisions in healthcare. More specifically, healthcare data analytics is the application of statistical techniques to allow informed decisions to be made based on the data (White 2016b, 510). The process of integrating healthcare facility systems requires the creation of: a. Data warehouses b. E-health initiatives c. Enterprise master patient indexes d. Electronic data interchange - CORRECT ANSWER c. Enterprise master patient indexes Data mining is a process that involves which of the following? a. Using reports to measure outcomes b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns c. Producing summary reports for management to run the daily activities of the healthcare entity d. Producing detailed reports to track productivity - CORRECT ANSWER b. Using sophisticated computer technology to sort through an entity's data to identify unusual patterns Which index, often considered the most important resource in a healthcare facility, is a database of patients within the facility or associated group of facilities? a. Facility-specific index b. Disease index c. Master patient index d. Operation index - CORRECT ANSWER c. Master patient index Which of the following is an organization that develops standards related to the interoperability of health information technology? a. National Health Information Network b. National Committee on Vital and Health Statistics c. Health Level 7 d. EHR Collaborative - CORRECT ANSWER c. Health Level 7 An analyst wishes to use the CMI for a set of MS-DRGs to determine if a documentation improvement program is having an impact. Use the MS-DRG volumes and weights in the table below to calculate the CMI for the three MS-DRGs. MS-DRG Description Weight Volume 034 CAROTID ARTERY STENT PROCEDURE W MCC 3.5998 | 100 035 CAROTID ARTERY STENT PROCEDURE W CC 2.2203 | 52 036 CAROTID ARTERY STENT PROCEDURE W/O CC/MCC1.7260 | 36 a. 2.3234 b. 2.8594 c. 2.9000 d. 3.5998 - CORRECT ANSWER b. 2.8594 This statistical inference measures both the strength of a relationship between two variables and the functional relationship between them. a. Correlation b. T-test c. Simple linear regression d. Standard deviation - CORRECT ANSWER c. Simple linear regression The HIM director is on the design team for the CPOE system. During a user interface design session, a sample of the electronic system is demonstrated. Two of the physicians are concerned about the overuse of alerts. What problem could the alert feature pose in the new system? a. Unnecessary alerts can lead to clinicians ignoring other important alerts. b. Alerts make order entry difficult. c. Physicians do not like to be reminded how to treat patients. d. The Joint Commission discourages an alert system. - CORRECT ANSWER a. Unnecessary alerts can lead to clinicians ignoring other important alerts. 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 d. X12N The probability of making a Type I error based on a particular set of data is called the ________. a. Sampling value b. Hypothesis test c. A-probability d. P-value - CORRECT ANSWER d. P-value Dictated and transcribed reports and notes written by the physicians and other practitioners are examples of: a. Standardized clinical information b. Codified data c. Aggregate data d. Unstructured clinical information - CORRECT ANSWER d. Unstructured clinical information Allowing different health information systems to work together within and across organizational boundaries is referred to as: a. Telehealth b. Interoperability c. Informatics d. Interfaces - CORRECT ANSWER b. Interoperability This data collection tool is used when one needs to gather data on sample observations in order to detect patterns. a. Check sheet b. Ordinal data tool c. Balance sheet d. Nominal data tool - CORRECT ANSWER a. Check sheet Which of the following ensures that procedures are in place to handle an emergency response in the event of an untoward event such as a power outage? a. An audit control b. A contingency plan c. Employee training d. Password protection - CORRECT ANSWER b. A contingency plan In this type of network configuration, individual computers are connected through a central hub that serves as a traffic cop for the data. a. Star topology b. Ring topology c. Bus topology d. Logical topology - CORRECT ANSWER a. Star topology What process must Colin, the HIM operations manager, perform to ensure that all patient information is contained within the correct electronic file in the EHR? a. Data modeling b. Data mapping c. Data audit d. Data architecture - CORRECT ANSWER c. Data audit Consumer informatics is focused on ________ a. Consumer activation b. Information structures and processes c. Personalized medicine d. Engagement - CORRECT ANSWER b. Information structures and processes Consumer health informatics is a field devoted to informatics from multiple consumer or patient views and includes patient-focused informatics, health literacy, and consumer education, with a focus on information structures and processes that empower consumers to manage their own health (AMIA 2015; Sandefer 2016b, 425). The generic formula for calculating rate of occurrence is used to calculate hospital-acquired infections in an intensive care unit in a given month. If the number of hospital-acquired infections is the numerator, the denominator would be the: a. Number of patients who died of infection b. Number of deaths in the ICU c. Number of discharges (including deaths) of ICU patients d. Total number of hospital discharges - CORRECT ANSWER c. Number of discharges (including deaths) of ICU patients Which numerical filing system results in an even distribution of records and ensures activity throughout the filing area? a. Serial-unit filing system b. Serial filing system c. Unit filing system d. Terminal-digit filing system - CORRECT ANSWER d. Terminal-digit filing system A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed? a. Randomly audit EHR documentation for patients readmitted within 30 days. b. Survey practitioners to determine if they are following hospital policy. c. Institute an in-service program for all hospital personnel. d. Observe the documentation practices of all clinical personnel. - CORRECT ANSWER a. Randomly audit EHR documentation for patients readmitted within 30 days. All computers on this type of network receive the same message at the same time, but only one computer at a time can transfer information; and if one segment of the network goes down, the entire network is affected. a. Star topology b. Ring topology c. Bus topology d. Logical topology - CORRECT ANSWER c. Bus topology Bus topology is the simplest network topology, connecting one device to another along a "backbone." A major disadvantage is that the central cable is a single point of failure. If this cable fails for any reason then the entire network goes down (Johns 2015, 57). A key element in effective systems implementation is: a. Contract negotiation b. User training c. System evaluation d. RFP analysis - CORRECT ANSWER b. User training A network made accessible to trusted individuals outside of the facility is called a(n): a. Extranet b. Intranet c. VPN d. LAN - CORRECT ANSWER a. Extranet Suppose that you are purchasing shelving units. The department has planned for units that are 5 shelves high, and each shelf is to be 36 inches wide and have 33 inches of actual filing space. From a sampling of records in the current files, you have determined that the average thickness of each record is 2 inches. You are planning to store 10 years' worth of records, and the average discharge rate is 2,000 per year. How many shelving units do you need to purchase? a. 165 b. 180 c. 242 d. 243 - CORRECT ANSWER d. 243 Which one of the following is an example of a clinical information system? a. Laboratory information system b. Human resource management system c. Patient registration system d. Staff management system - CORRECT ANSWER a. Laboratory information system Community Memorial Hospital discharged nine patients on April 1. The length of stay for each patient is shown in the following table. What is the median length of stay for this group of patients? Patient Length of Stay, in Days A | 1 B | 5 C | 3 D | 3 E | 8 F | 8 G | 8 H | 9 I | 9 a. 5 days b. 6 days c. 8 days d. 9 days - CORRECT ANSWER c. 8 daysq A radiology department is planning to develop a remote clinic and plans to transmit images for diagnostic purposes. The most important set of standards to implement in order to transmit images is: a. X12N b. LOINC c. IEEE 1073 d. DICOM - CORRECT ANSWER d. DICOM The Digital Imaging and Communications in Medicine (DICOM) standard supports retrieval of information from imaging devices and equipment to diagnostic and review workstations as well as short-term and long-term storage systems (Amatayakul 2017, 404-405). The Joint Commission requirement regarding delinquent records is that the number of delinquent records in a facility cannot exceed: a. 50 per week b. 2,000 per year c. 50 percent of the average number of discharges d. 25 percent of yearly admissions - CORRECT ANSWER c. 50 percent of the average number of discharges What term is used for a centralized database that captures, sorts, and processes patient data and then sends it back to the user? a. Clinical data repository b. Data exchange standard c. Central processor d. Digital system - CORRECT ANSWER a. Clinical data repository Identifying user information needs is part of which phase of the systems development life cycle? a. Analysis b. Design c. Implementation d. Evaluation - CORRECT ANSWER a. Analysis Tina is the EMPI coordinator for Smithtown Healthcare, a large medical center with many satellite clinics. Because so many patients visit the clinics, sometimes new health record numbers are mistakenly assigned to them (even though they may already have a number) when they register for a particular service. As the EMPI coordinator, Tina performs all of the following tasks as part of her regular job duties except: a. Unmerging overlays b. Merging duplicate records c. Confirming the health record contains all patient visits d. Verifying insurance status - CORRECT ANSWER d. Verifying insurance status 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 d. Secondary analysis The benefits patients experience when using a patient portal include all of the following except being able to: a. Edit their medical record information b. View lab results c. Update demographics d. Send messages to their providers - CORRECT ANSWER a. Edit their medical record information 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 a. Structured data In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n): a. Primary key interface (PKI) b. Application programming interface (API) c. Continuity of care record (CCR) d. Record locator service (RLS) - CORRECT ANSWER d. Record locator service (RLS) The HIM director is performing a staffing analysis to determine the number of employees needed to prep, scan, index, and carry out quality control on scanned medical records. Given a turnaround time of 24 hours and an average number of 48,000 images to be captured and considering the benchmarks listed here, what is the least number of employees the department needs, with each employee working an eight-hour shift? Benchmarks for Document Scanning Processes Function Expectations per Worked Hour Prepping 340-500 images Scanning 1,200-2,400 images Quality Control 1,600-2,000 images Indexing 600-800 images a. 25 employees b. 36 employees c. 36.1 employees d. 37 employees - CORRECT ANSWER a. 25 employees Which of the following basic services provided by an HIE entity identifies participating users and systems? a. Identity management b. Person identification c. Registry and directory d. Secure data transport - CORRECT ANSWER c. Registry and directory Which of the following are phases of the systems development life cycle (SDLC)? a. Design, analysis, and alignment b. Maintenance, implementation, and improvement c. Analysis, design, and implementation d. Analysis, alignment, and improvement - CORRECT ANSWER c. Analysis, design, and implementation In the following figure there is: a. No correlation between the variables b. A negative relationship between the variables c. A weak negative correlation between the variables d. A positive relationship between the variables - CORRECT ANSWER d. A positive relationship between the variables Scatter diagrams are used to plot the points for two continuous variables that may be related to each other in some way. Whenever a scatter diagram indicates that the points are moving together in one direction or another, conclusions about the variables' relationship, either positive or negative, become evident. In this case a positive relationship between the variables can be seen as the points gather together at the top of the diagram (Oachs 2016, 816-817). How long should the master patient index be maintained? a. For at least 5 years b. For at least 10 years c. For at least 25 years d. Permanently - CORRECT ANSWER d. Permanently To ensure quality of data, the cancer committee reviews the abstracting done by the cancer registry personnel. This type of reliability check is called: a. Precision b. Recheck c. Interrater d. Construct - CORRECT ANSWER c. Interrater In which record numbering system is the patient assigned a health record number on the first visit that is kept for all subsequent visits? a. Unit numbering b. Index unit numbering c. Serial-unit numbering d. Serial numbering - CORRECT ANSWER a. Unit numbering A director of a health information services department plans to do a research project on motivation that involves rewarding some employees for achieving specified goals. A control group will not be rewarded for achieving the same goals. Which entity will need to approve this study? a. Institutional Review Board b. Administrative team c. Accreditation organization d. Medical staff - CORRECT ANSWER a. Institutional Review Board The term used to describe breaking data elements into the level of detail needed to retrieve the data is: a. Normalization b. Data definitions c. Primary key d. A database management system - CORRECT ANSWER a. Normalization The capture of secondary diagnoses that increase the incidence of CCs and MCCs at final coding may have an impact on: a. Query rate b. Principal diagnosis c. Case-mix index d. Record review rate - CORRECT ANSWER c. Case-mix index A secure method of communication between the healthcare provider and the patient is: a. Personal health record b. E-mail c. Patient portal d. Online health information - CORRECT ANSWER c. Patient portal All of the following are a kind of technology that focuses on data security except ________. a. Encryption b. Biometrics c. Firewalls d. Telemedicine - CORRECT ANSWER d. Telemedicine In which of the following does an analyst perform exploratory data analysis to determine trends and identify patterns in the data set? a. Data quality b. Data mining c. Record analysis d. Inferential statistics - CORRECT ANSWER b. Data mining Which application uses statistical techniques to determine the likelihood of certain events occurring together? a. Predictive modeling b. Standard deviation c. T-test d. Serial numbering - CORRECT ANSWER a. Predictive modeling Dr. Jones comes into the HIM department and requests that the HIM director pull all of his records from the previous year in which the principal diagnosis of myocardial infarction was indicated. Where would the HIM director begin to pull these records? a. Disease index b. Master patient index c. Operative index d. Physician index - CORRECT ANSWER a. Disease index Which of the following lists represents recommended core data elements for the master patient index? a. Date of birth, revenue code, accession number, and address b. Name, address, revenue code, and accession number c. Name, gender, address, and date of birth d. Gender, address, accession number, and charge code - CORRECT ANSWER c. Name, gender, address, and date of birth One strategy for acquiring EHR components from various vendors and interfacing them is: a. Best-of-breed b. Best-of-fit c. Dual core d. Integration - CORRECT ANSWER a. Best-of-breed What is the most important factor in determining the best storage method for health records? a. Ensuring that the records are readily accessible and secure b. Ensuring that the records are factual and informational c. Ensuring that the records are both electronic and paper based d. Ensuring that the records are personal and private - CORRECT ANSWER a. Ensuring that the records are readily accessible and secure The ________ is a standardized assessment of consumer perspectives regarding healthcare access and quality in hospitals. a. HCAHPS b. CG-CAHPS c. AHRQ-CAHPS d. ONC-CAHPS - CORRECT ANSWER a. HCAHPS Which of the following is not a statistical technique used to create a model to assess the probability that current Medicare claims are fraudulent? a. Logistic regression b. Cluster analysis c. Decision trees d. Database warehousing - CORRECT ANSWER d. Database warehousing In which phase of the systems development life cycle does initial training on a new information system generally occur? a. Analysis b. Design c. Implementation d. Maintenance and evaluation - CORRECT ANSWER c. Implementation An evaluation of the benefits that have accrued from the EHR investment that is performed at specific milestones in the life of the project and used to help in future systems planning, designing, and implementing is called a: a. Benefits realization study b. Goal-setting exercise c. Cost-benefit feasibility study d. Productivity improvement study - CORRECT ANSWER a. Benefits realization study What technology creates images of paper documents that can be incorporated into an electronic health record? a. Clinical data repository b. Data exchange standards c. Central processor d. Document scanner - CORRECT ANSWER d. Document scanner The distribution in this curve is: a. Normal b. Bimodal c. Skewed left d. Skewed right - CORRECT ANSWER d. Skewed right Skewness is the horizontal stretching of a frequency distribution to one side or the other so that one tail is longer than the other. The direction of skewness is on the side of the long tail. Thus, if the longer tail is on the right, the curve is skewed to the right. If the longer tail is on the left, the curve is skewed to the left (Horton 2017, 234). The following graph of data security breaches shows a range of breaches from year one (YR-1) to year seven (YR-7). In year four (YR-4), a law came into effect for the mandatory reporting of security breaches. Given this information, which of the following is the best interpretation of the graph? a. Between YR-2 and YR-3, there were very few data security breaches. b. Security breaches were less prevalent from YR-4 to YR-7. c. The volume of security breaches cannot be adequately estimated prior to YR-4. d. In YR-4 there were more security breaches than YR-7. - CORRECT ANSWER c. The volume of security breaches cannot be adequately estimated prior to YR-4. 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 a. Prevalence The patient accounting department at Wildcat Hospital is concerned because last night's bill drop contained half the usual number of inpatient cases. Which of the following reports will be most useful in determining the reason for the low volume of bills? a. Accounts receivable aging report b. Discharged, no final bill report c. Case-mix index report d. Discharge summary report - CORRECT ANSWER b. Discharged, no final bill report Which of the following is the goal of an MPI ongoing maintenance program? a. To maintain low creation rates for duplicates, overlaps, and overlays b. To maintain the readmission rate for the facility c. To carry out treatment, payment, and operations d. To ensure appropriate state regulations of insurance and health plans - CORRECT ANSWER a. To maintain low creation rates for duplicates, overlaps, and overlays A research instrument that is used to gather data and information from respondents in a uniform manner through the administration of a predefined and structured set of questions and possible responses is called a(n): a. Survey b. Interview c. Process measure d. Affinity diagram - CORRECT ANSWER a. Survey What is an advantage of the unit numbering system? a. All records for a specific patient, both inpatient and outpatient, are kept together. b. The charts have to be split into volumes for filing. c. The hospital can accommodate a large outpatient clinic with many return visits. d. Joint Commission approval is automatic because all parts of the record are filed together. - CORRECT ANSWER a. All records for a specific patient, both inpatient and outpatient, are kept together. The process of recouping lost data or reconciling conflicting data after a system failure is called: a. Data backup b. Data mapping c. Data recovery d. Data warehouse - CORRECT ANSWER c. Data recovery Which of the following is an example of an e-health application? a. Bedside nursing care b. Appointment scheduling c. Direct patient care d. Emergency care records - CORRECT ANSWER b. Appointment scheduling All of the following are necessary to maintain an accurate MPI in an EHR environment except: a. Standardizing registration procedures b. Training all registration staff c. Identifying registration entry points d. Assigning registry accession numbers - CORRECT ANSWER d. Assigning registry accession numbers This EHR implementation strategy stops its paper processing immediately after the go-live of the system. a. Phased roll-out b. Big bang roll-out c. Pilot d. Straight turnover - CORRECT ANSWER d. Straight turnover In addition to bar codes on health record documents, what other forms of recognition characteristics enhance the accuracy of form indexing features? a. Access controls b. COLD c. OCR d. Workflow - CORRECT ANSWER c. OCR (optical character recognition) In analyzing the reason for changes in a hospital's Medicare case-mix index over time, the analyst should start with which of the following levels of detail? a. Account level b. MS-DRG level c. MDC level d. MS-DRG triples, pairs, and singles - CORRECT ANSWER d. MS-DRG triples, pairs, and singles Community Hospital just added a new system that changed the way data move throughout the facility. Which of the following would need to be updated to reflect this change? a. Data dictionary b. Entity relationship diagram c. Data flow diagram d. Semantic object model - CORRECT ANSWER c. Data flow diagram The process of preventing the spread of communicable diseases in compliance with applicable legal requirements is performed in this quality management function. a. Infection control b. Clinical quality assessment c. Utilization management d. Risk management - CORRECT ANSWER a. Infection control In this EHR implementation strategy, virtually every nursing unit, department, clinic, or other organizational unit goes live at the same time with a given component of the EHR. a. Phased roll-out b. Big bang roll-out c. Pilot d. Straight turnover - CORRECT ANSWER b. Big bang roll-out This type of chart is used to focus attention on any variation in a process and helps the team to determine whether that variation is normal or a result of special circumstances. a. Pareto chart b. Pie chart c. Control chart d. Line chart - CORRECT ANSWER c. Control chart Providers who do not implement an EHR will eventually be penalized through: a. Reduction in Medicare payments b. Reduction in amount of reimbursement from private insurance programs c. Increased administrative costs to process claims d. Restrictions from providing some patient care services - CORRECT ANSWER a. Reduction in Medicare payments The following table shows the LOS for a sample of 11 discharged patients. Using the data listed, calculate the range. Patient Length of Stay 1 1 2 3 3 5 4 3 5 2 6 29 7 3 8 4 9 2 10 1 11 2 a. 29 b. 1 c. 5 d. 28 - CORRECT ANSWER d. 28 The surgery department is evaluating its postoperative infection rate of 6 percent. The chief of surgery asks the quality improvement coordinator to find the postoperation infection rates of 10 similar hospitals in the same geographic region to see how the rates compare. This process is called: a. Benchmarking b. Critical pathway analysis c. Internal comparisons d. Universal precautions - CORRECT ANSWER a. Benchmarking In which type of health information exchange architectural model does the entity operate much like an application service provider (ASP) or bank vault? a. Consolidated b. Federated—consistent databases c. Federated—inconsistent databases d. Switch - CORRECT ANSWER b. Federated—consistent databases This type of data display tool is used to illustrate frequency distributions of continuous variables, such as age or length of stay (LOS). a. Bar graph b. Histogram c. Pie chart d. Scatter diagram - CORRECT ANSWER b. Histogram A ________ is a range of values, such that the probability of that range covering the true value of a parameter is a set probability or confidence. a. Confidence interval b. Hypothesis c. Proportion d. Median - CORRECT ANSWER a. Confidence interval The computer abstracting system in a facility has an edit that does not allow coders to assign obstetrical codes to male patients. This edit is called a(n): a. Preventive control b. Feedback control c. Performance measure d. Audit trail - CORRECT ANSWER a. Preventive control This EHR turnover strategy continues with its paper processing until the EHR works as planned. a. Parallel processing b. Phased roll-out c. Pilot d. Straight turnover - CORRECT ANSWER a. Parallel processing A technique that describes an interaction between a user and a system is called a(n): a. Use case analysis b. RHIO c. Test case d. Use description - CORRECT ANSWER a. Use case analysis A measure of variability that describes the deviation from the mean of a frequency distribution in the original units of measurement is called the: a. Mean b. Mode c. Standard deviation d. Standard variance - CORRECT ANSWER c. Standard deviation 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 c. It is based on the whole distribution. An EKG tracing is an example of ________ data. a. Structured b. Bit-mapped c. Free text d. Vector graphic - CORRECT ANSWER d. Vector graphic If a health plan analyst wanted to determine if the readmission rates for two hospitals were statistically different, what is the null hypothesis? a. The readmission rates are not equal. b. The readmission rates are equal. c. The readmission rate for one hospital is larger than the other. d. The readmission rate for one hospital is smaller than the other. - CORRECT ANSWER b. The readmission rates are equal. A healthcare entity remains committed to purchasing a vendor's product, which the entity finds solid in its financial and administrative applications but weaker in clinical applications. What is the term for this strategy? a. Bridge b. Best-of-fit c. Best-of-breed d. Legacy - CORRECT ANSWER b. Best-of-fit The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies would be most likely to correct this problem in the long term? a. Focused reviews on changes in MS-DRGs b. Facility top 10 to 15 DRGs by volume and charges c. Contracting with a larger consulting firm to do audits and education d. Development and implementation of a CDI program - CORRECT ANSWER d. Development and implementation of a CDI program The process in which a healthcare entity addresses the provider documentation issues of legibility, completeness, clarity, consistency, and precision is called: a. Query process b. Release of information process c. Coding process d. Case-finding process - CORRECT ANSWER a. Query process Nurse Joan is working in the ICU at University Hospital. She is carrying out Dr. Jones's order for a medication prescribed to one of her patients. She has received the medication and is preparing to administer it to the patient. Upon entering the patient's room, she asks the patient their name and date of birth and compares this information to the label on the medication. Joan then administers the medication to the patient. This scenario is an example of: a. Improving communication between hospital staff b. Preventing wrong-patient mistakes that can be made in surgery c. Using two patient identifiers to verify patient identity d. Identifying patient safety risks - CORRECT ANSWER c. Using two patient identifiers to verify patient identity You are the coding manager and are completing a review of a new coder's work. The case facts are that the patient was admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. The new coder sequenced the principal diagnosis as liver carcinoma. Which of the following would be the correct principal diagnosis? a. Liver carcinoma b. Admission for chemotherapy c. Dehydration d. Complication of chemotherapy - CORRECT ANSWER c. Dehydration Medicaid coverage is not identical in New Jersey, California, and Idaho. Which of the following reasons is correct? a. Federal funds allocated to each state are based on the size of the state. b. The program must cover infants born to Medicaid-eligible pregnant women. c. States that offer an SCHIP program do not have a Medicaid program. d. Medicaid allows states to maintain a unique program adapted to state residents' needs and average incomes. - CORRECT ANSWER d. Medicaid allows states to maintain a unique program adapted to state residents' needs and average incomes. In performing an internal audit for coding compliance, which of the following would be suitable case selections for auditing? a. Infrequent diagnosis and procedure codes b. Medical and surgical MS-DRGs by low dollar and low volume c. Medical and surgical MS-DRGs by high dollar and high volume d. Low-volume admission diagnoses - CORRECT ANSWER c. Medical and surgical MS-DRGs by high dollar and high volume It is the year 201X. The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? a. Conversion factor b. RVU c. GPCI d. Weighted discount - CORRECT ANSWER a. Conversion factor Reviewing claims to ensure appropriate coding for deserved payments is one method of: a. Achieving legitimate optimization b. Improving documentation c. Ensuring compliance d. Using data monitors - CORRECT ANSWER a. Achieving legitimate optimization From the figure, determine whether the plan covers Gill F. White, Jane's spouse. ABC Premiere Health PlanMEMBERPOLICY NUMBERJANE B.WHITE HS 123456 7890GROUPSTATETYPEEFFEC 01012005EMPLOYEE-ONLYSEND ALL BILLS TO:ABC Premiere Health Plan1500 Primrose PathFlowerville, XX 12345 a. No, the card states "Employee-Only" b. Yes, the policy number includes "S" c. Yes, the group is "State" d. Cannot be determined - CORRECT ANSWER a. No, the card states "Employee-Only" You are the coding manager and are completing a review of a new coder's work. The case facts are that the patient was treated in the emergency department for two forearm lacerations that were both repaired with simple closure. The new coder assigned one CPT code for the largest laceration. Which of the following would be the correct CPT code assignment for this case? a. One CPT code for the largest laceration b. Two CPT codes, one for each laceration c. One CPT code adding the lengths of the lacerations together d. One CPT code for the most complex closure - CORRECT ANSWER c. One CPT code adding the lengths of the lacerations together Which of the following is used to reconcile accounts in the patient accounting department? a. Explanation of benefits b. Medicare code editor c. Preauthorization form d. Fee schedule - CORRECT ANSWER a. Explanation of benefits In the claims reconciliation process, the healthcare facility uses the explanation of benefits, Medicare Summary Notice, and the remittance advice to reconcile accounts (Casto 2018, 240). In a typical acute-care setting, aging of accounts reports are monitored in which revenue cycle area? a. Preclaims submission b. Claims processing c. Accounts receivable d. Claims reconciliation or collections - CORRECT ANSWER c. Accounts receivable An internal coding audit at Community Hospital shows that the cause of improper coding is lack of proper physician documentation to support reimbursement at the appropriate level. Coders have found that coding issues result because physician documentation needs clarification. The HIM department staff has met periodically with each clinical specialty to improve communication and provide targeted education, but documentation problems still persist. Which of the following actions would be the most reliable and consistent method to improve communication and documentation? a. Revise medical staff bylaws to include documentation requirements. b. Suspend medical staff privileges after a specified number of documentation problems have occurred. c. Implement a standardized physician query form so that coders can request clarification from physicians about documentation issues. d. Allow coders to make clinical judgments in the absence of physician documentation. - CORRECT ANSWER c. Implement a standardized physician query form so that coders can request clarification from physicians about documentation issues. 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 the attending physician and ask him to validate a diagnosis based on the chest x-ray results Which of the following requires financial institutions to develop written medical identity theft programs? a. HIPAA Security Rule b. HITECH Act c. Fair and Accurate Credit Transactions Act d. HIPAA Privacy and Security Rule - CORRECT ANSWER c. Fair and Accurate Credit Transactions Act The following are the most common reasons for claim denials except: a. Billing noncovered services b. Lack of medical necessity c. Beneficiary not covered d. Coverage not in effect for date of service - CORRECT ANSWER d. Coverage not in effect for date of service Which of the following is an example of internal medical identity theft? a. Sue in her role as a patient registration clerk uses a patient's insurance information to see a specialist for cosmetic surgery. b. Joe uses a patient's information obtained through hacking the healthcare facility system. c. Joan, an ICU nurse accesses the record of the patient she is currently treating. d. Bob introduces a virus into the facility's health information system. - CORRECT ANSWER a. Sue in her role as a patient registration clerk uses a patient's insurance information to see a specialist for cosmetic surgery. A patient is admitted to the hospital with shortness of breath and congestive heart failure. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? a. Code congestive heart failure, respiratory failure, mechanical ventilation, and intubation b. Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis c. Query the attending physician about the adding the symptom of shortness of breath as a secondary diagnosis d. Code shortness of breath, congestive heart failure, mechanical ventilation, and intubation - CORRECT ANSWER b. Query the attending physician as to the reason for the intubation and mechanical ventilation to add as a secondary diagnosis Automated review efforts of recovery audit contractors (RAC) allow them to deny payments without ever reviewing a health record based on the information they gather without having access to the record. Which of the following would be an example of a potential denial based on information the RAC contractor would have without the health record? a. A coder assigning the wrong DRG for a patient b. Billing for two colonoscopies on the same day for the same Medicare beneficiary c. An inaccurate principal diagnosis d. A principal procedure code - CORRECT ANSWER b. Billing for two colonoscopies on the same day for the same Medicare beneficiary The health record review process and what other aspect allow for the highest level of quality in clinical documentation? a. Training on the revenue cycle b. Medical necessity c. Training on basics of coding d. Physician queries - CORRECT ANSWER d. Physician queries 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 b. MSN The lead coder in the HIM department is an acknowledged coding expert and is the go-to person in the healthcare entity for coding guidance. As the HIM director you learn that she is not following proper coding guidelines and her coding practices are not compliant. As the HIM director, the best steps to take would be which of the following? a. Report to the coder to the OIG and terminate the coder b. Notify the compliance officer and suspend the employee c. Review the coding errors and counsel the employee d. Ignore the coding errors - CORRECT ANSWER c. Review the coding errors and counsel the employee Which of the following statements about new technology items included on the charge description master (CDM) is false? a. The CDM maintenance committee should review new technology items for FDA approval. b. The CDM maintenance committee should review new technology items for OPPS pass-through assignment. c. The CDM maintenance committee should have a professional coder review code assignments even if codes are suggested by the manufacturer. d. The codes for new technology should not be included in the CDM until coverage has been determined. - CORRECT ANSWER d. The codes for new technology should not be included in the CDM until coverage has been determined. Which of the following items are packaged under the Medicare hospital outpatient prospective payment system (OPPS)? a. Recovery room and medical visits b. Medical visits and supplies (other than pass-through) c. Anesthesia and ambulance services d. Supplies (other than pass-through) and recovery room - CORRECT ANSWER d. Supplies (other than pass-through) and recovery room What is it called when accrediting bodies such as the Joint Commission can survey facilities for compliance with the Medicare Conditions of Participation for hospitals instead of the government? a. Deemed status b. Judicial decision c. Subpoena d. Credentialing - CORRECT ANSWER a. Deemed status Which of the following is the principal goal of internal auditing programs for billing and coding? a. Increase revenues b. Protect providers from sanctions or fines c. Improve patient care d. Limit unnecessary changes to the chargemaster - CORRECT ANSWER b. Protect providers from sanctions or fines 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 b. Based on principal diagnosis The universal protocol requires a "time-out" prior to the start of any surgical or invasive procedure to conduct a verification of: a. Patient and procedure b. Patient, procedure, and site c. Surgeon and site d. Surgeon, patient, and site - CORRECT ANSWER b. Patient, procedure, and site Which of the following organizations developed a set of National Patient Safety Goals (NPSGs) that all institutions participating in accreditation must promote and to which their staffs providing care must be trained to adhere?. a. American Hospital Association b. Joint Commission c. American College of Surgeons d. Institute of Medicine - CORRECT ANSWER b. Joint Commission With what agency may patients file a complaint if they suspect medical identity theft violations? a. Internal Revenue Service b. Office of Civil Rights c. Centers for Medicare and Medicaid Services d. Federal Trade Commission - CORRECT ANSWER d. Federal Trade Commission In a typical acute-care setting, the explanation of benefits, Medicare summary notice, and remittance advice documents (provided by the payer) are monitored in which revenue cycle area? a. Preclaims submission b. Claims processing c. Accounts receivable d. Claims reconciliation and collections - CORRECT ANSWER d. Claims reconciliation and collections The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit - CORRECT ANSWER b. Focused audit The discharged, not final billed report (also known as discharged, no final bill or accounts not selected for billing or DNFB) includes what types of accounts? a. Accounts that have been discharged and have not been billed for a variety of reasons b. Only discharged inpatient accounts awaiting generation of the bill c. Only uncoded patient records d. Accounts that are within the system hold days and not eligible to be billed - CORRECT ANSWER a. Accounts that have been discharged and have not been billed for a variety of reasons 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 d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service. Which Joint Commission survey methodology involves an evaluation that follows the hospital experiences of current patients? a. Priority focus review b. Periodic performance review c. Tracer methodology d. Performance improvement - CORRECT ANSWER c. Tracer methodology According to the Joint Commission, the unanticipated death of a full-term infant should be reported as a(n): a. Sentinel event b. Violation of clinical practice guideline c. Unfortunate accident d. Medical accident - CORRECT ANSWER a. Sentinel event Anywhere Hospital is implementing a new clinical documentation improvement (CDI) program. As part of the program, the clinical staff is educated on the components and procedures of the program. Which of the following would not be true about the CDI program? a. The need for postdischarge queries will be eliminated. b. Physicians will be consulted about nonspecific documentation while patients are still in-house. c. Effective communication between clinical staff and CDI specialist is vital. d. CDI reviewers will be on the inpatient units to review clinical documentation concurrently. - CORRECT ANSWER a. The need for postdischarge queries will be eliminated. Which of the following is a governmental designation by the state that is necessary for the facility to offer services? a. Survey b. Licensure c. Certification d. Accreditation - CORRECT ANSWER b. Licensure From the figure, determine which entity that has purchased the insurance policy. ABC Premiere Health PlanMEMBERPOLICY NUMBERJANE B.WHITE HS 123456 7890GROUPSTATETYPEEFFEC 01012005EMPLOYEE-ONLYSEND ALL BILLS TO:ABC Premiere Health Plan1500 Primrose PathFlowerville, XX 12345 a. 1234567890 b. STATE c. ABC Premiere Health Plan d. Jane B. White - CORRECT ANSWER b. STATE An outcome of coding audit reviews may be any of the following except: a. Coding documentation issues that prevent the coders from performing comprehensive coding are identified b. Redundant codes on the claims are identified c. Cases where excellent penmanship created challenges for the coders are identified d. Areas where coding could be improved if a physician was queried are identified - CORRECT ANSWER c. Cases where excellent penmanship created challenges for the coders are identified A Joint Commission accredited organization must review their formulary annually to ensure a medication's continued: a. Safety and dose b. Efficiency and efficacy c. Efficacy and safety d. Dose and efficiency - CORRECT ANSWER c. Efficacy and safety To meet the definition of an inpatient rehabilitation facility (IRF), facilities must have an inpatient population with at least a specified percentage of patients with certain conditions. Which of the following conditions is counted in the definition? a. Brain injury b. Chronic myelogenous leukemia c. Acute myocardial infarction d. Cancer - CORRECT ANSWER a. Brain injury Which of the following is a characteristic of an organized medical staff as recognized by the Joint Commission? a. Peer review activities are optional unless requested by a physician. b. Fully licensed physicians are permitted by law to provide patient care services. c. Delineation of clinical privileges is not necessary. d. The medical staff is not subject to medical staff bylaws or rules, regulations, and policies, and is subject to their professional code of ethics. - CORRECT ANSWER b. Fully licensed physicians are permitted by law to provide patient care services. The purpose of this program is to reduce improper Medicare payments and prevent future improper payments made on claims of healthcare services: a. Medicare provider analysis and review b. Recovery audit contractors c. Medicare Conditions of Participation d. Health Insurance Portability and Accountability Act - CORRECT ANSWER b. Recovery audit contractors Which of the following elements is found in a charge description master? a. ICD-10-CM code b. Procedure or service charge c. Patient disposition d. Procedural service date - CORRECT ANSWER b. Procedure or service charge 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 c. Health information management Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? Physician's normal charge = $340 Medicare Fee Schedule = $300 Patient has met his deductible a. $228 b. $240 c. $285 d. $300 - CORRECT ANSWER a. $228 Nonparticipating providers (nonPARs) do not sign a participation agreement with Medicare but may or may not accept assignment. If the nonPAR physician elects to accept assignment, he or she is paid 95 percent (5 percent less than participating physicians) of the Medicare fee schedule (MFS). For example, if the MFS amount is $200, the PAR provider receives $160 (80 percent of $200), but the nonPAR provider receives only $152 (95 percent of $160). In this case the physician is nonparticipating so he or she will receive 95 percent of the 80 percent of the MFS or 80 percent of 300, which is $240; 95 percent of the $240 is $228 (Casto 2018, 144, 320-321). During a recent coding audit, the coding manager identified the following error made by a coder. The coder assigned the following codes for a female patient who was admitted for stress incontinence and a urethral suspension without mesh was performed: N39.3 Stress incontinence (female) (male) 0TUD0JZ Urethral suspension What error was made by the coder? N23 Unspecified renal colic N39.3 Stress incontinence (female) (male) R32 Unspecified urinary incontinence SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalUrinarySystemRepositionUrethraOpenNo DeviceNo Qualifier 0TSD0ZZ SectionBody SystemRootOperationBody PartApproachDeviceQualifierMedical andSurgicalUrinarySystemSupplementUrethraOpenSyntheticSubstituteNo Qualifier 0TUD0JZ a. The coder assigned the correct diagnosis and procedure codes. b. The coder assigned the correct diagnosis code but assigned the incorrect root operation for the procedure. c. The coder assigned the correct procedure code but the incorrect diagnosis code. d. The coder assigned the correct diagnosis code but selected the incorrect device character for the procedure code. - CORRECT ANSWER b. The coder assigned the correct diagnosis code but assigned the incorrect root operation for the procedure. Charges for items that must be reported separately but are used together, such as interventional radiology imaging and injection procedures are called: a. Insurance code mappings b. Charge codes c. Exploding charges d. Revenue Codes - CORRECT ANSWER c. Exploding charges 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 c. Work value and practice expenses 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 2018, 143-144). The following are the most common reasons for claim denials except ________. a. Billing noncovered services b. Lack of medical necessity c. Beneficiary not covered d. Coverage not in effect for date of service - CORRECT ANSWER d. Coverage not in effect for date of service The accounts receivable collection cycle involves the time from: a. Discharge to receipt of the money b. Admission to billing the account c. Admission to deposit in the bank d. Billing of the account to deposit in the bank - CORRECT ANSWER c. Admission to deposit in the bank Bob Smith was admitted to Mercy Hospital on June 21. The physical was completed on June 23. According to CMS Conditions of Participation, which statement applies to this situation? a. The record is not in compliance as the physical exam must be completed within 24 hours of admission. b. The record is not in compliance as the physical exam must be completed within 48 hours of admission. c. The record is in compliance as the physical exam must be completed within 48 hours. d. The record is in compliance as the physical exam was completed within 72 hours of admission. - CORRECT ANSWER a. The record is not in compliance as the physical exam must be completed within 24 hours of admission. The coder assigned separate codes for individual tests when a combination code exists. This is an example of which of the following? a. Upcoding b. Complex coding c. Query d. Unbundling - CORRECT ANSWER d. Unbundling In the APC system, a high-cost outlier payment is paid when which of the following occurs? a. The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount. b. The LOS is greater than expected. c. The charges for the services provided are greater than the expected payment. d. The total cost of all the services is greater than the sum of APC payments by a fixed ratio and exceeds the sum of APC payments plus a threshold amount. - CORRECT ANSWER a. The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount Long-term care hospitals must meet state requirements for ________ and have an agreement with ________ in order to receive payments. a. Acute care hospitals, Medicare b. Medicare, acute care hospitals c. Fiscal intermediaries, Medicare d. Medicare, fiscal intermediaries - CORRECT ANSWER a. Acute care hospitals, Medicare A quality data review that is based on specific problems after an initial baseline review that has been completed in a hospital is called a(n): a. Focused inpatient review b. Compliance initiative c. Internal audit d. Concurrent review - CORRECT ANSWER a. Focused inpatient review A health information professional is preparing a bill for a patient who has two different third-party payers. Verification of the payers has been performed. Before either of the payers can be billed, the health information professional has to: a. Contact the attending physician b. Contact the patient c. Determine which policy is primary and which is secondary d. Determine who is the primary policy holder - CORRECT ANSWER c. Determine which policy is primary and which is secondary Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? a. Request that the CEO write a memorandum to all hospital staff b. Give the chairperson of the CDI committee authority to fire employees who do not improve their clinical documentation c. Include ancillary clinical staff and medical staff in the process d. Request a letter of support from the Joint Commission - CORRECT ANSWER c. Include ancillary clinical staff and medical staff in the process In the HHPPS system, which home healthcare services are consolidated into a single payment to home health agencies? a. Home health aide visits, routine and nonroutine medical supplies, durable medical equipment b. Routine and nonroutine medical supplies, durable medical equipment, medical social services c. Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits d. Nursing and therapy services, durable medical equipment, medical social services - CORRECT ANSWER c. Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits A clinical documentation improvement (CDI) program facilitates accurate coding and helps coders avoid: a. NCCI edits b. Upcoding c. Coding without a completed face sheet d. Assumption coding - CORRECT ANSWER d. Assumption coding 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 d. Write off the failed charges to bad debt and bill Medicare for the clean charges City Hospital's revenue cycle management (RCM) team has established the following benchmarks: (1) The value of discharged not final billed cases should not exceed two days of average daily revenue, and (2) AR days are not to exceed 60 days. The net average daily revenue is $1,000,000. What do the following data indicate about how City Hospital is meeting its benchmarks? a. DNFB cases met the benchmark 100 percent of the time. b. DNFB cases met the benchmark 75 percent of the time. c. DNFB cases met the benchmark 50 percent of the time. d. DNFB cases met the benchmark 25 percent of the time. - CORRECT ANSWER c. DNFB cases met the benchmark 50 percent of the time.