RHIA Mock Exam Practice 138 Questions with Verified Answers,100% CORRECT

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RHIA Mock Exam Practice 138 Questions with Verified Answers Authorizations are always required for the use or disclosure of psychotherapy notes except in which of the following situations: - emp... loyee and employment-related activities - health insurance carrier -media-related activities -carry out payment, treatment and operations - CORRECT ANSWER carry out payment, treatment and operations Steve has submitted a written authorization to request a copy of his medical chart. However, Steve's psychiatrist has determined that access to his PHI might endanger his life or safety. What should the covered entity do concerning the request? -release requested information to Steve's legal guardian -confirm the psychiatrist decision and deny the request -release requested information to Steve -provide an appeals process to Steve for the denial - CORRECT ANSWER -provide an appeals process to Steve for the denial A health information technician wants to obtain a chronological list of all patients admitted to the facility during the third quarter with a diagnosis of appendicitis. Which database should the technician utilize? accession register (is a unique and irreplaceable official administrative document that establishes the museum's legal right of ownership) disease index (an alphabetical list of diseases with information about each condition, such as the CDC's Diseases & Conditions A-Z Index.) master patient index ( is a patient database used by healthcare organizations to maintain accurate medical data across its various departments.) patient register (is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes.) - CORRECT ANSWER patient register Which of the following organizations is responsible for developing standards and conducting investigations to determine compliance in matters related to occupational safety and health? COBRA (Consolidated Omnibus Budget Reconciliation Act. It gives employees the right to pay premiums for and keep the group health insurance) CMS DHHS ( a cabinet-level department of the U.S. federal government with the goal of protecting the health of all Americans and providing essential human services.) OSHA ( Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance.) - CORRECT ANSWER OSHA Warren, a 12 year old Boy Scout breaks his leg while hiking with the troop. Which type of facility might Warren's Boy Scout leader take him to for emergent treatment? Ambulatory care clinic (is an outpatient facility for medical, surgical and diagnostic procedures) non emergent situations Surgicenter General hospital Specialty hospital - CORRECT ANSWER General hospital Tristan Vo brings a lawsuit against Houston Hospital for damages done to his knee during surgery. What term best describes Tristan? bailiff attorney plaintiff defendant - CORRECT ANSWER plaintiff Which of the following is an example of a government agency that has an interest in the standardization of records and data collection? -Department of Health and Human Services (HHS) - the Joint Commission -American Medical Association (AMA) -American Health Information Management Association (AHIMA) - CORRECT ANSWER Department of Health and Human Services (HHS) The health record may be used for personal and nonpersonal reasons. Which is an example of personal use of the health record? -patient reviews record with provider for understanding of health status - health information professional assigns ICD-10-CM codes -employer reviews healthcare data to evaluate job injuries -accrediting agency reviews record to assure quality health care - CORRECT ANSWER -patient reviews record with provider for understanding of health status Place the following in terminal digit order: 01-34-54, 01-35-55, 02-05-49, 02-66-48 02-05-49, 01-34-54, 01-35-55, 02-66-48 02-66-48, 02-05-49, 01-34-54, 01-35-55 01-34-54, 01-35-55, 02-05-49, 02-66-48 02-66-48, 02-05-49, 01-35-55, 01-34-54 - CORRECT ANSWER 02-66-48, 02-05-49, 01-34-54, 01-35-55 As director of health information of a newly established acute-care facility, where would you expect to find directives concerning the minimum health record contents? - Benchmarks from area acute-care facilities -Medical record committee meeting minutes -The Joint Commission -Credential committee meeting minutes - CORRECT ANSWER The Joint Commission Upon discharge analysis of a patient's record, the analyst does not see a discharge order written by the physician. What can the analyst assume? the family members requested hospice care the patient left against medical advice the patient will continue treatment on an outpatient basis the patient died prior to discharge - CORRECT ANSWER the patient left against medical advice The Hill-Burton Act of 1946: assured the provision of health care for the indigent. (ACA) provided health care to Americans 65 years of age and older (Medicare) enacted legislation funding the construction of hospitals and other healthcare facilities. established the retrospective payment system. - CORRECT ANSWER enacted legislation funding the construction of hospitals and other healthcare facilities. Dr. Thomas made an error in recording the progress notes in a patient's medical record. What is the first thing he should do to correct the error? draw a single line through the error obliterate the error and enter correct entry remove the page on which he made the error tell the nursing staff to ignore the statement - CORRECT ANSWER draw a single line through the error A patient is hospitalized for less than 48 hours. Which of the following is permissible in lieu of a discharge summary? final diagnosis discharge order final progress note discharge diagnosis - CORRECT ANSWER final progress note Who is responsible for developing bylaws governing physicians' completion of medical records? chief executive officer governing board chief of medicine medical staff - CORRECT ANSWER medical staff Which system avoids assigning a new number for each patient encounter? serial-unit numbering straight numerical serial numbering unit numbering - CORRECT ANSWER unit numbering By signing a consent for treatment, the patient agrees to: take all medications prescribed and dispensed by healthcare providers treatments and procedures to be performed by healthcare providers allow hospital to dispose of property and values in the case of death allow the hospital to release information to his or her insurance company - CORRECT ANSWER treatments and procedures to be performed by healthcare providers Reviewing the record to assure the presence of a discharge summary is referred to as: legal analysis ( refers to a statement by a court, judicial officer, or legal expert as to the legality or illegality of an action, condition, or intent.) quantitative analysis (analysis of a situation or event) documentation analysis ( a form of qualitative research in which documents are interpreted by the researcher to give voice and meaning around an assessment topic ) qualitative analysis ( documents are interpreted by the researcher to give voice and meaning around an assessment topic ) - CORRECT ANSWER quantitative analysis (analysis of a situation or event) A major advantage of the source-oriented medical record is the: strict chronology that keeps episode of care clearly defined by date ease with which healthcare providers can follow the course of one problem forms are designed to support numbering and tracking of problems speed at which individual sheets can be located - CORRECT ANSWER speed at which individual sheets can be located Which of the following would be most beneficial in locating a charged out medical record? master patient index requisition slip ( lists the items to be picked from inventory and used in the production process or in the provision of a service to a customer, Charge-out procedures should be followed regardless of who removes the medical record from the files, for what reason, or for how long. ) transfer notice outguide - CORRECT ANSWER requisition slip Which of the following filing systems would be most affected in the event of a divorce? family serial serial-unit unit - CORRECT ANSWER Family filing system A patient had an appendectomy due to appendicitis. This operative report must be completed when? within 15 days of discharge within 24 hours of surgery immediately after surgery within 48 hours of surgery - CORRECT ANSWER immediately after surgery A post-anesthesia note is required when? within 15 days of discharge within 24 hours of surgery within 48 hours of surgery immediately after surgery - CORRECT ANSWER within 24 hours of surgery A discharge summary: is not required when death occurs within 48 hours or less may be completed in lieu of a clinical resume is not required for a stay of 48 hours or less must be dictated and typed for ease of readability - CORRECT ANSWER is not required for a stay of 48 hours or less (CSR&I 108) A PEG tube would most likely be done to facilitate eating breathing urination none of the above - CORRECT ANSWER eating (CSR&I 11) A coder notes that a patient is taking prescription pilocarpine. The final diagnoses on the discharge summary are: congestive heart failure and diabetes mellitus. The code should query the physician about adding the diagnosis of laryngitis bronchitis arthritis glaucoma - CORRECT ANSWER laryngitis CSR&I 12) The patient is diagnosed with congestive heart failure. A drug of choice is digoxin oxytocin ibuprofen haloperidol - CORRECT ANSWER digoxin (CSR&I 4) A system of preferred terminology for naming disease processes is known as: classification system (grouping together of similar items) set of categories diagnosis listing medical nomenclature (preferred terminology) - CORRECT ANSWER medical nomenclature (CSR&I 41) A cancer program is surveyed for approval by the Joint Commission on Accreditation of Healthcare Organizations American Cancer Society State Department of Health Commission on Cancer of the American College of Surgeons - CORRECT ANSWER Commission on Cancer of the American College of Surgeons The transcription are has an opening for a transcriptionist with demonstrated skill in medical and surgical reports. Which of the following types of tests should be administered? aptitude ( determine a person's ability in a particular skill or field of knowledge) performance (skill) intelligence stress - CORRECT ANSWER performance (CSR&I 5) A patient who is taking the drug Antivert may have a diagnosis of arthritis dizziness (treats Vertigo) urinary tract infection congestive heart failure - CORRECT ANSWER dizziness (CSR&I 56) A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a master patient index disease index admissions register disease registry - CORRECT ANSWER disease registry (CSR&I 6) Which of the following is NOT included as a part of the minimum data maintained in the MPI? full name (last, first, and middle) patient medical record number date of birth principal diagnosis - CORRECT ANSWER principal diagnosis (HDC 10) As a new CTR you are interested in identifying every reportable case of cancer from the previous year. A key resource will be the facility's patient's index physician's index disease index number control index - CORRECT ANSWER disease index (HDC 11) Joint Commission requires the attending physician to countersign health record documentation that is entered by consulting physicians midwives interns or medical students physician partners - CORRECT ANSWER interns or medical students (HDC 3) A good first step toward protecting the security of data contained in a health information computer system would be to establish a good record tracking system define levels of security for different types of information, depending on sensitivity provide internet access to facility records provide remote terminals for improved access to the record - CORRECT ANSWER define levels of security for different types of information, depending on sensitivity (HDC 5) A risk manager needs to locate a full report of a patient's fall from his bed, including witness reports and probable reasons for the fall. She would most likely find this information in the doctor's progress notes nurse's notes incident report integrated progress notes - CORRECT ANSWER incident report As part of a quality improvement study you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of obstetrical records. The best place in the record to locate this information is the labor and delivery record discharge summary prenatal record postpartum record - CORRECT ANSWER prenatal record Before making recommendations to the Executive Committee regarding new physicians who have applied for active membership, the Credentials Committee must query the risk manager peer review organization Health Plan Employer Data and Information Set National Practitioner Data Bank - CORRECT ANSWER National Practitioner Data Bank Rules and principles determined by legislative bodies constitute which type of law? case law (the law as established by the outcome of former cases.) common law (derived from custom and judicial precedent rather than statutes) administrative law (law that regulates the operation and procedures of government agencies.) statutory law (written laws, usually enacted by a legislative body. ) - CORRECT ANSWER statutory law Your job description states that as Assistant Director of the Health Information Management Department, you will supervise day-to-day operations for the transcription, release of information, and coding areas. What principle of management is described? span of control delegation specialization centralized authority (organizational management structure where most of the major decision-making power and authority rests in the hands of a concentrated group of leaders) - CORRECT ANSWER span of control Gary's primary concern is providing food and housing for his large family. What level of Maslow's hierarchy of needs does Gary operate from? self-actualization ("the full realization of one's potential", and of one's "true self") physiological (survival needs like need for sleep, food, air, and reproduction.) esteem (needs refer to the need for respect, self-esteem, and self-confidence.) safety (need for security and protection) - CORRECT ANSWER physiological Under the ADA, prior to employment it is illegal to require a math aptitude test coding proficiency test typing skill test pre-employment physical exam - CORRECT ANSWER pre-employment physical exam Jason, an HIM director, plans to lecture on department design and the legislative act or agency that was created to ensure that workers have a safe and healthy work environment. He will describe which of the following? Wagner Act (stablished the National Labor Relations Board and addressed relations between unions and employers in the private sector.) Labor Management Relations Act ( United States federal law that restricts the activities and power of labor unions.) AKA Taft hartley act Taft-Hartley Law OSHA - CORRECT ANSWER OSHA Color coding of record folders is used to assist in the control of misfiles record tracking loose reports record completion - CORRECT ANSWER misfiles A new Health Information Department has purchased 200 units of 6-shelf files and plans to implement a terminal digit filing system. How many shelves should be allocated to each primary number? 10 6 12 8 - CORRECT ANSWER 12 If there is more than one patient with the identical last name, first name, and middle initial, the master patient index entries are then arranged according to social security number date of admission mother's maiden name date of birth - CORRECT ANSWER date of birth What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, 14-32-79? terminal digit social security number middle digit straight numeric - CORRECT ANSWER straight numeric If there are 150,000 records and the HIM Department receives 3,545 requests for records within a given period of time, what is the request rate? 2.4% (3545/150,000*100) 3.5% 5.1% 4.6% - CORRECT ANSWER 2.4% in a terminal digit filing system, what would be the record number immediately in front of number 01-06-26? 03-06-26 00-06-26 99-99-25 02-06-26 - CORRECT ANSWER 00-06-26 (IR&A 91) According to AHIMA's recommended retention standards, which one of the following types of health information does NOT need to be retained permanently? physician index register of surgical procedures register of births register of deaths - CORRECT ANSWER physician index (MB&RS 12) A computer software program that assigns appropriate MS-DRGs according to the information provided for each episode of care is called a(n) case-mix analyzer DRG creeper encoder grouper - CORRECT ANSWER grouper (MB&RS 16) Currently, payment to the physician for outpatient surgery performed on a Medicare patient is based upon which prospective payment system? MS-DRGs ASCs APGs RBRVS - CORRECT ANSWER ASCs How to calculate case mix index - CORRECT ANSWER Acute Inpatient PPS. This file contains hospitals case mix indexes (CMI) for discharges. A hospital's CMI represents the average diagnosis-related group (DRG) relative weight for that hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges. (MB&RS 24) All of the following elements are found in the charge description master, EXCEPT for narrative description HCPCS/CPT code ICD-9-CM code charge - CORRECT ANSWER ICD-9-CM code (MB&RS 3) __________ indicates that the claim has been released as complete for submission to the insurer for payment. Bill hold Accounts receivables Bill drop Concurrent review - CORRECT ANSWER (MB&RS 4) All of the following items are packaged under the Medicare outpatient prospective payment system, EXCEPT for recovery room anesthesia medical visits supplies - CORRECT ANSWER (MB&RS 60) There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by calling the physician's office leaving notes in the chart using physician query form emailing physician - CORRECT ANSWER using physician query form (MB&RS 65) Under APCs, payment status indicator "C" means significant procedure, discounted ancillary service inpatient procedure significant procedure, nondiscounted - CORRECT ANSWER (MB&RS 87) This accounting method attributes a dollar figure to every input required to provide a service. charge accounting reimbursement contractual allowance cost accounting - CORRECT ANSWER cost accounting The cause of aplastic anemia is chronic blood loss inadequate iron intake bone marrow failure acute blood loss - CORRECT ANSWER Each of the following pertains to COPD EXCEPT chronic bronchitis pneumonia smoking emphysema - CORRECT ANSWER A diagnostic test for meningitis usually involves stool C&S testing urine cerebrospinal fluid analysis blood cultures - CORRECT ANSWER cerebrospinal fluid analysis (O&M 11) In a filing system containing a total of 1,255 records, 48 records are identified as misfiles. What is the percentage of filing accuracy for this area? 26.14% 3.82% 96% 74% - CORRECT ANSWER 96% (O&M 16) Anna Claire is attending budget training for new supervisors. The representative from Finance explains that ________ costs will vary in direct proportion to changes in the volume of care provided. variable periodic semi-variable fixed - CORRECT ANSWER fixed (O&M 2) Strong lateral relationships within a facility are most likely when individual departments cooperate together to achieve organizational goals individual departments are only interested in their internal goals individual departments avoid one another vertical relationships are less than adequate - CORRECT ANSWER individual departments cooperate together to achieve organizational goals (O&M 32) In preparing a capital budget request, the first priority will be to document the cost of the new equipment where the new equipment will be located the specific type of equipment requested the need for the new equipment - CORRECT ANSWER (O&M 37) The most important consideration in planning the office layout for a HIS department is the types of furniture to be purchased workflow cost the number of employees - CORRECT ANSWER O&M 8) A rule is helpful to both managers and the employees in the decision-making process. A rule requires interpretation allows judgments to be made pre-decides issues provides the necessary details - CORRECT ANSWER (Q&PI 11) Most health care facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay. severity of illness/intensity of service criteria (SI/IS) Joint Commission defined and developed criteria HEDIS measures critical pathways - CORRECT ANSWER severity of illness/intensity of service criteria (SI/IS) (Q&PI 12) The process of comparing the outcomes of HIM abstracting functions at your facility with those of comparable departments of superior performance in other health care facilities to help improve accuracy and quality is referred to as focused review peer review occurrence screening benchmarking - CORRECT ANSWER benchmarking (Q&PI 13) With the passage of Medicare (Title XVIII of the Social Security Act) in 1965, which of the following functions became mandatory? risk management quality assessment quality improvement utilization review - CORRECT ANSWER utilization review (Q&PI 31) Joint Commission requires that medical record review by performed to evaluate adequacy, accuracy, completeness, and quality of documentation annually quarterly every 2 years on an ongoing basis - CORRECT ANSWER on an ongoing basis (Q&PI 32) Which of the following established legal liability for hospitals in 1965? Darling v. Charleston Community Memorial Hospital Health Care Financing Administration (HCFA) P.L. 92-603 Joint Commission - CORRECT ANSWER Darling v. Charleston Community Memorial Hospital A 16-year-old male was treated at your facility for a closed head injury. The patient's 18-year-old wife accompanied him to the hospital and signed the consent for admission and treatment because of the patient's incapacity at the time. The patient has requested that copies of his medical records be sent to his attorney. Who should sign the authorization to release the records? either of the patient's parents the patient's parent or legal guardian the patient's wife the patient - CORRECT ANSWER A 19 year old former patient faxes a request to your facility requesting the release of his medical records of all episodes of care to the Army. The release of informaiton clerk should send a letter informiong him that faxed requests are not accepted. inform the young man that specific reports must be identified in his request. send the records as requested. deny the request. - CORRECT ANSWER A __________ uses a private tunnel through the Internet as a transport medium between locations for secure access and transmission. VPN TCPIP protocol hub firewall - CORRECT ANSWER VPN A clerical level employee reports an incident in which the clerk felt the first-line supervisor discriminated on the basis of the clerk's gender. The best action for you to take at this time is to ask the clerk to provide objective evidence of the discrimination talk with the first-line supervisor to determine what happened thoroughly investigate the matter and document your findings ask the other clerical level staff if they had similar experiences - CORRECT ANSWER thoroughly investigate the matter and document your findings A common goal of the ONC for HIT, RHIO's and a national infrastructure for information is sharing information among providers transferring health information within a hospital system translating images into a digital format promoting telemedicine - CORRECT ANSWER sharing information among provider A patient initially consulted with Dr. Vince at the request of Dr. Matthews, the patient's primary care physician. Dr. Vince examined the patient, prescribed medication, and ordered tests. Additional visits to Dr. Vince's office for continuing care would be assigned from which E/M section? office and other outpatient services, established patient confirmatory consultations, new or established patient office or other outpatient consultations, new or established patient office and other outpatient services, new patient - CORRECT ANSWER office and other outpatient services, established patient A patient is admitted through the emergency department. Three days after admission, the physician documents uncontrolled diabetes mellitus. What is the "present on admission" (POA) indicator for uncontrolled diabetes mellitus? "W" "U" "Y" "N" - CORRECT ANSWER N A piece of objective data collected upon initial assessment of the patient is the chief complaint vital signs review of systems history of present illness - CORRECT ANSWER A section of a job description states that the incumbent will handle day-to-day operations in the transcription and ROI areas. This section defines the authority associated with the job skills required to perform the job scope of responsibility in the job time required for each function - CORRECT ANSWER scope of responsibility in the job A supervisor reviews a job to determine the required content, skils, knowledge, abilities and responsibilities for the position. The tasks are grouped and lines of responsibility and authority are defined. The supervisor is writing a job detail process description analysis - CORRECT ANSWER description A technique that uncovers new information from existing information by probing data sets is known as SQL data mining neural network analysis data warehousing - CORRECT ANSWER data mining A tool that is used to illustrate the various applications, support structures, and sequencing of implementation phases for a system is a PERTT diagram milestone chart migration path work flow diagram - CORRECT ANSWER A transcription unit has been asked to tally the number of times they have to leave sections of a report blank for various reasons (poor dictation technique, background noise, etc). The quality improvement tool most likely to help collect these data would be flowchart force field analysis check sheet decision matrix - CORRECT ANSWER A union campaign is being conducted at your facility. As a department manager, it is appropriate for you to tell employees that you are opposed to the union. wages will increase if the union is defeated. you need the names of those involved in union activities. a strike is inevitable if the union wins. - CORRECT ANSWER Access to radiologic images has been improved through the use of which of the following? PACS CPOE EDMS LOINC - CORRECT ANSWER PACS According to CPT, a biopsy of the breast that involves removal of only a portion of the lesion for pathologic examination is percutaneous incisional excisional punch - CORRECT ANSWER An effective means of protecting the security of computerized health information would be to install a system that would require fingerprint scanning and recognition for data access develop clear policies on data security that are supported by the top management of the facility require all facility employees to change their passwords at least once a month write detailed procedures for the entry of data into the computerized information systems - CORRECT ANSWER As supervisor of the cancer registry, you report the registry's annual caseload to administration. The most effecient way to retrieve this information would be to use accession register patient index patient abstracts follow-up files - CORRECT ANSWER As the Director of a HIT program, your community college has been selected to participate in the workforce development of EHR specialists as outlined by ARRA and HITECH. In order to keep abreast of changes in this program, you will need to regularly access the Web site of which governmental agency? OSHA ONC CMS CDC - CORRECT ANSWER ONC As the information security officer at your facility, you have been asked to provide examples of technical security safeguards adopted as a result of HIPAA legislation. Which of the following would you provide? evidence of security awareness training surge protectors workstation use and location audit controls - CORRECT ANSWER Authentication is one of the components necessary to produce a legal document in an EHR. This means identifying who created a document and when creating audit trails tracking changes in the EHR system establishing access controls for individual employees - CORRECT ANSWER Based on the information below, what was the net deah rate at Seaside Hospital in January? Seaside Hospital Selected Statistics (January) Admissions 280 Discharged to Home 212 Discharge Transfers 28 Death <48hours 8 Deaths >48 hours 6 2.8% 2.4% 3.8% 5.8% - CORRECT ANSWER (6 x 100)/(212 + 28+ 6)= 2.4% Collins Family Hospital had a bed count of 150 for the first 6 months of the year. On June 1, it added 15 beds when it opened a new wing. If you are given the average length of sta for the year, can you calculate the annual bed turnover rate? How? yes, using the direct method no, there is insufficient data to complete the calculation yes, using the Joint Commission method yes, using the indirect method - CORRECT ANSWER Encoding software was installed at your hospital 2 years ago. The coders are well trained on it and like using it. It functions well and only requires ICD code updates yearly. In terms of the Information System Life Cycle phases, the coding system is likely in the operation and maintenance phase design phase obsolescence or decline phase implementation phase - CORRECT ANSWER operation and maintenance phase Everyone in the HIM Department has been working overtime to complete a major record conversion. The supervisor will have to plan for overtime pay for all personnel who are not salaried nonexempt employees hourly employees temporary employees salaried exempt employees - CORRECT ANSWER In conducting an educational session for your staff about implementing a benchmarking program, you tell your staff that when an organization uses benchmarking, it is important to compare your facility's outcomes to nationally known facilities facilities within your corporation larger facilities facilities with superior performance - CORRECT ANSWER facilities with superior performance In order to perform their jobs, facility employees should have full and timely access only to the information they need to complete the task at hand. This is similar to HIPAA's provision for An informed consent a Notice of Privacy Practices (NOPP) Amending a record Accessing need to know information only - CORRECT ANSWER Accessing need to know information only In preparation for conversion to a computerized patient record, a committee at your facility is defining each of the data elements in a patient record to determine which elements should be required and to set parameters for each element. The committee is working on the data edits feasibility reasonableness dictionary - CORRECT ANSWER In reviewing a health record for coding purposes, the coder notes that the patient was put on Keflex post surgery. Thee is no mention of a postoperative complication in the attending physician's discharge summary. Before querying the doctor, the coder will seek to confirm the infection by reviewing the nurses' notes lab report operative report pathology report - CORRECT ANSWER In reviewing the policies on release of information in respect to the privacy rules, you note that it is still acceptable to allow release of protected health information without patient permission to a health care provider interested in the case the patient's spouse the quality assurance committee for review purposes a third-party payer with a direct interest in the case - CORRECT ANSWER the quality assurance committee for review purposes In the past, Joint Commission standards have focused on promoting the use of a facility approved abbreviation list to be used by hospital care providers. With the advent of the Commission's national patient safety goals, the focus has shifted to the use of prohibited or "dangerous" abbreviations. flagrant use of specialty-specific abbreviations prohibited use of any abbreviations. use of abbreviations used in the final diagnosis - CORRECT ANSWER use of prohibited or "dangerous" abbreviations. Joanie Howell presents to Dr. Franklin requesting rhinoplasty. Because Howell is covered by Medicare, Dr. Franklin must provide Howell with an ABN, because Howell's rhinoplasty may not be medically necessary a Notice of Exclusion, because rhinoplasty is not a Medicare covered service. an ABN, because rhinoplasty is not a Medicare covered service a Notice of Exclusion, because Howell's rhinoplasty may not be medically necessary. - CORRECT ANSWER an ABN, because Howell's rhinoplasty may not be medically necessary Many of the departments in your facility create and modify forms often. A major key to forms control in this setting is capturing every data item required by UHDDS consistent formatting of each page of each form providing instructions when necessary for appropriate data fields giving each form or view an identifiable name, number, and revision data - CORRECT ANSWER giving each form or view an identifiable name, number, and revision data Oryx is a program that was developed by Joint Commission to ink patient outcomes to accreditation NIH to track communicable diseases AMA to allow for rapid CPT updates CMS to track Medicare costs - CORRECT ANSWER Parker has type 1 diabetes with hypertension that is currently controlled with medication. Parker was admitted through the ED for an emergency appendectomy. Following surgery, the patient developed an infection at the wound stie that was treated with antibiotics. When making decision about sequencing the codes for this case, the coder should rely on definitions found in the UHDDS Coding Clinic Federal Registrar CMS Coding Guidelines - CORRECT ANSWER Part of your job description is to educate physicians regarding proper documentation policies and standards. You are the Information Security Manager Clinical Data Specialist Health Information Manager Risk Manager - CORRECT ANSWER Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be procedures and dates personal identification cognitive patterns principal diagnosis - CORRECT ANSWER Release of information has increased its use of part-time prn clerical support in order to respond to increased requests for release of information. The budget variance report will reflect both the increases in revenue and increased costs for clerical support in ROI the increase in revenue from increased volume in ROI but not the increased costs of part-time clerical support neither the increased costs nor increased revenue, as temporary changes are rarely reflected on variance reports the increase in the cost of part-time clerical support for ROI but not the increase in revenue from this area - CORRECT ANSWER Stage I of MU focuses on data capture and sharing. Which of the following is included in the menu set of objectives for eligible hospitals in this stage? Establish critical pathways for complex, high-dollar cases Appropriate use of HL7 standards Smoking cessation counseling for MI patients Use of CPOE for medication orders - CORRECT ANSWER Appropriate use of HL7 standards The CFO of your facility asks you to prepare a budget for the fiscal year based on the past volume and expected capacity for the coming year. This process is an example of using the "__________" budgeting method. flexible or statistics budget zero-based budget fixed budget rolling budget - CORRECT ANSWER The Chief of Staff, Chief of Medicine, President of the Governing Body, and most departmental managers have already completed CQI training. Unfortunately, the hospital administrator has not been to training, refuses to get involved with CQI, and refuses to et the administrative departmental staff get training. The Joint Commission only expects involvement from clinical staff If you can talk him into training his staff, you can let him skip the training This will not do because it violates Joint Commission standards and CQI philosophy This level of involvement is enough to meet Joint Commission standards - CORRECT ANSWER The Credentialing Committee discovered problems with Dr. Hernandez performing hip replacements by reviewing Dr. Hernandez's physician profile querying the National Physician Data Bank sampling and reviewing Dr. Hernandez's patient records interviewing the Chief of Surgery - CORRECT ANSWER The census taken at midnight on August 1 showed 99 patients remaining in the hospital. On August 2, four patients were admitted, there was one fetal death, one DOA, and seven patients were discharged. One of these patients was admitted in the morning and remained only 8 hours. How many inpatient service days were rendered on August 2? 94 97 95 96 - CORRECT ANSWER Remaining at midnight 8/1 99 Admissions +4 Discharges -7 In & out same day +1 Inpatient service days on 8/2 97 *Fetal deaths and DOA have NO impact on inpatient service days The coding supervisor tends to deal with issues as they come up, prioritizing only when problems are pressing or appear to be important to upper management. The supervisor is particularly weak in which management function? controlling planning organizing budgeting - CORRECT ANSWER The decision makers in the HIM department have decided to use the decision analysis matrix method to select coding software. Use of this method will help ensure all alternatives/vendors are evaluated subjectively the personalities of individual vendors will not influence the decision., consistent criteria are used to evaluate the alternatives/vendors the level of software support will be considered in the decision - CORRECT ANSWER consistent criteria are used to evaluate the alternatives/vendors The difference between the IRB and a hospital's Ethics Committee is that The Ethics Committee reviews ethics complaints and the IRB focuses on developing policies and procedures The IRB is made up entirely of patient care providers, and the Ethics Committee is multidisciplinary. the IRB focuses on patient care only and the Ethics Committee addresses both patient care and business practices. The IRB deals with the ethical treatment of human research subjects, and the Ethics Committee covers a wide range of issues. - CORRECT ANSWER The discharge diagnosis for this inpatient encounter is "rule out myocardial infarction." The coder would assign a code for the patient's symptoms. no code for this condition. a code for an impending myocardial infarction. a code for myocardial infarction. Code "rule out" as if it were a confirmed diagnosis. - CORRECT ANSWER The emergency department staff has complained that the clerical staff in your department is delaying stat reports. You decide to meet with your staff and develop a cause and effect diagram to determine possible reasons for the delay. You have explained the issue to your staff and have set up a blank cause & effect diagram. The next step is to discuss the importance of prompt delivery of stat reports brainstorm possible reasons for delays in deliverying the reports design a new system that will support prompt report delivery determine whether there are internal conflicts in the area - CORRECT ANSWER The most sophisticated level of interoperability of an EHR and other such systems is the __________ level. exchange functional basic semantic - CORRECT ANSWER semantic The purpose of the Correct Coding Initiative is to increase fines and penalties for bundling services into comprehensive CPT codes teach coders how to unbundle codes restrict Medicare reimbursement to hospitals for ancillary services detect and prevent payment for improperly coded services - CORRECT ANSWER detect and prevent payment for improperly coded services The use of public and private keys is part of what type of data protection? phishing biometrics firewalls encryption - CORRECT ANSWER When a patient is admitted because of a primary neoplasm with metastasis and treatment is directed toward the secondary neoplasm only, the primary neoplasm is coded as the principal diagnosis, and the secondary neoplasm is coded as an additional diagnosis. code only the primary neoplasm as the principal diagnosis. code only the secondary neoplasm as the principal diagnosis. the secondary diagnosis is coded as the principal diagnosis, and the primary neoplasm is coded as an additional diagnosis. - CORRECT ANSWER Which of the following are considered late effects regardless of time? congenital defect poisoning nonhealing fracture nonunion - CORRECT ANSWER Which of the following would be coded as a poisoning? Coumadin intoxication due to a cumulative effect. Idiosyncratic reaction to Artane. Intersection between Aldomet and a vasodilating agent. Reaction between Coumadin and an over-the-counter-medication. - CORRECT ANSWER You are a new supervisor in the HIM department and find it difficult to deal with performance issues. Laney, an employee in the ROI section has been late several times this month. She has already been given a verbal warning. She was late again today. According to the progressive discipline process, your next step will be to issue a written warning reinforce the institution's policies suspend the employee reissue the verbal warning - CORRECT ANSWER issue a written warning You are starting your new job as the sole HIM professional at a small psychiatric practice. The practice uses DSM for billing purposes. You find this "theoretically" reasonable because DSM codes are also valid ICD-10-CM codes is the industry standard for psychiatric billing systems codes are also valid CPT codes is a widely used and accepted classification system - CORRECT ANSWER You have been asked to reduce your department's operating budget by 20%. In order to do so, you will have to effect reductions in your largest budget line. You will have to make cuts in supplies contracts equipment personnel - CORRECT ANSWER personnel You supervise five clerical employeess who will be moving when a new wing of your facility is completed. When you meet with the architect to plan their space, you will ask for 250 square feet of space for your clerical staff. 350 square feet of space for your clerical staff. 200 square feet of space for your clerical staff. 300 square feet of space for your clerical staff. *You can't use Professor's Bond's approach of letting the administrative assistant "take care of this". Master every task of the Department. - CORRECT ANSWER 300 square feet of space for your clerical staff Your HIM Department is moving to a new location and in order to arrange your employees and functions for optimal work flow efficiency and to decide which employees need to be placed close to each other, the tool you decide to use is a PERT chart proximity chart or movement diagram data flow diagram flow process chart - CORRECT ANSWER our HMO manager has requested a report on the number of patient visits per year for preschool children. Which of the age groupings below will you use for your report? <12 months 12-24 months 25-37 months 38-50 months 51-63 months 0-2 years 3-4 years 5 years >12 months 12-24 months 25-37 months 38-50 months <51 months 0-1 year 1-2 years 2-3 years 3-4 years 4-5 years - CORRECT ANSWER 0-2 years 3-4 years 5 years Your facility has decided to purchase an integrated patient information system. Your part in the initial work plan is the develop system specifications that will ultimately be sent out to vendors who will potentially submit a bid on your system. You are working on the systems specs that will become part of the RFP CPR CRS IRB - CORRECT ANSWER Your facility is storing scanned records for long-term storage on optical disk. The Risk Management Committee's Disaster Task Force has recommended that copies of the disks be stored at a facility across town. The administrator is concerned that records may be altered on the disks stored off-site. You tell the administrator this is a legitimate concern; perhaps the committee should consider storing duplicates in two locations in this facility. this is not a concern; there is really no need to make and store duplicate disks as they are difficult to damage. this is not a concern because WORM technology makes it impossible to alter the documents. this is a legitimate concern; it should be addressed in the contract written with the storage facility. - CORRECT ANSWER this is a legitimate concern; perhaps the committee should consider storing duplicates in two locations in this facility. Your facility would like to improve physician documentation in order to allow improved coding. As coding supervisor, you have found it very effective to provide the physicians with regular in-service presentations on documentation, including its importance and tips for improvement the UHDDS and informaiton on where each data element is collected and/or verified in your facility feedback on specific instances where improved documentation would improve coding a copy of the facility coding guidelines, along with written informaiton on improved documentation - CORRECT ANSWER regular in-service presentations on documentation, including its importance and tips for improvement Your hospital has purchased a number of outpatient facilities. You have been assigned to chair an interdisciplinary committee that will write record retention policies for the new corporation. You begin by telling the committee their primary consideration when making retention decisions must be professional standards statutory requirements provider preferences space considerations - CORRECT ANSWER [Show More]

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