HIM final - Flashcards | StudyHippo.com

question

The HIM department is involved in the ____ process by making the health records of patients enrolled in a research study available to external monitors and auditors.

answer

IRB

question

Two providers bill for one service provided to one patient

answer

double billing

question

The first professional association for health information managers was established in:

answer

1928

question

The hospital standardization program was started by ___________________________.

answer

American College of Surgeons

question

The formal approval process for academic programs in health information management is called which of the following?

answer

Accreditation

question

Which of the following is the formal process for conferring a health information management credential?

answer

Certification

question

Which of the following is a traditional HIM role?

answer

Tracking record completion

question

Which of the following functions governs the HIM profession?

answer

AHIMA House of Delegates

question

Which of the following make up a virtual network of AHIMA members?

answer

AHIMA Engage

question

Which of the following is an arm of AHIMA that promotes research in health information management?

answer

AHIMA Foundation

question

Which of the following best describes the mission of the AHIMA?

answer

Community of professionals providing support to members and strengthening the industry and profession

question

Which professional organization sponsors the CTR certification?

answer

NCRA

question

Someone who wishes to sit for the Certified Professional Coder (CPC) certification should contact which organization?

answer

AAPC

question

In order to qualify for an AHIMA fellowship, what minimal educational level is needed?

answer

Master's degree

question

Which of the following qualify for CEUs?

answer

College course

question

Critique this statement: Once someone has earned the registered health information technician (RHIT) credential, it is a lifetime certification.

answer

This is incorrect as RHITs have to become recertified.

question

Which group is responsible for AHIMA's certification exams?

answer

CCHIIM

question

State College is applying for accreditation of the new HIM program. How long do they have to complete their candidacy?

answer

2 years

question

The two components of AHIMA's management structure are which of the following?

answer

Staff and volunteer

question

An RHIT who graduated from college 6 months ago is joining AHIMA for the first time. What membership is he or she qualified for?

answer

Active

question

Critique this statement: an RHIT must be at least 65 years old in order to qualify for emeritus membership.

answer

This is a true statement.

question

The requirement for an HIM professional to comply with all laws, regulations, and standards governing the practice of HIM is in the AHIMA _________.

answer

Code of Ethics

question

The accountability framework and decision rights to achieve enterprise information management is known as:

answer

Information governance

question

Prior to hospital standardization, health records were:

answer

essentially worthless

question

The number of charter members of the ARLNA was:

answer

58

question

To be recognized as a profession, which of the following did HIM need?

answer

Preliminary training

question

The emphasis on traditional practice of HIM was to ensure:

answer

complete and accurate health record

question

Who is responsible for communicating information relevant to national issues and keeping members informed of regional affairs that affect HIM?

answer

AHIMA Component state association

question

Which group brings together stakeholders to address issues related to the future of the HIM profession and education?

answer

Council for Excellence in Education

question

Which of the following activities is an information-oriented HIM function?

answer

Data manipulation

question

Which of the following is the accreditation organization for HIM programs?

answer

CAHIIM

question

Which of the following is true about the AHIMA certification program?

answer

Candidates must pass an examination before obtaining any of the credentials.

question

Which of the following classes of AHIMA membership requires that individuals have interest in HIM and will abide by the AHIMA code of ethics?

answer

Active membership

question

Which of the following entities are at the head of the AHIMA volunteer structure and hold responsibility for managing the property, affairs, and operations of AHIMA?

answer

Board of Directors

question

The accreditation program of AHIMA is concerned with which of the following?

answer

Establishing standards for the content of college programs in health information management

question

Which organization should be contacted regarding the certified healthcare documentation specialist exam?

answer

Association for Healthcare Documentation Integrity

question

Which of the following makes up a virtual network of AHIMA members who communicate via a web-based program managed by AHIMA?

answer

Engage

question

Which of the following carries out the operational tasks necessary to support the organization's mission and goals?

answer

Staff

question

Members of the AHIMA House of Delegates are:

answer

Elected by members in component state organizations

question

Who is responsible for final approval of the AHIMA Code of Ethics?

answer

AHIMA House of Delegates

question

The term used to describe controlling information is ______.

answer

Information governance

question

Which organization's goal is centered on health information technology?

answer

HIMSS

question

An RHIT is going back to earn her bachelor degree so that she can sit for the RHIA exam. What membership category is she qualified for?

answer

Active

question

A member of the AHIMA Board of Directors is which of the following?

answer

Elected

question

Which of the following is true about the AHIMA House of Delegates?

answer

They meet virtually throughout the year.

question

The AHIMA House of Delegates has power over which of the following?

answer

Amendments to AHIMA's bylaws

question

The role of the AHIMA chief executive officer is to:

answer

Manage the day-to-day operations

question

Where should new graduates begin their volunteer experience? Correct!

answer

CSA

question

Which step comes first in the accreditation process?

answer

Self-assessment

question

Sustained professional achievement is required by which of the following?

answer

Fellowship

question

AHIMA fellowship is conferred for:

answer

Life

question

Which of the following confers scholarships?

answer

AHIMA Foundation

question

Which of the following places an emphasis on treating individual patients at the level of care required by their course of treatment and extends from their primary care providers to specialists and ancillary providers?

answer

Continuum of care

question

As of 2014, what percent of the U.S. economy was represented by healthcare spending?

answer

17.5

question

What is the ideal ratio of medical generalist to specialist?

answer

40:60

question

Registered Nurses are only formally educated at the bachelor's degree.

answer

false

question

Which of the following is considered an Allied Health professional?

answer

Licensed Practical Nurses

question

Occupational Therapists are concerned with a patient's activities of daily living.

answer

true

question

Which of the following federal laws created Medicare and Medicaid?

answer

Public Law 89-97 of 1965

question

Medicare will pay the Medicaid premiums, deductibles, and coinsurance costs for some low-income Medicaid beneficiaries.

answer

false

question

What is the name of the process to determine whether medical care provided to a specific patient is necessary according to pre-established objective screening criteria at time frames specified.

answer

Utilization review

question

HITECH was a portion of which bill?

answer

American Recovery and Reinvestment Act of 2009

question

What is the name of the type of beds in a hospital that are defined by those authorized by the state?

answer

Licensed

question

To qualify as a Critical Access Hospital one of the criteria is to be located in a rural area.

answer

true

question

One of the functions of the board of directors is to approve the organization and makeup of the clinical staff.

answer

true

question

The "C" in CIO stands for:

answer

Chief

question

Health information management departments are considered which of the following?

answer

Ancillary Support Service

question

Hospital-owned group practices are considered ambulatory care organizations

answer

true

question

One group of patients that prefer treatment at urgent care centers are those whose insurance carriers treat urgent care centers preferentially when compared with physician offices.

answer

true

question

Which of the following is the fastest-growing sector to offer services for Medicare recipients?

answer

Home health

question

Rehabilitation hospitals are categorized as an acute care type of facility in treating patients.

answer

false

question

Which of the following is a main goal in treating hospice patients?

answer

Minimize the stress and trauma of death

question

Which of the following is the health profession that focuses on the eyes and related structures?

answer

Optometry

question

Public Law 89-97 of 1965 created a number of amendments to which Act?

answer

Social Security Act

question

The Office of the National Coordinator for Health Information Technology was created as part of which Act?

answer

American Recovery and Reinvestment Act

question

Who has the primary responsibility for setting the overall direction of the hospital?

answer

Board of directors

question

The medical staff operates according to a pre-determined set of policies called ___________.

answer

Medical staff bylaws

question

Managed care organizations deliver medical care and manage all aspects of patient care by limiting providers of care, discounting payments to providers of care, or limiting access to care.

answer

true

question

Two types of practitioners can hold the degree of Doctor of Medicine. They are:

answer

Physician and Surgeon

question

Which of the following is a surgical specialty?

answer

Anesthesiology

question

Nurse Practitioners often receive advanced training at the Masters level.

answer

true

question

Which of the following professionals is not mentioned in this text as requiring licensing by all 50 states?

answer

Health Information Management

question

Physical Therapists use work and play activities to improve patient's independent functioning, enhance their development, and prevent or decrease their level of disability.

answer

false

question

The Social Security Act of 1935 had a healthcare component added by the Republican president, Franklin D. Roosevelt.

answer

false

question

With the implementation of the Affordable Care Act, U.S. states were given the opportunity to expand Medicaid, though not all have done so.

answer

true

question

Which of the following persons were intended to be supported by Medicaid in Public Law 89-97 of 1965?

answer

Single-parent families

question

The average length of stay (LOS) for acute care hospitals is:

answer

25 days or less

question

The board of directors can also be called the board of trustees.

answer

true

question

What is the name given to the privileges assigned to physicians to provide clinical services in a hospital?

answer

Clinical

question

Traditionally physicians alone determine the timely and effective interventions in response to a wide range of problems related to a patient's treatment, comfort, and safety. Who else are playing a wider role in this function?

answer

Nurses

question

Long term care patients are referred to as residents of the healthcare facility administering care.

answer

true

question

What percentage of hospitals offers emergency services?

answer

More than 90%

question

Who is appointed by the President of the United States to provide leadership and science-based recommendations about the public's health?

answer

Surgeon General of the United States

question

Skilled nursing care is defined as skilled nursing observations and:

answer

Technical procedures

question

Long term care is mainly rehabilitative and supportive rather than curative.

answer

true

question

Patients in hospice care are expected to live a maximum of ___ days.

answer

180 days

question

The difference in health insurance coverage between medical and psychiatric care is referred to as:

answer

Non-parity

question

This type of facility is more homelike and less institutional than in the past

answer

Residential Care Facilities

question

Cell-based technologies include:

answer

Stem cells for transplant

question

Name the leading federal agency charged with protecting the public health.

answer

The CDC or Centers for Disease Control

question

Which of the following is a secondary purpose of the health record?

answer

Educate medical students

question

Which of the following is an institutional user of the health record?

answer

Government policy maker

question

How do patient care managers and support staff use the data documented in the health record?

answer

Evaluate the performance of employees

question

An HIM student asked an HIM director why the hybrid record is so challenging. What is the HIM director's response?

answer

It is because we have to manage both the electronic and paper media.

question

What is the process of ensuring that a record is available for every patient seen at the healthcare facility?

answer

Reconcilliation

question

Dr. Smith dictated his report and then immediately edited it. What type of speech recognition is being used?

answer

Front-end

question

Critique this statement: Data and information mean the same thing.

answer

This is a false statement because data is raw facts and figures and information is data converted into a meaningful format.

question

Which information system will track information provided to a requester?

answer

Release of information

question

The use of the health record by a clinician to facilitate quality patient care is considered ____________.

answer

A primary purpose of the health record

question

Why is only the most current version of a document displayed?

answer

To ensure there is no confusion on the correct document

question

How do accreditation organizations use the health record?

answer

To determine whether standards are being met

question

How long should the MPI be retained?

answer

Permanently

question

Deficiencies in a health record include which of the following?

answer

Missing document

question

Critique this statement: Patient care managers are individual users of health records.

answer

This is a true statement.

question

Removing health records of patients who have not been treated at the facility for a specific period of time from the storage area to allow space for more current records is called:

answer

Purging records

question

Which type of microfilm does not allow for a unit record to be maintained?

answer

Roll microfilm

question

Which of the following is true about document imaging?

answer

Documents can be indexed

question

Which system records the location of health records removed from the filing system and documents the return of the health records?

answer

Chart tracking system

question

"Loose" reports are health record forms that:

answer

Are received by the HIM department and added to the health record after it has been processed

question

Which of the following is the most efficient filing system?

answer

Unit numbering system

question

Which of the following is the key to the identification and location of a patient's health record?

answer

MPI

question

Which of the following numbering system assigns multiple health record numbers, or, one per visit?

answer

Serial

question

In which numbering system does a patient admitted to a healthcare facility on three different occasions receive three different health record numbers but the content is filed under the most recent health record number?

answer

Serial-unit number

question

Which of the following is part of qualitative analysis review?

answer

Checking that only approved abbreviations are used

question

Which of the following is true of good forms design for paper forms?

answer

Every form should have a unique identification number

question

Which of the following best describes the most important function of the health record?

answer

Storing patient care documentation

question

Who are the primary users of the health record?

answer

Clinical professionals who provide direct patient care

question

Which of the following elements is typically found in the paper health record?

answer

Patient identification

question

Which of the following is an example of information

answer

The number of patients discharged has increased 175% over the past year.

question

How many linear filing inches can a shelving unit hold based on the following data? Shelving unit shelf width = 36 inches Number of shelves per unit = 9 shelves Average record thickness = ½ inch

answer

324

question

Which of the following assists in locating misfiles in the paper-based filing systems?

answer

Color coding

question

Which one of the following are included in a list of institutional users of the health record?

answer

Blue Cross and Blue Shield

question

The services provided by HIM departments in acute care hospitals usually include all the following except:

answer

Medical billing

question

The patient registration department assists the HIM department in what way?

answer

Assigning the health record number

question

Which one of the following is an example of virtual HIM?

answer

Employees who code from home

question

Which of the following HIM tasks is eliminated by the electronic health record system?

answer

Assembly

question

The master patient index __________________.

answer

Contains basic demographic information about the patient

question

Consider the following sequence of numbers. What filing system is being used if these numbers represent the health record numbers of three records filed together within the filing system? 36-45-99 37-45-99 38-45-99

answer

Terminal digit

question

The annual volume statistics for General Hospital are noted below. How many shelving units will be required to store this year's inpatient discharge records? Average inpatient discharges = 12,000 Average inpatient record thickness = ¾ inch SReviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysishelving units shelf width = 36 inches Number of shelves per unit = 6

answer

42

question

Reviewing the health record for missing signatures, missing medical reports, and ensuring that all documents belong in the health record is an example of what type of analysis

answer

Quantitative

question

The coding of clinical diagnoses and healthcare procedures and services after the patient is discharged is what type of review?

answer

Retrospective

question

The release of information function requires the HIM professional to:

answer

Disclose patient identifiable information to a third party

question

Which system is best suited for a small healthcare facility such as a one-physician practice?

answer

Alphabetic filing system

question

In which of the following systems does an individual receive a unique numerical identifier at the time of first encounter with a healthcare facility and maintain that identifier for all subsequent encounters?

answer

Unit numbering system

question

A record not completed within the time frame specified in the medical staff rules and regulations is called a ____________.

answer

Delinquent record

question

Which of the following should be taken into consideration when designing a health record form?

answer

Including original and revised dates

question

Which of the following statements describes alphabetical filing?

answer

File the record alphabetically by the last name, followed by the first name, and then the middle initial.

question

Which of the following lists of names is in correct order for alphabetical filing?

answer

Smith, Carl J. Smith, Mary A. Smith, Paul M. Smith, Thomas

question

Which of the following is a micrographic method of storing health records in which each document page is placed sequentially on a long strip?

answer

Microfilm roll

question

Which of the following tools is usually used to track paper-based health records that have been removed from their permanent storage locations?

answer

Outguides

question

Which of the following filing methods is considered the most efficient?

answer

Terminal digit filing

question

Which of the following indexes is key to locating a health record?

answer

Master patient index

question

Which one of the following is in terminal digit order?

answer

Which one of the following is in terminal digit order?

question

An addendum to the health record should be dated _____.

answer

The day the addendum was created.

question

Why should the copy and paste function should not be used in the electronic health record?

answer

The content may contain outdated information

question

What committee oversees the development and approval of new forms for the health record?

answer

Health information management committee

question

What is the software that is used for voice recognition known as?

answer

Natural language processing

question

How can the healthcare facility determine which physician has the best patient outcomes?

answer

Data mining

question

Critique this statement: Version control is not an issue in the EHR.

answer

There are issues related to versions of documents, such as there must be a flag to indicate a previous version.

question

Dr. Smith wants to use a lot of free text in his EHR. What should be your response?

answer

Dr. Smith, we recommend that you use little, if any, free text in the EHR.

question

Which of the following is a secondary purpose of the health record?

answer

Support for research

question

Which of the following is a disadvantage of alphabetic filing

answer

Uneven expansion in file shelves or cabinets

question

Which of the terms below represents fixed rules that must be followed?

answer

Standard

question

Which of the following is a request from a clinical area to charge out a health record?

answer

Requisition

question

What would be the linear filing inch capacity for a shelving unit with 6 shelves, each measuring 36 inches?

answer

216 inches

question

A quantitative review of the health record for missing reports and signatures that occurs when the patient is in the hospital is referred to as a _______ review.

answer

Concurrent

question

A health record with deficiencies that is not complete within the timeframe specified in the medical staff rules and regulations is called a(n) _________ record.

answer

Delinquent

question

In which department or unit does the health record typically begin?

answer

Patient registration

question

The term used for health record moved to an inactive file area because they have not been at the healthcare facility for a predefined period of time is:

answer

Purged

question

Our transcription is performed by a company outside of our organization. What is this called?

answer

Outsourcing

question

Calculate the number of shelving units required for 35,000 linear filing inches of records if the shelving unit has 7 shelves and is 36 inches wide.

answer

139

question

Which of the following is an argument against the use of the copy and paste function in the EHR?

answer

Inability to identify the author

question

Which of the following creates a chronological report of the patient's condition and response to treatment during a hospital stay?

answer

Progress notes

question

Which health record format is most commonly used by healthcare settings as they transition to electronic records?

answer

Hybrid records

question

What is the end result of a review process that shows voluntary compliance with guidelines of an external, non-profit organization?

answer

Accreditation

question

Which part of a medical history documents the nature and duration of the symptoms that caused a patient to seek medical attention as stated in that patient's own words?

answer

Chief complaint

question

Which of the following is an example of administrative information?

answer

Patient's address

question

The federal Conditions of Participation apply to which type of healthcare organization?

answer

Organizations that treat Medicare or Medicaid patients

question

Which of the following materials is documented in an emergency care record?

answer

Time and means of the patient's arrival

question

Which of the following statements is true of the process that should be followed in making corrections in paper-based health record entries?

answer

The reason for the change should be noted

question

Which of the following types of facilities is generally governed by long-term care documentation standards?

answer

Subacute care

question

Which of the following includes names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed?

answer

Operative report

question

Which of the following is a function of the discharge summary?

answer

Ensuring the continuity of future care by providing information to healthcare providers.

question

A patient's registration forms, personal property list, RAI/MDS and care plan and discharge or transfer documentation would be found most frequently in which type of health record?

answer

Long-term care

question

Which group focuses on accreditation of rehabilitation programs and services?

answer

CARF

question

Results of a urinalysis and all blood tests performed would be found in what part of a healthcare record?

answer

Laboratory findings

question

Which of the following is clinical data?

answer

Physician orders

question

A healthcare provider organization, when defining its legal health record must ___________.

answer

Assess the legal environment, system limitations, and HIE agreements

question

Documentation standards have become more detailed and have become focused on ________.

answer

Patient care quality

question

Written or spoken permission to proceed with care is classified as ___________.

answer

Expressed consent

question

The Joint Commission places emphasis on ________________.

answer

Appropriate and standardized health record documentation

question

Which of the following electronic record technological capabilities would allow a paper-based x-ray report to be accessed?

answer

Documents imaging

question

The Subjective, Objective, Assessment Plan (SOAP) came from the:

answer

Problem-oriented health record

question

The overall goal of documentation standards is to

answer

Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient

question

What standard does a hospital that participates in the Medicare and Medicaid programs have to comply with that hospitals who do not accept Medicare and Medicaid patients do not?

answer

Conditions of Participation

question

Which of the following is an example of an acknowledgement?

answer

Notice of privacy practices

question

The management of health information is a fundamental component of which of the following?

answer

The overall information governance model

question

What is the general name for Medicare standards impacting healthcare organizations?

answer

Conditions of Participation

question

Which of the following groups is the primary accreditation organization for facilities that treat individuals who have functional disabilities?

answer

Commission on Accreditation of Rehabilitation Facilities

question

When correcting erroneous information in a paper health record, which of the following is appropriate?

answer

Add the reason for the change

question

Patient history questionnaires are most often used in what setting?

answer

Ambulatory care

question

An RAI/MDS and care plan are found in records of patients in what setting?

answer

Long-term care

question

Which of the following represents the attending physician's assessment of the patient's current health status?

answer

Physical examination

question

What is the function of a consultation report?

answer

Documents opinions about the patient's condition from the perspective of a physician not previously involved in the patient's care

question

Which of the following represents documentation of the patient's current and past health status?

answer

Medical history

question

Which of the following contains the physician's findings based on an examination of the patient?

answer

Physical exam

question

Which of the following is usually a component of acute care patient records?

answer

Progress notes

question

Which of the following is true of many electronic health records?

answer

They are interoperable

question

When defining the legal health record, what must the healthcare provider do?

answer

Assess the legal environment

question

The ambulatory surgery record contains information most similar to which records?

answer

Hospital operative records

question

Which type of health record contains information about the means by which the patient arrived at the healthcare setting and documentation of care provided to stabilize the patient?

answer

Emergency care

question

Patient Account Information includes

answer

Insurance

question

Which of the following is an example of a long-term care setting?

answer

Assisted living facility

question

Which specialized type of progress note provides healthcare professionals impressions of patient problems with detailed treatment action steps?

answer

Care plan

question

In what part of the health record would the social and personal history be found?

answer

Medical history

question

The overall goal of documentation standards is to _____________.

answer

Ensure what is documented in the health record is complete and accurately reflects the treatment provided to the patient

question

Healthcare provider organizations normally do not have patients sign an acknowledgement addressing the fact that the healthcare provider organization is not responsible for the loss or damage of the patient's valuables.

answer

false

question

An accreditation organization (AO) must participate in its own CMS review in order to receive deemed status, allowing the AO to survey other healthcare providers for compliance.

answer

true

question

CMS does not require healthcare providers to inform their patients about general patient rights afforded to them

answer

false

question

The Joint Commission surveys healthcare provider organizations for clinical and operational practice compliance

answer

true

question

Auto-authentication is not in compliance with the CMS Interpretive Guidelines for Hospitals.

answer

true

question

The term ambulatory is the same as the term outpatient

answer

true

question

Nursing documentation should only be subjective.

answer

false

question

An increase of healthcare-related identity theft has had no influence on a healthcare provider organization's decision not to collect Social Security Numbers from patients.

answer

false

question

Analysis of patient registration information can promote population health management.

answer

true

question

If data aggregation is the goal of collecting the data, ______ are the best choice.

answer

Classifications

question

The SNOMED CT _________ includes the semantic tag.

answer

Fully specified name

question

The ___________ is a core component of SNOMED CT.

answer

Concept

question

___________ is a nursing terminology.

answer

Clinical Care Classification

question

Category I CPT includes which of the following?

answer

Surgery

question

A ___________ is a set of terms representing the system of concepts for the medical field.

answer

Clinical terminology

question

ICD-10-PCS is a classification of _________.

answer

Inpatient procedures

question

Which of the following developed the Diagnostic and Statistical Manual of Mental Disorders?

answer

American Psychiatric Association

question

A classification provides clinical data to ______________.

answer

Allow collection and reporting of healthcare statistics

question

The ___________ is responsible for the development and maintenance of ICD-10-CM.

answer

NCHS

question

The _________ is a system for classifying the topography and morphology of neoplasm.

answer

ICD-O-3

question

WHO defines ___________ as a reference classification.

answer

ICF

question

An accumulation of numeric or alphanumeric representations or codes for exchanging or storing information is a ___________.

answer

Code system

question

Which of the following is the standard for clinical lab test results under the Meaningful Use program?

answer

LOINC

question

HCPCS is made up of which code systems?

answer

CPT and HCPCS Level II

question

If you were looking for a code for a medication taken orally, in which system is it found?

answer

RxNorm

question

The _______ is responsible for development and maintenance of RxNorm

answer

NLM

question

One of the two major groups of LOINC content is _________.

answer

Clinical observations

question

The ___________ is responsible for the publishing and maintaining HCPCS Level II.

answer

CMS

question

The ________ originated from federal reporting requirements tied to certification criteria found in the Meaningful Use regulations.

answer

Common Clinical Data Set

question

Home health agency process and improvement outcome measures are based on data from the _____.

answer

Outcomes and Assessment Information Set

question

The standardized HEDIS data elements are collected by

answer

Acute care hospitals

question

The UHDDS's core data elements were incorporated into the ___________ prospective payment system.

answer

Acute inpatient

question

Which standard is attached to the data element smoking status contained in the Common Clinical Data Set?

answer

SNOMED CT

question

LOINC would be found in the UMLS ____________.

answer

Metathesaurus

question

What is a system of terms that follows pre-established naming conventions.

answer

Nomenclature

question

Which of the following is a clinical terminology?

answer

CPT

question

Who drives which clinical terminology, classification, and code system is selected as the standard?

answer

Government regulation

question

One of the required descriptions for a SNOMED CT concept is _________________.

answer

Preferred term

question

Category II CPT is used for _______________ .

answer

Performance measurement

question

Nursing terminologies are ________________.

answer

Used to direct patient care given by nursing staff

question

The __________ is a component of ICD-10-CM.

answer

Index to External Causes

question

Which system would be used to classify a state of disability?

answer

ICF

question

Which system includes ICD-10-CM codes to assist with meeting administrative requirements?

answer

DSM-5

question

The ___________ is a derived classification of the WHO Family of International Classifications.

answer

ICD-O-3

question

Which of the following procedure classifications include definitions?

answer

ICD-10-PCS

question

If you were coding a patient with the diagnosis of congestive heart failure, which classification would you use?

answer

ICD-10-CM

question

CPT is a terminology and also a ________________.

answer

Code system

question

Which of the following is one of the parts of the LOINC fully specified name.

answer

Sample type

question

Which chapter of HCPCS would you find drugs administered intravenously?

answer

J Codes

question

Which of the following is the standard for healthcare equipment under HIPAA?

answer

HCPCS Level II

question

Ingredient plus strength plus dose form is known as the

answer

Semantic clinical drug term type

question

The objective of RxNorm is to normalize names of generic and branded drugs and attach a _________ to that name.

answer

RxNorm concept unique identifier

question

A list of recommended data elements with uniform definitions is a _______.

answer

Data set

question

According to CMS, who is qualified to collect the OASIS data?

answer

Registered nurse

question

The Healthcare Effectiveness Data and Information Set contains standard _______.

answer

Performance measures

question

The Uniform Hospital Discharge Data Set's core data elements are collected by ______.

answer

Acute care, short-term stay hospitals

question

The ___________ established the Common Clinical Data Set.

answer

ONC

question

The UMLS ___________ contains the terminology, classification and code system standards.

answer

Metathesaurus

question

The OASIS-C1 data elements originate from a _________.

answer

Medicare-certified home health agency

question

Which of the following is an example of an electronic data source in healthcare?

answer

Radiology Information System

question

Which of the following data sets was created to collect uniform data across the United States for inpatient patient stays?

answer

Uniform Hospital Discharge Data Set (UHDDS

question

Which of the following is a collection of data that is organized in a manner to be accessed, managed, reported, and updated electronically?

answer

Database

question

Which of the following is the process of execution, implementation, and management of databases within healthcare?

answer

Database life cycle

question

A/n ___________________ is a list that provides guidance, indication, or other references of information contained in a database?

answer

Index

question

The ______________ characteristic of quality data is the data being completely free from any errors?

answer

Accuracy

question

This concept includes the process of data governance, patient identification, authorization validation, amendments and record corrections, and audit validation.

answer

Data integrity

question

Which of the following describes the capability for two or more electronic systems to communicate and exchange information electronically?

answer

Interoperability

question

The evaluation of data collected based on business needs and strategy is part of _______.

answer

Data stewardship

question

The process that focuses on the improving the quality and integrity of patient data while supporting timely coding and reimbursement is known as ________.

answer

Clinical documentation improvement

question

What does a healthcare organization create when it has a unique numbering system to identify all forms used within the organization?

answer

Form tracking system

question

What data quality characteristic is met when documenting the specific height of a patient within the health record?

answer

Precision

question

A/n ________________________ is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider?

answer

Query

question

This document defines how records and documentation are assembled and authenticated within the hospital

answer

Medical staff bylaws

question

Which of the following is one of the principles of data stewardship as defined by the National Committee on Vital and Health Statistics (NCVHS)?

answer

Individual's rights

question

What concept refers to the process of creating management and oversight of data assets to support the organization's mission, vision, and values?

answer

Information governance

question

The process of completing an inventory of all electronic systems that create, transmit, and store health information is known as what?

answer

System characterization

question

Information is single elements that define a specific characteristic about a patient.

answer

false

question

Data modeling is the process of creating documentation to document any business decisions made on data collection and storage systems for data.

answer

true

question

Organization information management is the processes and functions created by an organization to help plan, organize, and coordinate people, processes, technology, and content to manage information systems.

answer

false

question

The term that refers to an individual's ability to analyze, assess, and reconstruct a situation to provide a solution is critical thinking.

answer

true

question

Structured data is data that is entered into a specific format that is capable of being read and analyzed without human intervention.

answer

true

question

The process of creating paper forms to serve a business need is referred to as form creation.

answer

false

question

The oversight of the definition of structure of data elements as well as the creation, storage, and transmission of data elements is referred to as data management

answer

true

question

Data field, definition, data type, and format are all common data elements in what?

answer

Data dictionary

question

A single or individual fact that represents a patient in healthcare is known as a/n ____________.

answer

Data element

question

A health information manager took the three elements, blood pressure, weight, and cholesterol to analyze for potential indicators of a heart attack. The combined data is referred to as?

answer

Information

question

The data characteristic that refers to promptly entering up-to-date information into the patient's medical record is which of the following?

answer

Timeliness

question

AHIMA has created 8 principles to help organizations create ________________ within their organization?

answer

Information governance

question

Authorship validation is one part of ___________________________?

answer

Data integrity

question

What is another term for the electronic sharing of patient data between two healthcare systems?

answer

Health information exchange

question

A patient's birth date and gender documented in the health record are examples of a data?

answer

Element

question

Which of the following data sets collect information on the provider, place of encounter, reason for encounter, problem, diagnosis, assessment, therapeutic services, preventative services, and disposition?

answer

Uniform Ambulatory Care Data Set (UACDS

question

Which of the following creates a visual process to understand the data being collected in two different systems and how it is linked to one another?

answer

Data mapping

question

What is the term that describes the data that defines and characterizes other data within an electronic system?

answer

Metadata

question

The Health Information Director is given responsibility to manage the information and access to the deficiency module, clinical coding module, and release of information module with the electronic health record. This is an example of what data strategy method?

answer

Data ownership

question

___________________________ are the information collected within a healthcare organization during the normal day to day operations that supports patient care and business operations?

answer

Information assets

question

Safeguards established to support the data is available when and where is it needed under the data quality model is called which of the following?

answer

Accessibility

question

This type of data entered into electronic systems is free text and has no specific requirements or rules for data entry.

answer

Unstructured data

question

An example of a clinical documentation improvement tool is computer-assisted coding (CAC).

answer

TRUE

question

When writing a query for clinical documentation questions, the requestor should specifically state what diagnosis they are evaluating.

answer

false

question

Interoperability is the capability of two or more systems and software applications to communicate electronically and exchange information.

answer

true

question

Data warehousing is the process of extracting information stored in structured data formats within a database.

answer

false

question

A healthcare organization must ensure that data is presented in a way that is appropriate for the purpose of the data.

answer

true

question

Hospital bylaws define the process for documentation within a health record for all members of the workforce.

answer

true

question

When documentation is unclear or needs more information in order to proper code the health record, the coder should call the provider, ask them the question, and document the answer in the health record.

answer

false

question

An example of a standard for forms development is to mandate that the title of the form appear on the top center of the page.

answer

true

question

Health Level 7

answer

creates standards to support the exchange of information

question

Institute of Electrical and Electronics Engineers

answer

Creates and develops different standards for hospital systems that need communication between bedside instruments and clinical information systems.

question

National Council for Prescription Drug Programs

answer

creates standards regarding exchanging prescription information and payment information

question

Digital Imaging and Communication in Medicine

answer

creates standards for the messaging of digital images

question

Accountability

answer

create authority over the information governance process within an organization

question

Transparency

answer

create a clear and open documentation process for the information governance strategy and activities within an organization

question

Compliance

answer

create a process for ensuring that all the information meetings requirements of appropriate laws, regulations, standards and organization.

question

Retention

answer

create a process for proper preservation based on requirements from regulations accrediting organizations, and company

question

Disposition

answer

creates processes for secure and appropriate destruction of information that is no longer needed to be maintained by the organization.

question

Patient-identifiable data

answer

information such as age and date of birth

question

Aggregate data

answer

data extracted from individual patient records and combined to form information about groups of patients

question

Primary data

answer

information about the patient that is documented by the clinicians who provides services to the patient

question

Secondary data

answer

Data derived from the primary patient record.

question

Accession registry

answer

list of cases in a cancer registry arranged in the order in which the cases were entered

question

Disease index

answer

list of diseases and conditions of patients treated in a facility sequenced according to classification code number

question

Disease registry

answer

central collection of data used to improve the quality of care and measure and effectiveness of a particular aspects of healthcare delivery.

question

Population-based registry

answer

Registry that includes information from more than one facility in a geopolitical region.

question

Facility-based registry

answer

registry that includes only cases for a specific facility

question

Operation index

answer

List of the questions and procedures performed in a facility sequenced according to classification code number.

question

Physician index

answer

list of patients by physician usually arranged by physician code numbers

question

Trauma registry

answer

list of patients with severe injuries

question

Critique this statement: The Medicare Provider Analysis and Review File is made up of patient demographic data collected by acute care and skilled nursing facilities.

answer

MEDPAR is made up of claims data which does include demographic data.

question

The creation of the National Practitioner Data Bank was mandated by ___________.

answer

the Health Care Quality Improvement Act

question

The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of ____________________________.

answer

the Healthcare Integrity and Protection Data Bank

question

The Healthcare Cost and Utilization Project is a major initiative of which organization within the federal government?

answer

The Agency for Healthcare Research and Quality

question

An accession number is a number assigned to cases as it is entered in a cancer registry.

answer

true

question

Which of the following is an example of an external user utilizing secondary data?

answer

Federal agencies

question

Which of the following databases was developed by the National Library of Medicine?

answer

The Medical Literature, Analysis, and Retrieval System Online

question

A record is considered a primary data source when it ____________________.

answer

contains information about the patient that has been documented by the professionals who provided care to the patient

question

Secondary data sources consist of ______________.

answer

Registries

question

A Level I trauma center provides care from initial evaluation through stabilization.

answer

false

question

A Level III trauma center provides advanced trauma life support prior to the transfer of patients to a higher level trauma center.

answer

false

question

The main goal of Healthy People 2020 is to focus on promoting vaccine safety in public and private provider settings.

answer

false

question

Identify the true statement about the health record.

answer

The health record is a primary data source.

question

Secondary data is generally used ________.

answer

by external users

question

The state cancer registry desires to become accredited. Who should they contact?

answer

North American Association of Central Cancer Registries

question

Choose the correct statement regarding population registries.

answer

Population registries may or may not contain follow-up information on patients.

question

The nature of an injury and its threat to life by body system is shown by the:

answer

Abbreviated Injury Scale

question

To identify cases to be entered into the trauma registry, where should someone look?

answer

Disease index

question

Explain what the accession number 16-214 means.

answer

The year that the patient was entered in the registry is 2016 and this was the 214th patient entered in the registry during 2016

question

Issues related to the efficiency and effectiveness of the healthcare delivery system are addressed by the _____.

answer

Agency for Healthcare Research and Quality

question

Health information exchange is used primarily for which of the following?

answer

patient care

question

A physician has a patient with a cancer that is not responding to treatment so he looks for research being conducted on the cancer. Who developed a database that he can use to locate any existing clinical trial?

answer

National Library of Medicine

question

The content of the health record _______________.

answer

Should facilitate retrieval of data

question

The length of time health information is retained ______________.

answer

Must account for state retention laws, if they exist

question

Which type of law defines the rights and duties among people and private businesses?

answer

Private law

question

Which stage of the litigation process focuses on how strong a case the opposing party has?

answer

Discovery

question

Which document directs an individual to bring originals or copies of records to court?

answer

Subpoena duces tecum

question

Errors in the health record should be which of the following?

answer

Corrected by drawing a single line in ink through the incorrect entry

question

Congress passes laws, which are then developed by federal agencies to provide a blueprint for carrying out these laws. What do the federal agencies develop?

answer

Regulations

question

In order for Susan to be able to prove negligence, she must be able to prove injury, standard of care, breach of standard of care and which of the following?

answer

Causation

question

Jeremiah files a medical malpractice lawsuit against Dr. Watson, who performed his surgery. He names no other defendants in the lawsuit. Dr. Watson files a complaint against his assistant surgeon, Dr. Crick. By doing this, Dr. Watson has completed which legal action? Counterclaim

answer

Joinder

question

In Lindsay's lawsuit against her physical therapist, her attorney a) obtained copies of most documents that he requested such as medical records, contracts, e-mail communications, bills, and receipts. However, at trial, Lindsay was surprised to learn that b) several of these documents were not permitted to be considered by the jury as evidence. The concepts associated with a) and b) are which of the following?

answer

Discovery; admissibility

question

Elizabeth arrived at the nearest urgent care facility after being bitten by her cat, Felix. The physician examined her and gave her a tetanus shot. Based on these facts, a physician-patient relationship has _________.

answer

Been created by implied contract

question

Alex fell from a tree and was taken to the emergency room. The physician did a physical exam and diagnosed Alex with contusions. In fact, Alex suffered a punctured lung that would have been detected by a radiologic image. In this case, the physician committed which of the following?

answer

Nonfeasance

question

If a patient is not asked to sign a general consent form when entering the hospital, and later sues the hospital for contact that was offensive, harmful, or not otherwise agreed to, what cause of action has the plaintiff most likely included in his lawsuit?

answer

Battery

question

A durable power of attorney for healthcare decisions ______________.

answer

Applies when the individual is no longer competent

question

The maintenance of health records ____________________.

answer

Is governed by Medicare Conditions of Participation for organizations that treat Medicare and Medicaid patients

question

Disclosure of health information without the patient's authorization _____________.

answer

May be required by specific state statutes

question

Metadata are which of the following?

answer

Data about data

question

Stacie is writing a health record retention policy. She is taking into account the statute of limitations for malpractice and contract actions in her state. A statute of limitations refers to which of the following?

answer

The period of time in which a lawsuit must be filed

question

The Registered Health Information Technician (RHIT) credential is an example of which of the following?

answer

Certification

question

Dr. Smith is being sued by a former patient. At issue is whether the care he provided the patient was consistent with that which would be provided by an ordinary and reasonable physician treating a patient in the plaintiff's condition. The concept in question is whether _____________.

answer

Dr. Smith met the standard of care

question

Which of the following tyeps of destruction is appropriate for paper health records?

answer

Pulping

question

A child's health record should be retained for how long?

answer

The age of majority plus the statute of limitation

question

Which of the following is a true statement about the legal health record?

answer

It includes PHI stored on any medium

question

Policies that address how PHI is used inside the organization deal with which of the

answer

Use

question

What type of negligence would apply when a physician does not order the necessary test?

answer

Nonfeasance

question

Arbitration

answer

Proceeding in which disputes one submitted to a third party or a panel of experts outside the judicial trial system

question

Public law

answer

law that involves the government and its relationships with individuals or organizations

question

Private law

answer

law that involves the government and its relationships with individuals or organizations

question

Subpoena duces tecum

answer

written documents directing individual to furnish documents and other records to court

question

Implied consent

answer

permission inferred when a patient voluntary subits to healthcare treatment

question

Deposition

answer

sworn testimony usually collected before a trial

question

Authorization

answer

written permission to use or disclose patient-identifiable health information

question

Defendant

answer

individual or party who is the object of a lawsuit

question

Statute

answer

law enacted by a legislative body

question

Administrative law

answer

rules developed by administrative bodies empowered by law to regulate specific activities

question

Plaintiff

answer

Individual who brings a lawsuit

question

Breach of contract

answer

failure to meet the conditions specified under a legal agreements

question

Complaint

answer

process by which a lawsuit is initiated

question

Discovery

answer

disclosure of pertinent facts or documents to the opposing parties in a legal case

question

Medical malpractice

answer

professional liability of healthcare providers in the delivery of care to patients

question

Express contract

answer

spoken or written agreement may be given by a patient to a healthcare provider to permit treatment

question

Tort

answer

civil wrongdoing

question

Which of the following is one of the four sources of law?

answer

Judicial decision

question

District court

answer

court in the lowest tier of the federal court system

question

US Court of Appeals

answer

court with the power to overturn the final judgements of district courts

question

US Supreme Court

answer

court with the power to overturn the final judgement of federal state court of appeal

question

State appellate court

answer

court with the power to overturn the final judgements of state trial courts

question

State supreme court

answer

generally term used to describe court in the highest tier of state court systems

question

Trial court

answer

generally term used to describe court in the lowest tier of state court systems

question

The form and content of the health record are determined in part by which of the following?

answer

The needs of individual healthcare organizations

question

When a healthcare provider purposely commits a wrongful act that results in injury to a patient, the provider can be held responsible for an intentional tort.

answer

true

question

The Joint Commission sets the official record retention standards for hospitals and other healthcare facilities.

answer

false

question

Which of the following spells out the powers of the three branches of the federal government?

answer

US Constitution

question

Which of the following are laws enacted by a legislative body?

answer

statutes

question

What is the individual who brings a lawsuit called?

answer

Plaintiff

question

What is the individual who is the object of a lawsuit called?

answer

Defendant

question

Which of the following may be a basis of professional liability?

answer

Intentional tort

question

AHIMA's record retention guidelines recommend that diagnostic images such as x-rays be maintained for what length of time?

answer

At least 5 years

question

AHIMA's record retention guidelines recommend that the master patient index be maintained for what length of time?

answer

Permanently

question

AHIMA's record retention guidelines recommend that the health records of adults be maintained for what length of time?

answer

At least 10 years after the most recent encounter

question

Which of the following should be considered first when establishing health record retention policies?

answer

State retention requirements

question

The services that a physician is allowed to perform in a healthcare facility is known as which of the following?

answer

Clinical privileges

question

The physical health record is usually considered the property of which entity?

answer

The organization or provider

question

In addition to a physician's order, the do-not-resuscitate order should include which of the following?

answer

Patient consent

question

A nurse cannot practice without:

answer

Licensure

question

Amber files a medical malpractice lawsuit against Dr. Mason, who performed her surgery. She names no other defendants in the lawsuit. Dr. Mason files a complaint against Amber. By doing this, Dr. Mason has completed which legal action?

answer

Counterclaim

question

Which of the following is a true statement about the content of the legal health record?

answer

The legal health record contains metadata

question

The legal authority to make decisions is known as which of the following?

answer

Jurisdiction

question

The source of law that is created by legislative bodies is which of the following?

answer

Statute

question

Which of the following is one of the causes of action?

answer

Breach of contract

question

Who prohibits specific abbreviations from being used in the health record?

answer

Joint Commission

question

Which of the following is true of the Health Insurance Portability and Accountability Act (HIPAA)?

answer

Provides a federal floor for healthcare privacy

question

Under the HIPAA Privacy Rule, which of the following is a covered entity category?

answer

Healthcare clearinghouse

question

Under the HIPAA Privacy Rule, an impermissible use or disclosure should be presumed to be a breach unless the covered entity or business associate demonstrates that the probability the PHI has been compromised is ___________.

answer

Low

question

Under usual circumstances, a covered entity must act on a patient's request to review or copy his or her health information within what time frame?

answer

30 days

question

The HIPAA Privacy Rule requires that covered entities limit use, access, and disclosure of PHI to the least amount necessary to accomplish the intended purpose. What concept is this?

answer

Minimum necessary

question

Which of the following should be included in a covered entity's notice of privacy practices?

answer

Description with one example of disclosures made for treatment purposes

question

Which of the following is true of the notice of privacy practices?

answer

It must be posted in a prominent place

question

Which of the following statements is true?

answer

An authorization must contain an expiration date or event

question

In which of the following instances must patient authorization be obtained prior to disclosure?

answer

To the patient's attorney

question

Which of the following is true about a facility's patient directory?

answer

The covered entity must inform the individual of the information to be included in the facility directory.

question

Which of the following statements about a business associate agreement is true?

answer

It requires the business associate to make available records relating to PHI use and disclosure to the HHS.

question

How many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHI is stored off-site?

answer

60 days

question

Which of the following statements is true of the notice of privacy practices?

answer

It must be provided to every individual at the first time of contact or service with the covered entity.

question

Which of the following statements about a facility directory of patients is true?

answer

Disclosures from the directory need not be included in an accounting of disclosures.

question

In which of the following situations can PHI be disclosed without authorization, as long as there was an opportunity for the individual to agree or object?

answer

Facility directory disclosures

question

Who of the following would be considered a member of a hospital's workforce?

answer

A clerk working in the hospital's registration office

question

When would PHI loses its status?

answer

After an individual has been deceased more than 50 years

question

A covered entity may deny an individual's amendment request for which of the following reasons?

answer

If the PHI in question is not part of the designated record set

question

Which of the following is a public interest and benefit exception to the authorization requirement?

answer

Judicial and administrative proceedings

question

The breach notification requirement applies to:

answer

Unsecured PHI only

question

A subpoena should be accompanied by which of the following?

answer

Patient authorization

question

In court, hearsay is generally ____________.

answer

Non-admissible

question

The American Recovery and Reinvestment Act expanded the definition of business associates to include which of the following?

answer

Patient safety organizations

question

Critique this statement: According to HIPAA, workforce members include students.

answer

This is a true statement

question

The designated record set includes which of the following?

answer

Billing records

question

In all cases, a covered entity may deny an individual's request to restrict the use or disclosure of his or her PHI.

answer

false

question

Stricter state statutes that provide greater confidentiality of healthcare information take precedence over the provisions of the HIPAA Privacy Rule.

answer

true

question

A notice of privacy practices should include a statement explaining that individuals may complain to the Secretary of the Department of Health and Human Services if they believe that their privacy rights have been violated.

answer

true

question

Which of the following is a covered entity under the HIPAA Privacy Rule?

answer

Pharmacy

question

What types of health records are subject to the HIPAA Privacy Rule?

answer

Health records in any format

question

What does the acronym PHI stand for?

answer

Protected health information

question

Under the HIPAA Privacy Rule, when an individual asks to see his or her own health information, a covered entity _______________.

answer

Can deny access to psychotherapy notes

question

In which of the following situations must a covered entity provide an appeal process for denials to requests from individuals to see their own health information?

answer

When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual

question

Which of the following statements is true in responding to requests from individuals who wish to access their PHI?

answer

A cost-based fee may be charged for making a copy of the PHI.

question

How many days does a covered entity have to respond to an individual's request for access to PHI under HIPAA rules?

answer

30 days

question

How many days does a covered entity have to respond to an individual's request for access to his or her PHI when the PHI is stored off-site?

answer

60 days

question

Which of the following provides a complete description to patients about how PHI is used in a healthcare facility?

answer

Notice of privacy practices

question

Which of the following statements is true of the notice of privacy practices?

answer

It must be provided to every individual at the first time of contact or service with the covered entity.

question

Which of the following is unsecured PHI?

answer

PHI that technology has not made unusable, unreadable, or indecipherable to an unauthorized person

question

Which of the following statements about the directory of patients maintained by a covered entity is true?

answer

Individuals must be given an opportunity to deny permission to place information about them in the directory.

question

Mary's PHI was breached by her physician office when it was disclosed in error to another patient. Which of the following breach notification statements is correct regarding the physician office's required action?

answer

It must report the breach to HHS within 60 days after the end of the calendar year in which the breach occurred

question

PHR vendors that are not part of a covered entity or business associate must report PHI breaches to

answer

The Federal Trade Commission

question

Which of the following actions by a physician requires the patient's authorization?

answer

Giving the name of an expectant mother to a baby formula manufacturer

question

HIPAA administrative requirements include which of the following?

answer

Designating a privacy officer

question

ARRA and HITECH granted which of the following the ability to bring civil actions in federal district court on behalf of residents believed to have been affected by a HIPAA violation?

answer

State attorneys general

question

A valid authorization requires which of the following?

answer

An expiration date or event

question

Which of the following situations is considered a breach of PHI?

answer

A patient's attorney is sent records not requested by that patient

question

In which of the following circumstances does the patient have an opportunity to agree or object?

answer

Whether the patient should be in the facility directory

question

Which of the following rights did HIPAA give patients?

answer

Right to request an amendment of the health record

question

Which of the following statements is true?

answer

State law preempts HIPAA

question

Data security includes protecting data availability, privacy, and ________.

answer

Integrity

question

Within the context of data security, protecting data privacy means defending or safeguarding _________.

answer

Access to information

question

The greatest threat category to electronic health information is which of the following?

answer

Humans

question

The first and most fundamental strategy for minimizing security threats is which of the following?

answer

Establish a secure organization

question

Administrative safeguards include policies and procedures that address which of the following regarding computer resources?

answer

Management

question

The individual responsible for ensuring that everyone follows the organization's data security policies and procedures is which of the following?

answer

Chief security officer

question

An employee accesses PHI on a computer system that does not relate to her job functions. What security mechanism should have been implemented to minimize this security breach?

answer

Access controls

question

A visitor to the hospital looks at the screen of the admitting clerk's computer workstation when she leaves her desk to copy some admitting documents. What security mechanism would best have minimized this security breach?

answer

Automatic logoff controls

question

A laboratory employee forgot his user ID badge at home and uses another lab employee's badge to access the computer system. What controls should have been in place to minimize this security breach?

answer

Workforce security awareness training

question

A dietary department donated its old microcomputer to a school. Some old patient data were still on the microcomputer. What controls would have minimized this security breach?

answer

Device and media controls

question

HIPAA requires that policies and procedures be maintained for a minimum of _______.

answer

Six years from date of creation or date when last in effect, whichever is later

question

A visitor walks through the computer department and picks up a CD from an employee's desk. What security controls should have been implemented to prevent this security breach?

answer

Facility access controls

question

Threats to data security are most likely to come from which of the following?

answer

Employees

question

These are automatic checks that help preserve data confidentiality and integrity.

answer

Application controls

question

An employee in the physical therapy department arrives early every morning to snoop through the EHR for potential information about neighbors and friends. What security mechanism should have been implemented that could minimize this security breach?

answer

Facility access controls

question

An employee observes an outside individual putting some computer disks in her purse. The employee does not report this security breach. What security measures should have been in place to minimize this threat?

answer

Security incident procedures

question

Locks on computer room doors illustrate a type of _________.

answer

Physical control

question

An admission coordinator consistently enters the wrong patient gender while entering data in the MPI. What security measures should be in place to minimize this security breach

answer

Edit checks

question

Which of the following statements is true regarding HIPAA security?

answer

HIPAA allows flexibility in the way an institution implements the security standards.

question

For HIPAA implementation specifications that are addressable, the covered entity _________.

answer

Must conduct a risk assessment to determine if the specification is appropriate to its environment

question

A user recently opened a file that they thought would help them with their job but it copied files to unsecure ares of the computer. What thpe of malware was activated?

answer

Trojan horse

question

Training that educates employees on the confidential nature of PHI is known as which of the following?

answer

Awareness

question

"Something you have" is demonstrated by:

answer

Token

question

Policies are which type of safeguards?

answer

Administrative

question

A hospital is looking to use something to act as a buffer between two networks. What should be recommended?

answer

Firewall

question

The primary reason that healthcare organizations develop business continuity plans is to minimize the effects of which of the following?

answer

Computer downtime

question

Critique this statement: HIPAA represents an attempt to establish best practices and standards for health information security.

answer

This is a true statement.

question

A risk analysis is useful to _________.

answer

Identify security threats

question

Which of the following is true regarding HIPAA security provisions?

answer

Covered entities must retain policies for 6 years after they are no longer used.

question

Which of the following is a technique that can be used to determine what information access privileges an employee should have?

answer

Context-based

question

The HIPAA data integrity standard requires that organizations do which of the following?

answer

Keep documented logs of system access and access attempts

question

Which of the following is required by HIPAA standards?

answer

A written contingency plan

question

Security controls built into a computer software program to protect information security and integrity are which of the following?

answer

Application controls

question

This type of control is designed to prevent damage cause by computer hackers.

answer

Network control

question

Policies and procedures that address the management of computer resources and security are which of the following?

answer

Administrative controls

question

Safeguarding system access

answer

privacy

question

Safeguarding data accuracy

answer

integrity

question

Ensuring system access when needed

answer

availability

question

Which of the following terms means that data should be complete, accurate, and consistent?

answer

Data integrity

question

What is the biggest threat to the security of healthcare data?

answer

Employees

question

What does the term access control mean?

answer

Identifying which data employees should have a right to use

question

Which of the following is a software program that tracks every access to data in the computer system?

answer

Audit trail

question

Which of the following is an organization's planned response to protect its information in the case of a natural disaster?

answer

Business continuity plan

question

Though the HIPAA Security Rule does not specify audit frequency, how often should an organization's security policies and procedures be reviewed?

answer

Once a year

question

Which of the following provide the objective and scope for the HIPAA Security Rule as a whole?

answer

General rules

question

Which of the following is an example of a physical safeguard that should be provided for in a data security program?

answer

Locking computer rooms

question

Which of the following best describes information security?

answer

The mechanisms for safeguarding information and information systems

question

A public key is part of what security measure?

answer

Digital certificates

question

Which of the following is an example of technical security?

answer

Integrity

question

Policies were recently rewritten. How long does the facility need to retain the obsolete policies?

answer

Six years

question

An audit identified that an employee accessed a patient whose name is the same as the employee. This is known as a/an _________.

answer

Trigger

question

In two computer systems the same data element is different. This is what type of issue?

answer

Data consistency

question

A radiology information system is which of the following?

answer

Source system

question

When an EHR is integrated into the daily routine of clinicians it is said to be in what stage of existence?

answer

Adoption

question

Which of the following is a fundamental change in how medicine is practiced using health IT?

answer

Clinical transformation

question

Which of the following is a program that assures there is documented approval for altering an application?

answer

Change control

question

What health information exchange is a sophisticated structure that enables both receipt of data and the ability to query an exchange for data?

answer

CONNECT

question

Infusion pumps and robotics are examples of which of the following?

answer

Smart peripherals

question

What is interoperability?

answer

The ability to share health information with other health IT systems

question

Revenue cycle management is accomplished through use of which of the following systems?

answer

Patient financial service system

question

Structured data are which of the following?

answer

Able to be processed by a computer

question

Ideally, clinical documentation in an EHR should be performed _____________.

answer

At the point of care

question

The source of drug-drug contraindication information in a computerized provider order entry system is ___________.

answer

Drug knowledge database

question

Which of the following is an example of clinical decision support?

answer

Workgroup tool

question

A standard vocabulary is used to achieve what type of interoperability?

answer

Semantic

question

A way to send secure messages over the Internet is which of the following?

answer

Virtual private network

question

In order to locate a patient via a health information exchange organization, there must be which of the following?

answer

Identity matching

question

The systems development life cycle

answer

Ensures all components for a system to achieve its value are in place

question

A form of clinical decision support that guides a user in appropriate documentation is which of the following?

answer

Template

question

What is the combination of quality and cost of healthcare?

answer

Value

question

Computerized provider order entry systems can be used to order narcotics.

answer

true

question

A clinical data repository supports sophisticated data analytics.

answer

false

question

An organization's goals that are supported by health IT can be achieved more quickly and completely if monitoring results is performed.

answer

true

question

A master patient index is used to locate where patients may have records within a health information exchange organization.

answer

false

question

Medication reconciliation is very difficult to implement and often one of the last applications within the medication management set of systems.

answer

true

question

The Logical Observations Identifiers Names and Codes (LOINC) vocabulary is used to encode laboratory orders and results

answer

true

question

A portal is the same as a personal health record.

answer

false

question

When a vendor is no longer selling or supporting a health IT product, it is said to be _________________.

answer

Sunset

question

The nationwide health information network is now called which of the following?

answer

eHealth Exchange

question

Security functionality provided in a health information exchange is collectively referred to as which of the following?

answer

Identity management

question

In a health information exchange, patients opt in or opt out of having their data exchanged via a(n)

answer

Consent directive

question

A person who is able to take advantage of all of the aids offered by health IT is referred to as which of the following?

answer

Power user

question

Which of the following is a core clinical EHR system?

answer

Results management system

question

In order for a hospital to generate a claim for reimbursement by a health plan, the EHR must have which of the following components?

answer

Charge capture

question

What does a form creation system do?

answer

Automates administrative forms processing

question

Clinical documentation systems that support clinical decision making capture data via ______________.

answer

Structured data templates

question

EHRs support evidence-based medicine, which refers to which of the following?

answer

Recommendations for care based on research

question

The standard used in e-prescribing systems to transmit a prescription to a retail pharmacy is which of the following?

answer

SCRIPT

question

Online transaction processing is conducted in which of the following?

answer

Clinical data repository

question

Semantic interoperability is achieved by using ____________.

answer

Standard vocabularies

question

In order for a physiological monitor, such as a device a patient may wear during exercise, to be connected to an EHR, there must be which of the following?

answer

Medical device integration

question

A registry is which of the following?

answer

Specialized database for a predefined set of data and its processing

question

Web service architecture does not require an interface.

answer

false

question

The ASTM International standardized the content of the continuity of care record.

answer

false

question

The system development lifecycle is repeated when monitoring reveals that the system is no longer producing the desired result.

answer

true

question

A physician champion is now referred to as a chief medical informatics officer.

answer

false

question

When almost all applications used in a hospital are acquired from the same vendor, the strategy being deployed is considered best-of-breed.

answer

false

question

A term that refers to a statistical process of data to reveal new information is which of the following?

answer

Analytics

question

Information

answer

data processed into usable form

question

Data

answer

basic facts

question

Knowledge

answer

understanding to make informed decisions

question

The Affordable Care Act is a regulation that was issued by CMS, outlining an incentive program for professionals that adopt and successfully demonstrate ________________ of certified EHR technology.

answer

Meaningful Use

question

Healthcare information is primarily for which of the following?

answer

Provider use in the management of care

question

To arrive at information, _________ are required.

answer

data

question

________ data analytics is where health information is captured, reviewed, and used to measure the quality of care provided.

answer

Clinical

question

What is the first stage of transforming raw data into meaningful analytics?

answer

Data capture

question

Which of the following may be used to capture the data for storage in a database?

answer

Natural language processing

question

Which of the following data visualization tool is used when displaying trends?

answer

Graphs

question

The _________ is a management report of process measures.

answer

Dashboard

question

Which of the following is where a nurse enters data using a tablet computer when conducting a patient assessment while at the bedside?

answer

Point-of-care charting

question

__________ is key to the knowledge discovery process.

answer

Data mining

question

The clinical data ___________ lends itself to data mining as it encompasses multiple sources of data.

answer

Warehouse

question

Which decision support systems could deliver a reminder to a physician that it is time for the patient's flu shot?

answer

Clinical

question

The _______ would be used to help find actionable insights to drive enterprise performance.

answer

Executive information system

question

A _________ generated scorecard could be used by a manager to monitor readmission rates in order to track trends and identify opportunities for improvement.

answer

Decision support system

question

The exchange of email communication between the patient and physician on a question regarding medication is an example of ____________ health informatics.

answer

Consumer

question

According to FDA guidance, a mobile app running on a smart phone to analyze and interpret EKG waveforms to detect heart function irregularities is a ___________.

answer

Medical device

question

Which access tool is used to view a subset of patient's health records after logging in to a secure online website?

answer

Patient portal

question

Which of the following is a type of electronic personal health record that allows access through a portal?

answer

Tethered

question

Connecting the PHR to the patient's legal health record protects it under the HIPAA ______.

answer

Privacy Rule

question

"Why did it happen?" is answered by _______ analytics.

answer

Diagnostic

question

Free text describing a patient's chief complaint is an example of _________.

answer

Unstructured data

question

Tracking and comparing over time the number of medical records coded per hour by individual coder to assess coder productivity is an example of a __________.

answer

Key indicator

question

Physicians correct misrecognitions at the time of dictation when _______ is used.

answer

Front-end speech recognition technology

question

___________ is a barrier to health information exchange users.

answer

State law

question

Which of the following is a benefit of HIE?

answer

Enhanced patient care coordination

question

A patient portal that allows personal health information to be uploaded for provider access is an example of _______________.

answer

Consumer-mediated exchange

question

A ________ would be used to define syntax conventions.

answer

Content and structure standard

question

The ONC's goal of advancing secure and interoperable health information requires_______.

answer

Sharing information among individuals, providers and the community

question

What happened?" is answered by _______ analytics.

answer

Descriptive

question

What is the second stage of transforming raw data into meaningful analytics?

answer

Data provisioning

question

___________ is a tool used for extracting data from a database.

answer

Data mining

question

Data from a wearable monitor, such as an exercise-tracking device, is an example of?

answer

Patient-generated health data

question

The use of a dropdown list to select a patient's diagnosis is an example of _________.

answer

Structured data

question

Sharing the contents of a PHR with providers creates an opportunity to ____________.

answer

Improve patient safety

question

The clinical data ___________ is a central database that focuses on clinical information.

answer

Repository

question

Which of the following data visualization tool is used to organize quantitative data?

answer

Tables

question

Which of the following data visualization tool is used to organize quantitative data?

answer

Scorecard

question

Tracking a _______ can help detect problems and identify opportunities for performance improvement.

answer

Key indicator

question

Editors correct misrecognitions after the physician completes dictation when _______ is used.

answer

Back-end speech recognition technology

question

___________ is a possible outcome of point-of-care charting.

answer

Unstructured or structured data

question

What role in consumer informatics is HIM filling in the following situation: Creation of policies and design workflows for accepting and managing patient-generated health information.

answer

Patient information coordinator

question

A smart phone app that analyzes and interprets blood pressure readings to detect irregularities is a _________ according to FDA guidance.

answer

Medical device

question

The problem being solved with the use of DSS is typically _______.

answer

Unstructured

question

Which system would be used to pull together operational and clinical information in order to uncover a problem with readmissions?

answer

Executive information system

question

If consumers were looking to interact and receive support from others with similar diseases via electronic means, which tool might they use?

answer

Social media

question

The eHealth Exchange is a _______________ of exchange partners.

answer

Nationwide community

question

Scheduling appointments is an example of a patient portal feature having a(n)_______.

answer

Administrative orientation

question

A _______ accepts data patients' select from external sources, which is then stored on their computer.

answer

Standalone PHR

question

When exchanging information about a patient's problem, a ________ would be used.

answer

Terminology standard

question

____________ in order to maintain patient identity data integrity.

answer

The data must be accurately entered

question

A _______ can assist a provider in obtaining a health record on a patient who is visiting from another state, resulting in more informed decisions about the care of the patient.

answer

Query-based exchange

question

All definitions of HIE mention which of the following?

answer

The capacity exists for different information systems and software applications to exchange data

question

What is the term used by the insurance industry that refers to the process of paying, denying, and adjusting claims based on patients' health insurance coverage benefits?

answer

Adjudication

question

Clinical data is used to identify an individual.

answer

false

question

________ protects a person from having to pay the full cost of healthcare.

answer

Health insurance

question

The ______ is the process of patient financial and health information moving into, through, and out of the healthcare facility.

answer

Revenue cycle

question

What is the term that is used to identify an insurance company that pays for the healthcare of covered individuals?

answer

Third party payer

question

If a patient is covered by more than one insurance plan, the process of coordination of benefits (COB) takes place.

answer

True

question

A Chargemaster is a financial management list that contains information about the organization's charges for healthcare services it provides to patients.

answer

true

question

______ is a type of incentive to improve clinical performance using the electronic health record resulting in additional reimbursement or eligibility for grants or other subsidies to support further HIT efforts.

answer

Pay-for-performance

question

______ is a specified amount of money paid to a health plan or doctor, used to cover the cost of a health plan member's healthcare services for a certain length of time.

answer

Capitation

question

Retrospective utilization review process involves review of utilization information before the patient has been discharge or the care has been completed.

answer

false

question

A type of prospective review involves ______ which is obtaining approval from a healthcare insurance company before a healthcare service is rendered.

answer

Precertification

question

What methodology involves payment that combines the professional and technical components of a procedure and disperses payments in a lump sum to be split between the physician and the healthcare facility?

answer

Global payment

question

The technical component of a service is considered the part of the service supplied by physicians, while the professional component is supplied by the hospital or freestanding surgical center.

answer

false

question

A prospective payment system is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.

answer

true

question

Payment method in which the third-party has implemented some provisions to control the costs of healthcare while maintaining quality care.

answer

managed care

question

A type of healthcare organization that delivers medical care and manages all aspects of the care and payment for care by limiting providers of care, discounting payment to providers of care, or limiting access to care.

answer

managed care

question

An entity that combines the provision of healthcare insurance and delivery of healthcare services, characterized by an organized healthcare delivery system to a geographic area, a set of basic and supplemental health maintenance and treatment services, voluntarily enrolled members, and predetermined fixed, periodic prepayments for members' coverage.

answer

HMO

question

A managed care contract coordinated care plan that has a network of providers that have agreed to a contractually specified reimbursement for covered benefits with the organization offering the plan.

answer

preferred provider organization ppo

question

A federally funded health program to assist with the medical care costs of American 65 years of age and older.

answer

medicare

question

Medicare prescription drug coverage

answer

medicare part d

question

A joint federal and state program that helps with medical costs for some people with low incomes.

answer

medicaid

question

Provides health coverage to eligible children through both Medicaid and individual state programs.

answer

state childrens health insurance program SCHIP

question

The federal healthcare program that provides coverage for the dependents of armed forces personnel and for retirees receiving care outside military treatment facilities.

answer

tricare

question

A federal agency within the Department of of Health and Human Services that is responsible for providing federal healthcare services to American Indians and Alaska Natives.

answer

ihs

question

Insurance that most employers in the US are required to carry and is used for employees who are injured on the job.

answer

workers compensation

question

What is a private not-for-profit organization with the mission to improve healthcare quality by accrediting, assessing and reporting on the quality of managed care plans?

answer

NCQA

question

The Health Maintenance Organization Act of 1973 made it harder for HMOs to grow and attract clients and required all employers that offered traditional health care to their employees to sign up for an HMO if they had more than 35 employees.

answer

false

question

Medicare enrollees are called ______ and must fall into a benefit category to be eligible for Medicare coverage.

answer

Beneficiaries

question

People who are enrolled in both Medicare and Medicaid known as _____.

answer

Dual eligible

question

______ includes verification that the patient is currently covered by the plan on the date of service the services being provided are covered by the plan.

answer

Eligibility

question

What is a pre-established percentage of eligible expenses after the deductible is met?

answer

Coinsurance

question

______ is a cost-sharing measure in which the policy holder pays a fixed dollar amount per service.

answer

Copayment

question

_____ means charging the patient for the remainder of the charges that were not paid by the insurance plan.

answer

Balance bill

question

Health insurance payers have a variety of reimbursement plans and contract with individual providers and employers for payment meaning the same type of service to two different patients may be paid differently depending on the type of contract or insurance each patient has.

answer

true

question

What is name of the form that details the way the payer processed the claim for payment?

answer

Explanation of benefits

question

Many Americans are covered by private insurance plans through their employer, purchased individually, or through a group, such as a professional association.

answer

true

question

Typically, insurance plans that have very high deductibles or limited covered services is called what?

answer

Private health insurance

question

Who is responsible for making payment for healthcare claims on behalf of the company?

answer

Third party administrator

question

In a network HMO the HMO contracts with a network of providers who provide multispecialty group practices

answer

true

question

In a _____ HMO the physicians are employed by the HMO. Physicians see only members of the HMO and are paid a salary by the HMO.

answer

Staff Model

question

What type of HMO model contracts with more than one physician, such as a medical group that includes physicians in multiple fields of expertise?

answer

Group Model HMO

question

______ is where uninsured, eligible Americans are able to purchase federally-regulated and subsidized health insurance.

answer

Health insurance marketplace or exchange

question

The Health Information and Accountability Act established the hospital-acquired conditions reduction program to encourage hospitals to reduce HAC's.

answer

false

question

_____ is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

answer

Utilization management

question

What refers to the review that takes place prior to elective procedures or admissions?

answer

Prospective review

question

Retrospective review involves screening for medical necessity and the appropriateness or timeliness of delivery of medical care from the time of admission until discharge.

answer

false

question

_____ is a collaboration between healthcare and service providers to aid in the process of assessment, planning, facilitation, care coordination, evaluation, and advocacy to meet an individual's and family's comprehensive health needs.

answer

Case management

question

A hospital's _______ represents the average DRG relative weight for a particular hospital.

answer

Case-mix index

question

In what system are payments for services determined by the resource cost needed to provide them?

answer

RBRVS

question

The Balance Budget Act (BBA) of 1997 modified how facilities are paid for skilled nursing facility (SNF) services. SNF's are paid a comprehensive per diem under a PPS, meaning they receive a set amount for each day of service instead of being paid on itemized charges or services.

answer

True

question

Fraud is when someone intentionally executes or attempts to execute a scheme to obtain money or property of any healthcare benefit program. The key word in the definition is which of the following?

answer

Intentionally

question

Which of the following is an example of abuse?

answer

A pattern of coding errors

question

The overutilization or inappropriate utilization of services and misuse of resources, typically not a criminal or intentional act is called which of the following?

answer

waste

question

The statue that dictates that physicians cannot receive money or other benefits for referring patients to a healthcare facility is known as which of the following?

answer

Anti-Kickback Statute

question

The Health Insurance Portability and Accountability Act was created through a joint venture between the Department of Health and Human Services and the Depart of Justice in what year?

answer

1996

question

Overpayments occur in which of the following scenarios?

answer

Payment is billed for non-covered services

question

Which governmental program has a goal to identify improper payments made on claims of healthcare services provided to Medicare beneficiaries?

answer

RAC

question

How many basic elements are included in an effective compliance program?

answer

7

question

Which of the following is the purpose of audits performed by QIOs?

answer

improving patient care

question

Audit planning includes which of the following?

answer

Establish policies, procedures, and standards of conduct

question

What is the process of extracting and translating dictated and then transcribed free-text data into ICD and CPT codes for billing and coding purposes?

answer

CAC

question

The benefits of a coding compliance plan include the following.

answer

Retention of high standard of coding

question

A complication is defined as which of the following?

answer

A medical condition that arises during an inpatient hospitalization

question

Which of the following is one of the most widely-used key indicators for a CDI program?

answer

CMI

question

Which of the following is a type of supportive documentation reflecting objective clinical indicators of a patient illness and refers to the extent of physiological decompensation or organ system loss of function?

answer

SOI

question

The coder used two separate procedure codes instead of a combination code. This practice known as which of the following?

answer

Unbundling

question

HHS has identified a healthcare facility guilty of fraud. HHS saw that the facility tried to comply but their efforts failed. What category does this fall into?

answer

Reasonable diligence

question

What practice do HIM departments use to protect themselves from RAC identifying coding and billing errors?

answer

Prebilling coding audits

question

Which of the following is one of the purposes of an audit?

answer

Improving patient care

question

What is the technology needed for computer-assisted coding?

answer

Natural language processing

question

Objective clinical indicators about the patient's illness are known as which of the following?

answer

Severity of illness

question

Choose the statement that would explain to a physician what a complication is.

answer

Complication is a medical condition that the patient has at the time of the patient's admission which affects treatment and length of stay.

question

Critique this statement: Computer-assisted coding eliminates coders.

answer

This is a false statement as coders will be needed but their role will change

question

Which of the following is a documentation issue?

answer

Copy and paste functionality

question

Dr. Smith does not understand queries. Which of the following explains it to him?

answer

A query requests additional clarifying documentation.

question

QIOs frequently conduct audits to determine if healthcare services have been provided in the appropriate setting. Which of the following is an example of the appropriate setting for healthcare services?

answer

A nursing home providing physical therapy for a post-operative hip replacement patient

question

The focus of RAC audits is patient-care focused.

answer

false

question

Before an audit can be conducted, an organization must first do which of the following?

answer

Identify the objective of the audit

question

Which of the following is an example of convenience sampling?

answer

All claims that are readily available to the auditor are audited

question

Which of the following is a good question for a supervisor of coding to ask when evaluating potential fraud or abuse risk areas in the coding area?

answer

Are the assigned codes supported by the health record documentation?

question

A study conducted by AHIMA found that credentialed coders who used a CAC were able to reduce the amount of time it took to code a record by 50%.

answer

false

question

A quantifiable measure used over time to determine whether some structure, process, or outcome in the provision of care to a patient supports high-quality performance measured against best practice criteria is the definition of which of the following?

answer

Key indicator

question

One of the most widely-used key indicators for a CDI program to use for monitoring is which of the following?

answer

CMI

question

HIM professionals are qualified to be CDI specialists.

answer

true

question

Which of the following is an example of a HAC?

answer

Catheter-associated urinary tract infection

question

A systematic comparison of the products, services, and outcomes of one organization with those of a similar organization is the definition of which of the following?

answer

Benchmarking

question

CAC used which of the following processing to review the documentation in the EHR and assign a code number?

answer

NLP

question

City Hospital submitted 175 claims where they unbundled laboratory charges. They were overpaid by $75 on each claim. What is the fine for City Hospital?

answer

$39,375

question

Fraud is when a healthcare provider or supplier performs an action that directly or indirectly results in unnecessary costs to any healthcare benefit program.

answer

false

question

The whistleblower provision of the False Claims Act is known as qui tam.

answer

true

question

This law prohibits a physician from referring patients to a business in which he or she or a member of the physician's immediate family has financial interests

answer

Stark Law

question

The Balanced Budget Act excludes healthcare organizations that are convicted for their first offense for

answer

10 years

question

The three categories that HHS uses to determine the level of effort put into fraud and abuse prevention include which of the following?

answer

Reasonable care, reasonable diligence, willful neglect

question

The Office of the Inspector General is responsible for which of the following?

answer

Monitoring Medicare and Medicaid programs

question

The Office of the Inspector General is organized into five divisions: Office of Audit Services, Office of Evaluation and Inspections, Office of Recovery, Office of Investigations, and the Office of Counsel to the Inspector General.

answer

false

question

Three different types of RAC audits include automated reviews, complex review, and annual reviews.

answer

false

question

The five levels of the appeal process include redetermination, reconsideration, administrative law judge, appeals council review, and final judicial review.

answer

true

question

Quality Improvement Organizations perform medical peer review of Medicare and Medicaid claims through a review of which of the following?

answer

Review of validity of hospital diagnosis and procedure coding data completeness

question

Meaningful Use (MU) does not provide incentives to eligible professionals, hospitals, and critical access hospitals participating in Medicare and Medicaid programs that adopt and successfully demonstrate meaningful use of certified EHR technology.

answer

false

question

Meaningful Use Stage 3 focuses on which of the following?

answer

Providers to report infectious diseases, immunizations, cancer and other reportable condition to public health officials

question

The legal term for "First do no harm" is which of the following?

answer

Nonmaleficence

question

Beneficence is an ethical principle meaning a patient has the right to choose their course of treatment.

answer

false

question

An ethical Dilemma occurs when one is faced with a choice between 2 or more situations.

answer

true

question

What is one assessing when addressing how one views language, communication style, belief systems, customs, attitudes, perception, and values?

answer

Personal cultural competence

question

A cultural audit is a strategy to define an organizations values, symbols, and routines and identify areas for improvement.

answer

true

question

What organization was established to help provide equality for minority groups, women, people with disabilities, and veterans?

answer

Equal Employment Opportunity Commission (EEOC)

question

Ethical Principles and values have been important to the HIM profession since 1942.

answer

false

question

If a patient receives a _____________ from a healthcare organization it indicated that the patient's protected health information was involved in a data breach.

answer

Protected Health Breach Notice

question

Codes are associated with reimbursement rates and therefore, there are inherent incentives to code so the healthcare facilities will receive the lowest reimbursement dollar amount possible.

answer

false

question

_____ is the fraudulent use of an individual's identifying information in a healthcare setting.

answer

Medical identity theft

question

HIM professionals are able to assist patients with the process of finding out what happened in case of medical identity theft and help guide the patient in fixing the errors in the record.

answer

true

question

What is the committee of the organization tasked with reviewing ethics violations and determining the course of action required to remedy the violations.

answer

Ethics Committee

question

If a patient notices an unknown item in the explanation of benefits they receive from an insurance company and they do not recognize the service being paid for, the patient should_____.

answer

Contact the insurer and the provider who billed for the services to correct the information

question

Breach of healthcare ethics is the situation in which ethics are violated, whether it is intentional or accidental.

answer

true

question

Healthcare providers add documentation after care has been given

answer

retrospective

question

The minimum necessary standard for ROI

answer

need to know principle

question

The practice of using multiple codes to bill for the various individual steps in a single procedure rather than using a single code that includes all of the steps

answer

unbundling

question

The practice of assigning diagnostic or procedural codes that represent higher payment rates than the codes that reflect the documentation

answer

upcoding

question

The committee that oversees the clinical research that is conducted for healthcare, and has the responsibility over the ethical application of research

answer

international review board for the protection of human subjects IRB

question

The report that provides the foundation for ethical research

answer

Belmont report

question

Helps control the cost of healthcare by providing services at a fixed cost

answer

managed care

question

Two providers bill for one service provided to one patient

answer

double billing

question

A researcher determines what the maximum potential is for society compared to the minimum risk of harm done

answer

beneficence

question

When more information is needed, or the information needs to be clarified, in regards to coding

answer

query the physician

question

The right to determine what does or does not happen to him or her, this includes the informed consent process for human research subjects

answer

autonomy

question

What is the ability to accept and understand the beliefs and values of other people and groups?

answer

Cultural competence

question

_____ is the perceived or actual difference among people.

answer

Cultural diversity

question

The classification of people based on national origin or culture is called what?

answer

Ethnicity

question

The assumption that everyone within a certain group are the same

answer

Stereotyping

question

Pre-judging a person based on something such as age, education, or religion without reviewing all the information

answer

Prejudice

question

Prevents a person from having an impartial judgment

answer

bias

question

Legal and ethical concept that requires healthcare providers to protect health records and other personal and private information from unauthorized use or disclosure

answer

confidentiality

question

The means to control and protect access of health information and records

answer

security

question

The right of a patient to control the disclosure of protected health information

answer

privacy

question

Openness in decision making, honesty in communication and activity and ethical practices that command trust and support collaboration

answer

integritary

question

Visionary thinking, decisions responsive to membership and mission, and accountability for actions and outcomes

answer

leadership

question

Appreciation of the value of differing perspective, enjoyable experiences, courteous interaction, and celebration of achievements that advance a common cause

answer

respect

question

An abiding commitment to innovation, relevance, and continuous improvement in programs, products, and services

answer

quality

question

A professional code of ethics is adopted by an organization to guide the members in determining right and wrong conduct when performing the duties of their job.

answer

true

question

Patients trust that the information they share with their healthcare provider will be protected

answer

true

question

Healthcare consumers are increasingly concerned about security and the potential loss of privacy.

answer

true

question

Ethical obligation to the _______ include advocating change when patterns or system problems are not in the best interest of the patients and reporting violation of practice standards to the proper authorities.

answer

public

question

It is not the responsibility of an HIM professional to ensure patient documentation is accurate, timely, and created by authorized parties.

answer

false

question

Report all healthcare _________ required for external reporting purposes completely and accurately, in accordance with regulatory and documentation standards, and requirement and applicable official coding conventions, rules, and guidelines

answer

data element

question

According to the Standards of Ethical Coding, Coders apply accurate, complete and consistent coding practices for the production of high-quality healthcare data

answer

true

question

Healthcare professionals are trained in the ethical issues related to what system because staff may have access to more information than what is needed to do their job

answer

EHR

question

With an increase in medical identify theft, it is important for HIM professionals to help find and correct fraudulent information within a health record.

answer

TRUE

question

HIM professionals are not ethically obliged to give back to the HIM community by providing practice opportunities for students.

answer

false

question

To refuse to participate in or conceal unethical practices or procedures and report such practices is a principle and guidelines to what?

answer

AHIMA Code of Ethics

question

To refuse to participate in or conceal unethical practices or procedures and report such practices is a principle and guidelines to what?

answer

AHIMA Code of Ethics

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