question

Which one of the following indices contains a list maintained in procedure code number order for patients who are discharged from a facility during a particular time period?

answer

Operation

question

Cancer registries receive approval as part of the facility cancer program from which of the following agencies?

answer

American College of Surgeons

question

Messaging standards for electronic data interchange in healthcare have been developed by:

answer

HL7

question

What is the term that is used to mean ensuring that data are not altered during transmission across a network or during storage?

answer

Integrity

question

The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system area?

answer

Laboratory

question

A secondary purpose of the health record is to provide support for which of the following?

answer

Research

question

Which of the following indexes and databases includes patient-identifiable information?

answer

Master patient/population index

question

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

answer

Operative report

question

Which of the following numbering systems us best for maintaining encounters of a patient's health record together?

answer

Unit

question

A health information technician is responsible for designing a data collection form to collect data on patients in an acute-care hospital. The first resource that she should use is:

answer

UHDDS

question

The practice of undercoding can affect a hospital's MS-DRG case mix in which of the following ways?

answer

Makes it lower than warranted by the actual service/resource intensity of the facility

question

Coding accuracy is best determined by:

answer

A predefined audit process

question

Cancer registries are established by hospitals:

answer

Voluntarily or by state law

question

A patient is admitted to the hospital with acute lower abdominal pain. The principal diagnosis is acute appendicitis. The patient also has a diagnosis of diabetes. The patient undergoes an appendectomy and subsequently develops two wound infections. In the DRG system, which of the following could be considered a comorbid condition?

answer

Diabetes

question

Medicare outpatients are grouped by:

answer

APC

question

A coder might find which of the following on a patient's problem list if the medication list contains the drug Procardia?

answer

Hypertension

question

When coding a benign neoplasm of skin of the vermilion border of the lip, which of the following codes should be used?

answer

D10.0

question

Placenta with delivery of twins. This patient had two prior cesarean sections. She also has a third-degree perineal laceration. This was an emergent C-section due to hemorrhage associated with the placenta previa. The appropriate principal diagnosis would be:

answer

Placenta previa

question

Quality standards for coding accuracy should be:

answer

As close to 100 percent as possible

question

Which of the following conditions are included on the hospital-acquired conditions provision list?

answer

Pressure ulcers, catheter-associated urinary tract infections, falls and fractures.

question

In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?

answer

Nursing staff

question

Which of the following is required by HIPAA law?

answer

A written contingency plan

question

what is the term for an explicit statement that directs clinical decision making?

answer

Evidence-based practice guideline

question

The protection measures and tools for safeguarding information and information systems is a definition of:

answer

Data security

question

Which of the following practices is not an appropriate coding compliance activity?

answer

Providing a financial incentive for coding claims improperly

question

Site-of-service documents to help providers develop compliance programs have been published by the:

answer

Office of the Inspector General (OJG)

question

A coding analyst consistently enters the wrong code for patient gender in the computer billing system. What security measures should be place to minimize this security breach?

answer

Edit checks

question

Which of the following would be the best technique to ensure nurses do not omit any essential information on the nursing intake assessment in an EHR?

answer

Make all essential data fields required

question

Which of the following dictates how a medical stall operates?

answer

Bylaws

question

Two coders have found the same abbreviation on two records. One abbreviation of "O.D." was used on an eye health record to mean "right eye." The other abbreviation on another patient's record was used to mean "overdose" on an abuse record. What data quality component is lacking here?

answer

Consistency

question

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

answer

State retention requirements

question

In a managed fee-for-service arrangement, which of the following would be used as a cost-control process for inpatient surgical services?

answer

Prospectively precertify the necessity of inpatient services

question

All of the following are steps in medical necessity and utilization review, except

answer

Access consideration

question

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.

answer

Commission on Accreditation of Rehabilitation Facilities

question

The OIG states that insufficient or missing documentation and one of the following are responsible for 70 percent of bad claims submitted to Medicare

answer

Failure to document medical necessity

question

Which of the following can be used the discover current hot areas of compliance?

answer

The OIG workplan

question

Which of the following would be part of the release of information system?

answer

Letter notifying individual that the authorization was invalid

question

Which of the following statements does not represent a principle of contemporary performance improvement?

answer

Performance improvement works by identifying the individuals responsible for quality problems and reprimanding them

question

The hospital is revising its policy on health record documentation. Currently, all entries in the health record must be legible, complete dated, and signed. The committee chairperson wants to add that all entries must have the time noted. However, another clinician suggests that adding the time of notation is difficult and rarely may be correct because personal watches and the hospital clocks may not be coordinated. Another committee member agrees and says that only electronic documentation needs a time stamp. Given this discussion, which of the following might the HIM director suggest?

answer

Inform the committee that according to the conditions of participation, all documentation must include date and time

question

An HIM professional is the leader of the quality improvement team. To ensure all team members understand purpose of the team, which of the following actions should be taken?

answer

Develop a mission statement

question

The HIM supervisor suspects that a departmental employee is accessing the EHR for personal reasons but has no specific data to support this suspicion. In this case, what should the supervisor do?

answer

Ask the security officer for audit trail data to confirm or disprove the suspicion

question

Community Hospital wants to provide transcription services for office notes of the private patients of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing to launch this service, the HIM director is asked whether a business associate agreement is necessary. Which of the following should the hospital HIM director advise in order to comply with HIPAA regulations?

answer

Each physician practice should obtain a business associate agreement with the hospital

question

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

answer

Employees

question

A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the HIM department and requests to review her health record. Of the options here, what is the best course of action?

answer

Allow her to review her record after obtaining authorization from her

question

What is the status conferred by a national professional organization that is dedicated to a specific area of healthcare practice?

answer

Credential

question

The scope of performance improvement measurements that help identify important areas of service used by a healthcare organization are:

answer

Volume, risk, problem-prone outcomes

question

An audit of the document imaging process reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard?

answer

114/0.60=190-114=76 pages

question

Which of the following is a data collection tool that records current processes?

answer

Flow chart

question

A record that fails quantitative analysis is missing the quality criterion of:

answer

Completeness

question

A Joint Commission -accredited organization must review its formulary annually to ensure a medication's continued:

answer

Efficacy and safety

question

This type of performance measure focuses on a process that leads to a certain outcome, meaning that a scientific or experiential basis exists for believing that the process, when executed well, will increase the probability if achieving a desired outcome

answer

Process measure

question

A coding supervisor who makes up the weekly work schedule would engage in what type of planning?

answer

Operational

question

Periodic performance reviews:

answer

Encourage good performance

question

As part of the clinic's performance improvement program, an HIM director wants to implement benchmarking for the transcriptionist division at large physician clinic. The clinic has 21 transcriptionists who average about 140 lines per hour. The transcription unit supports 80 physicians at a cost of 15 cents per line. What should be the first step that the supervisor takes to establish benchmarks for the transcription division?

answer

Clearly define what is to be studied and accomplished by instituting benchmarks

question

Which of the following should be the first step in any quality improvement decision-making process?

answer

Identifying the problem

question

The primary objective of quality in healthcare for both patient and provider is to:

answer

Arrive at the desired outcomes

question

Performance standards are used to:

answer

Communicate performance expectations

question

Total quality management and continuous quality improvement are well-known

answer

Performance improvement models

question

Which tool is used to display performance data over time?

answer

Run chart

question

Every healthcare organization's risk management plan should include the following components except:

answer

Peer review

question

The quality improvement organizations (QIOs) under contract with CMS conduct audits on high-risk and hospital-specific data from claims data in this report:

answer

Program for Evaluation Payment Patterns Electronic Report

question

The credentialing process o independent practitioners within a healthcare organization must be defined in:

answer

Medical staff bylaws

question

A performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements is called:

answer

Indicator

question

Many organizations and quality experts define quality as meeting or exceeding:

answer

Customer expectations

question

A hospital is reviewing the quantity and type of resources being used in the provision of chemotherapy treatments. This is an example of:

answer

FOCUS-PDCA review

question

When all required data elements are included in the health record, the quality characteristic for data _______ is met.

answer

Comprehensiveness

question

When the patient's physician contacts a healthcare organization to schedule an episode of care service, the healthcare organization begins which step in the case management process?

answer

Preadmission care planning

question

Which of the following is a technique used to generate a large number of creative ideas from a group?

answer

Brainstorming

question

"I reviewed the patient's record of Mr.Brown and found there was no H;P on the record at seven hours past this patient's admission time." This would be an example of:

answer

Quantitative analysis

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

An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system?

answer

Uniform Ambulatory Core Data Set (UACDS)

question

Standardizing medical terminology to avoid differences in naming various health conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallux valgus) is one purpose of:

answer

Vocabulary Standards

question

Patient care managers use the data and information documented in the health record to:

answer

Evaluate patterns and trends of patient care

question

The active storage area for health records at Community Hospital is almost filled. To create more space in the storage area, which of the following should be done?

answer

Purge oldest records to another location

question

As part of the initiative to improve data integrity, the Data Quality Committee conducted an inventory of all the hospital's databases. The review showed that more than 70 percent of the identified databases did not have data dictionaries. Given this data, what should be the committee's first section?

answer

Establish a data dictionary policy with associated standards

question

Community Hospital has more than 100 clinical databases. The Data Quality Committee is studying the comparability among the databases. The data elements and data definitions are cataloged for each database. What would be the next logical step to determine the degree of data comparability among the databases?

answer

Select ta representative set of data elements and track these across the databases to identify consistencies and differences

question

A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility?

answer

Identify data content requirements for all areas of the organization

question

At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a probem in:

answer

Data Consistency

question

A family practitioner requests the opinion of a physician specialist, who reviews the patient's health record and examines the patient. The physician specialist would record findings, impressions, and recommendations in what type of report?

answer

Consultation

question

Which of the following is a key characteristic of the problem-oriented health record?

answer

Uses an itemized list of the patient's past and present health problems

question

Based on the payment percentages provided in this table, which payer contributes most to the hospital's overall payments?

answer

Medicare

question

Which of the following is true regarding the reporting of communicable diseases?

answer

The diseases to be reported are established by state law

question

Data elements collected on large populations of individuals and stored in databases are referred to as

answer

Aggregate data

question

A health data analyst has been asked to compile a report of the percentage of patients who had a baseline partial thromboplastin time (PTT) test performed prior to receiving heparin. What clinical reports in the health record would the health data analyst need to consult in order to use prepare this report?

answer

Medication record and clinical laboratory reports

question

Community Hospital wants to compare its hospital-acquired urinary tract infection (UTI) rate for Medicare patients with the national average. The hospital is using the MEDPAR database for its comparison. The MEDPAR database contains 13,000,000 discharges. Of these individuals, 200,000 were admitted with a principal diagnosis of UTI: another 300,000 were admitted with a principal diagnosis of infectious disease, and 7000, 000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital?

answer

All individuals in the MEDPAR database except those admitted with a principal diagnosis of UTI or infectious disease.

question

A health data analyst has been asked to compile a listing of daily blood pressure readings for patients with a diagnosis of hypertension who were treated on the medicine unit within a two-week period. What clinical report would be the best source to gather this information?

answer

Vital signs record

question

Given the numbers 47, 20, 11, 33, 30, 30, 35, and 50, what is the median?

answer

([30+33]/2)=31.5

question

what format problem is in the following table?

answer

Column headings are missing

question

Community Hospital had 250 patients in the hospital at midnight on May 1. The hospital admitted 30 patients on May 2. The hospital discharged 40 patients, including deaths, on May 2. Two patients were both submitted and discharged on May 2. What was the total number of inpatient service days for May 2?

answer

[(250+30)-40]+2=242

question

An example of data collected by the Joint Commission for the ORYX initatives is:

answer

Intrahospital mortality data

question

Community Hospital's HIM department conducted a random sample of 600 health records to determine the rate of filing accuracy. Nine misfiles were identified. Which of the following percentages represents the filing accuracy at Community Hospital?

answer

9581/600) x 100=98.5%

question

Which of the following numbering systems is best for maintaining the encounters of a patient's health record together?

answer

Unit

question

The HIM manager is conducting a study in which she is comparing the ICD-9-CM and ICD-10-CM diabetes mellitus codes and documenting variations in order to assess the impact on the organization. This process creates a:

answer

Data map

question

Which of the following is considered the authoritative key in locating a health record?

answer

Master patient index

question

The paper-based health record format that organizes all forms in chronological order is known as a(n):

answer

Integrated health record

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

The RHIT supervisor for the filing and retrieval section of Community Clinic is developing a staffing schedule for the year. The clinic is open 260 days per year and has an average of 500 clinic visits per day. The standard for filing records is 50 records per hour. The standard for retrieval of records is 40 records per hour. Given these standards, how many filing hours will be required dailyg to retrieve and file records for each clinic day?

answer

(500/50)+(500/40)=22.5 hours/day

question

A HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan patient patient records at the time of discharge, providing a 24-hour turnaround time. The hospital has an average daily discharge of 120 patients, and each patient record has an average of 200 pages. Given the benchmarks listed here, what is the least amount of work hours needed each day to meet a 24-hour turnaround time?

answer

100 hours

question

Which of the following provides a means to record information about patients treated for substance abuse and mental disorders?

answer

International Classification of Diseases, Ninth Revision, Clinical Modifcation

question

The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and other data and to provide weekly productivity reports and analyses. Which of the following tools would be the best to use for this purpose?

answer

Database management system

question

Which of the following is a goal of ICD-10-PCS?

answer

Reduce inconsistency due to overlapping of terms

question

Which of the following elements of coding quality represent the degree to which the codes capture all the diagnoses and procedures documented in the patient's health record?

answer

Completes

question

All of the following are functions of the outpatient code editor except:

answer

Identify cases that don't meet medical necessity

question

A patient is admitted for the treatment of dehydration secondary to chemotherapy for primary liver cancer. IV fluids were administered to the patient. Which of the following should be sequenced as the principal diagnosis?

answer

dehydration

question

The APC payment system is based on what coding system?

answer

CPT/HCPCS codes

question

A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure?

answer

Extirpation

question

A patient was seen in the emergency department for chest pain. It was suspected that the patient may have gastroesophageal reflux disease (GERD). The final diagnosis was "Rule out GERD." The correct ICD-10-CM diagnosis code is:

answer

R07.9, Chest pain unspecified

question

Carcinoma of multiple overlapping sites of the bladder. Diagnostic cystoscopy and transurethral fulguration of bladder lesions (1.9 cm, 6.0 cm) are undertaken. Which of the following CPT codes would be most appropriate?

answer

52240

question

A laparoscopic tubal ligation is undertaken. Which of the following is the correct CPT code assignment?

answer

58760

question

A patient had a placenta previa with delivery of twins. The patient had prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be:

answer

Placenta previa

question

When coding a benign neoplasm of skin of the left eyelid, Which of the following codes should be used?

answer

D23.12

question

In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding?

answer

One CPT code, adding the lengths of the lacerations together

question

Carolyn works as a coder in a hospital inpatient department. She sees a lab report in a patient's health record that is positive for staph infection. However, there is no mention of staph in the physician's documentation. What should Carolyn do?

answer

Query the physician

question

To clarify documentation, the preferred method of contact between a coder and a physician is:

answer

Face-to-face communication

question

A skin lesion was removed from a patient's cheek in the dermatologist's office. The dermatologist documents skin lesion, probable basal cell carcinoma. Which of the following actions should the coding professional take to code this encounter?

answer

Code skin lesion

question

The patient was admitted to the hospital for treatment of a myocardial infarction (heart attack). A bypass procedure was performed on day two. On admission, the patient was diagnosed with sepsis. Sepsis is a major complication. Based soley on this information, which of the following is the correct MS-DRG assignment for this case?

answer

235, Coronary bypass w/o cardiac cath w MCC (major complication and comorbidities)

question

To use a data element for aggregation and reporting, that data element must be:

answer

Abstracted or indexed

question

Which of the following record types is most likely to repair and experienced coder's productivity?

answer

Hybrid record

question

Continuing coding education is required for:

answer

Inpatient coders

question

An alternative to the retrospective coding model is the _____ coding model in which records are coded while the patient is still an inpatient.

answer

Concurrent

question

An inpatient, acute-care coder must follow official ICD-10-CM/PCS coding guidelines established by the:

answer

Cooperating parties

question

A patient was admitted to the hospital with symptoms of a stroke and secondary diagnoses of COPD and hypertension. The patient was subsequently discharged from the hospital with a principal diagnosis of cerebral vascular accident and secondary diagnoses of catheter-associated urinary tract infection, COPD, and hypertension. Which of the following diagnoses should not be reported as POA?

answer

Cathetere-associated urinary tract infection

question

The first step in an inpatient record view is to verify correct assignment of the:

answer

Principal diagnosis

question

A patient has a malunion of an interochanteric fracture of the right hip, which is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure?

answer

0Q860ZZ

question

To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. Which of the following would be the best way to ensure the completeness of the health record?

answer

Review each patient's health record concurrently to make sure that history physicals are present

question

Local coverage determinations (LCD) describe when and under what circumstances which of the following is met:

answer

Medical necessity

question

What factor is medical necessity based on?

answer

The beneficial effects of a service for the patient's physical needs and quality of life

question

The HIM director is having difficulty with the emergency services on-call physicians completing their health records. Three deficiency notices are sent to the physicians including an initial notice, a second reminder, and a final notification. Which of the following would be the first step in trying to rectify the current situation?

answer

Consult with physician in charge of the on-call doctors for suggestions on how to improve response to the current notices.

question

Which of the following are basic functions of the utilization management process?

answer

Discharge planning, retrospective review, and preadmission review

question

In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited?

answer

ICD-10-CM and ICD-10-PCS coding

question

Access to health records based on protected health information within a healthcare facility should be limited to employees who have a:

answer

Legitimate need for access

question

In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit?

answer

Chargemaster description

question

In performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis and procedure codes specifically for the purpose of obtaining a higher level of reimbursement. The coder believes that this practice helps the hospital in increasing revenue. Which of the following should be done in this case?

answer

Counsel the coder and stop the practice immediately

question

If a physician does not provide a diagnosis to justify the medical necessity of a service, the provider may obtain payment from the patient:

answer

Only if properly executed ABN was obtained before the service was provided.

question

The utilization manager's role is essential to:

answer

Prevent denials for inappropriate levels of service

question

The goal of coding compliance programs is to prevent:

answer

Accusations of fraud and abuse

question

Which of the following is the approved method for implemented an organizational's formal position?

answer

Procedure

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):

answer

Delinquent record

question

Which of the following statements is true regarding HIPAA security?

answer

Institutions are allowed flexibility in the way they implemented HIPAA standards.

question

A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of:

answer

Healthcare fraud

question

How do accreditation organizations such as the Joint Commission use the health record?

answer

To determine whether standards of care are being met

question

Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs?

answer

Conditions of Participation

question

Which of the following specialized patient assessment tools must be used by Medicare-certified home care providers?

answer

Outcomes and Assessment Information Set

question

Before healthcare organizations can provide services, they usually must obtain _________ by government entities such as the state or country in which they are located.

answer

Licensure

question

The release of information function requires the HIM professional to have knowledge of:

answer

Federal and state confidentially laws

question

A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n):

answer

Audit trail

question

This database maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers.

answer

National Practitioner Data Bank

question

When data has been lost in an EHR, which action is taken to remedy this problem?

answer

Data recovery

question

Which of the following is used to support the work of professionals engaged in the design, diagnosis, or evaluation of complex situations requiring special knowledge in a limited area?

answer

Expert system

question

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approximately $100,000 with the expectation that password calls to the IT help desk will be reduced by 20 percent. The IT department has done a cost analysis of help desk calls solving password issues. Give this data and approximately 40 password calls per day, can the cost of the additional be justified?

answer

Training will provide $1460,00 savings in help desk support and can be justified.

question

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient submitted to the hospital; data type: date; field length: 15; required field: yes; default value: none; template: none. For this data element, data integrity would be better assured if:

answer

A template was defined

question

Which of the following would be used to control user access in an EHR?

answer

Database management system

question

Which of the following is not an advantage offered by computer-based clinical decision support tools?

answer

Automatically transcribe medical reports

question

Which of the following best represents the definition of the term data?

answer

Patient's laboratory value is 50

question

In designing an input screen for an EHR, which of the following would be the best to capture discrete data?

answer

Drop-down menus

question

A software interface is a:

answer

Program to exchange data

question

When a hospital uses many different vendors to support its information system needs, the information technology strategy being used is called:

answer

Best of breed

question

Before purchasing an EHR system, a clinical office practice should consult which of the following to ensure the system meets HL7 standards EHR system functionality?

answer

Certification Commission for Health Information Technology (CCHIT)

question

A hospital HIM department wants to purchase an electronic system that records the location of health records removed from the filing system and documents the date of their return to the HIM department. Which of the following electronic systems would fulfill this purpose?

answer

Chart tracking system

question

Which of the following computer architectures would be best for implementing an EHR for a healthcare system that needs to transmit data to its various campuses located across a wide geographic area?

answer

Wide area network

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

Which of the following is the traditional manner of planning and implementing an information system?

answer

SDLC

question

Which of the following is defined as an organized collection of data?

answer

Database

question

Which of the following is not true about a primary key in a database table?

answer

Dependent on the data in the table

question

Which of the following allows corporations to supply Internet services over their LANs?

answer

Intranet

question

The organization that coordinates the collection of performance data for managed care plans is the:

answer

National Committee for Quality Assurance

question

Problems in patient care and other areas of the healthcare organization are usually symptoms inherent in a(n):

answer

System

question

The Leapfrog Group seeks to voluntarily collect data from hospitals about:

answer

Medical errors

question

The leaders of healthcare organization are expected to select an organization-wide performance improvement approach and to elderly defined how all levels of the organization will monitor and address improvement issues. The Joint Commission requires ongoing data collection that might require improvement for which of the following areas?

answer

Operative and other invasive procedures, medication management, and blood and and blood product use.

question

As part of Community Hospital's organization-wide quality improvement initiative, the HIM director is establishing benchmarks for all of the divisions within the HIM department. The following table shows sample productivity benchmarks for record assembly the director found through a literature search. Given this information, how should the director proceed in establishing benchmarks for the department?

answer

Determine whether the source of benchmark data is from a comparable institution

question

A quality goal for the hospital is that 98 percent of the heart attack patients, the data showed that 94 percent of the patients received aspirin within 24 hours of arriving at the hospital. Given this data, which of the following actions would be best?

answer

Determine whether there was medical or other reason why patients were not given aspirin

question

The hospital's Performance Improvement Council has compiled the following data on the volume of procedures performed during 2011. Given this data, which procedures should the council scrutinize in evaluating performance?

answer

Procedures 1,4,6,7

question

A member of the hospital's documentation improvement team consistently interrupts others during team meetings. This practice hinders the efficiency of the team. Which of the following would be the best action to take to remedy this situation?

answer

Develop team ground rules for team communication

question

A coding supervisor wants to use a fixed percentage random sample of work output to determine coding quality for each coder. Given the work output for each of the four coders shown here, how many total records will be needed for the audit if a 5 percent random sample is used?

answer

82

question

The risk manager's principal tool for capturing the facts about potentially compensable events is the:

answer

Occurrence report

question

Which of the following statements does not apply to system thinking?

answer

Variations in the way a system works are always caused by factors outside the system

question

The medical staff is the aggregate of physicians who have been granted permission to provide services in the hospital. What is this permission called?

answer

Clinical privileges

question

The national patient safety goals score organizations on areas that:

answer

Commonly lead to patient injury

question

An audit of the document imaging reveals that the HIM department staff is scanning 250 pages per hour and indexing 114 pages per hour. If the department is meeting its productivity standard for scanning, but is only meeting 60 percent of the indexing standard, how many more pages per hour must be indexed to meet the indexing standard?

answer

76 pages

question

The HIM director has put together a group of department employees to develop coding benchmarks for the number and types of charts to be coded per work hour. The group includes seven employees from the analysis, transcription, release of information, and coding sections. No managers are included on the team because the HIM director wants a bottom-up approach to benchmark department. What fundamental team leadership mistake is the HIM director making with composition of the team?

answer

Insufficient knowledge of team members

question

The quality improvement organizations (QIOs) use peer review, data analysis, and other tools to:

answer

Identify areas that need improvement

question

Which of the following is an example of advance directive?

answer

Living will

question

Community Hospital is terminating its business associate leadership with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case, how should the director of HIM advise the CFO?

answer

Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned

question

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name int the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

answer

There is no violation of HIPAA in announcing a patient's name, but the committee may want to consider implementing practices that might reduce this practice

question

The admissions director maintains that a notice of privacy must be provided to the patient on each admission. How should the HIM director respond?

answer

Notice of privacy practices is required on the first provision of service

question

A hospital receives a valid request from a patient for copies of her health records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct?

answer

No; the records from the previous hospital are considered to be included in the designated record set and should be given to the patient

question

A patient requests copies of her medical records in an electronic format. The hospital does not maintain all of the designated records in an electronic format. How should the hospital respond?

answer

Provide the records paper format only

question

A patient requests a copy of his health records. When the request is received, the HIM clerk finds that the records are stored off-site. Which of the following actions must the hospital take to be in compliance with HIPAA regulations?

answer

Provide copies of the records within 60 days

question

Which of the following definitions best describes the concept of confidentially?

answer

The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose.

question

Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report?

answer

Present an authorization that at least one of them (Ted or Mary) has assigned

question

A health information technicians receives a subpoena ad testificandum. To respond to the subponea, which of the following should the technician do?

answer

Review the subpoena and appear at the time and place supplied to give testimony

question

A medical group practice has contracted with an HIM professional to help define the practice's legal health record. Which of the following should the HIM professional perform first to identify the components of the legal health record?

answer

Develop a list of statutes, regulations, rules, and guidelines that contain requirements affecting the release of health records

question

Hospital physical documents relating to the delivery of patient care such as health records, x-rays, laboratory reports, and consultation reports are owned:

answer

By the hospital

question

The right of an individual to keep personal health information from being disclosed to anyone is a definition of:

answer

Privacy

question

What types of covered entity health records are subject to the HIPAA privacy regulations?

answer

Health records in any format

question

The record custodian typically can testify about which of the following when a party in a legal proceeding is attempting to admit a health record as evidence?

answer

Identification of the record as the one subpoenaed.

question

Which of the following individuals may authorize release of information?

answer

A married 15-year-old father

question

On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this case, what should the supervisor do?

answer

Determine what information was printed and why

question

Using the charge description master (CDM) to automatically link a service to the appropriate CPT/HCPCS code is referred to as:

answer

Hard coding

question

From the information provided in this table, what percentage will the facility be paid for procedure 25500?

answer

100%

question

After appropriate diagnostic and procedural codes are assigned, which of the following must be performed for the provider to be reimbursed in a fee-for-service payment arrangement?

answer

Assign a fee to each service from the provider's standard fee schedule

question

Joe patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days. Community Hospital will receive from Medicare:

answer

A per diem rate for the two-day stay, and Big Medical Center will receive the full DRG payment

question

The accounts not selected for billing report is used to track accounts that are:

answer

In bill hold or in error and awaiting billing

question

Which of the following plans reimburses patients up to a specified amount?

answer

Indemnity

question

Which of the following terms is used for the amount charged for a medical insurance policy?

answer

Premium

question

Major medical insurance covers:

answer

Catastrophic illness and injures

question

In process a bill for healthcare services, which of the following would be excluded under Medicare Part A?

answer

Dental Services

question

Mrs. Smith is a 75-year-old patient who only has Medicare's Part A insurance. Using the following information how many benefit periods did the patient use during this calendar year?

answer

Three

question

Which of the following is an example of a common form of healthcare fraud and abuse?

answer

Billing for services not furnished to patients

question

An overarching limitation or maximum dollar plan limit on an insurance plan is also known as a:

answer

Benefit cap

question

In most instances, the "owner" of the charge description master (CDM) in a healthcare facility is the:

answer

Finance department

question

A Clinical documentation Improvement (CDI) program facilities accurate coding and helps coders avoid:

answer

Assumption coding

question

The deception or misrepresentation by a healthcare provider that may result in a false or fictitious claim for inappropriate payment by Medicare or other insurers for items or services either not rendered or rendered to a lesser extend than described in the claim is:

answer

Healthcare fraud

question

A ________ assists in educating medical staff members on documentation needed for accurate billing.

answer

Physician champion

question

Which of the following data sets would be most helpful in developing a hospital trauma data registry?

answer

DEEDS

question

Dr. Jones comes into the HIM department and requests that the HIM director pull all of his records from the previous year that show a principal diagnosis of myocardial infarction. What would the HIM director begin to pull these records?

answer

A disease index

question

Community Hospital's HIM department conducted a random sample of 540 health records to determine the rate of filing accuracy. Thirteen misfiles were identified. Which of the following percentages represent the filing accuracy at Community Hospital?

answer

(527/540) x 100=97.6%

question

Activities of daily living (ADL) are components of:

answer

OASIS

question

Managing an organization's data and those enter it is an ongoing challenge requiring active administration and oversight. This can be accomplished by the organization through management of which of the following?

answer

Data dictionary

question

A consumer nonprofit organization wants to conduct studies on the quality of care provided to Medicare patients in a specific region. A HIT professional has been hired to manage this project. The nonprofit organization asks the HIT professional about the viability of using billing data as the basis for its analysis. Which of the following would not be a quality consideration in using billing data?

answer

Cost to process the data

question

In a routine health record quantitative analysis review, it was found that a physician dictated a discharge summary on 1/26/2010. Because of unexpected complications, however, the patient was discharged two days after the discharge summary was dictated. What would be the best course of action in this case?

answer

Request that the physician dictate an addendum to the discharge summary

question

A hospital's EHR defines the expected values of the gender data element as female, male, and unknown. This type of specificity is known as:

answer

Data precision

question

Which of the following documentation must be included in a patient's health record prior to performing a surgical procedure?

answer

Consent for operative procedure, history, physical examination

question

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

answer

Operative Report

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