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A health record technician has been asked to review the discharge patient abstracting portion of a proposed new computer system. Which of the following data sets would the technician consult to ensure the system collects all the federally required data elements for discharged Medicare and Medicaid inpatients in an acute-care hospital?

UHDDS

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

UACDS

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

Vocabulary Standards

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

Evaluate patters and trends of patient care

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

Purge oldest records to another location

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

Establish a data dictionary policy with associated standards

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 catalogued for each database. What would be the next logical step to determine the degree of data comparability among the databases?

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

A new HIM director has been asked by the hospital CIO to ensure data content standards are identified, understood, and 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?

Identify data content requirements for all areas of the organization

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

Data consistency

A family practitioner request 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?

Consultation

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

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

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

Medicare

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

The diseases to be reported are established by state law

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

Aggregate data

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

Medication record and clinical laboratory reports

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. 200,000 of these individuals were admitted with a principal diagnosis of infectious disease, and 700,000 had a diagnosis of hypertension. Given this information, which of the following would provide the best comparison data for Community Hospital?

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

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

Vital Signs record

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

32

What is (are) the format problem(s) with the following table?

Column headings are missing

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 admitted and discharged on May 2. What was the total number of inpatient service days for May 2?

240

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

Intrahospital mortality data

Community Hospital 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?

98.5%

Which of the following numbering systems is best for maintaining the encounters of a patient together?

Unit

A critical element of data retrieval planning is designing a:

Screen Layout

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

Master Patient Index

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

Master Patient Index

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

Integrated Health Record

Which of the following is a retention concern with health records?

Hardward Obsolescence

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

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

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 daily to retrieve and file records for each clinic day?

22.5 hours/day

A HIM department is projecting workforce needs for its document scanning process. The intent of the department is to scan 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?

100 hours

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

Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision

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, medical record ID, type of records coded and other data, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose?

Database Management System

Which of the following statements does not apply to ICD-9-CM?

It can be used to collect data about nursing care

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

Completeness

All of the following are functions of the Outpatient Code Editor, except:

Identify cases that don't meet medical necessity

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

Dehydration

The APC payment system is based on what system?

CPT/HCPCS codes

A patient was diagnosed with L4-5 lumbar neuropathy and discogenic pain. The patient underwent an intradiscal electrothermal annulopasty (IDET) in the radiology suite. What ICD-9-CM procedure code is used?

80.59, Other destruction of intervertebral disc

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-9-CM diagnosis code is:

786.50, Unspecified chest pain

Coding accuracy is best determined by:

A predefined audit process

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

52240

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

52240

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

58670

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

Placenta Previa

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

216.1

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?

One CPT code, adding the lengths of the lacerations together

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?

Query the physician

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

Face-to-face communication

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

Code the skin lesion

The patient was admitted to the hospital for treatment of a myocardial infarction (heart attack). A bypass procedure was performed on day 2. On day 4, the patient was diagnosed with sepsis, which was not present on admission. Sepsis is a major complication. Based solely on this information, which of the following is the correct MS-DRG assignment for this case?

235, Coronary bypass w/o cardiac cath w/MCC

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

Abstracted or indexed

Which of the following record types is most likely to impair an exceptional coder's productivity?

Hybrid Record

Continuuing coding education is required for:

All coders

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

Concurrent

An inpatient, acute-care coder must follow official ICD-9-CM coding guidelines established by the:

Cooperating Parties

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 (present on admission)?

Catheter-associated urinary tract infection

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

Principal diagnosis

A patient was admitted to the hospital on September 15, 2011, and discharged on October 5, 2011. To code this record correctly, the coder must use the version of ICD-9-CM updated on:

October 1, 2011

To comply with the Joint Commission standards, the HIM director wants to be sure that history and physician 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?

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

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

Medical necessity

What factor is medical necessity based on?

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

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 best first step in trying to rectify the current situation?

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

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

Discharge planning, retrospective review, and preadmission review

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

ICD-9-CM and CPT Coding

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

Legitimate need for access

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

Chargemaster description

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

Providing a financial incentive for coding claims improperly

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 is helping the hospital in increasing revenue. Which of the following should be done in this case?

Counsel the coder and stop the practice immediately

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

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

The utilization manager's role is essential to:

Prevent denials for inappropriate levels of service

The goal of coding compliance programs is to prevent:

Accusations of fraud and abuse

Which of the following is the approved method for implementing an organization's formal position?

Procedure

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

Delinquent record

Which of the following statements is true regarding HIPAA security?

Institutions are allowed flexibility in the way they implement HIPAA standards

If the coder misrepresents the patient's clinical picture through intentional incorrect coding or the omission or addition of diagnosis or procedure codes, this would be an example of:

Healthcare fraud

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

To determine whether standards of care are being met

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?

Conditions of Participation

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

Outcomes and Assessment Information Set

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

Licensure

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

Federal and state confidentiality laws

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

Audit Trail

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

National Practitioners Data Bank

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

Data Recovery

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?

Expert System

The HIM and IT departments are working together to justify additional employee password training. The additional training would cost approxomately $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. Given this data and approximately 40 password calls per day, can the cost of the additional training be justified?

Training will provide $146,000 savings in help desk support and can be justified

The following descriptors about the data element ADMISSION_DATE are included in a data dictionary: definition: date patient admitted 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:

A template was defined

Which of the following would be used to control user access in an electronic health record?

Database managment system

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

Automatically transcribes medical reports

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

Patient's laboratory value is 50

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

Drop-down menu

A software interface is a:

Program to exchange data

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

Best of breed

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

Certification Commission on Health Information Technology (CCHIT)

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?

chart tracking system

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?

chart tracking system

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 that are located across a wide geographic area?

Wide area network

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?

Access controls

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

SDLC

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

Database

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

Dependent on the data in the table

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

Intranet

Which tool is used to display performance data over time?

Run chart

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

National Committee for Quality Assurance

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

System

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

Medical Errors

Which of the following statements represents a barrier to implementing performance improvement?

Employees should not be notified of the change in advance

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?

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

A quality goal for the hospital is that 98 percent of the heart attack patients receive aspirin within 24 hours of arrival at the hospital. In conducting an audit of 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?

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

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?

Develop team ground rules for team communication

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

Brainstorming

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?

82

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

Occurrence Report

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

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

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

Clinical privileges

The National Patient Safety Goals score organizations on areas that:

Commonly lead to patient injury

An audit of the document imaging process reveals that the HIM department staff is canning 250 pages per hours 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?

76 Pages

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 development. What fundamental team leadership mistake is the HIM director making with composition of the team?

Insufficient knowledge of team members

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

Identify areas that need improvement

Which of the following is an example of an advance directive?

Living Will

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

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

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 clini's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

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

The Admissions director maintains that a Notice of Privacy Practices must be provided to the patient on each admission. How should the HIM director respond?

Notice of Privacy Practices is required on the first provision of service

A hospital receives a valid request from a patient for copies of her medical 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?

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

A patient request copies of her medical records on CD. When the patient goes home, she finds that she cannot read the CD on her computer. The patient then requests the hospital to provide the records in paper format. How should the hospital respond?

Provide the records in paper format

A patient requests a copy of his medical 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?

Provide copies of the records within 60 days

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

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

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?

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

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

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

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 advise be done first for identifying the components of the legal health record?

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

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

By the hospital

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

Privacy

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

Health records in any format

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?

Identification of the record as the one subpoenaed

Which of the following individuals may authorize release of information?

A married 15-year-old father

On review of the audit trail for an EHR system, the HIM director discovers that a department 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?

Determine what information was printed and why

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

Hard coding

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

100%

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?

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

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:

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

The Accounts Not Selected for Billing Report is used to track accounts that are:

In bill hold or in error and awaiting billing

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

Indemnity

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

Premium

Major medical insurance covers:

Catastrophic illnesses and injuries

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

Dental Services

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 the calendar year?

Three

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

Billing for services not furnished to patients

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

Benefit cap

In most instances, the "owner" of the Charge Description Master (CDM) in a healthcare facility is the:

Finance Department

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