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Study Notes

In preparation for an EHR, you are conducting a total facility inventory of all forms currently used. You must name each form for bar coding and indexing into a document management system. The unnamed document in front of you includes a microscopic description of tissue excised during surgery. The document type you are most likely to give to this form is:

Pathology report

A health record analyst needs to quickly compare all lab values during one hospitalization. The paper-based health record format best suited for this purpose is

Source Oriented

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Federal Register

As a new HIM manager of an acute care facility, you have been asked to update the facility's policy for a physician's verbal orders in accordance with Joint Commission standards and state law. Your first area of concern is the qualifications of those individuals in your facility who have been authorized to record verbal orders. For this information, you will consult.

Hospital Bylaws, Rules, and Regulations

Medicare rules state that the use of verbal orders should be infrequent, and used only when the orders cannot be written or given electronically. In addition, verbal orders must be

accepted by persons authorized by hospital regulations and procedures

The lack of a discharge order may indicate that the patient left against medical advice. If this situation occurs, you would expect to see the circumstances of the leave.

documented in both the progress notes and discharge summary

Joint Commission standards require that at least one post-anesthesia visit be recorded on the health records of operative patient. Does this post-anesthesia note carry a time requirement?

yes, within 24 hours of surgery

Discharge summary documentation must include

significant findings during hospitalization

The protection of a patient's health information is addressed in each of the following EXCEPT:

A)Health Insurance Portability and Accountability Act
B)Privacy Act C) Drug Abuse and Treatment Act
* D) U.S. Patriot Act *

The failure to obtain the written consent of the patient before performing a surgical procedure may constitute


A written authorization from the patient releasing copies of his or her medical records is required by all of the following EXCEPT:

the hospital attorney for the facility where the patient is treated

When developing a record retention policy, the HIM professionals should consider all of the following EXCEPT:

the thickness of the records

A valid authorization for the disclosure of health information should not be

dated prior to discharge of the patient

Who is legally responsible for obtaining the patient's informed consent for surgery?

the surgeon performing the surgery

A signed consent for release of information dated December 1, 2005, is received with a request for the chart from the patient's admission of 12/5/05. Indicate the appropriate response from the options below.

Request another authorization dated after the discharge date

HIPAA requires that certain covered entities provide every patient a Notice of Privacy Practices that sets forth all of the following EXCEPT:

covered entities provide every patient with its annual business report

Which of the following is considered confidential information?

patient's diagnosis

Which would be the better "best practice" for handling fax transmission of a physician's orders?

Treat faxed orders like verbal orders and require authentication of the orders by appropriate medical staff within the required time period.

The proper method for correcting a documentation error in a medical record is for the author to

draw a single line through the incorrect information, date, and initial the change

Written consent from the patient is required for which of the following in order to learn a patient's HIV status?

insurance companies

Which of the following agencies is empowered to implement the law governing Medicare and Medicaid?

Health Care Financing Administration (now known as CMS)

What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, 14-32-79?

straight numeric

What is the chief criterion for determining record inactivity?

amount of space available for storage of newer records

According to terminal digit filing, what would be the number of the record immediately after record number 99-99-30?


A HIM Department, currently using 2,540 linear filing inches to store records, plans to purchase new open-shelf filing units. Each of the shelves in a new 6-shelf unit measures 36 linear filing inches. It is estimated that an additional 400 filing inches should be planned for to allow for 5-year expansion needs. How many new file shelving units should be purchased?


In planning for a file system conversion to a new physical location, it is wise to schedule the actual conversion process to occur

at an off-peak time for the department such as a weekend (Friday to Monday)

Unless state or federal laws require longer time periods, AHIMA recommends that patient health information for minors be retained for at least how long?

age of majority plus statute of limitation

The HIM Department receives a request for a certified copy of a birth certificate on a patient born in the hospital 30 years ago. The Department should

direct the request to the state's office of vital records

Coastal Hospital is a covered entity under HIPAA. In order to comply with the requirements, they must train their workforce on policies and procedures with respect to protected health information (PHI). Which of the following levels of the workforce would be exempt from training?

A)HIM staff because they have already received training in release of information. B)staff physicians because they have taken the Hippocratic oath. C)administrative staff because they do not perform hands-on care **D) None of the above - no one is exempt.**

Under the ADA, prior to employment it is illegal to require a

pre-employment physical exam

You are preparing a training program for specific functional areas of the department (e.g. coding, transcription, etc.). Which of the following is the primary factor to consider in developing an effective training program?

objectives of each functional area

Your job description states that as Assistant Director of the Health Information Management Department, you will supervise day-to-day operations for the transcription, release of information, and coding areas. What principle of management is described?

span of control

A well-designed orientation program can help new employees become comfortable in the workplace. Which of the following statements about orientation programs is NOT true?

A good orientation program can substitute for a job-specific departmental training

As HIM director, you receive a call from the CEO informing you that she has received a complaint from a patient. The patient reports that one of the coders in your department revealed the patient's diagnosis to the patient's neighbor. What action is recommended?

Gather all the facts prior to meeting with the employee

In order to improve efficiency and productivity, which of the following sequence of steps is the most effective?

Know the objective; break down the work into component activities, and group activities into proper organizational units.

In preparing a capital budget request, the first priority will be to document

the need for the new equipment.

A work environment that is not ergonomically sound could lead to


The most realistic approach that could encourage increased productivity in the tedious record file/retrieval area is to

vary and rotate the work assigned to each file clerk.

If the budgeted payroll expense was $24,300 and the actual payroll expense was $25,800, what is the percentage of cost variance?

6.17% (25800-24300=1500 difference/budget amt.)

A job analysis includes the

collection of data to determine the content of a job.

James is admitted to the hospital for severe anemia that is a result of the chemotherapy treatments he is receiving for metastatic prostate cancer to bone. James receives blood transfusions and is discharged home.
185-Malignant neoplasm of prostate
198.5-Secondary malignant neoplasm, bone and bone marrow-285.22-Anemia in neoplastic disease - E933.1-Adverse effect of antineoplastic and immunosuppressive drugs

285.22, 185, 198.5, E933.1

A patient who is HIV positive and currently asymptomatic is admitted with a compound fracture of the tibia. The patient was treated previously for pneumocystis carinii pneumonia. Given the following codes, which is the correct coding and sequencing?
042-Human Immunodeficiency Virus (HIV) disease -136.3-Pneumocytosis carinii pneumonia
V08-Asymptomatic HIV infection status
823.90-Open fracture of tibia
823.80-Closed fracture of tibia

823.90, 042

Julia is an 80-year-old female with osteoporosis. She presents to the emergency department complaining of severe back pain. X-rays revealed pathological compression fractures of several vertebrae.

733.13, 733.00

What is the correct sequencing of the codes for a patient who is six weeks post mastectomy for carcinoma of the breast and is admitted for chemotherapy?

V58.11, 174.9

Tom is admitted with acute chest pain. Final diagnoses listed include: acute pulmonary edema with congestive heart failure, subendocardial anterior wall myocardial infarction, hypertensive heart disease and chronic obstructive pulmonary disease.

410.71, 402.91, 496, 428.0

Vaginal delivery of a full term live born infant. Patient undergoes episiotomy with repair and post delivery elective tubal ligation
V25.2-Elective sterilization -66.32-Bilateral ligation and division of fallopian tubes-650-Normal Delivery-V27.0-Single liveborn

650, V25.2, V27.0, 73.6, 66.32

Patient is admitted for elective cholecystectomy for treatment of chronic cholecystitis with cholelithiasis. Prior to administration of general anesthesia, patient suffers cerebral thrombosis. Surgery is subsequently canceled. Code and sequence the coding from the following codes.

574.10, 434.00, V64.1
Surgery or other procedure not carried out because of contraindication, Cholecystitis with cholelithiasis, not otherwise specified, Cerebral thrombosis, without mention of cerebral infarction

Dr. Brown insists on the new EHR assisting physicians in their decision-making process by using technology that brings available information to the attention of the physician. This is called

push technology

With data exchange standards, the ability to transfer data from one system to another system is called


One of the problems facing National Health Information Network is:


You have been hired to work with a computer-assisted coding intiative. The technology that you will be working with is:

natural language processing

At our integrated delivery system, the hospital and clinic have separate networks. There are times when they need to share information across the network. This can be accomplished with a


Which of the following is an example of E-health?

hospital and insurer share data on referrals and claims online

What HIM health record function would best benefit from the use of barcoding?

record location/tracking

WORM technology is useful in storing medical information on optical disks or platters because

the write-once, read-many feature permanently stores information without the ability to alter or modify the original documentation

Cynthia wants to retrieve a list of patients from the new electronic document management system. She wants a list of patients admitted to the hospital by Dr. Smith. Which of the following would explain why she cannot generate this list?

the necessary indexing to retrieve this list was not done

The laboratory system was installed 3 years ago. It is running well and meeting the needs of the department. Which stage of the IS life cycle is the lab system in?

operations (maintenance)

Dr. Smith needs something small and lightweight to use for dictating reports and entering data on the go. You suggest he use


Webster Medical Center is installing a computerized provider order-entry system. Currently we are training the staff and testing this system. We must be in the

implementation phase

The case-mix management system that utilizes information from the minimum data set (MDS) in long-term care settings is called

resource utilization groups (RUGs)

The prospective payment system used to reimburse home health agencies for Medicare patients utilizes data from

OASIS (Outcome and Assessment Information Set)

The prospective payment system to hospitals for Medicare hospital outpatients is called ________ and became effective on ________.

APCs, August 1, 2000

The _________________ is a statement sent to the provider to explain payments made by third party payers.

remittance advice

According to the Federal Register, the definition of a "new" patient when assigning a CPT Evaluation and Management (medical visit) code to a physician office patient, is a patient that has :

not seen the physician within the last 3 years

The hospital outpatient prospective payment system for Medicare applies to all of the following, EXCEPT

physician reimbursement of observation services

This is a patient classification system that expands the CMS DRGs into three levels: MCC, CC, Not MCC or CC. These subclasses address the patient's severity of illness.

Medicare Severity Adjusted DRGs - MS-DRGs

The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete.

discharged not final billed

Under APCs, payment status indicator "S" means

significant procedure, non-discounted

There is a form locator on the UB-04 for "service units." This data field is used for indicating

the number of times a particular HCPCS/CPT code is reported

In employer-sponsored health plans, employees may select their health plan

during the open enrollment period

This information is published by the Medicare contractors to describe when and under what circumstances Medicare will cover a service. The ICD-9-CM and CPT/HCPCS codes are listed in the memoranda

LCD (Local Coverage Determinations)

Under Medicare Part B, Medicare participating providers

accepts, as payment in full, the allowed charge from the nonPAR fee schedule

Which of the following situations violate a patient's privacy?

The hospital provides patient names and addresses to a pharmaceutical company to be used in a mass mailing of free drug samples.

State law says that the hospital must keep a record of disclosures for 10 years. HIPAA says 6 years. What should the hospital do to comply with the conflicting laws?

Keep it the 10 years required by the state because it is stricter than HIPAA.

Your transcription system is set up to back up your hard drive every 5 minutes. The backup is on the hard drive of another computer. This computer is located in the room next door to the primary computer. What should be done to improve the backup process?

Move backup computer to an office 100 miles away.

Today is January 10, 2008. Barbara has received a written authorization from an attorney for records on John Marshall. The dates of service requested by the authorization are the admission of January 2, 2008, through January 8, 2008. The authorization is dated January 3, 2008. Which of the following is the appropriate response?

Return the authorization and request one dated after January 8, 2008.

Which of the following statements demonstrates a violation of protected health information?

"Mary, at work yesterday I saw that Susan had a hysterectomy."

Your facility had a hacker break in and data was altered in your facility's electronic information. What is the best way to ensure someone from the outside cannot do this again?


You are walking around the facility to identify any privacy and security issues. You walk onto the 6W nursing unit and stand in a public area to look for possible violations. From where you are standing, you see that anyone can watch the nurse entering confidential patient information. You make a note of this. What are you doing?

conducting a risk assessment

If HIPAA and state law conflicts, which prevails:

whichever is more protective of the patient's privacy

The term"deidentified" indicates

all of the HIPAA specified patient identifiers have been removed.

Which of the following causes a privacy concern?

Bob Jones viewed a chart of another patient with the last name of Jones.

If there are 150,000 medical records and the Health Information Department receives 3,545 requests for records in a week, what percentage of the records are requested weekly?


A small portion of the form you are using for a research study is reproduced below. This is an example of
Male 1
Female 2

nominal data

The ability to obtain the same results from different studies using different methodologies and different populations is


The inpatient census at midnight is 67. Two patients were admitted in the morning; 1 died two hours later; the second patient was transferred to another facility that same afternoon. The inpatient service days for that day will be


A patient admitted to the hospital on January 24 and discharged on February 9 has a length of stay of

16 days

Live Births 225
Intermediate and late fetal deaths 5
Early fetal deaths 4
Newborn discharges 235

to compute the fetal death rate at All Women's Hospital for March. 2.2%

William Rumple was pronounced dead on arrival (DOA). The hospital pathologist performed an autopsy on Mr. Rumple's body. This statistical event would be counted in the

hospital autopsy rate

The best form/graph for demonstrating trends over time would be

line graph

A bar graph which displays continuous data and the columns are placed directly next to each other is:

histogram, which is commonly used to display continuous data

Twelve new cases of a certain disease occurred during the month of August. If 4,000 persons were at risk during August, then the

incidence was 3 per 1,000 persons

You have been conducting productivity studies on your coders and find that 20% of their time is devoted to querying physicians about missing or unclear diagnoses. Assuming your coders work a 7-hour day, how many minutes do they spend per day querying physicians?

84 (7*20%=1.4hr convert to minutes=84)

You are conducting a patient satisfaction survey in your outpatient clinic using interviewers who administer a questionnaire. Because you typically see about 300 people per day in the clinic, you decide to have the interviewers administer the questionnaire on every tenth patient. You are using

systematic sampling

A patient, who is HIV positive, has raised lesions, red or purple in color, on the genitals and groin. What is the stage of his disease process in today's medical terminology?


A diagnostic test for meningitis usually involves

cerebrospinal fluid analysis

The presence of fluid in the alveoli of the lungs is characteristic of


An elevated serium amylase would be characteristic of

acute pancreatitis

Common kidney stone treatments that allow small particles to be flushed out of the body through the urinary system include all of the following EXCEPT

ureteroscopy and stone basketing

Henry experienced sudden sharp chest pain that he described as heavy and crushing. His pain and past medical history caused Dr. James to suspect that Henry was having a myocardial infarction. Which of the following tests is a more specific marker for a MI?

troponin I

Fractures occur in patients with osteoporosis due to

loss of bone mass

When a decubitus ulcer has progressed to a stage in which osteomyelitis is present, the ulcer has extended to the


What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?

performance improvement

Requirements for monitoring the quality and appropriateness of inpatient services to Medicare beneficiaries and federally funded patients are outlined in the

QIO Scope of Work

Needlesticks, patient or employee falls, medication errors, or any event not consistent with routine patient care activities would require risk reporting documentation in the form of an

incident report

What feature distinguishes the Nominal Group Technique (NGT) from brainstorming?

NGT determines the importance of responses through a rating system

Which quality management theorist believed that merit raises, formal evaluations, and quotas established through benchmarking hinder worker productivity and growth?

W. Edwards Deming

An indicator about the placement and number of fire extinguishers would be which type?


The manager of the utilization review department wants to monitor and evaluate the prevention of inappropriate admissions. When would the manager need to collect data?


The outpatient coding staff has been working to improve coding accuracy. The standard for the number of cases that must be coded has been raised four times in the past year. The staff states that "the more cases that must be coded, the greater the error rate will be for the corresponding time period." The department keeps statistics on both the numbers of cases coded and the corresponding error rate. What is the best QI tool for Testing the coding staff's theory?

scatter diagram

The following clinical findings represent severity of illness indicators for the utilization review function EXCEPT

IV medications at least every 12 hours

Historic accomplishments impacting quality in medical care include all EXCEPT

implementation of OTRA

Quality requirements of providers participating in the Medicare program are found in all EXCEPT the


Patient presents to the hospital for skin grafts due to previous third-degree burns. The burn eschar of the back was removed. Once the eschar was removed, the defect size measured 10 cm x 10 cm. A skin graft from a donor bank was placed onto the defect and sewn into place as a temporary wound closure.

15002, 15300

Patient was admitted for right upper quadrant pain. Workup included various x-rays that showed cholelithiasis. Patient was taken to the operating room where a laparoscopic cholecystectomy was performed. During the procedure, the physician was unable to visualize through the ports and an open cholecystectomy was elected to be performed. Intraoperative cholangiogram was performed. Operative report and discharge summary states acute and chronic cholecystitis with cholelithiasis.

574.00, 574.10, V64.41, 47605

Established 42 year old patient comes into your office to obtain vaccines required for his trip to Bora Bora. The nurse injects intramuscularly the following vaccines: hepatitis A and B vaccines, cholera vaccine, and yellow fever vaccine. As the coding specialist, what would you report on the CMS 1500 form?

Administration of two or more single vaccines; vaccine products for hepatitis A and B, cholera, and yellow fever
"key word Nurse"

Patient presents to the emergency room with lacerations of right lower leg that involved the fascia. Lacerations measured 5.0 cm and 2.7 cm.


Patient presents to the operationg room where a CABG x 3 is preformed using the mammary artery and two sections of the sephenous vein

33533, 33518

Attempted vaginal delivery in a previous cesarean seciton patient, which resulted in a repeat cesarean section.


Medicare Pt undergoes PTCA w/drug-eluting stent placement in the left anderior descending artery, and angioplasty onl in th rifht cornary artery.

92982-RC, G0290-LD

Which of the following is a valid ICD-9 principal diagnosis code?

V30.00 single liveborn, born in a hospital

A physician performed an outpatient surgical procedure on the eye orbit of a Medicare patient. Upon searching the CPT codes and consulting with the physician, the coder is unable to find a code for the procedure. The coder should assign

an unlisted procedure code located in the eye and ocular adnexa section

In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassium level on the laboratory report. In examining the physician's orders, the coder notices that intravenous potassium

confer with the physician and ask him or her to list the condition as a final diagnosis if he or she considers the abnormal potassium level to be clinically significant

DSM-IV-TR is used most frequently in what type of health care setting?

behavioral health centers

The patient is diagnosed with congestive heart failure. A drug of choice is


The local safety council requests statistics on the number of head injuries occurring as a result of skateboarding accidents during the last year. To retrieve this data, you will need to have the correct

E-codes and ICD-9-CM codes

Which classification system is used to classify neoplasms according to site, morphology, and behavior?

International Classification of Diseases for Oncology (ICD-O)

According to the UHDDS, a procedure that is surgical in nature, carries a procedural or anesthetic risk, or requires special training is defined as a

significant procedure

A patient is admitted with shortness of breath and hemoptysis. A chest x-ray revealed patchy infiltrates in the left lung and possible pneumonia. On the third day of hospitalization a bronchoscopy with biopsy was done which revealed a small cell carcinoma of the left upper lobe of the lung. A metastatic lesion in the brain was detected. The principal diagnosis is the

small cell lung carcinoma

Code 402, Hypertensive Heart Disease, would appropriately be used in which of the following situations?

hypertensive cardiovascular disease with congestive heart failure

Susan Dawn is status post mastectomy (6 weeks) due to carcinoma of the breast. She is admitted to the outpatient clinic for chemotherapy. What is the correct sequencing of the codes?

V58.11 chemotherapy; 174.9 malignant neoplasm of breast

The Level II (national) codes of the HCPCS coding system are maintained by the

Centers for Medicare and Medicaid Services

A physician excises a 3.1 cm malignant lesion of the scalp which requires full-thickness graft from the thigh to the scalp. In CPT, which of the following procedures should be coded?

excision of lesion; full-thickness skin graft to scalp

In assigning E & M codes, three key components are used. These are

history, examination, medical-decision making

A patient was admitted to the hospital with hemiplegia and aphasia. The hemiplegia and aphasia were resolved before discharge and the patient was diagnosed with cerebral thrombosis. What is the correct coding and sequencing?

cerebral thrombosis

In the ICD-9-CM classification system, an esophageal stricture due to a burn received in a house fire several years ago would be coded as a(n)

late effect

Tachycardia after taking a correct dosage of prescribed Lortab would be reported as a(n)

adverse reaction to a drug

A rare malignant tumor often associated with AIDS is

Kaposi's sarcoma

Brian Hiltz was discharged from the hospital after a 3-day hospitalization and instructed to return to the outpatient department for follow-up care. On his first visit as an outpatient, a new record was recreated and he was assigned a new record number. Following completion of the outpatient appointment, his outpatient record is filed permanently in the outpatient department. What is the filing system used in this situation?


The Director of the Health Information Services Department has asked that the supervisor of coding institute a method to monitor the accuracy of coding. What method would be the most effective approach?

Review a random sample of each employee's work monthly.

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