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383 terms

RHIT Exam Definition set

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Interdisciplinary patient care plan
The special form or view that plays the central role in planning and providing care at nursing, psychiatric, and rehabilitation facilities
case-mix index (entire facility)
[SUM(Relative Weight * # of Pt w/ that MS-DRG)] / Total # of Pt
Nationally uniform conversion factor
A numerical factor (dollar amount) used to multiply or divide a quantity when converting from one system of units to another. Determined annually by the legislature and published in the Federal Register, it is used by Medicare to make adjustments according to the changes in the cost of living index.
Joint Commission Accredited Facilities
Hospitals, Hospital-based ambulatory care, Freestanding ambulatory care, Managed Care, Correctional Facilities, Mental Health & Substance Abuse,
Direct Correlation
A positive relationship between two variables. Ex; Height & Weight, the taller one gets, the heavier they get.
Inverse Correlation
A negative relationship between two variables.
Net Autopsy Rate
(Total autopsies on InPt deaths for a period x 100)/
(Total InPt deaths - Unautopsied Corner/ME cases)
Critical Pathways
display goals for patients and provide the corresponding ideal sequence and timing of stqaff actions to achieve those goas with optimal efficiency.
Responsibilities for Planning & Implementing Clinical Quality Assessment programs
-Identify potential clinical quality problems
-Determine method for studying potential problems
-Participate in regular departmental meetings across the organization
Sentinel Event
A serious patient incident that should have a root cause analysis prepared
Avedis Donabedian
Advocated the assesment of healthcare from 4 perspectives:
Structure, Process, Outcome, and Cost
Total Quality Management
(1986)A management philosophy developed by W. Edwards Deming encouraging industrial organizations to focus on the quality of their products as their paramount mission as an alternative to authoritarian, top-down managment philosophies.
Further adapted by J.M. Juran & Philip Crosby
3 Computer sizes
Mainframe, Minicomputer, & Microcomputer
personal digital device
a handheld device used for computing, faxing, and networking
Administrative Information Systems
Patient Registration System
Financial Information System
Materials Management System
confidentiality
The expectation that information that an individual shares with a health care provider during the course of care will be used only for its intended purpose is referred to as _____
data security
The protection and tools that safeguard information and information systems is referred to as _____
data dictionary
A descriptive list of the data elements to be collected in an information system or database whose purpose is to ensure consistency of terminology
AHIMA Data Quality Management Model
[Application] the purpose for which the data are collected [Collection] the processes by which data elements are accumulated [Warehousing] and [Analysis] the process of translating data into information utilized for an application
Application
(In the AHIMA Data Quality Managment Model) the purpose for which the data are collected
Collection
(In the AHIMA Data Quality Managment Model) the processes by which data elements are accumulated
Warehousing
(In the AHIMA Data Quality Managment Model) processes and systems used to archive data and data journals
Analysis
(In the AHIMA Data Quality Managment Model) the process of translating data into information utilized for an application
Data Quality Characteristics
Accessibility, Accuracy, Consistency, Comprehensiveness, Currency, Definition, Granularity, Relevancy, Precision, Timeliness
longitudinal medical record
a single patient record that maintains health care information throughout a patient's lifetime
Joint Commission
Requires one record for each patient; entries made by authorized persons; preoperative and final diagnoses; and thorough documentation of all procedures
Freestanding Nursing Facility
A facility or a portion of a facility licensed by the state as a nursing facility where the majority of patients are regarded as permanent residents for long-term nursing care
Nursing home, Long-term care facility, Intermediate care facility
Freestanding Skilled Nursing Facility
A facility or a portion of a facility licensed by the state as a skilled nursing facility and certified, either wholly or in part, as a Medicare Part A skilled nursing facility provider.
Skilled nursing facility, Skilled nursing unit, Distinct part Medicare SNF unit
Acute Care Hospital
A designated area, attached wing, or a separate structure on the hospital campus that is licensed for skilled nursing care
Skilled nursing facility, Skilled nursing unit, SNF unit
Long-term Acute Hospital
A facility providing specialized acute care for patients averaging a LOS of 25 days or more
healthcare clearinghouse
a public or private entity (e.g., billing service, repricing company, etc...) that processes or facilitates the processing of health information received from another entity (e.g., provider, third-party payer, and so on) from a nonstandard into a standard format.
privacy officer
oversees all ongoing activities related to the development, implementation, maintenance of, and adherence to the organization's policies and procedures covering the privacy of, and access to, patient health information in compliance with federal and state laws and the health care organization's information privacy practices.
Title II: HIPAA Administrative Simplification
... require the DHHS to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.
Management By Objective
The process of setting objectives in the organization to give a sense of direction to the employees is called...
5 Functions of Management
The most widely accepted are ... given by KOONTZ and O'DONNEL:
Planning, Organizing, Staffing, Directing and Controlling.
http://www.managementstudyguide.com/management_functions.htm
Planning
Koontz & O'donnel's 5 Functions of Management
The basic function of management. It deals with chalking out a future course of action & deciding in advance the most appropriate course of actions for achievement of pre-determined goals. According to KOONTZ, "Planning is deciding in advance - what to do, when to do & how to do. It bridges the gap from where we are & where we want to be".
Organizing
Koontz & O'donnel's 5 Functions of Management
The process of bringing together physical, financial and human resources and developing productive relationship amongst them for achievement of organizational goals.
-Identification of activities.
-Classification of grouping of activities.
-Assignment of duties.
-Delegation of authority and creation of responsibility.
-Coordinating authority and responsibility relationships.
Staffing
Koontz & O'donnel's 5 Functions of Management
The function of manning the organization structure and keeping it manned.
-Manpower Planning (estimating man power in terms of searching, choose the person and giving the right place).
-Recruitment, selection & placement.
-Training & development.
-Remuneration.
-Performance appraisal.
-Promotions & transfer.
Directing/Leading
Koontz & O'donnel's 5 Functions of Management
Actuates the organizational methods to work efficiently for achievement of organizational purposes.
-Supervision
-Motivation
-Leadership
-Communication
Controlling
Koontz & O'donnel's 5 Functions of Management
Implies measurement of accomplishment against the standards and correction of deviation if any to ensure achievement of organizational goals.
a) Establishment of standard performance.
b) Measurement of actual performance.
c) Comparison of actual performance with the standards and finding out deviation if any.
d) Corrective action.
OASIS data are used to assess the ___ of home health services.
Outcome
Policy
A statement or guideline that directs decision making or behavior is called a:
Returned Overpayments
Examples of high-risk billing practices that create compliance risks for healthcare organizations include all of the following, except:
Federal Sentencing Guidelines
Corporate compliance programs became common after adoption of which of the following:
Accreditation
The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards
The Joint Commission
Accrediting organization has instituted continuous improvement and sentinel event monitoring and uses tracer methodology during survey visits?
The Joint Commission
This organization has been responsible for accrediting healthcare organizations since the mid 1950's and determines whether the organization is continually monitoring and improving the quality of care they provide.
The Deficit Reduction Act of 2005:
Made compliance programs mandatory
The Joint Commission
The largest healthcare standards-setting body in the world?
Physician Offices
Do not have to meet standards in the Conditions of Participation
Elements of performance
Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:
Health Care Quality Improvement Act
mandated by the creation of the National Practitioner Data Bank
Medical Staff Bylaws
Dictates how the medical staff operates?
Chief Executive Officer
Responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team
Data Security
The protection measures and tools for safeguarding information and information systems
A written contingency plan
required by HIPAA standards
Administrative safeguards
are policies and procedures required by HIPAA that address the management of computer resources and security
Employees
the biggest threat to the security of healthcare data
Utilization Review
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria
Physical Control
Placing locks on computer room doors type of security control
Conditions of Participation
general name for Medicare rules affecting healthcare organizations
During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log-on to view laboratory results. One physician suggest having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide?
Single sign-on is less frustrating for the end user and can provide better security
Physical Access Controls
security safeguards that protect equipment, media, and facilities
Audit Trail
a software program that tracks every access to data in the computer system
Cost Control
The one aspect of managed care that has had the greatest impact on healthcare organizations
Evidence-based practice guidelines
an explicit statement that directs clinical decision making
Safe Harbors
Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution
Commission on Accreditation of Rehabilitation Facilities
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.
Deemed Status
accrediting bodies such as The Joint Commission can survey facilities for compliance with the medicare Conditions of Participation for Hospitals instead of the government
Tracer Methodology
Joint Commission survey methodology involves an evaluation that follows the hospital experiences of past or current patients
Information Security
Case management coordinates an individual's care, especially in complex and high cost cases. Goals of case management include all of the following except:
ABN
When a service is not considered medically necessary based on the reason for encounter, the patient should be provided with this form indicating that Medicare might not pay and that the patient might be responsible for the entire charge.
Social Security Number
The number that has been proposed for use as a unique identification number but is controversial because of confidentiality and privacy concerns
Controlled Vocabulary
necessary to ensure that each term used in an EHR has a common meaning to all users
Electronic document management system
a transition strategy to achieve an EHR
Patient Number
the unique identifier in the relational database patient table
Implementation Plan
A step-by-step approach to installing, testing, training, and gaining adoption for an EHR
CPOE
an application that uses standard order sets and other clinical decision support that supports physician order entry into the computer
Electronic point-of-care charting
Electronic systems used by nurses and physicians to document assessments and findings
User training
A key element in effective systems implementation
Portal
A special web page that offers secure access to data
Client/server
some computers are used primarily to enter data and others to process data the architecture is called:
Interoperability
The ability to electronically send data from one electronic system to a different electronic system and still retain its meaning
Identity Matching Algorithim
The key for linking data about an individual who is seen in a variety of care settings
Physician
The primary user of computerized provider entry
Mainframe
uses a single large computer to process data received from terminals into which data are entered
Electronic document management system
A transition technology used by many hospitals is to increase access to medical record content
Dual Core strategy
a hospital develops its EHR system by selecting one vendor to provide financial and administrative applications and another vendor to supply the clinical applications
Transaction processing system
information system used for processing patient admissions, employee time cards, and purchase orders
Planning
The first phase of the SDLC
Transmitters, receivers, media, and data
basic components make up every electronic network communications system
Direct cutover
The most common approaches to converting from an old information system to a new one are the parallel approach, the phased approach, and the ____ approach.
Planning
phase of the systems development life cycle is the primary focus on identifying and assigning priorities to the various upgrades and changes that might be made in an organization's information systems
Implementation
phase of the systems development life cycle are trial runs of the new system conducted, backup and disaster recover procedures developed, and training of end users performed
Relational database
stores data in predefined tables consisting of rows and columns
Primary Key
uniquely identifies each record in a database table?
Train-the-trainer
An organization identifies key people in various functional areas to be trained first, and then asks them to subsequently train other users in this same functional area.
Network
connects computers together in a way that allows for the sharing of information and resources
Server redundancy
reduce the risk that information is not accessible during a server crash
A system that enables processing of diagnostic studies results into tables, graphs, or other structure is:
Results retrieval and management technology
Community Hospital's hardware has been placed on back-order; the network team is having trouble getting the network to function properly. This is an example of:
Issues management
Audit logs and alert pop-ups are examples of:
Metadata
Which of the following is a family of standards that aid the exchange of data among hospital systems and physician practices?
HL7
The following descriptors about the data element PATIENT_LAST_NAME are included in a data dictionary: definition: legal surname of the patient; field type: numeric: field length: 50; required field: yes; default value: none; input mask: none. Which of the following is true about the definition of this data element?
The field type should be changed to Character
Systems testing of a new information system should be conducted using:
Actual Patient Data
Which of the following are used to associate relationships between entities (tables) in a relational database?
Foreign Keys
Which of the following security controls are built into a computer software program?
Application Controls
Community Hospital is identifying strategies to minimize the security risks associated with employees leaving their workstations unattended. Which of the following solutions will minimize the security risk of unattended workstations?
Implement session termination
OASIS data are used to assess the ___ of home health services.
Outcome
The Deficit Reduction Act of 2005:
Made compliance programs mandatory
Which of the following statements best defines utilization management?
It is a set of processes used to determine the appropriateness of medical services provided during specific episodes of care
Which of the following is not a type of utilization review?
Peer review
Which of the following is not one of the basic functions of the utilization review process?
Claims management
The Medical Review Committee wants to determine if the hospital is in compliance with Joint Commission standards for medical record delinquency rates. The HIM Director has compiled a report that shows that records are delinquent for an average of 29 days after discharge. Given this information, what can the Committee conclude?
Data are insufficient to determine whether the hospital is in compliance
Which of the following is the largest healthcare standards-setting body in the world?
The Joint Commission
Which of the following is the largest healthcare standards-setting body in the world?
The Joint Commission
Community Hospital wants to offer information technology services to City Hospital, another smaller hospital in the area. This arrangement will financially help both institutions. In reviewing the process to establish this arrangement, the CEO asks the HIM director if there are any barriers to establishing this relationship with regard to HIPAA. In this situation, which of the following should the HIM director advise?
City Hospital should obtain a business associate agreement with Community Hospital
Which of the following facilities do not have to meet standards in the Conditions of Participation?
Physician offices
An audit trail may be used to detect which of the following:
Unauthorized access to a system
Specific performance expectations and/or structures and processes that provide detailed information for each of the Joint Commission standards are called:
Elements of performance
The creation of the National Practitioner Data Bank was mandated by the:
Health Care Quality Improvement Act
Which of the following dictates how the medical staff operates?
Medical Staff Bylaws
Who is responsible for implementing the policies and strategic direction of the hospital or healthcare organization and for building an effective executive management team?
Chief Executive Officer
Medical school graduates must pass a test before they can obtain a _____ to practice medicine.
License
Under HIPAA rules, when an individual asks to see his or her own health information, a covered entity:
Can deny access to psychotherapy notes
In which of the following situations must a covered entity provide an appeals process for denials to requests from individuals to see their own health information?
When a licensed healthcare professional has determined that access to PHI would likely endanger the life or safety of the individual
Which of the following statements is true in regard to responding to requests from individuals for access to their PHI?
A cost-based fee may be charged for making a copy of the PHI
Which of the following is not an automatic contgrol that helps preserve data confidentiality and integrity in an electronic system?
Security awareness program
Within the context of data security, protecting data privacy means defending or safeguarding:
Access to information
The protection measures and tools for safeguarding information and information systems is a definition of:
Data Security
To date the HIM department has not charged for copies of records requested by the patient. However, the policy is currently under review for revision. One HIM committee member suggests using the copying fee established by the state. Another committee member thinks that HIPAA will not allow for copying fees. What input should the HIM director provide?
Base charges on the cost of labor and supplies for copying and postage if copies are mailed
A risk analysis is useful to:
Identify security threats
Which of the following is required by HIPAA standards?
A written contingency plan
Which of the following are policies and procedures required by HIPAA that address the management of computer resources and security?
Administrative safeguards
What is the biggest threat to the security of healthcare data?
Employees
To ensure relevancy, an organization's security policies and procedures be reviewed at least:
Once a year
Which of the following is not true of good electronic forms design?
Use radio buttons to select multiple items from a set of options
What committee usually oversees the development and approval of new forms for the health record?
Use radio buttons to select multiple items from a set of options
The process of determining whether the medical care provided to a specific patient is necessary according to preestablished objective screening criteria is:
Utilization Review
Placing locks on computer room doors is considered what type of security control?
Physical control
Which of the following is recommended for design of forms for an EDMS?
24 lb. paper for double-sided forms
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?
Ask the security officer for audit trail data to confirm or disprove the suspicion.
Coding policies should include which of the following elements?
AHIMA Standards of Ethical Coding
The Medicare Integrity Program was established as part of Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities?
Payment determinations and audit of cost reports
An individual designated as an inpatient coder may have access to an electronic medical record to code the record. Under what access security mechanism is the coder allowed access to the system?
Role-based
A secretary in the Nursing Office was recently hospitalized with ketoacidosis. She comes to the health information management department and requests to review her health record. Of the options here, what is the best course of action?
Allow her to review her record after obtaining authorization from her
St. Joseph's Hospital has a psychiatric service on the sixth floor of the hospital. A 31-year old male has come to the HIM department and requested to see a copy of his medical record. He indicated he was a patient of Dr. Schmidt, a psychiatrist, and that he was on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. Of the options here, what is the best course of action?
Allow the patient to access his record if, after contacting his physician, his physician does not think it will be harmful to the patien
Minors are basically deemed legally incompetent to access, use or disclose their health information. What resource should be consulted in terms of who may authorize access, use, or disclose the health records of minors?
State law because HIPAA defers to state laws on matters related to minors
If an HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing:
Fraud
What is the general name for Medicare rules affecting healthcare organizations?
Conditions of Participation
The permanent RAC program was completely implemented in the United States by:
January 2010
During user acceptance testing of a new EHR system, physicians are complaining that they have to use multiple log-on screens to access all system modules. For example, they have to use one log-on for CPOE and another log-on to view laboratory results. One physician suggest having a single sign-on that would provide access to all the EHR system components. However, the hospital administrator thinks that one log-on would be a security issue. What information should the HIM director provide?
Single sign-on is less frustrating for the end user and can provide better security
Which of the following are security safeguards that protect equipment, media, and facilities?
Physical access controls
What does the term access control mean?
Identifying which data employees should have a right to use
Which of the following is a software program that tracks every access to data in the computer system?
Audit Trail
All of the following are steps in medical necessity and utilization review, except:
Access consideration
Which of the following can be used to discover current hot areas of compliance?
The OIG Workplan
In Medicare, the most common forms of fraud and abuse include all of the following, except:
Implementing a clinical documentation improvement program
The one aspect of managed care that has had the greatest impact on healthcare organizations is:
Cost control
The policies and procedures section of a coding compliance plan should include all of the following except:
Utilization Review
The policies and procedures section of a coding compliance plan should include all of the following except:
Evidence-based practice guideline
Gatekeepers determine the appropriateness of all of the following components, except:
Rate of capitation or reimbursement
Exceptions to the Federal Anti-Kickback Statute that allow legitimate business arrangements and are not subject to prosecution are:
Safe Harbors
How often are healthcare facilities required to practice their emergency preparedness plan annually?
Twice
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.
Commission on Accreditation of Rehabilitation Facilities
What is it called when accrediting bodies such as The Joint Commission can survey facilities for compliance with the medicare Conditions of Participation for Hospitals instead of the government?
Deemed Status
An HIM department is researching various options for scanning the hospital's health records. The department director would like to achieve efficiencies through scanning such as performing coding and cancer registry functions remotely. Given these considerations, which of the following would be the best scanning process?
Scanning all documents at the time of patient discharge
In conducting a qualitative analysis to ensure that documentation in the health record supports the diagnosis of the patient, what documentation would a coder look for to substantiate the diagnosis of aspiration pneumonia?
Patient has history of inhaled food, liquid, or oil
Which of the following is an organization's planned response to protect its information in the case of a natural disaster?
Business continuity plan
Which of the following is not a responsibility of a healthcare organization's quality management department?
Conducting medical peer review to identify patters of care
Which of the following has the ultimate responsibility for ensuring quality in a healthcare facility?
Board of Directors
The process that involves ongoing surveillance and prevention of infections so as to ensure the quality and safety of healthcare for patients and employees is known as:
Infection Control
Every healthcare organization's risk management plan should include the following components except:
Peer Review
Hospital A discharges 10,000 patients per year. Hospital B is located in the same town and discharges 5,000 patients per year. At Hospital B's medical staff committee meeting, a physician reports that he is concerned about the quality of care at Hospital B because the hospital has double the number of deaths per year than Hospital A. The HIM director is attending the meeting in a staff position. Which of the following actions should the director take?
Suggest that the data be adjusted for possible differences in type and volume of patients treated
Which of the following provide process measure metrics in a precise format?
Dashboard
Total quality management and continuous quality improvement are well-known:
Performance improvement models
Donabedian proposed three types of quality indicators: structure indicators, process indicators, and:
Outcome indicators
Many organizations and quality experts define quality as meeting or exceeding:
Customer Expectations
Managing the adoption and implementation of new processes is called:
Change management
How do health plans incentivize providers to use EHRs?
Paying for performance programs
A key feature of performance improvement is:
A continuous cycle of improvement
Brainstorming, affinity grouping, and nominal group techniques are tools and techniques used during performance improvement initiatives to facilitate ____ among employees.
Communication
Periodic performance reviews:
Encourage good performance
Which of the following is a data collection tool that records current processes?
flow chart
According to the Pareto Principle:
20% of the sources of a problem are responsible for 80% of its actual effects
Change management is the process of planning for change. It concentrates on:
Addressing employee resistance to changes in processes, procedures, and policies
Which of the following statements does not represent a fundamental principle of performance improvement?
Systems are static and do not demonstrate variation
Which of the following should be the first step in any quality improvement decision-making process?
Identifying the problem
As part of the clinic's performance improvement program, an HIM director wants to implement benchmarking for the transcription division at a 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?
Clearly define what is to be studied and accomplished by instituting benchmarks
A record that fails quantitative analysis is missing the quality criterion of:
Completeness
A report that lists the ICD-9-CM codes associated with each physician in a healthcare facility can be used to assess the quality of the physician's services before he or she is:
Recommended for staff reappointment
When all required data elements are included in the health record, the quality characteristic for ____ is met.
Data comprehensiveness
The sixth scope of work for quality improvement organizations (QIOs) introduced which of the following?
Payment error Prevention Program
The following table compares Community Hospital's pneumonia length of stay (observed LOS) to the pneumonia LOS of similar hospitals (expected LOS). Given this data, where might Community Hospital want to focus attention on its pneumonia LOS?
Family Practice
After an outpatient review, individual audit results by coder should become part of the:
Individual employee's performance evaluation
The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data?
Full-time coders are more productive than part-time coders
The following data has been collected about the HIM department's coding productivity as part of the organization's total quality improvement program. Which of the following is the best assessment of this data?
Full-time coders are more productive than part-time coders
The primary goal of the Hospital Standardization Program established in 1918 by the American College of Surgeons was to:
Establish minimum quality standards for hospitals
A quantitative tool that provides an indication of an organization's performance in relation to a specified process or outcome is a(n):
Performance measure
A standard of performance or best practice for a particular process or outcome is called a(n):
Benchmark
This type of performance measure focuses on a process that leads to a certain coutcome, meaning that a scientific or experimental basis exists for believing that the process, when executed well, will increase the probability of achieving a desired outcome.
Process Measure
Which of the following is not a step in quality improvement decision-making?
Determination of the quickest solution
The principal process by which organizations optimize the continuum of care for their patients is:
Case management
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?
Preadmission care planning
The National Patient Safety Goals (NPSGs) have effectively mandated all healthcare organizations to examine care processes that have a potential for error that can cause injury to patients. Which of the following processes are included in the NPSGs?
Check patient medicines, prevent infection, and identify patients correctly
The interrelated activities in healthcare organizations, which promote effective and safe patient outcomes across services and disciplines within an integrated environment, are included in what area of performance measurement?
Processes
A performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements is called:
Indicator
This status is conferred by a national professional organization that is dedicated to a specific are of healthcare practice.
Credential
The primary objective of quality in healthcare for both patient and provider is to:
Arrive at the desired outcomes
Who is responsible for ensuring the quality of health record documentation?
Provider
All of the following services are typically reviewed for medical necessity and utilization except:
Well-baby check
A Joint Commission-accredited organization must review its formulary annually to ensure a medication's continued:
Efficacy and Safety
Environmental assessments are performed as part of which of the following processes?
Strategic planning
Which of the following actions is not included about a physician in the National Practitioner Data Bank?
Personal bankruptcy
The Joint Commission's quality improvement activites for health record documentation include all but which of the following core performance measures for hospitals:
Seizure disorder
This data set was developed by the National Committee for Quality Assurance to aid consumers with health-related issues with information to compare performance of clinical measures for health plans:
HEDIS
In this case management step, the case manager confirms that the patient meets criteria for the care setting and that the services can be provided at the facility.
Care planning at the time of admission
The final results of care, treatment, and services in terms of the patient's expectations, needs, and quality of life, which may be positive and appropriate or negative and diminishing, are included in what are of performance measurement?
Outcomes
An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines is called:
Standards of care
An HIM director reviews the departmental scanning productivity reports for the past three months and sees that productivity is below that of the national average. Which of the following actions should the director take?
Investigate whether there are factors contributing to the low productivity that are not reflected in the national benchmarks
Through the establishment of the National Practitioner Data Bank (NPDB), the federal government became involved in malpractice issues and what other type of issue?
Quality of care
All of the following are Joint Commission core measure criteria sets except:
Diabetes mellitus
During training, the employee should be:
Evaluated to make sure work is error free
A coding supervisor who makes up the weekly work schedule would engage in what type of planning?
Operational
Performance standards are used to:
Communicate performance expectations
A supervisor wants to determine whether the release of information staff are working at optimal output. Which of the following would be most useful to determine this?
Set productivity standards for the area and review results on a regular basis
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:
Quantitative analysis
I reviewed the health record of Sally Williams and found the physician stated on her post-op note, "examined after surgery." This would be an example of:
Qualitative Analysis
Attorneys for healthcare organizations use the health record to:
Protect the legal interests of the facility and its healthcare providers
Under HIPAA, which of the following is not named as a covered entity?
Outsourced transcription company
The HIPAA Privacy Rule:
Sets a minimum (floor) of privacy requirements
Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule?
Contained within a personnel file
Which of the following is not an element that makes information "PHI" under the HIPAA Privacy Rule?
Contained within a personnel file
Which of the following is not an identifier under the Privacy Rule?
Age 75
Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true?
The Privacy Rule's minimum necessary requirement does not apply
Susan is completing her required high school community service hours by serving as a volunteer at the local hospital. Relative to the hospital, she is a(n):
Workforce member
Lane Hospital has a contact with Ready-Clean, a local company, to come into the hospital to pick up all of the facility's linen for off-site laundering, Ready-Clean is:
Not a business associate because it does not use or disclose individually identifiable health information
Jeremy Lykins was required to undergo a physical exam prior to becoming employed by San Fernando Hospital. Jeremy's medical information is:
Not protected by the Privacy Rule because it is part of a personnel record
The HIPAA Security Awareness and Training administrative safeguard requires all of the following addressable implementation programs for an entity's workforce except:
Disaster recovery plan
Burning, shredding, pulping, and pulverizing are all acceptable methods in which process?
Destruction of paper-based health records
Which of the following data sets would be most useful in developing a grid for identification of components of the legal health record in a hybrid record environment?
Document name, media type, source system, electronic storage start date, stop printing start date
The __ provide the objective and scope for the HIPAA Security Rule as a whole.
General Rules
Which of the following must covered entities do to comply with HIPAA security provisions?
Establish a contingency plan
For HIPAA implementation specifications that are addressable, which of the following statements is true?
The covered entity must conduct a risk assessment to determine whether the specification is appropriate to its environment
The medical record of Kathy Smith, the plaintiff, has been subpoenaed for a deposition. The plaintiff's attorney wishes to use the records as evidence to prove his client's case. In this situation, although the record constitutes hearsay, it may be used as evidence based on the:
Business records exception
From an evidentiary standpoint, incident reports:
Should not be placed in a patient's health record
A hospital employee destroyed a health record so that its contents - which would be damaging to the employee - could not be used at trial. In legal terms, the employee's action constitutes:
Spoliation
Authentication of a record refers to:
Establishment of its baseline trustworthiness
When served with a court order directing the release of health records, an individual:
Must comply with it
The following step should not be included in a health information department's procedure for preparing health records in response to a subpoena:
Remove pages containing detrimental information
Written or spoken permission to proceed with care is classified as:
Expressed Consent
To be in compliance with HIPAA regulations, a hospital would make its membership in a RHIO known to its patients through which of the following?
Notice of Privacy Practices
Law enacted by a legislative body is a(n):
Statute
What is the legal term used to describe the physical and electronic protection of health information?
Security
The "custodian of health records" refers to the individual within an organization who is responsible for the following action(s),except:
Testifies regarding the care of the patient
Who owns the health record?
Provider who generated the record
The process of releasing health record documentation originally created by a different provder is called:
Redisclosure
Which of the following is not true of notices of privacy practices?
Must contain content that may not be changed
Which document directs an individual to bring originals or copies of records to court?
Subpoena duces tecum
To comply with HIPAA, under usual circumstances, a covered entity must act on a patient's request to review or copy his or health information within __ days
30
This HIPAA Privacy Rule requires that covered entities must limit use, access, and disclosure of PHI to only the amount needed to accomplish the intended purpose. What concept is this an example of?
Minimum Necessary
Which of the following statements is false?
An authorization does not have to be obtained for uses and disclosures for treatment, payment, and operation
The legal term used to describe when a patient has the right to maintain control over certain personal information is referred to as:
Privacy
What is the legal term used to define the protection of health information in a patient-provider relationship?
Confidentiality
Which of the following statements is not true about a business associate agreement?
It allows the business associate to maintain PHI indefinitely
Under HIPAA regulations, how many days does a covered entity have to respond to an individual's request for access to his or her PHI is stored off-site?
60 days
The security officer is responsible for:
Advising administration on information security
Which of the following is an example of a business associate?
Contract coder
What type of health record policy dictates how long individual health records must remain available for authorized use?
Retention policies
If a patient wants to amend his or her health record, the covered entity may require the individual to:
Make an amendment request in writing and provide a rationale for the amendment
Which of the following statements about the directory of patients maintained by a covered entity is true?
Individuals must be given an opportunity to restrict or deny permission to place information about them in the directory
According to HIPAA, what does the abbreviation PHI stand for?
Protected health information
Which of the following is not true about the Notice of Privacy Practices?
Must include at least two examples of how information is used for both treatment and operations
The legal health record (LHR) is a(n):
Defined subset of all patient-specific data created and accumulated by a healthcare provider that may be released to third parties in response to a legally permissible request for patient information
When a patient revokes authorization for release of information after a healthcare facility has already released the information, the facility in this case:
Is protected by the Privacy Act
Which of the following has access to personally identifiable data without authorization or subpoena?
Public health department for disease reporting purposes
Which of the following statements represents an example of nonmaleficense?
HITs must ensure that patient-identifiable information is not released to unauthorized parties
An organization is served with a subpoena. An appropriate response to the reasonable anticipation of litigation would be to:
Make a copy of the paper-based record associated with the anticipated litigation and give the original paper-based record to the organization's legal counsel to be secured in a locked file
Which organization issues and maintains ethical standards for the health information management profession?
American Health Information Management Association
The sister of a patient requests the HIM department to release copies of her brother's health record to her. She states that because the doctor documented her name as her brother's caregiver that HIPAA regulations apply and that she may receive copies of her brother's health record. In this case, how should the HIM department proceed?
Refuse the request
Community Hospital is discussing restricting the access that physician have to electronic clinical records. The medical record committee is divided on how to approach this issue. Some committee members maintain that all information should be available, whereas others maintain that HIPAA restricts access. The HIM director is part of the committee. Which of the following should the director advise the committee?
The "minimum necessary" concept does not apply to disclosures made for treatment purposes, but the organization must define what physicians need as part of their treatment role
A physician takes the medical records of a group of HIV-positive patients out of the hospital to complete research tasks at home. The physician mistakenly leaves the records in a restaurant, where they are read by a newspaper reporter who publishes an article that identifies the patients. The physician can be sued for:
Invasion of privacy
Mrs. Bolton is an angry patient who resents her physicians "bossing her around." She refuses to take a portion of the medications the nurses bring to her pursuant to physicians orders and is verbally abusive to the patient care assistants. Of the following options, the most appropriate way to document Mrs. Bolton's behavior in the patient medical record is:
Non-compliant and hostile towads staff
As the corporate director of HIM Services and enterprise privacy officer, you are asked to review a patient's health record in preparation for a legal proceeding for a malpractice case. The lawsuit was brought by the patient 72 days after the procedure. The physician in question has a longstanding history of being lackadaisical with record completion practices. Previous concerns regarding this physician's record maintenance practices had been reported to the facility's Credentialing Committee. Is this information admissible in court?
This information could be rejected since the physician dictated the procedure note after the malpractice suit was filed
While auditing health records for incomplete documentation, the HIM specialist identifies written progress notes by Dr. Doe that she cannot read. She reports this to the hospital's risk manager. What is the best method to determine the scope of the documentation problem by Dr. Doe?
An HIM professional should conduct a more detailed audit of Dr. Doe's patients' records.
A Medicate patient had two physician office visits, underwent hospital radiology examinations, clinical laboratory tests, and received take-home surgical dressings. Which of the following could be reimbursed under the outpatient prospective payment system?
Radiology examination
In conducting a qualitative review, the clinical documentation specialist sees that the nursing staff has documented the patient's skin integrity on admission to support the presence of a stage I pressure ulcer. However, the physician's documentation is unclear as to whether this condition was present on admission. How should the clinical documentation specialist proceed?
Query the physician to determine if the condition was present on admission
Given the following information, from which payer does the hospital proportionately receive the least amount of payment?
Medicaid
Which of the following is the definition of revenue cycle management?
Coordination of all administrative and clinical functions that contribue to the capture, management, and collection of patient service revenue
Most facilities begin counting days in accounts receivable at which of the following times?
The date the bill drops
The amount of money owed a healthcare facility when claims are pending is called:
Dollars in accounts receivable
In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area?
Claims reconcilliation/collections
Most chief financial officers view the HIM department's most essential role in the revenue cycle management to be:
Coding of the record
When all third-party payments have been received and contractual allowances have been written off, the remaining balance is categorized as the patient responsibility. Best practice is to have the patient responsibility amount be less than what percentage of the total balance?
15
Which of the following types of hospitals are excluded from the Medicare inpatient prospective payment system?
Children's
When a provider agrees to accept assignment from Medicare, the provider has agreed to:
Not bill patients for the balance
In processing a medicare payment for outpatient radiology exams, a hospital outpatient services department would receive payment under which of the following?
OPPS
Which of the following is not reimbursed according to the Medicare prospective payment system?
Critical access hospitals
How often are the Medicare fee schedules updated?
Annually
Which of the following would a health record technician use to perform the billing function for a physician's office?
Screen 837P or CMS 1500
When a provider accepts assignment, this means that the:
Provider accepts as payment in full the allowed charge from the fee schedule
The coordination of benefits transaction (COB) is important so that:
There is no duplication of benefits paid
Community Hospital has launched a clinical documentation improvement (CDI) initiative. Currently, clinical documentation does not always adequately reflect the severity of illness of the patient or support optimal HIM coding accuracy. Given this situation, which of the following would be the best action to validate that the new program is achieving its goals?
Conduct a retrospective review of all query opportunities for the year
Which of the following is made up of claims data from Medicare claims submitted by acute-care hospitals and skilled nursing facilities?
MEDPAR
The collection of information on healthcare fraud and abuse was mandated by HIPAA and resulted in the development of:
Healthcare Integrity and Protection Data Bank
What is the name of the federally funded program that pays the medical bills of the spouces and dependents of persons on active duty in the uniformed services?
TRICARE
Mr. Jones is a 67-year-old patient who only has Medicare's Part A insurance. Given the information here, if Mr. Jones used 36 lifetime reserve days, how many does the patient have left to be used at a later date?
24 days
Under outpatient prospective payment system, Medicare decides how much a hospital or a community health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coninsurance amount (20%) or a fixed copayment amount, whichever is less. Mr. Smith who has paid his deductible for the year, was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. What would Mr. Smith need to pay in this case?
$15
The number of days Medicare will cover SNF inpatient care per benefit period is limited to which of the following?
100
Which of the following types of care is not covered by Medicare?
Long-term nursing care
Active armed services members and their qualified family members are covered by which of the following healthcare programs?
TRICARE
What is the name of the program funded by the federal government to provide medical care to people on low incomes or with limited financial resources?
Medicaid
Some services are covered and paid by Medicare before Medicaid makes payments because Medicaid is considered which of the following?
Payer of last resort
Which of the following groups of healthcare providers contracts with a self-insured employer to provide healthcare services?
Preferred provider organization
Which of the following reimbursement methods pays providers according to charges that are calculated before healthcare services are rendered?
Prospective payment method
Which of the following apply to radiological and other procedures that include professional and technical components and are paid as a lump sum to be divided between physician and healthcare facility?
Global payments
In a typical acute-care setting, which revenue cycle area uses an internal auditing system (scrubber) to ensure that error-free claims (clean claims) are submitted to third-party payers?
Claims processing
Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare?
Fiscal intermediary/MAC
Which of the following is a common registration error that will affect the revenue cycle?
Transposed digits in the social security number, date of birth, or policy number
In a typical acute-care setting, charge capture is located in which revenue cycle area?
Claims processing
Which of the following establish eligibility standards for enrollment in Medicaid?
Individual states
This program provides additional federal funds to states so that Medicaid eligibility can be expanded to include a greater number of children.
SCHIP
The charge description master relieves the HIM department of ___ that does not require documentation analysis
Repetitive coding
After a claim has been filed with Medicare, a healthcare organization had late charges posted to a patient's outpatient account that changed the calculation of the APC. What is the best practice for this organization to receive the correct reimbursement from Medicare?
Submit an adjusted claim to Medicare
Which term refers to the electronic transmission of information from a provider to a health plan to determine a patient's eligibility for services?
Coordination of benefits transaction
Which of the following agencies is responsible for providing healthcare services to American Indians and Alaska natives?
IHS
Which of the following insurance covers healthcare costs and lost income associated with work-related injuries?
Workers' Compensation
A Medicare benefit period is defined as:
Beginning the day the Medicare patient is admitted to the hospital and ending when the patient has been out of the hospital for 60 days in a row, including the day of discharge
The patient's account balance is displaying a negative balance. What should the health care organization do to resolve this situation?
Determine which payer overpaid and return the funds
The unique number that identifies each service or supply in the CDM and links each item to a particular department is known as the:
Charge code
All of the following are required elements of a charge description master except:
Date of service
The codes used in a charge description master are:
HCPCS Levels I and II
The codes used in a charge description master are:
HCPCS Levels I and II
The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed?
Focused audit
The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term?
Focused reviews on lower weighted MS-DRGs from triples and pairs
There should be four primary percentages that should be calculated and tracked to assess clinical documentation improvement (CDI) programs. These include all of the following except:
Record agreement rate
CDI staff should revisit cases:
Every 24 to 48 hours
The federal legislation that focused on healthcare fraud and abuse issues, especially as they relate to penalties, was the:
Balanced Budget Act of 1997
Which of the following services would be included in the 72-hour payment window and included in the inpatient MS-DRG payment to an acute-care hospital?
Diagnostic laboratory testing
The phrase "bad debt" refers to accounts that include money owed by the patient and are:
Determined by the facility to be uncollectible
The best practice for a system hold for all charges to be entered into the billing system and all coding to be completed is:
4 days post-discharge or visit
The "discharged, not final billed" report (also known as "discharged, no final bill" or "accounts not selected for billing") includes what type of accounts?
Accounts that have been discharged and have not been billed for a variety of reasons
Patient Accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should:
Write off the failed charges to bad debt and bill Medicare for the clean charges.
Robert Thompson was seen in the outpatient department with a chronic cough and the record states, "rule out lung cancer." What should be coded as the patient's diagnosis?
Chronic Cough
Which of the following is a valid ICD-9-CM principle diagnosis code?
V30.00 Single Live Born, Born in 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
A system of preferred terminolgy for naming disease processes is known as a
medical nomenclature
A patient who is taking the drug Antivert may be diagnosed with
dizziness
Which of the following is not included as a part of the minimum data maintained in the MPI?
Principle Diagnosis
The Health Information department receives research requests from various committees in the hospital. The Medicine Committee wishes to review all patients having a diagnosis of anterolateral myocardial infarction with the past six months. Which of the following would be the best source to identify the necessary charts?
Disease Index
One of the major functions of the cancer registry is to assure that patients receive regular and continued observation and management. How long should patient follow-up be continued?
For the life of the patient
In reviewing the medical record of a patient admitted for a left herniorrhaphy, the coder discovers an extremely low potassuim level on the laboratory report. In examing the physicians' orders. the coder notices that intravenous potassuim was ordered. The physician has not listed any indication of an abnormal potassium level or any related condition on the discharge summary. The best course of action for the coder to take is to
confer with the physician and ask him/her to list the condition as a final diagnosis if he/she considers the abnormal potassium level to be clinically significant.
DSM-IV-TR is used most frequently in what type of healthcare setting?
Behavioral Health Centers
A coder notes that a patient is taking a prescription for Pilocarpine. The final diagnosis on the discharge summary is noted as: congestive heart failure and diabetes mellitus. The coder should query the physician about adding a diagnosis of:
Glaucoma
The patient is diagnosed with congestive heart failure. A drug of choice is:
Digoxin
Physical Examination:

Physician notes distended abdomen and excessive weight gain in the last three weeks.Patient appears to be short of breath.
Vital signs: T: 98.6

Laboratory results: show decreased serum albumin level
Nurses' Notes: Abdominal girth measure daily; output monitored; daily weight taken.
Procedures: Paracentesis x3
Medications: Hydrodiuril
Final Diagnosis: Cirrhosis of the liver
The coder might query the physician to ask the following condition could be added to the discharge summary:
Ascites
A nomenclature of codes and medical terms which provides standard terminology for reporting physician's services for third party reimbursement is
Current Procedural Terminology (CPT)
A cancer program is surveyed for approval by the
Commission on Cancer of the American College of Surgeons
Abstracting of cancer cases must be completed within _____ months from the date of diagnosis.
Six
The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national and international levels.
ABC Codes
The Level II (national) codes of the HCPCS coding system are maintained by the
Centers for Medicare and Medicaid Services
A patient is admitted in alcohol withdrawal suffering from delirium tremens. The patient is a chronic alcoholic and cocaine addict. Which of the following is the principle diagnosis?
Delirium Tremens
A patient is admitted with pneumonia. Cultures are requested to determine the infecting organism. Which of the following, if present, would alert the coder to ask the physician whether or not this should be coded as gram-negative pneumonia?
Pseudomonas
The Level I (CPT) codes of the HCPCS coding system are maintained by the
American Medical Association
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 procedure should be coded?
Excision of lesion; Full-thickness skin graft to scalp
A patient is seen by a surgeon who determines that an emergency procedure is necessary. Identify the modifier that may be reported to indicate that the decision to do surgery was made on this office visit.
-57
A patient develops difficulty during surgery and the physician discontinues the procedure. Identify the modifier that may be reported by the physician to indicate that the procedure was discontinued.
-53
A patient has major surery and sees the surgeon 10 days later for an unrelated E&M service. Indicate the modifier that should be attached to the E&M code for the service provided.
-24
A barrier to widespread use of automated code assignment is
Poor Quality of documentation
In assigning E&M codes, three key components are used. These are
History, examination, medical decision-making
Mrs. Jones has an appendectomy on November 1. She was taken back to surgery on November 2 for evacuation of a hematoma of the wound site. Identify the modifier that may be reported for the November 2 visit.
-78
The primary goal of a hospital-based cancer registry is to:
Improve Patient Care
A pregnant patient was admitted to the hospital with uncontrolled diabetes mellitus. She is a type I diabetic and was brought under control and subsequently discharged. The following code was assigned: 648.03
Other current condition in the mother classifiable elsewhere but complicating pregnancy, childbirth of the puerperium, diabetes mellitus. Which of the following describes the coding error?
An additional code describing the diabetes mellitus should be used
A secondary data source that houses and aggregates extensive data about patients with a certain diagnosis is a:
Disease Registry
After reviewing the following excerpt from CPT, code 27646 would be interpreted as: 27645 - radical resection of tumor, bone; tibia
27646 - fibula
27647 - talus or calcaneus
27646 - radical resection of tumor, bone; fibula
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
A 36-year old woman was admitted to the hospital for an obstetrical delivery of her third child. During the admission, a sterilization procedure was performed for contraceptive purposes. The V25.2 code for sterilization would be:
Assigned as a secondary diagnosis
According to ICD-9-CM, which one of the following is not a mechanical complication of an internal implant?
inflammation of urethra due to indwelling catheter
A population-based cancer registry which is designed to determine rates and trends in a defined population is a (an):
incidence-only population-based registry
Given the following diagnosis: "Carcinoma of axillary lymph nodes and lungs, metastatic from breast." What is the primary cancer site(s)?
Breast
In the diagnosis, "first, second, and third degree burns of the chest wall," a code is required for
The Third Degree Burn only
When is is appropriate to use category V10, history of malignant neoplasm?
primary malignancy has been eradicated and no adjunct treatment is being given at this time
According to CPT, in which of the following cases would an established E&M code be used?
Tom is seen by Dr. X for a sore throat. Dr. X is on call for Tom's regular physician, Dr. Y. The last time that Tom saw Dr. Y was a couple of years ago.