Only $2.99/month

Memo RHIT Exam Practice

Terms in this set (203)

In which PPS is the RUG-IV group classification system used?
a) Acute Care Hospital
b) SNF
c) Children's hospital
d) Home Health Agency

b) Skilled Nurse Facility
assist Activities of Daily Living (ADL).

Which of these is required of Health Insurance Portability & Accountability Act (HIPAA) covered entity that experiences a security breach that resulted in unauthorized access of PHI of 650 individuals?
a) Notify the individuals only within 30 days.
b) Notify the individuals only within 30 days & provided an annual report to HHs.
c) Notify the individuals, HHS, and local news media within 60 days.
d) Notify the individuals, HHS, and local news media within 30 days.

c) Notify the individuals, HHS, and local news media within 60 days.

Under the IRF PPS, if a patient is discharged from a rehabilitation on July 16, which date is data transmission of the discharge Patient Assessment Instrument (PAI) to CMS considered late?
a) July 26
b) August 4
c) August 12
d) August 16

c) August 12
Data must be transmitted no later than 27 calendar days after the patient is being discharged. Patient Assessment Instrument (PAI) must be completed within 4 days of discharged & coded within an addtional 6 days.

A staff member of a healthcare facility has authorized access to ePHI but has given 2 weeks notice of intent to resign. What procedure must be implemented when the person resigns?
a) Workforce clearance.
b) Termination.
c) Access modification.
d) Password Management.

b) Termination procedure must be implemented for a staff with 2 weeks notice of intent to resign.

Patients in Acute Care Facilities usually don't stay more than :
a) 5 days
b) 15 days
c) 20 days
d) 30 days

d) 30 days
Because they will be transferred to other facilities like: rehab, nursing home, SNF, etc.

Which dept. in Acute Care Facility is considered an outpatient dept. rather than inpatient?
a) Ob-gyn
b) ED
c) Medical
d) Pediatrics

b) ED ( Emergency Dept.)
Because patient aren't admitted formally to the ACF & stay for a limited period of time. Other outpatient dept. may include laboratory, radiology services, ambulatory, and surgery centers where people have their procedure & discharge on the same day.

Which of the following allows healthcare organizations and pharmacies to communicate drug-related information efficiently?
a) SNOMED CT
b) NDC
c) RxNorm
d) LOINC

c) RxNorm allows health organizations & pharmacies to communicate drug-related information efficiently. RxNorm compromises a naming system for drug (generic & branded) & that tools allows interoperability.
SNOMED CT (System Nomenclature of Medicine) cross map other international terminologies, classification, and code.
LOINC(Logical Observations Identifiers, Names, Codes): standard health measurements, observations, and documents is important for lab test orders and results.

HL7 refers to :
a) Health Level 7
b) Health Label 7
c) Hardware Level 7
d) Hitech Level 7

a) Health Level 7

HIPAA was passed by congress in what year?
a) 1966
b) 1976
c) 1986
d) 1996

d) 1996
According to HIPAA's Privacy Rule regarding authorization forms, the NOT require element is consent for treatment.

The security rule of HIPAA applies to :
a) All PHI
b) Personally Identifiable Info
c) PHI in paper form only.
d) ePHI only

d) ePHI only
The security rule of HIPAA applies to ePHI whether created, received, stored, or transmitted only, while the Privacy rule applies to all forms PHI. The Security Rule is enforced by CMS while the Privacy Rule is enforce by Office of Civil Rights (OCR).

During the planning for implementation of a new EHR, the HIM dept. plans User Acceptance Testing (UAT) to determine if the end users are willing and able to use the new equipment & applications as intended. The 1st step to analyzing end-user acceptance is to :
a) Design test cases & testing plan.
b) Identify different acceptance scenarios.
c) Determine the basic system & organization requirements.
d) Describe the severity levels of the testing plan.

c) Determine the basic system & organization requirements, so that the test can be designed with the skills of the end users.

In a relation databases, the data are separated into defined logical groups by:
a) tables
b) fields
c) records
d) characters

b) fields , which can be alphanumeric ( text), numeric, dates, may be whole numbers / decimals.

When a patient is admitted to a hospital, what should the registration clerk do to ensure that a duplicate record is not created for a patient who is already registered in the system?
a) Ask the patient about prior admissions.
b) Assign a new ID number.
c) Check the Master Patient Index (MPI)
d) Call the records dept.

c) Check the Master Patient Index (MPI) to ensure that duplicate record isn't created for a patient who is already registered.

According to AHIMA's minimum retention schedule, how long should diagnostic images, such as x-rays, be retained?
a) 5 years
b) 10 years
c) Permanently
d) 20 years

a) 5 years

Which accrediting organization accredits a wide range of healthcare facilities and organizations, including acute care hospitals, children's hospitals, psychiatric institutions, rehabilitation centers, clinical laboratories, long-term care facilities, and home health agencies?
a) NCQA
b) AAAHC
c) CARF
d) TJC

d) The Joint Comission has the wide range of healthcare facilities & organizations.
While NCQA ( National Committe Quality Assurance) accredit managed care organizations as well as wellness & health promotion & managed behavioral.
AAAHC (Accreditation Association for Ambulatory Health Care) accredits ambulatory care facilities, office based surgery centers, and managed care organization.
CARF (Commission of Accreditation of Rehab Facilities) accredits rehab program

In paper chart filling system, an out guide is used to :
a) label sections in the filing system.
b) track records that have been checked out.
c) develop an index of filed records.
d) label the outside of records with identifying info.

b) track records that have been checked out.

The PHR differs from the EHR in that the PHR is:
a) controlled by the physician.
b) controlled by the individual.
c) not governed by rules about privacy / confidentiality.
d) contains only information from the individuals.

b) controlled by the individual, not only contains only information from the individual.

The repair costs associated with improper computer equipment use have resulted in overtime payments of approximately 40 hours per month at a cost of $125 per hour. The HIM director proposes training additional staff persons to carry out the repairs in order to decrease overtime to an average of 10 hours per month, but the cost of materials is $400, the instructor is $3000, and staff costs for release time are $2000 for each of 6 staff members. What would be the cost benefit of this training in the first year?
a) There would be cost benefit of $29,600.
b) There would be cost benefit of $39,600.
c) There would be cost benefit of $44,600.
d) There would be no cost benefit.

The current annual overtime cost are:
$125 x 40 hours= $5000 x 12 months = $60,000
The HIM dept. proposes reduction of 10 hours monthly, so : $125 x 10 hours = $1250 x 12 months = $15,000
Total cost = Supplies + instructor + 6 staff training
Total cost = $400 + $3000 + (6 x $2000) = $15,400
Cost benefit = $60,000 - $15,000 - $15,400
Cost benefit = $29,600

If the HIM dept. must purchase / lease new hardware to replace an outdated system. The HIM dept. has identified 4 potential vendors through attendance at conferences, research of publications, and recommendations from other organizations. The next step in the vendor selection process is to:
a) develop a contract.
b) narrow the vendors to 2.
c) send a Request for Information (RFI).
d) send a Request for Proposal (RFP).

c) send a Request for Information (RFI), so they can narrow down the company screen.

When conducting trending analysis of data in a run chart, a run can occurs with :
a)

...

The laboratory in an acute hospital has begun sending automated alerts by instant messaging to physicians for all abnormal lab results rather than telephoning to try to improve response time has only slightly improved. In order to improve response time, the best method is likely to :
a) reset parameters for alerts for all tests.
b) advise disciplinary action against physicians.
c) reward physicians for improving response time.
d) discontinue the automated system of alerts.

a) reset parameters for alerts for all tests.

Prior to upgrading to a new EHR, the HIM dept. conducts workflow analysis to ensure the EHR integrates well into the clinical workflow. Which of the following steps should be taken first?
a) determine future requirements.
b) determine benefits of the upgrade.
c) assess the current status.
d) assess utilization of physical space and equipment.

c) assess the current status.

Which of the following is the primary purposes for reviewing the audit trails of EHRs ?
a) to determine if the EHR has undergone unauthorized access.
b) to determine if the EHR is storing data properly.
c) to determine if the patient has been advised of privacy / security regulations.
d) to determine if the EHR data has been entered in a timely manner.

a) to determine if the EHR has undergone unauthorized access. Because the audit trail should show who has accessed an EHR, dowloading info & images.

The purpose of the compliance plans established by Office of the Inspector General (OIG) is to ensure that :
a) patients' right are respected.
b) organizations switch from paper records to EHRs.
c) organizations bill for services properly.
d) patient records are retained for specified periods of time.

c) organizations bill for services properly. If the organization routinely miscodes, overcharging, resulting in over payment, this can result in prosecution as an act of fraud.

In order to avoid medical records being classified as delinquent, within what period following discharge of patients from the hospital must records be completed, including inclusion of the final diagnosis?
a) 48 hours.
b) 7 days.
c) 21 days.
d) 30 days.

d) 30 days , and for accreditation by JC, hospitals must audit delinquency rates at least every 3 months.

If the HIM director is planning to make changes in order to make changes in order to increase efficiency and wants to begin carrying out a gap analysis, the first step in gap analysis is to identify:
a) best practices.
b) key individuals.
c) barriers.
d) timeline.

a) best practices because it represent the end target.

In a relational database, what are the 3 types of possible anomalies?
a) Deviation, update, and insertion.
b) Update, insertion, and deletion.
c) Insertion, translation, and deviation.
d) Translocation, insertion, and deletion.

b) Update, insertion, and deletion.
Update : Redundancies occur in the data, so updates must be done more than once to cover all redundancies / the data error will not be corrected.
Insertion : Data can't be added to database because of the absence of the other necessary data.
Deletion : Data are unintentionally lost when other data are deleted.

How far away from a healthcare organization should a "warm" site with patient data be located?
a) within 5 miles.
b) more than 20 miles.
c) at least 50 miles.
d) at least 100 miles.

c) at least 50 miles.
A warm site with patient data should be located at least 50 miles away from the healthcare and 20 miles away from the coast. The distance should be great enough to be secure in the event of natural disaster, but close enough that it can be accessed & activated within 8 hours. This back up system should be able to run EHR.

Physicians and other staff members at County Hospital are increasingly utilizing mobile devices & want to access patient records & enter data over the Internet via the devices. The HIM dept. is assisting in the development of a mobile device policy. All of the following are critical measures to include except:
a) establishment of VPN.
b) installation of remote disabling / wiping.
c) security / privacy training.
d) insurance policy against lost.

d) insurance policy against lost. because it's include in policy. The establishment of VPN (Virtual Private Network) is important because it allows data to be transmitted securely from unsecured environment. While the device should have remote disabling / wiping installed, in case, the device is lost.

When conducting an audit of narcotic prescriptions in the emergency dept. the HIM director notes that 1 physician had ordered 4 times more narcotics than any other physician in the dept. over a 1-month period, with multiple prescriptions to some individuals who returned frequently to the emergency dept. What is the most appropriate action?
a) No action is needed.
b) Notify the police.
c) Ask the physician for an explanation.
d) Alert the administration.

d) Alert the administration. Because the likelihood exists when the physicians is supplying the drugs that aren't necessary for medical health reasons.

Which of the following is a data set / initiative that supports collecting data from emergency dept in the hospitals?
a) ORYX
b) HEDIS
c) DEEDS
d) NHIN

c) DEEDS (Data Elemets for Emergancy Dept.) is published by CDC in order to collect uniform data from emergency depts in hospitals voluntary.
ORYX : perform measurement billing.
HEDIS ( Health Effectiveness Data & Info Set) : are collected through survey, medical charts, insurance claims for hospitalizations, medical office visits, and procedures.

County Hospital has received an administrative request from a law enforcement official for copies of a patients' records related to a criminal proceeding. According to HIPAA's Privacy Rule what are 3 criteria must be met before information is disclosed?
a) Relevance, specificity, and identifiable information necessary.
b) Reason, identifying information, and specificity.
c) Relevance, identifying information, and specificity.
d) Reason, relevance, and identifiable information necessary.

a) Relevance, specificity, and identifiable information necessary.
Relevance: The records provided must directly related to criminal proceeding.
Specificity : Only those records related to the proceeding should be released.
Identifiable : Info that hasn't been de-identified is necessary for the proceeding.

Which workload (data) distribution techniques are used with a distributed database?
a) Analysis, integration, and fragmentation.
b) Analysis, allocation, and integration.
c) Fragmentation, analysis, and integration.
d) Fragmentation, allocation, and replication.

d) Fragmentation(horizontal & vertical) , allocation, and replication.

If a hospital is among the 25% of hospitals with the highest rates of Hospital-Acquired Conditions( HACs) what percentage reduction in payment will the CMS impose?
a) 0.5%
b) 1%
c) 2%
d) 3%

b) 1%

The 3 criteria that electronic signatures must meet when used for medical records are :
a) User authentication, non-duplication, and conformation.
b) Conformation, non-repudiation, and user authentication.
c) Message integrity, non-repudiation, and user authentication.
d) Message integrity, non-duplication, and user authentication.

c) Message integrity, non-repudiation, and user authentication.
Message Integrity : conform that no alternation were made to the record after the signature.
Non-repudiation : Once a person signs the record using a distinct signature, the person shouldn't be able to deny having signed the record.
User Authentication : The receiver of the medical record should be able to confirm that the person whose signature is applied to the record was the actual person who signed the record.

If during a system upgrade, a system failure results in corrupted data, the immediate response should be:
a) revert to back up.
b) correct the data.
c) determine the exact cause.
d) consult with experts.

a) revert to back up. Data stored prior to the system failure because the larger HIM waits to take this action, the more data will have to be reentered, this can become very time consuming & difficult to manage.

A patient was hospitalized as an inpatient in an acute care hospital under Medicare A from March 7-15. If Medicare is to pay SNF care, within how many days after discharge must the patient be admitted to the Skilled Nursing Facility?
a) 14
b) 21
c) 30
d) 60

c) within 30 days of discharge. Patients are limited to 100 days of covered care in SNF during benefit period, beyond this time, the patient has long-term care insurance / is eligible for Medicaid.

According to the 6 stages of the revenue cycle, after services are provided, the next stage involves:
a) establishing charges.
b) documenting services.
c) submitting claim for services.
d) prepare bill for services.

b) documenting services.
If service isn't documented, then there is no supporting evidence for the claim.

When utilizing a charge explosion system for the charge master, 5 different chargeable items that are part of 1 service would be entered into te system under :
a) 1 code
b) 2 codes
c) 4 codes
d) 5 codes.

a) 1 code
They bundle the items together to make data entry more efficent.

If a claim for outpatient service is billed to Medicare & Outpatient Code Edits (OCE) result in a claim level disposition of suspension, what must the healthcare provider do?
a) File an appeal with Medicare.
b) Provide requested information.
c) Correct problems prior to re-submission.
d) Correct the claim prior to re-submission.

b) Provide requested information.
If it's rejected & return to health care provider must correct problems prior to re-submission.

If the hospital administrator wants to compare the caseloads of different oncologist asks the HIM director to prepare a report, the most appropriate place to find that data is the:
a) EHRs.
b) Physician Index.
c) Cancer Registry.
d) Disease Registry.

County Hospital wants to decrease the rate of re-admissions by providing high-risk patients with case managers. The best method to identify these patients is to:
a) use software application to mine data regarding risk factors from the EHRs.
b) ask unit supervisors to notify the case manager of potential cases.
c) conduct patient surveys, asking if they want case managers.
d) use software to trigger alerts of patients hospitalized for more than 3 days.

d) use software to trigger alerts of patients hospitalized for more than 3 days.

According to CMS, the 3 key components when selecting the correct level of E/M services (not including visits for counseling & / coordination of care) are history, __________________, and decision making.
a) examination.
b) recommendation.
c) documentation.
d) reason for referral.

a) examination.
These components are coded & billed differently.

An example of a finding associated with a qualitative review of an EHR is:
a) electronic signature missing from a progress report.
b) pathology report of surgical specimen not in the record.
c) dressing change not documented for 1 day.
d) results of an ordered CBC are not in the record.

c) dressing change not documented for 1 day.
Because this demonstrate an inconsistency between the physician order and the completion of the order, also indicate the failure to document the procedure.

Patients can ( may) have multiple hospitalization in

1 benefit period of 60 days.

County Hospital experienced a flood when a nearby river overflowed during a severe rainstorm, inundating the records room located in the records room located in the basement and saturating a large volume of records. The best salvage method is to :
a) separate the papers in the records and air dry.
b) separate the papers in the records and apply heat & fans.
c) keep the records intact and freeze them.
d) separate the papers in the records and freeze them.

d) separate the papers in the records and freeze them.
+/- 20 degrees Fahrenheit or minus 29 degrees Celcius in preparation for freeze-drying procedure, and the papers in the files shouldn't be sepaarated.

With ICD-10-PCS, if a patient undergoes a thrombectomy to remove a clot from the leg, which of the following is the root operation for this surgical procedure?
a) Extraction.
b) Excision.
c) Extirpation.
d) Removal.

c) Extirpation.
Excision = cut out / off a body part by force.
Extraction = puling / stripping out a body part by force, such as : vein stripping.
Removal = removing device from body part,
such as : pacemaker removal.

As part of denials management, if coding has been missing for some services because physicians frequently forget to document bedside procedures, such as wound care, the best solution may be to :
a) provide coders access to account charges.
b) institute back-end editing.
c) send out reminders to physicians.
d) provide better training for coders.

a) provide coders access to account charges , so they can look for discrepancy between supplies used and procedures.

When an enterprise-wide Master Patient Index (MPI) fails to link 2 medical files for a patient who has been treated at 2 participating organizations & the patient ends up with 2 identifiers in the MPI, this type of error is a(n):
a) duplication.
b) distortion.
c) overlay.
d) overlap.

d) overlap.

A patient had a skin tag removed on March 1 & returned to the same physician on March 3 for a laceration repair unrelated to the first surgery. How many days total would the patient be covered under the Medicare's global surgical package for the minor surgical procedures ?
a) 10
b) 11
c) 13
d) 22

c) 13
2 days would be covered for the 1st procedure, the day of surgery & the following day, but that time period stops when the 2nd one starts. 11 days are covered for the 2nd procedure, the day of the surgery & the next 10 days.

An 8-year-old child is brought to the emergency dept. .by a non-related family friend after the child fell & complained of leg pain, but the child walked into the emergency dept. The parents could not be reached. Which of the following is appropriate before the parents are reached ?
a) A medical screening exam only should be conducted.
b) The family friend can sign consent form for tests & treatment.
c) Because this is an emergency, the physician can order tests & treatment.
d) A court order should be obtained before providing care.

a) A medical screening exam only should be conducted, and then wait for the consent from the parents before conducting further tests / providing treatment. A friend of the family has no legal right to grant consent, and a court order isn't warranted for a minor injury.

All of the following are critical roles that the HIM dept. plays in data standardization except :
a) Identifying key elements requiring standardization.
b) Carrying out clinical document improvement functions.
c) Ensuring national data standards are in use in the organization.
d) Ensuring that data support financial goals of the organization.

d) Ensuring that data support financial goals of the organization.

Considering the domains of quality management, which of the following refers to the purpose of the collection of data?
a) Collection
b) Application
c) Analysis
d) Warehousing

b) Application refers to the purpose of the collection of data, how the data will be utilized. Collection refers to the manner in which data are collected, all of the steps involved in the process. Warehousing refers to the storage and archiving of data & should include security measures to prevent breaches of confidentiality. Analysis refers to the manner in which data are translated into information that can be utilized by an application.

Which of the following can trigger the requirement for an Eligible Professional (EP) or group practice under CMS guidelines for PQRS to report cross-cutting measures?
a) tele-health visit.
b) acceptance of assignment.
c) surgical procedure code.
d) hospital privileges.

c) Submitting surgical procedure code can trigger the requirement to report cross-cutting measures to CMS to PQRS.

An external audit coding practices should be conducted at least:
a) monthly.
b) yearly.
c) every 2 years.
d) every 5 years.

b) yearly to analyze the operations, detect any gaps in performance, and identify problems.

Following a 60-day hospitalization for complications related to diabetes and amputation of the right lower leg, the patient requested copies of the entire health record. Which of the following is not correct?
a) The patient has a right to access the entire record.
b) The hospital may charge a reasonable fee to cover costs.
c) The hospital can withhold sensitive notes.
d) The patient must provide the copies within 30 days.

c) The hospital can withhold sensitive notes.
Generally, patients have the right to access all their healthcare records, however, if the requests are extensive, the hospital has the right to charge reasonable copying fees. According to HIPAA requirements, the copies of the record must be provided within 30 days of request. Patients have the right to ask that errors in their records to be corrected.

If an RHIT receives a subpoena duces tecum, the technician is being directed to :
a) verify that records are authentic.
b) review records for fraudulent practices.
c) testify about patient care.
d) bring records (copies / originals).

d) bring records (copies / originals).
The subpoena should specify exactly which documents or images are wanted because state laws vary, the RHIT should verify responsibilities in regard to responding. A subpoena testificandum is directing the RHIT to appear to testify that the records are authentic (not altered / incomplete).

In preparation for an HHS Office of Civil Rights (OCR) HIPAA audit, an organization should begin by :
a) completing a risk assessment.
b) requesting preliminary guidelines.
c) warning all staff members of the impending audit.
d) conducting staff training.

a) completing a risk assessment. This includes reviewing all requirements for compliance. The security of PHI must be assessed as well the type & effectiveness of security controls. The organization should also review all policies regarding privacy & breach notification.

The HIM director is responsible for conducting an internal coding audit. The first step should be to :
a) determine the scope of the audit.
b) identify those who will perform the audit.
c) gather reference materials needed for the audit.
d) identify items needed, such as charge tickets.

a) determine the scope of the audit, including the type of services to audit & whether to do the audit retrospectively / prospectively in relation to filling claims. A baseline audit may be conducted to help determine the scope. Then, the individuals who will conduct the audit should identified materials (such as coding manuals) & made decision about supplementary items (such as charge tickets & claim forms).

When reviewing hospital statistics for hospital-acquired infections (HACs), the HIM director finds that the predicted number of Surgical Site Infections (SSIs) for the hospital is 15, but 26 patients developed surgical site infections. This represents a Standardized Infection Ratio (SIR) of :
a) 3.90
b) 0.57
c) 17.3
d) 1.73

d) 1.73 (26/15) this indicates that the hospital experienced approximately 73% more infections than was predicted for the size & type of hospital based on national data since it's more than 1.

Knowledge Discovery in Databases (KDD) is a method utilized to search databases in order to:
a) collect and summarize data.
b) identify patterns and relationships.
c) apply a standardized coding system.
d) translate analog data into digital.

b) identify patterns and relationships.
KDD is commonly used as a tool of research & includes data mining methods (including decision tree, nonlinear regression, classification, and relational) to extract knowledge. With KDD, data are selected, preprocessed, mined, and interpreted. The primary goal of KDD is to draw conclusions about data.

Which of the following healthcare providers is allowed to file a CMS claim for "incident to" services provide to a patient by auxiliary personnel ?
a) the patient's physician.
b) any physician certifying the services were provided.
c) the physician providing direct supervision.
d) any physician with knowledge about the services provided.

c) Only the physician ( or other practitioner, such as a nurse practitioner) who provide direct supervision can file a CMS for "incident to" services provided by auxiliary personnel. The supervising healthcare provider may, in fact, be different from the patient's physician or the who ordered the service. Auxiliary personnel may be employees, independent contractors, or leased

Following FDA approval of an item & during the time when a new code is being considered for this item through the HCPCS level II code should be utilized?
a) Permanent national codes.
b) Temporary codes.
c) Miscellaneous codes.
d) No codes can be utilized.

c) Miscellaneous codes are used when there is no national code that is appropriate for the item / service. Documentation regarding the claim should be submitted to the payer. Temporary codes are those assigned by insurers before the next code update / when a consensus about coding the item / service hasn't been reached.

A 70-year-old patient came to Emergency Dept. for a right wrist injury and an x-ray showed a non-displaced. Colles fracture. A short arm prefabricated splint was applied. How would the diagnosis, x-ray, splint, and splint application be coded for CMS billing?
a) ICD-10-CM for diagnosis, CPT for x-ray, CPT for splint application, and HCPCS level II L code for the splint.
b) ICD-10-CM for diagnosis, CPT for x-ray, CPT for splint application, and CPT for splint.
c) ICD-10-CM for diagnosis, HCPCS level II R code for x-ray, CPT for splint application, and CPT for splint.
d) ICD-10-CM for diagnosis, CPT for X-ray, and HCPCS level II code L for splint (includes application).

d) ICD-10-CM for diagnosis, CPT for X-ray, and HCPCS level II code L for splint (includes application).
No manipulation was required because the fracture was non-displaced. A CPT code for application of a splint is only utilized if the splint is specifically made & fitted to the patient, but in this case a prefabricated splint was used & application is included in the L code for the splint.

If a neoplasm is described with the term "adenoma" or "lipoma" , which column in the ICD-10-CM 'table of Neoplasms would the RHIT use to identify the correct code?
a) Malignant primary.
b) Malignant secondary.
c) Unspecified.
d) Benign

d) Benign code column in the ICD-10-CM Table of Neoplasm to identify the correct because these terms refer to non-malignant lesions. However, if the description includes the word "malignant" / "cancerous", such as "malignant adenoma", then the diagnosis should be coded as a malignancy.

A patient has a primary diagnosis of prostatic cancer (C61) but is admitted for radiation treatment (Z51.0) for metastasis to the bones (C79.51), and has also been receiving long-term treatment for diabetes mellitus, type 2, with polyneuropathy (E11.42). How would these diagnoses be sequenced (first to last) ?
a) Z51.0 , C79.51 , C61 , E11. 42
b) Z51.0 , C 61 , C79.51 , E11.42
c) E11.42 , Z51.0 , C61 , C79.51
d) E11.42 , C79.51 , C61 , Z51.0

a) Z51.0 , C79.51 , C61 , E11. 42
The primary diagnosis of prostatis cancer (C61) would be next in the sequence followed by the chronic condition, diabetes mellitus with neuropathy (E11.42)

Which of the following NDCs is in the correct format for filling a CMS claim for a drug administered to a patient in an outpatient clinic?
a) 21695-0245-20
b) 0069-5510-16
c) 76237-134-30
d) 17856-0079-1

a) 21695-0245-20
NCD codes contain a labeler code, product code, and package code with these 3 sub-codes separated by a hyphen. To comply with HIPAA standards, CMS requires the 5-4-2 (11 digit) code configuration & utilizes leading zeroes if the code has fewer than 11 digits.

If a patient's diagnosis is "MRSA (Methicilin-Resistant Staphylococcus Aureus) Septicemia," which of the following is the most specific supporting documentation in the EHR?
a) Blood cultured and sensitivities.
b) Chest x-ray.
c) Metabolic panel.
d) Complete blood cell count.

a) Blood cultured and sensitivities (-) for response to methicilin. To complete blood cell count is also supporting, but less specific because provides no info about the organism / resistance to antibiotics.

Which of the following is generally not part of the criteria for medical necessity?
a) Care is provided within clinically accepted medical practice standards.
b) Care is appropriate to the patient's diagnosis, need, and condition.
c) Care is provided to restore health / prevent deterioration of health.
d) Care is provided for maintenance / caregiver convenience.

d) Providing care for maintenance / caregiver convenience isn't a criteria for medical necessity & isn't generally covered by Medicare / secondary insurance companies. Criteria include care that's appropriate to the patient's diagnosis, needs, and condition, care provided to restore health / prevent deterioration of health, care provided within clinically accepted medical practice standards, and care provided to prevent a likely health problem / diagnose a problem.

If the same information about a patient is entered into more than 1 table in a database, this is an example of :
a) data inconsistency.
b) data redundancy.
c) data replication.
d) data disparity.

b) data redundancy in database can pose problems if it's done accidentally because 1 table is updated & another isn't may result inconsistency where data that should be the same are different. It may also be done purposefully as part of backup to ensure that data can be recovered.

Which of following is a provision of a Voluntary Data Sharing Agreement (VDSA) with CMS?
a) Electronic exchange of health insurance benefit info.
b) Increased administrative costs.
c) Increased risk of repayment claims & penalties.
d) Electronic security system to protect info.

a)Electronic exchange of health insurance benefit info to simplify coordination of healthcare benefit payments between employers & Medicare. Each quarter, the employer forwrds group health entitlement information to CMS's Benefits Coordination & Recovery Center, and Medicare, in turn, provides the employer info that identifies group health plan members who are eligible for Medicare benefits.

If, under HIPAA's Security Rule, a healthcare organization determines that an "addressable" implementation specification isn't applicable or appropriate for the organization, the healthcare organization must :
a) Implement an alternate measure in place of addressable measure.
b) Document the decision and rationale and show how the standard is met.
c) Implement the addressable implementation specification anyway.
d) File an appeal requesting the organization be excused from implementation.

b) Document the decision and rationale and show how the standard is met because the implementation are labeled as "required" or "addressable" doesn't mean the specification is optional, in all cases, the standard must be met in someway.

Which of the TRICARE programs is an HMO style plan ?
a) TRICARE Standard.
b) TRICARE Extra.
c) TRICARE Prime.
d) TRICARE Guard & Reserve.

c) TRICARE Prime can cover not only active duty service members but also retirees from active duty or military reserves who are 60 years & older & their eligible family members. Enrollees select a primary care physician who can provide a referral to specialists. Because of the restrictions in access to physicians, the co-payment is small & those on active duty and their families are not required to pay a fee for enrollment.

A patient was hospitalized under Medicare 2 times in 1 year for extended periods of time because of complications associated with a BK amputation & sepsis. 60 days separated the discharge from first hospitalization to the admission for the second: 92 days & 106 days. If the daily coinsurance er each lifetime reserve day is $644, for how much of the costs will the patient be financially responsible?
a) None.
b) $3,864
c) $5796
d) $11,592

Since the lifetime reserve is 90 days, the patient owes for 2 days (92-90=2) for the first hospitalization & 16 days (106-90=16) for the second, for a total of 18 days.
18 days x 644 = $11,592 / D.

Under the APC guidelines, to qualify for outlier payments, the cost must exceed __________ times the APC payment.
a) 1.5
b) 2
c) 2.5
d) 3

c) 2.5 Any amount below that is considered a normal fluctuation & no additional payment is made. If, for example, costs exceed APC payment by $400, then the outlier payment would be $300 (75% of excess cost). Outlier is an exception to the usual fixed payment rates. Other exceptions are made for pass-through items and new technology.

When calculating the CMI, the required data include:
a) Wage index of each MS-DRG & the number of discharges in the MS-DRG.
b) Wage index of each MS-DRG & the number of admissions in the MS-DRG.
c) Relative weight of each MS-DRG & the number of admissions in the MS-DRG.
d) Relative weight of each MS-DRG & number of discharges in the MS-DRG.

d) Relative weight of each MS-DRG & number of discharges in the MS-DRG. The total weight for each MS-DRG is calculated by multiplying the relative weight by the number of discharges. The total weights of all of the MS-DRGs are added together and that number is divided by the total number of discharges in order to obtain the case mix index.

138) After a claim is entered into a payer's system, which action occurs next?
a) A payer data file is established.
b) Claim information is reviewed against the payer's data file.
c) Computerized edits are conducted to assess services & coding.
d) Allowable charges are determined & payment sent.

b) Claim information is reviewed against the payer's data file in order to determine if coverage was active at the time the service was provided. The claim is reviewed to ensure preauthorization requirements were met & the LOS was appropriate. Once this completed,
computerized edits are conducted to determine if any procedures were medically necessary & that bundled services weren't unbundled then a payment determination is made & payment sent.

139) The 3 types of edits that are carried out by the Medicare Code Editor (MCE) are:
a) inpatient coding, coverage, and inpatient clinical.
b) inpatient coding, claims, and coverage.
c) inpatient coding, claims, and inpatient clinical.
d) claims, coverage, and clinical.

a) inpatient coding, coverage, and inpatient clinical.
Inpatient coding: Ensures diagnosis / procedures codes are correct & that the 4th / 5th digit of the diagnosis code is correct. Checks for age & gender conflicts & ensures principal diagnosis matches claim for services.
Coverage : Ensures procedure is covered & completes Medicare Secondary Payer (MSP) alert.
Inpatient Clinical : Checks for bilateral procedures, validity of age & gender, and valid discharge status.

141) According to the Federal False Claim Act, if a provider bills Medicare $250.00 for services that were not provided to the patient and later submits another claim for $125 for services not provided, how much would the fine be if the provider were found guilty of filling fraudulent claims?
a) $375
b) $10,375
c) $11,125
d) $21,125

d) $21,125
The fine is 3 times the billed amounts plus $10,000 for each claim :
$250 + $125 = $375 x 3 = $1125 + $20,000 = $21,125

144) In the conversation from paper records to the EHR, the HIM dept. must make a decision about back-scanning. Back-scanning refers to scanning:
a) paper records already in existence.
b) planned for a future time.
c) claim-supporting documents only.
d) discharge summaries only of paper records.

a) paper records already in existence, so they can be accessed electronically. For example, a HIM dept. may decide to back-scan only the previous year's records or may decide to begin scanning records only at a future point in the conversion project. Back-scanning saves physical storage space, but may increase costs of digital storage.

145) The best method of establishing productivity goals for coding professionals is to :
a) calculate goals based on needs, number of staff, and number of hours.
b) measure actual production over a specified period of time.
c) survey staff about what they consider reasonable goals.
d) estimate based on past experience & observation.

b) measure actual production over a specified period of time, usually 4-6 weeks. Once the statistics have been gathered & compiled, the average for the group as a whole should be calculated because this rate is affected by outliers, such as a staff person with very low productivity, an additional average of that average productivity rate of the group & the rate of most productive worker should provide a reasonable, but not too easy goal.

147) If using CPT code 20680 (removal of implant, deep) for a hardware removal procedure after a physician removed a plate and 3 screws for an orthopedic injury because of a metal sensitivity reaction, how many times should the code be entered on the claim form?
a) 1 time.
b) 2 times.
c) 3 times.
d) 4 times.

a) 1 time. Even though 4 pieces of hardware were removed, the removal was done during 1 procedure. CPT code 20680 should be used only if the removal was done during 1 procedure. CPT code 20680 should be used only if the removal involves an incision through multiple layers of tissue. Superficial removals should be coded 20670.

148) What is the recommended time period that a healthcare facility should retain the register of surgical procedures?
a) 1 year.
b) 5 years.
c) 10 years.
d) permanently.

d) permanently. While most records are maintained for 10 years, diagnostic images, mammography for 5 years, and some records should be maintained permanently, including registers of births & deaths ; MPI . However, there are no clear national regulations regarding retention & state requirements may vary.

150) If the Master Patient Index (MPI) includes a Soundex field, how would the name "Parker" be coded ?
LETTER CODE
B, F, P , V 1
C,G, J, K, Q, S, X, Z 2
D, T 3
L 4
M,N 5
R 6
A,E,I,O, W,Y No code
If less than 3 digits long Add 0
a) 1626
b) P626
c) P6-6
d) 16-6

b) P626
The code starts with the first letter of the person's name followed by codes that correspond to the consonants in the name. If the digital code is less than 3 digits long, then an ending 0 is added.For longer names, the coding stops with 3 digits. Soundex files may be used to look up a file if the spelling of the person's name is unknown.

152) A "bill-hold period" is used by HIM to ensure that:
a) all charges are posted on the claim.
b) copies of the bills are retained for a specified time period.
c) claims are sent out in batches.
d) payers have adequate time to make payment.

a) all charges are posted on the claim before it is submitted. The period may vary but it's typically relatively short, but about 3-5 days after discharge. During this time, the coding of the record should be completed. However, if the record is incomplete, coding may take longer, and rushing to finish may result in missed codes & lower rates of reimbursement.

153) What is the purpose of grouper software?
a) Classify patients into the correct MS-DRG.
b) Facilities data mining for clinical research.
c) Group patients according to admitting diagnosis.
d) Group patients according to demographic info.

a) Classify patients into the correct MS-DRG based on ICD-10-CM code, severity of illness, and risk of mortality. Healthcare organizations often purchase Grouper software to calculate expected reimbursement, so that healthcare organization can budget accordingly. While it's possible to manually assign MS-DRGs, doing so is very complex because there are many factors to consider.

155) In a Transaction-Processing System (TPS), a detailed report about admissions would be classified as a(n) :
a) transaction.
b) product.
c) input.
d) output.

b) product.
Data from different types of products may be used to make staffing / other decisions. TPS managers

156) For the Medicare fee schedule that lists allowable charges for physicians under Medicare B, the factors that are utilized when utilized when calculating Relative Value Units (RVUs) & Geographic Practice Cost Indices (GPCIs) include all of the following except :
a) physician work.
b) practice expense.
c) specialty licensure.
d) malpractice costs.

c) specialty licensure.
Physician work : Time & intensity of services provided to patients.
Practice expenses : Includes both direct costs (staff labor, medical equipment, medical supplies) and indirect costs.
Malpractice costs : Cost of malpractice insurance premiums according to specialty.

157) In the OPPS, what does an "N" status indicator mean?
a) No APC rate exists for this service.
b) Service will receive partial payment.
c) Service will will be discounted.
d) Service / item is packaged into the APC rate.

d) Service / item is packaged into the APC rate may include: minor medications, medical supplies, and devices. CMS assigns a status indicator to each HCPCS/CPT code, indicating how the service / item will be reimbursed. Status indicators A,B,C, and D all services / items that won't receive reimbursement for various reasons.

158) If further information is needed to complete coding of a patient's record & the physician must be queried, which of the following is likely the most efficient method ?
a) telephone call.
b) query form.
c) text message.
d) personal interview.

b) send query form
because it can contain detailed information & cover specific questions. For example, if a number of abnormal findings are documented on the history & physical with no responding diagnosis, these findings can be documented on the query. Query form may be transmitted electronically / on paper.

159) With medical & surgical procedures in ICD-10-PCS, which meanings are missing in the chart demonstrating the 7 characters utilized for coding ?
1= Section. 4 & 5 = Nothing
2 = Body System 6= Device
3 = Root Operation 7 = Qualifier
a. (4) Body part , (5) Approach
b. (4) Approach , (5) Body part
c. (4) Body part, (5) Severity
d. (4) Approach , (5) Severity

a. (4) Body part , (5) Approach
Section: General type of procedure.
Body system : Indicate by numbers / letters.
Root operations : 31 different procedures.
Approach : Varies according to body part, but may include open, percutaneous, via natural / artificial opening, and via natural / artificial opening endoscopic.
Device : Z is used

161) If 2 hospitals each have the same number of licensed beds but the first hospital (X) has an ALOS of 3 & discharges 30,000 patients per year & the second hospital (Y) has an ALOS of 6 & discharges 15,000 per year, which hospital has the greater capacity?
a) Capacity is equal.
b) Data are insufficient.
c) Hospital Y.
d) Hospital X.

d) Hospital X has the greater capacity because the lower assessed either according to the number of licensed beds / through comparing the ALOS & the discharges.

162) As part of utilization management, Intensity-of-Service screening & Severity of Illness (ISSI) criteria are used to :
a) determine whether a patient needs continued inpatient care.
b) determine if proposed inpatient care is a medical necessity.
c) determine whether a patient needs inpatient care based on physical impairment.
d) determine whether a patient requires impatient / outpatient care.

d) determine whether a patient requires impatient / outpatient care. This type of screening is often used to decide if a patient's surgical procedure should be done as an inpatient care based on physical impairment. Continued-stay / concurrent utilization determines whether a patient needs continued inpatient care / care at the same level. Prospective utilization determines whether inpatient care is a medical necessity.

164) When conducting testing on HIT projects in the HIM dept, testing should be done in which of the following orders?
a. (1) system , (2) integration , (3) units, (4) usability
b. (1) unit , (2) integration , (3) system , (4) usability
c. (1) system , (2) unit , (3) usability , (4) integration
d. (1) unit , (2) system , (3) integration, (4) usability

b. (1) unit , (2) integration , (3) system , (4) usability
(1) Unit : Testing of individual components & programs.
(2) Integration : Testing to determine how system subsets work together.
(3) System : Testing of the entire system.
(4) Usability : Testing by end users to determine if the system fits workflow & other end-user needs.

165) Which data set is designed to gather data about Medicare patients who are under the care of a home health agency?
a) OASIS-CI.
b) MDS
c) UCDS.
d) DEEDS

a) OASIS-CI is the version developed for use with
ICD-10-CM. OASIS data is about a patient's condition & therapy needs are used to determine the case-mix adjustment to the base payment rate. HHA providers complete an HH patient tracking sheet that includes CMS certification number, NPI, and patient demographic information, as well as the date of start of care & resumption of care & current payment source for HH care.

When calculating the fetal death rate for hospital, which of the following should be included in the calculations?
a) All fetal deaths, regardless of weeks of gestation / weight.
b) All fetal deaths occurring / after 20 weeks' gestation / weight of at least 501 g.
c) All fetal deaths occurring at / after 10 weeks' gestation.
d) Only fetal deaths occurring at / after 28 weeks' gestation / weight of greater than 1000 g.

[b) All fetal deaths occurring / after 20 weeks' gestation or weight of at least 501 g.
Fetal deaths are classified by gestation & weight :
Early : under 20 weeks & under 500 g.
Intermediate : 20-28 weeks/more & weight of 501-1000g
Late : 28 weeks / more & weight over 1000 g.
To calculate fetal death rate :
Total # intermediate & late fetal deaths divided to
[Total # live births] + [Total # intermediate & late fetal deaths]

If insurer, such as Blue Cross/Blue shield, denies claim, within how many days of denial must internal appeal be submitted?
a) 30.
b) 60.
c) 90.
d) 180.

d) 180.
The insurance company must complete the appeals process & render a decision within 30 days for future services & 60 days for services already received. If the insurer continues to deny the claim, the claimant has 60 days after notification of the denial to request an external review carried out by a third party.

Which of the following is an example of malware that copies itself and spread throughout a system ?
a) Computer virus.
b) Trojan horse.
c) Computer worm.
d) Rootkit.

c) Computer worm is a program that is able to duplicate itself (rather than attaching to another program) & spread throughout a system.
A computer virus is a program that reproduces itself & then attaches to a program in order to corrupt data.
A Trojan horse allows unauthorized access to a computer in order to gain information / to send emails.
A rootkit is a program that gains access to a computer's operating system in order to modify it.

A patient receives care from a physician who is a non-participating Medicare provider who does not accept assignment, and the actual charge for visit is $300. However, the usual, customary, and reasonable (UCR) charge is $240.00, and patient has no supplementary insurance. How much out-of-pocket cost will the patient incur?
a) $108.00
b) $117.60
c) $48.40
d) $60.00

b) $117.60
Since Medicare pays only 80% of the UCR charge ($240x.80), Medicare normally pays $192 for the visit. However, because the physician is non-participating, and has not accepted assignment the physician receives only 95% of the usual payment ($192x .95) or $182.40 ( $300 - $182.40 = $117.60 )

...

If a healthcare organization wants a classification system to quantify levels of functional ability & disability, which of the following is the best option?
a) LOINC
b) ICPCC
c) ICF
d) ICD-O

c) ICF (International Classification of Functioning, Disability, and Health). There are 4 code components to the ICF in 2 parts:
Part I : Functioning & Disability: Body Structure & Body Function.
Part II : Contextual Factors : Activities & Participation & Environmental Factors.
Impairment is quantified from 0 (none) to 4 (complete) with code 8 indicating "not specified" & 9 "not applicable".

A patient is being treated specifically with antineoplastic immunotheraphy (Z51.12) for multiple myeloma (C90.00), which has not yet achieved remission. The patient also has a history of supra-ventricular tachycardia (I46.1), controlled by medication. How would these diagnoses be sequenced, first to last ?
a) Z51.12 , C90.00, and I46.1
b) I46.1, C90.00, and Z51.12
c) I46.1, Z51.12, and C90.00
d) C90.00, Z51.12, and I46.1

a) Z51.12 , C90.00, and I46.1
If a patient is being treated specifically with immunotheraphy (or chemo therapy / radiation therapy) for a malignancy, the therapy is listed as the principle diagnosis ( Z51.12), followed by the condition to which the therapy applies, multiple myeloma (C90.00). Other chronic conditions are then listed, such as SVT (I46.1).
Codes sequence is : Z51.12, C90.00, and I46.1

When calculating the Readmission Adjustment Factor (RAF) for MS-DRG base rate, if the base operating DRG is $5040 & the readmission adjustment factor is 0.9990 less 1.0, the adjustment to the base rate is
a) +$5.04
b) (-$5.04)
c) +$4.03
d) (-$4.03)

b) (-$5.04)
The adjustment to the base rate is (-$5.04) to bring this rate to $5034.96 calculation are made based on whether the RAF is more / less than 1 :
0.0990 - 1 = (-0.0010)
$5040 x (-0.0010) = (-$5.04)
Under provisions of the Affordable Care Act, payments to IPPS hospitals are reduced if they have excess readmissions.

When billing for dental claims, which coding system is utilized?
a) CPT.
b) ICD-10-PCS.
c) NDC
d) CDT.

d) CDT (Current Dental Terminology), coding system is utilized. CDT was developed by the American Dental Association (ADA). The codes contains 12

In HCPCS level II codes, which type of code would be used for drugs that are not administered orally, such as chemotherapy drugs and inhalation drugs?
a) A codes.
b) D codes.
c) E codes.
d) J codes.

d) J codes.
A codes are used for transportation services, such as ground and air ambulance.
D codes are used for dental procedures & compromise a CDT code set copyrighted by the American Dental Association (ADA).
E codes are used for durable medical equipment, such as bathtub wall rail & oxygen equipment & supplies.

Forms control is a process in which :
a) information is entered into the computer.
b) records holding patient information are protected.
c) specific form are created for specific purposes.
d) documents are imaged.

c) specific form are created for specific purposes, and then maintained by medical records departments. Usually committees meet to design forms, such as admission, history and physical, and nursing note, which will be used by a facility. While forms are not completely standardized, they must contain certain information, so forms from 1 facility to another are often similar. The documents are contained in charts (paper/electronic) & are examined for completeness before being filed / stored.

The purpose of clinical pertinence review is to :
a) ensure documentation is appropriate.
b) institute disciplinary procedures.
c) determine if forms are require modification to meet standards.
d) compare physicians' competency levels.

a) ensure documentation is appropriate. The clinical pertinence review is done retrospectively, usually by pulling a % of each physician's charts / a % from each dept. Forms usually evaluated for completion include the history & physical, family history, and discharge summary. If handwritten notes are included, they are evaluated for legibility. Proper use of abbreviations & symbols is evaluated. Laboratory findings are assessed as well as follow-up for abnormal results.

If 1 procedure always involves 5 separate charges, but errors in coding for the charges frequently result in 1 / 2 charges. The best solution may be to :
a) post directions for staff members.
b) utilize a charge explosion code.
c) institute disciplinary measures.
d) have entry of 1 code trigger a reminder alert.

b) utilize a charge explosion code.
With this type of coding, the healthcare provider has to only enter 1 code for the procedure. This code is linked to the 5 different charges so that when the procedure code is selected, it pulls up all of the charges.

A patient was hospitalized in the psychiatric unit for 60 days following a suicide attempt. The insurance company has requested a copy of the psychiatrist's psychotherapy notes. The correct response is to :
a) send a copy of the notes.
b) ask the psychiatrist for permission to send the notes.
c) refer the request to the ethics committee.
d) decline to send a copy of the notes.

d) decline to send a copy of the notes.
Psychotherapy notes aren't considered part of the EHR by HIPAA & don't contain info needed for claims. Psychotherapy notes can be released by court order or with express authorization of the patient.

17) When should the RHIT expect an organization to begin to prepare for accreditation review by The Joint Comission?
a) Every day.
b) A year before the review.
c) A month before review.
d) When new standards are issued.

a) Every day rather than just as preparation for reviews. TJC does a complete survey on a minimum 3 year cycle, but TJC issues yearly standards updates, and organizations accredited by TJC are expected to meet these standards. The Joint Commission accredits acute care, ambulatory care, and rehabilitation organizations as well as hospices and home health aagencies.

18) The primary difference between licensed beds in a facility & the bed count is that the bed count is the
a) actual number of beds in a facility.
b) number of beds that are ready for patients & staffed.
c) no. of beds that have been approved for the facility by the state.
d) number of beds that actually are assigned to patients.

b) number of beds that are ready for patients & staffed, whether / not they are filled with patients. The licensed bed count is the number of beds that have been approved for the facility by the state. If the census drop, but if the bed count consistently lower than the licensed beds, this may indicate there is insufficient need for beds.

20) If a patient is treated in the emergency dept. for 2 hours & then kept for observation in a special unit adjacent to the emergency dept. for 36 hours following a concussion & episodes of confusion, how is the patient classified?
a) Outpatient for 2 hours & inpatient for 36 hours.
b) Out patient for 24 hours & inpatient for 12 hours.
c) Inpatient for the entire stay.
d) Outpatient for the entire stay.

d) Outpatient for the entire stay.
Patients may be kept as outpatients for the observations for up to 48 hours, regardless of where in the facility they are maintained. If they must remain after this period of time, they are admitted as inpatient.

22) Which of the following is NOT classified as a clinical allied health professional ?
a) OT
b) RT
c) RN
d) PT

c) RN
The RN, including NPs and CRNAs and other nursing specialties, is a direct care provider along with MDs, LVNs/LPNs, and PAs. Clinical allied health professionals include a wide range of health professionals who provide audiologists, speech pathologists, phlebotomists, medical assistants, home health aides, and social workers.

23) The size of an outpatient facility is determined by its
a) licensed beds.
b) bed count.
c) visits / encounters per day.
d) square feet of facility.

c) visits / encounters per day, so size is efficiency based. Thus, a facility that serves 200 patients per day is twice the size of 1 that serves 100 patients per day, regardless of the physical size of the facility / the no. of beds / other pieces of equipment available.

26) The American College of Surgeons first developed a health initiative that required hospitals to keep records of care & treatment in what year ?
a) 1948.
b) 1938.
c) 1928.
d) 1918.

d) 1918. Before 1918, it was physician's responsibility to keep records of care & treatment, and there were no established standards for what the records should include / how long they should be retained. It was lacked of important information such as diagnosis, history, and physical examination.

27) Under HIPAA's Privacy Rule, consent is for:
a) treatment.
b) storage of PHI.
c) use of PHI.
d) marketing of PHI.

c) use of PHI ( not for treatment as with informed consent).

30) In ACSII (American Standard Code for Information Interchange), bytes with a value of 32 to 126 are used to represent :
a) numbers, letters, and punctuation.
b) extended characters.
c) images.
d) audio files.

a) numbers, letters, and punctuation.
The letter A represents the number represents the start of text. Higher values, 127 to 257 are used for extended characters and symbols.
ASCII standardized text bytes in 1963.

31) In a database, which of the following compromises groups of fields?
a) Files.
b) Tables.
c) Records.
d) Characters.

c) Records.
A database is essentially a collection of data. The smallest unit of text data is the character, which may be letters, numbers, spaces, or punctuation marks. Data are divided into defined logical units by fields (numeric, text, dates). Groups of fields the compromise records, which are about a specific thing. For example, database may contain many records showing individual's names & addresses. Records are grouped into tables, which can then linked.

32) Images, such as MRI images, CT images, and x-rays are captured and stored in a database according to which of the following standards?
a) ASCII.
b) PDF.
c) DICOM.
d) TIFF

c) DICOM ( Digital Imaging & Communication in Medicine) standards allows various types of hardware (such as scanner, servers, printers, and computer workstations) produced by different manufactures to integrate & form a Picture Archiving & Communication systems (PACS).

33) Payment floor refers to :
a) a negotiated payment that is less that the standard change for healthcare services.
b) the time period when Medicare / insurance companies delay sending reimbursement after adjudication.
c) a payment for outlier changes that are lower than usual payments.
d) a list of change items that are no longer utilized but still in the chargemaster.

b) the time period when Medicare / insurance companies delay sending reimbursement after adjudication.
A floor refers to the minimum time a claim is held & a ceiling to the maximum. Medicare has a 28-day payment floor for paper claims & a 13-day payment floor for electronic claims, which are less time-intensive to adjudicate. Therefore, it is the advantage of healthcare organizations to utilize electronic billing.

34) A healthcare organization plans to use software applications from different vendors as part of its new electronic health record, but each application requires the user log in. What should be implemented to allow the user to log in all the different applications at the same time?
a) IMAP.
b) POP3
c) DICOM.
d) CCOM

d) CCOM (Clinical Context Object Workgroup) is a subset of HL7. With an electronic health record that utilizes software applications from different vendors, the CCOM standards allow the user to log in 1 time for all of the applications. 1 logged in, as the user switches applications, the person is automatically logged in to the new application & the necessary information (patient ID, provider, and visit) is carried over through context management. Setting up CCOM is quite complex & requires special servers.

37) With the ICD-10-PCS procedure code, which letters are NOT used?
a) I & O.
b) Q & X.
c) Y & Z.
d) O & Q.

a) I & O because they could be confused with the numbers 1 or 0. The ICD-10-PCS code requires 7 digits & is a combination of letters (not case sensitive) & numbers.

38) Which of the following data sets are required by CMS for long-term care facilities?
a) OASIS-CI.
b) UCDS.
c) DEEDS.
d) RAI.

d) The Resident Assessment Instrument (RAI) is required by CMS for long term care facilities. It contains the Minimum Data Set (MDS), the Care Area Assessment ( CAA) & a guide to utilization. MDS is used to assess clinical & functional status. CAA is then utilized to make decisions about any problems identified & to develop a plan care, implement the plan & evaluate outcomes. RAI promotes individualized care & improved communication among staff members.

41) Upon review of a patient's electronic health record, it is noted that a rash on the patient's torso is described by different healthcare providers as "macular", "papular", "measles-like", "red ", "raised", and "allergic". Which of the following quality characteristics of data quality management does this violate?
a) Data consistency.
b) Data accuracy.
c) Data precision
d) Data definition.

a) Data consistency.
Because the quality characteristics of data quality management & the information provided is not reliable. The actual appearance of the rash isn't evident from the various descriptions that may interfere with diagnosis & treatment which make coding for reimbursement difficult. Some inconsistencies, such as change in diagnosis over time, may legitimately occur.

42) Which system of numbering for charts is used when a patient is assigned a no. on a first admission to a hospital & is assigned the same number with each subsequent admission?
a) Unit.
b) Serial
c) Family.
d) Serial Unit.

a) Unit.
Unit numbering makes accessing previous records of a patient easier than other number types, such as serial numbering in which 1 patient could end up with multiple

44) The Security Management Process for HIPAA's Security Management Standard begins with which implementation?
a) Sanction policy.
b) Risk Management.
c) Information system activity review.
d) Risk analysis.

d) Risk analysis. Potential risks to security should be identified & evaluated in terms of the likelihood of occurrence & the degree of seriousness. Other implementations include risk management, which requires decisions regarding how to manage security risks & developing strategies to protect data; sanction policy, which should outline sanctions and/ or disciplinary actions for those who fail to maintain security standards; and information systems activity review, which requires audit & review of records to determine if EPHI has been secure.

47) Which type of patient record typically includes a problem list?
a) Inpatient care.
b) Emergency care.
c) Ambulatory care.
d) Ambulatory surgical care.

Answer : C. Ambulatory care records typically contain a problem list to help with the management of ongoing problems. Problem list are utilized in situation where a patient likely to be followed for a n extended period of time, such as clinics, outpatient facilities, or physician's office. Problems are typically number & the date noted when they are added to the list. Typically, a problem list includes current health problems & significant past conditions, injuries, surgeries, or illnesses. The date should be noted when a problem is resolved.

49) Before institution of a new EHR, the HIM dept. conducts a series of small-scale cognitive walk through usability studies with up to 8 participants who practice with prototypes. While the participants practice with the prototypes, they should :
a) take notes for later review.
b) "think aloud" about their experience & thoughts.
c) avoid talking / taking notes.
d) video tape the exercise for later review.

Answer : B. If the HIM dept. is conducting a series of small-scale cognitive walk-through usability studies up to 8 participants, while the participants practice, they should talk aloud (referred to as "think loud") about their experiences, feelings, and concerns. Observers take notes of what the participants are saying, and these notes are later reviewed to determine areas of concern. These types of studies are especially valuable to determine how much difficult is involved in the use of hardware / software & how much training will be necessary prior to implementation.

50) A healthcare organization has a software license from a software company for 400 networked computers but has opened a new dept. with 20 additional computers. The dept. head has copied the application & is using it on the additional computers without notifying the software company. This is an example of :
a) fair use.
b) uninformed use.
c) misuse.
d) theft.

Answer : D.
This is an example of theft because proprietary software developed & licensed by a company is protected by patent &/or copyright & can't be used beyond the terms of the contract & license.

51) If changes in software applications will result in the need for completely different procedures to access patient data, including laboratory reports, which of the following is the best way to convey this information to staff?
a) Workshops & demonstrations.
b) Email / paper notes.
c) Posters & printed notices.
d) Discussions in staff meetings.

Answer : A.
This should be carried out before implementation, so that the staff is prepared for the changes. Written guidelines, such as in handbooks / posters should also be available for staff members to refer to if the need arises.

56) To reduce overtime costs, 8 employees in the HIM dept. are being switched from a 40-hour, 5-day-a-week schedule to a 12-hour, 3-day-a-week schedule in order to provide uninterrupted coverage in the evening. Management projects that only 75% of the lost hours will need to be replaced with part-time workers because of increased efficiency. How many FTE staff members will be needed to replace lost time?
a) 0.4 FTE
b) 0.5 FTE
c) 0.6 FTE
d) 0.8 FTE

Answer : C.
calculations :
no. of employees (8) x no. of lost hours (4) = 32
32 x 0.75% = 24
24 / 40 = 0.6 FTE

57) If the HIM dept. plans to initiate a quality improvement process, staff members should begin with problem identification by :
a) identifying key performance measures.
b) creating a flow chart.
c) conducting a survey.
d) brainstorming problems.

Answer : A. Identifying key performance measures, such as the member of records processed per hour / the time needed to respond to a service call. This may entail measuring current performance in order to arrive at realistic measures. Then, a flow chart should be created showing the current process & brainstorming carried out to identify problems with be created showing the current process & brainstorming carried out to identify problems with the process. Regulatory requirements should be investigated & performance compared with benchmark standards. Survey may be conducted for input & problems prioritized.

58) An acute care hospital is planning to change to bar-coded patient ID bracelets to meet National Patient Safety Goals of ensuring 2 different forms of ID & reducing medical error. Which barcode scanner type is likely to be the best choice?
a) Linear
b) 2-dimensional
c) Laser
d) There is no essential difference.

Answer : B. 2-dimensional scanner type. While the linear & laser barcode scanner types can only be scanned in 1 direction - horizontally & lined up with the barcode - the 2 dimensional scanner type can be scanned from any direction, saving time, and allowing easier scanning without disturbing the patient.

59) A well-known actor was admitted to an acute care hospital for a drug overdose. When the HIM director reviewed the audit trail for the patient's EHR, it showed that 4 members of the staff who weren't authorized to access the patient's EHR did so. What initial action should the HIM director take?
a) Notify the staff members to stop accessing the EHR.
b) Notify the police of unlawful activity.
c) Notify the administration of unauthorized access.
d) Notify the Secretary of Health & Human Services.

Answer : D. If an audit trail showed that 4 members of the staff who were not authorized to access a famous actor's EHR did so, the initial action should be to notify the administration so that action can be taken against the staff members unless mitigating circumstances apply (such as request by a physician to check information on an EHR)

60) In the 5-stage performance management process of planning, monitoring, developing, rating, and rewarding the primary process that occurs during the developing stage is:
a) recognizing achievements.
b) providing feedback.
c) providing training to employees.
d) carrying out performance evaluations.

Answer : C. The 5 stage process is as follow :
1) Planning : Define goals & decide how to apply performance standards.
2) Monitoring : Monitor performance standards.
3) Developing : Train employees.
4) Rating : Conduct performance evaluations to determine if procedures are being carried out appropriately.
5) Rewarding : Recognize compliance & excellence.

61) Under the 2-Midnight rule of CMS, a patient who is admitted to the hospital as an inpatient but stays less than 2 midnight is eligible for coverage under Medicare A:
a) under no circumstances.
b) based on physician's expectation of stay beyond 2 midnight.
c) under all circumstances.
d) for heart-related admissions only.

Answer : B. based on the physician's expectation that the patient's condition is such a stay of beyond 2 midnights is warranted. Generally, the 2-midnight rule states that patient's with stays of less than 2 midnight are billed as outpatients under Medicare B & those of more than 2 midnights as inpatients under Medicare A.

63) A patient in respiratory distress was placed on BIPAP without intubation for 16 hours & then removed from BIPAP for 2 hours placed back on BIPAP for 4 hours, removed for 3 hours, and then placed back on BIPAP for an additional 8 hours prior to discontinuation. How would the duration be coded for mechanical ventilation under ICD-10-PCS?
a) Less than 24 hours.
b) 24 to 96 hours.
c) Grater than 96 hours.
d) Coding as mechanical ventilation is incorrect.

Answer : D. Regardless of the duration of the BIPAP without intubation, coding as mechanical ventilation is incorrect because BIPAP without intubation is coded as "assistance with respiratory ventilation" rather than "respiratory ventilation", which means that respirations are completely under control of the ventilation equipment. The duration of all type of respiratory ventilation should be carefully calculated & the exact hours noted when ventilation is started & discontinued. Calculation based on hours & not days.

64) If the ICD-10-PCS code for an imaging study of the left clavicle is BP05ZZZ, what type of contrast was used?
a) None.
b) Low osmolar.
c) High osmolar.
d) Other.

Answer : A. Code contains 7 characters : 1.Section (imaging) : B

65) If doing SWOT analysis to assess proposed changes to the information management system, negative attitudes toward change by staff members would be classified as a(n) :
a) strength.
b) weakness.
c) opportunity.
d) Threat

Answer : D . Threats & weaknesses because in planning process attitudes are often overlooked, but positive attitudes toward proposed changes are often critical to success. For this reason, staff members should be engaged in planning & implementation at all stages in the change process.

66) Which of the following is the primary advantage of an enterprise-wide information system ?
a) Cost savings related to hardware & software.
b) Reduced staffing needs to manage the information system.
c) Integration among all departments.
d) Improved monitoring of departments.

Answer : C. The primary advantage of an enterprise-wide information system is integration among all departments because the system manages all aspects of the healthcare business. This integration improves the ability to gather & analyze data to make decisions. In some cases, entreprise-costly so increased efficiency is usually the primary benefit.

68) States have the right to set eligibility criteria for individuals within federal minimum standards for which program?
a) Medicaid.
b) Medicare.
c) TRICARE.
d) Veteran's Health Administration

Answer : A. Medicare because states must cover some groups, such as: low-income families with children, children below age 6, and pregnant women with family income at / below 133% of the Federal Poverty Level. States may, if they choose, cover additional groups through expanded coverage. Laws regarding Medicaid include estate recovery, meaning that the state can recover some benefits paid to an individual from the individual's estate after the person dies.

69) If a healthcare provider is unable to determine whether a patient's condition at the time the patient was admitted into care was Present on Admission (POA), which POA option should be selected?
a) Y
b) N
c) U
d) W

Answer : D. W . The choice is considered by CMS as a "Y" (yes) for payment purposes. If the conditions are present, the POA options is "Y", and if it isn't present, "N." The option "U" is used if documentation isn't adequate to determine whether/ not the condition was POA. "U" is considered by CMS as an "N" for payment purposes.

70) Which of the following is an example of prospective utilization management?
a) Insurance company requires preauthorization for surgical procedures.
b) Patient's care is moved from ICU to cardiac unit as condition improves.
c) Patient's care is reviewed to determine if level of care is appropriate.
d) Patient's medical claims are denied.

Answer : A. When an insurance company requires preauthorization for surgical procedures. This allows the company to review the case & determine if the medical services proposed are appropriate. Utilization may also be done concurrently, such as when a patient's level of care is evaluated & the patient is moved from ICU to a cardiac unit as condition improves. Retrospective utilization management is carried out when records are reviewed after medical services are provided, such as when a patient's level of care is evaluated & the patient is moved from ICU to a cardiac unit as condition improves. Retrospective utilization management is carried out when records are reviewed after medical services are provided, such as when medical claims are denied.

74) A newer version of the software currently running the EHR has been issued. What type of testing is usually indicated when a new version of software is issued and will be uploaded into the system?
a) White-box testing
b) Regression testing
c) Non-regression testing.
d) Usability testing.

Answer : C. Non-regression testing to determine if the software does what it is intended to do. Regression testing is often done with brand new software to determine if it causes errors / regressions as new software may adversely affect other parts of the system.

75) In order to submit immunization data electronically to an immunization registry, the organization must first have:
a) VPN
b) CEHRT
c) EHR
d) MAN

Answer : B. CEHRT (Certification Electronic Health Record Technology) ensures that data are stored in a structured format & are secure. If the EHR meets criteria & is on the Certified Health IT Product List (CHPL) for certification, the healthcare organization must obtain a CMS EHR Certification ID from the Office of the National Coordinator of Health Information Technology (ONC).

76) During registration, a patient must sign an assignment of benefits form so that :
a) the patient can receive reimbursement for claims.
b) the provider is prohibited from releasing information about the patient.
c) the provider can have access to the healthcare record.
d) the provider can bill the insurance companies.

Answer : D. the provider can bill the insurance companies & receive reimbursement for claims directly. If there is no assignment of benefits, then the patient files the claim with the insurance company rather than the provider. This is sometimes the case if a patient is seeing a physician that isn't in his / her network, therefore, they bill the insurance for care provided.

80) Hospitals may receive Medicare outlier payments for which of the following?
a) Patient care cases involving clinical trials.
b) Patient care cases with exceptionally high cost.
c) Patient care cases with no supplementary insurance coverage.
d) Patient care cases that involve rare diseases.

Answer : b) Patient care cases with exceptionally high cost as a means to prevent hospitals from experiencing excessive financial losses for complex cases. In most cases, outlier payments account for 2-3% off IPPS payments although some hospitals may have higher rates. Certain high-risk procedures, such as solid organ transplants & tracheostomy with mechanical ventilation, are more likely to trigger outlier payments. CMS applies a formula with hospitals-specific criteria to determine the amount of payment.

81) County Hospital has received a court order requesting documents from a patient's EHR for an attorney representing the patient in a negligence claim. The attorney for the hospital has also requested a copy of the records. The records can be presented in various formats. All of the following are correct about the legal requirements for producing records EXCEPT :
a) only records specifically requested should be provided.
b) records must be presented in exactly the same format to both attorneys.
c) records must be presented in PDF format.
d) all records including those not specifically asked for, should be provided.

Answer : D. all records including those not specifically asked for, should be provided. Other records should not be provided unless they are covered in the court order. Records must, be presented in exactly the same format to both attorneys. While it isn't required to provide records in the PDF format, many facilities choose to provide documents in this form because the file can be easily duplicated to ensure all parties have the same exact copy.

83) When beginning the design of workload distribution for a distributed database, the initial step should be to analyze :
a) potential outcomes.
b) data access requirements.
c) system & data storage requirements.
d) costs associated with the project.

Answer : C. system & data storage requirements. Then, the global scheme is outlined followed by the designs for data distribution. In a distribution database, decisions must be made about how data are distributed across various sites in a network. Data are fragmented, partitioned into fragments that are allocated to different sites for storage. Fragmentation may be horizontal / vertical.

84) If a patient is admitted to an acute care hospital on Sept 6 & discharged on Sept 18, when does the Medicare benefit period end?
a) Nov 10.
b) Nov 13.
c) Nov 15
d) Nov 16

Answer : D. Nov 16, the Medicare benefit period ends 60 days in a row after discharge (counting the day of the discharge) on Nov. 16. Patients may have multiple stays in a hospital during 1 benefit period, but may have only 90 days of hospitalization during 1 benefit period although each person has a once-in-a-lifetime 60-days extension that can be used for extended hospitalization.

85) Following a Medicare qualifying stay in acute care hospital, a patient may be qualified for additional care in a Skilled Nursing Facility (SNF) after discharge from the acute care hospital if admission to the SNF occurs within :
a) 3 days.
b) 10 days.
c) 30 days.
d) 60 days.

Answer : C. 30 days. The patient is covered for a stay not to exceed 100 days per benefit period. Payment is in full for the first 20 days only. After that, the patient has a daily co-payment.

86) If a healthcare provider has accepted assignment for services covered under Medicare, this means that the healthcare provider agrees :
a) to charge the patient no more than 115% of allowed charge.
b) to accept the allowed charge as payment in full.
c) to accept Medicare payment as partial reimbursement only.
d) to accept 95% of payment participating providers receive.

Answer : B. to accept the allowed charge as payment in full. Medicare, which is an 80-20 plan, pays 80% of Usual, Customary, and Reasonable (UCR) charges, but payment varies from 1 area to another depending on a number of different factors. Many patients have supplemental insurance plans to cover the charges in excess of those allowed by Medicare.

87) The HIM director is reviewing the chargemaster for accuracy & mapping services to CPS/HCPCS codes. Hard-coding is typically used to ensure accurate billing for all of the following EXCEPT :
a) room charges.
b) laboratory services.
c) ECG.
d) respiratory therapy.

Answer : A. room charges.
Hard coding is typically used for professional services, such as laboratory services, respiratory therapy, and ECGs but not for room charges. With hard coding, the code is generated when the charge is made rather than assigned at a later time by a coder. This practice can improve the revenue cycle because there is no delay in charging for services. Hardcoded services are those that generally do not change.

88) Although the volume of patients in the outpatients services has increased by 20% over the previous year, a review of revenue shows that services typically provided to outpatients have decreased by 12%, resulting in a loss of revenue. The problem reason for this discrepancy is :
a) failure to code for services.
b) database error.
c) change in procedures.
d) inaccurate chargemaster.

Answer : A. failure to code for services. The charges should be carefully audited to determined if a pattern emerges. For example, Medicare pays separately for injectable medications & administrations, furthermore, the administration charge may be overlooked.

89) Prior to a facility carrying out diagnostic studies to be billed to Medicare, the healthcare provider must :
a) notify Medicare.
b) document medical necessity.
c) seek prior authorization.
d) verify supplemental insurance.

Answer : B. document medical necessity. This is done by applying the appropriate diagnostic coding to the order. Some types of tests, such as those for research only / tests that aren't FDA approved aren't covered by Medicare, therefore, the patient must sign an Advance Beneficiary Notice.

90) A healthcare provider has submitted a claim to Medicare under the Outpatient Prospective Payment System (OPPS), & Outpatient Code Edits (OCE) indicate that there is a diagnosis code for vaginal bleeding during the first trimester of pregnancy but the gender selected is male (edit #3, diagnosis & sex conflict). What claim-level disposition should the healthcare provider expect?
a) Denial.
b) Suspension.
c) Rejection.
d) Return.

Answer : D. returned to the provider, so that the problems can be corrected prior to resubmitting the claim.

96) Information in the disease index is considered patient-identifiable data because :
a) patients with rare diseases may be identifiable.
b) the patient's name is listed with the disease.
c) all healthcare information is considered patient-identifiable data.
d) the disease index links to the EHR by ID number.

Answer : D. the disease index links to the EHR by ID number. The disease index lists the disease codes
(ICD-10-CM) for patients who are discharged. It may contain various other info, such as: the name of patient's physician & the date of discharge.

97) When setting up a disease registry from existing data, the first step is to :
a) establish a time frame.
b) obtain patient authorization.
c) develop a case definition.
d) identify costs associated with the registry.

Answer : C. develop a case definition. The case definition establishes the guidelines for the information that will be included in the registry.For example, the case definition may be all patients with a specific diagnostic code, or it may be even more limited according to age, gender, or co-morbidities (1/more disease conditions that occur along with another condition in the same person at the same time). It's important that the case definition remain consistent over the course of the registry / comparing data may be meaningless.

98) A patient's discharge summary lists medications as:
Metoprolol 50 mg twice daily.
Hydrochlorothiazide 12.5 mg daily.
Acetaminophen 600 mg every 4 hours as needed for pain.
Metformin 850 mg daily.
The diagnostic information includes primary hypertension
(ICD-10-CM, 110), supra-ventricular tachycardia (ICD-10-CM, I47.1) and bilateral primary osteoarthritis of the knee (ICD-10-CM, M17.0).
Based on the list of medications, which diagnosis is missing?
a) Diabetes mellitus, type 2 (E11).
b) Heart attack / Myocardial infraction (I21.4)
c) COPD (491.22)
d) Viral pneumonia ( J12)

Answer : A. Metformin is a medication frequently used to treat Diabetes Mellitus type 2(E11) & this diagnostic information is missing. Chronic conditions may be overlooked because if they aren't the focus of care. In this case, the metoprolol is used to treat both primary hypertension & tachycardia. The hydrochlorothiazide is a diuretic used to control hypertension, and acetaminophen to control the pain of osteoarthritis.

99) If the hospital administration wants to develop a facility specific cancer registry, which of the following should the HIM director recommend as the best sources for case finding ?
a) Discharge summary & disease index.
b) Physician index & disease index.
c) MPI & physician index.
d) MPI & disease index.

Answer : A. Discharge summary & disease index as the best sources for case finding. Once a case definition is established, coders can identify cases when reviewing the discharge data, and cases can be pulled from the disease index. The cancer registry may be used to assess mortality rates & treatment effectiveness & to facilitate patient follow-up after discharge.

101) If a medical scribe is used to enter documentation into an EHR for an attending physician, the individual who has the most responsibility to ensure that the EHR is complete & accurate is the :
a) attending physician.
b) director of HIM.
c) director of nursing.
d) medical scribe.

Answer : A. attending physician. The physician should review the scribe-entered information & verify that it is correct. The physician is always most responsible for the health record. The HIM department reviews the record to assist the physician by pointing out deficiencies / errors.

102) When reviewing orders of medications, the RHIT should be concerned if a physician has written the following order :
a) 40 units regular insulin SQ.
b) Amlodipine, 10.0 mg PO.
c) Metoprolol, 25 mg BID.
d) Synthroid, 0,112 mcg daily PO.

Answer : B. Amlodipine, 10.0 mg PO.
The trailing zero (.0) should not be utilized as the period (.) could be overlooked & the dosage read as 100mg. The JC has developed a "Do not use" list that applies to all hand-written / free text orders for medications & documentation of medication-related information. Other restrictions include the use of "MS" instead of morphine sulfate, the abbreviation "u" for unit, "IU" for International Unit, QD, and QOD (or variations).

103) CMS provides the following E/M guidelines for determining the type of history (Hx) needed to determine the level of service. Assuming that all 4 elements in a row must be met to meet the criteria for the type of history, how would a visit with a patient be coded as an E/M service if the physician documented the chief complaint, an extended review of systems, and a pertinent past, family, and / or social history?
Type of Hx Chief Hx of present Review of Past, family,
Complaint illness systems & / or social Hx
Problem focused Required Brief N/A N / A
Expended Required Brief Problem N / A
problem pertinent
focused
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
a) Expanded problem focused
b) Detailed
c) Comprehensive
d) Does not qualify as an E/M service.

Answer : D. Does not qualify as an E/M service b'coz only 3 of 4 elements were met. The physician should be contacted to determine if the physician actually completed a history of present illness & simply failed to document it and, if so, whether it was brief / extended. If physician failed to complete the history of the present illness, then the visit can't be coded as an E/M service.

104) In the process of transitioning to an EHR & scanning paper documents, the HIM dept. has decided to contract with a private agency to destroy paper health records that have been stored for over 10 years. Assuming there are no specific state laws to the contrary, which of the following is NOT necessary to include in the contract ?
a) Destruction method.
b) Time between acquisition & destruction.
c) Inclusive dates of records.
d) Security measures.

Answer : C. Inclusive dates of records because the hospital should include that info in its documentation.
What's necessary to be include are: the destruction method, security measures to prevent breach , provisions for loss if unauthorized disclosure occurs, and details of liability insurance, including specified amounts.

107) With ICD-10-PCS, which of the following terms is NOT a root operation?
a) Anastomosis.
b) Alternation.
c) Fragmentation.
d) Map.

Answer: A. Anastomosis is the connection of two things that are normally diverging. In medicine, typically refers to a connection between blood vessels or between two loops of the intestine & isn't a root operation because it's integral to another procedure, such as a bypass operation. The root operation is the objective of the medical / surgical procedure. There are 31 root operations that are separated into 9 different groups depending on the function, including the removal of a body part; removing solids / fluid/ gasses from a body part; cutting / separating; moving or replacing some or part of a body part, alternating the diameter / route of a tubular body part, using a device, examination only, other repairs, and other objectives. Multiple codes may be assigned.

109) In a health information organizations with multiple sites accessing the same Master Patient Index(MPI), the registration clerk at 1 facility mistakenly pulls up a record from the MPI for a person with a similar name & demographic information when registering a patient for a procedure. This type of error is referred to as a(n) :
a) overlap.
b) duplicate.
c) corruption.
d) overlay.

Answer : A/D ? Overlap because 1 MPI entry (identifier) contains the records of 2 different people. Overlays may also occur if 2 records are accidentally merged.

113) A patient was schedule for a bilateral simple complete mastectomy but, following the procedure on the right breast & after an incision was made for the left, the patient developed severe cardiac dysrhythmias that could not be stabilized. The surgery was discontinued, the incision closed, and the patient sent to the cardiac care unit. Possible modifier include : incision closed, and the patient sent to the cardiac care unit. Possible modifiers include :
53, Reduced services.
52, Discontinued procedure.
50, Bilateral
RT, Right Side
Lt, Left side
How could the procedure be coded?
CPT/HCPCS Code Description of Procedure
19303 Mastectomy, simple, complete
a) 19303-50-53
b) 19303-50-52
c) 19303-50-52-53
d) 19393-53-LT

Answer : A. 19303-50-53. The first part (19303) is the planned procedure. This is followed by 50 to show that the procedure was bilateral. The code 53 indicates that the surgery was discontinued.

115) If paper records that need to be maintained are being moved into a new storage space with bookcase units that are 48 inches wide with 6 shelves per unit, and the average record is 0ne-half inch thick, how many shelving units are needed for 10,080 records ?
a) 15
b) 18
c) 25
d) 35

Answer : C. 25 calculation : 10,080 records times 0.5 thick = 5040 inches of bookshelf needed divided to 288 ( from 48 inches times 6 shelves / unit ) = 17.5 round up to 18.

116) The HIM dept. has used document imaging to archive medical records. Which of the following can be expected of the imaged records?
a) They can capture discrete data elements.
b) They can be accessed for decision support.
c) They are immediately accessible.
d) They provide access to patient records.

Answer : D. They provide access to patient records, but they are much more limited in scope than an EHR because they can't capture discrete data elements, which might be desired for research. The imaged records are generally not immediately accessible but may take from 1 to 24 hours to access. The imaged records can't be utilized for decision support, and they don't support alerts.

117) Which characteristic of data quality refers to the use of the specific level of detail required for a data element, such as ensuring 3 decimal spaces for the laboratory test for specific gravity (1.021)?
a) Data currency
b) Data definition
c) Data granularity
d) Data precision

Answer : C. Data granularity is the characteristic of data that refers to the use of the specific level of detailed required for a data element, such as ensuring 3 decimal spaces for the laboratory test of specific gravity (1.021) Data definition refers to the exact meaning of a data element. Data currency is the extent to which data is up-to-date. Data precision is how clearly the data values support the purpose.

118) Under PQRS Measure #46, Medication Reconciliation, this crosscutting measure must be reported for :
a) all office / outpatient visits for patients of any age regardless on inpatient status.
b) outpatient visits with patients 18 & older occurring within 30 days of discharge from inpatient facility.
c) outpatient visits with patients 65 occurring within 30 days of discharge from inpatient facility.
d) outpatient visits with patients of any age occurring within 30 days of discharge from inpatient facility.

Answer : B. outpatient visits with patients 18 & older occurring within 30 days of discharge from inpatient facility. Out patient visits are classified as face-to-face encounters, such as office visits & outpatient visits, but don't include telehealth visits. This measure must be reported for 2 groups : (1) 18-64 years (2) 65 & older. At least 1 cross-cutting measure must be reported for eligible professionals with face-to-face encounters.

121) Which of the following ICD-10-PCS codes indicates a procedure carried out through an open approach ?
a) 02703DZ
b) 0U5B4ZZ
c) 0T9B70Z
d) 0FT40ZZ

Answer : D. The 5th character in the ICD-10-PCS codes represents the medical & surgical approach used for a procedure. In this case, 0FT40ZZ (open cholecystectomy) is the correct answer because the 5th character is 0. Other codes include 3(percutaneous), 4(percutaneous endoscopic), 7 (via natural / artificial opening), 8(via natural / artificial endoscopic), F ( via natural / artificial opening with percutaneous endoscopic assistance, and X (external).

122) If a patient is severely allergic to penicillin, which of the following codes is most likely to trigger an alarm any time a penicillin drug is ordered when using a controlled terminology that lists ingredients for the CPOE?
a) If ORDER = "penicillin" & ALLERGY = "penicillin" then print "Alert!"
b) If ORDER = {any ingredient of ordered drug} = {any ingredient of allergic drug} then print "Alert!"
c) If ORDER = ALLERGY then print "Alert!"
d) If ORDER = "penicillin" & ALLERGY = "Amoxicillin" then print "Alert!'

Answer : B. If ORDER = {any ingredient of ordered drug} = {any ingredient of allergic drug} then print "Alert!" This same code should trigger an alert if any other drug to which the patient is allergic is ordered.

123) If an adult hospital wants to meet Leapfrog Group's standards for CPOE, what percentage of physician orders must be made with CPOE system that contains error-prevention software?
a) 25%
b) 50%
c) 75%
d) 90%

Answer : C. 75%. An additional requirement is that the hospital must conduct tests that show that physicians are alerted to promotes quality in healthcare, safety, and affordability & applies letter grades (A-F) to participating hospitals.

127) With ICD-10-PCS, if a patient's gastrosnomy tube develops a leak and is removed & a new gastrostomy tube placed into the same opening, the root operation utilized for this procedure is :
a) replacement.
b) change.
c) insertion.
d) revision.

Answer : B. change. Replacement is used when a body part is removed & replaced with synthetic material, into a body part to monitor, assist, or prevent a physiological function. Revision involves correcting a malfunctioning / displaced device, such as a pacemaker.

131) Which of the following would require a HCPCS level II for the CMS claim ?
a) Ambulance service.
b) Blood typing
c) Diagnostic screening.
d) Cryoperservation, reproductive tissue, and ovarian.

Answer : A. Ambulance service. HCPCS level I compromises CPT codes while HCPCS level II compromises services that are not included in the CPT codes. Others examples of supplies, services / products are covered by HCPCS level II codes include Durable Medical Equipment (DME), orthotics, and prostheses. There are 4 types of HCPCS level II codes: permanent national codes, dental codes, miscellaneous codes, and temporary national codes.

132) If an organization wants to file a Medicare claim for Durable Medical Equipment Prosthetics, orthodontics, or supplies (DMEPOS) for which no code currently exists, which of the following is the appropriate action ?
a) Use a miscellaneous HCPCS code.
b) Send documentation with the claim.
c) Contract the DME MAcs PDAC.
d) No claim can be filed.

Answer : C. Contract the DME MAcs PDAC (Pricing, Data, and Analysis Contractor). The PDAC can help in determining which HCPCS code is most appropriate & can provide guidance regarding appropriate supporting documentation. The PDAC may assign a miscellaneous code / non-covered item / service code. It also has a product classification list available on-line.

133) If a patient had a kidney removed for "renal cell carcinoma," which column on the ICD-10-CM Table of Neoplasms would the RHIT use to identify the correct code?
a) Malignant primary.
b) Malignant secondary.
c) Benign.
d) Unspecified behavior.

Answer : A. Malignant primary as a renal cell carcinoma in the kidney would be a primary lesion. The terms "carcinoma" & "sarcoma" either by themselves, such as in "renal carcinoma", or combined , such as in "osteosarcoma" refer to malignant neoplasms.

134) A complete NDC consists of 3 different sub-codes :
(1) labeler code, (2) product code, (3) :
a) FDA code.
b) company code.
c) package code.
d) RX norm code.

Answer : C. A complete NDC consists of 3 different sub-codes : 1. Labeler code : The firm that manufactures, re-packages, or distributes, supplied to the firm by the FDA. 2. Product code : The code identifying the drug & dosage, supplied by the firm. 3. Package code : The code identifying the size & type of package, supplied by the firm. Code configuration (in digits) may be 4-4-2, 5-3-2, 5-4-1, or 5-4-2, but CMA follows the HIPAA standard of 5-4-2 (11 digits) & uses leading zeroes for shorter codes.

135) The primary purpose of the RxNorm dose form below is to :
Form Definition & Usage Notes
Foam : bubbles of gas that are introduced into a liquid.
Injectable Foam : A foam intended to be injected.
Oral Foam : A foam intended to be administered into the mouth.
Rectal Foam : A foam intended for use in the rectum.
Source : National Library of Medicine (NLM).
a) describe the way in which a drug is administered.
b) describe the form in which a drug is presented.
c) suggest the most common uses of a drug.
d) classify drugs into different categories.

Answer : B. describe the form in which a drug is presented.

137) If a database provides an alert when the patient's birth-date entered into a field shows that the secondary insurers that the primary insurer is identified as well as secondary insurers & the extent of their contributions?
a) Coordination of Benefits
b) Review of Medical Appeals Council.
c) Beneficiary Notices Initiative
d) Employer Services

Answer : A. If a database provides an alert when a patient's birth date entered into a field that a patient is being admitted for delivery of an infant is 4 years old, this type of validation is a consistency check. A consistency check compares data in 2 different fields to determine if the values entered are reasonable. A consistency check can't identify all errors & is limited by parameters that are set for the fields & for the validation.

139) In order to receive Meaningful Use payments, an organization must do all of the following EXCEPT :
a) conduct a risk analysis.
b) correct security risks that are identified.
c) document completion of MU requirements.
d) Attest that PHI is 100% secure.

Answer : D. In order to receive Meaningful Use payments, an organization must carry out a risk analysis to determine if there are security breach of PHI. Once a risk analysis has identified areas of potential security breaches, then the organization must take the steps necessary to secure PHI & must document & provide evidence of compliance to CMS. While 100% security is the aim, it isn't possible to absolutely ensure 100% security.

140) According to HIPAA's Privacy Rule, which of the following elements can remain in a health record when the record is
de-identified?
a) Names
b) Dates (except year) directly related to the individual.
c) Diagnoses
d) Medical record numbers

Answer : C. Diagnoses don't have to be removed when de-identifying data as diagnoses are essential for research purposes. Elements that must be removed include names, date (except year) directly related to the individual ( such as birthdate, date of death), identifying numbers (medical record, FAZ, email addresses, health plan, account, certificate/license, vehicle identifier, device identifier, and IP address), identifying geographic information, biometric information, full face photographic images, and comparable images.

143) The 3 level of severity (MCC, CC, Non-CC) in the MS-DRG system are assigned based on :
a) primary diagnosis.
b) secondary diagnoses.
c) LOS.
d) Wage Index.

Answer : B. The 3 levels of severity in the MS-DRG system are: MCC (Major Complications Comorbidities), CC (Complications / Comorbidities), and Non-CC (No Complications / comorbidities). These levels are based on secondary diagnoses. For example, if a patient has open heart surgery, the MS-DRG would be assigned for that primary diagnosis, however, if the patient developed sepsis, the level of severity would be assigned based on the secondary diagnosis of sepsis.

144) MS-DRG adjustments to base rate are made based on all of the following EXCEPT:
a) Transfer Policy (TP).
b) Value Based Purchasing (VBP).
c) Disproportionate Share Hospital (DSH).
d) Indirect Medical Education. (IME).

Answer : C. MS-DRG adjustments to base rate aren't made based on transfer policy although the transfer policy affects the amount of payment each facility receives. MS-DRG adjustments are made based on 4 criteria :
1) Value based purchasing : increase / decrease depending on positive / negative VBP.
2) Hospital readmission reduction program : Increase or decrease depending on whether hospital readmission are decreased / not.
3) Disproportionate share hospitals : Increased payments for hospitals with disproportionate share of low-income patients.
4) Indirect medical education : Increased payment for teaching hospitals.

145) A physician on staff of Country Hospital requests copies of his sister's health records following her hospitalization for an MI. Which is the appropriate response?
a) Ask the physician to sign a formal request.
b) Provide access since the physician is on staff.
c) Report the physician to the ethics committee.
d) Refuse the request.

Answer : D. Refuse the request because allowing him unauthorized access to PHI is a HIPAA violation. The sister can request copies of the health record & allow the physician to look at the records / she can grant the physician power of attorney, so that he can legally request the records.

146) A patient is being treated for recent onset of depression (F06.31), associated with uncontrolled hypothyroidism due to atrophy of the thyroid gland ( E03.4). The patient has a history of breast cancer 10 years previously, treated with no current evidence of any existing malignancy (Z85). The patient is currently also receiving treatment for long-term essential hypertension (I10). How would these diagnoses be sequenced (first to last)?
a) F06.31, E03.4, I10, and Z85.
b) E03.4, F06.31, Z85, and I10.
c) E03.4, F06.31, I10, and Z85.
d) F06.31, E03.4, Z85, and I10.

Answer : C. The primary diagnosis is hypothyroidism because it's the underlying cause of the depression. Since the patient is currently still receiving treatment for hypothyroidism(I10) that code would come next. The last code is the history of malignancy (Z85). Therefore, the code sequence will be: E03.4, F06.31, I10, and Z85.

147) If county hospital has an average cost per patient day of $2000 & a Case Mix Index (CMI) of 1.10, its adjusted cost per patient day is :
a) $2200.00.
b) $2001.10.
c) $2420.00.
d) $1818.18.

Answer : D. $1818.18.
Calculation : 2000 / 1.10 = $1818.18.
A CMI higher than 1.0 results in decreased cost per patient & a CMI lower than 1.0 results in increased cost per patient. Generally the higher the CMI the better off the hospital is financially, so any drop in CMI should be rigorously evaluated to determine what measure can be taken to increase the CMI.

148) If a patient has undergone ambulatory surgery & the physician has written "suspected cholelithiasis" as the first-listed diagnosis on the front sheet of patient's record, in order to code the first-listed diagnosis correctly, the coding professional should :
a) review the operative report for the diagnosis.
b) use "suspected cholelithiasis" as the diagnosis.
c) refer the matter to a supervisor for resolution.
d) send a query to the physician regarding the correct diagnosis.

Answer : A. review the operative report for the diagnosis. If a preoperative diagnosis & a postoperative diagnosis differ, then the post-operative diagnosis should be coded. Codes should never be assigned to diagnoses that are qualified ("suspected").

149) If a RHIT conducting a record analysis notes that a patient's health record is missing the Consent for Operation and/or Procedures, the RHIT should:
a) send a notice to the physician to obtain the consent.
b) take no action as it is unrelated to coding.
c) assume the patient was unable to sign.
d) notify a supervisor who can address the issue.

Answer : D. notify a supervisor who can address the issue. The physician who performed the operation / procedure without assuring a consent was formed should received appropriate education. A consent form can't be signed & added to a record after the fact, and if for some reason a procedure was performed without a consent (such as in an emergent situation), then the reason should be fully documented.

151) The total charges for a healthcare organization for May are $132,000.00 & net collections are $92,000.00. The organization's average monthly charges are $128,000. What is the A/R ratio, expressed in percentage?
a) 31.25%
b) 71.8%
c) 14%
d) 69.6%

Answer : A.
Account Receivable (A/R) management is the process by which outstanding accounts are monitored to facilitate timely reimbursement. Outstanding accounts are those charges for which a patient / payer have failed to reimburse the healthcare organization. The A/R ratio shows the % of outstanding charges compared to total charges:
A/R = Total charges - net collections
A/R = 132,000 - 92,000 = 40,000
A/R ratio = A/R divided to average monthly charges.
A/R ratio = 40,000 / 128,000 = 0.3125 (= 31.25%)

153) A large hospital has the same coders coding both inpatient & outpatient records, but a coding audit shows there have been increasing numbers of errors in coding over the previous 6 months. The best solution may be to :
a) change to coding specialization.
b) provide increased training.
c) provide incentives for improved performance.
d) provide disciplinary action for poor performance.

Answer : a) change to coding specialization , with some coders working only on inpatient records & some only on outpatient records. This may improve performance because there are significant differences between the 2 types of records & the coding requirements.

154) If a physician at an ambulatory surgery center carries out a procedure normally done only as an inpatient, and the OPPS status indicator for the HCPCS/CPT code is "C," what type of OPPS reimbursement should be expected?
a) Standard reimbursement for procedure.
b) No reimbursement.
c) Partial reimbursement.
d) Partial reimbursement, equipment, and supplies only.

Answer : B. No reimbursement should be expected. A "C" status indicator means that the procedure must be done an an inpatient & should not have been done as an outpatient because of risks to the patient. This type of error should not occur because it indicates a failure to follow procedure in verifying codes.

155) The supervisor of the cardiac care unit and the HIM director are reviewing statistics regarding selected DRG codes for the unit. Based on the number of discharges & the relative weights for each DRG, which code has resulted in the highest reimbursement?
Diagnosis Related Group Code in Description|

Answer : C. According to

156) If a hospital had 826 discharges over a 30-day period & experienced 32 deaths, including 2 newborns, 4 children, and 3 adults who died within 48 hours of admission, the gross death rate (rounded to 1 decimal point) for this period is:
a) 3.8 %
b) 3.6%
c) 3.5%
d) 3.1%

Answer : A
calculation : 32/826 = 0.03847 = 0.038 x 100% = 3.8%

157) From an ethical perspective, which of the follow principles is operational if the HIM professional releases information about a patient only with proper authorization & for the good of the patient?
a) Justice.
b) Autonomy.
c) Non-maleficence.
d) Beneficence.

Answer : D. Beneficence.
The principle of beneficence is operational if the HIM professional releases information about a patient only with proper authorization & for the good of the patient. This may include releasing records to the patient, so that the patient can monitor healthcare or to the insurance companies, so that claims can be reimbursed. Non-maleficence is operational when the HIM professional checks authorization to make sure no authorized access. Justice is allowing all patients equal access, and autonomy is allowing the patient to make decisions about access information.

158) A potentially compensable event is :
a) an event for which an organization can bill an insurance co.
b) a claim for which an insurance company has requested info.
c) an action for which a provider can file a claim for reimbursement.
d) an incident that can lead to financial loss / legal action.

Answer : D. an incident that can lead to financial loss / legal action, such as a medicine / surgical error. When a potential compensable event occurs, an incident report must be filed immediately by those involved in or witnessing the event. This incident report is filed separately from the health record. Risk management reviews potentially compensable events to determine liability issues & necessary actions to reduce risk.

159) According to the physician's notes, an outpatient complained of pain in the right knee. The physician ordered an x-ray of the right knee as well as a Complete Blood Count (CBC), metabolic panel, and chest x-ray. The CBC showed an elevated white count (10,000) and the metabolic panel showed a slightly elevated glucose (106). How should the coding professional code the diagnosis?
a) Code M25.561, Pain in right knee only.
b) Code M25.561, Pain in right knee, and query physician regarding further diagnoses.
c) Code M25.561, Pain in right knee; and A49.9 bacterial infection, unspecified.
d) Code M25.561, Pain in right knee; A49.9 bacterial infection, unspecified; and Z13.1 encounter for screening for diabetes.

Answer : B. Code M25.561, Pain in right knee, and query physician regarding further diagnoses.
Pain in right knee, and query the physician regarding further diagnoses to explain the additional lab work and chest x-ray. The coder should never guess at a diagnosis / chose a diagnosis that supports medical necessity if the documentation in the patient's health record provides no supporting evidence.

161) In a recent 30-day period, 46 infants were discharged from the NICU. During that time, an outbreak of Enterobacteriaceae occurred with 8 infants infected. What is the infection rate for this 30-day period (rounded to 1 decimal point)?
a) 16.8%
b) 17.4%
c) 26.6%
d) 38.0%

Answer : B.
calculation : 8/46= 0.17391 = 0.174 x 100% = 17.4%

162) If an outpatient radiological procedure with contrast resulted in a lump-sum payment for both the technical component of the procedure & the professional component, this type of payment is referred to as:
a) prospective.
b) fee-for-service.
c) bundled.
d) global.

Answer : D. global payment are commonly used for radiological & other similar outpatient services. The professional component involves injection of the contrast material & the technical component is the X-ray or CT. It may be paid in some instances as well.

165) If a patient was admitted to the hospital with severe headache but the physician failed to order a head CT & discharged the patient, who subsequently died with a subdural hemorrhage, the type of negligence that could be charged is :
a) nonfeasance.
b) malfeasance.
c) misfeasance.
d) defeasance.

Answer : A. nonfeasance : a failure to act in accordance to standard medical practice. In this case, the harm would be unintentional. This differs slightly from malfeasance, which is causing intentional injury, such as with the removal of the wrong body part. Misfeasance is unintentional injury that occurs as the result of a correct act, such as perforating the intestines during a colonoscopy.

THIS SET IS OFTEN IN FOLDERS WITH...

HIT101 - Chapter 9

22 terms

Quality Quizzes Chapters 8-11, 16 and 19

41 terms

RHIT EXAM PREP DOMAIN VI PRACTICE QUESTIONS (Legal)

59 terms

RHIT Practice Exam: Chapter 3: Health Care Privacy…

66 terms

Chapter Three:Professional Review Guide(quiz one),…

606 terms

Module 7 Study Guide #2

134 terms

Domain 3

133 terms

RHIT Prep Book Missed Questions

239 terms

OTHER SETS BY THIS CREATOR

Chapter 19 Exam

10 terms

ICD-10PCS ch 16&17

45 terms

HIT-230 Chapter 16 Weekly Exam

17 terms

HIT230 chapter 13, 14

75 terms

OTHER QUIZLET SETS

vet team

23 terms

CNA Class Q's

60 terms

PHM 111 FINAL EXAM ONE

17 terms

Sports Med Final

51 terms

Memo RHIT Exam Practice

Terms in this set (203)

THIS SET IS OFTEN IN FOLDERS WITH...

HIT101 - Chapter 9

Quality Quizzes Chapters 8-11, 16 and 19

RHIT EXAM PREP DOMAIN VI PRACTICE QUESTIONS (Legal)

RHIT Practice Exam: Chapter 3: Health Care Privacy…

YOU MIGHT ALSO LIKE...

Chapter Three:Professional Review Guide(quiz one),…

Module 7 Study Guide #2

Domain 3

RHIT Prep Book Missed Questions

OTHER SETS BY THIS CREATOR

Chapter 19 Exam

ICD-10PCS ch 16&17

HIT-230 Chapter 16 Weekly Exam

HIT230 chapter 13, 14

OTHER QUIZLET SETS

vet team

CNA Class Q's

PHM 111 FINAL EXAM ONE

Sports Med Final