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RHIA Exam 267 Questions with Verified Answers,100% CORRECT

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RHIA Exam 267 Questions with Verified Answers A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:... - CORRECT ANSWER Charting by exception The discharge summary must be completed within _________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than _______ hours. - CORRECT ANSWER 30 days, 24 hours, 48 hours If an analyst is studying the wait times at a clinic and the only list of patients available is on hard copy, which sampling technique is the easiest to use? - CORRECT ANSWER Systematic sampling In a long term care setting, these are problem oriented frameworks for additional patient assessment based on problem identification items (triggered conditions) - CORRECT ANSWER Resident Assessment Protocols (RAPs) What data model is most widely used to illustrate a relational database structure? - CORRECT ANSWER Entity-relationship diagram (ERD) Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a: - CORRECT ANSWER Concurrent Review In assessing the quality of care given to patients with diabetes mellitus, the quality team collects data regarding blood sugar levels on admission and on discharge. These data are called a (n): - CORRECT ANSWER Indicator Which of the following is used by a long term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care? - CORRECT ANSWER Minimum Data Set Dr. Collins admitted Mr. Smith to the University Hospital, Blue Cross Insurance will pay Mr. Smith's hospital bill. Upon discharge from the hospital, who owns the health record of Mr. Smith? - CORRECT ANSWER University Hospital In a relational database, which of the following is an example of a many to many relationship? - CORRECT ANSWER Patients to consulting physicians Anywhere Hospital has mandated that the Social Security number will be displayed in the XXX-XX-XXX format for their patients. This is an example of the use of a: - CORRECT ANSWER Mask Sue is updating the data dictionary for her organization. In this dat dictionary, the data element name is considered which of the following? - CORRECT ANSWER Metadata Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information? - CORRECT ANSWER It can exist in seperate and multiple paper-based or electronic systems. According to the Joint commission accreditation standards, which document must be placed in patient's record before a surgical procedure may be performed? - CORRECT ANSWER report of history and physicial examination When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as: - CORRECT ANSWER Health Record Matrix A subpoena duces tecum compels the recipient to: - CORRECT ANSWER Bring records to a legal proceeding A researcher's informed consent form stated that the patients' information would be anonymous. Later in the application form for institutional review board( (IRB) approval, the researcher described a coding system to trach respondents and nonrespondents. The IRB returned the application to the researcher with the stipulation that the informed consent must be changed. What raised the red flag? - CORRECT ANSWER The description of the use of a coding system to track respondents and nonrespondents. What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident - CORRECT ANSWER The data, documents, reports and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA security rule. What type of network uses a private tunnel through the internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely? - CORRECT ANSWER Virtual private network An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the3 coder allowed access to the system? - CORRECT ANSWER Role-based The privacy rule generally requires documentation related to its requirements to be retained: - CORRECT ANSWER 6 Years Which legal doctrine was established by the Darling v. Charleston Community Hospital case of 1965? - CORRECT ANSWER Corporate Negligence Linda Wallace is being admitted to the hospital. She is presented with a "Notice of Privacy Practices" In the Notice, it is explained to her that PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she doesn't want her PHI used for those purposes. Of the options listed here, what is the best course of action? - CORRECT ANSWER The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only. St Joseph Hospital has a psychiatric service on the sixth floor. A 31 year old male came to the HIM department and requested to see a copy of his health record. he told the3 clerk he was a patient of Dr. Schmidt, as psychiatrist, and had been on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is: - CORRECT ANSWER Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient. You are a member of the hospital's health information management committee. The committee has created a HIPAA compliant authorization form. Which of the following items does the privacy rule require for the form? - CORRECT ANSWER Identification of the person or entity authorized to receive PHI What is the implication regarding the confidentiality of incident reports in legal proceedings when a staff member documents in the health record that an incident report was completed about a specific incident? - CORRECT ANSWER The incident report cannot be discovered even though it is mentioned in a discoverable document. The security rule leaves the methods for conducting the security risk analysis to discretion of the healthcare entity. The first consideration for a healthcare facility should be: - CORRECT ANSWER Its own characteristics and environment Addressable security rule implementation specifications: - CORRECT ANSWER Should be implemented unless a healthcare entity determines that the specification is not reasonable and appropriate and documents their reasoning. In order for health information exchange participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by an - CORRECT ANSWER Record Locator Service (RLS) A possible justification for building an information system in house rather than purchasing one from a vendor is that: - CORRECT ANSWER The facility has development teams they do not want to give up Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was: - CORRECT ANSWER 5% You want to graph the average length of stay by sex and service for the month of April. Which graphic tool would you use? - CORRECT ANSWER Bar graph In the data warehouse, the patient's last name and first name are entered into separate fields. This is an example of what? - CORRECT ANSWER Normalization The health information services department at Medical Center Hospital identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do? - CORRECT ANSWER The manager should have each employee complete a work distribution chart. A requirements specification that lists what is needed from the vendor to support interoperability is necessary to: - CORRECT ANSWER Identify specific features and functions that must be in an information system During the influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 35 cases represent 30 percent of the nursing home's population. This rate represents the: - CORRECT ANSWER Incidence The user needs a list of the patients that were diagnosed a cerebral infarction or a cerebral hemorrhage. This is an example of a situation in which what type of search should be used? - CORRECT ANSWER Boolean search A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as: - CORRECT ANSWER Monitor Results What type of data display tool is used to display discrete categories? - CORRECT ANSWER Histogram Assume you are the manager of a 10 physician primary care practice. The physicians are interested in contracting with an application service provider to develop and manage patient records electronically. Which of the following statements is an indication that an application service provider(ASP) may be a good idea for this practice? - CORRECT ANSWER The practice does not have the up-front capital or IT staff needed to purchase and implement a system from a health information systems vendor. Which of the following do HIE participants use to search for health records on other healthcare organization systems using patient indexing and identification software? - CORRECT ANSWER Record locator service A physician is concerned that the data patients enter into an EHR is not as reliable as data entered by another provider. What function serves to distinguish the source of data in an EHR? - CORRECT ANSWER Data provenance A coding manager wants to display the patient types that have the most coding errors in relationship to coder years of service. The desire of the coding manager is to display how coder years of service is responsible for coding errors. The type of graph or chart best suited for this is a: - CORRECT ANSWER Pareto Chart For Medicare patients, how often must the home health agency's assessment and case plan be updated? - CORRECT ANSWER At least every 60 days or as often as the severity of the patient's condition requires A physician query may not be appropriate in which of the following instances? - CORRECT ANSWER Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis Allowing patterns of retrospective documentation, hiding or ignoring negative quality review outcomes, and hiding incomplete health records from accreditation surveyors are unethical behaviors according to which of the following Code of Ethics principles? - CORRECT ANSWER Put service before self-interest Which of the following healthcare entities' mission is to reduce Medicare improper payments through detection and collection of overpayments, identification of underpayments, and implementation of actions that will prevent future improper payments? - CORRECT ANSWER Recovery audit contractor (RAC) Phil White had coronary artery bypass graft surgery. Unfortunately during the surgery Phil suffered a severe stroke. Phil's recovery included several settings in the continuum of care: acute care hospital, physician office, rehabilitation center, and home health agency. This initial service and subsequent recovery lasted 10 months. As a member of a managed care organization in an integrated delivery system, how should Phil expect that his healthcare billing will be handled? - CORRECT ANSWER One fixed amount for the entire episode that is divided among all the physicians, facilities, and other healthcare providers The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of dix errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information what action should the coding supervisor take? - CORRECT ANSWER Take no action since not enough information is given to make a judgement Community hospital is trying to improve its compliance with Medicare quality reporting requirements and in turn its reimbursement from Medicare's hospital value based purchasing program. The hospital has added a _________ to assist in educating medical staff members on documentation needed for accurate billing. - CORRECT ANSWER Physician advisor Which of the following is not a characteristic of leadership strategy? - CORRECT ANSWER A description of specific implementation plans Which joint commission survey methodology involves an evaluation that follows the hospital experiences of current patients? - CORRECT ANSWER Tracer methodology Employees covered by the provisions of the fair labor standards act are called ____________employees. - CORRECT ANSWER Nonexpempt A technique for measuring healthcare entity performance across the four prospectives of customer, financial, internal processes, and learning and growth is called: - CORRECT ANSWER Balanced scorecard methodology The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a (n): - CORRECT ANSWER Unfavorable variance of $2,000 Which of the following best differentiates the role of strategic management and strategic thinking as compared to other management tools and approaches? - CORRECT ANSWER A component of each of the major function of management What is data granularity? - CORRECT ANSWER requires that the attributes and values of data be defined at the correct level of detail for the intended use of the data Where can you find guidelines for the retention and destruction of healthcare information? - CORRECT ANSWER Accreditation Standards Firewalls - CORRECT ANSWER hardware and software security devices situated between the routers of a private and public network. They are designed to protect computer networks from unauthorized outsiders. One of the four general requirements a covered entity must adhere to in order to be in compliance with HIPAA Security Rule is to ensure the confidentiality, integrity, and ___________ of ePHI - CORRECT ANSWER Availability. Think of it as people having access to that information, or that information being available to them. A visitor sign-in sheet to a computer area is an example of what type of control? - CORRECT ANSWER Facility Access Administrative safeguards - CORRECT ANSWER administrative actions such as policies and procedures and documentation retention to manage the selection, development, and maintenance of security measures to safeguard ePHI and manage the conduct of the covered entities or business associates' workforce. Order of next of kin: - CORRECT ANSWER Spouse, adult child, parent, adult sibling. Respondeat Superior - CORRECT ANSWER Latin for "let the master answer." Also referred to as vicarious lability, under the doctrine the hospital holds itself out as responsible for the actions of its employees, provided that these individuals were acting within the scope of their employment of at the hospital's direction at the time they conducted the tortious activity in question. A hospital releases information to an insurance company with proper authorization by the patient. The insurance company forwards the information to a medical data clearinghouse. This process is referred to as: - CORRECT ANSWER Redisclosure AHIMA recommends that documents of health record destruction include all of the following except: - CORRECT ANSWER Reason for destruction Central City Clinic has requested that Ghent Hospital send its hospital records from Susan Hall's most recent admission to the clinic for her follow-up appointment. Which of the following statements is true? - CORRECT ANSWER The Privacy Rule's minimum necessary requirement does not apply The confidentiality of incident reports is generally protected in cases when the report is filed in: - CORRECT ANSWER The hospital risk manager's office An original goal of HIPAA Administrative Simplification was to standardize: - CORRECT ANSWER The electronic transmission of health data The Administrative simplification portion of Title 2 of HIPAA addresses which of the following? - CORRECT ANSWER Uniform standards for transactions and code sets Ted and Mary are the adoptive parents of Susan, a minor. What is the best way for them to obtain a copy of Susan's operative report? - CORRECT ANSWER Present an authorization that at least one of them has signed Which of the following would be included in an accounting of disclosures? - Incidental to an otherwise permitted or required use of disclosure - Disclosures to the individual about whom the information pertains - Disclosures made pursuant to an authorization -Patient information faxed to the bank - CORRECT ANSWER Patient information faxed to the bank A valid subpoena duces tectum seeking health records does NOT have to: - CORRECT ANSWER Be signed by the plaintiff and the defendant Which of the following presents the greatest risk of large scale health information breaches? -Unlocked rooms - Computer monitors positioned toward high traffic areas - Unattended computer workstations - Laptop theft - CORRECT ANSWER Laptop Theft In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? - CORRECT ANSWER X12N Interrater - CORRECT ANSWER Reliability is checked by having more than one person abstract data for the same case. The results are then compared to identify any discrepancies. A clinic that is expanding its service offerings and needs an individual to help design a new database will be searching for a: - CORRECT ANSWER Data administrator A data model is used to: - CORRECT ANSWER Describe how data are used in creating information This type of chart is used to focus attention on any variation in a process and helps the team to determine whether or that variation is normal or a result of special circumstances: - CORRECT ANSWER A control chart Association learning - CORRECT ANSWER type of data mining that identifies interesting relationships between two concepts in the database. For example, it may identify that patients who are treated with drug A have a better outcome than patients who are treated with drug B. Natural language queries - CORRECT ANSWER Use common words to tell the database which data are needed. The following question was typed into the system: how many patients were discharged on November 12, 2020? This is an example of what type of query? - CORRECT ANSWER Natural Language Query How long should the master patient index be maintained? - CORRECT ANSWER Permanently In which information system would the data element "principal procedure" be found? - CORRECT ANSWER Encoder/Grouper Providing a process's policy and procedure guide to a user who has never used the information system and then asking the user to perform the process could be used in what type of testing? - CORRECT ANSWER Documentation What process must the HIM operations manager perform to ensure that all patient information is contained within the correct electronic file in the EHR? - CORRECT ANSWER Data Audit The term used to describe breaking data elements into the level of detail needed to retrieve the data is: - CORRECT ANSWER Normalization Normalization - CORRECT ANSWER breaking the data elements into the level of detail desired by the facility Consumer informatics is based on: - CORRECT ANSWER Information structures and processes The probability of making a Type 1 error based on a particular set of data is called the: - CORRECT ANSWER P-value LOINC - CORRECT ANSWER set of terminology standards that provide a standard set of universal names and codes for identifying individual laboratory and clinical results. Lab data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? - CORRECT ANSWER LOINC OCR (Optical Character Recognition) - CORRECT ANSWER enhances the accuracy of indexing features on forms In which of the following processes does an analyst perform exploratory data analysis to determine trends and identify patterns in the data set? - CORRECT ANSWER Data mining DICOM (Digital Imaging and Communications in Medicine) - CORRECT ANSWER supports retrieval of information from imaging devices and equipment to diagnostic and review workstations as well as short term and long term storage systems. Protocols that support communication between applications are often referred to as: - CORRECT ANSWER Messaging standards The process of integrating healthcare facility systems requires the creation of: - CORRECT ANSWER Enterprise master patient indexes Which of the following is NOT a statistical technique used to create a model to assess the probability that current Medicare claims are fraudulent? - CORRECT ANSWER Database warehousing A quality coding review that is based on specific problems identified during an initial baseline review in a hospital is called a: - CORRECT ANSWER Focused coding review Which model for HIE stores patient records in a single database built to allow queries into the system? - CORRECT ANSWER Centralized Which of the following is an organization that develops standards related to the interoperability of health information technology? - CORRECT ANSWER Health level 7 Which of the following processes are financial counselors typically responsible for? - CORRECT ANSWER determining whether the patient is eligible for charity care The insurance verification process involves confirming the patient is a member of the insurance plan communicated to the provider. Which of the following describes the most common time when insurance verification occurs for an unscheduled patient? - CORRECT ANSWER After medical screening. Patient accounting is reporting an increase in national coverage decisions and local coverage determinations failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue? - CORRECT ANSWER The HIM department Patient accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should: - CORRECT ANSWER Write off the failed charges to bad debt and bill Medicare for the clean charges What's the rule for NON PAR (NON PARTICIPATING) physicians? - CORRECT ANSWER 95%/80%. 95% of medicare fee, then 80% of that. When attempting to build patient relations and customer service in the revenue cycle related to the patient's financial obligations, providers should focus which of the following approaches? - CORRECT ANSWER Transparency approach A CDI program facilitates accurate coding and helps coders avoid: - CORRECT ANSWER Assumption coding Which of the following is NOT a reason to deliver a hospital issued notice of noncoverage to a medicare beneficiary? - CORRECT ANSWER Service was not preauthorized Reviewing claims to ensure appropriate coding for deserved payments is one method of: - CORRECT ANSWER Achieving legitimate optimization The federal government is determined to lower the overall payments to physicians. To incur the least administrative work, which of the following elements of the physician payment system would the government reduce? - CORRECT ANSWER Conversion factor The provider staff who are involved with communicating adverse determinations to patients and their families are considered - CORRECT ANSWER Utilization management staff the accounts recievable collection cycle involves the time from: - CORRECT ANSWER Admission to deposit in the bank Which of the following terms does NOT describe the requirement for a healthcare provider to obtain permission from the health insurer to provide predefined services to the patient? - CORRECT ANSWER Preassesment In terms of grouping and reimbursement, how are the MS-LTC-DRGs and acute care MS-DRGs similar? - CORRECT ANSWER based on principal diagnosis In a typical acute-care setting, the Explanation of Benefits, Medicare Summary Notice, and Remittance Advice documents (provided by the payer) are monitored in which revenue cycle area? - CORRECT ANSWER Claims reconciliation and collections The purpose of this program is to reduce improper Medicare payments and prevent future improper payments made on claims of healthcare services: - CORRECT ANSWER Recovery audit contractors A payer has advised your hospital that it is auditing records from last year due to a suspected payment error. Your hospital's first action should be to: - CORRECT ANSWER Review the contract to determine whether this is a violation of the look back period clause Exploding charges - CORRECT ANSWER items that must be reported seperately but are used together, such as interventional radiology imaging and injection procedures. There has been a recent increase in errors regarding the posting of the admitting diagnosis. Correction of this error falls to the coding staff. With which department will HIM have to partner in order to identify and eliminate this recurring error? - CORRECT ANSWER Patient access With what agency may patients file a complaint if they suspect medical identity theft violations? - CORRECT ANSWER Federal Trade Commission In the APC system, a high-cost outlier payment is paid when which of the following occurs? - CORRECT ANSWER The cost of the service is greater than the APC payment by a fixed ratio and exceeds the APC payment plus a threshold amount. The facility's Medicare CMI has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? - CORRECT ANSWER Focused Audit Which of the following is the principal goal of internal auditing programs for billing and coding? - CORRECT ANSWER Protect providers from sanctions or fines Which of the following requires financial institutions to develop written medical identity theft programs? - CORRECT ANSWER Fair and Accurate Credit Transactions Act A patient is admitted to the hospital with SOB and CHF. The patient undergoes intubation with mechanical ventilation. The final diagnoses documented by the attending physician are: Congestive heart failure, mechanical ventilation, and intubation. Which of the following actions should the coder take in this case? - CORRECT ANSWER Query the attending physician as to the reason for the intubation and mechanical ventilation to add a secondary diagnosis The joint commission has published a list of abbreviations classified as "DO NOT USE" for the purpose of: - CORRECT ANSWER Preventing potential medication errors due to misinterpretation Which of the following is an example of a budget used as a controlling tool? - CORRECT ANSWER Responding to a monthly budget variance report The time required to recoup the cost of an investment is called the: - CORRECT ANSWER Payback period Which of the following is true about contracts? a. they must be in writing b. they must be expressed. c. they must contain an offer and acceptance. d. they must contain a request for approval. - CORRECT ANSWER They must contain an offer and acceptance. One of the most common issues that healthcare organizations fail to do well in the strategic process is: - CORRECT ANSWER Execute the implementation plan The percent of antibiotics administered immediately prior to open reduction and internal fixation surgeries or the percent of deliveries accomplished by cesarean section are examples of what type of performance measure? - CORRECT ANSWER Process measure All of the following are risks that must be considered when entering into an outsourcing contract EXCEPT: - CORRECT ANSWER Efficient productivity At the beginning of a recent accreditation visit, the surveyors met with key leaders of the organization. During the meeting an outline of the schedule was discussed and key interviewees were identified. What is the term for this important accreditation meeting? - CORRECT ANSWER Opening conference The act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area is called - CORRECT ANSWER Licensure Which tool is used to determine the most critical areas for training and education for a group of employees? - CORRECT ANSWER Needs analysis Which of the following is a statement made by one party to induce another party to enter a contract? - CORRECT ANSWER Warranty A strategy map can be a useful tool because it: - CORRECT ANSWER Provides a visual framework for integrating strategies Sarah is not clear about why she needs to collect so much data as she performs her HIM job. Sarah's manager explains that the basic premise behind collecting job analysis data is to determine the job requirements and delineate appropriate _____________and ___________________. - CORRECT ANSWER Position classification; grade level assignments Which of the following would NOT be included in a healthcare entity's strategic profile? - CORRECT ANSWER Nature of its threats and opportunities If parties to a contract agree to hold each other harmless for each other's actions or inactions, this is referred to as: - CORRECT ANSWER Indemnification Which one of the following statements best reflects the current strategic planning environment? - CORRECT ANSWER Because the environment is volatile, strategic planning must be fluid and open to change. During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30 percent of the nursing home's population. This rate represents the: - CORRECT ANSWER Incidence Patient accounts has submitted a report to the revenue cycle team detailing $100,000 of outpatient accounts that are failing NCD edits. All attempts to clear the edits have failed. There are no ABNs on file for these accounts. Based only on this information, the revenue cycle team should: - CORRECT ANSWER Write off the failed charges to bad debt and bill Medicare for the clean charges Following a motor vehicle accident, a patient presents to the emergency department (ED) with obvious head trauma and lower abdominal pain. The patient also notes recent hematuria prior to the accident and has a slight fever. A CT brain scan reveals the presence of a skull fracture with a hematoma, and the patient is admitted. During the hospital stay, the patient is treated for a urinary tract infection. The coder assigns the skull fracture and hematoma as present on admission, and the urinary tract infection as not present on admission. The coding manager reviews this case and identifies the following error: - CORRECT ANSWER The urinary tract infection was present on admission because fever and hematuria were documented in the ED, so the coder was incorrect by not identifying it as present on admission. Which graph is the best choice to use when comparing lengths of stay across three hospitals? - CORRECT ANSWER BAR GRAPH Using the information provided, if the physician is a non-PAR who accepts assignment, how much can he or she expect to be reimbursed by Medicare? Physician's normal charge = $340Medicare Fee Schedule = $300Patient has met his deductible - CORRECT ANSWER $228 The basic component of a(n) ________ is an object that contains both data and their relationships in a single structure. - CORRECT ANSWER Object-oriented database According to the Medicare Conditions of Participation, how long must health records be retained? - CORRECT ANSWER 5 years The most recent coding audit has revealed a tendency to miss secondary diagnoses that would have increased the reimbursement for the case. Which of the following strategies will help to identify and correct these cases in the short term? - CORRECT ANSWER Focus reviews on lower-weighted MS-DRGs from triples and pairs The Kids' Foundation, a foundation related to Children's Hospital, is mailing fundraising information to the families of all patients who have been treated at Children's in the past three years. Based on the facts given: - CORRECT ANSWER Children's Hospital must have notified the patients or patients' guardians of this disclosure in the Notice of Privacy Practices. Data mining is a process that involves which of the following? - CORRECT ANSWER Using sophisticated computer technology to sort through an entity's data to identify unusual patterns In the Hospital Value-Based Purchasing Program, a facility's total performance score (TPS) is used to determine the amount of holdback dollars the facility has earned. In regard to the TPS, which is better? - CORRECT ANSWER A higher TPS is better. What information process must the legal counsel of Smithville Hospital perform to prepare for a lawsuit against the hospital? - CORRECT ANSWER E-Discovery A nurse tried to enter a temperature of 134 degrees and the system would not accept it. What is this an example of? - CORRECT ANSWER Edit check The relationship between patient gender and readmission to the hospital is best displayed using a: - CORRECT ANSWER Contingency table Dr. Smith, a surgeon at Community Hospital, is trying to understand how she can help the hospital improve reimbursement from Medicare. The HIM manager explains to Dr. Smith that reducing catheter-associated UTIs and surgical site infections would improve the hospital's scores in which of the following domains of the Medicare Value-Based Purchasing program? - CORRECT ANSWER sAFETY In long-term care, the resident's comprehensive assessment is based on data collected in the: - CORRECT ANSWER MDS Providing a process's policy and procedure guide to a user who has never used the information system and then asking the user to perform the process could be used in what type of testing? - CORRECT ANSWER Application Today, Janet Kim had her first appointment with a new dentist. She was not presented with a Notice of Privacy Practices. Is this acceptable? - CORRECT ANSWER No, it is a violation of the HIPAA Privacy Rule. A physician query may not be appropriate in which of the following instances? - CORRECT ANSWER Acute respiratory failure in a patient whose lab report findings appear to not support this diagnosis The following information was abstracted from Community Hospital's balance sheet. Total assets$25,000,000Current assets$4,000,000Total liabilities$10,000,000Current liabilities$5,000,000 - CORRECT ANSWER c. Be somewhat concerned because the current ratio is less than one The HIM director at University Hospital would like to perform a mock survey on the Joint Commission information management standards. The committee that the HIM director should contact is the: - CORRECT ANSWER Accrediation committee Who is responsible for the content, quality, and authentication of the discharge summary? - CORRECT ANSWER Attending physician In order to expedite basic performance improvement team functioning, the team should: - CORRECT ANSWER establish ground rules Identifying future health information needs for a healthcare entity and projecting specific initiatives required to meet those needs is part of: - CORRECT ANSWER Strategic planning The coding supervisor has compiled a report on the number of coding errors made each day by the coding staff. The report data show that Tim makes an average of six errors per day, Jane makes an average of five errors per day, and Bob and Susan each make an average of two errors per day. Given this information, what action should the coding supervisor take? - CORRECT ANSWER Take no action since not enough information is given to make a judgment System configuration refers to a process of: - CORRECT ANSWER Preparing underlying software for the specific organization in which a system is being implemented Jennifer's widowed mother is elderly and often confused. She has asked Jennifer to accompany her to physician office visits because she often forgets to tell the physician vital information. Under the Privacy Rule, the release of her mother's PHI to Jennifer is: - CORRECT ANSWER Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment A comprehensive retrospective review should be conducted at least once a year of what aspect of the CDI program? - CORRECT ANSWER All query opportunities A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as: - CORRECT ANSWER monitor results The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data? - CORRECT ANSWER The lab Which of the following is an operational element that should be included in a migration path for a hospital with an existing EHR and wishing to improve its population health data for value-based care reimbursement? - CORRECT ANSWER Coordinating the collection and use of social determinants of health The health information management (HIM) manager is concerned with a backlog in transcription of surgical reports. The medical staff rules and regulations stipulate that the surgeon should: - CORRECT ANSWER Write a detailed postoperative progress note about the procedure performed The user needs a list of all of the patients that were diagnosed a cerebral infarction or a cerebral hemorrhage. This is an example of a situation in which what type of search should be used? - CORRECT ANSWER Boolean Search The leadership and organizational structures, policies, procedures, technology, and controls that ensure that patient and other enterprise data and information sustain and extend the entity's mission and strategies, deliver value, comply with laws and regulations, minimize risk to all stakeholders, and advance the public good is called: - CORRECT ANSWER information governance The process by which a person or entity who authored an EHR entry or document seeks to validate that they are responsible for the data contained within it is called: - CORRECT ANSWER Authentication Which of the following is most applicable to describing utilization management functions? - CORRECT ANSWER Screens for the appropriate use of hospital services and resources The _____ requires organizations to implement policies and procedures to safeguard the facility and equipment from unauthorized access, tampering, and theft. - CORRECT ANSWER Security rule A Joint Commission accredited organization must review their formulary annually to ensure a medication's continued: - CORRECT ANSWER Efficacy and safety The HIM department records copy fees as revenue. For the year the budgeted fees were $25,000 and the actual fees received are $23,000. The director may be asked to explain a(n): - CORRECT ANSWER Unfavorable variance of $2,000 The insurance verification process involves confirming the patient is a member of the insurance plan communicated to the provider. Which of the following describes the most common time when insurance verification occurs for an unscheduled patient? - CORRECT ANSWER after the medical screening Which of the following is true about the advance beneficiary notification of noncoverage? - CORRECT ANSWER Required to be issued when outpatient service is considered not likely to be covered by Medicare The health information services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do? - CORRECT ANSWER The manager should have each employee complete a work distribution chart. Most facilities begin counting days in accounts receivable at which of the following times? - CORRECT ANSWER Date the claim drops Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of: - CORRECT ANSWER Unstructured clinical information In data quality management, the process of translating data into information to be utilized by an application is called: - CORRECT ANSWER Analysis What process must Colin, the HIM operations manager, perform to ensure that all patient information is contained within the correct electronic file in the EHR? - CORRECT ANSWER Data audit Systems linked by ________ allow HIE participants to search for health records on each of the other systems using patient indexing and identification software. - CORRECT ANSWER RLS's When a healthcare professional complains that the EHR produces too many alerts, action should be taken to: - CORRECT ANSWER Set up a process to evaluate and correct alert fatigue overall for the EHR An organization's productivity standards should reflect its: - CORRECT ANSWER Goals A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This code auditing process addresses the data quality element of: - CORRECT ANSWER Accuracy In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed? - CORRECT ANSWER Testing When a physician office acquires a new EHR in place of its old EHR, the old EHR data will require: - CORRECT ANSWER data conversion A visitor walks through the work area and picks up a flash drive from an employee's desk. What security controls should have been implemented to prevent this security breach? - CORRECT ANSWER Facility access controls Contracting for staffing to handle a complete function within the HIM department, such as the Cancer Registry function, would be considered what type of contracting arrangement? - CORRECT ANSWER Full-Service When implementing health information management training, determining who needs to be trained, who should do the training, how much training is required, and how the training will be accomplished is the responsibility of: - CORRECT ANSWER The implementation team The practices or methods that defend against charges questioning the integrity of the data and documents are called: - CORRECT ANSWER Nonrepudiation Over the last 10 years, the number of ICU beds in your state decreased by 20 percent. How might this trend impact your tertiary-level healthcare facility? - CORRECT ANSWER The volume of patients in your ICU has the potential to increase. A report developed by a PI team on the occurrence of methicillin-resistant Staphylococcus aureus infection in a neonatal intensive care unit was subsequently used by the perinatal morbidity and mortality committee in a monthly review of infant morbidity. Access to this report was possible because it was housed in the organization's: - CORRECT ANSWER Information warehouse Which data collection program is the basis for the CMS value-based purchasing program? - CORRECT ANSWER hospital compare Which of the following is the process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status? - CORRECT ANSWER compliance Which of the following is an example of a 1:1 relationship? - CORRECT ANSWER patients to hospital beds The HIPAA Privacy Rule permits charging patients for labor and supply costs associated with copying health records. Mercy Hospital is located in a state where state law allows charging patients a $100 search fee associated with locating records that have been requested. Which of the following statements is true when applied to this scenario? - CORRECT ANSWER The Privacy Rule will preempt state law in this situation. Due to an influenza epidemic in Smithtown, the hospital is almost at full capacity. Which information system would be used to efficiently manage resources such as personnel, beds, and appointments of surgeries and CT scans, to coordinate equipment and staff as needed? - CORRECT ANSWER Scheduling A number assigned to patients in a cancer registry in the order that the patients are entered in the registry every year (for example, 03-0001) is a(n) ________ number. - CORRECT ANSWER Accession Joan is educating the physicians in her hospital about the Medicare Hospital Value-Based Purchasing (VBP) Program. As part of this education she explains to her audience that the HCAHPS survey results are a part of the ________ domain in the Medicare VBP program. - CORRECT ANSWER Person/Community Engagement The fact that a patient entered data into an EHR via a portal is: - CORRECT ANSWER Administrative metadata Which of the following is a conflict management method in which both parties meet with an objective third party to explore their perceptions and feelings? - CORRECT ANSWER Constructive confrontation A coding service had 400 discharged accounts to code in March. The service coded 200 within 3 days, 100 within 5 days, 50 within 8 days, and 50 within 10 days. The average turnaround time for coding in March was: - CORRECT ANSWER 5 days. The average turnaround time was calculated by dividing the total response days attributed to the volume of routine requests that were responded to within the reporting period by the volume of routine requests responded to. The calculation is: (200 × 3) + (100 × 5) + (50 × 8) + (50 × 10)/400 = 5 days (Oachs 2020, 778). An analyst wishes to test the hypothesis that the wait time in the emergency department is longer on weekends than weekdays. What is the alternative hypothesis? - CORRECT ANSWER The average wait time is longer on weekends. Follow-up data about a patient's progress or status collected at regular intervals is primarily associated with a(n): - CORRECT ANSWER Disease registry Which of the following basic services provided by an HIE entity ensures that information can be retrieved as needed? - CORRECT ANSWER Secure data transport HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors. But that information often is not shared with other departments within the healthcare entity. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems? - CORRECT ANSWER Registration or patient access For a contract to be valid, it must include three elements. Which of the following is one of those elements? - CORRECT ANSWER Consideration The Hay method is used to measure the three levels of major compensable factors: the know-how, problem-solving, and accountability requirements of each position. This system is used for: - CORRECT ANSWER Job evaluation Agreements that are reached in a participant agreement or vendor contract should be developed into: - CORRECT ANSWER Operational policies The root cause of poor quality of data in the EHR can be determined by: - CORRECT ANSWER Observing how an EHR is used Review of disease indexes, pathology reports, and radiation therapy reports is part of which function in the cancer registry? - CORRECT ANSWER Case finding A collection of data that is organized so its contents can be easily accessed, managed, and updated is called a: - CORRECT ANSWER Database Successful strategic managers understand that three competencies are common to all successful change and that these competencies can and must be developed. These three competencies are: - CORRECT ANSWER Leadership, change management, and strategic development The HIM director hired an HIM data integrity analyst. This is a new position with a newly created job description. The director needs to develop performance standards for this job and will review a random selection of the job tasks performed in order to develop baseline data for future job performance assessments. This method is called: - CORRECT ANSWER work sampling The following question was typed into the system: How many patients were discharged on November 12, 2020? This is an example of what type of query? - CORRECT ANSWER Natural language query Working with the healthcare entity's integration team to ensure that registration interfaces are properly built and tested is the responsibility of the: - CORRECT ANSWER MPI manager What is the biggest problem with using mean length of stay as a facility statistic? - CORRECT ANSWER It is influenced by outlier values. Community Hospital just added a new system that changed the way data move throughout the facility. Which of the following would need to be updated to reflect this change? - CORRECT ANSWER Dataflow diagram For the following excerpt from a patient satisfaction survey, determine if in the development of this survey the designer is adhering to good survey design principles. What is your zip code? ________Sex (circle one):What is your age?MaleFemale0-17 ________________________18-35 ________________________36-45 ________________________46-60 ________________________ - CORRECT ANSWER The survey design principles were not applied in the development of this survey. How do providers benefit from the health insurance exchanges created under the Affordable Care Act? - CORRECT ANSWER Providers should see an increase in reimbursement both from newly insured patients and from patients who are now eligible for Medicaid under the expanded programs. When adopting value-based care, what technology helps healthcare professionals appropriately use financial information that may impact their choice of drugs, referrals, need for care coordination, and other factors for their patients? - CORRECT ANSWER Integration of EHR and RCM The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration is called: - CORRECT ANSWER Telehealth Keith is the supervisor of the MPI and chart deficiency review staff in the HIM department, which also includes being the liaison for the billing department and the R-ADT staff. He frequently meets with Michael, the R-ADT supervisor, to discuss methods to combat healthcare fraud and to verify that the patients are who they say they are and that they have the appropriate documentation for verification. This process is called: - CORRECT ANSWER Identity matching The process of taking what is known at the highest level of understanding and working downward to identify the underlying causes for the high-level observation is called: - CORRECT ANSWER Slicing and dicing The decision has been made to perform data mining to determine where the skilled nursing facility is profitable and where there is a loss. Identify a data mining technique that could be used. - CORRECT ANSWER Association rule learning In the HHPPS system, which home healthcare services are consolidated into a single payment to home health agencies? - CORRECT ANSWER Nursing and therapy services, routine and nonroutine medical supplies, home health aide visits Which statistical inference measures both the strength of a relationship between two variables and the functional relationship between them? - CORRECT ANSWER Sample linear regression In which type of health information exchange architectural model does the entity operate much like an application service provider (ASP) or bank vault? - CORRECT ANSWER Federated—consistent databases The department of surgery has acquired an analytics engine to enable it to provide predictive information at the point of care via the EHR. However, the department is struggling to get physicians to use the functionality because it does not have support staff to program or train users. This situation refers to the fact that the project plan did not illustrate: - CORRECT ANSWER Dependencies In a typical acute-care setting, the explanation of benefits, Medicare summary notice, and remittance advice documents (provided by the payer) are monitored in which revenue cycle area? - CORRECT ANSWER Claims reconciliation and collections The provider staff who are involved with communicating adverse determinations to patients and their families are considered: - CORRECT ANSWER Utilization management staff A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers' compensation insurance. The workers' compensation insurance paid the neurosurgeon fees. Which entity is the "third party"? - CORRECT ANSWER Workers' compensation insurance A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? - CORRECT ANSWER Secondary analysis A community hospital looking to cut cost out of a vendor's proposal for health IT should consider: - CORRECT ANSWER Conducting process improvement in advance to improve return on investment This type of data display tool is used to illustrate frequency distributions of continuous variables, such as age or length of stay (LOS). - CORRECT ANSWER Histogram All of the following are considered the most common types of registration errors affecting the revenue cycle, except: - CORRECT ANSWER Inpatient registered with observation stay type Laboratory data are successfully transmitted back and forth from Community Hospital to three local physician clinics. This successful transmission is dependent on which of the following standards? - CORRECT ANSWER LOINC If a health plan analyst wanted to determine if the readmission rates for two hospitals were statistically different, what is the null hypothesis? - CORRECT ANSWER The readmission rates are equal. Consumer informatics is focused on: - CORRECT ANSWER Information structures and processes All of the following are necessary to maintain an accurate MPI in an EHR environment except: - CORRECT ANSWER Assigning registry accession numbers For an EHR to provide robust clinical decision support, what critical element must be present? - CORRECT ANSWER Structured data Allowing different health information systems to work together within and across organizational boundaries is referred to as: - CORRECT ANSWER Interoperability A financial counselor assumes responsibility for which of the following? - CORRECT ANSWER Determines sources of payment for healthcare services rendered Which of the following is not a reason to deliver a hospital-issued notice of noncoverage (HINN) to a Medicare beneficiary? - CORRECT ANSWER Service was not preauthorized The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? - CORRECT ANSWER Focused Audit The physical therapy department keeps a separate database on patient outcomes for physical therapy. The workflow for most of the other health professionals is impeded because they do not have access to this physical therapy database. This is an example of: - CORRECT ANSWER A data silo Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? - CORRECT ANSWER Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service. Which graph is the best choice when exploring the relationship between length of stay and charge for a set of patients? - CORRECT ANSWER Scatter diagram In order to determine the hospital's expected MS-DRG payment, the hospital's blended rate is multiplied by the MS-DRG's ________ to determine the dollar amount paid. - CORRECT ANSWER Relative weight Which of the following is not a statistical technique used to create a model to assess the probability that current Medicare claims are fraudulent? - CORRECT ANSWER Database warehousing What architectural model of health information exchange allows participants to access data in point-to-point exchange? - CORRECT ANSWER Federated—inconsistent databases Which of the following is the goal of an MPI ongoing maintenance program? - CORRECT ANSWER To maintain low creation rates for duplicates, overlaps, and overlays An example of EHR data stewardship that would be required of the average healthcare professional is: - CORRECT ANSWER Ensuring that structured data is entered when such a choice is available in an EHR The performance standard to "assign the correct health record number to a returning patient with 99 percent accuracy" is an example of a: - CORRECT ANSWER Quality standard Which of the following is a task performed during system customization? - CORRECT ANSWER Adjusting decision support rules Regulatory requirements and revisions regarding national and local coverage determinations (NCDs and LCDs) can be found in all of the following documents except: - CORRECT ANSWER Local managed care contract language Dr. Jones comes into the HIM department and requests that the HIM director provide a list of all of his patients from the previous year in which the principal diagnosis of myocardial infarction was indicated. Which index would the HIM director query from to provide Dr. Jones with this information? - CORRECT ANSWER Disease index Physicians use the ________ to access multiple sources of patient information within the healthcare organization's network. - CORRECT ANSWER Clinician web portal - CORRECT ANSWER [Show More]

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