A coding supervisor audits coded records to ensure the codes reflect the actual documentation in the health record. This coding auditing process addresses the data quality element of: a. Granularity b. Reliability c. Timeliness d. Accuracy - Correct Answer: D The quality of coded clinical data depe...
AHIMA RHIA Exam Prep (7th Edition) | 158
Questions with 100% Correct Answers | 46 Pages
A patient requests copies of her medical records in an electronic format. The hospital maintains a
portion of the designated record set in a paper format and a portion of the designated record set
in an electronic format. How should the hospital respond?
a. Provide the records in paper format only
b. Scan the paper documents so that all records can be sent electronically
c. Provide the patient with both paper and electronic copies of the record
d. Inform the patient that PHI cannot be sent electronically Correct Answer: c. Provide the
patient with both paper and electronic copies of the record
The HIPAA Privacy Rule states that the covered entity must provide individuals with their
information in the form that is requested by the individuals, if it is readily producible in the
requested format. The covered entity can certainly decide, along with the individual, the easiest
and least expensive way to provide the copies they request. Per the request of an individual, a
covered entity must provide an electronic copy of any and all health information that the covered
entity maintains electronically in a designated record set. If a covered entity does not maintain
the entire designated record set electronically, there is not a requirement that the covered entity
scan paper documents so the documents can be delivered electronically (Thomason 2013, 102).
For an EHR to provide robust clinical decision support, what critical element must be present?
a. Structured data
b. Internet connection
c. Physician portal
d. Standard vocabulary Correct Answer: If an EHR is to provide clinical decision support it
requires two things: structured data and a clinical data repository (Sandefer 2016a, 364).
Which of the following is considered a two-factor authentication system?
a. User ID and password
b. User ID and voice scan
c. Password and swipe card
d. Password and PIN Correct Answer: c. Password and swipe card
The three methods of two-factor authentication are something you know, such as a password or
PIN; something you have, such as an ATM card, token, or swipe/smart card; and something you
are, such as a biometric fingerprint, voice scan, iris, or retinal scan (Sayles and Trawick 2014,
219).
Under RBRVS, which elements are used to calculate a Medicare payment?
,a. Work value and extent of the physical exam
b. Malpractice expenses and detail of the patient history
c. Work value and practice expenses
d. Practice expenses and review of systems Correct Answer: Each Resource-Based Relative
Value Scale (RBRVS) comprises three elements: physician work, physician practice expense,
and malpractice, each of which is a national average available in the Federal Register (Casto and
Forrestal 2015, 150).
The predefined process icon is used in flowcharting to indicate:
a. A process in which actions are being performed by humans
b. A point in the process at which participants must evaluate the status of the process
c. Formal procedures that participants are expected to carry out the same way every time
d. A point in the process at which the participants must record data in paper-based or computer-
based formats Correct Answer: The rectangle with double lines on the side in a flowchart is a
predefined process icon. This symbol represents the formal procedure that participants are
expected to carry out the same way every time (Shaw and Carter 2015, 198).
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?
a. Content analysis
b. Effect size review
c. Psychometric assay
d. Secondary analysis Correct Answer: Secondary analysis is the analysis of the original work of
others. In secondary analysis, researchers reanalyze original data by combining data sets to
answer new questions or by using more sophisticated statistical techniques. The work of others
created the MEDPAR file (Forrestal 2016, 586).
In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic
obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in
one progress note, but no medication, treatment, or further evaluation is provided. Which of the
following actions should the coder take in this case?
a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray
results
b. Code COPD because the documentation substantiates it
c. Query the radiologist to determine whether the patient has COPD
d. Assign a code from the abnormal findings to reflect the condition Correct Answer: A query is
routine communication and education tool used to advocate for complete and compliant
documentation. The intent is to clarify what has been recorded, not to call into question the
provider's clinical judgment or medical expertise. This is an example of a circumstance where
the chronic condition must be verified. All secondary conditions must match the definition in the
UHDDS and whether the COPD does is not clear (Hunt 2016, 276-277).
,Per the HITECH breach notification requirements, which of the following is the threshold in
which the media and the Secretary of Health and Human Services should be notified of the
breach?
a. more than 1,000 individuals affected
b. more than 500 individuals affected
c. more than 250 individuals affected
d. Any number of individuals affected requires notification Correct Answer: Reporting
requirements mandate notification to the individual whose information was breached, and in the
case of breaches of more than 500 individuals' information, to the media and the Secretary of
Health and Human Services (Biedermann and Dolezel 2017, 401).
Determining costs associated with EHR hardware and software acquisition, implementation, and
ongoing maintenance represents which type of analysis?
a. Benefits realization study
b. Goal-setting exercise
c. Cost-benefit feasibility study
d. Productivity improvement study Correct Answer: Cost-benefit feasibility is used to determine
if an EHR initiative is appropriate for the organization at this time; it measures the costs
associated with acquisition of hardware and software, installation, implementation, and ongoing
maintenance (Amatayakul 2016, 104-105).
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?
a. Delete the code from the CDM because it should not be there.
b. Refer the case to the chargemaster coordinator.
c. Force a final bill on the accounts since the duplication will not affect the UB-04.
d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this
service. Correct Answer: If a service is hard-coded into the charge description master (CDM), it
is important that this decision is communicated to the coding staff. If the decision is not
effectively communicated, the result could be duplicate billing that in turn could result in
overpayment to the facility (Casto and Forrestal 2015, 253).
Which health record format is arranged in chronological order with documentation from various
sources intermingled?
a. Electronic
b. Source-oriented
c. Problem-oriented
d. Integrated Correct Answer: The integrated health record is arranged so that the documentation
from various sources is intermingled and follows a strict chronological or reverse-chronological
, order. The advantage of the integrated format is that it is easy for caregivers to follow the course
of the patient's diagnosis and treatment (Russo 2013b, 305).
The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic.
One of the members of the committee remarks that he feels that the clinic's practice of calling out
a patient's full name in the waiting room is not in compliance with HIPAA regulations and that
only the patient's first name should be used. Other committee members disagree with this
assessment. What should the HIM director advise the committee?
a. HIPAA does not allow a patient's name to be announced in a waiting room.
b. There is no violation of HIPAA in announcing a patient's name, but the committee may want
to consider implementing practices that might reduce this practice.
c. HIPAA allows only the use of the patient's first name.
d. HIPAA requires that patients be given numbers and that only the number be announced.
Correct Answer: The HIPAA Privacy Rule allows communications to occur for treatment
purposes. The preamble repeatedly states the intent of the rule is not to interfere with customary
and necessary communications in the healthcare of the individual. Calling out a patient's name in
a waiting room, or even on the facility's paging system, is considered an incidental disclosure
and, therefore, allowed in the Privacy Rule (Thomason 2013, 37).
Which of the following is a graphical display of the relationships between tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS Correct Answer: An entity relationship diagram (ERD) is used to describe how the
tables work together. The diagram is a graphic representation of the entities, attributes, and
relationships that are part of a database and is a data modeling tool (White 2016a, 46).
What term refers to information that provides physicians with pertinent health information
beyond the health record itself used to determine treatment options?
a. Core measures
b. Enhanced discharge planning
c. Data mining
d. Clinical practice guidelines Correct Answer: Clinicians use health record information to
develop clinical pathways and other clinical practice guidelines, which help clinicians make
knowledge- and experience-based decisions on medical treatment. These guidelines make it
easier to coordinate multidisciplinary care and services (Fahrenholz 2013b, 78).
Which of the following are alternate work scheduling techniques?
a. Compressed workweek, open systems, and job sharing
b. Flextime, telecommuting, and compressed workweek
c. Telecommuting, open systems, and flextime
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