AHIMA RHIA Exam Prep (7th Edition) with complete solution
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AHIMA RHIA Exam Prep (7th Edition) with complete solution
17. 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 t...
ahima rhia exam prep 7th edition with complete solution 17 a patient requests copies of her medical records in an electronic format the hospital maintains a portion of the designated record set i
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AHIMA RHIA Exam Prep (7th Edition) with complete
solution
17. 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
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).
15. 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
If an EHR is to provide clinical decision support it requires two things: structured data
and a clinical data repository (Sandefer 2016a, 364).
14. 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
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
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).
12. 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
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
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
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
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
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.
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
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.
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).
4. Which of the following is a graphical display of the relationships between
tables in a database?
a. RDMS
b. SQL
c. ERD
d. SAS
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
Clinicians use health record information to develop clinical pathways and other clinical
practice guidelines, which help clinicians make knowledge- and experience-based
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