AHIMA RHIA Exam Prep (7th Edition) 158 Questions with Verified Answers
17. A patient requests copies of her medical records in an electronic format.
... [Show More] 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).
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 - 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).
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 - 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).
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 - 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).
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 - 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
d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795).
Which of the following is a kind of technology that focuses on data security?
a. Clinical decision support
b. Bitmapped data
c. Firewalls
d. Smart cards - CORRECT ANSWER Firewalls are 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 (Sandefer 2016a, 366).
9. What is the name of the statement sent after the provider files a claim that details amounts billed by the provider, amounts approved by Medicare, amount Medicare paid, and amount the patient must pay?
a. EOB
b. MSN
c. EOMB
d. ABN - CORRECT ANSWER Correct Answer: B
For Medicare patients, the fiscal intermediary and carriers prepare Medicare summary notices or MSNs. The MSN details amounts billed by the provider, amounts approved by Medicare, how much Medicare reimbursed the provider, and what the patient must pay the provider by way of deductible and copayments (Casto and Forrestal 2015, 256).
20. Secondary data sources provide information that is ________ available by looking at individual health records.
a. not easily
b. easily
c. often
d. never - CORRECT ANSWER Correct Answer: A
Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2013c, 159).
Use of a variety of content delivery methods to accommodate different types of learners is called:
a. Blended learning
b. Programmed learning
c. Classroom learning
d. Online learning - CORRECT ANSWER Correct Answer: A
Blended learning uses several delivery methods thereby gaining the advantages and reducing the disadvantages of each method alone (Patena 2016, 772).
22. In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards?
a. DICOM
b. IEEE 1073
c. LOINC
d. X12N - CORRECT ANSWER Correct Answer: D
X12N refers to standards adopted for electronic data interchange. In order for transmission of healthcare data between a provider and payer, both parties must adhere to these standards (Sayles and Trawick 2014, 175).
Which of the following terms is defined as the proportion of people in a population who have a particular disease at a specific point in time or over a specified period of time?
a. Prevalence
b. Incidence
c. Frequency
d. Distribution - CORRECT ANSWER Correct Answer: A
The prevalence rate is the proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time. The prevalence rate describes the magnitude of an epidemic and can be an indicator of the medical resources needed in a community for the duration of the epidemic (Edgerton 2016, 503).
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1. In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education?
a. Current coding personnel
b. Medical staff
c. Newly hired coding personnel
d. Nursing staff - CORRECT ANSWER Correct Answer: D
In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff. Coding is based primarily on physician documentation, so nursing staff would not be included in the education process (Hunt 2016, 288).
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2. A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a:
a. Problem-oriented health record
b. Patient-centric record
c. Longitudinal health record
d. Health record - CORRECT ANSWER Correct Answer: C
A longitudinal health record maintains information throughout the lifespan of the patient, ideally from birth to death (Fahrenholz 2013a, 45).
3. 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. This data is called a(n):
a. Indicator
b. Measurement
c. Assessment
d. Outcome - CORRECT ANSWER Correct Answer: A
An indicator is a performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements. Monitoring blood sugars on admission and discharge is an indicator of the quality of care delivered to the diabetes patient during the stay (Shaw and Carter 2015, 153).
The coding manager at Community Hospital is seeing an increased number of physicians failing to document the cause and effect of diabetes and its manifestations. Which of the following will provide the most comprehensive solution to handle this documentation issue?
a. Have coders continue to query the attending physician for this documentation.
b. Present this information at the next medical staff meeting to inform physicians on documentation standards and guidelines.
c. Do nothing because coding compliance guidelines do not allow any action.
d. Place all offending physicians on suspension if the documentation issues continue. - CORRECT ANSWER Correct Answer: B
The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Hunt 2016, 275).
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
d. Flextime, outsourcing, compressed workweek - CORRECT ANSWER Correct Answer: B
Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795).
For a contract to be valid, it must include three elements. Which of the following is one of those elements?
a. Assumption of risk
b. Consideration
c. Statute of limitations
d. Notice of liability - CORRECT ANSWER Correct Answer: B
The elements of a contract must be stated clearly and specifically. A contract cannot exist unless all the following elements exist: there must be an agreement between two or more persons or entities and the agreement must include a valid offer, acceptance, and exchange of consideration (Rinehart-Thompson 2016, 56).
For Medicare patients, how often must the home health agency's assessment and care plan be updated?
a. At least every 60 days or as often as the severity of the patient's condition requires
b. Every 30 days
c. As often as the severity of the patient's condition requires
d. Every 60 days - CORRECT ANSWER Correct Answer: A
Home health agencies are expected to conduct an assessment that accurately reflects the patient's current health status and includes information to establish and monitor a plan of care. The plan of care must be reviewed and updated at least every 60 days or as often as the severity of the patient's condition requires (White 2013, 558).
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:
a. Never allowed
b. Allowed when the information is directly relevant to Jennifer's involvement in her mother's care or treatment
c. Allowed only if Jennifer's mother is declared incompetent by a court of law
d. Allowed access to PHI; any family member is always allowed access to PHI - CORRECT ANSWER Correct Answer: B
The Privacy Rule lists two circumstances where protected health information (PHI) can be used or disclosed without the individual's authorization (although the individual must be informed in advance and given an opportunity to agree or object). One of these circumstances is disclosing PHI to a family member or a close friend that is directly relevant to his or her involvement with the patient's care or payment. Likewise, a covered entity may disclose PHI, including the patient's location, general condition, or death, to notify or assist in the notification of a family member, personal representative, or some other person responsible for the patient's care (Rinehart-Thompson 2017d, 225-226).
10. Using the data in the following graph, we can see changes in this hospital's profile. What concerns might the hospital's quality council need to address based on these changes in their customer base?
a. Staffing changes might be necessary to accommodate patients who have cultural differences.
b. Data collection has improved.
c. No changes in staffing are necessary because the patient mix is appropriate.
d. The quality council should ask for more detailed data. - CORRECT ANSWER Correct Answer: A
The graph shows that the Asian population has increased in the last five years, so the organization may need to adjust staffing, offer a wider variety in dietary choices, and ensure patient rights and safety are appropriate in the face of possible language barriers and cultural differences (Shaw and Carter 2015, 95-97)
A technique for measuring healthcare entity performance across the four perspectives of customer, financial, internal processes, and learning and growth is called:
a. Strategy map
b. Process innovations
c. Balanced scorecard methodology
d. SWOT analysis - CORRECT ANSWER Correct Answer: C
Balanced scorecard methodology is a technique for measuring organization performance across the four perspectives of customer, financial, internal processes, and learning and growth (McClernon 2016, 951).
The Joint Commission has published a list of abbreviations classified as "Do Not Use" for the purpose of:
a. Assisting coders to read physician handwriting
b. Preventing potential medication errors due to misinterpretation
c. Making terminology consistent in preparation for electronic records
d. Identifying physicians who are dispensing large quantities of drugs - CORRECT ANSWER Correct Answer: B
Healthcare organizations need to be very clear about which abbreviations are not acceptable to use when writing or communicating medication orders. The organization's policy should also define whether or when the diagnosis, condition, or indication for use is included on a medication order (Shaw and Carter 2015, 248-249).
Which of the following is true of the median?
a. It is a measure of variability.
b. It is difficult to calculate.
c. It is based on the whole distribution.
d. It is sensitive to extreme values. - CORRECT ANSWER Correct Answer: C
The median offers the following three advantages: relatively easy to calculate; based on the whole distribution and not just a portion of it, as is the case with the mode; and unlike the mean, it is not influenced by extreme values or unusual outliers in the frequency distribution (Horton 2016, 222).
4. This type of data display tool is a plotted chart of data that shows the progress of a process over time.
a. Bar graph
b. Histogram
c. Pie chart
d. Line graph or plot - CORRECT ANSWER Correct Answer: D
A line graph or plot may be used to display time trends. The x-axis shows the unit of time from left to right, and the y-axis measures the values of the variable being plotted (Marc 2016, 546).
Jack Mitchell, a patient in Ross Hospital, is being treated for gallstones. He has not opted out of the facility directory. Callers who request information about him may be given:
a. No information due to the highly sensitive nature of his illness
b. Admission date and location in the facility
c. General condition and acknowledgment of admission
d. Location in the facility and diagnosis - CORRECT ANSWER Correct Answer: C
A facility may maintain a facility directory of patients being treated. HIPAA's Privacy Rule permits the facility to maintain in its directory the following information about an individual if the individual has not objected: name, location in the facility, and condition described in general terms. This information may be disclosed to persons who ask for the individual by name (Rinehart-Thompson 2017d, 227).
17. 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?
a. Survey sampling
b. Systematic sampling
c. Cluster sampling
d. Stratified sampling - CORRECT ANSWER Correct Answer: B
A systematic random sample is a simple random sample that may be generated by selecting every fifth or every tenth member of the sampling frame. In order to ensure that a systematic random sample is truly random, the sample frame should not be sorted in an order that might bias the sample (White 2016a, 140).
. If a patient has health insurance but pays in full for a healthcare service and asks that the information be kept private, under HIPAA the covered entity must:
a. Release the information to the health insurance provider
b. Get special patient consent to release the information
c. Comply with the patient's request and keep the information private
d. Request permission from HHS to release the information - CORRECT ANSWER Correct Answer: C
The 2013 HIPAA Omnibus Rule finalized regulations give patients the right to request that their PHI not be disclosed to a health plan if they pay out of pocket in full for the services or items. A provider who accepts the payment and provides the service is compelled to abide by this request (Rinehart-Thompson 2017d, 220-221).
Which of the following would be the best approach in starting a data governance program?
a. Focus on one or a few small business imperatives
b. Begin with developing policies and procedures
c. Identify HIPAA requirements
d. Establish success metrics - CORRECT ANSWER Correct Answer: A
Data governance is an iterative process. It initially prioritizes initiatives and focuses on small select business imperatives that quickly deliver value and expand as the program matures (Johns 2016, 88).
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Patient accounting is reporting an increase in national coverage decisions (NCDs), and local coverage determinations (LCDs) failed edits in observation accounts. Which of the following departments will be tasked to resolve this issue?
a. Utilization management
b. Patient access
c. Health information management
d. Patient accounts - CORRECT ANSWER Correct Answer: C
Resolving failed edits is one of many duties of the health information management (HIM) department. Various medical departments depend on the coding expertise of HIM professionals to avoid incorrect coding and potential compliance issues (Schraffenberger and Kuehn 2011, 237-238).
The legal health record for disclosure consists of:
a. Any and all protected health information data collected or used by a healthcare entity when delivering care
b. Only the protected health information requested by an attorney for a legal proceeding
c. The data, documents, reports, and information that comprise the formal business records of any healthcare entity that are to be utilized during legal proceedings
d. All of the data and information included in the HIPAA Designated Record Set - CORRECT ANSWER Correct Answer: C
The concept of legal health records was created to describe the data, documents, reports, and information that comprise the formal business record(s) of any healthcare organization that are to be utilized during legal proceedings. Understanding legal health records requires knowledge of not only what comprises business records used as legal health records, but also the processes as well as the physical and electronic systems used to manage these records (Biedermann and Dolezel 2017, 424). [Show Less]