(A) The patient has the right to control everyone who reviews his or her medical record.
(B) The patient has rights regarding their individually identifiable health information.
(C) Access to medical record information has to be controlled by technical controls.
(D) Access to patient identifiable health information is available only to healthcare professionals.
2) Which of the following is a system in which the patient health record is kept in the same order on the nursing station and in the complete record?
(A) reverse chronological order
3) Tracking when employees were logged on the system and what they did is called:
(A) error detection
(B) audit trails
(C) data misuse
(D) data recovery
4) While performing routine quantitative analysis of a record, a medical record employee finds an incident report in the record. The employee brings this to the attention of her supervisor. The supervisor should
(A) remove the incident report and send it to the patient
(B) tell the employee to leave the report in the record
(C) remove the incident report and have nursing personnel transfer all documentation from the report to the medical
(D) refer this record to the Risk Manager for further review and removal of the incident report
5) Patient authorization to release information is required for
(A) peer review
(B) payment purposes
(C) quality assurance
(D) non identifying research
6) A 21-year-old employee of PRG Publishing was treated in an acute care hospital for an illness unrelated to work. A representative from the Personnel department of PRG Publishing calls to request information regarding the employee’s diagnosis. What would be the appropriate course of action?
(A) request that the personnel office send an authorization for release of information that is signed and dated by the patient
(B) require parental consent
(C) release the information as the employer is paying the patient’s bill
(D) call the patient to obtain verbal permission
7) The term ____________________ refers to accounts that are to be refunded to an insurer or a patient that a healthcare facility has defined as uncollectible.
(A) credit balances
(B) accounts receivable
(C) late charges
(D) bad debt
8) Upon retrospective review of Rose Hunter’s inpatient health record, the health information clerk notes that on day four of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?
(A) utilization review
(B) quantitative review
(C) therapeutic review
(D) qualitative review
9) In quality review activities departments are directed to focus on clinical processes that are
(A) high volume
(B) high risk
(C) problem prone
(D) All of the above
(B) charting by exception
(C) open record review
(D) charting by abnormality
11) Your organization is sending confidential patient information across the Internet using technology that will transform the original data into unintelligible code that can be re-created by authorized users. This technique is called
(A) a firewall
(B) validity processing
(C) a call back process
(D) data encryption
12) Most healthcare facilities use this type of screening criteria for utilization review purposes to determine the need for inpatient services and justification for continued stay
(A) severity of illness/intensity of service criteria (SI/IS)
(B) critical pathways
(C) JCAHO defined and developed criteria
(D) HEDIS measures
(A) Peer Review Improvement Act
(B) QIO (formerly PRO) Scope of Work
(C) Manual of National Healthcare Policy
(D) National Practitioner Data Bank
14) Which department will most likely be responsible for taking corrective action regarding the following quality indicator?
Number of insurance claims requiring resubmission due to errors (not related to coding) will not exceed 3%.
(B) Business Office
(C) Health Information Department
(D) Medical Staff Office
15) Use the exhibit provided. The coder with the highest over-all accuracy rating will get the day after Thanksgiving off. Which coder will get to spend the day after Thanksgiving shopping rather than coding?
(A) Coder A
(B) Coder B
(C) Coder C
(D) Coder D (Where is the exhibit?)
16) Dr. LaHasty has signed a statement that all of her dictated records should be automatically considered approved and signed unless she makes corrections within 48 hours of dictating. This is called:
(B) charting by exception
(C) open record review
(D) electronic authentication
17) With regards to a health care organization’s compliance plan, special emphasis should be directed towards
(A) preventing fraudulent coding and billing practices
(B) only meeting the standards of JCAHO
(C) satisfying the desires of the health care facility’s physicians
(D) complying with the instructions of the health care facility’s attorney
18) The JCAHO requirement regarding delinquent records is that the number of delinquent records in a facility cannot exceed:
(A) 50% of the average admissions per week
(B) 150% of the average number of discharges
(C) 50% of the average number of discharges
(D) 25% of yearly admissions
(C) audit trail
20) The supervisor over coding reviewed the productivity logs of four newly hired coders after their first month. The report in the exhibit illustrates each coder’s output. Based on analysis of this report, which employee will require additional assistance in order to meet the coding standards?
(A) Coder 1
(B) Coder 2
(C) Coder 3
(D) Coder 4
21) The federal law that directed the Secretary of Health and Human Services to develop healthcare standards governing electronic data exchange and data security is the _____________________
(A) Health Insurance Portability and Accountability Act of 1996
(B) Omnibus Budget Reconciliation Act of 1989
(C) Social Security Act of 1935
(D) Health Care Quality Improvement Act of 1986
22) The recommended best practice for the ‘system hold’ is
(A) two days after the date of service or date of discharge
(B) three days after the date of service or date of discharge
(C) four days after the date of service or date of discharge
(D) seven days after the date of service or date of discharge
23) Which department will most likely be responsible for taking corrective action regarding the following quality indicator?
QUALITY INDICATOR: The number of DRG validation changes made by the QIO (formerly PRO) will not exceed 2%.
(B) Business Office
(C) Health Information Department
(D) Medical Staff Office
24) The following clinical findings represent severity of illness indicators for the utilization review function EXCEPT:
(A) blood pH 7.30 or 7.50
(B) loss of speech
(C) loss of sensation or movement of body part
(D) IV medications at least every 12 hours
25) Where in the health record would the following statement be located? “Microscopic Diagnosis: Liver (needle biopsy) metastatic adenocarcinoma”
(A) operative report
(B) pathology report
(C) anesthesia report
(D) radiology report
26) What is the traditional format for a hospital patient care record?
27) HEDIS gathers data in the following area:
(A) measures of access (i.e. at least one visit to a provider within three years)
(B) measures of quality (i.e. cholesterol screenings)
(C) measures of financial performance (i.e. cost per member)
(D) all of the above
28) In order to take part in the Medicare program, a hospital must be in compliance to a satisfactory degree with the standards for delivery of health care set forth in the:
(A) Hospital medical staff bylaws
(B) Journal of the American Hospital Association
(C) JCAHO Hospital Accreditation Standards
(D) Conditions of Participation
29) When designing a data collection process, the HIM professional will be concerned with determining
(A) who will be responsible for monitoring the quality of the data collection
(B) the source of the data
(C) the logical sequence of data collection
(D)aII of the above
30) Which data set was developed for collecting data on outpatients?
(B) Uniform Ambulatory Care Data Set
(C) Minimum Data Set
(D) Uniform Clinical Data Set
31) When did CMS implement the Correct Coding Initiative (CCI) for physician claims?
32) Data that is accumulated in large populations of people and stored in databases for analysis and review is referred to as
(A) aggregate data
(B) statistical analyses
(C) discharge data sets
(D) minimum data sets
33) It takes approximately 18 minutes to code an average inpatient chart. If there are 15,620 discharges for the month, how many personnel hours are needed for this volume of work?
34) The data in the column on the far right of the exhibit provided was collected when the coders traded records for re-coding. This is a common practice used to check
(A) interrater reliability
(B) intrarater reliability
(C) interrater validity
(D) intrarater validity
35) Which of the following remains exempt from CMST prospective payment system legislation?
(A) rehabilitation hospitals
(B) psychiatric hospitals
(C) ong-term acute care hospitals
(D) children’s hospitals
36) You are developing a tool to help you calculate incentive pay for the coders. Which one of the following would you most likely use?
(A) word processor
37) Release of information without the patient’s authorization is permissible in which of the following circumstances?
(A) release to an attorney
(B) release to third party payers
(C) release to state workers’ compensation agencies
(D) release to insurance companies
38) The Utilization Review Coordinator reviews inpatient records at regular intervals to justify necessity and appropriateness of care to warrant further hospitalization. Which of the following utilization review activities is being performed?
(A) admission review
(C) retrospective review
(D) continued stay review
39) A computer program that is used to calculate DRGs is referred to as a(an)
(C) case mix index
40) Which of the following acts was passed to stimulate the development of standards to facilitate electronic maintenance and transmission of health information?
(A) Health Insurance for the Aged
(B) Health Insurance Portability and Accountability Act
(C) Conditions of Participation
(D) Hospital Survey and Construction Act
41) When the coding supervisor audits charts to make sure that the codes selected reflect the documentation in the record, she is checking for
(A) timeliness of coding
(B) validity of coding
(C) use of 5th digits
(D) reliability of coding
42) You are developing a categorical data field for discharge disposition.
The categories that you have selected are:
01 Alive, home health
02 Alive, nursing home
03 Alive transfer to other hospital
What is wrong with the categories chosen?
(A) not specific enough
(B) patient could be classified into more than one category
(C) does not include all possibilities
(D) no problems identified
43) Your facility uses generic screening criteria of different types working to monitor the quality of care and identify problems. You are looking at a report with a listing of patients returned to the ICU within 24 hours of transfer to the nursing unit. Which type of indicator/screening criteria are you monitoring?
(A) OS - Occurrence Screening Criteria
(B) DI - Discharge Indicator
(C) SI - Severity of Illness Criteria
(D) IS - Intensity of Service
44) The extent to which data is within time parameters to be relevant refers to:
45) Initial efforts in health record standardization were led by the:
(A) American Health Information Management Association
(B) American College of Surgeons
(C) American Medical Association
(D) Centers for Medicare and Medicaid Services
46) A valid authorization for release of information contains
(A) the name, agency, or institution to whom the information is to be provided
(B) the name of the hospital or provider who is releasing the medical information
(C) the date and signature of the patient or their authorized representative
(D)aII of the above
47) The Conditions of Participation require that the medical staff bylaws, rules, and regulations address the status of consultants. Which of the following reports would normally be a considered a consultation?
(A) tissue examination done by the pathologist
(B) impressions of a cardiologist asked to determine whether patient is a good surgical risk
(C) interpretation of a radiologic study
(D) technical interpretation of electrocardiogram
48) 42 Code of Federal Regulations Part 2 refers to
(C) Prospective Payment System
(D) Confidentiality rules for alcohol and drug abuse patients
49) A Health Information Management department of a local hospital will experience a 20% increase in the number of discharges processed per day as the result of a merger with a smaller facility. This 20% increase is projected as 120 additional records per day. The standard time for coding a record is 15 minutes. Compute the number of FTET5 required to handle this increased volume in coding based on an eight hour day.
50) Physicians who are members of the Surgery Committee meet to review surgical cases referred for quality issues and deviations from standard care norms. This type of review in which a physician’s record is reviewed by his/her professional colleagues is known as
(A) concurrent review
(B) clinical pertinence review
(C) incident screening
(D) peer review
51) A coder would use the following to determine whether a service is considered medically necessary.
(A) the American Hospital Association’s Coding Clinic
(B) national coverage decisions (NCDs)
(C) the American Medical Association’s CPT Assistant
(D) correct coding initiatives
52) Determine the number of full time employees (FTE5) needed to code 600 discharges per week if it takes an average of 20 minutes to code each record and each coder will work 40 hours per week. How many coders are needed?
53) You have been conducting productivity studies on your coders and find that 20% of their time is devoted to querying physicians about missing or unclear diagnoses. Assuming your coders work a 7-hour day, how many minutes do they spend per day querying physicians?
54) If administrators of a home health agency wanted to measure the outcomes of adult patients receiving their agency’s services which tool would they use?
55) You want to know the amount of time 8 employees had spent on coding this month. You have the following information. It took 12 minutes to code 1 chart, and 725 charts were coded in the month. There was a total of 1,280 hours worked by the 8 employees. What percentage of time did the 8 employees spend on coding?