RHIT Capstone Final Exam Latest Updated Graded A+

Document Content and Description Below

integrated health record - ANSWER The paper based health record format that organizes all forms in chronological order is known as a(n): Wide area network - ANSWER Which of the following computer a... rchitectures would be best for implementing an EHR for a healthcare system that needs to transmit data to its various campuses that are located across a wide geographic area? privacy - ANSWER The right of an individual to keep information about themselves from being disclosed to anyone is a definition of: drop-down menus - ANSWER In designing an input screen for an electronic health record, which of the following would be best to capture discrete data? providing a financial incentive for coding claims improperly - ANSWER Which of the following practices is not an appropriate coding compliance activity? physician work, practice expense, and malpractice insurance expense - ANSWER Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are: Patient's laboratory value is 50 - ANSWER Which of the following best represents the definition of the term data? access controls, audit trails, and authentication systems - ANSWER An EHR system can provide better security than a paper record for protected health information system due to _____ One CPT code, adding the lengths of the lacerations together - ANSWER In CPT, if a patient has two lacerations of the arm that are repaired with simple closures, which of the following would apply for correct coding? accusations of fraud and abuse - ANSWER The goal of coding compliance programs is to prevent _______- Over time, the data can reveal trends and point out areas for improvement - ANSWER Reporting the number of incomplete charts over a 6 month period using a run or line chart will prove valuable in which of the following two ways? the date the bill drops - ANSWER Most facilities begin counting days in accounts receivable at which of the following times? episode-of-care - ANSWER Health plans that use ___________reimbursement methods issue lump-sum payments to providers to compensate them for all the health care services delivered to a patient for a specific illness and/or over a specific period of time. write a detailed operative note in the record - ANSWER A surgeon on the Health Record Committee voices a concerns that, although he has been told that the operative report is to be dictated immediately after surgery, he has often had to deal with the problem of transcription backlog, which prevented the report from getting on the health record in a timely manner. Your advice to this doctor is that when a known backlog exists, he should: payment determinations and audit of cost reports - ANSWER The Medicare Integrity Program was established as part of the Title II of HIPAA to battle fraud and abuse and is charged with which of the following responsibilities? Conditions of Participation - ANSWER Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet in order to become certified for these programs? Dental services - ANSWER In processing a bill for healthcare services, which of the following would be excluded under Medicare Part A? deemed status - ANSWER When a hospital accredited by the Joint Commission is considered to be in compliance with Medicare's Conditions of Participation, this is called: evaluate the performance of individual patient care providers - ANSWER Patient care managers use the data documented in the health record to: electronic medication prescribing system - ANSWER Which of the following best describes e-RX? MDS - ANSWER The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components, including the new care area assessment, utilization guidelines, and the: Identify data content requirements for all areas of the organization - ANSWER A new HIM director has been asked by the hospital CIO to ensure that data content standards are identified, understood, implemented, and managed for the hospital's planned EHR system. Which of the following should be the HIM director's first step in carrying out this responsibility? Medical staff bylaws - ANSWER Which of the following dictates how the medical staff operates? The expectation that personal information shared by an individual with a healthcare provider during the course of care will be used only for its intended purpose - ANSWER Which of the following definitions best described the concept of confidentiality? 69 - ANSWER The inpatient census at midnight is 67. Two patients were admitted in the morning; one dies 2 hours later; the second patient was transferred to another facility that same afternoon. The inpatient service days for that day will be: National Committee for Quality Assurance - ANSWER The organization that coordinates the collection of performance data for managed care plans is the: Fiscal Intermediary/MAC - ANSWER Which entity is responsible for processing Part A claims and hospital-based Part B claims for institutional services on behalf of Medicare? delinquent record - ANSWER A health record with deficiencies that is not complete within the time frame specified in the medical staff rules and regulations is called a(n) ___________ by the hospital - ANSWER Hospital physical documents relating to the delivery of patient care such as medical records, x-rays, laboratory reports, and consultation reports are owned: fraud - ANSWER The HIM department acts in deliberate ignorance or in disregard of official coding guidelines, it may be committing: Confirm that a formal letter of termination is required and that the transcription company must provide the hospital with a certification that all PHI that it had in its possession has been destroyed or returned. - ANSWER Community Hospital is terminating its business associate relationship with a medical transcription company. The transcription company has no further need for any identifiable information that it may have obtained in the course of its business with the hospital. The CFO of the hospital believes that to be HIPAA compliant all that is necessary is for the termination to be in a formal letter signed by the CEO. In this case how should the Director of HIM advise the CFO? program to exchange data - ANSWER A software interface is a _______________ premium - ANSWER Which of the following terms is used for the amount charged for a medical insurance policy? standards of care - ANSWER An established set of clinical decisions and actions taken by clinicians and other representatives of healthcare organizations in accordance with state and federal laws, regulations, and guidelines is called: Federal Sentencing Guidelines - ANSWER Corporate compliance programs became common after the adoption of which of the following? aggregate data - ANSWER Data that are collected on large populations of individuals and stored in databases are referred to as: 27646 radical resection of tumor; fibula - ANSWER After reviewing the following excerpt from CPT, code 27646 would be interpreted as: 27645 Radical section of tumor, tibia 27646 fibular 27647 talus or calcaneus vocabulary standards - ANSWER Standardizing medical terminology to avoid differences in naming various medical conditions and procedures (such as the synonyms bunionectomy, McBride procedure, and repair of hallus valgus) is one purpose of ___________ ARRA - ANSWER As the Compliance Officer for an acute care facility, you are interested in researching recent legislation designed to provide significant funding for health information technology for your next committee meeting. You begin by googling: Claims management - ANSWER Which of the following is not one of the basic functions of the utilization review process? Database management system - ANSWER The HIM Department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, type of records coded and other data, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use to develop this type of database? to determine whether standards of care are being met - ANSWER How do accreditation organizations such as the Joint Commission use the health record? Procedure - ANSWER Which of the following is the approved method for conducting business in an organization? Occlusion - ANSWER What is the correct root operation for uterine artery embolization? pie diagram - ANSWER You are trying to improve communications with your staff by posting graphs of significant statistics on the employee bulletin board. You recently calculated the percentage of time employees spend on each of six major tasks. Because you would like the employees to appreciate each task as a percentage of their whole day, you will post this figures using a transposed digits in the SS#, date of birth, or policy # - ANSWER Which of the following is a common registration error that will affect the revenue cycle? ICD-10-CM and CPT Coding - ANSWER In developing a monitoring program for coding compliance, which of the following should be regularly audited? indicator - ANSWER A performance measure that enables healthcare organizations to monitor a process to determine whether it is meeting process requirements is called: XML - ANSWER A universal language to aid storage and transmission of Web-based data is: Funding is a joint federal and state initiative - ANSWER Which of the following statements most accurately describes funding for the Medicaid program? Placenta Previa - ANSWER A patient had a placenta previa with delivery of twins. The patient had two prior Cesarean sections. This was an emergent C-Section due to hemorrhage. The appropriate principle diagnosis would be: utilization review - ANSWER The policies and procedures section of a coding compliance plan should include all of the following except: Yes, within 2.5% below SD - ANSWER The quality improvement (QI) plan for your hospital requires each coder maintain a minimum of 94.5% accuracy in coding. You manage the coding department, and the past year's average accuracy rating was 95.3%. The QI plan allows a standard deviation (SD) of 2.5% against best practices of 97% accuracy. Did your coding staff's overall average meet within the standard deviation range? No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient. - ANSWER A hospital receives a valid request from a patient for copies of her medical records. The HIM clerk who is preparing the records removes copies of the patient's records from another hospital where the patient was previously treated. According to HIPAA regulations, was this action correct? recover audit contractors - ANSWER As the Coding Supervisor, your job description includes working with agents who have been charged with detecting and correcting overpayments made to your hospital in the Medicare Fee for Service program. You will need to develop a professional relationship with: the H&P copy is acceptable as long as she documents any interval changes - ANSWER As a concurrent record reviewer for an acute care facility, you have asked Dr. Crossman to provide an updated history and physical for one of her recent admissions. Dr. Crossman pages through the medical record to a copy of an H&P performed in her office a week before admission. You tell Dr. Crossman: Each physician practice obtain a business associate agreement with the hospital - ANSWER Community Hospital wants to provide transcription services for transcription of office notes of the private patient of physicians. All of these physicians have medical staff privileges at the hospital. This will provide an essential service to the physicians as well as provide additional revenue for the hospital. In preparing for launching this service the HIM Director is asked if a business associate agreement is necessary. Which of the following should the hospital HIM Director advise to comply with HIPAA regulations? capital budget - ANSWER What component of the budget would include money for the purchase of an EHR? 34203 - ANSWER The patient had a thrombectomy, without catheter, of the Perineal artery, by leg incision. 34203 Embolectomy or thrombectomy, with or without catheter; popliteal-tibioperoneal artery, by leg incision 35226 Repair blood vessel, direct; lower extremity 35302 Thromboendarterectomy, including patch graft if performed; superficial femoral artery 37799 Unlisted procedure, vascular surgery On all codes from chapter 15, Pregnancy, Childbirth and the Puerperium - ANSWER A code from category Z3A (Weeks of gestation of a pregnancy) should be used . . . . Prolonged pregnancy - ANSWER A maternity patient is admitted in labor at 43 weeks. She has a normal delivery with vacuum extraction to facilitate the baby's delivery. Which of the following would be the principal diagnosis? privacy - ANSWER An individual's right to control access to his or her personal information is known as: 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 - ANSWER 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? It is the set of processes used to determine the appropriateness of medical services provided during specific episodes of care - ANSWER Which of the following statements best defines utilization management? consultation report - ANSWER You notice on the admission H&P that Mr. McKahan, a Medicare patient, was admitted for disc surgery, but the progress notes indicate that [Show More]

Last updated: 1 year ago

Preview 1 out of 13 pages