RHIA 2024 PRACTICE EXAM 1

1. Sally is the HIM director at Memorial Hospital and has been asked to compose a record retention policy for the hospital. What should be her first consideration in determining how long paper and electronic records must be retained?

a. The amount of space allocated for record filing and server set up

b. The number of paper records currently filed and the number of electronic files added on a daily basis

c. The most stringent law or regulation in the state, CMS, and accrediting body guidelines and standards

d. The cost of filing space and equipment

C

2. A 65-year-old white male was admitted to the hospital on 1/15 complaining of abdominal pain. The attending physician requested an upper GI series and laboratory evaluation of CBC and UA. The x-ray revealed possible cholelithiasis, and the UA showed an increased white blood cell count. The patient was taken to surgery for an exploratory laparoscopy, and a ruptured appendix was discovered. The chief complaint was:

a. Abdominal pain

b. Cholelithiasis

c. Exploratory laparoscopy

d. Ruptured appendix

A

3. Mrs. Smith's admitting data indicates that her birth date is March 21, 1948. On the discharge summary, Mrs. Smith's birth date is recorded as July 21, 1948. Which data quality element is missing from Mrs. Smith's health record?

a. Data accuracy

b. Data consistency

c. Data accessibility

d. Data comprehensiveness

B

4. The discharge summary must be completed within ________ after discharge for most patients but within ________ for patients transferred to other facilities. Discharge summaries are not always required for patients who were hospitalized for fewer than ________ hours.

a. 30 days, 48 hours, 24 hours

b. 14 days, 24 hours, 48 hours

c. 14 days, 48 hours, 24 hours

d. 30 days, 24 hours, 48 hours

D

5. Which of the following is an acceptable means of authenticating a record entry?

a. The physician's assistant electronically signs for the physician.

b. The HIM clerk electronically signs using the physician's login.

c. The charge nurse electronically signs for the physician.

d. The physician personally signs the entry electronically.

D

6. A method of documenting nurses' progress notes by recording only abnormal or unusual findings or deviations from the prescribed plan of care is called:

a. Problem-oriented progress notes

b. Charting by exception

c. Consultative notations

d. Open charting

B

7. In a long-term care setting, these are problem-oriented frameworks for additional patient assessment based on problem identification items (triggered conditions):

a. Resident Assessment Protocols (RAPs)

b. Resident Assessment Instrument (RAI)

c. Utilization Guidelines (UG)

d. Minimum Data Sets (MDS)

A

8. HIM departments may be the hub of identifying, mitigating, and correcting master patient index (MPI) errors. Often that information is not shared with other departments within the healthcare entity. After identifying procedural problems that contribute to the creation of the MPI errors, which department should the MPI manager work with to correct these procedural problems?

a. Administration

b. Registration or patient access

c. Risk management

d. Radiology and laboratory

B

9. Alex, an HIM analyst, reviews the record of Patty Eastly, a patient in the facility, to ensure that all documents are complete and signatures are present. This is an example of a:

a. Closed review

b. Qualitative review

c. Concurrent review

d. Delinquent review

C

10. What type of information makes it easy for hospitals to compare and combine the contents of multiple patient health records?

a. Administrative information

b. Demographic information

c. Progress notes

d. Uniform data sets

D

11. The data elements in a patient's automated laboratory result are examples of:

a. Unstructured data

b. Free-text data

c. Financial data

d. Structured data

D

12. Which of the following materials are required elements in an emergency care record?

a. Patient's instructions at discharge and a complete medical history

b. Time and means of the patient's arrival, treatment rendered, and instructions at discharge

c. Time and means of the patient's arrival, patient's complete medical history, and instructions at discharge

d. Treatment rendered, instructions at discharge, and the patient's complete medical history

B

13. 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. These data are called a(n):

a. Indicator

b. Measurement

c. Assessment

d. Outcome

A

14. Sue is updating the data dictionary for her organization. In this data dictionary, the data element name is considered which of the following?

a. Master data

b. Metadata

c. Structured data

d. Unstructured data

B

15. Which of the following is used by a long-term care facility to gather information about specific health status factors and includes information about specific risk factors in the resident's care?

a. Case management

b. Minimum Data Set

c. Outcomes and assessment information set

d. Core measure abstracting

B

16. Dr. Collins admitted John Baker to University Hospital. Blue Cross Insurance will pay John's hospital bill. Upon discharge from the hospital, who owns John's health record?

a. John

b. Blue Cross

c. University Hospital

d. Dr. Collins

C

17. What should be done about the email exchange between Jane Smith and her doctor, Dr. Ward, regarding Jane's concerns about an abnormal lab result and the doctor's response providing explanations and treatment options?

a. Since this is an email correspondence, the facility has no responsibility to keep it as part of the patient's medical record.

b. Since this email correspondence relates to communication between a physician and a patient and includes PHI, the facility should include the email in the patient's medical record.

c. Since this is an email correspondence, it should be kept in a separate social media file within the health information management department.

d. Since this is an email correspondence, it should be immediately deleted from the server and the physician should be disciplined for discussing PHI related topics via social media.

B

18. Derek, an HIM technician, reviews each record in the EHR system upon discharge of the patient to ensure that the system correctly assigned all documentation to the correct tab category (for example, all lab reports under the lab tab and x-ray reports under the radiology tab). This system utilizes which format for its patient care record?

a. Integrated

b. Practice-oriented

c. Chronological

d. Source-oriented

D

19. A local skilled nursing facility has been working to improve the quality of care it provides to residents. Facility staff have engaged in several PI initiatives recently, and the facility's internal data shows an improvement in quality metrics. The facility administrator is pleased with these findings but is also interested in determining how this facility is performing in contrast to other nearby skilled nursing facilities. Which of the following should the HIM professional use to inform management on how the facility compares to others in the area?

a. Comparative performance data

b. Internal infection reporting

c. Master patient index

d. Provider performance data

A

20. According to Joint Commission Accreditation Standards, which document must be placed in the patient's record before a surgical procedure may be performed?

a. Admission record

b. Physician's order

c. Report of history and physical examination

d. Discharge summary

C

21. The following data have been collected by the hospital quality committee. What conclusions can be made from the data on the hospital's quality of care between the first and second quarters?

Measure/ 1st Quarter/ 2nd Quarter

Medication errors/ 3.2%/ 10.4%

Patient falls/ 4.2%/ 8.6%

Hospital-acquired infections/ 1.8%/ 4.9%

Transfusion reactions/ 1.4%/ 2.5%

a. Quality of care improved between the first and second quarters.

b. Quality of care is about the same between the first and second quarters.

c. Quality of care declined between the first and second quarters.

d. Quality of care should not be judged by these types of measures.

C

22. The MPI manager has identified a pattern of duplicate health record numbers from the specimen processing area of the hospital. After spending time merging the patient information and correcting the duplicates in the patient information system, the MPI manager needs to notify which department to correct the source system data?

a. Laboratory

b. Radiology

c. Quality management

d. Registration

A

23. Borrowing record entries from another source as well as representing or displaying past documentation as current are examples of a potential breach of:

a. Identification and demographic integrity

b. Authorship integrity

c. Statistical integrity

d. Auditing integrity

B

24. When defining the legal health record in a healthcare entity, it is best practice to establish a policy statement of the legal health record as well as a:

a. Case-mix index

b. Master patient index

c. Health record matrix

d. Retention schedule

C

25. Notes written by physicians and other practitioners as well as dictated and transcribed reports are examples of:

a. Standardized data

b. Codified data

c. Aggregate data

d. Unstructured clinical information

D

26. Documentation including the date of action, method of action, description of the disposed record series of numbers or items, service dates, a statement that the records were eliminated in the normal course of business, and the signatures of the individuals supervising and witnessing the process must be included in this:

a. Authorization

b. Certificate of destruction

c. Informed consent

d. Continuity of care record

B

27. Decision-making and authority over data-related matters is known as:

a. Data management

b. Data administration

c. Data governance

d. Data modeling

C

28. A professional basketball player from the local team was admitted to your facility for a procedure. During this patient's hospital stay, access logs may need to be checked daily in order to determine:

a. Whether access by employees is appropriate

b. If the patient is satisfied with their stay

c. If it is necessary to order prescriptions for the patient

d. Whether the care to the patient meets quality standards

A

29. A patient has the right to request a(n) ________, which describes where the covered entity has disclosed patient information for the past six years outside of treatment, payment, and healthcare operations.

a. Disclosure list

b. Designated record set

c. Amendment of medical record

d. Accounting of disclosures

D

30. Why could it be difficult for a healthcare entity to respond to pulling an entire, legal health record together for an authorized request for information?

a. It can exist in separate and multiple paper-based or electronic systems.

b. The record is incomplete.

c. Numerous physicians have not given consent to release the record.

d. Risk management will not allow the legal health record to be released.

A

31. Dr. Hansen saw a patient with measles in his office. He directed his office staff to call the local department of health to report this case of measles. The office manager called right away and completed the report as instructed. Which of the following provides the correct analysis of the actions taken by Dr. Hansen's office?

a. Dr. Hansen's office followed protocol and reported this case of measles correctly.

b. Dr. Hansen's office did not need to report this case to the local health department.

c. Dr. Hansen's office should have mailed a letter to the local health department to report this case.

d. Dr. Hansen's office should have reported the case to the local hospital and not to the health department.

A

32. What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?

a. There is no impact.

b. The person making the entry in the health record may not be called as a witness in trial.

c. The incident report likely becomes discoverable because it is mentioned in a discoverable document.

d. The incident report cannot be discovered even though it is mentioned in a discoverable document.

C

33. 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?

a. Yes, HIPAA only requires that current records be produced for the patient.

b. Yes, this is hospital policy over which HIPAA has no control.

c. No, the records from the previous hospital are considered to be included in the designated record set and should be given to the patient.

d. No, the records from the previous hospital are not included in the designated record set but should be released anyway.

C

34. John is the privacy officer at General Hospital and conducts audit log checks as part of his job duties. What does an audit log check for?

a. Loss of data

b. Presence of a virus

c. Successful completion of a backup

d. Unauthorized access to a system

D

35. An outpatient laboratory routinely mails the results of health screening exams to its patients. The lab has received numerous complaints from patients who have received another patient's health information. Even though multiple complaints have been received, no change in process has occurred because the error rate is low in comparison to the volume of mail that is processed daily for the lab. How should the Privacy Officer for this healthcare entity respond to this situation?

a. Determine why the lab results are being sent to incorrect patients and train the laboratory staff on the HIPAA Privacy Rule

b. Fire the responsible employees

c. Do nothing, as these types of errors occur in every healthcare entity

d. Retrain the entire hospital entity because these types of errors could result in a huge fine from the Office of Inspector General

A

36. Anywhere Hospital's coding staff will be working remotely. The entity wants to ensure that they are complying with the HIPAA Security Rule. What type of network uses a private tunnel through the Internet as a transport medium that will allow the transmission of ePHI to occur between the coder and the facility securely?

a. Intranet

b. Local area network

c. Virtual private network

d. Wide area network

C

37. An individual designated as an inpatient coder may have access to an electronic medical record in order to code the record. Under what access security mechanism is the coder allowed access to the system?

a. Context-based

b. Role-based

c. Situation-based

d. User-based

B

38. The Security Rule leaves the methods for conducting the security risk analysis to the discretion of the healthcare entity. The first consideration for a healthcare facility should be:

a. Its own characteristics and environment

b. The potential threats and vulnerabilities

c. The level of risk

d. An assessment of current security measures

A

39. Sally Mitchell was treated for kidney stones at Graham Hospital last year. She now wants to review her medical record in person. She has requested to review it by herself in a closed room.

a. Failure to accommodate her wishes will be a violation under the HIPAA Privacy Rule.

b. Sally owns the information in her record, so she must be granted her request.

c. Sally's request does not have to be granted because the hospital is responsible for the integrity of the medical record.

d. Patients should never be given access to their actual medical records.

C

40. Who has the legal right to refuse treatment?

1. 98 yr old sound of mind

2. 10 yr old sound of mind

3. 35 yr old, incompetent, did not express treatment wished prior

4. 35 yr old, incompetent, created living will prior, refused living by artificial means

5. 35 yr old, intellectual disability, metal capacity of 12 yr old

a. 1 and 2

b. 1 and 3

c. 1 and 4

d. 4 and 5

C

41. Linda Wallace is being admitted to the hospital. She is presented with a Notice of Privacy

Practices. In the Notice, it is explained that her PHI will be used and disclosed for treatment, payment, and operations (TPO) purposes. Linda states that she does not want her PHI used for those purposes. Of the options listed here, what is the best course of action?

a. The hospital must honor her wishes and not use her PHI for TPO.

b. The hospital may decline to treat Linda because of her refusal.

c. The hospital is not required to honor her wishes in this situation, as the Notice of Privacy Practices is informational only.

d. The hospital is not required to honor her wishes for treatment purposes but must honor them for payment and operations purposes.

C

42. Jack Mitchell, a patient in Ross Hospital, is being treated for heart failure. 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

C

43. A data breach occurred in your organization, and after the investigation it was determined that a total of 785 individuals were impacted by the data breach. What must be completed within 60 days of learning about the data breach?

a. Update the notice of privacy practices and send to all patients

b. Report the incident to the individuals impacted, local media, and the Department of Health and Human Services

c. Conduct privacy training for members of the organization

d. Document a note mentioning the data breach in each of the patients' charts and tell the local media

B

44. The "custodian of health records" refers to the individual within a healthcare entity who is responsible for which of the following actions?

a. Determining alternative treatment for the patient

b. Preparing physicians to testify

c. Testifying to the authenticity of records

d. Testifying regarding the care of the patient

C

45. Dr. Smith, a member of the medical staff, asks to see the medical records of his adult daughter who was hospitalized in your institution for a tonsillectomy at age 16. The daughter is now 25. Dr. Jones was the patient's physician. Of the options listed here, what is the best course of action?

a. Allow Dr. Smith to see the records because he was the daughter's guardian at the time of the tonsillectomy.

b. Call the hospital administrator for authorization to release the record to Dr. Smith since he is

on the medical staff.

c. Inform Dr. Smith that he cannot access his daughter's health record without her signed authorization allowing him access to the record.

d. Refer Dr. Smith to Dr. Jones and release the record if Dr. Jones agrees.

C

46. St. Joseph's Hospital has a psychiatric service on the sixth floor. A 31-year-old male came to the HIM department and requested to see a copy of his health record. He told the clerk he was a patient of Dr. Schmidt, a psychiatrist, and had been on the sixth floor of St. Joseph's for the last two months. These records are not psychotherapy notes. The best course of action for you to take as the HIM director is:

a. Prohibit the patient from accessing his record as it contains psychiatric diagnoses that may greatly upset him.

b. Allow the patient to access his record.

c. Allow the patient to access his record if, after contacting his physician, his physician does not feel it will be harmful to the patient.

d. Deny access because HIPAA prevents patients from reviewing their psychiatric records.

C

47. You are a member of the hospital's Health Information Management Committee. The committee has created a HIPAA-compliant authorization form. Which of the following items does the Privacy Rule require for the form?

a. Signature of the patient's attending physician

b. Identification of the patient's next of kin

c. Identification of the person or entity authorized to receive PHI

d. Patient's insurance information

C

48. Protected health information that is maintained in a designated record set can be accessed by the patient or other authorized party upon request. Covered entities must respond to requests within what timeframe after receipt of the request?

a. 15 days

b. 30 days

c. 60 days

d. 90 days

B

49. A hospital health information department receives a subpoena duces tecum for records of a former patient. When the health record professional goes to retrieve the patient's medical records, it is discovered that the records being subpoenaed have been purged in accordance with the state retention laws. In this situation, how should the HIM department respond to the subpoena?

a. Inform defense and plaintiff lawyers that the records no longer exist

b. Submit a certification of destruction in response to the subpoena

c. Refuse the subpoena since no records exist

d. Contact the clerk of the court and explain the situation

B

50. An HIM professional violates privacy protection under the HIPAA Privacy Rule when he or she releases ________ without specific authorization from the patient(s) or patient representative(s).

a. A list of newborns to the local newspaper for publication in the birth announcements section

b. Data about cancer patients to the state health department cancer surveillance program

c. Birth information to the country registrar

d. Information about patients with sexually transmitted infections to the county health department

A

51. What is the implication regarding the confidentiality of incident reports in a legal proceeding when a staff member documents in the health record that an incident report was completed about a specific incident?

a. There is no impact.

b. The person making the entry in the health record may not be called as a witness in trial.

c. The incident report likely becomes discoverable because it is mentioned in a discoverable document.

d. The incident report cannot be discovered even though it is mentioned in a discoverable document.

C

52. The use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health, and health administration is called:

a. Secure messaging

b. Consumer informatics

c. Personalized medicine

d. Telehealth

D

53. In order for health information exchange (HIE) participants to search for health records on each of the other systems using patient indexing and identification software, the systems must be linked by a(n):

a. Primary key interface (PKI)

b. Application programming interface (API)

c. Continuity of care record (CCR)

d. Record locator service (RLS)

D

54. Which of the following is the unique identifier in the relational database patient table?

Patient #/ Patient Last Name/ Patient First Name/ Date of Birth

021234/ Smith/ Donna/ 03/21/1944

022366/ Jones/ Donna/ 04/09/1960

034457/ Smith/ Mary/ 08/21/1977

a. Patient last name

b. Patient last and first name

c. Patient date of birth

d. Patient number

D

55. In a relational database, which of the following is an example of a many-to-many relationship?

a. Patients to hospital admissions

b. Patients to consulting physicians

c. Patients to hospital health records

d. Primary care physician to patients

B

56. A possible justification for building an information system in-house rather than purchasing one from a vendor is that:

a. It is cheaper to buy than to build

b. The facility has development teams they do not want to give up

c. Integration of systems will be easier

d. Vendor products are not comprehensive enough

B

57. What is the formatting problem in the following table?

Medical Center Hospital Admission Types

Elective 2,843/ 62.4

Emergency admission 942/ 37.6

Total 3,785/ 100.0

a. The variable names are missing

b. The title of the table is missing

c. The column headings are missing

d. The column totals are inaccurate

C

58. Community Memorial Hospital had 25 inpatient deaths, including newborns, during the month of June. The hospital had a total of 500 discharges for the same period, including deaths of adults, children, and newborns. The hospital's gross death rate for the month of June was:

a. 0.05%

b. 2%

c. 5%

d. 20%

C

59. In which of the following phases of systems selection and implementation would the process of running a mock query to assess the functionality of a database be performed?

a. Initial study

b. Design

c. Testing

d. Operation

C

60. In the data warehouse, the patient's last name and first name are entered into separate fields. This is an example of what?

a. Query

b. Normalization

c. Key field

d. Slicing and dicing

B

61. A physician is interested in conducting research on herniated intervertebral disc disease. She wants to compare the success of conservative medical care versus surgical intervention. The best source of this information is the:

a. Disease index

b. Operative index

c. Master patient index

d. Trauma registry

A

62. The health information services department at Medical Center Hospital has identified problems with its work processes. Too much time is spent on unimportant tasks, there is duplication of effort, and task assignment is uneven in quality and volume among employees. What should the manager do?

a. The manager should have each employee complete a serial work request.

b. The manager should have each employee complete a work distribution chart.

c. The manager should have the employees complete a use case analysis.

d. The manager should develop a flow process chart.

B

63. By querying the healthcare entity data, you find that patients admitted on a weekend have a mean length of stay that is 1.3 days longer than patients who are admitted Monday through Friday. This method of finding information is called:

a. Structuring query language

b. Data mining

c. Multidimensional data structuring

d. Satisficing

B

64. A health information professional is preparing statistical information about the third-party payers that reimburse care in the facility. She finds the following information: Medicare reimburses 46 percent; Medicaid reimburses 13 percent; Blue Cross reimburses 21 percent; workers' compensation reimburses 1 percent; commercial plans reimburse 15 percent; and other payers or self-payers reimburse 4 percent. What is the best graphic tool to use to display this data?

a. Histogram

b. Pie chart

c. Line graph

d. Table

B

65. During an influenza outbreak, a nursing home reports 25 new cases of influenza in a given month. These 25 cases represent 30 percent of the nursing home's population. This rate represents the:

a. Distribution

b. Frequency

c. Incidence

d. Prevalence

C

66. When a physician office acquires a new EHR in place of its old EHR, the old EHR data will

require:

a. Chart conversion

b. Chart transition

c. Data conversion

d. Data processing

C

67. Using the admission criteria provided, determine if the following patient meets the severity of illness and intensity of service criteria for admission.

Severity of Illness/ Intensity of Service

Persistent fever/ Inpatient-approved surgery/procedure within 24 hours of admission

Active bleeding/ Intravenous medications or fluid replacement

Wound dehiscence/ Vital signs every 2 hours or more often

Sue presents with vaginal bleeding. An ultrasound showed a missed abortion so she is being admitted to the outpatient surgery suite for a D&C.

a. The patient does not meet both severity of illness and intensity of service criteria.

b. The patient does meet both severity of illness and intensity of service criteria.

c. The patient meets intensity of service criteria but not severity of illness.

d. The patient meets severity of illness criteria but not intensity of service.

D

68. The user needs a list of all of the patients that were diagnosed with a cerebral infarction or a cerebral hemorrhage. What type of search would be used in this situation?

a. Structured query language

b. Wildcard search

c. Truncation

d. Boolean search

D

69. A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step is typically referred to as:

a. Identify needs

b. Monitor results

c. Record feedback

d. Specify requirements

B

70. Community Memorial Hospital discharged nine patients on April 1. The length of stay for each patient is shown in the following table. The average length of stay for these nine patients was:

Patient/ Number of Days

A/ 1

B/ 5

C/ 3

D/ 3

E/ 8

F/ 8

G/ 8

H/ 9

I/ 9

a. 5 days

b. 6 days

c. 8 days

d. 9 days

B

71. The department of surgery has acquired an analytics engine to enable it to provide predictive information at the point of care via the EHR. However, the department is struggling to get physicians to use the functionality because it does not have support staff to program or train users. This situation refers to the fact that the project plan did not illustrate:

a. Conflicts

b. Dependencies

c. Environmental issues

d. Policy decisions

B

72. This Health Information Exchange (HIE) consent model requires the patient to give their consent for the inclusion of their data in the HIE.

a. Opt-in

b. Opt-out

c. Automatic consent

d. No-consent

A

73. Given the information here, the case-mix index would be:

MS-DRG/ MDC/ Type/ MS-DRG Title/ Weight/ Discharges/ Geometric Mean/ Arithmetic Mean

191/ 04/ MED/ COPD w CC/ 0.8642/ 10/ 2.7/ 3.3

192/ 04/ MED/ COPD w/o CC/MCC/ 0.6521/ 20/ 2.2/ 2.6

193/ 04/ MED/ Simple PNA & pleurisy w MCC/ 1.2987/ 10/ 4.0/ 5.1

194/ 04/ MED/ Simple PNA & pleurisy w CC/ 0.8402/ 20/ 2.9/ 3.6

195/ 04/ MED/ Simple PNA & pleurisy w/o CC/MCC/ 0.6418/ 10/ 2.3/ 2.8

a. 0.09

b. 0.6521

c. 0.8270

d. 82.70

C

74. A super user of health IT has complained to her supervisor that she is being asked by a physician to perform his data entry. What should the super user's role be?

a. Aid others in using a new system during go-live and getting to adoption

b. Serve as a scribe for physicians who are new to data entry

c. Train users to learn how to use the system prior to go-live

d. Troubleshoot issues with the system that did not come to light during testing

A

75. Which of the following do HIE participants use to search for health records on other healthcare organization systems using patient indexing and identification software?

a. Admit, discharge, transfer

b. Advance patient identifier

c. Continuity of care document

d. Record locator service

D

76. Which of the following would likely be recorded on an information systems issues log?

a. Alan is present every day there is a system test.

b. Betty reported receiving 25 erroneous e-mail messages.

c. Dr. Brown effectively uses e-prescribing.

d. John requested a supply of tamperproof paper for his office.

B

77. A physician is concerned that the data patients enter into an EHR is not as reliable as data entered by another provider. What function serves to distinguish the source of data in an EHR?

a. Data dictionary

b. Data provenance

c. Data quality

d. Data registry

B

78. A coding manager wants to display the patient types that have the most coding errors in relationship to coder years of service. The desire of the coding manager is to display how coder years of service is responsible for coding errors. The type of graph or chart best suited for this is a:

a. Bar graph

b. Pareto chart

c. Pie chart

d. Line graph

B

79. The best way to ensure that elements of a health information system work together is to:

a. Adopt all components from a single vendor

b. Ensure standards are applied to software development that support interoperability

c. Use an application service provider that supports all vendors

d. Verify that a vendor applies a systems' view to its product development

B

80. Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity. Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity. Attributes and the CLINIC Entity Attributes. What does the attribute PATIENT_MRN represent?

a. It is the foreign key in PATIENT and the primary key in VISIT.

b. It is the primary key in PATIENT and the foreign key in VISIT.s

c. It is the primary key in both PATIENT and VISIT.

d. It is the foreign key in both PATIENT and VISIT.

B

81. A hospital is conducting an analysis of its existing health information systems and is looking at potential areas that need attention. This step in the systems development life cycle is typically referred to as _____.

a. Identify needs

b. Monitor results

c. Record feedback

d. Specify requirements

B

82. Patients at the new cardiac clinic at ABC Hospital are given smart watches with special sensors to monitor their blood pressure, heart rate, and rhythm in ECG format to identify any abnormalities during their daily routine. The information generated from these smart devices is considered a:

a. Source system

b.iInteroperability system

c. Virtual system

d. Hybrid system

A

83. One of the older cardiologists expressed dissatisfaction with using an EHR, stating that he does not understand why it's necessary. Sandy, as the EHR Clinical Coordinator, talks about his work as the first physician at ABC Hospital to use computerized technology for cardiac patients, and how cardiac diagnosis outcomes improved. She relates to him that the EHR will have the same impact and that the best reason to implement an EHR is to:

a. Determine the cost of care

b. Improve patient care

c. Eliminate medical errors

d. Meet Joint Commission mandate for the HER

C

84. Dr. Wilson asks you, the EHR Manager, to explain the difference between an alert and a reminder. You explain that reminders are typically used for things that can be scheduled or that occur on a regular basis. An example of a reminder that would be given to Dr. Wilson would be:

a. Use of anticoagulant is contraindicated

b. Patient is due for MMR immunization

c. Patient is allergic to sulfa drugs

d. Drug does not come in this format

B

85. Using the information in these partial attribute lists for the PATIENT, VISIT, and CLINIC columns in a relational database, the attribute PATIENT_MRN is listed in both the PATIENT Entity Attributes and the VISIT Entity Attributes, and CLINIC_ID is listed in both the VISIT Entity Attributes and the CLINIC Entity Attributes. What does the attribute CLINIC_ID represent?

a. It is the foreign key in CLINIC and the primary key in VISIT.

b. It is the primary key in CLINIC and the foreign key in VISIT.

c. It is the primary key in both CLINIC and VISIT.

d. It is the foreign key in both CLINIC and VISIT.

B

86. A 45-year-old woman is admitted for blood loss anemia due to dysfunctional uterine bleeding.

D25.9 leiomyoma of uterus, unspecified

D50.0 Iron def anemia secondary to blood loss (chronic)

D62 Acute posthemorrhagic anemia

N93.8 Other specified abnormal uterine and vaginal bleeding

a. D50.0, N93.8

b. D62, N93.8

c. N93.8, D50.0

d. D50.0, D25.9

A

87. A coder notes that the patient is taking prescribed Haldol. The final diagnoses on the progress notes include diabetes mellitus, acute pharyngitis, and malnutrition. What condition might the coder suspect the patient has that the physician should be queried to confirm?

a. Insomnia

b. Hypertension

c. Mental or behavioral problems

d. Rheumatoid arthritis

C

88. A patient has a malunion of an intertrochanteric fracture of the right hip that is treated with a proximal femoral osteotomy by incision. What is the correct ICD-10-PCS code for this procedure?

a. 0QB60ZZ

b. 0Q860ZZ

c. 0SB90ZZ

d. 0SN90ZZ

B

89. Medical identity thefts are situations in which the following occurs:

a. When health information on the wrong patient is put in the incorrect record

b. When financial information is used to purchase nonmedical items

c. When demographic and financial information is used to acquire medical services

d. When demographic information is used to purchase nonmedical items

C

90. A patient is admitted with right diabetic cataract and extracapsular cataract extraction with simultaneous insertion of intraocular lens.

E11.36 T2 DM w diabetic cataract

E11.9 T2 DM wo complications

H25.9 Unspecified age-related cataract

H26.9 Unspecified cataract

a. H25.9, E11.36, 08DJ3ZZ

b. E11.36, 08RJ3JZ

c. E11.9, E11.36, H26.9, 08DJ3ZZ

d. E25.9, E11.9, 08RJ3JZ

B

91. The practice of using a code that results in a higher payment to the provider than the code that actually reflects the service or item provided is known as:

a. Unbundling

b. Billing for services not provided

c. Medically unnecessary services

d. Upcoding

D

92. You are the coding supervisor and you are doing an audit of outpatient coding. Robert Thompson was seen in the outpatient department with a chronic cough, and the record states "rule out lung cancer." What should have been coded as the patient's diagnosis?

a. Chronic cough

b. Observation and evaluation without need for further medical care

c. Diagnosis of unknown etiology

d. Lung cancer

A

93. Using the following custom revenue production report, which coding error may be demonstrated in the report?

Revenue Production Report—Small Multispecialty Group Month: January

Code/ Quantity/ Fee/ Projected Revenue/ Actual Insurance Revenue

99202/ 3/ $75/ $225/ $164.10

99203/ 4/ $90/ $360/ $267.94

99204/ 0/ $120/ $0/ $0.00

99205/ 0/ $150/ $0/ $0.00

99211/ 703/ $28/ $19,684/ $14,988.32

99212/ 489/ $47/ $22,983/ $18,092.65

99213/ 1853/ $63/ $116,739/ $92,890.38

99214/ 41/ $89/ $3,649/ $2,799.11

99215/ 7/ $135/ $945/ $722.87

99242/ 9/ $125/ $1,125/ $156.23

99243/ 27/ $150/ $4,050/ $610.45

a. Clustering

b. Unbundling

c. Missed charges

d. Overcoding

A

94. Jim was admitted for hip replacement surgery, and during his procedure he was administered blood products. Postoperatively, Jim developed a rash and fever. The presence of these symptoms will be investigated by the hospital as a possible:

a. Blood verification

b. Core measure

c. Comorbidity

d. Transfusion reaction

D

95. Community Hospital has received a large number of claims denials for CT scans that were provided to patients. After review of the denied claims, the hospital has determined that clinical indications for the CT scan were not present. For which of the following reasons were these claims denied for payment?

a. Patient preferences were ignored.

b. These scans did not meet medical necessity.

c. No order was present in the record for the scans.

d. Best practices for billing were not used.

B

96. The health plan reimburses Dr. Tan $15 per patient per month. In January, Dr. Tan saw 300 patients, so he received $4,500 from the health plan. What method is the health plan using to reimburse Dr. Tan?

a. Traditional retrospective

b. Capitated rate

c. Relative value

d. Discounted fee schedule

B

97. Jennifer, the HIM Assistant Director, is establishing her yearly calendar with all the dates for standing monthly committee meetings, weekly production reports, daily census tracking graphs, quarterly payroll accounts, etc. Identify the frequency Jennifer would schedule the chargemaster software updates.

a. Annually

b. Quarterly

c. Monthly

d. Weekly

A

98. The technology commonly utilized for automated claims processing (sending bills directly to third-party payers) is:

a. Optical character recognition

b. Bar coding

c. Neural networks

d. Electronic data interchange

D

99. A physician performed a total abdominal hysterectomy with bilateral salpingo-oophorectomy on his patient at Community Hospital. His office billed the following:

58150 Total abd hysterectomy, w or wo removal of tubes, w or wo removal of ovary

58720 Salpingo-oophorectomy, complete or partial, uni or bilat

Why was this claim rejected?

a. Billed hysterectomy with wrong CPT code

b. Not a covered procedure

c. Unbundled procedures

d. Covered procedure but insurance company requires additional information

C

100. A patient saw a neurosurgeon for treatment of a nerve that was severed in an industrial accident. The patient worked for Basic Manufacturing Company where the industrial accident occurred. Basic Manufacturing carried workers' compensation insurance. The workers' compensation insurance paid the neurosurgeon fees. Which entity is the "third party"?

a. Patient

b. Neurosurgeon

c. Basic Manufacturing Company

d. Workers' compensation insurance

D