Term
The computer notified the compliance officer that a user accessed the PHI of a patient with the same last name. This is an example of a(n):
A. Transmission security
B. Trigger
C. Integrity
D. Authentication |
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Definition
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Term
A hospital allows the use of the copy functionality in its EHR system for documentation purposes. The hospital has established explicit policies that define when the copy function may be used. Which of the following would be the best approach for conducting a retrospective analysis to determine if hospital copy policies are being followed?
A. Survey practitioners to determine if they are following hospital policy
B. Observe the documentation practices of all clinical personnel
C. Institute an in-service program for all hospital peronnel
D. Randomly audit EHR documentation for patients readmitted within 30 days
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Definition
| D. Randomly audit EHR documentation for patients readmitted within 30 days |
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Term
A healthcare enterprise wants to analyze data from multiple computer systems across the organization to determine trends in patient care services. Which of the following would be the best application to perform this function?
A. Spreadsheet
B. Data warehouse
C. WAN
D. Database |
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Definition
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Term
Which of the following is a key feature of a problem-oriented health record?
A. Chronological list of solved problems
B. Itemized list of patient's present condition
C. Itemized list of patient's present and past conditions
D. Sequential list of patient's confirmed diagnoses |
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Definition
| C. itemized list of patient's present and past conditions |
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Term
A quality data review that is based on specific problems after an initial baseline review that has been completed in a hospital is called a:
A. Focused inpatient review
B. Intern audit
C. Concurrent review
D. Compliance initiative |
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Definition
| A. Focused inpatient review |
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Term
Which of the following organizations is responsible for updating the diagnosis classifications of ICD-10-CM?
A. Centers of Disease Control (CDC)
B. World Health Organiztion (WHO)
C. Centers of Medicare and Medicaid Services (CMS)
D. National Centers for Health Statistics (HCHS) |
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Definition
| D. National Centers for Health Statistics (HCHS) |
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Term
A coder uses an LCD or an NCD to identify:
A. What services need prior approval before payment is made
B. What services require documentation to be submitted to Medicare
C. What diagnosis codes justify the medical necessity of a test or service
D. What CPT codes justify the medical necessity of a test or service |
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Definition
| C. What diagnosis codes justify the medical necessity of a test or service |
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Term
Which of the following CPT coding guidelines is true when a reduction of a fracture is performed with cast application?
A. Do not differentiate between open ancd closed treatment: CPT only specifies the site of the fracture
B. Use the termnology "manipulation" rather than "reduction" of fracture
C. Include internal fixation in all codes
D. Do not include application of cast separately |
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Definition
| D. Do not include application of cast separately |
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Term
When coding, what is the best source of documentation to determine the size of a removed malignant lesion?
A. Physical examination
B. Pathology report
C. Operative report
D. Laboratory report |
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Definition
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Term
The Medical Record Committee is assessing various strategies to improve documenation in the heath record. Which of the following would be the best first step to help improve physician documentation?
A. Implement a documentation score card
B. Determine the type and volume of documenation problems
C. Contact CMS for assistance
D. Change the medical staff bylaws |
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Definition
| B. Determine the type and volume of documenation problems |
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Term
The policies and procedures section of a Coding Compliance Plan should include all of the following except:
A. Assignment of discharge destination codes
B. Unbundling
C. Physician query process
D. Vender selection process |
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Definition
| D. Vender selection process |
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Term
Charts are scanned at the time of discharge. The record is then stored for six months before being destroyed. Which of the following statements is true?
A. paper medical record must be retained for the statute of limitations
B. scanned record can never be the legal record so we should not destroy the paper record
C. scanned record becomes the legal record as soon as the original chart is destroyed
D. scanned record is the legal record effective from the moment of scanning |
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Definition
| C. scanned record becomes the legal record as soon as the original chart is destroyed |
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Term
The Joint Commission will cite hospitals if the total average health record delinquency exceeds _____ of the average monthly discharges in any one quarter.
A. 25%
B. 75%
C. 50%
D. 100% |
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Definition
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Term
The hospital's public relations department in conjunction with the local high school is holding a "job-shadowing" day. The public relations department asks for input on this event from the standpoint of HIPAA compliance.
A. Job shadowing is specifically prohibited by HIPAA
B. Job shadowing is allowed by HIPAA under the provision of volunteers
C. Job shadowing is allowed by HIPAA under the provision allowing students and trainees to practice
D. Job shadowing should be limited to areas in which exposure to PHI is very limited |
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Definition
| D. Job shadowing should be limited to areas in which exposure to PHI is limited |
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