Medicare Physician Fee Schedule (MPFS)

This prospective payment system replaced the Medicare physician payment system of "customary, prevailing, and reasonable (CPR)" charges whereby physicians were reimbursed according to their historical record of the charge for the provision of each service.

Full-blown AIDS sets in as

helper T-cell concentrations decrease

Common kidney stone treatments that allow small particles to be flushed out of the body through the urinary system include

using medication to dissolve the stone(s)

fluid hydration

extracorporeal shock wave lithotripsy

Clinical privileges are granted to the physician for an interval specified in the medical staff by laws, but not longer than

2 years

An ophthalmologist has requested permission to perform specialized laser procedures within the hospital. His request is evaluated by the Credentials Committee through a process to determine the specific procedures and services this physician can perform. This is known as

delineation of privileges

What is a disadvantage of retrospective data collection?

Deficiencies in documentation can effect reimbursement.

A patient, who is HIV positive, has raised red or purple lesions that appear on his skin, in his mouth, and most anywhere on his body. What is the stage of his disease process in today's medical terminology?

AIDS

Traditional management functions, such as ________, must be applied to performance improvement initiatives.

planning

The Joint Commission recently surveyed an acute care hospital. The hospital just received the survey report and the accreditation decision. Which of the following categories should the hospital leaders address first?

Requirements for Improvement

What common vitamin should be taken by pregnant women to substantially reduce the occurrence of neural tube defects, such as spina bifida, in a developing fetus?

folic acid

The process of reviewing and validating qualifications, granting professional or medical staff membership, and awarding delineated privileges is called the _____.

credentialing

Without even performing any complex calculations, you can get a quick, simple measure of dispersion in the LOS for yesterday's discharges by computing the

range of the data set

What is the correct sequence that depicts the flow of blood through the heart to the lungs in order for gas exchange to occur?

right atrium, right ventricle, pulmonary artery, lungs

A stapedectomy is a common treatment for

otosclerosis

In which brain lobe is the processing of emotions, intellect, and personality performed?

frontal

What process assists a health care facility in continuously looking at the ways that problems develop and seeking ways to prevent problems from happening in the future?

performance improvement

The board of directors of a 400-bed women's hospital receives a report of key quality indicator results on a periodic basis. The report always includes the quarterly cesarean section rate. This reporting period, they see a rise in the rate and want to know if it is a significant increase. What is the best QI tool for this purpose?

control chart

these items are "packaged" under the Medicare outpatient prospective payment system

medical supplies

anesthesia

recovery room

Under APCs, payment status indicator "V" means

clinic or emergency department visit (medical visits)

The hospital Quality Department adopted the Lean Management quality model using JIT, which ensures required process items and resources are

available at the right place and the right time.

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

MDS

The Minimum Data Set is

a basic component of the long-term care RAI

UHDDS is used in

acute care

OASIS is used in

home health

DEEDS is used in

emergency departments

Most carbon dioxide is carried in the

red blood cells

The most common bloodborne infection in the United States is

hepatitis C

Under the RBRVS, each HCPCS/CPT code contains three components, each having assigned relative value units. These three components are

physician work, practice expense, and malpractice insurance expense.

The etiology of aplastic anemia is

bone marrow failure

The ability to obtain the same results from different studies using different methodologies and different populations is

reliability

modified radical mastectomy

A standard surgical procedure used for the treatment of early-stage breast cancer involves the removal of the cancerous tumor, skin, breast tissue, areola, nipple, and most of the axillary lymph nodes, but leaves the underlying chest muscles intact.

In systemic circulation, what vessels carries oxygenated blood?

left ventricle

HEDIS gathers data in

breast cancer screenings

Which valve is between the left atrium and left ventricle?

mitral

In determining your acute care facility's degree of compliance with prospective payment requirements for Medicare, the best resource to reference for recent certification standards is the

Federal Register

On his 12/23/15 admission to Metropolitan Hospital, David Robinson was assigned the medical record number 07-23-38. The previous record number assigned to Mr. Robinson during a 9/1/15 admission was 07-10-47. In a serial numbering/filing system, how would these records be filed?

Each admission is filed under its own number.

A pathological diagnosis of transitional cell carcinoma is made. The examined tissue was removed from the

bladder

Using a template to collect data for key reports may help to prompt caregivers to document all required data elements in the patient record. This practice contributes to data

comprehensiveness

The Six Sigma methodology differs from other quality improvement models by defining improvement opportunities using

critical quality tree

Pasadena Bay Hospital reports an average LOS in January of 3.7 days with a standard deviation of 20. This tells us that

there was a large variation in the LOS.

The most fatal type of lung cancer is

small cell cancer

In 1987, OBRA helped shift the focus in long-term care to patient outcomes. As a result, core assessment data elements are collected on each SNF resident as defined in the

MDS

The PQRS is a reporting system established by the federal government for physician practices who participate in Medicare for

quality measure reporting

Amanda, an EHR project manager, wants to increase her implementation staff's problem-solving skills. Which of the following approaches is likely to have the best and most long-lasting results?

providing training to develop an EHR implementation work team

Units that provide support services to the organization, such as human resources, finances, and information systems, are referred to as

staff departments.

You have been asked to develop scenarios that will be used to design and program a new release of information system. These scenarios will include the processes to be used in detail. What are you designing?

use cases

The credentialing process requires healthcare facilities to

watch the provider perform surgery.

Which type of joint, such as the sutures of the skull, has no movement?

synarthrosis

This document is published by the Office of Inspector General (OIG) every year. It details the OIG's focus for Medicare fraud and abuse for that year. It gives health care providers an indication of general and specific areas that are targeted for review. It can be found on the Internet on CMS's Web site.

the OIG's Workplan

The major purpose of random assignment in a clinical trial is to

reduce selection bias in allocation of treatment.

What types of members are best for a committee?

There is no clear benefit to one form or another.

The DNFB report includes all patients who have been discharged from the facility but for whom, for one reason or another, the billing process is not complete. DNFB is an acronym for _____________.

discharged no final bill

The manager of the Quality Department is listing various sources of data. What data source would be an example of an external source?

quality improvement organization (QIO) information

South Beach Medical Center is preparing to open as a new 250-bed acute care hospital. This facility is located in a growing area of the city and is projected to have 85% occupancy within 3 years. To determine the number of employees needed in the HIM department, the director must first

identify the departmental functions to be performed.

A work environment that is not ergonomically sound could lead to

injuries.

What helps the organization prioritize investment opportunities?

profitability index

The most realistic approach that could encourage increased productivity in the tedious prepping area is to

vary and rotate the work assigned to each prepper.

A liver panel includes

albumin

bilirubin

alkaline phosphatase

cross-sectional or prevalence studies are known for

concurrently describing characteristics and health outcomes at one specific point in time.

What reflects the stage where teams may experience disequilibrium?

storming

The researchers at AHIMA started by assuming there was no relationship between job stress and job satisfaction. This statement is generally called the

null hypothesis.

pathophysiological factors in anemia include

excessive RBC breakdown

lack of RBC maturation

loss of bone marrow function

An anatomical part involved in both the respiratory and digestive systems

pharynx

Human Resources use a systematic procedure to determine the relative worth of a position to the organization. When this approach is used, compensation for the position is most likely based on

job evaluation.

In order to improve efficiency and productivity, what sequence of steps is the most effective?

Know the objective; break down the work into component activities, and the group activities into proper organizational units.

There were some HIM professionals who refused to participate in a job stress/job satisfaction study. This is of great concern to the AHIMA researchers, who worry about the introduction of

nonresponse bias.

The Director of a Health Information Department prepared a document in which the following information could be obtained: job title, reporting line, span of control, and routes of promotion. The document she was preparing was an

organizational chart

Using Donabedian's framework for quality assessment (structure, process, and outcome), what is an appropriate human resource outcome?

turn-over rate

Scabies, a highly contagious condition that produces intense pruritus and a rash, is caused by

itch mites

The expense budget is also known as the

operating budget.

Your facility has decided to implement the new laboratory information system on one unit and then add more units as your confidence in the system grows. What go-live model are you using?

pilot

_______________ refers to the flatness or peakedness of one distribution in relation to another distribution.

Kurtosis

What emphasizes the work climate in which harmony and cohesion promote good work?

esprit de corps

The EHR utilizes existing source systems to supply data.

This is true because the EHR obtains information SOLELY from the source documents

A type of job evaluation that requires the identification of essential factors or elements common to all jobs and the comparison of jobs on the basis of rating those elements (not the job as a whole), refers to

factor comparison.

The leading cause of blindness in the United States is a vision-related pathology caused by diabetes. It is called

retinopathy.

Human Resource managers increasingly advise what as the best approach for obtaining a legally sound and reliable reference?

a telephone reference from a former supervisor of the applicant

In developing a training "to-do list," Susan is reviewing the staff and what general training and specialized training topics would be necessary. What tool would be most helpful in organizing this information?

spreadsheet with grids identifying who needs what type of training

The hospital is undergoing the development of an information system strategic plan. The part of the process where changes in the community, legislation, and other factors are monitored is called

environmental scanning.

One of the most common rater biases that affect an employee's evaluation is the "halo effect," which suggests that the supervisor

rates the employee on the basis of a strong like or dislike of the person.

The vendor that you work for has decided to get into the EHR market. What standard should you suggest using in developing the functions performed by the EHR?

Digital Imaging and Communications in Medicine (DICOM)

Treponema pallidum infection

syphilis

What method of performance appraisal requires the supervisor to document exceptional behavior by the employee?

Critical Incident Method

A PEG procedure would most likely be done to facilitate

eating

You have been asked to make a recommendation about the framework for the state's health information exchange. The committee wants a system that does not require the health information exchange to store the patient information. What model should you recommend?

federated

Under APCs, payment status indicator "S" means

significant procedure, multiple procedure reduction does not apply.

In a hospital, a document that contains a computer-generated list of procedures, services, and supplies, along with their revenue codes and charges for each item, is known as a

Chargemaster

The standard deviation of a particular set of measures was found to be 20.00. The sample variance would then be:

400

principles illustrated in an organizational chart

unity of command

chain of authority

span of control

These are assigned to every HCPCS/CPT code under the Medicare hospital outpatient prospective payment system to identify how the service or procedure described by the code would be paid.

payment status indicator

Summer is the document imaging manager. She has had a meeting with the scanning clerks. They are complaining that the pay rate for their position is too low in their facility. What would be the best way to deal with this complaint?

Work with HR on a job evaluation and current wage and salary survey.

Mark Beck is a new graduate preparing for an interview. In school, he had the opportunity to role-play a technique that requires applicants to give specific examples of how they have performed a specific task or handled a specific problem in the past. This technique is becoming more popular and is known as a

behavioral interview

As part of a quality improvement study, you have been asked to provide information on the menstrual history, number of pregnancies, and number of living children on each OB patient from a stack of old obstetrical records. The best place in the record to locate this information is the

prenatal record

Discharge summary documentation must include

significant findings during hospitalization

The limiting charge is a percentage limit on fees specified by legislation that the nonparticipating physician may bill Medicare beneficiaries above the non-PAR fee schedule amount. The limiting charge is

15%

What classification system was designed with electronic systems in mind and is currently being used for problem lists, ICU unit monitoring, patient care assessments, data collection, medical research studies, clinical trials, disease surveillance, and images?

SNOMED CT

You have been asked how to handle versioning of documents in the EDMS. What should be your response?

Display the second version but identify that a previous version exists.

myelomeningocele

a congenital condition that is the most severe neural tube defect

Patient mortality, infection and complication rates, adherence to living will requirements, adequate pain control, and other documentation that describe end results of care or a measurable change in the patient's health are examples of

outcome measures.

What quality improvement (QI) tool uses criteria to weigh different alternatives? This display would assist in viewing all relevant information at the same time.

a decision matrix

The most secure model of signatures used in information systems is

digital signature

Penicillin is effective in the treatment of

Lyme disease

cells that produce histamine in a type I hypersensitivity reaction

mast cells

The major sources of case findings for cancer registry programs are

the pathology department, the disease index, and the logs of patients treated in radiology and other outpatient departments.

The number index identifies

new health record numbers and the patients to whom they were assigned

The physicians' index identifies

all patients treated by each doctor

The patient index links

each patient treated in a facility with the health number under which the clinical information can be located

The facility is implementing a new PACS. They know that the volume of data that will be passing over the Internet will significantly increase. As a result, they have updated their network. They want to determine if the updated network can handle the amount of data that is expected to be sent across the system. Which type of testing would they use?

load or volume

In your department, employee performance is rated using a continuous scale range of unsatisfactory through average to outstanding. Some other departments use a discrete system in which the supervisor assigns "fails to meet standards," "meets standards," and "exceeds standards." Both systems being used are

rating scales

capitation

the payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.

Patient data collection requirements vary according to health care setting. A data element you would expect to be collected in the MDS, but NOT in the UHDDS would be

cognitive patterns

The opposing interaction of two drugs in which one decreases or cancels out the effects of the other is termed a

antagonistic effect

Many of the principles of forms design apply to both paper-based and computer-based systems. For example, the physical layout of the form and/or screen should be organized to match the way the information is requested. Facilities that are scanning and imaging paper records as part of a computer-based system must give careful consideration to

bar code placement

The _____ is the largest solid organ of the body, but the ____ is the largest organ overall.

liver, skin

In ICD-10-PCS, to code "removal of a thumbnail," the root operation would be

extraction

The category “Commercial payers” includes private health information and

employer-based group health insurers

____________ is the most common type of skin cancer and _________ is the most deadly type of skin cancer.

Basal cell carcinoma, malignant melanoma

A chronic inflammatory bowel disease where affected segments of the bowel may be separated by normal bowel tissue is characteristic of

Crohn's disease

The medical malpractice crisis of the 1970s prompted the development of _____________________ in health care facilities.

risk management

scalar or chain of command principle

There is a clear flow of authority from superior to subordinate throughout the organization.

The project definition justifies the need for the new project. What would you expect to see in the project justification?

project scope, resources needed, and amount of time required

A toxic goiter has what distinguishing characteristic?

thyroid hyperfunction

The Director of Health Information Services has recently received approval to purchase a new high-speed scanner. The director plans to redo the department layout to accommodate the equipment and to ensure that the equipment is placed in the most appropriate area of the department. Which of the following tools will best assist the director with this new layout?

proximity chart

What organ has endocrine and exocrine functions?

pancreas

Huntington's disease

a hereditary disease of the cerebral cortex that includes progressive muscle spasticity and mental impairment leading to dementia

myringotomy with tympanostomy tubes

procedure typically performed on children to facilitate the drainage of serous exudate behind the tympanic membrane in chronic otitis media

Administration has asked the clinical provider order-entry task force to select the method of implementation that will reduce risk to the hospital. What method should they choose?

Implement one module in one unit while running the current system in parallel.

What federal legislation passed in 1986 gave immunity from legal action to practitioners regarding some peer review process activities?

Healthcare Quality Improvement Act

A histogram is a valuable tool for representing

a frequency distribution with continuous-interval data.

An elevated serum amylase would be characteristic of

acute pancreatitis.

What two types of budgets are often prepared by managers of health information departments?

capital budget and the operational or revenue and expense budget

The Assistant Director of HIM is evaluating software that would use electronic logging of the location of incomplete and delinquent records as they move through the completion process. What departmental function is this most useful for?

chart tracking

You are developing a complete data dictionary for your facility. What resources will be most helpful in providing standard definitions for data commonly collected in acute care hospitals?

Uniform Hospital Discharge Data Set

The primary goal of a hospital-based cancer registry is to

improve patient care.

For inpatients, the first data item collected of a clinical nature is usually

admitting diagnosis.

As part of Joint Commission's National Patient Safety Goal initiative, acute care hospitals are now required to use a preoperative verification process to confirm the patient's true identity, and to confirm that necessary documents such as x-rays or medical records are available. They must also develop and use a process for

marking the surgical site.

Which quality management theorist believed that merit raises, formal evaluations, and quotas established through benchmarking hinder worker productivity and growth?

W. Edwards Deming

Which filing system would provide the most convenient method for the record retrieval of 200 patients consecutively admitted to the hospital?

straight numeric

Necrosis extending down to the underlying fascia is characteristic of a decubitus ulcer in stage

three.

PTCA

Percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA)

a minimally invasive procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed to the heart muscle.

CAD

Coronary Artery Disease

Coronary Artery Disease (CAD)

the most common type of heart disease, the arteries that supply blood to heart muscle become hardened and narrowed.

LAD

left anterior descending

left anterior descending (LAD) and the circumflex (Cx) coronary arteries

The left coronary artery divides into two branches

IUP

intrauterine pregnancy

SROM

spontaneous rupture of membranes

Pfannenstiel incision

a type of abdominal surgical incision that allows access to the abdomen for a caesarian section closed with surgical staples.

EMG

Electromyography

Electromyography (EMG)

a diagnostic procedure to assess the health of muscles and the nerve cells that control them (motor neurons)

MRA

magnetic resonance angiogram

magnetic resonance angiogram (MRA)

a type of magnetic resonance imaging (MRI) scan that uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body.

ESRD

end-stage renal disease

RYGB

Roux-en-Y Gastric Bypass

esprit de corps

a feeling of pride, fellowship, and common loyalty shared by the members of a particular group

Human Resources has recently provided training for and implemented a new performance appraisal system that includes input from managers, peers, and staff. This approach is typically known as

360-degree evaluation

This registry collects data on recipients of heart valves and pacemakers.

Implant registry

Currently, which prospective payment system is used to determine the payment to the "physician" for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient?

APCs

A nomenclature of codes and medical terms that provides standard terminology for reporting physicians' services for third-party reimbursement is

Current Procedural Terminology (CPT).

the time period for completion of the history and physical exam documentation should be set at

24 hours after admission or prior to surgery.

What is considered a risky practice in the EHR?

copy and paste

A new strain of influenza, H1N1, is a highly virulent strain that spread all over the world. This type of epidemiological disease pattern is referred to as a

pandemic

Reporting the monthly average turnaround time for the release of information (ROI) over a 6-month period using a run or line chart will reflect

trends and detect if improvements were made

The abstract completed on the patients in your hospital contains the following items: patient demographics; prehospital interventions; vital signs on admission; procedures and treatment prior to hospitalization; transport modality; and injury severity score. The hospital uses these data for its

trauma registry

CPT provides Level I modifiers to explain

when one surgeon provides only postoperative services.

when the same laboratory test is repeated multiple times on the same day.

when a service or procedure is partially reduced or eliminated at the physician's discretion.

There was an unexpected hardware failure for our EHR. It is expected to be up and operational in 3 hours. Until then, what plan would you need to initiate?

business continuity plan

RHIT continuing education requirements

20 CEUs

RHIA continuing education requirements

30 CEUs

CCS continuing education requirements

20 CEUs, including two mandatory annual coding self-reviews

CCHIIM

Commission on Certification for Health Informatics and Information Management

<p>There are times when documentation is incomplete or insufficient to support the diagnoses found in the chart. The most common way of communicating with the physician for answers is by</p> <br>

using physician query forms.

The use of metrics to conduct root cause analysis that will facilitate changes throughout the organization can best be presented using a

fishbone diagram

Which endocrine gland secretes epinephrine, which activates the “fight or flight” response and increases blood pressure and metabolism?

adrenal medulla

Charles Jones is employed as a regional coding consultant by a corporate hospital chain. In the organization chart, this position would be

shown as a staff position

A fetal death occurring during the 21st week of pregnancy, weighing 1,000 g is considered to be an

intermediate fetal death.

What is the large serous membrane that covers the abdominal organs and lines the abdominal wall?

peritoneum

A system of preferred terminology for naming disease processes is known as a

medical nomenclature

You have had a problem with duplicate medical record numbers in your facility's MPI. Now you are joining a health information exchange, so you will need to clean up your database and prevent the duplicates from happening again. If you want to find near matches as well as identical matches in your MPI, you should implement a _________ algorithm.

probabilistic

ICD-10-PCS procedure codes are used on what form to report services provided to a patient?

UB-04

Accreditation by Joint Commission is a voluntary activity for a facility and it is

required for reimbursement of certain patient groups.

Electronic health record built-in tools that can make data capture easier include

clinical decision support systems

data dictionaries

automated quality measures

The patient’s blood pressure is automatically being recorded. This is an example of what type of clinical information system?

patient monitoring system

As an HIM coding supervisor, you are asked to compare the current coding process with a proposed concurrent coding process. What visual tool would be the best to identify all the logical steps and sequence of each procedure?

flowchart

In which brain lobe is the processing of smell and hearing stimuli performed?

temporal

What type of filing system is being used if records are filed in the following order: 12-23-75, 12-34-29, 12-35-71, 13-42-14, and 14-32-79?

straight numeric

In a terminal digit filing system, what would be the record number immediately in front of record number 01-06-26?

00-06-26

Lewis-Beck Medical Center has been collecting data on patient satisfaction for six months. It is ready to start retrieving data from the database to improve clinical services. Which tool should be used?

SQL

University Hospital, a 900-bed tertiary health care organization, is undergoing an information systems development. What system would best meet its needs?

application service provider model

A file area has limited space, medium file activity, and two file clerks. The HIM department would benefit from choosing which type of storage equipment?

compressible filing units

The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?

executive information system

As Director of the HIM Department you have become aware of instances of unauthorized access to the record file area. After considering several options to limit or restrict access to the area, you decide to

install a computerized access control panel.

The master patient index must, at a minimum, include sufficient information to

uniquely identify the patient.

What data cannot be retrieved from the MEDPAR?

Non-Medicare patient data

Which appraisal method places the employees into a set of ordered groups (e.g., top 10%, above average 20%, middle 40%) on the basis of a global measure?

forced ranking

unintentional destruction of evidence is called

spoliation

Intrusion detection systems analyze

network traffic.

The name given to the error committed when the null hypothesis is rejected and it is actually true is

type I error

considered a late effect regardless of time

nonunion

Which valve is between the left atrium and left ventricle?

mitral

How many years does the Food and Drug Administration require research records pertaining to cancer patients be maintained?

30

A common contraceptive that is implanted in the uterus induces slight endometrial inflammation, which attracts neutrophils to the uterus. These neutrophils are toxic to sperm and prevent the fertilization of the ovum. This contraception is termed

an IUD.

What is expected to enable hospitals to collect more specific information for use in patient care, benchmarking, quality assessment, research, public health reporting, strategic planning, and reimbursement?

ICD-10-CM

In systemic circulation, what vessels carries oxygenated blood?

left ventricle

What test is a more specific marker for an AMI?

CK-MB

What cells produces antibodies?

plasma cells

One record documentation requirement shared by BOTH acute care and emergency departments is

patient's condition on discharge.

On an EKG, what signifies the electronic stimulation of the ventricles?

the QRS wave

In CPT, Category III codes include codes

to describe emerging technologies.

methods improvement is referred to as

work simplification

The hospital administrator is making a strategic decision by querying various institutional databases for information. What type of system is the hospital administrator using?

executive information system

reporting of traffic fatalities

NOT a mandatory disclosure according to the HIPAA Privacy Rule

What group maintains healthcare databases in the public and private sectors?

Healthcare data organizations

MDR-TB

Multi-drug-resistant tuberculosis (AKA Vank's disease)

a severe, chronic, two-phased, bacterial respiratory infection that has become increasingly difficult to treat because many antibiotics are no longer effective against it

Multi-drug-resistant tuberculosis (MDR-TB)

The progress of a disease, including initiating factors, signs and symptoms, physical manifestations, residual sequela, prognosis, and finally, the end result, is termed

pathogenesis.

The prevention of illness through vaccination occurs due to the formation of

memory cells.

Hodgkin's disease is

a malignancy of the lymphatic system?

Fifteen percent of delinquent records show

missing operative reports

The foundation for communicating all patient care goals in long-term care settings is the

interdisciplinary plan of care.

The nursing staff would most likely use which of the following to facilitate aggregation of data for comparison at local, regional, national, and international levels?

ABC codes

ABC Code Set

is recognized by the American Nurses Association (ANA) and is already integrated with other coding systems including the CPT

Information found in _________________ would not be considered secondary data.

the health record

The hypothalamus, thalamus, and pituitary gland are all parts of the

limbic system.

For continuity of care, ambulatory care providers are more likely than providers of acute care services to rely on the documentation found in the

problem list

In addition to diagnostic and therapeutic orders from the attending physician, you would expect every completed inpatient health record to contain

discharge order

Slander is

oral

libel is

written

HAVEN (Home Assessment Validation and Entry)

Home Health Agencies (HHAs) utilize a data entry software system developed by the Centers for Medicare and Medicaid Services (CMS). This software is available to HHAs at no cost through the CMS Web site or on a CD-ROM.

An area identified for needed improvement through benchmarking and continuous quality improvement is known as a ____________.

key performance indicator

A three-digit code that describes a classification of a product or service provided to a patient is a

Revenue code

The patient's pathology report revealed the presence of Reed-Sternberg cells. This is indicative of

Hodgkin's disease

You are developing a list of functions needed by users of a release of information system. You are also evaluating the current system to see what opportunities there are to improve the system. Which stage of the system developmental life cycle stages are you in?

analysis

A patient is being cared for in her home by a qualified agency participating in Medicare. The data-entry software used to conduct all patient assessments is known as

HAVEN.

When a health care facility fails to investigate the qualifications of a physician hired to work as an independent contractor in the emergency room and is accused of negligence, the health care facility can be held liable under

corporate negligence

Regarding hospital emergency department and hospital outpatient evaluation and management CPT code assignment,

Each facility is accountable for developing and implementing its own methodology.

Increasing peristalsis of the intestines, increasing salivation, and a slowing heart rate are examples of

parasympathetic nervous system responses

In calculating the fee for a physician's reimbursement, the three relative value units are each multiplied by the

geographic practice cost indices.

The case-mix management system that utilizes information from the Minimum Data Set (MDS) in long-term care settings is called

Resource Utilization Groups (RUGs)

the Age Discrimination in Employment Act (ADEA) protects employees and applicants between what ages?

40 and 70

Under the inpatient prospective payment system (IPPS), there is a 3-day payment window

This rule requires that outpatient preadmission services that are provided by a hospital up to three calendar days prior to a patient's inpatient admission be covered by the IPPS MS-DRG payment for diagnostic services and therapeutic (or nondiagnostic) services whereby the inpatient principal diagnosis code (ICD-10-CM) exactly matches the code used for preadmission services.

When a patient is discharged from the inpatient rehabilitation facility and returns within three calendar days (prior to midnight on the third day) this is called a(n)

interrupted stay.

With data exchange standards, the ability to transfer data from one system to another system is called

interoperability.

You are interested in performing some data analysis on patients with cardiac problems. You have downloaded the data that you need on the cardiology patients from the data warehouse into a smaller database that you can work with. You are using a

data mart.

These services are excluded under the Hospital Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) methodology.

Durable Medical Equipment

The HIPAA Privacy and Security Rule requires that training be documented. What methods of documenting training efforts need to be used?

training content, training dates, and attendee names

The Health Insurance Portability and Accountability Act (HIPAA) requires the retention of health insurance claims and accounting records for a minimum of ____ years, unless state law specifies a longer period.

six

This is the amount the facility actually bills for the services it provides.

charges

Physician can ______________ and collect from the patient the difference between the non-PAR Medicare fee schedule amount and the total charge amount.

balance bill

Gary's primary concern is job continuity and adequate health insurance for his large family. What level of Maslow's hierarchy of needs does Gary operate from?

safety

This accounting method attributes a dollar figure to every input required to provide a service.

cost accounting

______ classify inpatient hospital cases into groups that are expected to consume similar hospital resources.

DRG

What tubes conveys sperm from the seminal vesicle to the urethra?

ejaculatory duct

CMS assigns one _______________ to each APC and each ______________ code.

payment status indicator, HCPCS

<p>You are given the task of choosing the type of database that your facility will use. You choose one that stores the data in tables. What model did you choose?</p> <br>

relational

Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets

CMS standards

This is the amount collected by the facility for the services it bills.

reimbursement

trigeminal neuralgia

A condition that involves the fifth cranial nerve, also known as "tic douloureux," causes intense pain in the eye and forehead; lower lip, the section of the cheek closest to the ear and the outer segment of the tongue; or the upper lip, nose, and cheek.

The administrator has asked us to develop a patient satisfaction database internally. This database will be used to collect data that can be used to improve our services. He does not want this to be a long, drawn-out process. What could speed up this process?

prototyping

The UB-04 is used by

hospitals.

The CMS-1500 is used by

physicians and other noninstitutional providers and suppliers.

The CMS-1491 is used by

ambulance services.

The first prospective payment system (PPS) for inpatient care was developed in 1983. The newest PPS is used to manage the costs for

inpatient psychiatric facilities.

The Joint Commission has a standard stating that a hospital must plan and design information management processes to meet _____________ information needs.

both internal and external

CDT code set

Current Dental Terminology

CPR charges

customary, prevailing, and reasonable

CEA test

A test for certain kinds of cancers, especially cancer of the large intestine (colon and rectal cancer)

What federal legislation passed in 1986 gave immunity from legal action to practitioners regarding some peer review process activities?

Healthcare Quality Improvement Act

Discharge summary documentation must include

significant findings during hospitalization.

A hematology laboratory test that evaluates the oxygen-carrying capacity of blood is referred to as a

hemoglobin determination.

Under APCs, the payment status indicator "N" means that the payment

is packaged into the payment for other services.

Under the APC methodology, discounted payments occur when

there are two or more (multiple) procedures that are assigned to status indicator "T."

The process by which health care facilities and providers ensure their financial viability by increasing revenue, improving cash flow and enhancing the patient’s experience is called

revenue cycle management.

Which quality management theorist focused on zero defects as the goal of performance improvement efforts?

Crosby

Currently, which prospective payment system is used to determine the payment to the "physician" for physician services covered under Medicare Part B, such as outpatient surgery performed on a Medicare patient?

APCs

On an EKG, what signifies the electronic stimulation of the ventricles?

the QRS wave

Diastole occurs when

the ventricles fill.

In performing a "what if" query to determine if the facility should expand the emergency department, which of the following systems would be used?

decision support system

Under APCs, payment status indicator "C" means

inpatient procedures/services.

A serum potassium level of 2.8 would indicate

diabetic ketoacidosis.

Which endocrine gland secretes melatonin, which controls the circadian rhythm of an individual?

pineal

Portal hypertension can contribute to

ascites

dilation of the blood vessels lining the intestinal tract

esophageal varices

not among the Joint Commission's initial core measure sets for hospitals

diabetes

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

ARRA (American Recovery and Reinvestment Act )

ARRA

American Recovery and Reinvestment Act

<p>To properly implement performance improvement (PI), organizations should ensure that all employees participate in an integrated, continuous PI program. This is known as ______.</p> <br>

shared leadership

DNFB stands for

Discharged, No Final Bill

When operating under the Health Insurance Portability and Accountability Act of 1996, what is a basic tenet in information security for health care professionals to follow?

Security training is provided to all levels of staff.

Ultimate responsibility for the quality and completion of entries in patient health records belongs to the

attending physician.

An accreditation agency counterpart to the Joint Commission for managed care organizations is the

NCQA

Dr. Zambrano ordered a CEA test for Mr. Logan, a 67-year-old African American male patient. Dr. Zambrano may be considering a diagnosis of

cancer

The ability to obtain the same results from different studies using different methodologies and different populations is

reliability

Under ASC-PPS, the patient is responsible for paying the coinsurance amount based upon ____ of the national median charge for the services rendered.

20%

The database being implemented must be able to store video, images, and audio. Which of the following database models should be considered?

object oriented

Full time = _________ hours per year

2,080

What is the primary factor to consider in developing an effective training program?

objectives of each functional area

Under APCs, payment status indicator "T" means

significant procedure, multiple procedure reduction applies.

Integration of decision support systems and best practices in medicine is known as the practice of __________.

evidence-based medicine

Which department will most likely be responsible for taking corrective action regarding the following quality indicator:

Ninety-five percent (95%) of physician appointments/reappointments will be completed within 90 days of receipt of all required materials.

Medical Staff Office

The primary difference between an experimental (randomized) clinical trial and other observational study designs in epidemiology is that in an experimental trial, the

investigator determines who is and who is not exposed.

OIG

Office of Inspector General

MEDPAR

Medicare Provider Analysis and Review

QIO

Quality Improvement Organization

The RAC program is mandated to

find and correct improper Medicare payments paid to health care providers participating in the Medicare reimbursement program

A HIPPS (Health Insurance Prospective Payment System) code is a five-character alphanumeric code. A HIPPS code is used by home health agencies (HHA) and ____

skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs)

An elevated serum amylase would be characteristic of

acute pancreatitis.

A major consideration in a hospital or facility closure is to

ensure that authorized parties have access to the information as provided by law.

Under the APC methodology, discounted payments occur when

there are two or more (multiple) procedures that are assigned to status indicator "T."

Discounts are applied to those multiple procedures identified by CPT codes with status indicator

"T."

The standards for the history and physical exam documentation completion should be set at

24 hours after admission or prior to surgery.

The process of cancer development, from exposure through the cellular changes of hyperplasia to neoplasia, is termed

carcinogenesis.

Under APCs, payment status indicator "C" means

inpatient procedures/services.

An accreditation agency counterpart to the Joint Commission for managed care organizations is the

NCQA

Which quality management theorist focused on zero defects as the goal of performance improvement efforts?

Crosby

The database being implemented must be able to store video, images, and audio. What database model should be considered?

object oriented

On an EKG, what signifies the electronic stimulation of the ventricles?

the QRS wave

The type of documentation that uses drop boxes, radio buttons, and pick lists is called

structured data entry.

In quality review activities, departments are directed to focus on clinical processes that are

high risk.

quality indicators for patients with acute myocardial infarction

"Beta blocker at discharge" and "early administration of aspirin"

a quality indicator for stroke patients

"discharged on antithrombotic"

A typical indicator for patients with pneumonia is

blood culture before first antibiotic received.

pineal

endocrine gland secretes melatonin

Under APCs, the payment status indicator "N" means that the payment

is packaged into the payment for other services.

Under APCs, payment status indicator "T" means

significant procedure, multiple procedure reduction applies.

In selecting a messaging standard for use in a picture archival communication system, the BEST choice would be

DICOM

An Advance Beneficiary Notice (ABN) is a document signed by the

patient indicating whether he/she wants to receive services that Medicare probably will not pay for

A rule

predecides issues.

The doctrine that the decisions of the court should stand as precedents for future guidance is

stare decisis.

What quality improvement (QI) tool uses criteria to weigh different alternatives? This display would assist in viewing all relevant information at the same time.

a decision matrix

epidemiology

the branch of medicine that deals with the incidence, distribution, and possible control of diseases and other factors relating to health.

IDDM

Insulin-Dependent Diabetes Mellitus, now known as Diabetes mellitus type 1

A major contribution to a successful CDI program is the ability to demonstrate the impact that documentation has on data reporting to a large percentage of the facility's staff. In this role, the Clinical Documentation specialist is acting as a(n)

educator.

frequency polygon

a graphical device for understanding the shapes of distributions. They serve the same purpose as histograms.

frequency distribution

a mathematical function showing the number of instances in which a variable takes each of its possible values.

tuberculosis

a chronic, systemic disease whose initial infection is in the lungs

The causative organism for severe acute respiratory syndrome (SARS) is a

coronavirus.

the flow of blood through the heart to the lungs in order for gas exchange

right atrium, right ventricle, pulmonary artery, lungs

Your job description states that as Assistant Director of the HIM Department, you will supervise day-to-day operations for the record processing, transcription, and release of information areas. What principle of management is described?

span of control

The ________________________ refers to a statement sent to the patient to show how much the provider billed, how much Medicare reimbursed the provider, and what the patient must pay the provider.

Medicare summary notice

A plaintiff must establish which burden of proof to recover damages for medical negligence or malpractice?

1. A breach of the duty to care by the defendant.
2. Damages or injury resulted from the defendant's negligence.
3. A duty of care relationship between the defendant and patient.
4. Causation existed for harm to the plaintiff from the defendant's conduct.

When the third-party payer refuses to grant payment to the provider, this is called a

denied claim.

seven criteria for high-quality clinical documentation

Legible

Reliable

Precise

Complete

Consistent

Clear

Timely

What is the best tool for differentiating between common cause variation and special cause variation?

control chart

Data accuracy denotes that

data are correct values.

Data comprehensiveness denotes that

all data items are included.

Data granularity denotes that

the attributes and values of data should be defined at the correct level of detail.

Data precision denotes that

data values should be just large enough to support the application of process.

Under ASC PPSs, bilateral procedures are reimbursed at _______ of the payment rate for their group.

150%

A fetal death occurring during the 21st week of pregnancy, weighing 1,000 g is considered to be an

intermediate fetal death.

What is the large serous membrane that covers the abdominal organs and lines the abdominal wall?

peritoneum

What types of software provide a front-end structure/interface that presents information in a familiar format leading to a natural style of interaction through the use of icons and a mouse?

graphical user interface

A new three-shot vaccination series protects against the types of HPV that cause most cervical cancer cases

BEST summarizes the current treatment of cervical cancer

The responsibility for performing quality monitoring and evaluation activities in a departmentalized hospital is delegated to the

clinical chairpersons of medical staff committees or ancillary department directors.

In your facility it has become critical that information regarding patients who are transferred to the oncology unit be sent to an outpatient scheduling system to facilitate outpatient appointments. This information can be obtained most efficiently from

R-ADT system.

R-ADT

registration-admission, discharge, and transfer system.

the following elements of negligence must be present in order to recover damages

duty of care; breach of duty of care; suffered an injury; defendant's conduct caused the plaintiff harm

An example of a primary data source for health care statistics is the

hospital census.

The performance of ongoing record reviews is an important tool in ensuring data quality. These reviews evaluate

the overall quality of documentation in the record.

A 75-year-old patient has a sore tongue with tingling and numbness of the hands and feet. She has headaches and is fatigued. Following diagnostic workup, the doctor orders monthly injections of vitamin B12. This patient most likely has

pernicious anemia

Joint Commission does not approve of auto authentication of entries in a health record. The primary objection to this practice is that

evidence cannot be provided that the physician actually reviewed and approved each report.

During a retrospective review of Rose Hunter's inpatient health record, the health information clerk notes that on day 4 of hospitalization there was one missed dose of insulin. What type of review is this clerk performing?

qualitative review

The prospective payment system used to reimburse hospitals for Medicare hospital outpatients is called

APCs.

this organ has endocrine and exocrine functions

pancreas

If the department staff are having trouble locating the terminal digit sections quickly, the supervisor could add more

file guides.

The term used to indicate that the service or procedure is reasonable and necessary for the diagnosis or treatment of illness or injury consistent with generally accepted standards of care is

medical necessity.

The hospital Quality Department adopted the Lean Management quality model using JIT, which ensures required process items and resources are

available at the right place and the right time.

In an acute care facility, the responsibility for educating physicians and other health care providers regarding proper documentation policies belongs to the

health information manager.

In which brain lobe is the processing of emotions, intellect, and personality performed?

frontal

The hospital implemented an electronic query system to allow more effective communication with physicians and other health practitioners to improve clinical documentation in the patient record. This program is known as

clinical documentation improvement (CDI).

A lump-sum payment distributed among the physicians who performed the procedure or interpreted its results and the health care facility that provided equipment, supplies, and technical support is known as

a global payment.

The payment of a fee or grant to a doctor, school, or other person or body providing services to a number of people, such that the amount paid is determined by the number of patients, students, or customers.

capitation

CMS adjusts the Medicare Severity DRGs and the reimbursement rates every

fiscal year beginning October 1.

Reporting the monthly average turnaround time for the release of information (ROI) over a 6-month period using a run or line chart will reflect

trends and detect if improvements were made.