Final Exam

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Question #1

Jane Doe requests that a correction be made to the date of her last menstrual period in her patient care record at General Hospital. She has the right to make this request based on which legislation?

A Hill-Burton

B HITECH

C HIPAA

D Meaningful Use

Question #2

Using the health information provided in the patient record, the social worker within an acute care hospital makes arrangements to place the patient with a home health service so that oxygen can be arranged at home with the appropriate directions and precautions. This is representative of:

A all of these.

B medical home modeling.

C continuity of care.

D coordination of care.

Question #3

Sarah Jones is an awake and alert emergency room patient in the city where her children live, away from her home community hospital. She is currently a cancer patient at a tertiary care facility. A speedy option for obtaining her medical history from either of these facilities would be the use of:

A a personal health record.

B secure email.

C patient portal records.

D all of these

Question #4

Which of the following percentages accurately describes the portion of adults in the United States who utilize their smartphones to research health information?

A 25%

B 10%

C Over 50%

D Nearly 100%

Question #5

Which of the following smartphone applications demonstrate patient engagement and activation?

A Exercise apps

B Patient education apps

C All of these applications

D Medication reminder apps

Question #6

A patient’s knowledge, skills, ability, and willingness to manage his or her own healthcare is known as:

A patient activation.

B patient outcome.

C patient engagement.

D patient disease management.

Question #7

Currently, services for remote monitoring devices are provided primarily by:

A third-party monitoring/security services.

B insurance companies.

C CMS.

D HCFA.

Question #8

Jail inmates treated through the use of videoconferencing in which the clinician is present in an area care facility and the inmate remains in the prison is an example of the use of:

A ihealth.

B infrastructure medicine.

C telehealth.

D network medicine.

Question #9

Mary calls an area dermatologist to have a skin consultation set up for cancer evaluation. The staff lets her know that she must have a referral from her primary care provider before she can be seen. This is an example of a managed care plan that requires that a __________ (often a generalist) be the first point of contact for the patient.

A primary portal

B physician consultant

C patient-centric provider

D gatekeeper

Question #10

Dr. Blume took patient files home that were in a research study on HIV/AIDS and left them in a local restaurant. A newspaper reporter saw the files, picked them up, and wrote an article on the study. What was this?

A Security breach

B Confidentiality breach

C Privacy breach

D Research so it doesn’t matter

Question #11

Johnny Smith has just been arrested and told the police he is on insulin for his diabetes, but he cannot remember the name or the dosage. The police go to the doctor’s office and ask for a copy of Johnny Smith’s records. What should the response be?

A Call risk management and tell them the police are here about Johnny Smith.

B Tell the police he has to sign an authorization for release of the information.

C Give the records to the police because he is incarcerated.

D Call the hospital attorney and tell them the police want medical records on Johnny Smith.

Question #12

Computer room doors that are locked are considered what type of security control?

A Access control

B Technical control

C Security breach

D Physical control

Question #13

Audit trails are used to detect which of the following?

A Loss of data

B Successful completion of a backup

C Unauthorized access to a system

D Presence of a virus

Question #14

Which of the following would not belong on the accounting disclosure of protected health information?

A Medical records sent to the patient at the patient’s request

B Medical records sent to an outside attorney for a lawsuit

C Medical records sent to another hospital for treatment

D Medical records sent to a life insurance company

Question #15

The terms consent and authorize are both used in the HIPAA privacy rule. What does authorization mean?

A There is not a difference between consent and authorization.

B It is a specific document that gives permission to use or disclose PHI.

C Signing the facility’s NPP gives the right to release information.

D All of these

Question #16

Workers’ compensation has sent a release of information for Sally Smith, who was hurt on her job, asking for any and all of her medical records. Date of injury was October 10, 2014; her medical records have alcohol abuse and treatment. How should this release be handled by the HIM department?

A Release records dated for October10, 2014.

B Do not release records and send letter to workers’ comp.

C Release all records including alcohol abuse records.

D Release all records except the alcohol abuse records.

Question #17

Patient’s rights have been expanded under the Omnibus Rule and include all of the following EXCEPT:

A provide patient health record in electronic form.

B cannot bill patient’s insurance company if patient pays cash.

C cannot divulge any information about a patient’s services if paying cash.

D must have the patient sign an authorization.

Question #18

The first stage of Meaningful Use occurred during what time frame and focused on capturing data by EHRs?

A 2011–2012

B 2012–2014

C 2009–2010

D 2005–2006

Question #19

A health information network initiative used by providers to easily and securely send patient information directly to another healthcare professional is known as:

A DIRECT.

B DEFINED.

C LOINC.

D INDIRECT.

Question #20

Karen Hayes must sign a consent form upon admission indicating that she would allow her records to be a part of a health information exchange. This procedure is called a(n):

A authorization option.

B confidentiality release.

C opt-out.

D opt-in.

Question #21

Using hospital mandatory reporting of infectious diseases through an online system is representative of what type of use, in which health information exchanges can improve healthcare?

A Patient-generated data

B Clinical decision support

C Disease registry

D Public health

Question #22

Kathy is utilizing a computer-based application to assign CPT codes to outpatient cases in which she answers a series of prompts based on the documentation available in the record. This system is called a(n):

A abstracting.

B grouper.

C computer-assisted coding.

D encoder.

Question #23

Incomplete records long after the patient is discharged can cast legal doubt on the:

A accuracy of the documentation.

B competence of the provider.

C validity of the documentation.

D coding process.

Question #24

Patient access to tools and alert systems that may help them monitor and assess their own health should be accomplished under which stage of Meaningful Use?

A Stage 4

B Stage 3

C Stage 1

D Stage 2

Question #25

Jane Doe is scheduled for an elective cholecystectomy. The staff at her primary care physician has called for approval of reimbursement for this admission through a process referred to as:

A synchronous review.

B outcomes review.

C pre-surgery application.

D pre-authorization.

Question #26

The average length of stay determined by CMS for acute myocardial infarctions has been established at four days. Mr. Carson’s recent MI stay consisted of seventeen days. This is identified through PPS as a(an):

A complication.

B severe illness.

C comorbidity.

D outlier.

Question #27

Based on the patient’s principal diagnosis and procedure, what tool drives the reimbursement rate for patients using similar resources within a facility?

A MS-DRG

B IPPS

C TEFRA

D PPS

Question #28

Amanda Miller’s recent appendectomy charges from General Hospital totaled $4,500. Her insurance payment was maximized at $3,000 to the facility. This is an example of:

A a premium reimbursement.

B allowed charges.

C inefficiency in a cost center.

D all of these.

Question #29

What party administers the Medicare program?

A Individual state

B QIO

C Fiscal intermediary

D CMS

Question #30

Title XVIII of the Social Security Act provided for:

A Social Security.

B disability insurance.

C Medicaid.

D Medicare.

Question #31

Six Sigma was developed in 1986 by:

A Dell.

B Motorola.

C Apple.

D Sony.

Question #32

Where does the healthcare information begin?

A Admission

B Emergency room

C Registration

D Physician office

Question #33

Dr. Blume has ordered lab work to be done immediately on Mary Smith; what is the correct term?

A INSTANTLY

B STAT

C ASAP

D NOW

Question #34

Billing codes that physicians, pharmacies, hospitals, and other healthcare providers submit to payers are called:

A claims data.

B diagnosis codes.

C SNOMED-CT.

D ICD-9-CM.

Question #35

Helen, the HIM supervisor, has two lab reports on her desk, both with the name of Mary Smith. Where would Helen look to determine into whose record these labs should go?

A COPE

B ADT

C MPI

D CPOE

Question #36

Mary Smith is to have vital signs taken every 4 hours, and NPO after midnight for total knee arthroscopy according to Dr. Blume. What is Dr. Blume doing?

A CPOE

B Verbal order

C Authorizing treatment

D Giving orders

Question #37

John Jones is 70 years old and fell and broke his left hip. He has had a total left hip replacement and needs to go to a rehab facility for 3–4 weeks. The Conditions of Participation (CoP) require which of the following in John’s case?

A Nursing services

B Discharge planning

C Medical staff

D Quality assessment and performance improvement

Question #38

A new notice of privacy practices was implemented when?

A 2013

B 2014

C 2012

D It has not been implemented yet.

Question #39

What was the original intent of HIPAA?

A Portable healthcare coverage

B Privacy

C Standardizing coding

D Moving to the electronic health record

Question #40

If a HIM director wanted to locate the licensing regulations for the state the hospital was located in, how would the information be accessed on the Internet?

A Licensure regulations hospitals (then state name)

B Licensure regulations (name of state)

C Licensure regulations hospitals Medicare

D Licensure regulations

Question #41

Bobby Jones just had an emergency appendectomy and is now in recovery. Over lunch in the cafeteria, two nurses were discussing Bobby Jones and the surgery he had just had and how lucky he was he came in when he did. They used his name along with details of some very important issues with his surgery. What rule did they breach?

A Integrity

B Security

C Confidentiality

D Privacy

Question #42

A mental health facility is using the Diagnostic and Statistical Manual for coding health information of its mental health patients. Which rule is it breaking?

A Code sets

B Enforcement and compliance

C Confidentiality

D Privacy

Question #43

When storing digital records, which of the following is too expensive to use?

A Server storage

B Printing and warehousing

C Magnetic tape storage

D Optical disk

Question #44

HIPAA has specific guidelines for the destruction of records. They include all of the following EXCEPT:

A how the facility intends to safeguard against breach of confidentiality.

B the method used to destroy the records.

C the length of time between acquisition of records and destruction.

D a list of preferred business associates.

Question #45

What is one method of archiving records before the retention date expires?

A Microfiche

B Warehousing

C Jukebox

D None of these

Question #46

A written plan that states the length of time a healthcare facility retains its health records is called a(n):

A audit plan.

B record retention plan.

C storage plan.

D HR policy.

Question #47

Being able to extract information from the data system within an ACO and to construct a plan of care for the patient at the time of his/her encounter and subsequent discharge is characteristic of:

A real-time data analysis.

B all of these.

C data mining.

D population health management.

Question #48

In order to move to pay-for-performance, providers need to compare data across the delivery system from physician offices, acute care hospitals, and long-term care providers. The collection of data to provide information for this transition will demand increased:

A all of these.

B software applications.

C interoperability.

D infrastructure.

Question #49

A network of providers that share financial and clinical responsibility to coordinate care of their assigned patients led by one primary care physician is known as a(n):

A CMS.

B accountable care organization.

C population health manager.

D affordable care action group.

Question #50

Also known as “pay for performance,” what reimbursement method rewards clinicians for better patient health outcomes, such as preventative programs to lower blood pressure, and penalizes them for medical errors?

A Fee-for-value

B Meaningful fee

C Wellness fee

D Fee-for-service

Question #51

What happened in the late 1960s that significantly changed healthcare and medical records?

A Medicare and Medicaid were signed into law.

B The American Recovery and Reinvestment Act was signed into law.

C The Health Insurance Portability and Accountability Act was signed into law.

D The Affordable Healthcare Act was signed into law.

Question #52

The Bureau of Labor Statistics states that there will be a rise in the need for health information technicians by what percent?

A 15 percent

B 21 percent

C 25 percent

D 50 percent

Question #53

While the coding auditor was reviewing a chart, he noticed that a claim had gone out with a diagnosis of right ventricular heart failure when the documentation clearly stated the patient had left ventricular heart failure. What should the next step be?

A Submit a corrected claim to the carrier

B Ask the coder why it was coded that way

C Speak to the coder’s supervisor regarding the error

D Wait for the claim to be paid

Question #54

Mary Smith is working late one evening in her office when she notices that the cleaning people are there and are looking at Tim’s desk, where it appears some work has been left. She inquires what the cleaning people are looking at and they say that there was a note about their neighbors and they wanted to be sure they were alright. What should Mary do about this situation?

A Speak to compliance in the morning

B Speak to risk management in the morning

C Act as if nothing happened

D Speak to the cleaning supervisor

Question #55

Ginny Jones has been missing work frequently, so her boss has Sally, his assistant, call Ginny’s doctor and ask for a copy of Ginny’s medical records. Which of the following is the INCORRECT procedure for the HIM staff at the doctor’s office to follow?

A Speak to the compliance officer regarding the call

B Pull the record and send it to Sally

C Talk with the supervisor

D Ask Sally for a release of information form signed by Ginny Jones

Question #56

A group of physicians that contracts with a managed care organization to provide care at a pre-determined, pre-negotiated rate is a(an):

A independent practice association.

B capitated practice.

C ambulatory practice association.

D integrated delivery network.

Question #57

What type of ambulatory care is provided for patients who are seen without a prior appointment for problems that need prompt attention but are not emergency in level?

A Urgent care center

B Ambulatory clinic

C Ambulatory surgery center

D Independent practice association

Question #58

In a single course of illness, the patient was seen by her primary care physician, referred to a specialist, admitted for outpatient surgery, and then discharged with home health. These episodes are an example of a(an):

A high-level medical encounter.

B managed care plan.

C patient engagement.

D continuum of care.

Question #59

Communications, information sharing, and decision making that include the patient and are managed by both the patient and the provider are part of:

A meaningful use of documentation.

B health information management.

C clinical decision support.

D patient-centric care.

Question #60

The maximum range for incentive payments among Medicare and Medicaid incentive programs for the electronic health record is:

A $25,775–$50,755.

B $44,000–$63,750.

C $10,000–$20,000.

D $50,000–$75,750.

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