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 HIPAA

B HITECH

C Meaningful Use

D Hill-Burton

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 coordination of care.

B all of these.

C medical home modeling.

D continuity 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 secure email.

B patient portal records.

C a personal health record.

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 Nearly 100%

B 25%

C Over 50%

D 10%

Question #5

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

A All of these applications

B Exercise apps

C Medication reminder apps

D Patient education 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 disease management.

D patient engagement.

Question #7

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

A insurance companies.

B CMS.

C HCFA.

D third-party monitoring/security services.

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 telehealth.

B ihealth.

C network medicine.

D infrastructure 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 patient-centric provider

B primary portal

C gatekeeper

D physician consultant

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 Confidentiality breach

B Privacy breach

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

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

Question #12

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

A Security breach

B Access control

C Physical control

D Technical control

Question #13

Audit trails are used to detect which of the following?

A Presence of a virus

B Loss of data

C Successful completion of a backup

D Unauthorized access to a system

Question #14

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

A Medical records sent to another hospital for treatment

B Medical records sent to an outside attorney for a lawsuit

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

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 All of these

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

C There is not a difference between consent and authorization.

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

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 all records including alcohol abuse records.

B Release all records except the alcohol abuse records.

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

D Release records dated for October10, 2014.

Question #17

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

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

B must have the patient sign an authorization.

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

D provide patient health record in electronic form.

Question #18

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

A 2011–2012

B 2009–2010

C 2012–2014

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 DEFINED.

B LOINC.

C INDIRECT.

D DIRECT.

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 opt-in.

B confidentiality release.

C opt-out.

D authorization option.

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 Public health

B Clinical decision support

C Disease registry

D Patient-generated data

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 grouper.

B abstracting.

C computer-assisted coding.

D encoder.

Question #23

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

A validity of the documentation.

B competence of the provider.

C accuracy 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 2

B Stage 4

C Stage 1

D Stage 3

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 outcomes review.

B pre-authorization.

C pre-surgery application.

D synchronous review.

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 outlier.

B complication.

C severe illness.

D comorbidity.

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 PPS

C IPPS

D TEFRA

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 inefficiency in a cost center.

B allowed charges.

C a premium reimbursement.

D all of these.

Question #29

What party administers the Medicare program?

A CMS

B Individual state

C Fiscal intermediary

D QIO

Question #30

Title XVIII of the Social Security Act provided for:

A Social Security.

B disability insurance.

C Medicare.

D Medicaid.

Question #31

Six Sigma was developed in 1986 by:

A Dell.

B Sony.

C Apple.

D Motorola.

Question #32

Where does the healthcare information begin?

A Physician office

B Admission

C Emergency room

D Registration

Question #33

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

A INSTANTLY

B NOW

C STAT

D ASAP

Question #34

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

A SNOMED-CT.

B ICD-9-CM.

C claims data.

D diagnosis codes.

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 MPI

C ADT

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 Verbal order

B CPOE

C Giving orders

D Authorizing treatment

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 Medical staff

B Quality assessment and performance improvement

C Nursing services

D Discharge planning

Question #38

A new notice of privacy practices was implemented when?

A 2013

B It has not been implemented yet.

C 2012

D 2014

Question #39

What was the original intent of HIPAA?

A Portable healthcare coverage

B Moving to the electronic health record

C Privacy

D Standardizing coding

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 (name of state)

B Licensure regulations hospitals Medicare

C Licensure regulations

D Licensure regulations hospitals (then state name)

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 Confidentiality

B Integrity

C Security

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 Privacy

C Confidentiality

D Enforcement and compliance

Question #43

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

A Printing and warehousing

B Magnetic tape storage

C Optical disk

D Server storage

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 a list of preferred business associates.

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

Question #45

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

A Microfiche

B Jukebox

C None of these

D Warehousing

Question #46

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

A HR policy.

B audit plan.

C record retention plan.

D storage plan.

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 data mining.

B population health management.

C real-time data analysis.

D all of these.

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 interoperability.

B infrastructure.

C all of these.

D software applications.

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 accountable care organization.

B CMS.

C affordable care action group.

D population health manager.

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 Meaningful fee

B Fee-for-value

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 Health Insurance Portability and Accountability Act was signed into law.

C The American Recovery and Reinvestment 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 Wait for the claim to be paid

B Ask the coder why it was coded that way

C Submit a corrected claim to the carrier

D Speak to the coder’s supervisor regarding the error

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 Act as if nothing happened

B Speak to compliance in the morning

C Speak to risk management in the morning

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 Pull the record and send it to Sally

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

C Speak to the compliance officer regarding the call

D Talk with the supervisor

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 integrated delivery network.

B capitated practice.

C independent practice association.

D ambulatory practice association.

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 Ambulatory surgery center

B Urgent care center

C Ambulatory clinic

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 clinical decision support.

B health information management.

C patient-centric care.

D meaningful use of documentation.

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 $10,000–$20,000.

C $50,000–$75,750.

D $44,000–$63,750.

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