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RHIT Exam Prep with Accurate Solutions
Patient care managers use the data documented in the health record to: a. Determine the extent & effects of occupational hazards b. Evaluate patterns and trends of patient care c. Generate patient bills and third-party payer claims for reimbursement d. Provide direct patient care - ANS-b. Evaluate patterns and trends of patient care At admission, Mrs. Smith's date of birth is recorded as 3/25/1948. An audit of the EHR discovers that the numbers in the date of birth are transposed in reports. This situation reflects a problem in: a. Data comprehensiveness b. Data consistency c. Data currency d. Data granularity - ANS-b. Data consistency The HIM manager is conducting a study in which she is comparing the current years diagnosis codes to the proposed new codes for the next fiscal year & documenting variations in order to assess the impact on the organization. This process creates a: a. Data charge master report b. Data dictionary c. Database management system d. Data map - ANS-d. Data map An outpatient clinic is reviewing the functionality of an EHR it is considering for purchase. Which of the following data sets should the clinic consult to ensure that all the federally recommended data elements for Medicare and Medicaid outpatients are collected by the system? a. DEEDS b. EMEDS c. UACDS d. UHDDS - ANS-c. UACDS Before healthcare organizations can provide services, they usually must obtain ____ by government entities such as the state or county in which they are located. a. Accreditation b. Certification
c. Licensure d. Permission - ANS-c. Licensure Which of the following terms below represents fixed rules that must be followed? a. Standard b. Guidelines c. Forms control program d. Policy - ANS-a. Standard Which of the following is a true statement about the content of the legal health record? a. The legal health record contains only clinical data b. The legal health record may contain metadata c. The legal health record should not include email d. The legal health record should not include diagnostic images - ANS-b. The legal health record may contain metadata The advent of the EHR has increased the amount of documentation largely due to: a. Storage capabilities b. Joint Commission requirements c. Ease of entry d. Reporting - ANS-c. Ease of entry Two patients' records were filed together by mistake. This is an example of: a. Overlap b. Overlay c. Duplicate d. Purge - ANS-b. Overlay Which of the following is the health record component that addresses the patient's current complaints & symptoms and lists that patient's past medical, personal, and family history? a. Problem list b. Medical history c. Physical examination d. Clinical observation - ANS-b. Medical history Which of the following is characteristic of the legal health record? a. It must be electronic b. It includes the designated record set c. It is the record disclosed upon request
Sally has requested an accounting of PHI disclosures from Community Hospital. Which of the following must be included in an accounting of disclosures to comply with this request? a. PHI related to treatment, payment, and operations b. PHI provided to meet national security or intelligence requirements c. PHI sent to a physician who has not treated Sally d. PHI release to Sally's attorney upon her request - ANS-c. PHI sent to a physician who has not treated Sally Data elements collected on large populations of individuals and stored in databases are referred to as: a. Statistics b. Information c. Aggregate data d. Standard - ANS-c. Aggregate data Which tool is used to display performance data over time? a. Status process control chart b. Run chart c. Benchmark d. Time ladder - ANS-b. Run chart After the types of cases to be included in a registry have been determined, what is the next step in data acquisition? a. Case registration b. Case definition c. Case abstracting d. Case finding - ANS-d. Case finding For research purposes, an advantage of the Healthcare Cost and Utilization Project (HCUP) is that it: a. Contains only Medicare data b. Is used to determine pay for performance c. Contains data on all payer types d. Contains bibliographic listings from medical journals - ANS-c. Contains data on all payer types What resource should the facility compliance officer consult to provide information on new and ongoing reviews or audits each year in programs administered by the Department of Health and Human Services?
a. Regional health information organizations b. Corporate compliance plan c. OIG workplans d. Federal registrar - ANS-c. OIG workplans When a staff member documents in the health record that an incident report was completed about a specific incident, in a legal proceeding how is the confidentiality of the incident report affected? a. There is no impact b. The person making the entry in the health record may not be called as a witness in trial c. The incident report is likely to become discoverable because it is mentioned in a discoverable document d. The incident report cannot be discovered even though it is mentioned in a discoverable document - ANS-c. The incident report is likely to become discoverable because it is mentioned in a discoverable document The basic functions of healthcare risk management programs are similar for most organizations and should include which of the following? a. Reporting of claims, initial investigation of claims, protection of primary & secondary health records, ... b. Risk acceptance, risk avoidance, risk reduction or minimization, & risk transfer c. Safety management, security management, claims management, technology management, & facilities management d. Risk identification & analysis, loss prevention & reduction, & claims management - ANS-d. Risk identification & analysis, loss prevention & reduction, & claims management The HIM department is developing a system to track coding productivity. The director wants the system to track the productivity of each coder by productive hours worked per day, health record ID, type of records coded, and to provide weekly productivity reports and analyses. Which of the following tools would be best to use for this purpose? a. Word-processing documents b. Paper log book c. Spreadsheet d. Database management system - ANS-d. Database management system Coding accuracy is best determined by: a. A predefined audit process b. Medicare Conditions of Participation c. Payer audits
An inpatient, acute-care coder must follow official ICD-10-CM/PCS coding guidelines established by the: a. American Health Information Management Association b. American Medical Association c. Centers for Medicare and Medicaid Services d. Cooperating Parties - ANS-d. Cooperating Parties A patient had a placenta previa with delivery of twins. The patient had two prior cesarean sections. This was an emergency C-section due to hemorrhage. The appropriate principal diagnosis would be: a. Normal delivery b. Placenta previa c. Twin gestation d. Vaginal hemmorhage - ANS-b. Placenta previa Continuing education is required for: a. Certified coders b. Inpatient coders c. All coders d. Inpatient and ambulatory surgery codes - ANS-a. Certified coders The facility's Medicare case-mix index has dropped, although other statistical measures appear constant. The CFO suspects coding errors. What type of coding quality review should be performed? a. Random audit b. Focused audit c. Compliance audit d. External audit - ANS-b. Focused audit A Staghorn calculus of the left renal pelvis was treated earlier in the week by lithotripsy and is now removed via a percutaneous nephrostomy tube. What is the root operation performed for this procedure? a. Destruction b. Extirpation c. Extraction d. Fragmentation - ANS-b. Extirpation Local coverage determinations (LCD) describe when and under what circumstances which of the following is met:
a. MACs b. Medical necessity c. NCDs d. Proper administration of benefits - ANS-b. Medical necessity The utilization manager's role is essential to: a. Analyze the EOBs received b. Capture all relevant charges for the patient's account c. Prevent denials for inappropriate levels of service d. Verify the patient actually has insurance - ANS-c. Prevent denials for inappropriate levels of service Joe Patient was admitted to Community Hospital. Two days later, he was transferred to Big Medical Center for further evaluation and treatment. He was discharged to home after three days with a qualified transfer DRG from Big Medical Center. Community Hospital will receive from Medicare: a. The full DRG amount, & Big Medical Center will receive a per diem rate for the 3-day stay b. A per diem rate for the 2-day stay, and Big Medical Center will receive the full DRG payment c. The full DRG amount, and Big Medical Center will bill Community Hospital a per diem rate for the 3-day stay d. No payment; Community Hospital must bill Big Medical Center a per diem rate for the 2-day stay - ANS-b. A per diem rate for the 2-day stay, and Big Medical Center will receive the full DRG payment In developing an internal audit review program, which of the following would be risk areas that should be targeted for audit? a. Admission diagnosis & complaints b. Chargemaster description c. Clinical laboratory results d. Radiology orders - ANS-b. Chargemaster description The goal of coding compliance programs is to prevent: a. Accusations of fraud and abuse b. Delays in claim processing c. Billing errors d. Inaccurate code assignments - ANS-a. Accusations of fraud and abuse The risk manager's principal tool for capturing the facts about potentially compensable events is the:
a. Employees are in the best position to provide an objective review without overstatement b. The supervisor is kept informed of the employee's accomplishments c. Appraiser and employee training on the purpose and procedures of this process is essential d. Peer pressure of evaluation can motivate team members to be more productive - ANS-b. The supervisor is kept informed of the employee's accomplishments When reviewing the monthly performance report, a manager noticed the coding accuracy rate was below standard. She considered whether this difference might be related to a recent change in systems or attributed to another factor. This manager is performing which of the following? a. Performance measurement b. Workforce planning c. Work observation study d. Variance analysis - ANS-d. Variance analysis In designing input by clinicians for an EHR system, which of the following would be effective for a clinician when the data are repetitive and the vocabulary used is fairly limited? a. Drop-down menu b. Point and click fields c. Speech recognition d. Structured templates - ANS-c. Speech recognition The medical transcription improvement team wants to identify the cause of poor transcription quality. Which of the following tools would best aid the team in identifying the root cause of the problem? a. Flowchart b. Fishbone diagram c. Pareto chart d. Scatter diagram - ANS-b. Fishbone diagram (a cause-and-effect diagram)
