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During an audit of health records, the HIM director finds that transcribed reports are being changed by the author up to a week after initial transcription. The director is concerned that changes occurring this long after transcription jeopardize the legal principle that documentation must occur near the time of the event. To remedy this situation, the HIM director should recommend which of the following? Develop a facility policy that defines the acceptable period of time allowed for a transcribed document to remain in a draft form. What is the basic formula for calculating each MS-DRG hospital payments? Hospital payment = DRG relative weight x hospital base rate Which of the following activities would be in violation of AHIMA's Code of Ethics? Coding an intentionally inappropriate level of service What is abstracting? Compiling the pertinent information from the medical record based on predetermined data sets ICD-9-CM defines the "newborn period" as birth through the ___________ day following birth. 28th What healthcare organization collects UHDDS data? All non-outpatient settings including acute care, short term care, long term care, an psychiatric hospitals, home health agencies, rehabilitation facilities, and nursing home. A coding analyst consistently enters the wrong code for patient gender in the electronic billing system. What security measures should be in place to minimize this security breach? Edit checks Mercy Hospital personnel need to review the medical records for Katie Grace for utilization review purposes (1). They will also be sending her records to her physician for continuity of care (2). Under HIPAA, these two functions are: Use and disclosure Who is responsible for writing and signing discharge summaries and discharge instructions? Attending physician Although the HIPAA Rule allows patient access to personal health information about themselves, which of the following cannot be disclosed to patients? Psychotherapy notes Identify the punctuation mark that is used to supplement words or explanatory information that may or may not be present in the statement of diagnosis or procedure in ICD-9-CM coding. The punctuation does not affect the code number assigned to the case. The punctuation is considered a nonessential modifier, and all three volumes of ICD-9-CM use them. Parentheses ( ) What is the name of the organization that develops the billing form that hospitals are required to use? National Uniform Billing Committee (NUBC) Which of the following ethical principles is being followed when an HIT professional ensures that patient information is only released to those who have a legal right to access it? Beneficence A hospital currently includes the patient's social security number on the face sheet of the paper medical record and in the electronic version of the record. The hospital risk manager has identified this as a potential identity fraud risk and wants the information removed. The risk manager is not getting cooperation from the physicians and others in the hospital who say that they need the information for identification and other purposes. Given this situation, what should the HIM director suggest? Avoid displaying the number on any document, screen, or data collection field. Both HEDIS and the Joint Commission's ORYX program are designed to collect data to be used for ______________. Performance improvement programs Which of the following would be classified to an ICD-9-CM category for bacterial diseases? Staphylococcus aureous A patient with known COPD and hypertension under treatment was admitted to the hospital with symptoms of a lower abdominal pain. He undergoes a laparoscopic appendectomy and develops a fever. The patient was subsequently discharged from the hospital with a principal diagnosis of acute appendicitis and secondary diagnoses of post-operative infection, COPD, and hypertension. Which of the following diagnoses should not be tagged as POA? Postoperative infection CPT was developed and is maintained by: AMA Which organization developed the first hospital standardization program? American College of Surgeon On review of the audit trail for an EHR system, the HIM director discovers that a departmental employee who has authorized access to patient records is printing far more records than the average user. In this cases, what should the supervisor do? Determine what information was printed and why What are possible "add-on" payments that a hospital could receive in addition to the basic Medicare DRG payment? Additional payments may be made to disproportionate share hospitals, for indirect medical education, for new technologies, and for cost outlier cases. The ___________ is a type of coding that is a natural outgrowth of the electronic heath record. Computer-assisted coding Today, Janet Kim visited her new dentist for an appointment. She was not presented with a Notice of Privacy Practices. Is this acceptable? No, it is a violation of the HIPAA Privacy rule Which of the following would be the best technique to ensure that registration clerks consistently use the correct notation for assigning admission date in an electronic health record (EHR)? Provide an input mask for entering data in the field What should a hospital do when a state law requires more stringent privacy protection than the federal HIPAA privacy standard? Comply with both the state law and the HIPAA Standard An employee in the physical therapy department arrives early every morning to snoop through the clinical information system for potential information about neighbors and friends. What security mechanisms should be implemented to prevent this security breach? Information access controls According to ICD-9-C.M, an elderly primigravida is defined as a woman who gives birth to her first child at the age of ______ or older: 35 Which of the following reports include names of the surgeon and assistants, date, duration, and description of the procedure and any specimens removed. Operative report Which answer below is not correct for assignment of the MS-DRG? Attending and consulting physicians Which of the following documentation must be included in a patient's medical record prior to performing a surgical procedure? Consent for operative procedure, history, physical examination. What is the maximum number of diagnosis codes that can appear on the UB-04 paper claim form locator 67 for a hospital inpatient principle and secondary diagnoses? 25 Documentation in the history of use of drugs, alcohol, and/or tobacco is considered part of the: Social history Which of the following is a core ethical obligation of health information staff? Protecting patients privacy and confidential communications Documentation regarding a patient's marital status, dietary, sleep, and exercise patterns, use of coffee, tabacco, alcohol, and other drugs may be found in the _____________. History record Which of the following provides organizations with the ability to access data from multiple databases and to combine the results into a single questions-and-reporting interface? Data warehouse Community Hospital implemented a clinical document improvement (CDI) program six months ago. The goal of the program was to improve clinical documentation to support quality of care, data quality, and HIM coding accuracy. Which of the following would be best to ensure that everyone understands the importance of this program? Include ancillary clinical and medical staff in the process Which of the following activities is considered an unethical practice? Backdating progress notes In a routine health record quantitative analysis review it was fund that a physician dictated a discharge summary on 1/26/2009. The patient, however, was discharged two days later. In this case, what would be the best course of action? Request the physician dictate an addendum to the discharge summary Mohs micrographic surgery involves the surgeon acting as: Both surgeon and pathologist A hospital is planning on allowing coding professionals to work at home. The hospital is in the process of identifying strategies to minimize the security risks associated with this practice. Which of the following would be best to ensure that data breaches are minimized when the home computer is unattended? Automatic session terminations Dr. Jones has signed a statement that all of her dictated reports should be automatically considered approved and signed unless she makes correction within 72 hours of dictating. This is called _____________. Autoauthentication What type of standard establishes methods for creating unique designations for individual patients, healthcare professionals, healthcare provider organizations, and healthcare vendors and suppliers? Identifier standard When coding a selective catheterization in CPT, how are codes assigned? One code for the final vessel entered What is the maximum number of procedure codes that can appear on a UB-04 paper claim form for a hospital inpatient? six In hospitals, automated systems for registering patients and tracking their encounters are commonly known as _________ systems. ADT Category II codes cover all but one of the following topics. Which is not addressed by Category II codes? New technology Referencing the CPT codebook, a list of codes describing procedures that include conscious sedation, if administered by the same surgeon as performs the procedure, can be found in: Appendix G Per the HIPAA Privacy Rule, which of the following requires authorization for research purposes? Use of Mary's individually identifiable information related to her asthma treatments When correcting erroneous information in a health record, which of the following is not appropriate? Use black pen to obliterate the entry What penalties can be enforced against a person or entity that willfully and knowingly violates the HIPAA Privacy Rule with the intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm? A fine of not more than $250.000, not more than 10 years in jail, or both The clinical statement, "microscopic sections of the gallbladder reveals a surface lined by tall columnar cells of uniform size and shape" would be documented on which medical record form? Operative report Which of the following specialized patient assessment tools must be used to Medicare-certified home care providers? Outcomes and Assessment Protocol How does Medicare or other third-party payers determine whether the patient has medical necessity for the tests, procedures, or treatment billed on a claim form? By reviewing all the diagnosis codes assigned to explain the reasons the services were provided Under the HIPAA privacy standard, which of the following types of protected health information (PHI) must be specifically identified in an authorization? Psychotherapy notes