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RHIT CERTIFICATION EXAM VOCABULARY DOMAIN 1 DATA CONTENT, STRUCTURE, AND INFORMATION GOVERNANCE.
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RHIT CERTIFICATION EXAM VOCABULARY DOMAIN 1 DATA CONTENT, STRUCTURE, AND INFORMATION GOVERNANCE.
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RHIT CERTIFICATION EXAMVOCABULARY DOMAIN 1 DATA
CONTENT, STRUCTURE, AND
INFORMATION GOVERNANCE
Discuss vvthe vvpurpose vvof vvfollowing vvoutpatient vvcoding vvguidelines vv- vvAnswer
vvThe vvCurrent vvProcedural vvTerminology vv(CPT) vvcode vvset vvis vvthe vvmost vvwidely
vvaccepted vvnomenclature vvfor vvthe vvreporting vvof vvphysician vvprocedures vvand
vvservices. vvIt vvis vvendorsed vvby vvthe vvU.S. vvDepartment vvof vvHealth vvand vvHuman
vvServices vvas vvthe vvnationally vvaccepted vvcoding vvstandard. vvEach vvsection vvof vvthe
vvCPT vvcode vvbook vvincludes vvspecific vvguidelines. vvThese vvcoding vvguidelines vvare
vva vvset vvof vvrules vvfor vvcoders vvto vvfollow vvin vvorder vvto vvappropriate vvinterpret vvand
vvreport vvprocedures vvand vvservices vvprovided vvin vvphysicians' vvoffices vvand/ vvor
vvoutpatient vvsettings. vvAs vvwith vvall vvcoding vvguidelines, vvthey vvpromote vvconsistency
vvamong vvcoders vvand vvhealthcare vvproviders vvin vvthe vvassignment vvof vvcodes.
Identify vvtips vvfor vvthe vvestablishment vvof vvcoding vvproductivity vvstandards vv- vvAnswer
vvThe vvformula vvto vvcalculate vva vvcoder's vvproduction vvis vvsimple: vvSubtract vvthe
vvhours vvof vvnoncoding vvtasks vv(also vvknown vvas vv"downtime") vvfrom vvthe vvtotal
vvhours vvof vvcoding vvtasks. vvOf vvnote, vvnoncoding vvtasks vvshould vvinclude vvthe
vvfollowing: vveducation/training vvsystem vvtechnical vvproblems, vvdata vvanalysis
vvprojects, vvetc. vvThen vvdivide vvthe vvnumber vvof vvaccounts vvcoded vvper vvhour. vvThis
vvformula vvcan vvbe vvbuilt vvinto vvdatabase vvfunctions, vvavailable vvfor vvthe vvcoder vvand
vvmanager vvto vvacknowledge. vvThis vvformula vvmay vvbe vveasy, vvbut vvthere vvare vvother
vvfactors vvto vvconsider vvwhen vvdetermining vvthe vvcoder's vvoverall vvskill vvlevel. vvFor
vvexample, vvquality vvof vvwork vvor vvcoding vvaccuracy vvmust vvbe vvmonitored, vvstriving
vvto vvreach vvor vvsurpass vvthe vvnational vvstandard vvof vv95% vvcoding vvaccuracy.
Explain vvthe vvtypes vvof vvcoding vvreference vvmaterials vvavailable vvin vvan vvencoder vv-
vvAnswer vvAn vvencoder vvis vvan vvelectronic vvtool vvthat vvreceives vvdiagnostic vvor
vvprocedural vvdata vvmanually vventered vvby vva vvcoder, vvwhich vvthen vvconverts vvthe
vvdata vvinto vva vvnumerical vvcode. vvAn vvencoder vvis vva vvlogic-driven vvtool vvthat
vvprompts vvthe vvcoder vvthrough vvseveral vvchoices/ vvoptions vvuntil vvthe vvappropriate
vvcode vvis vvachieved. vvInevitably, vvthe vvcoder vvwill vvencounter vvinsufficient
,vvdocumentation, vvwhich vvleaves vvthe vvcoder vvquestioning vvwhich vvcode vvto vvassign.
vvIn vvthese vvsituations, vvthe vvcoder vvshould vvaccess vvcoding vvreferences vvto vvguide
vvin vvhis/ vvher vvcode vvselection vvprocess. vvThese vvcoding vvreferences vvare vvavailable
vvin vvan vvencoder. vvThe vvreferences vvmay vvinclude vvthe vvInternational vvClassification
vvof vvDiseases vv(ICD) vvICD-9 vvand vvICD-10 vvOfficial vvCoding vvGuidelines, vvAmerican
vvHospital vvAssociation's vvCoding vvClinics vvdating vvback vvto vvthe vv1990's, vvthe
vvAmerican vvMedical vvAssociation's vvCPT vvAssistant, vvFaye vvBrown's vvcoding
vvhandbooks, vvapproved vvmedical vvabbreviation vvlists, vvElsevier's vvAtlas vvof vvHuman
vvAnatomy, vvetc.
Explain vvthe vvimportance vvof vvusing vvthe vvfollowing vvresources vvwhen vvresearching
vvcoding vvchanges: vvCoding vvClinic, vvCPT vvAssistant, vvand vv3M vvNosology vv-
vvAnswer vvAn vvexperienced vvcoder vvunderstands vvthe vvimportance vvof vvaccessing
vvreliable vvresources vvfor vvcompliant vvcoding. vvCoding vvClinic, vvCPT vvAssistant, vvand
vv3M vvNosology vvare vvreliable vvresources vvfrequently vvreferenced vvby vvseasoned
vvcoders. vvThe vvAmerican vvHospital vvAssociation vv(AHA) vvpublishes vvthe vvCoding
vvClinic, vvan vvofficial vvpublication vvof vvcoding vvguidelines vvand vvadvice. vvThe vvAHA
vvCentral vvOffice vvworks vvwith vvthe vvNational vvCenter vvfor vvHealth vvStatistics vvand
vvthe vvCenters vvfor vvMedicare vv& vvMedicaid vvservices vvto vvmaintain vvthe vvintegrity vvof
vvthe vvICD-10 vvcoding vvclassification vvsystem. vvCPT vvAssistant vvis vvpublished vvand
vvmaintained vvby vvthe vvAmerican vvMedical vvAssociation vvas vvthe vvofficial vvword vvon
vvproper vvCurrent vvProcedural vvTerminology vvcoding. vv3M vvNosology vvis vva vvsupport
vvsystem vvwhose vvemployees vvfield vvcoding vvquestions vvand vvprovide vvadvice vvon
vvappropriate vvcode vvassignment. vvAll vvthree vvresources vvare vvvaluable vvtools vvfor
vvcoding vvprofessionals.
Define vvdata vvworkflow, vvexplain vvits vvsignificance, vvand vvdescribe vvhow vvflowcharts
vvare vvused vvto vvdisplay vvit vv- vvAnswer vvA vvworkflow vvis vva vvspecific vvsequence vvof
vvsteps vvin vva vvprocess. vvTherefore, vvthe vvdata vvworkflow vvdescribes vvsystem vvdesign
vvand vvhow vva vvparticular vvset vvof vvdata vvmoves vvthrough vva vvsystem vvto vvsupport vva
vvcertain vvtask. vvData vvworkflow vvprovides vvinsights vvinto vvproblem vvareas vvin
vvperformance vvand vvallows vvorganizations vvto vvoptimize vvwork vvprocedures vvor
vvelectronic vvsystems. vvWhen vvdata vvworkflow vvand vvend vvusers' vvdaily vvactivities
vvare vvwell vvunderstood, vvprocesses vvcan vvbe vvstreamlined vvto vvresult vvin vvthe
vvgreatest vvefficiency. vv
Data vvflow vvdiagrams, vvalso vvknown vvas vvflowcharts, vvare vva vvperformance
vvimprovement vvtool vvoften vvused vvto vvgraphically vvdisplay vvworkflow vvto
vvnontechnical vvusers. vvVarious vvshapes vvare vvconnected vvby vvarrows vv(flow vvlines)
vvto vvillustrate vvhow vvdata vvflow vvthroughout vva vvsystem vvor vvdatabase. vvA vvfew
vvexamples vvof vvcommon vvsymbols vvused vvin vvflowcharts vvinclude vvovals vvto
vvrepresent vvstart vvand vvend vvsteps, vvsquares vvto vvrepresent vvtasks vvor vvsteps vvin
vvthe vvprocess, vvdiamonds vvto vvrepresent vvdecisions, vvand vvcylinders vvto vvrepresent
vvdatabases.
,Identify vvand vvdescribe vvcurrent vvtrends vvin vvhealthcare vvdata vv- vvAnswer vvThe vvrole
vvof vva vvhealth vvinformation vvdata vvanalyst vvcontinues vvto vvevolve vvas vvthe vvworld vvof
vvelectronic vvhealth vvrecords vvmatures. vvIn vvthis vvpresent vvelectronic vvage,
vvhealthcare vvdata vv(whether vvclinically, vvadministratively, vvor vvfinancially vvrelated vvis
vvlimitless. vvThe vvfollowing vvdata vvtrends vvrepresent vvthe vvlimitless vvopportunities vvof
vvhealth vvinformation vvmanagement vv(this vvlist vvis vvnot vvexhaustive): vv
Calculation vvof vvpatient vvwait vvtimes vvto vvbe vvseen vvby vva vvhealthcare vvprovider. vv
Calculation vvof vvreadmission vvrates vv(which vvcan vvhave vva vvsignificant vvfinancial
vvimpact). vv
Monitoring vvof vvcomplication vvand/ vvor vvmortality vvrates vv
Monitoring vvof vvpublic vvhealth vvdata vv
Monitoring vvthe vvaverage vvlength vvof vvstay vv
Analysis vvof vvpatient vvquality vvscores vv
Trending vvthese vvdata vvsets vvwill vva vvstory vvupon vvwhich vvthe vvhealthcare vventity
vvcan vvmake vvimportant vvhealthcare vvdecisions vv(administratively, vvclinically, vvand
vvfinancially) vvmoving vvforward.
Identify vvdata vvorganizational vvguidelines vvin vvExcel vv- vvAnswer vvExcel vvspreadsheets
vvare vvan vvexcellent vvtool vvfor vvdata vvorganization. vvFor vvthe vvspreadsheets vvto
vvcontribute vvvalue vvto vvoperations, vvit vvis vvimperative vvthat vvdata vvbe vvorganized.
vvThe vvfollowing vvare vvtips vvon vvhow vvto vvorganize vvdata vvin vvExcel: vv
Categorize vvcolumns vvof vvsimilar vvdata vv
Identify vvcritical vvdata vvwith vva vvdifferent-colored vvfont vvor vvapply vvspecial vvfont vv(e.g.,
vvitalics, vvbold). vv
Use vvcell vvborders vvto vvdesignate vvrelated vvdata vv
Avoid vvleading vvspaces vvin vvcells vvbecause vvthe vvspaces vvcan vvcause vvproblems
vvwith vvsearch vvfunctionality vv
Use vvformulas vvacross vvmultiple vvcells vvfor vvease vvof vvcalculations vv
Use vvdata vvfilters vvto vvlocate vvspecific vvdata vvquickly vv
Use vvfeatures vvsuch vvas vvwrap vvtext vvto vvcontain vvlengthy vvdata vvfields vvand
vvimprove vvreadability vv
Use vvnumbering vvoptions vvacross vvmultiple vvcells vvfor vvaccounting, vvpercentages,
vvcurrency, vvdate/ vvtime, vvetc., vvto vvimprove vvreadability
Briefly vvdiscuss vvmandates vvthat vvpromote vvclinical vvdocumentation vvimprovement
vv(CDI) vvopportunities vv- vvAnswer vvClinical vvdocumentation vvimprovement vv(CDI)
vvinitiatives vvare vvnot vvimplemented vvbecause vvof vvpicky vvhealth vvinformation
vvmanagement vvprofessionals vvwho vvjust vvdesire vvbetter vvdocumentation vvto vvassist
vvwith vvtheir vvcode vvassignments. vvRather, vvthere vvare vvmultiple vvCDI vvmandates
vvthat vvare vvbehind vvthe vvpush vvfor vvbetter vvdocumentation.
Briefly vvexplain vvMedicare vvfraud vvand vvMedicare vvabuse vv- vvAnswer vvIn vvgeneral,
vvMedicare vvfraud vvcan vvbe vvdefined vvas vvknowingly vvsubmitting vvfalse vvclaims vvto
, vvobtain vvfederal vvreimbursement. vvExamples vvof vvMedicare vvfraud vvmay vvinclude
vvbilling vvfor vvservices vvnot vvrendered, vvbilling vvfor vvservices vvat vva vvhigher vvlevel vvof
vvcomplexity vvthan vvactually vvperformed, vvbilling vvfor vvsupplies vvnot vvprovided, vvand
vvfalsifying vvdocumentation. vvCommitting vvMedicare vvfraud vvmay vvresult vvin vvcivil vvor
vvcriminal vvliability, vvleading vvto vvimprisonment, vvmonetary vvpenalties, vvloss vvof
vvcredentials, vvand vvloss vvof vvMedicare vvfunding. vvMedicare vvabuse vvcan vvbe vvdefine
vvas vvpractices vvthat vvresult vvin vvunnecessary vvcosts vvto vvthe vvMedicare vvprogram.
vvExamples vvof vvabuse vvmay vvinclude vvbilling vvfor vvmedically vvunnecessary vvservices,
vvcharging vvbeyond vvthe vvfair vvmarket vvvalue vvfor vvservices vvor vvsupplies, vvupcoding
vvor vvunbundling vvof vvcodes vvon vva vvclaim, vvetc. vvMedicare vvabuse vvviolations vvmay
vvresult vvin vvcivil vvor vvcriminal vvliability.
Briefly vvexplain vvthe vvprocess vvof vvbecoming vvaccredited vvby vvthe vvJoint
vvCommission vv- vvAnswer vvBefore vvthe vvinitial vvJoint vvCommission vvsurvey vvis
vvconducted, vvthe vvhealthcare vvorganization vvshould vvcomplete vvthe vvfollowing vvsteps,
vvat vva vvminimum: vv
Ensure vvthat vvstate vvlicensure vvrequirements vvhave vvbeen vvmet vv
Ensure vvthat vvthe vvCenters vvfor vvMedicare vv& vvMedicaid vvServices vv855A
vvapplication vvhas vvbeen vvverified vv
Ensure vvthat vvpatient vvcensus vvrequirements vvare vvmet vvin vvorder vvto vvprovide vvan
vvample vvsupply vvof vvrecords vvto vvJoint vvCommission vvsurveyors vv
Request vva vvfree vvtrial vvedition vvof vvJoint vvCommission vvstandards vv
Request vvan vvaccreditation vvguide vv
Apply vvfor vvan vvaccreditation vvsurvey vvand vvpay vvthe vvnonrefundable vvfee vv
Before vvthe vvsurvey vvhas vvended, vvJoint vvCommission vvsurveyors vvwill vvschedule vvan
vvexit vvconference vvto vvreview vva vvpreliminary vvsummary vvof vvfindings. vvThe
vvpreliminary vvreport vvmay vvbe vvfurther vvreviewed vvby vvthe vvJoint vvCommission's
vvcentral vvoffice. vvOnce vvthe vvreview vvis vvfinalized, vva vvfinal vvsummary vvwill vvbe
vvposted vvon vvthe vvJoint vvCommissions vvextranet vvsite. vvPost-survey vvrequests vvfor
vvadditional vvinformation vvmay vvbe vvsubmitted vvby vvthe vvJoint vvCommission vvwith
vvtime vvlimits vvset vvat vveither vv45 vvor vv60 vvdays. vvThese vvare vvknown vvas vvevidence
vvof vvstandards vvcompliance vvrequests. vvOnce vvthese vvare vvsubmitted vvby vvthe
vvhealthcare vvorganization, vvthe vvaccreditation vvdecision vvwill vvbe vvrendered.
Elaborate vvupon vvthe vvmeaning vvof vvhospital vvaccreditation vv- vvAnswer vvHospital
vvaccreditation vvis vva vvpeer vvassessment vvprocess vvconducted vvby vvan vvexternal
vvagency vvwhose vvprimary vvpurpose vvis vvto vvevaluate vvhealthcare vvperformance
vvagainst vvestablished vvstandards vvand vvthen vvrecommended vvsteps vvto vvimprove
vvthe vvdelivery vvof vvhealthcare. vvThe vvJoint vvCommission vvis vvthe vvnation's vvtop
vvaccreditor vvfor vvhospitals. vvThe vvJoint vvCommission vvwill vvaward vva vvgold vvseal vvof
vvapproval, vvwhich vvis vvinternationally vvrecognized, vvwhen vva vvhospital vvmeets vvthe
vvevidence-based vvstandards vvpertaining vvto vvquality vvof vvcare vvand vvpatient vvsafety.
vvAll vvtypes vvof vvhospitals vv(e.g., vvgovernment-owned, vvlong-term vvrehab, vvpsychiatric,
vvetc.) vvand vvtreatment vvprovided vvby vvfacilities vv(e.g., vvhome vvhealth vvambulatory
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