AHIMA RHIA Exam Prep 7th Edition

AHIMA RHIA Exam Prep (7th Edition) Questions And Answers 2023

• A patient requests copies of her medical records in an electronic format. The

hospital maintains a portion of the designated record set in a paper format and a portion of the designated record set in an electronic format. How should the hospital respond?

• Provide the records in paper format only
• Scan the paper documents so that all records can be sent electronically
• Provide the patient with both paper and electronic copies of the record
• Inform the patient that PHI cannot be sent electronically - Correct answer-c. Provide

the patient with both paper and electronic copies of the record

The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be delivered electronically (Thomason 2013, 102).

• For an EHR to provide robust clinical decision support, what critical element must be

present?

• Structured data
• Internet connection
• Physician portal
• Standard vocabulary - Correct answer-If an EHR is to provide clinical decision

support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364).

• Which of the following is considered a two-factor authentication system?

• User ID and password
• User ID and voice scan
• Password and swipe card
• Password and PIN - Correct answer-c. Password and swipe card

The three methods of two-factor authentication are something you know, such as a password or PIN; something you have, such as an ATM card, token, or swipe/smart

card; and something you are, such as a biometric fingerprint, voice scan, iris, or retinal scan (Sayles and Trawick 2014, 219).

Under RBRVS, which elements are used to calculate a Medicare payment?

• Work value and extent of the physical exam
• Malpractice expenses and detail of the patient history
• Work value and practice expenses
• Practice expenses and review of systems - Correct answer-Each Resource-Based

Relative Value Scale (RBRVS) comprises three elements: physician work, physician practice expense, and malpractice, each of which is a national average available in the Federal Register (Casto and Forrestal 2015, 150).

12. The predefined process icon is used in flowcharting to indicate:

• A process in which actions are being performed by humans
• A point in the process at which participants must evaluate the status of the process
• Formal procedures that participants are expected to carry out the same way every

time

• A point in the process at which the participants must record data in paper-based or

computer- based formats - Correct answer-The rectangle with double lines on the side in a flowchart is a predefined process icon. This symbol represents the formal procedure that participants are expected to carry out the same way every time (Shaw and Carter 2015, 198).

. A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting?

• Content analysis
• Effect size review
• Psychometric assay
• Secondary analysis - Correct answer-Secondary analysis is the analysis of the

original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586).

In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case?

• Query the attending physician and ask him to validate a diagnosis based on the chest

x-ray results

• Code COPD because the documentation substantiates it
• Query the radiologist to determine whether the patient has COPD

• Assign a code from the abnormal findings to reflect the condition - Correct answer-A

query is routine communication and education tool used to advocate for complete and compliant documentation. The intent is to clarify what has been recorded, not to call into question the provider's clinical judgment or medical expertise. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS and whether the COPD does is not clear (Hunt

2016, 276-277).

Per the HITECH breach notification requirements, which of the following is the threshold in which the media and the Secretary of Health and Human Services should be notified of the breach?

• more than 1,000 individuals affected
• more than 500 individuals affected
• more than 250 individuals affected
• Any number of individuals affected requires notification - Correct answer-Reporting

requirements mandate notification to the individual whose information was breached, and in the case of breaches of more than 500 individuals' information, to the media and the Secretary of Health and Human Services (Biedermann and Dolezel 2017, 401).

Determining costs associated with EHR hardware and software acquisition, implementation, and ongoing maintenance represents which type of analysis?

• Benefits realization study
• Goal-setting exercise
• Cost-benefit feasibility study
• Productivity improvement study - Correct answer-Cost-benefit feasibility is used to

determine if an EHR initiative is appropriate for the organization at this time; it measures the costs associated with acquisition of hardware and software, installation, implementation, and ongoing maintenance (Amatayakul 2016, 104-105).

Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded.The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected?

• Delete the code from the CDM because it should not be there.
• Refer the case to the chargemaster coordinator.
• Force a final bill on the accounts since the duplication will not affect the UB-04.
• Remove the code from the abstract and counsel the coder regarding CDM hard

codes in this service. - Correct answer-If a service is hard-coded into the charge description master (CDM), it is important that this decision is communicated to the coding staff. If the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and Forrestal 2015, 253).

Which health record format is arranged in chronological order with documentation from various sources intermingled?

• Electronic
• Source-oriented
• Problem-oriented
• Integrated - Correct answer-The integrated health record is arranged so that the

documentation from various sources is intermingled and follows a strict chronological or reverse-chronological order. The advantage of the integrated format is that it is easy for caregivers to follow the course of the patient's diagnosis and treatment (Russo 2013b, 305).

The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee?

• HIPAA does not allow a patient's name to be announced in a waiting room.
• There is no violation of HIPAA in announcing a patient's name, but the committee

may want to consider implementing practices that might reduce this practice.

• HIPAA allows only the use of the patient's first name.
• HIPAA requires that patients be given numbers and that only the number be

announced. - Correct answer-The HIPAA Privacy Rule allows communications to occur for treatment purposes. The preamble repeatedly states the intent of the rule is not to interfere with customary and necessary communications in the healthcare of the individual. Calling out a patient's name in a waiting room, or even on the facility's paging system, is considered an incidental disclosure and, therefore, allowed in the Privacy Rule (Thomason 2013, 37).

• Which of the following is a graphical display of the relationships between tables in a

database?

• RDMS
• SQL
• ERD
• SAS - Correct answer-An entity relationship diagram (ERD) is used to describe how

the tables work together. The diagram is a graphic representation of the entities, attributes, and relationships that are part of a database and is a data modeling tool (White 2016a, 46).

What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options?