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Question 1 reset

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A patient requests copies of their medical record from their recent hospital stay. According to HIPAA, what is the standard timeframe for the covered entity to provide these copies?

15 calendar days

30 calendar days

60 calendar days

90 calendar days

Question 2 reset

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A physician documents "acute kidney injury likely due to dehydration." The coder assigns a code for acute kidney injury without querying the physician. This action violates which coding principle?

Coding to the highest degree of certainty

Sequencing the principal diagnosis correctly

Reporting all documented conditions

Linking diagnoses to procedures

Question 3 reset

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During a routine audit of electronic health records, you notice several instances where the user accessed records of patients with the same last name as themselves but are not in their care team. This is a potential breach of:

Data integrity

System availability

Confidentiality

Data validity

Question 4 reset

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Your facility is implementing a new electronic health record (EHR) system. To ensure data consistency across all patient encounters, which of the following should be established and maintained?

A list of all system users

Standardized data definitions

Security access logs

System downtime procedures

Question 5 reset

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A patient's paper chart is misplaced in the HIM department. After a thorough search, it cannot be located. What is the most appropriate initial step according to best practices?

Notify the patient immediately

Document the incident and initiate the facility's lost record policy

Assume the record will eventually be found

Discipline all staff who had access to the record

Question 6 reset

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A healthcare organization wants to use patient data for research purposes. Which of the following is required to ensure compliance with HIPAA?

Obtain patient consent for all research activities

Remove all direct identifiers to create de-identified data

Share the data only with internal researchers

Publish the research findings regardless of patient consent

Question 7 reset

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A coder is abstracting data for quality reporting and identifies that the physician's documentation regarding the stage of a pressure ulcer is missing. What is the most appropriate action?

Assign the unspecified code for pressure ulcer

Query the physician for clarification on the stage

Assume the stage based on other documentation

Exclude the pressure ulcer from the quality report

Question 8 reset

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Which of the following is a key characteristic of the designated record set (DRS)?

It includes all patient health information within the covered entity.

It is determined solely by the patient's request.

It includes only information used for treatment, payment, and operations.

It is a subset of records that are legally required to be maintained.

Question 9 reset

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A hospital is undergoing a Joint Commission survey. The surveyor asks to see the process for ensuring the accuracy and completeness of patient records. Which of the following would be the most relevant documentation to present?

Staff training logs on EHR use

The facility's chart completion policy

Meeting minutes from the medical staff committee

Patient satisfaction surveys

Question 10 reset

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A clinic is implementing a patient portal. What is a crucial step to ensure patient privacy and security when they access their health information online?

Using the same password for all patients

Providing access to all parts of the health record

Implementing strong authentication methods

Allowing patients to edit their medical history

Question 11 reset

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A healthcare organization receives a subpoena for a patient's medical record. What is the HIM professional's responsibility in this situation?

Immediately release the entire medical record

Verify the validity of the subpoena

Inform the patient before releasing any information

Release only the information specifically requested in the subpoena

Question 12 reset

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Which of the following data quality characteristics refers to the reliability and consistency of data values?

Accuracy

Completeness

Validity

Reliability

Question 13 reset

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A hospital's coding productivity has significantly decreased. Which data metric would be most useful in investigating the potential causes of this decline?

Case Mix Index (CMI)

Discharged Not Final Billed (DNFB) days

Number of coding queries issued

Average length of stay (ALOS)

Question 14 reset

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A patient believes their health information was disclosed inappropriately by a clinic employee. Under HIPAA, what is the patient's right in this situation?

To receive monetary compensation

To file a criminal complaint

To request an accounting of disclosures

To immediately access all employee records

Question 15 reset

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What is the primary purpose of a Clinical Documentation Improvement (CDI) program?

To improve coding accuracy and completeness

To reduce the number of denied claims

To ensure timely chart completion

To enhance patient satisfaction scores

Question 16 reset

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A hospital is implementing a new policy regarding the retention of electronic health records. Which of the following should be a key consideration when establishing retention periods?

The cost of data storage

Federal and state regulations

The preferences of the medical staff

The limitations of the EHR system

Question 17 reset

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In an outpatient setting, what is the primary purpose of the Charge Description Master (CDM)?

To track physician productivity

To list all services and supplies with associated charges

To manage patient demographics

To generate insurance pre-authorizations

Question 18 reset

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A patient is admitted with pneumonia and a history of chronic obstructive pulmonary disease (COPD). Which condition should be sequenced as the principal diagnosis for billing purposes if the pneumonia was the main reason for the admission?

Pneumonia

COPD

Both pneumonia and COPD equally

The condition with the higher relative weight

Question 19 reset

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A healthcare organization is conducting a risk assessment. Identifying vulnerabilities in their information systems and potential threats is a crucial step in:

Developing contingency plans

Implementing security safeguards

Mitigating privacy and security risks

Responding to security incidents

Question 20 reset

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What is the primary goal of utilization review?

To ensure accurate coding

To manage the cost-effectiveness and medical necessity of services

To improve patient satisfaction

To comply with Joint Commission standards

Question 21 reset

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A physician documents a procedure in the progress notes but forgets to include it in the discharge summary. During a record audit, this discrepancy is identified. This is an example of a lack of:

Timeliness

Completeness

Legibility

Accuracy

Question 22 reset

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Which of the following is a fundamental principle of data governance?

Centralized data storage

Unrestricted data access

Accountability for data quality

Elimination of data redundancy

Question 23 reset

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A hospital wants to analyze the average length of stay for patients with congestive heart failure. Which data element is essential for this analysis?

Patient's insurance provider

Discharge date

Referring physician

Patient's age

Question 24 reset

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A patient requests an amendment to their medical record, stating that a documented allergy is incorrect. What is the covered entity's responsibility?

To immediately delete the incorrect information

To investigate the request and make a determination

To forward the request to the physician for approval

To ignore the request if it contradicts physician documentation

Question 25 reset

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What is the purpose of a coding compliance plan?

To ensure coders meet productivity standards

To prevent fraudulent and abusive coding practices

To standardize coding workflows across departments

To provide ongoing coding education to staff

Question 26 reset

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A new HIM director is reviewing the department's policies and procedures. Which of the following is a critical element to include in the Release of Information (ROI) policy?

The process for coding inpatient records

The turnaround time for processing ROI requests

The procedure for chart retrieval for physician review

The guidelines for staff training on HIPAA

Question 27 reset

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Which of the following is a common characteristic of a prospective payment system (PPS)?

Payment is based on the actual cost of services provided.

Payment is a fixed amount determined before services are rendered.

Payment varies based on the physician's charges.

Payment is negotiated between the provider and the payer after services are provided.

Question 28 reset

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A hospital is experiencing a high number of denials due to "medical necessity." Which department should the HIM department collaborate with to address this issue?

Patient Registration

Finance

Utilization Review/Management

Health Information Technology

Question 29 reset

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What is the primary purpose of the Master Patient Index (MPI)?

To assign unique medical record numbers to patients

To track the location of paper medical records

To store scanned images of patient documents

To manage physician credentials and privileges

Question 30 reset

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A healthcare organization is implementing a new data analytics tool. What is a critical consideration to ensure the privacy and security of the data being analyzed?

Limiting the number of users with access to the tool

De-identifying data whenever possible

Storing the data on a separate server

Requiring users to sign a confidentiality agreement

Question 31 reset

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A physician's order is illegible. What is the most appropriate action for the HIM professional to take?

Make an educated guess based on other documentation

Transcribe the order as best as possible

Contact the physician for clarification

Ask another physician to interpret the order

Question 32 reset

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Which of the following is a key component of information governance?

Implementing the latest EHR technology

Establishing data backup procedures

Defining roles and responsibilities for data management

Providing staff training on computer skills

Question 33 reset

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A hospital wants to track the number of patients readmitted within 30 days for the same condition. This is an example of a:

Financial metric

Quality metric

Operational metric

Compliance metric

Question 34 reset

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A patient requests access to their psychotherapy notes. Under HIPAA, what is the covered entity's responsibility?

To provide immediate access to the notes

To deny access as psychotherapy notes have special protection

To provide a summary of the notes instead

To obtain the psychotherapist's authorization before releasing the notes

Question 35 reset

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What is the primary goal of a Clinical Documentation Integrity (CDI) query?

To increase the reimbursement for a patient encounter

To ensure the documentation supports the codes assigned

To identify physician performance issues

To expedite the chart completion process

Question 36 reset

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A healthcare organization is considering cloud-based storage for its electronic health records. What is a critical security consideration they must address with the cloud provider?

The physical location of the servers

The provider's data encryption methods

The number of employees the provider has

The provider's marketing strategies

Question 37 reset

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Which of the following is a common reason for a denial of an outpatient claim?

The patient's insurance deductible has not been met.

The diagnosis code does not support the medical necessity of the procedure code.

The patient was not eligible for services on the date of service.

All of the above

Question 38 reset

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What is the role of the chargemaster coordinator?

To perform coding audits

To manage the facility's charge description master

To process patient payments

To negotiate contracts with insurance companies

Question 39 reset

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A hospital experiences a power outage, and the EHR system is unavailable. What should the facility have in place to ensure business continuity and patient safety?

A policy for delaying all non-emergent care

A detailed downtime procedure

A requirement for all staff to work remotely

A plan to revert to a completely paper-based system indefinitely

Question 40 reset

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Which of the following is a key principle of project management that is relevant to EHR implementation?

Ignoring stakeholder feedback to maintain the timeline

Focusing solely on the technical aspects of the system

Establishing clear goals and timelines

Avoiding communication with the end-users

Question 41 reset

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A coder notices a pattern of physicians frequently documenting the same vague diagnosis code. What is the HIM professional's role in addressing this issue?

To independently assign more specific codes

To educate the physicians on the importance of detailed documentation

To report the physicians to the medical board

To ignore the pattern if the claims are being paid

Question 42 reset

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Which of the following is a primary benefit of using standardized data sets in healthcare?

Reduced data storage costs

Improved data comparability and analysis

Increased patient satisfaction

Simplified billing processes

Question 43 reset

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A hospital wants to assess the efficiency of its Release of Information (ROI) process. Which metric would be most useful to track?

The number of ROI requests received per month

The cost per ROI request

The turnaround time for processing ROI requests

The number of staff dedicated to ROI

Question 44 reset

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A patient discovers an error in their medical record and requests a correction. The physician refuses to amend the record. What is the patient's right according to HIPAA?

To have the incorrect information deleted immediately

To file a lawsuit against the physician

To submit a statement of disagreement to be included in the record

To demand a second opinion from another physician

Question 45 reset

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What is the primary purpose of a healthcare compliance program?

To maximize reimbursement

To ensure adherence to laws, regulations, and ethical standards

To streamline administrative processes

To improve employee morale

Question 46 reset

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A new policy regarding the use of portable electronic devices containing PHI is being developed. Which of the following security measures should be included?

Allowing personal devices without restrictions

Requiring password protection and encryption

Discouraging the use of portable devices altogether

Only allowing access to a limited subset of patient data

Question 47 reset

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What is the difference between Medicare Part A and Medicare Part B?

Part A covers physician services, while Part B covers hospital services.

Part A is mandatory for most, covering inpatient hospital stays, while Part B is voluntary, covering outpatient services and physician fees.

Part A covers prescription drugs, while Part B covers durable medical equipment.

There is no significant difference between Part A and Part B.

Question 48 reset

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A hospital's Discharged Not Final Billed (DNFB) report shows a high number of records held for coding-related issues. Which of the following could contribute to this?

Efficient communication between HIM and billing

Timely physician documentation

Automated coding software

Low patient census

Question 49 reset

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A healthcare organization is implementing a new EHR system. What is a critical step to ensure data integrity during the migration process?

Transferring all data without any validation

Conducting thorough data mapping and validation

Relying solely on the vendor for data conversion

Skipping user training to expedite the go-live process

Question 50 reset

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Which of the following leadership skills is essential for an HIM manager to effectively guide their team through a significant change, such as an EHR implementation?

Micromanagement

Autocratic decision-making

Effective communication and change management

Ignoring employee concerns to maintain the project timeline

Timezupp!!

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