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RHIA Exam Prep

AHIMA RHIA exam

Question	Answer
Permission granted by the government to operate a facility or practice health care profession	Licensure
QI	Quality Improvement
Publishes Coding Clinics	American Hospital Association
Responsible for hospital overall financial plan and accounting practice Publishes the CPT coding Manuals	CFO
Hospital Insurance part of Medicare	Part A
Hospital are considered __________ care	acute
State and federally funded health benefits for the low income.	Medicaid
Addressed issues of insurance portability and also security of health information	HIPAA Health Insurance Portability and Accountability Act of 1996
3 Level of care in nursing facilities	skilled, intermediate, subacute
CCA	Certified Coding Associate
Agency that administers the Medicare program	CMS (know what this stands for )
Voluntary process of meeting standards set forth by an association or agency.	Accreditation (Joint Commission is the most common voluntary accreditation in health care)
UR	Utilization Review
Process of determining the appropriateness of care	Utilization Review
Established Medicare and Medicaid	Public Law 89-97 of 1965 (amendment to the Social Security Act)
Established Social Security	Social Security Act of 1935
RM	risk management
outpatient care such as emergency visit, outpatient surgery, physician office visit is also called.....	Ambulatory care
Physicians that practice at the hospital comprise the ______	Medical Staff
Provided funding for construction of hospitals	Hill-Burton Act
Second highest management position in a hospital.	COO (Chief Operating officer)
Reviews the quality of services provided by the hospital.	quality improvement
Range of health care services provided to a patient	continuum of care
# of CE hours required for RHIA	30 every 2 years
Which is not considered an Allied Health profession? nursing respiratory laboratory HIM medical staff	nursing & medical staff
Process of identifying potential causes of liability	Risk Management
President of the hospital responsible for day to day operations	CEO
Hospital department where the medical record begins	admitting or registration
Administrator responsible for the overall information technology and process in a hospital?	CIO
Medical Insurance part of Medicare	Part B
what term is used in reference to objective descriptions of processes, procedures, people and other observable objects and activities	Data
provide vital clinical and administrative support services to patients, medical staff, visitors and employees	ANCILLARY SUPPORT SERVICES
ancillary function of the health record	BIOMEDICAL RESEARCH
systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances	CLINICAL PRACTICE GUIDELINES
To what authority do hospitals report vital statistics?	The National Vital Statistics System
An attempt to contain hospital inpatient costs and improve quality by restructuring services	PATIENT-FOCUSED CARE
Level of skilled care needed by patients with complex medical conditions, typically Medicare patients who have multiple medical problems	SUB-ACUTE CARE
Quality components	ACCESSIBILITY, APPROPRIATENESS, TECHNICAL EXCELLENCE AND ACCEPTABILITY
T or F: Turnaround times are examples of qualitative standards and error rates are examples of quantitative standards	FALSE
Specify the level of service quality expected from a function: Accuracy Rate and Error Rate	Qualitative Standard
Specify the level of measurable work or productivity expected for a specific function: Number of units of work for a specified period of time or turnaround time	quantitative
Protects medical records and other individually identifiable health information from being used or disclosed in any form	Privacy Rule
groups that classify patients into clinically cohesive groups that demonstrate similar consumption of hospital resources and LOS patterns	DRG
based on the grouping of procedures by CPT/HCPCS codes that have similar costs or resource inputs	APC-Ambulatory Payment Classification
the exchange standard for laboratory results, enabling standards to be developed and adopted relatively quickly	LOINC- Logical Identifier Names and Codes
Diagnosis described as "possible", "probable", "likely" and "rule out" are reported as if present for which type of patient records	Inpatient
The Federal physician self-referral statute is known as....	Stark Law
Responsible for ensuring the quality of health record documentation	provider
Codes assigned to a patient who is seeking health services but is not necessarily sick	V codes
Insufficient and missing documentation and __________ are two areas that the OIG says is responsible for 70 percent of bad claims	Failure to document medical necesity
If the nonPar physician chooses to accept assignment, he or she is paid ___ of the MFS.	95%
reimburses phyicians according to a fee schedule based on predetermined values assigned to specific services	RBRVS -Resource-Based Relative Value Scale
a number used to multiply each RVU so that it better reflect a geographical area's relative costs	GPCI Geographic Pricing Cost Index
converts RVUs into payments	National Conversion Factor
method of grouping patients according to a predefined set of characteristics	Case mix
average DRG weight for the patients discharged from the hospital	case-mix index
a measure of the resources used in treating patients in each or group of hospitals	CMI ( case mix index)
established in 1847 to represent the interests of physicians across the US	AMA
AMA	American Medical Association
dedicated to standardizing the curriculum for the US medical schools and to developing the public's understanding	AAMC
AAMC	American Association of Medical Colleges
UR	Utilization Review
goal is to ensure that services provided to Medicare beneficiaries were medically necessary	UR (Utilization Review)
CMS	Centers for Medicare and Medicaid Services
NPDB	National Practitioner Data Bank
Provides a clearinghouse for information about medical practitioners who have a history of malpractice suits and other quality problems.	NPDB (National Practitioner Data Bank)
Hospitals are required to consult the _______ before granting medical staff privileges to healthcare practitioners	NPDB (National Practitioner Data Bank)
maximum number of inpatients the hospitals can care for	bed capacity
IDS	Integrated Delivery System
fastest growing sector of Medicare	Home care service
Goal is to organize the continuum of care from health promotion and disease prevention to hospice care to maxmize its effectiveness across episodes of illness	IDS (Integrated Delivery System)
LTCH	Long Term Care Hospital
RAI	Resident Assessment Instrument
PHI	Protected health information
a category of PHI which may be used or disclosed only in certain circumstances or under certain conditions	Privacy Rule
RDBMS	relational database management system
a database management system in which data are organized and managed as a collection of tables	RDMBS relational database management system
a type of database that uses commands that act as small self contained instructional units that may be combined in various ways	Object-Oriented Database
UHDDS	Uniform Hospital Discharge Data Set
NCHS	National Center for Health Services Research and Developement
help coding supervisors become aware of coding errors so that they can be corrected	coding audits
if the diagnosis documented at the time is qualifiable as "probable", "suspected" or likely in this setting the condition should be coded as if it existed or was established	outpatient
In what year did the US begin using ICD-10 to report mortality statistics under its agreement with WHO	1999
factors that need to be addressed when assessing data quality	validity, reliability, completeness, and timeliness
refers to the accuracy of the data	validity
the extent to which data can be reproduced by subsequent measures or tests	reliability
used to increase the accuracy and efficiency of the coding process	encoder
patients who are admitted for an HIV-related illness should be assigned a minimum of two codes:	042 to identify the HIV disease and additional codes to identify the related diagnoses. (in that order)
NEC	not elsewhere classifiable
NOS	not otherwise specified
type of health record that is compiled about a person from birth to death	longitudinal record
advantages of a longitudinal record	avoids repetition of details and repeat testing prevents medical errors
Who is responsible for for ensuring entries made into the health record are of high quality?	the provider of care
In what part of the health record would a microscopic description of tissue excised during surgery be found?	pathology report
MDS	Minimum Data Set 2.0
preventative or corrective healthcare services provided on a nonresident basis in an a provider's office, clinic setting or hospital outpatient setting	ambulatory
medical care of a limited duration that is provided in an inpatient hospital setting to diagnose and/or treat an injury or short-term illness	acute care
medical and surgical care provided to patients who return to their homes the same day they receive the care	ambulatory care
UACDS	Uniform Ambulatory Care Data Set
This data set includes optional data elements to describe patients' living condition and marital status to manage at-home care (if needed)	UACDS (Uniform Ambulatory Care Data Set)
data set used for long-term care	MDS
federally mandated standard assessment form used to collect demographic and clinical data on nursing home residents	MDS
Data collected via the MDS are used to develop a _____ summary for each resident which assists in creating the plan of care.	RAP (Resident Assessment Protocol)
OASIS	outcomes assessment information set
data set used in home healthcare setting	OASIS (outcomes assessment information set)
DEEDS	Data Elements for Emergency Care Services
Data set used in the Emergency Department	DEEDS (Data Elements for Emergency Care Services)
Patient care plans, pharmacy consultations, and and transfer summaries are likely to be found on the records of acute care/ ambulatory patients?	acute care
collaborated integration of health care providers	integrated health system
the combination of everyone's effort accomplishes more than one person acting alone	synergy
For financial reasons, a fiscal year is divided into how many quarters? How many months in each quarter?	4, 3
Influence by force of personality in which the leader inspires commitment, loyalty, faith, and vision.	charismatic leadership
health care payment method in which providers receive one lump sum for all the services they provided related to a condition or a disease	episode-of-care
a chronological set of computerized records that provides evidence of information system activity used to determine security violations	audit trail
a liability that is created when the organization has received goods or payment, but has not yet remitted the compensation	accounts payable
Steps to evaluating an ethical problem	1.determine the facts 2.consider the values and obligations of others 3.consider the choices that are both justified and not justified 4. identify prevention options
occurs when the actual results are worse than what was budgeted	unfavorable variance
considers sentence structure(syntax), meaning (semantics), and context to accurately process and extract free-text data, including speech data for application purposes	natural language processing
medicare restructuring of reimbursement of inpatient hospital admissions	MS-DRG
NCVHS	National Committee on Vital Health and Statistics
advisory body on health data, statistics and national health information policy	NCVHS
Works to improve data collected in the ambulatory care setting	UACDS
UACDS	Uniform Ambulatory Care Data Set
HIPPA	Health Insurance Portability and Accountability Act of 1996
Legislation in 1996 whose focus is health insurance and health information	HIPPA
ANSI	American National Standards Institute
Oversees and accredits private standards developing organizations in the US	ANSI
DEEDS	Data Elements for Emergency Department Systems
Uniform specifications for data entered in ED patient records	DEEDS
OASIS	Outcome and Assessment Information Set
Standardized reproducible assessment instrument used to monitor home health care	OASIS
concerned with communicable diseases and environmental health	CDC
CDC	Center for Disease Control and Prevention
DHHS	Department of Health and HUman Services
Branch of the federal government who has responsibility for regulatory programs affecting the health care industry	DHHS
JCAHO	Joint Commission on Accreditation of Healthcare Organizations
private accrediting organization whose goal is to improve the quality of patient care through the developement/assessment standards of performance by health care organizations	JCAHO
NCQA	National Committee for Quality Assurance
Accrediting agency for MCOs	NCQA
HEDIS	Health Plan Employer Data and information Set
standardized set of performance measures designed to allow purchaser /consumers of managed care plans to compare performance	HEDIS
ASTM	American Society for Testing Materials
National standard development body	ASTM
AMIA	American Medical Informatics Association
Provides leadership and developement of information systems to improve patient care	AMIA
HIMSS	Health Information Management and Systems Society
focuses on optimal use of health care information technology and management systems for the betterment of human health	HIMSS
committed to the creation of quality health record reports from dictation by health care providers	AAMT
AAMT	American Association for Medical Transcription
AHRQ	Agency for Healthcare Research and Quality
a formally recognized list of preferred medical terms and their corresponding definitions	clinical vocabularies
a set of standardized terms and their synonyms that record patient findings, circumstances, events, interventions, with sufficient detail to support clinical care, outcomes research and quality improvement.	clinical terminology
a recognized system of terms used in a science or art that follows pre-established naming conventions	nomenclature
SNOMED-CT	Clinical and anatomic pathology clinical vocab
NDC/NDF-RT	Pharmaceuticals vocab
NIC/NOC	Nursing vocab
process of identifying/describing the link between two or more distinct databases	data mapping
cross linking between current terminology and new terminology between organizations or in an organization	data mapping
provides a graphical depiction of the sequencing of the steps in a process	flowchart
illustrate hierarchical relationships between entities	organizational chart
useful to present projected indications of achievement of deadlines	time lines
used to provide likely completion times for projects to accmplish larger goals	PERT charts
a common project scheduling tool used to emphasize the work time needed to meet an identified goal	Gantt Charts
According to the Joint Commission in what time frame should a chart be fully completed?	30 days
finding a better, more proficient way to perform a process is known as	work simplification
when analysis of a patient chart evaluates the proper correction of entry error in the chart, the t ype of analysis performed is	legal
occurs when data are correct and valid	accuracy
four data components to ensure accuracy are;	education, training, communication, and timeliness
indicates the data are true to source, there have been no alterations or destruction by unauthorized users in an unauthorized manor	integrity
IRB	Institutional Review Board
protect the rights and welfare of human subjects as they engage in research activities	IRB -Institutional Review Board
a standards development organization that addresses issues at the seventh or application level of healthcare system interconnections	HL7
For Medicare Patients how often must the HHAs assessment care plan be updated?	at least every 60 days or as often as the severity of the patient's condition requires
the time required to recoup the cost of the investment	payback period
a healthcare payment reimbursement method in which providers receive on lump sum for all the services they provide related to a condition or a disease	episode-of-care
RBAC	Role Based Access Control
control system in which access decisions are based on the roles of individual users as part of an organization	RBAC
MMA	Medicare Modernization Act of 2006 - medicare part d offers outpatient drug coverage
ASP	Application Service Provider
service firms that deliver, manage, and remotely host through centralized servers via a network	ASP
SDLC	Systems Development Life Cycle
What Act expanded CMS quality initiatives to hospital outpatient departments and and ambulatory surgical centers	tax relief and health care act of 2006
the proportion of persons in a population who have a particular disease at a specific point in time or over a specified period of time	prevalence rate
members of a team offering ideas as they come to mind	unstructured brainstorming
rectangle with double lines on either side in is a flowchart is a ______ ______ _____. What does it represent?	predefined process icon A formal procedure that is to be carried out the same way every time.
a graphic tool used to organize and prioritize ideas after a brainstorming session	affinity diagram
services rendered and billed to customers for future payment create transactions that are posted to:	accounts receivable and revenue
basic accounting principle that requires that organizations follow the same accounting rules from year to year	consistency
stages of reflective learning	doing, reflection, interpretation, and application
collects information on all goods and services the facility provides to its clients	charge description master
Fayol's management functions	Planning Organizing Leading Controlling
Describe the Acceptance Theory of Authority	Theory of Chester Barnard that states that people have the free will to choose whether or not to follow work orders
a situation that can affect the success of the project	risk
cost that does not vary with changes in volumes or units of production	variable
when a company compares their processes to other companies or industries	benchmarking
a decision making process in which the decision maker accepts a solution to a problem that is satisfactory rather than optimal	satisficing
a graphic tool used to organize and prioritize ideas	affinity diagram
a belief that employees will advance to their highest level of competence and then be promoted to their level of incompetence where they will remain	Peter Principle
a formal document sent to vendors inviting them to submit bids for the organization's EHR project	RFP (Request for Proposal)
Systems Development Life Cycle	Analysis Design Implementation Maintenance/Evaluation
Most common language used for relational databases. A nonprocedural or fourth-generation, language. The user specifies what must be done, but not how it must be done	SQL structured query language
What is considered a primary data source?	Health record
data taken from the primary health record and entered into regestries and data bases is considered _______________ data.	secondary
data on groups of people or patients without indentifying any particular patient individually	aggregate data
contains patient identifible data: name, address, birthdate, dates of hospitalization, etc.	MPI
the health record is organized according to the source or the dept that rendered the service	source-oriented record
type of record where the problem list serves as the table of contents-- uses the SOAP method of progress notes	problem-oriented health record
SOAP	Subjective Objective Analysis Plan
health record where the content is arranged in strict chronological order	integrated health record
accuracy of data	validity
consistency of data	reliability
data quality elements	validity, reliability, completeness, and timeliness
HITECH	Health Information Technology for Economic and Clinical Health
HITECH ACT	in the event of a breach of PHI, the CE must notify each patient who's unsecured PHI has been acquired or used or disclosed as a result of the breach
Types of PHI that can NOT be provided w/o signed consent	-patient's HIV/AIDS status -mental helath treatment -drug or alcohol treatment
Minors can consent to non-emergent treatment in the following situations:	-HIV testing -Dx and treatment for a venereal diseas -DX and treatment for diseases caused by alcohol or abuse -abortion
Law of the Land	the constitution
takes precedence over constitutions and laws in the individual states and local jurisdictions	constitutional law
unwritten law originating from court decisions where no applicable statute exists	common law
law established by federal and state legislatives	statutory law
Medicare Conditions of Participation are published in the ________.	Federal Register
the party bringing the action or complaint in a civil case	plaintiff
an entity or individual against whom the civil complaint has been filed	defendant
an action brought when one party believes that another party caused harm through wrongful conduct	tort
careless conduct that results outside of the standard of care	negligence
what an individual is expected to do or NOT to do in any given situation	standard of care
negligence or carelessness of a professional	malpractice
reckless direguard for the safety of another	criminal negligence
execution of an unlawful or improper act	malfeasance
the improper performance of an act resulting in an injury to another	misfeasance
the failure to act when there is a duty to act as a reasonably prudent person would act in a similar situation	nonfeasance
4 things that MUST be present to recover damages from negligence:	-duty of care: patient-caregiver relationship must be present -breach of the duty of care -plaintiff must have suffered an injury -plaintiff must show that the defendent caused harm
the person committed the act knowing that harm would likely occur	intentional tort
a deliberate threat that is combined with the apparent present ability to cause physical harm to another person	assault
intentionally touching another person in a socially impermissable manner without the person's consent	battery
a false communication about someone to a person other that the person defamed that tends to injure the person's reputation	defamation of character
the written form of defamation	libel
the spoken form of defamation	slander
to recover damages in an action for defamation,these must be present:	-the defendant made a false and defamatory statement about the plaintiff -the statement was not a privelaged publication and was made to a third person -at least negligence occured -actual or presumable damages occured
gives individuals some control over the information collected about them by the federal government	Privacy Act of 1974
According to the Privacy Act of 1974 people have the right to:	-learn what information is collected about them -view and have a copy of that information -maintain limited control over disclosures of that information
a federal law through which individuals can seek access to information without authorization of the person to whom the info applies	Freedom of Information Act
what does RHIA stand for	registered health information administrator

Created by: fiwilliams

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