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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 |
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