Chap 1

Question 1

5 different types or groups of people who could read medical records you create:

Answer 1

1) attorneys, (2) researchers, (3) consulting providers, (4) patient, (5) peer reviewers, (6) insurance companies, (7) state or federal payers

Question 2

List at least 5 general principles of documentation that are based on CMS guidelines.

Answer 2

(1) record should be complete and legible; (2) for each encounter, document reason, relevant history, exam findings and diagnostic test results, assessment, and plan for care; (3) date and legible identity of person documenting; (4) rationale for ordering test or services; (5) past and present diagnoses; (6) health risk factor identification; (7) patient’s progress and response to treatment; (8) identify CPT codes and ICD-9 codes.

Question 3

Describe how to make a correction in a medical record.

Answer 3

Draw a single line through the entry, label it as an error, initial and date it.

Question 4

Is this an acceptable or unacceptable documentation guideline: A Use of either the 1995 or 1997 CMS guidelines?

Answer 4

A

Question 5

Is this an acceptable or unacceptable documentation guideline: Making a late entry in a chart or medical record

Answer 5

A

Question 6

Is this an acceptable or unacceptable documentation guideline: Using correction fluid or tape to obliterate an entry in a record?

Answer 6

U

Question 7

Is this an acceptable or unacceptable documentation guideline: Making an entry in a record before seeing a patient

Answer 7

U

Question 8

Is this an acceptable or unacceptable documentation guideline: Amending an entry in a medical record?

Answer 8

A

Question 9

Is this an acceptable or unacceptable documentation guideline: Stamping a record “signed but not read”?

Answer 9

U

Question 10

T/F: CPT codes reflect the level of evaluation and management services provided.

Answer 10

T

Question 11

T/F: The three key elements of determining the level of service are history, review of systems, and physical examination.

Answer 11

F

Question 12

T/F: Time spent counseling the patient and the nature of the presenting problem are two factors that affect the level of service provided.

Answer 12

T

Question 13

T/F: ICD-9 codes indicate the reason for patient services.

Answer 13

T

Question 14

T/F:CD-9 codes are used to track mortality and morbidity statistics internationally.

Answer 14

T

Question 15

T/F: ICD-10 code sets have more than 155,000 codes but do not have the capacity to accommodate new diagnoses and procedures.

Answer 15

F

Question 16

T/F:“V” codes are used for reasons other than illness or disease.

Answer 16

T

Question 17

T/F: The medical record must include documentation that supports the assessment.

Answer 17

T

Question 18

T/F: Assignment of appropriate CPT and ICD-9 codes that support the level of E/M services provided is only dependent on adequate documentation of the history and physical examination.

Answer 18

F

Question 19

T/F: An ICD-9 code should be as broad and encompassing as possible.

Answer 19

F

Question 20

T/F: There is no code for “rule out.”

Answer 20

T

Question 21

T/F: The complexity of medical decision making takes into account the number of treatment options.

Answer 21

T

Question 22

What are ICD-9 codes used to identify?

Answer 22

diagnosis
symptoms
complaint
complications

Question 23

rash =

Answer 23

exanthem

Question 24

fever =

Answer 24

influenza

Question 25

navel =

Answer 25

umbilicus

Question 26

heartburn =

Answer 26

GERD

Question 27

stroke =

Answer 27

cerebrovascular incident

Question 28

kidney stones =

Answer 28

renal calculus

Question 29

flat feet =

Answer 29

pes planus

Question 30

B12 def =

Answer 30

pernicious anemia

Question 31

sugar diabetes =

Answer 31

DM

Question 32

stomach =

Answer 32

abdomen

Question 33

tiredness =

Answer 33

fatigue

Question 34

tennis elbow =

Answer 34

lateral epicondylitis

Question 35

heel =

Answer 35

calcaneous

Question 36

heart attack =

Answer 36

MI

Question 37

pink eye =

Answer 37

conjunctivitis

Question 38

emphysema =

Answer 38

COPD

Question 39

light intolerance =

Answer 39

photophobia

Question 40

tubal pregnancy =

Answer 40

ectopic pregnancy

Question 41

ear drum -

Answer 41

tympanic membrane

Question 42

blood thinner -

Answer 42

anti coag

Question 43

List at least five functions that an EMR system should be able to perform.

Answer 43

Any of the following: (1) store health information and data; (2) result management for diagnostic tests; (3) order management; (4) decision support; (5) electronic communication and connectivity; (6) patient support; (7) administrative processes; (8) reporting.

Question 44

Identify at least five perceived benefits of an EMR system.

Answer 44

Any of the following: (1) immediate access to key information such as allergies, lab results; (2) alert to duplicate orders; (3) alert to drug interactions; (4) reduce duplication; (5) enhance legibility; (6) reduce fragmentation; (7) improve the speed with which orders are executed; (8) alert to screenings and preventive measures needed; (9) improve continuity of care; (10) reduce frequency of adverse events; (11) increase timeliness of diagnoses and treatment; (12) provide decision-making support to increase compliance with best clinical practices.

Question 45

Identify at least five potential barriers to implementing an EMR system.

Answer 45

Any of the following: (1) cost of implementation; (2) reduced workflow and productivity during implementation; (3) unreliable technology; (4) lack of interoperability; (5) safety and security of systems; (6) debate over who owns data; (7) technical matters such as accessibility, vendor support, down time.

Question 46

List at least two criteria required to meet F “meaningful” use standards.

Answer 46

Any of the following: (1) certified system; (2) electronic prescribing; (3) quality reporting; (4) capable of exchanging data with other systems

Question 47

T/F: Establishes standards for the electronic transfers of health data

Answer 47

T

Question 48

T/F: Provides health care for everyone

Answer 48

F

Question 49

T/F: everyone limits exclusion of preexisting medical conditions to 24 months

Answer 49

F

Question 50

T/F: Gives patients more access to their medical records

Answer 50

T

Question 51

T/F: Protects medical records from improper uses and disclosures

Answer 51

T

Question 52

T/F: Federal HIPAA regulations preempt state laws.

Answer 52

F

Question 53

T/F: The Privacy Rule only applies to covered entities that transmit medical information electronically.

Answer 53

T

Question 54

T/F: Protected Health Information is data that could be used to identify an individual.

Answer 54

T

Question 55

T/F: Covered entities include doctors, clinics, dentists, nursing homes, chiropractors, psychologists, pharmacies, and insurance companies.

Answer 55

T

Question 56

T/F: A covered entity may disclose PHI without patient authorization for purposes of treatment, payment, or its health-care operations.

Answer 56

T

Question 57

T/F: PHI cannot be transmitted between covered entities by e-mail.

Answer 57

F

Question 58

T/F: Patients are entitled to a listing of everyone with whom their health-care provider has shared their PHI.

Answer 58

F

Question 59

T/F: PHI may be disclosed to someone involved in the patient’s health care without written authorization.

Answer 59

T

Question 60

T/F: The Privacy Rule allows certain minors access to specified health care,

Answer 60

T

Question 61

T/F: A Notice of Privacy Practice explains how patients’PHI is used and disclosed by the covered entity.

Answer 61

T

Question 62

T/F: An employee cannot be terminated for violating the Privacy Rule.

Answer 62

F

Question 63

T/F: An individual may not sue the insurance company over an HIPAA violation.

Answer 63

T

Question 64

T/F: Criminal penalties for HIPAA violations can result in fines and imprisonment.

Answer 64

T

Question 65

T/F: The confidentiality, integrity, and availability of PHI only need to be protected when the PHI is transmitted, not when it is stored.

Answer 65

F

Question 66

T/F: Employees are required to attend periodic security awareness and training.

Answer 66

T

Question 67

T/F: The Security Rule requires covered entities to install and regularly update antivirus, anti-spyware, and firewall software.

Answer 67

T

Question 68

T/F: Physical and technical safeguards must be in place to prevent PHI from being transmitted over the Internet.

Answer 68

T

Question 69

T/F: A process to develop contracts with business associates that will ensure they will safeguard PHI is required by HIPAA.

Answer 69

T

Question 70

HIPAA may not audit a practice for compliance without notice.

Answer 70

F

Question 71

Indicate by a yes (Y) or no (N) whether disclosure of PHI to the specific entity would require patient authorization.

Answer 71

N Specialist/consultant N Patient’s health plan Y Life insurance company N Hospital accounting department Y Patient’s employer Y Pharmaceutical companies N Reporting a gunshot wound to police N Reporting names of patients with a communicable disease to a county health department N Reporting suspected child abuse to a child protection agency N Medical billing and coding department Y Friends and family not involved in a patient’s health care

Question 72

Identify at least two conditions that are considered sensitive PHI.

Answer 72

Any of the following: (1) HIV status; (2) mental health conditions; (3) substance abuse

Question 73

Patients have the right to review and obtain copies of their medical records except in certain circumstances. List two.

Answer 73

Any of the following: (1) psychotherapy notes; (2) information compiled for a lawsuit; (3) information that, in the opinion of the health-care provider, may cause harm to the individual or another.