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Health Record And Data > Health Information Governance > Flashcards

Health Information Governance Flashcards

1
Q

Coding _______is important function of Healthcare operation secondary to federal regulation to identify discripency between coded data and supporting documentation

Audit
Compliance
Governance
Retention

A

Compliance

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2
Q

Coders responsibility to use related terms of PCs to operation root term

True
False

A

True

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3
Q

If there is conflict in documentation process between multiple entries of authers, coders should include clinical indicators to assign proper codes

True
False

A

True

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4
Q

To ensure coders ________, coders should be certified and clinical documentation improvement specialist as well

Coding compliance
Coding ethical standard
Coding quality

A

Coding ethical standard

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5
Q

_______ tool of communication that CIDS/coders and physician to clarify incomplete documentation

A

Physician query

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6
Q

What 8 examples of physician query may be initiated

A 
POA
organism
Stages of Ckd
Severity of asthma
Ruled in or rule out
Conflict information
Pneumonia (whether) caused by aspiration
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7
Q

Example of clinical indicators that coders/CIPD are depends on while raise quiry to physician?

A

Temperature
WBC
Blood pressure

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8
Q

Coders and CPID are not crediatialy Healthcare providers

True
False

A

True

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9
Q

_________ communication tools between coders/CIPD and physician without out clinical indicators and can be as quiry that direct health providers to spasific diagnosis

A

Leading query

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10
Q

Annual coding changes has been done
Icd 10 cm and PCs has update on

October
Jan
Dec

A

October 1

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11
Q

CPT has annually updated on

October
Jan
Nov

A

Jan 1

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12
Q

What are 3 coding changes resource that reliable

For coders

A

Coding clinic
CPT assistance
3m nosology

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13
Q

_______is central office works with NCHS and CMS to maintain integrity of coding

AHA
AMA
AHIMA

A

AHA

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14
Q

CPT assistant is published and maintain by

AMA
AHA
CMS

A

AMA

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15
Q

AHA has published ________the official publication of coding guideline and advice

Coding clinic
3M

A

Coding clinic

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16
Q

Who are the responsible on CPT annual update?

A

CPT advice committee

Editorial panel

17
Q

Who is responsible on icd10 annual updating

A

CDC and NCHS join as committee

18
Q

In which year announce that icd9 has retired and icd10 has implemented

A

1st Oct 2015

19
Q

Translation reference tool that demonstrate the network relationship between Icd 9 code and Icd 10 code

A

GEMs

General equivalence mappings

20
Q

When Icd9 code is available and Icd 10 cod is needed, this is called

Forward mapping
Backward mapping

A

Forward mapping

21
Q

When icd10 code is available and Icd9 code is needed, this called

Forward mapping
Backward mapping

A

Backward mapping

22
Q

Physician office should update Charge ticket or encounter form as _____baise

Annually
Monthly
Every 2 year

A

Annually

23
Q

Hospital has database that containe all charges of services rendered, what this database called

A

Chargmaster

Or Charge descriptions master

24
Q

What are the 6 element that typical data should contain in hospital chargmaster?

A 
CDM number/code
Dollar charge amount
Charge descriptions
CPT /hcpic code and modifiers
Charge status 
Revenue code
25
Q

What is 3 digit code that represent the location of pateint that rendered or the type of service that pateint received

Revenue code
Charge code
Invoice code

A

Revenue code

26
Q

__________ should engage with the process of convenient other physician to provide valuable and supportive documentation to support HIM with coding compliance

A

Physician champion

27
Q

_____________publish a work plan each year, an excellent indicator for hospital where should focus during internal audit

HHS
CMS
OIG

A

OIG

28
Q

The _________audit goal is to reduce improper payments

RAC
OIG
DOJ

A

RAC

29
Q

ACT the ensure all people has access to emergency regardless of ability to pay ___________

A

EMTALA

Emergency medical treatment and labor act

30
Q

MAC medicare administrators contractor is considered one of external auditor

True
False

A

True

31
Q

EMTALA is enforced by _____________and either one of them can conduct an audit

CMS and HHS
CMS AND OIG
CMS and Doj

A

CMS AND OIG

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