PART 4 Flashcards
Steve submitted a written authorization to request a copy of his medical record. However, Steve’s psychiatrist has determined that access to his PHI might endanger his life or safety. What should the covered entity do concerning the request?
a. release requested information to Steve’s legal guardian
b. confirm the psychiatrist decision and deny the request
c. release requested information to Steve
d. provide an appeals process to Steve for the denial
Provide an appeals process to Steve for the denial
Skilled nursing facilities may choose to submit MDS data using RAVEN software, or software purchased commercially through a vendor, provided that the software meets
A. CMS standards.
B. NHIN standards.
C. Joint Commission standards.
D. HL-7 standards.
CMS Standards
A primary focus of screen format and design in a health record computer application should be to ensure that
A) the users is capturing essential data elements
B) data fields can be randomly accessed
C) programmers develop standard screens for all hospitals
D) Paper forms are easily converted to computer forms
The user is capturing essential data elements
A patient presented to the physician’s office for removal of 10 skin tags on his torso. During the procedure, the patient became anxious and the procedure was discontinued. No skin tags were removed. Which code is reported?
a.11200-52
b.11200-53
c.11200-73
d.11200-74
11200-53
A researcher needs information on acute care hospital Medicare patients, specifically claims data which (includes demographic data, operating room, therapy, pharmacy), ICD-10 diagnosis and procedure codes and DRGs. The claims data file that can be accessed to obtain this information is
A: Medicare Provider Analysis and Review (MEDPAR)
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Determine if this is a leading or non-leading query- Dear Doctor Johnson, Mrs. Smith, a 68 year old female with a history of osteoporosis was admitted with a fracture of the femur after falling from a set of bleachers to the ground. Coding guidelines require explicit physician documentation regarding that nature of the fracture. Based on the information provided could you please specify the etiology of the fracture
A: This is a non-leading query
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A patient is admitted for repair of a fracture of the hip following a fall down stairs. She delivered a baby 2 weeks ago.While she was hospitalized for the fracture, she developed a postpartum pulmonary embolism. She responded well to treatment for the embolism and the hip surgery and was subsequently discharged home. What is the principal diagnosis?
A: Fracture of hip
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Setting a standard for data capture, such as identifying the pattern for date of birth (DDMMYY or DDMMYYYY) and determining the number of possible characters per data field is described in a
A: Data dictionary
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A patient is admitted to the ambulatory care unit of the hospital for a planned cholecystectomy because she has cholelithiasis. Shortly before surgery, she developed tachycardia and elevated blood pressure, and the surgery was cancelled. After a workup for the unit. This outpatient admission should have which diagnosis code sequenced first?
A: Cholelithiasis
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Listed below are the findings from a recent coding audit
50 records reviewed
15 coding errors were identified with an average of 2 per record
a total of 250 codes were reviewed
Calculate the coding accuracy rate using the code-over-code method
A: 94%
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