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Cca Devry

The document is a test bank for DeVry's HIT 220/HIM2233 course, containing over 90 multiple-choice questions with verified answers related to health information technology and management. It covers various topics including coding, HIPAA regulations, patient records, and reimbursement methods. Each question is accompanied by an answer and a brief explanation for clarity.

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0% found this document useful (0 votes)
47 views29 pages

Cca Devry

The document is a test bank for DeVry's HIT 220/HIM2233 course, containing over 90 multiple-choice questions with verified answers related to health information technology and management. It covers various topics including coding, HIPAA regulations, patient records, and reimbursement methods. Each question is accompanied by an answer and a brief explanation for clarity.

Uploaded by

mwanikicollins74
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CCA DEVRY’S HIT 220/HIM2233

FINAL EXAM-STYLE TEST BANK


(2025)
DeVry’s HIT 220/HIM2233
CCA EXAM-STYLE TEST BANK : 90+ MCQS WITH
100% VERIFIED ANSWERS

1. A patient receives epinephrine and nebulizer treatments with no relief from wheezing or
shortness of breath. Which diagnosis is most likely?
A. Acute bronchitis
B. Asthma with status asthmaticus
C. Chronic obstructive asthma
D. Acute bronchitis with COPD

Answer: B. Asthma with status asthmaticus


Failure to respond to typical asthma treatments suggests status asthmaticus.

2. An HIM clerk removes previous hospital records from a patient’s disclosure. According
to HIPAA, this action is:
A. Correct, only current records are required
B. Acceptable under hospital policy
C. Incorrect; previous records are part of the designated record set
D. Recommended to avoid confusion

Answer: C. Incorrect; previous records are part of the designated record set
HIPAA defines the designated record set to include relevant past medical records.

3. Which type of review checks for missing signatures, documents, and report placement in
the health record?
A. Outcomes review
B. Statistical review
C. Quantitative review
D. Qualitative review

Answer: C. Quantitative review


Quantitative review ensures required elements are present and properly signed.
4. What code modifier is used when a colonoscopy is started but not completed due to
sudden patient instability?
A. -52
B. -74
C. -76
D. -59

Answer: B. -74
Modifier -74 indicates a procedure was started but discontinued after anesthesia.

5. What concept ensures health data is not altered during transmission across networks?
A. Confidentiality
B. Data accuracy
C. Audit trails
D. Data integrity

Answer: D. Data integrity


Data integrity maintains unaltered content from origin to destination.

6. Which payment method determines reimbursement before a service is provided?


A. Retrospective
B. Per diem
C. Fee-for-service
D. Prospective

Answer: D. Prospective
Prospective payment systems predetermine the reimbursement amount.

7. A coding analyst enters the wrong gender code. What data control should be in place?
A. Access logs
B. Password strength
C. Edit checks
D. Encryption
Answer: C. Edit checks
Edit checks prevent incorrect data from being entered into specific fields.

8. Which diagnosis code is appropriate for a patient seen for chest pain with possible
GERD, but no final confirmation?
A. K21.9
B. Z03.89
C. R07.9
D. R10.11

Answer: C. R07.9
When no definitive diagnosis is made, symptom codes like chest pain (R07.9) are used.

9. Under HIPAA, an individual must be able to:


A. Edit their medical record
B. Restrict certain PHI disclosures
C. Deny provider changes
D. Remove content they disagree with

Answer: B. Restrict certain PHI disclosures


Patients have the right to request limitations on the use of their PHI.

10. The appropriate location to begin a search for all myocardial infarction cases for Dr.
Jones is:
A. Operative index
B. Disease index
C. Physician index
D. MPI

Answer: B. Disease index


The disease index is used to identify records based on diagnoses.
11. In a problem-oriented medical record, “Continue with Diuril 500 mg daily” falls under:
A. Subjective
B. Assessment
C. Plan
D. Objective

Answer: C. Plan
The plan section contains treatment strategies and medication orders.

12. Which of the following edits would NOT trigger a denial of an outpatient claim?
A. NCCI
B. OCE
C. Outpatient claims editor
D. National/local policy

Answer: C. Outpatient claims editor


OCE is an edit system, but "outpatient claims editor" isn't a formal edit name.

13. Which of the following is NOT required for MS-DRG assignment?


A. Diagnoses and procedures
B. Discharge status
C. Attending physician
D. MCC or CC presence

Answer: C. Attending physician


Physician identity is not used in DRG grouping logic.

14. What code system is the APC outpatient prospective payment system based on?
A. ICD-10-CM
B. CPT/HCPCS
C. MS-DRG
D. CDT
Answer: B. CPT/HCPCS
APC uses CPT and HCPCS codes to determine outpatient service payments.

15. Which of the following conditions is considered a hospital-acquired condition by CMS?


A. Present on admission sepsis
B. Pressure ulcer that develops in hospital
C. COPD exacerbation
D. Diabetes

Answer: B. Pressure ulcer that develops in hospital


Preventable events like pressure ulcers acquired during the stay are not reimbursed extra.

16. A patient develops hematuria after properly taking Coumadin. The event should be
coded as:
A. Poisoning
B. Adverse effect
C. Unspecified reaction
D. Medication error

Answer: B. Adverse effect


Adverse effects result from a correctly administered drug producing harmful effects.

17. Which section of the health record would you find the “vital signs and mobility status”?
A. Pathology report
B. Physical exam
C. H&P
D. Discharge summary

Answer: B. Physical exam


The physical exam records objective data including vital signs and general appearance.

18. In CPT coding, unbundling refers to:


A. Assigning multiple codes for a single comprehensive procedure
B. Grouping separate procedures into one
C. Using a code from the wrong category
D. Submitting under a different provider
Answer: A. Assigning multiple codes for a single comprehensive procedure
Unbundling inflates charges by coding each step of a procedure separately.

19. The UHDDS is used primarily in:


A. Outpatient clinics
B. Psychiatric outpatient care
C. Acute care hospitals
D. Dental offices

Answer: C. Acute care hospitals


UHDDS data elements are required in short-term inpatient hospital settings.

20. What code describes incomplete expulsion of products of conception?


A. Complete abortion
B. Spontaneous abortion
C. Incomplete abortion
D. Threatened abortion

Answer: C. Incomplete abortion


This term indicates not all products of conception were expelled.

21. What system calculates DRG assignment from coded data?


A. Grouper
B. Encoder
C. DSS
D. UACDS

Answer: A. Grouper
The grouper uses ICD codes to assign MS-DRGs for payment.

22. In a coding compliance program, who is typically excluded from training?


A. Coders
B. Medical staff
C. Nurses
D. Newly hired coders
Answer: C. Nurses
While important, nurses are not typically trained in coding-specific compliance.

23. The term for a secure web-based access portal to medical data is:
A. Interface
B. VPN
C. Portal
D. Gateway

Answer: C. Portal
A portal is used to provide secure access to health information for providers or patients.

24. Which act first mandated standards for electronic health records?
A. HIPAA (1996)
B. HITECH (2009)
C. ACA (2010)
D. ARRA (2009)

Answer: A. HIPAA (1996)


HIPAA first introduced electronic health standards and privacy rules.

25. The component of security concerned with ensuring that data is accessible when needed
is:
A. Confidentiality
B. Integrity
C. Privacy
D. Availability

Answer: D. Availability
Availability ensures timely and reliable access to information systems and data.
26. In the UHDDS, which condition is defined as the condition after study that is mainly
responsible for the admission?
A. Discharge diagnosis
B. Principal diagnosis
C. Primary symptom
D. Secondary diagnosis

Answer: B. Principal diagnosis


The principal diagnosis is the main reason for the inpatient admission after study.

27. A healthcare facility's data breach must be reported to HHS within:


A. 7 days
B. 10 business days
C. 60 calendar days
D. 90 calendar days

Answer: C. 60 calendar days


HIPAA requires notification to HHS within 60 days of discovering a breach affecting 500+
individuals.

28. A security incident involving unauthorized access to ePHI is called a:


A. Compliance audit
B. Breach

C. Privacy lapse
D. Policy violation

Answer: B. Breach
A breach involves access, use, or disclosure of PHI that compromises its security or privacy.
29. Which document outlines the patient's rights regarding their PHI?
A. Advance directive
B. Notice of Privacy Practices (NPP)
C. HIPAA Privacy Rule
D. Consent form

Answer: B. Notice of Privacy Practices (NPP)


NPP is a document required by HIPAA that informs patients of their rights and how their
data is used.

30. A medical record with the wrong patient’s name and ID number presents a:
A. Delinquency
B. Duplicate
C. Overlay
D. Overlap

Answer: C. Overlay
An overlay occurs when one patient's data is overwritten onto another’s record.

31. Which is a formal method for analyzing the root cause of an error?
A. Audit trail
B. Peer review
C. Root cause analysis (RCA)
D. Incident report

Answer: C. Root cause analysis (RCA)


RCA investigates system issues and identifies the underlying cause of an event.

32. Which is a characteristic of CPT Category III codes?


A. They describe emerging technology
B. They are temporary and rarely used
C. They are for evaluation and management services
D. They are used only in inpatient coding
Answer: A. They describe emerging technology
Category III CPT codes are used for new and experimental procedures.

33. The data entry field that will only accept dates in MM/DD/YYYY format is an example
of a(n):
A. Access log
B. Format control
C. Data security measure
D. Natural language processor

Answer: B. Format control


Format controls restrict data entry to a specific structure or pattern.

34. What does the “present on admission” (POA) indicator help identify?
A. Payment method
B. Coding redundancy
C. Hospital-acquired conditions
D. DRG weight

Answer: C. Hospital-acquired conditions


POA indicators distinguish between pre-existing conditions and those developed during
hospitalization.

35. A health information technician is validating that coded diagnoses align with physician
documentation. This is an example of:
A. Utilization review
B. Clinical validation
C. Fee abstraction
D. Reimbursement analysis

Answer: B. Clinical validation


Clinical validation confirms that documented diagnoses are supported by clinical evidence.
36. A CPT code is needed for which of the following settings?
A. Home health coding
B. Inpatient hospital stay
C. Outpatient surgical center
D. Long-term care

Answer: C. Outpatient surgical center


CPT codes are primarily used in outpatient and physician services.

37. A report that groups patients by diagnosis and length of stay is part of:
A. Data abstraction
B. Productivity reporting
C. Case mix analysis
D. Utilization management

Answer: D. Utilization management


UM tracks patient care efficiency, including LOS and diagnosis clusters.

38. If a healthcare organization wants to measure coding productivity, they should


calculate:
A. Time per record
B. Number of records coded per hour/day
C. Chart review accuracy
D. Quality improvement rate

Answer: B. Number of records coded per hour/day


Productivity measures output—how much is completed in a time period.

39. In CPT, a triangle symbol (▲) before a code means:


A. New code
B. Deleted code
C. Revised code
D. Add-on code
Answer: C. Revised code
The triangle indicates the description has been revised in that coding year.

40. Which federal agency is responsible for enforcing HIPAA privacy regulations?
A. CMS
B. OCR
C. ONC
D. AHRQ

Answer: B. OCR
The Office for Civil Rights (OCR) enforces HIPAA rules.

41. A valid authorization for PHI disclosure must include all of the following EXCEPT:
A. Signature
B. Description of info disclosed
C. Diagnoses listed
D. Expiration date

Answer: C. Diagnoses listed


The diagnoses do not need to be specified unless part of the requested disclosure.

42. When can a facility disclose PHI without patient authorization?


A. For marketing purposes
B. To a health plan for payment
C. To an employer
D. For research without IRB approval

Answer: B. To a health plan for payment


HIPAA allows PHI disclosures for treatment, payment, and healthcare operations without
consent.

43. In MS-DRG assignment, which factor can impact reimbursement?


A. Physician specialty
B. Discharge disposition
C. Room number
D. Length of stay

Answer: B. Discharge disposition


Certain discharge statuses (e.g., home vs. another facility) may change DRG assignment and
payment.

44. The process of abstracting and coding clinical data is called:


A. Registration
B. Documentation
C. Clinical coding
D. Data warehousing

Answer: C. Clinical coding


Clinical coding transforms documented diagnoses and procedures into standardized codes.

45. Which data model represents relationships in tabular format using rows and columns?
A. Object-oriented
B. Network
C. Relational
D. Hierarchical

Answer: C. Relational
Relational databases use tables to store and manage data.

46. A patient’s lab values and test results fall under which part of the health record?
A. H&P
B. Progress notes
C. Diagnostic/laboratory section
D. Discharge summary

Answer: C. Diagnostic/laboratory section


All ordered tests and results are documented in the diagnostics section.
47. What is the purpose of the MPI (Master Patient Index)?
A. Store billing codes
B. List provider credentials
C. Track patient encounters across the organization
D. Control data entry permissions

Answer: C. Track patient encounters across the organization


MPI links all patient records by unique identifier across systems.

48. In a SOAP note, the “O” refers to:


A. Onset
B. Observation
C. Objective data
D. Ongoing care

Answer: C. Objective data


"O" in SOAP documents measurable, observable information (e.g., vitals, labs).

49. A coder is reviewing a patient chart and sees "CC" listed next to a secondary diagnosis.
This means:
A. Coding clarification
B. Complication or comorbidity
C. Chart complete
D. Chronic condition

Answer: B. Complication or comorbidity


CCs increase the severity level of the case and may impact DRG.
50. A “Query” is used in coding to:
A. Deny incomplete records
B. Clarify physician documentation
C. Request insurance preauthorization
D. Close out a delinquent chart

Answer: B. Clarify physician documentation


Queries ask providers to clarify ambiguous or missing data to support accurate coding.

51. What is the role of the National Correct Coding Initiative (NCCI)?
A. Set fee schedules
B. Prevent coding and billing errors
C. Approve new medical procedures
D. Maintain HIPAA security standards

Answer: B. Prevent coding and billing errors


NCCI edits help identify improper code combinations and prevent unbundling.

52. A female patient has a breast biopsy, and the pathology shows atypical ductal
hyperplasia. This is classified as:
A. Malignant neoplasm
B. Benign condition
C. Uncertain behavior
D. Inflammatory process

Answer: C. Uncertain behavior


Atypical hyperplasia is not clearly benign or malignant—coded as uncertain behavior.

53. What is the primary purpose of a chargemaster?


A. Assign DRGs
B. Track patient payments
C. List all billable services and charges
D. Store CPT and ICD-10-CM codes

Answer: C. List all billable services and charges


The chargemaster is a pricing tool used for billing hospital services.

54. According to HIPAA, a covered entity includes all of the following EXCEPT:
A. Health plans
B. Healthcare clearinghouses
C. Employers
D. Providers who transmit claims electronically

Answer: C. Employers
Employers are not covered entities unless they provide healthcare services electronically.

55. A record with all necessary reports but unsigned physician orders is considered:
A. Complete
B. Deficient
C. Suspended
D. Rejected

Answer: B. Deficient
Records lacking required signatures or reports are considered incomplete or deficient.

56. In ICD-10-CM, a dash (-) at the end of a code indicates:


A. Invalid code
B. Code requires a placeholder
C. Incomplete code—requires additional characters
D. Repeating code

Answer: C. Incomplete code—requires additional characters


A dash signals that more characters are required for code specificity.
57. The primary data source for coding and billing in healthcare is the:
A. Physician schedule
B. Patient portal
C. Health record
D. Discharge instructions

Answer: C. Health record


Coding must be based on provider documentation in the patient’s health record.

58. Which type of code is used to classify the reason for an encounter other than disease or
injury?
A. Z codes
B. S codes
C. Y codes
D. M codes

Answer: A. Z codes
Z codes report factors influencing health status (e.g., screenings, history, aftercare).

59. An encoder helps coders by:


A. Auto-populating claims
B. Automating queries to physicians
C. Providing code suggestions based on documentation
D. Editing medical charts

Answer: C. Providing code suggestions based on documentation


Encoders guide coders to proper codes using decision trees and prompts.

60. Which form is used to bill professional services (e.g., physician visits)?
A. UB-04
B. CMS-1500
C. 837I
D. 837D

Answer: B. CMS-1500
CMS-1500 is used for physician and outpatient professional services.
61. A data field that limits entries to predefined values is called a:
A. Text block
B. Pick list
C. Free text
D. Numeric only field

Answer: B. Pick list


Pick lists help standardize data by offering only selectable values.

62. A coder finds a surgical procedure without an operative report. What should the coder
do first?
A. Query the physician
B. Code based on the schedule
C. Assign a default code
D. Skip the code

Answer: A. Query the physician


Queries clarify unclear, missing, or conflicting documentation.

63. What type of data is “patient gender” in a database?


A. Text
B. Identifier
C. Demographic
D. Clinical

Answer: C. Demographic
Demographics include non-clinical identifiers such as gender, age, and race.

64. What is the standard vocabulary for describing laboratory and clinical observations?
A. LOINC
B. SNOMED
C. ICD-10-CM
D. CPT

Answer: A. LOINC
LOINC is used for lab tests and clinical measurement coding.
65. When multiple procedures are performed during one surgical session, which CPT rule
applies?
A. Only the first procedure is coded
B. List all codes in random order
C. Use modifier -51 on secondary procedures
D. Add modifier -25 to all codes

Answer: C. Use modifier -51 on secondary procedures


Modifier -51 indicates multiple procedures in a single session.

66. A newborn is delivered via cesarean section. What is the correct place of service for the
newborn’s hospital care?
A. 11 – Office
B. 21 – Inpatient hospital
C. 22 – Outpatient hospital
D. 24 – Ambulatory surgical center

Answer: B. 21 – Inpatient hospital


Place of service 21 is used for inpatient hospital services, including newborn care.

67. A histogram is best used to:


A. Track infections
B. Show process variation over time
C. Display frequency distribution
D. Graph patient satisfaction by department

Answer: C. Display frequency distribution


Histograms show how often values occur within data ranges.

68. A provider performs a laceration repair and also removes a skin tag during the same
visit. What modifier is appropriate?
A. -50
B. -59
C. -25
D. -76

Answer: B. -59
Modifier -59 indicates a distinct and separate procedure done on the same day.

69. What does the abbreviation “MS-DRG” stand for?


A. Medical Severity Diagnosis-Related Group
B. Multiple Standard Diagnosis Related Groups
C. Major Service Diagnostic Rating Guide
D. Medical Services Department Resource Guide

Answer: A. Medical Severity Diagnosis-Related Group


MS-DRG adjusts reimbursement based on patient severity.

70. A master file containing all codes and rates for procedures is known as the:
A. Provider contract
B. Charge description master (CDM)
C. CPT crosswalk
D. Medicare fee schedule
Answer: B. Charge description master (CDM)
The CDM lists all procedures and prices for hospital billing.

71. What is the best method to reduce duplicate records in an MPI?


A. Manual chart review
B. Routine audits
C. Unique patient identifiers
D. Random sampling

Answer: C. Unique patient identifiers


Assigning unique identifiers helps distinguish records for each patient.

72. In outpatient coding, what determines if a procedure is billable with an E/M service?
A. If the procedures are unrelated
B. The procedure was scheduled
C. The service was provided in a clinic
D. Patient was over 18

Answer: A. If the procedures are unrelated


Modifier -25 is used when a separately identifiable E/M service is provided.

73. A patient has COPD and pneumonia. How are the diagnoses sequenced?
A. Pneumonia first
B. COPD first
C. Whichever required more care
D. Based on lab values

Answer: A. Pneumonia first


The acute condition (pneumonia) is sequenced first as the principal diagnosis.
74. What data element is a key component of the legal health record?
A. Appointment schedule
B. Staff vacation log
C. Progress notes
D. Coding abstract

Answer: C. Progress notes


Progress notes contain the provider's clinical judgment and are part of the legal record.

75. When submitting claims, which system standardizes electronic data exchange?
A. SNOMED
B. HL7
C. LOINC
D. X12N

Answer: D. X12N
X12N is the HIPAA-adopted standard for electronic claim transactions.

76. In CPT coding, which modifier indicates a professional component only?


A. -50
B. -26
C. -TC
D. -59

Answer: B. -26
Modifier -26 is used when only the physician’s professional interpretation is being billed.

77. What is the primary purpose of the "present on admission" (POA) indicator in
inpatient coding?
A. To report chronic conditions
B. To validate procedure codes
C. To identify conditions not present at admission
D. To assign MS-DRGs

Answer: C. To identify conditions not present at admission


POA indicators help distinguish between community-acquired and hospital-acquired
conditions.
78. A patient's record includes multiple episodes across various departments. To unify this
data, what system is essential?
A. Encoder
B. Relational database
C. Master patient index (MPI)
D. Abstracting system

Answer: C. Master patient index (MPI)


The MPI ensures each patient has one unique record across the entire facility.

79. Which of the following codes reflects a bilateral procedure?


A. 11720-50
B. 99214
C. 10061-59
D. 17000-26

Answer: A. 11720-50
Modifier -50 is used to report bilateral procedures performed at the same session.

80. Which data quality characteristic ensures the data reflects what it is intended to
measure?
A. Timeliness
B. Accuracy
C. Validity
D. Completeness

Answer: C. Validity
Validity ensures the data accurately represents the real-world concept.

81. The benefit of using structured data entry is:


A. Faster typing
B. Improved legibility only
C. Better decision support and interoperability
D. Requires no training
Answer: C. Better decision support and interoperability
Structured data improves system compatibility, searching, and data exchange.

82. Which organization manages the ICD-10-CM system in the U.S.?


A. AHIMA
B. AMA
C. CMS and NCHS
D. WHO

Answer: C. CMS and NCHS


CMS and the National Center for Health Statistics co-manage ICD-10-CM in the U.S.

83. What does the abbreviation “ROI” stand for in health information management?
A. Return of Identifier
B. Release of Information
C. Record of Interaction
D. Record of Insurance

Answer: B. Release of Information


ROI is the process of disclosing PHI to authorized individuals or entities.

84. What documentation is required to support the use of a Z code for a screening exam?
A. Physician order
B. Pathology report
C. Surgical report
D. Consent form

Answer: A. Physician order


Screenings require an order to justify the service and support the Z code.

85. The Revenue Cycle begins with:


A. Claim submission
B. Patient registration
C. Charge entry
D. Coding
Answer: B. Patient registration
Accurate registration starts the revenue cycle and impacts the entire billing process.

86. In risk adjustment, HCC stands for:


A. Hospital Coding Classification
B. Hierarchical Condition Category
C. Health Compliance Category
D. Healthcare Claim Coding

Answer: B. Hierarchical Condition Category


HCCs are used to predict future healthcare costs based on documented conditions.

87. A claim denied for missing or incorrect information must be:


A. Canceled
B. Reopened after 6 months
C. Corrected and resubmitted
D. Rewritten entirely

Answer: C. Corrected and resubmitted


Clean claims require corrections for errors before resubmission.

88. A HIPAA violation must be reported to HHS if it affects:


A. 10 or more patients
B. 25 patients in 1 location
C. 500 or more individuals
D. Any hospital staff

Answer: C. 500 or more individuals


Breaches affecting 500+ must be reported to HHS and publicized.

89. Who can legally authorize access to a deceased patient’s medical records?
A. Any relative
B. Medical assistant
C. The executor of the estate
D. Funeral director
Answer: C. The executor of the estate
Only legally designated representatives can authorize release of a deceased patient's
records.

90. The first step in the data life cycle is:


A. Storage
B. Processing
C. Collection
D. Archiving

Answer: C. Collection
Data must be collected before it can be used, analyzed, or shared.

91. Which of the following supports continuity of care?


A. MPI audits
B. Patient care summary
C. Billing reports
D. Facility licensing

Answer: B. Patient care summary


Summaries provide key information to ensure consistent treatment across providers.

92. CPT Category II codes are used for:


A. Experimental services
B. Performance measurement
C. Surgical procedures
D. Emergency services

Answer: B. Performance measurement


Category II codes track quality metrics and reporting outcomes.

93. Which ICD-10-CM code is appropriate for a screening colonoscopy in a healthy adult?
A. Z12.11
B. K63.5
C. R19.5
D. Z00.00

Answer: A. Z12.11
Z12.11 indicates screening for malignant neoplasm of the colon.

94. A progress note documents "patient with uncontrolled diabetes and recent weight loss."
What is the correct action?
A. Code only diabetes
B. Code diabetes with complication
C. Query for specificity
D. Code weight loss as primary

Answer: C. Query for specificity


A query is needed to clarify the relationship between weight loss and diabetes.

95. A DRG weight of 3.200 suggests:


A. A minor complication
B. A short stay
C. Higher resource use
D. Incorrect sequencing

Answer: C. Higher resource use


The higher the weight, the more complex and costly the case.

96. In the SOAP format, where is the provider’s diagnosis listed?


A. Subjective
B. Objective
C. Assessment
D. Plan

Answer: C. Assessment
The assessment includes diagnoses or impressions based on findings.

97. A query to the physician should be:


A. Leading
B. Ambiguous
C. Clear and compliant
D. Based on coder preference

Answer: C. Clear and compliant


Compliant queries must be non-leading and based on evidence in the record.

98. What is the minimum necessary standard under HIPAA?


A. All patient info must be disclosed
B. Only the minimum PHI necessary should be shared
C. Patients can block any data sharing
D. All disclosures require court order

Answer: B. Only the minimum PHI necessary should be shared


HIPAA restricts disclosures to the minimum needed to accomplish the purpose.

99. A delinquent record rate is calculated using:


A. Completed records only
B. All unsigned records
C. Number of delinquent records divided by discharges
D. Length of stay

Answer: C. Number of delinquent records divided by discharges


This formula tracks compliance with record completion timeliness.

100. Which is the best safeguard for protecting ePHI on portable devices?
A. Anti-virus software
B. Wireless connectivity
C. Full device encryption
D. Password-only access

Answer: C. Full device encryption


Encryption protects data if the device is lost or stolen.

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