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2025 - 2026 AHIMA RHIA EXAM PREP (7TH EDITION)
200 QUESTIONS & ANSWERS WITH
RATIONALES|GRADED A+
A patient requests copies of her medical records in an electronic format. The hospital maintains a portion of the designated record set in a paper format and a portion of the designated record set in an electronic format. How should the hospital respond? a. Provide the records in paper format only b. Scan the paper documents so that all records can be sent electronically c. Provide the patient with both paper and electronic copies of the record d. Inform the patient that PHI cannot be sent electronically ANS:->>>c. Provide the patient with both paper and electronic copies of the record RATIONALE : The HIPAA Privacy Rule states that the covered entity must provide individuals with their information in the form that is requested by the individuals, if it is readily producible in the requested format. The covered entity can certainly decide, along with the individual, the easiest and least expensive way to provide the copies they request. Per the request of an individual, a covered entity must provide an electronic copy of any and all health information that the
covered entity maintains electronically in a designated record set. If a covered entity does not maintain the entire designated record set electronically, there is not a requirement that the covered entity scan paper documents so the documents can be delivered electronically (Thomason 2013, 102).
- For an EHR to provide robust clinical decision support, what critical element must be present? a. Structured data b. Internet connection c. Physician portal d. Standard vocabulary - Correct answer A RATIONALE - If an EHR is to provide clinical decision support it requires two things: structured data and a clinical data repository (Sandefer 2016a, 364).
- Which of the following is considered a two-factor authentication system? a. User ID and password b. User ID and voice scan c. Password and swipe card
the same way every time d. A point in the process at which the participants must record data in paper- based or computer- based formats RATIONALE - Correct answer - The rectangle with double lines on the side in a flowchart is a predefined process icon. This symbol represents the formal procedure that participants are expected to carry out the same way every time (Shaw and Carter 2015, 198).
. A researcher mined the Medicare Provider Analysis Review (MEDPAR) file. The analysis revealed trends in lengths of stay for rural hospitals. What type of investigation was the researcher conducting? a. Content analysis b. Effect size review c. Psychometric assay d. Secondary analysis Correct answer- D RATIONALE Secondary analysis is the analysis of the original work of others. In secondary analysis, researchers reanalyze original data by combining data sets to answer new questions or by using more sophisticated statistical techniques. The work of others created the MEDPAR file (Forrestal 2016, 586).
In reviewing a patient chart, the coder finds that the patient's chest x-ray is suggestive of chronic obstructive pulmonary disease (COPD). The attending physician mentions the x-ray finding in one progress note, but no medication, treatment, or further evaluation is provided. Which of the following actions should the coder take in this case? a. Query the attending physician and ask him to validate a diagnosis based on the chest x-ray results b. Code COPD because the documentation substantiates it c. Query the radiologist to determine whether the patient has COPD d. Assign a code from the abnormal findings to reflect the condition Correct answer-A RATIONALE query is routine communication and education tool used to advocate for complete and compliant documentation. The intent is to clarify what has been recorded, not to call into question the provider's clinical judgment or medical expertise. This is an example of a circumstance where the chronic condition must be verified. All secondary conditions must match the definition in the UHDDS and whether the COPD does is not clear (Hunt 2016, 276 - 277). Per the HITECH breach notification requirements, which of the following is the
measures the costs associated with acquisition of hardware and software, installation, implementation, and ongoing maintenance (Amatayakul 2016, 104 - 105). Part of the coding supervisor's responsibility is to review accounts that have not been final billed due to errors. One of the accounts on the list is a same-day procedure. Upon review, the coding supervisor notices that the charge code on the bill was hard-coded. The ambulatory procedure coder added the same CPT code to the abstract. How should this error be corrected? a. Delete the code from the CDM because it should not be there. b. Refer the case to the chargemaster coordinator. c. Force a final bill on the accounts since the duplication will not affect the UB-04. d. Remove the code from the abstract and counsel the coder regarding CDM hard codes in this service. ANS:->>>If a service is hard- coded into the charge description master (CDM), it is important that this decision is communicated to the coding staff. If the decision is not effectively communicated, the result could be duplicate billing that in turn could result in overpayment to the facility (Casto and Forrestal 2015, 253).
Which health record format is arranged in chronological order with documentation fromvarious sources intermingled? a. Electronic b. Source-oriented c. Problem- oriented d. Integrated ANS:->>>The integrated health record is arranged so that the documentation from various sources is intermingled and follows a strict chronological or reverse-chronological order. The advantage of the integrated format is that it is easy for caregivers to follow the course of the patient's diagnosis and treatment (Russo 2013b, 305). The Medical Record Committee is reviewing the privacy policies for a large outpatient clinic. One of the members of the committee remarks that he feels that the clinic's practice of calling out a patient's full name in the waiting room is not in compliance with HIPAA regulations and that only the patient's first name should be used. Other committee members disagree with this assessment. What should the HIM director advise the committee? a. HIPAA does not allow a patient's name to be announced in a waiting room.
tool (White 2016a, 46). What term refers to information that provides physicians with pertinent health information beyond the health record itself used to determine treatment options?
a. Core measures b. Enhanced discharge planning c. Data mining d. Clinical practice guidelines ANS:->>>Clinicians use health record information to develop clinical pathways and other clinical practice guidelines, which help clinicians make knowledge- and experience-based decisions on medical treatment. These guidelines make it easier to coordinate multidisciplinary care and services (Fahrenholz 2013b, 78). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharingb. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek ANS:->>>Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). Which of the following is a kind of technology that focuses on data security? a. Clinical decision
a. not easilyb. easily c. often d. never ANS:->>>Correct Answer: A
Secondary data sources provide information that is not readily available from individual health records. Data taken from health records and entered into disease-oriented databases can help researchers determine the effectiveness of alternative treatment methods and monitor outcomes (Fahrenholz 2013c, 159). Use of a variety of content delivery methods to accommodate different types of learners is called: a. Blended learning b. Programmed learning c. Classroom learning d. Online learning ANS:->>>Correct Answer: A Blended learning uses several delivery methods thereby gaining the advantages and reducing the disadvantages of each method alone (Patena 2016, 772).
- In order to effectively transmit healthcare data between a provider and a payer, both parties must adhere to which electronic data interchange standards? a. DICOM b. IEEE 1073 c. LOINC d. X12N ANS:->>>Correct Answer: D
- In developing a coding compliance program, which of the following would not be ordinarily included as participants in coding compliance education? a. Current coding personnel b. Medical staff c. Newly hired coding personnel
d. Nursing staff ANS:->>>Correct Answer: D In conjunction with the corporate compliance officer, the health information manager should provide education and training related to the importance of complete and accurate coding, documentation, and billing on an annual basis. Technical education for all coders should be provided. Documentation education is also part of compliance education. A focused effort should be made to provide documentation education to the medical staff. Coding is based primarily on physician documentation, so nursing staff would not be included in the education process (Hunt 2016, 288). 18 5 Correct Wrong Unanswere d
- A health record that maintains information throughout the lifespan of the patient, ideally from birth to death, is known as a: a. Problem-oriented health record b. Patient-centric record c. Longitudinal health record d. Health record ANS:->>>Correct Answer: C A longitudinal health record maintains information throughout the lifespan of the
c. Do nothing because coding compliance guidelines do not allow any action. d. Place all offending physicians on suspension if the documentation issues continue. ANS:->>>Correct Answer: B
The quality of the documentation entered in the health record by providers can have major impacts on the ability of coding staff to perform their clinical analyses and assign accurate codes. In this situation, the best solution would be to educate the entire medical staff on their roles in the clinical documentation improvement process. Explaining to them the documentation guidelines and what documentation is needed in the record to support the more accurate coding of diabetes and its manifestations will reduce the need for coders to continue to query for this clarification (Hunt 2016, 275). Which of the following are alternate work scheduling techniques? a. Compressed workweek, open systems, and job sharing b. Flextime, telecommuting, and compressed workweek c. Telecommuting, open systems, and flextime d. Flextime, outsourcing, compressed workweek ANS:->>>Correct Answer: B Alternate work schedules are alternatives to the regular 40-hour workweek; the following are examples: compressed workweek, flextime, and job sharing (Oachs 2016, 795). For a contract to be valid, it must include three elements. Which of the
