Utilization Management and Medical Necessity Review in Healthcare, Exams of Community Health

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IAHCSMM Domain 3 Healthcare Regulations

and Compliance Exam Review Questions and

Answers 100% Pass | Graded A+

David Mungai [Date] [Course title]

IAHCSMM Domain 3 Healthcare

Regulations and Compliance Exam

Review Questions and Answers 100%

Pass | Graded A+

Which of the following would be the best way to ensure the completeness of the health record? - Answer>> To comply with the Joint Commission standards, the HIM director wants to be sure that history and physical examinations are documented in the patient's health record no later than 24 hours after admission. The quantitative analysis or record content review process can be handled in a number of ways. Some acute-care facilities conduct record review on a continuing basis during a patient's hospital stay. Using this method, personnel from the HIM - Answer>> Review each patient's health record concurrently to make sure that history and physicals are present

• Answer>> department go to the nursing unit daily or periodically to review each patient's record. This type of process is usually referred to as a concurrent review because review occurs concurrently with the patient's stay in the hospital Medical necessity - Answer>> Local coverage determinations (LCD) describe when and under what circumstances which of the following is met:
• Answer>> Local coverage determination LCD refers to coverage rules, at a fiscal intermediary FI or carrier level, that provide information on what diagnoses indicate the medical necessity of a test Audit trail - Answer>> A tool that identifies when a user logs in and out, what actions he or she takes, and more is called a(n):

appropriateness of the services provided. UM ensures the medical necessity of treatment management process

• Answer>> Claims management, review of potentially compensable events, and loss prevention are not basic functions of the utilization Institutions are allowed flexibility in the way they implement HIPAA standards. - Answer>> Which of the following statements is true regarding HIPAA security? Security protections in a large medical facility will be more complex than those implemented in a small group practice - Answer>> HIPAA allows a covered entity to adopt security protection measures that are appropriate for its organization as long as they meet the minimum HIPAA security standards. Legitimate need for access - Answer>> Access to health records based on protected health information within a healthcare facility should be limited to employees who have a: integrated information detailing not only their department's input, but also other parts of the record, they must request such reports through the HIM department - Answer>> In its role as guardian of patient information, the HIM department tracks requests for information and ensures that a legitimate need for access to it is present. Departmental users generally have access to data only from their own department's system. If users need Chargemaster description - Answer>> In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit?

• Answer>> One of the elements of the auditing process is identification of risk areas. Selecting the types of cases to review is also important. Examples of various case selection possibilities include chargemaster description Developing procedures for identifying coding errors - Answer>> Which of the following practices is an appropriate coding compliance activity? improperly would be against any coding compliance plan and would also be a violation of AHIMA's Standards of Ethical Coding. One of the - Answer>> Coding compliance activities would not include a financial incentive for coders to commit fraud, to code diagnoses and procedures before documentation is complete, or to spend resources reviewing accurately paid claims. Providing a financial incentive to coders for coding claims
• Answer>> basic elements of a coding compliance program includes developing policies and procedures for identifying coding errors Conditions of Participation - Answer>> Valley High, a skilled nursing facility, wants to become certified to take part in federal government reimbursement programs such as Medicare and Medicaid. What standards must the facility meet to become certified for these programs? participate in the Medicare program. In other words, participating organizations receive federal funds from the Medicare program for services provided to patients and thus must follow the Medicare Conditions of Participation - Answer>> Administered by the federal government Centers for Medicare and Medicaid Services CMS, the Medicare Conditions of Participation or

• Answer>> The government and other third-party payers are concerned about potential fraud and abuse in claims processing. Therefore, ensuring that bills and claims are accurate and correctly presented is an important focus of healthcare compliance Federal and state confidentiality laws - Answer>> The release of information function requires the HIM professional to have knowledge of: release of patient information. Thus, the department's ROI function is instrumental in monitoring compliance with the Joint Commission's standards regarding access to protected health information - Answer>> The HIM department's daily release of information ROI activities can help ensure and monitor access to patient-specific information after discharge. HIM personnel are knowledgeable in the laws and regulations governing the Delinquent record - Answer>> A health record with deficiencies that is not completed within the timeframe specified in the medical staff rules and regulations is called a(n): The HIM department monitors the delinquent record rate very closely to ensure compliance with accrediting standards - Answer>> When an incomplete record is not rectified within a specific number of days as indicated in the medical staff rules and regulations, the record is considered to be a delinquent record. ICD-10-CM and ICD-10-PCS coding - Answer>> In developing a monitoring program for inpatient coding compliance, which of the following should be regularly audited? determine the provider payment, the coding compliance program should regularly audit these codes. It is important that healthcare

organizations have a strong coding compliance program - Answer>> The corporate compliance program addresses the coding function. Because the accuracy and completeness of ICD- 10-CM and ICD-10-PCS for inpatient code assignment Healthcare fraud - Answer>> A coder's misrepresentation of the patient's clinical picture through intentional incorrect coding or the omission of diagnosis or procedure codes would be an example of:

• Answer>> Healthcare fraud is an intended and deliberate deception or misrepresentation by a provider, or by representative of a provider, that results in a false or fictitious claim. These false claims then result in an inappropriate payment by Medicare or other insurers . To determine whether standards of care are being met - Answer>> How do accreditation organizations such as the Joint Commission use the health record? component of every accreditation survey is a review of the facility's health records. Surveyors review the documentation of patient care services to determine whether the standards for care are being met - Answer>> Every participating healthcare organization is subject to a periodic accreditation survey. Surveyors visit each facility and compare its programs, policies, and procedures to a prepublished set of performance standards. A key The coder believes that this practice helps the hospital in increasing revenue. Which of the following should be done in this case? - Answer>> In performing a coding audit, a health record technician discovers that an inpatient coder is assigning diagnosis

procedures also can be considered organizational tools. Policies are written descriptions of the organization's formal positions. Procedures are the The beneficial effects of a service for the patient's physical needs and quality of life - Answer>> What factor is medical necessity based on?

• Answer>> Medical necessity is based on the effects of a service for the patient's physical needs and quality of life . National Practitioner Data Bank - Answer>> This database maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers The NPDB maintains reports on medical malpractice settlements, clinical privilege actions, and professional society membership actions against licensed healthcare providers - Answer>> Healthcare organizations are required by law to query for information on applicants requesting clinical privileges. Accessibility - Answer>> What Joint Commission mandate does the chart location system assist with compliance? Joint Commission regulations require health records to be readily accessible for patient care. The chart locator supports that mandate - Answer>> The chart location system is designed to track the paper health record. This tracking is important because paper records are moved from place to place for patient care, quality reviews, coding, and many other purposes. The Which of the following should the HIM director do to ensure that the nurses are following acceptable documentation practices? -

Answer>> During a review of documentation practices, the HIM director finds that nurses are routinely using the copy and paste functionality of the hospital's EHR system for documenting nursing notes. The ability to copy previous entries and paste into a current entry lead to a record in which a clinician may, upon signing the documentation, unwittingly swear to the accuracy and - Answer>> Develop policy and procedures related to cutting, copying, and pasting documentation in the EHR system The HIM professional plays a critical role in developing policies and procedures to ensure the integrity of patient information - Answer>> comprehensiveness of substantial amounts of duplicated or inapplicable information as well as the incorporation of misleading or erroneous documentation. Failure to document medical necessity - Answer>> The OIG states that insufficient or missing documentation and one of the following are responsible for 70 percent of bad claims submitted to Medicare. and the other is failure to document medical necessity appropriately, which would include the claims submission process

• Answer>> There are two areas that are consistently identified by the OIG as being responsible for 70 percent of bad claims; one is insufficient or missing documentation, Shading of bars or lines that contain text - Answer>> Which of the following should be avoided when designing forms for an electronic document management system EDMS?
  • Answer>> The use of colored paper or ink other than black, or shading of text in EDMS should be minimized or eliminated

the creation, organization, and dissemination of business or clinical knowledge and expertise to providers, employees, and managers throughout the healthcare enterprise - Answer>> A knowledge management system (KMS) is a more recent type of information system that has the potential to increase work effectiveness. This type of system supports Credentialing - Answer>> The National Practitioner Data Bank is associated most closely with which hospital function? disciplinary actions, and credentialing information on physicians, dentists, and other facility-based practitioners to the National Practitioner Data Bank NPDB - Answer>> According to the Health Care Quality Improvement Act of 1986, facilities are required to report professional review actions such as malpractice, Device and media controls - Answer>> A dietary department donated its old microcomputer to a school. Some old patient data were still on the computer. What controls would have minimized this security breach? protected health information and the movement of such data within the facility. The entity must also address procedures for the transfer, removal, or disposal, including reuse or redeployment, of electronic media - Answer>> Device and media controls require the facility to specify proper use of electronic media and devices external drives, backup devices, etc. Included in this requirement are controls and procedures regarding the receipt and removal of electronic media that contain Compliance with - Answer>> Precise coding helps to ensure ________ regulatory requirements.

Coding compliance plans are implemented to demonstrate the steps being taken to ensure correct coding - Answer>> Coding usually determines a facility's reimbursement for services rendered, and as a high-risk area it should be continuously monitored to ensure compliance with all applicable regulations. Operation Restore Trust - Answer>> Which governmental fraud and abuse effort focused on recouping lost funds for the Medicare program due to inaccurate coding and billing?

• Answer>> Operation Restore Trust was released in 1995 to target fraud and abuse among healthcare providers. This major push for accurate coding and reimbursement has expanded to multiple nationwide efforts Develop, implement, and monitor written policies and procedures
• Answer>> One way for a hospital to demonstrate compliance with OIG guidelines is to:
• Answer>> Over the past several years, the OIG has published several documents to help providers develop internal programs that include elements for ensuring compliance. One of the elements included is written policies and procedures Chargemaster description and medical necessity - Answer>> In developing an internal coding audit review program, which of the following would be risk areas that should be targeted for audit? Admission diagnosis and complaints, clinical laboratory results, and radiology orders are not risk areas that should be targeted for audit - Answer>> An auditing process identifies risk areas such as chargemaster description, medical necessity, MS-DRG coding accuracy, variations in case mix, and the like.

finds that transcribed reports are being changed by the author up to a week after initial transcription. To remedy this situation, the HIM director should recommend which of the following? should have a policy in place to address transcribed reports remaining in draft form. The professional Code of Ethics requires the HIM professional to assure accurate and timely documentation - Answer>> Unacceptable documentation practices include back-dating progress notes or other documentation in the patient's record and changing the documentation to reflect the known outcomes of care. Health care facilities Letter notifying individual that the authorization was invalid - Answer>> Which of the following would be part of the release of information system?

• Answer>> Customized letters are critical to the ROI system. Customized letters and forms may be used to communicate with the requestor for many purposes including a letter notifying the individual making a request that the authorization is invalid Audit trail - Answer>> A coding compliance manager is reviewing a tool that identifies when a user logs in and out, what he or she does, and more. What is the manager reviewing? actions. It also records user-identification information and the date and time of the activity. Audits should be scheduled periodically, but can also be performed when a problem is suspected - Answer>> Audit controls are required by HIPAA. One method of monitoring is the use of audit trails. Audit trails are a recording of activities occurring in an information system. Audit trails can monitor system level controls such as login, logout, unsuccessful logins, print, query, and other

Accreditation - Answer>> Which of the following can be defined as a voluntary system of institutional review in which a quasi- independent body periodically evaluates the quality of the services provided by healthcare organizations against written criteria? standards. The accreditation process is voluntary; healthcare organizations choose to participate in order to improve the care they provide to their patients - Answer>> Accreditation standards are developed to reflect reasonable quality standards. The performance of each participating organization is evaluated annually against the Office of the Inspector General OIG - Answer>> Site-of-service documents to help providers develop compliance programs have been published by the:

• Answer>> Over the past several years, OIG has published documents to assist providers in developing internal compliance programs that include the seven elements for ensuring compliance as outlined in the U.S. Sentencing Guidelines in 1991 State retention requirements - Answer>> Which of the following should be considered first when establishing health record retention policies? retained for at least the period specified by the state's statute of limitations for malpractice, and other claims must be taken into consideration when determining the length of time to retain records as evidence - Answer>> Health record retention policies depend on a number of factors. They must comply with state and federal statutes and regulations. Retention regulations

from unsound medical, business, or fiscal practices that directly or indirectly result in

• Answer>> Test Outcome - Answer>> OASIS-C data are used to assess the ________ of home health services.
• Answer>> The Outcomes and Assessment Information Set OASIS-C consists of data elements that represent core items for the comprehensive assessment of an adult home care patient and form the basis for measuring patient outcomes for the purpose of outcome-based quality improvement Policy - Answer>> A statement or guideline that directs decision making or behavior is called a:
• Answer>> A policy is a statement that describes general guidelines that direct behavior or direct and constrain decision making in the organization Ability to subpoena audit trails - Answer>> Which of the following is a legal concern regarding the EHR? Healthcare providers frequently receive subpoenas requesting the production of the health record. The subpoena may require the production of audit trails - Answer>> There are a number of legal issues facing the electronic health record (EHR). State laws vary as to what is and is not acceptable in a court of law regarding EHRs. Unnecessary costs to a program - Answer>> Healthcare fraud is all except which of the following?

other party. Healthcare abuse related to provider, supplier, and practitioner that are inconsistent with accepted sound fiscal, business, or medical practices directly or indirectly result in: unnecessary costs to the program, false - Answer>> The National Health Care Anti-Fraud Association defines healthcare fraud as an intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, the entity, or some

• Answer>> representation of a fact, damage to another party that reasonably relied on misrepresentation, failure to disclose a material fact, and the like Federal Sentencing Guidelines - Answer>> Corporate compliance programs became common after adoption of which of the following?
• Answer>> The U.S. Federal Sentencing Guidelines outline seven steps as the hallmark of an effective program to prevent and detect violations of law. These seven steps have become the blueprint for an effective compliance program for healthcare organizations Staffing tools - Answer>> Position descriptions, policies and procedures, training checklists, and performance standards are all examples of: work will be accomplished, written policies and procedures explaining staffing requirements and scheduling, which assist the supervisor in being fair and objective and help the staff understand the rules - Answer>> Staffing tools may be used to plan and manage staff resources. Staffing tools include: position descriptions, which outline the work and qualifications required by