Domain III – Compliance (16%)

1. Domain III – Compliance (16%) RHIT Prep Workshop Exam Year 2014

2. Compliance Content OutlineTasks 1&4 Ensure patient record documentation meets state and federal regulations; and, monitor documentation for completeness Federal regulation Oversight organizations Accrediting organizations Quality indicators Health record data structure, content & stds

3. Compliance Content OutlineTasks 1&4 (Cont’d) Summary of Domain III, #1&4: Know what types of information is found in various types of medical records (e.g. Inpatient OB/delivery record) based on requirements of fed regs (e.g., CMS COP), accrediting organizations (e.g., Joint Commission), etc., regarding accuracy/completeness (quantitative - is it there- AND qualitative analysis - how good is it) of medical record documents. Also documentation quality indicators (e.g., ORYX)

4. Which part of a Problem-Oriented Medical Record (POMR) progress note would a physician document that as of 6:00 a.m. on day 3 of an inpatient hospital admission, the patient’s blood pressure has stabilized and is now adequately controlled? Subjective Objective Assessment Plan

5. In a health record for a hospital inpatient admission, where would the specific blood and urine test results be found • Pathology report • Imaging report • Laboratory report • Physician’s Orders for blood and urine tests

6. Which of the following is not likely to be found during a quantitative analysis of an inpatient record after the patient has been discharged? • A radiology report was ordered by the physician but is not in the medical record as of 3 days after the patient was discharged from the hospital • Dr. Numbness has not signed or dated his anesthesiology report • March 21 and 23rd progress notes are in the record but not the 22nd • The pathology report lists adenocarcinoma but the discharge summary states the patient had no carcinoma.

7. Which organization developed standards that are currently used in defining the structure, content and standardized data definitions for use in electronic health records? Joint Commission American Society for Testing and Measurement Centers for Medicare and Medicaid Services American Health Information Management Society

8. Compliance Content OutlineTasks 2, 3, 6 & 17 Ensure compliance with privacy and security guidelines (HIPAA, state, hospital) 3) Control access to health information and (17) analyze access audit trails 6) Manage release of information

9. Compliance Content OutlineTASKS 2, 3, 6 & 17 (Cont’d) Federal regulation Confidentiality guidelines Healthcare/HIM computer apps & support systems (Types/examples of HIPAA-required security safeguards: Tech/Admin/Physical; audit trails) Ethical practices Health record data structure, content, stds Healthcare delivery systems Legal Aspects of the health record

10. Compliance Content OutlineTASKS 2, 3, 6 & 17 (Cont’d) Summary of Domain III, Tasks 2, 3 and 6: Understand how to maintain/update and apply any regulatory policies and procedures for access and disclosure of protected health information (PHI) in any format. Understand how user access logs/systems work to track access to and disclosure of PHI Understand how to apply confidentiality and security measures to PHI and departmental/organizational data and information systems security policies.

11. What concept of the HIPAA Privacy Rule is the requirement that a covered entity limits the use, access and disclosure of PHI to include only that information that is needed to accomplish the intended purpose? • Authorization to release only specified documents • The concept of Consent to release certain information • The concept of Minimum Necessary • The concept of if it isn’t documented, it didn’t happen

12. What purpose does the HIPAA-required Notice of Privacy Practices serve? • To inform patients why their consent is necessary before any of their healthcare information can be used for any purpose • To give patients a complete description of how that covered entity uses PHI • To give patients a summary of their rights to receive a copy of their medical record • To inform patients that if they don’t sign the notice, then they have to pay for services rendered and then submit their own request for reimbursement to their insurance company

13. According to HIPAA rules, which of the following statements is true when a patient asks a covered entity to see her own medical record? • The covered entity may deny access to psychotherapy notes • The covered entity must always provide access to the patient • The covered entity may always deny access • The covered entity may charge the patient to view her own record without making a copy

14. Which of the following definitions describes privacy? • An individual has the right to be left alone • An individual has the right to control all use and disclosures of private information • An individual has the right to demand a health provider has mechanisms in place to protect the private information from unauthorized disclosure, loss or modifications • An individual has the right to access all of his or her own PHI

15. Which of the following HIPAA-required controls are designed to identify any person who views or alters electronic protected health information without proper authorization? • Information access controls • Network controls • Administrative controls • Physical Environment controls

16. Compliance Content OutlineTASKS 5 & 13 Develop a Coding Compliance Plan and Respond to fraud and abuse (Some of these points are covered under Domain II Coding and Domain VII Revenue Cycle ) Official Coding Guidelines Ethical practices Oversight Organizations Federal Regulation

17. Compliance Content OutlineTASKS 5 & 13 (Cont’d) Understand how to use and monitor applications and work processes to support clinical classification and coding Ensure accuracy of diagnostic/procedural groupings (e.g., APC; DRG etc.) Be aware of current regulations and official guidelines in code assignment Validate coding accuracy (based on hlth rec)

18. Compliance Content OutlineTASKS 5 & 13 (Cont’d) Identify discrepancies between coded data and supporting documentation (med record) Be aware of the legal and regulatory requirements related to health information-especially fraud and abuse (task is to implement and monitor these requirements) Report compliance issues according to organizational policy

19. ICD-10-PCS code set is used to report _? • A) Diagnoses • B) Ambulance services • C) Physician services • D) Inpatient procedures

20. A 75 year old male patient is admitted as an inpatient to an acute care hospital with chest pain caused by coronary atherosclerosis. The patient also has type 1 diabetes mellitus. A coronary artery bypass graft of the native arteries is performed. The patient goes into respiratory failure in the recovery room and undergoes intubation and mechanical ventilation. Which condition is a comorbidity? Coronary atherosclerosis Chest pain Type 1 diabetes mellitus Respiratory failure

21. Which of the following prospective payment systems is based on the principle diagnosis, any significant/major comorbidities or complications (MCCs), other secondary diagnoses; principle procedure; other procedures and the patient age, gender and discharge status? • A. APCs • B. MS-DRGs • C. UHDDS • D. HACs

22. Which of the following is a written guideline that gives direction when a decision has to be made or describes the behavior that is desired? • A) A Rule • B) A Procedure • C) A Policy • D) A Mission Statement

23. A compliance plan for outpatient hospital surgery coding should include regular auditing of which of the following codes? • Principle diagnosis and ICD-10-PCS principle procedure • B) All diagnoses and all ICD-10-PCS procedures • C) Primary diagnosis and primary CPT/HCPCS procedure including modifiers • D) All diagnoses and all CPT/HCPCS codes including modifiers

24. Compliance Content Outline7, 8, 10 & 18 Perform continual updates to policies and procedures Implement internal and external audit guidelines 10) Collaborate with staff to prepare the organization for accreditation, licensing and/or certification surveys 18) Ensure valid healthcare provider credentials

25. Compliance Content Outline7, 8, 10 & 18 (Cont’d) Health record data structure, content and standards Official coding guidelines (covered under III.5 and Domains II and VII) C) Federal regulation D) Oversight organizations E) Accrediting organizations F) Confidentiality guidelines

26. Compliance Content Outline7, 8, 10 & 18 (Cont’d) G) Credentialing guidelines H) Quality indicators Analytical Skills Summary of Domain III, Tasks 7, 8, 10 & 18: Comply with accreditation, licensure, and certification standards from national, state and local levels and private organizations to: differentiate and understand the roles of providers throughout the continuum of healthcare delivery; use and summarize data compiled from audit trail, collect and report data on incomplete record & timeliness of record completion (policies/procedures)

27. The HIPAA Privacy and Security rules require which of the following? • A. Daily review of the audit trails • B. User passwords are different for each application • C. A written contingency plan • D. Specified formats for user passwords

28. Which of the following statements best describes the concept of access control? • A. Requiring password-protected entrances to all departments where the computes may have PHI visible on the screens • B. Conducting a risk assessment • C. Reporting unauthorized viewing of any PHI • D. Identifying which employees should have the right to view or edit PHI

29. Which of the following govern(s) a hospital’s medical staff? • A. Medical staff management • B. Medical staff committees • C. Medical staff organization • D. Medical staff bylaws

30. Compliance Content Outline9, 11, 12, 14 & 16 Evaluate medical necessity using established guidelines (including NCCI and NCD/LCDs) for: 9) CDMP-clinical documentation management program Outpatient Services; (12)Data Management; 14)Intensity of Service/Severity of Illness (IS/SI) for utilization management (UM); and 16) Case management processes

31. Compliance Content Outline9, 11, 12, 14 & 16 (Cont’d) Understand clinical documentation in the health record to determine medical necessity according to guidelines Understand health record structure, content and standards Utilization management medical necessity Case management medical necessity

32. The director of health information services at Sunshine Hospital put a clinical documentation improvement process into place after discovering that the hospital’s documentation was not consistently reflecting the IS/SI criteria necessary for accurate processing of UM or case management decisions or to optimize coding accuracy. Which of the following would best confirm that the new initiative is working? A. Hire a consultant to audit a sample of medical records and their corresponding UM/case management actions. B. Have the coders increase queries so they can determine if any significant clinical information is missing from the documentation C. Have the coders determine if the documentation has improved since implementation. D. Conduct a retrospective review after the first 6 months of all query opportunities.

33. Compliance Content Outline 15 15) Develop Forms (i.e., chart review, documentation, EHR, etc.) forms/screen design, revision & implementation (paper and electronic screen design) relevant computer applications and support systems to ensure data collection, storage, analysis, retrieval and reporting of info.

34. Of the following design options, which one is not a good forms-design practice? • A. Use radio buttons to select multiple items from a set of choices • B. Minimize keystrokes by using pop-up menus • C. Use text boxes when free text is necessary • D. Have system perform a completeness check for all required data elements

35. Additional Domain III Questions The remaining slides for Domain III include sample questions from any of the Domain topics.

36. In which part of a medical record would you expect to find a review of systems (ROS)? • A. The history portion of the H&P • B. The physical portion of the H&P • C. Lab results • D. Discharge summary

37. Which of the following would be the best source of finding out the minimum content of all medical records for a large hospital? • A. Find the documentation from the most recent audit of that hospital’s records and find out what missing documentation deficiencies were found • B. Review the minutes from the initial meeting of the Forms committee • C. Review the minutes from the most current medical record committee • D. Check with the Joint Commission

38. Which of the following is a government agency that promotes standardizing the content of health records? • A. AHIMA • B. Joint Commission • C. AHA • D. HHS

39. When a hospital inpatient undergoes non-emergency surgery, when does the report of surgery have to be in the health record? • A. Immediately after surgery • B. Within 24 hours of surgery • C. Within 48 hours of surgery • D. Within 72 hours of surgery

40. Which of the following federal Acts was designed to improve the quality, effectiveness and efficiency of health care? • A. HIPAA • B. OBRA • C. TEFRA • D. OSHA

41. What does every covered entity have to provide to every patient that explains all the ways a facility might use protected health information (PHI)? • A. A copy of the health information policies • B. A notice of the entity’s rules, regulations and bylaws related to health information • C. A notice of privacy practices • D. A notice of security practices

42. What is the maximum amount of time a covered entity has to provide copies of a patient’s medical record if that record is stored at a remote facility and the facility is not granted a one-time extension for cause? • A. 30 days • B. 45 days • C. 60 days • D. 90 days

43. Which type of ICD-10-CM codes are used to describe factors influencing health status and contact with health services? • A. C codes • B. Z codes • C. W codes • D. R codes

44. Procedures explain how to accomplish a task. What guidelines or statements are procedures designed to support? • A. Vision statement • B. Rules • C. Policies • D. Mission statement

45. Any Questions??