Mixed Deck — All AHIMA Topics Flashcards
100 cards from real AHIMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 20 Mixed Deck — All AHIMA Topics flashcards as text
Under HIPAA, a 'business associate' is best defined as:
Answer: A person or entity that performs functions involving PHI on behalf of a covered entity
A business associate is an external person or organization that performs activities or functions involving PHI on behalf of or for a covered entity, such as billing companies or IT vendors.
A covered entity must provide patients with a Notice of Privacy Practices (NPP):
Answer: At first service delivery and upon request thereafter
Covered entities must provide the NPP no later than the first date of service and must make it available upon request at any subsequent time.
How many CEHs must an RHIT credential holder complete per two-year renewal cycle?
Answer: 20 CEHs
RHIT credential holders are required to earn 20 CEHs every two years to maintain active status.
Which CPT modifier indicates a service was performed by a resident under the supervision of a teaching physician?
Answer: -GE
Modifier -GE indicates that a service was rendered by a resident without the presence of a teaching physician under the primary care exception.
Under AHIMA coding quality standards, what is the minimum recommended accuracy rate for principal diagnosis assignment?
Answer: 95%
AHIMA recommends a minimum coding accuracy rate of 95% for principal diagnosis, secondary diagnoses, and procedures to ensure data integrity and appropriate reimbursement.
What is Protected Health Information (PHI)?
Answer: Any individually identifiable health information including demographics, diagnoses, and treatment records
PHI includes any information that can identify an individual and relates to their health condition, care, or payment, in any form (paper, electronic, oral).
Which standard protocol is most commonly used to exchange clinical documents between healthcare systems in the United States?
Answer: HL7 C-CDA
HL7 Consolidated Clinical Document Architecture (C-CDA) is the primary standard for exchanging clinical documents such as discharge summaries and progress notes.
What does the acronym 'NEC' mean when encountered in the ICD-10-CM Tabular List?
Answer: Not Elsewhere Classifiable
NEC stands for 'Not Elsewhere Classifiable' and is used when the available codes do not fully describe a specific condition.
Which record-keeping practice best supports the admissibility of an electronic health record in court?
Answer: Maintaining a reliable audit trail showing who entered or modified data
An audit trail demonstrating consistent, accurate record-keeping practices supports the business records exception and EHR admissibility.
In CDI, what is the 'case mix index' (CMI)?
Answer: The average relative weight of all MS-DRGs for a given period
The case mix index is the average relative weight of MS-DRGs for a hospital's patient population, reflecting the complexity and resource intensity of cases treated.
Benchmarking in healthcare quality improvement is BEST described as:
Answer: Comparing organizational performance against best practices or peer organizations
Benchmarking uses external reference points — industry best practices or comparable organizations — to set meaningful performance targets and identify improvement gaps.
Which quality improvement tool displays process variation over time and distinguishes between common-cause and special-cause variation?
Answer: Control chart
A control chart plots data points over time with upper and lower control limits, helping identify whether variation is inherent to the process or caused by an unusual event.
A hospital's health information management department receives a subpoena for a patient's records. The correct first action is to:
Answer: Notify the patient and consult legal counsel before releasing
Upon receiving a subpoena, HIM professionals should notify the patient (when required) and consult legal counsel to determine if the subpoena meets HIPAA requirements before releasing records.
A good opening step toward maintaining the security of data included in a health information computer system would be ______________________.
Answer: define security levels for various sorts of information based on their sensitivity.
A crucial initial step in maintaining the security of data in a health information computer system is to define security levels based on the sensitivity of various types of information. This allows for the implementation of appropriate access controls and safeguards tailored to the risk associated with different data, ensuring that highly sensitive information receives the strongest protection and preventing unauthorized access.
Which HIPAA transaction set is used to transmit an electronic remittance advice (ERA)?
Answer: HIPAA 835
The HIPAA 835 transaction is the electronic remittance advice used by payers to communicate payment details and adjustments to providers.
The primary purpose of a data dictionary in a health information system is to:
Answer: Define the structure, format, and meaning of each data element
A data dictionary is a metadata repository that documents the definition, format, source, and relationships of each data element to ensure consistent interpretation and use.
What is information lifecycle management?
Answer: Managing data from creation through use, maintenance, and ultimate disposition or destruction
ILM addresses all phases of information existence: creation, use, maintenance, archival, and destruction, with appropriate policies for each phase.
A hospital must report a breach affecting 600 patients to which entities under the HIPAA Breach Notification Rule?
Answer: The affected patients, HHS, and prominent media outlets in the affected area
Breaches affecting 500 or more individuals require notification to affected individuals, HHS, and prominent media outlets serving the affected area.
Which standard defines the structure and content of electronic health records to support longitudinal patient care across multiple providers?
Answer: ISO/TR 20514
ISO/TR 20514 defines the electronic health record architecture and content requirements to support continuity of care across settings and time.
In healthcare compliance, a 'corporate integrity agreement' (CIA) is typically entered into between a provider and:
Answer: The Office of Inspector General (OIG)
Corporate Integrity Agreements are negotiated between the OIG and providers as an alternative to exclusion from federal healthcare programs following fraud or abuse settlements.