AHIMA Quality Improvement 3

Question 1

Which type of health record analysis verifies that all required components and signatures are physically present in the medical record?

Accepted Answer

Quantitative analysis

Answer

Quantitative analysis checks for the physical presence of required record components such as history and physical reports, operative notes, and physician signatures.

Question 2

Qualitative analysis of health records primarily evaluates:

Accepted Answer

The clinical consistency, accuracy, and completeness of documentation content

Answer

Qualitative analysis goes beyond document presence to assess whether clinical content is consistent, legible, and supports the diagnoses and treatments documented.

Question 3

Under AHIMA coding quality standards, what is the minimum recommended accuracy rate for principal diagnosis assignment?

Accepted Answer

95%

Answer

AHIMA recommends a minimum coding accuracy rate of 95% for principal diagnosis, secondary diagnoses, and procedures to ensure data integrity and appropriate reimbursement.

Question 4

A focused coding audit is MOST commonly triggered by:

Accepted Answer

Significant variation from expected coding patterns or elevated payer denials

Answer

Focused audits are initiated when data analysis reveals unusual coding patterns, high denial rates, or OIG Work Plan risk areas that warrant targeted review.

Question 5

What is the primary objective of a Clinical Documentation Improvement (CDI) program?

Accepted Answer

To ensure documentation accurately reflects patient severity, complexity, and resource use

Answer

CDI programs work concurrently with clinicians to clarify ambiguous or incomplete documentation so coded data accurately represents the patient's true clinical picture.

(AHIMA) American Health Information Management Association Practice Test

(AHIMA) American Health Information Management Association Practice Test

AHIMA Quality Improvement 3