Health Information Management & Data Accuracy Flashcards
6 cards from real CCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Health Information Management & Data Accuracy flashcards as text
Which organization is responsible for maintaining and updating the ICD-10-CM code set in the United States?
Answer: National Center for Health Statistics (NCHS) and CMS, as cooperating parties
ICD-10-CM is maintained by NCHS (National Center for Health Statistics), a division of CDC, in cooperation with CMS. Updates are effective each October 1.
What is the function of the Hospital Compare database maintained by CMS?
Answer: To publicly report quality measures allowing consumers to compare hospital performance
Hospital Compare (now Care Compare) is a CMS consumer tool that publicly reports hospital quality measures including mortality rates, readmissions, patient experience (HCAHPS), and process measures.
In health information management, what does 'data integrity' specifically mean?
Answer: Data is accurate, complete, consistent, and has not been altered or destroyed in an unauthorized manner
Data integrity means health information is accurate, complete, consistent, unaltered, and trustworthy - encompassing both data quality and data security dimensions.
A coder records that a patient was discharged to a skilled nursing facility (SNF), but the physician's discharge summary states home discharge. Which data quality issue is present?
Answer: Consistency
Consistency means data values are the same across all records and systems for the same item. Conflicting discharge disposition between the coder's entry and physician summary is a consistency failure.
Which standard is used to exchange health information electronically between disparate healthcare systems (e.g., hospitals and labs)?
Answer: HL7 (Health Level Seven)
HL7 (Health Level Seven) is the international messaging standard used for exchanging clinical and administrative data between healthcare information systems.
What is the purpose of a clinical documentation improvement (CDI) program in a hospital?
Answer: To improve the accuracy and completeness of clinical documentation to support coding, reimbursement, and quality reporting
CDI programs proactively review and improve clinical documentation to ensure it accurately reflects patient severity, supports correct code assignment, and accurately represents quality outcomes.