Certified Coding Associate Exam Health Information Management 2 — Questions and Answers
Question 1: What is the purpose of a master patient index (MPI)?
- To store all clinical notes for a patient
- To uniquely identify and link all health records for each patient in a facility (Correct answer)
- To track insurance billing information
- To schedule patient appointments
Correct answer: To uniquely identify and link all health records for each patient in a facility
The MPI is a database that uniquely identifies each patient and links all encounters and health records associated with that patient.
Question 2: Which document authorizes a provider to treat a patient and indicates the patient understands the nature of the treatment?
- Advance directive
- Informed consent (Correct answer)
- Authorization for release of information
- Assignment of benefits
Correct answer: Informed consent
Informed consent is the process by which a patient is informed about a procedure and voluntarily agrees to undergo it.
Question 3: How long must hospitals generally retain adult patient health records under most state laws?
- 3 years from last treatment
- 5–10 years from last treatment or discharge (Correct answer)
- 1 year from last treatment
- Permanently for all patients
Correct answer: 5–10 years from last treatment or discharge
Most states require adult health records to be retained for a minimum of 5–10 years from the date of last treatment or discharge.
Question 4: What is the main goal of clinical documentation improvement (CDI)?
- Reducing the number of diagnoses documented
- Ensuring documentation accurately reflects the patient's clinical status to support coding and quality reporting (Correct answer)
- Speeding up the discharge process
- Replacing physician documentation with coding staff entries
Correct answer: Ensuring documentation accurately reflects the patient's clinical status to support coding and quality reporting
CDI aims to improve the quality and completeness of clinical documentation so that coding accurately reflects the patient's condition and care.
Question 5: Which of the following is a key component of a health record for inpatient encounters?
- Marketing materials and brochures
- History and physical examination (H&P) (Correct answer)
- Staff scheduling records
- Financial audit reports
Correct answer: History and physical examination (H&P)
A history and physical examination (H&P) is a required component of the inpatient health record and must be completed within a defined timeframe.
Question 6: What does the term 'deficiency analysis' mean in health information management?
- Reviewing financial performance of a department
- Identifying incomplete or missing elements in health records (Correct answer)
- Analyzing coding errors in claims
- Reviewing patient satisfaction surveys
Correct answer: Identifying incomplete or missing elements in health records
Deficiency analysis involves reviewing health records to identify incomplete or missing documentation that must be completed by the responsible provider.
Certified Coding Associate Exam Health Information Management 2
What is the purpose of a master patient index (MPI)?