Certified Coding Associate Exam Health Information Management 1 — Questions and Answers
Question 1: Which of the following is considered the primary purpose of the health record?
- Billing and reimbursement
- Patient care documentation and continuity of care (Correct answer)
- Legal evidence in malpractice cases
- Quality assurance reporting
Correct answer: Patient care documentation and continuity of care
The primary purpose of the health record is to document patient care and support continuity of care among healthcare providers.
Question 2: What does the term 'legal health record' refer to?
- Only records stored in paper format
- The official business record of a healthcare organization used in legal proceedings (Correct answer)
- Records created by the legal department
- Records older than 10 years
Correct answer: The official business record of a healthcare organization used in legal proceedings
The legal health record is the official business record of a healthcare organization that can be used as evidence in legal proceedings.
Question 3: Which of the following is an example of protected health information (PHI) under HIPAA?
- De-identified patient statistics published in a research study
- A patient's name combined with their diagnosis (Correct answer)
- Aggregate hospital discharge data
- Employee health and safety records
Correct answer: A patient's name combined with their diagnosis
PHI includes individually identifiable health information, such as a patient's name combined with their medical condition or diagnosis.
Question 4: The minimum necessary standard under HIPAA requires covered entities to:
- Share all PHI with any requesting party
- Use or disclose only the minimum PHI needed to accomplish the intended purpose (Correct answer)
- Encrypt all electronic health records
- Obtain written authorization for all disclosures
Correct answer: Use or disclose only the minimum PHI needed to accomplish the intended purpose
The minimum necessary standard requires that only the least amount of PHI needed to accomplish the task be used or disclosed.
Question 5: What is the primary function of a Release of Information (ROI) process?
- To update patient demographic information
- To manage and control the disclosure of patient health information (Correct answer)
- To convert paper records to electronic format
- To schedule patient appointments
Correct answer: To manage and control the disclosure of patient health information
The ROI process ensures patient health information is disclosed appropriately, with proper authorization and in compliance with laws and regulations.
Question 6: Which accreditation organization sets standards for hospitals including health information management practices?
- AHIMA
- The Joint Commission (TJC) (Correct answer)
- CMS
- AAPC
Correct answer: The Joint Commission (TJC)
The Joint Commission (TJC) is a major accrediting body that sets standards for hospital operations including medical record management.
Certified Coding Associate Exam Health Information Management 1
Which of the following is considered the primary purpose of the health record?