Technology & Digital Applications Flashcards
7 cards from real Certified Medical Coding Specialist practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Technology & Digital Applications flashcards as text
Which type of EHR audit trail feature is MOST critical for HIPAA compliance monitoring?
Answer: Logs recording who accessed or modified records and when
HIPAA requires covered entities to maintain audit controls that record and examine activity in systems containing PHI, including access and modification logs.
A coder notices the EHR auto-populated a diagnosis code from a prior visit. What is the BEST action?
Answer: Verify the code reflects the current encounter's documented diagnosis
Auto-populated data must always be verified against current documentation because coding each encounter based on its own clinical findings is a fundamental coding principle.
What does the acronym 'API' stand for in the context of healthcare IT interoperability?
Answer: Application Programming Interface
API (Application Programming Interface) is a software mechanism that allows different systems to communicate and exchange data, crucial for EHR interoperability mandates.
Which federal rule requires EHR vendors and providers to support standardized APIs for patient data access?
Answer: 21st Century Cures Act Final Rule
The 21st Century Cures Act Final Rule mandates that certified EHR technology support standardized APIs and prohibits information blocking.
A medical coder uses encoder software that suggests additional codes not documented in the chart. The coder should:
Answer: Query the provider to clarify if the conditions are present and documented
Codes may only be assigned based on documentation; encoder suggestions prompt the coder to query the provider if clinical indicators suggest an undocumented condition.
In a practice management system (PMS), what is the PRIMARY purpose of the charge capture module?
Answer: Recording services rendered and linking them to billing codes for claim submission
Charge capture translates clinical services into billable codes and fees, forming the foundation of the revenue cycle workflow.
Which data standard is used to transmit electronic health care claims between providers and payers in the US?
Answer: X12 837
The X12 837 transaction set (837P for professional, 837I for institutional) is the HIPAA-mandated standard for electronic claim submission.