Certified Medical Coding Specialist Technology & Digital Applications 2

Question 1

Which type of EHR audit trail feature is MOST critical for HIPAA compliance monitoring?

Accepted Answer

Logs recording who accessed or modified records and when

Answer

HIPAA requires covered entities to maintain audit controls that record and examine activity in systems containing PHI, including access and modification logs.

Question 2

A coder notices the EHR auto-populated a diagnosis code from a prior visit. What is the BEST action?

Accepted Answer

Verify the code reflects the current encounter's documented diagnosis

Answer

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.

Question 3

What does the acronym 'API' stand for in the context of healthcare IT interoperability?

Accepted Answer

Application Programming Interface

Answer

API (Application Programming Interface) is a software mechanism that allows different systems to communicate and exchange data, crucial for EHR interoperability mandates.

Question 4

Which federal rule requires EHR vendors and providers to support standardized APIs for patient data access?

Accepted Answer

21st Century Cures Act Final Rule

Answer

The 21st Century Cures Act Final Rule mandates that certified EHR technology support standardized APIs and prohibits information blocking.

Question 5

A medical coder uses encoder software that suggests additional codes not documented in the chart. The coder should:

Accepted Answer

Query the provider to clarify if the conditions are present and documented

Answer

Codes may only be assigned based on documentation; encoder suggestions prompt the coder to query the provider if clinical indicators suggest an undocumented condition.

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Practice Test

Certified Medical Coding Specialist Technology & Digital Applications 2