Registered Health Information Technician Flashcards

What is the difference between computer-assisted coding (CAC) and autonomous coding?

Answer: CAC suggests codes for human review while autonomous coding assigns codes without human intervention

CAC uses NLP to suggest codes for review by a human coder, while autonomous coding assigns codes automatically without human review.

A hospital's case mix index (CMI) has been declining over the past quarter. Which department should be consulted first?

Answer: Clinical documentation improvement (CDI)

A declining CMI often indicates documentation gaps that result in lower-weighted DRG assignments.

What type of audit examines health records while the patient is still receiving care in the facility?

Answer: Concurrent review

A concurrent review examines health records during the patient's current stay, allowing documentation issues to be addressed in real-time.

Which of the following is a key responsibility of the HIM department regarding release of information (ROI)?

Answer: Verifying the validity of authorizations and ensuring only authorized information is disclosed

The HIM department is responsible for verifying that all release of information requests include valid authorization.

What is the primary purpose of healthcare data analytics in health information management?

Answer: To transform raw health data into actionable insights for improving care quality, operations, and outcomes

Healthcare data analytics transforms raw data into meaningful insights that support evidence-based decision making.

What is the role of a data dictionary in health information systems?

Answer: To define each data element including its name, definition, format, allowable values, and source

A data dictionary provides standardized definitions for all data elements in an information system.