Which of the following refers to the presentation of patient information in a useful form and the association of other relevant details with it?

Question 1 options:

	Computer data
	Health information
	Patient data
	Health data

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Question 2 (5 points)

The word data refers to:

Question 2 options:

	records of facts.
	computer information.
	patient information.
	presentation of information.

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Question 3 (5 points)

HCPCS II codes were created for billing:

Question 3 options:

	surgical procedures.
	outpatient services.
	inpatient treatments.
	supplies, injectable medications, and blood products.

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Question 4 (5 points)

All of the following are examples of secondary health records EXCEPT:

Question 4 options:

	master patient indexes.
	reports from other providers.
	health insurance claims.
	aggregate data.

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Question 5 (5 points)

Records gathered directly from the patient and his or her providers that document the patient's history and state of health are:

Question 5 options:

	secondary records.
	research records.
	data records.
	primary records.

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Question 6 (5 points)

An ICD-9-CM V code is used to code a(n):

Question 6 options:

	non-illness condition.
	accident.
	medication error.
	disease.

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Question 7 (5 points)

All of the following are an unethical and/or illegal practice EXCEPT:

Question 7 options:

	upcoding.
	unbundling.
	billing for services provided.
	billing for levels of service not supported by documentation.

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Question 8 (5 points)

A coding specialist is also sometimes called a(n):

Question 8 options:

	reimbursement specialist.
	insurance specialist.
	payment specialist.
	billing department specialist.

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Question 9 (5 points)

Which of the following positions is responsible for both the health information management department and the information technology department?

Question 9 options:

	Hospital administrator
	Chief information officer
	Health information manager
	Risk manager

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Question 10 (5 points)

The first step in an inpatient admission and discharge is:

Question 10 options:

	an attending physician is assigned.
	procedures are ordered by a physician.
	patient care is provided by the nursing staff.
	patient demographic and insurance information is collected.

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Question 11 (5 points)

Inpatient acute care hospitals are reimbursed a single total payment for each patient discharge based on a(n) ________ code, which assumes that patients with the same sort of diagnoses require about the same length of stay and use approximately the same amount of resources.

Question 11 options:

	ICD-9-CM
	HCPCS
	CPT-4
	DRG

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Question 12 (5 points)

Records that are created by abstracting and summarizing information from primary records are:

Question 12 options:

	primary records.
	secondary records.
	compiled records.
	research records.

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Question 13 (5 points)

The reason (after study) that the patient was admitted to the hospital is called the:

Question 13 options:

	principle diagnosis.
	discharge diagnosis.
	final diagnosis.
	Both A and B

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Question 14 (5 points)

All of the following statements are true of the patient health record EXCEPT:

Question 14 options:

	it is not used for billing and reimbursement.
	it provides information about the patient's treatment.
	it is the primary communication document for those who care for the patient.
	medical bills will not be paid if the patient record does not contain necessary documentation.

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Question 15 (5 points)

The American Health Information Management Association was previously known as the:

Question 15 options:

	American Association of Record Librarians.
	American Medical Record Association.
	Association of Record Librarians of North America.
	All of the above

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Question 16 (5 points)

Which of the following are standardized codes for reporting medical services, procedures, and treatments performed for patients by the medical staff?

Question 16 options:

	ICD-9-CM
	CPT-4
	HCPCS II
	ABC

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Question 17 (5 points)

________ allied health positions do NOT involve direct patient care but do manage and protect patient medical information.

Question 17 options:

	Nonclinical
	Clinical
	Supportive
	Clerical

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Question 18 (5 points)

The American Health Information Management Association offers which of the following credentials by a certification exam?

Question 18 options:

	Certified Coding Specialist
	Registered Health Information Technician
	Registered Health Information Administrator
	All of the above

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Question 19 (5 points)

Hospital billing includes which of the following codes?

Question 19 options:

	ICD-9-CM codes
	HCPCS codes
	Principle diagnosis codes
	All of the above

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Question 20 (5 points)

Reports such as discharge summaries, history and physicals, and operative reports are created by listening to a dictated report by which of the following positions?

Question 20 options:

	Optical imaging coordinator
	Clinical analyst
	Medical transcriptionist
	Clinical vocabulary manager