C802 Foundations in Healthcare Information Management
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Free C802 Foundations in Healthcare Information Management Questions
1. The federally mandated resident assessment instrument used in long-term care facilities consists of three basic components. Two of these components are the new care area assessment and utilization guidelines. What is the third basic component in the resident assessment instrument?
- Minimum Data Set (MDS)
- Uniform Hospital Discharge Data Set (UHDDS)
- Outcome and Assessment Information Set (OASIS)
- Data Elements for Emergency Department Systems (DEEDS)
Explanation
The Resident Assessment Instrument (RAI) used in long-term care facilities is composed of three essential components: the Minimum Data Set (MDS), the Care Area Assessment (CAA), and the Utilization Guidelines. The MDS serves as the foundation of the RAI by providing a standardized, comprehensive assessment of each resident’s functional capabilities and health needs. This data helps guide individualized care planning, ensure quality of care, and support federal reporting requirements for nursing homes. The MDS is distinct from other datasets such as OASIS, which is used in home health care, and DEEDS or UHDDS, which are used in hospital settings.
2. The ICD-10-CM/PCS Coordination and Maintenance Committee is responsible for overseeing all changes and modifications to ICD-10-CM and ICD-10-PCS codes, including the creation and update of general equivalency mappings. ICD-10-CM codes are reported for _____, while ICD-10-PCS codes are reported for _____
- Diagnoses; Procedures
- Diagnoses; Conditions
- Procedures; Diagnoses
- Services; Procedures
Explanation
ICD-10-CM codes are used to classify and report diagnoses and reasons for patient encounters, while ICD-10-PCS codes are used exclusively for reporting procedures performed in inpatient hospital settings. The ICD-10-CM (Clinical Modification) is applied to all healthcare settings for diagnostic coding, whereas ICD-10-PCS (Procedure Coding System) provides detailed procedural coding that captures the specific techniques and body systems involved. Together, they support clinical documentation, billing, and statistical analysis across healthcare systems.
3. Identify a characteristic of the legal health record:
- It must be electronic
- It includes the designated record set
- It is the record disclosed upon request
- It includes a patient's personal health record
Explanation
The legal health record (LHR) is the official business record of a healthcare organization and represents the documentation that may be released in response to legal or official requests. It includes all patient-specific data that the organization defines as part of its official record for legal and evidentiary purposes. While it may exist in paper or electronic form, its defining feature is that it is the record disclosed upon request. It does not include personal health records maintained by the patient.
4. Which of the following activities is considered a secondary function of the health record?
- Quality assurance and improvement
- Clinical decision support
- Patient education and counseling
- Public health reporting
Explanation
Secondary functions of the health record involve uses beyond direct patient care. These include quality assurance, research, education, and public health activities that depend on aggregated data rather than individual patient management. Quality assurance and improvement use health record data to assess the effectiveness, safety, and efficiency of care delivery. While primary functions of health records center on patient care and clinical decision-making, secondary functions support system-level improvements and policy development.
5. What is a primary advantage of utilizing unstructured data in healthcare documentation?
- It is easier to analyze
- It allows for more nuanced patient narratives
- It is less time-consuming to collect
- It is always more accurate
Explanation
Unstructured data in healthcare, such as narrative notes, free-text entries, and dictated reports, allows clinicians to record detailed observations and complex patient stories that structured data fields may not accommodate. This type of data captures the context, tone, and subtle nuances of a patient’s condition, which can be invaluable for clinical decision-making and holistic patient care. While unstructured data may be harder to analyze quantitatively, it provides depth and richness that structured formats often lack.
6. A healthcare professional attempted to input a blood pressure reading of 250/150 mmHg, but the system rejected the entry. What does this scenario illustrate?
- Data validation
- Edit check
- Data entry
- Data accuracy
Explanation
This scenario illustrates an edit check, which is a system control designed to prevent the entry of implausible or out-of-range values into electronic health records. The system automatically evaluates the input against predefined rules or thresholds (e.g., normal physiologic limits for blood pressure) and rejects values that are inconsistent with these rules. Edit checks are a key component of data validation processes, helping to maintain data accuracy and integrity in clinical information systems.
7. A healthcare provider must document the administration of a flu vaccine to a child in which of the following registries?
- Diabetes registry
- Immunization registry
- Cancer registry
- Surgical registry
Explanation
An immunization registry is a confidential, population-based system that collects and maintains vaccination data for individuals within a specific region or jurisdiction. Healthcare providers use these registries to document vaccine administration, track immunization histories, and identify individuals who are due for vaccinations. For a child receiving a flu vaccine, the information must be entered into the immunization registry to ensure accurate tracking and to support public health monitoring. This allows for effective vaccine coverage assessments and helps prevent missed or duplicate immunizations.
8. What is the correct sequence of data flow for processing a hospital outpatient visit?
- Patient check-in > services rendered > charges captured > coding completed
- Patient check-in > coding completed > services rendered > charges captured
- Services rendered > charges captured > patient check-in > coding completed
- Coding completed > patient check-in > services rendered > charges captured
Explanation
The correct data flow in processing a hospital outpatient visit follows a logical order based on patient encounter and billing workflow. It begins with patient check-in, where demographic and insurance information is verified. Next, services are rendered by clinical staff or providers. After services are provided, charges are captured to record what procedures or services were performed. Finally, coding is completed to assign appropriate ICD-10-CM and CPT/HCPCS codes for billing and data reporting. This sequence ensures accuracy in documentation, billing, and compliance with reimbursement guidelines.
9. Reviewing the health record to ensure required reports are completed and authenticated is called
- indexing.
- analysis.
- coding.
- abstracting.
Explanation
Analysis is the process of reviewing health records to verify that all necessary documentation, signatures, and reports are complete and properly authenticated before the record is considered final. This step ensures compliance with legal, accreditation, and organizational standards for record integrity. Analysts check for missing physician signatures, incomplete diagnostic reports, and other documentation deficiencies that could affect the accuracy or legality of the health record. It is a critical quality control function performed before record closure or release.
10. The patient had a left femoral herniorrhaphy for a recurrent reducible hernia. What is the correct code assignment?
- 45821
- 47152
- 47521
- 49555
Explanation
The correct CPT code for a recurrent, reducible femoral hernia repair is 49555. This code specifically describes “Repair initial femoral hernia, recurrent, reducible.” Femoral hernias occur near the femoral canal in the groin, and when the hernia is recurrent (previously repaired but has reappeared) and reducible (able to be pushed back into place), code 49555 accurately represents the procedure. The other listed codes correspond to unrelated procedures—such as vascular or hepatic surgeries—and do not apply to herniorrhaphy cases.
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